Rates, percentages, and trends in lap versus open

[Good intentions]

I came across a short SAGES presentation, from 2020, about ten year trends in laparoscopic hernia repair. With all of the articles and videos about laparoscopy a person gets the impression that laparoscopy dominates the hernia repair market. But, apparently, lap is only about 40% of the market, open is 60%.

Which begs the question of “where are the open repair problem stories?”. I think that the reason might be a matter of degree and paths to a solution. Open repair problems seem to be less significant to the patient than lap mesh problems so the people that have them don’t end up on forums like this one seeking solutions. There might be other reasons but I can’t think of them. To a normal patient, surgery is surgery. Get the diagnosis, get a referral, go to surgery, hope that you get healed. If lap mesh is 2/3 the volume of open surgery (probably mostly mesh – Lichtenstein or other) why are the stories on this forum mostly about lap mesh? Something doesn’t seem right.

The presenter notes that the CPT codes he used for the study don’t distinguish between TEP, TAPP, or robotic (still not calling robotic TAPP although that’s what it is), but he doesn’t say anything at all about the types of open repair. Another one of those blind spots. All mesh types are “mesh” and all open surgeries are “open” to a lap surgeon, apparently.

Anyway, another one of those things that makes you wonder. Why are there so many lap mesh complaints on this forum when lap mesh is not the predominant method of repair? The ratios don’t follow the overall volume of methods used.

“Ten Year Trends in Laparoscopic Hernia Repair: A NSQIP Database Review”

[David M]

It could be just luck, but assuming the higher pain rates for lap that we see on here are representative, do you have any theory as to why lap might cause more pain?

[Watchful]

There’s a tiny number of people on this forum. No meaningful conclusions can be drawn from this miniscule population.

The surprising thing to me is that so few people pop up here. You would think that a lot more would find their way here since there’s a very large number of hernia surgeries.

[Good intentions]

David M I think that is a whole separate discussion, about the cause. At this point many surgeons are dismissing the problem as unreal or just the result of people in today’s world being weaker than people in the past. The problem has to be recognised first, as Dr. Campanelli did in his Editorial, so that professional researchers at the medical device companies and universities have a reason to work on solutions, and/or so that consumers can avoid the bad products. As long as the denial continues not many people will put effort in to working on it.

The point of my post here is about the relationship between the volumes. If more product is sued you would expect more problems to be reported. The ratio of problems to product used gives the probability of problems for specific products. A similar comparison, which the professionals should have figured out and which the medical device companies probably already know, is “what is the ratio of problems to the specific device?”. For example, plugs have been identified as “not a first choice” or “evil”. But, according to Dr. Towfigh’s past remark, and a past forum post, linked below, plugs are a very high volume product. So, are the bad plug cases actually a small percentage of overall plug usage? Or not.

If you get on to the MAUDE database you can find a huge number of reports about specific devices but there is no context with the total volume of their usage. This is what the FDA should be doing, identifying the probability of problems with a product. If I knew that 20% of people with plugs had problems, and only 10% of people with Lichtenstein had problems that would help me make a decision, along with other information about the work needed to fix the problems. But I don’t know if a database exists that would allow someone to define those percentages. The numbers have to be out there. Somebody should be drawing those correlations.

Plug and Patch Hernia Repair

I had created a Topic about the MAUDE database in the past but Google and the forum’s search engine can’t find it. Here is a link to the database.

https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/search.cfm

[Good intentions]

In short – just trying to find another tool to use for a “process of elimination”. A patient might not be able to find the best procedure but they can avoid the worst.

[William Bryant]

Not sure but with open can more be seen and did Watchful say it’s placed differently depending on open or lap.

It’s this sort of analysis that I can’t believe the medical profession/Industry don’t follow up… If one is obviously causing more issues than the other it should be noted and patient informed at the very least or the worst method dropped totally.

Ive just read a British hernia centre, hospital not group, saying their mesh is placed between something’s as though it’s unique..I’ll see if I can find it and let the brainier posters decipher it!

[Good intentions]

And, of course, this circles back around to a registry. With a well-designed registry these numbers would fall right out. Which is, of course, a reason that the device companies would not want to have one. The less people know the better off they are.

[William Bryant]

Yes it does point to a registry. It’s a must have … For patients at least.

Here’s the British hernia centres description of their open operation, they make it sound unique, I don’t know if it is it just worded to imply so…

https://www.hernia.org/tension-free-mesh-2/

Interestingly enough, and tying in with this thread, on the previous page the BHC say pain is more likely with robotic mesh repairs, they put this down to surgeons not being sufficiently trained or experienced enough in the practice amongst other things.

[William Bryant]

From the link

“The peritoneal bulge is returned to where it belongs, but the repair is achieved by placing a piece of fine (inert and sterile) mesh at the opening in the tissue. This is firmly held in place and the outer incision closed. The whole operation takes minutes to perform.

