Pros and Cons of Open vs Lapro
02/10/2020 at 5:31 pm #21736
Can anyone please in general terms explain what the pros, and cons, are of open VS laproscopic techniques?
Such as one can more easily damage (which) nerves, but..
Or one doesn’t split the oblique, but…
Just in general terms, is that possible?
02/10/2020 at 5:57 pm #21737
I have not watched this video yet but it has your question in the title.
You did not distinguish between mesh or non-mesh. Somewhere out there is series of four tutorial videos describing the four main ways to implant mesh. In the last video the surgeon says it doesn’t really matter which way is chosen as long as the surgeon feels comfortable with it. As long as the mesh gets in, any of them is good enough. All that matters is getting the mesh in. I had created a Topic about it but the Search function is not finding it.
Search the SAGES library on youtube and you’ll find a lot. Here’s another.
02/10/2020 at 6:30 pm #21739
@good-intentions Thanks. I’ll check out that video.
I saw where @drtowfigh mentioned there are benefits and risks more inherent to each without going into them. I was hoping for an unbiased condensed response. I hear from some no-mesh Drs that say you can get up and back in action in a matter of a week or two. And I hear where some people with mesh have pain for up to a year.
I guess I was thinking more like “open can cut nerves more readily, but gives a clearer view of the anatomy”… and “lapro doesn’t risk particular nerve damage as much, but”… a general list like that.
I don’t know what the risks are there, maybe it’s harder to navigate the anatomy and there is more risk to a particular part of the anatomy via lapro, and you need general anesthesia.
I am trying to put together a resource on FB where answers to common questions can be easily found, the questions that keep getting asked over, and over, and over… there are support groups, but a lot is the (suffering) blind leading the (suffering) blind.
Along with a list of Drs that do particular techniques, and in what part of the US they are in.
There are the questions I see being asked over and over and over on forums. For instance I myself didn’t know there were so many great non-mesh docs around. BUT MY GOD IN HEAVED — I WISH I DID! Whey is it so hard to learn this? And I am an internet marketer. And I looked. Something is wrong.
I didn’t know what the differences were or advantages of the different techniques — most of what you find is very clinically spoken and written for academia, draws unclear conclusions unto the technique itself, not in a comparison manner, and not allowing a prospective patient to have any influence in their path forward based on being informed with the big picture.
I feel very strongly that there is a need for that, that an opportunity exists for a solid resource, from 1) what to find out and ask about regarding YOUR hernia, to 2) what generally are options for various situations so someone can understand options in general and 3) a list of drs if they want to be listed with what they specialize in, so the path form start to finish could be assisted if surgery is desired.
I’d like to have interviews with doctors posted. Basically, a resource for this ailment which is so mysterious and can cause so much despair, and where so many feel so lost.
I’m trying to do make positive from my own terrible experience that might help others avoid it happening to them, basically.
02/12/2020 at 3:36 pm #21764DrBrownParticipant
The lap repair requires the use of mesh which can be a source of chronic pain.
The open pure tissue repairs allow the surgeon to visualize all the important structures such as nerves and blood vessels. It is the operation that I advise for all my patients.
Bill Brown MD
02/12/2020 at 3:57 pm #21768
I am working on making a private group FB page for people searching for consolidated information, not so much a discussion group (as consolidated information does not exist as far as I can tell in an effective manner) as they start on the healing path from a hernia. This is due to my own experience which was seriously misguided and flawed at large financial and emotional cost, even as I tried to do what I thought was best, where something like this would have made a big difference in my life, and now to help others that are in the same situation that can be helped — and there are so many — scared and feeling helpless.
The group is here:
I have these topics so far:
Inguinal – Checklist
Inguinal – Open Pros / Cons
Inguinal – Lapro Pros / Cons
Inguinal – Mesh Procedured
Inguinal – Non Mesh Procedues
Non Mesh Doctors
Revision Resources (drs who specialize in post 1st surgery issues)
I’m missing the other hernia types. But I’ll get to them.
