[pszotek]

Too small to be “real hernia” …. ultrasound vs MRI?

Thanks for the follow up Robo. Appreciate your kind thanks and not a problem at all. So they are definitely identifying something on the ultrasound which is hard to interpret as whether it is causing your pain. I asked the belt question because this is a common cause of irritation of the nerves in that area with tool belts. Any exercises you have started (p90X, crossfit, etc) recently that may be to blame. Any specific circumstances at work? As far as the block goes that would require a referral to a pain management specialist that specializes in nerve blocks. Most surgeons know “the guy” in their area and your PCP or surgeon could refer you. All it really does is say that if we numb the nerve does the pain go away. In some cases it is yes and that indicates there is inflammation associate with the nerve or something impinging it. In that case I often explore, repair the hernia, and if the nerve looks super inflammed or like it is bow stringing on the external ring in a thin patient (which happens more often than we think, then I will often excise the nerve at the orginal surgery. Not ideal but alleviates the pain and fixes any hernia or weakness in the floor of the inguinal canal. I am not sure this will be of super benefit unless it helps guide your decision on surgery or no surgery. With neurectomy you will often get numbness on the medial thigh, lateral scrotum, and sometime in suprapubic area to varying degrees. Most often I tell my male patients to think about when they are walking and they dont feel their testicles clanging against their legs for the most part so you really will not even notice that much and everything will work just fine in the bedroom. I have never had someone complain about this long term but I have had patients with chronic pain that is worse to deal with. Best of luck and happy to review the films if you wanted to send them over to my office. Just let me know. Paul [email protected]

[pszotek]

Could this be a hernia???

Great to hear you are making some progress and something was identified. Although you are correct that many folks complain about pain on the left it can really be located on either side. Hopefully the antibiotics clear it up. Appreciate the follow up and let us know hoe you are doing.

[pszotek]

Too small to be “real hernia” …. ultrasound vs MRI?

Robo,

Thanks for using the forum for your question. I think this is a difficult situation. Do you wear a belt at work? Unfortunately radiographically it seems like very little is turning up. Did the final report on the ultrasound say the same as the tech? Often techs tell patients what they see but may be misinterpreting the images which are then later confirmed or denied by the radiologist. Also did the tech notice this when you were bearing down?

One way to confirm or deny the pain is coming from a possible hernia is to have a nerve block and see if it relieves the pain. If it does then I would consider a hernia repair with possible neurectomy. Might be a bit aggressive but if any defect is causing pain then I think it needs to be fixed. Often what is found in these cases is a week floor with the nerves being bow stringed on the external ring and this often cases the pain. I don’t think any of the other work up studies would help very much after the two studies you had. One thing to consider is an appointment from a urologist to check the testicle if you are concerned. Hope that helps a bit. Take care and good luck. Dr. Szotek

[pszotek]

Having second thoughts! Input please.

Gretarae,

You describe a pretty common conundrum that patients face with multiple opinions. It will be difficult to tell you which repair you need without a complete history and at least a view of your CT scan. I don’t think either surgeon is completely right or completely wrong. I think that you have to also take into account the techniques being employed. For example, if you are a good surgical candidate and meet all criteria for a low risk of wound complication and the defect is such that you require large repair then I would prefer to perform the repair with polypropylene in the retrorectus space and what I am assuming is a TAR (transversus abdominis release) procedure you are describing as a “modified component separation”. This operation for morbidity and long term outcomes is second to none in a surgeons hands that has a lot of experience with the procedure like all the surgeons on herniatalk. I do not think that the plastic surgeon is incorrect but in my practice it would be exceedingly rare that I would offer a biologic hernia repair in a patient that meets criteria for a more durable repair with synthetic in the retrorectus space. One deciding factor that I would advise you is the technique the plastic surgeon will use to put the biologic in. If he is going to use a retrorectus approach with a biologic then I would not burn that bridge with a biologic at the current time because of the higher recurrence rates and greater morbidity. I hope this makes sense and helps a little bit with your decision. Regardless you should remember that it is impossible to direct you without the entire history of your problem and seeing the images as there are a lot of factors that go into deciding the procedure and mesh that cannot be judged accurately without all the information.

[pszotek]

Can I masturbate after 12 days of Inguinal hernia (mesh) surgery

Should be able to masturbate to comfort level. Thanks. Dr. Szotek

[pszotek]

Could this be a hernia???

