Good intentions
Forum Replies Created
-
Whatever method you choose, it will affect the rest of your life. The procedures are not reversible and they all involve dissection (separation) of tissues, either via scalpel or blunt instrument, despite the size of the entry point in to the abdomen or inguinal canal. Put the appropriate amount of effort in to learning about the pros and cons of each. “Blowouts” are not really a thing with hernia mesh. Chronic pain is though.
The long-term results should be your focus. Don’t be persuaded by saving a day or two today if it will risk the decades ahead of you. Read the posts on the forum, search around the internet, ask your surgeon hard questions and see if they give direct honest answers. Good luck.
Shouldice is a good option if you go to the Hospital in Canada.
-
Here is a collection of hernia focused articles from GSN. The format is difficult to use, some of the articles can be found on the main site using the search function there.
-
If you don’t search out a surgeon who will do a non-mesh repair (better known as pure tissue repair) and specify that you want a pure tissue repair, then you will almost certainly get a mesh repair. International Guidelines have been created that recommend mesh as the first choice for hernia repair.
There is a ton on the forum. Read as many of the posts as you can.
-
I just don’t understand Dr. Towfigh. I search for reasons and write them down, hoping (dreaming) that some young surgeons or students will see the travesty of using mesh for any and all hernia repairs of any type when there are safer methods available, and choose to take a different path. I try to describe things in a way that seems rational, because what’s happening does not seem rational. Money seems simple and rational.
But my comment was about the total cost, not just the remuneration for a single procedure. The investment in equipment, training, risk of extraneous costs, risk to reputation, risk of using the change as evidence in lawsuits, etc. The costs of running a business after it has been established. Change costs money.
These lawsuits are the best thing that can happen for future hernia repair patients. And surgeons. Because not much is happening at the professional guidance level besides talking. I think that mesh has become incorporated in to the hernia repair field body and will be very difficult to remove. The lawsuits are analogous to a mesh patient’s chronic pain. A strange parallel but appropriate, I think. The lawsuit pain will continue until the mesh is removed.
You wrote an article a short while back titled “Hernia Mesh and Why We Remove It”. The next in a series could be “Hernia Mesh and Why We Use It”. That would be an interesting read if it was backed by good solid data with real precise numbers. Why do surgeons use mesh? Is mesh really appropriate for any and all hernia repairs? Should mesh be used to cover all future hernia sites?
Are all meshes the same? Are there safer repair methods that don’t involve mesh?It’s a decades old problem but it is heartening to see some change even if it is small and inadequate. Thanks for continuing to support at least one small place to discuss the issues.
-
What are your criteria for reputation? You’ve covered quite a range of methods in your list, from open pure tissue to open mesh implantation to laparoscopic mesh implantation.
The last name is interesting. He is an inventor/entrepreneur. Beware of people who have a vested interest in seeing a product sold. Cognitive bias is a powerful psychological force.
https://surgery.ucsf.edu/faculty/general-surgery/hobart-w-harris,-md,-mph.aspx
https://surgicalinnovations.ucsf.edu/spotlight/innovator-profiles/hobart-harris,-md,-mph.aspx
-
Sorry Paul, my post must seem like a real downer. I really do believe though that part of today’s chronic pain problem is the fact that the influencers, the device makers and the surgeons that they sponsor, are pushing surgeons to use more mesh to cover more area. “Cover as much area as you can to avoid future recurrence. Prophylactic mesh placement is good, the other side is just going to herniate too.”, which, of course, benefits the device makers with higher revenue.
Hopefully, at least, more surgeons will realize that less might be better, and resist.
-
Thanks for the detailed reply Paul. The answer is in the story that you told. Dr. Chen was looking for a problem with the implantation from the very beginning and, even when he found that his initial explanation was very wrong, he still tried to find a flaw with the implantation. Too high, misplaced, etc. but he didn’t seem to explain or understand why the mesh was hard. In principle, it’s supposed to “become one” with the surrounding tissue, remaining soft and pliable. So, in the end, he still believes in “mesh” despite what his own eyes saw. “Do you believe the device makers or your own lying eyes?” Paraphrased joke there. I wonder if Dr. Chen could explain why Progrip is better than Bard.
Dr. Chen might not be aware that the Progrip mesh is made from the same material as the Bard mesh, polypropylene. Progrip has polylactic acid (PLA) hooks attached to it though, to give an initial grip after implantation. Once the PLA dissolves and is absorbed the mesh will be the same. But you’ll probably be fine in the long run because he covered less area.
I don’t want to make you nervous, but knowing the facts is always good in the long run. Good luck.
P.s. personally, I don’t know if I would do any “planks” for a while. I would avoid the things that increase abdominal pressure, especially with the PLA material on the mesh. The PLA will cause its own inflammation as it is absorbed, and probably takes longer for full “incorporation”, meaning tissue ingrowth. Which is what is supposed to keep the mesh from moving.
-
Could you ask Dr. Chen if he plans to do anything with the knowledge that he’s gaining from these chronic pain mesh removals? Does he report the incidents to the FDA for inclusion in their MAUDE database? Did he have any comments about why you had a bad result? Did he assign cause to poor technique from the surgeon or just the nature of the mesh? Can he explain how the mesh ended up where it did? Could it have moved because of the inflammation, not vice-versa?
