Good intentions
Forum Replies Created
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I’ve been curious, actually fascinated, about how the massively influential “International guidelines for groin hernia management” got produced so have been collecting the documents about its development. The original document was produced by the European Hernia Society in 2009 and listed all of the authors. It was updated in 2014, again with all of the authors listed. In 2018 they created a new group that they called the “HerniaSurge” group, and described making supporting data available and ways to contact the group if there were questions. Since then the Group has gone almost completely dark, only appearing as buried references in various documents, under a changed name, the “HerniaSurge Collaboration”. I posted about this collaboration earlier in this thread. The web site link for the Group is dead. Their Facebook page has only a few posts. Basically all of the foundational work for the Guidelines is inaccessible. The document exists as gospel, referenced with confidence by surgeons around the world, but they don’t realize that it is now an empty shell and that the original authors seem to be second-guessing their work on it.
2018 was really not that long ago. Since then Dr. Campanelli has written several editorials in Hernia journal about the chronic pain from hernia repair problem, first proclaiming that the problem was real and describing a future collection and special issue about the problem. But then finishing the project with an Editorial that suggested that the problem was not real, and that it had arisen because people expected too much from life.
https://link.springer.com/article/10.1007/s10029-017-1668-x
Published: 12 January 2018
International guidelines for groin hernia management
The HerniaSurge Group
Hernia volume 22, pages1–165 (2018)Here is one of 80 references to the HerniaSurge group, with a dead link to a web site –
“All search strategies, tables with articles and background information will be published on HerniaSurge’s website (https://www.herniasurge.com). All articles are filed per chapter in MendeleyR reference manager.
We would like to emphasize the fact that the “International Guidelines for Groin Hernia Management” is NOT a legal document, merely guidelines. If surgeons choose not to follow strong recommendations, they should do so in consultation with their patients and document this in the medical record. …”
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It’s interesting that Dr. Conze is one of the original members of the HerniaSurge group, which seems to be a shadow group now. Is this the same Conze? J. Conze?
https://link.springer.com/article/10.1007/s10029-009-0529-7
Published: 28 July 2009
European Hernia Society guidelines on the treatment of inguinal hernia in adult patients
M. P. Simons, T. Aufenacker, M. Bay-Nielsen, J. L. Bouillot, G. Campanelli, J. Conze, D. de Lange, R. Fortelny, T. Heikkinen, A. Kingsnorth, J. Kukleta, S. Morales-Conde, P. Nordin, V. Schumpelick, S. Smedberg, M. Smietanski, G. Weber & M. Miserez
Hernia volume 13, pages343–403 (2009) -
Another update. Somebody has to be doing the math about how many new cases are being produced every day. If nothing is changing in the hernia repair field, and nothing is expected to change in the legal field, then, of course, these lawsuits will continue even after a settlement. It’s very simple logic. Who will end up paying for these payouts?
“May 15, 2023 Update
As the hernia mesh class action MDL involving C.R. Bard continues to drag itself towards a conclusion, large numbers of new plaintiffs continue to join. Over the last month, 206 more cases were added to the MDL. That swells the total number of hernia mesh plaintiffs to 19,476. Since the start of the year, 1,000 new cases have been added to the Bard hernia mesh MDL.” -
For what it’s worth, Dr. Billing uses the TAPP mesh implantation procedure for his hernia repairs. At least he did when I talked to him. I can’t remember the type of mesh but I think he used the procedure taught at the Mayo Clinic when he was there as a resident. Smaller well-placed pieces of mesh, only covering the defect. Not the large “cover everything” method used today. Probably similar to the procedure used in the study above. He seemed confident in his results and he stays in touch with his patients. I can’t imagine that one of his former patients would not contact him first if they had pain. He mentioned one person that had pain but I did not get the details, and I don’t know how many hernia repairs he does per year.
