Considering repair, and options

[William Bryant]

Just recently discovered that Greg Sandler, the UK Bassini and mesh surgeon in Oxford, now mainly does open mesh after having done keyhole as he finds better results. Which is the same as the British Hernia Centre who dropped it too in favour of open.

[Watchful]

I still like tissue repair more, but only in cases where it’s a good fit for the patient. Unfortunately, it’s not really possible to tell for sure before surgery. You don’t want to go to a tissue repair surgeon who will force a tissue repair on you even when it’s not a good fit for your particular situation.

Like I said many times before, my recommendation is to go to a surgeon who can do both tissue repair and mesh very well, such as Conze and Lorenz, and let them decide based on what they see during surgery.

[David M]

Chuck, No name is obviously a very intelligent and we’ll researched poster, but I could see someone new dropping in and reading your post and getting the wrong idea about how dangerous open mesh is. Recently you were saying that you had questioned 70-100 people who had had open mesh with no major problems. So, I was trying to clarify some perspective on where these friends/acquaintances with the problems were from. I think it’s important to not exaggerate the problems so we/they can actually decide which is best. If a person is set on mesh, have you turned 180 and are now more in favor of lap?

[Good intentions]

No Name, I wrote another novella. Hard to stop sometimes. The method described in that Northshore paper is really just a typical Lichtenstein and/or plug and patch method. Open the canal, move things around, place the mesh, fixate it, close and hope.

Dr. Reinhorn’s TREPP method does not enter the inguinal canal at all. It’s like laparoscopic surgery mesh placement without general anesthesia or close exposure to bowel. As far as inguinal hernia repairs go it might be the least invasive.

[Good intentions]

I wrote a bunch of stuff below then realised that it didn’t really address your question. I think that the method described is completely different from the TREPP method of Dr. Reinhorn. TREPP comes in from the side and creates a space behind the inguinal canal in to which a piece of mesh with is placed. The inguinal canal and spermatic cord are not touched. In the paper you linked the method describes that the inguinal canal is opened and the cord manipulated just like a Lichtenstein repair.

Here’s some of what I got from the paper –

I’m not as clear on the different methods as some of the other forum members, but it looks to me like the Northshore people have created a sort of combined Lichtenstein plus plug repair. One disturbing thing about their explanation is that they conflate the use of a mesh with an absorbable component with the new method of placement and fixation. They introduce the Ultrapro as the primary factor and the new slitting and fixation as secondary. They didn’t clearly explain why they needed to do things differently. The fact they decided that they needed something new suggests that they have been having problems with their own patients. Northshore is one of the typical hernia mills. And the study is tiny, just 24 patients.

Overall it really looks like somebody doodled up a new method on a napkin and started using it on patients. They’re not happy with the results of whatever they have been using, they came up with something new, tried it on 24 patients, and now are publishing a paper about it. Pretty amazing when you sit and try to absorb it. Any surgeon can do whatever they want with a piece of mesh as long as they get the patient to take liability for problems. Same problematic material, just different ways to get it in there.

https://www.northshore.org/gi-and-general-surgery/general-surgery-programs/comprehensive-hernia-surgery/

From the paper –

“Methods
Upon Institutional Review Board approval, all patients who had undergone open repair of an indirect inguinal hernia using the Ultrapro mesh and the “double slit” technique between June 1, 2007 and November 1, 2012 at a single institution by one surgeon were contacted. Written consent was obtained for retrospective analysis of operative data as well as an additional office visit for prospective collection of long term follow up data. Inclusion criteria included males who were at least 18 years of age and at least 6 months out from the operation. Chart review was conducted to obtain retrospective perioperative and short term follow-up data. Long term outcome data was obtained prospectively at the additional office visit by having the patient complete a Carolina Comfort Scale and be examined by the
operating surgeon. This data was then analyzed with particular attention to chronic pain and incidence of recurrence.

