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Researching surgeons – what questions to ask
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To ajm22 – one more good reason to wait, at least a short while (relative to the rest of your life) is because the tools to understand the effects of all of the new materials, technology, and techniques, are still being developed.
Defocus your research to the more general “quality of life” definition and the state of the hernia repair field becomes more clear. So many new things have been developed, and pushed, and put in to use, that nobody can really say which is better. I’ve struggled myself to call my problems “pain”- related. It’s not really pain, it’s discomfort, some pain with certain activities, the knowledge that you can’t do what you used to do without pain, etc. You become less of a person. You’re able to live without pain if you want to, but you can’t do what you used to do. I’ve thought at times, that it’s much like an amputation of a limb. If you search for chronic pain issues, you’ll get low numbers, just like if you search for recurrence.
This doctor, below, Dr. Todd Heniford, seems to be leading the push for better data collection and the proper usage of it. Read and view some of his work. It’s very informative. The link below is a recent paper, from after I had my surgery, published barely over a year ago. I wish that I had done more research before I had my surgery.
Here’s another, showing how long they’ve been working on it. https://www.carolinashealthcare.org/documents/cmcsurgery/CCSarticle.pdf
He demonstrates how surgeons can be comfortable that what they’re doing works fine, because they don’t really know the long-term outcomes. There’s very little data collected, and what is collected isn’t very useful.
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Direct Hernia’s are more likely to recur than indirect.
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Very interesting. Any data for people like myself who had both a direct and indirect hernia at the time of repair. If there is a recurrence is it likely to be one or the other or both?
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The history of hernia recurrence has shown that if you repair an indirect hernia only, then you if you get a recurrence it will most likely be a direct hernia. The opposite has not yet been shown.
For laparoscopic mesh repair with mesh, the indirect, direct and femoral hernias are all covered.
For open inguinal hernia repair with mesh, the direct and indirect inguinal Hernia areas are covered.
For Shouldice and Bassini, both the direct and indirect spaces are involved.
For the Marcy, only the indirect space is repaired, which is why it’s mostly reserved for children and some women.
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Thanks dr. Kang for your follow up. I have a few more questions regarding the pure tisuue repairs
for indirect and direct hernias.
1) do you know if the shouldice repair for either a direct or a indirect hernia covers both spaces? In other words if you have an indirect hernia will the shouldice repair also reinforce the direct space?2) the reason I ask is Bc I have had my laparoscopic mesh removed by the Same method.
when mesh was originally put in it was noted that I had both a direct and indirect hernia. However, when the mesh was removed there were no hernias noted by the removal surgeon. The direct hernia was completely filled in by scar tissue and there was weakeness in the indirect space that the surgeon repaired by bringing the internal oblique muscle down to the illiopubic tract and sutured with absorbable sutures. I’m curious if only one hernia should reoccur in the future is there a pure tissue repair that can reinforce both areas even if only one hernia reoccurs. I guess my question is since I had Both types of hernias (and don’t want mesh again) if i should have say a indirect hernia that reoccurs I’d hate to Just have a pure tissue repair of the indirect space knowing I’m susceptible to having a direct hernia and might need a second repair down the line-I’d definitely prefer if possible a pure tissue repair that can not only repair one hernia but in essence also reinforce the other space as well.
just curios if that is possible. How would you handle a patient like me?
thanks in advance -looking forward to your input. -
quote Jnomesh:In America (and I’m guessing a lot of other countries) we need more options to mesh repair. And to piggy back on a point you made earlier about how mesh looks once it has been inside the body for a while-I bet if you opened up people who have mesh and no symptoms you would see that the mesh is messed up inside but for whatever reason it don’t bothering the person and is probably still doing its job of preventing a hernia recurrence.
also how is the Marcy operation performed/Carried out. Is it very different from a bassini approach?Hi Jnomesh,
I was on a bit long holiday, so I couldn’t answer your above question quickly.Almost all tissue repair, including Bassini operation, are reinforcing the Hasselbach triangle. Shouldice or Desarda repair is also included.
These procedures are suitable for direct inguinal hernia which breaks out through the weakened and torn floor of Hasselbach triangle.
These are called ‘the posterior wall repair’.However, Marcy operation is just closing the internal inguinal ring. So, it is the most suitable tissue repair for the indirect inguinal hernia which is coming through the widened internal inguinal ring.
