[Good intentions]

Nothing substantial on the Updates. As I have noted in two other threads, Medtronic and BD have both introduced new polypropylene products to market. Progrip Polypropylene, and Bard 3d Max MID. I think that the damaged patients and the litigation are just calculated in to the price of the products. These are not companies that exist for the betterment of humanity’s health. They’re just business ventures.

From the link in the post above –

“June 12, 2023 Update
Bard continues to struggle with product liability lawsuits. The latest is the Bard PowerPort device which provides a port for patients to receive medication without the need to start a fresh IV. Like the hermia mesh claims, Bard PowerPort lawsuits involve allegations that the device was poorly made.

June 5, 2023 Update
Bard no longer believes Stinton should go to trial. Why? Because it says the plaintiff’s injuries have escalated to the point where it is no longer a good bellwether trial. Bard is saying we want to avoid a significant verdict in Stinson because that will lead to greater settlement expectations.

This is nonsense. The first two bellwether trials were not great cases for plaintiffs, so those cases could be said to be unrepresentative. This tactic coincides nicely with Bard’s strategy of prolonging the process, which aims to hold onto their capital as long as they can, with the hope that persistent delays will persuade plaintiffs to settle for smaller settlement payouts when this ordeal finally reaches a resolution. Should the judge agree to postpone the Stinson trial – and the bet here is that he will not – that will cause even greater delay to get the next case ready for trial.

June 1, 2023 Update
As many of you reading this know all too well, mass tort lawsuits can move slowly. Some plaintiffs try to make arguments to steer clear of a class action lawsuit to pursue an independent claim. In Vaughn, et al. v. Kentuckiana Surgical Specialists, P.S.C., et al., plainitff filed a hernia mesh lawsuit in the Western District of Kentucky to the Southern District of Ohio. She asked to stay out of the Bard MDL because the transfer would cause inconvenience to them and non-Bard healthcare defendants. But the MDL Panel determined that the case shares common factual questions with those already transferred to MDL No. 2846 because the focus of the case is the claim that Bard’s polypropylene hernia mesh products have defects, leading to complications, such as adhesions, organ damage, and infections, when implanted in patients.”

[Good intentions]

SN’s recent query about the types of mesh used in hernia repair sent me out on the internet to review what’s out there, and to see who, if anybody, specifies theirs for Lichtenstein repair. Most manufacturers only distinguish between laparoscopy and open, and many don’t distinguish beyond “soft tissue repair” or “hernia repair”. You can understand why many surgeons just use whatever is in the cupboard at the ambulatory surgery center. It’s a mad-house.

Here is another absorbable that I didn’t really notice in the past. It is, somewhat ironically, from the company that makes what is probably the most stable material, the fluoropolymers. Gore Medical.

The description is kind of funny. Why would “shiny” be important? I assume that the word gives the impression that adhesions are less likely on a shiny surface.

They have two forms, one for inside the peritoneum and one for outside.

https://www.goremedical.com/products/enform

The GORE® ENFORM Biomaterial is used to reinforce soft tissue during the phases of wound healing by filling soft-tissue deficits. Typical procedures include:

– Abdominal wall reconstruction
– Hernia repair
– Muscle flap (i.e. TRAM, DIEP) procedures

The GORE® ENFORM Preperitoneal Biomaterial is designed with a textured porous fibrous web surface on both sides.

…

The GORE® ENFORM Intraperitoneal Biomaterial is a dual-sided device where one side is textured and the other is a smooth, shiny surface. ”

[Good intentions]

I had been meaning to add an update to this Topic, but as often happens, I had a minor setback that made me reconsider. I like to deliver good news, not bad.

But, the good news now is that the setback has resolved. I have been slowly and steadily expanding my range of activities over the years, walking and running farther, and working harder, with pain/discomfort being the limiting factor. At this point in time, the area of the mesh implantation and removal is still my limiting factor. It’s the weak point.

The setback a few weeks ago was that I started to feel groin pain on both sides and pressure that made me think I might be having some sort of recurrence. This was after a week of rigorous hiking, running, walking long distances, and physical effort moving heavy boxes, along with taking up some contorted positions while working on various things. Normal active life stuff. After a week of resting with no real progress in minimizing the discomfort I went back to my old standby of trying new strenuous things to see if things got worse or better. They got better and I feel very good now.

So, the message is that after mesh removal it takes a long time for things to get closer to “normal”. This might be good news for anyone who’s having problems and bad news for anyone who’s having problems. I had the last piece removed in December of 2017 so it’s been about 5 1/2 years since then.

