[pszotek]

How long can I wait?

CKBUZZ,

Thanks for finding us here and posting your question. I think it is an interesting one. There is data that suggests it would be safe to wait for a period of time. However, if you are unable to push it back in, pain is increasing, and your scrotum is enlarging then I would suggest getting re-evaluated. Although you are correct about it becoming an emergency there are mechanisms in place to deal with things that are becoming an urgency. Would be happy to discuss in more detail if you desire over the phone or our telehealth platform. You can signup at http://www.indianahernia.com and we will be in touch.

Hope that helps a bit. In general though if you are not incarcerated or strangulated you can wait a reasonable period of time before repair but it is impossible to estimate this without further discussion and exam.

Thanks
Dr. Szotek

[pszotek]

How long can I wait?

CKBUZZ,

Thanks for finding us here and posting your question. I think it is an interesting one. There is data that suggests it would be safe to wait for a period of time. However, if you are unable to push it back in, pain is increasing, and your scrotum is enlarging then I would suggest getting re-evaluated. Although you are correct about it becoming an emergency there are mechanisms in place to deal with things that are becoming an urgency. Would be happy to discuss in more detail if you desire over the phone or our telehealth platform. You can signup at http://www.indianahernia.com and we will be in touch.

Hope that helps a bit. In general though if you are not incarcerated or strangulated you can wait a reasonable period of time before repair but it is impossible to estimate this without further discussion and exam.

Thanks
Dr. Szotek

[pszotek]

How long can I wait?

CKBUZZ,

Thanks for finding us here and posting your question. I think it is an interesting one. There is data that suggests it would be safe to wait for a period of time. However, if you are unable to push it back in, pain is increasing, and your scrotum is enlarging then I would suggest getting re-evaluated. Although you are correct about it becoming an emergency there are mechanisms in place to deal with things that are becoming an urgency. Would be happy to discuss in more detail if you desire over the phone or our telehealth platform. You can signup at http://www.indianahernia.com and we will be in touch.

Hope that helps a bit. In general though if you are not incarcerated or strangulated you can wait a reasonable period of time before repair but it is impossible to estimate this without further discussion and exam.

Thanks
Dr. Szotek

[pszotek]

How long can I wait?

CKBUZZ,

Thanks for finding us here and posting your question. I think it is an interesting one. There is data that suggests it would be safe to wait for a period of time. However, if you are unable to push it back in, pain is increasing, and your scrotum is enlarging then I would suggest getting re-evaluated. Although you are correct about it becoming an emergency there are mechanisms in place to deal with things that are becoming an urgency. Would be happy to discuss in more detail if you desire over the phone or our telehealth platform. You can signup at http://www.indianahernia.com and we will be in touch.

Hope that helps a bit. In general though if you are not incarcerated or strangulated you can wait a reasonable period of time before repair but it is impossible to estimate this without further discussion and exam.

We would be happy to recommend some hernia surgeons in your area also if you can be more specific where in Texas?

Thanks
Dr. Szotek

[pszotek]

Having a Difficult Time Deciding

Stephent,

Very nice post and well thought out. I understand your dilemma. However, I believe you are young in the grand scheme. I often have this conversation with patients in your age group and even older. I find this story the best example:

At 83 yo a patient of mine had a similar story as you regarding a bulge in his groin.

His primary care physician saw him and told him that something else was likely get him before this small hernia would cause him a problem.

At 87 yo this gentleman had to quit golfing, his only source of activity and his favorite thing to do, because his small bulge had grown so large that it was interfering with his swing and he could not get around as well because his scrotum was essentially hanging down to his knee.

At 92 he presented to the ER with an acute incarcerated and strangulated hernia. I told him our two options are to fix you and you could die or you will die if we do nothing. He said well I have nothing to lose so fix me.

At 93, and last I heard, he was golfing again.

Moral: He missed 5 years of golf.

I think you are relatively young and healthy and if your hernia is getting bigger then the natural history is for it to continue to grow. I would recommend getting it fixed before your golf game is interrupted and you out live all the other things that “will get you” before the hernia will become a problem.

I hope this helps. Many thanks for your post. I think this is a common theme and will serve others well.

Feel free to shoot me an email and we can discuss over the phone if you like.

[email protected]

Dr. Szotek
http://www.indianahernia.com

[pszotek]

Surgery VS Watchful Waiting

MO

Difficult to quote for sure but your particular hernia is on the higher end of the risk spectrum than a non-incarcerated, reducible hernia as I am assuming by your post that you cannot push it back in? Some data will suggest the risk in the range of 2% / year that you watch it that it will require surgery on an urgent/emergent basis. In my opinion your would be higher but unable to predict to my knowledge.

