Continued proliferation of Millikan tension-free plug and patch repair?

[pszotek]

Continued proliferation of Millikan tension-free plug and patch repair?

Completely agree with Dr. Towfigh. I learned the advanced techniques because I had a desire not to use what I had learned in some cases in residency as I saw the failures from those techniques when I went into practice. I asked myself….why would my repair using the same technique be any better than the last 3 attempts by experienced surgeons….that’s when I decided I needed more tools to choose from in my shed and went and learned some of the advanced techniques and the rest is history. I will say that I am learning everyday and everyday I grow as a hernia surgeon. I will also admit that I was a plug and patch guy when I went out into practice and thought it was great and I was a stud….I learned I was not and that my technique could be better so I adapted and pushed the envelope. All the surgeons on here are similar in their innovation and skill set as Dr. Towfigh has pointed out. Same goes for dedicated hernia specialists. Best wishes. Dr. Szotek

[Chaunce123]

Continued proliferation of Millikan tension-free plug and patch repair?

UhOh, maybe consider a road trip to Canada and to Shouldice?

[UhOh!]

Continued proliferation of Millikan tension-free plug and patch repair?

Agree 100%, and that goes well beyond hernias!! Besides asking other doctors and finding communities like this, how would you recommend laypeople go about looking for the most up-to-date specialists in any field? Where/how much they publish? Which institutions they are with?

I’ve been a bit lost looking for the right person to consult here in Chicago. Thought I was onto something when I first read the plug study, but have serious misgivings about a surgeon who named a procedure after himself, cited it as the “gold standard” only to have specialists abandon it within a decade (seemingly without replacing it with something significantly better).

[drtowfigh]

Continued proliferation of Millikan tension-free plug and patch repair?

Depends on the surgeon. The reason why we on this forum urge that you seek consultation from true hernia specialists is because we know that these surgeons are constantly learning and thereby changing what they are doing to improve outcomes among their patients. For example, almost everything I do now for hernia repair I learned after residency training. And I trained at one of the top universities for surgery. It’s just following the science and the times.

[UhOh!]

Continued proliferation of Millikan tension-free plug and patch repair?

[quote]Allow me to provide a different view]

And therein lies the greatest dilemma in picking a surgeon (any type of surgeon): By the time they are experienced enough for you to trust their skills and judgement, you risk the protocols and methods they were taught being outdated :ohmy: !

[drtowfigh]

Continued proliferation of Millikan tension-free plug and patch repair?

Allow me to provide a different view:

Most hernia specialists no longer implant the plug and patch. Many many general surgeons still use it. It remains among the most sold mesh types in the US. It’s hard for surgeons to get rid of old habits.

[UhOh!]

Continued proliferation of Millikan tension-free plug and patch repair?

quote :

I would echo Dr.Szotek’s comments. I remove at least one plug a month for pain. I highly recommend finding an experienced laparoscopic surgeon to fix your hernia.

Thanks. Am I being shortsighted in having a bias (based on what little I’ve read so far) towards an open repair because of its single incision and avoidance of general anesthesia?

[sngoldstein]

Continued proliferation of Millikan tension-free plug and patch repair?

I would echo Dr.Szotek’s comments. I remove at least one plug a month for pain. I highly recommend finding an experienced laparoscopic surgeon to fix your hernia.

[pszotek]

Continued proliferation of Millikan tension-free plug and patch repair?

Anytime. Best of luck with your search and ultimate decision. Paul

[UhOh!]

Continued proliferation of Millikan tension-free plug and patch repair?

Thanks for the very detailed response, it’s very helpful!

[pszotek]

Continued proliferation of Millikan tension-free plug and patch repair?

The plug and patch repair has gone out of favor because of chronic pain and associated erosions of the plug. I personally have dealt with it eroding into the colon on a left sided repair. Many others have described similar complications. In my practice I have found less pain and equivalent long term results with a combo suture repair of the floor of the canal and onlay with Pro-Grip self griping mesh for open repairs. However one of the biggest reasons that it has lost some steam is that many of us have switched to Lap repairs due to the decreased pain, decreased time to return to work, and the complete coverage of the Myopectineal Orifice with the lap repair. I initially used the plug and patch and felt like I was getting good results but the chronic groin pain and discomfort that my patients complained about was unacceptable in my opinion. That being said many surgeons get excellent results with many different techniques and sometimes the best technique is the one that your surgeon you choose is best at.

Any open repair can be done under local/IV anesthesia if you desire in most cases.

I would say in my experience that the recovery time and speed of operation are no different than with the classic Lichtenstein repair or a floor repair plus Lichtenstein. In fact, using the self-gripping mesh requires less fixation, minimizes pain, has very low recurrence, and is probably one of the fastest repairs that can be done.

If you are looking for low pain, least risk for chronic groin pain, low recurrence rate, and fastest return to work time then the Lap repair would be the most likely to accomplish all those things for you at the cost of cosmesis to some degree. With a Lap repair although small incisions, they will be visible to some degree when you have your shirt off. Most open repairs are hidden below the belt line.

That being said there are various permutations that make a Lap versus open repair make sense one way or the other. If there is any suggestion for weakness of the floor or possible hernia on the contralateral side then I would get an ultrasound with valsalva to confirm/rule out before suggesting one repair over the other. If clearly a contralateral hernia on exam then would lean toward Lap repair because you can fix both through the same incisions.

As far as watchful waiting that depends on the exam and on your size of hernia. If your hernia is reducible then the risk is as low as 2% per year for you having an adverse event/requiring repair. In other words watchful waiting is definitely something that can be done safely. On the other hand the natural progression is for these hernias to get worse over time and depending on your age and activity it is best to get them fixed electively when convenient. If on exam it is incarcerated/not reducible, causing significant pain, or contains intestines on imaging then I would proceed to fixing sooner than later.

Hope this helps a bit and feel free to be in touch and we can discuss on the phone if you like. Thanks for posting and doing such an excellent job at researching the different techniques and options to inform yourself so well. You will ultimately be glad and comfortable that you made the right choice of repair.

Dr. Szotek

317-660-5362
[email protected]

[UhOh!]

Continued proliferation of Millikan tension-free plug and patch repair?

Thanks for the info, and the link to your clinic (as Indy certainly is in the neighborhood!). Has it gone out of favor because it turned out to perform poorly long term, or because other methods proved better?

The purported short duration of the operation, use of local anesthesia/IV sedation and quick recovery time sounded attractive but then again, so did the Theranos blood diagnostic technology…

Above all else, I obviously want to see a surgeon who follows the latest developments, knows which methods have stood the test of time and what approaches (including watch/wait) are best supported by today’s evidence. Thanks again, Dr. Szotek.

[pszotek]

Continued proliferation of Millikan tension-free plug and patch repair?

Plug and patch repair has gone out of favor. I think you would be hard pressed to find a surgeon that has had to deal with the potential complications using this technique. I do not know of any surgeon that travels anywhere to learn plug and patch anymore. I would say there is no support for this repair in general. Thanks. Dr. Szotek

Happy to discuss your options in Indianapolis.
http://www.indyhernia.com
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