Good intentions
Forum Replies Created
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Never mind, I found it. Overlooked it the first time. Good luck.
“he spent thousands of hours researching hernias…traveled all over visiting surgeons…”
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Who is JF? If he wants to stay anonymous, what are his qualifications, at least?
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I don’t know how big it was. I had a visible peaked bump, probably about one inch wide and 1/4 inch tall (guessing) when standing that disappeared when laying down. It was only a problem after intense physical activity. Not during, but after, like the day after a soccer game I would have pain while raking leaves in the yard. Occasionally things like a twisted testicle would occur. The pain and problems always resolved after a few days. I was aware of the issues with hernia repair and had decided to try to live with it and keep doing the things I wanted to do.
Eventually it was a choice of giving some things up or having surgery. I was leaning heavily toward Dr. Brown or Shouldice but then found the head of surgery at a big clinic who was part of a group that trained people in laparoscopy, who also had a very good referral from my friend who was a surgeon (in a different specialty) and had had his own hernia repaired years before. I found out afterward that he had had a Lichtenstein repair. I also found out later that my surgeon was still fine-tuning his implantation method from the year before but he never said what he was trying to fix. I also found out later that he had had a semi-professional soccer player as a patient before and the patient had ended up going to Florida to have his mesh problems worked out. Yet he still took a chance on me.
My experience has all of the hallmarks of what is wrong with hernia repair today. Surgeons mindlessly doing what they do, because it is what everyone else does, and they can’t admit mistakes. If my surgeon had been honest he would have discussed the problems that he had with the other soccer player with me before he accepted me as a patient. But he hid it from me and downplayed it later. Pretended that he didn’t know why the guy had problems. But he did know that there were problems with the repair that he did.
In the big scheme of things my big mistake was not trusting my own judgement, using what I had learned about hernia repair at the time. There was really no reason for me to believe that the surgeon I chose was any different from all of the other hernia repair surgeons. They are all learning from the same sources. People like Dr. Felix, traveling the world giving presentations about the 10 Golden Rules, and the Repair Guidelines that were sponsored by Bard and Ethicon years ago.
If I was starting over I would trust the most the surgeon that can clearly describe the pros and cons of each repair method. The ones that can only talk about “here’s what I do” are really just automatons.
Sorry for the diatribe. It really is a dangerous and difficult process. Good luck.
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Here is the last notice about the updated guidelines. From the EHS newsletter of October 2022. The prior newsletters seemed to be about every 3-4 months. They are way behind.
https://www.europeanherniasociety.eu/ehsnewsletter18
And here is what appears to be the official EHS publication, according to the newsletter. I would expect the updates to be published here, possibly. The scrotal inguinal hernia guidelines are.
https://www.frontierspartnerships.org/journals/journal-of-abdominal-wall-surgery
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I just realized that even the EHS has a piece of mesh as part of their logo. Basically they are flying a mesh flag. It is really very strange. It’s almost like worship.
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Here is a short reminder/summary of where my cynicism and skepticism come from. Dr. Towfigh provided the LinkedIn link above, recopied below, that showed that HerniaSurge is an extension of the efforts of the European Hernia Society (EHS). Supposedly they were almost finished with the updates to the 2018 Hernia Repair Guidelines, which were originally supposed to be updated every two years. So far there are no updates, only a new subset of Guidelines for scrotal inguinal hernias.
We are now three months past the promised date. There is no sign that some significant event has occurred that would cause a delay. What is going on? I see now that they only promised “recommendations”, with a publication of some sort. Where is it? Who decides on whether or not to update the Guidelines with the recommendations? Even if there is no change there should be a communication about the results.
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Hello watchful. One of your paragraphs caught my eye. I think that you have over-simplified, maybe kind of extrapolated from how easy it looks to implant the mesh. The thought that the peritoneum is a weakly attached membrane that can be easily peeled from the fascia, to allow a piece of innocuous woven plastic mesh to be placed between it and the fascia.
