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"Increasing Number Of Patients Refusing Mesh" for hernia repair – SAGES 2018 topic
I thought this would be an interesting topic of discussion for this forum. SAGES is an annual conference for surgeons, and so it can offer some interesting insight for curious patients as to what the talk/discussion is among surgical professionals. This year, I noticed that hernia mesh is a big topic, as is groin pain, sports hernia, and inguinal hernias, with sessions with the following titles:
– “Mesh: Must Avoid or Must Have?”
– “Groin Pain and Sports Hernia”
– “Reoperation For Recurrence With Pain Being A Significant Complaint – Should The Approach Be Different?”
– “The Increasing Number Of Patients Refusing Mesh– Is This Justified. And What Should We Offer?”
Topics found at: http://www.sages.org/wp-content/uploads/2013/09/SAGES-2018-Final-Program.pdf
The last topic about patients refusing mesh in particular caught my eye, since it’s a near constant topic on these forums where patients are seeking out non-mesh repairs, and yet there are fewer and fewer surgeons who are performing them. It is clear there is strong patient demand for non-mesh hernia repairs, when applicable, especially if this topic is now something discussed at a surgical conference. Trying to research this further I stumbled upon an internet discussion thread between a few surgeons from the SAGES conference, and it appeared their conclusion was basically to “decline the patient” and that a very few number of surgeons know how to do a non-mesh repair at all, and very few are comfortable performing a non-mesh hernia repair.
It’s known that non-mesh hernia repair is a very skilled procedure that is complex and difficult, requiring substantial repetition to master, but rather than “declining the patient” wouldn’t it make more sense to start teaching and learning these increasingly desired skills, so that a patient can have treatment they are more comfortable with? If we went back in time 50 years ago, every general surgeon was able to perform a non-mesh hernia repair, so it’s not like it’s an impossible task.
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13 Replies
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Sharon Bachman looks like an interesting surgeon also. “Hernia geek”. Not clear where she’s based. MO or VA, or both.
https://www.google.com/search?client=opera&hs=K7n&ei=npHqWpHlIeSU0gLt-7_oAg&q=Sharon+L.+Bachman&oq=Sharon+L.+Bachman&gs_l=psy-ab.3..0i30k1l2.57905.59272.0.60544.3.3.0.0.0.0.67.171.3.3.0….0…1.1.64.psy-ab..0.3.171…0i7i30k1.0.ejKjQ0KTtXE
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Thank you for that link Chaunce1234. Andrew Wright looks like an interesting person. I can’t tell if he’s chosen a side. Of course, it’s best to be open-minded. Some interesting comments on the Twitter feed though.
Here is Andrew Wright’s bio from the University of Washington. Also a link to another Twitter feed that says Andrew Wright is “tackling the tough topic of Conflict of Interest and surgical research. “We all have implicit bias.”” I think that the thought can be applied to just general practice. Who is “running the show” and what are their motives?
https://www.uwmedicine.org/bios/andrew-wright
https://twitter.com/JohnRomanelli2/status/985213199476637696
@andrewswright tackling the tough topic of Conflict of Interest and surgical research. "We all have implicit bias." #SAGES2018 #WCES pic.twitter.com/1w1c4cjP81
— John Romanelli (@JohnRomanelli2) April 14, 2018
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quote Good intentions:Chaunce, do you have a link to the internet forum thread with the surgeon’s discussion?
Many of the SAGES presentations end up on youtube. I don’t know who decides what gets released but I hope that the mesh discussions are.
The discussion I stumbled onto was found on Google between surgeons discussing the SAGES conference on the website Twitter, it is sort of hard to follow the discussions as the Twitter format is not laid out like this forum is. Here is one of the threads:
https://twitter.com/andrewswright/status/984184051404652544
Another thread on Twitter which I can not locate at the moment included several other doctors discussing patients who do not want mesh, or who have chronic pain, etc. Some of them I found to be very dismissive of this as a problem or a patient concern, which seems odd and not particularly patient focused.
I did notice that two of the surgeons who were sympathetic and understanding on this topic were two surgeons who also happen to frequent these forums: Dr Szotek and Dr Towfigh, so credit where due, and huge bonus points to those two doctors for being patient focused and listening to patient concerns!
