*** OFFICIAL INGUINAL HERNIA RECOVERY Thread ***

[drgephys]

I think the main fact we can all agree on is that hernia repair is not simple and your best bet is to choose the best and most experienced surgeon you can find.

Regarding different procedures, they all have different risks. I'm worried about the scarred peritoneal plane in laparoscopic repair with spermatic cord structures having been permanently peeled away from the peritoneum and lied bare and flat against the artificial mesh without any protection. Therefore, I'm currently leaning toward Lichtenstein open with mesh because my surgeon is the top expert on that, although he is also an expert on TEP (without entering the abdominal cavity [staying outside the fully intact peritoneum]) and TAPP (with entering the abdominal cavity [cutting and going inside the peritoneum and operating right next to the bowels]) laparoscopic repairs and he suggested laparoscopic in my case. The main risk in open repair is a somewhat higher risk of nerve damage and/or contact with mesh, causing chronic pain. It's otherwise usually safer and simpler.

I just read the Shouldice Hospital's (Toronto) hernia paper. Their technique is very invasive -- it involves full dissection of the area, including the full dissection of the cremasteric (testicular) muscle protecting the spermatic cord structures (vas and testicular veins), and at the end basically they suture everything (four different layers) together with stainless-steel or polypropylene wires. Yes, this excessive tissue joining and suturing results in recurrence rates comparable to Lichtenstein tension-free repair with mesh and avoids the mesh that could cause complications in some cases, but it is more invasive than the Lichtenstein tension-free method with mesh. Cases of severe chronic pain have also been reported with Shouldice.

Shouldice method fully described
ncbi.nlm.nih.gov/pmc/articles/PMC2999770/

Last but not least, one size doesn't fit all in hernia repairs. Some may benefit from open while others from lap, and this may unfortunately come only in hindsight.

Tomorrow morning I need to choose the operation method when I see my surgeon. He can do lap, Lichtenstein open with mesh, and Shouldice open tissue repair.

[KungFuFighting]

Hi all,

Just a brief followup on my surgery, 1 year + 1 month ago, nothing hugely interesting to report bar what I've previously written (page 34). My experience has been very positive, I've never really had any pain to speak of, either from the hernia itself, or from the surgery/recovery.

I had open mesh repair for a right hand side inguinal hernia, I'm UK based and went to a private hernia specialist. I noticed my hernia (which I think was a medium sized one) whilst showering, I'd never experienced pain from it, and had likely done some Kung Fu/ground fighting with it (this was not the cause). The surgeon said it was a long standing hernia which had enlarged.

1 year on I don't notice any difference in the repair area in any activities, although I'm obviously aware I've had the repair done, so am perhaps more conscious of the region before. That said, I try not to do overly strenuous core focussed excercises and am a more mindful of the region in general.

I'm very happy with my decision to undergo the repair/method used. My surgeon said the hernia would have enlarged further eventually, so in my mind there was nothing really to be gained by waiting.

I'll continue to try and check in from time to time.

Just a post to check in shortly after the 2 year mark; you can look at my earlier post for finer details, but the abridged version was in the quote. In short, nothing really to report, which is good; I haven't felt any pain from the repair, as active as before, and still happy I had the procedure.

Happy to restate any details if helpful; good luck with recoveries everyone!

[SoccerAgain]

I think the main fact we can all agree on is that hernia repair is not simple and your best bet is to choose the best and most experienced surgeon you can find.

No, that is the meme that I am saying is wrong. My surgeon had about 350 procedures behind him and was Chair of Surgery. Top-notch. But he did not know how his patients were doing. Most surgeons don't know, they don't check, and the patients don't come back when they have problems. Because the expert already screwed them up.

What I am saying is to ask for verification that their procedure has good long-term results. Most of them will say "well, I haven't heard any bad news". That's it, they take the absence of information as positive results. No news is good news.

[SoccerAgain]

Just a post to check in shortly after the 2 year mark; you can look at my earlier post for finer details, but the abridged version was in the quote. In short, nothing really to report, which is good; I haven't felt any pain from the repair, as active as before, and still happy I had the procedure.

Happy to restate any details if helpful; good luck with recoveries everyone!

Thanks for checking in Kung Fu. Just to simplify, you had open surgery with mesh. That's useful information.

My thoughts are leaning toward the possibility that it's the mass or total coverage of the mesh that causes long-term problems. The trend today is to cover as much area as possible, via laparoscopic implantation. They will cover from hip bone to hip bone and navel to pubic bone, not so much for the sake of the patient but to avoid future recurrence. Locking up all of the lower abdominal wall. Recurrence has been the primary concern for surgeons. It represents their failure to plug the defect. Long term pain is not their fault, it's somebody else's problem.

One reason I post is to try to get the details of what works and what doesn't.

[SoccerAgain]

I've sent a bunch of messages out to people who reported getting a hernia repaired, way back at the start of this thread. Hopefully some replies will come through.

No replies so far. Usually people are happy to share good news. I'm not sure that messaging is turned on for people unless they change the setting in their profile. Maybe I'll track them down in threads that they're active in.

[flanaganshane]

8 weeks and 3 days out: I’m still feeling amazing without any complications! I feel like I did prior to my hernia and I’m doing the same activities without any restrictions or limitations.

I’ll do my best to remember to come back in a year to update. If I have any negative issues at all I’ll update...

[drgephys]

t - 6 days to surgery.

