[Good intentions]

Recent research on open versus laparoscopic umbilical hernia repair with mesh. Might help you in your search for a solution.

https://youtu.be/sxzEdevWckE

[Good intentions]

Here is an interesting article about the financial aspects of the use of robotics. It raises the influence of other large institutions, besides the technology companies – the medical institutions that the surgeons work with, and the insurance companies (related to other recent posts). It’s a hot topic.

https://www.sciencedirect.com/science/article/pii/S1878788611000300

Financial aspects, or how to use a robot assistance without losing money. Perspectives from private practice
Aspects financiers ou comment utiliser le robot et maintenir un équilibre financier ? Point de vue libéral
P. Monod

[Good intentions]

And it is linked directly to the International Hernia Symposium, but not directly on the main page. Very similar to “dark money” in politics. Click, click, click… how did I end up on a mesh supplier’s web page?

The surface changes but underneath things are the same.

[Good intentions]

Thanks for the reply Dr. Towfigh. My comment about returning to the pre-mesh state by removing mesh was not about the benefits of mesh removal. It was about the irreversible damage of mesh implantation. Most of my posts are about why things are the way they are now, corporate influence, etc., and about preventing or avoiding the problems rather than believing that more surgeries or “pain management” is a reasonable response to problems.

This might feel offensive but I think that you are so deep in to the use of mesh for hernia repair, and modern surgical technology, that your natural inclination in your replies is to defend the status quo. Most of your replies seem to do that.

My original post was just restating, almost verbatim, what the presenter shows in his video, and adding a comment about what he did not state but which seems clear. Longer procedure time (under anesthesia), and higher equipment costs. The actual value of robotics technology is a hot topic today, there are many publications about it.

I did not mention Intuitive Surgical in my post, or you specifically, except as a co-author of the work presented in the video.

[Good intentions]

It looks like the word “Progrip” is being used to describe any mesh that has the polylactic acid (PLA) absorbable component. That is approximately 40% of the weight of the material. Apparently, Progrip is applied to both polyester and polypropylene meshes.

The word “Parietex” appears to be a trademark that was originally used for polyester meshes. But now appears to be used for other materials also.

There used to be more information readily available through the internet but Medtronic seems to have removed much of it and now asks people to contact them for information. It wouldn’t be a surprise if this is due to the lawsuits. If you search Progrip and/or Parietex on the internet a bunch of law firm results show up along with Medtronic web sites. There is some poor information on those sites about the difference between polyester and polypropylene.

Sorry, that probably doesn’t help much. The basic materials are essentially the same, of those three. The form is different, and I think that one or two of them might be polypropylene.

I don’t think that you will be able to find any studies that will clearly tell you which of these materials has less risk for chronic pain. Good luck.

https://www.medtronic.com/covidien/en-us/products/hernia-repair/mesh-products.html

https://www.medtronic.com/covidien/en-us/products/hernia-repair/progrip-laparoscopic-self-fixating-mesh.html

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Here is a symposium, a virtual meeting, supposedly supported by “societies” (bottom of the main page). But if you click the Surgical Education link under Courses you might get a different impression. They are hidden but still present. How can they be directly linked to the symposium through the main web page?

“Mastering the art of Hernia Surgery”

https://www.herniau.com/events/virtual-ihs-2023/

https://www.bd.com/en-us/resource-and-education/surgical-education

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If you’ve ever seen the initial bills, the first set, for a procedure from a provider to an insurer you’ll realize that the whole process is very complex and bureaucratic. Mine were sent to me for some reason that I didn’t understand and I watched them go from 10’s (multiple 10’s, shockingly high) of thousands of dollars down to the thousands after the process completed. The first bills come through and then they are negotiated in to a form that fits the process.

