Mesh Question For Doctors

[Good intentions]

Implantation and removal might be getting mixed up here. It’s difficult to remove mesh via TEP. TEP basically means keeping the peritoneum intact during the procedure, entering at a single point and splitting the peritoneum from the fascia to create a space to work in. Dr. Towfigh has said in past posts that sometimes she is able to do a TEP removal. TEP is important because by keeping the peritoneum intact the chance of adhesions is almost zero.

TAPP was used to remove my TEP-implanted mesh. The abdominal cavity is entered and the intestines moved out of the way leaving the back of the peritoneum exposed. The mesh is located through the peritoneum and the peritoneum is cut to gain access to the mesh. It is then split away from its attachment points and removed. Then the peritoneum is closed up. Side effects are adhesions, apparently.

https://www.cochrane.org/CD004703/COLOCA_two-different-laparoscopic-techniques-for-repairing-a-hernia-in-the-groin

[bmul100]

[USER=”2042″]Jnomesh[/USER] I’m not following on the difference between TEP and TAP? I know my surgery was open and the mesh was 3d so it’s underneath and on top of the muscle, I think.

[USER=”1916″]Chaunce1234[/USER] I have not tried nerve block. My issue are with the immune system response and the inflammation and muscle pain. I’ve felt nerve pain but it comes and goes based on activity level and is not constant like the muscle pain, ringing in ears, etc.

[Chaunce1234]

quote Jnomesh:

Chaunce123,
agree. With mesh removal seemingly being done more often focus needs to be on products and ways to deal with the unfortunate event should the mesh need to be explanted.
BTW the surgeon I was speaking of who made the statement of removing TEP implanated meh was dr. Belyanski. The takeaway wasn’t that TEP placed mesh can’t be removed but that in his opinion or statement it is much more challenging to do so..

Interesting thanks for info, I was always under the impression that both TAP and TEP were basically the same, aside from initial approach, and so I assumed removal would be the same for either case too.

[Jnomesh]

Chaunce123,
agree. With mesh removal seemingly being done more often focus needs to be on products and ways to deal with the unfortunate event should the mesh need to be explanted.
BTW the surgeon I was speaking of who made the statement of removing TEP implanated meh was dr. Belyanski. The takeaway wasn’t that TEP placed mesh can’t be removed but that in his opinion or statement it is much more challenging to do so..

[Chaunce1234]

quote Jnomesh:

Amongst other things it would be a great step if surgeons would also consider mesh “type” and procedure “TAAP” vs TEP in regards to how easy or difficult it is to be removed/explanted.
i too have heard that a TEP procedure of implanted mesh is much harder to remove as one top removal surgeon said it would be much more difficult and like “filleting” the patient open.
The same removal surgeon also told someone the type of mesh he had was a kind that was berry difficult to remove.
Since we are dealing with a device that is meant to be permanent it seems logical that the only criteria shouldn’t be how well theoretically the mesh can fix the hernia but god forbid if the mesh needs to be removed how easily can it be.

It sounds like the important part for optimal outcome for these surgeries is using the same method of the original surgery – open for open, laparoscopic for laparoscopic.

I believe Dr Towfigh and Dr Belyansky both have significant experience with removing mesh that was placed with TEP (and presumably TAPP), on this forum I think [USER=”2029″]Good intentions[/USER] originally had a TEP repair that was successfully removed from Dr Billings. So I think it can be done with sufficient experience.

I agree that significant consideration should be put into how easy the products are to remove, not just to be place, in the event they need to be removed for any reason (pain, infection, complications, etc). I suspect that would require a redesign of mesh and maybe usage of different materials, or a combination of different materials. Maybe something like a patch where the edges are intended to be integrated into the tissue so it holds in place, while the interior of the patch is something truly inert (titanium?) that does not integrate at all? Or maybe there’s a material that would bond well, but easily be removed with the application of some adhesive removal? I don’t know, hopefully someone is doing heavy research on this stuff.

[Jnomesh]

Amongst other things it would be a great step if surgeons would also consider mesh “type” and procedure “TAAP” vs TEP in regards to how easy or difficult it is to be removed/explanted.
i too have heard that a TEP procedure of implanted mesh is much harder to remove as one top removal surgeon said it would be much more difficult and like “filleting” the patient open.
The same removal surgeon also told someone the type of mesh he had was a kind that was berry difficult to remove.
Since we are dealing with a device that is meant to be permanent it seems logical that the only criteria shouldn’t be how well theoretically the mesh can fix the hernia but god forbid if the mesh needs to be removed how easily can it be.