I just met with my surgeon and discussed whether I should have laparoscopic or open. I asked him what he would do if he could operate on himself but he was vague. He said for bilateral he would definitely go with lap and for small unilateral perhaps open but it certainly depends on how he feels about general anesthesia (used in lap but not in open). My guess is that he doesn't like general anesthesia himself, even though he told me I would be fine with it because I'm young and healthy.

He uses 3 in x 6 in Ethicon UltraPro partially absorbable (50% absorbable) flat mesh for open Lichtenstein tension-free repairs. He uses (approximately 6 in x 6 in) Medtronic/Covidien ProGrip self-gripping mesh for lap (normally the TEP method) repairs, which has absorbable Velcro-like hooks that stick the whole thing on the underlying tissue without other fixation. Both types of meshes are light-weight and large-pore, which is important.

I asked him dozens of questions. He said that the most important thing is the choice of the surgeon and whether he/she knows what he/she's doing. In his patients the incidence of chronic pain in either open or lap repair is 0.5%. This is about ten times better than a typical surgeon.

I'm uncomfortable with lap because they dissect the bladder, peritoneum, and sperm-cord structures away so that they could make space and place the approximately 6 in x 6 in mesh flat against your inner abdominal wall. Sperm-cord structures are peeled away from the peritoneum, lied flat against the inner abdominal wall, left bare and touching the mesh for the rest of your life with the peritoneum no longer wrapped around and protecting them as it normally is. There is a very small but serious and/or life-threatening risk to internal organs such as the bladder, intestines, and vital veins. Even if everything feels normal, I'm not sure how scarred inner abdomen fares when you get older with your bladder etc. Then there is general anesthesia, where your brain cells are left with less than normal levels of oxygen for one hour as you're breathing only partially. He said the open repair is virtually free of any serious risks and done with local anesthesia. I also asked him about nerve damage (intentional and nonintentional) in open repair and it only happens in 2% of patients in his case but it's no big deal even if it happens.

I asked him about Shouldice tissue repair (without mesh) and he said, don't do it. He had offered it as an option if I was really worried about the mesh but the risk of recurrence and painful recovery don't warrant it. He said some of his open Lichtenstein tension-free patients never feel any pain from Day 1 and go back to their normal life the next day. In that sense open could result in even a quicker recovery than lap in some patients.

I will go with open unless I change my mind again. He did say though I would be fine with either open or lap.

[KonaKoffee]

t - 6 days to surgery.

I just met with my surgeon and discussed whether I should have laparoscopic or open. I asked him what he would do if he could operate on himself but he was vague. He said for bilateral he would definitely go with lap and for small unilateral perhaps open but it certainly depends on how he feels about general anesthesia (used in lap but not in open). My guess is that he doesn't like general anesthesia himself, even though he told me I would be fine with it because I'm young and healthy.

He uses 3 in x 6 in Ethicon UltraPro partially absorbable (50% absorbable) flat mesh for open Lichtenstein tension-free repairs. He uses (approximately 6 in x 6 in) Medtronic/Covidien ProGrip self-gripping mesh for lap (normally the TEP method) repairs, which has absorbable Velcro-like hooks that stick the whole thing on the underlying tissue without other fixation. Both types of meshes are light-weight and large-pore, which is important.

I asked him dozens of questions. He said that the most important thing is the choice of the surgeon and whether he/she knows what he/she's doing. In his patients the incidence of chronic pain in either open or lap repair is 0.5%. This is about ten times better than a typical surgeon.

I'm uncomfortable with lap because they dissect the bladder, peritoneum, and sperm-cord structures away so that they could make space and place the approximately 6 in x 6 in mesh flat against your inner abdominal wall. Sperm-cord structures are peeled away from the peritoneum, lied flat against the inner abdominal wall, left bare and touching the mesh for the rest of your life with the peritoneum no longer wrapped around and protecting them as it normally is. There is a very small but serious and/or life-threatening risk to internal organs such as the bladder, intestines, and vital veins. Even if everything feels normal, I'm not sure how scarred inner abdomen fares when you get older with your bladder etc. Then there is general anesthesia, where your brain cells are left with less than normal levels of oxygen for one hour as you're breathing only partially. He said the open repair is virtually free of any serious risks and done with local anesthesia. I also asked him about nerve damage (intentional and nonintentional) in open repair and it only happens in 2% of patients in his case but it's no big deal even if it happens.

I asked him about Shouldice tissue repair (without mesh) and he said, don't do it. He had offered it as an option if I was really worried about the mesh but the risk of recurrence and painful recovery don't warrant it. He said some of his open Lichtenstein tension-free patients never feel any pain from Day 1 and go back to their normal life the next day. In that sense open could result in even a quicker recovery than lap in some patients.

I will go with open unless I change my mind again. He did say though I would be fine with either open or lap.

Hey there Gephys, I wish you had donated your research here before I had mine. Probably the most valuable rundown yet on the pre-repair considerations. When I first checked in on this thread, I had read up on the topic, but felt like I still didn't have a grip on what I should query the doc with in the pre-op meeting. When I asked "what questions should I ask" for the pre-op, Socceragain gave me a slap down saying "you're not going to get a different answer than what has already been posted here... go back and read." Sorry, but most of the info was post-op experiences (which was valuable, but not for going into the meeting).

Soccer, you had a bad experience and your POV is definitely welcome. We need to hear what risks are out there and how you navigated your issues. But you come off almost angry and totally negative.... Gephys asked you the key question in the excellent exchange you had with him: After all you had to say, "WHAT ARE YOU RECOMMENDING?" You are all negativity with no direction or advice other than "do your research... look out! it could go bad!" Roger that. But how does that help people who need to have it repaired? One can get paralysis by analysis after a while.

