pszotek
Forum Replies Created
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Hard to Detect Femoral Hernia Advice. Please Help!
I would agree. If you are looking for answers in NYC then Dr. Jacob is your man. Also would recommend Dr. Goldstein. Best of luck.
Dr. Szotek -
Continued proliferation of Millikan tension-free plug and patch repair?
Anytime. Best of luck with your search and ultimate decision. Paul
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Continued proliferation of Millikan tension-free plug and patch repair?
The plug and patch repair has gone out of favor because of chronic pain and associated erosions of the plug. I personally have dealt with it eroding into the colon on a left sided repair. Many others have described similar complications. In my practice I have found less pain and equivalent long term results with a combo suture repair of the floor of the canal and onlay with Pro-Grip self griping mesh for open repairs. However one of the biggest reasons that it has lost some steam is that many of us have switched to Lap repairs due to the decreased pain, decreased time to return to work, and the complete coverage of the Myopectineal Orifice with the lap repair. I initially used the plug and patch and felt like I was getting good results but the chronic groin pain and discomfort that my patients complained about was unacceptable in my opinion. That being said many surgeons get excellent results with many different techniques and sometimes the best technique is the one that your surgeon you choose is best at.
Any open repair can be done under local/IV anesthesia if you desire in most cases.
I would say in my experience that the recovery time and speed of operation are no different than with the classic Lichtenstein repair or a floor repair plus Lichtenstein. In fact, using the self-gripping mesh requires less fixation, minimizes pain, has very low recurrence, and is probably one of the fastest repairs that can be done.
If you are looking for low pain, least risk for chronic groin pain, low recurrence rate, and fastest return to work time then the Lap repair would be the most likely to accomplish all those things for you at the cost of cosmesis to some degree. With a Lap repair although small incisions, they will be visible to some degree when you have your shirt off. Most open repairs are hidden below the belt line.
That being said there are various permutations that make a Lap versus open repair make sense one way or the other. If there is any suggestion for weakness of the floor or possible hernia on the contralateral side then I would get an ultrasound with valsalva to confirm/rule out before suggesting one repair over the other. If clearly a contralateral hernia on exam then would lean toward Lap repair because you can fix both through the same incisions.
As far as watchful waiting that depends on the exam and on your size of hernia. If your hernia is reducible then the risk is as low as 2% per year for you having an adverse event/requiring repair. In other words watchful waiting is definitely something that can be done safely. On the other hand the natural progression is for these hernias to get worse over time and depending on your age and activity it is best to get them fixed electively when convenient. If on exam it is incarcerated/not reducible, causing significant pain, or contains intestines on imaging then I would proceed to fixing sooner than later.
Hope this helps a bit and feel free to be in touch and we can discuss on the phone if you like. Thanks for posting and doing such an excellent job at researching the different techniques and options to inform yourself so well. You will ultimately be glad and comfortable that you made the right choice of repair.
Dr. Szotek
317-660-5362
pszotek@gmail.com -
Continued proliferation of Millikan tension-free plug and patch repair?
Plug and patch repair has gone out of favor. I think you would be hard pressed to find a surgeon that has had to deal with the potential complications using this technique. I do not know of any surgeon that travels anywhere to learn plug and patch anymore. I would say there is no support for this repair in general. Thanks. Dr. Szotek
Happy to discuss your options in Indianapolis.
http://www.indyhernia.com
#indyhernia -
Alternatives to mesh
Simpsom
The TelaBio product is completely different in that it combines a biologic product with a synthetic product. We do not know many of the answers to your questions. If you would like more infor I would be happy to discuss with you. I have used it for ventral hernia repair and in fact we put the first piece in about a year ago.
I would be happy to discuss your case in detail. Feel free to shoot me an email and we will set up a phone conversation or you can come see me in the office.
Dr. Szotek
pszotek@gmail.com
http://www.indyhernia.com -
Physiomesh Recall… Should I be concerned?
