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Mesh – the risk of chronic pain. Is anybody trying to minimize the risk?
Rather than post on individual threads, telling my story about three years of chronic pain after TEP implantation of Bard Soft Mesh, I think that a thread with some background might help the general discussion about the state of hernia repair today. I hope the organizers of the forum don’t mind, since this is “Hernia Talk”. I’ve collected some links and publications that span many years of the use of mesh for hernia repair. I’ll try to keep the links, references, and discussion mostly science and fact-based. It’s all pretty fascinating from a professional and sociological perspective, but also disturbing.
I am not a trained medical professional. These are just things that I’ve found that seem to make the situation much more clear.
The first is a link from 2005 which looks like essentially the instruction manual for hernia repair. Many of today’s surgeons have probably learned from it. Watch a video from recent years (I’ve included one, the third link) and you’ll see that things were set in place many years ago. Not much has changed, not even the materials. They’re even recommending today that more mesh be used.
The second link is from 2014, a paper on recent research in to the possible causes of mesh-related pain. It has some good background also on the state of the mesh-based repair procedure. The introduction is very worth reading for anybody considering mesh implantation.
The third is a video of a typical laparoscopic mesh implantation, from a paid consultant of Ethicon.
https://www.med.unc.edu/surgery/education/files/articles/Lap.%20Hernia%20Repair.pdf
http://file.scirp.org/pdf/IJCM_2014072117033945.pdf “Mesh-Related SIN Syndrome. A Surreptitious Irreversible Neuralgia and Its Morphologic Background in the Etiology of Post-Herniorrhaphy Pain Robert Bendavid, Wendy Lou, Andreas Koch, Vladimir Iakovlev”
http://www.ethiconinstitute.com/node/885/asset “Ultrapro Laparoscopic TAPP Inguinal Hernia Repair with Dr. Kent Kercher”
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5 Replies
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Re the paper I linked above, the excerpt below might the most concerning part. The authors did a very extensive review but in the conclusion did not acknowledge or even mention chronic pain and discomfort reduction as a goal. Hard to believe that they are unaware. Incredible really.
Review Past, Present and Future of Surgical Meshes: A Review Karen Baylón 1 , Perla Rodríguez-Camarillo 1 , Alex Elías-Zúñiga 1 , Jose Antonio Díaz-Elizondo, Robert Gilkerson and Karen Lozano
“5. Conclusions Surgical meshes have become the system of choice for hernia repair. Even though it is not the optimum method, so far it is the one that has shown a lower rate of recurrence. Currently, there are more than 70 types of meshes commercially available. These are constructed from synthetic materials (absorbable, non-absorbable, or a combination of both) and animal tissue. Despite reducing rates of recurrence, hernia repair with surgical meshes still faces adverse effects such as infection, adhesion, and bowel obstruction. Most of these drawbacks are related to the chemical and structural nature of the mesh itself.”
They only mention chronic pain in the discussion as a result of adhesions. Makes a person question their expertise in the field, as a whole. At least they collected many references.
“Furthermore, adhesions between the visceral side of the mesh and adjacent organs still occur. These complications may have serious consequences, such as chronic pain, intestinal obstruction, bowel erosion, or hernia recurrence.”
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I found a good review of mesh materials used in hernia repair, pdf link below. I noticed some flaws in thinking, for instance, associating fiber fragmentation during usage with flexibility instead of fatigue resistance, but I think that the authors are not experts in materials. It’s a very broad-based review and seems well-done.
It’s from 2017, so it’s good to see that there is still development work ongoing. Unfortunately, in the meantime, there are still surgeons working from what they learned in 2005, with the same materials. That should be a takeaway for anyone considering hernia repair today. Make sure that your surgeon is up to speed on advancements, and can address the very well-known problems with hernia mesh. Chronic pain and discomfort being the issue most overlooked or discounted.
The section on knitting, on page 12, is very interesting in that it relates back to Bendavid’s paper about SIN (post #1 above), perhaps caused by small “pores” created by the knots and loops of the knitting process. The knit fabrics are designed for flexibility and feel by hand, outside of the abdomen, and one time placement during surgery. The issues with shrinkage and SIN don’t seem to be addressed. This seems to be a big oversight, probably due to “out of sight, out of mind” once the material is implanted, so “easily adapts to the movement of the human body” (from the review) is nonsense, in the long-term. Once the material binds up and shrinks, in the abdomen, it feels like a playing card has been placed inside. It’s no longer soft.
There is hope for better materials, I think, if the right people are working on new materials and design. As better mesh is introduced to the market, maybe the old bad ones can be whittled away, and replaced.
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Thank you, Dr. Earle, for reading and commenting, and the article.
My impression is that the “industry” is aware. The’re getting sued on a regular basis so it’s hard to believe that they’re not. Cost seems to be playing a much greater role in their decisions than you would hope or expect.
Coincidentally, somebody sent me a link to a very recent NPR podcast, an interview with Jeanne Lenzer, a former “physician’s associate” (I don’t really know what that means), who has written a book about the medical profession and how they seem to be captured or controlled (my words) by the medical device suppliers.
I also added a link to an article transcribing a panel discussion of some well-known surgeons, describing among other things, how their choices are controlled by their organizations, often based primarily on cost.
Here are links to the audio and the transcriptions.
https://itunes.apple.com/us/podcast/fresh-air/id214089682?mt=2&i=1000400086850
https://www.npr.org/2018/01/17/578562873/are-implanted-medical-devices-creating-a-danger-within-us
“On the Spot With Colleen Hutchinson: The Art of Herniology 2016”
Just click “Cancel” and the article will appear, or go ahead and print it. Or just read it in the preview window.
https://www.generalsurgerynews.com/Article/PrintArticle?articleID=34826
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This is a critically important discussion and topic that seems largely ignored by industry and the medical community, to the detriment of both patients and doctors.
Anyway, here’s a new interesting large scale study (22,000 groin hernia patients) demonstrating a 15% chronic pain rate after mesh hernia repair.
http://onlinelibrary.wiley.com/doi/1…bjs.10652/full
15% of patients having life altering chronic pain after a “routine” procedure is incredibly high, why is this not considered an urgent problem that needs immediate mitigation by the medical community?
The paper you reference from Dr Bendavid of Shouldice is noteworthy, and he has other interesting papers that have been published on the topic as well. Personally I am just shocked and disappointed that the non-mesh repairs are largely not even taught anymore, and are becoming extinct despite plenty of evidence suggesting they can be equally as good if not better than mesh, particularly for some patient groups, with fewer potential severe side effects.
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Another interesting paper, with some good references. It’s a shame though that Dr. Bendavid’s ego and offputting bravado in his writing style overwhelms the material that he’s reporting, and probably fortifies the people advocating mesh usage to resist what he’s saying, based on that alone. It’s human nature. He seems to have lost his objectivity. I got irritated reading it and I’m kind of on his side.
Still worth a look.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4734928/
in PDF form – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4734928/pdf/05900e3.pdf
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