Herniasurge – what happened to it? No updates, no contact points

[Good intentions]

When the “International Guidelines for Groin Hernia Management” were introduced in 2018, even though they seemed biased and flawed, at least they said that they had plans to review and update the Guidelines on a regular basis. Many of the recommendations had the warning that the research was poor and more was needed, but it was the best that they could do at the time.

But the updates do not seem to have occurred and the Herniasurge group has been inactive for years. They seem to have gone dormant. The web site is dead even though it is still shown in the document as the place to go to get clarification and supporting data. It makes you wonder if the people involved in putting the whole thing together really still believe in what they did.

If it truly has value surely it is worth maintaining. Who is running the show now? Dr. Ramshaw has moved on, who is left?

Here is the latest version of the “Guidelines” available from Google Scholar, published January 2018, and an excerpt.

https://link.springer.com/article/10.1007/s10029-017-1668-x

“The HerniaSurge Group has formulated a large number of new research questions. The guidelines will be updated every 2 years as new evidence is published. The expiration date for this document is June 1, 2018.

The guidelines were externally reviewed by professors Jeekel (Europe), Ramshaw (USA) and Sharma (Asia). The Agree scores are published in the website of HerniaSurge (https://www.herniasurge.com).”

[Good intentions]

Here’s the Facebook page. https://www.facebook.com/herniasurge/

[drtowfigh]

HerniaSurge is an impromptu group of experts led by the European surgeons. They are working in their next updated guidelines.

Read more about that here: https://www.linkedin.com/posts/european-hernia-society_inguinalhernia-euroherniasnews-herniaguidelines-activity-6970116740076732416-3hGD?utm_source=share&utm_medium=member_ios

Should have their publications by the end of this year.

[Good intentions]

Thanks for the reply Dr. Towfigh. There is really nothing substantial to read in that single month old LinkedIn posting, but it is something, at least.

My understanding is that Herniasurge is just a formalization of a combined effort, based on past efforts by several organizations. The same group that put together the 2009 European Hernia Society guidelines was involved. The same names plus some new ones. So, not really “impromptu”. Looks like a pretty long-term plan.

It will be interesting to see what they come up with. Especially after Dr. Campanelli’s Editorial about how “chronic pain is real” and that there will be a focus on it this year. Strange though that the Herniasurge web site is dead, and the Facebook page inactive, but somebody found the time to post on EHS’s Linkedin page.

Here is a good summary of the efforts that resulted in the Herniasurge Guidelines. And a link to the EHS guidelines of 2009.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6048651/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719730/

[Good intentions]

Dr. Lorenz was in the LinkedIn picture and he posted soon after the Guidelines were published about one of the deficiencies of the Guidelines. It will be interesting to see if they take the obvious step, as Dr. Towfigh noted in her recent presentation, of recommending more pure tissue repairs. It’s hard to see how they could avoid it.

https://www.herniasurgeryjournal.org/article.asp?issn=2589-8736;year=2019;volume=2;issue=1;spage=23;epage=24;aulast=Lorenz

Excerpt –

“For many years, the only quality criteria used after a hernia operation was the recurrence rate. Subsequently, the tension-free concept was developed and is now used throughout the world. In recent years, the focus has increasingly shifted to possible chronic pain after hernia surgery. Based on these two criteria, the currently applicable “International Guidelines for Groin Hernia Management” published by the HerniaSurge Group recommends the use of mesh as a rule, either endoscopically via transabdominal preperitoneal or total extraperitoneal or in open surgery using the Lichtenstein technique.[1]

However, newer studies have shown that use of the Lichtenstein technique is possibly linked to a higher rate of postoperative pain.[2] The guidelines currently do not include alternative open surgical techniques, particularly mesh-free techniques, due to the small amount of scientific evidence. However, in recent years, numerous reports on postoperative pain after mesh implantation[3] and mesh-related complications[4] have led to increasing uncertainty among patients. Moreover, there have recently been register studies that showed at least equally good results for the mesh-free procedures for selected patients.[5],[6] Thus, the mesh-free procedures are regaining importance.[7]”

[MarkT]

GI, maybe you have come across this somewhere…

There was some mention recently of an institution considering amendments to its surgical training program, including more attention to tissue repairs ‘in part due to the desires of its young surgical students’ or something to that effect. I’m almost positive this was somewhere in Europe, but for the life of me I can’t recall where I read it and it doesn’t seem to be in any of the articles I’ve saved.

