-
Could laparoscopy be the reason for the significant rise in chronic pain reports?
A timeline of materials, methods, and chronic pain should show a correlation.
The original Lichtenstein procedure was very well developed, if I’ve been reading the right material, and was the procedure that really jump-started the concept of using mesh materials to repair hernias. From that point it’s been a wild west of onlays, preperitoneal placement, plugs, plugs and patches, sophisticated two layer plus a plug systems (like the Prolene Hernia System), laparoscopic placement via TAPP and finally the most invasive and complete coverage of all of them, TEP.
As with the types of mesh and the terms used to describe its action in the body, like incorporation and ingrowth, instead of inflammation and encapsulation, the terms used to describe laparoscopy have also been developed to give a feeling of comfort and advancement. “Minimally invasive” is used as a proxy term for laparoscopy, even though laparoscopy is actually more invasive, as far as the human body is concerned, actually penetrating the abdominal cavity, risking organ damage, to place an inflammatory material inside. “Scarless” is another, along with the comforting descriptions of no fixation, and “ambulatory” surgery centers, ignoring the dangers of general anesthesia. The TEP procedure is seen as the ultimate lap procedure by many, because it stays away from the bowels, minimizing the chance of bowel damage. But TEP is used to cover as much internal area as possible, from pubic bone to navel, and hip bone to hip bone, with an inflammatory material that is known to shrink, pulling and scarring surrounding structures. But it looks so clean from the outside.
So, a timeline of materials and methods might show that chronic pain correlates actually most closely to the growth of laparoscopy. The mesh materials are just along for the ride. A timeline of techniques and materials, with chronic pain reporting overlaid. Of course, again, just like the use of mesh materials, if this correlation were defined, it would be anathema to today’s surgeon. Today’s surgeons are fully invested in the use of laparoscopy for hernia repair. Most new surgeons have spent their medical school and residency time learning laparoscopy, and the older ones have retrained themselves and given up the old suture-based methods. As several have said, on various Twitter feeds and video presentations, they don’t even know how to do a proper suture repair. They probably also conflate open mesh with lap mesh, so would not see a need to know open mesh repair either.
If it is true that lap correlates with chronic pain and everybody is converting to lap, then, obviously, chronic pain reports will increase even more in the future. The International Guidelines will be recommending the worst methods for chronic pain, except for “low resource settings”. We’ll all be better off traveling to poor countries for hernia repair. That data might show a correlation by itself. Chronic pain in poor countries versus developed countries.
Kavic described the growth of chronic pain reports with the increase in “mesh” usage in his recent review paper, linked below. But he did not distinguish between the types of mesh and the types of repair methods. He describes before “mesh” and after, with after being the time of his writing, but does not separate the types and methods along the way. I’ve attached an excerpt from his review below.
A next step to that review would be to fill in the details. Until somebody does that the good materials and methods will continue to be blended together with the bad. Chronic pain reports will continue to increase. The law firms will continue to sue. Closing ranks to protect flawed methods will not help anyone involved.
So, in summary, maybe it actually isn’t the “mesh”. Maybe it’s the way it’s being used.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5000866/
“Chronic pain, as a complication of pure tissue repair of inguinal hernia, on the other hand, was an unusual occurrence in the decades preceding large-scale use of prosthetic mesh. The incidence of pain following open repair without mesh was usually related to the entrapment of a nerve by suture or the formation of a neuroma following section of a nerve.12,13 Postinguinal herniorrhaphy pain rarely rated more than a sentence or two in major textbooks.
Complications of hernia repair have changed dramatically since the widespread introduction of synthetic mesh for repair of inguinal hernia. Current literature suggests that hernia recurrence following repair with mesh is quite low, varying between 0 and 1.7%.9 Chronic pain, defined as pain persisting beyond the normal tissue healing time of 3 months, however, has increased dramatically.1”
p.s. one thought that gave me a somewhat perverse feeling of hope and joy, is that if this is true, the people in the underdeveloped, low resource countries,will actually have lower rates of chronic pain. Something good coming from being poor.
-
3 Replies
-
Colon, and a fibrosis reaction.
All this from one piece of mesh and believe me I can associate pain symptoms and complications from I believe the compromised integrity of the mesh And how it affected all the above mentioned structures.
Thats why it is so important in my opinion for “pain “ symptoms to be defined to when taking about complications from mesh
I’ve had 3 surgeries in my life, broken bones , torn ligaments, strained muscles, TMJ and the “pain” I experienced form my mesh ordeal was like noting I ever experienced.
it was as abnormal as abnormal can be and I believe this not only had to do with the mesh but how it was implanted-laparoscopically! -
Great post Good intentions. I believe it’s both .
incesse in chronic pain due to the usage of mesh and a more expensive list of pain symptoms and complaints about large pieces of mesh implanted laparoscopically in which more structured can be affected by the mesh. It was quite amazing to learn that my single piece of mesh had attached to my bladder, spermatic cord, illiac vein and illiac artery, meshoma, mesh hard as a rock and pressed into my c -
Informative article! Thank you, GoodIntentions. Author, Kavic, distinguished surgeon, professor, and editor, writes as recently as 2016:
“The evidence is mounting that mesh, which was generally thought—and promoted—to be inert, now appears not to be so.”
Reading the article, a valuable overview of the history of IH methods, one gets the sense that this history is purely of trial and error. Each step along the way, a feeling of advancement yet eventual recognition of new problems. Ladies and gentlemen, that is not the impression I got after talking with two IH surgeons or reading what other surgeons have written.Reread what Kavic, a heavyweight in medical science said: mesh might not be what it was cranked up to be. Further he highlights a serious overlooked problem: long-term post-operative pain, which apparently has been underestimated. When you couple this with the fact that apparently also doctors presume success if patients do not come back with complaints, then the image that surgeons have given me of a highly developed field is hokum. As Kavic suggests, present-day pain complaints may be just the tip of the iceberg. Patients must undergo far more risk than I had previously been led to believe. Fifty years from now present methods might be looked upon as primitive.
Log in to reply.