Huge topic: what to do when patients refuse mesh. By show of hands only tiny fraction of audience comfortable doing tissue repairs. @SLBachman #SAGES2018 pic.twitter.com/A5rZGGWv2I
— Andrew Wright MD (@andrewswright) April 11, 2018
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I wanted to just say THANK YOU!!!!! for your reply Dr. Kang and for putting that out there…you have no idea what that means to me when I read your well respected opinion and how I wish I read this 7 years before my mesh surgery as I am looking to get it removed now due to growing systematic complications.
IT SEEMS SO OBVIOUS OF A CHOICE!!!! > (So I have a hernia, to repair should I… A. Insist on using my own tissue with a skilled hernia surgeon and technique OR …. B. Use a FDA grandfathered polypropylene plastic with who knows what chemical coatings with no long term testing in the human body and then ADD IN the potentials for oxidation+FBR+chronic mesh inflammation+deep infection risk (bacteria colonies possibly hiding in biofilm around mesh) + time (months, years) = WHAT CAN GO WRONG?? HOW DO WE TURN THIS SHIP AROUND?) I honestly can not believe how this still is going on. I hope your words can help others who are blindly following these mesh recommendations citing “better re-occurance rates” over potential quality of life issues.
Also, thank you Dr. Towfigh and all the others who understand this and push for more pure tissue training. It makes me happy to see this. We need to go back to the old days in a lot of areas in the medical field, removing mesh included…people still got hernias back then and then they got them fixed and moved on with their lives without worries about what a piece of plastic in a sensitive area can do down the road…
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Thanks Dr. kang. It’s just a shame that here in the United States there are so few surgeons who specialize in tissue repairs. Thus The patient is pushed into a repair using mesh. If the patient requests a non mesh repair the surgeon either says they aren’t proficient enough in this type of repair or quotes a high recurrence rate that I believe is used to cover up the fact that they just aren’t comfortable doing them. So if a hernia returns the surgeon can then say I told you that was a higher risk.
We need more specialists like you here in the US.
it is very unfortunate that a patient had to most likely revel out of state or out of country to avoid mesh. -
quote Jnomesh:Thanks for sharing Chaunce. Super important. Glad that Concerns regarding mesh seems to be making its way to the forefront. Hoping that in the near future surgeons will be equally trained in mesh and non mesh repairs so that not only can the patient be presented with a choice but receive expert care in either procedure.
the thing that I always come back to that is quite remarkable is the “mis-truths” that surgeons and the industry seem to spread regarding the inferiority of non mesh repairs-that they carry a higher recurrence rate than mesh-I’ve even heard this quoted by some surgeons on this forum-yet the shouldice Hospital (non mesh repairs) has data showing less than 1% recurrence rates and less than 1% chronic pain. There it is in black and white-if a surgeon has a expertise in doing non mesh repairs these repairs blow out and are far superior in regards to both the recurrent rate and chronic pain rate of mesh repairs.
so when you hear a surgeon say that mesh is superior to non mesh repair it is really code speak for either the use of mesh or for the fact that they don’t have the expertise , confidence because they just don’t do enough of these type of non mesh repairs-which is a huge problem and disservice to patients. It’s a shame that one has to travel to another country for a non mesh repair or at the very least travel out of state to see one of the few surgeons left who specialize in non mesh repairs. Sad.I completely agree with you except for one thing. You mentioned that you hope that in the near future surgeons will be equally trained in both mesh and non-mesh repairs so that not only can the patient be presented with a choice but receive expert care in either procedure. For the past 5 years, I have been executing non-mesh inguinal hernia repair that I have developed. Through such experience, I have developed strong conviction that non-mesh repair can be successfully applied to all patients with no exception.
At first, I was hesitant in writing this as it may be misunderstood as an act of advertising. However, I decided to speak my thoughts since the topic of the necessity of non-mesh repair came up, and I thought it’d be meaningful to share my experience based opinion.