Most surgeons tend to place blame on some sort of error by the surgeon who implanted the mesh, and stick with their training that mesh is inherently harmless. I wonder if Dr. Chen is one of those or if he has a more objective and reasoned view. He is one of the big names on the professional presentation and publishing circuit. His opinions could probably have a positive effect on the chronic pain problem or they could lend power to the device makers and their efforts to maintain revenue.
https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/textsearch.cfm
-
I just looked at my notes and realize that I did not really suffer any immediate ill effects from the mesh removal beyond a few days of initial pain. The only thing really holding me back was my awareness of what had been done with worries about proper healing. I drove about 200 miles two days after the first half of the mesh was removed. I was doing yard work and light lifting about 6 days after. Eight days after surgery I ran ten laps at a local track.
I was in very good shape when the mesh was removed. I had spent most of my time trying to live with the mesh and doing what I wanted to do, trying to “work” the mesh in, so I had been just suffering through the pain until mesh removal. Dr. Billing also mentioned that the tissue around the mesh had been very inflamed, to a level he had not seen before and that the mesh had dropped down and moved medially. So I think that my body was already “detaching” from the mesh so when it was removed as far as my body was concerned the surfaces were the same, just with some new incisions.
Since then most of my issues have been with the damaged stiff tissues readjusting to the new mesh-free environment. Twinges and pains and pulls, and soreness at the area of the mesh remnant. My flexibility had been limited and doing things with my arms above my head would often cause soreness at the pubic bone area but that has resolved since then.
At 2 weeks and 3 days it’s still early for you, but you’re pretty close to being allowed more activity I think. Dr. Billing suggested as much for me at just one week after the first half of the mesh was removed. I’ve mentioned before that sometimes getting out and moving was better than resting. It might be worthwhile for you to be a little more active, especially after Dr Chen says you’re ready. One thing that is often mentioned in writings about surgery is that the growth of veins in to the surgery site (vascularization) is a good sign. Meaning that right after surgery the area will be suffering from lack of oxygen and nutrients due to a lack of vascularization. If you’re only doing 30 minutes of walking per day that means you’re really not moving much for most of the day. You’ll have “stagnant” areas around the cauterized tissues that won’t be getting good fluid transfer, I would guess.
That might be contributing to your pain.Our situations seem different but activity is almost always best for regaining health. Good luck.
-
Have you tried to consult with Dr. Chen? I don’t know what “total image of Dr. Chen” means.
Dr. Meyers of the Vincera Institute will look at your files and give a brief opinion of whether he thinks he can help or not. I think that I might have suggested him earlier when you described the popping and clicking. I would get all of my records together and see if Dr. Chen or Dr. Meyers has ideas. I don’t know much but it seems to me that the doctor who did the “Shouldice” repair did not do it correctly.
https://vincerainstitute.com/practice/physicians/dr-william-meyers
-
Sorry for the long post above. It might help you to make a list of the various types of open mesh repairs. Here are a few. I think that any of the various flat sheet materials can be formed in to the shapes of the devices used. Anything with a plug seems to be bad, by the collected accounts and discussion and tweets, even the “Guidelines” recommend avoiding plugs. But there are still surgeons using it. How can they change now, how would they explain it?
Lichtenstein seems to have the best track record, although it still has chronic pain problems too, just like all mesh procedures.
The two layer system is a lot of mesh, connected by a plug.
Onflex is too new to know much about it, it has already had a redesign due to insufficient testing before market introduction. The first patients were the lab subjects, involuntarily assisting in product development.
Lichtenstein
Plug
Plug and patch
Two layer system (PHS, for example)
Onflex/Modified Onflex -
Surgeons are taught that mesh will repair, and prevent, all types of groin hernias. They are not taught to distinguish or compare the results of different methods or materials. Finding a surgeon who can confidently tell you what you’re looking for will be impossible, I think. You can find videos from the professional societies where new surgeons say that pure tissue methods are not taught, and the pros and cons of the numerous types of mesh are not taught either. “Mesh” is a vague generalized word that is used to describe all types of sheet-like repair material.
An indirect hernia is the result of the space that the spermatic cord passes through becoming enlarged or never fully shrinking down to its correct size. Abdominal contents squeeze through the opening alongside the cord. The pure tissue methods typically just pull the material out then use sutures to make the opening smaller. Mesh is a one procedure “fix-all” method that is easier to teach and easier to implement in a professional practice.
Here is a pretty good video, below, describing the two types, although he kind of confuses things when he talks about the epigastric artery. If it follows the cord then the artery is irrelevant. I think that artery is used to identify, but not define. 6:40 is where he describes the two types. I had a direct hernia and it exerted pressure on the canal and the cord, affecting the testicle, but did not allow contents in to the scrotum. It created a small pyramid shaped bump about an inch inside of the upper crease of the groin when I stood up, that disappeared when I laid down.
