Good intentions
Forum Replies Created
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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. ”
Acknowledgement that chronic pain is real by the Editor-in-Chief of Hernia
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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
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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/
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.
https://herniatalk.com/forums/topic/pinto-dr-kang/
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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