saro
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quote Momof4:I will weigh in on this subject since I have had a triple neurectomy, performed laparoscopically, near to the spine. I didn’t have any problems with the procedure itself. It was performed by a top hernia specialist in 2014. The area of numbness has not been bothersome and is still significant, 5 years later. In an appt with Dr. Chen, 2 years later, for chronic groin pain and mesh reaction, he noted that I wasn’t as numb as was expected after triple neurectomy. Some nerves regenerate over time, so some of my sensation had returned. Before my surgery I asked if there were any effects besides sensory and was old No. This hasn’t proved to be the case. I think as time has gone on and more triple neurectomies performed, the thinking on that has changed and physicians now realize there are some other effects. I am having some muscle wall laxity that is contributing to my long list of problems since the neurectomy, problems with recurrent hernias and mesh reactions that aren’t related to the triple neurectomy.Also, I have been a patient at The Dellon Nerve Institute In Baltimore, MD. Dr. Eric Williams is a top nerve specialist and would be a great person to see next. He specializes in all things related to nerves and is very familiar with nerve problems after hernia repair and mesh removal. He performs ultrasound guided, diagnostic nerve blocks in office, if possible. If not, he can send you to Johns Hopkins for further, more extensive diagnostic testing. He also offers surgery for this problem, when appropriate. We are holding off on surgery for my nerve problem, for now, due to the complexity of my condition and number of previous abdominal/groin surgeries and multiple recurrent hernias. He referred me to Johns Hopkins to pursue Cryo-ablation. He is still willing to help me if the less invasive treatments are unsuccessful.
I hope this helps. Best wishes on finding the optimal treatment for your problem. If you would like to ask more specific questions, feel free to message me privately on this forum.
ok, i sent you private message.
While I was in the hospital waiting room, I talked to some patients on a follow-up visit about a month after the surgery.I must say that they looked good, although they had undergone surgery, including neurectomy of two nerves.They only reported a tolerable loss of sensitivity (as you write in this post).Therefore I am pleased for their success, but I remain skeptical about the procedure, which I would prefer to avoid for the reasons listed by Dr. Brown and, according to your experience, this sensation is irreversible, and other problems will be added -
thank You Dr Towfigh for your illustrious opinion. I follow the debate on the nerves, like an ignorant reader, and it is very difficult to navigate between the different methods. I hope I don’t make big mistakes if I expose what appears to me (I am a patient). The anterior abdominal access meets the three important nerves; on this the guidelines leave the choice to the surgeon: if the nerve is in the operating field, if an injury is feared, the nerve can be cut ( Better a hypoesthesia (or paresthesia) than a pain) . On the other hand, the alternatives to anterior access are the Laparoscopic and the posterior access: but I know that both require prostheses. You can save your nerves but wear a mesh. In America, porcine prosthesis is also spreading; frankly it is not easy to understand if it is a “natural” alternative or if it takes risks like any prosthesis.
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I read that prophylactic neurolysis would be preferable to prophylactic surgical blocking of the nerves, because it interrupts the sensoriality, injuring a nerve, but saving its basal lamina, where the nerve will grow back. While the surgical block also cuts the basal lamina.
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quote DrBrown:To treat pain after mesh hernia repair it is important to try to determine the exact cause of the pain. Check for a recurrent hernia. A nerve block will help determine if the nerves are involved. The mesh can also be injected with local anesthesia to help determine if the mesh is the source of the trouble. Other structures that can be also be injected such as the inguinal ligament, the spermatic cord, etc. Once the etiology of the pain is identified the appropriate plans can be made.
Mesh pain is a difficult problem and is the source of my gray hair.
Regards.
Bill Brown MDI came across an accredited site where a surgeon questioned colleagues about the opportunity to practice preventive neurectomy in elective surgery to avoid possible chronic pain. Fortunately, almost all the colleagues from all parts of the world have especially supported the need to preserve nerves. Even when a nerve was wrongly damaged during the elective procedure, it could be caustic. Also for dont risk to damage the nervs in the surgery which occurs in the case of incidental resection or stress, some doctors instead practice a preventive neurolysis …what do you think about preventive neurolysis, is it a safe practice to preserve nerves?
