Topics in hernia repair – humans as performance animals and CPIP effects

[Good intentions]

Thanks for the discussion Mark T. I wrote a bunch then realized I was just rehashing things that I’ve already said many times.

It is interesting to imagine that maybe the focus on people with pre-existing psychosocial problems could lead the hernia repair community to make better choices overall. What if they decide/realize that a pure tissue repair is the best choice for a person with pre-existing psychosocial issues, because potentially subjecting a person in a weakened mental state to the years of complications from mesh could drive them over the edge. Today’s thought seems to be that it’s okay to subject healthy people to that risk. The risks and complications are clear but they do it anyway. Maybe they’ll realize that subjecting weakened people to that risk is not “right”.

It’s a double-edged sword though. The realization could result in the holding back of care for people with psychosocial issues, because the logical extension to healthy people won’t fit the paradigm. When I first saw Dr. Ramshaw’s comments on the subject my first thought was that they were developing a screening tool to reject patients that might be a problem in the future if they developed CPIP. Reject care because they might complain.

In these types of conversations I haven’t seen the proposal of how to handle the people with psychological problems, to get their hernia repaired in a way that is best for the patient. The efforts seem to be on identifying the correlation, but it’s not clear what they will do afterward.

[Watchful]

@markt

This is dangerous territory. Pretty much anyone who has significant medical issues (including surgeries or sequelae of surgeries) can be diagnosed with “psychological disorders” by one mental health practitioner or another. It’s a field where pretty much everyone can be diagnosed with something by someone, and they’ll be happy to “treat” it with some therapy or dangerous drugs.

Throwing people with hernia into their hands is scary. Also, those poor souls who go there and have it on their records will be dismissed in perpetuity by gaslighting doctors and potentially insurance companies as well.

[MarkT]

I should add that while I see merit in this line of research, I also *highly* doubt that it is the case that pre-existing mental health issues are directly and solely responsible for CPIP in any significant number of patients.

While there are no doubt at least some ‘it’s all in the head’ cases, it seems FAR more likely that having pre-existing mental health issues might result in a ‘worse experience’ when there is CPIP…that is, that causality would go in the other direction: that CPIP worsens existing issues. It also seems FAR more likely that CPIP causes issues for many people who previously did not have them. This is why the research needs to be done though.

Regardless of the direction and direct/indirect causality, the advocacy for more comprehensive pre-surgery assessment seems useful. Establishing whether someone has pre-existing mental health issues can inform the pre-surgery consultations (what to expect, the risks, etc.), post-surgical therapy options, and even the decision on whether to operate in the first place or wait (perhaps trying to address or mitigate the mental health issues first).

[MarkT]

Unfortunately, abstracts are very abbreviated and often insufficient. They are meant to give researchers enough of an idea to determine if that study is relevant to their specific interests and is worth reading…they are not meant to provide enough information to critique it.

Despite the admittedly not-so-well-written abstract, I don’t see any confusion of cause and effect…in the body and conclusion of the study, they specifically state that causality in either direction has not been established (and it is not their purpose to establish it, which is not possible to do in a retrospective study of this nature anyway).

The first sentence notes that many patients with CPIP have mental health issues…and the purpose of the study is to determine the prevelance of mental health problems in patients with CPIP. Before you can explore causality or address a problem, even if you have a hypothesis about it, you need to establish prevalence…because if studies suggest little to no prevalence of mental health issues in patients with CPIP, then there would be little point in investing further resources to address a problem that apparently does not exist.

The intro states “Although psychological disturbances, like depressed mood and poor emotional health, have been associated with CPIP [7], the prevalence of these diagnoses in this population is unknown. A better understanding of the prevalence of psychological disorders in patients with CPIP may enable surgeons to optimize patient assessments and treatment approaches. Using the data from our groin pain clinic, we aimed to describe the prevalence of psychological distress, pre-existing psychological disorders, and other psychosocial issues in a group of patients with CPIP.”

