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Absorbable mesh study and possible alternate interpretation of results?
Perhaps this study is familiar to the surgeons on this site already:
The conclusion, obviously, was that fully absorbable mesh was unsuited to direct hernia repair because of the very high recurrence rate. However, my question is this:
Is that true, or is it true that it is not suitable for use with direct hernias as a one-for-one substitution for non-absorbable mesh in conjunction with the Lichtenstein technique?
In other words, is this possibly the ultimate confirmation of [USER=”2019″]drkang[/USER] ‘s assertion that any repair is faulty if it doesn’t fix the actual defect?
The really interesting test would be to see the results if adding the step of sewing back together the torn fascia prior to mesh insertion. It seems logical that you might see different results down the road between a patient who literally had a patch of scar tissue covering a hole vs. a patient who had scar tissue reinforcing the (at the time of surgery) delicate repair of a hole, no?
[USER=”2019″]drkang[/USER] : for a surgeon not completely ready to abandon mesh, or learn an entirely new technique, could current techniques, with minimal modification, be adapted to actually make this type of product work? -
11 Replies
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quote drkang:I am afraid that few fellow surgeons will agree with me.
Unfortunately, everyone seems to fear the unknown, and there is a long history of assumption that, at least with a direct hernia, it is not enough to simply stitch the torn fascia back together. Therefore, even once you publish, I think it will be hard to convince surgeons of this, given what they have been taught to believe.
Patients, on the other hand, have the opposite problem: they buy into whatever they want to believe most, whether or not it is right.
That is why I wonder if absorbable mesh becomes a “compromise” when the patient tells the surgeon they want this new repair they read about (yours), but the surgeon says that it won’t work because more reinforcement is necessary (in spite of the evidence). Surgeon agrees to try it, provided they can use some prosthesis to support the repair as it heals; patient agrees because once the mesh has been absorbed, they have exactly what they ask for.
Importantly, perhaps, you will give the device/pharma industry something to “chase” (new absorbable mesh patents) instead of galvanizing them to lobby for use of mesh vs. tissue repairs (as I’m sure they do now).
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Hi dog,
I said before that ‘if the tissue repair is performed properly’ at post #7. Actually, it has a very long and complicated story in it.
I think it is still hard to find the ‘properly designed’ tissue repair technics for the inguinal hernia. In my point of view, most of them are type non-specific repair technics, and it means that the hernia defect(s) sometimes could not be repaired properly. Shouldice or Desarda also belongs to that category, I think. They are one of the ‘one-fits-all’ kind of repair technics.
So I think that the new concept tissue repair method should be developed to meet the condition of ‘if the tissue repair is performed properly’. Hopefully, it should be a kind of type-specific technic.Lack of expertises doesn’t justify us to accept the present situation. Doctors, I think, must be properly prepared to meet the patients’ needs
I am afraid that few fellow surgeons will agree with me.
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quote dog:drkang Very good point! But it will work just if doctor totally specializes in tissue repair. Here is what happened with one person
The person did repair with Good old school doctor … first time Desarda…second time Shouldice
It was more of a Shouldice type repair. it was a tiny hernia so he put two stitches in it. Here is the thing, Sometimes people have more weaknesses than one in the abdominal wall. In theory, the surgeon notices that as he is doing the surgery and repairs both at the same time. But in my case Dr. ..didn’t (at least that is what I am being told). After the second surgery Dr. …. said the first surgery looked great and was holding fine and his fix seems to be fine now too. But I can’t actually verify any of this as I am asleep as it is all being done. So if there was an issue with the original Desarda repair and he fixed it I would have no way of knowing that was the case. That said, I did some research and there are cases of two weaknesses in the abdominal wall in slightly different locations in some individuals so Dr. …story is certainly possible. The bottom line is that either the Shouldice or Desarda repairs require more expertise than mesh repairs and more expertise than most surgeons have. So there just isn’t a whole lot of choices if you want to go that route. And as you know, if you do have issues with either of those repairs, there is a fall back. With mesh not so much. Good luck. Overall I wish I had not had to go through it twice. The second time it was a lot easier as it was just so much less painful. And so far so good. I
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If the surgeon found additional weaknesses or repaired a ruptured previous repair, that should all be in the surgical report. You can request a copy of this report from the surgeon.
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drkang Very good point! But it will work just if doctor totally specializes in tissue repair. Here is what happened with one person
The person did repair with Good old school doctor … first time Desarda…second time Shouldice
It was more of a Shouldice type repair. it was a tiny hernia so he put two stitches in it. Here is the thing, Sometimes people have more weaknesses than one in the abdominal wall. In theory, the surgeon notices that as he is doing the surgery and repairs both at the same time. But in my case Dr. ..didn’t (at least that is what I am being told). After the second surgery Dr. …. said the first surgery looked great and was holding fine and his fix seems to be fine now too. But I can’t actually verify any of this as I am asleep as it is all being done. So if there was an issue with the original Desarda repair and he fixed it I would have no way of knowing that was the case. That said, I did some research and there are cases of two weaknesses in the abdominal wall in slightly different locations in some individuals so Dr. …story is certainly possible. The bottom line is that either the Shouldice or Desarda repairs require more expertise than mesh repairs and more expertise than most surgeons have. So there just isn’t a whole lot of choices if you want to go that route. And as you know, if you do have issues with either of those repairs, there is a fall back. With mesh not so much. Good luck. Overall I wish I had not had to go through it twice. The second time it was a lot easier as it was just so much less painful. And so far so good. I
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No, I don’t think that the mesh support is necessary no matter how the patient’s condition is if the tissue repair is performed properly.
