Patience with Mesh Removal

Episode 167: Patience with Mesh Removal | Hernia Talk Live Q&A

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Speaker 1 (00:00:10):

Hi everyone. It’s Dr. Towfigh. I hope you can all hear me well. Welcome to Hernia Talk. I am your host, Dr. Shirin Towfigh hernia and laparoscopic surgery specialist. Thanks for joining me on Tuesday afternoon. As you know, you can follow me on all the different social media channels including X and Instagram @hernia doc. Specifically, many of you’re joining me on Facebook as at Dr. Towfigh, so thank you for that. I see you all and also for those of you who are coming on as a Zoom Live, thank you for joining me. So I decided to make today’s episode as you know. Let’s go back. So as I see my patients, I am inspired by certain topics and things that come up among our patients, and a lot of times I choose my topics based on a patient’s story, a certain series of events that happen.

Speaker 1 (00:01:15):

For example, what I could have done, the talk book on this week was on neuromas because I had back to back multiple patients, all of whom traveled to see me from out of state or out of country who had legit huge neuromas that was causing their pain from prior hernia surgeries. But we can discuss that at a different session. I chose today’s topic to be related to patients and specifically patients with need for revisional surgery or more specifically mesh removal. So every so often I get a patient that is freaking out that they have mesh in them and they want out of them as if it’s a poison that must be removed immediately. Now, as you know, there are patients that would benefit from mesh removal. There are patients that need to have a mesh in place. So the discussion is very intense and I put patients through a lot of informed consent, but also studies to make sure that the procedure they undergo is the right procedure.

Speaker 1 (00:02:27):

As you know, I’m not a fan of just willy-nilly going in and doing procedures, whether it’s first surgery or multiple revisional surgeries without really having the patient and myself understand the purpose and the outcome for that kind of procedure. So specifically today, the question is how do I encourage surgeons as well as patients PATS, to practice patients when discussing or considering mesh removal or really we can expand that to any revisional surgery or even any primary surgery. So it used to be that if a patient had a hernia, they were rushed to surgery. When I was a resident even, which is more than 20 years ago, the patient came to our office with a hernia in the training clinic. We would book them for surgery, and the discussion was, you have hernias. There’s a risk that intestine may get stuck in that hernia. You may end up in the emergency room or the intensive care unit with dead bowel, what we would call strangulate hernia.

Speaker 1 (00:03:53):

And in order to prevent that bad outcome, we should schedule you for surgery. And there was an urgency about it in many places, and it wasn’t until many years later that the watchful waiting trial in the United States and in the United Kingdom were both published discussing patients, which is, let’s see what happens in patients that don’t undergo surgery, really, how bad is it? And the results were very interesting. At five years, about a quarter of those patients started having more symptoms in their groin and ended up having surgery. And by 10 years, about two thirds of those patients ended up having more symptoms in the groin and electing to undergo hernia surgery, but no one died from their hernia not being operated on. They may have died of a heart attack or a stroke or other unrelated problem, but specifically delaying hernia surgery was considered no longer unsafe.

Speaker 1 (00:05:03):

In fact, it was considered safe in many patients. And so now many of us believe that watchful waiting is not a bad option and therefore you should have some patience. There’s no need to rush anyone into surgery. Okay? What I’m seeing now is a little bit of anxiety and pressure to immediately remove your Mesh. So there are patients that come to me within days of having had surgery elsewhere, wanting their mesh immediately removed. It said it’s a huge burden on them. They have buyer’s remorse. Why were they pushed by whoever the other surgeon was to put mesh in them? Now I’m feeling headaches and dizziness and joint pains and my whole life has gone upside down. Please remove this mesh. I suggest that at the same time that you should not be pushed into urgent hernia surgery. And for the most part, reversing that surgery should also be performed with caution and with patients.

Speaker 1 (00:06:16):

And the reason why I say this is the following, first of all, revisional surgery should not be taken lightly. A revisional surgery implies that redoing a Hernia repair or in this particular situation removing Mesh because of the patient’s, let’s say anxiety and concern over having this implant in them, there’s risks with revision surgery. There’s risks with mesh removal. That’s why most people who perform hernia surgery do not reverse Hernia surgery. Most surgeons who put in mesh are not comfortable removing that mesh. There’s only a handful of us that do that for a living and operate like that for a living and actually enjoy it and think they’re good at it and so on.

Speaker 1 (00:07:13):

We understand there are risks with the procedure. Perhaps it’s a lower risk when we perform it than someone who’s not an expert, but regardless, there are risks. So when a patient comes to me and there have been several over the years, comes to me with severe anxiety and concern that they now have an implant in them that they are now wishing they did not agree to, I do not immediately agree to remove that mesh. Why? First of all, I can maim them and make them worse, and whatever their perception is about the mesh implant in them may not be a physiologically valid and maybe it’s better for them to give some time to understand how their new world is with Mesh in them and perhaps some of their symptoms will improve over time, number one. Number two, let’s say I remove your mesh. Then what do you want me to do?

