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  • Advice sought about anesthesia and questions to ask during a consult

    Hi, All--Well I have finally found an in-network surgeon whose office at least says he will be willing to do a no-mesh hernia repair on a fairly large inguinal hernia. What questions should I ask during the consult? I know just enough to be still ignorant. I want no mesh because I know myself and will visualize foreign object and I'd like twilight and local anesthesia because my mother reacted very poorly to general once (I've never had it--never had surgery before). I would like nothing to be cut. Just repaired. I have read that suturing rather than mesh can cause more pain but I'm thinking that is temporal? One of the reasons I've waited so long to have this surgery (10 years) is that I haven't had pain and trading no pain for pain seems stupid--however the hernia has this year started to grow. Also, another doctor's website (willing to do no mesh but out of my network) states this: "Most of our surgeries are done under light general anesthesia, but can be done under “twilight” sedation or even local anesthesia only. We find light general anesthesia to work best and have minimal grogginess or other side effects and makes surgery go quickly. We also inject a long lasting local “numbing” anesthesia that lasts several days. Many patients take no pain pills after surgery." I am curious about this local "numbing" anesthesia. Does anyone use it (doctors) or have had it (patients?). Thanks for any responses.

  • #2
    Personally I'd ask:

    1. Which technique he uses.
    2. How many tissue repairs he does each year.
    3. Recurrence rate of tissue repairs he does.

    There are other questions I might ask that have to do with impact on other anatomical structures, but they are male-specific.

    Out of curiosity, can you share the name of the surgeons you found (both in and out-of-network)? I seem to recall you are also in the midwest and would be interested in knowing if other options exist within a short distance of me.

    Comment


    • #3
      Most open operations can be performed with IV sedation only and a lot of local anesthesia. That is my practice. It’s also referred to as conscious sedation. The anesthetic recovery is simpler and quite nice.
      #ItsNotJustAHernia
      www.BeverlyHillsHerniaCenter.com

      Comment


      • #4
        Dill : your comment about “I would like nothing to be cut” needs clarification.”

        Are you referring to nerves?

        Because the open non-mesh repair involves the most amount of muscle and fascia cutting.
        #ItsNotJustAHernia
        www.BeverlyHillsHerniaCenter.com

        Comment


        • #5
          What kind of hernia do you have?

          I don't know what this "long lasting local “numbing” anesthesia that lasts several days" is. You could ask (the other doctor) what this is.

          As for painkillers, I think I used 2 x 6 tablets, 6 smaller ones and 6 bigger ones. I received several blisters of both types and 1 which I think was a strong opiate for severe pain, which I never used. I didn't really have to use the others either, but I took them as I was told to take them at least for the first 2 to 3 days after surgery. Sure, I did have some pain after surgery, but it was not something I could not tolerate. If you can tolerate the pain, there is no need for painkillers really.

          For the record, I'm a male in my 30s and I had open inguinal hernia surgery without mesh, and I had it done under general anesthesia. For me, having general anesthesia was just like falling asleep and then waking up and wondering when I would go in for surgery, only to be told that it's all done. So it was like nothing. You don't know what you're made of unless you go find out. I also never had any surgery before, this was the first time for me, and I honestly would rather do it again under general anesthesia than having to watch and listen to the doctors working on me. I had no adverse effects from the anesthesia.

          As for cutting... well, something will have to be cut if you're going in for surgery. If you want to limit the amount of cutting then the minimally invasive, laparoscopic approach is probably the way to go. However, that nearly always entails mesh repair. In other words, if you want no-mesh repair, then you have to do open surgery. If you want minimally invasive i.e. laparoscopic repair, then you have to get a mesh. Dr. Towfigh is to my knowledge the only surgeon who offers laparoscopic repairs without mesh. There may be others, but she's the only one I know of.

          As for pain as a result of suturing, that's only the case when suturing is done in a way that causes tension, i.e. tugging and tearing on the tissue. There is more than one way to make incisions and suture tissues together. These are the surgical techniques that are so often discussed on these forums. So here is an important question you can ask the surgeon/doctor, what type of surgical technique he or she uses.
          Last edited by John Fortem; 1 week ago.