The internal inguinal ring, together with the spermatic cord, is located within the bundle of cremaster muscle and has nothing to do with the Hasselbach triangle which is underneath and medial to the cremaster muscle.Therefore, it is unfortunate for most surgeons to perform the posterior wall repair for indirect inguinal hernia instead of closing the internal inguinal ring as Marcy operation does.
I think the high recurrence rate after tissue repair for inguinal hernia, in the past, is probably due to this mistake.So, my Kangs repair consists of two surgical methods.
The Kangs repair for indirect inguinal hernia is similar to the Marcy operation and that for direct inguinal hernia is similar to Desarda method.
Since the skin incision is made at a specific position for each type of inguinal hernia, it is possible to operate with a smaller skin wound.
The indirect and the direct inguinal hernia are about 2 cm apart from each other.Thank you!
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Thanks. Good to know. Great advice. Surprised at the size of the mesh. Very interesting.
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The people I was referencing were people I communicate with online I do not know them personally.
Again I don’t want to go around in circles but I think the point that most of us are making about mesh isn’t whether it is bad or good or whether it will cause you harm or not (yes I have my personal opinions on many of these matters) but thentake away the big take away is if it does go bad it is a nightmare to deal with on so many levels-you can’t even fathom to imagine it.
on some of your other thoughts-no I don’t think in my opinion many doctors have removed mesh in their careers-maybe if it is infected (easier to remove) and maybe some abdminal meshes but I’d guess most haven’t.
i think dr. Krang’s point is that the mesh is supposed to remain flat and not become hard when it is implanted in you-but when he has gone in the mesh can be and often is folded, squished up, moved or attaching to things it shouldn’t.
Also ask your surgeon to show you the actual size of the mesh he will be using-good ones and ones that do a lot should have some examples handy-I guarantee you will do a double take-average size even for small hernias or about 5″x7″ a huge surface area. It has to be way bigger than necessary mostly Bc it is known without a shadow of a doubt to shrink by 30-50% this is a fact.
anyways when I had my surgery I thought the mesh was probably the size of a bandaid. Nope picture a small plate and hold it over your groin to get a better idea.
anyways I highly rx you get a MRI or a cat scan maybe both if one comes up negative. If they both come up negative I’d send them to the surgeons I already mentioned for review.
if after that they come back negative you can loook into other reasons why you have this pain/ bump
id they come back positive you can decide whether to wait or not
if you decide for surgery you can then decide how you want it repaired and make you own best informed decision.
i brought up the other people I correspond with not as a scare story but to give examples of people who rushed into surgery. It was meant to reinforce your decision not to rush into surgery when you don’t know exactly what is going on.
tou are fortunate that whatever is going on with you isn’t bothering you much so take your time gather as much information as possible (please get something scans) get second and third opinions and then you can make the best informed decision. -
quote Jnomesh:Yes by all means don’t rush into anything-surgery should be a last resort and you should have a definitive reason for the surgery. I know of at least 3 people who had no symptoms and it was debatable whether small hernias showed up on scans. They were encouraged by their surgeons to have them repaired laparoscopically with mesh. All three suffered serious complications from the mesh (2 had allergic reactions that led to not only pain but other severe auto immune symptoms)
all three ended up having mesh removal and although all three are overall better since having the mesh removed they all still have some issues that mesh originally caused. They all say they wish they just waited Bc they all had small hernias ( or maybe not) and they didn’t have any problems.
again my advice is to skip the aberahebfemeral surgeon or even specialist and get and send your scans to someone who can definitely interpret what’s going on. The only two I know of are dr. Towfigh and dr. Belyanski. There was another thread of someone experience pain and dr. Belyanski diagnosed that it was a lipoma and not a hernia (still needed surgery) but that person was in pain.Unfortunately I don’t really have any images at this point. I’ve just been examined physically by all the doctors. Perhaps if I do see this last general surgeon next week I can inquire about possibly getting some imaging, though I suspect he will say it’s unnecessary. I can’t say I have any pain, but just some occasional discomfort, and a small bump that gets a little bigger or smaller depending upon the time of day and activity. PCP thought the bump was related to the weakened area of the abdominal wall, but didn’t feel like anything had broken through yet I guess you would say. And I had read on the California Hernia Specialists website that up to 50% of small hernias may never progress or need surgery. I don’t know if this means they stay at a stage where they don’t fully come through the fascia, or if it means they just don’t get larger. I’m only 41 and I am suspecting that over time if I continue to be normally active, that eventually this is going to need attention. But I don’t really know for sure. I also need to get back to exercising and moving around normally again so that I can really gauge my pain and discomfort. Ever since the diagnosis by the surgeon I’ve been extremely cautious and scared to do anything for fear of making this worse quickly. So I don’t really know, but I think I’ve decided to cancel my 10/18 surgery because it feels premature. All have said that there is no serious danger in waiting. I don’t want to wait too long if I do end up needing it repaired, but another month or three should be fine.
