This page is meant to give some guidance to surgeons who are interested in doing hernia mesh removal. These are lessons Dr. Petersen has learned over 28 years of doing hernia mesh removal for chronic hernia mesh pain.
The approach he uses depends on how the mesh was placed. If it was placed with an anterior approach through a single incision he will go through that incision. If it was placed laparoscopically or with a robot he will do a formal open laparotomy which allows him to safely remove all of the mesh using his sense of touch which is not possible with laparoscopic or robotic removal. This also allows him to inspect the inguinal floor by palpation after the mesh is removed.
The dissection is preformed with care. Using a scalpel he basically shaves the mesh off of surrounding tissue he can in nearly all cases preserve nerves and spermatic cord structures such as the vas deferens and testicular vasculature. He leaves scar tissue undisturbed. Scar tissue without the constant provocation of the foreign body reaction is not a problem. In time the body will remodel scar tissue partially reabsorbing and softening it. He preserves the cremasteric muscle and fascia on the spermatic cord. This is where the collateral circulation for the testicle comes from and prevents ischemic orchitis. If the testicular vasculature is compromised he does not do a prophylactic orchiectomy. Many of these testicles will survive on collateral circulation. If the mesh is placed posterior to the abdominal wall I preserve as much of the transversalis fascia as is possible. If the mesh is placed anteriorly on the external oblique fascia it becomes incorporated into the fascia it may be impossible to remove with out destroying the fascia. This is the only mesh that he has failed to remove. Removal of plugs is very hazardous. He grasps the plug with a Kocher clamp and basically rolls the plug out of the preperitoneal space and dissect with a #15 scalpel blade. This allows him to see and avoid injury to the inferior epigastric vessels and the femoral vein. The basic principle app[lied here is to dissect slowly right on the surface of the mesh plug. Do not replace the old mesh with newer supposedly better mesh. Do a non-mesh repair. There is no such thing as problem free mesh.
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