          Comment


          • #6
            Thank you Dr. Trowfigh--I hope you are teaching others to do the laparoscopy without mesh. No I realize I have to have some things cut in order to do the surgery but I read about some procedures maybe Shouldice where I muscle (maybe Crester? something like that) is intentionally cut--that doesn't sound great to me, perhaps because I don't understand why.

            Comment


            • #7
              Cremaster muscle is cut. I believe i heard shouldice hospital say they do it bc they believe of you don’t it can lead to higher rate of recurrence

              Comment


              • #8
                Originally posted by Jnomesh View Post
                Cremaster muscle is cut. I believe i heard shouldice hospital say they do it bc they believe of you don’t it can lead to higher rate of recurrence
                But isn't that an anatomical feature exclusive to men? Is there a female equivalent? Otherwise, wouldn't apply to the OP.

                Comment


                • #9
                  Women have a structure called the round ligament that is in the same position as the spermatic cord.
                  It supports the uterus. The spermatic cord in men carries the blood supply, nerves, Vas deferens, and cremasteric muscle. The cremasteric muscle does not have to be cut during hernia repair. I agree that the shouldice clinic advises cutting the muscle, but I do not feel that cutting is necessary.
                  Regards
                  Bill Brown MD

                  Comment


                  • #10
                    Originally posted by UhOh! View Post

                    But isn't that an anatomical feature exclusive to men? Is there a female equivalent? Otherwise, wouldn't apply to the OP.
                    Exactly! That's anatomical feature in men. I wouldn't know what the equivalent female version of that is, but the only reason that's even brought up in discussions is because inguinal hernias are primarily a male problem. Primarily! But apparently women can also get inguinal hernias, but it's far less common then in men. I can see now that the poster did report having an inguinal hernia, I didn't see that at first or neglected that fact (lost in details).

                    I did a quick web search and found some interesting information:

                    "The cremaster develops to its full extent only in males; in females it is represented by only a few muscle loops."

                    "In female humans, the cremaster muscle is smaller and is found on the round ligament."

                    So as it turns out, women also have the cremaster muscle and while it's anatomically or even physiologically different then in men, it's situated in roughly the same area.

                    Comment


                    • #11
                      Originally posted by DrBrown View Post
                      The cremasteric muscle does not have to be cut during hernia repair. I agree that the shouldice clinic advises cutting the muscle, but I do not feel that cutting is necessary.
                      Regards
                      Bill Brown MD
                      As someone who had an inguinal hernia repair done 2 months ago, I can agree on that. I had the "fake" (as some patients on this forum will suggest) Shouldice repair done in Germany, without steel sutures, without a mesh and without cutting the musculus cremaster. I'm a male in my 30s and I train 5 times a week (strength and conditioning), and I have not once had a problem with my testicle migrating up into the abdomen. And let me tell you, I should know what that feels like, because as a young teenager I used to play ping pong with that thing, my testicle would slide up into my abdomen and drop back out as if it was nothing! It's only later in life that I got my hernia and that I learned that this is not exactly normal and something to consult a doctor about. It's not something to laugh about and have fun with, that only aggravates the condition.

                      The take home message here is two-fold:

                      1. Cutting the cremaster muscle contributes nothing in preventing hernia recurrence. If anything, it should be cut long before a hernia develops in the first place... which doesn't help someone who already has a hernia, and when the repair is done right there is no reason to cut the muscle if you're a skillful surgeon. I would argue that if the cremaster muscle contributes to hernia formation at all, then it does so in the very early years in life, and in cases where the internal inguinal ring is not properly closed (which is the primarily what we have in indirect hernia cases in males).

                      2. Migrating or traveling testicle is an early warning sign. It's a sign that this person may develop hernia later in life and therefore it should be taken seriously. I strongly believe that if insightful and knowledgeable advice is given at this early stage, it may help someone prevent hernia development later in life, or at very least postpone it. Like many ailments, hernia develops cumulatively. But clinically, it only becomes a "hernia" once it's too late to prevent it. That's all the more reason to catch the early warning signs. After all, prevention is the best medicine! And finally, of course, if we ask the Shouldice clinic, any young person that presents with a traveling testicle should have the cremaster muscle cut... just in case! It tells you something about the medical community and especially the Shouldice clinic. But who knows, at this stage, cremaster cutting may even be effective.