Our of curiousity, are the three people you said you know with complications people that you know personally, or those who you’ve met online at similar forums? Just trying to get a sense of what kind of demographic we’re looking at here. I hear from someone like Dr Kang who almost makes it sound like all mesh hernia repairs may be doing damage inside the body but some just aren’t bothered by it, while most surgeons will suggest the rate of complications and truly chronic pain is probably only around 3% after a year or so from surgery (which is very small). It just makes it so hard for a person to decide what to do (not that there are many options – it’s mostly either live with a steadily worsening hernia or get a mesh repair, which may or may not be a bad thing). And I wonder if the description Dr Kang had about what the mesh is doing inside the body actually explains why the mesh is doing good rather than bad in many cases. You would think the whole point of the mesh is to actually get very incorporated into the surrounding tissue. While that could be bad for some people if it irritates or damages important structures like the bowels or spermatic cord or various nerves, you would certainly expect the mesh to be very much intertwined with things around it to strengthen the area and feel more natural. This of course is the challenge a patient has in making medical decisions – very little intimate knowledge of the anatomy and actually seeing all of these things in person, no medical training, and relying on a variety of different opinions from medical professionals.
The challenge for the average person when researching things online I suppose is that we don’t have the medical training or in most cases the scientific background to examine things critically in the same the way doctors do, and we don’t really have access to a lot of the medical papers and studies that many doctors use. We also mostly have to rely on corners of the internet where people are concentrated into groups that are probably overrepresented by 1. people who have had bad experiences or 2. those like myself who have a tendency to maybe over analyze things. To be fair, the latter category isn’t necessarily always a bad thing, because clearly people like myself will tend to ask important questions and spur discussion that didn’t occur to the average person and could be useful to people contemplating surgery. And those in the first category are certainly not to be dismissed. Anyone who has had complications or some kind of bad experience should be taken very seriously. But the point I guess is that the high concentration of bad experiences you see online gives the perception that MOST people have bad experiences, and this this surgery and the use of mesh is usually a bad idea. While that is DEFINITELY the case with those who have chronic pain, it’s not determinate of anyone else’s result.
Anyway, just rambling at this point I guess. I think at this point my main concern is this notion that Dr Kang mentioned suggesting mesh is often doing harm inside the body. I’d be interested to know if I misinterpreted his words, and maybe more detail about what exactly it’s doing in the body that is so concerning. I get the impression that many surgeons have in fact done emergency mesh removal at one time or another and have seen what mesh does in the body over the course of months or years. Perhaps some of them could chime in.
Sorry to be so wordy. Just had a large coffee.
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Thanks for your reply dr. Kang. I think your real world instincts mirror the article I found. I think they called it herniosis: the three stage formation of a hernia.
Anyways I found it really interesting Bc before having mesh surgery (and eventual removal) I had so much burning and a swelling sensation in my left groin and it felt like it was in two places not one-I even felt a sensation of something pushing through more medially and a swelling- but i cat scan showed nothing, them three months later an MRI showed nothing, then 6 months later a physical by a hernia surgeon showed nothing-but man I was in so much pain.
And 13 months later it was finally diagnosed by the surgeon who would docmy surgery. In the report it said significant weakeness in the Heaschel triangle area with fat in it and fat in the indirect space-2 hernias.
so for 13 months I was dealing with two hernias that couldn’t be diagnosed. So maybe I was one of the few that had a lot of discomfort while the hernia was “forming).
also I wonder why the Marcy repair is no longer used in the US. Of the few dr.’a that do pure tissue repair it is either a Bassinin, or modified bassini, desarda or shouldice.
Again thanks for a your insight and feedback. It is so welcomed.
