Another fascinating article, focused on psychology rather than physical results.

[Good intentions]

And, of course, as often happens, the remedy for the chronic pain is not discussed. The patients that have chronic pain from mesh implantation have very few avenues available to remedy the pain. The possible solutions are dangerous and expensive and often fail. When a person considers the full risk/reward situation for the patient alone, pure tissue repair is the obvious first choice. The push for mesh implantation over pure tissue repair is driven by the industry, not the improved welfare of the typical patient. The typical patient has more risk of permanent chronic pain today than they did twenty years ago. And that is where the lawsuits are coming from.

Promoting mesh at the various meetings will not change the reality of the situation. The chronic pain problem comes along with the mesh. It will be here as long as mesh is here.

• This reply was modified 2 years, 4 months ago by  Good intentions.

[Good intentions]

Here is a study comparing TEP to Lichtenstein. TEP ends up at about 10% after 5 years, compared to about 19% for Lichtenstein. So a case can be made for TEP over Lichtenstein but the overall rate of chronic pain due to mesh cannot be downplayed.

https://academic.oup.com/bjs/article/97/4/600/6150225?login=true

“The total incidence of chronic pain in the TEP and the Lichtenstein groups respectively was 11·0 per cent (60 of 546) versus 21·7 per cent (125 of 577) at 1 year, 11·0 per cent (60 of 545) versus 24·8 per cent (144 of 581) at 2 years, 9·9 per cent (55 of 554) versus 20·2 per cent (119 of 589) at 3 years and 9·4 per cent (58 of 616) versus 18·8 per cent (124 of 659) at 5 years (Fig. 2). The frequency of any degree of chronic pain up to 5 years after operation was therefore twice as high in the Lichtenstein group as in the TEP group.”

[Good intentions]

Dr. Towfigh you are presenting unverifiable numbers from a group that most likely does not represent reality. At least tell people the sample size. Is this 20 patients or 200? You must realize that the numbers have little value except to show that the quality of available data is poor.

“It’s not a database that is mandatory and most surgeons performing hernia repair are not members.

1) the surgeons entering this data from their practice may not represent the whole of US surgeons

2) the majority of patients whose data is entered by the surgeon do not enter their followup long term data re how they’re doing.”

Here is a more proper, professionally done study. It is focused on open repair, but you can see where the numbers came from.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5896652/

Excerpt –

“Postoperative chronic pain is a special entity within the domain of chronic pain. Chronic postoperative pain occurs following numerous kinds of surgery, from amputations to thoracotomies to inguinal hernia surgery. The chronic pain after inguinal hernia repair has been extensively studied; however, the management is still difficult. Around the globe, millions of groin hernia repairs are conducted annually1 and 8%–16% of these patients experience chronic pain to a degree that impairs their daily lives 6 months postoperatively.2,3 A few percent of these patients experience disabling pain, and due to the large number of groin hernia repairs, the number of patients with disabling pain and discomfort is an important clinical problem.4”

[drtowfigh]

The ACHQC is the only national database in the US that tracks hernia patients and their outcomes. It’s not a database that is mandatory and most surgeons performing hernia repair are not members. For those of us who are, it’s the only tool we have to look at hernia and outcomes trends, understanding that
1) the surgeons entering this data from their practice may not represent the whole of US surgeons
2) the majority of patients whose data is entered by the surgeon do not enter their followup long term data re how they’re doing.

So, though in the perfect world we would have crisp data for everyone to munch on about hernia repair and their outcomes, in the US we don’t.

That said, the 15% number describes the % of patients that have ANY symptoms at 3 months postoperatively. This number significantly reduces to single digits at 1 year postoperatively. This number also does not reflect symptoms that affect quality of life. That number is also in the single digits. Finally, that % is reflective of inguinal hernias only. It is much less for ventral hernias.

Meanwhile, more surgeons in the US are offering minimally invasive hernia repairs nowadays. Almost all studies show the chronic pain rate after laparoscopic and robotic inguinal hernia repair is significantly lower than the open repair.