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Here is the 2007 paper again. It has more detail, and a different author line-up.
https://academic.oup.com/bjs/article/94/5/562/6142702
Long-term results of a randomized clinical trial of Shouldice, Lichtenstein and transabdominal preperitoneal hernia repairs
M Butters, J Redecke, J Köninger
British Journal of Surgery, Volume 94, Issue 5, May 2007, Pages 562–565, https://doi.org/10.1002/bjs.5733
Published: 19 April 2007“Results
Hernia recurrence occurred in six patients after Shouldice repair, and in one patient each after Lichtenstein and TAPP repairs. All recurrences after tension-free repairs were diagnosed within the first year after surgery. Nerve injuries were significantly more frequent after open Shouldice and Lichtenstein repairs. Patient satisfaction was greatest after laparoscopic TAPP repair.” -
Was it modified Shouldice or the Shouldice Hospital method of Shouldice? Polypropylene or SS or absorbable sutures? What type of hernias were repaired? How many recurrences were there?
The 2nd to last statement in the summary is odd. Lichtenstein is a mesh procedure. They changed the verbiage to postoperative complaints. Not clear why.
” The presence of the prosthetic mesh was not associated with significant postoperative complaints.”
It is an odd effort compared to the main author’s other work. I did find a different paper in which he was a co-author, from three years later, which seems to use the same 280 patients. I linked it below the excerpt below. Just seems strange.
“Results: Chronic pain was present in 36% of patients after Shouldice repair, in 31% after Lichtenstein repair and in 15% after TAPP repair. Pain correlated with physical strain in 25% of patients after Shouldice, in 20% after Lichtenstein and in 11% after TAPP repair. Limitations to daily life, leisure activities and sports occurred in 14% of patients after Shouldice, 13% after Lichtenstein and 2.4% after TAPP repair.
Conclusion: Chronic pain after hernia surgery is significantly more common with the open approach to the groin by Shouldice and Lichtenstein methods. The presence of the prosthetic mesh was not associated with significant postoperative complaints. The TAPP repair represents the most effective approach of the three techniques in the hands of an experienced surgeon.”
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When you guys are researching pain and chronic pain and discomfort you should try to differentiate static pain from dynamic pain. My discomfort from mesh was mostly static. Sitting in a chair, like a person would do to work on a computer, was not tolerable. I actually progressed from an office chair, to a straight-backed dining table chair, to standing up while trying to work on a computer. So that I could focus on what I was trying to do for more than a few minutes. I built a stand for my monitor and keyboard to raise them up so that I could stand. I tried kneeling on the dining table chair so that I wouldn’t have to stand for so long. None of it worked well.
On the other hand, movement made the surgery area feel better. Exercise, running, bike riding all felt good while in motion. But the effects of the movement made the static discomfort worse. I found that I could get about a half-day’s worth of feeling “normal” the day after exercise. But the discomfort always came back. I ended up in a cycle of 2-3 days trying to find some balance that would make life bearable. While this was going on other family members who could have used my presence did not get it. I was almost completely preoccupied with trying to learn how to live with the mesh in my body.
I have often thought that implanting mesh would be a good torture technique. Implant two large pieces of mesh, make the victim exercise then lock them in a cell where they have no freedom to move. Promise to remove the mesh if they tell their secrets.
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Delay, delay, delay seems to be the current state of the Bard litigation. New motions made by lawyers who know that they will be rejected. Expectations of a settlement were proposed as the reason for the delay to May, now the trial has been delayed to October of 2023. This major healthcare problem has become a purely financial and legal problem. Also interesting that worker’s compensation is handled by a government agency formed to protect workers, but the agency formed to protect the general public is doing nothing.
“May 13, 2023 Update
Things have been slow in the hernia mesh litigation while we wait for the Stinson trial and hope for a settlement before that. Yesterday, a new motion was filed in Stinson that revolves around the admissibility of evidence related to Mr. Stinson’s workers’ compensation claim. Bard wants to admit that there was an award and the amount of the award received by Mr. Stinson from his workers’ compensation claim be excluded.The plaintiff’s counsel argues that the defendants should be barred from mentioning workers’ compensation during the trial under the collateral source rule. It is hard to imagine a scenario where the plaintiff loses this motion. The whole point of the rule is to referencing a collateral source would risk leading the jury to reduce Mr. Stinson’s damages award, assuming he had already received some compensation. Moreover, workers’ compensation claim holds no evidentiary value.
