Good intentions
Forum Replies Created
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Here is an article exploring procedural causes for mesh migration.
Apparently there are concerns about the method of placement or the patient’s actions immediately after surgery allowing mesh migration. I can only assume, because I can’t afford to buy these articles, that surgeons are finding mesh where it is not supposed to be and they are trying to figure out how it happens, so these people set up a little experiment.
It’s a bit humorous that there is almost some victim-blaming going on. “You sat up too fast, it’s your fault!”.
https://link.springer.com/article/10.1007/s00464-003-8183-0
“Conclusions
Concern about mesh migration attributable to patients sitting up immediately after surgery appears to be unfounded, at least according to the findings for the current, small, simulated study group.” -
I would consider any portion of the mesh sheet that moves from its original placement to have “migrated”. Wrinkling, balling up, folding, or the whole flat piece moving downward or sideways or upward are all “migration”.
You will find accounts of surgeons finding mesh where it is not supposed to be. The assumption is that once the mesh is placed that it never moves, therefore the surgeon who placed it must have made a mistake.
I combined wound healing and mesh migration so that a person could try to understand how collagen restructuring can allow the mesh, or portions of it, to move. Most surgeons seem to think of the abdominal wall as a static structure. They don’t seem to consider the stretching and bending that occurs during normal physical activities. Many people get on to this site and discuss situations where “everything has been fine” for months or years then they strained the area and now nothing is the same. If a piece of mesh pulls from its placement on the abdominal wall, does it lay back down exactly where it came free from? If it doesn’t then it can be considered to have migrated. Many of these displacements over time can result in a lot of movement.
I just posted to broaden the view and give some more things to think about. No matter what the method or material a synthetic mesh is a foreign body that the body will continue to try to encapsulate and/or reject for as long as it is contact with body tissue.
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A 1/2% recurrence rate seems worthy of replication.
Also, I don’t think that Dr. Kang has fully described his methods. There are two, apparently. So a person can’t really determine that it’s like any other method unless they know what his is. He’s either obfuscating or he has disclosed. Sorry, but I see a contradiction there.
If you read through Dr. Kang’s post from the beginning, not just the last week or two, you can get a good idea of what his goals are. I don’t think that he’s trying to become famous. I think that he just wants people to know about successful alternatives to mesh. Not many people have the ability and/or time to research and understand the variety of non-mesh possibilities like you did. Plus he’s competing against very very powerful marketing of mesh products from the mesh makers.
Here’s the Gibbeum web site link, if anyone wants to see the marketing.
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When thinking about mesh migration, the process of wound-healing should also be considered. I think that they are linked, just by the nature of the biochemistry.
Laparoscopy is also called minimally invasive surgery (MIS) even though the actual “wound” that is created is very large. The exposed tissue is either created by tearing apart layers (peritoneum bluntly dissected from fascia) or by burning it free using a cauterizing tool. It is then exposed to the toxic gases of cauterization and the dry toxic CO2 sufflation gas during the procedure. After the mesh is placed the newly damaged tissue (the wound) has to heal, then restructuring of the tissues takes places, for years. The typical surgeon considers their job done at about 3 to 6 weeks, after the very early stages of healing have locked the damaged tissues together.
There are many sources to learn about wound-healing but here is one that is concise.
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I don’t think that the premise that open implantation requires open removal and laparoscopic implantation requires laparoscopic removal is correct. I think that the premise is based on the thought that only disturbing tissue that has already been disturbed is desirable. But the muscle wall has already been penetrated by the hernia and the mesh itself has damaged the muscle wall due to constant inflammation.
Unfortunately, because there is no effort to track or study the facts of mesh removal, we are all just left with educated guesses and opinions, or the track records of people that have removed mesh.
It’s all part of the avoidance of the reality that mesh is not the great benefit to society that it is sold as, and that there are corporate interests that only see the large revenue stream that mesh generates. It is a multi-billion dollar industry.
Still no registry of mesh devices, and certainly no conferences that include mesh removal as a topic. And, even worse, skilled surgeons are apparently deciding not to remove mesh anymore. But they still implant it.
