Good intentions
Forum Replies Created
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Thanks for the reply Pinto. The description of immediate pain after the first surgery was a distraction, it was not clear to me that you had apparently healed and been okay for two full years after the initial pain of the first repair. My new understanding is that the pain resolved and you were fine for two years. Then you had another hernia.
I have noticed that some surgeons will refer to a new hernia after a previous hernia as a “recurrence”. But, literally, recurrence means the same thing happened again. Was your second hernia the same, original, sliding hernia reappearing? Or a new type of hernia. This is an important distinction.
“Recurrence” implies a failure of the original repair. The appearance of a a different type of hernia could be a side effect of the original repair, from abnormal distribution of tension, or just a naturally occuring follow-through of weakening tissue.
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Sorry Pinto but I can’t understand what you’re saying in your account in the other thread. The writing style is strange, from first person to third person and there are details missing. It seems to say that you had intense pain immediately after the first surgery and lived with it for two years. My memory was that you had the pain but it was addressed soon afterward. Maybe it did take two years, I was uninvolved with the forum for a while as I was dealing with my own issues.
If you could just write a simple description, from the realization that you had a hernia all the way through the diagnosis and imaging and first and second repairs it would help people understand. You seem to be saying that prior imaging showed a sliding hernia and that Dr. Kang would have known this. Is this the case? It implies that Dr. Kang’s initial thought about how to repair a sliding hernia were not good enough or that he missed the sliding hernia. Did he say which it was?
Here is your account of “a” surgery. Doesn’t identify it as from Dr. Kang but I assume it was. Not clear.
“Overall, I had a painless surgery and quite pleased with my hospital experience. However there were two difficult post-op aspects in the first four days: immense pain getting out of bed and immense pain walking. After one-day hospital stay, I was discharged but only after requesting crutches. Bumps during my taxi ride back to my hotel were pure agony.”
Then you describe a second surgery two years later. By the writing, you had an attempted repair at the Gibbeum Hospital, had immediate pain and lived with it for two years, then went back to Gibbeum Hospital and had another repair. You’re implying that your “recurrence” happened immediately, probably from just getting out of bed. That’s what the words say.
“Given that Pinto followed the surgeons guide for a safe post-op, he believes if he was able to stay in the hospital in a motorized bed for at least three days, recurrence might not have occurred. It might have even proved the surgery was done flawlessly. He subsequently had a successful operation by the same surgeon two years later without any trouble—- without need for crutches or motorized bed.”
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Good luck Oceanic. Could you describe the experience in broader terms? Where you stayed, the facilities, languages spoken, type of anesthetic used, any notes from the operation?
Also, when you say you could barely walk, what type of pain were you experiencing? Not much is known about Dr. Conze’s work, on the forum.
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Actually, the point is that the expensive meshes are really no different than cheap mosquito netting. Your statement should really have any “petroleum-based mesh currently on the market” in place of “mosquito netting”. Except that the one you recommended is probably petroleum-based after the absorbable component disappear. It’s the same as mosquito netting.
Synthetic meshes are well-known for stiffening and shrinking very soon after implantation. The “replication” of abdominal wall movement disappears and the mesh becomes something completely different than when it was implanted. All hernia repair surgeons know this.
Most of the marketing that you read for any medical device is designed to make the sale. I hate to use the word “lie”, disingenuous is probably the best word for it.
“50% volume dissolvable and have multidirectional tensile stretch to replicate the way the abdomen moves”
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I thought that pinto’s case was one of a missed sliding hernia. Not a recurrence. People keep calling it a recurrence like it happened months or years later. It happened within hours or days, as I recall. As I understand things sliding hernias are unusual and often missed. It’s one of the reasons that Shouldice dissects the cremaster muscle. So they don’t miss anything.
https://herniatalk.com/forums/topic/pintos-2nd-surgery-with-dr-kang/
Pinto makes a good comment about being a lifer once you have a hernia. Besides the fear of future hernias, it really opens a person’s eye to how messed up the medical field is and how machine-like it is in treating patients. It’s actually very industrial and getting more so, with robotics and ambulatory surgery centers. The surgeon can walk in and perform the surgery without actually seeing the body of the patient on the table. It can all be done by video screen and control panel.
