Hernia mesh fixation questions

[pinto]

First, thank you to the doctors who kindly responded here and also to Dr T for her patience. The post by Jnomesh should be framed on display in every dr.’s office as a reminder of the importance of listening and as well alternative explanations.

Stories by Jnomesh and Good intentions (here and elsewhere) of mesh mishaps appear authentic and well deserving our attention. The biggest element that strikes me—but seems overlooked—is the powerlessness of patients. The loneliness of a harmed and ignored patient is a feeling like almost no other!

I challenge all medical practitioners to put themselves in like situation so as to really, really know what it feels like. Sadly though I doubt if many would think it important or necessary. A common thread I see among the many stories of medical mishaps at this website is getting or feeling ignored by their doctor. No wonder litigation has become a huge industry. Doctors have only themselves to blame for it.

[Good intentions]

Here’s another that kind of shows where my thoughts were way back then. Things are actually getting better, there’s more of a focus on quality of life now, but a lot of the old ways still exist. A person can walk in to any of hundreds of hernia repair clinics or hospitals today and be back in 2014, where I started.

[Jnomesh]

I’m a little late to the game here but I would like to echo some of good intentions points. When I had my mesh implanted I had a hematoma and ER visit a few days post surgery. Only now do I know that this was a very large hematoma and that it was right where the mesh was placed.
when I went back to the implanting surgeon 3 times during the first year to complain I didn’t feel right, he did an examination and said no reoccurrence. I told him I felt heaviness and burning in the stomach. Now when I search the web and see studies concerning mesh things pop up like a hematoma, or heaviness in the stomach/abdomen are signs that should ne considered that something may be wrong with the mesh.
but all my surgeon looked for was a recurrence. Fast forward 6 years later and when the pain took a turn for the worse and became debilitating I saw two other hernia “experts” again after examination I heard the words “no recurrence”. Then a cat scan was ordered and cam back normal. And then both sent me off to pain management. fortunately I didn’t give up and since the medical community couldn’t advocate for me I had to for myself. 6 months of tons of tests tons of doctors and tons of research led me to a surgeon who saw in the same exact cat scan what the other two surgeons were given-that indeed the mesh was bent. And when he went in to operate it was even worse then the cat scan showed-it was balled up and hard as a rock. It was the bard 3D maxx hernia mesh and while I’m not a fan of any mesh this is pure crap. There are a lot of people suffering from this mesh but i degress.
again put aside the mesh whether it is good or bad argument-and I certainly have my views on this topic-but my story like so many others who HAVE suffered from mesh gone bad is the reason mesh being the gold standard has to be revisited.
it is unequivocally wrong that when mesh goes wrong the patient is left by himself, isolated and quite frankly left to think he or she is going crazy.
i can’t think of anything so cruel. The fact that there are only a handful of surgeons who can handle the challenge of removing mesh and can read a damn cat scan or MRI to see if something is indeed wrong is again disturbing and wrong.
the fact that dr. Ramshaw has a year long waiting list and I’ve recently heard isn’t seeing new patients for mesh issues Bc he is backed up again is beyond troubling-to few surgeons who can handle this procedure and to many patients that need there help.
the fact that I had to do hundreds of hours of research to find a surgeon to remove my mesh travel out of state and pay thousands of dollars for the surgery again is cruel and completely unfair.
ive read numerous testimonies from people that when they’ve asked surgeons about mesh removal they’ve been told they will die, lose a testicle or a limb or it just can’t be done. We know now that isn’t true. One surgeon told me removingmymesh would be like prying tar off the the cement floor with pliers. So patients, yes patients are being lied to or if not lied to and the surgeon truly
believes this then this is a problem.
so what is the solution to the “gold standard” of mesh that took away 6 1/2 years of my life and affected my wife and 2 kids and that has left me with a uncertain future going forward?
well how about this?
line up the thousands upon thousands of surgeons who implant mesh for hernias and ask them these two questions:
if something goes wrong with the mesh do you feel confident you can remove it?
can you confidently read cat scans or MRI’s to determine mesh issues?
an answer of no to either of these questions and sorry but you can’t implant hernia mesh!
or at least make it mandatory that they have to provide patients with these facts.
Hi MR or Mrs blank-you have a hernia and it should be repaired with mesh but I have to to tell you if something:
mesh shrinks, can get entangled in your nerves, migrate, become rock hard, fold over, attach itself to the bladder spermatic cord and other structures, become infected, cause a hematoma and If something goes wrong with the mesh
a) I don’t know how to remove it and yeah also
b) if there is a issue with the mesh-when I order a MRI or cat scan I don’t know how to read it to look for mesh complications.
would you like to proceed?
lets see how fast pure tissue repairs make a come back and at the very least are offered as an option
for hernia repair again Bc it was never made an option for me.

