Good intentions
Forum Replies Created
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Here is an interesting (to me anyway) old Topic about the Guidelines. Post #18513 especially, two posts above this one. Dr. Bendavid is one of the few surgeons who actually did focused work on trying to understand why mesh causes pain.
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Watchful, your commentary doesn’t really say anything. It has little substance. You’re implying chronic pain equivalence based on a few forum stories and some comments from a few surgeons. “A number of people on this forum”? You know better, you spent all of that time using real research methodology before you chose Shouldice. Now you’re doing something else. Using vague words like “most” and “significant”. That is exactly what the mesh repair surgeons do.
Post up the studies you mentioned. The numbers matter. People get killed riding bicycles but that doesn’t mean that bicycles are just as dangerous as cars.
” Chronic pain is a significant issue with tissue repair as well as with mesh. It’s hard to know the exact chronic pain numbers for different types of mesh procedures, and tissue repair procedures, but it is known that tissue repair has a significant incidence of chronic pain and discomfort. There are a number of people on this forum with that problem after tissue repair (including me), studies show this problem, and most tissue repair surgeons (including the Shouldice Hospital) admit that this is an issue.”
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Here it is. The authors choose whether or not to pay for open access. Dr. Netto and his co-authors, most of who work at Shouldice, chose the paywall.
https://www.springer.com/journal/10029/how-to-publish-with-us
“Hernia is a Transformative Journal (TJ). Once the article is accepted for publication, authors will have the option to choose how their article is published:
Traditional publishing model – published articles are made available to institutions and individuals who subscribe to Hernia or who pay to read specific articles.
Open Access – when an article is accepted for publication, the author/s or funder/s pay an Article Processing Charge (APC). The final version of the published article is then free to read for everyone.
Hernia is actively committed to becoming a fully Open Access journal. We will increase the number of articles we publish OA, with the eventual goal of becoming a fully Open Access journal. A journal that commits to this process is known as a Transformative Journal.”
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Shouldice can publish the paper on their own web site. And the Hernia journal also publishes open access articles. If you want to add to the discussion, find out out how the decision is made to publish as a pay-per-view versus open access. Who makes that decision?
I am actually disparaging the hernia repair industry in whole. “They” (the people involved in the industry) have created a narrative of “informed consent” but the information that the patients need to be informed is often hidden behind paywalls.
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What type of hernia will he be repairing? How active are you? How did you get the hernia? Those are interesting questions, I think.
Good luck.
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It is saying that the type of recurrence is indirect more often for laparoscopic. The type, not the quantity. In other words, the surgeon is more likely to find an indirect recurrence in a patient that had laparoscopic surgery than in a patient that had open mesh or Shouldice.
The terminology is not very good in that strictly interpreting “recurrence” should mean that the same type of hernia re-happened. If the patient started with a direct hernia then came back with an indirect hernia that would, strictly speaking, be a new hernia. Not a recurrence. “Recurrence” is imprecise.
They also take the lax approach of, as far as can be told from the short summary, lumping all types of lap surgery and all types of mesh in to one pile of “lap mesh”. It seems wasteful to compile all of that data then do such a poor job of learning from it.
It is interesting though that Dr. Netto, who seems to have the urge to get involved in the hernia repair narrative, chose this topic to research. Trying to define the type of recurrence (or occurrence) to be expected from the type of repair. Not really clear why he thought that was important.
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It might be worthwhile to revisit some of the possibilities from the past. Here is an old Topic about Dr. Repta.
https://herniatalk.com/forums/topic/open-mesh-removal-and-non-mesh-hernia-repair-dr-remus-repta/
Open mesh removal and non mesh hernia repair-dr. Remus Repta
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Chuck and Harry, your stories are so similar you could be the same person. Writing styles and opinions too. Very interesting.
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I select and copy everything that I wrote before I hit the Submit button. I’ve lost a few posts in the past.
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A thought that I just had – any surgeon out there that uses the Bassini method will probably be considered an eccentric. Mesh has grown in to the repair field at a steady rate through the training programs at places like the Mayo Clinic. Many or most surgeons in practice today never learned how to do a pure tissue repair method.
So, when you’re talking to various medical professionals, like nurses, doctors or surgeons, ask about the oddballs that don’t use mesh or those that know the “old arts”. Many of them have probably converted to mesh or laparoscopic but there are probably resisters out there. It is dangerous to leave the herd though. They will not be “state of the art”.