I think this would really without exaggeration have the potential to save many many peoples quality of life by helping them make better, more informed decisions and to find corresponding help.
If any doctors would be interested in helping with this, or being listed in the doctors section just let me know.
I think interviews with doctors would be good to have as well. I think there is a really large and important opportunity to help, and address a real void.
02/12/2020 at 4:08 pm #21769JnomeshParticipant
I think this is a great idea.
Especially about the most of doctors that specialize in no mesh repairs (besides the 3 or 4 that routinely pop up and are widely known) and the best of the best surgeons for mesh removal and post mesh complications.
There are a few other FB mesh forums that also have comprehensive lists of surgeons who do mesh removal and non mesh repairs. For a while I was helping contribute to one of them as I cane across People who had successfull removals and non mesh repairs. The name KD the forum is Hernia mesh hurts too. It may be a good resource for you to cross reference and or possibly find new names of surgeons etc.
02/12/2020 at 5:33 pm #21770
02/16/2020 at 8:42 am #21804drtowfighKeymaster
OPEN WITH MESH
– can be done under local anesthesia with sedation. Ie, no general anesthesia.
– allows for plication of tissue in case of direct hernia.
– allows for reconstruction of giant inguinal hernias with complete pelvic floor blowout
– cosmetically hidden scar in hairline
– mesh interacts with spermatic cord and can cause testicular pain and affect sexual function
– mesh can interact with nerves.
– mesh at risk for infection (low risk)
– mesh-based chronic pain, tightness, shrinkage
– larger scar than laparoscopic
– longer recovery than laparoscopic
– higher recurrence than laparoscopic if done by specialist.
OPEN REPAIR WITHOUT MESH
– can be done under local anesthesia with sedation. Ie, no general anesthesia.
– no mesh-related complications
– cosmetically hidden scar in hairline
– highest recurrence rate of all options (Data claiming lower recurrence rate is based on cherry picked low risk patients)
– chronic pain risk due to tightness, tear, nerve injury/entrapment. This is important. Chronic pain is a real problem with tissue repair as well.
– larger scar than laparoscopic
– longer recovery than laparoscopic or open with mesh
LAPAROSCOPIC REPAIR WITH MESH
– small scars
– short recovery
– lowest recurrence rates of all options
– lower risk of mesh-related complications than open repair with mesh
– less nerves at risk of injury as compared to open repairs
– requires general anesthesia
– visible scars, cosmetically
– mesh-related complications, including adherence to spermatic cord, folding
– direct hernias and giant hernias are mostly patched and not plicated or sewn (robotic approach allows for sewing).
02/16/2020 at 9:11 am #21805ajm222Participant
This is very helpful info. Confusing though as to why I have tightness and discomfort and pulling after a robotic mesh repair. Seems like that would be very unusual. Not much pain and soreness, though some. But mostly just foreign body stuff. Very frustrating and it’s making me very hesitant to get removal despite knowing it definitely must be the mesh.
02/16/2020 at 12:28 pm #21809
02/16/2020 at 12:40 pm #21810
02/16/2020 at 3:58 pm #21812
Without numbers, the percentages or odds of certain things happening, AND the type of damage that each causes, debilitating versus uncomfortable, for example, a case could be made to use any of the methods, using a list like Dr. Towfigh’s. Lower, higher, majority, more, less, etc. don’t have much meaning without quantification. 51% is more than 49%. 51% is a majority. The list is a great start but needs filling in to be useful to a patient.
You might actually be helping those that want more of the “bad” methods. For example, Johnson & Johnson has their “International” Hernia Mesh Registry which they delay publication of every year, but cherry pick data from in the meantime to support their products. e.g. The only mesh product that the “International” Guidelines recommend against, the plug, is promoted by Ethicon (a J&J company) using IHMR cheery-picked data, in their professional marketing literature. J&J supported the group that put the Guidelines together, financially. So you have a J&J supported effort that defines plugs as bad, but at the same time you have J&J supported data saying that they are good and should be used. If J&J (Ethicon) was an honest company they would take the Guideline data as evidence for discontinuing plugs. But they have done the opposite.