Gephys, not everyone has access to a doctor like you have with his premier credentials and experience but I think in the end his most sagacious comment was: "Don't overthink it. They both are ok (in the hands of a competent surgeon)."

I am 6 weeks post op. Double IH mesh lap repair. I couldn't research forever and wanted it fixed, so in the end I just made sure I had an experienced surgeon (KEY). I'm doing fantastic. While Soccer would want me to weigh in at 6 years vs 6 weeks jussssst to make sure it was good, I am happy so far and would do the same exact thing. I'm running two miles, lifting moderately and life is normal with no pain or discomfort. Still keeping anything I lift under 50# for the time being.

A very interesting footnote to reading through your posts... you said "in the Hernia Surge Guidelines I linked above, low BMI is also mentioned as a risk. I got my hernia when my body fat dropped to around 8% and I'm suspecting that could have been a factor. They repeatedly emphasize that overweight but not obese people are much less likely to get hernias. So, perhaps, preperitoneal fat protects against hernia formation."

Funny, I was suspecting the very same thing! Mine showed up at the end of an 11 month cut that took me down from 210# to 162# (10%-ish). I read some anecdotal cases where they mentioned that factoid without connecting those dots. I also suspected the collagen factor as well. It certainly is a critical factor in the healing process as your body is packing in that scar tissue at the repair site. I loaded up on the bone broth and went heavy with the vitamin C (just made sure to slam a grapefruit, oranges or a couple of kiwis a day).

Again, good contribution. If your doc is all that and a bag of chips, go lap. It's fine. No regrets here.

[SoccerAgain]

Kona, my replay to drgephys was specifically to him. His degree is research-based, as you can see in his followup remarks, and my replay was to look again, which is, basically, what research is.

It's how the internet works, you can't tailor your replies to fit everybody. Sorry if you're offended but this isn't really an argument, it's a sharing of stories, so that other people can avoid the pitfalls. I see people repeating the same mistakes I made, as I've noted in my replies. It would be unconscionable, for me, to watch people go down this path without saying something. I wouldn't waste your time focusing on anything I write, if it's not of value to you.

drgephys seems to recognize that his doctor is avoiding certain topics. That's good. I realized today, as I thought about this thread, that most of the surgeons doing this work are more like engineers or mechanics. What they tell you is not what they "know" it's what they've read or learned in residency. They're just following instructions, like the SAGES guidelines. And the instructions are outdated and incomplete. They don't "know" if what they're doing really works in the long-term or not. That is the most essential point - they don't know. Nobody is collecting good data.

KungFu is the longest term good result that I have documented. I have memories of other open mesh surgeries with good results but I wasn't collecting them at the time, so can't verify. Based on reported long-term results, open with mesh is better than lap with mesh. I would love to hear from anybody who had laparoscopic mesh implantation over two years ago and recommended it. I've been searching.

As I've said many times, mesh implantation is meant to be permanent. Put the time in before you make that permanent decision. People live for many years with hernias, so a few weeks or months of living with it could be well worth the time.


BMI is an example of how the medical industry is bureaucratic and hangs on to old outdated principles. Any doctor will tell you that the BMI numbers are meaningless. But they still have to collect and report for the databases. Most of the guys on here who are in shape and have built muscle mass will show as overweight by their BMI numbers. I have a BMI if 26, which is overweight. Nobody who looks at me would ever say that I am overweight.

Yes Kona, I am angry. But trying to do something positive with it. Good luck with your recovery. I want you to weigh in at over a year or two, because, otherwise, nobody knows if you're in good shape or if you've given up on life. There's an information void that needs filling. Help fill it.

[drgephys]

drgephys seems to recognize that his doctor is avoiding certain topics. That's good. I realized today, as I thought about this thread, that most of the surgeons doing this work are more like engineers or mechanics. What they tell you is not what they "know" it's what they've read or learned in residency. They're just following instructions, like the SAGES guidelines. And the instructions are outdated and incomplete. They don't "know" if what they're doing really works in the long-term or not. That is the most essential point - they don't know. Nobody is collecting good data.

...

Yes Kona, I am angry. But trying to do something positive with it. Good luck with your recovery. I want you to weigh in at over a year or two, because, otherwise, nobody knows if you're in good shape or if you've given up on life. There's an information void that needs filling. Help fill it.

My surgeon is actually one of the two American members of the International Hernia Society (Hernia Surge) and he is one of the authors who wrote the 2018 Hernia Surge guidelines I linked. He is an associate professor at the medical school and active researcher. He is an expert on Lichtenstein anterior mesh repair -- he runs the Lichtenstein Clinic in US, analogue of the Shouldice Clinic in Canada -- and he is an expert in laparoscopic TEP. He also does laparoscopic TAPP and robotic TAPP. He said he can also do Shouldice tissue repair but I don't think he has extensive experience on that. I get to choose the repair method until the moment they make the incision.