Can you share some details on your mesh ordeal? The type of hernia you started with all the way to mesh removal, if you can stand reliving it. Every story is helpful in showing people what is happening out there. How even the smartest people get fooled (including the surgeons).
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Here is an older Topic from someone who was talking to a surgeon who used the Bassini method. She did not find out if it was the modified or original method though and has not been back. His name is in the last post, Dr. Wade Rosenberg, of Texas.
https://herniatalk.com/forums/topic/found-a-tissue-repair-surgeon-have-many-questions/
This is probably him –
https://www.houstonmethodist.org/doctor/wade-rosenberg/
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I have not had a recurrence. Dr. Billing did leave a small piece of mesh in the area of the original hernia though. He said it was too tangled up with critical structures to attempt its removal.
If I did have a recurrence or a new hernia I would seriously consider Dr. Kang. But I would probably also contact Dr. Billing again, because he is, to me, obviously very thorough and rigorous in choosing the best surgery for his patients. I am fairly certain that he has converted to open surgery from lap in the past, at times, and knows the anatomy well. It would be interesting to know if knows the difference between the original Bassini and the modified Bassini, and which he would choose. He started as a lap TAPP mesh surgeon but apparently has a robotics system now.
I would also spend some time researching smaller names in the hernia repair field. We are all so used to the internet now we tend to overlook people that are out there but not active or talked about on the internet. I just moved to a new place and had to find a new dentist. I was surprised at the variation in ideas about care among the few dentists I talked to. I also realized that my previous dentist had been very good.
There are good skilled surgeons out there who are just not well-known.
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It’s hard to find a clearly described comparison of chronic pain rates between the two methods. And, of course, each attempted study mashes all of the lap methods and meshes in to one big pile. Then they run the statistics and report a “significant” difference.
To the average person the word significant means “a lot” or many or something largely positive. In the world of statistics it just means that a difference can be quantified using the statistical methodology chosen. Samuel Clemens created a famous quote through his Mark Twain pen name – “Lies, damn lies, and statistics”. It could be 13% versus 15%.
Here are a couple of recent papers. It’s interesting that the other big selling point for lap mesh (the blob of materials and methods), recurrence, appears to be the same. Statistically.
https://link.springer.com/article/10.1007/s10029-019-01989-7
In this one, below, they can only “suggest” that lap mesh is better for chronic pain. Decades on and this is the best of the best – can’t really tell. People really should focus on how to fix the problem if it occurs. Include that in the how to avoid it calculation. Lap mesh removal is drastic.
https://link.springer.com/article/10.1007/s00464-022-09161-6
“Conclusion
Meta-analyses suggest that laparoscopic repairs have a lower incidence of chronic groin pain than open repair, but there is no evidence of differences in recurrence rates between laparoscopic and open repairs.” -
I only looked at the web page advertising the clinic. You mentioned a pdf file, I did not see it. It looks like you’ve checked his publications also.
Regardless, he is apparently, a Lichtenstein surgeon who uses Progrip mesh. I would guess that 99% of the web pages and brochures advertising a surgeon’s clinic all do the same thing. They show their knowledge by describing possible causes of pain, describe how they do their repair, and give no firm data about results. The closest Dr. Sadler got is “appears to be about 2%”. They use vague terms like “vast majority” and “very small” but then show that they really have no idea if their patients are doing well or not. “Endeavor to try”, “all possible steps”…he means well.
Sorry to be so critical but his web page shows that he’s just a guy who does the Lichtenstein procedure using Progrip mesh. If you want to use the one patient sample size to judge his quality, I am fairly sure that I have seen a post on the site from somebody that had Lichtenstein with Progrip.
I found this with a quick search – https://herniatalk.com/forums/topic/anyone-got-their-mesh-removed-by-dr-muschaweck/
Again, no offense intended. Just applying the critical eye to what he says. It’s a typical sales pitch.
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I don’t see him mentioning chronic pain. I pulled out a few sections below. Overall it is the typical “this is what I do and why it’s better” presentation that most hernia repair surgeons use.
The front page is odd in the way he describes using the most Pro-Grip mesh of anyone in the UK. Who would care about that, why would it matter? I think he’s trying to benefit from Medtronic’s marketing of Progrip. Riding the Pro-Grip bandwagon.
“Mr Sadler now only performs local aneasthetic hernia surgery. He is the largest single user of ProGrip mesh in the United Kingdom (approximately 4000 procedures) and has performed almost 6000 career hernia operations.”
