Inguinal Hernia: Phasix Resorbable Mesh and Resorbable Suture?

[ed]

i see you got your surgery. i just had a rt inguinal hernia done with phasix mesh. i had didn’t have much pain so far. almost 2 weeks now. not sure what they used for sutures. the Dr said he has been using phasix for about 5 years with minimal issues

• This reply was modified 7 months, 3 weeks ago by  ed.

[roger555]

This probably gives the best answer. Dr Kang gave me the choice to use either absorbable or non-absorbable sutures. He said that absorbable sutures have a recurrance of 2-3% whereas non-absorbable prolene sutures have a recurrance of .5%. He has done 20,000 hernia surgeries so I think that would be by far the biggest study there is.

It’s not an easy decision and I went with the prolene sutures which have been used over 100 million times on coronary bypass surgeries. Most of us ingest plastic every day from drinking bottled water and it doesn’ seem to cause serious problems. I think a small amount of toxins are detoxified or excreted by the body or stored in fat tissue and it’s only a problem when there is a toxic overload.

• This reply was modified 9 months, 2 weeks ago by  roger555.

[Côme]

Nice of him to give you the choice.

I had my surgery last week. Small (1.4cm), painless, uncomplicated, right side, very lateral, indirect hernia.

I had agreed with the surgeon that if he was to judge the quality of my tissues good enough and the intra-operative situation fitted for the use of entirely absorbable sutures, I would prefer that he uses them.

In the end he told me that tissues were good enough, the fact that it was very lateral and uncomplicated made him decide for kind of minimal repair (an interesting variation of the Shouldice) along with entirely long-term absorbable sutures.

Minimal Repair technique of sportsmen’s groin: an innovative open-suture repair to treat chronic inguinal pain
-> https://www.hernien.de/fileadmin/docs/Minimal-Repair.pdf

Also on the hypothesis that my collagen metabolism will be good enough to strengthen the repair.

This question of collagen metabolism is rarely taken into account, just like nutrition. As someone into high level sports, I did a lot on the nutrition level before the surgery and now during the recovery, including diet, collagen intake, chondroitine and glucosamine intake, various minerals and vitamines (see the study down there), glutamine and arginine, curcumine and peperine, etc. Many of those could help with wound healing and help maintain a high enough concentration of those nutriments in the wound area.

Pre-operative and post-operative nutrition can really help, if not the speed of recovery, at least the quality of the recovery and most doctors ignore entirely this aspect :

Multinutrient
Supplementation Increases Collagen Synthesis during Early Wound Repair
in a Randomized Controlled Trial in Patients with Inguinal Hernia
-> https://www.sciencedirect.com/science/article/pii/S0022316622021277

I’m at day 8 of recovery and everything is getting better day after day, off painkiller at day 5. The first few days are no joke through, but mostly because of the propofol and fentanyl used for the sedation.

• This reply was modified 9 months ago by  Côme.

[drtowfigh]

It would be great if Dr. Kang would publish his study.

[drtowfigh]

Bienvenue to our Forum.

– the short stitch trial is relevant to abdominal wall hernias, not inguinal

– tissue based repairs are an excellent option for you based on your need to remain extremely flexible

– absorbable mesh for inguinal hernias is not standard and has a high risk of recurrence.

[Côme]

Thank you for your answer.

Based on what I’ve read, the recurrence risk is pretty much the same. There isn’t much recent study, but from the 4 studies I could find, one states clearly comparing non-absorbable polypropylene or absorbable polydioxanone suture threads : “Recurrence rates in both groups were higher than expected, but there was no difference between the two groups.” ( https://pubmed.ncbi.nlm.nih.gov/10365834 )

I’m still hesitating on that. And while most studies seem reassuring, most surgeons seem to be afraid of that, so it creates a gap between surgeon’s feedbacks and scientifical studies, make it hard to decide.

Here too, not directly about inguinal hernia but for abdominal closure : “Conclusion Primary and secondary outcomes manifested that PD Synth and PDS slowly
absorbed polydioxanone sutures are clinically equivalent, and can be
used for abdominal fascial closure following midline laparotomy.” https://pubmed.ncbi.nlm.nih.gov/38205458/

And of course the Desarda study of polydioxanone suture with no reccurence : https://pubmed.ncbi.nlm.nih.gov/19568520/

I found the old study (1996) that states 5.22% reccurence (but not sure if it is Polyglycolic sutures or PDS sutures) rate compared to iron wires in Shouldice, but since then most studies seem to prove otherwise compared to prolene sutures…

My surgeon told me he would let me choose as long as I understand the risk. But this divergence between studies and surgeons make it hard to decide.

• This reply was modified 9 months, 2 weeks ago by  Côme.

