drtowfigh
Forum Replies Created
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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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Hernia U is completely funded by BD/Bard-Davol.
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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 approachThere 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.