[David M]

This raises a question in my mind of whether anyone is actually keeping track of the explants.

I mean do any of the registries actually keep track of whether an explant was lap, lictenstein or plug and patch. That should indicate a lot. I know some of this must be known, because it’s obvious to Dr Towfigh that plug and patch has been a negative.

Information about nerves vs inflammation etc. would be a little more dubious, but still helpful.

[David M]

I wish I could add this without bumping the thread.

Add Paco as an expand of the plug and patch.

https://herniatalk.com/forums/topic/my-explanted-mesh-photos/

My explanted mesh photos

[David M]

In this article it says that the sac is found within the internal spermatic fascia.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4455911/#:~:text=Indirect%20inguinal%20hernias%20are%20usually,external%20spermatic%20fasciae1%E2%88%923.

[David M]

Ok, that didnt work and I missed the edit window.

There’s a good picture of the spermatic cord contents here.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7393947/

So, I have a question that might seem dumb. When the indirect hernia comes down through the cord, within which layer does the hernia sac lie?

Ive been assuming that the major purpose of stripping away the cremasteric muscle is to get to the hernia sac, so does it come down between the muscle and the internal spermatic fascia?

Thanks for anyone who can shed light on this.

[David M]

I guess they say in the survey to choose the worst level you experienced in the past week. Hopefully, by the end of a year you’ll be down to 1 or 1s and 2s at the most.

[David M]

Good point, GI.

Obviously, there is a tremendous amount of inertia in the industry. It doesn’t help when things also get mischaracterized.

[David M]

By the way, Watchful, would you be willing to grade your own pain according to the scale from the Swedish study?

“The question put to the patient was: grade the worst pain you have felt in the operated groin during the past week. The seven possible scores were: 1, no pain; 2, pain present, but easily ignored; 3, pain present, cannot be ignored, but does not interfere with everyday activities; 4, pain present, cannot be ignored, and interferes with concentration on everyday activities; 5, pain present, interferes with most activities; 6, pain present, necessitating bed rest; and 7, pain present, prompt medical advice sought.”

[David M]

thought I would add this paragraph from the EU Trialist Collaboration of 2002, which gave the advantage to mesh over non mesh with regard to pain. They themselves seem to recognize the limitations of what they report, and which would seem to show why the Swedish study discussed here is better.

“Worldwide, there is a widely varying use of mesh techniques for groin hernia repair. One reason for not using mesh is concern about long-term morbidity. We found only two cases of mesh infection (one laparoscopically placed 56 and one placed by an open procedure 52). The 7,157 people repaired with mesh had very variable follow-up, however (Table 1). A second concern is the possibility of groin pain. 4 Our data indicate that it is more likely that mesh reduces rather than increases persisting pain. This finding should be interpreted cautiously. We adopted a broad definition and included any pain in the groin region (including testicular pain), regardless of severity or impact, reported around 1 year after the operation. As a consequence, prevalence rates differed widely between trials. ”

I mean, two cases of mesh infection out of 7000 sounds unbelievable.

The other major flaw which they recognize is that the pain that they speak of is not graded in any way, such as was done, seemingly well, in the Swedish study.

[David M]

Chronic pain defined as the following or worse occurring in the previous week….

4, pain present, cannot be ignored, and interferes with concentration on everyday activities;

• This reply was modified 1 year, 4 months ago by  David M.

[David M]

William,

From worst to best…for chance of chronic pain remaining after one year

These first three were from the same Swedish study..

Tapp 18.4%
Open anterior mesh…15.1%
Tep 14.9%

These next two are extrapolated guesses based on an earlier Danish/Swedish study that compared tissue based repairs to Lichtenstein…

Shouldice for indirect hernia ….10.6%
Marcy for indirect hernia…..9.64%

Finally, from Dr Kang’s recent telephone survey using the standards from the original Swedish survey

Kang (marcy type for indirect, I think)….1.7%

Some Caveats….

the Swedish study probably had other non-posterior types of open anterior mesh included besides Lichtenstein (I dunno, maybe plug and patch?…or others?). That might throw off the already shaky numbers in the second group.