“Oxford Hernia Clinic was pleased to be the first hernia clinic in the UK to use ProGrip™ as its preferred mesh for hernia repair and we are currently the largest user of the mesh in the UK, having performed over 4000 procedures.”
Here is one reason doctors and surgeons don’t show any interest in determining whether a hernia is direct or indirect.
“There are of two types of inguinal hernia, direct and indirect. For patients this distinction is irrelevant as the same operation fixes both types.”
He says “less painful” but does not mention long-term pain. Looks like it’s faster and cheaper. Those are good things, of course.
“Open repair is the most commonly performed procedure for inguinal hernia surgery and for the majority of hernia patients would be the technique of choice. After over 5 years of laparoscopic repair Mr Sadler reverted back to this technique because he believes when performed under local anaesthetic using it is quicker, more effective, less painful, safer (complications are very rare and less harmful compared to keyhole surgery) and far more cost effective for self paying patients compared with general anaesthetic.”
“After performing TAPP (and TEP) for many years, Mr Sadler no longer performs any keyhole surgery, favouring local anaesthetic repair (even for bilateral hernias) as he believes it is safer and more comfortable for patients.”
He uses the typical way of downplaying other methods with vague statements about risk. Mentions informed consent. Doesn’t give any numbers.
“No Mesh Technique (Bassini Type) Repair
We can repair your hernia with a “No Mesh Technique”, this is called a Bassini Type Repair, after the surgeon who described the technique in 1884. This is remained the standard way of fixing a hernia for over 100 years until the “tension free Mesh technique” became more popular. The technique works very well and many patients who had this type of repair have never had any problems.However, a ‘No Mesh Technique” will not reduce the chance of having chronic discomfort after surgery (it may even increase) and statistically your hernia is more likely to come back, especially if it is a direct hernia. Mr Sadler will discuss this option with you as part of your consent process.”
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Replying to watchful – I wonder what the Munich Hernia Center would have recommended. Linked below, I posted it in William Bryant’s Topic.
I see people on the forum doing what is done across the hernia repair industry, in over-simplifying, and suffering from the “recency” effect. The last thing they read or their strongest memory becomes their personal “status quo”. If you don’t look at the statistics you’ll end up with a different conclusion every week. The shameful thing is that we, the patients, should not have to do all of this work. The pros should have the answers for us. They don’t. Businesses are focused on getting the customers (the patients) in and out and paid up.
https://www.hernia-centre.com/hernia.html
I don’t know if they actually follow this path (every hernia repair center ad looks about the same), but they do lay out what looks like a logical approach.
“INGUINAL HERNIA SURGERY REQUIRES AN ACCURATE DIAGNOSIS TO BE MADE FIRST
Your doctor will only be able to determine which option is best for treating your inguinal hernia after a detailed examination.
Only once an accurate diagnosis has been made will your doctor draw up a meticulous plan for surgery with you and explain to you in detail what happens next.
Given that there are a great number of techniques and surgical methods available, your physical condition and past medical history will also be taken into consideration.” -
Not sure if these are the same video relabeled.
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You might have some luck looking at their repair centers and their publications.
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Here is the sequence of statements Mike M. Watchful must have been feeling down, he interpreted your words in the worst way and added his own. Sorry watchful, I know you’re disappointed about your results but your path to Shouldice was correct, based on the hernia that you thought you had. Your real problem is the poor diagnosis in the beginning, and the fact that surgeons, generally, lock in on a technique instead of having a broad skill set that allows them to choose the best option. That is, I think, a more general failing of the medical profession. Another example of surgeons doing what they do, so the diagnosis doesn’t really matter. Shouldice surgeons do Shouldice, lap TEP surgeons do lap TEP, robotic equipment surgeons do robotic lap TAPP.
Post #34620 Mike M: Pain was only bad that first week. Some tension the weeks that followed and then it fades into nothing. I can still feel something in that area but nothing of mention. You can only really feel the scar tissue the first few months maybe. The nerves seem settle down and accept the repair after a while. I am starting to “forget” I even had hernia surgery now which was the end goal.
Post #34621 watchful: This doesn’t sound so great. Having symptoms for months after surgery, and still feeling something there after a year (even if minor) isn’t great. Not bad, but not the most desired result. We need to remember that you didn’t even have a large hernia.
Excellent discussion with hernia genius JF–Watchful bryant pinto..mike m