[Chaunce1234]

quote bmul100:

On my follow up the surgeon said that it’s one that shrinks a lot. I have spoken with another surgeon who said it was regarded as more difficult to remove due to it having two layers. Basically removing it leaves you with no flesh. But I am sure some of those comments vary based on the surgeon and their technique.

Have you tried nerve block and/or steroid injections or anything of that sort? If so, did it provide any relief? It might be helpful to find a doctor with significant experience in dealing with post-hernia surgery complications.

If you’re considering a re-do surgery or thinking about mesh removal, find an expert on those specific surgery types. There are not many surgeons with a ton of experience removing hernia mesh or dealing with PHPS problems, and so you would want to speak with one who has managed the conditions, done the related procedures many times and preferably with the same type of mesh you have, and of course with good outcomes.

If you feel like sharing your general location, perhaps someone on this forum could offer a doctor that is somewhat near to you. You may need to travel to find an expert with sufficient experience.

[bmul100]

quote Good intentions:

Your description sounds like the Prolene Hernia System. I don’t think that it is impossible to remove. It might actually be easier than removing a full coverage TEP mesh placement, since it’s localized to the groin and inguinal canal.

Thanks. I think that is it but am trying to get the details to verify. On my follow up the surgeon said that it’s one that shrinks a lot. I have spoken with another surgeon who said it was regarded as more difficult to remove due to it having two layers. Basically removing it leaves you with no flesh. But I am sure some of those comments vary based on the surgeon and their technique.

[Good intentions]

quote bmul100:

a complex 2 layer mesh inside that is next to impossible to remove.

Your description sounds like the Prolene Hernia System. I don’t think that it is impossible to remove. It might actually be easier than removing a full coverage TEP mesh placement, since it’s localized to the groin and inguinal canal.

Just posting so that you can add it to your list of options.

I saw your description in another topic of what seems like an allergic reaction. I know of at least one person who had that type of reaction from a second mesh placement, years after a successful mesh repair. He battled it for years.

It helps to be aware of all of your options so that you can make good decisions. You might start contacting surgeons who have removed mesh just to see if they recognize your symptoms.

Also, get the details of your surgery, including type of material, with lot numbers. Occasionally, bad materials are produced, even counterfeit. There is no guarantee that anyone will contact you if a recall happens. Best to keep your own records. Good luck.

[bmul100]

quote Good intentions:

If the industry is going to handle the situation by increasing “informed consent’ then the use of real numbers is even more important. Tell people the odds, that there’s a one in six chance that they might wish that they had chosen a non-mesh repair. They might have to have the mesh removed and there’s a chance that they will still feel discomfort and/or pain, for years afterward. That would be true informed consent.

In my case informed consent didn’t even come close to happening. Patients would probably be able to handle the expectations of these devices much better if they weren’t lied to during consultation by general surgeons. Why does everyone in the medical field say it’s inert when heavyweight polypropylene shrinks considerably? Those are facts. My surgeon looked me in the eye and told me he would hate for me to have to call him from the hospital if my hernia got stuck. I had a small indirect hernia as a completely healthy 30 year old. He stuffed a complex 2 layer mesh inside that is next to impossible to remove. Now every aspect of my life has come to a screeching halt. It seems unconscionable that this is happening in modern medicine. Generally speaking doctors that use these devices without informed consent are not helping people feel better. They are running a business with no regard for the outcome of their patients.

[dog]

My famous clients Beverly hills plastic surgeons told me

That in plastic surgery unwritten rule.” Don’t put anything inside if it cant be safely removed” .It just makes sense !

[drtowfigh]

A lot of great comments.

A surgeon hernia specialist is the best starting point as they will know whether you need a rheumatologist or allergist to get involved or if the mesh or operation needs to be surgically addressed.

In my my experience with mesh reaction patients, and we have published this, the blood tests are all normal.

[Good intentions]

quote drtowfigh:

The majority of patients fortunately do not clinically react to the mesh.

Those that do react must get their needs addressed by a specialist, as it’s an uncommon problem and specialists are the ones who see this problem more often and have an algorithm to address how to manage it (including need for surgery).