[MarkT]

I doubt they are unaware of the status quo. Part of the purpose behind publishing research is to advocate for progress or change. This type of instrument and paper were no doubt developed (at least in part) because the status quo is to neglect this facet of patient care.

It is true that this is not *all* about the patients though…there is benefit for the surgeons too, in being able to better manage patient expectations. That type of dual-benefit is necessary to demonstrate if there is any hope for buy-in by stakeholders. If the benefit is 100% for patients, and otherwise just represents an additional cost or burden on the system, then it will go nowhere.

I’m equally pessimistic as to how responsive the overall healthcare system will be. Sadly, there probably needs to be a ‘bottom line’ benefit for something like this to gain traction. I know an orthopaedic surgeon who started using his own survey instrument to better understand his patients and track outcomes, but that was entirely his own initiative, due to his own motivation.

Getting back to the hernia community, I find it *appalling* that the problems of mesh remain what they are. I’m also dismayed to see that tissue repair is the exception, rather than the norm, in terms of training and practise, given these problems. More than anything though, I find it highly unacceptable that much better data is not kept and shared that would better inform (and hold accountable) everyone involved…from medical device suppliers to surgeons to patients. How is it that we don’t have a much more clear idea of who those ‘15%’ are in terms of patient characteristics, the nature of their problems, how those problems have been addressed, their long-term outcomes, who operated on them (specialist vs. generalist), etc? I know one complicating variable is privacy vs. info sharing…but that can’t be an insurmountable hurdle.

[Good intentions]

Thanks for the comment Mark T. My main point was to show the great distance between how things are now and what the authors are promoting. If they are unaware of the state of things today then they are writing about things they don’t understand. If they do know how things are then they are just writing fluff about an ideal world that will never exist. Or, as I implied, they are suggesting a tool to weed out the problem patients.

90+% of the people who visit a surgeon today with an obvious hernia will be assured of a fine result and scheduled for surgery as soon as possible with no questions asked or answered.

Again, I hate to be so cynical. I have been posting on the site for quite a while and I have not had a solid response from any surgeon showing that progress is being made to lower the 15% number. Work continues, and the people suffering with mesh problems are shunted aside. Well-meaning surgeons speak up and supply studies showing that the problem is real, but nothing is done, and vague comments are written about other possible causes. Meanwhile, every day, 15% of the people getting a hernia repaired will probably suffer pain. More will suffer discomfort, people who hear the news will lose trust in the medical profession, and the mesh-makers will collect their profits.

The failure of the hernia repair field is actually a big part of the loss of trust in the medical profession, since hernia repair is one of the most common surgeries performed today. That seems hyperbolic but anyone who is told that they need surgery will probably get on the internet and find stories about mesh.

The authors of the article are way beyond the very simple steps of just removing the bad from surgery today. The bad is allowed to coexist with the good. That just makes everything bad.

[MarkT]

I would say it is focusing on psychology *in addition to* physical results.

This is advocating for brief psychological engagement with individual patients, ideally by the actual surgeon (“Although the POPS could be delegated to another member of the surgeon’s team, we strongly suggest the surgeon engage the patient”).

It is not a comprehensive psyc eval and many surgeons already do something similar…this proposes a more consistent process and instrument rather than the ad hoc method that currently exists (if it does at all).

This might *seem* naive or asking a lot…but it shouldn’t be. There should be no reason that a surgeon (or at least a member of the surgical team) can’t spend 15 minutes at some point with EVERY patient before they operate on them (barring emergency surgery, of course) to address their beliefs, concerns, understanding, and expectations in a more streamlined, consistent manner. A surgeon can only perform so many procedures in a day…how onerous could such a practise possibly be?

I don’t interpret this as a ‘lowering expectations’ exercise at all. Understanding and addressing a patient’s prior beliefs, concerns, and expectations, etc. and paying attention to the psychological component of a condition, surgery, and recovery, is a good thing. We should get behind this type of initiative, IMHO.