Dr Towfigh says over and over and over that lap tep mesh
05/14/2022 at 9:14 am #31572ChuckParticipant
is the best hernia repair when considering recurrance…and chronic pain long term and short term….i have seen this statement repeated over and over and over by her and others…on other sites. But i cant find any studies that show this to be the case. In fact most studies appear to show that shoudice and desarda are comparable in terms of these factors without the longterm risks of mesh…not only does Dr Towfigh say lao is the best method but she says there is overwhelming evidence ..yet i can find nothing…GJ prompts her for info and she doesnt respond…
05/15/2022 at 7:41 pm #31584drtowfighKeymaster
Here is a nice study that reviews all high quality studies that actually look at laparoscopic vs open inguinal hernia repairs. You can see that laparoscopic repair is either statistically superior or tends to be better than open repair in most categories.
When we surgeons talk about data, we provide you with the overview of large, higher quality data. If one study with a few patients shows one technique is no different than another, that is not really a study that we consider significant on its own. We prefer large population studies or prospective trials.
05/16/2022 at 11:50 am #31586WimParticipant
I watched a presentation of Dr Kang where he states the the low complications rate (e.g. re-occurencees) of mesh as always mentioned in studies doesn’ match the database of medical interventions.
In the sudy you refer: mesh vs shouldice for occurences : “Favoured neither” So Shouldice is as good as Mesh?
05/16/2022 at 2:13 pm #31587Good intentionsParticipant
The use of “Favoured” to describe the results of each analysis, with many of them undefinable, is a sign of the low degree of definition of the data.
You can find several papers over the last few years about how early surveys or questionnaires did not define things like “pain” or chronic pain very well, so the results were vague and of not much use. It is also mentioned in the discussion. “Dichotomous” means the questions were yes or no questions, no measure of how much. The data studied goes all the way back to 1998, well before chronic pain had grown to become the number one problem in hernia repair.
Look at the range of the reported results in the various statements. 0 – 34.9%, for example, see excerpt below, reported as 13.4%, and 0 – 27.7% reported as 10.3. I am not a statistician but I think that “margin of error” which we’re all familiar with from political polls, makes these two numbers undistinguishable. Essentially the same.
“All studies reported this as a dichotomous variable. The crude rate of pain at last follow-up during this interval was 13·4 (range 0–34·9) per cent in the open repair group and 10·3 (0–27·7) per cent in the laparoscopic group, after a mean(s.d.) of 9·7(3·0) (range 6–12) months.”
Finally, the last statement in the paper does not suggest at all that laparoscopic TEP is the best method of hernia repair. A person can look at the tables and find lap TEP as “favourable” but the authors recognize that the data is not definitive.
“Nevertheless, this study suggests that laparoscopic inguinal hernia repair has patient-centred advantages over open inguinal hernia repair.”
There are other statements in the discussion that show how poorly defined the state of hernia repair today is. For example –
“Meta-analysis showed no significant difference in hernia recurrence between laparoscopic and open repairs. ”
The main takeaway from the meta-analysis, it’s true value, is that the available dats is poor and undefined. Nobody can really make a statement for or against anything. It’s chaos.
05/16/2022 at 3:04 pm #31588Good intentionsParticipant
Another problem with using the word “best” to define a hernia repair method is that different people are focused on different outcomes.
The patient typically wants to get their life back with minimal pain and cost.
The surgeon has to focus on the business first and the patient second. They have to get the commitment to have surgery then get the patient in and out with no complications, and do it all in the most cost-effective way. Their definition of “best” to accomplish those goals might not be what the patient considers best. You will find “return to work quickly” often defined as a goal in the descriptions of various methods, for example. The patient is typically not so focused on returning to work quickly if it means suffering while they work.
Here is a recent comparison of methods that almost completely ignores the patient’s desires. It was deemed worthy of publication in the journal Hernia. It is very business focused.
Just adding a perspective on how what looks best to the surgeon might not match what is best for the patient.
Here is what the authors evaluated –
“Complications, 30-day readmission, mortality, LOS, and intra-hospital opiate utilization were analyzed using IBM SPSS v.23.0”
05/16/2022 at 3:36 pm #31589MarkTParticipant
The broader conclusion of lap > open seems somewhat misleading…
Table 1 in the study Dr. Towfigh posted shows subgroup comparisons between specific techniques (TAP and TEPP laparoscopic repairs vs. Shouldice, Lichtenstein, and Stoppa open repairs).
Of the studies that compared TAPP/TEPP with Shouldice, no outcome variable was found to significantly favour either one. This included acute and chronic pain, patient satisfaction, and recurrence.
Every comparison where outcomes were found to favour lap repairs, it was when TEP/TAPP was compared with Lichtenstein or Stoppa (both of which also happen to be open mesh repairs, unlike Shouldice).
05/16/2022 at 7:39 pm #31590Thunder RoseParticipant
Here’s one where hernioplasty was found to have better outcomes open than laparoscopic, while 3 other types of surgery were found to have the opposite:
05/17/2022 at 5:41 am #31591JackParticipant
You can go round and round with these studies, it’s dizzying. Thunder Rose, I love your posts. Though think a 2000 study on Lapp results may not be best as this was fairly early days for Lapp and the techniques, and standardization of best practices (like the Felix/Daes “10 commandments”) has been more widely accepted by the better surgeons.
Personally I find the 2018 Kockerling and Koch study of Herniamed data to be most interesting. It showed that, with matched pairs (age, sex, Bmi, etc), and a high number of cases there was no statistical difference in outcomes between Shouldice and TAPP and TEP (and these three techniques scored better than Lichtenstein). The conclusion of the paper was that in select patients Shouldice could be used. My guess is Shouldice supporters would say the data set did not necessarily come from
Shouldice centers of excellence (like the Shouldice Hospital), but you could make the same argument that the Lapp repairs were not necessarily performed by centers of excellence either.
The whole thing is confusing. To me the tissue argument is to not close a door, and to avoid mesh specific complications. The negatives seem to be a tougher short term recovery, and that you have to travel for it (which can make an anxious person like me feel even more so).
05/17/2022 at 10:33 am #31592
I’m grateful, not just to Thunder Rose, Jack, but all have contributed to this thread.
I’d be lost without their analysis.
So much so I’m wondering if education standards are lower in UK than USA/rest of world.
I don’t consider myself exceptionally poorly educated – but I didn’t have a clue until all these posts.
I’m wondering if it was sort of thing that leads people to have mesh as it is all so difficult to interprete.
05/17/2022 at 11:17 am #31593WimParticipant
Da Vinci robots are veing installed everywhere and these have to be repaid also. Kang repair with local sedation and with his incision of 4cm seems to me a better approach then going into full Anesthesia and your belly being inflated.
That a 4cm incision has to heal a week longer doesn’t bother me.
05/18/2022 at 10:14 am #31594
I had a lymphoma removed, fat tissue limo, and the incision and scar is much bigger than 4cm. It isn’t bothering me.
05/18/2022 at 1:01 pm #31595
Sorry that should be lipoma, fatty tissue lump.
I can’t see the edit facility.
Does it work on phone?
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