Speaker 1 (00:08:10):

Do you want me to ignore your hernia? Do you want me to put another type of mesh in? Do you want me to do a tissue repair? Can I even do a tissue repair? What are your risk factors for going into surgery? Are you diabetic? Do you have an active cough or cold? Are you morbidly obese? Those are all factors that should be taken into account in any patient who may need to have their mesh removed or have revisional surgery because what you don’t want to do is now cripple the patient or make them worse than they were when they had the Mesh. There are many patients that I see who have actually buyer’s remorse from having had their mesh removed because now they are a worse situation, more pain, more ischemia, they lost their testicle, they have chronic groin pain, they have a neuroma because they agree to undergo a mesh removal that maybe they shouldn’t have had or maybe someone else should have done.

Speaker 1 (00:09:11):

So that’s kind of where we’re at. I would like to say that in my patients who may benefit from Mesh removal because there’s a meshoma folded mesh, there’s an inflammatory reaction to the mesh that’s not going away. They’re having what’s called mesh implant illness, which is maybe a systemic autoimmune disorder induced by the mesh and so on with one exception, which is mesh infection. In all other situations, Mesh related pain, hernia, recurrence, meshoma, folding of the Mesh, et cetera, there’s multiple steps in the planning that should be done in a systematic way before committing to surgery. And I’m not a fan of jumping into surgery on most patients. I rarely do that. I get imaging and I document their symptoms very carefully before surgery. How is it different after surgery and how can mesh removal or any revision surgery fix that and what are the risks of doing that as opposed to not doing that?

Speaker 1 (00:10:20):

So I hope that’s clear because that’s kind of my bent on it. I really do not like being pushed into, I really don’t like being pushed into operating on patients. There are patients that are highly anxious, highly motivated, I would say pushy that just want what they want. That doesn’t work well with me. I don’t like to be pushed to do an operation that I’m not yet ready to perform because I understand the global picture. I understand all the potential risks and benefits of the operation and the patient may not. Now some patients tell me, I know my body and this mesh is ruining my life and I understand that, but I know the surgical complication of it. So there are patients who have lost their testicle because they’ve had multiple surgeons be convinced. There are patients that have had abdominal wall destroyed because they’ve had multiple operations, and many times if you read the chart, it was a patient pushing the surgeon.

Speaker 1 (00:11:41):

I really, really don’t like to be put into that situation. So I would like to urge you as patients to have patience and allow yourself and the surgeon to go through a phase of understanding the main problem and then figuring out what is the least amount of procedure and time may be the only thing to get better and follow an algorithm based on that. So there’s a comment here that says, well, the patient wants what they want because they’re suffering for years. I’m not saying they shouldn’t get something to make them better. I’m saying that an immediate response of I need this mesh out without further workup, further testing, further understanding of why they have those symptoms in my opinion, is a disservice to the patient. Because let’s say I have a patient who had surgery and immediately wants a mesh out, I can take out the Mesh physically, technically I’m able to perform that operation.

Speaker 1 (00:12:55):

So now how do I fix that patient’s hernia, are they okay living with a hernia? Because that may be the consequence is that we just remove the Mesh and see how their symptoms are because it’s not very clear whether their symptoms are from the mesh. What if they have another problem? Let’s say it’s their hip or their spine, and we’re ignoring that. So now I’m going to take out the mesh, put you at risk for all the nerve damage, losing testicle, a recurrent hernia, the pain that comes with it, and then it turns out it was your hip this whole time. So guess what? Now you have a hip surgery you need, let’s say, and you have a Hernia that’s now a worse Hernia than what you had before the hernia was repaired with mesh. So that’s where I’m getting at. I’m not discounting the symptoms of the patient.

Speaker 1 (00:13:51):

What I want to urge is that you’re very clear that those symptoms are evaluated with the idea of what procedure, medication, amount of time or surgery is best chosen to treat those symptoms. That’s where I’m heading at. So let’s say you have symptoms within hours of surgery. How do I know that it’s not, your fevers aren’t because of the mesh, but they’re actually because of, but your fevers are actually because of influenza that you have or COVID. How do I know that the joint pain that you’re suffering isn’t related to an undiagnosed rheumatoid arthritis osteoarthritis or psoriatic arthritis or other rheumatologic problem? How do I know which by the way, the mesh removal will not because that’s a known diagnostic problem. How do I know that the bloating and nausea that you have is not from the mesh in your abdomen, but the fact that you now have a gastric ulcer because you were taking pain medications or because you have intestinal bacterial overgrowth because you got antibiotics from the surgery.

Speaker 1 (00:15:11):

These are everything that goes in my mind and I need patients by the surgeon, myself or your surgeon and patients from the patient to slow down. Understand that this is not a quick fix necessarily, and we’re going to move in a stepwise manner to figure out whether any of your symptoms can be related to your mesh. If so, what should we do to remove it? What kind of procedure, for example, and then what do we do with that hernia, right? So you may say, just don’t put mesh in fine, but I still need to put something in the tissue repair. Has to use permanent mesh. Sorry, permanent suture. Which suture do I choose? Do I choose the same type of suture? Do I choose a different type of suture? How do I know you’re not going to react to that suture? These are all questions that go in my mind and I’m thinking 2, 3, 4 steps ahead of time ahead of all that here.

