hernia mesh repair question

[Brad Davis]

Coach Rippetoe,

What are some of the largest weights you've seen someone lift after having a mesh op? Have you seen anyone fail the repair?

Thank you very much.
DBD

[Mark Rippetoe]

I've had it done, and I'm rack pulling in the high 400s x 5 now, squatted 405 three weeks ago. They don't usually fail, but I have no access to the epidemiology.

[Brad Davis]

Thanks Coach.

I've worked my way from near nothing right after the repair to the low 300s on squat and mid 300s on deadlift and am still going up. I started wondering if there was a big enough experience base out there to know if there's an upper limit.

I went to see my surgeon yesterday (I had some pretty nasty pain right after a press 1RM attempt last Wednesday and went to see him.) and he said he didn't have anybody lifting anywhere near as much as I am and he had no idea how much the repair will hold. However, he said that he is confident that it'll hold more than I can lift, but he couldn't guarantee it.

[Kerpal]

I got a hernia earlier this month and had a consultation with a surgeon today. He told me the area will be stronger with the mesh after the surgery than it was before. So I don't see any reason why having the mesh put in would limit the amount you can lift.

I actually had another hernia question and don't want to derail this thread, but maybe someone who knows about this can give input - the surgeon told me he doesn't like to do laparoscopic hernia repairs because with that method there is a chance that the mesh can interfere with your prostate, causing problems later in life if you get prostate cancer. Has anyone heard of this?

He recommended the tension-free method of repair because the recovery time is almost as fast without the risk of future prostate complications.

[Brad Davis]

I got a hernia earlier this month and had a consultation with a surgeon today. He told me the area will be stronger with the mesh after the surgery than it was before. So I don't see any reason why having the mesh put in would limit the amount you can lift.
Right, but think about what this means. My hernia showed up when I was squatting 235. The repair must be at least 2x as strong as my original equipment if I hope to squat 470. Hence the question.


...there is a chance that the mesh can interfere with your prostate, causing problems later in life if you get prostate cancer. Has anyone heard of this?
My surgeon and I went over complications and risks ad nauseam and this never came up. Also spent a lot of time online researching before surgery and never read about this.

[kyleb]

Right, but think about what this means. My hernia showed up when I was squatting 235. The repair must be at least 2x as strong as my original equipment if I hope to squat 470. Hence the question.

Not necessarily true. You assume that the squat at 235 is what ruptured your original equipment, when it is possible that your original equipment was faulty from the get-go or weakened from other activities (or lack thereof).

Measure the repair from the base of an average human's "stuff." Most of us squat 400+ without any problems. You're getting a standard upgrade (or a suitable replacement at worst) from an average human's area and a huge one from yours.

[Mark Rippetoe]

He didn't get the hernia from 235. He got it from his loving parents.

[Brad Davis]

Kyle, you're right that my 2x comparison is probably not an accurate way to look at it.

On the lighter (LOL) side, I talked with one of my buddies who is a very high level PLer and one of his pals had the surgery done also. He squatted 750+ and deadlifted 800+ at 275, 6 months after surgery with no problem. I'm not saying that proves that my repair could do that, but I think it's a neat data point anyway.

My surgeon agreed with Coach Rippetoe that genetics are the dominant issue at play here. I found it interesting that age played a role also. When I was 22, I squatted and DLed 500 at 181 and had no noticeable hernia issue. My surgeon said that the equipment loosened up over the years, allowing the hernia which was noticed with just 235 when I was 37.

At this point, I'm going to keep moving ahead and have faith in the repair. What's the worst that can happen IF I get strong enough to fail it? I'll be very strong and will have it repaired again. Seems like that's unlikely to happen, though.

[kyleb]

He didn't get the hernia from 235. He got it from his loving parents.

Much more to the point than my long-winded statement.

[TPrewittMD]

He didn't get the hernia from 235. He got it from his loving parents.

That's right, Rip.

A few observations on inguinal hernia surgery after having done in the hundreds of them when I practiced general surgery:

-I performed a tension-free plug and patch technique under local anesthesia with heavy sedation. Most patients took minimal pain meds after surgery. After return to work time was 4.8 days, better than reported for laparoscopic approaches at the time.

-No restrictions post-op. Returned to any activity as tolerated.

-Recurrence rate was around 2%. Could have been higher if patients with recurrences went to another surgeon.

-No early recurrences. Activity was not a factor in those that did recur.

-Worked in two college towns with competitive, well-known athletic programs, including prominent football programs. Number of inguinal hernias seen in college athletes who weight train: zero.