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to avoid permanent nerve damage, which occurs in the case of incidental resection or stress, some doctors instead practice a preventive neurolysis … from what I could understand neurolysis is a practice used especially in the case of irreducible pain, however it is not equivalent to nerve cutting (neurectomy) and differs from nerve block … but of the three practices mentioned, only neurolysis is practiced during a primary intervention in some specialists, but I don’t know how successful …it would be interesting to know the opinion of the doctors of the site on neurolysis, the drtowfigh pls
if they read me, because this subject is of strict competence for the specialist doctors and for anesthesiologists .. -
quote dog:i think dr. Kang made Great Comment …almost like he knows ours most surgeons .:} ..Yes it isn’t common to meet surgeons with very detailed with delicate approaches ! .Here is the Best Statement that every surgeon[B] must learn by heart .. Made By one German doctor credited his success. Once again for a few here who didn’t read it ![ before /B]
Dr. Reinpold of Hernia Centre Hamburg-Wilhelmsburg[B]”The avoidance of chronic pain is a primary concern in inguinal hernia repair and may be considered the most important clinical outcome. This problem preceded modern mesh-based techniques; however, as recurrence rates have decreased, pain has become the more prevalent and important complication. Understanding the causative mechanisms and risk factors of inguinodynia help to prevent, diagnose, and treat this condition. Groin pain, especially in the absence of a bulge, often needs interdisciplinary diagnostics and no operation. Detailed diagnostics, meticulous operative technique with profound knowledge of the anatomy, proper nerve identification and handling, optimization of prosthetic materials, and careful fixation are of utmost importance. Further research on how to avoid CPIP and explore the effectiveness of treating it is necessary.”[/
[h=1]I found a publication of two great surgeons, in which Fitgibons, from page 121 also examines the Guarnieri method, expressing very positive evaluations, and claims that it would be more difficult to write oneself than to practice oneself. Even I, not being a doctor, just pass on some passages, which may be of interest.Nyhus and Condon’s Hernia[/h] a cura di Robert J. Fitzgibbons, A. Gerson Greenburg, Lloyd Milton Nyhus
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quote drtowfigh:Nope. No risk.
they are patients who operate from a distant surgeon and travel by airplane, or by train. The question to the surgeon is whether it is appropriate to undergo a long journey to have a tailor-made intervention, and what risks this decision may entail, given that the patient will have to face a return trip after an operation to the abdomen.
worth the effort?? -
quote Good intentions:I found this calculator on the American College of Surgeons page. It’s interesting. I also found another interesting page when looking for an APC code. 49650 is “Laparoscopy, surgical; repair initial inguinal hernia”. We can pretend that we are surgeons.
According to the calculator, even though I was in excellent shape with low body fat at the time of my surgery, I was “overweight”. My surgery risk was below average.
http://riskcalculator.facs.org/RiskCalculator/
https://www.aapc.com/blog/23842-mastering-hernia-repair-and-mesh-placement/
This passage, below, shows where mesh removal falls in the scheme of the “payers”. These would be the insurance companies. Apparently there is no “mesh removal” code, and mesh removal can’t be claimed as a foreign body removal. Looks like it gets a catch-all, non-specific, code. Maybe we should be lobbying the insurance companies to create a specific mesh removal code so that the correlation will be more clear, showing up in their databases. Even if the specific cause is not known the ratio of implantations to removals might be telling and worthy of action.
“Finally, a surgeon might remove previously implanted mesh without a recurrent hernia repair, such as when the patient has erosion of the skin over the mesh or pain related to the implant. In these cases, you can report the mesh removal separately. Payers do not consider mesh removal a proper foreign body removal. Therefore, you must use an unlisted procedure code, such as 49999, to report the service. Be sure to include a full operative report with your claim that describes exactly what the surgeon did and why it was necessary, and you should suggest a value for the procedure.”
Please Good intention, you can check the first link (http://riskcalculator.facs.org/RiskCalculator/), because I can not open it, while for the second everything is fine
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quote paco:I think the future should be something like taylor made mesh with autologous stem cells culture in a cell matrix, stimulating the right type of fibers (through CRISPR or whatever). But it sounds like Sci-Fi.
But the nerve entrapment will remain a problem.
I’m not so expert, but I think the research of biological prosthesis, remodeling, which would have the characteristic of developing an autonomous response in the form of collagen .. I notice that they do not develop fibrosis, but I am too ignorant to understand if they can trap a nerve
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quote seeker:It is not my intention to belittle your experience with mesh. In fact, I waited two years and tried to avoid having it implanted myself. I came to this forum and read thouroughly and sought the advise of the best surgeons mentioned on it. I had some scary painful experiences with my hernia pre surgery and had to make a decision. My posting was to explain that sometimes hard choices must be made. I spoke with two friends who had mesh implanted 10 years + and were doing well. I appreciate yours and others efforts to alert future patients of what can go wrong. But there are many good outcomes from hernia surgeries with mesh and I feel that must be acknowledged too.
It would be interesting to know the type of mesh and technique used by your friends successfully, but I realize that the question is not always asked, nor is the answer known
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quote drtowfigh:This requires examination by your surgeon. It may or may not be a recurrence. Most likely it’s not.
Curiously: why did you have it done open and not laparoscopic?
if I can softly insert myself in the conversation to understand the suggestion of dr:Towfigh: the preference to be given to laparoscopic intervention would be for bilateral hernia, or in any case?
