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Not sure how our data is misinterpreted. It’s pretty clear in the short video and you can choose to read the published paper online for more details.

In summary:
– in my experience lap vs robotic mesh removal outcomes were similar
– patients significantly improved after mesh removal regardless of technique
– with lap mesh removal, I had 2 conversions to open due to major external vein injury and statistically higher blood loss with lap, so in my practice I prefer robotic over lap.
– thought robotic time was higher, it was because we could do more robotically that we could not do lap, Eg, tissue based hernia repair and salvaging of the peritoneum, which are both additional reasons why I prefer robotic approach

There is no obvious superiority to laparoscopic approach, looking at facts and data, especially when we show there is higher incidence of major vessel injury and conversion to open. At the most we can claim it’s non-inferior, which is the most conservative interpretation of our data and what we concluded. And I don’t see how Intuitive Surgical is influencing my data interpretation.

Also, to address your comments, revisional surgery can never claim to return someone back to their original state. But our experience is that mesh removal significantly improves outcome in those who need it. More surgeons should share their mesh removal outcomes. Our paper is the first to do so for laparoscopic and robotic mesh removal.

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The “ACS Bulletin” is the name of their monthly newsletter. It does not function as a bulletin, per se. It’s just the title of their newsletter to members.

Also, the way the video was edited is not clear. Read the full article, which provides much more clarity and description about hernia surgery and mesh and the current status of things. https://www.facs.org/for-medical-professionals/news-publications/news-and-articles/bulletin/march-2023-volume-108-issue-3/new-approaches-trends-are-emerging-in-hernia-repair/

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You are right!

Inguinal hernias can cause pelvic floor spasm. This can result in urinary frequency as well as other possible pelvic floor ailments. Hernia repair can thereby improve pelvic floor spasm and urinary symptoms.

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Very good find.

The EU doesn’t have as strict a policy as the US on how industry can interact with doctors. Also the EHS has no significant budget or income to support a staff or its publications of guidelines, etc. I think their only income may be from royalties from the journal publisher. So, they are even more reliant than US societies on industry support. And of course. Industry gobbles that up.

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Mesh removal should be taken seriously. Most patients do really well, but the operation has to be worth doing in case you fall in the 15% of patients who are not cured or may even be worse off.

Mesh implant illness needs a full work up before committing to mesh removal. I have a full protocol that I follow.

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Great posts on this thread.

Yup, agree that plug meshes should be off the market and the main reason they aren’t being pulled is because it would look like they are admitting it is a poor design. Also, plug mesh still seems to be among the best sellers, if you can believe it.

Interestingly, BD is switching to an all Phasix (synthetic absorbable) panel of meshes. And get this: they are making the Perfix plug under the Phasix umbrella too. Unbelievable. They could have easily done away with the plug in their newer generation of products.

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Thanks for the heads up. It should have been uploaded on my YouTube page http://www.YouTube.com/@herniadoc

Will get it up asap.

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Numbness after open surgery is completely normal initially and usually resolves as the swelling resolves. You should also check with your surgeon to see if any nerves were cut.

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That’s an incorrect interpretation of the study and not the purpose of the manuscript.

This is not a population study of all patients undergoing hernia repair. Thus it is incorrect to say that ? of patients are unhappy with their repair.

The research study compares the different values and outcomes of those happy vs unhappy with their repairs. The proportion of unhappy patients is skewed from the normal population of patients undergoing hernia repair as most patients were recruited from hernia/mesh support groups.

The takeaway is for surgeons to focus on what is important to patients and help improve hernia care based on that.

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Yup. A lot of ways to analyze the pros/cons of robotic inguinal hernia repair.

It’s certainly never been show to be cost effective purely from the surgery/Hospital utilization standpoint. But it the technology has made it so that more surgeons are offering minimally invasive inguinal hernia repairs, which is a good thing, as the alternative would be an open repair with mesh.

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In general, incisional hernias are best repaired with mesh. Studies show 50-60% recurrence when repaired without mesh.

Incisional hernia in the midline of up to 2cm can be considered reparable without mesh if combined with a fascial plication.

A multiply recurrent incisional herniaeasuring 7cm requires some amount of fascial components separation and mesh.

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@ajm222
– I don’t trust imaging reports. I look at the imaging myself and based on our own published study, 3 out of 4 times the imaging report is incorrect. So, I do not rely on a radiology report to determine my plan of care. Also, CT scan is not sensitive enough for small hernias which may be symptomatic. Also, the technique of the imaging is important. Valsalva (bear down) helps demonstrate hernias that may not be evident when lying supine. So, there are many reasons to believe that your CT scan results do not accurately reflect your clinical situation.
– The reason why the entire floor (including the direct space) is opened for tissue repairs even if there is only an indirect inguinal hernia is because in doing so, you are taking tension off the repair of the indirect inguinal hernia by spreading the tension over a wider space. Marcy repair does not do that, hence the poor results for most male hernias. We must not forget history. These questions have been battled out for decades before many of us were born.