Unlike other techniques, even those now using mesh, our approach does not require any stitching together of the muscle tissue at all, thus eliminating the tension induced by other methods.

The healing process starts to take place immediately whereby, (sensing the presence of the fine mesh) the muscle and tendon send out fibrous tissue which grows around and through the mesh, incorporating it in a way similar to the placing of the steelwork inside reinforced concrete. It is not a “patch” stuck on the outside, (as is relatively common with mesh repairs) but a total, tension-free reinforcement inside the abdominal wall itself. The results are also similar to the concrete analogy, in that the mechanical load is spread over the whole area, precisely at the area of weakness, rather than on high pressure points of stitching through the deep, sensitive tissue with older methods.”

[William Bryant]

Good Intentions you may be interested in this from the British Hernia Centre, it’s their view of why robotic causes pain

“When done well, by well-trained and experienced surgeons in appropriately selected cases, the results of keyhole inguinal hernia repair can be very good and where appropriate we use it ourselves.

The problem is that well-trained surgeons who are experienced in laparoscopic surgery and specialise in hernia repair are few and far between. The consequences of a poorly carried out keyhole repair can be serious.

The advantage put forward for laparoscopic surgery is that no large cut is made on the abdomen so in theory there is less post-operative pain and a faster return to normal activities. For example, with major bowel surgery, where large cuts have traditionally been made, the laparoscopic option is a good one.

But for inguinal hernia repair the incision for our described open local anaesthetic repair is small anyway, particularly in the hands of surgeons who specialise, so the difference in that regard is not at all significant.

Pain after Keyhole Surgery

In practice and depending upon how it is performed, you can get quite a lot of pain after a laparoscopic inguinal hernia repair, because the pain does not come from the skin cut anyway. The pain is more likely to be related to the fact that the deep tissues have been cut and pulled, and staples may have been used to fix the mesh.

Disadvantages of Keyhole Hernia Surgery

It is technically demanding for the surgeon.

What that really means is that its difficult to learn and difficult to do well. He has to practice a great deal and perform a large number to become really good at it.
Due to the nature of operating by using a 2D video image of the site rather than proper 3D visualisation there is the risk of major organ damage (blood vessel, bowel and bladder).
Keyhole repairs have to be done under general anaesthesia. That carries risks on its own and certainly not so good if you are elderly or have other medical conditions.”.

[Good intentions]

Thanks William. I looked through some of the BHS pages and they are the typical “we do it best” marketing pages of almost all hernia repair facilities. They seem to be claiming credit for all of the “tension-free” mesh methods. Pretty proud of themselves.

But, without the numbers, it’s just more salesmanship. At this point, I barely look at work reported without the numbers. It’s just chest-beating and crowing without the long-term measurements of success, using the things like quality of life, chronic pain, and recurrence as measures. Their publications page is dated, the most recent is from 2009.

The patient stories page is full of the typical vague terms and words. One patient climbed Mt. Kilimanjaro. Woohoo? There are few dates on the patient blog site and there are only 146 reports. Sorry, but to me the BHS looks like a typical hernia repair mill.

This Topic is really about finding numbers that will allow a patient to eliminate the worst choices. Worst mesh product, worst procedure, even worst surgeons or clinics. The BHS site doesn’t have any numbers that help.

[William Bryant]

Oh yes I agree, I just found it interesting, and, a big, coincidence they should say robotic causes pain.

I wouldn’t personally consider them as apart from not wanting mesh I’ve read they can charge up to 12k.

[David M]

Watchful, there are two different ways to look at the small numbers here.

First, yes, you would think there would be more people coming to seek help with their meshes-gone-wrong and that may suggest that the actual number of bad cases is relatively small.

On the other hand, without knowing what the actual combined totals’ percentage is, can we begin to get a picture of the way the pain is divided relative to type representation. I think maybe so.

I cant remember a single person on here who had open mesh and came to complain about the pain, but I can think of five off hand that had lap mesh removal due to pain. Chuck, GI, AJM, N**, and Herminius come to mind and I think there are more. If you fill a big hopper with 400000 black balls and 600000 white balls, representing the proportions of lap and open mesh surgeries according to the above chart, what are the chances that the first five balls drawn would all be black? The answer for .4 to the fifth is about 1%.

The proportion of lap surgery snafus here is therefore not that easily ignored. Is this not true?

[David M]

Add Sensei and Edward to the lap pain group.

[Watchful]

We’ve had open mesh cases complaining about pain, such as Baris who ended up having his removed at Shouldice I believe.

A big part of Dr. Brown’s practice was treating chronic pain patients after Lichtenstein procedures. He used to post here before his retirement.

The first surgeon I approached regarding my hernia had chronic pain himself from Lichtenstein and needed a neurectomy.

A colleague of mine still has occasional pain 20 years after his Lichtenstein.

Studies show pretty high rates of chronic pain for Lichtenstein. It’s far from a safe procedure in that regard.

