Good intentions
Forum Replies Created
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Here is an interesting but frustrating article about athletes and inguinal hernias. It goes in to depth about using unltrasound and Valsava to diagnose hernias. The frustrating part is that they do not describe at all the hernia repair method, but do report that the repairs seemed to alleviate pain and allow the athlete to continue in their sport.
But they do use the word “herniorrhaphy” which, by definition means no mesh is used. So, even without the details, here is a small positive study showing that non-mesh repairs can be successful for the athlete. Off the topic of the thread title but it follows from the discussion. The authors would be worth seeking out if you’re in the upper midwest area of the US.
Excerpt –
“Clinical Relevance:
Persistent groin pain in the athlete may relate to inguinal hernia, which can be diagnosed with dynamic ultrasound imaging. Herniorrhaphy is successful at returning athletes to sports activity.” -
There have been comments about how surgeons use mesh in athletes but, so far, no specific success stories. Not even anonymous stories. If you follow sports you’ll often see stories about athletes who go to specific clinics to have their knee, ankle or shoulder repaired. Or stories about sports hernias. But no stories about inguinal hernia repair. The one common thing you’ll see about the clinics that operate on athletes is that they avoid mesh.
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I think that I would focus less on the fact they specialize in athletic pubalgia and more on the fact that professional athletes seek them out for their core injuries. To them a common inguinal hernia is probably simpler to repair than a “sports hernia”. They all avoid mesh for any purpose in repairing an injury. I think that that is telling. The common man/woman gets mesh, the elite athlete avoids it. Search “dai greene mesh” to see what happens when an elite athlete gets the run-of-the-mill repair.
Dr. Brown also has athletes that seek him out and, as you probably know, avoids mesh, even though he was in the original group of surgeons who used the Kugel plug repair method. He saw firsthand the damage that mesh causes and stopped using it. Dr. Kang also used mesh and stopped using it because he had too many patients returning with pain.
Those are basically the two types of surgeon that are out there. Those who know mesh causes more damage than a pure tissue repair but say “oh well, that’s just how things are done today”, and those who see the damage and refuse to participate. People who just do what they’re told and collect the paycheck and those who control their own lives and destiny, doing the things that made them want to become surgeons. So that they can help people.
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Dr. Muschaweck is known for repairing hernias, groin strains, athletic pubalgia (sports hernia), and other ills of the professional athlete.
My reference to the porcine material was because the article mentioned specific people with “hernias”, then started talking about porcine mesh. A typical lazy journalist method of trying to add interest to to an article. But the lazy comment led me to the Biohernia site when I started researching Lampard’s injury.
It looks like Lampard’s injury, and Glenn Murray’s, were both of the “sports hernia” type, maybe leading to full tears in the groin area.
Dr. William Meyer of the Vincera Institute is also known for working on professional athletes, with an emphasis on “sports hernias”. I think that he also avoids the use of mesh, but it looks like they have hired others that do use mesh. I’m not sure how they use it though. I’ve had correspondence with the Institute and asked if they could share their knowledge but, unfortunately, in today’s world, knowledge is money. If they show everybody how to do a better repair they’ll probably lose business. Capitalism.
https://vincerainstitute.com/core-muscle-injury-treatment/mesh
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The critical error message is new, I just got the same thing. You clicked in the right place, but there is a problem with the site software.
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Do you know the details of the repair? The type of mesh, and the surgery notes? There are many different types of mesh implanted via open surgery. And many surgeons do more than just implant mess, like performing neurectomy (cutting nerves to avoid future pain). The details might offer some clues about your best path forward.
Also, the imt elapsed before pain started would help. 12/16 to 1/17 is different than 1/16 to 12/17.
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Here is the ACHQC youtube channel video page and a video showing how the PRO form is used.
https://www.youtube.com/channel/UCtsURlxpeI3s6zIzOmLYxKA/videos
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Here is a link to the AHCQC web site and a link to the inguinal hernia Patient Reported Outcome survey form.
The results do not appear to be freely available, it has to be requested. If the news is good, why not broadcast it to the world?
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I saw your post about porcine mesh material and read the attached article. It led me to look for more about Frank Lampard’s hernia (Lampard is a famous soccer player). The article seems to imply that maybe Lampard had porcine mesh used to repair a hernia. But it turns out that he had Dr. Muschaweck (I think) repair his hernia.