[drtowfigh]

All good points, Good Intentions.

The problem is partly that patients and surgeons look at the same problem differently and perhaps there is some loss in translation.

When I mention the importance of listening by the surgeon, you validate my point because it frustrates you when your surgeon barely hears your words. Also, listening and learning from the patient allows the surgeon to tailor the operative plan to each patient’s needs.

Recurrence is not the only outcome by which we measure hernia repair success. That was proven to us in the mesh era, when recurrence became a much lower problem (as compared to non-mesh tissue repairs), and chronic pain raised as a more important outcome of measurements. Almost all modern studies, including outcomes databases such as the AHSQC, include short term and long term quality of life parameters as a measure of outcome, and therefore success, of hernia repairs. That said, hernia recurrence can significantly affect quality of life, so it should not be discounted as one of many outcomes factors. Europeans are much more advanced in tracking population data than in the US.

There are a few surgeons, Dr. Ramshaw being one of them, where research is being performed with the goal of helping predict the best plan of care/surgical technique/mesh implant, etc., for each patient characteristic. It is quite a complex system of analysis. To date, there is no science that can predict the best surgeon/technique/implant for each individual patient. Each surgeon can only apply his/her best knowledge and experience to help determine that on an individual basis.

[Good intentions]

To be clear – I’m not normally so wordy and argumentative. But I do see a common response from surgeons about focusing on fixing the hernia and avoiding recurrence. But they almost never talk about getting back to the quality of life the patient had before. Even my own surgeon, who I have stuck with so that he can see the results of his work, always reports in a firm voice “no hernia recurrence” whenever he examines me. It’s all that he can think about. He barely hears my words about discomfort and soreness and other problems.

The goal should be to get the patient mentally, emotionally, and physically back to where they were before the hernia. Not just physically.

[Good intentions]

Again, thank you. But how do we, the patients, get this information? How do we know if our surgeon is a contributor to the AHSQC? And what “quality” is measured? A simple questionnaire would probably tell a lot. My surgeon is close to one thousand mesh implantations. I would love to see the comments or results of people who are doing fantastically. Then I could just focus on my problem. But I have no idea if it’s my surgeon, or the materials, or me that are the problem. It’s all hidden. If he doesn’t hear from them, they’re considered a success.

I have a degree in a science and the art versus science argument is really not relevant. The art would be used on top of a solid scientific base. Starting at art suggests that success is in the eye of the beholder and that the surgeon is not responsible for any outcome. Because it’s art.

“What is most important is that your surgeon has an interest in doing what they are doing, listens to the patient, and is involved in self-education.” What is most important is that the results of the surgery give a good outcome with a long-lasting high quality of life. I don’t care if my surgeon is interested or listens, but I do care that they use what works and not what doesn’t.

Besides that, how do we find out which surgeons are learning and keeping up? Where is that information?

