Mesh: Must Avoid or Must Have? 2018 SAGES Meeting

[Chaunce1234]

quote Good intentions:

I wrote half a page Chaunce but I’ll try to condense it. Before the mesh I was a very active member of society and family, engaged in many ways. With the mesh, my life slowly shrank down to a daily check of the state of the mesh site, and a plan for how I was going to try to make it better, today. I wouldn’t say that I was clinically depressed but I knew that my life was much worse. I was more frustrated and angry than depressed.

Now, with the mesh gone, I am planning weeks, months, and years ahead. I’m getting better, physically, every day, and that allows me to be healthy, mentally and emotionally.

One important thing for me though was that I had resources, money in the bank, and time, to solve my new mesh problem. So I had hope. The problems that you are describing will be made much worse for people who aren’t as lucky as I am. I had the ability to find a solution. Many people don’t, and their symptoms are denied when they seek help, as has been documented in many stories.

I think that if this situation was a project under a single entity, like a large corporation, it might have been halted already, just based on a comparison of the old way of hernia repair versus the new way. The new way is full of problems that never existed before.

That makes perfect sense and it follows my belief that the “psychological” symptoms are a result of the discomfort/pain/etc – how can someone be in constant pain and not be bothered by it? Of course there are different brain-level things that can occur when chronic pain has caused changes to how the brain processes pain or sensitivity, and I am not sure how that is addressed or if it’s being studied with regard to groin pain and/or post-herniography pain. Some practitioners believe in treating the pain first as if it’s a separate entity, but how does anyone really know if the pain is caused by the hernia, or the mesh? And what if it is caused by that, how could that be treated first before having a surgery?

“I think that if this situation was a project under a single entity, like a large corporation, it might have been halted already”

I certainly agree with that statement. My particular industry would fail immediately with even a 1% failure rate, as I think most other fields and businesses would fail too. So it’s hard to imagine it acceptable for 15% to 35% of surgeries to be failing in some way or another in a catastrophic way with chronic pain and that is considered normal or tolerable. It’s all the more absurd given the ongoing assault on chronic pain patients, nobody would be needing the pain pills or expensive and tedious pain management if they did not have the chronic pain to begin with.

[MO]

quote Good intentions:

I just came across this recent video by Dr. Bruce Ramshaw. There might be others from the session, I haven’t looked yet.

It’s an interesting and thoughtful presentation about the current state of the “mesh” repair problem. The whole thing is worth watching. A few specific things caught my attention.

He describes the huge number of “mesh” variations at one point but then later does not distinguish between the variations when showing explanted mesh properties. I think that in his mind they might still all “be” the same. Even though he is working with several device makers and should be well-versed in the qualities of the different materials. He is either not seeing any differences because there are none or the test procedures aren’t recording those differences. Is Gore’s PTFE no different than Bard’s polypropylene, for example? Is there room for improvement by tailoring material properties to the problem?

At ~3:48 he says that misinformation to patients is causing “negative cognitive neural wiring in their brain that results in poor outcome”. I had to watch it several times to be sure that’s what he said. It seems to be along the “it’s all in your head” explanation. Not sure what to make of that comment. My neural wiring was well-developed to have a fantastic outcome when I had mesh implantation. I actually had to overcome that neural wiring to realize that I would have to deal with the real physical problems that the mesh caused.

Later, at ~5:35 he shows how the various combinations of mesh and patient lead to dramatically different compliance properties in the body, measured from explanted meshes. Real differences in physical properties, explaining the stiff “boardy” feeling from the mesh that many patients end up with. That doesn’t jibe with the psychosomatic approach.

At the end he suggests that open pure tissue repair should be an option for patients that don’t want mesh, and that the possible complications of that approach should be discussed with the patient.

Another promising development, but there’s a long way to go.

In this video he stated that patients should be allowed to choose between mesh repair, non-mesh repair and watchful waiting. I know an intellectually challenged person who is afraid to go to unknown doctors that may insist he have his painless hernia repaired.

It is HUGE that Dr. Ramshaw cares about the right of patients to make informed decisions.

