Good intentions
Forum Replies Created
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These lists of important factors to consider are a good example of how people should approach such an important event in their life.
I think that anybody trying to use somebody else’s list should be careful though. Thunder Rose is a woman, with requirements/needs/wants specific to that factor. And Mike M. had a specific demand that no women be involved in preparing him for surgery or being present during surgery.
Sorry Mike M. but you left that important disqualifier out of your list. Dr. Yunis might meet all of your requirements otherwise. I assume that might be why Shouldice is out also.
Good luck to all.
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Yes, he was doing pure tissue repairs, but I don’t know anatomy or the details of the different to be able to identify what he was doing.
I read several of his papers and abstracts of papers over the years. Also those of several other surgeons. It’s fascinating how they can write about doing thousands of repairs over many years, tracking the results, via interviewing past patients, and drawing conclusions for their communications. As opposed to today where some doctors publish conclusions after 31 patients and two years of time, and voila, a new product is on the market, ready for use everywhere.
It looks like Dr. Lichtenstein was trying to solve the problem of recurrences, mainly. He went through a polypropylene fiber “plug” phase also, similar to the Kugel repair, I believe, except that there was no onlay patch associated. I didn’t get the details, many of those old publications have to be paid for. The American Medical Association has to get paid to share the knowledge.
I found some early papers that suggest that Lichtenstein was convinced that there was a “better way”. This one is from 1976. Very ironic in that we have new “sacred principles” and a new failure to improve. History repeats.
https://www.sciencedirect.com/science/article/abs/pii/0002961076903810
From the abstract –
“Sacred principles guiding surgical repair of groin hernias have remained basically unaltered since their inception. This may explain the failure of results to improve significantly over the years. ”
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Here’s his Twitter page but you can only see a few posts before you have to sign up.
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Bumping this thread to the top. Not sure what Dai Greene is doing today, I’ll see what I can find.
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The two most interesting things to me are – One, that they would wait even though almost any surgeon you talk to about a hernia today will imply that if you wait you could end up in the emergency room or dead, due to incarceration of the hernia. So, if the results represent the views of the surgical community, then surgeons are giving advice to their patients that they would not follow themselves.
And two, that so many surgeons choose laparoscopic methods even though there is little data to support long-term results. They have been convinced, but for unknown reasons. I did just find one paper from 2019 in which patients were identified from the Danish Inguinal Hernia Database and asked to participate in a study. The authors conclude that 13% of people who have bilateral TAPP mesh placement suffer from chronic pain.
So, the information is out there, if the professionals want to find it. I wonder what the people in the Twitter survey would answer if they had read of these results beforehand.
It is a fascinating real-time story. Like living in a documentary.
“Decreased functional performance” = debilitating.
https://journals.sagepub.com/doi/10.1177/1457496919874483
Excerpt –
“Conclusion:
Bilateral transabdominal preperitoneal inguinal hernia repair for symptomatic inguinal hernias was related to a high incidence (13%) of chronic postoperative inguinal pain and decreased functional performance status.” -
I was able to find this old post after searching for it because of the recent posts about most surgeons choosing mesh. Apparently they do, after avoiding surgery completely.
I just can’t understand the logic of the thought process. The numbers about mesh implantation say that a pure tissue repair is the safest for long-term welfare. But, apparently, get mesh is what the professionals think. They will take that one in six chance of chronic pain. Of course, it’s all that they’ve been trained to know.
They will put their trust in the surgeon, but, as the survey shows, the majority of surgeons will choose mesh. It’s an odd circular argument, self-reinforcing. I wonder if there is some “taking one for the team” psychology going on.
https://twitter.com/Herniadoc/status/1114246402950012930
Fascinating audience polling by @DrMicki of laparoscopic general / hernia surgeons. Here are 3 questions:
Q1: how many of you would have your minimally symptomatic inguinal hernia repaired?
A: 56% choose watchful waiting. pic.twitter.com/oZ0RCpcknH— Dr. Shirin Towfigh (@Herniadoc) April 5, 2019
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I just came across a really fascinating comment from Dr. Guy Voeller about guidelines. Hard to figure out where he is coming from. He says that most guidelines are too long and too hard to read and nobody pays attention to them. Which kind of fits with his past comments implying that the chronic pain problem was just too big to deal with. He seems to be getting overwhelmed, in general.
Dr. Voeller is a big name in the hernia repair field. That’s why he is in many of these types of interviews. Hard to believe.
Excerpt (statements are made and the surgeon responds) –
“Guidelines for hernia repair are valuable.”
“Guy Voeller, MD: Disagree I am really tired of all these guidelines. Hernia, lap cholecystectomy, whatever—I hate them. They are too long and tiring to read, and are usually based on flimsy data. Laypeople (i.e., lawyers and hospitals) see them as “standard of care,” which they are not. They are a waste of time for the most part. Practicing surgeons never read them and it has become an ego thing for the many of the people who make up the guidelines. They serve no real purpose and need to be stopped, now! That’s how I really feel. Does that mean some of what is in guidelines is not useful? Not at all. I think some of the points in so-called “guidelines” could be more effectively communicated than what occurs with guidelines as they are presently done. It is like putting something on the OR wall for all to read because it is important for all to read. No one reads that stuff.”
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You would want to ask the surgeon why they chose the mesh that they did. Many of them do not actually have a choice.