I do appreciate your bringing of awareness against the mesh. Yes, body reacts to the mesh as a foreign object, which is part of the healing mechanism that mesh becomes part of your abdominal wall. However, this could also destroy your sperm vessels, testicles, and nerves and cause other problems. They did a study on pigs and chinchilla rabbits. I am against such studies because of humane reasons and they are not really useful as they only vaguely apply to humans. They found that posterior meshes (such as laparoscopic meshes) greatly ruined the sexual function and testicles. Anterior meshes (used in open repairs) also caused a lot of damage on the sexual function. Shouldice tissue repair on the other hand did very little damage if any. However, again, this is an animal study.

link.springer.com/article/10.1007%2Fs10029-005-0055-1

However, a recent Dutch study found only a small effect on sexual function by laparoscopic TEP repair. It's important to note that the doctors who performed the laparoscopic TEP in the study were experts with a lot of experience (greater than 500 TEP surgeries each). Your results in the hands of doctors with less experience could greatly vary.

link.springer.com/article/10.1007%2Fs10029-017-1657-0

In the hands of less experienced doctors, Lichtenstein anterior mesh repair can also cause a lot of problems, including testicular.

In your case your doctor probably made a technical error which caused your pain and suffering. However, when you have a foreign body in your object, even misaligned stars and planets could lead to long-term complications. So, thank you for bringing up attention against the mesh. Unfortunately there is no clean way of repairing a hernia and mesh is the result of a necessity, not convenience. Nothing causes more serious risk, damage, and pain than a recurrent hernia. Tissue repair avoids the foreign object in your body at the expense of anatomical modifications and risk of recurrence.

[drgephys]

A very interesting footnote to reading through your posts... you said "in the Hernia Surge Guidelines I linked above, low BMI is also mentioned as a risk. I got my hernia when my body fat dropped to around 8% and I'm suspecting that could have been a factor. They repeatedly emphasize that overweight but not obese people are much less likely to get hernias. So, perhaps, preperitoneal fat protects against hernia formation."

Funny, I was suspecting the very same thing! Mine showed up at the end of an 11 month cut that took me down from 210# to 162# (10%-ish). I read some anecdotal cases where they mentioned that factoid without connecting those dots.

I am pretty sure that my abs area getting too lean was the biggest factor causing my hernia. Other factors would be genetic and heavy lifting. Another thing I suspect is that sometimes I would tighten the belt extremely hard while doing squats, which could have messed me up. Finally, occasionally hitting my groin with the bar while doing heavy shrugs might have also caused a tear.

There are two fat layers in your abdomen. The subcutaneous fat is between your skin and muscles and the preperitoneal fat is between your muscles and peritoneum (thick membrane that encloses your intestines). Hernia happens when a sharp fold of intestine surrounded by the peritoneum called the hernia sack manages to pierce through your thin inner muscle layers and pushes against your thick outer muscle layer (external oblique). It makes sense that the preperitoneal fat helps distribute the extreme pressures causes by sharp folds of your intestines pushing outward. So, preperitoneal fat acts a semifluid cushion between your abdominal wall and your peritoneum containing the folds of your intestines. When preperitoneal fat gets very thin, this cushion layer that reduces the pressures by distributing the forces over a wider area disappears and a sharp fold of intestine could manage to pierce your abdominal wall during heavy lifting, sudden movements, jumping, coughing, etc. Remember that the pressure is the force per area and if you don't have a cushion (such as the layer of preperitoneal fat) that increases the area where the force is applied, a sharp object (such as an intestine fold or tip) can create an enormous pressure.

So, I have learned my lessons regarding body fat! If your body is too lean, simply avoid heavy lifting, especially heavy squats and heavy dead lifts and perhaps also heavy pulls such as heavy shrugs. If you are competing and leaning up for a competition, put the heavy weights aside and pay great attention to form. Or if you like to stay very lean all the time, simply avoid heavy weights that test the limits of your body and concentrate on the form. As anyone who went through this thread realizes, getting a hernia is not fun to say the least!

[SoccerAgain]

In your case your doctor probably made a technical error which caused your pain and suffering. However, when you have a foreign body in your object, even misaligned stars and planets could lead to long-term complications. So, thank you for bringing up attention against the mesh. Unfortunately there is no clean way of repairing a hernia and mesh is the result of a necessity, not convenience. Nothing causes more serious risk, damage, and pain than a recurrent hernia. Tissue repair avoids the foreign object in your body at the expense of anatomical modifications and risk of recurrence.

I appreciate your efforts to control the narrative, of course, just like I am. But you can't know these things. Especially the comment about "nothing is worse than a recurrence". That's just made up nonsense. Overall, you're just repeating the meme, which I also understand. It's all you know.

I also appreciate the need to find an expert that you can trust. But, the people that you're talking to are generalists. To them, the 10 - 20% chronic pain is acceptable, and can be dealt with by prescribing pain pills. Their views are based on the masses, and the economics of repairing hernias on many patients. It's the way that they think. When he's talking to you and answering your questions he doesn't really see you as an individual, he sees you as a probability of recurrence. That's their gauge. Not chronic pain.

And chronic pain is not an intense episodic pain. It's almost not even real pain, it's constant discomfort, that eats in to your thinking. Makes it very difficult to concentrate or enjoy life.

I wish you the best. You have a 5 of 6 chance of not having enough irritation/soreness/pain to "count" as a chronic pain sufferer. As a research-oriented person you can also appreciate the normal distribution, statistically. The bell curve. That's a more rational reason for why I have it and others don't. The comment about my surgeon's skill level, and technical error, is just an excuse for not understanding. It's nonsense. Beside that, the symptoms and findings when the mesh was removed don't support that view at all. It was just the mesh.

So, good luck. As I said, I'm mainly posting to provide the other side of the industry's "don't worry, just do it" pablum. For the deeper thinkers.

