Good intentions
Forum Replies Created
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I clicked a couple more things and see that Dr. Towfigh is involved.
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These discussions about the fine details of the repair techniques are interesting, but, in the end, I think, the results are what matter.
If you want to extend the understanding over to mesh repairs then you should consider the peritoneum, the omentum, the fascia, and muscles and ligaments that get pulled as the mesh (actually mesh/tissue composite) shrinks. Omentum is often one of the materials that gets pushed through a hernia. The omentum is actually a folded portion of peritoneum. It is considered as an organ of the body.
Here is a good starting point for the peritoneum and the omentum. These parts of the body are involved in the foreign body response to the mesh. More mesh contact probably means more response, a person would guess.
https://www.frontiersin.org/articles/10.3389/fphys.2018.00738/full
A couple of excerpts –
“Background: Despite its complexity, the peritoneum is usually underestimated in classical medical texts simply as the surrounding tissue (serous membrane) of the gut.”
“Nonetheless, peritoneal cavity is usually disregarded as an empty space without clear clinical significance (Sasaki, 1999) and the peritoneum simply as the covering tissue (serous membrane) of abdominal viscera in classic physiology (Hall and Guyton, 2015; Boron and Boulpaep, 2017), and histology texts (Ross and Pawlina, 2012).”
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4723480/
Excerpt –
“A more conventional view of the omentum is that it plays a central role in peritoneal defence by adhering to sites of inflammation, absorbing bacteria and other contaminants, and providing leukocytes for a local immune response[3]. This review details current knowledge on the origins, structure, and function of the omentum, and discusses its role in the peritoneal cavity during various disease states.”
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Make sure that you talk about Google Scholar. It searches for professionally created journal articles, just like those that would be found in any medical library. It is not opinions and unsupported facts, but professional journals, many of them refereed.
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A recent paper with Dr. Campanelli as a co-author. Might be related to why he wrote the letter. Who knows. He started out as an author of the original mesh Guidelines and now is moving back to Shouldice as a possible choice, before mesh in certain situations. At least, a surgeon should know both, and choose appropriately. That seems like progress to me.
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Here is an interesting new article, 2021, about Shouldice, with some comments about modified methods. Dr. Campanelli, who wrote the Hernia letter about the reality of chronic pain, is a co-author.
https://pubmed.ncbi.nlm.nih.gov/33502639/
Excerpt –
“Conclusion: After a 75-year history of the Shouldice repair the technique should continue to merit consideration by all hernia surgeons. After this consensus meeting a clear binding standard of the Shouldice technique for all interested surgeons is proposed.”
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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.