Good intentions
Forum Replies Created
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Here is something to think about. Dr. Campanelli was one of the original authors of the “Guidelines”. The original was published in 2009, almost thirteen years ago.
https://link.springer.com/article/10.1007/s10029-009-0529-7
I am not sure that they have kept up with their stated goals though.
” In between revisions, it is the intention of the Working Group to provide every year, during the EHS annual congress, a short update of new high-level evidence (randomised controlled trials [RCTs] and meta-analyses). Developing guidelines leads to questions that remain to be answered by specific research.”
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I posted it mainly as an example of studies over the years, and what seem like efforts to make mesh repairs look better than they are.
Dr. Towfigh, you often make statements but never supply your references. Could you supply a reference or two that support your statements? One of the studies you mentioned in the other thread.
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Good luck with your search. I think that you will find that everybody and anybody who had bad results would run naked through their hometown if the bad results could be undone.
I think that you might also find that surgeons will see a patient with unreasonable expectations and might avoid you. So, your demands might actually end up being a big part of your selection process, limiting your choices.
Good luck.
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I’d rather have a heartless punk for one to two hours of my life with good lifelong results, than a considerate surgeon who gave bad results. The goal is the hernia repair results.
In the same vein to Mike M the original poster. The hernia itself is “damage”. The hernia repair will not undo that damage. Your goal is to get through the surgery to the other side with the best potential future ahead of you. Surgery will be traumatic. You’ll be naked under a thin gown, various people will be cleaning, shaving, poking, probing and cutting down in your nether regions. They have seen hundreds of patients. Plan to suffer through the indiginites of the day of surgery so that the rest of your life will be better.
As far as hoping that nothing foreign is left in your body – it seems unrealistic for hernia repair. As an older guy who used to be a young active guy, I can say that you will probably suffer more damage over time that will make a few Prolene or SS sutures in your groin area seem like nothing. Focus on getting the good long-term results from the repair. Don’t worry about surgeon attitude or a few sutures, or a testicle that hangs a little bit lower.
The hernia is a much bigger deal than most surgeons will say. To them it’s just another procedure to perform on another patient. To you, it’s a lifetime of normalcy or a lifetime of struggling with what happened. Focus on the long-term results, pay the price in the short-term.
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My mesh problems were very severe. And I continued to work through them, doing lots of physical labor in the third year. And before then, I had been running and working out, trying to “believe” that the mesh would become incorporated and that my body would adapt. So the thickening of the tissue around the mesh was probably substantial, which probably helps avoid recurrence.
With the pandemic still active, I do not know what I would do if I had a recurrence. I might just live with it. If I could manage it, I would probably go to Dr. Kang, because he seems to understand how the abdominal muscles work in great detail and might have better ideas of what to do with the damaged tissues left behind. I think that many hernia surgeons today can identify certain things but I don’t think that they understand the dynamics of their movements. Dr. Meyers at the Vincera Institute is another possibility.
Yes, Dr. Billing and I discussed just removing the mesh, then waiting to see how things progressed. I got the impression that he did not see many recurrences after mesh removal.
I can’t offer any more guidance than what I’m writing. I don’t want to talk anyone in to having mesh removed, I can’t predict the results.
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Actually, I see on second read that the hernias they are talking about are more of the ventral type, after abdominal wall reconstruction. A different class of hernia than an inguinal hernia.
It is interesting though that the abdominal wall, which is essentially a wall of muscle, was not considered for post-surgery therapy, until now.
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I’ve seen the discussions about stainless steel and Prolene and, no offense intended, I don’t see much science behind the discussions. They are both inert materials in the body. Prolene is actually made of the same material that many of the synthetic meshes are made of – polypropylene. Made by the mother company of Ethicon, who manufactures Ultrapro and Prolene mesh.
I would look at the results. Has anyone seen any reports of SS sutures being the cause of problems?
https://www.jnjmedicaldevices.com/en-US/product/prolene-polypropylene-suture
https://www.ethicon.com/na/epc/search/platform/hernia%20mesh%20&%20fixation?lang=en-default
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And here is the latest summary of the Guidelines for those who don’t want to read the whole document (by “those” I mean surgeons). Notice how they say that Shouldice gives good results but should only be considered if mesh is not available. There seems to be much talking out of both sides of the mouth. And, no signs that they would revise the Guidelines if new studies show different results. And, most telling of all, all forms of mesh are classified as one – “mesh”.
If you track the development and growth of mesh in hernia repair you find these inconsistencies all along the way, and the same companies involved in promoting them.
This is one the first summarized facts in the whole summary document. Use mesh if it’s available, only consider pure tissue if the patient asks or mesh is not available.