[drgephys]

Well, SoccerAgain, this is exactly your case from a very recent paper, "Laparoscopic mesh removal for otherwise intractable inguinal pain following endoscopic hernia repair is feasible, safe and may be effective in selected patients."

link.springer.com/article/10.1007%2Fs00464-017-5824-2

Mesh removal is particularly difficult after laparoscopic surgery, since the mesh gets attached to vital structures inside the abdominal wall.

The following recent paper, "Mesh Removal and Selective Neurectomy for Persistent Groin Pain Following Lichtenstein Repair," describes mesh removal following open Lichtenstein hernia repair.

link.springer.com/article/10.1007%2Fs00268-016-3780-y

It looks like I will go with open Lichtenstein anterior mesh. I don't think I will opt for Shouldice tissue repair or a laparoscopic posterior mesh. Shouldice tissue repair involves a lot of manipulation of the sperm cord, which could lead to sexual problems; so, I'm not convinced about its benefits regarding pain and complications. Laparoscopic repair involves a quarter square feet of dissection deep inside and placing the mesh adjacent to vital structures, from which I'm chickening out.

[SoccerAgain]

Good luck. Sorry to be so blunt.

I just received a message from someone who had an open repair, about eight years ago and reports excellent results. I'm going to see if he's okay with me posting his reply here in this thread. I might also start another thread focused on long-term results.

I appreciate the discussion, and the links. Obviously, there's room of improvement in the hernia repair field, in general.

[drgephys]

I had my surgery about eight hours ago!

I'll describe what happened. It's a little bit technical. Overall, I can say that it went extremely well as I watched the whole operation on a screen!

While I was in the preparation room, I talked to the guy across from me. He has had exactly what SoccerAgain had, except he had open surgery with anterior mesh rather than laparoscopic surgery with posterior mesh. Ever-increasing pain, painful ejaculation, testicular problems have been making him miserable. He had his operation at another healthcare system and he was going to have a thorough open and laparoscopic surgery today with my surgeon to fix things up and possibly remove the mesh, as a previous neurectomy attempt by him hadn't helped.

I opted for open repair with mesh with only local anesthesia (injections in the surgical area). They gave me a small doze of sedation and I was fully awake in less than five minutes and they had just made the skin incision. To my delight it was a very small incision for an open surgery -- it seemed no more than two inches!

I had read hundreds of papers on hernia repairs and watched many videos and i loved watching exactly what they were doing to me!

There was little or no subcutaneous fat under my skin. To my delight again, my nerves were very thin and well-defined and I didn't have spider-web nerves some people have, which greatly reduces chances of nerve injury and chronic pain.

Next, he spliced the fibers of my external oblique to gain access to my inguinal canal. There was no direct hernia on my inguinal floor, which is caused by the abdominal wall in the inguinal floor weakening by age and tearing up, and the hernia sac coming out of there.

Next, he sliced my cremaster muscle that makes up my cord to look for an indirect hernia, which means hernia sac is coming through a genetically too wide internal/deep inguinal ring that opens up into the abdomen. There it was -- first came preperitoneal fat (fat between your peritoneum and abdominal wall) and then a large indirect sac containing part of my intestines. When I coughed, a several-inch hernia sac that contains my inestines would come through the cord!

He then sliced the sac open, which is made of peritoneum. The peritoneum had got very thick as a result of the hernia. He peeled the sack from cord, and then excised it. He then ligated (tied) the neck of the sack and pushed it back into the deep/internal ring.

He used sutures on the internal ring to narrow it just too be on the safe side, even though the two tails of the mesh would be wrapped around the cord at it to make a new internal ring.

He told me that my inguinal floor had weakened, which could cause a direct hernia in the future. He used some sutures to strengthen it, even though the mesh would still be placed on it.

Then the Ethicon Ultrapro Advanced mesh was placed, with permanent sutures on one side and absorbable sutures on the other. I asked him about the new DynaMesh PVDF mesh -- a new material that induces less foreign-body reaction -- and he said it's great but not available in the US as FDA hasn't approved it, even thought it's been in use for several years in many other countries.

He carefully brought the two tails of the mesh across the cord at my deep/internal ring to make the new mesh-supported ring. He carefully adjusted it so that it would be neither to tight chafing my cord nor too loose leading to hernia recurrence.

I asked him whether my hernia was from lifting and he told me I probably had it for decades since I was a child but it only grew recently. So, I was wrong about getting too lean while lifting heavy was a factor in my case. It was simply genetic due to a too wide internal/deep ring. I had an hernia on my other side when I was ten and had a tissue repair on it when I was eleven.

Next, he carefully put my external oblique together. He was joking about stapling my skin when I asked him about it, and to my delight again, he had a bystanding plastic surgeon to do my skin closure! They then put surgical tape on it and put the dressing pad over that.

As I said before, he runs the Lichtenstein Hernia Clinic and I was in very good hands. There were two hernia experts from Denmark watching my operation. I would probably be fine if I had opted for laparoscopic but it was great peace of mind to be able to watch the operation (not possible with laparoscopic) and I was somewhat uncomfortable with internal dissection as opposed to external dissection.

I was fully wake but pain slowly started settling in. By the time I was discharged, I had some trouble getting up and down because of pain. The bumps on the road didn't hurt.

All this said I'm in considerable pain right now. However, this is what is expected during the first night. Norco helped a notch. No appreciable swelling, hematoma (blood collecting in skin), or seroma (serum connecting under skin), which are common in laparoscopic surgery. I can lie on my back no problem and sit comfortably with my legs extended but walking is difficult because of pain and getting up and down is challenging.

