Good intentions
Forum Replies Created
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Thanks for the links and the quotes Watchful. I don’t really know what to make of them. Glib comments are often the ones that last.
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Progrip has an absorbable/degradable polymer component that might explain your autoimmune issues. It takes a while for the polymer to fully degrade, I posted a link below.
Spend some time and read the posts on the forum. As a person who was very active you probably understnad what your body is telling you. Mesh removal is mainstream now, a standard area of expertise that many surgeons are learning and touting. Robotic surgery methods are being developed to make mesh removal easier and safer. It’s just the new reality.
If you do decide to have the mesh removed be very careful in who you choose to do it. Two names that seem to get good results are Dr. Belyansky and Dr. Peter Billing.
One thing that I found when I was trying to live with mesh was that sometimes being more active actually made the pain better. I attributed it to getting fluids to move through the new poorly vascularized tissue around the mesh. If you’ve been holding back thinking that rest is best you might try to get some workouts or runs in and see what happens.
Good luck and sorry that that you’ve been caught up in the mesh mess.
Here is the link to the Progrip product, which is owned by Medtronic now. Polylactic acid (PLA) is the material that the little knobs are made from. It is unclear how long it takes for all of the PLA to disappear. 40% of the mesh is PLA.
Here is a link that actually mentions PLA.
“ProGrip™ Technology in Abdominal Hernia Surgery
Provides immediate tension-free fixation on the entire surface of the mesh – and offers surgical efficiencies and patient benefits.2,3
It does this by combining monofilament polyester with a resorbable polylactic acid (PLA) microgrip technology. So surgeons get immediate fixation that is strong, durable and comfortable.3,4,5” -
I wasn’t aware of that. Do you have a reference? I have not seen any stories about his opinions on cutting nerves.
His work on mesh-caused pain seems logical. And it leads to ideas for possible changes in the design of mesh. But, the mesh makers control the product design even though they don’t understand the medical side, and the surgeons control the medical side but don’t understand mesh design. Besides the fact that creating a new pattern of knit knots is cheap and easy to get through the 510(k) process. Doing nothing or very little is the most profitable path at this point in time.
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I hope you don’t mind ajm22 if I add a couple more articles about nerves to your Topic.
Here is a recent one that addresses specific nerves. And also an older one from Dr. Bendavid that addresses the general nerve environment. It’s interesting to contrast the two perspectives. Today’s hernia repair surgeons are trying to find a way to not create chronic pain by avoiding specific nerves, assuming that it’s the nerves that they can see that cause the pain. But Dr. Bendavid’s work proposes that the generally unhealthy environment of the tissue in vicinity of the mesh, in to which new nerves grow, can cause pain.
My chronic pain was both specific, a sharp pain where the original direct hernia was, and non-specific, a general feeling of discomfort and/or pain over the whole of the area in contact with mesh. Most surgeons have problems understanding the second scenario. They will talk about nerves regenerating but don’t seem to really think deeply about what that could mean.
https://link.springer.com/article/10.1007/s10029-019-02070-z
Dr. Bendavid’s work, with co-authors. Dr. Koch is one of them. In HTML and pdf format.
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I just posted a video from SAGES 2021 that had at least two plug removal videos contained within it. The next “bellwether” trial for hernia mesh is apparently scheduled to begin in May. It is about the Perfix plug. The process takes so long. After this trial another trial is scheduled for later in the year.
Still fascinated by the huge dilemma the mesh producers have, considering the scale of the problem. The products are still on the market, maybe because removing them from the market would be admitting that they are flawed. Plugs have been around for decades. There are thousands of potential cases waiting in the future. Johnson and Johnson tried to encapsulate their liability for asbestos/talc by spinning off that part of the business so it could go bankrupt but the courts would not allow it. How do they get out of this mess? When do they start removing bad products and trying to develop products that are actually better?
Davol was part of Bard, which is now part of Becton Dickinson, known as BD now in the medical field.