The Kang numbers weren’t independently done. I mostly trust Dr Kang based on his posts and believe these numbers were told to us for education. Still, there could be cultural or other differences in the way Koreans would respond on the telephone vs the way the Swedes would respond in a written survey. There could also be minor differences in Korean anatomy that might make pain less of a problem in that area.

The original Swedish numbers had possibly significant differences in the expertise of the surgeon for the particular type of surgery. Over half of the open surgeries were done by surgeons doing less than 26 per year, while only around a quarter of the lap surgeons were than inexperienced. On the other hand, lap is harder to master, so these factors may have balanced out somewhat.

• This reply was modified 1 year, 4 months ago by  David M.

[David M]

Of note: the Danish study referenced in the previous two posts gives results for indirect hernia. So, tissue repair for direct hernia still requires some comparison for pain vs Lichtenstein, Tep and Tapp.

[David M]

With the Danish study, which had an average followup time for the questionnaire of 31 months, the rankings for substantial discomfort were Shouldice 3.3%. Lichtenstein 4.7%. Marcy 3%.

While I’m sure it’s probably a little careless to try to extrapolate these numbers as a comparison to the Swedish study numbers, dividing the Lichtenstein Swedish number of 15.1% by the 4.7% of this study, and then multiplying that number by the 3.3% of the Shouldice, gives a hypothetical 4 pain rating for Shouldice of 10.6%. Doing a similar extrapolation for Marcy gives us a hypothetical 9.64% rating for it.

• This reply was modified 1 year, 4 months ago by  David M.

[David M]

Sounds great. Mine is right side tennis ball, as well. My exercise consists of purposeful walking and that doesn’t seem to really have a pain effect. Due to some recent coughing it may have gotten a little bigger. There does seem to be slightly more pain as the day wears on. The pain and turgidity of the hernia might be being affected in my case by the meal cycle.

Anyway, looking forward to hearing your continued improvement.

[David M]

This sounds good, Spinotza. I’ll add that in this time of proliferating sock puppets, you sound real to me. Can you give us more detail about how big your hernias had progressed and whether they were direct or indirect?

[David M]

Here’s a link to the Danish study that Dr. Towfigh alluded to earlier. This study was a breakdown of pain for surgeries done by open Mesh, Shouldice and Marcy. Unfortunately, this was earlier(2004) than the Swedish study and doesn’t define the levels of pain as well. The one takeaway seems to be that Shouldice and Marcy were slightly less pain causing than open Mesh in the overall cohort.

https://academic.oup.com/bjs/article/91/10/1372/6150885?login=false

[David M]

Dr Kang reported 4 or higher on 1.7% of his patients. His survey was by telephone and he didnt say how many he surveyed. He finished his post with this quote.

“These results have not been officially reported. So some might question the veracity of these results. However, I would like to say that my main interest is to find and improve problems rather than beautify the results of Kang repair.”

[David M]

As referenced from his post on o6/05/2023, Dr. Kang used the same survey questions.

https://herniatalk.com/forums/topic/summary-of-research-forum-experts-watchful-jf-nfg-gi-mike-m-bryant/

Summary of research-forum experts? Watchful-JF -NFG- GI- Mike M- Bryant

[David M]

Ok, here were the levels in the Swedish questionnaire.

“The question put to the patient was: grade the worst pain you have felt in the operated groin during the past week. The seven possible scores were: 1, no pain; 2, pain present, but easily ignored; 3, pain present, cannot be ignored, but does not interfere with everyday activities; 4, pain present, cannot be ignored, and interferes with concentration on everyday activities; 5, pain present, interferes with most activities; 6, pain present, necessitating bed rest; and 7, pain present, prompt medical advice sought.”

[David M]

Later today it might be helpful to bring over the open tissue and open mesh numbers from the Danish study.

Also, it will be interesting to bring over the Kang numbers for comparison.

[David M]

The ability to compare results is one of the two basic reasons why a graded pain standard is good.

I do think that choosing 4 and 5 as primary focus points is also helpful to people trying to understand what they are getting into. And, generally, those will probably be benchmarks that are somewhat telling for the overall pain numbers. For instance, the 5 numbers in the Swedish study fell off more or less proportionally in all three surgery types from the 4 numbers.