Speaker 1 (00:16:20):

Let’s see, questions. I I’m scared tissue up bad. I’m not sure what that means. I’m scared tissue up bad. I was going to set up a call with you, but I’m not sure you can help me. Do you do a free consultation? So I do not do free consultations, but I do free Hernia, Talk, Live, and we have a free discussion forum. So for people that have questions that I can perhaps answer during my time on Hernia Talk Live or hernia, that’s free. But no, if you want individualized care where I need to sit down and review all your chart and come up with a dedicated plan that requires a formal consultation, would you say inguinal removal is one of the most complicated? So I would say yes. Removal of inguinal hernia mesh is the most complicated of the Mesh removal options. So basically hernia mesh removal of the groin puts at risk the blood vessels to your leg, the blood vessels to your testicle if you’re a male, your bladder, your intestines, the vas deferens, which carries a sperm from your testicle to your prostate if you’re a male, the muscle in that region and all the nerves that includes potentially the lateral from a cutaneous genital femoral nerve, ileal inguinal nerve, ileal hypogastric nerve, maybe even the obturator or the femoral nerve, very, very uncommon, but it is part of that risk.

Speaker 1 (00:17:58):

So lots of potential for injury, whereas removing the mesh from the abdominal wall is often relatively straightforward because the main issue is not to injure the bowel, which may be nearby or attached number one and number two, not to injure too much of the muscle. So when you’re shaving off the mesh off the attached muscle that you’re allowing enough muscle available for the patient. Either way, it’s a delicate procedure. I do not recommend a heavy handed surgeon to do this operation. I do not recommend someone who doesn’t understand anatomy and phasix to do this operation. And so there’s a handful of us that do mesh removals and enjoy it and understand the anatomy for it. Here’s a question. I had symptoms within a week after surgery. It was awful. I lost so much weight and now a great deal of abdominal pain. So if the mesh was placed in the abdomen and you have abdominal pain, the question is where was the Mesh placed and what type of mesh was placed and what’s the technique in which it was placed?

Speaker 1 (00:19:13):

In other words, do you have abdominal pain because you’re a thin patient with a very thick mesh that it feels like armor? Do you have pain because the mesh is folded and you’re feeling the folding? Whereas you would ideally want a very flat piece of mesh? Do you have pain because actually the hernias recurred let’s say, or was the mesh put too tight and the repair put too tight and either you feel the tightness and that’s causing you pain Or the sutures that’s sewing the mesh in place is so tight that it’s tearing through the muscle and that causes pain. So those are all things to consider for abdominal hernias, including belly bone hernias or umbilical hernias with Mesh. And every so often you’ve heard me talk about Meshomas and balled up meshes, especially with the mesh plug. Every so often people use the plug for the umbilical hernias, which is not considered a recommended procedure, but it is performed often.

Speaker 1 (00:20:26):

In fact, I had a friend of mine who is an excellent, excellent surgeon and she was covering for this other surgeon in this part of town and that surgeon puts multiple plugs in multiple holes with no problem at all, thinks that’s perfectly okay. And those of us that know better highly recommend against the use of plugs. Now, we didn’t know this before, but now we do feel that felt like something dropped in my lady area. So that’s not umbilical, that’s in the groin area. So many of us with Mesh feel like we’re being stabbed repeatedly. How do you rule other issues out in that case? So some people who actually either feel the mesh or there’s a sharp edge to the Mesh or they’re trying to tear the mesh, either feel like a sandpaper type symptom, that’s the Mesh itself or a sharp stabbing pain, which may be where it’s either stabbing them or it’s burning or what do you call it, poking at them or the tissue is trying to tear.

Speaker 1 (00:21:45):

So that is not necessarily, if it’s a Hernia that’s recurred, you may need to have a better repair, but it’s not Mesh. Removal alone is not going to treat you for those. You need more than that. Here’s a question. What do you know think about mesh, if it were available in the us, would you use it? Yeah, so mesh is only available in Europe. I believe it’s a German company that makes it. Of course, I’m a big fan of the German surgeons and Hernia surgery has made the most impact and hernia surgery has been by German surgeons historically, and I would say that dynamesh is an interesting product. Most surgeons who use it love it. We do not have access to the United States. I am told they try to get access to cell it in the United States and the company decided that the FDA process to get it approved was too expensive and it would not be worth them seeking approval for Dynamesh in the United States.

Speaker 1 (00:22:56):

So that’s the story behind dynamesh. Dynamesh is kind of like fabricy and it’s made by PVDF, which is I am believe a type of polypropylene but a different kind of polypropylene. It’s much softer. It’s not supposed to shrink as much. It’s not supposed to be as taught. It’s put in place and a lot of the surgeons that use it love it. Do you also recommend patients with regards to mesh rule if the indication is pain rather than mesh reaction? Yes. Now what I don’t like is this idea that every single patient has to wait a year before they have any type of procedure. That’s a complete misunderstanding of patients who have mesh related pain. So there is a study, there are multiple studies that show that most patients who have chronic pain get better over time. So the same patient at three months.