I went back and looked at my notes, basically a diary of daily physical activities, and found that in January of 2019, one year and a month after mesh removal, I had drafted a letter to Dr. Brown about hernia repair and removal of that last piece of mesh. That is the type of pain I was having at the time. I thought that I might have two indirect hernias and pain from the last piece of mesh. But, the pain and discomfort resolved and I moved on.

Over the next year my notes show that I had periods of strange feelings in the groins and lower abdomen, like tissues were stretching and things were breaking loose and moving around exposing new tissue/nerves, with feelings of pressure when sitting, but things continued to get better. Then there are about nine months of random observations but no significant reports of problems. My last entry was in October of 2020.

Anyway five years is a long time, plus the three years before the removal. Eight years and seven months since I went in for the walk-in walk-out mesh implantation at the Ambulatory Surgery Center that was supposed to make me bullet-proof. Over 10% of my life so far, at least.

I still recommend that people keep a diary or log of what they’re doing and what happens afterward. The strangeness of constant discomfort and occasional pain really affects your thought process and memory. It is a radical shift if you’ve been healthy up to the point of the hernia repair. I look back at my notes and realize that I would not remember much of what I had written. I might not realize the progress that I’ve made.

[Good intentions]

Here is an opinion, from a non-expert –

If the pain is the same as before the repair it seems most likely that the defective area is being stressed in the same way. This could be because you’ve had a recurrence as Dr. Towfigh suggested, or because the mesh has come free from the abdominal wall in that defect area and is allowing the stressed area to to be pressurized/distorted again.

Since Dr. Sheen implanted mesh via the TEP procedure, there really are only a few options. Pain treatment, which could involve various pharmaceutical agents. Neurectomy, which has its own hazards. Open exploratory surgery and either a pure tissue repair to tighten the herniated area or a mesh repair to do the same. Mesh on the outside and inside. TAPP (the other laparoscopic method) exploratory surgery, probably with full or partial mesh removal and some other method of hernia repair.

Often though, as I understand things, the peritoneum looks fine from the viscera side during a TAPP exploration, even though problems exist on the anterior side. Before my mesh removal surgeon opened the peritoneum and removed the mesh, mine looked as it should, smooth and distortion free, but my surgeon found a folded area and movement of the mesh plus much edema. So if you get the wrong lap surgeon they might not see anything and just leave everything alone.

Your dilemma, I think, is choosing between mesh removal or another type of hernia repair. Since your pain is the same as it was with the hernia it seems like another repair should give similar results. My mesh pain was completely different from my hernia pain. I knew absolutely that the mesh was the problem and that removal was probably the best solution. Your case is different.

It is not uncommon to have mesh on both sides of the abdominal wall, if, for example, you got an anterior mesh repair by open surgery. The Prolene Hernia System (PHS) is designed that way. But I don’t know much at all about the repair methods used for female anatomy, it might not be appropriate.

Frankly, I would find an expert in female hernias. The ratio of female to male hernias is about 2 to 25. There are probably surgeons out there who have never repaired a woman’s hernia. Even those that have do not have much experience. They can’t, there just aren’t enough cases.

If Dr. Towfigh comes back maybe she can recommend an expert in your area. Since Dr. Sheen is apparently not available.

[Good intentions]

Polypropylene Progrip is not indicated for laparoscopic repair by Medtronic. So you can only really compare Bard 3D Max with polyester Progrip.

Unfortunately, you can find supposed “studies” around the medical research world that will support either over the other.

Also, many of the studies are not actually comparisons of the materials but studies of fixation versus no fixation. Even though BD’s own literature says that fixation in not necessary for 3D MAx.

Sorry. There is no simple answer.

https://www.bd.com/en-us/products-and-solutions/products/product-families/3dmax-mesh#overview

[Good intentions]

I mis-wrote above. Dr. Lorenz seems to be one of the newer members of the HerniaSurge group. His name is not shown on the 2018 list of members that were involved in the Bard and Ethicon sponsored meeting that bumped the Guidelines up to the “International” label.