Thanks
Dr. Szotek

[pszotek]

Laparoscopic Hernia Repair after Laparoscopic Prostate Surgery

Thanks for following up. This is great news. I agree with his assessment and would do the same. I did a gentleman with an old suprapubic tube yesterday and with care and skill it can be done. Dr. Jacob has both these talents and will do the best possible operation to fit your needs. Look forward to your updates. Paul

[pszotek]

Diagnostic laparoscopy as the definitive means of hernia detection?

I believe it is best to have intact and often do most of my inguinal hernias through a TEPP or total extraperitoneal approach. Could you theoretically take it down and not replace it yes. Here are some images from today. One shows me with grasper and scissors and this is what peritoneum looks like before you take it down. Next image shows the flap down and looking into the prepetitoneal space at the cord structures. The final image shown a how you close it. I use a suture. Hopefully Dr. Towfigh can answer your question about research protocol regarding the robot. Regardless of you have a hernia and I fix it whether I suture it plus mesh or just suture it then I fixed a hernia and it will be covered. I don’t have any other experience as like I said regardless I fixed the hernia. In fact for many years we fixed hernias without mesh. Hope this

[pszotek]

Diagnostic laparoscopy as the definitive means of hernia detection?

I believe it is best to have intact and often do most of my inguinal hernias through a TEPP or total extraperitoneal approach. Could you theoretically take it down and not replace it yes. Here are some images from today. One shows me with grasper and scissors and this is what peritoneum looks like before you take it down. Next image shows the flap down and looking into the prepetitoneal space at the cord structures. The final image shown a how you close it. I use a suture. Hopefully Dr. Towfigh can answer your question about research protocol regarding the robot. Regardless of you have a hernia and I fix it whether I suture it plus mesh or just suture it then I fixed a hernia and it will be covered. I don’t have any other experience as like I said regardless I fixed the hernia. In fact for many years we fixed hernias without mesh. Hope this

[pszotek]

Diagnostic laparoscopy as the definitive means of hernia detection?

I believe it is best to have intact and often do most of my inguinal hernias through a TEPP or total extraperitoneal approach. Could you theoretically take it down and not replace it yes. Here are some images from today. One shows me with grasper and scissors and this is what peritoneum looks like before you take it down. Next image shows the flap down and looking into the prepetitoneal space at the cord structures. The final image shown a how you close it. I use a suture. Hopefully Dr. Towfigh can answer your question about research protocol regarding the robot. Regardless of you have a hernia and I fix it whether I suture it plus mesh or just suture it then I fixed a hernia and it will be covered. I don’t have any other experience as like I said regardless I fixed the hernia. In fact for many years we fixed hernias without mesh.

[pszotek]

Diagnostic laparoscopy as the definitive means of hernia detection?

Wes
In the event that I take the peritoneum down and there is a cord lipoma (prepetitoneal fat) that I reduce then IMO it is necessary to either close down the internal ring with a stitch (most commonly robotically) or place a mesh. I personally place a mesh but as Dr. Towfigh said, on experimental protocol using the robot there are folks closing the internal ring without mesh placement. We will have to see how this pans out over the coming years. A straight forward diagnostic lap without taking the peritoneum down I would not put an intraperitoneal piece of mesh and yes this is different than taking down the peritoneum. A missed prepetitoneal fat piece referred to as a cord lipoma could be missed as it would have been in my case today and was likely missed in the original open repair. If you take down the peritoneum and no hernia or cord lipoma then I would say you could consider not placing mesh. I will say that most often when I go back for recurrence or persisten pain laparoscopically after anterior repair I often find a cord lipoma that was not previously reduced. Hope that makes sense. If I can get a minute I will put a short video of my case together from today that we can maybe get some stills or video showing the difference. What you see in this case is clear reduction of the sac with residual cord lipoma that was not evident as part of the initial indirect hernia which is clearly visualized. Hope that helps. Dr. Szotek.

[pszotek]

Diagnostic laparoscopy as the definitive means of hernia detection?

On this topic. I just did a case today that I completely reduced the hernia sac through TAPP approach and there was large prepetitoneal cord lipoma that was not evident intra-abdominally. This is the prime example of something that could possibly be missed with diagnostic lap alone and not taking the peritoneal reflection down. There was no evidence of this on intra-abdominal exam.