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I have had correspondence with the Vincera Institute in the past. They might offer some advice on what is possible. They have seen mesh problems and know how to deal with them. I wish that somebody like Dr. Meyers would write a book about what he’s seen and what he thinks could/should be done to correct the mesh pain pandemic.
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I just realized that I wrote TEPP instead of TEP, copying what you wrote. But, it might be that you actually meant TAPP.
TEP does not let the surgeon come in to contact with the bowels during the procedure. TAPP requires the surgeon to move the bowels aside so that they can get to the area of the repair.
That is an important distinction. TAP is more likely to lead to adhesions, where the bowel becomes attached to the abdominal wall. Adhesions can be very painful. There are mesh products designed specially to avoid adhesions.
So, the exact details of your operation are important. Good luck.
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Parietex is a brand name used by Medtronic for a wide variety of products. I attached a link below.
I asked about the left side because you said “bilateral” repair. Bilateral means both sides. Sometimes a surgeon will explore the other side and do nothing if they find nothing, but sometimes they will go ahead and implant mesh on the other side anyway. Also, it is common to overlap the two pieces of mesh at the midline when they do a bilateral repair. If you only got two pieces of mesh and they were both on the right side, that would mean that the left side was opened and closed without implanting mesh. There would still be healing and scarring afterward though. The TEPP procedure opens both sides equally at the start just due to the nature of the blunt dissection, from the navel entry point.
I had a bilateral TEPP mesh implantation in late 2014. The hernia was not very large, a direct hernia on the right side, and there was no hernia on the left side. But the surgeon implanted two large pieces of mesh and overlapped them at the midline. It’s just “what they do”, recommended in various training videos for TEPP mesh implantation. There is often some small defect that can be rationalized as a potential future hernia. Some surgeons implant mesh prophylactically even though it is not recommended, in general.
If you got the Parietex with the absorbable polylactic acid grips, Progrip, that could be the source of your pain. Others have reported pain after getting Progrip. The polylactic acid breaks down into small molecules which then have to be further broken down until the body can remove the fragments. The process would occur across the full surface of the mesh.
https://www.medtronic.com/covidien/en-us/products/hernia-repair/mesh-products.html
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Are you taking pain medications? They can cause constipation.
Have you tired resting completely, avoiding all undue effort, to see how the areas respond? I know that it is difficult if you have been active in the past, when physical activity made you feel good, but it might offer some clues.
It has been documented that mesh alone can cause pain. Doctors and surgeons have difficulty understanding pain if they cannot see a nerve that is being impinged, plus they have been trained that mesh can not cause pain. But, for example, simplistically, if a person gets a bee sting it is painful, even though there is not a specific nerve that can be identified. The inflammation itself causes pain.
You said that you had bilateral repair using TEPP. That would mean that you had mesh placed on both sides. It is very common, TEPP offers the ability to place mesh over very large areas of the abdomen. General thinking today is to place as much mesh as they can create a space for. To avoid future hernias.
Can you get your surgery notes? The type of mesh and how the doctor fixated it might offer more clues. There are many types of mesh used for laparoscopic repair. 3D shaped mesh, flat mesh, self-gripping mesh, biologic mesh, composite meshes that are partially absorbable…many varieties.
Spend some time reading past posts on the website. There is a lot here, people have been posting about mesh pain here for at least the last 6 years. There is a lot of good information already posted. Nothing has changed, except for a few new materials that also cause pain.
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Here is one type of plug and patch. Where your surgeon wrote”only” he probably meant “onlay”.
“The only patch was then placed and a new internal ring was created with the obdurated arms of the patch ”
https://www.bd.com/assets/documents/pdh/initial/perfix-light-plug-technique-guide.pdf
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The plug and patch is the only system that the mesh-supported “study” groups recommended avoiding. The description your surgeon wrote suggests that yours was one of the more complex plug and patch systems.
I will link this Topic to your other one so that people know more about your issue.
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Removing mesh is tedious work if the surgeon wants to take extra care to not damage any nerves or critical structures. I asked my surgeon about doing both sides in one go and he said it was really just too hard on him, he needed a break in between. Each side took 2-3 hours, I think. Plus I don’t think it’s good for the patient to be unconscious for so long.
I’d give the person removing the mesh as much time as they need.
