In the 70s and 80s hernias were no big deal –now they are hell

[pinto]

LC, Welcome!

[William Bryant]

Good luck, LC, most posters are reluctant and hesitant about mesh so you’re in good company. Your earlier repair backs up the experience my colleague had who had a non mesh repair years ago then spent working life lugging tvs and videos around. These were heavy at one time. Very.

Could you ask about your medical records to see what the old repair technique was?

[LC]

Hi,
I’m new here and wanted to chime in with my experience with a 1980’s hernia repair. I had a direct inguinal hernia (left side) 40 years ago while pregnant at age 23. The open repair was performed 2 days postpartum with sedation and local. I have no idea what approach was used during this open procedure, but I’m pretty sure there was no mesh installed given it was 1983. My recovery was quite easy and uneventful.

Fast forward 40 years to 2023 where I find myself with a new, direct inguinal hernia on the right side. I have spent the past forty years engaging in weight lifting and other various fitness activities nearly everyday. Here I am with a 40-year-old repair holding strong, and anguishing about the upcoming repair for the new one.

All of the current information about hernia repair is causing me great anxiety. I’ve read tons of literature, particularly meta analyses about outcomes and complications. I reallllllly dislike the idea of a foreign body being placed inside me, irrespective to what the statistics reflect.

I’m a small person (5’3” 115 lbs) and hope that I can receive another open, non-mesh repair. I do suffer from allergies, post-nasal drip, occasional asthma flairs, and I’m a CPAP user— all of which can/do cause some coughing. I am medicated for these issues but they persist on some level. None of the aforementioned issues, plus lifting weights, managed to crack open my old repair over all these years.

Anyway, just wanted to share my story. Wish me luck with figuring out the new one.🤞🫤

LC

[pinto]

I totally agree with @ajm222
“it doesn’t do everyone else any good when exaggeration is employed. just saying we should try and be as precise and level-headed as we possibly can when sharing stories, and as detailed as possible, as we have seen that the devil is in the details. age, type of repair, type of hernia, past medical history, any other extenuating circumstances…”

Although I didn’t offer the case of a 50 year-repair, it’s quite reasonable that a 20 year old patient repaired could continue weight training thru to age 70. I don’t see how that could be hyperbolic unless well established in the hernia field, such is impossible. I don’t think that Chuck meant it literally true but his tenor I took as quite a long-lasting repair. In fact I have an uncle, though not presently a weight trainer, who had a repair decades ago under the “old regime” and never has had a problem.

I still agree with you @ajm222 on your main point while wishing to point out how mysterious hernia matters are still in the 21st century by the lack of studies.

[William Bryant]

Wow that surprises me. You’d certainly think it was possible to compare the two fur chronic pain. Can this not be done even in countries that have registers?

It’s a very lax approach really in my opinion.

[Good intentions]

It’s hard to find a clearly described comparison of chronic pain rates between the two methods. And, of course, each attempted study mashes all of the lap methods and meshes in to one big pile. Then they run the statistics and report a “significant” difference.

To the average person the word significant means “a lot” or many or something largely positive. In the world of statistics it just means that a difference can be quantified using the statistical methodology chosen. Samuel Clemens created a famous quote through his Mark Twain pen name – “Lies, damn lies, and statistics”. It could be 13% versus 15%.

Here are a couple of recent papers. It’s interesting that the other big selling point for lap mesh (the blob of materials and methods), recurrence, appears to be the same. Statistically.

https://link.springer.com/article/10.1007/s10029-019-01989-7

In this one, below, they can only “suggest” that lap mesh is better for chronic pain. Decades on and this is the best of the best – can’t really tell. People really should focus on how to fix the problem if it occurs. Include that in the how to avoid it calculation. Lap mesh removal is drastic.

https://link.springer.com/article/10.1007/s00464-022-09161-6

“Conclusion
Meta-analyses suggest that laparoscopic repairs have a lower incidence of chronic groin pain than open repair, but there is no evidence of differences in recurrence rates between laparoscopic and open repairs.”