-Hernias common in older men because most hernias are due to a patent processus vaginalis, the embryologic canal through which the testicle descends into the scrotum. These congenital "indirect" hernias can take decades to manifest themselves, and they comprise 85% of groin hernias.

-Long term data show that the complication rate of surgery (e.g. chronic pain, recurrence) equals the complication rate of the hernia (i.e. incarceration.) So despite having done a lot of these things, I became quite conservative, particularly with small, asymptomatic hernias in older patients.

[Mark Rippetoe]

Excellent info as usual. Thanks.

[mike]

A few observations on inguinal hernia surgery after having done in the hundreds of them when I practiced general surgery

would these observations apply to umbilical hernias as well? or do the anatomical differences between the two types generate unique problems with the umbilical?

thanks

[TPrewittMD]

would these observations apply to umbilical hernias as well? or do the anatomical differences between the two types generate unique problems with the umbilical?

thanks

Great question.

There are some similarities. UH typical presents as a soft bulge in the umbilicus. Sometimes the bulge is a bit tender and cannot be reduced back into the abdomen. UH develops when a small defect in the umbilicus dilates over time, allowing abdominal contents to protrude through the fascial defect. Usually this is omental fat, not bowel, and the only thing between the abdominal cavity and the outside is skin and a thin layer of peritoneum.

The hernia develops where the umblical cord that supports the baby in utero connects to the placenta. I believe there is probably a very small defect that never closes and because of intra abdominal pressure, enlarges over time. Others believe that this thin fascial layer tears, and the the defect enlarges.

Patients will notice the asymptomatic bulge and just leave it alone, eventually seeking surgical evaluation as it enlarges. I have found quite a few asymptomatic UH on simple physical exam, and have fixed these incidentally when patients are laparoscopic cholecystectomy.

The risk of UH is incarceration and strangulation. I have fixed a few emergently due to pain and tenderness, and these have been small. I have fixed a couple due to bowel obstruction, and these are larger hernias with small intestine in the hernia sac. Most of the ones I have fixed had enlargement or chronic discomfort.

Vast majority I have done as outpatients. Great majority in recent years done under local with IV sedation using a tension-free repair with Ventralex mesh. Large ones I have repaired laparoscopically with mesh.

I manage these a bit differently post op and restrict patient from heavy lifting for a couple of weeks postop as opposed to indirect inguinal hernias who I left go back to full activities when they felt ok.

I am more conservative with UH repairs because the anatomy is different. An indirect inguinal hernia descends down a canal, and the Perfix plug sits in the canal. The mesh has a velcro-like effect and just sits there. A single stitch can keep it in place (and many surgeons over do this repair with too many sutures of the onlay mesh, negating many of the benefits of the repair).

A Ventralex mesh repair sits just inside the fascia and is sewn to the fascia with at least several sutures. It likewise is tension free. I doubt there are any data to support restricted activities, but the fact that there is only skin separating the mesh from the environment with a intervening canal to help keep things in places made me more conservative.

And I would usually see UH patients, at least larger ones, for about 3 months.

Complications of UH are usually recurrence and wound. Not unusual to see some superficial epidermalysis (dead skin) in a UH because of the aforementioned anatomy, but this typically does well with conservative management. Can't remember seeing chronic pain from a UH, and can't remember taking out an infected mesh.

[Mark Rippetoe]

Boys and girls, you can't get this information just anywhere -- the input of a surgeon that understands and advocates heavy training. We thank you again, Tom.

[nisora33]

Boys and girls, you can't get this information just anywhere -- the input of a surgeon that understands and advocates heavy training. We thank you again, Tom.

Yes, thanks for donating your time here.

-Stacey

[gordonrumble]

Agreed, very interesting stuff.

[TPrewittMD]

Hey Rip, thanks to you and everyone else for the kind comments. It's my honor to participate.

I get much more out of you guys than I will ever be able to contribute myself.

And that's the reason for the "MD" at the end of my name, just to substantiate my comments on personal medical topics that seem to be important to folks on the board

Kinda embarrassing though; I'm not into the whole "doctor" thing.

tp

[stef]

I'm not into the whole "doctor" thing.

None of the good ones are.

s.

[Sgsolberg]

Rip, since you're tired of dealing with hernia questions, perhaps this should be a stickied thread.

Or maybe not, since it still doesn't help the standing leg press... I mean squat checks.

[BIGGUY6FT6]

That's right, Rip.

A few observations on inguinal hernia surgery after having done in the hundreds of them when I practiced general surgery:

What are you practicing now? Thank you for your time on here.