@good-intentions
– my strong statement is based on my own experience as well as that of others. I can no longer study it, as I rarely remove mesh without fixing the hernia (except in cases of mesh infection). Every time I have done so, the hernia has recurred, and I have told the patient to expect that, and they have come back for the recurrent hernia repair. The options for recurrent hernia repair at time of mesh removal are plenty and are dependent on the needs of the patient. They include: a) lap/robotic repair with synthetic mesh, b) lap/robotic repair with hybrid mesh, c) robotic iliopubic tract repair (r-IPT) without mesh, d) open tissue-based repair, usually a Shouldice.

@hernia2012
– laparoscopic removal of mesh should not disrupt a Shouldice repair.

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@ajm222

I don’t know the specifics of your situation since you’re not my patient, but based on what you’ve shared, it sounds pretty convincing to me that you have a hernia recurrence. A) you have a bulge, B) you have symptoms, C) CT scan shows a hernia via the cord lipoma/retroperitoneal fat, D) you had no hernia repair once the mesh was removed.

– If you have mesh removal after a hernia repair with mesh, you will have a hernia recurrence. Scar tissue alone is not strong enough to keep the hernia from recurring (except in some cases related to mesh removal due to infection).
– CT scan is inadequate to fully evaluate the pelvis for recurrence. A) the imaging must include valsalva (beardown views) and B) MRI is much more sensitive to detect occult or smaller hernias.
– sounds like the CT scan actually does show abnormalities. Sounds like it shows retroperitoneal fat and/or spermatic cord lipoma. That is a hernia.
– assuming you have a hernia recurrence, you need a bonafide hernia repair. There are a lot of options. Shouldice is one of them that would not involve any type of mesh. I would not do a Marcy, which seems to be where Dr B is alluding to. That does not work for male inguinal hernias, let alone a recurrent one.

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@ajm222

I don’t know the specifics of your situation since you’re not my patient, but based on what you’ve shared, it sounds pretty convincing to me that you have a hernia recurrence. A) you have a bulge, B) you have symptoms, C) CT scan shows a hernia via the cord lipoma/retroperitoneal fat, D) you had no hernia repair once the mesh was removed.

– If you have mesh removal after a hernia repair with mesh, you will have a hernia recurrence. Scar tissue alone is not strong enough to keep the hernia from recurring (except in some cases related to mesh removal due to infection).
– CT scan is inadequate to fully evaluate the pelvis for recurrence. A) the imaging must include valsalva (beardown views) and B) MRI is much more sensitive to detect occult or smaller hernias.
– sounds like the CT scan actually does show abnormalities. Sounds like it shows retroperitoneal fat and/or spermatic cord lipoma. That is a hernia.
– assuming you have a hernia recurrence, you need a bonafide hernia repair. There are a lot of options. Shouldice is one of them that would not involve any type of mesh. I would not do a Marcy, which seems to be where Dr B is alluding to. That does not work for male inguinal hernias, let alone a recurrent one.

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Shouldice, etc are for inguinal hernias. If you have a ventral hernia, first it’s important to know if you are eligible for a non-mesh repair. It is not as easy or reliable to not use mesh if the hernia is large. Dr. Beanes is a good resource to ask this question for ventral hernias.

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Regarding first line of care for those with allergies and urticaria, it depends on the extent of and details of that. It also depends on the hernia.

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Will ask her!

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The Marcy repair is a great option for children and women with very small inguinal hernias. It’s an old technique that has been around for over 50 years. I use it in specifically those situations. It is not appropriate for direct inguinal hernias or in most male hernias.

I believe Dr Kang’s repair for indirect inguinal hernias is a modified Marcy repair as well.

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Happy to help:

1- bulging in the groin during pregnancy can be inguinal hernia, femoral hernia, or round ligament varices (varicose veins). Does the bulging go away when lying flat? A simple hernia ultrasound performed to help find the answer.

2- Pregnancy rarely causes hernia emergencies. Also, delivery rarely causes hernia emergencies.

3. The choices for delivery are undergo labor or have elective C-section and don’t undergo labor. There is no right answer from a hernia standpoint. Both are considered safe from a primary hernia standpoint. If a patient has pain from the hernia or had a repair (let’s say tissue repair) that is at risk of recurrence, then elective C-section is preferred, but I have no objective data to show you about it.

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Not a fair statement, in my opinion.

Dr Felix was the first to introduce the TEP laparoscopic inguinal hernia repair. He was trained under Dr Nyhus, who performed a similar repair in open fashion.

Drs Felix & Daes wrote the initial paper in 2017, discussing the importance of defining the critical view for laparoscopic or robotic inguinal hernia repairs.
http://www.nugits.nhs.uk/wp-content/uploads/sites/14/2019/07/Lap-inguinal-checklist.pdf

Their work is so important, as it helps reduce poorly performed laparoscopic repairs, which is rampant. Just read my paper on review of the top 50 YouTube videos of these operations. Absolutely horribly done by most of them. https://link.springer.com/article/10.1007/s00464-020-08035-z

The critical view is not relevant to any open anterior approach operations for inguinal hernias.

Dr Felix is retired. He could just be basking in the beach. Instead he is using his expertise to continue to advance safe laparoscopic hernia care.