Lessons learned removing hernia mesh

The diagnosis of hernia mesh pain is pretty simple and straightforward

If you did not have the pain prior to surgery and now you have pain exactly where your mesh is after it is installed then your mesh is the cause of your pain. Early on in my mesh remedial surgery career I used to think it was important to rule out other possible causes of the pain using expensive medical imaging. I found that to be a waste of time and money. I now use imaging rarely and selectively when after a careful clinical evaluation I suspect that something else may be going on. The point is, mesh causes pain in a significant number of patients. It should be at the top of the differential diagnosis list.

Mesh pain defies anatomical explanation

Mesh can cause pain anywhere in the abdomen. Mesh typically causes pain where the mesh is located but I commonly see it cause pain in places that cannot be explained anatomically. Patients complain of pain on the opposite side, in the thigh and leg, in the testicle, in the upper abdomen, in the shoulder and in the back. Patients also complain of achy joints and headaches. When the mesh is removed these pains go away. Part of the explanation is central pain sensitization (CPS). Widening of the pain field is a feature of CPS. In the central nervous system nearby neural pathways are recruited into the active pain neural pathways. Another possible cause is that nerve growth factor is generated by chronic inflammation and can have systemic and regional effects.

Referral to pain management is a doctors denial that mesh causes chronic pain

When a patient has pain why would the recommended treatment be to cover up the pain. It is because the doctor refuses to acknowledge the cause of the pain is mesh and also refuses to admit the logical treatment of this pain may benefit the patient. Mesh causes chronic pain. Removal of the mesh greatly benefits most patients.

Central Pain Sensitization is a prominent feature of chronic hernia mesh pain

This is what makes mesh pain so confusing to clinicians and patients. When a patient is exposed to chronic severe pain there are anatomical changes that occur in the spinal cord that lead to permanent excitation and sensitization of the spinal cord. This causes phantom pain, allodynia, hyperalgesia and widening of the pain field. The doctor who is examining such a patient is confused because the pain is way out of proportion to the history and physical findings. This is phantom pain, allodynia and hyperalgesia. Even more confusing is that the pain is not localized. It radiates everywhere. That is widening of the pain field. Removing mesh does not instantly relieve central pain sensitization. We have no specific treatment for central pain sensitization but in many patients after the noxious stimulus, the mesh, is removed the sensitization will renormalize over time. Sometimes it takes a long time. We do not have enough follow up data but it is possible that for some patients it will never get better.

Mesh pain does not follow one specific time line

I have seen patients perfectly happy with their mesh hernia repairs then develop crippling mesh pain ten years after their hernia surgery.

Mesh patients develop posttraumatic stress disorder (PTSD).

Patients commonly tell me their doctors have told them it can’t possibly be the mesh and that they are crazy and that it is all in their head. Mesh patients are different, it is true. But if you understand PTSD then a mesh patient’s behavior makes sense.

Mesh patients suffer abandonment

The doctor’s denial and dismissal of their patients’ concerns and symptoms amounts to abandonment. The worst thing that a doctor can do to a patient is to abandon them. This results in loss of trust in their doctors and the system, confusion, depression and loss of hope. I know of mesh patients who have taken their own life because of their pain and despair.

It takes at least 50 cases for a surgeon to master mesh removal

In the first fifty cases that I did I did a good job but I was definitely learning. After several hundred cases now I have an established routine and the surgery goes much more efficiently. My results continue to improve.

Removal technique

Use sharp and blunt dissection only. Electrocautery leads to prolonged pain. Do not remove scar tissue. Keep the dissection plane on the surface of the mesh.

Removing mesh does not cure everyone’s pain

Somewhere between 20% and 10% of patients who have mesh removed do not have significant improvement in their pain.  There are some prognostic factors, which helps a little to identify these patients. For patients who have significant disability from their pain an 80% to 90% chance of improvement makes a lot of sense. If there is no significant disability then these odds are not so compelling.

Pain after mesh hernia surgery is not likely a hernia recurrence.