…

At follow up, 18 (79.3%) reported no groin pain (0/10) while 4 (16.6%) had mild groin pain (1/10), and one had (4.1%) moderate groin pain (4/10), none of the patients experienced testicular pain (Table 2). Carolinas Comfort Scale was given to all patients and revealed very minimal pain, mesh sensation and movement limitations (Table 3).
…”

https://www.northshore.org/gi-and-general-surgery/general-surgery-programs/comprehensive-hernia-surgery/

[David M]

Very interesting that No Name is Uhoh! It only rang a bell after Good Intention’s post that he was the poster who had the great questions for Dr Kang on what was maybe the best thread ever.

https://herniatalk.com/forums/topic/kang-repair-question/#post-17479

Kang Repair question

[Watchful]

Chuck – There is no answer. Both types of approaches are problematic, and the variations between different patients and different surgeons are likely more significant to the outcomes.

I don’t know yet what I’ll do about my chronic pain and discomfort. Obviously, there is no “mesh removal” option in tissue repair… I haven’t consulted with anyone yet. I’m guessing that a neurectomy would be the only option, and it’s not clear to what degree it will help, and what issues such a surgery could introduce. I’m still waiting with the hope that things get better with more time.

[No Name]

Good intentions, thanks for posting that link, as the new account was merely a matter of convenience.

I’m aware that any mesh will involve tissue ingrowth, which isn’t of concern so much as some of the other things I’ve read about lap mesh and its ability to fold, migrate, entangle nerves, etc. These open methods that place mesh behind the internal ring are intriguing, though, as they seem to have been developed (at least to some degree) with long-term comfort in mind, as opposed to previous methods meant only to avoid recurrence.

My opinions on mesh, in aggregate, have evolved some, but now the question is about the right type of reinforcement, put in the right place.

Can you tell, how similar is the method in link I posted (about the UltraPro) to TREPP? I realize that Dr. Reinhorn is a participant here, so perhaps he has thoughts, too.

[Good intentions]

I have to admire Chuck’s ability to draw people in to responding, like I’m doing now. And his persistence. It really is a shame that he’s wasting these qualities for this mission that he’s on, to create chaos and confusion on the forum. One giant “acting out”, to use the psych term.

Here is No Name/ UhOh!’s old profile page with his backstory.

https://herniatalk.com/members/uhoh/

I think that any mesh method that has mesh inside the internal ring next to the spermatic cord would be considered as a plug method and has the potential for problems. If you read the papers about TREPP, the main point is that the nerves and structures inside and around the inguinal canal are not disrupted during mesh placement. TREPP is about how to place the mesh with the least damage possible.

Reinhorn’s work is also interesting because he uses a type of mesh that is not common for inguinal hernia repair. He has not described why he chose that mesh over the standard open-pore uncoated mesh. In the end though there is still mesh sitting on top of structures that tend to get bound to the mesh as the body tries to encapsulate the fibers. It’s probably just as hard to remove as lap placed mesh.

[Watchful]

The same can and does happen with tissue repair as well. This kind of bad outcome isn’t limited to mesh. It’s rare in both types of repair, but it happens.

[David M]

I have to ask whether you actually know these people, or are they people that you read about and possibly shared info with on a website? I can’t really see how an open lichtenstein mesh is likely to merge with the colon. The testicle loss could happen, I guess, but I think it’s rare. And someone laying in bed for ten years would also have to have been very rare. The odds of actually knowing all of these people by happenstance in one’s regular life seems about as likely as winning the lottery, or more rare.

[No Name]

1. Don’t want general anesthesia.
2. Issues with lap mesh repairs seem hardest to correct.
3. Sounds like lap mesh also has higher potential to become entangled with things it shouldn’t.
4. I used to be anti-mesh but am also not a huge fan of all the cutting and sewing (and attachment of things not meant to be attached to each other) needed for non-mesh, plus the possibility that tissue quality is an issue.

That said, I’m also realizing that not all open mesh are the same – neither the technique nor mesh used – so I’m curious whether one version has better results than another. The statement that “all of my complications are open mesh” has many possible interpretations/reasons for being true. For example, one surgeon I met with does almost exclusively lap, and suggested that he only does open in situations where lap isn’t feasible meaning he does fewer and he’s doing them in already suboptimal circumstances. It’s also why I’d go to a surgeon that still does open very regularly.