Simpsom,
Thanks for your post. I have been one of the largest volume hernia repair surgeons in Indiana for the past 4 years and I do not use Physiomesh for any type of repair. This recent recall was initiated by the manufacture because of their analysis that the mesh was having central failure. We do a variety of the most advanced techniques in Indiana and Lap may or may not be what is warranted in your case. There are very few surgeons who do Retrorectus repairs open or Lap in Indiana. We have by far the most experience at these procedures in Indiana and would be happy to discuss your case with you.Thanks
Dr. Szotek (see profile on HerniaTalk website)
Indiana Hernia Center
http://www.indyhernia.com -
Symptoms of possible internal hernia
WesternWilson,
Thanks for taking the time to write us and hopefully we will be able to provide you with some guidance. First, I was hoping you could provide us a little more information regarding what has already been done from a testing standpoint: Upper Endoscopy, Small Bowel Follow Through, CT scan with Oral Contrast, Colonoscopy, etc?
Thanks
Dr. Szotek -
Umbilical hernia question
ds2003,
As you have said there is little information on this subject so it is a bit of a gray area. If the hernia is small like you have described and you are planning to get pregnant again soon then I usually wait in my patients until after the pregnancy in asymptomatic situations. If it is causing you pain and discomfort or there is a small piece of fat contained in it that is incarcerated and unable to push back in then it may be worth considering getting it done now as it is usually an outpatient procedure. In these situations I explain to patients that I am going to fix it primarily with sutures right now and if it recurs we will do a bigger mesh repair when you are done having children. Especially at the size you describe. Others might be more agressive and put mesh in now but I have seen the mesh migrate with pregnancy so I prefer to delay until after child bearing. Hope that helps a little bit.
Dr. Szotek -
top hernia doctors in georgia or tn
Great! Thanks for the feedback. Dr. Chen is the ultimate example of professionalism and knowledge in growing pain. Glad it went well. Please update us with your progress. Dr. Szotek
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Mission Complete! Hernia(s) repaired.
Congrats and thanks for the feedback. It is amazing how far an appreciative patient like yourself goes to making our day. All too often this is ignored. Thanks for your feedback and I hope that your recovery continues as well in the coming days. Dr. Szotek
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Did my Hernia Re-Occur
I would agree with Dr. Earle. I would try rest, ice, and naproxen or other NSAIDs for a period of time and see where things go. If this works than likely just strain on the tissue. However, if you notice a bulge or things get worse please see your surgeon as although it is a small risk, on occasion hernias can recur.
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Help!
I would agree with Dr. Earle. All of those are world class recs and leaders in the field in your area. Dr. Szotek
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Colonoscopy possible hernia
LindaS,
Thanks for your message and joining us on HerniaTalk. Off the top of my head I do not a have specific recommendation in Minnesota. I hope one of the other surgeons might. Here is a link to the American Hernia Society Specialist page. http://americanherniasociety.org/find-a-hernia-specialist/
Depending on your location in MN there are a variety of folks who have a special interest in hernia surgery here. I would also be happy to discuss with you online and see you just outside Indianapolis if you wish. http://www.indyhernia.com (website not complete but can contact us through the website via email)
I see you have had many tests but have you had your surgeon do an ultrasound with you bearing down at any point? Also have you had any surgery in the low abdomen/pelvic area. During any of your studies have you been directed to valsalva / squeeze your abdomen like having a BM?
I actually identified an inguinal hernia this way in the office this week that had been missed by our radiology department because they did not make the patient valsalva.
Have you discussed the possibility of “round ligament pain” with your Gyn? Had Gyn surgery or Endometriosis?
Thanks! Hope we can help you out.
Dr. Szotek
pszotek@gmail.com -
Sports Hernia – Convo with dr. Shirin Towfigh
Lynx,
Based on what you have related regarding your full diagnosis I would recommend exactly as Dr. Towfigh has for at least 6 weeks. I use exactly the same treatment protocol plus or minus the steroids which I often add if not making progress in a few weeks. Overall is seems that you are in the best of hands and following right along with what would be the standard recommendations. Hope that helps reassure you. Dr. Szotek -
Surgery VS Watchful Waiting
Tilbis,
Thanks for the very thoughtful and researched post. I will try to do my best to answer some of your questions and I think once we all weight in you should have a nice overall sense of a small consensus.
