Good intentions
Forum Replies Created
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These two references are very descriptive. I am far from an expert. I became more aware of this possibility after my own personal experience with imaging.
About 2 minutes in in the video.
https://www.youtube.com/watch?v=OZP2CYFNfeY
And a summarized publication, with an excerpt of the conclusion.
https://pubmed.ncbi.nlm.nih.gov/30368312/
“Conclusions: Most radiologic reports issued for CT and MRI studies were incorrect for evaluation of occult inguinal hernia. Over-read radiologist reports were more than twice as accurate when evaluating the same images. The physician who is relying on radiologic reports to determine plan of care for a patient with groin or pelvic pain should inquire further into any negative study, especially if there is strong clinical suspicion for inguinal hernia.”
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Doctors trained to read/interpret images are generalists. They will only recognize the common signs of a hernia. They interpret images for a whole range of problems, and basically just look for abnormalities.
Hernia specialists who have learned to interpret images will have the advantage of correlating what they see on the image with what they saw during the physical exam plus the discussion with the patient. They will have all of it in their head at the same time.
That’s just my view. I had imaging done for my mesh problems, Bard SoftMesh implanted via TEP, and the report just listed things that might cause pain but said that they did not see anything significantly wrong. My surgeon did not want to hear about problems because problems are supposed to be the fault of the surgeon, for mesh implantations, so he used the image interpretation as a reason to pass me on to someone else. He did the same thing with other issues, passing me off to a urologist who said that they knew nothing about mesh, except that it got in the way when they did prostate surgery.
That’s also an example of how my surgone was a “mesh implantation expert” but not a hernia expert. He could get the mesh in but was lost when there were problems.
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pinto, you are right, it shouldn’t take such extreme measures. I thought of Dr. Kang first because I remembered the post about the imaging work that they do before surgery, plus the fact that he has examined thousands (I think) of patients.
A better answer is that anyone who thinks that they might have a hernia should find a surgeon who does pure tissue repairs as the first choice,and mesh repairs only for the circumstance where a pure tissue repair would give poorer long-term results. Any surgeon that recommends mesh as a first choice would not be a hernia repair expert. They would be a mesh implantation expert. Find a hernia repair expert.
My views have shifted more and more toward the thought that any surgeon who recommends a mesh repair as the first, or only, choice, is captured by the mesh repair industry. The evidence just seems overwhelming that a pure tissue repair for a typical hernia is the best choice for the long-term welfare of the patient. The deviations that we all see, with all of the variations on mesh devices, and the focus on laparoscopic methods for mesh implantation, just aren’t supported in terms of patient welfare. The patient is paying the price, with their long-term health, for all of these new devices and new technology.
Somehow the hernia repair field has been warped in to a business that has to be maintained by using mesh where it is not best for the patient.
Dr. Brown, Dr. Muschaweck and colleagues, and others that do pure tissue repairs would be where NickMaybe should focus his efforts. Because they have already chosen the best method for the patient’s health and welfare. The others have not, they have chosen the mesh implantation business model, which is constantly working to avoid addressing the problems of mesh.
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Quite a bit has been written on the forum about how difficult it is to identify a hernia by imaging methods. Dr. Towfigh has presented and published about it.
Have you considered Dr. Kang’s Gibbeum Hospital? Apparently they do imaging the day of surgery to confirm the details of the problem. Here is a post from the forum from a patient who had a hernia repaired there. They probably have an extensive record of the various side effects of hernias and might recognize your symptoms. At the least they might be able to tell you that you definitely do not have a hernia, if that is the case.
https://herniatalk.com/members/patientfriedman/forums/replies/
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Here is the conclusion, pasted below. PIH = primary inguinal hernias. NNT = number needed to treat, wiki link in the post above.
From wiki – “A higher NNT indicates that treatment is less effective.”
“Conclusion
The idea that mesh techniques reduce the recurrence rate in all PIHs is not supported by high level of evidence. The NNT for pure lateral hernias was very high and should be interpreted taking into account chronic pain rates and costs.” -
Second one (the site does weird things with Twitter):
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Bruce Ramshaw has created a new Twitter account, leaving MD off of the end of his name. Part of the shift.
First one:
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I don’t want to “pile on” with criticizing Dr. Ramshaw. His disclosure about his surgery mistake showed that he was close to burnout. And I’m not a psychiatrist. But it seems like spreading the word about what he’s seen with his research on “mesh” (he says he’s a scientist on his web page) would be therapeutic for him, in dealing with the damage he caused his patient through his oversight. Make up for the mistakes with truly helpful work, that can actually be seen and measured.
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It looks like Dr. Ramshaw is a consultant now, and has given up being a physician.
His goals seem to be so lofty that the hernia mesh problem is small to him. He has a “mission”. Like a man walking past a car accident with victims that need help because he has to get to work to design safer cars. He has important work to do and can’t be bothered with the small stuff. That sounds insulting but that’s what comes across to me, considering his history and his new career path. He showed that he knows how to identify a problem, but not how to go about solving it.