Speaker 1 (00:24:06):

I think the study was like 20%, and don’t quote me exactly the numbers, but on average about 20% of patients had some type of chronic pain at three months and the definition of chronic pain was any pain after surgery at three months and then by one year it was down to 6% or something like that. And therefore people said, just wait. Don’t act on people with chronic pain after inguinal hernia repair. Give them a year and they’ll get better. And the reason for that is a lot of the pain is due to inflammation, due to tearing, due to tightness feeling, and it just gets better over time and due to scar tissue perhaps. Now if your mesh is balled up, there’s no amount of time that’s going to make your pain from the balled up mesh go away. It’s like putting a pebble in your shoe.

Speaker 1 (00:25:04):

No amount of time is going to make that pebble in the shoe feel better. You just have to remove it. So I’m very much against just watching and not doing anything for patients until a year goes by, even though I’ve heard that story multiple times where patients have chronic pain and they’re told just wait, don’t worry about it. Come back in a year. I’m not going to do anything for a year. Here’s some pain medications completely wrong. You can help the patient with medication. Let’s say it’s nerve type pain. You can start with nerve pain medication, even nerve block to see how much of your symptoms are improved and that may be enough to buy you some time to see how much pain that gets better mesh implant illness. It’s something I’m very interested in and yet we don’t know enough about it. So I’m trying to learn and gain knowledge about it through my own patients and by talking to others and doing research on it.

Speaker 1 (00:26:03):

So do I believe every patient that feels nausea or has hair loss after their Hernia surgery is because of the Mesh? No. Can I objectively test anyone for mesh implant illness also? No. So it’s a matter of using judgment and understanding that we don’t know enough as surgeons and some patients need to be taken through multiple studies to make sure they don’t have a known neurological rheumatological, infectious diseases or gastroenterology problem rule, all those out that involves a lot of blood tests, allergy testing, potentially imaging, et cetera, and then kind of still using your judgment to say, okay, you’ve suffered enough. We haven’t figured out anything wrong with you. Maybe it is the mesh, let’s take out the mesh.

Speaker 1 (00:27:05):

As opposed to saying, oh yeah, let’s take out the mesh in everyone. Let’s see. a lot of questions guys. I love this. You’re very active today. I have heard that over time polypro. Okay, let’s start this one in another episode. I think I heard you say that it is very rare to need to remove Mesh, which has been placed retro rectus. Is this correct? Yes. A surgeon told me that mesh infections are reasonably common, incorrect, although he was talking about an open retrorectus repair, also incorrect rather than a robotic procedure. And I assume this makes quite a big difference to infection risk. Yes, so in general, open surgery has a higher risk of any type of infection as compared to robotic or laparoscopic, and the reason is a larger incision. So the larger your incision, the greater the exposure to bacteria, smaller incision, lower risk of exposure to bacteria.

Speaker 1 (00:28:06):

So all types of infection, whether it’s a wound infection or a mesh infection is lower with laparoscopic and robotic surgery than with open surgery where you open the skin, make a scar. Mesh infection is also lower with laparoscopic and robotic surgery than with open surgery. But of all the types of hernia repairs, regardless of open or laparoscopic, when the mesh is placed in the retro rectus or behind the muscle region, that is the lowest risk of mesh infection open or laparoscopic or robotic. Why? Because the rectus muscle is a very well vascularized, lots of blood flow to it. Organ. If you put a mesh against a nice bloody healthy muscle that brings a lot of good blood flow to the mesh area, lower risk of infection because the blood takes care of any risk of bacteria and so on. So to say that it’s reasonably common for a mesh infection is a completely incorrect because mesh infection should be in the less than 1% risk of all Hernia surgeries is a clean operation.

Speaker 1 (00:29:27):

We’re not talking about emergency surgeries or where intestines are cut. That’s completely different. But in clean elective Hernia repairs, the risk of any infection should be less than 1% and the risk of Mesh infections should be a fraction of that. I have heard that over time polypropylene mesh can oxidize and become brittle. Yes. Making it more likely to break and cause a recurrence and have to be removed. No. What time period are we talking about here? Does polyester mesh or any other material fa any better? No. Which one do we have more long-term data on? Polypropylene, I’m about 60 and I want this to be one and done. So I want something that’s going to be good for 20 to 30 years, which I can take to my grave with me. Okay, thank you for your message. So mesh has been around since the sixties or seventies and became most popular kind of in the eighties and since then, the original studies on mesh was on mersiline, which was polyester.

Speaker 1 (00:30:41):

Then polypropylene came about and there’s a whole story and there are multiple myths as to why we went to polyester, but polyester came about. One of the reasons was they were seeing a lot more infections with poly polyester, so polypropylene came about. Anyway, we have long-term data on all of them. This idea of oxidization and brittleness of the Mesh is a microscopic electron microscopic phenomenon. If you look at the Mesh itself, most meshes look somewhat similar or very hardened, hardened, not brittle, hardened inside the body, then outside the body before it was put in place. The brittleness and the oxidization is a microscopic phenomenon. You can’t see oxidization and you don’t see it being brittle. So it doesn’t break in the sense that you’re breaking, what’s that bread called like a saltine cracker When you break it and it falls into pieces, that’s not the kind of break you see with that you’re talking about which would cause a recurrence.