[William Bryant]

No offense taken Good Intentions, it isn’t the mesh options I was interested in. It was the Bassini description and his quote about it being stable and satisfactorily used for 100 years that were salient to the thread I felt. I did try to direct people to the menu button, select info booklet and it opens that pdf. That’s where all the stuff about chronic pain is.

I’m not pushing the doctor or his mesh strategies. Out of interest I thought convention was laproscopic was less likely to lead to chronic pain. (This surgeon doesn’t think so which is interesting, not that I’m considering mesh).

[Good intentions]

I only looked at the web page advertising the clinic. You mentioned a pdf file, I did not see it. It looks like you’ve checked his publications also.

Regardless, he is apparently, a Lichtenstein surgeon who uses Progrip mesh. I would guess that 99% of the web pages and brochures advertising a surgeon’s clinic all do the same thing. They show their knowledge by describing possible causes of pain, describe how they do their repair, and give no firm data about results. The closest Dr. Sadler got is “appears to be about 2%”. They use vague terms like “vast majority” and “very small” but then show that they really have no idea if their patients are doing well or not. “Endeavor to try”, “all possible steps”…he means well.

Sorry to be so critical but his web page shows that he’s just a guy who does the Lichtenstein procedure using Progrip mesh. If you want to use the one patient sample size to judge his quality, I am fairly sure that I have seen a post on the site from somebody that had Lichtenstein with Progrip.

I found this with a quick search – https://herniatalk.com/forums/topic/anyone-got-their-mesh-removed-by-dr-muschaweck/

Again, no offense intended. Just applying the critical eye to what he says. It’s a typical sales pitch.

Anyone got their mesh removed by Dr. Muschaweck?

[William Bryant]

He also says I relation to chronic pain… whether open or keyhole, “mesh or no mesh, there is always a potential to develop long term pain after the surgery. We will take all possible steps to try and ensure that this does not happen and if it does, we will endeavour to try and remedy it for you. However, despite all these efforts a very small number of patients will have pain that proves difficult to remedy, it is an unfortunate rare longterm downside of hernia surgery”.

I did notice the mention/praise of one type of mesh… I understand he is very pro mesh but it was really the quote about Bassini being the standard repair for a century claim that was interesting in the context of this thread. I thought so anyway.

[William Bryant]

There’s quite a lot on chronic pain Good Intentions…

” Putting tension on the inguinal ligament through stitching this up to the muscle (the Bassini Repair is a tension repair) may also lead to this problem. Neuralgia Another cause of chronic discomfort can be chronic pain from dam aged nerves. The nerve may be caught up in scar tissue or the nerve may have been cut and the raw end form a neuroma (a swelling on the end of the nerve) or the nerve could get caught with a stitch (this is potentially one advantage of not stitching the mesh in place). Experience, careful surgery and attention to identifying nerves during the procedure will help reduce this problem. Neuralgia is less common but more difficult to treat than osteitis pubica. It may respond to one or all of the following; steroid injection, reoperation and dividing the affected nerve (neurectomy) or very rarely actually removing the mesh. Mr Sadler is not aware of any of his patients ever requiring mesh removal. To try and reduce the chances of chronic pain we favour the use of a mesh that requires no stiches to hold the mesh in place, this has both the advantage or performing a tension free mesh repair and avoids potentially catching nerves with stitches. However, we still have pa tients who have discomfort that comes on after surgery (usually os teitis pubica) this appears to be about 2% of inguinal hernia patients. It still means that most patients don’t have any problems at all with a mesh repair. Chronic pain after umbilical, epigastric or femoral repair appears to be rare. If you develop chronic pain, then obviously Mr Sadler will be happy to see you in clinic to discuss treatment options. “.