Again, I appreciate what you’re doing, and I know that working in the medical industry bureaucracy is frustrating, but there must be some way to define what is best for the patient besides waiting for a lawsuit? That seems to be the main driver for change. It shouldn’t be that way. There should be more weeding out of the materials and methods that don’t work, and less independent experimentation. We’re not supposed to be lab animals.

[drtowfigh]

Good Intetions:

The American Hernia Society has a Quality Collaborative (AHSQC) that many of us submit our patient lists to in order to provide some quality comparisons with national outcomes and those of our peers. Please encourage your surgeons to register and submit their patient outcomes into this prospective database.

The reality is surgery is as much an art as it is a science. Surgical technique is one determinant of outcome. Patient characteristics are very different and also affect outcome. No one technique is the best for all patients.

Also, it may seem true that surgeons with longer number of years may be better at what they do, but that is not always the case. One can do the same procedure one was taught in residency, and perhaps newer and better techniques have been developed since then. What is most important is that your surgeon has an interest in doing what they are doing, listens to the patient, and is involved in self-education.

[Good intentions]

quote sngoldstein:

Hernia mesh fixation questions

I don’t fixate mesh except in rare circumstances. Other people fixate all the time. What works for one surgeon may not work for another and we are all quite opinionated and maybe a touch egotistical. Either way, what matters is that your surgeon does what works for them, has good results and happy patients.

How can there be so many different ways to do things, that all give good and happy patients? Who is keeping score? If a surgeon has bad results does he/she tell their fellow surgeons to avoid this method? How does a patient know which surgeon has good and happy patients and who doesn’t?

If every surgeon is learning as they go, and developing their own special way of doing things, that would mean there has to be mistakes early in a surgeon’s career. It suggests that we should all avoid new young surgeons because they are still experimenting, and we should only use surgeons with tens of years of experience, because we want tens of years of good life after the surgery.

There should be standard methods, proven to give good and happy patients, after hundreds of thousands of mesh implantations. It seems like it’s still the wild west out there.

[drtowfigh]

Mesh shifting, movement or folding is dependent on the technique, the amount of dissection, the types of fixation, the places where fixation are applied, the type of hernia, and the patient’s risk factors for recurrence.

[cm-rom]

Can you please elaborate further on the reasons making the mesh slip/move when sutured to the muscular structures around the fascia defect, considering a reasonable shrink rate (currently achievable with the new introduced materials)?

[Chaunce1234]

Hernia mesh fixation questions

Agree with Dr. Towfigh. I couldn’t have said it better myself.

[dsdjuey2983d]

Hernia mesh fixation questions

Great answer, thank you!

[orothyfosti]

Hernia mesh fixation questions

Thank you for your response.

[drtowfigh]

Hernia mesh fixation questions

There is no standard. There are randomized controlled trials that have proven that a variety of techniques (tacks or no tacks, glue or no glue) are all adequate. I typically do not tack or glue. For larger hernias or in larger build patients, I tack, because the rate of mesh billowing into the hernia defect is much higher. With the robotic technique, I prefer to sew rather than tack, as it is a more elegant technique to fix the mesh. And I feel that there is less pain than tacking, but that has not been proven. I use titanium permanent tacks and permanent sutures. There is no proof that absorbable tacks are superior or cause less pain. They are just much more expensive. Regardless of the fixation or lack of fixation, mesh can move or fold.

Surgery is as much an art as it is a science. The technique should be tailored to the needs of the patient. A small hernia in a thin patient is treated differently by me than a large hernia in an obese patient. They cannot all be provided the same repair. And still, with the same repair performed on similar patients, two different outcomes may be expected. Each patient reacts to surgery, mesh, etc., differently. We don’t know enough to predict who will do best with which mesh or which technique.

[sngoldstein]

Hernia mesh fixation questions

I don’t fixate mesh except in rare circumstances. Other people fixate all the time. What works for one surgeon may not work for another and we are all quite opinionated and maybe a touch egotistical. Either way, what matters is that your surgeon does what works for them, has good results and happy patients.