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quote UhOh!:So you’re saying that the current generation of surgeons at that center have abandoned the mesh-free version of the founder’s signature technique entirely?
I have a friend operated right there in direct abdominal hernia: I can visit him, and I will ask details next weeck
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quote drtowfigh:[USER=”2029″]Good intentions[/USER] this is an important discussion to have.
Chronic pain comes in various flavors. There is mesh-related chronic pain, but there is also non-mesh related chronic pain.
We know that there is risk fo chronic pain with any operation, regardless of technique. We also know that each patient will have their own risk of chronic pain, different than their neighbor. We haven’t figured out why that is. It’s the billion dollar question no one has been able to figure out yet.
The most recent study published this past year put mesh and non-mesh repairs head-to-head and showed the risk of chronic pain is similar. It’s important to not that historically, tissue repairs were very painful and patients had to miss work and some were maimed by the repair. That is why a tension-free mesh repair was developed. For the first time, an inguinal hernia repair could be done as an outpatient and didn’t require a 3-day hospital stay. People tend to forget these details.
The reality is there is no one ideal repair. Some will do best with non-mesh repair. Others with mesh repair.
My doctor, congratulations on the excellent work done to guide people to the best solution. We know a lot from your words. You have argued, unfortunately, that chronic pain remains an unknown quantity and does not depend on the type of intervention, mesh or non-mesh. You have also argued that laparoscopic surgery has a lower incidence of chronic pain, yet it seems to me to apply only synthetic networks, not biological, so it may feel in some subjects also the presence of the network, I suppose. However, from what is evident, the idea of making me fall asleep and inflate a gas …. I can not ask you to go beyond your already clear exposure. But, as I said, every word of yours adds knowledge to our experience and helps us
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Good morning, I went to visit this center 2 years ago just because the videos showed that we practice a technique without prosthesis, developed by a great surgeon, the father Guarnieri Antonio.
At the medical examination I asked if the ernioraffia was practiced, but the surgeon replied that now they all use the prosthesis -
I consider this basic mesh-non-mesh discussion more interesting (About the onestep method. The authors boast of saving the cremaster muscle. But the method requires total anesthesia. The authors boast a fall in inguinal side effects with the Onestep method compared to Liechtenstein, but support their thesis with a questionnaire that leaves me doubtful. Although the questions were the same for patients operated with both methods, it emerged that some patients with onestep complained of sexual disorders before surgery, resolved with the intervention (:rolleyes:). :eek:)
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quote drkang:What you’ are saying is to some extent true concerning femoral hernia, umbilical hernia or incisional hernia. That is because for these types of hernias, the margin of the hernia hole is composed of ligaments or ligament-like fibrous tissue. This leads to the possibility of recurrence as the hard and inelastic tissue may tear after tissue repair. Despite this, based on my personal experience, the majority cases of femoral hernia and umbilical hernia with less than 2cm in diameter underwent pure tissue repair without recurrence.
It is however very different for the circumstances of inguinal hernia. The defect margin of inguinal hernia is composed of soft and elastic muscle instead of hard ligamentous tissue. And, not only for indirect hernia but for direct types of hernia as well, almost all cases have only a definite single defect. Thus, pure tissue repair can be performed on inguinal hernia for all patients very successfully. The high recurrence rate that existing tissue repairs have is not because of a tissue problem but because they are not the ideal surgical methods.
Therefore, what I believe was needed to solve the high recurrence rate of previous tissue repairs was not a surgery that uses durable mesh as reinforcement but rather the development of a new ideal tissue repair method. I think that the fundamental approach of solving the mesh problem is even now leaving aside the attempt to develop a so-called safe mesh and instead come up with a new optimal tissue repair method.
iI apologize if one day I understand one thing and the other the opposite .. now I read again the very interesting thesis, but I don’t understand if the conclusion suggests to study pure mesh or tissue repair
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I found a large difference in the volume of the hernia on the same day in relation to a stress event
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quote drtowfigh:Capricious is an excellent term. And everyone is different in how and when they get symptoms.
You have claimed that magnitude is not a decisive factor in recommending surgery. Do I guess this has limits (when the hernia develops too much, could it damage the nearby organs?)
can we consider symptomatic or little syntomatic a hernia that is painless? perhaps reducible, perhaps even of average magnitude?
A similar hernia, which allows the daily vital functions to be carried out, could be handled without harm? -
quote drtowfigh:With some exceptions, if a hernia is not affecting your daily life then it can be watched until it does get to that point.
Thanks for clarifying the drtowfigh.
I do not wonder what the exceptions are
As far as I’m concerned, I have been afraid of getting out of this maintenance condition some times because, after an effort, the hinged door seemed widened, and the discomfort was increased
With tenacity every time I accused me of strain or fatigue, I pledged to seek to recover the lost condition.
Lately I wonder if it is possible that the hernial door, apart from enlarging, is narrowing.