Hello Dr. Towfigh. Is using words like “majority” and “manage” really appropriate for this situation? It seems to be justifying the use of mesh, even though there are other hernia repair methods available that seem to give better results. 51% is a majority. That leaves 49% that do have a bad reaction.

What is the fundamental reason that mesh is used for hernia repair? It doesn’t seem to be that it’s best for the patients, on average. The results of a mesh reaction are terrible and tortuous. If you factor that in the situation is even worse. It seems that the industry is trying to save their “investment” in this new technology, forcing patients to “pay” with their own well-being. It’s counter to the reason that people become doctors, to help people, taking the Hippocratic oath at the end of their training. I can’t comprehend what is happening.

If the community of surgeons could start using real numbers, and accepting the fact that mesh might not be the wonder material that it seemed to be in the early days, or that maybe people have gone too far with mesh and need to pull back, there might be fewer patients needing to have their surgeon-caused problem to be managed. There is no mystery.

I really appreciate this forum and how you’re keeping it going. But we need to start using real numbers so that people understand the magnitude of the problem. Planning to manage problems that were created by the use of mesh seems unconscionable, especially when it is used on people that were otherwise very healthy.

If the industry is going to handle the situation by increasing “informed consent’ then the use of real numbers is even more important. Tell people the odds, that there’s a one in six chance that they might wish that they had chosen a non-mesh repair. They might have to have the mesh removed and there’s a chance that they will still feel discomfort and/or pain, for years afterward. That would be true informed consent.

Maybe I just don’t understand what it means to be a physician. Apparently, times are changing, see link below. No offense intended, I mean that sincerely, I know that it’s a difficult field with much happening these days. All the more reason though, to clearly expose these things before they grow.

[Good intentions]

quote drtowfigh:

The majority of patients fortunately do not clinically react to the mesh.

Those that do react must get their needs addressed by a specialist, as it’s an uncommon problem and specialists are the ones who see this problem more often and have an algorithm to address how to manage it (including need for surgery).

Hello Dr. Towfigh. Is using words like “majority” and “manage” really appropriate for this situation? It seems to be justifying the use of mesh, even though there are other hernia repair methods available that seem to give better results. 51% is a majority. That leaves 49% that do have a bad reaction.

What is the fundamental reason that mesh is used for hernia repair? It doesn’t seem to be that it’s best for the patients, on average. The results of a mesh reaction are terrible and tortuous. If you factor that in the situation is even worse. It seems that the industry is trying to save their “investment” in this new technology, forcing patients to “pay” with their own well-being. It’s counter to the reason that people become doctors, to help people, taking the Hippocratic oath at the end of their training. I can’t comprehend what is happening.

If the community of surgeons could start using real numbers, and accepting the fact that mesh might not be the wonder material that it seemed to be in the early days, or that maybe people have gone too far with mesh and need to pull back, there might be fewer patients needing to have their surgeon-caused problem to be managed. There is no mystery.

I really appreciate this forum and how you’re keeping it going. But we need to start using real numbers so that people understand the magnitude of the problem. Planning to manage problems that were created by the use of mesh seems unconscionable, especially when it is used on people that were otherwise very healthy.

If the industry is going to handle the situation by increasing “informed consent’ then the use of real numbers is even more important. Tell people the odds, that there’s a one in six chance that they might wish that they had chosen a non-mesh repair. They might have to have the mesh removed and there’s a chance that they will still feel discomfort and/or pain, for years afterward. That would be true informed consent.

Maybe I just don’t understand what it means to be a physician. Apparently, times are changing, see link below. No offense intended, I mean that sincerely, I know that it’s a difficult field with much happening these days. All the more reason though, to clearly expose these things before they grow.

https://www.beckershospitalreview.com/hospital-physician-relationships/millennial-physicians-opting-out-of-the-hippocratic-oath-in-favor-of-alternatives.html

[Good intentions]

quote drtowfigh:

The majority of patients fortunately do not clinically react to the mesh.

Those that do react must get their needs addressed by a specialist, as it’s an uncommon problem and specialists are the ones who see this problem more often and have an algorithm to address how to manage it (including need for surgery).

Hello Dr. Towfigh. Is using words like “majority” and “manage” really appropriate for this situation? It seems to be justifying the use of mesh, even though there are other hernia repair methods available that seem to give better results. 51% is a majority. That leaves 49% that do have a bad reaction.