I use J&J as an example often because what they do is so obvious and documented. Contradictory efforts and data everywhere you look. But my main point is that without objective conflict-free measurements, real numbers, your effort can be manipulated to support the method that makes the most money. Not what you intended.
And, if you’re not very thorough and careful things can get overlooked, maybe because you’ve seen them so often. No offense Dr. Towfigh, but despite almost all of the chronic pain stories on the forum being of the laparsocopic mesh implantation type, you did not mention pain of any kind in your “Cons” section for lap mesh. Many people have also questioned the recurrence rate numbers. Is “Highest” recurrence rate, 5% vs. 4% or 10 vs. 4? Which method has the “highest” chronic pain rate?
And, one more thing – “open” and “mesh” are just way too broadly defined. You just posted in a different Topic about PTFE mesh shrinking 40% and “others” 10 – 25%. That needs to be part of the list, I think, if the list will really be useful in making a decision. Shouldice is open without mesh and they have data that does not match the list, as I understand things.
I hate to be a downer, but I think that you have to be careful not to lead people down the wrong path, as well-intentioned as your effort might be. What you’e proposing is a huge effort to do correctly. And the “pros” have done it, several times over the years, with their SAGES Hernia Repair manual.
Good luck, but be careful.
- This reply was modified 4 days, 19 hours ago by Good intentions.
02/16/2020 at 4:03 pm #21814
What you’re proposing should be in this, below, already. If it is, but does not represent reality, that’s the hurdle that needs to be overcome. Something is skewing the effort.
02/16/2020 at 8:13 pm #21820
@good-intentions I would respectfully counter that academic argument can go on forever, without consensus. For the practical purposes of providing laypeople who are looking at surgery with points that they can potentially bring up with their doctor, and open up these valuable discussions in greater detail, and become their own advocate, this can be the roadmap of points to consider or ask about that otherwise may never have entered into a conversation — which can only be an asset. As in my case, I had almost none of these point top of mind — or even in mind. That lead to a lack of dialogue I could initiate. Which largely led to my situation now. In practical terms, this list would have benefited me immeasurably and that’s said as an understatement. And I again thank @drtowfigh for taking the time to assemble her thoughts and provide her take on the question.
02/16/2020 at 10:05 pm #21821AlephyParticipant
I think any such list should always start from the medical problem first eg direct vs indirect IH, recurrence vs incisional, age weight etc. One of the few things I got loud and clear is that the hernia treatment requires a tailored approach to be successful. I personally think that the problem is to find a doctor that does that which would mean getting out of the numbers churning mill, which requires money as health insurances might not support you. That patients should be kept in the dark or even worse be lied is something that is not far from criminal…also having myself a scientific background to see people publish papers on small biased samples or even without any accessible and verifiable data makes me shiver….
02/16/2020 at 11:08 pm #21822
I appreciate the thought, effort and objective of this thread.
1)Is one or the other methods recommended based on size of the hernia? If so, at what size, generally, would one method gain preference? (my hernia on the right side is about the size of the top half of a tennis ball.)
2)I’ve read on this forum that thinner folks who engage in sports to some degree are more prone to have problems after laparoscopic. How much importance should be given to weight in making a determination? Is there a bmi dividing line?
3) How does age affect outcomes with regard to pain and recurrence for the mesh-open, tissue open, and laparoscopic methods?
02/16/2020 at 11:34 pm #21823
In the following video, one of the doctors asks the audience(at the 17:25 mark) of doctors how many “take” the illioinguinal nerve and the answer was 20%! Then he said that he also did in the older patients, but tried to preserve it in the younger. He then says that they don’t notice.