Thanks for replying. Let me try to systematically answer your questions.

1) I have never heard of endometriosis being visualized on CT or Ultrasound and to my knowledge I would agree w/ Dr. Earle.

2) A herniated disc could indeed be causing referred pain like this. Another example to think about is left arm pain with a heart attack or right shoulder pain with gallbladder pain. These are all types of referred pain. The nerves are like guitar strings coming out of the spine and wrapping around to the front. A pinch of pressure anywhere along them can be transmitted along their length and cause referred pain. Although this may not be your case it can occur. Do you wear any kind of work belt?

3) enema – this is a good idea and your pain definitely could be related to diverticula but the duration and description do not seem to fit perfectly. I would have the test to confirm this though.

4) Gyn: I would see what the results of your tests are and inquire about possible causes as I mentioned earlier.

5) ultimately I suspect you will end up w/ diagnostic lap/TAPP Inguinal hernia repair like Dr. Earle suggested.

Hope that helps a bit.
Dr. Szotek

[pszotek]

top hernia doctors in georgia or tn

Sounds like you are in the hands of 3 of the best hernia surgeons in the world and close colleagues. Best of luck and I hope your pain is ultimately resolved. Dr. Szotek

[pszotek]

top hernia doctors in georgia or tn

There are probably other options but Dr. Chen is the standard for groin pain that most of us use as a reference and has specialized his practice in caring for chronic groin pain. He definitely has one of the largest series specifically related to groin pain and I would recommend him second to none. That being said there are likely others that would be closer that could assist in a similar manner. In NYC there is Brian Jacob who co-authored the SAGES Manual of groin pain with Dr. Chen and Dr. Towfigh. If you would like to see him that would be easy to arrange and we would be happy to do so. Hope that helps and if you would like to start on the East Coast let us know and we will arrange. Since he works closely with Dr. Chen then they could easily discuss the case and save a trip out to California.

[pszotek]

Could this be a hernia???

Thanks for the quick reply Sharon. Based on your history I am assuming they left the ovaries and you are not on hormone replacement therapy.

Here is a basic framework to break down groin pain/thigh pain/ right lower abdomen pain:

1) Hernia – for the most part one of the studies you had should have at least shown some bulging with valsalva if there was a weakness in the posterior layer which could then be stretching the nerve and causing pain. Also a femoral hernia can be present or even some pressure from some retroperitoneal tissue in that area but these two things were not present on your studies so we will assume they are not the cause. Also had you had a low transverse incision this could have been a cause. One other question that arises is: Do you have a scar in that general area from previous port placement for your laparoscopic surgery?

2) Intestines/Colon/Appendix:
– Constipation can cause some RLQ pain but unlikely the cause as you describe.

– Did they take your Appendix with any of your surgeries?

– Scar tissue from previous surgery pulling on your intestines.

3) Back/Spine:
– if the pain feels like it is wrapping all the way around from posterior then sometimes it is. I have had several patients go through the entire work up like you have and ultimately it was related to an impinging nerve at the spinal level. Did they look at spine on your MRI? Sometimes they have to do a special MRI. You mentioned some back problems. If the nerve is impinging at the level of the spinal cord this can cause what is called referred pain to the level of the groin.

4) Hip/Adductor tear
– there are a variety of Orthopaedic issues that can cause pain in this area from tearing of the rectus insertion point at the pubic/tearing of the adductor muscle/labrum tears. These should have been visualized on MRI if they were present but I want to mention because it seems things are worse being on your feet for long periods of time.

5) Gynecological:
– residual endometriosis can cause something similar and is partly why I asked. It does not fit the picture completely but is possible.
– rare occasion you can get some endometriosis at an old port site and partly why I asked if u have a scar from pervious surgery.

– if ovaries still present should be assessed by Gyn as could be causing pain.

– round ligament pain: this may be a consideration in your case. The round ligament exits the internal ring and then heads towards the pubic bone. It was cut somewhere along the line in your surgery but could be scarred to your bladder or in the area there. If the MRI is showing that your bladder is “dropped” on one side then the possibility exists that this is causing pressure/pain. Just a thought.