The Biohernia project is getting very sophisticated. Here is the latest from their web page.
https://biohernia.com/en-ie/inguinal-hernia-elite-athletes/
https://biohernia.com/en-ie/inguinal-hernia/non-mesh-hernia-operation-methods/
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Tela-Bio’s Ovitex is the latest biologic to hit the market. It is made from sheep intestine, but the premise is the same – strip the tissue down to its basic collagen and assume that the human body will remodel it into human tissue.
Dr. Towfigh and Dr. Szotek are both proponents of Ovitex for inguinal hernia repair. Dr. Szotek presents at the big meetings nad has made youtube videos.
https://finance.yahoo.com/news/tela-bios-ovitex-reinforced-tissue-110000926.html
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The lack of regulation in the field for new products means that many new products get introduced and sold with claims that turn out to be untrue. This is from 2014.
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You can look back over the years and see that blaming technique is the tool that the mesh-makers and users have used to deflect attention from the mesh. Blame the technique, but don’t name a specific technique. Claim that there is no evidence of problems inherent to mesh alone but provide no evidence, and ignore the fact that there is no evidence that mesh is not the problem either. It’s just a coincidence that mesh is there, and that the pain disappears when the mesh is removed..
Simple logic can be used to draw a solid correlation between mesh implantation and chronic pain, if enough data is collected. Laparoscopic procedures that involve peeling the peritoneum from the abdominal wall but with no mesh implantation, for example. Explaining why removing mesh removes the pain. That one seems very clear. I had mesh with pain, the mesh was removed and the pain was removed. How can the cause of the pain not be considered an intrinsic property of the mesh? There was no neurectomy done during the mesh removal.
I think that the word game here is the same word game used to make jokes, or to retain something that makes money, or continues something that a person has invested time and money in to. It’s not the fall, it’s the sudden stop at the end that injures people. Guns don’t kill people, people do. It’s not the mesh causing the pain, it’s the shrinking and buildup of tissue around the mesh that causes the pain.
In the big picture, the mesh-makers plan has worked. They have delayed and deflected and convinced for many many years and today’s surgeons have their whole careers invested in supporting mesh-based hernia repair, and, therefore, they have to support mesh. They have investments and bills and don’t know any other way. Pure tissue repair is not taught in the major medical schools. Everywhere you look, behind the scenes, you will find mesh-maker support, for the conferences, paying the huge exhibitor fees to the various surgery or hernia societies (75,000 – 100,000 for a booth in an exhibit hall), at the universities with their on-campus robotic surgery training centers, consultancies, and complimenting the surgeons who say good things about mesh.
Dr. Towfigh, can you give a few examples of the “problem in surgical technique” that you have seen? And explain how it was the cause of the pain, and not the mesh? It shouldn’t take long. A presentation on the topic at one of the big meetings would surely be well-received, even applauded, if you could show your colleagues what mistakes to avoid. Much more impactful to patients and colleagues than busting myths. Busting myths helps the mesh-makers but does not help your colleagues and their patients. Think of all of the patients you could help by speaking up. I think that it would be much more personally satisfying and fulfilling also, than just defending the use of “mesh” in all of its forms.
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Hello @drtowfigh . Could you provide some follow-up on your meeting with the FDA. I know that the times have been tough, and all government agencies were seriously handicapped by the last administration (no offense to anyone’s political views, it’s just a reality), and the ongoing COVID pandmeic, but, maybe, efforts can be re-initiated? The FDA is the supposed regulatory body that would be monitoring product problems. There is little sign of their efforts in the past.
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I just checked, and Ethicon’s “Two Year Study”, started in 2007, is still pending. It’s a good example of an industry-managed registry.
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And, of course, as often happens, the remedy for the chronic pain is not discussed. The patients that have chronic pain from mesh implantation have very few avenues available to remedy the pain. The possible solutions are dangerous and expensive and often fail. When a person considers the full risk/reward situation for the patient alone, pure tissue repair is the obvious first choice. The push for mesh implantation over pure tissue repair is driven by the industry, not the improved welfare of the typical patient. The typical patient has more risk of permanent chronic pain today than they did twenty years ago. And that is where the lawsuits are coming from.