[Côme]

The more I dig into it, the more it seems that absorbable sutures in open meshless surgery, result in less pain and about the same risk of recurrence :

Less pain

A comparative study of inguinal hernia using
monofilament non-absorbable suture versus monofilament absorbable suture
in Lichtenstein tension free hernia repair at tertiary care government
hospital

“Monofilament absorbable suture is associated with less chronic groin pain and compared to monofilament non-absorbable sutures.”

https://www.ijsurgery.com/index.php/isj/article/view/5011

Late absorbable sutures comparable (very slight increase in risk) to non-absorbable sutures in open Shouldice :

“… whereas the outcome of repair using late absorbable sutures did not
differ significantly from that with non-absorbable material.”

https://academic.oup.com/bjs/article/90/8/1004/6143297

[Good intentions]

You are conflating mesh repair results with pure tissue results. And, as is common with many of these types of studies, the data set is small and the time frame is short. Many of these studies are essentially worthless. A simple question is posed, poor work is done, and the results are presented as fact. Look at the numbers reported and the margin of error. It’s nonsense.

“A comparative study of inguinal hernia using monofilament non-absorbable suture versus monofilament absorbable suture in Lichtenstein tension free hernia repair at tertiary care government hospital.”

“Results: Total 152 patients of unilateral or bilateral inguinal hernia were studied 76 in each group. Chronic groin pain mean visual analogue scale score at 3 months was higher in group with non-absorbable suture compared to monofilament absorbable group (1.3±0.9 v/s 0.95±0.8 p value <0.05).”

[Côme]

Most of the studies I posted above are about mesh less repair. In the last study, the data set on reccurence’s risk is huge : Between 1992 and 2000 and 46 745 cases.

I honestly don’t see where this fear comes for surgeons if it isn’t backed by research. Perhaps the idea of something permanent told “hold it up” is reassuring, but the studies are clear : statistically it’s not necessary.

I have been searching and reading because leaving a foreign body, even as small as the suture thread, generates fibrosis and inflammation (which are definitely not good thing to have permanently in your body).

The question remains open for me but I really don’t see where this fear of absorbable sutures come from (given that the tissues quality is good enough to regenerate and recover its strength / elasticity).

• This reply was modified 9 months, 2 weeks ago by  Côme.

[MarkT]

As I have done here in the past, I would caution readers against simply accepting the conclusions of authors without taking a deeper dive…

I had a quick look at the study <font face=”inherit”>concluding less pain with absorbable sutures vs. non-absorbable (Patel et al., 2019) since I found it interesting that suture material would be implicated as meaningfully relevant.</font>

<font face=”inherit” style=”font-family: inherit; font-size: inherit;”>Note the study had a small sample size, a short (inadequate) follow-up timeframe, and (IMHO) a problematic and overly simplistic methodology. Marginally statistically </font>significant<font face=”inherit” style=”font-family: inherit; font-size: inherit;”> findings aside, it is simply not possible to conclude from this study that any difference in pain was attributable to the suture material. The authors do not appear to have accounted for various patient, hernia, or surgeon characteristics (many of which have been implicated as relevant to post-op outcomes), and merely randomizing patients into suture groups does not address this shortfall. Further, they even noted that some patients had bilateral repairs, and in their own limitations acknowledge that different surgical teams were involved, yet apparently accounted for neither. </font>Personally, I would place very little weight on the conclusions from this study.

As an aside, it is also worth keeping in mind that there is quite a difference between ‘foreign body’ issues with mesh vs. sutures, given the size and placement of mesh and given that concerns with mesh extend well beyond inflammation.

[Côme]

Next week, I’m scheduled for a mesh-less repair of my inguinal hernia by a specialized surgeon. While I’m not overly concerned about pain, the potential for fibrosis and inflammation without pain is still a consideration I have.

Regarding pain, I am of the belief that most it mostly arises from suboptimal surgical techniques, such as poor nerve management or improper mesh placement.

“… in daily practice, surgeons identify all three inguinal nerves as three single nerves in less than 40% of the cases, while the literature shows that this identification can be done in 70-90% of the cases. The challenge is that the course of both ilioinguinal and iliohypogastric nerves is found to be consistent with that described in anatomical texts in only 42% of patients. However, these anatomical variations are readily identifiable.” (https://en.wikipedia.org/wiki/Post_herniorraphy_pain_syndrome)

I have confidence that the surgeon will prioritize a meticulous approach to minimize any potential pain. However, I’m still deliberating between opting for a late-absorbable or non-absorbable suture.

• This reply was modified 9 months, 2 weeks ago by  Côme.

[Good intentions]

Thanks for the reply Mark T. I did read through the last paper cited. I had written some comments about unintended bias by researchers trying to prove an opinion rather than finding or defining the truth of a situation. It is a big problem, especially in the medical field where many of the authors don’t seem to have real training in reearch methods. Many of them want to state a clear conclusion when the data just says “we can’t tell a difference”. Or the difference is real but it’s very small.