I am at five years plus since mesh removal and the area that has had the peritoneum peeled off of the mesh, repositioned, and sewed back together is not really close to the way it was before surgery, although some fo my past posts seem hopeful. It is still stiff and gets sore after things like extended walks. It is much better than with the mesh but the damage that was done is still very obvious, even today. I still feel like somebody who suffered a severe accident eight years ago (a mesh-based hernia repair) and is still recovering. My broken collar bone and damaged ankles and knee all seemed very significant when they happened but they have recovered to a much higher degree than the ravaged mesh area.
“One last thing on this is that most tissue repairs (including Shouldice) aren’t really reversible. The anatomy is changed, and you can’t go back to the original if you have problems. With mesh, you can have the mesh removed. This can be a difficult and complex surgery, but it’s at least possible to get pretty close to a “normal” groin since the anatomy isn’t modified.”
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I think that mesh is over-used and I think that the reason is corporate influence. Money over medicine. My posts are very clear on this. My experience working for large corporations probably gives me more insight in to the details of how the business world works, although the news media is full of stories of corporate influence affecting the welfare of the people that they are supposed to be serving. Guns, tobacco, self-driving cars, opioids, asbestos-containing talc, herbicides (Roundup), etc. Hernia repair mesh is part of the club now, there are large class action lawsuits in progress at this moment.
Dr. Towfigh has also suggested that mesh might be over-used in women. I have not kept up with her efforts but I suspect and have suggested that they will have little effect. Once somebody shows that mesh is over-used in one area it will give impetus to reducing its use on other areas. That will be profit lost.
There is a place for mesh in the world of hernia repair. But its over-use is a violation of the Hippocratic oath, because of the harm that is caused in trying to fix the problems that it causes. Although I think that many surgeons are ignorant of what they are doing, or don’t feel responsible, because they have no ready and reasonable alternative. Because they have been trained in the medical institutions that are being supported financially by the corporations that profit from the over-use of mesh, then joining organizations that have established mesh repair standards. They have been captured and are being used.
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Here is an interesting new paper about the effect of smoking on short-term outcomes after inguinal hernia surgery. They use ACHQC data for the study. Almost 20,000 subjects. There must be some correlations with mesh type and/or surgery method.
A focus on smoking is a start. Hopefully somebody will be brave enough some day to call out the bad mesh products. I wonder if the lawyers have thought about discovery as a way to get access to the data. Or maybe the mesh makers also, to show how their product is better than the competition’s. Assuming that mesh information is part of the information acquired. It’s easy to imagine though that all of the meshes are lumped together in to one category – mesh.
https://link.springer.com/article/10.1007/s00464-023-10055-4
Published: 12 April 2023
The effect of smoking status on inguinal hernia repair outcomes: An ACHQC analysis
Celeste G. Yergin, Delaney D. Ding, Sharon Phillips, Thomas E. Read & Mazen R. Al-Mansour
Surgical Endoscopy (2023)“Background
Smoking has been shown to negatively affect surgical outcomes, so smoking cessation prior to elective operations is often recommended. …Results
19,866 inguinal hernia repairs were included (current smokers?=?2239, former smokers?=?4064 and never smokers?=?13,563). …Conclusions
Smoking status is not associated with short-term adverse outcomes following inguinal hernia repair. Mandating smoking cessation does not appear necessary to prevent short-term adverse outcomes.” -
Here are a couple of things from Dr. Towfigh about imaging, linked below. You are in a risky spot, with your assumption that you might have a hernia. The edge of a slippery slope leading to hernia surgery. Inguinal hernia repair is not the same as umbilical repair. Don’t assume that good results for one means that you’ll have good results for the other.
Have you taken a long rest period since you first had the pain or have you continued doing your normal activities? When I had my direct hernia I could rest and recover to a pain-free condition, even to the level where I could go for training runs and do light workouts. I chose surgery in an attempt to get back to my high level of physical activity, playing soccer several times per week. I think that I would have been better off retiring soccer and just living healthily at a lower level of physical activity. Surgery is very risky.