As far as the medical-industrial-insurance complex don’t forget that the insurers have codes for each procedure that they will readily reimburse. Procedures that do not have a code have to be explained. The surgeon that implanted my mesh had to go before a board, of surgeon-peers if I recall correctly, to explain what he was proposing when I had mesh problems. I had forgotten about that. Actually I can’t remember clearly who exactly had to go before the board it might have been the one that removed the mesh, Dr. Billing. Often I feel like I have PSTD from that time in my life. I could probably find it in my notes but it’s probably not relevant. The approval boards do exist.

My basic point is that the high volume nature of the industry leads to it becoming very bureaucratized. Once bureaucracy takes hold then results matter much less. The process becomes the goal, not the results.

[Good intentions]

Attacking me personally and posting in the Topics I create is not helping you “offer hope to others”.

If your argument is strong you won’t need to attack the character of other people on the forum. What you’re doing has been well-known and described for centuries. It is the sign of a weak or losing argument or lack of knowledge about the subject being discussed.

It’s called “ad hominem”.

https://en.wikipedia.org/wiki/Ad_hominem

https://www.google.com/search?q=ad+hominem

[Good intentions]

You missed the point of my post Chuck. It’s about the influence of large corporations and the unwillingness, maybe even fear, of today’s surgeon representatives to speak ill of corporate influence.

The rest of the world does not revolve around you Chuck, even though you are in the center of your own small universe. I’m sure that you have heard that before. Try to be objective and let other people express their opinions. It will actually make your opinions look stronger. Your constant efforts to undermine people that don’t share your views, or didn’t “help” you when you demanded it (why would any rational person want to give somebody like you have been on this forum their phone number. That would be insane), clearly shows your lack of objectivity. Everything is about Chuck. Ironically, making your views less trustworthy. The more you try to shut other people down, the worse your opinions look.

Best to stay silent or just express a different, rational, view, a counterpoint, in a separate thread as you have been trying to do. Since you’ve called me out directly, again, I feel compelled to point out your self-centered nature. It’s a vicious cycle that doesn’t really help anyone. I assume that you will, of course, create another venting session after I post this. Hopefully not though. Good luck.

[Good intentions]

Here is a new article with Dr. Poulose as co-author. I have to assume that the other authors are the ones recognizing chronic pain as a major issue.

There seems to be some slight avoidance of an obvious conclusion – if nerve management during surgery is not a cause of pain, then what else could it be? Could it be caused by the mesh itself?

https://www.sciencedirect.com/science/article/abs/pii/S002248042200734X

Are Nerves Left In Situ Associated With Less Chronic Pain Than Manipulation During Inguinal Hernia Repair?
Emily George MD, Molly A. Olson MS, Benjamin K. Poulose MD, MPH, FACS

“Conclusions
Although guidelines emphasize three nerve preservation, the management strategies evaluated were not associated with statistically significant differences in pain 6 mo after operation. These findings suggest that nerve manipulation may not contribute as a significant role in chronic groin pain after open inguinal hernia repair.

…

Introduction
Chronic pain is defined as pain that persists for more than 3 to 6 mo past the appropriate healing time for an injury.1 Pain can be neuropathic, which is defined as nerve damage, either via entrapment or dissection, or nociceptive, which is a peripheral sensory stimulation from localized inflammation.2 The rates of chronic pain after inguinal repair can be as high as 18%-51%.2, 3, 4 Given that more than one million inguinal hernia repairs are done in the United States every year, this rate of postoperative chronic pain leaves much opportunity for improvement.5

…

Disclosure
Emily George, MD: Nothing to disclose.

Molly A Olson, MS: The ACHQC has contracted with Weill Cornell Medicine to provide biostatistical support for ACHQC projects. The work provided for this manuscript was performed under the umbrella of the Weill Cornell Medicine and ACHQC collaboration plan.

Benjamin K Poulose, MD, MPH, FACS: Receives salary support from Abdominal Core Health Quality Collaborative (ACHQC). Receives research grant funds from BD Interventional and Advanced Medical Solutions.”