[Jnomesh]

Two things. When researching surgeons for mesh removal I had spoken to people who had mesh removed by Ramshaw and they all said before mesh removal the did have to take/complete some cognitive behavioral program. What was expressed to me was the program was meant to help with the recovery process after removal. I have no idea what the content was all I knew from my end was there was already a long with to get get a consultation with Ramshaw (this was almost 2 years ago) and I couldn’t imagine with the pain I was going through that I’d have to finish a program after waiting so long to get a appointment .
Which leads me to a point that I think reinforced what good intentions was saying. The word pain can mean different things to different people and I think most people associate the word pain with what they have experienced during their lifetime.
i think I’d describe this as “normal pain”. Not that it isn’t and can’t be debilitating but it’s what we experience with a pulled back, strained neck, stomach virus, broken bone or strained ligaments.
From my Personal experience and form others I speak too the “pain” I had from mesh was like nothing I had ever experienced. And it was so GM is k and effected a lot of things. Because the mesh is so large and in laparoscopic procedures can infiltrate so many anatomical areas : the bladder, the colon, spermatic cord, nerves etc the potential for systematic complications are great. That being said the “pain” was so different and awful. It was a gross pain. And when you consider the area in which the mesh is inserted for inguinal hernias the male private area can be awfully affected.
For me the onset of symptoms felt like I was being operated on but I was awake. It felt mine I was being ripped apart inside. This then turned into a sever burning in the groin and thigh-like I was being burned alive. When I told this to one friend he said come on if you were being burned alive you’d be in the emergency room. But this is what it felt like especially when sitting.
I also had a feeling like a brick was stuck in my abdomen-don’t think many people ever felt that kind of pain, I also had a feeling that something was tightening or clamping down on a area near my genetalia
i had to urinate often and it would take a while for the pee to come out, the urine stream was weak and would stop and start. My private always felt like they were under pressure-like one was being immersed in a cold tank of water but this lasted all day and night.
low labido.
Difficulty deficating
My lower stomach would feel swollen for days if I lifted something somewhat heavy.
All these crazy symptoms and I didn’t even experience a lot of the traditional “pain symptoms “ from mesh like a stabbing pain or infection
So when I hear a surgeon say traditional non mesh repairs have “pain” symptoms too I’m like no way can a puré tissue repair cause this global
“pain” that mesh can cause.
it can be truly devastating. You literally don’t feel normal anyway-the anatomy itself feel grossly different in a disgusting way.
I would tell people all the time I don’t feel whole.
It was in essence kind of inexplainable. If a hernia surgeon had these “pain “ symptoms after having mesh inonanted in them I think they would understand so much more.

[Good intentions]

quote Chaunce1234:

More specifically, I meant to ask you if your experience with feeling pain and discomfort impacted you in any mental or psychological fashion, basically as a side effect of experiencing the pain. For example, did you develop any sort of depression or insomnia due to the pain or discomfort you experienced? Or anything of that nature? And if you had, did you find those psychological side effects of dealing with pain to change again after your second procedure to remove the mesh?

I wrote half a page Chaunce but I’ll try to condense it. Before the mesh I was a very active member of society and family, engaged in many ways. With the mesh, my life slowly shrank down to a daily check of the state of the mesh site, and a plan for how I was going to try to make it better, today. I wouldn’t say that I was clinically depressed but I knew that my life was much worse. I was more frustrated and angry than depressed.

Now, with the mesh gone, I am planning weeks, months, and years ahead. I’m getting better, physically, every day, and that allows me to be healthy, mentally and emotionally.

One important thing for me though was that I had resources, money in the bank, and time, to solve my new mesh problem. So I had hope. The problems that you are describing will be made much worse for people who aren’t as lucky as I am. I had the ability to find a solution. Many people don’t, and their symptoms are denied when they seek help, as has been documented in many stories.

I think that if this situation was a project under a single entity, like a large corporation, it might have been halted already, just based on a comparison of the old way of hernia repair versus the new way. The new way is full of problems that never existed before.

[drtowfigh]

From what i understand, Dr Ramshaw’s protocol submitted all patients with chronic pain into a Cognitive Brain Therapy session. Once they completed that, they were ready for their surgical care.

[Chaunce1234]

quote Good intentions:

I mentioned in the first post, quoted below. I do not have any psych problems that I know of. No treatment, or thoughts of seeking help. I’m lucky. I thought that I would get my simple direct hernia problem fixed and be back to living my full and healthy life.

