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Patients with hernias are questioning how to avoid mesh because of a deluge of press and unsolicited email focused on a flood of lawsuit related to complications of mesh.  I'll review, in general, the groin hernia repair options, having had substantial experience and success with many techniques, and again offering the revived preference, open surgery with native tissues without mesh.

Recent surgical training has focused on Laparoscopic technique which limits trainee experience with open classical surgical techniques.  When open surgery is indicated, they depend on mesh techniques for security as needed in using Tension free or plug technique instead of laparoscopic hernia repairs which also requires mesh.

What follows is my perspective about options, after 50 years of ongoing surgical experienc...

Persistent pain after hernia surgery is said to occur between 6-10% of cases.  I have treated different specific causes for pain.  Pain Management and Neurologic consultations are frequently helpful in determining a cause.

Recurrence OF A REPAIRED GROIN HERNIA is rare (~2%) with mesh and not uncommon (>10%) without using mesh in the repair and is the initial consideration as the cause of pain.

Pain, which is frequently incapacitating, can occur after all repair techniques without recurrence.  Some reasons are shared and others are specific to approaches, technique and materials.  The reason for the original preoperative and postoperative symptoms must be reconciled with the preoperative anatomy, symptoms and radiography.  Persistent postoperative pain is more common when there was preoperative...

Persistent pain after hernia surgery is said to occur between 6-10% of cases.

I am interested in trying to solve the troublesome problem of persistent pain after hernia surgery.  Complications, recurrence and long-term pain can occur in some percentage after all methods.  Long term pain can interfere with daily habits, work, sleep, exercise and require analgesics and their side effects.  Then follows a cascade of problems related to persistent sedentary habits, weight gain, stress, occupational difficulties, muscle loss, sexual participation, home maintenance and depression.

All established primary care practices have referred patients for treatment of primary groin hernia.  Patients and many primary care physicians consider primary hernia surgery as a routine commodity and the choice of s...

September 16, 2016

For the purpose of clarification, a problem that persists six months after surgery is a long-term problem.  Some minor aches, pulling, stiffness or limited numbness will still improve after this point.  More troublesome symptoms are of greater concern.

Pain is a significant complaint after the early phase of wound healing.  Significantly, the same pain might have been noted immediately after surgery and continuously required consistent narcotic usage.  The pain may be under the wound and in the area of the preoperative hernia bulge or the pain might radiate from the wound into the thigh, pubic area or testicle.  Motion or position changes might worsen symptoms.  If the pain prevents return to normal activity and work after 4-6 weeks, the complaint is of significant concern assuming that maling...

If a hernia is present before pregnancy, it will become more prominent as the pregnancy proceeds.  Umbilical hernias might present as a “belly button” (umbilical) bulge, or an increased preexisting “outey.”  Inguinal bulges may develop in the groin for a few reasons.  Some of these bulges are hernias and others are fluid collection.  Some are painful.  Groin pain can also occur without bulges in the third trimester because of pressure from the enlarging uterus or strain on the round ligaments of the uterus that exit the pelvis through the groin.  A sensitive nerve (genital branch of the genitofemoral nerve) accompanies this ligament.  The risk of an enlarging hernia is that bowel can become incarcerated or stuck causing severe pain and bowel blockage.  Fortunately, this is rare.  If the hernia is...

Patients present to their physicians and are referred to a surgeon for evaluation of groin pain with a suspicion of an undetectable hernia.  This pain must be tenaciously evaluated and correlated with diagnostic findings.  If a hernia does NOT cause the pain, pain will persist postoperatively.  Patients with preoperative pain with hernias also have an increased risk of postoperative pain.  There are other reasons for postoperative pain that should be discussed preoperatively.  All of the causes of pain in patients without hernias can be experienced by patients who have had hernia surgery and might not be related to the surgery.

For example, a young man who notices an uncomfortable hernia after weight lifting has a repair and recovers uneventfully with no residual symptoms for th...