[William Bryant]

Greg Sadler oxford clinic on chronic pain

” Chronic pain or discomfort can occur after hernia surgery. The most common cause appears to be inflammation around the attachment of the ingui nal ligament to the pubic bone. The area becomes very tender to touch and the condition is called osteitis pubica. It is possibly caused by scarring around the inguinal ligament (coloured orange in the figure) causing tension on the ligament, result ing in a ‘traction injury’ to the bony attachment of the ligament (very similar to ‘Tennis/ Golfer’s Elbow’). The discomfort often doesn’t start for 39 months after surgery and prior to this everything can be fine. Patients are usually aware of an initial slight discomfort, sometimes in certain positions like driving or sitting, often walking around or standing up straight relieves the discomfort. There is no associated lump or bulge. The discomfort is often similar to the ache patients had from their hernia in the first place and they may worry that the hernia has come back. The good news is that the problem is usually fixable through a com bination of a small steroid injection and massage (much the same way that Tennis Elbow can be fixed). If the pain is not relieved, then a second injection may help and in very rare cases it may be necess ary to release the attachment of the ligament off the bone. This problem still exists with ‘no mesh’ surgery and may actually be more likely because of the increased ‘tension’ in the repair. Having a ‘nomesh’ repair will not remove the chances of having chronic dis comfort. Surgeons performing the Bassini Repair were often taught to put the first stitch through the bone to secure the stitch, so osteitis

[William Bryant]

Here is the praise for Bassini and a mention of chronic pain, Good Intentions… Bassini was the ….

“standard way of fixing an inguinal hernia for the next 100 years until the “tension free mesh” technique was shown to be more effective in reducing recurrence rates. Any operation that we perform for over 100 years must be a good one! There are many people walking around with Bassini Type repairs that they had performed many years ago and we are happy to repair your inguinal hernia with this tech nique. However, having a Bassini Type repair without mesh will not remove the possibility of chronic post op pain and the chances of your hernia returning are significantly higher. This is possibly more likely if you have a direct hernia”.

[Good intentions]

I don’t see him mentioning chronic pain. I pulled out a few sections below. Overall it is the typical “this is what I do and why it’s better” presentation that most hernia repair surgeons use.

The front page is odd in the way he describes using the most Pro-Grip mesh of anyone in the UK. Who would care about that, why would it matter? I think he’s trying to benefit from Medtronic’s marketing of Progrip. Riding the Pro-Grip bandwagon.

“Mr Sadler now only performs local aneasthetic hernia surgery. He is the largest single user of ProGrip mesh in the United Kingdom (approximately 4000 procedures) and has performed almost 6000 career hernia operations.”

“Oxford Hernia Clinic was pleased to be the first hernia clinic in the UK to use ProGrip™ as its preferred mesh for hernia repair and we are currently the largest user of the mesh in the UK, having performed over 4000 procedures.”

Here is one reason doctors and surgeons don’t show any interest in determining whether a hernia is direct or indirect.

“There are of two types of inguinal hernia, direct and indirect. For patients this distinction is irrelevant as the same operation fixes both types.”

He says “less painful” but does not mention long-term pain. Looks like it’s faster and cheaper. Those are good things, of course.

“Open repair is the most commonly performed procedure for inguinal hernia surgery and for the majority of hernia patients would be the technique of choice. After over 5 years of laparoscopic repair Mr Sadler reverted back to this technique because he believes when performed under local anaesthetic using it is quicker, more effective, less painful, safer (complications are very rare and less harmful compared to keyhole surgery) and far more cost effective for self paying patients compared with general anaesthetic.”

“After performing TAPP (and TEP) for many years, Mr Sadler no longer performs any keyhole surgery, favouring local anaesthetic repair (even for bilateral hernias) as he believes it is safer and more comfortable for patients.”

He uses the typical way of downplaying other methods with vague statements about risk. Mentions informed consent. Doesn’t give any numbers.

“No Mesh Technique (Bassini Type) Repair
We can repair your hernia with a “No Mesh Technique”, this is called a Bassini Type Repair, after the surgeon who described the technique in 1884. This is remained the standard way of fixing a hernia for over 100 years until the “tension free Mesh technique” became more popular. The technique works very well and many patients who had this type of repair have never had any problems.

However, a ‘No Mesh Technique” will not reduce the chance of having chronic discomfort after surgery (it may even increase) and statistically your hernia is more likely to come back, especially if it is a direct hernia. Mr Sadler will discuss this option with you as part of your consent process.”