On various posters on the forum – there is a lot of “recency” effect happening here. Taking something they read on another web site, or heard from some guy down the street, within the last few months as indicative of the probability of success in the future. And very poor understanding of numbers overall, or willful misstatement. All of the decisions we make in life have a possibility/probability of being wrong or going wrong. If a surgeon has done 1,000 hernia repairs and had 20 pain or recurrence cases, that would be worse than a surgeon with 5,000 repairs and 20 pain or recurrence cases. A rational person would choose the 20/5000 surgeon over the 20/1000 surgeon. People are comparing only the 20 cases that they heard or read about, within the last few months, as indicative of the probability of a successful repair, without considering the successful repairs from the same surgeon. Numbers don’t work that way.
In the end it’s an educated gamble. Watchful went about his research in the right way. But he ended up as one of the 20. That doesn’t mean his decision-making process was wrong. It means he had poor information to work with or he just ended up as one of the unlucky ones. Not much different than getting killed by a drunk driver, or bitten by a shark, or struck by lightning. Don’t drive after midnight, don’t swim in shark-infested waters, don’t go outside in a thunderstorm. It can still happen though. Nothing is certain.
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An older article about mosquito netting. What’s really interesting is that they don’t raise the larger more obvious question of why cheap mosquito netting shouldn’t be used everywhere. There seems to be no reason to pay the extra money for the products of the big medical device makers.
https://onlinelibrary.wiley.com/doi/abs/10.1111/ans.17174
REVIEW ARTICLE
Inguinal hernia repair: a global perspective
James O’Brien MBBS, BMedSci, Sankar Sinha MS, MEd, FRACS, FACS, Richard Turner MBBS, BMedSc, PhD, FRACS
First published: 22 September 2021 https://doi.org/10.1111/ans.17174“… Conclusion
We postulate that the most cost-beneficial method of hernia repair for implementation in LMICs is using open-mesh procedures with sterilised mosquito net under local anaesthetic. Further cost–benefit research is required in this area. “ -
Here is what I had originally tried to post. I pulled out the two links above so it should work this time.
Here is an article that demonstrates how chaotic the mesh business really is. All of the big manufacturers have promotional material describing the advantages of their products. But, at the end of the day, it’s really simple fish net or mosquito netting material. Might even be made at the same factories.
Pretty crazy. It’s just a letter to the Editor of the BJS. Links below. The time frame is 15 months.
Link in post above –
Fully extraperitoneal laparoscopic inguinal hernia repair using conventional mesh versus tailor-made mosquito mesh: a randomized controlled trial from Cameroon
B. Essola, J. Himpens, A. Limgba, J. Landenne, D. D. Tamchom, E. Ngaroua, P. Lingier, E. T. Mboudou, J. Souopgui, M. P. Hermans … Show more
British Journal of Surgery, Volume 108, Issue 9, September 2021, Pages e294–e295, https://doi.org/10.1093/bjs/znab188“… In this prospective study, the authors found no difference between the groups in short-term complications and medium-term outcomes. The perioperative financial benefit of mosquito mesh is clear, as are the economic value and clinical non-inferiority, with low-cost mosquito mesh 1/1000 the price of commercial meshes …”
Here’s the about page for BJS.
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Here is a link to Medtronic’s Progrip pages. They just introduced a polypropylene Progrip to complement the polyester.
https://www.medtronic.com/covidien/en-us/search.html#q=progrip
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Six months, 1/2 year, past the committed-to deadline and still not a word about the update or the delay. Five years since the original commitment of update every two years.
It’s really looking like there’s either conflict behind the scenes or that they are just going to pretend that the commitment was never made. It must be disappointing, and embarrassing, to be a part of the whole fiasco.
The law firms certainly must be aware of the Guidelines, and should be aware of these statements about updating them to keep them current. If I was a law firm I would dig in to what is happening with this group, which now seems to be called the Herniasurge Collaboration. The whole foundation of the Guidelines was built on it being supported by a professional organization, with a contact point, and known members, with regular updates to the Guidelines. All of that has changed, in strange ways, with regular names changes and dead web sites and Facebook pages, and the commitments have not been kept.
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Another update from the Lawsuit Information Center web site. The number is huge and it’s just a single person. And the foundation of the case was built on the material used, so it could be used for suits involving all devices made using that material.
It’s not polypropylene and it’s not an inguinal hernia repair device but still interesting that juries believe that the damage is real and that Bard bears responsibility.