Speaker 1 (00:31:54):

These are microscopic tears within the mesh that do not cause recurrence. The only quote breakage that we have seen with meshes is when you’re using a very lightweight mesh, let’s say silk, like a silk shirt, and you’re using it to take on a load from a very large hernia and that may tear in the middle, and that’s called bridging. We don’t do that anymore. We shouldn’t be doing that anymore. So we try not to bridge. Bridge means you have a hole and you kind of bridge it with a mesh, whereas we prefer you close the hole and then use the Mesh to support that closure. There was a situation with a mesh called I believe Proceed mesh, which was made by Ethibond where they found that it’s a great lightweight Mesh and that lightweight mesh was used unfortunately to bridge very wide gaps. And so it was basically like puncturing, you could puncture through the hole, through the Mesh in the tour. So it was taken off the market. It was otherwise a fairly good mesh.

Speaker 1 (00:33:01):

But that’s kind of the situation. Most meshes have more than 20 to 30 years of data already where we’ve been using it. And so I wouldn’t worry about that aspect of it. In fact, what I would worry about is the fact that the newer meshes, even though still technically polypropylene, let’s say may be of a lesser quality than the ones we were using 20 or 30 years ago, there is some evidence to show that many companies are nefariously going towards cheaper, less pure products for higher profit and then patients are getting less quality. And the surgeons like us, we have no choice because we don’t make our own meshes. We only have available to us what is provided by the industry, which is really sucky. By the way. What kind of precautions are taken in the operating room that the ME is handled appropriately before given to the surgeon to avoid infection, especially in outpatient centers where resources may not be as good as in the hospital.

Speaker 1 (00:34:09):

So I disagree that outpatient centers are any different in terms of resources related to surgical site infection than hospitals. In fact, it’s very possible that surgery at an outpatient surgery center will have lower risk of surgical site infection than operating at a hospital. Number one. Number two, surgery that’s performed on humans is tried to be performed elective surgery as sterily as possible. So we have sterile gowns, we have sterile gloves. The mesh that’s provided to us is provided to us using sterile precautions. I personally change my gloves when it’s time to handle the mesh so I have a fresh pair of gloves in case there’s any bacteria in the past hour that I’ve been using that glove, let’s say. And so I use a fresh pair of gloves every time I touch a new implant and many surgeons also do that.

Speaker 1 (00:35:01):

Let’s see. Lots of questions. Let me go through this. I hope I didn’t miss some of you. Can you explain this to our South African doctors in South Africa? I was in the hospital yesterday. The doctor didn’t bother that I have mesh plus I have a hernia. She just gave me panados. Oh, pain pills. So please help us in South Africa. There’s a great, I will, I have a friend in South Africa. She’s a great surgeon, really amazing, very involved in the hernia world. She may be the only one that I know of in South Africa that has any interest in the abdominal wall world, but I’ll bring her on as a guest because I think it would be great to get her perspective on how care is in South Africa and so on. So thank you for that comment. Let’s see.

Speaker 1 (00:36:04):

I’m looking at the comments here. I had symptoms within a week after surgery. It was so awful. I lost so much weight and now I have a great deal of abdominal pain. Okay, here’s another one I have followed with great interests, your shared discoveries on meshed implant illness. Cool, thank you. Thank you for publishing. It gives credit and hope for patients. Thank you to the journal to allowing it to be published. I’ve explained in my prior shows that it was really hard to get my data published because it is kind of a new topic. No one’s really discussed it before. And so there was some sentiment among peer reviewers that it was fufu or not real and they didn’t want to be associated with an article that brings in a topic that is so new. But that said, it is now I believe either the top or the second most popular article in that journal.

Speaker 1 (00:37:04):

So kudos to the Journal of Abdominal Wall surgery. Okay, since a TEP inguinal hernia mesh surgery last July. So that’s a laparoscopic TEP, totally extra peritoneal inguinal hernia mesh surgery last July. My symptoms include weight loss of 17 kilos in three months, loss of appetite, constant ear buzzing, chronic fatigue, joint pain, brain fog and bloating. I was told, I mean those are real symptoms. I wonder if he had any rashes, but those are symptoms potentially due to mesh implant illness. I was told at first that I probably have had depression. Really? I’ve done so many exams in the past seven months. I can’t keep track. I took antidepressants to no avail. I simply have no quality of life. You also said once that Mesh removal is not indicated if you have a psychological problem with your Mesh. Okay, here’s my question. It’s a metaphysical one. Given that some Asia symptoms, Asia standing for a autoimmune or autoinflammatory syndrome induced by adjuvants, given that some Asian symptoms can mimic a depression or the other way around, how do you decide that you need removal at some point?