Chronic pain is much more common than hernia recurrence after mesh hernia surgery. I have seen many cases of pain misdiagnosed as hernia recurrence.

Do not treat mesh pain by putting in more mesh

By far the worst cases of mesh pain that I have seen are patients who had mesh implanted twice. It goes like this: A patient has a mesh hernia repair. The patient is pain free for a while and then develops pain. The surgeon sees nothing wrong but assumes that the patient must have a small hernia recurrence, re-operates and puts in more mesh.  Sandwiched mesh is particularly difficult to remove then reconstruct. This occurs when a patient has an open mesh repair followed by a laparoscopic mesh hernia repair. A plug and patch repair is also similar to this.

If you take out mesh you should not put it back in

I have seen many mesh explant patients who have failed to get pain relief because the surgeon put more mesh, usually a different type, back in. If you are going to remove mesh for pain do a non mesh revision of the repair. A patient who reacts to one mesh is very likely to react to any other kind of mesh including PTFE and biological grafts.

Repair of asymptomatic hernia with mesh may be a bad idea

Of the patients who I have seen who had bilateral laparoscopic mesh inguinal hernia repair it is usually the side of the asymptomatic hernia that develops the worst pain. Also when I remove this mesh I have yet to find a hernia. It makes me wonder if a hernia can heal if it is temporarily reinforced. Do a laparoscopic repair with absorbable mesh that takes a long time to reabsorb. This idea first occurred to me in 2012.

Removing mesh is as safe as other standard operations

No surgery is without risk. As a general surgeon I do many different types of surgery. I do not exaggerate either risk or safety of an operation to either discourage or encourage a patient to have surgery. That is not fair to the patient. There are certain operations that I do not do because I know I will never do enough cases to become proficient. If a patient needs an operation that I am not proficient at I refer them to somebody who is. Unfortunately many mesh pain patients have been discouraged from having their mesh removed by doctors exaggerating the risk. Removing mesh does have risk as does any surgery. I try to explain to my patients in the most fair terms what those risks are. Then patients can make the right choices for themselves.

Bilateral inguinal mesh removal should be staged

For a patient who has bilateral mesh inguinodynia removal should be done one side at a time separated by 6 months. Bilateral mesh removal that is not staged creates a very difficult recovery for the patient. Risks of complications are more than that of the staged approach. If the surgery is staged the patient has the opportunity to decide if he wants the second side done based on his first removal experience.

This is analogous to the debate about the safety of single stage bilateral hip replacements. It is clear in the medical literature that transfusion requirements and the incidence of deep venous thrombosis is elevated when bilateral hip replacement is done as a single stage. Studies however have not shown that the mortality rate is different. I take this with a grain of salt because the numbers are small and do not have enough power to show a difference.

Some of my patients are disappointed because they would like to be on the road to complete recovery sooner and because of the increased financial burden of two separate procedures. I apologize but I have to error on the side of caution.

Hip joint disease can cause groin pain

I rarely order imaging studies for patients with mesh pain. The appearance of the mesh has little bearing on diagnosing the cause of groin pain. A ct or mri will however pick up hip joint disease that is not otherwise clinically evident.

Mesh pain patients are severely psychologically stressed

This is part of the disease of mesh pain. They are understandably angry. At times their anger is misdirected and aimed at physicians who try to help them and fail. The doctors at fault are the ones who put mesh in them needlessly. Other doctors at fault are the ones who fail to recognize the problem.  Mesh pain is a horrible disease. 25% of patients never get better. But 75% do.

If you are going to remove mesh for pain, remove it all.

There are two critical areas where removal is difficult but failure leads to persistence of pain. Do not leave mesh around the spermatic cord and do not leave mesh attached to major blood vessels. The spermatic cord and blood vessels have rich sympathetic innervation. This is why standard peripheral neurectomy does not work well. Take the time to do the delicate, time consuming dissection to remove the mesh in these areas. Mesh, however, can cause permanent symptomatic damage to the vas deferens and may require resection of the vas deferens. Risking losing the testicle may be a warranted risk for the sake of helping a suffering patient.