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quote drkang:Your last question is not easy to answer. If they follow the principle of closuring the hernia defect, then as you mentioned, it could be helpful to use prosthesis until they get familiar with and confident of their new trial of tissue-based repair. However, I believe there is no point in using prosthesis if the principle is not followed. Tissue repair that does not close the defect directly is in effect the same as existing tissue repair which, in my point of view, is not type-specific repair closing the hernia defect directly.[/FONT][/SIZE]
In addition to becoming familiar with the technique, would the absorbable prosthesis be helpful in cases where tissue quality is questionable, and it is determined that some additional support is necessary in helping the repair (of the defect) heal completely?
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Hi UhOh!,
I completely agree with you. It would be better for now to set aside mesh complication issues and focus on the recurrence.
The majority of doctors believe that the biggest reason for hernia recurrence is the tension. That is why they began to use prosthesis for a so-called tension-free repair. Mesh and autologous aponeurosis (in the case of Desarda) are all prostheses for such objective.
However, I believe that a more important reason for hernia recurrence is that existing surgical methods do not directly close the muscular defect, through which the bowel is coming out. I think, therefore, the best way to prevent recurrence is to precisely close the hernia opening (muscular defect). So, I believe it is necessary to perform the type-specific repairs for direct and indirect hernia respectively. Unfortunately, however, it seems rather difficult to find the doctors who agree with me.
Despite, I still stand by my claim that the most important principle of hernia repair is to close the defect completely. The importance of this principle can be realized in the incisional hernia repair.
Due to the big size of the defect in some cases of incisional hernia, some doctors disregard closing the muscular defect completely because it is technically difficult to do so. So they just cover the open defect with mesh but it results in a very high risk of recurrence. That is why the defect has to be completely closed with its own tissue no matter how hard it is. Mesh is, of course, needed for a large incisional hernia, but it is only plays an auxiliary role to protect the stitched muscular defect from opening again. Thus, for the case of incisional hernia, whether to use mesh or not could be decided upon considering the size of the muscular defect but the procedure of closing the defect is an absolutely necessary step that should not be disregarded.
This principle applies to the inguinal hernia repair as well. Closing the defect is an essential procedure. Also, whether to use or not use prosthesis such as mesh depends on the patient’s condition or the doctor’s preferences. This stage is where mesh complications should be seriously considered. From personal experience, for inguinal hernia repair, I believe there is really no reason to use mesh while risking complications because closing the defect is sufficient.
Therefore, as you have doubted, there may be problems concerning the conclusion on the effectiveness of absorbable mesh made in the study that you have quoted because they probably did not close the hernia defects properly. I believe the results could have been different if the defect was properly closed and then supported by absorbable mesh.
Your last question is not easy to answer. If they follow the principle of closuring the hernia defect, then as you mentioned, it could be helpful to use prosthesis until they get familiar with and confident of their new trial of tissue-based repair. However, I believe there is no point in using prosthesis if the principle is not followed. Tissue repair that does not close the defect directly is in effect the same as existing tissue repair which, in my point of view, is not type-specific repair closing the hernia defect directly.
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quote UhOh!:I think the difference is that the “autologous” prosthetic in Desarda isn’t absorbed, mirroring non-absorbable mesh in that regard, no?
Simple put …Desarda it is ” mesh ” made from your own tissues/ Tissue Patch . My point Desarda like a Mesh doesn’t fix the actual defect…… But give us much better option .
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I think the difference is that the “autologous” prosthetic in Desarda isn’t absorbed, mirroring non-absorbable mesh in that regard, no?
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quote UhOh!:Perhaps this study is familiar to the surgeons on this site already:
The conclusion, obviously, was that fully absorbable mesh was unsuited to direct hernia repair because of the very high recurrence rate. However, my question is this:
Is that true, or is it true that it is not suitable for use with direct hernias as a one-for-one substitution for non-absorbable mesh in conjunction with the Lichtenstein technique?
In other words, is this possibly the ultimate confirmation of [USER=”2019″]drkang[/USER] ‘s assertion that any repair is faulty if it doesn’t fix the actual defect?
The really interesting test would be to see the results if adding the step of sewing back together the torn fascia prior to mesh insertion. It seems logical that you might see different results down the road between a patient who literally had a patch of scar tissue covering a hole vs. a patient who had scar tissue reinforcing the (at the time of surgery) delicate repair of a hole, no?
[USER=”2019″]drkang[/USER] : for a surgeon not completely ready to abandon mesh, or learn an entirely new technique, could current techniques, with minimal modification, be adapted to actually make this type of product work?Very good question …Desarda also doesn’t fix the actual defect… [h=2][/h]
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