Good intentions
Forum Replies Created
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Thanks David M. It is described by Dr. Kang himself, in post #35303 for anyone who wants to go directly to it.
I see that you have stuck with level #4 as the break point but in that thread Watchful had chosen #2. Defining any pain at all as chronic pain. Then followed up in several other posts reporting very high levels of pain for Dr. Kang’s repair method. No offense intended to Watchful but that is the way the words come out.
So, using #4 as the cutoff point, as the authors of the Swedish study did, in a one-to-one comparison, the Kang repair is at 1.7% and there are none at 5 or higher. The Swedish study is as as you show aboe, with any mesh repair being at 14.9% or higher for a level of #4. Kang – 1.7%, mesh – ~15%. Mesh also shows levels of significantly higher pain, level 5 or higher.
I am going to cross-post this thread in to that other thread so that people can see the one-to-one comparison.
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The questionnaire that Dr. Kang used would be important to know also. I remember the posts about it but can’t remember if they used the same study, or if somebody assumed a correlation.
One thing that I see missing that would be important to know is whether or not the patients thought the pain was getting worse, better, or had leveled out. One year seems like a long time but it’s really not considering how long the mesh will be there. The choice of one year is arbitrary. Also, whether or not the patients had recovered their prior activity level or had reduced it to avoid the pain.
The study also has the same basic flaw that many do in not identifying the type of mesh used. All are lumped together as “mesh”. Maybe because the Registry does not record that data.
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That is an interesting perspective. Another of those things that doesn’t seem to be discussed in depth – how does one method affect recurrence repairs? Generally, like many of the complex questions, it seems to be oversimplified. Open or lap. Mesh or non-mesh.
I haven’t studied or thought much about the pure tissue methods. But, these “layered” techniques have to be creating weaknesses in other areas of the abdominal wall. The body does not create “free” spare tissue, ready to be moved to some other part of the body. A person should consider the time factor involved for the area around the layer that has been removed to regain its strength or to fill in.
It would be very interesting to hear an expert in the various repair methods describe what method they would choose for repair and how they would handle the healing process. Would they trust the method to bring them back to full strength in a week or two? Or would they have a plan to take months or even years to work their way back to full strength?
In the early days of ACL repair of the knee, recurrences (re-ruptures) were pretty common because the athletes tried to get back in to action too quickly. Now, it’s not uncommon for an athlete to expect a year of time to recover after an ACL operation. They’ve learned.
It’s a good idea to think past the initial repair. Really, a person should plan out the rest of their life. Include financial realities, time available, responsibilities, etc. before choosing a hernia repair. It’s not really just outpatient surgery. Good luck with the research.
The Cleveland Clinic has an interesting page about the layers involved in pure tissue repairs.
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When you say “reoperation with mesh” do you mean open mesh? Lichtenstein? Plug and patch (still popular)? Or laparoscopy? Placing mesh on the backside would be easy I think. Just cover it all up.
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We are seven months through 2023, over halfway through the year, and still no word from the EHS or the HerniaSurge people about the delay in the new Groin Hernia Guidelines. Maybe they’ve realized that the title should be “Guidelines for mesh repair of groin hernias”. They are on the wrong side of the trend now. Fighting the tide.
“this year!” on the LinkedIn page was last year. 2022.
Also just noticed that if you scroll down the EHS Guidelines page linked in the post above the three “Platinum” sponsors of the EHS pop up at the bottom. Mesh, mesh, and robotic surgery (also mesh by default).
PLATINUM CORPORATE ALLIANCE OF THE EHS
BD, Medtronics, and Intuitive. -
Here is an interesting story about how the big corporations try to avoid liability for faulty products. I’ve posted about it before. If this type of maneuver succeeds then corporations can just rake in the money from bad products until the lawsuits build up, then split the division off and declare bankruptcy. Johnson & Johnson owns Ethicon, one of the big hernia mesh product suppliers.
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Thanks for posting that William. If you look further, links below, you can see how it shows that medicine is a business with the purpose of keeping the majority of the workforce working. The injured people are collateral damage. As individuals we all need to be aware of that, I think. Surgeons need to be aware of that also. They are seen as tools to be used to keep the workforce functioning.
Despite the results of the engagement survey that you posted, completed in 2021, the SHTG still recommended the use of mesh for hernia repair for elective hernia repair. Also interesting, as usual, that all mesh is blobbed together and all surgery methods are blobbed together. A sign, to me, that the people involved in this type of work don’t really understand what they are seeing. They see a surgeon and a piece of mesh, both disappearing in to a clinic, and a patient walking out ready to go back to work.
https://shtg.scot/search-results/?q=hernia
https://shtg.scot/our-advice/surgical-mesh-repair-of-primary-inguinal-hernia-in-men/
Notice the focus on cost. It’s not cost to the patient. It’s cost to the healthcare system. Whose purpose is to keep the workforce working.
