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New article by Dr. David Chen, President of the Americas Hernia Society
Here is another article worth reading, linked at the bottom. Again, as is common, I am struck by the use of precise numbers to support a view when they support the case (recurrence rates) but a fall back to vague terms when the numbers don’t work or are unavailable (“excellent outcomes with benefits of early recovery and lower rates of chronic pain.” – no citations). It seems ingrained in the minds of the professionals that work in the field. Repeat the talking points. But, he does still mention chronic pain rates above 5%, even though 15% seems clearly established as the rate today. Downplaying the chronic pain rate.
On top of that, he tells a story about an attempt to use the latest “state-of-the-art” repair procedure on a colleague and friend, laparoscopic TEP mesh placement, having problems, and falling back to a Shouldice repair after mesh removal. Then he says the problems could have been avoided if he had used a Lichtenstein repair.
The reason he started with TEP is because, quoted, “The data and guidelines clearly support a minimally invasive approach; ” and “if only the patient had an open Lichtenstein repair, he would have not been a victim of anatomy and probability.”
So, instead of questioning the data and Guidelines he writes on about how complex things are becoming today and more research needs to be done. Overall, the article is much like Dr. Ramshaw’s discussion of his error and the damage it caused and how the “system” led him astray.
If these doctors could just realize that the data and Guidelines are skewed toward the use of more mesh, not for the benefit of the patient, they might be able to avoid the damage they’re causing. Dr. Chen seems to infer that, he seems to understand it, but he does not say it outright. Following the Guidelines caused him to injure his friend and colleague. The data being used and the Guidelines are wrong.
The key word in one of his statements is “evidence”. That’s what is being hidden and is what will guide the society to the truth. I hope that he can find a way to expose it. It will be difficult.
“With such rapid progress and change, never has it been more important to optimize patient outcomes though education, standardization of techniques, and research to provide evidence that progress translates to better outcomes and value. ”
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5 Replies
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I believe Dr. Towfigh uses it occasionally, but not in large hernias. She told me mine didn’t qualify for it because it was large.
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I came across this old Topic when I was searching for a post about Dr. Chen. I found the publication that Herniahelper referred to and am adding it here to fill out the discussion. It’s a very small study, 13 patients. Yet the new method is recommended as “safe”. Another market for robotic surgery. It is the state of the hernia repair field. New methods to add to the smorgasboard. No long-term results. I wonder who is using it.
https://link.springer.com/article/10.1007/s10029-020-02259-7
Robotic iliopubic tract (r-IPT) repair: technique and preliminary outcomes of a minimally invasive tissue repair for inguinal hernia
D. Huynh, N. Fadaee, B. Al-Aufey, I. Capati & S. Towfigh
Hernia volume 24, pages1041–1047 (2020)“Conclusion
The Nyhus-inspired robotic iliopubic tract (r-IPT) repair is an MIS approach to provide a non-mesh repair in inguinal hernia. The repair is safe with acceptable preliminary outcomes in low-risk patients. We propose the r-IPT repair to be a MIS option for non-mesh inguinal hernia repair in low-risk patients.” -
Everyone has their biasis. He runs the “Lichtenstein…” Clinic. It was a huge part of his up bringing as a surgeon so I’m not surprised he touts it as a strong option in his hands. However what I find most interesting here is the admission that because he was operating on a VIP, he selected the TEP repair. Presumably because I’m his mind, out of all the repair options in his armormentarium, he believed it to be the “best” in terms of chronic pain rate and other complications.
… And then he got screwed by an unforseen complication of prior surgery. “#LOL”
The blind dissection with TEP intuitively seems like a drawback where adhesions lay in wait. Good old TAP has the drawback bowel injury or adhesions but you can see what’s going.
The second thing I find interesting here is that due to the bowel injury he likely needed to select a tissue repair, and he chose an open shouldice.
Dr. Towfigh has published a novel robotic primary tissue repair technique. I’m certain Dr. Chen is aware of this technique as they collaborate togeather.
I’m just curious if this would have been an option in such a case since they were already in there and if so does anyone know if Dr. Chen ever performs this repair as well?
While this case had the modifying factor of bowl injury, I’m curious if for those undergoing mesh removal who don’t want more mesh, is an open shouldice a ‘better’ option or does this robotic tissue repair seem similar in the right population?
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As always, thanks Good Intentions for keeping us up to date on all things hernia. I am impressed with your research skills! You make it easy for all of us to read what’s new and relevant and I truly appreciate your efforts!
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It might seem like I am targeting Dr. Chen, with my recent comments in another thread and then this new Topic. It’s just coincidence. But Dr. Chen is the President of the largest hernia centered organization in the Americas, and also a director at a famous hernia repair center at a world-renowned medical center and university. He is also a Professor, teachng new surgeons about how things are done. Students, and colleagues, will be looking to him for guidance on what is right and what is wrong.
Here is a fairly recent paper about the poor quality of work behind the “Guidelines”. These are the same Guidelines that are on the AHS web site, recommended to all surgeons doing hernia repairs. It doesn’t take much looking to start to wonder how these Guidelines were created and how they could become the gospel for all hernia repair surgeons. It’s pretty incredible, from any viewpoint, subjective or objective. How can so many professionals be blindly following these recommendations, without question?
https://link.springer.com/article/10.1007/s10029-021-02423-7
I had already linked this paper in a recent Topic.
https://herniatalk.com/forums/topic/new-article-questioning-the-validity-of-the-hernia-guidelines/
New article questioning the validity of the Hernia Guidelines
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