What is the fundamental reason that mesh is used for hernia repair? It doesn’t seem to be that it’s best for the patients, on average. The results of a mesh reaction are terrible and tortuous. If you factor that in the situation is even worse. It seems that the industry is trying to save their “investment” in this new technology, forcing patients to “pay” with their own well-being. It’s counter to the reason that people become doctors, to help people, taking the Hippocratic oath at the end of their training. I can’t comprehend what is happening.

If the community of surgeons could start using real numbers, and accepting the fact that mesh might not be the wonder material that it seemed to be in the early days, or that maybe people have gone too far with mesh and need to pull back, there might be fewer patients needing to have their surgeon-caused problem to be managed. There is no mystery.

I really appreciate this forum and how you’re keeping it going. But we need to start using real numbers so that people understand the magnitude of the problem. Planning to manage problems that were created by the use of mesh seems unconscionable, especially when it is used on people that were otherwise very healthy.

If the industry is going to handle the situation by increasing “informed consent’ then the use of real numbers is even more important. Tell people the odds, that there’s a one in six chance that they might wish that they had chosen a non-mesh repair. They might have to have the mesh removed and there’s a chance that they will still feel discomfort and/or pain, for years afterward. That would be true informed consent.

Maybe I just don’t understand what it means to be a physician. Apparently, times are changing, see link below. No offense intended, I mean that sincerely, I know that it’s a difficult field with much happening these days. All the more reason though, to clearly expose these things before they grow.

https://www.beckershospitalreview.co…ernatives.html

[dog]

quote drtowfigh:

Though microscopic pathology will show that mesh results in a foreign body reaction at the tissue level, that does not necessarily mean that the patient will clinically manifest a reaction to the mesh. The majority of patients fortunately do not clinically react to the mesh. Those that do react must get their needs addressed by a specialist, as it’s an uncommon problem and specialists are the ones who see this problem more often and have an algorithm to address how to manage it (including need for surgery).

I would wonder if people with mesh would do the test to see if any elevation marks ..like C protein for Systematic inflammation..?

[ajm222]

But also clearly definitely possible to have a systemic reaction st some point that does spread beyond the implant

[ajm222]

From a lay person perspective, and someone who recently read up on this, my understanding was that, as with most implants (of whatever material they may be made of, and wherever they are in the body), at some point the body reaches kind of an equilibrium where it stops actively making a full-on assault against the material (presumable pretty soon after the actual surgery). Scar tissue builds up and a sort of protective barrier forms around the material within the body to sort of seal it off a bit from the surrounding tissue. The body continues to mildly react to it on a microscopic level at the very surface, but in a way sort of ignores it otherwise, and it shouldn’t impact the rest of the body in any other way at that point, unless it gets infected.

But its it’s a great question, and like you I didn’t really understand how and at what point the body sort of settles down and just kind of accepts the implant if you will. If you have any sort of pain, it would seem like one possibility is that the body is still attacking the implant and going haywire, in such a way that other parts of the body would be impacted by the immunological reaction. But the pain and other symptoms of course could also be caused by many other things.

im not sure if I even have any of that correct (the good doctor could correct), but clearly people get foreign material put into their bodies all the time and are ok. I often think of teeth and how most people have fillings (though perhaps that’s a little different than pins and screws and plastic mesh placed into soft tissue).

Its a a fascinating subject. It also saw it compared to getting a splinter (the way the body surrounds it with hardened tissue to seal it off), and even a tattoo (which remains because of a neverending immunological assault).

[bmul100]

Thank you for your response [USER=”935″]drtowfigh[/USER]. It sounds like you are saying everyone has a foreign body reaction at the local level but few have one at the systemic level. If that is the case I need to cast a wider net with specialists. Do you recommend starting with an immunologist or a surgeon or some other kind of specialist?

[drtowfigh]

Though microscopic pathology will show that mesh results in a foreign body reaction at the tissue level, that does not necessarily mean that the patient will clinically manifest a reaction to the mesh. The majority of patients fortunately do not clinically react to the mesh. Those that do react must get their needs addressed by a specialist, as it’s an uncommon problem and specialists are the ones who see this problem more often and have an algorithm to address how to manage it (including need for surgery).