[Retained ForeignBodies causing pain or Chronic pain from Hernia?]

Medium inguinal Hernia – Traditional Tension Repair

Dr. Earle – Thank you. I am assuming Dr. Ramon Berguer does not do the traditional tension repair since he is a laparoscopic surgeon. Can you recommend someone closer to San Jose that does traditional tension repairs? I reside in the Santa Cruz area.

[Retained ForeignBodies causing pain or Chronic pain from Hernia?]

Hernia or Psoas?

Thank you, Dr. Towfigh – I appreciate your thoughts.

My pain now (2 years after onset) is improved in that I feel it less often and less severely than I did a year ago. It now falls in the grey area between ‘definitely wanting surgery’ and ‘thinking I can live with this’ – do you see any drawbacks or dangers in waiting until it gets worse ?

Also, do you often (or ever) encounter confusion between inguinal and femoral hernias on radiology reports and is it important to be rescanned prior to surgery? The exact centre of my pain is hard to pinpoint but it does extend from lateral of pubic bone to just below hip bone.

[Retained ForeignBodies causing pain or Chronic pain from Hernia?]

Hernia or Psoas?

Hello Doctors,

I have an update: As I happened to be visiting Montreal in November, I took Dr. Earle’s recommendation, and arranged an appointment with Dr. Vassiliou. I explained my history and symptoms and gave her a copy of the ultrasound report which reads as follows:

“A very small left inguinal hernia located just lateral to the inferior epigastric artery. It contains only fat. It does not reduce completely at rest or with lying down. It increases slightly with Valsalva. The neck measures approximately 6mm”

There was no physical exam. She recommended I get the hernia fixed and that, if I didn’t mind traveling, she would be happy to perform the surgery (laparoscopically, with mesh) in the next few months.

Just last week I met with a local general surgeon (I am based in Calgary). In her opinion, a 6mm hernia is “insignificant” and barely bigger than the naturally occurring opening in that area. She explained that unless there is tissue further in the canal and creating a bulge, she would not recommend surgery. I asked about ‘hidden hernias’ and she did not seem to be aware of the concept.

Furthermore, she is not convinced that my symptoms are due to this hernia. She performed a physical exam and thought the area I indicated as most tender (just left of pubic bone) was a little low for an inguinal hernia. (It should be noted that when I had the ultrasound, the technician said it was femoral – I was surprised when the radiology report said inguinal). Also, when I mentioned that the pain at times extends up to the hip and wraps around to the back, she did not feel this was consistent with hernia. Her guess is that it is a pinched nerve or something musculoskeletal.

Also, in her opinion, patients who go into surgery with pain are more likely to have continued pain post-surgery. Her guess as to why is that the pain was not due to the hernia in the first place. (I am wondering if this is why the Shouldice Clinic won’t touch patients unless their hernias are palpable?)

This doctor suggests doing nothing except possibly acupuncture which might help if it is nerve pain. If or when the hernia gets bigger and detectable, she would then recommend I revisit the possibility of surgery.

Though I am not eager to have surgery and am willing to take a wait and see approach, I am dismayed at the notion that the hernia does not explain my pain! I feel intuitively that it IS the cause but know this could be wishful thinking. Needless to say, the second surgeon casts enough doubt that I am wary to go ahead with Dr. Vassiliou.

Does anyone have any thoughts or recommendations? Should I seek a third opinion? Wait and see? Thank you!

[Retained ForeignBodies causing pain or Chronic pain from Hernia?]

Hernia or Psoas?

Hello Dr. Towfigh,

Well, I finally had a dynamic hernia ultrasound and a small hidden, inguinal hernia was found! The technician was very good and it was not until I was standing up and bearing down that she was able to detect it. There was no hint of it when I was lying flat – even after she knew exactly where to look. I’ve been told that the hernia is composed of fat and not intestine which (presumably?) means there is no risk of bowel incarceration.

After 2 years, I am greatly relieved to know the source of my pain even though my GP has warned that surgery is risky and could result in more pain. I am now in the queue to meet with a surgeon. I’m not sure who it will be or exactly how long I will wait. In the meantime, I hope you don’t mind if I run a few questions past you:

– can you explain why small hernias are often more painful than large ones?
– are small hernias any easier to repair? Is there a greater chance that a mesh would not be required (I am thin and so am wary of the mesh).
– are painful hernias trickier to repair because nerves are involved?
– does the fact that the hernia is ‘occult’ mean that it is literally deeper in the groin and therefore more difficult (riskier) to repair?
– if left untreated, what is the likelihood of it getting bigger?
– is there an advantage to getting it repaired sooner (while I am still relatively young at 55) rather than later?

I gather from other posts on your forum that the expertise of the surgeon is critical and that he/she should have 250 to 500 laparoscopies under her or her belt. Is it important that I ask if they’ve had specific experience with hidden hernias in women?

I have not contacted the Shouldice Clinic but have seen some negative reviews online. I have concerns about traveling across the country only to discover that they won’t believe a hernia is there because they can’t see it or feel it! (I’ve read that they don’t want to see scans?)

Again, thank you for this invaluable forum!

[Retained ForeignBodies causing pain or Chronic pain from Hernia?]

Hernia or Psoas?

Thank you, Dr. Towfigh – this information is very helpful. I have one final question:

Even though my pain is not provoked by lifting, coughing, or getting out of a car – you would still say that a hernia is possible if not likely?

[Retained ForeignBodies causing pain or Chronic pain from Hernia?]

Hernia or Psoas?

Dear Dr. Towfigh,

Thank YOU for your helpful and thorough response! I’m glad I hit all your points (and no, I didn’t peek at your questionnaire!).

As neither the ultrasound nor MRI showed anything, my doctor and I had ruled out hernia. Also, as I had assumed that pain with coughing or lifting are hallmarks of hernias, I didn’t think one likely for me. Can you please confirm that this isn’t necessarily so? Is it dependent upon where in the groin the hernia is located? As my pain seems to extend from the left side of pubic bone up to the hip, I’ve often wondered if what I’m feeling is pressure on the inguinal ligament – does this make any sense to you?

I was interested in your quote to another poster regarding hidden hernias and strong core muscles:

“the hole is maintained and supported by strong surrounding muscles. I.e., you do not have a gaping hole with contents flowing out easily. Your abdominal muscles are trying to keep the hole as closed as possible”.

I’m assuming this means there is a hole in the muscle but that the bowel (or fat) only intermittently pokes through? And that the hole itself – with nothing poking through – is difficult to detect with imaging which is why you suggest manoeuvres during the scans? Would abdominal exercises (like pilates) be counter productive if trying to get a diagnosis as this would increase the chances of muscles closing the hole? Is it possible to actually mend a hernia with abdominal exercises (I’ll bet not!)

I will speak to my doctor and hopefully get a dynamic ultrasound and a referral to a surgeon. In your experience, are exploratory laparoscopies ever performed without a positive scan?

I only recently discovered that my mother has a hernia which prompted me to do more research. I’m glad I did – your forum and insights are most appreciated!