My apologies to anyone who knows him and is offended. It’s just disappointing to see somebody with the knowledge and abilities and background to help with a problem, and the problem sitting right in front of them, well-defined, asking to be worked on, just ignore it to do something that’s more enjoyable and/or more profitable. He has profited from the use of mesh over his career so far, and is now leaving the problems behind for others to deal with.
“Dr. Ramshaw’s mission is to shift the mindset in healthcare by reimagining patient care through applied Systems Science.”
His upcoming book:
“Finding the W(H)ole in Healthcare”“Healthcare data consulting for the real world.”
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Glad to hear that you’re finally getting in, the pandemic has really made a mess of things.
I still have a lump on my side/flank lower back from when I pulled a muscle in the gym lifting a heavy weight. I felt it tear and it was painful for a few days. I think that the muscle fibers ball up at the point where they tear, creating the lump. In my case the lump has never gone away, but it’s not painful anymore. It might be that the lump you feel is torn muscle fiber. I assume that that would show on imaging, with the density of muscle fiber.
Good luck with Dr. Martindale. Hopefully he’s been studying hard while his case load has been down and he will have some new ideas.
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In 2011 the method was probably very similar to what was done to me in 2014. A single procedure bilateral repair was probably laparoscopic TEP or TAPP. A large cavity is created between the peritoneum and the fascia and two large pieces of mesh are slipped in between. The top of the cavity would be below the navel but pretty close to it. So after implantation there is a line from side-to-side below which is the inflexible, boardy, mesh/tissue composite after “mesh incorporation”, and above which is normal flexible tissue, although it is scarred from the blunt dissection process, the peeling apart of the two layers.
So, it might be that your efforts are tearing/damaging that area, as the flexible tissue stretches and the inflexible mesh composite does not. In engineering terms it might be called a “stress riser”. One side effect of the repeated damage is that more scar tissue will be created as the body heals the new damage.
I still have a stiff thick bowl shaped area where the mesh used to be in my abdomen. It’s getting softer and more flexible over time since mesh removal, and my after-effort pain levels are significantly lower now, at 3 1/2 years after removal, than they were at one and two years. I only had the mesh for three years but I was very active and I think the constant damage created a very thick layer of repair tissue from the constant damage.
None of this really helps your immediate problem but it might help you understand what’s going on in there. I think that your best option might be to let the area settle down and heal completely.
Don’t try to “work” it back into shape like you would a normal muscle injury. It’s not normal muscle or tissue. The foreign body reaction is constant and any newly exposed mesh increases the reaction rate, I think. I spent a lot of time and effort trying to exercise the mesh area in to something healthy, get it to “adapt” to the mesh, but the reality was that it was just damaged tissue that could never fully heal.
The typical surgeon will only see the mechanics of your problem. Is the mesh where it was placed, is there a recurrence, is the mesh impinging on any specific structure that could cause pain? That’s it. If you keep coming back they’ll send you to pain management.
Good luck. Read through as many posts on the site as you have time to. There is a lot already here.
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Forever seems to be the answer. The research in to the absorbable/resorbable biologic materials is done in the hope that the FBR will destroy/replace the foreign biologic material and replace it with human tissue that is strong enough to function properly.
https://link.springer.com/article/10.1007/s00423-011-0780-0
“Abstract
Mesh biocompatibility is basically determined by the foreign body reaction (FBR). In contrast to physiological wound healing and scar formation, the FBR at the host-tissue/biomaterial interface is present for the lifetime of the medical device. The cellular interactions at the mesh/tissue interface proceed over time ending up in a chronic inflammatory process. ” -
I think that mesh is over-used. I think that for the common inguinal hernia a pure tissue repair should be used first. There is no way to undo the results of a mesh implantation, and problems with mesh are not uncommon.
The selling points used today by the surgeons that use mesh are that the results are “about” the same for mesh and pure tissue repairs. But when there are problems with mesh it’s usually a disaster for the patient. Lives ruined.
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That’s a shame Jay. Hope you get through it indecent shape.
Can you share the details of the procedure that was attempted? A surgeon might have some ideas of what to expect.
@drbrown has done many open pure tissue repairs. There are a variety of open mesh repairs, involving different types and shapes of mesh, and different methods of placement. Some of them are placed pretty deeply in to the abdomen even though the procedure is “open”.
It sounds like they cut off the blood supply to your testicle, whatever method they tried. Even a pure tissue repair can have problems like yours.
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You should just read through the posts on the forum. There is nothing new today that wasn’t the same ten years ago. Your odds of having problems are the same. It will be tempting to think that the stories from many years ago are the past, and that “there’s no way they would not have solved these problems by now”. But that is not the case. Everything is the same, actually getting worse, as they increase the area of dissection and the size of the implant.
Be very careful. Do as much reading as you can. Remember that the various clinics and hospitals need customers to survive. Business.
There is nothing special about robotic as far as the final result for the patient. It is a different form of laparoscopy. The same meshes are used and they are placed in the same areas.