Happy lifting!

[drgephys]

24 hours after surgery:

There is still severe pain. However, it may have just started lessening. I'm hoping the pain will be a lot more tolerable after 48 hours. Getting in and out of the bed is still difficult.

There is some swelling in my groin at where the surgery took place. It's probably part of the natural healing process. There is no swelling elsewhere.

Things otherwise look normal. There is no bruising or bluish skin and the testicles are normal. I'm very happy with the repair.

I just took a walk around the block, fairly slowly because of the pain.

[drgephys]

48 hours after surgery.

Worst day so far. Woke up to severe pain in the morning. Ate a little and took a Norco. My groin was swollen a lot more and there was some redness to the side of the dressing pad. My testicle on the surgery side was hanging an inch or more lower than the other one.

The pain has been the worst today. I hope I don't have an infection. I was able to clean the litter boxes by sitting on a nine-inch-high stool. Interestingly it doesn't hurt when I squat or sit very low. It hurts most when I'm standing upright without bending at the waist or when I try to pull my legs toward my abs to put my shorts on.

Hopefully things will get better tomorrow. I will probably remove the dressing pad tonight to check the condition of the incision. Typically it's removed around 48 hours.

[KungFuFighting]

Good luck with your recovery. From memory, the first few days are the worst, I didn't have pain, but felt very delicate and took everything very cautiously; it was a good few days before I could easily put socks on.

Look forward to hearing you're doing well.

[drgephys]

Thank you KungFuFighting!

72 hours after surgery.

Last night (~ 58 hours after surgery), I had tears in my eyes from intense burning pain while standing when I was about to go to bed. As I said, Day 2 was the worst. Removed the dressing pad in the evening. The redness was due to the tape irritating my skin. There seemed to be no infection. Slept for more than 7 hours last night.

This morning I woke up to no pain but when I stood to walk around, the pain came back. Then, finally, after three days, I went to the bathroom with fair constipation despite the Docusate stool softener since the surgery. Sat about 15 - 20 minutes with success at the end. When I stood up, the pain was gone but then it came back again. Later in the afternoon, I went to the bathroom again but this time with no trouble at all.

Certainly today I'm feeling a lot better. The swelling in my groin has reduced and my testicle seems to have risen a little. Things are starting to look up! I have pain only when I'm standing -- a usually severe burning pain -- but I'm optimistic that by tomorrow it will get milder. I have no problem squatting up and down but there is no way I can lift my feet more than a foot high from the ground to put my socks on. That's when I will go back to work -- when I can put my socks on. Hopefully later this week.

The source of pain in my case is probably my ligated (tied) peritoneal indirect hernia sack. Front part of the peritoneum has a lot of nerves shared with the muscles and skin and it turns out that the ligation causes severe pain that may last for weeks. However, I'm OK with that, as not ligating the sack after excising (cutting) it increases the risk of recurrence, as it leaves a hole there.

Overall I'm very happy with my choice of the doctor and repair technique. In my case it turned out to be a somewhat-large indirect hernia. An indirect hernia is when a long, condom-resembling sack made of the peritoneum containing your intestine pushes through your testicular cord and it then can descend as deep as your scrotum inside your cord. Indirect hernia is always congenital and it's not caused by activity or lifting. It's caused by an embryonic process, where the internal ring the testicular cord is released through doesn't properly close. A direct hernia on the other hand is a direct acquired tear on the abdominal wall, not congenital. The hernia sack in that case stays out of and parallels the cord descending into your scrotum. However, my doctor said, even in the direct-hernia case, the reason is genetic (weak or improperly functioning abdominal wall).

In indirect hernias it could be simply sufficient to tighten the internal ring with sutures after excising and ligating the hernia sac in an open surgery. However, large indirect hernias as in my case can weaken the abdominal wall and mesh or tissue repair is also needed to prevent recurrence. In my case my doctor put sutures on the internal ring as well as the inguinal floor (section of the abdominal wall where direct-hernia tears happen) and then placed the state-of-the-art large-pore, lightweight, high-elasticity, 50%-absorbale Ethicon Ultrapro Advanced mesh that was introduced less than three years ago from now, which will strengthen both the direct-hernia space (inguinal floor) and the indirect-hernia space (internal ring).

Nyhus 1991 paper is an old but classic reference on hernia types and repair methods. It's somewhat antipathetic to the Lichtenstein anterior-mesh method because it was invented only in 1984 and it's before the laparoscopic methods were invented. However, he's the guy who invented the open posterior-mesh method, which eventually lead to the laparoscopic posterior-mesh method.

currprobsurg.com/article/0011-3840(91)90028-N/fulltext

My recommendations:

1. Every hernia and every person is different. You should individualize the treatment according to your condition.

2. Choose the best, most experienced doctor you can find! This is the key. If your insurance or care group doesn't let you choose, change insurance and/or care group. Avoid one-stop-shopping-hospital care groups and consider medical-school-based care groups, which do research. Then discuss all the techniques he's an expert on (more than 500 surgeries each) and pick up the one you want. Don't pick up a technique he's not too familiar with. Also, you should pick up a technique based both on the doctor's recommendation and your individual preference.

3. Absolutely avoid Shouldice ("Canadian repair"), Bassini, Desarda, McVay, and similar tissue repairs! These techniques are archaic and invasive! They modify your anatomy in ways you don't want. Most or all of them eliminate the two crucial groin reflexes -- the shutter mechanism and sphincter mechanism -- that tighten the abdominal wall and close your internal ring, respectively, when the internal abdominal pressure rises. (See the reference linked above.) This plus the tension created by the sutures mean high risk of recurrence and possibly problems with athletic performance due to modified anatomy.

