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Alternatives to mesh
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Alternatives to mesh
John,
New Zealand, a place I’ve wanted to visit; yet, it puts you in limited situations much like people who live in Hawaii and get “land-locked.”
From what we know, if Australia does not have an option with a pure tissue repair such as the Desarda, or possibly Shouldice with less tension, then your closes option ( as you have surmised) is Burns in Newport Beach, CA for the Desarda technique. I have known of people flying to India to Dr. Desarda’s office and have the surgery. This would be your next option after Burns.
If you are looking at the least possible tension it seems from my studies of Biomedical Physiology and Anatomy plus many conversations with surgeons, the Desarda technique would be the option you want with no foreign bodies and little anesthesia. Keep in mind, general anesthesia will effect the mitochondria of the brain. Find a surgeon who will use a “twilight” option; many will. Dr. Kevin Peterson in Las Vegas is a “no-mesh” leader, yet, he prefers a general anesthesia. Good guy, but I am adamant about two things: No mesh and little anesthesia.
As far as the “on your own” factor, this is where you must make sure you get both sides done correctly the first time. You could get an MRI of both sides and send to several surgeons. Then discuss with them their take. If they do not treat you with dignity or professionally then find someone else. In the end, I have thought it would be best to live with the hernia than to live with errors or reconstruction of my inguinal floor to the point of sending my health toward a decline.
Best regards John,
Connier
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Alternatives to mesh
Hi Connier
Thanks for your advice.
Unfortunately the bit – “You should be in proximity to one of these” is a bit off target.
I live in New Zealand, east coast USA is 12/14 hours flight one way, Asia ditto, India 16 or more, East Canada 16 and Europe 25 at least.
Given the relative NZD v USD the cost of flying & accomodation is an issue, but much worse is the fact I’d be on my own afterwards. I have checked this – no NZ surgeon will want to know about an overseas operation that has gone wrong & neither would my insurance company.
Hard calls either way. -
Alternatives to mesh
John,
You should do more research to prevent the limitations in your thinking. There are two other surgeons who perform the Desarda, one in southern CA (Burns), one in NM (Parvez). You have Dr. Myers in Philly who does the NFL players who can do it without mesh and is one of the best, hence, why the NFL uses him (he is expensive). And, you have Dr. Grischkan in Ohio who developed the Modified Shouldice and is probably the most experienced surgeon alive for hernias today (look at his numbers). He uses a Gortex, yet, he says he can do it without. Call there offices and ask questions. You should be in proximity to one of these, and how much is your health worth?
Most of your surgeons, especially in the U.S., will use mesh because they are convinced it reduces recovery time, and convinced it lessens re-occurrence. And, the training for these other techniques is limited if any. The first may be true, especially for athletes, however, the second on re-occurrence is debatable. When you place a foreign body in your tissue (mesh), no one can tell you how your physiology will respond, nor in what time duration it may occur, or if it will be cumulative with other heavy metals and chemicals you expose yourself. Everyone has a unique genome and biochemistry. To get a surgery without any foreign body left to infiltrate your tissue is with the Desarda, and the technique in Italy (Guarnieri) I think is using your own tissue as well because it focuses on your physiology. The Shouldice in Canada has the numbers and many surgeons from the U.S. travel to Canada to have their own surgery. I had one surgeon to tell me this is where they would go personally, and the hospital told me many have done the same.
Many say they know someone with a bi-lateral mesh repair and is doing fine. But, what is fine, how do you know the short or long term effects internally? I’m sure many will trust the mainstream even though they can get a tissue repair. From my observation and conversations with a manifold of people, mesh has affected people in major indices and in minor ones though few surgeons will support this statement.
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Alternatives to mesh
Hi Connier
Thanks for your comments. I have extensively researched Desarda & Shouldice techniques, less so the Guarneri. The difficulty for me is the travel distance – to have any of those techniques done by experienced surgeons mean somewhere around 18 to 25 hours flying time each way. And I’m on my own if it goes wrong once back home. Not attractive, but of course compared to mesh issues (if they go wrong) a small price to pay.