One thing that I haven’t seen described explicitly is how fixation via sutures or tacks affects the shrinkage of the mesh. Shrinkage is well-known, but nobody seems to ponder how the fixation points of the mesh are pulled by the shrinkage. It seems obvious when visualizing what must be happening. But it is not discussed. Does fixation stop shrinkage but create tension? Or does shrinkage happen anyway but pull the fixation material through the tissue it’s attached to?

Overall though, the one constant is the knitted mesh structure. All of the synthetic fiber meshes consist of an assembly of many tiny knots through which nerves, veins and new tissue form. It’s very cheap to make, it’s just aquarium fishnet material, and very profitable. I think that there are new ideas in the mesh maker companies but they are not supplying the funding to develop them. The lawsuits might drive them to do so in the future. It’s all the motivation that they have. The surgeons just keep going around in circles studying different ways to use bad materials. My standard soapbox proclamation.

By the way, if you “paste as plain text” all of the extra formatting garbage will get left behind.

Still a shame that people’s posts get sprinkled randomly through the threads instead of chronologically. Hard to understand. Even Dr. Towfigh must have trouble reading her own comments.

[Côme]

I understand but all this concern mesh-related problems. Again here I opted for a mesh-less solution, so the only real question for me (as I’m not doing it for the sole sack of science) is about the suture material.

Originally I came here to find people who had mesh-less repair with absorbable sutures to get a per-case but nonetheless important feedback of their experience. But they are obviously hard to find…

[Good intentions]

Actual experiences will definitely be hard to find especially on this forum since traffic has dropped so dramatically. Beside the fact that there is so much chaos across all forms of hernia repair.

Don’t overlook that the Shouldice repair has been done with stainless steel sutures for decades.

It’s not clear what you’re trying to define. Looks like you might be looking for the perfect repair, taking you all the way back to undamaged tissue with no foreign material inside. That is a dream, I think.

I went through that large study paper again and see that they don’t really define why anyone would choose even a late absorbable suture over a permanent one. They seem to imply that a permanent suture “might” be more likely to allow a recurrence. But that doesn’t really make sense. They don’t talk about pain at all. So, why use absorbable at all? What is the potential benefit? They don’t say. They just did a study about recurrence rates by suture material, and reported what most people would expect. Permanent gives the lowest recurrence rate.

For some reason they also blended in Shouldice versus other non-mesh methods. Really, kind of an odd paper. “By the way, Shouldice is better…”

[Côme]

It seems pretty obviously to me that the human body isn’t made to hace foreign synthetic material inside it. I think its reaction to it (basically encapsulating through fibrosis) is clear enough.

I have read the Dasarda paper that claim such a solution, what I didn’t like is that it takes undamaged tissue from a fascia to repair the defect, basically damaging another tissue.

If the absorbable suture is only 0.5% more likely to generate a reccurence compared to non-absorbable, I think it’s a low enough risk to try not leaving any foreign material inside my body that could cause regular fibrosis and inflammation.

https://scholar.google.fr/scholar?q=fibrosis+inflammation+scarring+cancer&hl=fr&as_sdt=0&as_vis=1&oi=scholart

• This reply was modified 9 months, 2 weeks ago by  Côme.

scholar.google.fr

Google Scholar

Google Scholar

[Good intentions]

The numbers that you just cited come from a paper in which the researchers thenselves concluded that permanent (non-absorbable) or “late absorbable” (long-lasting) sutures are both recommended. They don’t distinguish between the two, so, in other words permanent is just as good as late absorbable. As fas as reoperation is concerned.

If you read more about absorbable sutures you might find that they don’t react the same way in the people that they are used in. Why take a chance on an absorbable suture if a permanent suture gives the same results? That seems a reasonable cause for “fear”. Fear of the unknown.

It is interesting though that they don’t mention pain at all. The paper was published in 2003. The primary author did eventually get involved in pain studies though. Here’s one from 2020.

https://www.sciencedirect.com/science/article/abs/pii/S0039606019307676

“Discussion

This nationwide registry-based questionnaire study showed a high prevalence of chronic pain 1 y after open, anterior mesh repair of 14.8% for self-gripping mesh and of 15.7% for lightweight sutured mesh. We observed no difference regarding the prevalence of chronic pain and recurrence between the 2 types of mesh; however, the use of self-gripping mesh was associated with a markedly decreased operative time.

This study represents a large number of patients, and the high rate of chronic pain…”

sciencedirect.com

Just a moment...

Just a moment...

[Côme]

Update : so it seems that Monomax isn’t suitable for inguinal hernia because its elasticity is too high, it is used to abdominal wall closure. Therefor it seems that, at this moment, only polydioxanone (PDS) is suitable as an absorbable thread for inguinal hernia.

Did anyone had polydioxanone sutures ? Feedback ?