Good luck. Be careful.
https://jamanetwork.com/journals/jamasurgery/fullarticle/1893806
Role of Imaging in the Diagnosis of Occult Hernias
Joseph Miller, MD, MS; Janice Cho, BA; Meina Joseph Michael, BS; Rola Saouaf, MD; Shirin Towfigh, MD
Author Affiliations Article Information
JAMA Surg. 2014;149(10):1077-1080. doi:10.1001/jamasurg.2014.484 -
SAGES has an interesting article about it.
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One more. Corporations really don’t care about anything except shareholder value. Their ethos is that anything that makes a profit is good and that if harm is done they will just pay the lawsuit costs.
https://www.reuters.com/investigates/special-report/johnsonandjohnson-cancer/
“Facing thousands of lawsuits alleging that its talc caused cancer, J&J insists on the safety and purity of its iconic product. But internal documents examined by Reuters show that the company’s powder was sometimes tainted with carcinogenic asbestos and that J&J kept that information from regulators and the public.”
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Here is an interesting recent article about the topic.
Talc, Asbestos, and Epidemiology: Corporate Influence and Scientific Incognizance
Tran, Triet H.a; Steffen, Joan E.a; Clancy, Kate M.a,b; Bird, Tessa,c; Egilman, David S.a,d
Epidemiology 30(6):p 783-788, November 2019. | DOI: 10.1097/EDE.0000000000001091
Here is the first paragraph –
“In the early 1970s, findings of asbestos in talc, and findings of talc colocated in ovarian tumor tissue, led to public controversy.1–5 For over 40 years, talc mining and manufacturing companies attempted to obfuscate the importance of these findings by keeping exposure information behind a corporate veil and otherwise influencing medical information concerning the health effects and asbestos content of talc used in cosmetics.6–9 Control over information is a recognized method by which industries maintain sales and avoid regulation and tort liability.10–16 There are many examples when companies have concealed the presence of hazardous components in products; failed to publish study results indicating that their products presented health risks; and manipulated studies to publish false results that encouraged product use or hid side effects.10–16 For example, in 1971, Henderson et al. found talc in an ovarian cancer tissue sample and raised concerns about the relation between talc use and ovarian cancer.17 Johnson & Johnson hired Arthur Langer, a mineralogist at Mount Sinai, to reexamine the tissue.9,17 Langer confirmed the presence of talc, and also found asbestos in ovarian cancer tissue. Evidence shows that Johnson & Johnson successfully dissuaded him from publishing these findings.9”
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A recent example of the power of the lawsuit. Johnson & Johnson, owners of Ethicon, have stopped selling a product that was making them money because the lawsuits were so strong that it would be too expensive to keep the product. The story of asbestos in talc is long and complex, but it has been in the news for decades.
They’ve stopped selling the product and they’re trying to minimize their losses with a settlement agreement.
https://finance.yahoo.com/news/j-j-proposes-paying-8-220350173.html
“The lawsuits filed against J&J had alleged its talcum powder caused users to develop ovarian cancer, through use for feminine hygiene, or mesothelioma, a cancer that strikes the lungs and other organs.
The claims contributed to drop in J&J’s sales of baby powder, prompting the company to stop selling its talc-based products in 2020. Last year, J&J announced plans to cease sales of the product worldwide.”
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The notes seem to refer to a preloaded Medtronic fixation device. 30 5mm absorbable tacks are preloaded in the instrument, ready for use. The tacks are absorbable so would not show up on any imaging after a certain period of time. The surgeon could have used anything from one to 30 of them. I pasted a link below that shows many details.
Many surgeons cut and paste their post-surgery notes together, from what I’ve seen. My implantation surgeon reported 5 titanium tacks in his notes. When I talked to him afterward about how the mesh didn’t need fixation so fixation shouldn’t be the cause of my pain he rambled about using some tacks because the hernia was bigger than he thought it would be. No titanium tacks showed up in the MRI that I had done as part of the path to mesh removal.