Still in the watchful waiting & research mode, hoping someone will invent the perfect operation :unsure: -
Alternatives to mesh
John,
If you are looking for a pure tissue repair from my research over the last 3.5 years is the Desarda and the Shouldice. Guarnieri in Italy is another tension-free repair that can be performed without mesh. The Desarda technique uses your own tissue and the sutures are dis-solvable so you are left with “NO” foreign body. The Shouldice uses a SS316 alloy. Test yourself for Nickle as there will be four layers with these sutures permanently inside your tissue. The Shouldice Hospital has impressive numbers over time. The Desarda is new to the U.S. and Dr. Tomas has increased his number of repairs. As far as accuracy of re-occurrence, who would know if the stats are accurate because many patients do not return to the performing physician, and the physicians in most cases do not offer a free surgery if it re-occurs. The Shouldice Hospital is very secure and confident and you can ask them about what they would do if it reoccurred.
Do your research and do not be discouraged from asking educated questions. This is your body and your life.
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Alternatives to mesh
Hi DrBachman
Many thanks of your information & ideas.
I haven’t had too many foreign body implants, however after a small operation to remove a BCC my body tried to reject the internal stitches. Also, over the past two decades I have worked hard to rid myself of toxins such mercury fillings, lead (from paint) & other toxins from my youth. I certainly feel fitter and better for that detoxifying processes. Implanting polypropylene seems a retrograde step in that regard. Like one of the other comments, I do tend to feel anything going on in my body, I would hate to feel a wad of scare tissue & mesh in my core (Pilates) muscles.
Your comments about biosynthetic mesh were really interesting and informative. The Tigr people have competed a three year study on using Tigr mesh for inguinal hernias (open technique), which seems to work well on indirect hernias, less well on direct ones. They have just started another three year study on Tigr mesh (laprascopic technique), but as its just started its way to soon to tell anything. However in theory biosynthetic mesh sounds great – mesh to allow the body to heal itself, gradually dissolve away and all gone after three years.
Regarding your other suggestion, I have been using a hernia support for 18 months now. It was great to start with but its less effective now. I am resigned to some form of surgery, the missing part of the equation is what type. -
Alternatives to mesh
John – Sorry you have to have surgery, but that is the only way to fix the problem, In addition the the excellent feedback you have already received, all of the non-mesh repairs use permanent sutures made of the same or similar material that mesh is made from. Sounds like you are primarily interested in a permanent cure at a single operation for your problem. Laparoscopic repair of both hernias at the same time with mesh (by someone with enough training and experience which is difficult, if not impossible to sort out for patients) has the highest chance of achieving your goals with the lowest chance of chronic pain. Whatever lap technique the surgeon does best (TAPP or TEP) should be used. Hope this helps! Dr. Earle
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Alternatives to mesh
John,
I’d be interested to hear a little more detail about your experience with foreign implants and the specific symptoms you had. There is definitely a huge variation in the body’s response to foreign bodies. The immune and inflammatory pathways clearly have genetic variation at a level which we can’t yet detect. We know that certain populations of patients (for example people with red hair) have a higher rate of aggressive FB reactions than others, but we don’t understand all the subtleties (yet).
Biologic meshes and resorbable synthetic meshes (such as phasix and tigr) do eventually go away, but it is via the same biologic pathway as the foreign body response to a permanent mesh. So, if you tend to have a brisk or aggressive inflammatory response, it may still occur with these mesh types (it just will end, eventually). There are some surgeons who have published results on inguinal repairs with biologic mesh, so it can be done with ok short-term outcomes. But none of us know how long a hernia defect needs to be covered by mesh to prevent a recurrence. Weeks? Months? Years? Forever? We really don’t know. The published follow-up for biologic mesh inguinal hernia repairs has been very short, only a year or two. It’s unclear why no-one has published long term results, as it has been almost 10 years since the first papers came out.