Overall it is really hard to speculate without seeing the images and examining you. I am sure that one of us would be happy to either see you or find a highly trusted and skilled colleague in your area to see you in the office if you wish. I am sure that I may have missed something as I am working on my iPhone so please ask questions if there are other thoughts you might have or discrepancies in my response. I hope this is a nice framework for you to uses as you continue to work through this problem. Thanks again and let me know if I can be of assistance. Paul Szotek

[pszotek]

Could this be a hernia???

Sharon,

Sorry for all your pain. A couple clarifications I would like to make prior to entertaining your question more fully is what incision did you have for your hysterectomy and FT work? Midline? Low Transverse (bikini line)? Laparoscopic?

Why did you have hysterectomy?

History of Endometriosis, etc?

Thanks. Dr. Szotek

[pszotek]

Day 3 – post bilateral inguinal hernia surgery

I would agree with Dr. Earle and Dr. Towfigh completely. In my experience my patients seem to do really well with 2 Aleve in the AM and Two in the evening if no contraindications. I also have my patients ice for 15 minutes every two hours which seems to bring down the inflammation. I would also recommend early follow up to make sure nothing is going on that needs to be addressed to relieve your pain.

[pszotek]

top hernia doctors in georgia or tn

TN – Gregory Mancini, Bruce Ramshaw, Melissa Phillips.

GA – not entirely sure.

Fl- any specific region?

[pszotek]

Epigastric hernia repair — 2 weeks post-op

I usually tell my patients to minimize intra-abdominal pressure as much as possible for 2-4 weeks. Bending over can be particularly painful and difficult after umbilical hernia repair.

I would agree with Dr. Towfigh’s comments as well as its a low likelihood that it will recur.

[pszotek]

Diagnosing

An inguinal hernia and a sports hernia are two funamentally different entities. Sports Hernia is a confusing misnomer for pubitis/tear of the rectus muscle insertion on the pubic bone in its simplest terms. This is not truly a hernia. A true inguinal hernia involves a defect in either the floor of the inguinal canal (direct inguinal hernia) or lateral to the epigastric vessels at the internal inguinal ring (indirect inguinal hernia).

[pszotek]

Which Mesh System

Autoimmune conditions do not necessarily change my choice of mesh. What type of meds are you on? Steroids, etc.

In my experience Bard SoftMesh or Covidien Pro-grip work fine in these cases. This depends on the overall case picture though. Opinions may differ on this subject but I do not believe there is good evidence to alter my choice of mesh based solely on an autoimmune condition. If other factors pushed me toward biologic then I would consider biologic. In either case the risk is elevated with such conditions to develop mesh infection or chronic drainage. I quite regularly use SoftMesh or Pro-grip in heart transplant patients who are on multiple immune suppressants and they do well. Probably any macroporous prolene would work but those are the two I use most often. I like the pro-grip in the transplant cases because I don’t have to use sutures and thus no knots. Knots often cause suture granulomas, chronic drainage in immune suppressed folks. Just my two cents. I hope it helps. Paul

[pszotek]

Exercising

I do not have specific experience with the brand but many of my patients buy the spanx type undergarments on Amazon and are pleased.
http://www.amazon.com/s/ref=nb_sb_noss_2?url=search-alias%3Daps&field-keywords=compression+undergarments

Some medical grade companies that I do not have a lot of experience with from a patient feedback standpoint but are out there are:
Marena Group 770-822-6311
Underworks, Inc
Jobst/BSN Medical
Nouvelle Products

to name a few that I have heard of. Really anything that provides support will be helpful.

Hope that helps
Paul Szotek

[pszotek]

1 week post op… horrible nerve pain

Sean,

Sorry for your post-operative pain. Often the nerve is stretched when dissected and becomes inflamed. The vast majority of these resolve within 2-4 weeks in my experience. Often we will wait as hernia surgeons for a prolonged period of time 6mo to a year if the pain persists unless there is a high suspicion for nerve entrapment. Your positional pain suggest that the nerve may be being irritated by the external inguinal ring when you stand or walk. This often resolves with time and decreased inflammation. None of this is certain however without being there during the surgery. Hope that helps a bit. Although a bit ambiguous, so is the management of the problem as its difficult to decide who will resolve and who will not. I usually use the tincture of time and determine if you are making progress. Not entirely sure why you experience the pain with erection. Was it immediately after erection or during intercourse?

Thanks
Paul