May 1, 2023 Update
The new trial date for Stinson v. C.R. Bard, the third MDL bellwether trial, is now reset for October 16, 2023. This trial date is the pressure point for settlement not only for this case but for the entire litigation.” -
My first inclination to go with Dr. Kang is based on the interactions over the years on this forum. You really should just search his name and go back to the early posts on the forum and follow them up to today. He started his career in hernia repair as a patch and plug mesh practitioner. He saw the damage that the plug caused as patients started coming back with problems. He went back to the pure tissue repair and studied the problems that were being expressed about it. He is of the opinion that the problems with early methods like the Bassini repair are due to surgeons modifying (cutting corners) on the original method. He calls today’s Bassini repair the corrupted Bassini method. Apparently, as I understand things, the method he uses today is based on those early proven methods, but with his own subtle changes, based on his years of experience performing hernia repairs. And he addresses each situation based on what he finds during surgery, besides having what looks like a very modern set of imaging machines so that he knows what to expect before he even starts. Unlike many surgeons today who promise to wing it to the best of their ability if they find something unexpected.
But, to be frank, Dr Wiese looked like a good option also. I added a few posts to another thread after Freeman posted about him.
One odd problem that you’ll find when discussing the big names in hernia repair is that many of them got roped in to creating the “International guidelines for groin hernia management”, the sponsored effort by Ethicon and Bard, two big mesh makers at the time. Which begin by stating that mesh repair is the preferred hernia repair method. But with very little supporting data for that claim. Each surgeon who was part of that effort has their name tied to the document that has pushed mesh on to the world, and several of them seem to be walking back their support. But the Guidelines have become gospel in the world of hernia repair. The standard of care.
In short, there is no clear answer. You have to use a blend of personal and professional trust to make a choice. Honest well-meaning people can be fooled also.
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It would be very interesting to know what she considers “trouble”, and how she could differentiate your hernia from others. Does she have a belief that she can predict “trouble” with a patient based on the type of hernia repair performed?
I doubt that the trouble she referred to was chronic pain. The vast majority of attempts to define an avoidable cause of chronic pain from mesh have been failures. If anyone has a provable way to continue to use mesh and reduce the chronic pain rate they have not made a good case for it in the literature.
The mesh products seem to have inherent chronic pain properties.
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One often cited factor to consider when choosing a surgeon is experience. I am certain that Dr. Kang has much more experience in pure tissue repairs than Dr. Towfigh does.
The text on the web page does not describe what a patient who is a good candidate for pure tissue repair would look like. I think that if a person went to Dr. Towfigh with a hernia and did not request a pure tissue repair they would get a lap TEP mesh repair. That is just a feeling derived from her posts on the forum. She has mentioned in the past that, maybe, women should be getting more pure tissue repairs than mesh. Implying that mesh repairs are over-prescribed for women. Not clear where that thought process is going though. It was just a comment on the forum.
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@drkang might work. Or you can go directly to the Gibbeum hospital web site.
Stephen Kwon is the contact person for travelers. His email address is at the bottom of the web page. I copied it from there.
http://gibbeum.com/abroad/From-abroad.php
Dr. Towfigh is a proponent of lap TEP mesh implantation. And, I believe, very expensive. Beverly Hills.
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Why would everything in the Library of the EHS be for members only?
https://europeanherniasociety.eu/category/video/
Here is what they provide for patients that happen to find the site. Embarrassing to watch. (Beside the word patient being misspelled.)
The EHS also has no Mission Statement. What is its purpose? The more you look the more it looks like a front for the medical device companies.
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If you scroll down to the German Hernia society on the EHS chapters page and open the + button you’ll see some familiar names. Kockerling, Conze, Lorenz. I think that William might be right to focus on what’s happening in Germany. They don’t seem as tied to mesh as the EHS is. The EHS started the push to mesh and is fully invested in promoting its use, no matter what.