” My neural wiring was well-developed to have a fantastic outcome when I had mesh implantation. I actually had to overcome that neural wiring to realize that I would have to deal with the real physical problems that the mesh caused.”

By that I meant that I believed that I would be okay. I had the bias that many healthy people have toward others with problems, that they must be unhealthy or out-of-shape, or old, or whatever other rationalization that people use to believe that they’ll be better off than the unlucky ones. I had a friend who was a surgeon who had had his own hernia in the past, who recommended the surgeon who did the repair. The surgeon was accomplished, well-respected, chair of surgery, at a big clinic. I had the state-of-the-art TEP repair using light weight Bard Soft Mesh. Everything said that I should be a poster-person for how to make the right decision and get a good result.

My issues, besides the discomfort and pain, were some that I cannot imagine are psychological. Penis issues, not just ED, bowel issues – bowel movements the size of a cats, physical manifestations like a very tight and flat abdomen, almost like a drum head. Feeling the edges of the mesh poking in to my groin, and irritated at the center where they had originally overlapped.

I even tried to work up some sort of routine where I could do healthy things like biking or running, then wait a few days for the problems to disappear. But the overall trajectory was down, getting less and less healthy, unable to focus on things after exercise, realizing that whole weeks were passing by where I hadn’t really accomplished anything. I was taking care of my mesh, like it was a baby, it was my sole focus.

The main reason that I am more active here is because the mesh is gone.

For clarification, I don’t mean to suggest that pain is a psychological problem or in the realm of psych issues. I’m strongly of the opinion that pain is the primary symptom of a problem, and that experiencing pain is what might then cause a brain-related or psychological side effect. If someone is miserably uncomfortable or experiencing pain all the time, or had a failed surgery, it is no surprise (to me) if they might then feel down, depressed, anxious, have insomnia etc, as those are simply side effects of experiencing the pain in the first place.

More specifically, I meant to ask you if your experience with feeling pain and discomfort impacted you in any mental or psychological fashion, basically as a side effect of experiencing the pain. For example, did you develop any sort of depression or insomnia due to the pain or discomfort you experienced? Or anything of that nature? And if you had, did you find those psychological side effects of dealing with pain to change again after your second procedure to remove the mesh?

Where I think pain gets more complicated, and into the realm of neural plasticity or some other brain change, is when pain persists despite the cause of the pain being remedied through corrective surgery, and it’s for those situations where I wonder if the cutting-edge pain management therapies aimed at neural plasticity could be particularly beneficial.

[Good intentions]

quote Chaunce1234:

[USER=”2029″]Good intentions[/USER] do you mind sharing if you had any of the brain-related aspects of chronic pain, and how or if they developed or changed before and after your particular surgery?

I mentioned in the first post, quoted below. I do not have any psych problems that I know of. No treatment, or thoughts of seeking help. I’m lucky. I thought that I would get my simple direct hernia problem fixed and be back to living my full and healthy life.

” My neural wiring was well-developed to have a fantastic outcome when I had mesh implantation. I actually had to overcome that neural wiring to realize that I would have to deal with the real physical problems that the mesh caused.”

By that I meant that I believed that I would be okay. I had the bias that many healthy people have toward others with problems, that they must be unhealthy or out-of-shape, or old, or whatever other rationalization that people use to believe that they’ll be better off than the unlucky ones. I had a friend who was a surgeon who had had his own hernia in the past, who recommended the surgeon who did the repair. The surgeon was accomplished, well-respected, chair of surgery, at a big clinic. I had the state-of-the-art TEP repair using light weight Bard Soft Mesh. Everything said that I should be a poster-person for how to make the right decision and get a good result.

My issues, besides the discomfort and pain, were some that I cannot imagine are psychological. Penis issues, not just ED, bowel issues – bowel movements the size of a cats, physical manifestations like a very tight and flat abdomen, almost like a drum head. Feeling the edges of the mesh poking in to my groin, and irritated at the center where they had originally overlapped.

I even tried to work up some sort of routine where I could do healthy things like biking or running, then wait a few days for the problems to disappear. But the overall trajectory was down, getting less and less healthy, unable to focus on things after exercise, realizing that whole weeks were passing by where I hadn’t really accomplished anything. I was taking care of my mesh, like it was a baby, it was my sole focus.

The main reason that I am more active here is because the mesh is gone.