4. For small or not too large indirect hernias and small or medium direct hernias, I would go with the open Lichtenstein tension-free repair with flat anterior mesh. If you're young and it's a small indirect hernia, you may even avoid the mesh and just have your internal ring tightened with a few sutures through a very simple open surgery without mesh.

5. Avoid 3D meshes, 3D mesh systems, and plug-and-patch. Always choose a doctor that uses a state-of-the-art flat mesh.

6. Ask your doctor about nerve damage and preserving nerves and nerve fascia. If your doctor doesn't know about how to identify the nerves and how to avoid them and preserve the nerve fascia, run! Ask your doctor if he/she finger-dissects the cord or removes the cremaster muscle. If he/she says yes, run again! These points are crucial in open anterior mesh repairs (Lichtenstein) to avoid chronic pain.

7. For bilateral hernias, femoral hernias, multiple hernias, and perhaps large direct hernias, I would probably go with the laparoscopic posterior mesh. The laparoscopic posterior mesh method is a one-size-fits-all method where a very large mesh (or two if you have bilateral hernia) is placed to cover all possible defects. These days they use it for even small, uncomplicated indirect hernias, simply because it's a one-size-fits-all approach. I have some reservations against it because of messy internal dissection of a large area including the bladder, putting the mesh against the bare vas deference and spermatic vessels, and very rare but serious organ or vessel injuries; however, it probably works well for most people.

8. Don't delay the surgery! Hernias don't heal. They just get larger and in some cases cause serious, life-threatening complications. A larger hernia is somewhat more difficult to repair. However, don't rush into surgery either, as you first need to research an excellent, highly experinced doctor and learn about and choose from the available repair techniques!

Happy lifting!

[drgephys]

96 hours after surgery.

The last time I took Norco was 69 hours after the surgery. I have stopped taking it since.

I still have considerable pain when I stand for a while. However, it seems to be getting gradually better. Swelling in my groin has been lessening. It will be a few more days before I can go back to work.

[drgephys]

Five days after surgery (open Lichtenstein anterior mesh).

I was miserable the first two - three days, although still barely able to move and take care of myself and my cats. The pain was no big deal afterwards. I've been off the pain medication (Norco) for two days. Pain is gradually improving everyday. I will probably go back to work tomorrow.

I feel like I can go back to the gym and max out on the bench press now. Obviously I won't be able to do anything that involves the groin or abs anytime soon. Chances are that the squats can also be resumed very soon but not the dead lifts. Nevertheless, I have no intention of going back to the gym for at least a month after surgery until the healing process has somewhat advanced. The mesh used is the new Ethicon ULTRAPRO ADVANCED™ partially (50%) absorbable large-pore, lightweight flat mesh. According to the data sheet, "The absorbable component is essentially absorbed within 91 days, whereas the polypropylene material is not absorbed."

[drgephys]

Six days after surgery.

Light to moderate static pain (mostly dull) and moderate swelling in my groin remain. However, dynamic pain, associated with movement, has mostly disappeared. For example I have no problem lifting up my foot for putting my sock on anymore, which would have been impossible to do during the first few days. Interestingly, there seems to be no pain related to abs movements. People who had laparoscopic surgery seem to have found abs exercises impossible to do for several weeks after surgery. So, perhaps this is another advantage of the open surgery with Lichtenstein anterior flat mesh over laparoscopic surgery-- no pain in the abs muscles when you go back to the gym.

[drgephys]

Seven days after surgery:

I went back to work. It felt great to get out of the house!

I can walk and move mostly normally now but I have a sore groin. Pain is probably coming from where they split the external oblique. Swelling is mostly under the incision now.

[drgephys]

Eight days after surgery.

I probably overdid yesterday with going back to work and grocery shopping. My groin feels pretty sore today -- similar feeling to having a groin pull or athletic groin injury, probably hurting at where they split and sutured the external oblique.

It looks like it will be a couple of weeks after surgery before I have almost full relief.

[drgephys]

Eleven days after surgery.

Discomfort in my groin continues, probably due to some swelling under the incision. However, there is no pain associated with movement at all. A few days ago, I started running to catch a train and I only stopped when I remembered that I had a surgery. I feel like I could go back to the gym and do whatever I want now.

It looks like as far as going back to the gym is concerned, the open Lichtenstein anterior mesh is far superior to the laparoscopic posterior mesh. From what I've read in this thread and seen on YouTube, people who had laparoscopic surgery seem to have had a painful recovery in the gym, preventing them from being able to do anything that involves the core. This seems to be in sharp contrast to my case with open surgery, in which I seem to have been hardly affected after the initial week of pain, and I seem to be able to do anything I want with my core.

However, your mileage will vary greatly according to the surgeon you pick. I will have a follow-up on Friday (fifteen days after surgery) and have the Steri-Strips removed.

[drgephys]

Fifteen days after surgery (open Lichtenstein with anterior mesh, left side).

I had my post-op visit today. My surgeon said everything looked normal. I got to see my wound for the first time as he removed the Steri-Strips. It's almost exactly 2.0 inches (5.0 cm), horizontal, and in my upper groin. So, it's hardly visible or noticeable. Half of the wound (random sections of it) has healed like there was no cut at all and the other half has a raised pink tissue. He said the raised ridge under the wound, which feels like a hard bump under the skin, doesn't go away until ten to twelve weeks.