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Here is more from Dr. Wiese’s bio.
https://www.chirurgie-hessen.de/Martin+G.+Wiese
“Since my training in the clinics of the Main-Taunus-Kreis Bad Soden under Professor Peter Wendling, I have increasingly dealt with the topic of hernias, i.e. soft tissue fractures, in addition to general surgery. Since then I have helped to develop new procedures and have been a guest center for hernia surgery for years, and since 2016 also for international guests. With us you get an individual concept for the care of your inguinal, navel or incisional hernia, also in cooperation with neighboring clinics. A specialty is chronic groin pain and groin pain in athletes. I regularly give lectures on these topics and have performed several live pre-operations at international congresses.
Since 2016 I can be found in the Focus list of top physicians for hernia surgery without interruption.
Along with PD. dr medical Guido Woeste, I am the conference president of the German Hernia Society 2022 and a member of the extended board of the German Hernia Society.”
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I got back on to Dr. Wiese’s practice web page to see what types of procedures he performs. It looks like he has the ability to do several and chooses the one that he feels will give the best results. In another current thread there is much discussion about how surgeons tend to be “one-trick ponies”, only performing a single type of hernia repair. This is the training that today’s surgeons get, to use only mesh for hernia repair, codified by the suspect Guidelines that the EHS promotes. Very interesting that Dr. Wiese is there in Europe but chooses his own path.
Here is the text from the web site, to add to Freeman’s report of receiving a Shouldice type repair.
https://www.chirurgie-hessen.de/Leistungen
“Hernia Surgery
Individual concepts for the treatment of inguinal, navel and abdominal wall hernias, including incisional hernias
Training center for years and now international internship center and Milos training center
Conference President of the German Hernia Society 2022 together with PD. dr medical Guido Woeste
Member of the extended board of the German Hernia Society
Inguinal hernia operations with and without synthetic mesh
Abdominal wall hernias with diastasis recti using the MILOS technique
Second opinions and advice for athletes” -
Thanks for posting your story Freeman. It is great that you had a good result and know some of the details of the method.
I found a link to Dr. Wiese’s profile on the internet. It is in German but anybody can use Google to translate it.
https://www.chirurgie-hessen.de/
Also, the jameda link –
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How do you know that guy knew what he was talking about? He’s just one guy. There was probably another guy right down the hallway that would have a completely different opinion.
The guy said that they were “seeing new chronic pain cases on a weekly basis”? What does that mean? How new, like one week old, or one year since surgery? How does he know that lap mesh has a lower rate if they don’t know what the rate is for Shouldice? The conversation has the hallmarks of somebody who wanted to seem knowledgeable, but was not. Or somebody who gets their knowledge from General Surgery News.
Anyway, it’s good that the people at Shouldice seem to be continuing to learn about hernia repair in general. If they are quantifying recurrence rates then you’d think that they would be quantifying all of the “new chronic pain cases”.
In the big scheme of things, the lawsuits will still have the biggest impact I think. Money will be the driver of change. I just found another new paper about “surveillance of medical devices” that I will post.
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Four months in to 2023 and still no sign of updated Guidelines. And the link to the newsletter does not work anymore.
EHS seems to have revised their web site. Some material that you’d think would be free is members only.
https://europeanherniasociety.eu/do-mesh-devices-make-hernia-repair-easier/
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Without reading the full paper and seeing how they performed the surgeries, and defined pain, and queried the patients, there’s not much value in the summary. The summary is not clear, and for some odd reason, a different primary author led the effort to rewrite and republish the study results. The link to the 2007 paper contains the full publication, with data.
You can find presentations by experts in each method describing ways to go wrong. Dr. Chen produced a video about the Lichtenstein method and potential problems.
Shocking numbers can be found pretty easily on the internet.
https://www.tandfonline.com/doi/abs/10.1080/00325481.2016.1121090