drtowfigh
Forum Replies Created
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Every physician and hospital has their own billing practices. Mine is more similar to the Shouldice Clinic. To know how it works in your specific situation with your insurance, you can call or email my office to help explain it for you.
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Just to clarify. I offer Marcy, Shouldice, Bassini, McVay, and r-IPT (robotic Nyhus-Condon) repairs.
It all depends on the needs of the patient.
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Just fyi, it is a mandate by the American Board of Surgery that all surgeons must collect outcomes data. There are a handful of approved databases. I’m not sure if the SRC database qualifies as a Board-approved database. So, the SRC is not offering any more rigorousness than what is demanded of all Board-certified surgeons.
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fascinating.
Some corrections:
– Drs. Brown & Kingsnorth are retired
– Dr. Bendavid has passed
– Dr. Novitsky is in New York
– Dr. Cobb is in South Carolina
– Dr. Voeller is in Memphis and not part of UT
– I am not familiar with Dr. Kang Kim -
I’ve had my own share of bad outcomes. There is no perfect surgeon. We are all human. Specialists should have lower risks of complications. And when we do have complications we are usually much better at knowing what to do next.
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I stand behind all the surgeons who I’ve had in as guests in HerniaTalk LIVE. It’s my quiet way of showing my preference for them as the chosen ones from whom you may choose to seek consultation.
Also, just because I don’t like their surgical technique doesn’t mean they are bad surgeons. These surgeons have excellent outcomes.
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Based on the little information provided, I would say this is a hip problem. The comment of catching pain when going from sitting to standing is classically hip related. Also pain from iliac crest to groin is more typical of hernia.
If you’d like more help, please contact my office for an official consultation.
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This is not the first time you’ve asked me to support my claims. I’ve done it before for you. I cannot force you to agree with me. Nevertheless, you asked again and I shall answer again. As you know, I prefer dealing with facts and not anecdote. So here it goes:
I interpret your situation as someone who got injured in a plane crash and is now claiming he should have driven cross country. Whereas all studies show it’s safer to fly than drive. And your focus is that flying can’t be safer or better because it causes so much emissions, isn’t carbon neutral, and isn’t minimally invasive mode of transportation.
Here are the facts:
– every major large population database study shows laparoscopic inguinal hernia repair has multiple benefits over open repair with or without mesh, including less chronic pain, less nerve injury risk, lower recurrence risk, shorter recovery time, and so on. The more advanced we get, the stronger the data in favor of laparoscopic repair, all things being equal. These are just a handful of review papers that include a lot of references in support in addition to multiple consensus reports by the European Hernia Society.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001785/full
https://pubmed.ncbi.nlm.nih.gov/35286471/
https://link.springer.com/article/10.1007/s00464-022-09161-6
https://www.sciencedirect.com/science/article/abs/pii/S0002961022003051
– the term minimally invasive commonly refers to the lesser tissue trauma and need for healing involved with lap as opposed to an open operation which involves a large cut and a longer recovery. Less cutting, less retracting, less sewing = less swelling, pain, and shorter recovery.
– not sure what you mean by “huge” number of tacks. If used, less than 5 tacks are needed. If you had more than 5 tacks per side, that is outside of common recommendations
– your tacks, if absorbable, are not petroleum based. The non-absorbable tacks are typically titanium.
– it is common to catheterize when performing pelvic surgery. Every urologist would recommend it. The risk is bladder injury if you are not catheterized. There are general surgeons who do not routinely catheterize. Most large population studies show that catheterization is otherwise riskier than not catheterizing.
https://pubmed.ncbi.nlm.nih.gov/31657302/
– 3D Max only has a tendency to ball up if the surgeon doesn’t make the space wide enough to fit it or the mesh is curled prior to placement. Analogy is putting paper in an envelope that is too small for it.
– the weight of 3D Max is 137.1 g/m2, which is heavyweight. They also have middleweight and lightweight 3D Max. It is also not microporous or macroporous. Pore size is 5×10-4 inches2.
– 3D Max instructions from the company specifically shy away from recommending no fixation. In some hernias, fixation may not be necessary. We know fixation is recommended for direct, femoral, and large indirect inguinal hernias.
– mesh fixation does not prevent balling up of mesh
– it is not true that “immense tissue injury” is initiated by laparoscopic surgery.
– it is not true that the peritoneum is “shredded” by laparoscopic surgery
– the mesh standard is 10x15cm. That is 150cm2, which is
Also know that laparoscopic surgery came after Dr Lloyd Nyhus started doing open posterior repairs in late 1950s/early 1960s. That came first. Then laparoscopic repair option was introduced.
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Most likely the comment is logging in what disposable implant was used. The tacker used comes with 30 tacks in them. Though I’ve seen 30 deployed in someone, that would be way outside standard. A simple X-ray or CT scan can show how many tacks have been used and where they are.
US op reports btw are so much more informative than non-US.