Speaker 1 (00:38:23):

Is it a leap of faith once you’re out of other options? It kind of is. Currently we have no objective way, no blood tests, no imaging, no enzymes to reliably predict whether a patient’s at risk for Mesh implant illness and once the mesh is in you, whether the mesh is the cause of your symptoms. However, I do ask a slew of questions of my patients and based on years of experience, there are certain symptoms that I hear over and over again. They include all, not all, but some of the following. Hair loss, visual changes like blurry vision, ringing in the year, change in taste, chronic fatigue, brain fog, problem sleeping, problems with concentration, joint pain, zapping or tingling at the fingers or toes, rashes away from the mesh though sometimes weight loss, bloating, sometimes nausea, feeling hot. Those are all potentially related to a Mesh implant. First you have to have none of those before the mesh implant. Then you have to have the mesh implanted and then within days, weeks, months, less often a year, you get those symptoms and the symptoms don’t get better over time.

Speaker 1 (00:40:01):

And the only reason why we’ve kind of narrowed it down to these symptoms is because then we remove the mesh and the symptoms go away. And we found in our study about two thirds of patients, just under two thirds of patients are cured with complete mesh removal. And the other one third, we don’t know, are you not better because you always had some autoimmune potential and now the mesh has turned that on earlier than expected and now it’s on forever or was it never the mesh and we just don’t know. So we’re not right a hundred percent of the time. We’re wrong almost 40% of the time. I think 44% of the time and it takes time for some people to get better.

Speaker 1 (00:40:52):

Let’s see. Another question I have all over body pain now, would a pop and burning sensation be a mesh coming undone? Typically yes. If you’ve had a mesh that does pop, not all meshes, pop burning sensation is often from a tearing sensation in the muscle. So often it’s really just a nerve issue. Let’s see, I want mine out so bad I can barely walk. So walking and gait problems are usually not related to hernia problems. Those are usually hip issues. Now, could you be in so much pain that you can’t walk or change your gait? Uncommon even in people that I see that are in severe severe pain, it usually doesn’t affect their gait. Isn’t burning pain more in tune with nerve damage? It can be, but it can also be from tearing of the muscle. So if you have burning pain that shoots within an actual direction of a nerve, then you have to think maybe nerve pain or nerve injury.

Speaker 1 (00:42:13):

But if the shooting pain or the burning pain is related to a local area where there were sutures, let’s say especially for abdominal wall mesh, you can have burning pain where they put to or they put sutures and that’s because it’s tearing through the muscle. Can you see infected polypropylene mesh on ct and does it always have to be removed? Good question. In fact, I heard about a patient recently, which was exactly this situation. So here’s a situation. Patient had hernia repair, polypropylene mesh was put in typical scenario, right? Abdominal wall Hernia, they had a belly button hernia. Let’s say many years later, let’s say three or more years later, the patient comes in with kind of a chronic pain in the abdominal wall, right where the meshes points right to the belly, right where the mesh is, they get a CAT scan. CAT scan shows this kind of fuzzy grayish looking thing and it’s interpreted as scar tissue from the hernia repair.

Speaker 1 (00:43:21):

No, no, no, no. Scar tissue from a hernia repair. You’ll see a month, six months after surgery, maybe a year after surgery. By that time you should not be seeing that much scar tissue on a CT scan. If you’re seeing tons of scar tissue or what’s interpreted as scar tissue on a CT scan, you have to think that’s a mesh infection until proven otherwise. Now, MRI is different. MRI will be able to distinguish scar from infection, from fluid from inflammation. That’s the beauty of MRI. But you don’t have to have an MRI if you just use your logic or you have experience to say, okay, this patient’s more than three years out from surgery, there shouldn’t be this much scar tissue. Maybe this is really fluid collection or abscess or inflammation or infection of the mesh as opposed to scar tissue. So that’s the answer to that. The second part of your question was does it always have to be removed? Almost always. And by almost always, I mean over 90, 95% of the time, are there situations where people have gotten antibiotics and their pain and infection went away? In the short term, yes. In the long term, no. So you’re treating if you have a mesh infection and you take antibiotics and you feel better, then you’re just switching an acute infection to a chronic infection.

Speaker 1 (00:44:55):

What does that mean? That means you no longer have pus, let’s say, but there’s still bacteria there and the minute you’re off antibiotics, you’re going to get sick again or feel pain again or swelling or redness again. Or you can just take antibiotics for let’s say six months and that will kind of hold the infection at bay. But now you have what’s called a chronic infection, so there’s still bacteria in your system. You get joint pain and swelling and chronic fatigue and brain fog because your body is in this inflamed state that because it’s constantly trying to fight this bacterial infection, mine will be a year in one month. Mine hurts all night sometimes, yeah. If you have chronic pain from a hurting repair and it’s been a year, there’s a treatment for that. You have to see a specialist. The treatment can include mass removal, it can include nerve blocks, it can include current medications.