Click “Cancel” on this page and the article from General Surgery News will show. Read the 3rd statement down the page.
https://www.generalsurgerynews.com/Article/PrintArticle?articleID=34826
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The surgeon can use whatever suture material they want to use. There is a variety and many of them are synthetic polymers. Silk is another material that is used sometimes.
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Another link –
from here –
https://my.clevelandclinic.org/departments/digestive/depts/hernia#resources-tab
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I wanted to see what they recommend for hernia repair but for some reason you have to enter personal information to see their “Free” hernia treatment guide. Name, email, date of birth.
Not sure why that would be necessary. Very strange. The Hernia Center is run by Dr. Rosen. -
Here are some Cleveland Clinic links.
https://my.clevelandclinic.org/departments/digestive/depts/hernia
https://my.clevelandclinic.org/departments/digestive/depts/hernia/chronic-groin-pain
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Thank you Jordan and good luck with the removal. Please come back with details on your interaction with the Vincera Institute. I get the impression that it is growing and might be changing. Dr. Meyers seems to be stepping back somewhat.
I found a recent HerniaTalk video with Dr. Krpata. It’s interesting that he is at the Cleveland Clinic. It is one of the big mesh implantation clinics. They even have a Chronic Groin Center, of which Dr. Krpata is the Director. They use 10% as their chronic groin pain number.
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By “surgeon perspective” will you be speaking for yourself or speaking for all hernia surgeons?
It would be good if you had a legal expert involved in the discussion. I’m trying to imagine what benefit a person planning hernia repair or mesh removal would get from the discussion. Or even a patient considering a lawsuit. What is the lesson of the discussion?
Good luck, I hope it turns out well.
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This could be an interesting topic but I think that most people would like to hear from the surgeons and medical institution managers, and lawyers involved in the lawsuits, from either side.
What individual is going to want to talk about how their personal pain caused them to take the drastic step of suing their doctor? Lawyers cost money and energy and after a bad hernia repair experience, most people are low on both. And nobody really wants to sue the person that they thought was going to make them whole again.
It would be informative if you could talk about any times that you have been sued, or colleagues that you know of, and the causes and results of the suits. Did the lawsuits change anything for the surgeons being sued or did they just assume it was the cost of doing business? Something bad that happened. How do other surgeons feel about the lawsuits?
Dr. Ramshaw just talked about his major surgical error but did not really end up saying much about the legal ramifications of it. His story might be a good starting point for the discussion. It covers individuals but also systemic problems.
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I’m just providing information, with sources, for people trying to make decisions. Most of my comments have a link to a professional source behind them.
I often compare the chance of chronic pain from mesh to the game of “Russian Roulette”. One chance in six of getting a bad result. That is what numerous studies have shown, which I have linked to in numerous posts at various times over the years.
But, besides the odds of getting a bad results, people should consider the “weight” of that bad result. A recurrence with a pure tissue repair is most often just like going back to where you started. “My hernia is back”. With a pure tissue repair, even the body is almost back to where it started.
I can’t speak to chronic pain from a pure tissue repair because I don’t recall seeing any descriptions of chronic pain from a pure tissue repair. If you can find some please post them.
With a recurrence from a mesh repair, the apparent solution is more mesh or a different type of mesh. Probably after mesh removal, if I recall past posts from Dr. Towfigh correctly. That is an example of the “weight” of the problem of recurrence from mesh. Mesh removal, then more mesh implanted.
With chronic pain from mesh, the weight is also very heavy. Neurectomy, mesh removal, pain medications, etc.
An analogy might be jumping across two ditches. If one ditch is two feet deep and you don’t make it, you can climb back out and try again (pure tissue). If the other ditch is 30 feet deep and you don’t make it you’re probably going to suffer some damage (mesh implant).
That’s what it boils down to from my way of seeing it – the odds of a problem and the magnitude of the problem if it happens. Most of the surgeons promoting mesh deflect from the magnitude of the problem if it happens. They stop considering the patient’s welfare.
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It’s hard to imagine that Dr. Campanelli would not mention chronic pain from pure tissue repairs if the problem was significant. He has every reason to, as an author of the ordinal recommendations to use mesh as the first choice for hernia repair. Not a hint in his letter that he was even trying to draw an equivalence.
Actually, he even hinted at the possibility that the recurrence argument for mesh might not be what it was claimed to be.
From his letter –
“In the past, the most negative long-term effect was recurrence, the incidence rate of which seems to have fallen significantly since prostheses came on the scene. This latter observation, however, remains to be assessed in light of the doubts we have often expressed about the effectiveness and reliability of reported follow ups.”
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“Also, if we apply here the argument of “many procedures are done, and there isn’t a widespread outcry about results”, then we can equally apply it to mesh. Hundreds of thousands of those are done a year in the US, and if this was truly a bad procedure, we would see a lot more bad cases. ”
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Actually Dr. Voeller is at the UT Health Science Center.
https://www.uthsc.edu/faculty/profile/?netid=gvoeller
Dr. Bendavid was a surgeon at the Shouldice Hospital but has died.
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Here is a good discussion from 2018, between Dr. Bendavid and Dr. Voeller, about the use of mesh compared to pure tissue repairs. Dr. Voeller speaks of studies but does not list any. And he is a professor at the University of Tennessee Knoxville Medical Center. He says that the improvement in recurrence rate cannot be argued, it is supported in “most every study”, but Dr. Campanelli, in his editorial, says that the data about recurrences is unclear.
There does not seem to be any consensus at all about what is best for the patient. The only consensus is that mesh is here and predominant.
https://link.springer.com/article/10.1007/s10029-022-02576-z