Anyway, good luck. I think that you’re going to find that the surgeons you talk to will tell you that whatever they do is best, of course. Otherwise, why would they do it. You won’t be able to find an objective view. And, most clinics have to follow a billing protocol. 15 minutes for the first exam and discussion, then the patient has to decide if they want the surgery, schedule the surgery, do the surgery, a 15 minute follow-up meeting, interaction is over. Clinics are not designed to educate, they’re designed to perform procedures. In the big scheme of things, that what surgeons do, procedures. Read Dr. Ramshaw’s account of his big mistake.
Ironically, considering how it annoys doctors, the internet is probably the best place to get your information.
-
I found that keeping a log my activities and the way I felt in the days afterward helped me figure out what was helping and what was not. I was able to see that effects of certain activities sometimes took one or two days to manifest.
I also found at times that resting to wait for pain to subside didn’t work, and, counterintuitively, being more active did help. I think it might have something to do with the diminished blood flow after all of the dissection and cauterization. That’s where the activity log helped to keep track of how many days I’d felt pain in a certain area and the level of the pain. If things weren’t getting better I’d just go out and try to get things moving along. I’m not suggesting that you should expect long-term pain just that you might get stuck a few times along the way.
Also, Progrip has an absorbable component that degrades over time and needs to get removed by the body. Apparently it takes months to completely degrade so you’d expect that you might feel some things along the way.
You’re read my account of my experience so you know that it’s a slow process. I’m sitting here right now though, in great shape, feeling good. You’ll get there soon too, I’m sure. Good luck.
-
It doesn’t look like Dr. Ramshaw plans to treat patients again. He has moved on to a different profession. Expert witness is one aspect of his new consulting business. Based on his history I imagine that the mesh makers will be using his services often.
https://www.generalsurgerynews.com/In-the-News/Article/07-21/Tips-on-Being-an-Expert-Witness/64041
“The work pays well, averaging $350 per hour for medical expert witnesses and $500 per hour for medical expert testimony, but this varies by degree and with experience.
“As I’ve gained experience and expertise in multiple areas, I’ve raised my rates,” said Bruce Ramshaw, MD, a managing partner at CQInsights, a health care data analytics firm in Knoxville, Tenn. “Consulting as a medical expert is one of the few areas for physicians in health care where you can be reimbursed what your expertise is worth, whereas most of what we do clinically is negotiate with insurers for rates based on negotiating power rather than expertise or outcomes.” “
-
“Chaplain” is Steven Kwon’s official title at the Gibbeum Hospital. So the usage is correct. And, you cannot know Steven Kwon’s intentions so insulting his character by implying that you know his motives is not right. We’re all a bit cynical but we need to be reasonable.
There are old posts on the site referring to Steven Kwon and I think that he might also have posted some himself.
https://herniatalk.com/forums/topic/new-no-mesh-surgery-in-korea/
And Steven is probably aware of Dr. Brown from past references in the forum and possibly direct correspondence. They are the two most talked about pure tissue hernia repair surgeons on the forum.
https://herniatalk.com/forums/topic/who-is-dr-kang/
-
Thanks for posting your experience. I can’t imagine living with a grapefruit sized hernia for long. How long did you wait to have the surgery after you knew that you had hernias. Two years? Did the big one just keep growing or did it grow quickly then stabilize.
I hope that more surgeons are relearning the pure tissue techniques. The professional societies seem to be “technology and innovation” focused, presumably because that’s where the investors see a way to profit. Not much money in sutures. Robotics is big now, but it’s just another way to implant mesh.
Good luck.
-
Did you have the surgery at the Shouldice Hospital or was it done by somebody who trained there, or learned it elsewhere? Won’t help your problems, I’m just curious.
I had the tip of my finger surgically reattached and the nerves eventually grew back. It took a long time though. I don’t think that there is any way to speed things up besides using the affected part. So, accepting it and being glad for any improvement seems like your best option.
The low hanging testicle is a common effect of the Shouldice procedure, as I understand things. I don’t know what happens in the long-term though. I think that people just move on.
Good luck.
-
I just came across Dr. Reiner’s web site, linked below. It looks new, copyright 2021. It seems to be a standard surgery practice site, listing the procedures he performs. But, of course, ironically, even though he does remove mesh, he also implants mesh, and uses the typical reasons about recurrence and benefits outweighing risks argument to support the use of mesh. But no numbers supporting the arguments. He’ll put it in and he’ll take it out.
He also performs neurectomies for chronic pain treatment, apparently, although the page is not complete yet. So, odds are a mesh removal will also involve neurectomy.
-
No, I mean the area of polymer fiber exposed to the body’s fluids. Macrophages, etc., the things that react to foreign material. More fiber surface means more macrophage reaction. There’s no weight involved, just exposed area. The body can’t detect what’s under the surface it only reacts to surfaces, not interior.
-
BD’s advertising doesn’t even really give a reason to use their lightweight mesh. Notice how they refer to actual weight. 60% lighter. Bad rationale.
“For surgeons who may prefer to implant less material, it is approximately 60% lighter than traditional polypropylene mesh*,”
“* As compared to other traditional polypropylene mesh, such as Classic Bard™ Mesh”