https://link.springer.com/article/10.1007/s10029-017-1668-x

HerniaSurge in 2018 –

“The HerniaSurge Group
M. P. Simons, M. Smietanski, H. J. Bonjer, R. Bittner, M. Miserez, Th. J. Aufenacker, R. J. Fitzgibbons, P. K. Chowbey, H. M. Tran, R. Sani, F. Berrevoet, J. Bingener, T. Bisgaard, K. Bury, G. Campanelli, D. C. Chen, J. Conze, D. Cuccurullo, A. C. de Beaux, H. H. Eker, R. H. Fortelny, J. F. Gillion, B. J. van den Heuvel, W. W. Hope, L. N. Jorgensen, U. Klinge, F. Köckerling, J. F. Kukleta, I. Konate, A. L. Liem, D. Lomanto, M. J. A. Loos, M. Lopez-Cano, M. C. Misra, A. Montgomery, S. Morales-Conde, F. E. Muysoms, H. Niebuhr, P. Nordin, M. Pawlak, G. H. van Ramshorst, W. M. J. Reinpold, D. L. Sanders, N. Schouten, S. Smedberg, R. K. J. Simmermacher, S. Tumtavitikul, N. van Veenendaal, D. Weyhe & A. R. Wijsmuller”

[Good intentions]

Here is a cross-post to a recent interview with Dr. Lorenz, one of the newer HerniaSurge members.

https://herniatalk.com/forums/topic/dr-ralph-lorenz-hernia-talk-6th-june/#post-35821

Dr Ralph Lorenz Hernia Talk 6th June

[Good intentions]

I did not watch the Lorenz interview. Did Dr. Towfigh ask Dr. Lorenz about the HerniaSurge Collaboration’s release of the “International Guidelines for Groin Hernia Management” update that is almost six month’s behind the promised release date? Dr. Towfigh vouched for the group in the Topic I created about HerniaSurge, so she was/is aware of the delay. It was an opportune time to ask, especially since Dr. Lorenz is becoming known for non-mesh repairs but was also one of the original authors of the mesh Guidelines. Maybe she could follow-up with him?

Choose HerniaSurge Collaboration from the side menu if the link below does not take you directly there.

https://www.frontierspartnerships.org/articles/10.3389/jaws.2023.11195/full#h7

“HerniaSurge Collaboration
F. Agresta, F. Berrevoet, I. Burgmans, D. C. Chen (AHS), A. de Beaux, B. East, N. Henriksen, F. Köckerling, M. Lopez-Cano, R. Lorenz, M. Miserez, A. Montgomery, S. Morales-Conde, C. Oppong, M. Pawlak, M. Podda, D. Sanders, A. Sartori, M.P. Simons (former EHS secretary for quality), C. Stabilini (EHS secretary for Science), H. M. Tran (Australasian Hernia Society), N. van Veenendaal, M. Verdauguer, R. Wiessner.”

https://herniatalk.com/forums/topic/herniasurge-what-happened-to-it-no-updates-no-contact-points/

Herniasurge – what happened to it? No updates, no contact points

[Good intentions]

I had also suggested that in the past. A brand new member sounded a lot like an older member, the same tone and the insinuations, but better grammar and spelling. I think that I might call them clones or doppelgangers.

What can you do? I stopped replying to both of them.

[Good intentions]

I see. There was one of those new accounts with a new Topic on the forum for a short while this morning. Looks like it’s been removed. Obviously not related to the forum’s goals.

[Good intentions]

Bumping this thread from the past. More food for thought on considering what you want from your hernia repair. If you live a fairly sedentary life you might be fine with a mesh implant. If you are very active, you might have problems. I think that the vast majority of surgeons don’t even ask about their patients’ activities. Mine knew that I played soccer and he even had a former patient who was a semi-pro soccer player, as I recall, who had problems with his mesh implant and eventually went to another surgeon for help (like I did). I learned this after I had my own problems. He told me himself. He put the mesh in me anyway.

[Good intentions]

What is a sock puppet? Is that an internet slang word? Haven’t seen it before.

I’ve found that it is pointless to try to correct people’s behavior on internet forums. I just stop reading posts from certain people.

[Good intentions]

Sensei, just posting here to add to your recent post on Chuck’s other thread. Post #35483, for anyone wondering. Another option for mesh removal in Florida.

https://herniatalk.com/forums/topic/dr-twofigh-chronic-pain/#post-35483

Dr. Twofigh – Chronic Pain

[Good intentions]

It looks like Dr. Sheen used the “sportsman’s hernia” diagnosis as the premise to do surgery. His observations once he got in and could see and poke around were some combination of direct and indirect hernias. In a TEP procedure a large piece of mesh is used to cover both areas.

In sum, he felt confident that surgery would help, and it did. But there was a recurrence. Recurrences are known for laparoscopic mesh implantation, even with large pieces of mesh. 15 x 12 cm = about 6 x 4 3/4 inches.