There was a recent review of TiMesh in the hernia literature. Much of the research is in animal models. There are only a few studies looking at inguinal repair in humans. They rated the data as moderately good. Here were their conclusions:
1. Titanized polypropylene meshes can be used in inguinal hernia repair in Lichtenstein technique instead of heavy-weight pure
polypropylene meshes2. In the TAPP technique for inguinal hernia repair, the ultra-light titanized polypropylene mesh can be preferred to heavy-weight
meshes in defect sizes less than or equal to 3 cm3. Titanized polypropylene meshes can be used for laparoscopic (TAPP) and endoscopic (TEP) repair for unilateral and bilateral inguinal hernias
So, to interpret these recommendations, in the first two studies lightweight TiMesh was put head to head with heavyweight mesh. That isn’t a fair comparison, as many of use would no longer use heavyweight mesh in the groin, because we know those patients are more symptomatic post-operatively. The last statement just says TiMesh can be used for hernia repair. There really isn’t convincing data in humans that TiMesh has significant decrease in post-op symptoms compared to uncoated light/medium weight mesh.
What we do know without doubt is that the greater the density of material in your mesh, the more chronic inflammatory cells will be present trying to attack the mesh, increasing your risk of pain or sensation. Lightweight mesh definitely decreases the local inflammation; nothing totally obliterates it, but most patients aren’t aware of that low-level of response.
You are in a tough bind. I spent a lot of time earlier in my career removing mesh from patients with chronic pain. It was usually due to a heavyweight material or a plug, and as more surgeons have transitioned to lighter-weight materials, the number of patients seeking mesh removal seems to have fallen, in my experience. The number of patients I saw who truly seemed to react to having any foreign material at all in their body were very few. But they were miserable.
If your hernias are reducible and you haven’t had complications from them, you could always try a mechanical support such as a truss to help support your weak areas during exercise and activity. But I would agree with Dr. Towfigh that a lightweight synthetic mesh is probably your best bet to allow you unlimited activity long-term. One option might be having one side repaired and seeing how it goes before having the second side fixed. That means undergoing two procedures, but if you are very concerned about chronic pain, it is a viable option.
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Alternatives to mesh
It’s been really interesting seeing the various replies to my post and I am grateful to people making the time to respond.
I have four further queries;
1. I was especially interested in Dr Towfigh writing “As a 60-year old, and an athlete, I would not recommend a tissue repair unless you have true contraindications to mesh implantation.”
Can you please elaborate on your reasons for giving this answer?2. Also I was very keen on the Desarda technique. However Dr Towfigh writes elsewhere on the forum that;
“The Desarda technique is a revival of an old technique that was abandoned in the 1950’s and 1960’s because the recurrence rate was too high.”
Could you please elaborate on this statement?3. Another option I have been investigating is the use of biosynthetic mesh such as Phasic, and Tigr. Reportedly these act as standard mesh for some months, while stimulating the body to rebuild natural tissue, before disclosing away completely within 18 months to three years? Has Dr Towfigh had any experience with these meshes?
4. Another mesh option is the TiMesh, which as I understand it is standard polypropylene coated with titanium, which apparently causes less of a foreign body reaction. Has Dr Towfigh had any experience with this mesh? And if so what doe she think off it?
As always, answers and posts are very interesting and much appreciated.
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Alternatives to mesh
As usual, Dr. Towfigh is right on the money. I would like to add that hernia repair is not a minor surgery. It is a reconstruction of the abdominal wall. The tissue you were born with was not strong enough and that is why you have a hernia. Hence, something strong like mesh is needed for an adequate repair. Laparoscopic mesh repair by an expert surgeon has a very low risk of problems.
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Alternatives to mesh
John, I really liked your post. I have been wondering all of the same things. I am a thin, active female and I notice the most subtle changes in my body. I have a questionable hernia at this time. MRI was negative and it was the sole reason for the MRI so radiologist was looking for a hernia. US was positive after bearing down. I felt like the bearing down was just like giving birth as they kept having me bear down harder. I think I created a hernia that day…LOL So I only want mesh in my body if I absolutely need it. I have consulted with excellent surgeons, and they all say I should have surgery. I really wish there were hernia specialists that would try other methods. Seems like surgery is the only solution. I don’t fully understand why. After a lot of reading in general about healing…most experts state that the body has a way of healing itself. Wish this were true for hernias. I would do the work as I think it would improve one’s health anyways. If you know of any hernia specialists who have alternatives to surgery I would like to consult with them prior to any surgery….