[Good intentions]

quote drtowfigh:

As you know, many undergo what we believe is the right approach to address their chronic pain but they are not cured of their symptoms. Dr Ramshaw has shown that that negative result may be related to the unaddressed neural wiring side effect of chronic pain that is not addressed by the operation.

Are the symptoms new symptoms, from the surgery and/or the mesh, or are they the old symptoms from the hernia?, would be a clarifying question.

I think that much of this problem gets lost in the description and definition of “pain”, maybe assuming that the pain is from the original problem. A cognitive bias toward believing that the mesh should not cause pain. My problems were definitely tied to the mesh. I was better before the mesh, and am better after its removal. Time with the mesh implant was the worst.

[Chaunce1234]

quote drtowfigh:

Dr Ramshaw’s discussion abaiut neural wiring is based on his research and that of others:

Patients with chronic pain suffer from somatic and neuropathic pain in their body. They also suffer psychologically from the chronic pain. This manifests in depression, PTSD, anxiety, insomnia, etc.

he he has shown that patients who can get attention to the brain-related negative effects of chronic pain will have a better outcome from the surgical approach to treating the chronic pain (eg, by mesh removal). As you know, many undergo what we believe is the right approach to address their chronic pain but they are not cured of their symptoms. Dr Ramshaw has shown that that negative result may be related to the unaddressed neural wiring side effect of chronic pain that is not addressed by the operation.

This is fascinating, that might suggest for patients with chronic pain it may be beneficial to follow corrective surgery with some of the more cutting-edge pain management approaches that are aimed specifically at neural plasticity.

Things like intensive learning focused on mentally taxing endeavors (like math, programming, puzzles, learning foreign languages, learning to play music), ketamine infusion therapy (currently cost prohibitive for most), medical marijuana, neurofeedback, transcranial magnetic stimulation, physical therapy and exercise, etc might be particularly helpful for those patients. Hopefully studies will be done on this, it’s a very important topic.

[USER=”2029″]Good intentions[/USER] do you mind sharing if you had any of the brain-related aspects of chronic pain, and how or if they developed or changed before and after your particular surgery?

[Good intentions]

Here is the TAPP presentation from the “Perfect Repair” series. Shows how it’s done, says it as “just as good” as any other method. At the end he just says “pick what you’re good at”. He did not really address long-term complications at all.

One thing I realized as I watched this one was that none of the presentations addressed pure tissue repairs, except Dr. Ramshaw’s, whose presentation was not actually in the “Perfect Repair” session. They are just comparing the mesh procedures. The title of the session should have been “Perfect Mesh-Based Hernia Repair”. And, as in the others, time and money are major concerns. The economics of health care are driving much of what is happening.

TAPP repair: Who, when, how & why? – YouTube
https://www.youtube.com
This talk was presented at the 2018 SAGES Meeting/16th World Congress of Endoscopic Surgery by Jacob Andrew Greenberg during the The Great Video Debate: Perf…

[Good intentions]

quote drtowfigh:

Dr Ramshaw’s discussion abaiut neural wiring is based on his research and that of others:

Patients with chronic pain suffer from somatic and neuropathic pain in their body. They also suffer psychologically from the chronic pain. This manifests in depression, PTSD, anxiety, insomnia, etc.

he he has shown that patients who can get attention to the brain-related negative effects of chronic pain will have a better outcome from the surgical approach to treating the chronic pain (eg, by mesh removal). As you know, many undergo what we believe is the right approach to address their chronic pain but they are not cured of their symptoms. Dr Ramshaw has shown that that negative result may be related to the unaddressed neural wiring side effect of chronic pain that is not addressed by the operation.

Actually, the start of his comment was “influence from outside of healthcare, the lawyers” as the source of that “misinformation”. He didn’t explain clearly that he meant that the patient had inherent psychological problems. He almost explicitly blamed other people for putting ideas in to patients’ heads.

Looked at alongside his other comment “Let me be clear: mesh does not cause chronic pain”, he seems like somebody struggling to know what to believe himself. You can find him on both sides of the debate.

He seems like a great guy, and hard-working. But there does seem to be some internal conflict and bias to his comments. I wish him well with whatever his new situation is.