In America (and I’m guessing a lot of other countries) we need more options to mesh repair. And to piggy back on a point you made earlier about how mesh looks once it has been inside the body for a while-I bet if you opened up people who have mesh and no symptoms you would see that the mesh is messed up inside but for whatever reason it don’t bothering the person and is probably still doing its job of preventing a hernia recurrence.
also how is the Marcy operation performed/Carried out. Is it very different from a bassini approach? -
Yes by all means don’t rush into anything-surgery should be a last resort and you should have a definitive reason for the surgery. I know of at least 3 people who had no symptoms and it was debatable whether small hernias showed up on scans. They were encouraged by their surgeons to have them repaired laparoscopically with mesh. All three suffered serious complications from the mesh (2 had allergic reactions that led to not only pain but other severe auto immune symptoms)
all three ended up having mesh removal and although all three are overall better since having the mesh removed they all still have some issues that mesh originally caused. They all say they wish they just waited Bc they all had small hernias ( or maybe not) and they didn’t have any problems.
again my advice is to skip the aberahebfemeral surgeon or even specialist and get and send your scans to someone who can definitely interpret what’s going on. The only two I know of are dr. Towfigh and dr. Belyanski. There was another thread of someone experience pain and dr. Belyanski diagnosed that it was a lipoma and not a hernia (still needed surgery) but that person was in pain. -
Just got another opinion from my old PCP and he says the same as the first – that it doesn’t appear that things have broken through just yet and though there might be some weakened areas in the abdomen/inguinal canal, he’s not detecting a full hernia yet. Very small weak spot that may or may not eventually become a full hernia. So two opinions from non-surgeons saying leave it alone, and another opinion from surgeon saying repair it (and that i likely have bilateral). Very confused at this point. Made appt with another surgeon at another practice to see what he says and then will decide probably one way or another. Would be a real shame to get surgery while having minor or no symptoms most of the time and not have a full blown hernia.
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Well that’s a bit concerning (especially considering I feel as though my options are almost exclusively limited to get surgery and getting it done with mesh), but I appreciate your candor and response. My father had prostate cancer so that kind of hits home for me. My potential surgeon does Desarda as well but doesn’t seem to think it’s the best option.
quote drkang:Hi, ajm222Yes, I have a lot of concern with the mesh inguinal hernia repair. In fact, I performed more than 6,000 open hernia repairs using a mesh plug until the spring of 2013. Sadly I have no exact my statistics of mesh complication, but I had quite many patients who complained of chronic pain after repair. I agree with the statistics saying that the chronic pain after mesh repairs would be over 10% incidence.
In 2012, I performed the first mesh removal for the patient suffering from very severe chronic pain after receiving a mesh repair at other hospital. His pain was so severe that he couldn’t do even normal daily activity. That operation was terrible experience to me as well. As the mesh was so clumped with the surrounding important structure that the operation was too dangerous. After that operation, I got sick from mesh repair and I began to make a lot of effort to develop a new no mesh repair with low recurrence rate.I think every surgeon performing mesh hernia repairs should try an experience of removing the mesh which he himself inserted. I am sure if they learn from experience how terrible the state of the inserted mesh is and how dangerous mesh removal is, then many of them would stop doing mesh operation any more. But they do not really try to do that.They always tell the patient suffering from chronic pain that there is no recurrence. They don’t like to take the responsibility to solve the patient’s problem by removing the cause. That’s a pity.
Anyway I have removed more than 50 meshes so far ever since. But I have more patients who are still suffering from quite severe pain after mesh hernia repair.
I totally support Jnomesh’s and Good Intention’s claims. I think their knowledge and assertions are very accurate and are based on facts.
And just one more thing to know. Laparoscopically inserted mesh might hinder the future prostatectomy for prostatic cancer.
Thank you! -
quote ajm222:Dr Kang – do you have any concerns with mesh? Do you do mesh repairs, and if so how often do you see issues and people returning for removal and chronic pain more than a year or two later?
Hi, ajm222
Yes, I have a lot of concern with the mesh inguinal hernia repair. In fact, I performed more than 6,000 open hernia repairs using a mesh plug until the spring of 2013. Sadly I have no exact my statistics of mesh complication, but I had quite many patients who complained of chronic pain after repair. I agree with the statistics saying that the chronic pain after mesh repairs would be over 10% incidence.