The large pieces of mesh that have been encapsulated by your body are part of the new decision. Mesh removal could cause new problems. Overall, an open mesh or open pure tissue repair seem to make the most sense. Leave the 5 year old mesh in place if it has not been bothering. Fix the recurrence by another method. The 5 year old mesh is probably tied up with other critical nerves and vessels. It’s how “incorporation” works.

Don’t fret over what has already happened. You’re in a new situation. Listen carefully to the surgeons, take a list of questions with you and don’t commit to anything unless you really understand what is being proposed. You’ve already had one failure by a top well-known expert in the field using the most publicized repair method. Dr. Sheen is one of the HerniaTalk surgeons, listed at the top of the page. Good luck.

[Good intentions]

That is unfortunate that his “Main findings:” don’t match his “Inspection:”. Some surgeons cut and paste their reports using parts from past reports.

The thing about mesh implantations though, is that it doesn’t really matter. The mesh will cover the same area, for either direct or indirect hernias. Since you had good results from the first mesh implantation a new surgeon will probably just do the same thing over again.

For what it’s worth, Parietex mesh is a brand name for a series of polyester (PET) meshes. I would guess that he used the Parietex lightweight monofilament flat mesh, since he did use fixation with the Tisseel fibrin glue. The monofilament Parietex is the polyester analog of the common polypropylene flat meshes, which are very commonly used for TEP procedures.

https://www.medtronic.com/covidien/en-us/products/hernia-repair/mesh-products.html

[Good intentions]

Here is a search page about treatment of athletic pubalgia, with fairly recent results. Opinions have changed over the years.

https://scholar.google.com/scholar?hl=en&scisbd=1&as_sdt=0%2C48&q=treatment+pubalgia&btnG=

[Good intentions]

I don’t know if this will help you or not but Dr. Sheen seems to run counter to prevailing opinion on treatment of athletic pubalgia. Many surgeons say that they do not use or recommend mesh for its treatment. But there also seems to be some discussion about how to define the problem.

You are in an odd spot, since Dr. Sheen is a firm proponent of mesh. He publishes often about mesh implantations. You might consider getting away from the mesh repair experts and see what an open repair surgeon thinks.

Here is a fairly recent paper by Sheen et al trying to show the efficacy of the TEP mesh procedure compared to open repair.

https://academic.oup.com/bjs/article/106/7/837/6092871

Here is another paper describing an open repair method on young athletes. It has some good diagnostic methods based on where the pain is that might help you understand your condition.

https://kosovajournalofsurgery.net/wp-content/uploads/2023/03/D-Litwin-2-KJS7_merged.pdf

[Good intentions]

Did the pain return suddenly after a specific action? Or more slowly, like days/weeks/months? Have you been very active over the five years or more sedentary?

Sportsman’s hernias (athletic pubalgia) pain usually happens during activity, not so much afterward. While running or sprinting, for example.

If the pain is the same as before it seems reasonable to suspect that the same nerves are being affected. Not sure how a surgeon would address that since mesh has already been implanted. Mesh is known to shrink over time, so one possibility is that the mesh moved far enough that the previous weakness has been exposed. It is also known to fold and bunch up as it shrinks.

I am not an expert or a surgeon or a doctor but a TAPP procedure to view the abdominal wall from behind, followed by adjustment and/or placement of new mesh seems possible. I can imagine a surgeon recommending that as a possibility.

Just some ideas. Good that you got five pain-free years though. Hopefully the next will last longer. Good luck.

[Good intentions]

Here is an interesting description of all of the mechanisms that occur when abdominal pressure is increased and the muscles are activated. There are more than I had realized. I would imagine that the disrupted tissues from any type of repair need to be worked in order for new collagen to form/align correctly and to resist the natural tightening of the scar tissue. It seems like a balance between too much and too little, in order to get the complete and correct healing process.

https://worldsurgeryforum.net/2017/07/surgical-anatomy-of-inguinal-canal.html

[Good intentions]

sensei I was wondering about your second surgery. It’s good to hear that other surgeons are getting involved in the mesh removal business but, of course, also bad to hear.

Are you saying that everything was good after the first left removal until the second right removal? It reads like you’re saying that the left side felt good until the right side was removed.

Not trying to defend Dr. Billing just trying to understand overall. Dr. Parra-Davila is a new name in mesh removal. Good luck going forward. My views on hernia repair keep evolving. The latest is that TREPP makes a lot of sense.

https://www.palmbeachdigitalsurgeryinstitute.com/find-a-doctor/detail/eduardo-parra-davila-1609864925

Good luck and stay in touch.