[William Bryant]

https://www.sciencedirect.com/science/article/pii/S2405857221001066

More about Bassini efficacy

[William Bryant]

If Ive read it right, as well as talking about Bassini being used for years, I think it says the oxford clinic has stopped laproscopic surgery as it is more likely to cause chronic pain if keyhole is used!

Isn’t that the exact opposite of the consenesus?

[William Bryant]

https://www.oxfordherniaclinic.com/about/meet-the-team/mr-greg-sadler/

If you go to the menu and click on info booklet

[William Bryant]

I think the repair that may have been common before mesh would have been Bassini. That’s the impression I get from Dr Greg Sadler at the uks Oxford hernia centre

If you look at his pdf notes he talks about it being a repair used for 100 years.

[ajm222]

i think it’s probably fair to say that it’s a bit hyperbolic to suggest an adult weight lifter has lived with a tissue repair for 50 years, unless indeed that person had the repair as a child. i’ve seen a lot of hyperbolic statements from some quarters here recently, probably partially to get a reaction out of the readers, and partially out of exasperation or desperation. it’s totally understandable. but just saying it doesn’t do everyone else any good when exaggeration is employed. just saying we should try and be as precise and level-headed as we possibly can when sharing stories, and as detailed as possible, as we have seen that the devil is in the details. age, type of repair, type of hernia, past medical history, any other extenuating circumstances, and accuracy on all other fronts is most helpful when discussing successes and failures. hard to nail down those details most of the time, but the more the better. especially given the state of the science regarding hernia repair and some of the mystery surrounding it.

[pinto]

Hyperbole??? Can you claim such when the science of herniae is so young? Many many questions are left unanswered due to the dearth of studies. Of course empirical studies ought to be the guiding light, but anecdotal information is mainly what we got. Nothing wrong with entertaining observations that hernia repairs last 5 years or they last 50. If a set of them were happen to be valid, it could save one’s life.
Perhaps a member expresses hyperbole about something but discussion will often clarify it. I wouldn’t be too worried about it (though it could be concerning if talk became uncivil).

[ajm222]

i think we should be very careful with hyperbole. getting the numbers precisely right, especially when dealing with ‘anecdata,’ is very important on a forum like this. it’s admittedly very difficult though as individuals often even forget their own timelines in short order. but when people read that someone had a certain type of repair that only lasted a few years, and someone had one that lasted decades, they tend to take that to the bank. but the reality is often that these numbers are very inaccurate, especially second-hand. even careful scientific studies are often shown later to be incorrect. and definitely if one of your peers had a tissue repair 45-55 years ago, they were certainly a teen or younger. and people that age even today generally get tissue repairs (because they are still growing), and with greater success given their age.

i think the broader conundrum stands, though – that in the fairly recent past tissue repairs were the standard, and all of our parents, grandparents and great grandparents probably had tissue repairs, and i don’t recall a lot of problems being discussed. seems they generally worked fairly well. though older folks may be less likely to complain out loud about their medical issues. regardless, i know a number of people with mesh repairs, and when i’ve probed them they have admitted having issues in several cases to varying degrees. it really doesn’t seem like overall chronic pain rates and recurrences etc etc have improved all that much with the advent of mesh. but again, that’s just what I have personally encountered. many studies suggest that those metrics have indeed improved. though it may primarily be with the average general surgeon who doesn’t specialize.

also, it’s still fairly early. mesh repairs aren’t being followed super carefully, and many are less than 20 years old. jury is still out to some degree about long-term impacts. when you’re in your 40s and get a mesh repair, you’re told it should be a life-long repair without problems. but you may have that mesh for decades. we’re probably getting close to the point that some folks now in their 60s, 70s and 80s who had mesh repairs in the late 90s or early aughts are coming of age. tissue repairs can last a long time, but there seem to be a lot of folks who have failures after 20 or 25 years. do we know for certain yet mesh won’t be the same? and if mesh does fail at that point, what is the fix? removal? more mesh?