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Wow, that is a scary story. What happened? Was it supposed to be a routine hernia repair? Was the orchiectomy part of the plan or the result of an error?
Normally, the function of the penis should not be affected by a hernia repair. The don’t get near any of the critical parts for erection. Your pain medication might be causing problems. If they are only for the pain from the operation you might ask about getting off of them. Sometimes they prescribe them for other reasons though, so ask your doctor.
As I understand things, pain is the sign that there might be problems with swelling. If “no sensation” means numbness that might not help you.
Are you doing anything different to try to reduce the swelling? It’s a difficult area. It seems like submerging the lower half of your body might help due to hydrostatic pressure. Pool walking or swimming. Just a guess. After two weeks your external wounds should be healed.
Good luck.
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Thanks for posting Colin. Parents with children would get great value out of your experience with the Shouldice repair. 20 years, and passage through puberty to adulthood, with no problems, is a success and what any parent would want for their child. Even many of the mesh proponents in the community of surgeons recommend against mesh for adolescents, but there are probably thousands of kids who get it anyway.
And the experience at Gibbeum Hospital is one more verification of a non-mesh option. I have the same question as mitchtom6 about your lifestyle and activities, and also how long it’s been since the Kang repair. Are you a runner or biker, do you play sports, physical labor, etc.?
Good luck.
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Any surgeon who tries to justify the use of mesh based on equivalent chronic pain rates needs to also consider the damage done in relieving the patient of the chronic pain. The damage from mesh removal as compared to whatever methods are used to cure non-mesh repair chronic pain.
Which hernia repair method gives the patient the best odds of a pain-free life, in the long-term, considering also the damage done in trying to cure the chronic pain, if it occurs.
No matter how you talk around it, a non-mesh repair is the right first choice of repair. It is the best long-term potential solution for the patient.
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Here is the abstract of the paper that seems to be the foundation for Dr. Orenstein’s conclusions. Dr. Orenstein is, apparently, a research scientist. This is a very shaky foundation for any conclusions. A single paper put together from databases which do not accurately define or quantify chronic pain.
The work in the paper seems to have been done with a goal already defined. To imply that non-mesh repairs cause just as much chronic pain as mesh repairs. Dr. Andresen is the developer of the Onstep hernia repair system, which uses a mesh product sold by Bard. Dr. Rosen also consults for Bard.
The major flaw in the paper is so obvious that it’s almost ludicrous. The pain has to be reported, and defined, as chronic pain.
“The main outcome was chronic pain reported a minimum of six months after mesh and nonmesh repair in adult patients with a primary inguinal hernia. ”
https://www.sciencedirect.com/science/article/abs/pii/S0039606017308905
Background
Chronic pain affects 10%–12% of patients after inguinal hernia repairs. Some have suggested that less foreign material may theoretically prevent pain. If the prevalence of chronic pain is less after nonmesh repairs, selected hernias might be repaired without mesh. Our aim was to clarify if nonmesh repairs are superior to mesh repairs regarding chronic pain.Methods
For this systematic review, searches were conducted in five databases. The main outcome was chronic pain reported a minimum of six months after mesh and nonmesh repair in adult patients with a primary inguinal hernia. Only randomized controlled trials (RCTs) were included.Results
A total of 23 RCTs with 5,444 patients were included. The median follow up was 1.4 years (range 0.5–10). Twenty-one studies reported crude chronic pain rates, and when considering moderate and severe pain, the prevalences of pain after nonmesh repairs and mesh repairs were similar: median 3.5% (0%–16.2%) versus median 2.9% (0%–27.6%), respectively. Both the meta-analyses and the network meta-analysis indicated no difference in chronic pain rates when comparing nonmesh repairs with open- and laparoscopic mesh repairs.Conclusion
Mesh may be used without fear of causing a greater rate of chronic pain. -
I was trying to make you aware of the potential problems with any mesh at all. I am saying “avoid mesh if you can”.
If you do choose a mesh repair, make sure that you know the details of the material and the method. It is more complex than just “open” or “robotic”. There is a very wide variety of mesh products that can be implanted, and whether or not all are the same or not is not known. Also, ask your surgeon if he does a preventive neurectomy. Some surgeons cut nerves, just-in-case, sometimes leading to problems after surgery.
Open mesh could be a plug and patch repair which is one of the materials most difficult to work with if there are problems. Open repair could be a Lichtenstein repair. It could be an Onflex repair. It could be a PHS repair. These are all different, but all “open” hernia repair methods.
Robotic repair is just a form of laparoscopic repair. The same mesh is implanted as a non-robotic laparoscopic repair. So, anything that you read about laparoscopic TAPP repair will apply to robotic repair.
Sorry. I wish it was as simple as choosing “open” or “robotic”. But it is much more than that. Robotic repair is the “new thing”, there is still much discussion about its true value.
Most surgeons are going to tell you to just choose a good surgeon and take their advice. Good luck.