I have been reading several posts on this forum and I have come to notice that the majority of participants have the perception that the patient’s body type or lifestyle decides whether mesh repair or non-mesh repair is suitable. I believe the objective here is to minimize recurrence and complications.However, I have not felt the necessity of mesh repair while performing only non-mesh repair on over 6,000 inguinal hernia patients for the past 5 years. There were many patients that I had to conduct partial omentectomy concurrently because they had incarcerated omentum, and many came to me due to recucurrence after open repair or laparoscopic repair. And there were two patients over 100 years old, some with massive ascites due to liver cirrhosis, and some receiving hemodialysis due to chronic renal failure. Furthermore, I treated a professional body builder who had to continue weight training even after surgery, a professional weightlifter who have to lift 200kg(440lb), and obese patients weighing over 100kg(220lbs). As such, I have performed non-mesh repair to very diverse patients. Yet, the recurrence rate is less than 1%.
Some doctors claim that non-mesh repair increases the risk of nerve injury and therefore can increase the frequency of chronic postsurgical pain compared to mesh repair. However, I do not agree with this. I believe you will agree with me on that it’s not logically admittable for an operation using absolutely no foreign matieral has a higher possibility of complications than an operation where a big plastic mesh is implanted in the body.
Thus, I do not believe there are certain cases where mesh repair or non-mesh repair is better.
I believe if an experienced surgeon takes an appropriate approach, non-mesh repair can result to successful outcomes for inguinal hernia patients in any sort of condition. A successful outcome here means very low possibility of recurrence and complications.Thank you!
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There is discussion to have Hernia fellowships, ie, extra training focusing on complex hernia repairs, Hernia-related complications. It would include tissue repair training. Some of us are involved and look forward to offering these fellowships. It may help deal with the drought of experts in this field.
[USER=”2491″]SomeGreyBIoke[/USER] – no data to support standard use of dissolvable meshes yet.
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Hi All,
What are your views on dissolvable meshes? I have got a very painful inguinal hernia and want to get it done asap, but wanted to be more educated about this subject.
Thank you for any answers in advance.
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A surgeon I saw on mesh repairs I felt gave a honest answer when it came to non mesh repairs. He said they were just as strong done by the right hands. However he said he didnt know how to do them and would not attempt them without being trained extensively by someone else. I think the training is becoming more and more difficult to get.
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Thanks for sharing Chaunce. Super important. Glad that Concerns regarding mesh seems to be making its way to the forefront. Hoping that in the near future surgeons will be equally trained in mesh and non mesh repairs so that not only can the patient be presented with a choice but receive expert care in either procedure.
the thing that I always come back to that is quite remarkable is the “mis-truths” that surgeons and the industry seem to spread regarding the inferiority of non mesh repairs-that they carry a higher recurrence rate than mesh-I’ve even heard this quoted by some surgeons on this forum-yet the shouldice Hospital (non mesh repairs) has data showing less than 1% recurrence rates and less than 1% chronic pain. There it is in black and white-if a surgeon has a expertise in doing non mesh repairs these repairs blow out and are far superior in regards to both the recurrent rate and chronic pain rate of mesh repairs.
so when you hear a surgeon say that mesh is superior to non mesh repair it is really code speak for either the use of mesh or for the fact that they don’t have the expertise , confidence because they just don’t do enough of these type of non mesh repairs-which is a huge problem and disservice to patients. It’s a shame that one has to travel to another country for a non mesh repair or at the very least travel out of state to see one of the few surgeons left who specialize in non mesh repairs. Sad. -
Chaunce, do you have a link to the internet forum thread with the surgeon’s discussion?
Many of the SAGES presentations end up on youtube. I don’t know who decides what gets released but I hope that the mesh discussions are.
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Just clicked the link: It think you may well find a bias towards mesh among the attendees if the focus is endoscopic surgery. Aren’t virtually all endoscopic/laparoscopic hernia repairs done with mesh? Perhaps there are a greater number of surgeons doing open repairs that are actually doing more tissue repairs?
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Are general surgeons properly incentivized to develop this type of specialty? With an increase in the number of doctors that are hospital/health system employees (vs. in private practice), and increasingly restrictive health insurance plans, it becomes a “take it or leave it” for patients.
As a general surgeon, I’m not sure that the ROI is there for learning these techniques so long as the belief is that the avoidance of mesh is about “patient preference” vs. better outcomes (at which point there will be an increasing interest in it).
Personally, this is why I’ve declined to do anything about the hernia I have: It’s not particularly bothersome, it’s unlikely to become an emergency overnight and I doubt that waiting will make it more difficult to treat if/when I do. Any potential damage from a mesh repair, however, is far harder to undo.
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