Listen during your consultation and be convinced that your surgeon is thinking about what is best for your personal and individual situation. Then a smooth and successful repair will be accomplished. Organized surgeons must integrate technique, craft, art, science, data bits and experience at stages of preoperative evaluation and planning and during the steps of surgery. Surgical procedures require accomplishing many successful steps, not one cut-and–paste maneuver. At times the steps are obvious, simple and fast. At other times, repair is elusive, complex and tedious. Each problem requires an individual solution. Frequently the solutions are similar, but rarely exactly identical. An experienced surgeon knows that ”there are no small operations, only small operators.” The “easiest” procedures some...

The surgeon who performs your hernia repair should educate you with enough information for you to confidently participate in the decision-making processes. Because one repair does not fit all patient’s requirements, explanation of the options of treatment and description of the alternative techniques require an orderly two-way communication including verbal and visual descriptions of techniques, clarification of ambiguities and misconceptions, establishing realistic expectations, and evaluation of risks and benefits, advantages and disadvantages. You may have special needs or conditions that require integration into the equation including fears, past surgical experiences, coexisting medical risk factors, employment needs, exercise habits, cosmesis and psychological predisposition. Institutional co...

The obvious objective of surgical repair is to eliminate the hernia and reconstruct the anatomy that caused that hernia in such a way that there is a minimized chance that it will ever recur again. This objective must also minimize pain and discomfort, complications, scarring, psychological trauma and recovery time. It must maximize safety, comfort, success and the patient’s ability to return to a normal routine of activity and work as soon as possible. Because surgery will be an unfamiliar and therefore anxiety producing experience, the surgeon must reinforce your confidence by communicating that he is anticipating, planning for and attending to many details and assisting you to understand in advance the gist of his planned experience.

 

The repair must be accomplished with maximum safety and minim...

Let’s assume that  you are referred to a surgeon and after a thorough consultation, you want a Laparoscopic Hernia repair. You can query your insurance company with a procedural code supplied by your surgeon and ask for an out of network allowance and payment. The person on the phone is unlikely to provide you with a clear and accurate answer. First, that person who probably has little medical or surgical knowledge, will try to convince you to seek out an in-network surgeon, Dr. X and Dr Z who are listed as doing laparoscopic hernia repairs. They have no idea which technique, the success rate or the experience of that surgeon. In fact, the accomplished surgeon that you consulted and chose may have taught the insurance company’s surgeons a year or two previously. The insurance company interferes wi...

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About Panagiotis Manolas, MD FACS. 
Over 50 years of experience.

HERNIAS: A COMFORTABLE UNDERSTANDING OF SURGERY AND RECOVERY

 

INTRODUCTION by Dr. Heymann

About 700,000 inguinal hernia operations are performed each year in the United States.  An estimated 5-10 times that number have untreated hernia.  Hernias can occur at any age from birth to old age.  Some people have a small unchanging weakness or bulge that has minimal impact except for the likelihood that the hernia will ultimately enlarge.  Of this group that decide to “ live with” their hernia, many independently limit exercise and change life style.  Some people allow the hernia to become large and ignore physical deformity.  With enlargement and containment of bowel serious risks may be unknowingly accepted.  This book is designed to help patients to understand how hernias develop and the rational behind treatment and to discuss the information, thinking and planning that need be incorporated into the process of successfully achieving  surgical repair of a hernia.

Inguinal hernias can be confused with their next-door neighbor, a less common variety, the femoral hernia that is more likely to cause problems when small.  Another common abdominal wall hernia is umbilical.  As children we point out our “inney” and “outey” naval.  “Outeys” are hernias.  Many do not change for a lifetime.  Others especially under the influence of weight gain and pregnancy enlarge.  Hernias can be acquired as a result of inadequate healing of an abdominal incision, an Incisional hernia.  Millions of Abdominal Operations are performed in the United States for many reasons and from 5-10% of these are followed by hernia formation.  Other  types of rare hernias include lumbar, obturator and sciatic.. 

The scientific surgical literature is replete with papers, data, symposia and anatomic studies.  Even surgeons can be confused by inconsistent anatomic descriptions, terms and results based on incomplete follow-up.  The attempt to convey important information to a concerned patient in the office at the time of consultation is oft times befuddled by misunderstandings.  If you are worried about having a hernia and how to deal with it, the following information will facilitate your participation in the decision-making process.  Your satisfaction will depend on knowledge of reasonable expectations of results and the orderly progression of your surgical experience.

Dr. Manolas (photo).
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