Pure tissue repair combined with a fully absorbable mesh

[Chaunce1234]

If I recall correctly [USER=”1197″]pszotek[/USER] Dr Szotek in Indiana has performed this type of double-repair (absorbable mesh with tissue repair) before, but perhaps he has shifted away from it, or into another direction. I am not sure if he still participates in these forums but if so, any insight would be interesting.

[Jnomesh]

Good point Chaunce 123. One of the reasons I posted this question is when I was consulting/interviewing surgeons for my mesh removal the three I visited all said if there were hernias present after removal and I didn’t want mesh they all said the would and could do a pure tissue repair but I knew that this isnt something they routinely did-they were all laparoscopic skilled surgeons and robotic experts as well. They all also quoted me a higher recurrence rate that seemed a little a high to me-not crazy high-maybe 10-12% and I just kind of feel instinctively that this % rate had built into it the fact that they just don’t have expertise in this type of repair.
so as a patient I feel like the absorbable mesh in addition to a pure tissue repair by a skilled surgeon but not one of the top non mesh repairs surgeons or hospital could be not only a solution but make the patient feel a little more confident in the repair too.
another point is that although the mesh disappears the main healing and scarification is promoted by the mesh in the first year. That is his mesh mainly works in repairing hernias-it promotes scarring to close the defect and the strengthening the surrounding areas.
its one reason a lot of people like myself who have had lapascoocslly places mesh and later had it removed (the same way) have no hernias upon removal-because the area filled in it closed up by scar tissue caused by the inflammatory reaction caused by the mesh.
Im certainly not saying because of this absorbable meshes are better than permanent meshes but I do see a combination of the non mesh repair and the absorbable mesh for people who don’t want mesh and can’t travel to the few surgeons and hospitals that do non mesh repairs can maybe have a better outcome by the combination of both and surgeons who maybe have the skill to do a non mesh repair but don’t do many can have more confidence in the outcome if both approaches are combined.
What I’m also interested in form the surgeon on this forum is are there any contraindications to using absorbable mesh in addition to a pure tissue repair-ie can the absorbable mesh interfere with the healing or have any adverse affects to the pure tissue repair ?
And I’m specifically referring to inguinal hernias

[MO]

Chaunce1234 said, “So how does an interested surgeon learn the non-mesh hernia repair skill, let alone master it?” I have been wondering about this, too.

[Chaunce1234]

This is a fair idea, but it still requires that a pure tissue hernia repair is mastered to a degree that inspires confidence of both the patient and the performing surgeon, since the absorbable mesh will vanish in time.

I think the problem is that pure tissue repairs are not commonly taught anymore in US med schools nowadays as I understand it, which is part of why they have largely vanished in the USA. So how does an interested surgeon learn the non-mesh hernia repair skill, let alone master it? Maybe on cadavers in their spare time? I genuinely do not know the answer to that.

[dog]

Yes it is exactly what i am asking ! Jnomesh

[Jnomesh]

Hi dr. Towfigh. What about the idea of a combination of pure tissue repair to close the defect (which from what I understand isn’t done in mesh repairs) and a absorbable mesh in the same surgery (for inguinal hernias) for extra reinforcement and possible strengthening of the area.
i understand experts on both sides of the pendulum (pure tissue experts and mesh experts) may think this unnecessary.
But there is a huge middle ground especially with people searching for surgeons who do none mesh repairs. Often having to travel out of state and country to get a non mesh repair.
i spoken to many who say their kicks surgeons either say they don’t do mesh repairs, don’t do many, or don’t think there is a high probability the non mesh repair won’t hold.
However, what if the local surgeon does a non mesh repair supporter further with a absorbable mesh.
Seems like a possible solution that should be studied further?

[dog]

quote drtowfigh:

Some comments:

– there is still risk of chronic pain after surgery with absorbable mesh because it’s still surgery. This is more common in the groin area, where you have to cut and sew around sensitive areas including nerves. Don’t forget there is chronic pain for hernia repair without any mesh (for inguinal hernias).
– with abdominal wall (not groin) hernia, we tend to close the defect and not patch it, though the patch remains a common and accepted repair option.
– Are you referring to groin hernias only? I believe that is what Sr Kang has been referring.
– the slowly absorbable new synthethic absorbable mesh (Tigr and Phasix) are inflammatory products. They are also quite expensive.
– We have not proven the theory that though the first year’s healing time is most important, absorbing afterward will not adversely affect the recurrence rate. It’s a good marketing idea. Likely, the recurrence rate may just be shifted over by a year or two.