1. Pre-Op = Post-Op: I don’s know that there is scientific evidence one way or the other. I think that sometimes its because the original pain was from other sources and I think sometimes that the pain is caused by the patients anatomy/neurogenic in nature and not necessarily the hernia regardless of size.2. Intermittent is typical – Many folks say the pressure and pain gets worse with standing for long hours. Over the say the muscles get tired and become weaker so its a combination of the hernia pushing out and the overall increased stretch of the abdominal wall secondary to fatigue from standing long periods in an already weak tissue.
3. Yes and no on the small hernias – Very small less than 1.5cm or so are extremely rare to have bowel incarceration and strangulation. ” Small hernia’s in the 2-6cm range do demonstrate an increased risk of incarceration and strangulation. Large and very large hernias rarely incarcerate and strangulate in my experience.
4. Yes the hernia can become less painful over time but the pressure is likely to remain the same or get worse.
5. Nerve blocks – Yes and No – Short term they are great but it is a lot of work to get them setup and also a lot of work to maintain the injections every couple of days for long periods of time.
6. Its hard to answer the question with such a broad range of possibilities ( true inguinal hernia or incision hernia from c-Section, etc?) I will say that I do not treat my female patients any different than men and watchful waiting does not have any different effects on women as on men. I believe subjects in that study were indeed men.
Hope that helps a little bit and hope to be of service in the future. Dr. Szotek
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Alternatives to mesh
John,
My apologies for the delay. The two products that Dr. Earle has mentioned are 2/3 that I was referring to. I have not put either of those products in for an inguinal hernia. The 3rd product that I was referring to is one by a new company called TelaBio that Dr. Towfigh, Dr. Stephen Ferzoco from Boston, and myself have all used and recently just had a poster at the American Hernia Society regarding. This particular product combined biologic with a sewn in macroporous permanent synthetic mesh. In my experience it was pliable and we did not see any ill affects. Dr. Ferzoco put the largest number in inguinal hernias out of the 3 of us I believe and he reported no issues up to this point at about a year out. I will say that these meshes are unproven for long term results as Dr. Earle so eloquently pointed out. I will say that I will be launching this mesh again in my practice in the next 2-4 weeks. The first product will be completely resorbable/remodeled without synthetic mesh at all. I plan to combine this with a traditional tissue repair for added strength. In the 4-8 week time frame I will be once again using the bio+sythetic mesh again hopefully. If you know anyone needing a hernia repair that is interested in this type of mesh and being part of the initial experience please have them contact me. In addition if you would like to speak with Dr. Ferzoco directly about his patients experience in more detail let me know and I will see if I can arrange with him. Indiana Hernia Center 317-660-5326 pszotek@gmail.com -
How long did you wait?
Sean85,
Thanks for your post and we are glad to hear some positive feedback. Can you elaborate for the group on what type of repair technique you had and how long after surgery did you return to normal activity in the gym. Thanks! Dr. Szotek
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Alternatives to mesh
I would agree with Dr. Earle. Long term follow up is needed and unknown and unfortunately we cannot give you an accurate answer that would be beyond speculation for your questions. In fact speculation is even hard to give because the use of the biologics/hybrids/absorbable synthetics in the groin is extremely rare. I will say that even though I make an effort to follow up my patients for at least two years, it is extremely rare that they actually do return long term as Dr. Earle pointed out.
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Alternatives to mesh
Agree with Dr. Towfigh and Dr. Earle. In addition when you analyze the Gore BioA study the data is questionable because the exact types of hernias within the study is u clear. If you look at the range for time of surgery and size of hernia defect you are quick to question whether there is some padding of the data going on with small, easily repaired defects. In my experience there is no abdominal wall reconstruction hernia that take 60 minutes or has a defect size in the 10cm2 range. I plan to continue aggressive selection of patients and use permanent as much as possible. In addition I am looking at combined products that have both biologic and synthetic products in a single mesh.
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Have I messed up my hernia surgery?
quote :Hi there,I agree with comments by Dr. Earle. And the mesh repair is intended to cover all future hernias, too, so a femoral space on the opposite side is already covered by the mesh with the hope that a future femoral hernia does not occur.
If the pain continues, which it seems like it is, perhaps it is best to get that MRI pelvis, with valsalva preferably if they can do it. Send it to me and I will evaluate it. It will take some guessing out of the picture.
Good luck!
I would agree with both Dr. Earle and Dr. Towfigh on this one. Hope we can help you! Dr. Szotek