Excerpt –
“NON-MESH REPAIR
Non-mesh repair is an option if mesh is not available or in shared decision situations with patients that do not want mesh. The Shouldice is best tissue repair although in general practice the recurrence rate is higher than mesh repair and risks of pain are comparable. More research is needed into the value of non-mesh in cases where risk of recurrence is low (for example young men with indirect hernia) and into the results of expert clinics.”
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Here is a paper discussing the Guidelines, by Kockerling, just a few months after the paper discussed in this thread.
https://pubmed.ncbi.nlm.nih.gov/29888245/
And here is a post about a fairly recent study of the Guidelines. It just seems like the Guidelines were shoved through and published with financial help from the major mesh-makers.
Thank you for critiquing my reply above, I appreciate it. I have become very jaded over this whole situation.
https://herniatalk.com/forums/topic/new-article-questioning-the-validity-of-the-hernia-guidelines/
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I see that you are right, I should have went back and read the full paper again before my last reply.
I think their own discussion shows that they underemphasized the superiority of Shouldice in their short summary at the end. They could even have split the four in to two open methods and two laparoscopic methods. What’s fascinating is how they have completely flipped the narrative, talking about the mesh methods as the established ones and the Shouldice method as the “new” one, trying to displace mesh. When the reality is the complete opposite. Some of the same people were involved in the production of the Guidelines and they did the same thing. Stated flatly that mesh was the preferred repair method and that Shouldice should only be considered if mesh was not available. Kockerling is interesting because he seems to switch from side to side. It seems like he wants to believe in mesh but his logical side won’t let him.
Excerpt –
“The Herniamed data now demonstrate that this selected patient group can be operated on with a good outcome with the Shouldice technique and with no evidence of any major disadvantages coming to light up to the end of first postoperative year compared with TAPP. The Shouldice technique was even found to have advantages over the Lichtenstein operation thanks to lower rates of pain at rest and on exertion at one-year follow-up. Compared with TEP, the intraoperative complication rate was significantly lower, but the postoperative complication rate was somewhat higher. Similarly, an Austrian prospective randomized control trial did not find any significant difference between the Shouldice, Bassini, Lichtenstein, TEP and TAPP surgical techniques with regard to the recurrence rate and complications up to three years following surgery”
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How about Canada? The Shouldice Hospital is a full service institution.
Yes, pinto apparently had a recurrence almost immediately after his surgery. Then had issuescommunicating his problem through the people at Gibbeum hospital. It’s not clear how his situation ended. Dr. Kang did reply on the forum though.
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Pain at rest and pain on exertion were both better, the last two statements in the Results. Those are the reasons people get their hernias fixed, to stop the pain and to be safe from incarcerated hernias. Everything else being equal, less pain is a valid and significant reason to choose Shouldice over the mesh implantations they studied. Choose Shouldice and more of your patients will be pain free. Why would a surgeon choose the odds of more pain for their patients? It makes no sense that they did not say that.
But, the most significant reason to use a pure tissue repair is not mentioned in the paper – if there are long-term problems with a pure tissue repair they are much easier to deal with than with a mesh repair. Mesh is much riskier in the long-term. Even the surgery is riskier although that is not mentioned often either. General anesthesia has issues.
Look at the “Sponsors” for Herniamed. What happens to your sponsors if your work shows that mesh is not preferable to pure tissue? They probably stop sponsoring.
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My first post seems cynical and skeptical about the stated effort to discuss chronic pain from hernia repair but here is why. Two of the various hernia societies associated with Hernia use the “Guidelines” as their guide to hernia repair surgeons. The Guidelines were created by the Herniasurge group through an effort funded by Ethicon and Bard (before Bard was purchased by BD). The Guidelines state clearly at the beginning of the document that they are meant as guidelines for the use of mesh in hernia repair. They assert that mesh is the preferred method for hernia repair, but do not provide reasons why. The “Guidelines” are not hernia repair guidelines they are mesh usage for hernia repair guidelines. So, there is an inherent conflict of interest at the very foundation of Hernia. It’s just the way things are.
It might be that Hernia is somehow independent of these large organization but it seems unlikely. The details of the “affiliations” are not clear. I hope that the editors and staff at Hernia can find the will to push past this inherent conflict. There is a lot invested in the promotion of mesh for hernia repair and it is stated clearly in his letter that chronic pain is a new problem that parallels the use of mesh prosthetics.
https://www.springer.com/journal/10029/aims-and-scope
“Hernia is a rigorously peer reviewed journal that regularly publishes specific topical issues and collections in addition to original articles, and is affiliated with the European Hernia Society (EHS), the Americas Hernia Society (AHS), the Canadian Hernia Society, and the Asia Pacific Hernia Society (APHS).”
https://www.europeanherniasociety.eu/science
https://americanherniasociety.org/surgeon-resources/guidelines
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Here are some links describing Hernia.
https://www.springer.com/journal/10029
https://www.springer.com/journal/10029/ethics-and-disclosures
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A thought that occurs to me now and then is that a mesh repair is like an “all-in” bet in gambling. The overall odds might be in your favor but if you lose you lose a lot. A pure tissue repair is like a small bet, that, if you lose, you can still continue to seek a win.