All I remember is that this was more of a side note in the discussion rather than the focal point of the article, which unfortunately makes it harder to find…but it was good to know that there was some desire for institutional training rather than having to seek it out later.

[drtowfigh]

HerniaSurge provided their updates at this week’s European Hernia Society meeting in Manchester. Go to my Twitter account, as I am live tweeting from the meeting, to read more. The official publication is coming up soon.

[Good intentions]

Thanks Dr. Towfigh. You might not be aware that people without Twitter accounts can only see a few Tweets before Twitter blocks access to the site, until the person signs in or signs up. So your EHS live tweets will soon be unviewable to people without accounts, as you add other tweets behind them.

The Guidelines on the EHS web site have not changed (https://www.europeanherniasociety.eu/ ). The 2018 version is still up. I assume that EHS will update them, and their summary of them, as soon as possible. (I just noticed that Medtronic managed to get their name on to the Guidelines summary page, at the end. The Guidelines should really be called “Guidelines for Mesh Repair of Hernias”. https://www.europeanherniasociety.eu/sites/www.europeanherniasociety.eu/files/medias/cov13178_ehs_groin_hernia_management_a5_en_10_lr_1.pdf)

[Good intentions]

The Herniasurge web page is still inactive, and their Facebook page has no activity either.

I hope that something good happens but history suggests that the effort will be mainly to reaffirm what has already been created, as shown by their very recent survey of surgeons to reaffirm (or really, just to affirm) support of the Guidelines. Why would they do that if significant changes were in progress? Any changes would be used by the lawyers for current lawsuits. I will be surprised if there is any suggestion to reduce the use of mesh. It’s just how corporations work.

Good luck with your efforts to drive change for hernia repair for women. I think that there is real possibility there since the volume is so small compared to male hernias.

https://twitter.com/Herniadoc?ref_src=twsrc%5Egoogle%7Ctwcamp%5Eserp%7Ctwgr%5Eauthor

https://twitter.com/eurohernias?ref_src=twsrc%5Egoogle%7Ctwcamp%5Eserp%7Ctwgr%5Eauthor

[William Bryant]

Mart T it rings a bell with me tok I do recall Dr Pawlak from NHS in UK wrote tissue repair should be considered for small hernias but can’t remember if he said training too.

[Good intentions]

I don’t remember anything specific to Mark T’s comment but I did post something in the past about Dr. Pawlak and his views on Guidelines. He was on the presentation list at the Manchester conference.

The Manchester conference seems primed to drive change but Dr. Pawlak’s editorial shows why what the Herniasurge group manufactured is so powerful. They have defined an artificial “standard of care” that perpetuates the use of mesh for hernia repair. I think that that is why they get so much support from companies like Medtronic. If I was an executive at Medtronic I would be all-in on helping the Herniasurge group get heir message out. Full funding, whatever they need.

Here is my old Topic. I will pull out the Editorial in the post after this.

Dr. M. Pawlak – a new surgeon worth following (and hoping for)

And the Topic about the Manchester conference.

European Hernia Society Manchester 2022

[Good intentions]

It would have been interesting to see how Dr. Pawlak’s views were received at the conference. Herniasurge on one side, promoting mesh, others expressing solid counterpoints.

https://www.herniasurgeryjournal.org/article.asp?aulast=Pawlak&epage=77&issn=2589-8736&issue=3&spage=75&volume=2&year=2019

Here is their final paragraph –

“Guidelines – friend or foe? Guidelines that conform to current development standards should be our friend. There seems to be a fear among many herniologists that guidelines set a standard of care. And deviation from them will thus become ammunition for patients and their lawyers to trip us up. This is a view that is very wrong, both for what guidelines are for and what they mean. We end this editorial with the words of John Kinsella, recently retired Chair of the Scottish Intercollegiate Guidelines Network (SIGN). “In the era of realistic medicine, SIGN guidelines should be the starting point for decision-making at the clinician-patient interface, and should inform the joint decision, not dictate a particular course of action.”[21]”

[Good intentions]

Still nothing. Running out of time.

