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Forum Name: Surgery Topics

Question: Laparoscopic Hernia Repair


 jamesb8 - Sun Aug 01, 2010 9:35 pm

I was diagnosed with a right inguinal hernia this past october. We decided to have it repaired laparoscopically. I thought everything was going great with my recovery until now, 7-8 months later, I am experiencing pain where the uppermost internal staple has been placed (right below my belt line off center a couple of inches to the right) for the mesh I assume. I can feel the staple from the outside. The pain seems to happen when I wear pants that have any weight to them (jeans with phone and wallet) or tightness around the belt line. I especially feel the pain while I am walking or flexing in certain positions. I am a skinny young man who can't stand when his pants are sagging, so I keep my belt relatively snug. Is this something that will go away? Should I revisit my surgeon? Should I attempt more ab exercisises to build the muscle around it? I am about to head off to college, and I do not particularly want this nagging pain.
Thanks,
Braden
 Dr.M.Aroon kamath - Thu Aug 05, 2010 8:33 am

User avatar HI,
I would prefer not to get into the get into the ongoing debates on "to fix or not to fix a mesh".

Mesh fixation in laparoscopic hernia repairs typically involves the use of tacks(mesh fixation devices), transabdominal sutures(transfascial sutures/transparietal sutures), or both of these.

Modern meshes get sufficiently (sufficient enough not to get displaced) incorporated into the body in approximately 2 weeks following insertion. This occurs by in growth of fibroblasts into the pores present in these mashes and subsequent laying down of collagen.In course of time, the meshes undergo a small degree of contraction(shrinkage).Some form of fixation is thought to be necessary during the first 2 weeks at least to prevent mesh from getting displaced.Generally. the sutures are inserted 2-3 cm apart and tacks are typically placed less than 1 to 2 cm apart.

Anecdotally, pain is generally believed to be worse after repair with sutures than with tacks causing reluctance among some surgeons to use multiple trans-parietal sutures. Sutures penetrate through the full thickness of abdominal wall musculature and fascia and this have a potential to cause muscular ischaemia or entrapment neuropathy. .

Whether tacks afford a reliable anchorage to the mesh(in comparison to sutures) is another aspect which is debated. Tacks are usually 4 or 5 mm long. A 4 mm-long tack would be expected to penetrate only 2 mm into the abdominal wall. In obese patients, the tack may only penetrate up to the extra-peritoneal fat without significant purchase into the muscle layer. At least one experimental study has demonstrated that the tensile strength of trans-parietal sutures is up to 2.5 times greater than that of tacks.These are some of the reasons why some surgeons prefer to use both sutures and tacks during a hernia repair.

Several studies which have compared use of sutures and tacks have found no significant differences between them as far as the post operative pain is concerned.

Newer modifications(among other benefits,to reduce the incidence of post operative pain) include,
- use of delayed-absorbable suture-material, such as PDS,
- use of absorbable tacks.


Most authors recommend the use of oral anti-inflammatory medications or injections of a local anesthetic to alleviate the symptoms in the majority of cases. Also, there are reports of re-explorations for persistent pain, demonstrating prompt relief after the release of an offending suture ot tack from the site of pain.

The pain attributable to the sutures or tacks usually starts soon after surgery. In your case, it has taken 7-8 months since the procedure, which is rather unusual.Tacks have been reported to migrate within the peritoneal cavity but i am not aware of any reports of migration outwards through the abdominal wall.

In your case,certain details should be ascertained before any conclusions are drawn or management is planned.
- was the mesh fixed or not fixed?,
- whether tacks, sutures or both had been used,
- whether newer techniques such as use of absorbable tacks, absorbable sutures or fibrin glue fixation had been used.

Best wishes!

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