                      Disclosure:
                      I am not a doctor. I am just an average John. I know just enough about the topic to get by. And then there is my own personal experience of course, which gives me some insights that average doctors don't have. Then finally, there is that thing called common sense... which sadly is no longer as common as one might think.

                      Comment


                      • #12
                        Originally posted by John Fortem View Post

                        As someone who had an inguinal hernia repair done 2 months ago, I can agree on that. I had the "fake" (as some patients on this forum will suggest) Shouldice repair done in Germany, without steel sutures, without a mesh and without cutting the musculus cremaster. I'm a male in my 30s and I train 5 times a week (strength and conditioning), and I have not once had a problem with my testicle migrating up into the abdomen. And let me tell you, I should know what that feels like, because as a young teenager I used to play ping pong with that thing, my testicle would slide up into my abdomen and drop back out as if it was nothing! It's only later in life that I got my hernia and that I learned that this is not exactly normal and something to consult a doctor about. It's not something to laugh about and have fun with, that only aggravates the condition.

                        The take home message here is two-fold:

                        1. Cutting the cremaster muscle contributes nothing in preventing hernia recurrence. If anything, it should be cut long before a hernia develops in the first place... which doesn't help someone who already has a hernia, and when the repair is done right there is no reason to cut the muscle if you're a skillful surgeon. I would argue that if the cremaster muscle contributes to hernia formation at all, then it does so in the very early years in life, and in cases where the internal inguinal ring is not properly closed (which is the primarily what we have in indirect hernia cases in males).

                        2. Migrating or traveling testicle is an early warning sign. It's a sign that this person may develop hernia later in life and therefore it should be taken seriously. I strongly believe that if insightful and knowledgeable advice is given at this early stage, it may help someone prevent hernia development later in life, or at very least postpone it. Like many ailments, hernia develops cumulatively. But clinically, it only becomes a "hernia" once it's too late to prevent it. That's all the more reason to catch the early warning signs. After all, prevention is the best medicine! And finally, of course, if we ask the Shouldice clinic, any young person that presents with a traveling testicle should have the cremaster muscle cut... just in case! It tells you something about the medical community and especially the Shouldice clinic. But who knows, at this stage, cremaster cutting may even be effective.

                        Disclosure:
                        I am not a doctor. I am just an average John. I know just enough about the topic to get by. And then there is my own personal experience of course, which gives me some insights that average doctors don't have. Then finally, there is that thing called common sense... which sadly is no longer as common as one might think.
                        Interesting... I’ve always been able to clench like I’m performing a kegel, and have my right testicle ascend upwards. Now I have a right inguinal hernia.

                        Comment


                        • #13
                          Originally posted by Km8888 View Post

                          Interesting... I’ve always been able to clench like I’m performing a kegel, and have my right testicle ascend upwards. Now I have a right inguinal hernia.
                          On the same side, right? This is a sign of weakness, and it's likely that you were born this way, with inguinal ring not properly closed off. And as we age, the risk of developing a hernia in this area only grows bigger. Especially if you are not even aware of your weakness.

                          I am convinced that doing certain exercises can aggravate the already weakened tissue and cause a hernia. I know what finally caused my tissue to give in and cause a bulge (which I later learned is called a hernia). I was doing an asymmetrical stretch of my abdomen and legs. At one point I just felt instant pain in the right side of my groin, it felt like a tear, like quickly pulling up a zipper. I could instantly see and feel a small bulge, less than an inch in diameter underneath the skin. It was painful in the beginning, as the hole was still small and the pressure was high. I asked Dr. Google what it was, and that's when I learned it's a hernia. I never went to a doctor for this until later in life when I decided to take care of it. Like most men I presume, I didn't feel comfortable having a doctor examine my junk. I just dealt with it on my own for about 8 years. I had it repaired 2 months ago, without a mesh and without cutting the cremaster muscle.

                          If you have a hernia, I would recommend having it repaired. Don't play the waiting game, even if it's asymptomatic. You will have to do it sooner or later, and sooner is much better. Just make sure you do it as naturally as possible for best possible outcome. First and foremost, that means doing it without a mesh, at the hands of an highly experienced surgeon.
                          Last edited by John Fortem; 1 day ago.

                          Comment


                          • #14
                            Originally posted by John Fortem View Post

                            On the same side, right? This is a sign of weakness, and it's likely that you were born this way, with inguinal ring not properly closed off. And as we age, the risk of developing a hernia in this area only grows bigger. Especially if you are not even aware of your weakness.