I pulled a few of the past reports together. PET is polyethylene terephthalate, called “polyester” in a typical knitted hernia repair mesh. Polypropylene and polyester are the two main materials used in the meshes.
“May 25, 2023 Update
The Rhode Island judge in Trevino took $250,000 off the verdict but left $4.55 million intact in post-trial motions. It is hard to understand the logic behind reducing the jury’s award by even a penny after all that plaintiff has been through based on the evidence offered at trial. But in the big picture of things, the judge’s ruling is a win because leaves the lion’s share of the award intact and affirmed the key rulings that Bard had opposed.…
August 29, 2022 Update
We have a verdict from Rhode Island: $4.8 million. Paul Trevino’s lawsuit alleged that C.R. Bard’s Ventralex hernia patch eroded into his bowel because they chose the materials they used based on price instead of safety. The jury agreed, finding both that the design was defective and that Bard to failed to warn of the risk. I’ve been saying all along I have no idea why Bard let this case go to trial. But the settlement value of Bard hernia mesh cases just went up.
August 26, 2022 Update
We could have a Rhode Island state court verdict today in a Bard Ventralex patch case, Trevino v. Bard …. stay tuned.In Trevino, the plaintiff claims that the defendants knew or should have known that the PET ring, a component of the Ventralex Mesh, was prone to breaking or buckling, thereby increasing the risk of severe, permanent injuries. Despite these risks, the defendants intended for their product to be implanted for the purposes and in the manner that the plaintiff and her implanting physician used it.”
Here is the link.
https://www.lawsuit-information-center.com/bard-hernia-mesh-lawsuits.html
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Watchful was probably referring to the words below. The notes imply that it was problematic/unexpected, and had occurred recently, but “nonetheless” they got things done.
“bulky intact transversalis muscle that had just separated from the inguinal ligament. Nonetheless, we were able to get good reapproximation of the floor and reinforcement with mesh.”
It looks like you had a normal Lichtenstein repair. You can find quite a bit about it on the internet, and Youtube.
On the pain at night, of course, there are normal bodily functions that happen at night for men. It might be related to that. You say that you have to take ibuprofen but I wonder what would happen if you just walked around for a bit. It seems odd that a pain would appear for no reason and remain.
Anyway,as Watchful said, it’s early. Tissues got stretched out of shape when you had the hernia and then got stretched back to where they were supposed to be when you had the repair. You might try adding some things to your walking routine. Weights or stretching. See what happens. Good luck.
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Some of the open mesh repairs extend all the way down to the pubic bone. That could cause pain/sensations much lower than the external incision point. There is a variety of methods and materials described as “open mesh”. That’s why I asked for details. Good luck.
One example –
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What type of activities have you been doing during the day? I have found that sometimes more activity is better than less for pain after surgery. It’s counterintuitive.
Can you share the details of the repair method? Lichtenstein, plug and patch, PHS? And the type of hernia that was repaired.
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Here is a link to their practice website. The publications and the website imply that they do many Lichtenstein repairs.
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Here is an earlier paper that is open access, on the same general topic. It has some very good illustrations, showing how the nerves exit the abdominal wall at different places, and of the inguinal canal and spermatic cord.
The authors seems to be well-informed. It would be interesting to know what their repair choices are.
https://www.scirp.org/html/7-2100840_47865.htm
Inguinal Neuritis in Open Recurrent Hernia Repair
Robert Charles Wright, Robert James Wright
Cascade Hernia & Heartburn Institute, Meridian Surgical Center, Puyallup, USA“PURPOSE: To investigate the pattern of occurrence of inguinal neuritis in recurrent inguinal hernia. We hypothesize that neuritis will occur in more nerves with a wider distribution than in primary repair. METHODS: Retrospective chart review of thirty consecutive recurrent inguinal hernia repairs concentrating on the occurrence of inguinal neuritis. These are not chronic pain patients. Nerves suspected of containing inguinal neuritis were sent for histologic examination. Ilioinguinal nerves were routinely resected. Operative parameters and nerve pathology reports were reviewed. These data were compared with a recent series of one hundred consecutive primary inguinal hernia repairs with a 34% incidence of inguinal neuritis. An independent statistician from Whitman University reviewed the data. … ”
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There seems to be a discrepancy between the information the authors think is collected and what they show. Identifying a bad product, one to avoid, will be impossible if the brand and trade name of the product are not collected with the rest of the operational details. It seems reasonable to assume that the industry funded registries would not collect that information.