Promoting mesh at the various meetings will not change the reality of the situation. The chronic pain problem comes along with the mesh. It will be here as long as mesh is here.
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Here is a study comparing TEP to Lichtenstein. TEP ends up at about 10% after 5 years, compared to about 19% for Lichtenstein. So a case can be made for TEP over Lichtenstein but the overall rate of chronic pain due to mesh cannot be downplayed.
https://academic.oup.com/bjs/article/97/4/600/6150225?login=true
“The total incidence of chronic pain in the TEP and the Lichtenstein groups respectively was 11·0 per cent (60 of 546) versus 21·7 per cent (125 of 577) at 1 year, 11·0 per cent (60 of 545) versus 24·8 per cent (144 of 581) at 2 years, 9·9 per cent (55 of 554) versus 20·2 per cent (119 of 589) at 3 years and 9·4 per cent (58 of 616) versus 18·8 per cent (124 of 659) at 5 years (Fig. 2). The frequency of any degree of chronic pain up to 5 years after operation was therefore twice as high in the Lichtenstein group as in the TEP group.”
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Dr. Towfigh you are presenting unverifiable numbers from a group that most likely does not represent reality. At least tell people the sample size. Is this 20 patients or 200? You must realize that the numbers have little value except to show that the quality of available data is poor.
“It’s not a database that is mandatory and most surgeons performing hernia repair are not members.
1) the surgeons entering this data from their practice may not represent the whole of US surgeons
2) the majority of patients whose data is entered by the surgeon do not enter their followup long term data re how they’re doing.”
Here is a more proper, professionally done study. It is focused on open repair, but you can see where the numbers came from.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5896652/
Excerpt –
“Postoperative chronic pain is a special entity within the domain of chronic pain. Chronic postoperative pain occurs following numerous kinds of surgery, from amputations to thoracotomies to inguinal hernia surgery. The chronic pain after inguinal hernia repair has been extensively studied; however, the management is still difficult. Around the globe, millions of groin hernia repairs are conducted annually1 and 8%–16% of these patients experience chronic pain to a degree that impairs their daily lives 6 months postoperatively.2,3 A few percent of these patients experience disabling pain, and due to the large number of groin hernia repairs, the number of patients with disabling pain and discomfort is an important clinical problem.4”
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Thanks for the comment Mark T. My main point was to show the great distance between how things are now and what the authors are promoting. If they are unaware of the state of things today then they are writing about things they don’t understand. If they do know how things are then they are just writing fluff about an ideal world that will never exist. Or, as I implied, they are suggesting a tool to weed out the problem patients.
90+% of the people who visit a surgeon today with an obvious hernia will be assured of a fine result and scheduled for surgery as soon as possible with no questions asked or answered.
Again, I hate to be so cynical. I have been posting on the site for quite a while and I have not had a solid response from any surgeon showing that progress is being made to lower the 15% number. Work continues, and the people suffering with mesh problems are shunted aside. Well-meaning surgeons speak up and supply studies showing that the problem is real, but nothing is done, and vague comments are written about other possible causes. Meanwhile, every day, 15% of the people getting a hernia repaired will probably suffer pain. More will suffer discomfort, people who hear the news will lose trust in the medical profession, and the mesh-makers will collect their profits.
The failure of the hernia repair field is actually a big part of the loss of trust in the medical profession, since hernia repair is one of the most common surgeries performed today. That seems hyperbolic but anyone who is told that they need surgery will probably get on the internet and find stories about mesh.
The authors of the article are way beyond the very simple steps of just removing the bad from surgery today. The bad is allowed to coexist with the good. That just makes everything bad.
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“it isn’t the mesh causing the problem but the way it’s put in”
Was the comment from Dr. Horne? I have not watched the video. That is in the same vein as blaming mesh problems on fixation. Without the details of what is the right way to “put it in” or the wrong way, it is a useless comment meant to divert attention from the problems with mesh. It’s just one more surgeon “protecting” the mesh industry.
Any surgeon who makes a comment protecting mesh should have information about how to make things better. Otherwise they are just acting as tools for the mesh makers. If they truly believe in what they are doing then they should be actively working to remove the “evil-doers” that are destroying their reputations.
Start removing the bad and all that’s left will be good. The mesh-makers might lose some business but without surgeons promoting the right way to do things, they’re all contaminated. Silence just lets the bad continue.