“February 9, 2023 Update
In an Order issued earlier this week, the Bard MDL judge set forth a detailed schedule for the third hernia mesh bellwether test trial (Stinson v. C.R. Bard et al.). Pretrial conferences will be held on May 2nd and 3rd and the trial itself will begin on May 15, 2023. Final witness lists are due from both sides this month. The judge also requires lawyers for all parties to submit proposed dates for a 4th bellwether trial later in the year.” -
Dr. David Chen had some interesting comments about nerves in his presentation about open Lichtenstein. At 7:20 in the video linked below.
It’s interesting that he feels the need to place so much emphasis on protecting the nerves and talks about the wrong way to do it. Suggesting that many surgeons are/were doing it the wrong way. Also good to hear that Dr. Belyansky is open-minded and confident enough to realize that his methods can be improved.
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Coming up on a month and half past the end of 2022 and still no updated hernia repair guidelines. All of the HerniaSurge links are still dead.
The last update was for abdominal wall incisions, in August of 2022.
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Numbness after surgery is not uncommon. It’s called hypoesthesia. Some surgeons cut nerves as a part of their procedure, to try to prevent future pain. And, sometimes nerves are damaged during the procedure. It can happen during laparoscopy (aka “keyhole surgery”). They do repair themselves though and grow back if cut.
You should get your medical records. They might have notes about what happened during your surgery. Talking to your surgeon would be a good idea, although you should be going in soon for the post-surgery follow-up. Good luck.
If you have time maybe you could describe your hernia and the repair surgery. Was it robotic? Do you know the type of mesh? Who performed the procedure?
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I remember Dr. Brown mentioning that silk sutures do degrade or dissolve over time. I found an interesting research paper about suture materials from 1970, linked below. It also talks about polypropylene and has an interesting aside about the quality of the polypropylene material changing, affecting the way the suture responded in the body.
Very interesting also to see a time when doctors did real research. A two+ year study, with microscopy and analysis. Real critical thinking instead of the common “meta-study” that is done today, where old databases of dubious quality are collected and parsed through using search terms that the researcher thinks will define the area of study, or support the researcher’s premise.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1396901/
Here’s a direct link to the pdf file.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1396901/pdf/annsurg00414-0086.pdf
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Dr. Ponsky is a very interesting surgeon. His specialty is hernia repair in children, but in the video that William posted you can see that they are exploring non-mesh repair in adults. He mentions it at about 11:48, a study in Norway. His father is a well-known mesh repair surgeon at the Cleveland Clinic, so the contrast is intriguing. He must know quite a bit about mesh repairs.
The video is from four years ago. I can’t find a publication about the results of the study in Norway that included adults. I had some correspondence with him and he seems to have lost his passion for promoting non-mesh repairs. It was a short email exchange and I hope that I am wrong but I got the impression of another surgeon beaten down by the mesh industry. He also has a video with Dr. Towfigh where he talks about mesh repair as something that he leaves to the “experts”. Overall, disappointing, but there’s always hope.
https://scholar.google.com/citations?hl=en&user=biO4e40AAAAJ&view_op=list_works&sortby=pubdate
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Here is the next. For some reason the authors decided to consider pelvic prolapse mesh, aka transvaginal mesh, pain along with inguinal hernia repair mesh. An example of how generalized the knowledge of mesh is for so many surgeons.
This one looks at results after revision surgery for pain. Another after-the-fact study with no recommendations for prevention. Business is good, many return customers.
The Conclusion only mentions inguinal hernia repair but seems very illogical. 70 months is almost six years. Are they suggesting that a suffering patient wait six years before having surgery? The fact popped out from the statistical analysis apparently. Does not seem of much use. They do use it to suggest that pain relief is still possible after many years. That is the logical conclusion.
https://link.springer.com/article/10.1007/s10029-023-02748-5
Prediction of successful revision surgery for mesh-related complaints after inguinal hernia and pelvic organ prolapse repair
K. L. C. Van Rest, M. J. C. A. M. Gielen, L. M. Warmerdam, C. R. Kowalik, J. P. W. R. Roovers & W. A. R. Zwaans
Hernia (2023“Purpose
With this retrospective case series, we aim to identify predictors for reduction of pain after mesh revision surgery in patients operated for inguinal hernia or pelvic organ prolapse with a polypropylene implant. Identifying these predictors may aid surgeons to counsel patients and select appropriate candidates for mesh revision surgery.…
Conclusion
A longer duration of at least 70 months between implantation of inguinal mesh and revision surgery seems to give a higher chance on improvement of pain. Caregivers should not avoid surgery based on a longer duration of symptoms when an association between symptoms and the location of the mesh is found.” -
Here are a couple more articles. Looks like some will be pay-per-view and some will be open access.