I still have mild swelling and discomfort in my groin -- things are a little tender including my testicle, probably mostly because of the mild swelling. He said this was normal. I can walk, run, bend, move, etc. without any pain otherwise. I also don't have any pain when I cough etc.

I asked him about the gym. He said go easy with the activities, listen to your body. Don't do anything that hurts. He said it's very unlikely that you would undo the repair but still you should listen to your body. He said 80% healing is achieved after four weeks and afterwards it's a plateau (basically a slow exponential healing toward 100% after that). So, basically he told me that I can pretty much do whatever I want without worry after four weeks from the surgery.

So, things are looking good other than some mild discomfort and soreness. I can probably go back to the gym now and I wouldn't feel pain but I want to wait at least until four weeks after surgery so that I can reach the 80% healing before I do that. Overall, I'm very satisfied with the method of the repair and outcome. I'm glad I passed on the offer for laparoscopic repair. My surgeon was very good with the open technique.

[linksjack]

This thread is gold. Read every post before my hernia repair, which was yesterday.

Open surgery with mesh (Lichtenstein) with spinal anesthesia.

Day 1 (day of surgery): Anesthesia was great, only mild pain when the needle was stuck in my back, afterwards no pain. I was awake the whole time and felt that "something" was happening. Somewhat like being at the dentist. Hernia was about 4x2 cm. Directly after the surgery I got an diclofenac infusion for the pain.

Throughout the day, only mild pain when moving (3/10) and a little more when laughing (5/10). Walked around a bit in the afternoon.

Day 2: Almost no pain when lying in bed (2/10) or sitting up and mild pain (3/10) when walking around (very slowly). My skin is still completely numb at the surgery-area, but that doesn't bother me much. No testicular swelling or pain, although I felt how the surgeon was pulling on the spermatic cord and some nerve. Overall feeling surprisingly good, with no painkillers needed.

Just wanted to give an update: It's been 19 months since my hernia surgery (see quote) and I'm still happy with the outcome. Every once in a while when doing very heavy lifting I'm still feeling something is different in the patched up area, but nothing problematic.

I was pretty much painfree from the beginning and didn't need any painkillers except directly after the surgery.

Open surgery with mesh was the right decision for me and I'd do it again if I had a hernia on the other side some time in the future. Next time I won't wait too long and just go ahead with it.

[jaswanth022]

I had my surgery on 30th June 2018 and I’m getting home today from hospital. I’m not sure how I acquired hernia but I want to find out if anyone of you brothers here had problems due to lifting after the surgery. My doctor mentioned (here in India) to stay away from bending or any diet of lifting for one year. I can use this time 1-1.5 hr a day to do something else other than lifting to improve myself. But I want to get back to lifting after complete recovery. Please share your experience and precautions need to be taken in this 1 year and after starting lifting.

[drgephys]

Just wanted to give an update: It's been 19 months since my hernia surgery (see quote) and I'm still happy with the outcome. Every once in a while when doing very heavy lifting I'm still feeling something is different in the patched up area, but nothing problematic.

I was pretty much painfree from the beginning and didn't need any painkillers except directly after the surgery.

Open surgery with mesh was the right decision for me and I'd do it again if I had a hernia on the other side some time in the future. Next time I won't wait too long and just go ahead with it.

I'm glad to hear that you're doing well!

You probably had an indirect hernia since you mention pulling on your cord. Actually it's not the cord but the indirect hernia sack. It's a condom-shaped deformation of your peritoneum that protrudes through inside your cord and contains your large intestine. They open the cord made of the cremaster muscle, open the hernia sack, push the intestine back, then pull the sack and peel it off from the cord, excise the sack, and ligate the remaining high end (neck) of the sack with an absorbable-suture loop. Cremaster muscle then folds back as if it has never been sliced.

These days it's normally local anesthesia (injection in the surgical area), which works great. There is no need for spinal anesthesia, which carries some risks.

Happy lifting!

[drgephys]

I had my surgery on 30th June 2018 and I’m getting home today from hospital. I’m not sure how I acquired hernia but I want to find out if anyone of you brothers here had problems due to lifting after the surgery. My doctor mentioned (here in India) to stay away from bending or any diet of lifting for one year. I can use this time 1-1.5 hr a day to do something else other than lifting to improve myself. But I want to get back to lifting after complete recovery. Please share your experience and precautions need to be taken in this 1 year and after starting lifting.

This is certainly not how modern hernia surgery is done these days. Modern hernia surgery is outpatient surgery, which is also called day surgery or ambulatory surgery. You go home as soon as you can urinate. You don't stay in the hospital.

International hernia guidelines state that after three to five days, patients can return to their normal activities without any restrictions. My doctor told me to lift according to how I feel comfortable -- listen to your body and don't do anything that hurts. He said after four weeks 80% healing is reached.

I don't know what kind of hernia you had. Indirect hernia is congenital (acquired in the embryo) and direct hernia may be caused by lifting or be associated with genetic inner-abdominal-wall weakness, genetic or surgery-caused malfunctioning of groin reflexes, or old age.

You can ask your doctor what kind of hernia you had and what kind of technique was used (mesh or tissue repair).

I would say go back to the gym after a month and start with lighter weights and see how it feels. Increase the weight gradually over the weeks as you feel comfortable. One-year restriction of activities is unheard of these days. It sounds like your doctor may be trying to protect himself and put the blame on the patient if the hernia recurs.

Get well soon!