NIS

Who is a candidate for mesh removal?

The decision to remove hernia mesh is often easy but can also be very difficult. It is almost always based on a patients subjective complaints. Mesh pain is a clinical diagnosis. There are no blood tests or imaging studies that makes the case. Even physical exams are immaterial.

Twenty years ago I saw in consultation a middle aged man who was unable to work due to severe groin pain. He had two years previously had mesh inguinal hernia surgery on the exact location where he developed pain. He rated his pain as a ten out of ten. He had seen a dozen doctors trying to find help. Pain medications, various injections and physical therapy all failed to provide sustained relief. CT scan, MRI and Ultrasound showed no hernia recurrence or any other abnormality. I offered the patient mesh removal because it was obvious to me that the mesh was causing his pain. I had to tell the patient I had never done the surgery before, I had never heard of anyone doing it and I could not tell him with certainty what the results would be. I told him I thought something had to be done but I had nothing else to offer. The patient, who I thought was a very intelligent and reasonable man, told me he understood and asked me to do the surgery. I removed his mesh, he recovered, his pain went away and he returned to work. At one follow up visit he told me I saved his life. This was immensely  gratifying for me. I had helped somebody that nobody else would or could.

If I had not been successful with my first case I probably would have stopped there. But I was encouraged to do my next case and then the case after that selecting new cases similar to my first. By the time I had my first patient who did not improve after the surgery the successes gave me enough confidence that I could tell the next patient what the odds were of success and failure.

As time goes on and case experience grows I am able to loosen my selection criterion. At this time I believe anyone with a pain rating of 7/10 or above is a solid candidate. I have found that patients with severe mesh pain who have mesh removed and only a little better are still happy that the mesh is out.

Patients with lesser pain may be a candidate but that decision is a lot more complicated. I will turn down patients who I think have unreasonable expectations. I will turn down patients who I think will need mesh replaced. I do not think that operation makes sense or works. I will remove mesh for any patient who simply wants it out and does not have unreasonable expectations.

Non-pain indications for mesh removal are evolving at this time. Our second annual mesh pain survey gave us a lot of information about other symptoms and problems that mesh pain patients attribute to their mesh. It is a very interesting observation that in many of these cases the symptom or problem goes away when the mesh is removed.

Confounding factors in selecting and successfully treating patients with hernia mesh pain include post traumatic stress disorder, complex regional pain disorder, secondary gain, depression, body dismorphic disorders and others. But hernia mesh pain is real and is not a psychological condition.

When a life is completely ruined by severe pain, mesh removal is justified. It is important that patient understand the risks and the statistical results. Patients must have reasonable expectations. Mesh removal helps most patients but not everybody. We are working on that.
- Dr.P.