Mesh vs No Mesh

[drtowfigh]

I understand what you’re saying. It’s very possible that our data is flawed. We cannot test what we are not measuring. Before mesh, postoperative chronic pain was not tested. It wasn’t until the 1990’s in the US that pain was considered an important vital sign. (This practice is partially contributing to the opioid crisis, I should add!)

Your experience is one scenario. I know and have treated many with the opposite experience: Shouldice repair at the Shouldice clinic vs laparoscopic with mesh and they did better on the lap side.

This just proves that everyone is different AND every surgeon has different outcomes.

It’s often frustrating For patients as we don’t have the perfect answer for them. Some, such as Dr Ramshaw, devote their life to figuring out the puzzle. It’s complicated.

As a Hernia Society, the best recommendation we give is not to choose the technique but to choose the surgeon. A skilled surgeon will always give you the best outcome possible.

[JamesDoncaster]

@drtowfigh First, I want to say how much I appreciate the work you have done to create and run this forum. Having a place to discuss these issues is important for everybody.

One thing that I would like your thoughts on is the following: do you think there is a disconnect between what studies say about chronic pain and what patients are feeling?

The reason I ask is first, because of my own experience (one operation with mesh, another without) but also because of what I have heard from others. I had horrible pain for 6 months on hernia that had mesh (eventually resolved with mesh-removal) and zero complications on the hernia that had no mesh. Additionally, when I mentioned the pain I was having to others, I would very often hear “oh…my [insert relative or friend] has chronic pain from mesh as well.” I cannot think of a single person I have run accross who has complained of chronic pain from a non-mesh repair.

Now, it could be that, the reason I only hear about mesh-related pain is because mesh-based repairs are almost the only option offered in the USA. But, it is also entirely possible that the statistics and the data are not an accurate reflection of the reality patients feel. As @good-intentions mentioned, it is difficult to quantify “chronic pain” and document the severity of it.

Also, as surgeons that specialize exclusively in non-mesh hernia repairs tend to have better results (in terms of recurrence and pain) than surgeons who perform non-mesh repairs as one of many other things, perhaps the medical establishment should be looking towards having surgeons specialize just in repairing hernias (a kind of Shouldice model). This, to me, seems like a better path forward than constantly trying to find the “ideal mesh.”

• This reply was modified 3 years, 7 months ago by  JamesDoncaster.

[drtowfigh]

As you know, nothing is perfect in medicine. The complications of tissue repair would involve neurectomy, pain management, and probably need for mesh repair in a revisional operation. My point is that it is not a benign pain-free perfect repair. There is a reason why we moved to mesh—-because the results from tissue repair were not good. I have a book with hundreds of tissue repairs described. Many failed. Some of the same tissue surgeons (eg, Nyhus) moved to mesh because their tissue repair options were not satisfactory.

I do believe we are over using mesh. There are plenty of patients who would do just as well if not better with a non-mesh repair. But we don’t have enough data to choose those patients based on hard evidence. I do it based on my own experience.

And that is why this is a complex system. What’s good for one patient may not be for the other. Bruce Ramshaw is the pioneer for this.

I just want people to understand that we are always learning because we never know the best answer.

And as for the ACHQC: their data is published on a regular basis.

[Good intentions]

If the pain rates are similar, but the solution to the “chronic pain” is much more complicated for mesh, with pain management or neurectomy or mesh removal, or all three in series, then how can mesh be the first choice?.

Besides that, many reviews have shown that the definition of “chronic pain” is often vague. The surveys are poorly designed and don’t define the truth. Many of the people on this very forum have described chronic discomfort, not necessarily “pain”, an awareness of the mesh in their body, and inability to do the things that they used to be able to do, as the source of what depresses them and can bring on thoughts of suicide. And leads them on the search to have the mesh removed.

Where is the ACHQC data, and how can a patient planning a hernia repair access it and use it? So that they can avoid the bad products. Let the free market work as it’s designed to, if the patient is supposed to be informed. Is it only for the corporations and surgeons? The talk continues but not much seems to be changing. Look at the partners in the AHSQC, linked below. Foxes and hen houses.

How can a patient find the truth? Is there anyone out there who is not tied to the mesh industry? Or is everyone just accepting their fate?

https://www.achqc.org/data

https://www.achqc.org/faqs/achqc-foundation-1

• This reply was modified 3 years, 7 months ago by  Good intentions.

[drtowfigh]

Multiple large population studies, modern and older, have shown that chronic pain rates are similar for mesh and non-mesh inguinal hernia repairs.

These are both US and European studies.

Let’s not forget that when mesh repair was invented, patients were admitted to the hospital for 1-2 weeks after their tissue repair. Pain was considered a given with the tissue repair. The invention of mesh repair was to reduce the pain by patching the hernia and thus reducing tension, which was why there was so much pain.

[JamesDoncaster]

Based on anecdotal evidence from myself and the people I have encountered in person and online, I simply don’t understand how any legitimate medical study could conclude that chronic pain rates for mesh are similar to non-mesh operations. There seems to be a huge disconnect between what the vast majority of surgeon think and what patients experience.

[DrBrown]

Most recent articles state the the chance for chronic pain is the same with or without mesh. But it is not stated how the non mesh repairs were done and if the non mesh repairs were done by an experienced surgeon.
If you try to find an article about chronic pain after hernia repair from the 1980’s (i.e. before mesh). There are no articles discussing pain.
Regards.
Bill Brown MD

[JamesDoncaster]

It would be very interesting to see a similar study that compares the rate and seriousness of chronic pain with mesh and non-mesh repairs.