In 2012, I performed the first mesh removal for the patient suffering from very severe chronic pain after receiving a mesh repair at other hospital. His pain was so severe that he couldn’t do even normal daily activity. That operation was terrible experience to me as well. As the mesh was so clumped with the surrounding important structure that the operation was too dangerous. After that operation, I got sick from mesh repair and I began to make a lot of effort to develop a new no mesh repair with low recurrence rate.I think every surgeon performing mesh hernia repairs should try an experience of removing the mesh which he himself inserted. I am sure if they learn from experience how terrible the state of the inserted mesh is and how dangerous mesh removal is, then many of them would stop doing mesh operation any more. But they do not really try to do that.They always tell the patient suffering from chronic pain that there is no recurrence. They don’t like to take the responsibility to solve the patient’s problem by removing the cause. That’s a pity.
Anyway I have removed more than 50 meshes so far ever since. But I have more patients who are still suffering from quite severe pain after mesh hernia repair.
I totally support Jnomesh’s and Good Intention’s claims. I think their knowledge and assertions are very accurate and are based on facts.
And just one more thing to know. Laparoscopically inserted mesh might hinder the future prostatectomy for prostatic cancer.
Thank you! -
Hi, Jnomesh.
I am very careful to answer your question, because there is a sensitive point.
I am afraid that I don’t know of the research you mentioned. However, I personally made the same guess as the study mentioned with some patients. Often, the inguinal hernia is not confirmed on the inguinal sonogram among those who complain of inguinal discomfort including pain. In this case, I personally guess it may be the precusor symptom which can appear before the overt hernia(it means buldging) development.
Continuous pressure is applied to the weak point of internal inguinal ring(in case of indirect hernia) or of the floor of Hasselbach triangle(in case of direct hernia), and the resulting minute damage in the process of wedge widening may produce pain or other discomfort. I do not think that this condition can be diagnosed as a hernia yet, even though there may be the possibility of processing to an overt hernia in the near future.Physical examination is not precise, I think. Although I have performed more than 12,000 inguinal hernia repairs so far, there are still many cases where the results of physical and ultrasound examinations (I do ultrasound exam for inguinal hernia, because it is safe-no radiation, easy and can be done in a standing posture which helps precise diagnosis) are not consistent, especially in borderline cases. So I trust the results of the ultrasound examination rather than trusting my physical examination.
Thank you!
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Dr. Kang,
im curious if you have done any research or are aware of research regarding hernia formation as a process. I read an interesting article where it is suggested that the actual hernia one see as a bulge is actually the final stage of a three step process. And ongoing this interesting for me Bc I never had the classic bulge and the hernias never showed up on MRI or cat scan or during physical examination. But I felt internal heaviness and pressure in the groin. It went undiagnosed for 13 months until I went to a surgeon to rule out a sports hernia and he said I did have a hernia when he did the physical examination. I should not he did the classical examination the finger in the scrotum and cough test but he also did something other before Him hadn’t and that was with me lying down he put his finger at different spots in the surface of the groin and asked me to cough. Anyways when he operated he found a direc and a indirect hernia. Before him at different intervals I had the MRI, the Cst scan and another surgeon spread out months apart all said or showed no hernia-when I actually had two!!!
Anyways the article suggested that the hernia formation is a three stage process and people could feel pain along any three of the stages: weakness in the muscle, fat being hammered into a wedge and then finally entering the inguinal canal. It says this can explain why people may present with groin pain but show no bulge, no confirmation on physical examination and does not show up on scans Bc it has not gone into the canal-which most radiologists are looking for.
just curious as to your thoughts. Thanks -
If I can chime in a little bit. The whole topic of recurrence rate is really quite silly when you put it in context. Since mesh is still relatively new in becoming the gold standard there is no way anyone knows the recurrent rate down the line. Are they really following up with people 10, 15 , 20, 30, 40 years down the line? No way.
So as you can see it’s really quite silly to focus on recurrence rates as the main reason to support the use of mesh. Maybe this doesn’t matter as much if you are in your 70’s or 80’s but if you are in your 20’s-50’s it sure does.