                            I am convinced that doing certain exercises can aggravate the already weakened tissue and cause a hernia. I know what finally caused my tissue to give in and cause a bulge (which I later learned is called a hernia). I was doing an asymmetrical stretch of my abdomen and legs. At one point I just felt instant pain in the right side of my groin, it felt like a tear, like quickly pulling up a zipper. I could instantly see and feel a small bulge, less than an inch in diameter underneath the skin. It was painful in the beginning, as the hole was still small and the pressure was high. I asked Dr. Google what it was, and that's when I learned it's a hernia. I never went to a doctor for this until later in life when I decided to take care of it. Like most men I presume, I didn't feel comfortable having a doctor examine my junk. I just dealt with it on my own for about 8 years. I had it repaired 2 months ago, without a mesh and without cutting the cremaster muscle.

                            If you have a hernia, I would recommend having it repaired. Don't play the waiting game, even if it's asymptomatic. You will have to do it sooner or later, and sooner is much better. Just make sure you do it as naturally as possible for best possible outcome. First and foremost, that means doing it without a mesh, at the hands of an highly experienced surgeon.
                            Yup, same side. My brother also had a hernia operation on the right side as an infant.
                            I also remember having “episodes” of strong, sharp pain in the right lower groin area while playing soccer as a kid (ages 7-12) that would go away in 2-5 minutes, similar to cramps, but always on the right side. Those went away during my teenage years. I don’t know if it was gaining weight, or not playing soccer as often after I moved to the US.

                            I lost a lot of weight over the last year and significantly increased my physical activity, including doing squats with weight at the gym, and squat-jumps without weights on my lunch breaks.
                            I believe this is what put me over the edge and brought back the hernia, or worsened it to where I now have symptoms and a bulge I can feel whenever I stand for more than 30 seconds.

                            I have a consultation scheduled for August 20th with Dr. Brown, who I now see actually posts on this forum, so hopefully sometime soon I can get the hernia repaired without mesh and it’s associated side-effects and dangers.
                            Last edited by Km8888; 23 hours ago.

                            Comment


                            • #15
                              Originally posted by Km8888 View Post

                              Yup, same side. My brother also had a hernia operation on the right side as an infant.
                              I also remember having “episodes” of strong, sharp pain in the right lower groin area while playing soccer as a kid (ages 7-12) that would go away in 2-5 minutes, similar to cramps, but always on the right side. Those went away during my teenage years. I don’t know if it was gaining weight, or not playing soccer as often after I moved to the US.

                              I lost a lot of weight over the last year and significantly increased my physical activity, including doing squats with weight at the gym, and squat-jumps without weights on my lunch breaks.
                              I believe this is what put me over the edge and brought back the hernia, or worsened it to where I now have symptoms and a bulge I can feel whenever I stand for more than 30 seconds.

                              I have a consultation scheduled for August 20th with Dr. Brown, who I now see actually posts on this forum, so hopefully sometime soon I can get the hernia repaired without mesh and it’s associated side-effects and dangers.
                              That's interesting. My brother also had a hernia, also on the right side. Yeah, I know I also gained some excess belly fat in my early 20s. As I recall I was 23 when I got my hernia. I used to train and compete in athletics from when I was 14 years old up until I was 19 years old. So I was definitely less physically active in the years that preceded my hernia formation.

                              Although, according to some studies the risk of developing a hernia is higher in people who are physically active such as athletes than in sedentary and obese people. They suggest that the fat somewhat acts as padding that suppresses herniation. I'm not sure what to make of that... but I am pretty sure that if athletes are more likely to develop a hernia then it is not because they lift heavy weights, but because they have poor form and body mechanics. It is a common misconception, almost a universal one, that hernias form by lifting heavy weights. That's a myth! The best recipe for hernia formation is asymmetric overload in the lower abdomen/groin area, especially in a person who already has a weakness there from birth.

                              I have read great things about Dr. Brown. I think he is one of few surgeons in the US who does mesh free repairs. It's a smart move finding a surgeon that fits your criteria and not prolonging the inevitable, you should not wait any more than you have to, especially if you already have bad symptoms from your hernia. I wish you good luck with everything and I hope you will get well soon!

                              Comment

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