So far, nothing very useful seems to be coming from these articles. It might be why Dr. Campanelli was so resigned and dismissive in his last editorial. There are no paths to improvement being created, and the papers just seem to accentuate the chaos. But each one identifies CPIP as a real problem.
This one says that TEP, Dr. Towfigh’s favored method, has an 11.9% CPIP rate. Overall, the paper just compares four ways to use mesh. The results are from 2011 to 2021, from a French hernia registry, the French Hernia Registry.
https://link.springer.com/article/10.1007/s10029-023-02737-8
“Results
After PS matching analysis, Lichtenstein group showed disadvantage over TIPP, TAPP and TEP groups with significantly more CPIP at one year (15.2% vs 9.6%, p?<?0.0001; 15.9% vs. 10.0%, p?<?0.0001 and 16.1% vs. 12.4%, p?=?0.002, respectively). The 1-year CPIP rates were similar comparing TIPP versus TAPP and TEP groups (9.3% vs 10.5%, p?=?0.19 and 9.8% vs 11.8%, p?=?0.05, respectively). There was significantly less CPIP rate after TAPP versus TEP repair (1.00% vs 11.9%, p?=?0.02).” -
If you put ( site:herniatalk.com dog brown ) in a Google search box you’ll get a link to Dog’s Dr. Brown open surgery comments and others who saw Dr. Brown.
Nine days seems like far enough along to where you could sit and be comfortable.
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Here is the latest article from the new Special Issue. It is about “autoimmunity”, a word that describes when the body develops an autoimmune problem. The conclusion is that mesh does not appear to cause an autoimmune condition. The chronic pain and discomfort results solely from the body’s foreign body reaction to the mesh. It is a physical problem tied to the mesh. Which fits with the result that the problems disappear when the mesh is removed.
It is an interesting article that clarifies the problem, but, again, does not offer a solution or a way to prevent it. So far, the releases for the Special Issue only seem to confirm the problem.
https://link.springer.com/article/10.1007/s10029-023-02749-4
Review
Open Access
Published: 04 February 2023
Autoimmunity and hernia mesh: fact or fiction?
B. Jisova, J. Wolesky, Z. Strizova, A. de Beaux & B. East
Hernia (2023)The authors confirm the ~15% chronic pain rate –
“The use of synthetic mesh in hernia repair is well-established [1, 2]. Indeed, hernia guidelines recommend mesh in most hernias to minimise hernia recurrence. Local complications are well described clinically yet they are not quite so well understood from the histological perspective [10]. For example, it is known that approximately 10–20% of patients after inguinal hernia repair suffer from chronic pain to some degree [5, 35]. However, causes of this pain are variable and most likely linked to nerve injury rather than to mesh-related autoimmunity. To add to this confusion, many authors incorrectly mix autoimmunity and chronic foreign body reaction.
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Conclusion
Currently, there is little evidence that the use of polypropylene mesh can lead to autoimmunity. A large number of potential triggers of autoimmunity along with the genetic predisposition to autoimmune disease and the commonality of hernia, make a cause and effect difficult to unravel at present. Biomaterials cause foreign body reactions, but a chronic foreign body reaction does not indicate autoimmunity, a common misunderstanding in the literature.” -
Here is a link showing T-Line mesh. It’s funny how the product is designed to fix the problem of tension in a “tension-free” repair material. Mesh. The attempts just go on and on. 510(k).
Sorry ajm22, I’m not trying to divert away from your subject. Just filling out my comment about suture pullout and tissue strength. Good luck.
