rational take from 2013

[William Bryant]

Ive never really understood why recurrence is the worst thing, especially when it can be done again.

It’s not ideal and uses health resources, especially in ‘free’ systems like the NHS, but it’s got to be better than living in pain.

Put it thus way if it was a choice between a possible recurrence or possible pain which would most people choose?

[JamesDoncaster]

I have read a number of studies that claim chronic pain is roughly equal in mesh and non-mesh repairs. I believe Dr Towfigh has mentioned this. However, no matter what the medical data and analysis may say, have any of you run across somebody (either in person or on the internet) that had chronic pain after a first hernia repair done without mesh? I haven’t. And I have done EXTENSIVE looking. Now, how many of you have read of or met people with horror stories of what a mesh-based operation has done to them? I would wager all of us have. Indeed, many times when I mentioned to somebody that i had experienced chronic pain after a mesh repair, that person would respond “oh, I know so-and-so and they also had a lot of pain.”

If the statistics about chronic pain after hernia repairs indicate equal occurrence and severity of chronic pain for both mesh and non-mesh repair, then I would say that those statistics are not in line with reality.

[Watchful]

My preference is also tissue repair. To be fair, though, chronic pain can happen with tissue repair as well. I don’t know if there are reliable statistics comparing the incidence and severity. My impression from what I’ve read is that it’s worse with mesh, but I’m not sure. One thing that’s pretty clear is that when things go wrong with mesh, corrective surgeries are more problematic.

[JamesDoncaster]

Thanks @markt for the concise review of the article.

I find it absolutely astounding that any surgeon would perform a mesh-based repair for a patient that is having his/her first hernia repair. Every surgeon knows (or should know), that a portion of their patients will have chronic pain after a mesh-repair. And, those patients will have to deal with either life-long pain, a complicated mesh-removal operation or both, and will likely suffer PTSD. What is the worst-case outcome of a tissue repair? A recurrence. Big deal.

I work in a field that has a rather advanced understanding of risk-management. Either the vast majority of surgeons are not adequately trained in risk-management, or they do not care about their patients.

[MarkT]

I pulled a copy of the paper. It is a relatively brief editorial opinion, rather than a formal study.

Worth noting the author (Joseph E. Fischer) was at Harvard since 1970 and passed away just last year. He was quite a prolific researcher: https://en.wikipedia.org/wiki/Josef_E._Fischer

He notes that ‘fads’ exist in surgery and that some procedures have become the norm without a whole lot of evidence behind them, sometimes simply because some ‘important’ person championed them…and he believes this to apply to hernia repair.

When he was a resident (mid-late 60’s?), the Cooper’s Ligament repair (Anson-McVay repair) was the standard being taught…although he was not sure why, because while it was purported to prevent femoral hernias, such hernias made up only ~1% of male hernias. He said that a few years later, when he was doing more surgeries, “…I noticed that there was more postoperative pain with the Cooper’s ligament repair, so I started doing the conventional repair but with special attention to the transversalis fascia. It was not the Shouldice type of repair, of which all of us were aware, which in its classic execution demands that one cut through the transversalis fascia and then reef it up, repairing it, but we did in fact tighten up the transversalis fascia, resulting in increased strength of the repair. I also noted that there was less pain with this transversalis fascia repair, paying special attention to the inguinal ligament and the conjoined tendon, and I observed few recurrences and noted very little pain.” (p.620)

He goes on to say that recurrence became the primary outcome consideration of most hernia surgeons, despite recurrence rates of 4%-6% and pain rates between 2%-4%, both of which he deemed to be ‘satisfactory’.

He states that a ‘cottage industry’ of mesh repair then developed, with numerous post-grad courses teaching various repairs with various meshes. His friend (Arthur Gilbert) developed the plug and patch, and there was Kugel, Lichtenstein, and variations on the plug and patch…with surgeons being happy to believe that recurrence rates would drop.

But he then saw many patients who had post-op pain, given that much of his practise was dealing with problem cases of patients from other surgeons. Inguinodynia (chronic pain) was an issue for many, though he noted it was often very hard for him and other surgeons to determine if patients had real chronic pain or purported to have it because they were seeking legal recourse.

He claims that most hernia surgeons denied there was such things as inguinodynia at the time. He disputes this and says there were simply too many cases for them to all be bogus and that many patients indeed had life-altering pain. He therefore questions why there was a movement to introduce mesh to reduce an already ‘acceptable’ recurrence rate, given the terrible chronic pain that resulted for a small but significant number of mesh repair patients.

What he finds particularly interesting is that while most surgeons denied that inguinodynia exists, they still took great steps to prevent it via neurectomy. He also suggests that chronic pain can result from “osteitis pubis from permanent sutures in the pubic bone, cord entrapment, and sutures catching the cord or the genitofemoral nerve” (p.620).

He then does a bit of a literature review, but there is just too much info to summarize it all here. A couple of studies found that chronic pain was a bigger concern than recurrence and that neurectomy reduced chronic pain (despite others, like Lichtenstein, claiming inguinodynia does not exist and that all nerves should be preserved).

He criticizes one study that found neurectomy to not be effective, stating they didn’t perform what he believed to be the right excision, which would be “the isolation of all 3 nerves, dissecting it as far back as one can laterally, tying it off with 6-0 Prolene, touching the end of the nerve with phenol and alcohol, and then burying it in the muscle” (p.621).

He feels that there is a ‘steep learning curve’ for doing a good neurectomy that many surgeons are simply not willing to overcome.

After the lit review, he says “…whatever the incidence, there is a small but significant group of patients who undergo a mesh repair who are seriously inconvenienced by the amount of pain in both the near and remote postoperative periods” (p.622).

He maintains that a 6% (max) recurrence rate is worthwhile to accept in order to avoid the small, but significant number of cases of debilitating chronic pain that has a major impact on quality of life and even results is some mesh repair patients being suicidal (we have at least one on this forum).

He says that his preferred (tissue) repair method is no longer readily taught and most surgeons today would not even understand it.

The big takeaway in his discussion: “…there is no question in my mind that patients will be better off if we abandon mesh repairs with or without neurectomy and return to an old-fashioned transversalis type of repair, taking care to reef up the transversalis, and to doing a careful repair of the conjoined tendon and Poupart’s ligament, somewhat along the lines of the Shouldice Hospital repair” (p. 623)

That is a pretty strong statement.

He notes “…there is now a considerable body of patients, numbering in the thousands, who report inguinodynia to a US Food and Drug Administration (FDA) database, and it is only increasing…The inguinodynia database that the companies allegedly collect is imperfect, and companies keep asking for the piece of mesh that was removed from the hernia site, examining it for defects. I think this is a sham. It is not a deficit in the mesh that gets these patients into trouble, it is the inflammatory response of the 3 nerves to whatever kind of mesh is inserted, and adherence to the mesh and/or the inflammation around the mesh is what causes the inguinodynia, which I think is a miserable disease” (p.623).

His parting words are that “recurrence of a hernia is not the most terrible thing in the world. It can be repaired. But patients are not miserable and do not take narcotics, they can go about their ordinary business, and the pain is relieved by simple medications, and if it is not tolerated, these patients can undergo repair of the reoccurrence. It is time that we stop creating inguinodynia in inguinal herniorrhaphy. The public health problem of herniorrhaphy in 5% of the adult male population in this country undergoing mesh repairs will sooner or later create an enormous problem” (p.623).

[William Bryant]

Really interesting.

So right, ruining people’s lives to keep recurrence rate low is wrong. Misguided.