“Recommendation for NHSScotland
Surgical mesh should be used for elective repair of primary inguinal hernia in adult males in Scotland. Mesh repair of inguinal hernia provides lower rates of hernia recurrence, lower rates of serious adverse events and similar or reduced risk of chronic pain, compared with non-mesh procedures. Mesh repair of inguinal hernias is a cost-effective treatment option.”
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I miswrote above. An indirect hernia would be evidenced by abdominal contents squeezing through the deep ring inside the spermatic cord casing, the parietal peritoneum (I think). Not beside it, but inside it.
Anyway, I think that you can imagine that with the peritoneum peeled back to the deep ring you would be able to see any extra space around the cord itself, that might provide room for material to squeeze in, Fat or omentum or intestine. I have images captured during the surgery, I might go back and see if I can identify anything. They’re pretty bloody though and I don’t really know what I’m looking at.
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I was trying to make that point in my two posts. He said that he saw an indirect hernia when he had the peritoneum down and was removing the mesh. But afterward there was no indication of a hernia.
From what I’ve read about indirect hernias, defining them is often a matter of degree. How much stuff is squeezing through next to the spermatic cord? Or, how much extra space is there around the spermatic cord? That would be the “hernia”, the extra space that stuff might squeeze through.
My takeaway is that the ring was visibly stretched but nothing substantial was happening there. Once the peritoneum was stitched up and healed he could not see a depression that would indicate a hernia. So, I just take extra care to avoid pressure-causing activities. So far it seems to be working. Nothing extra seems to be moving down in to the canal with either of my cords.
Compare the above to descriptions of direct hernias. Oftentimes they are just called posterior wall weaknesses.
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Above, when I say that he did not see an indirect hernia before opening the peritoneum, I meant when he went back in to do the left side he said that both groins were examined and no hernia was seen on either side. Even though he had said he saw an indirect hernia when he took the right side out. I did have some small bowel attached to the right side port area though.
Just completing the observation. I was so happy to get the mesh out that I wasn’t and still am not too worried about an indirect hernia. The mesh was worse.
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Here are the basics, at the bottom. It’s interesting that he does not see an indirect hernia when the peritoneum is closed, on first viewing, but after he opens it up and removes the mesh he apparently sees an indirect hernia. Not sure how that works, maybe it means that the internal ring is enlarged.
The left side went smoothly so I haven’t included the Procedure notes. The mesh that came out was smaller than what went in, but I think that he meant inches, not cm, in his description. I have the pictures and they are next to what looks like a 6 inch ruler for scale and they are about 2 x 5 inches. The piece started as 6 x 6.
I had been exercising more after the right side had been removed so that might have caused some of the edema. I had been considering leaving the left side in (still trying to believe that the mesh implantation alone wasn’t the problem, that maybe a mistake had been made and the left would be okay) but after exercising, the left side was now the worst side, compared to what had been the worst, the right side.
Any typos are mine. I had to retype from an image of his notes.
Right side, where the original direct hernia was.
“Findings: The right groin was densely adherent to surrounding tissues. I was able to remove about 90% of the mesh. I left some mesh laying over the iliac vessels and near the spermatic cord. The left side looked normal and not explored. The colon and small bowel were normal.
Procedure:
…The left groin was examined and looked normal with no hernia. The right groin looked normal too, but we agreed to explore the right groin because of his pain and to remove the mesh. I dissected the mesh off the anterior and lateral wall of the groin. It was densely adherent to the tissues, more than expected. I then went medially and dissected the mesh down to Cooper’s ligament. I removed the mesh in this area. I dissected up to the cord and freed as much as I felt comfortable doing. The cord structures and major vessels going into the groin were carefully protected and I left some mesh there. The spermatic cord and vessels were dissected of the mesh. The epigastric artery was adherent to the mesh and I was not able to preserve it. I ligated it with ligaclips. The excised mesh was removed through the 12mm trocar in three pieces. There was an indirect inguinal hernia but it was small. The area was irrigated. There was no evidence of intestinal injury.
…”Left side:
“Findings: The tissue was edematous. Essentially, all of the mesh was removed from the left groin. He has a small indirect inguinal hernia. This was not repaired. The dissection was tedious due to the inflammation and the contraction of the mesh to the tissues of the abdominal wall. A 2×5 cm piece was removed.”