That seems to be the disconnect a person finds when they are talking to surgeons. The surgeon sees the wins of many patients, and the losers just cease to exist, in their minds. Oh well, too bad, but look at all of these winners.
So, long-term, the results of chronic pain from mesh need to be compared to the results of chronic pain from a pure tissue repair. What are the odds of having chronic pain, what are the odds of successfully removing the chronic pain if it occurs? Chronic pain has to be considered in depth for hernia repair. If it isn’t then the patient is just making an uninformed gamble.
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It might be worthwhile to contact the Vincera Institute. Dr. Meyers has a different approach to abdominal injuries.
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Where did the thoughts originate? Where is the supporting information?
The AHSQC seems to be collecting some useful information. Apparently it is only good for a 30 day evaluation though, at this time. It says that open, lap, robotic, and Shouldice all have about the same rate of problems, for 30 days. I have not seen any studies that show that Shouldice causes more chronic pain than any mesh repair.
Finally, the major and main question of how a mesh problem is addressed compared to how a pure tissue problem is addressed is not covered. Mesh problems are much more difficult to solve than pure tissue problems.
The AHSQC is a new effort to understand the problem and, at this time, the best that they can do is to say the situation is undefined in the long-term.
https://link.springer.com/article/10.1007/s10029-019-01968-y
“Results
4613 patients met inclusion criteria. 1925 were repaired using an open technique (42%), 1841 were repaired using a laparoscopic technique (40%), and 847 were repaired using a robotic technique (18%). The Shouldice technique remains the most common tissue-based repair performed in the AHSQC. The Lichtenstein repair is the most common open mesh-based repair. Minimally invasive approaches to unilateral inguinal hernia repairs remained very common in our series. The robotic approach accounted for nearly one-third of the minimally invasive inguinal hernia repairs.Conclusion
In general, all of the repair techniques reported similar and low rates of 30-day complications. The AHSQC continues on-going efforts to improve long-term follow-up and looks forward to addressing long-term outcomes such as recurrence and chronic pain with increasing data acquisition.” -
If you want to do some research use the words erosion and migration on a search site like Google Scholar.
Here is an example, linked below. It might have some good references. Inflammation weakens tissue and weak tissue would be more prone to tears. But determining an actual cause-effect relationship seems difficult. A study of athletes with mesh implants would probably provide useful insight but athletes generally avoid the use of mesh.
Even if you determined that the mesh caused the tear would it affect your decision-making process?
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4746983/
https://scholar.google.com/scholar?hl=en&as_sdt=0%2C48&q=mesh+erosion+inguinal&btnG=
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There is another, supposed registry, that was created years ago by Ethicon (Johnson & Johnson) but it is a commercial marketing endeavor. The IHMR. The results have been used to promote positive aspects of their mesh products in their sales literature but the completion of the registry and report have been delayed time after time. Only positive news is released, internally.
This is one of the foundational elements of my cynicism about corporate involvement. Beware the things that have fancy powerful names.
https://clinicaltrials.gov/ct2/show/study/NCT00622583
https://ichgcp.net/clinical-trials-registry/NCT00622583
https://www.jnjmedicaldevices.com/en-US/product/ultrapro-mesh-ethicon
Excerpt (the misspellings are in the literature) –
“ULTRAPRO® Macroporous Partially Absorbable Mesh offers strength with reduced foreign body mass1,5 and may reduce the risk of patient complications compared with mircroporous mesh.2,6 In a study of patients from the International Mesh Hernia Registry (IHMR), patients demonstrated low rates of intra- and postoperative complications, such as seromas, and recurrence (<1%) after 1 year.2-4,7-12 In the same study, patients reported improvement in pain and movement limitations from baseline at 1 year postsurgery.2,3,7,8 ULTRAPRO Mesh withstands more than 2x the maximum abdominal pressure in healthy adults.13,14 ”
3. Data from a prospective, longitudinal study of 151 patients receiving open hernia repair with ULTRAPRO fat mesh from the International Hernia Mesh Registry (53.0% ventral/incisional, 39.7% inguinal, 7.3% other).
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There is also a Danish Registry (Database). I have seen it referenced in several papers.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5096723/
https://www.dovepress.com/the-danish-inguinal-hernia-database-peer-reviewed-fulltext-article-CLEP