[David M]

Sure, no one is saying that there aren’t some problems of pain with Lichtenstein, but youre pulling in people from other fields of representation.

Baris, of course, belongs in this pool of posters with pain complications from mesh. But certainly in recent memory, the lap pain numbers here have far outnumbered the Lichtenstein pain.

A better view of this would be the relative explanation numbers, Lictenstein vs lap, from a surgeon who does removals. Barring that information or some other well thought out statistical pool, the mounting number of lap removals here is still concerning.

[David M]

Above post should say explantation numbers, not explanation.

I found this older thread about mesh removal doctors. Having gone through part of it, there are two (counting the original poster seekng removal) for Lichtenstein removal and two who had lap removal.

Jnomesh and Lucas S were the two for Lichtenstein, and James Doncaster and Esm were lap removals. Some of the others I havent determined yet.

Best surgeons for mesh removal?

• This reply was modified 2 months ago by David M.

[David M]

Two more lap surgery removals- mitchtom6 and Josh V.

[Good intentions]

Jnomesh was actually one of the first 3DMax patients on the forum, as I recall. He often described how his removal surgeon found it balled up and hard inside him.

I came across another lap mesh patient. Ian J. A new mesh, a product called Polymesh. He was on the forum about a year ago but stopped responding after Chuck asked him to “chat”. Not sure why.

https://herniatalk.com/members/ianj/

I searched for Jnomesh and came across another lap mesh patient looking for solutions. dmpain. Honestly, they are so common that you almost don’t notice them. On for a few posts, gone, back for a few more later.

Long-term pain: bounced between sports hernia and complications from hernia repair

https://herniatalk.com/members/jnomesh/

[David M]

GI, Jnomesh does say in the post I linked just above that his mesh was open placed.

Be sure and bring back any open removals, as well, so we are not distorting the numbers.

I found someone named paul who had lap removal.

[Good intentions]

I think that he was saying that Dr. Belyansky does remove mesh that had been placed via open surgery. He does both.

” had my mesh removed by Dr. Igor Belyankski-Although he removed open placed mesh his expertise is definitely in robotic/laparoscopic removal of mesh placed this way.”

Here is one his older posts where he describes the 3DMax. There are others with more detail. He used the term “hard as a rock” often, as I recall.

right laproscopic inguinal hernia surgery with numbness and pain on right leg

“I really don’t want to worry you but wanted to chime in that I had the 3D maxx mesh implanted 6 years ago and had issues from day one. They weren’t debilitating but occasional flare ups were.
about 10 months ago I did experienced debilitating pain and after much exhausting journey found out that the mesh had folded. The only surgeon to see this on a cat scan was dr. Igor Belyanski in MD. I ended up having to have the mesh removed.”

[David M]

I guess you’re right, because in the link you gave, Jnomesh also said his mesh covered all three spots, including the femoral. That would have to be a lap mesh.

[David M]

Ok, here are the lists so far.

Had lap mesh removal…

Good Intentions
Chuck
AJM
Herminius
NGP (I think those are the initials)
Sensei
Edward
Jnomesh
James Doncaster
Esm
Mitchtom6
Josh V
Ian J
Dmpain

For open mesh removal…
Lucas S
Baris

• This reply was modified 2 months ago by David M.

[David M]

Someone named Timothy had pain after open mesh surgery,though his pain went below knee and may not have been related to the mesh. Doesn’t say that he had it removed.

Chronic Pain affecting most of one side

Forgot to add Paul to the above list.

[David M]

Someone named Forest. He doesn’t say anything about removal, but he came here pre lap surgery and 7 or 8 months later was having trouble sitting as of his last message.

[David M]

Forestt’s story:

Patulous bilateral inguinal canals containing fat

[William Bryant]

As far as I remember Baris did not have mesh removed at Shouldice. They left it and used it to help the repair he had there on one side. The mesh was put in by Dr Koch at Biohernia even though Baris wanted no mesh.

I’m not sure if he had it removed elsewhere though, I think he wanted to.

Hope I have this right!

Brilliant research and idea David M. You must have some patience! Also Good Intentions too.

[David M]

I wish I could add this without bumping the thread.

Add Paco as an expand of the plug and patch.

My explanted mesh photos

[David M]

It’s just one study, but seems to indicate that open removal of mesh slightly less complications than lap removal.

https://www.ormanagement.net/Clinical-News/Article/03-22/Mesh-Removal-How-Much-Does-Surgical-Approach-Matter-/66120

[drtowfigh]

We looked at why we remove mesh over a span of about 5 yrs. The majority of mesh removal was after prior open operations (83% total). However, over time, we noted that the need to remove mesh after prior laparoscopic/robotic surgery significantly increased in a stepwise fashion. So, your observations are valid: we are seeing more complications after lap/robotic surgery than we were seeing before.

The full article can be found here: https://pubmed.ncbi.nlm.nih.gov/30382481/

[William Bryant]

So open would or should be less problematic long term hopefully?

[Author]

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