Feeling overwhelmed and scared….Linda -
Alternatives to mesh
As usual brilliant answer by Dr.Towfigh.In this part of the world(India) pain incidences (early and chronic) of 20 percent and 3 percent appear to be higher than what we actually see.I have not published on this but I think the incidences of such pain are 10 percent and 1 percent approximately,much lower than western world.My take on this is, our patient are far too busy in making a living they are kind of immune to such pain,it being highly subjective feeling!!
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Alternatives to mesh
Fantastic post!
I’m going to give my opinion here, sprinkled with some evidence based data from accepted literature. I urge the surgeons on this Board to give their take, too, as the answers to this post are very subjective.
Hernia surgery and the mesh question has not yet become a science. We just don’t know enough to be able to match the perfect technique or mesh implant to the perfect patient. There is an art to it. We can extrapolate from our experience and from research done on patient populations that are typically heterogeneous in some respects and homogeneous (ie, controlled) in other respects.
First, the “30% chronic pain” data is an exaggeration and should be understood in context. There is a 20% chronic pain incidence after open inguinal hernia repair with mesh for all-comers. There are papers that have shown lower numbers and other studies that have shown higher numbers. Most surgeons accept this 20% number. “Chronic pain” is defined as any pain or sensation noted after 3 months after surgery. This includes tugging, pulling, twinges, catching, fleeting pains. Almost all of these pains are rated to be low level, non-debilitating, and short-lived (ie, many can last a few seconds and then they are gone when they happen). The incidence decreases when the data is followed to 12 months, and so on. There is a 3% risk of chronic debilitating pain. This is the really important number. This is pain that seriously affects the patient’s life, they cannot perform normal daily activities, cannot work, and/or the pain level is greater than a 5 or 6 out of 10.
Also note that the numbers quotes are for open inguinal hernia repair with normal weight mesh. Patients undergoing the same operation with lighter weight mesh have been shown to have lower rate of chronic pain in many studies, though some studies show no difference.
Depending on the surgeon, laparoscopic surgery is also expected to result in a significantly lower risk of chronic pain. The outcomes from this technique of operation, which includes implantation of mesh, is highly dependent on the expertise of the surgeon, moreso than with open procedures. One study showed a significant difference in recurrence rate and complications after 250 operations. Many of us believe at least 500 operations must be performed before the learning curve is surpassed. It is considered one of the main reasons why laparoscopy for hernia repairs has not become more common than open surgery (unlike gallbladder surgery).
With regard to your comments about specific populations at most risk for chronic mesh-related pain: they are young thin females. Mesh causes inflammation and I think perhaps if you don’t have enough far to buffer the inflammation, perhaps there is more perceived pain. Also, thinner patients may have more of a foreign body sensation, which can also be perceived as pain with the normal weight mesh, and so lighter weight mesh may be more appropriate for their habitus. Once again, it is less of an issue for laparoscopy, as the mesh is placed deeper, behind the muscle, but we still take these mesh weight factors into consideration.
With regard to tissue repair, it is no longer considered the “gold standard” for hernia repair, as mesh repair has a significantly lower recurrence rate. As a result, most modern surgeons do not have a large experience performing these. Those of us who employ the tissue repair into our practice may use it sparingly based on the needs of a patient. For example, I use the Bassini or Shouldice repair for inguinal hernias in some women, in those of any gender who do not wish a mesh repair, and in those with contraindications to mesh repair, such as infection or with specific reactions. The Shouldice clinic in Toronto is most famous for their tissue repair experience and have the lowest published rates of recurrence and complications. No one has been able to reproduce their data. In countries such as China, where 80-90% of hernias do not get mesh, there must be a lot of good experience with tissue repair. A rate of 30% recurrence is too high for a tissue repair. If you choose to have a tissue repair, I would seek out a surgeon who can perform this with results around 10-15% at the most, which is what the data used to show before mesh was introduced.
In conclusion, you need a consultation from a surgeon who can help you determine a) if you even need a hernia repair, b) which repair will best meet your needs with the best outcomes. As a 60-year old, and an athlete, I would not recommend a tissue repair unless you have true contraindications to mesh implantation. If you are thin, definitely a lightweight mesh is a good option. If you’re fit and healthy, laparoscopy is another good option. The type of hernia and size also factor in place (direct vs indirect).
Hope this helps!
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