“Operative data
Most registries record details of the operation such as urgency of the operation, hernia classification, hernia localization, operating time, operative technique, anesthesia type, mesh type, fixation technique, defect closure, drain utilization and antibiotic prophylaxis (Table 5).”There is no mesh type category shown in the table. Beside that, how detailed would “mesh type” be? Bard 3D Max? Anatomically shaped mesh? Or just polypropylene? It would be interesting to get in to one of these registries and see the actual information that is collected.
https://link.springer.com/article/10.1007/s10029-017-1724-6/tables/5
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SN, here is a video that you should watch that might add to the discussion. It is Dr. David Chen’s explanation of why he chooses open Lichtenstein. He describes possible reasons that people have problems after the procedure.
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I came across this old Topic when I was searching for a post about Dr. Chen. I found the publication that Herniahelper referred to and am adding it here to fill out the discussion. It’s a very small study, 13 patients. Yet the new method is recommended as “safe”. Another market for robotic surgery. It is the state of the hernia repair field. New methods to add to the smorgasboard. No long-term results. I wonder who is using it.
https://link.springer.com/article/10.1007/s10029-020-02259-7
Robotic iliopubic tract (r-IPT) repair: technique and preliminary outcomes of a minimally invasive tissue repair for inguinal hernia
D. Huynh, N. Fadaee, B. Al-Aufey, I. Capati & S. Towfigh
Hernia volume 24, pages1041–1047 (2020)“Conclusion
The Nyhus-inspired robotic iliopubic tract (r-IPT) repair is an MIS approach to provide a non-mesh repair in inguinal hernia. The repair is safe with acceptable preliminary outcomes in low-risk patients. We propose the r-IPT repair to be a MIS option for non-mesh inguinal hernia repair in low-risk patients.” -
Sorry to fill your thread with more research papers SN. If I were considering a repair I would focus more on the qualities of the surgeon. Not so much their skill level, but who they are as people. The surgeon that implanted the mesh in me was skilled but was more of a businessman than a true doctor.
Here is the initial paper about the study I referenced above. It has a good writeup of the lack of knowledge about biologic materials, despite the fact that they were already prevalent in the market.
https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-018-3122-5
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I think that the type of hernia and the results hoped for would play a big part in a decision.
I also think that the quality of the data available for a broad evaluation like that is poor. Most of what has been published over the decades has been inconclusive. For example, a few years ago Ovitex was in the news, with many surgeons promoting it. The company “went public”, meaning that they entered the stock market where investors could buy shares, and now the fanfare has died down. The stock price has dropped and the company is branching out in to other areas. There is no data other than the initial 31 patient inguinal hernia repair study by a single surgeon that suggests that Ovitex is a good idea for inguinal hernia repair.
The new biologic being promoted is Strattice. Similar to the way in which TelaBio created a white paper showing the weaknesses of synthetic mesh, now the Strattice people have produced a paper showing the weaknesses of Ovitex. Most of these “scientific” papers have a corporate purpose behind them.
https://link.springer.com/article/10.1007/s10029-023-02769-0
Here is a recent short paper (supplement) describing a study comparing synthetic mesh and biologic mesh. In the same person! I don’t know how they convinced these patients to be experimental subjects, but there it is. So far, at 6 months, they see no difference. 6 months is a very short time frame of course.
https://academic.oup.com/bjs/article/110/Supplement_2/znad080.012/7155931
OC-005 COMPARISON OF POSTOPERATIVE PAIN: BIOLOGICAL VERSUS SYNTHETIC MESH SIX MONTHS AFTER LAPAROENDOSCOPIC HERNIA REPAIR – RESULTS OF THE RANDOMIZED, MULTICENTER, SELF-CONTROLLED BIOLAP TRIAL
C S Seefeldt, J Knievel, J Meyer-Zillekens, J Lange, R Lefering, M Heiss
British Journal of Surgery, Volume 110, Issue Supplement_2, May 2023“… To test the hypothesis that the use of biological meshes results in significantly less pain postoperatively than the use of synthetic meshes, without an increased recurrence rate, patients with bilateral primary inguinal hernias were included. Patients received biological mesh on one side and synthetic mesh on the other. …”