Dear Dr Towfigh, Thank you for your feedback! regarding chronic pain ….would you kindly agree that ” to cut and sew around sensitive areas
and nerves” would it be more matter of picking method and masterclass to implement meticulously { but not blame that surgery itself and risk associated with it.
I would understand if person have heart attack ,some body unusual reaction ..blood too thin or something non related or unpredictable .
If surgeon would work like a plastic surgeon that would not be a problem…
Please correct me if i am wrong..drtowfigh

[drtowfigh]

Some comments:

– there is still risk of chronic pain after surgery with absorbable mesh because it’s still surgery. This is more common in the groin area, where you have to cut and sew around sensitive areas including nerves. Don’t forget there is chronic pain for hernia repair without any mesh (for inguinal hernias).
– with abdominal wall (not groin) hernia, we tend to close the defect and not patch it, though the patch remains a common and accepted repair option.
– Are you referring to groin hernias only? I believe that is what Sr Kang has been referring.
– the slowly absorbable new synthethic absorbable mesh (Tigr and Phasix) are inflammatory products. They are also quite expensive.
– We have not proven the theory that though the first year’s healing time is most important, absorbing afterward will not adversely affect the recurrence rate. It’s a good marketing idea. Likely, the recurrence rate may just be shifted over by a year or two.

[dog]

I still cant understand why chronic pain still is the problem with [h=2]fully absorbable mesh ?[/h]

[UhOh!]

quote Jnomesh:

Thanks uhoh. I think your post illustrated my initial post. Those who are experts at non mesh repairs like dr. Kang would most likely think and say absorbable mesh is not necessary to use along with a pure tissue repair Bc they are experts in this type of surgery and deem it uneccessary. Surgeons who are experts at mesh repairs would most likely say absorbable mesh is inadequate and permanent mesh should be the gold standard.
The problem lies in that there are very very very few surgeons in the US that do non mesh repairs and on top of that are expertise in pure tissue repairs- meaning people wanting a natural repair will have to either travel out of state or out of country for what back in the day would be a routine non mesh repair. Many people won’t do this endeavor either because of travel or cost or both.
on top of that most surgeons except for a few (I count maybe 5 surgeons in the US who only do non mesh repairs) day they will do a pure tissue repair but that there will be a high recurrence chance-I believe they say this Bc they just aren’t confident that there repair will hold Bc they just don’t do many if any of this type of repairz
Thats why I think a pure tissue repair with absorbable mesh may be the great compromise for s large number of people who don’t want mesh but also can’t travel to one of the few surgeons who do non mesh repairs.
For the surgeon who says I can do a pure tissue repair but there will be a high recurrence rate maybe this rate will come down greatly if a absorbable mesh is used in addition to the natural repair.
This may also be a option for people who have had their mesh removed like me, who even though there were no hernias upon removal the area is surely weakened and if I ever re-herniate and don’t want mesh but a natural repair may not hold Bc of the weakened tissue maybe a absorbable mesh on top of the non mesh repair may be an answer.
Could be the great compromise!
ofcourse more data needs to come in on absorbable mesh (for me would be more if a chronic pain question then recurrence rates)
but im more curious if there are contraindications to a absorbable mesh on top of a pure tissue repair?

What I think absorbable mesh will offer is for those who use and believe in pure tissue repairs to be able to do less extensive repairs, with less damage to healthy tissue. This would also likely make it easier to teach the method to surgical residents.

And, while this shouldn’t be a factor for doctors or patients, the fact is that it will have the support (instead of opposition) from device companies. One less hurdle to overcome.

[Jnomesh]

Thanks uhoh. I think your post illustrated my initial post. Those who are experts at non mesh repairs like dr. Kang would most likely think and say absorbable mesh is not necessary to use along with a pure tissue repair Bc they are experts in this type of surgery and deem it uneccessary. Surgeons who are experts at mesh repairs would most likely say absorbable mesh is inadequate and permanent mesh should be the gold standard.
The problem lies in that there are very very very few surgeons in the US that do non mesh repairs and on top of that are expertise in pure tissue repairs- meaning people wanting a natural repair will have to either travel out of state or out of country for what back in the day would be a routine non mesh repair. Many people won’t do this endeavor either because of travel or cost or both.
on top of that most surgeons except for a few (I count maybe 5 surgeons in the US who only do non mesh repairs) day they will do a pure tissue repair but that there will be a high recurrence chance-I believe they say this Bc they just aren’t confident that there repair will hold Bc they just don’t do many if any of this type of repairz
Thats why I think a pure tissue repair with absorbable mesh may be the great compromise for s large number of people who don’t want mesh but also can’t travel to one of the few surgeons who do non mesh repairs.
For the surgeon who says I can do a pure tissue repair but there will be a high recurrence rate maybe this rate will come down greatly if a absorbable mesh is used in addition to the natural repair.
This may also be a option for people who have had their mesh removed like me, who even though there were no hernias upon removal the area is surely weakened and if I ever re-herniate and don’t want mesh but a natural repair may not hold Bc of the weakened tissue maybe a absorbable mesh on top of the non mesh repair may be an answer.
Could be the great compromise!
ofcourse more data needs to come in on absorbable mesh (for me would be more if a chronic pain question then recurrence rates)
but im more curious if there are contraindications to a absorbable mesh on top of a pure tissue repair?