The presumptiveness is bothersome. What justification is there for this way of thinking? Is the nerve in an older person more fragile?
02/16/2020 at 11:35 pm #21824
It posted before I could provide the link.
02/17/2020 at 12:48 am #21825AlephyParticipant
Age certainly plays a role, although being young vs old is often a stereotype (is 40/50 old/middle aged or even young?) and considering that we live longer and longer and so having a surgery at age 60 might mean dealing with the aftermath and possible complications for another 20 or more years…
what would be important to me is that this or that doctor, whatever the procedure, tell the patients BEFORE going in: if they take the nerve out as a planned action, the patient MUST know that they will do that! If not, it is a criminal action in my opinion
02/17/2020 at 6:20 am #21827
@alephy Agree. An accessible, digestible, general informational set, of which this is just a part, has hope to help some potentially avert situations you and others like me can personally describe…available where many people also are looking, possibly saving some from unneeded suffering — one of many seeds found that might open up an important dialog down the road. Positive things.
The tailored approach is a topic I plan to cover, and even thought that could make a great podcast topic, or article-format interview, with a surgeon. 🙂
02/17/2020 at 11:44 am #21834
I overwrote in my reply. Got a little bit carried away. I was struck by the lack of quantification (quantitation?) though, which is common in all of the discussions of “best” practice, when it comes to hernia repair, and the difficulty you will have in trying to “rank” methods, based on outcomes. Much opinion and feel but not much clear verification.
I went out to find something similar to what the people who followed up proposed. I think that a “decision-tree” is the thing. Engineering and science types might call this a flow-chart. Here is a paper about forming a “decision-tree” for hernia repair methods. Digging deeper though, of course, it leads back to the European Hernia Society, which leads to Herniasurge, which leads to Johnon & Johnson and Bard, and other device makers.
Again, you’ll find numbers when they support mesh, and words like “significantly lower” when things aren’t clear. And, despite the Guidelines recommending against it, Dr. Kockerling includes the plug systems in his tree. And if you search for the word “pain” it only appears two times. The paper was published just over 5 years ago. Dr. Kockerling was in the working group of the Guidelines effort.
Anyway, I think that something like this is along the lines of what you’re trying to do. It would be interesting to see what the tree looks like, if it was generated from a patient’s long-term quality of life viewpoint. Including “pain” and “pure tissue” as variables, instead of setting them aside.
02/17/2020 at 12:05 pm #21835
I just found what is essentially the updated version of that 2014 paper. Things are much more clear, pain is mentioned 26 times instead of just 2. Herniasurge still looms over the effort though.
Here is the Herniasurge page, with their mesh logo. Those that might have seen earlier posts about Herniasurge will see that the sponsors are no longer highlighted. Johnson & Johnson used to get about 1/3 of the front page.
They are not there anymore. Pretty fascinating, in a macabre way. Funding apparently comes through the European Hernia Society now. But where does EHS get their money?
It’s worth following what these guys are doing. They might be the most influential group on hernia repair in the world.
02/17/2020 at 12:07 pm #21836
02/17/2020 at 12:13 pm #21837
02/17/2020 at 12:17 pm #21838
Can we upload images?…
02/17/2020 at 12:49 pm #21839
It doesn’t look possible. I was going to post the old herniasurge page with the
J&J logo (I copied it and saved the image) but there’s no option for attaching or pasting images.
But I did find it on the “Wayback Machine”. Internet archive.
02/17/2020 at 1:12 pm #21840
02/18/2020 at 2:54 pm #21877ColtParticipant
One of the surgeons not on forum that were recommended girls answering phone said
They didn’t take Medicare, I asked who they would recommend they said whatever you do
Or use don’t get it laparoscopically
02/18/2020 at 2:55 pm #21878ColtParticipant
I asked why not laproscopic they said had a higher recurrence rate
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