[pszotek]

Diagnostic laparoscopy as the definitive means of hernia detection?

I do not know anyone performing TEPP without mesh placement although it would theoretically be possibly by simply suturing the defect closed from the TEPP space and not placing mesh. Most surgeons do not close the defect from behind and just place mesh. Closing increasing chances of pain form nerve entrapment also. Some folks are starting to close on the robot but that is a TAPP approach.

[pszotek]

Continued proliferation of Millikan tension-free plug and patch repair?

Completely agree with Dr. Towfigh. I learned the advanced techniques because I had a desire not to use what I had learned in some cases in residency as I saw the failures from those techniques when I went into practice. I asked myself….why would my repair using the same technique be any better than the last 3 attempts by experienced surgeons….that’s when I decided I needed more tools to choose from in my shed and went and learned some of the advanced techniques and the rest is history. I will say that I am learning everyday and everyday I grow as a hernia surgeon. I will also admit that I was a plug and patch guy when I went out into practice and thought it was great and I was a stud….I learned I was not and that my technique could be better so I adapted and pushed the envelope. All the surgeons on here are similar in their innovation and skill set as Dr. Towfigh has pointed out. Same goes for dedicated hernia specialists. Best wishes. Dr. Szotek

[pszotek]

top hernia doctors in georgia or tn

In my opinion Dr. Chen is correct on this one. Since all nerves originate in the back and wrap around to the front the idea is to block/numb the nerve at the base and theoretically pain should not be conducted from the distal area to the spinal cord and thus the pain is alleviated. This is my view and likely Dr. Chen’s. Sorry if I am misinterpreting your post and this helps understand what Dr. Chen is likely thinking. Take care. Dr. Szotek

[pszotek]

Mesh Sutures

Thanks. I know, as do the other experts on the discussion feed, Dr. Dumanian well and am aware that he his developing these sutures and technique. I personally have not used these sutures in a live OR setting. I have tested them in various laboratory scenarios. I suspect there is a very select number of surgeons that would have tried these sutures and even in that case I would recommend going straight to Dr. Dumanian for repair with this technique if you are interested in this repair as he is the founder of the operation and the sutures. The idea is that the larger surface area of the mesh sutures will integrate into the tissue and prevent the sutures from cutting through the tissue and or pulling out. I think in many ways the concept makes sense but I do not suspect that the sutures alone will replace a sheet of mesh in the repair of a hernia although this is merely speculation without long term data. In general I would recommend turning directly to Dr. Dumanian for the best results and more information on his particular technique as he has the best knowledge related to the use of these sutures.

I hope that helps a bit and sorry about the lack of experience with these sutures in particular and the lack of long term equivalence/superiority/inferiority data on these sutures.

Dr. Szotek

[pszotek]

Mesh Sutures

Just wanted to clarify exactly what type of mesh and hernia repair you are referring to?

In general many robotic surgeons suture the mesh into the peritoneum when doing underlay mesh. Many also suture it in when doing other types of repairs. Open inguinals often suture the mesh in.

Hope this helps and please clarify so we can provide you with a more precise and accurate answer.

Thanks
Dr. Szotek

[pszotek]

Laparoscopic Hernia Repair after Laparoscopic Prostate Surgery

Yes. Sorry about the delay. Dr. Brian Jacob is a world leader in hernia repair. He uses the same self gripping mesh that I do (no tacks in most cases) and he does robotics so you could discuss the possibility with him. Obviously I cannot gaurantee that he would offer it but he would be the hernia Doctor I would recommend in NYC area.
Here is his website:
http://www.nychernia.com

Hope that helps.
Dr. Szotek

PS – if you would like to send me an email I can forward your contact to Dr. Jacob if you have problems getting in touch with him. My email is [email protected]

[pszotek]

Laparoscopic Hernia Repair after Laparoscopic Prostate Surgery

The simple answer is yes but it can be much more difficult. Many surgeons would say no and we are taught to avoid this situation. However, using a transabdominal approach with the robot has made these cases possible. That being said the complication rates would be slightly higher and there would be a higher risk of conversion to open. Would be difficult to predict the possibility of repair without imaging on the hernia and an exam. Hope that helps a bit.
Dr. Szotek

[pszotek]

Diagnostic laparoscopy as the definitive means of hernia detection?

I would agree with Dr. Goldstein. Often there is fat from the retroperitoneum that is contained in a small hernia or at least as a cord lipoma that can cause pain when a transabdominal lap approach is used. This often is not seen intra-abdominal and the peritoneum must be opened to see it. Dr. Szotek