Herminius, let me know if you’d like me or others to start new Topics instead of adding to yours.
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Thanks Herminius. My inferior epigastric artery couldn’t be saved either. I suppose that the lack of blood supply to the areas it supplied could have caused some of my longer term healing soreness. The body’s other supply lines will grow in to provide new supply over time, as I understand things. Something to be aware of if you have some pain. It should resolve, although I can’t find much about it on the old internet. Lots about where it goes and how it gets damaged. Not much about the effects on the body of removal or damage.
Good luck. Hopefully your original symptoms don’t come back.
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The paper linked by Dr. Towfigh is interesting in that it suggests that either there is no such thing as “mesh reaction” (it’s all just common foreign body response) or that all mesh implant patients suffer from mesh reaction, just to differing degrees of discomfort.
What is left out the “mesh reaction” discussion is the subject of what causes the reaction. Is it just the presence of the material itself? If the mesh was unraveled and implanted as a ball of fibers would it cause the same reaction? Or is it the movement or lack of movement of the mesh as the body moves around it. All Prolene sutures should cause a “mesh reaction”. The Shouldice procedure done with Prolene should have a line of mesh reaction. The depth of research in to the problem seems not deep at all. Observations and RCT’s but nobody, besides Bendavid, seems to be looking for root cause.
Good luck with recovery Herminius. Can you share more of the surgery notes? Any observations about nerves or vessels or the original indirect hernia would be interesting.
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I couldn’t say, I only know what I’ve seen on the internet. Is the Facebook group private? Post a link.
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SAGES recently, March 8 2023, created a document attempting to explain the different types of mesh to their members. Many authors. The document is a good general primer about mesh but doesn’t seem to offer much advice on how to choose one. It’s a good start though, and they do acknowledge that much is still unknown about the materials in general. They end with a hopeful statement about registries, similar to what Dr. Heniford was calling for about five years ago.
https://www.sages.org/publications/tavac/mesh-review-and-catalog/
“…
Considerations for the Future
Given the current wide use of products in many clinical situations by surgeons with differing expertise, it is critical that surgeons follow patients over time to determine the outcome of interventions. The implantation of a device with the intent of lifelong placement carries with it a responsibility to ensure safety and efficacy of the product over the long-term. This is especially true in the off-label use of these products. By combining the rich clinical data obtained through well-designed registries with administrative data linkages and patient reported outcomes, we can help ensure that innovations in our field ultimately benefit our patients while minimizing harm.…”
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Here is another mesh product from a company I had not heard of, Betatech. Based in Turkey.
It has on odd pattern, it looks like a combination of braided material with monofilament.
https://www.betatechmedical.com/en-US/Contact/Contact-Info
A forum member was looking for a surgeon to remove it recently.
https://herniatalk.com/forums/topic/inguinal-hernia-mesh-removal-stats/
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Jnomesh posted about a prosthetic made from a person’s own tissue.
https://herniatalk.com/forums/topic/new-personalized-hernia-patch-made-out-of-skin/
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So far I have not got back into the soccer scene. I was out for three years with the mesh before the mesh removal, and it’s been up and down since then as far as figuring out what my actual level of fitness is, and whether or not I could handle a game. In the last few months I’ve started doing more hard running and sprinting, similar to what I might do in a game and have had thoughts that I could be ready to play again. But, at this point, I’m just enjoying being healthy again. Plus I have moved to a different state so don’t have the connections anymore. Nobody looking for players.
Once you’ve been down that far you really don’t want to take a chance on being there again. I hope things are going well for you.
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This Topic reminded me of a recent (2021) article in Hernia about the flaws in the EHS Guidelines. I am not an expert in data analysis so can’t add much to what is shown in the abstract. Hopefully the EHS is doing a better job before they release their update.
The title of the article is telling.
https://link.springer.com/article/10.1007/s10029-021-02423-7
Original Article
Published: 13 May 2021
Mesh repair for lateral inguinal hernias: a non-evidence-based practice
D. E. Tripoloni, M. I. Canaro García, F. Cassani, M. Zanni & A. Sosa Mercado
Hernia volume 25, pages1183–1187 (2021)“…
Conclusion
The idea that mesh techniques reduce the recurrence rate in all PIHs is not supported by high level of evidence. The NNT for pure lateral hernias was very high and should be interpreted taking into account chronic pain rates and costs.” -
64 years ago? 1959? You must have been very young. Do you remember the details?
Your surgeon said “there’s nowhere to go”? Do you mean to find a Shouldice or Desarda surgeon? How did you learn about Shouldice and Desarda? That’s a bit deep in to the hernia repair methods, for a person new to the field.
Good luck.