From the discussion, after the results: “Psychological testing in our inter-disciplinary groin pain clinic revealed that patients with CPIP may have higher rates of psychological disorders than the general population. We do not know if antecedent psychological disorders placed patients at risk for developing CPIP or vice versa. Nevertheless, a psychological evaluation for patients with CPIP, or referral to a center that can provide this expertise, may be wise before attempting surgical intervention. After psychological assessment in our groin pain clinic, recommendations are made by the psychologist for appropriate next steps in care. These recommendations, based on clinical judgement and the results of the psychological testing, may include pain rehabilitation or additional psychological evaluation and treatment prior to surgical intervention. The psychologist may also conclude that there are no psychological contraindications to surgery.”
…
“This study has limitations. It represents the retrospective findings of a single institution and is a small sample size. This study is further limited in that we did not compare the CPIP group to a control group to determine statistical significance of any results evaluated. Additionally, we do not know if the psychological assessments and interventions in this population impacted clinical outcomes. We also do not know if the higher than expected rates of psychological disorders seen in this cohort are due to pre-existing psychological disorders that place these patients at higher risk of developing CPIP, or because patients with CPIP are more likely to develop psychological disorders. Further prospective work needs to be done in this area. Finally, this study represents the findings of a high-volume hernia center, and our results may not be generalizable.

In conclusion, an inter-disciplinary groin pain clinic has revealed that patients with CPIP often have complex psychosocial issues, including mental illness, a history of childhood abuse, pain catastrophizing, disability, and a history of substance misuse. A multispecialty approach to CPIP may improve preoperative assessments and identify patients who may benefit from further psychological evaluation and treatment. Future research should also seek to identify the relationship of these psychological disorders with outcomes after the surgical treatment of CPIP.”

Having said all that…I have little doubt that a key idea is that some subset of cases of CPIP are at least partially attributable or worsened due to pre-existing mental health conditions….but the authors wisely avoid making this direct implication and instead stick to what CAN be shown: that patients with CPIP may have higher rates of mental health issues.

The real work will come later…trying to determine whether, what kind, and to what extent, pre-existing mental health issues predict CPIP…and to what extent CPIP predicts subsequent mental health issues in previously ‘healthy’ patients. Establishing causality in either direction will necessitate experimental studies (plural) with appropriate controls. In the meantime, their advocacy for more comprehensive pre-surgical evaluation seems to have merit, simply based on the prevalence findings.

[Watchful]

@good-intentions

This confusion of cause and effect (as well as correlation and causation) is really disturbing to see. How can it be one thing in the abstract, and then the opposite in the conclusion? Some sort of circular logic?

This kind of vague ammunition for dismissing patients with chronic pain after groin surgery is likely to be abused. There are already way too many doctors who belong to the “it’s all in your head” school of medicine. Encouraging this convenient escape is not good.

[Good intentions]

Here is the performance paper. From the military.

It assesses repair methods and the ability to get back to military duty quickly. An issue that seems very important and relevant to the military. Understanding how to get the troops back in action as soon as possible. I’ve often though that lap mesh repair was ideal for this purpose. Worry about the problems after the war is won. But, they did not come to that conclusion. Open and lap gave the same results. Note that “hernioplasty” means mesh is used, by definition.

They only assessed physical performance, apparently. Although mental and emotional states are also very important for members of the military. The paper seems very “old school”. A vision of General Patton comes to mind.

https://link.springer.com/article/10.1007/s10029-022-02650-6

“Purpose
The advantages of minimally invasive inguinal hernia repair (MIHR) over open hernia repair (OHR) continue to be debated. We compared MIHR to OHR by utilizing the Army Physical Fitness Test (APFT) as an outcome measure.”

“Conclusion
Overall, no differences in post-operative APFT scores, military profile time, or time to first post-operative APFT were observed between minimally invasive or open hernioplasty in this military population.”