All there is are updated incisional closure guidelines. Or singular “guideline” as they label it.

https://linktr.ee/EHSguidelines

https://www.linkedin.com/posts/european-hernia-society_inguinalhernia-euroherniasnews-herniaguidelines-activity-6970116740076732416-3hGD/

• This reply was modified 5 months ago by Good intentions.

[Good intentions]

Another interesting paper that mentions “HerniaSurge” even though the group does not seem to exist anymore.

Also interesting in that they refer to their work as assisting in the update of the Guidelines, but note that the recurrence rates for hernia repair are still very high. The whole premise of laparoscopic mesh repair is that recurrence rates are lower. References 4-7 are all from 2018 – 2020.

It wouldn’t be a surprise if EHS or the “HerniaSurge” group have found themselves in a bind, where the review of new data shows that the 2018 Guidelines are seriously flawed. The delay and lack of communication is telling.

https://journals.lww.com/journalacs/Fulltext/2022/03000/Association_of_Mesh_and_Fixation_Options_with.10.aspx

“The routine use of mesh in groin hernia surgery has engendered substantially decreased recurrence risk.1,2 However, current long-term reoperation rates for recurrence are still disappointing, in the range of 8% to 15%.3-7”

[Good intentions]

Coming up on a month and half past the end of 2022 and still no updated hernia repair guidelines. All of the HerniaSurge links are still dead.

The last update was for abdominal wall incisions, in August of 2022.

https://www.linkedin.com/posts/european-hernia-society_inguinalhernia-euroherniasnews-herniaguidelines-activity-6970116740076732416-3hGD/

https://linktr.ee/EHSguidelines

[Good intentions]

The EHS Facebook page is up to date. They have a notice about the new Hernia issue on chronic pain. Apparently they just had a board meeting two days ago. They had to have discussed the delay in the new Guidelines. Nothing wrong with delaying if they are attempting to get things right but they really should be providing updates. And there should be a note on the current web page that the Guidelines are out of date and new ones are coming.

It’s a good place to catch links to new papers about hernia surgery.

https://www.facebook.com/people/European-Hernia-Society/100070922043834/

[Good intentions]

Very strange that the European Hernia Society would promote a link from their Facebook page directly to the guidelines page. Even though they are coming up on three months behind schedule for the updated Inguinal Hernia Guidelines they promised in 2022.

This is from one day ago.

https://www.facebook.com/permalink.php?story_fbid=pfbid02eeycTA4xgMLivnfckFY3BuQXUqFxp7iY9dGTG94a6arYc3xAcZRqkN8YVgByoX34l&id=100070922043834&__cft__%5B0%5D=AZUEnQzXkMvpTwZgGUT0TaysqExDfJKse2FDL6LOgz8WIyztkBpbMJgkt7Q9Mv85v3E7S9NBEG660WFq_TK78qEA7SIRaGi2mQcHTDQEE0fyvMFU_c6NAAtyfQ2esVcAnWYONKAStKGHfL0KjdBmLQZ9vSSKnApY7usUmicfRROFaE949xOilsK0nb3hirgNC_5hOoTNWR-ddlHJVkc-BMpA&__tn__=%2CO%2CP-R

https://www.linkedin.com/posts/european-hernia-society_inguinalhernia-euroherniasnews-herniaguidelines-activity-6970116740076732416-3hGD/

[Good intentions]

Two and a half months in to 2023 and no mention at all of the updated inguinal hernia repair guidelines. It really looks like they are going to pretend that no commitments were made. If they believe that the current Guidelines are sufficient then ethics and professionalism suggest that they should just say so. Why are they hiding? Dr. Towfigh believed in them. That must be a disappointment.

This is from their LinkedIn page –

https://www.linkedin.com/posts/european-hernia-society_inguinalhernia-euroherniasnews-herniaguidelines-activity-6970116740076732416-3hGD/

“European Hernia Society
European Hernia SocietyEuropean Hernia Society
2,088 followers2,088 followers
7mo • 7 months ago

Follow

HerniaSurge #InguinalHernia updates guidelines team discussing recommendations. Publication this year!”