When the mesh was removed Dr. Billing did not find any tacks.Here is a pdf file from Medtronic about the tacking device and its contents.
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The authors categorized the results. Hernia surgery would most likely be under general surgery or undifferentiated surgery. It’s not clear why you would think that expectations from hernia surgery would be different than expectations from any other surgery. They all start from the same place – patient has medical problem, sees doctor, gets referred to surgeon, expects surgery to heal them and make them whole again. Except, of course, for amputation surgery, which is actually called out in the paper.
A scoping study is basically a broad review of how widespread a certain area of interest is being studied.
This didn’t copy over very well but you can see that they created categories and assigned each individual study to a category.
Table 1. Surgical Focus of Included Literature: Number of Studies
Orthopedic surgery General surgery Obstetric surgery Cardiac surgery Neuro-surgery Urological surgery Mixed or not defined surgery Spine surgery Reconstructive surgery
6 6 3 3 1 1 8 2 1 -
Here is a short video from General Surgery News.
https://www.generalsurgerynews.com/Video/Article/05-22/Hernias-in-Women/66994
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You might find something on her Youtube channel.
https://www.youtube.com/@herniadoc
And here are some of her professional publications. Some of them are the full paper, free to view. “Occult” or “hidden” seem to be the words to use for searching. Many of them are “pay-per-view” unfortunately.
https://scholar.google.com/scholar?hl=en&as_sdt=0%2C48&q=towfigh+occult&btnG=
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Watchful and NFG12, what do you think about the math that resulted in this conclusion? When discussing complex subjects it’s very important that the “facts” are real, and relevant to the discussion. This math seems off unless the person used weight instead of volume for the comparison. Stainless steel sutures compared to polypropylene mesh. 8 gm/cm^3 versus 0.9 gm/cm^3. About a 9 to 1 weight ratio.
Even then, it seems off. “Facts” can be twisted.
“A friend did some math and said with all the suturing—you get as much plastic with shouldice as you do with mesh.”
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The name HerniaSurge has made a new appearance. It’s been modified again, it’s now HerniaSurge Collaboration. Dr. Maarten Simons is the representative. At the end of the article the full HerniaSurge Collaboration list of members is shown. Still odd in how mysterious the group is. Who pays for their efforts?
Apparently the Collaboration has identified a specific sub-category of hernia and determined that it needs specific guidelines. The study follows the same general format as the original guidelines. It’s interesting to see how almost all of the levels of evidence are low and the recommendations are weak (by their definitions). In other words, of little real value except to show that nobody knows what’s best.
The Collaboration seems to be generally defining the world in terms of low resource and high resource. In other words, poor and rich.
The original 2018 Guidelines remain unchanged, despite promises of updates. But it is still the first reference in this paper.
https://linktr.ee/EHSguidelines
https://www.frontierspartnerships.org/articles/10.3389/jaws.2023.11195/full
ORIGINAL RESEARCH
J. Abdom. Wall Surg., 27 March 2023
https://doi.org/10.3389/jaws.2023.11195
Systematic Review and Guidelines for Management of Scrotal Inguinal Hernias
Hanh Minh Tran1*, Ian MacQueen, David Chen, Maarten Simons on behalf of HerniaSurge Collaboration“…In high resource settings, an open anterior repair is the default operation. The Lichtenstein operation is still considered the gold standard for anterior open repair (1). The endoscopic hernia repair methods have been shown to be safe and effective with acceptable low complication rates in specialized centers (5, 15, 17, 20). There is a high conversion rate when starting with an endo-laparoscopic technique, especially TEP. Low resource countries may not be able to afford the mesh and/or consider their operative settings to be sufficient for sterile standards to prevent mesh infection and its sequelae. Therefore, suture repair still remains a standard option in these settings. Teaching and training to master the Shouldice technique remains an important cornerstone for surgical management of inguinal hernias in low resource settings. …
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.”