Speaker 1 (00:46:00):

You may just need injections into the area. You may have a hernia recurrence. So if you go to a hernia specialist that treats chronic pain on a regular basis, then they should be able to figure out why you have the problems. Question. Is there a way to tell if it’s the mesh causing pain all the time or reoccurring hernia? Yes, there is. My husband had Hernia repairs 15 years ago and is chronic pain since every day and has chronic pain since every day his doctor says the body is rejecting the Mesh. They think, but I don’t know. Okay, if you had mesh put into 15 years ago and now you have pain, you’re not rejecting the mesh, you reject the Mesh at the time of its placement, not do well, and then 15 years later, anyone? I’m going to say this very clearly. Anyone who had a Hernia repair of 15 years ago ended well until recently has a Hernia recurrence until proven otherwise. That’s just a hernia recurrence. It’s not a Mesh implant illness. It can be a Mesh infection, just a late presentation of one. It is not a Mesh usually, and it’s not a mesh related pain issue. It is either a mesh infection or a hernia recurrence until proven otherwise and most likely a hernia recurrence imaging is the best way to identify that.

Speaker 1 (00:47:36):

I had so much more hair before all of this. Hair is a difficult one because with age you also lose hair. My surgery was robotic. Can my body not like mesh and B, toxic toxics? Not the right term, but the question is, is, okay, let’s clarify this. Mesh implant illness of all the reasons for Mesh related pain is the lowest one, least frequent one. Mesh Hernia recurrence is number one, mesh balled up. meshoma is number two, nerve pain. Number three, maybe mesh infection kind of low, low number four, way, way, way down low as mesh and implant illness. Matzo crackers. Yes, thank you. Okay. I could see the matza crackers in my mind, but I couldn’t remember the name and I had to use salting crackers. But when I was talking about the brutalness of the mesh, it’s not like matza crackers where you just break in.

Speaker 1 (00:48:41):

You got 10 million crumbs and pieces all over the place. It’s very brutal. That’s not how Mesh is in real life. My umbilical hernia was three centimeters. Sounds like you put Mesh. Thank you. You are a great, great surgeon. Thank you for your knowledge and care. Appreciate you. Three ultrasounds in the past few months after surgery demonstrate that my testicle is slowly shrinking in size despite correct vascularization. I only have one and can’t spare it. Have you ever seen this? Can I reverse this with mesh removal? Should I act fast? Okay, so let’s talk this very, very good question.

Speaker 1 (00:49:18):

Men who have shrinkage of their testicle after al hernia repair, it’s because the blood flow to the mesh has shrunk. Sorry, has decreased. And eventually over time the testicle shrinks and becomes very soft compared to the non-operated side. Nothing can reverse it. You can potentially prevent it from getting worse if you’re actually being obstructed, the blood flow is being obstructed by the mesh, but more likely what’s happening is the blood flow was damaged at the time of the surgery, not years later from the mesh itself. So no, it cannot be reversed. Acting fasts will not make it any better and unless you have other signs which show there’s a blockage higher up the testicle by the Mesh, there’s really no purpose in removing the Mesh once the damage is done.

Speaker 1 (00:50:29):

Three centimeter umbilical Hernia, they use 12 centimeter mesh. That sounds about right. I’m in Houston, Texas. Great. We’ve interviewed multiple surgeons from Houston, Texas on Hernia, Talk, Live. Just search either my YouTube channel or hernia to see who can help you. Is polypropylene infected mesh visible on a CT scan? Number one, can the infection go away? Number two, does it happen? I already answered that. Let’s see. You just know. Yeah. Yes, Dr. All facts. Let’s see. Here’s our wonderful patient from South Africa again, is having back pain normal with Mesh? I would not say normal. I would say hernias can cause back pain, but hernia repairs do not usually cause back pain. So my problem in South Africa is that our doctors don’t want us to mention mesh because they still use it in my country. Well, I mean they use it in my country too.

Speaker 1 (00:51:38):

What are the risks of having these sharp pains that I’m getting now you may just have a hernia recurrence. If you’re having back pain surges around here, do not want to remove the mesh, just add more. Then you should find other surgeons if that’s what you need. Then you have to find other surgeons. And I say this over and I’ve had multiple episodes where I’ve discussed how patients need to empower themselves and take control. You’re not limited by your geography. You have cars, there’s trains, there’s airplanes. You can see more than one surgeon in the United States, especially doctors. Most patients can see other surgeons. You’re not limited like you are in a socialized medicine to who you can see there are specialists if not in your town than in your state, if not in your state, than in adjoining states. And you’re perfectly free to travel to see them. And if finances are a problem, then you should save for it and invest in that because it is your health and it’s your quality of life. My body is rejecting the foreign body. I don’t like to use the word rejection. That’s actually a technical term that has to do with actual like a rejection, like an organ transplant rejection. But I understand what you’re saying. You may be reacting to the product.