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I don’t think that being back to 100% tissue strength is necessary to get back to normal living. I am not arguing for or against anything just showing some different perspectives.
You can find quite a bit in the mesh repair literature about “burst strength”, where the surgeon/scientist is considering the mesh as prosthetic tissue. A patch over the hernia defect. In theory, the defect area is “tension-free”. But the edges of the mesh do feel tension. Otherwise there would be no need to worry about burst strength. You can also find literature about “small bites” for closing wounds, to avoid suture pullout. That was a hot topic a couple of years ago. There is even a new type of suture material called T-Line that is being promoted for its width, apparently for the benefit of avoiding suture pullout. There is discussion about using a running suture (a single filament passed through the edges of the wound to close it), as opposed to a series of separate sutures. But, like many of the many things to consider in hernia repair the final decision is left up to whatever the surgeon feels comfortable doing.
As far as healing after a suture repair, here is a good review of the healing process. It covers a wide area of healing responses, but it is well-written and understandable. It has an interesting comment about the size of the gap between the two surfaces that are expected to knit together. It made me wonder about how the two surfaces of the layers in a Shouldice procedure knit together. What is the impetus for the body to realize that the pristine surfaces are damaged? Only the edges have been cut. What parts actually form new collagen?
Anyway, it’s easy to get lost in the fine elements of what actually happens during healing of a pure tissue repair. But those fine elements might help explain why surgeons using what seems to be the same technique get different results.
The article doesn’t use the word years, but it does use months.
https://www.ncbi.nlm.nih.gov/books/NBK3938/
“Chapter 1
Overview of Wound Healing in Different Tissue Types
John D. Stroncek and W. Monty Reichert.””’
“1.4.1. Non-CNS Tissue
The first stage of tissue repair is stabilization of the discontinuity created by the injury. Traditionally, there are two broad classifications of healing. Tissue that has little to no gap separating the wound boundaries will undergo “primary healing” from the apposed edges of the tissue. Tissue that is unstable with a large gap or discontinuity injury will undergo “secondary healing,” where excess ECM is produced to secure and fill the lesion. The ECM of secondary healing, which subsequently becomes vascularized, is referred to as granulation tissue—a term arising from its appearance. In general, the amount of granulation tissue formed is proportional to the eventual level of scarring.” -
You might consider the strength of the new tissue/collagen that is holding the layers together. It takes months or years for the collagen to fully convert to the strongest form. Permanent sutures could be considered as a backup or insurance against accidental extreme exertions or increases in abdominal pressure.
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I created a new Topic about the Special Issue itself. As new papers become available I will post the links there. I included a link back to this Topic to keep the chain of information intact.
https://herniatalk.com/forums/topic/hernia-journal-special-issue-on-chronic-pain/#post-33726
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Here is a link to Hernia’s web site. They list the latest articles on the page. They also show the latest Journal that has been released. January 2023 has not been released yet.
https://www.springer.com/journal/10029
Here is a link to a Topic about the Hernia Editor’s original introduction to the project.
Acknowledgement that chronic pain is real by the Editor-in-Chief of Hernia
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The purpose of the study seemed reasonable but it’s not clear why they went to social media to gather results. As Dr. Towfigh implied, people who don’t have problems rarely talk about their surgeries on social media. Their “aim” really should have said “perspectives of patients around their hernia repair problems”.
“The aim of this study was to explore the perspectives of patients around their hernia and its management, to aid future planning of hernia services to maximise patient experience, and good outcomes for the patient.”
I’ve often thought that a good study for helping to define the hernia repair chronic pain problem would be to compare hernia surgery to other similar surgeries. Classify the surgery by type. For example, survey patients who have had laparoscopic surgery for gall bladder removal or appendectomy or prostate removal in addition to hernia repair. If all of the groups have similar chronic pain problems that might shed some light on something besides mesh. If the other groups have a very low level of problems but only lap mesh patients have the 10 – 15% chronic pain problem, that’s pretty good evidence that mesh might be involved.
It is good to see other groups exploring the problem though. Thanks for posting that article.