[Good intentions]

The name HerniaSurge has made a new appearance. It’s been modified again, it’s now HerniaSurge Collaboration. Dr. Maarten Simons is the representative. At the end of the article the full HerniaSurge Collaboration list of members is shown. Still odd in how mysterious the group is. Who pays for their efforts?

Apparently the Collaboration has identified a specific sub-category of hernia and determined that it needs specific guidelines. The study follows the same general format as the original guidelines. It’s interesting to see how almost all of the levels of evidence are low and the recommendations are weak (by their definitions). In other words, of little real value except to show that nobody knows what’s best.

The Collaboration seems to be generally defining the world in terms of low resource and high resource. In other words, poor and rich.

The original 2018 Guidelines remain unchanged, despite promises of updates. But it is still the first reference in this paper.

https://linktr.ee/EHSguidelines

https://www.frontierspartnerships.org/articles/10.3389/jaws.2023.11195/full

ORIGINAL RESEARCH
J. Abdom. Wall Surg., 27 March 2023
https://doi.org/10.3389/jaws.2023.11195
Systematic Review and Guidelines for Management of Scrotal Inguinal Hernias
Hanh Minh Tran1*, Ian MacQueen, David Chen, Maarten Simons on behalf of HerniaSurge Collaboration

“…In high resource settings, an open anterior repair is the default operation. The Lichtenstein operation is still considered the gold standard for anterior open repair (1). The endoscopic hernia repair methods have been shown to be safe and effective with acceptable low complication rates in specialized centers (5, 15, 17, 20). There is a high conversion rate when starting with an endo-laparoscopic technique, especially TEP. Low resource countries may not be able to afford the mesh and/or consider their operative settings to be sufficient for sterile standards to prevent mesh infection and its sequelae. Therefore, suture repair still remains a standard option in these settings. Teaching and training to master the Shouldice technique remains an important cornerstone for surgical management of inguinal hernias in low resource settings. …

HerniaSurge Collaboration
F. Agresta, F. Berrevoet, I. Burgmans, D. C. Chen (AHS), A. de Beaux, B. East, N. Henriksen, F. Köckerling, M. Lopez-Cano, R. Lorenz, M. Miserez, A. Montgomery, S. Morales-Conde, C. Oppong, M. Pawlak, M. Podda, D. Sanders, A. Sartori, M.P. Simons (former EHS secretary for quality), C. Stabilini (EHS secretary for Science), H. M. Tran (Australasian Hernia Society), N. van Veenendaal, M. Verdauguer, R. Wiessner.”

[Good intentions]

Here is a short reminder/summary of where my cynicism and skepticism come from. Dr. Towfigh provided the LinkedIn link above, recopied below, that showed that HerniaSurge is an extension of the efforts of the European Hernia Society (EHS). Supposedly they were almost finished with the updates to the 2018 Hernia Repair Guidelines, which were originally supposed to be updated every two years. So far there are no updates, only a new subset of Guidelines for scrotal inguinal hernias.

We are now three months past the promised date. There is no sign that some significant event has occurred that would cause a delay. What is going on? I see now that they only promised “recommendations”, with a publication of some sort. Where is it? Who decides on whether or not to update the Guidelines with the recommendations? Even if there is no change there should be a communication about the results.

https://www.linkedin.com/posts/european-hernia-society_inguinalhernia-euroherniasnews-herniaguidelines-activity-6970116740076732416-3hGD/?utm_source=share&utm_medium=member_ios

https://linktr.ee/EHSguidelines

https://www.europeanherniasociety.eu/sponsors

[Good intentions]

I just realized that even the EHS has a piece of mesh as part of their logo. Basically they are flying a mesh flag. It is really very strange. It’s almost like worship.

[Good intentions]

Here is the last notice about the updated guidelines. From the EHS newsletter of October 2022. The prior newsletters seemed to be about every 3-4 months. They are way behind.

https://www.europeanherniasociety.eu/ehsnewsletter18

And here is what appears to be the official EHS publication, according to the newsletter. I would expect the updates to be published here, possibly. The scrotal inguinal hernia guidelines are.

https://www.frontierspartnerships.org/journals/journal-of-abdominal-wall-surgery

[Good intentions]

Four months in to 2023 and still no sign of updated Guidelines. And the link to the newsletter does not work anymore.