Speaker 1 (00:53:02):

Wow. So often we hear it is just scar tissue. Yeah, it’s almost never scar tissue. I mean it could be, but it almost never is. What lab do you use for explant, if any, for pathology? Have you heard of MicroGen Diagnostics? So we send the pathology specimen to the local surgical pathology lab. We actually published our results on whether it makes any difference to send those to the pathologist to actually look microscopically or not. And we found that regardless of what type of measure you remove and what reason you remove it for do I remove it because they happen to be there or do I remove it because it actually needed to be removed because the patient is reacting to it. We have not found a difference in the pathology findings. Everyone who has any implant removed, including the mesh, will have giant cell foreign bodies, chronic inflammation and foreign body reaction.

Speaker 1 (00:54:03):

Those three things on pathology, it is where it is. My body is inflamed. Yeah, that could be a Mesh implant issue. Can it make it hurt in my back as well? We already discussed that, so usually not. Is it normal to see the Mesh through the skin? Are you kidding me? No. Now there are situations where the patient is super, super, super thin and has no fat and the Mesh is put very close to the skin. Or you may be able to see the Mesh, but you should not be able to see the mesh. Now if you have mesh poking, if you have Mesh poking through your skin, that’s a different story. You’re not technically seeing the mesh. You’re seeing the poking of the Mesh. And that can happen if the mesh is folded.

Speaker 1 (00:54:56):

I am the one who has reactions to many, many things. Well, that’s a good story because we do notice that people who react to a lot of things are also, I think 60% of the people in our study that had mesh implant illness also had allergies to a lot of things or an autoimmune disorder. I had Mesh installed September. Now I have pain throughout my vast nerves to my testicle and down my leg, up my stomach. I have requested them to remove the mesh and repair with the plastic surgeon. Okay, couple things. Plastic surgeons tend not to know what to do with the testicle and the urologic procedure area. That’s a generalization, but that’s typically true. Secondly, what you need is a spermatic cord block because mesh removal alone may not be the right procedure. You may just need some blocks to see if any type of problem is related to the vast nerves at all. I have a whole algorithm for people with testicular pain after hernia repair.

Speaker 1 (00:56:08):

I tried to find DR in Houston on your talk. Okay, good. I can barely bend over and also get these new kidney pains as I was healthy before this running 10 ks a day. Great. Thank you for addressing the fact. Mesh removal isn’t always the best solution. I had aggressive removal. My surgeon stated I did what I needed to get the Mesh out. I had female mesh. Oh yeah. There’s a lot of critical structures there that can be damaged. My mesh was infected and needed to get out. But at what cost? Yeah, I agree. See, that’s the kind of story that I see, but maybe is not as popular online, let’s say. So everyone wants their mesh out. But then you have people that we know that we’ve treated, let’s say, who have been maimed by the Mesh removal process. And so you don’t want to be that patient because then you’re going to think back, I wish there are patients I’ve seen that said, I wished I had not pushed the surgeon to undo my mesh or remove my mesh because now I am a cripple, et cetera.

Speaker 1 (00:57:17):

I have a new hernia under my Mesh seven years ago and it’s compromised, but we can see the Mesh. I have a new Hernia under my mesh seven years ago and it’s compromised, but we can see the mesh. Okay, so the Mesh was placed as what’s called an Onlay. So the Onlay, which is the mesh on top of the muscle, has been pulled away by mesh, by hernia, pushing under it maybe when I was in the military, we were told that women are prone to reject foreign objects in their body. Could this be why my body rejected the mesh? So I’m not sure your body rejected the mesh, but it is true that women have in our study, women were more likely to have been in that mesh implant illness group than men. Can you share the doctors’ names with me for doctors here in Houston? I can’t find them. Just Google Houston on hernia or Google Texas. Actually, you should be able to see them. I’m so ready to get my flank hernia repaired. Hopefully I don’t have any Mesh issues.

Speaker 1 (00:58:25):

Great. Yeah, flank hernias really can’t get treated well without mesh, unfortunately. Do you ever have to take a patient back to the OR immediately after mesh implant to remove the Mesh because of severe pain in their recovery room? Especially if nerve injury indicate by location of pain. Do you always check patient in recovery room before discharge? I do always check the patient in the recovery room before discharge. My patients are not allowed to leave the recovery room unless I have physically seen them and talked to them and made sure that they’re ready for discharge. I personally have never had the situation where I had to return a patient to the operating room due to inadvertently injuring a nerve during surgery. But that is something we do teach the residents that if you ever see a patient in the operating room, sorry, after surgery in the recovery room and they’re in severe pain, consistent with a nerve impingement or entrapment by suture, take them back to surgery and remove that suture. But if you do the surgery right and you find all the nerves before you put your sutures, that is kind of unnecessary or it never really happens.

Speaker 1 (00:59:45):

Okay, so that’s it guys. That was, wow. What a fast that was a lot of questions. I hope I answered as much of them as I could. Some of you had turned in questions beforehand and I apologize that I didn’t get to those at all, but I hope that was satisfying to you. Go to and register to via someone on there who can maybe ask more questions there if you want. But if not, I will see you again next week on Hernia Talk Live Tuesday and in a couple of weeks we have another a great, great guest. So I’m really excited to bring in new guests every week as much as I can. And thanks everyone for helping and for talking and being involved. Thank you. See you next week.