[Good intentions]

Here is a fairly recent paper with Dr. Poulose as co-author. They seem to be living in a completely different world. Hard to understand. It’s published in Hernia, I assume that he reads the journal. Published April 2022, claiming that “little is known regarding the patient experience of mesh-related complications…”. Where have they been?

https://www.sciencedirect.com/science/article/abs/pii/S0039606021009429

Hernia
Patient perspectives on mesh-related complications after hernia repair
Madison A. Hooper MA, MEd, Savannah M. Renshaw MPA, MPH, Benjamin K. Poulose MD, MPH

“Background
To explore the thoughts, feelings, and experiences of patients with mesh-related complications after hernia repair. The rate of long-term mesh-related complications requiring procedural intervention after abdominal core surgery, including hernia repair, is unknown. Determining this rate is challenging due to its anticipated low chance of occuring and historically poor systematic long-term follow-up in patients’ hernia repair. The lived experience of these patients is also not well understood.

…

Conclusion
Despite the widespread use of mesh in abdominal wall operations, little is known regarding the patient experience of mesh-related complications. …”

[Good intentions]

Thank you for the explanation and the link Dr. Towfigh. I read through the article several times and have to say that it is depressing to read. It has all of the hallmarks of “gaslighting”. Making statements with no foundation in fact and ignoring major issues that have been well publicized for decades. Suggesting artificial intelligence and robotic surgery methods will solve the problems.

Downplaying the rate of problems and suggesting that a solution is on the way by reducing “overlap”. Pretending that pure tissue repairs are some sort of new development, “becoming more popular”. Ignoring the fact that the use of mesh has grown so quickly that it is has become the cause of the new problems.

Dr. Poulose seems to be a new “mouthpiece” for the mesh industry and the ACS is supporting his/their efforts with the article interview and the weird video. Contrast this article with the Editorials by Dr. Campanelli in Hernia and the complete special issue of Hernia dealing with chronic pain from hernia repair. The word pain was only used one time in the article in reference to post-operative pain and that was with the absurd proposal that “overlap” is a cause of pain.

I feel embarrassed for Dr. Poulose, and the community of surgeons as a whole. Stuck with these problems and with no apparent solution except giving up the bright lights of new technology. Dr. Poulose is either completely ignorant of what’s happening to patients in the field of hernia repair or he has convinced himself that the scientific studies published over the decades in the refereed journals are false. And he publishes himself, so he must know.

“Tackling the Problems of Mesh
…
But using mesh to repair hernias is not the permanent solution that it was intended to be. Mesh occasionally can get infected, and hernias can recur even if permanent mesh is used. In addition, mesh-related complications are increasing in frequency as more patients live longer. Mesh also can grow into the small intestine, colon, or bladder, Dr. Poulose explained.

“Although these complications occur at a low rate, if you have one, it is obviously a big deal to you as a patient,” Dr. Poulose said. “
…
Just as permanent mesh was once seen as a durable solution, it also was once thought that more mesh overlap is better than less. Recent research, however, does not necessarily support this assertion. The more overlap, the more likely there is to be postoperative pain for the patient, according to a study recently published in the Journal of the American College of Surgeons (JACS).4
…
Finally, “no mesh” repairs are becoming more popular, especially when it comes to inguinal hernia or umbilical hernia surgery. Some repairs—such as with the Shouldice technique—can be done successfully without mesh. Even when no-mesh repair presents a higher chance of recurrence, many patients are willing to make the tradeoff, Dr. Poulose said.”

[Good intentions]

I think that natural umbilical hernias can also be difficult to correct. But, also, as I understand things, they are best corrected early, before they get too large.

Read through the many posts on the forum and you’ll get a feel for what is happening in the hernia repair field. It is not as simple as the typical surgeon will make it sound. You want to get things right the first time. A typical surgeon will have 85-90 % of their patients not reporting problems after surgery. But if you get in to that 10-15 % of patients with problems it can cost you a lot. Time, money, and overall health.

Good luck. Don’t travel to another country just because you think that you’ll be saving a few dollars. The results will be with you for the rest of your life. Be careful.