EHS seems to have revised their web site. Some material that you’d think would be free is members only.

Do mesh devices make hernia repair easier?

[Good intentions]

I’ve been curious, actually fascinated, about how the massively influential “International guidelines for groin hernia management” got produced so have been collecting the documents about its development. The original document was produced by the European Hernia Society in 2009 and listed all of the authors. It was updated in 2014, again with all of the authors listed. In 2018 they created a new group that they called the “HerniaSurge” group, and described making supporting data available and ways to contact the group if there were questions. Since then the Group has gone almost completely dark, only appearing as buried references in various documents, under a changed name, the “HerniaSurge Collaboration”. I posted about this collaboration earlier in this thread. The web site link for the Group is dead. Their Facebook page has only a few posts. Basically all of the foundational work for the Guidelines is inaccessible. The document exists as gospel, referenced with confidence by surgeons around the world, but they don’t realize that it is now an empty shell and that the original authors seem to be second-guessing their work on it.

2018 was really not that long ago. Since then Dr. Campanelli has written several editorials in Hernia journal about the chronic pain from hernia repair problem, first proclaiming that the problem was real and describing a future collection and special issue about the problem. But then finishing the project with an Editorial that suggested that the problem was not real, and that it had arisen because people expected too much from life.

https://link.springer.com/article/10.1007/s10029-017-1668-x

Published: 12 January 2018
International guidelines for groin hernia management
The HerniaSurge Group
Hernia volume 22, pages1–165 (2018)

Here is one of 80 references to the HerniaSurge group, with a dead link to a web site –

“All search strategies, tables with articles and background information will be published on HerniaSurge’s website (https://www.herniasurge.com). All articles are filed per chapter in MendeleyR reference manager.

We would like to emphasize the fact that the “International Guidelines for Groin Hernia Management” is NOT a legal document, merely guidelines. If surgeons choose not to follow strong recommendations, they should do so in consultation with their patients and document this in the medical record. …”

[Good intentions]

Here are the three Guidelines links, 2009, 2014, and 2018.

https://link.springer.com/article/10.1007/s10029-009-0529-7

https://link.springer.com/article/10.1007/s10029-014-1236-6

https://link.springer.com/article/10.1007/s10029-017-1668-x

[Good intentions]

This is a replay for William from Oceanic’s Topic.

I think that many surgeons got roped in to the Guidelines effort without realizing what was actually happening. It seemed like a good idea to create a baseline of methods, at least to use for future reference. But the failure to follow-up on the promises to update the document, and the constant and growing problem with mesh-related pain, has probably made many of them question their association with the document. Dr. Campanelli and Dr. Conze are not shown as members of the new Collaboration group.

The Collaboration and some or all of the members were shown in a recent publication about the fairly new Scrotal Inguinal Hernia guidelines. Post #34383 in my other thread. The Journal of Abdominal Wall Surgery (JAWS, ha ha ha) is the official publication of the European Hernia Society. You can see how powerful the EHS is getting.

Herniasurge – what happened to it? No updates, no contact points

https://www.frontierspartnerships.org/articles/10.3389/jaws.2023.11195/full

Here is the list of members at that time, apparently. Notice that they still talk about HerniaSurge as an existing authoritative entity but only suggest contacting authors of individual segments directly if there are questions.

HerniaSurge Collaboration
F. Agresta, F. Berrevoet, I. Burgmans, D. C. Chen (AHS), A. de Beaux, B. East, N. Henriksen, F. Köckerling, M. Lopez-Cano, R. Lorenz, M. Miserez, A. Montgomery, S. Morales-Conde, C. Oppong, M. Pawlak, M. Podda, D. Sanders, A. Sartori, M.P. Simons (former EHS secretary for quality), C. Stabilini (EHS secretary for Science), H. M. Tran (Australasian Hernia Society), N. van Veenendaal, M. Verdauguer, R. Wiessner.

[Author]

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