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Need imaging and operative report to identify type of mesh, where it is placed, and relationship of seroma to mesh.
This determines treatment. If it’s infected seroma, that needs its own treatment. If the mesh is infected, most likely needs mesh removal but sometimes, depending on consequences, it can be salvaged.
A specialist with experience treating mesh infections can help.
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I know my responses sound defensive. But one of my roles here is to provide a counterpoint. Surgical care cannot only be seen from the patient’s viewpoint.
I also point out inaccuracies, as I don’t want this platform to run on promoting too much negativity without understanding the counterpoint.
Eg, we did discuss the longer procedure time in our study. And in our paper we analyzed why. Also, cost is usually not as important if outcomes are better or safer.
Lastly, I enjoy reading different viewpoints. It has certainly affected how I practice. I definitely don’t believe in status quo. If anything, my reputation is the direct opposite in the surgical world. It just goes to show how perspective affects interpretation.
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Definitely confusing
The Progrip mesh for open inguinals hernia is specifically designed for an onlay Lichtenstein patch technique repair. It was originally polyester. As the company is growing, they are carrying more polypropylene based meshes too, as a means of securing hospital contracts from its competitors.
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Progrip refers to the Velcro like technology of the mesh.
Progrip lap self fixating mesh is typically used for lap inguinal hernias. It comes in rectangular or anatomical shapes. The rectangle one can also be used for any appropriate sized ventral/incisional hernias as long as it is not against bowel.
Parietex Progrip is specifically meant for open inguinal hernia repair in Lichtenstein fashion.
All above are polyester.
Our paper on why we remove mesh quantified the different mesh types and polyester meshes seemed to be less of an issue than polypropylene. However, less polyester based mesh was in the market then as well.
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Early (6 weeks or so) from a ventral or umbilical hernia repair, torso extension is not preferred. Depends on the situation, of course. The burning may be due to tugging on the sutures or mesh. It is usually not a hernia recurrence.
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Inguinal hernias can cause bloating even if no intestine involved. It’s mostly a reaction to the pelvic pain.
But severe bloating is likely a GI problem. Consider SIBO hydrogen breath testing and also evaluation of your gallbladder with a HIDA scan.
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The difference in sedation options also has to do with patient safety. At the Shouldice, unless things have changed since I last visited, there is no anesthesiologist. Therefore, deep sedation cannot be safely provided. It’s a cost saving decision.
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– he is right that little is known about patient perspectives in an objective studied manner. There are very few publications addressing it. He is not referring to patient perspectives on social media and online, if that’s your take.
– there are so many reasons for chronic pain postop. How the nerves are handled is considered one of them, as first proposed by Dr Amid, Dr Poulose’s study hints it may not be an important factor. Other causes can include too tight a repair or other surgical technique problems, choice of repair, hernia recurrence, infection, and mesh related problems.
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Here’s your answer regarding insurance reimbursement:
Open inguinal hernia: surgeon gets paid the same from insurance whether they use mesh or not, regardless of time spent
Laparoscopic or robotic inguinal hernia repair: surgeon gets paid the same by insurance regardless of laparoscopic or robotic approach. This payment is LESS than open approach. Yes. For real.
How much the facility (hospital or surgery center) gets paid is much more convoluted and depends on various contracts. Some insurances pay more to the facility if you use mesh. Others don’t and thus the profit margin for the facility is less if you use mesh as an implant. Also, most insurances do not pay more to the facility if the robot is used vs laparoscopic, even though robotic repairs can be much more expensive. Most insurances do pay a little bit more to the facility for laparoscopic vs open, but often not enough to make lap more profitable.
I hope this settles any questions about surgeon or facility incentives to use mesh or the robot. There are none.
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This reply was modified 1 year, 9 months ago by drtowfigh.
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This reply was modified 1 year, 9 months ago by
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Hernia U is completely funded by BD/Bard-Davol.
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@chucktaylor
I’d like to see which articles you are referencing that shows worse outcomes from lap vs open. Just because something is published doesn’t mean it’s a valid study. You have to analyze the strengths and weaknesses of the study.Yes, “though rare,” as the studies point out, serious complications (bladder, bowel and vascular injury) are more likely with laparoscopic repair. That’s a given, because it’s a posterior repair. Most of us specialists have never had these rare complications and they are rare and typically associated with lack of experience. On the other hand, you have much nerve injury and chronic pain risk with open surgery because the nerves are exposed with open anterior surgery. They are much less likely to be injured with laparoscopy. So, you are comparing a fraction of a fraction of 1% risk of serious complication with laparoscopy vs an approximately 5% risk of just nerve related pain with open surgery.
How data is analyzed is very important.
For myself, I’ve always wondered who I would choose if I had a hernia. There are a lot of great surgeons out there by reputation. I’ve seen some of them operate and for some of them I was unhappy with their technique. I feel I do a much better repair and a more dainty one. So, I don’t have an answer.