Inguinal Hernia

The First Surgeon

Frankly, this whole matter came at a very busy time. I only had time to do a brief search on the Internet on “hernia surgery” (better known as “hernia repair”). I discovered that in England, where hernia repair is an elective surgery with a fairly long wait time, patients wear a truss for many weeks until their surgery date. On mesh, I discovered that some patients continue to have pain and/or feel the presence of the mesh for a few months.

I checked the surgeon’s bio online. He was young and appeared to be very talented and qualified. Since he had taught at two prestigious medical schools, I expected to have a very lively and intellectual discussion with him.

When I went for my appointment, the surgeon examined me carefully and told me about laparoscopic surgery and how the mesh works. He gave me a plastic mesh to hold, and, while I was holding it, he brought out a denser and heavier one to hold with my other hand so that I could feel how the new, improved one was so much lighter and less dense. “Is he a mesh salesman?!” I wondered to myself. “Why does he keep old, useless mesh in his office?” When I asked him what his thoughts were about wearing a truss, he said, “C’mon, you are not 99 years old. Why would you want to wear a truss?” I was frankly taken aback with this manipulative, salesman-like approach. I guess he had just started his practice and was eager to sell me on the most profitable treatment option.

I left the surgeon’s office feeling very uncomfortable about him. I realized I needed to do more in-depth research to find the best option for treating my inguinal hernia, and definitely to find a different surgeon!

What Should Have Happened

The surgeon should have explained to me that, for a small hernia like mine, an open repair under local anesthesia—where an incision is made on the abdomen and the hernia is repaired—would have been the safest and best treatment. Laparoscopic surgery is riskier since it is done under general anesthesia, and the sharp probes used in the procedure may damage internal organs and cause other, more serious complications. One of the largest studies comparing the two types of repair, published in 2004 in the New England Journal of Medicine, concluded, “The open technique is superior to the laparoscopic technique for mesh repair of primary hernias.”

The Truss

As soon as I left the surgeon’s office, I bought a truss. There are several types of trusses. Some are like underwear with a padding that presses against the hernia, and others are like belts that provide support for the area adjacent to the hernia but do not press on the hernia itself.

I found the underwear type difficult to use when sitting or driving. The belt type was easy to fasten or unfasten as needed, depending on how long I needed to sit or drive, and comfortable to wear when standing or walking. It really helped with my pain and discomfort, which made it easier to delay surgery. Wearing a truss is usually encouraged for the elderly who are not good candidates for surgery.

Frankly, I believe doctors and popular medical websites in the United States do not advise patients to use a truss so that their pain and discomfort force them to rush into having surgery. As mentioned earlier, in England, patients are advised to wear a truss since hernia repair is an elective surgery and, under their medical system, it may be weeks before one is scheduled for surgery.

The Search Began

I searched online using Google, Google Scholar, Google Books, the National Library of Medicine website (pubmed.gov), and various medical and surgical journals. I scoured the medical literature for answers.

My first concern was having a synthetic material like a mesh, which is usually made of Gore-Tex, Teflon, Dacron, Marlex, or Prolene, placed in my body. It has become common medical practice to surgically insert mesh since early 1990s. A mesh provides a tension-free repair, and we are told that the recurrence rate is lower than that of repairs done without mesh.

Without a mesh, the traditional open repair is done in a way that the repair area is under tension. The surgeon would close the defect by firmly stitching muscle to the inguinal ligament below. Even at rest, this creates tension in the muscles, and it gets aggravated manyfold during acts of coughing or straining. Secondly, this displaced muscle, by natural virtue, would try to move back to its original place over a period of time. Already weak muscle gets weaker by suturing it under tension, and repair with such weak muscle fails to give any lifetime protection, even if it is securely sutured. Natural scarring of tissues and muscular shrinking further increases the tension and also weaken the tissues, resulting in a high level of recurrence. Despite this, I have met people whose open repair without mesh has lasted 25 or 30 years, and some 85% have never had a recurrence.

In majority of cases, use of a mesh does not cause complications; however, once you place a foreign object into the body, it may react in unexpected ways. According to Timothy Kuwada, MD, Assistant Clinical Professor, Department of Surgery, University of North Carolina, Chapel Hill, “With the increased utilization of hernia prosthetics, the incidence of mesh-related complications has also risen. Although rare, mesh infections and enterocutaneous fistulas are a devastating complication that can have significant effects on long-term quality of life. Furthermore, a growing body of literature suggests that mesh can increase chronic pain and discomfort in the form of a foreign body sensation, excessive rigidity, and collateral nerve and tissue inflammation. Multiple high volume (>1000 cases) studies have demonstrated a relatively high incidence of chronic pain after inguinal hernia repair.”

There have also been several recalls of various mesh brands and models. In 2005, the Food and Drug Administration recalled 100,000 Kugel meshes. If you had the mesh inside you causing pain, bloody stool, infection, etc., you would have to go through another operation to remove the mesh. This would not always be easy, as body tissue grows into the mesh.

Also, regarding recurrence rate, a 10-year study published in 2009 in The Surgeon, the journal of the Royal College of Surgeons of England and Ireland, concluded that using mesh had not reduced the recurrence rate: “Our findings help to explain why there has been no significant fall in the incidence of recurrent inguinal hernias in national data sets and large scale audits, despite a widespread use of mesh.”

Another study published in 2010 in The American Surgeon found no advantage for the use of in regards to infection, testicular swelling, post-operative chronic pain, or recurrence. The study concluded, “The anatomic procedure without mesh should continue to be offered to patients who have an initial inguinal hernia repair.”

Some 750,000 hernia repairs are done annually in the United States. The more mesh that is used in these repairs, the more profits the mesh manufacturers make. Thus, they are in competition to bring new, improved meshes into the market and capture more of the market share. Of course, every time a new mesh is introduced—like the recalled Kugel or PROCEED meshes—complications may arise.

In fact, complications are not limited to use of mesh in hernia repair. Serious complications, including pain, infection, bleeding, organ perforation, urinary problems, recurrent prolapse, and vaginal scarring/shrinkage, associated with transvaginal placement of surgical mesh for pelvic organ prolapse (POP) led the United States Food and Drug Administration to issue a warning on July 13, 2011. The warning stated, “The FDA is issuing this update to inform you that serious complications associated with surgical mesh for transvaginal repair of POP are not rare.”

All of this made me realize that having a synthetic material like mesh placed inside of me was like playing Russian roulette with my health. I decided to have an open repair without mesh under local anesthesia, and I hoped that I would be one of those without recurrence.

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