[Good intentions]

It might help to know the details of the first surgery. It sounds like it was laparoscopic and you have developed an incisional/ventral hernia. Those can be, apparently, difficult to treat effectively. The recurrence rates are high. If it was done just ten years ago you might have a mesh implant, which can affect your surgery options. You’ll want to find a skilled surgeon to avoid repeat surgeries in the future. Diastasis and an incisional hernia puts you in a risky position.

How did you choose Columbia, Turkey and Brazil as potential destinations? That is an odd mix.

[Good intentions]

I just noticed that there was a recent publication in Hernia baout hiatal hernias.

https://link.springer.com/article/10.1007/s10029-023-02756-5

Published: 24 February 2023
The effect of surgical repair of hiatal hernia (HH) on pulmonary function: a systematic review and meta-analysis
Y. Wang, Y. Lv, Y. Liu & C. Xie
Hernia (2023)

“Introduction
…
The related symptoms include digestive symptoms, such as regurgitation, dysphagia, dyspepsia, or reflux, and extra respiratory symptoms, such as dyspnea, cough, hoarseness, or anemia [3]. For all symptomatic hiatal hernias, surgical repair is necessary. Therefore, perceiving symptoms and ascertaining what role the hernias play in those symptoms is of crucial importance. However, the majority of clinical manifestations appear to be nonspecific, making it hard to determine the true extent of hiatal hernia impact.”

[Good intentions]

It’s not clear what repair method the Centre prefers for inguinal hernias. It is worth researching their method and understanding the pros and cons. Many surgeons that used to do open repair have converted to laparoscopy and even robotic repair. There is a huge push to get the new technology in to the field.

The Centre’s web page is very dated. The last publication referred to is from 2009. The Inguinal Hernia page has a reference from 1972, not clear why.

https://www.hernia.org/types/inguinal/

[Good intentions]

Often in inguinal hernias, especially small ones, there is no intestine protruding. It is fat or omentum. The small intestine is not involved at all.

I would not assume anything. I have become cynical and skeptical so have a jaundiced view. Learn as much as you can and beware the “we’ll try” approach. Many surgeons have the view that if problems persist the patient is free to come back and they’ll make another attempt. In the hernia repair field today, new industries have grown from the problems that typical hernia repair causes. Pain clinics (which you seem to be familiar with) and mesh removal are two big ones. Each new industry has investments behind it and needs a steady flow of customers. It takes the pressure off of the surgeon to get it right the first time. If there are problems they will just pass you down the line to the next specialist.

There are definitely surgeons who are experts in multiple disciplines though, and will take a more holistic approach. You just have to find them.

[Good intentions]

Perineal hernias are a thing.

I just posted in someone else’s Topic about seeking out a different type of specialist for non-inguinal hernias. Inguinal hernias are high volume run-of-the-mill hernias. If you read up on inguinal hernia repair you won’t find anything about looking for perineal hernias while repairing an inguinal hernia.

https://my.clevelandclinic.org/health/diseases/23473-perineal-hernia

[Good intentions]

Just curious and I hope you don’t mind the discussion – but have you already been referred to a hernia specialist? When I was diagnosed with a hernia by my primary care physician he immediately offered to refer me to a surgeon. I took the referral and began researching. If I had followed the normal path and went directly to the referred surgeon, I probably would have had the surgery within a week or two. It would have been open surgery, probably Lichtenstein or a plug and patch.

[Good intentions]

By definition I think that he is being disingenuous when he talks about mesh repairs. An honest assessment of his pure tissue repairs would talk about the quality of life for the 40 years that he had with a pure tissue repair, not just the recurrence at the end. Ignoring the quality of life issue is willful ignorance of the main problem of mesh.

But, it would interfere with his goal of having his name tied to laparoscopic mesh implantation as one of the “inventors”. His legacy.

I sometimes wonder if his high level of activity, traveling the world spreading the 10 Golden Rules, is because it takes his mind off of the discomfort of the mesh implants. Who knows. Maybe he’ll become a convert someday.