However the more important question in my mind is does anyone really know how well mesh holds up in the human body for 30 or 50 years?
so even if you know people who are doing well with mesh and I know them too, how will they be many many years down the line.
the other problem is if you do get a recurrent hernia with mesh, the common paractice is to repair the hernia with more mesh with the opposite way it was inserted. So if you had it placed openly it would be repaired laparoscopically and vice Versa. What you end up having is a what is called a mesh sand which-which is disasterous if you should ever develop pain and want/need mesh removal Bc both meshes can’t be removed Bc your whole inguinal floor will be shredded. So you have to determine and guess which mesh is giving you problems.
And when you think it about it more it is bery disconcerting that failed mesh is left inside of you.
Hmm the mesh failed and was strong enough or good enough to hold the hernia so let’s just leave it inside you. It’s just bizarre and foolish.
There are plenty of people who develop mesh symptoms down the road i.e. 10 years later. It can happen.
so when you look at the totality of the issue with mesh it is just maddening that it is the gold standard with so few alternatives being offered.
i believe from what I’ve researched that even if you just look at recurrence rates-if you look at the best most experienced surgeons doing mesh repairs and the nest most experienced surgeons doing pure tissue repairs recurrence rates would be very similar (shouldice hospital reports recurrence rates below 1%).
but chronic pain? Way higher with mesh.
ill say it again make your best most informed decision and then once you do please find a surgeon who this all they do-hernia repairs whether with mesh or non mesh. And is throw in find a surgeon that is an expert in removing mesh too if that’s what you decide to do. You have NO idea the ringer you will put through if something should go wrong. You will never hear-it’s the mesh!
And good intention has hit on the head-mesh products are continually being introduced to the market. If they are so great why is this? Why are some discontinued or pulled off the market. And others are litigated against.
i came across a post online where a lady was in so much pain from mesh and she finally found a surgeon after years of complaing of pain and every other test being performed instead of looking at the mesh. Anyways this surgeon finally said it’s the mesh and followed with “we don’t use this type of mesh anymore Bc of its bad results”
so she had to go under another operation jus to remove the mesh Bc they have now learned it is no good. So in affect she was a guinea pig-we all are.
do you hear about the numerous new tissue repairs that come out yearly? No.
again if mesh were similar to a walking boot and a walking boot for foot issues turned out to be bad or faulty OK you change the walking boot by simply taking it off and trying a new one.
if a certain type of mesh turns out to be bad you now have to have a prosecutor inside of you meant to be permanent removed surgically. -
i didn’t really ask specifically about chronic pain which is why he didn’t address it. i asked about recurrence rate. but i’ll see what he says when i bring that topic up.
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quote ajm222:I do like that this surgeon said he’s been using the same mesh for ages (at least a decade I believe). He gave me the name but I’ve forgotten and plan to ask him specifically what it was. And he also did say he’s happy to do the non-mesh repair if I choose. And he said one study suggested mesh versus non-mesh at three years had the exact same recurrence rate. No better or worse. They just don’t really know beyond that perhaps what the recurrence rate is. He did say it looked great, though, and he seemed confident in that method.
It’s good that you asked. But the answers are focused on the same thing – recurrence rate. It’s like old-time brain-washing. Ask a question about chronic pain, get an answer about recurrence rate.
My surgeon was very confident about his number of repairs also.
Good luck with whatever you end up doing. Try to lead the conversation though. The environment is intimidating and it’s difficult to challenge the experts.
Here’s one thing you can think about to maintain your curiosity – if “mesh” is perfected and is the superior method, why is so much research being done on new mesh products? Are all of those researchers deluded, and wasting their time? Why do the medical device suppliers keep introducing new mesh materials, if there’s no problem? What need are they addressing?
Here’s a pretty good article (it leans toward industry a bit) that explains how these things happen. The same people are working in hernia repair products. Replace just a few words and it’s easy to imagine that it was written about hernia repair.
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Interestingly, my aunt had an umbilical hernia repaired that she had left alone for like 25 years. And the surgeon didn’t use any kind of mesh to fix her up. Just spoke with her. Very large umbilical hernia and just stitched up presumably with tissue. If that’s possible, it would seem the same could be done with a smaller inguinal hernia without issue, especially considering the study mentioned above. Sort of surprised mesh is still the gold standard for what sounds like 95% of all inguinal hernia repairs when non-mesh repairs seem to be pretty successful. Maybe it’s just not enough people trained to do it. I should ask this surgeon why he doesn’t do more non-mesh repairs.
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