[UhOh!]

quote Jnomesh:

Hi Dog. Seems pain rate is significantly less with absorbable mesh. They still worry about recurrence with absorbable mesh that’s why I think it would be interesting to examine a pure tissue repair to close the hole and then a absorbable mesh to further reinforce the area to help it heal fully during the first year of healing ( a time period researchers note is imperative as the area gets stronger and this is the time period a lot of recurrences happen-within the first year) then by the end of that year the mesh will be fully or hopefully fully absorbed or disintegrate fully.
would love to hear some of the surgeons weigh in.

I recall asking Dr. Kang about exactly this not that long ago (I’m sure the thread isn’t buried too deep). His opinion is that the mesh is unnecessary if the tissue repair is done properly.

The study, as I recall, found that absorbable mesh was not a good one-for-one substitute for traditional mesh in direct hernia repair and had a high recurrence rate (probably due to lack of defect closure).

[Jnomesh]

Hi Dog. Seems pain rate is significantly less with absorbable mesh. They still worry about recurrence with absorbable mesh that’s why I think it would be interesting to examine a pure tissue repair to close the hole and then a absorbable mesh to further reinforce the area to help it heal fully during the first year of healing ( a time period researchers note is imperative as the area gets stronger and this is the time period a lot of recurrences happen-within the first year) then by the end of that year the mesh will be fully or hopefully fully absorbed or disintegrate fully.
would love to hear some of the surgeons weigh in.

[dog]

Outcome according this publication is better but pain still there.. https://www.ncbi.nlm.nih.gov/pubmed/28492358

[dog]

quote dog:

I also was interested in this and raised that question in the past…Goods point Jnomesh

Dear drkang .What is professional opinion about this combination ?

[dog]

quote Jnomesh:

Hi dr. Towfigh.
i have spoken to a few people who have had mesh removal and didn’t want new mesh implanted if the area was weak or if there was a hernia present post removal. These people were offered absorbable mesh (tiger mesh) as a compromise.
it got me thinking: dr. Kang has weighed in on this forum and he mentioned one problem with using permanent mesh (besides the nasty side effects it can cause) is that he feels the hernia defect isn’t closed or repaired when using permanent t mesh thus the defect is never properly repaired/closed and relies slowly on the scarification that the mesh causes to prevent a recurrence and some additional reinforcement that the mesh also offers.
He feels that this may be one of the reason a hernia may recurr with the use of mesh because the defect was never closed. Then you have a faulty piece of mesh inside with the most likely solution to have another piece of permanent mesh implanted the opposite way it was put in to fix the hernia.
so my question is : for people who don’t want permanent plastic based mesh implanted or for people who it is determined their hernias are to big or not enough strong surrounding tissue for a natural repair what about using a combination of a pure tissue repair (closing the hernia defect ) and placing a absorbable mesh that fully dissolves over say a year as a viable alternative to a permanent mesh repair for those that don’t want mesh.
This way the defect is closed and the absorbable mesh gives another layer of protection during the first year of healing which is the most important time frame after a hernia repair.
Seems like this idea could bridge the two sides of the debate between permanent mesh and non mesh repairs for concerned patients who today are primarily offered only one solution by most surgeons: permanent mesh.
The absorbable mesh also would offer some insurance for surgeons who aren’t experts on pure tissue repairs ( ie don’t do many) that in case they don’t do a perfect tissue repair they have the absorbable mesh as a “back up” or insurance to help fix the hernia.
curious as to your thoughts Dr. Towfigh and any other surgeons on the forum as well as any other members feedback.

Thanks

Dear dr. drkang That is your experience please with tissue repair combined with absorbable mesh for hernia repair. Point is tissues are week after removal and recurrence chances is HI….Did YOU TRY THIS APPROACH?

For everyone else chronic pain still problem with that mesh as well….but outcome is better..
https://www.ncbi.nlm.nih.gov/pubmed/28492358

[dog]

I also was interested in this and raised that question in the past…Goods point Jnomesh