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The state of teaching hernia repair – Dr. Felix
Here is a Twitter page showing Dr. Felix’s “Ten Commandments” of mesh repair. I posted a youtube video from him in the past where he implied that people with mesh pain should just be tougher. He had a mesh repair and said that he had pain, but downplayed it. Just “tough it out”.
In his slide show you can see that they are now recommending the largest piece of mesh that can be fit in to the space, essentially. covering areas with no hernia, prophylactially, although just a few years ago that was not standard practice. You can also see why people have pain and discomfort over the pubic bone, since the mesh is laid all the way down past the pubic symphysis, under the bladder. When I had my problems I could actually feel it sliding over the pubic bone when riding a stationary bicycle.
Anyway, this is the “state of the art”. People like Dr. Felix are traveling the country teaching young medical students how to use mesh. I don’t think that there is any way to stop this juggernaut, only do your best to avoid getting run over by it.
Click on an image and you can see all of the slides.
https://twitter.com/UMichSurgery/status/915993293929947136
https://www.youtube.com/watch?v=mk7kF7oCRqk
Great pearls and Dr. Edward Felix’s 10 Commandments of inguinal hernia repair during today’s resident lecture. #UMSurgUpdates pic.twitter.com/rEpJEslXE5
— Michigan Surgery (@UMichSurgery) October 5, 2017
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7 Replies
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I wonder if the doctors on this forum could comment on their patients, and how many of them suffered from chronic pain..of course assuming there was some follow up…
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The shame of it all though, is that the “10 Commandments” or 9 Commandments, from the pioneers of the mesh implantation lead to a 15% or more chronic pain rate.
The conversation about mesh always get diverted away from the numbers. The chronic pain numbers. The one in six chance of having chronic pain/discomfort. Focus on recurrence, and blame past mistakes or the surgeon’s skill for chronic pain, even though the data shows otherwise.
You can find that many of these surgeons that are trying materials and methods outside of the “Guidelines” (which also ignore the 15% pain rate), are best “guesses” at what causes the chronic pain. You will find surgeons using adhesives, thinking that it’s fixation that causes pain, or using the two-sided materials, or new “bio”-materials, thinking that some sort of adhesion is causing the pain. But the people behind the mesh products, the device makers, are not doing anything at all, as long as a product is still selling.
A couple of years ago it was well-accepted, and a major topic of discussion, that chronic pain was the #1 problem with mesh-based hernia repair. People like Dr. Felix ignore the #1 problem and only focus on training more mesh followers. I think that he enjoys the limelight.
Chronic pain is still the #1 problem with mesh repairs. The materials are the same and the new surgeons are being trained to the same Commandments. The use of the word Commandments is almost blasphemous.
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This reply was modified 3 years, 10 months ago by Good intentions.
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This reply was modified 3 years, 10 months ago by
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If I give you a button-down shirt that is 2 sizes too small for you to wear, what are the consequences?
– it will tear
– you will be very uncomfortable in itIf I use a patch over your sweater’s elbow that just barely covers the torn/worn area, what are the consequences?
– it will have minimal durability
– it will pull off and expose the worn area againIt’s all about physics, tension, area.
The same is true of open anterior repair for inguinals. The standard is 3×6 inches. Smaller mesh causes more recurrence and more chronic pain because they are pulling.
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Interesting as I would have thought the smaller the mesh the less the possible adverse reaction of the body…so you see cases of complications because of a too small mesh?
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Just to clarify:
Dr. Felix is one of the original pioneers of laparoscopic hernia repair. The 9 Commandments was published by him and Dr. Daes with the goal of communicating the best techniques for critical view of laparoscopic/robotic inguinal hernia repair. The concepts are nothing new to those of use that perform hernia repair regularly, and yet they are regularly “violated” in many of the situations that I see that come to me for complications. Use of 10x15cm mesh for laparoscopic repair has been standard for the past 2-3 decades. Smaller mesh causes recurrences and an unstable repair, which contributes to groin pain.
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I find it strange that the students do not question the teaching in the first place (or maybe they do?). Not only because they should be at a point in their studies where the skill to independently assess and judge something rationally should have been acquired, but also because many of them probably know somebody who had an hernia repair, and possibly even somebody with serious issues from it…
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@good-intentions
It is scary what is being taught.
Bill Brown MD
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