Good intentions
Forum Replies Created
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I should add also say that the one of the major flaws in almost every discussion of hernia repair is the lumping of all materials and techniques in to simple categories. “Mesh”, “lap”, “open”, are about as vague and undefined as can be. Now “robotic” has been introduced, as somehow separate from laparoscopy, but it’s not separate. It is actually robotic laparoscopy. The tools are controlled remotely, and moved by machinery. One of the early problems in robotic lap is that the feedback to the controls in the surgeon’s hands was poor. In other words they couldn’t tell how hard they were pulling or pushing. So, somewhat ironically, the surgeon can see more clearly, and pause to think, but has less ability to manipulate what they are seeing.
Anyway, the situation is so varied and complex that it’s easy to understand why even the pros fall back on vague and undefined descriptions of what they do. Something that people should always be aware of.
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Watchful, could you provide some references or at least more commentary about your opinions below?
Not to insult you but I’ve noticed that you seem to be trending away from the logical and rigorous approach that led you to Shouldice. Your statements are getting vague and as you say below, “generalized”. “least bad”? What does that even mean?
Again, no offense intended. I just hate to see people slide down that path of falling for the marketing and advertising, or, in your case, doubting that the good research work they did was the right way to do things.
A couple of quotes from your posts above –
“However, if I knew mesh was the way to go in my case, I would seriously consider lap mesh instead of open. You and a couple others here had a bad experience with it, but it seems to have better results overall based on studies.”
“I think that objectively and generally speaking, it has been shown to be the least bad approach all things considered. “
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Here is another reason a surgeon might pay for the accreditation. Marketing services. Never overlook that the practice of medicine is also a business.
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12 x 20 is a large piece of mesh. Was it placed for an incisional hernia or an injury of some sort? That might be part of the reason surgeons don’t want to mess with it. There is probably no viable alternative for repair after they remove it.
Dr. Muschaweck and her colleagues are probably your best possibility. She is very active in making her services available around Europe. Good luck.
https://www.fortiusclinic.com/specialists/dr-ulrike-muschaweck
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The surgeon who implanted the mesh in me was part of one of those, almost identical. I was impressed and thought it meant something. Really though, I think, it’s just side-money. “Non-profit” just means that all money collected is spent on operating the business. That includes salaries of the employees of the non-profit.
It’s just a place to get a certificate that says you do things a certain way. There is nothing in the requirements about positive results though.
It is interesting though that they apparently have an “Outcomes Database”. That’s what I would want to see. Ask to see that if you talk to the surgeon.
https://www.surgicalreview.org/wp-content/uploads/2022/10/MS-Hernia-One-Pager-101322.pdf
“7. CONTINUOUS QUALITY ASSESSMENT
All applicant surgeon must collect outcomes data on all patients who undergo hernia surgery procedures in SRC’s Outcomes Database (or a similar qualifying database).”The surgeon pays, provides supporting data, and gets a certificate.
https://www.surgicalreview.org/medical-professionals/programs/
Click through the menus on the left to see what the business is about.
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An interesting Editorial in Hernia from Dr. Campanelli. I don’t think that he understands that the people that control the narrative, by controlling the money, end up controlling the consensus. It starts with education. The societies funded by the corporations run the schools that he appears to be talking about.
He should write an Editorial suggesting full transparency about where, exactly, professional societies get their funding, in order to allow people to trust the various societies’ motives. Many nonprofits have their accounting information available on their web sites. Free for all to see. There is nothing on, for example, the EHS web site except the Sponsors page, full of logos of the device makers. It is very hard to imagine that there is no connection. Mesh is the EHS logo.
https://link.springer.com/article/10.1007/s10029-023-02788-x
EDITOR’S CORNER
Published: 15 April 2023
Evidence, consensus and schools of hernia surgery
G. Campanelli
Hernia (2023)“…
And consensus gathering becomes even more commendable when it is supported by the schools of hernia repair and abdominal wall surgery that are run by the relevant national scientific societies. …” -
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.”