[Good intentions]

Here is the TEP video from the “Perfect Repair” series. The presenter shows how she does her TEP repair, but at the end, even though she says it’s not a competition, it’s a debate, she “bashes” the other methods. Maybe trying to be funny, but there was no pros versus cons comparison to the other methods. I assume that it happened in the discussion.

The video also shows the dramatic difference in amount of dissection, between TEP and open mesh implantation. TEP splits open a very large are in the abdomen, side-to-side and top-to-bottom, then places mesh in that space. Very large pieces, she says “at least” 4 x 6″ pieces should be placed You can imagine a voice in the surgeon’s head saying “I really really hope this person does not have a mesh reaction”. Open repair is very focused on only the defect, TEP is a big exploration.

TEP really is a go-for-broke approach, huge dissection, peeling apart tissues in the most sensitive area of the body, and large placement of a potentially dangerous material. It looks so clean and neat but when you really look at what’s happening, it seems like a very drastic approach. I appreciate even more the time that Dr. Billing took to remove all of the two 6×6″ pieces that were placed in me. It takes much more time to undo a TEP placement than the few minutes it takes to put it in there.

TEP repair – YouTube
https://www.youtube.com
This talk was presented at the 2018 SAGES Meeting/16th World Congress of Endoscopic Surgery by Archana Ramaswamy during the The Great Video Debate: Perfect I…

[drtowfigh]

Dr Ramshaw’s discussion about neural wiring is based on his research and that of others:

Patients with chronic pain suffer from somatic and neuropathic pain in their body. They also suffer psychologically from the chronic pain. This manifests in depression, PTSD, anxiety, insomnia, etc.

he he has shown that patients who can get attention to the brain-related negative effects of chronic pain will have a better outcome from the surgical approach to treating the chronic pain (eg, by mesh removal). As you know, many undergo what we believe is the right approach to address their chronic pain but they are not cured of their symptoms. Dr Ramshaw has shown that that negative result may be related to the unaddressed neural wiring side effect of chronic pain that is not addressed by the operation.

[Good intentions]

quote Chaunce1234:

It is curious to me that this particular subject seems to defy all laws of supply and demand. You’d think given the large number of consumers (patients) interested in pure tissue repairs, that the market would respond and there would be a significant supply of surgeons growing to meet that demand for non-mesh repairs, but that does not appear to be happening.

Dr. Ramshaw talks often about the business aspects of medicine. Much of what’s happening now is due to pressure to standardize health care. One common solution covering all of the patient variations. It’s not really a free market supply/demand situation. It’s like the old joke about Henry Ford’s first cars, and choice of color – you can have any color you want as long as it’s black.

[Chaunce1234]

quote Good intentions:

At the end he suggests that open pure tissue repair should be an option for patients that don’t want mesh, and that the possible complications of that approach should be discussed with the patient.

I wholeheartedly agree with that statement.

Unfortunately there are fewer and fewer surgeons who are able or willing to perform a pure tissue repair, so I am not sure where these suggestions of offering pure tissue repairs to interested patients will be implemented.

It is curious to me that this particular subject seems to defy all laws of supply and demand. You’d think given the large number of consumers (patients) interested in pure tissue repairs, that the market would respond and there would be a significant supply of surgeons growing to meet that demand for non-mesh repairs, but that does not appear to be happening.

[Good intentions]

Here is a video titled “Inguinal hernia-Open mesh repair” in the “Perfect Inguinal Hernia Repair” sub-category. It’s really just a collection of “state-of-the-art” techniques, I believe. No actual measurement of “perfection”.

It doesn’t really instill confidence. The presenter makes an off-hand comment that if the patient has a non-painful hernia when they come in that they will certainly not have pain afterward. “They’ll be fine” at 4:00. He cites a one year study. This does not fit with many stories on this forum and around the internet. People who got their hernia repaired to be safe, and ended up with more pain afterward. Anecdotal, of course. The pain discussion starts at 2:50.

Inguinal hernia-Open mesh repair – YouTube
https://www.youtube.com
This talk was presented at the 2018 SAGES Meeting/16th World Congress of Endoscopic Surgery by Matthew I Goldblatt during the The Great Video Debate: Perfect…

[Good intentions]

Here is a link to the whole 2018 “playlist”. There are a few more hernia, and mesh, presentations.

SAGES 2018 Annual Meeting – YouTube
https://www.youtube.com