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Shrinking, or flattening, is common with all mesh implants. Actually, it’s part of the healing process, scar tissue forms then tightens up. Many people, myself included, have experienced tightening of the area in contact with the mesh. Bard Polypropylene Soft Mesh was used on me.
I think that it is best to not try too hard to restretch the area. The tissue on the edges of the mesh is not as strong as the mesh-covered area. People sometimes report pain at the edges of their mesh repairs after high exertion.
Here is a description of the healing of external wounds. The proliferative phase is where shrinking occurs.
“The proliferative phase of wound healing is when the wound is rebuilt with new tissue made up of collagen and extracellular matrix. In the proliferative phase, the wound contracts as new tissues are built.”
https://www.woundsource.com/blog/four-stages-wound-healing
Here is the material that was used on you. It’s a porcine-based “mesh” material.
Dr. Towfigh has extensive experience with biologic meshes and might have more specific advice. Good luck.
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“Lightweight” mesh is an idea or concept that was proposed as a potential solution to the problem of chronic pain from mesh. It was pushed to market through the 510(k) process, with no long-term studies. Your surgeon is just repeating what he was told or read in the product sales pamphlets. Sorry, but that is where the doctors get their information. They rely on the device makers to tell them about the products that they are selling, in a very competitive market. The sales and marketing people are rewarded for making sales.
Recent studies seem to show that the lightweight mesh concept has no benefits.
https://academic.oup.com/bjs/article/107/12/1659/6120845?login=true
This doesn’t help you with your problem directly but might help you to understand why you’re hearing what you’re hearing from your surgeon. They are at the mercy of the device makers also.
And, you should be aware that many urologists know very little about how to handle mesh problems. You might end up stuck between two parties that consider your problem as “not their area of expertise”. The urologist will not know about mesh and the mesh implanter will not know urology. This is where I ended up with my problems.
Good luck. You might have to search far and wide to get relief.
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Here is his LinkedIn page. No signs of medicine, I think that he has moved on. He teaches business courses at the University of Tennessee now.
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The correct term is Cognitive “Behavioral” Therapy. One area of focus for its usage today is in depression, or suicidal thoughts. The “Behavior” therapy is in helping the patient stop the thoughts that lead them to feel suicidal. Controlling the behavior of their own mind.
Of course, it’s easy to see how this is not the same as stopping physical pain. One originates in the mind, the other originates in the body. It’s actually somewhat ironic that Dr. Ramshaw is focused on CBT to help patients with physical pain. He could probably use it himself to change his thought processes to accept the true source of the physical pain.
Unfortunately, for whatever reason, he has put great effort over the years in to avoiding the possibility that the foreign object itself, the mesh, is the cause of the physical pain. It is the simplest explanation, learned over millennia by humans, that foreign objects in the body – splinters, teeth, knives, needles, bullets, etc. – cause pain and must be removed if the pain is to be relieved. But, somehow, this possibility just seems to be unacceptable to him. It’s hard to understand how he can think this way, as a physician.
Dr. Ramshaw’s case is especially fascinating because he seems to be very intelligent and capable, with high energy, but his focus is on making mesh “work”, so that the “system” can continue. His approach is like that of a farmer tending to his livestock. Keep the animals functional and working, so that the farm can continue to function.
It will be interesting to see how far he gets with his efforts. At this time it looks like he is giving up surgery and developing a new profession. He went on sabbatical quite a while ago and does not seem to have reappeared as a surgeon.
https://adventhealth.cloud-cme.com/assets/AdventHealth/Uploads/42988/Documents/42988_Bio.pdf
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A recent paper for Patsient. If you’re young, why take the chance? Too much to lose.
https://herniatalk.com/forums/topic/mesh-vs-no-mesh-in-young-males-a-recent-study/
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Hello Dr. Towfigh. As a researcher and a scholar you, of course, know that a person should cite their references when they make statements like yours. “Head to head” studies are numerous and show vastly different results, among the multitude. Which one are you referring to? Type of surgery and type of mesh will be important to know, of course.
To Patsient’s point – could you choose the mesh product most likely to give Patsient a good result, and the one that is most likely to give a poor result? I have compiled an incomplete list of choices, so if you know of others, please offer them up. I put the link to my other Topic below. At the least, he can increase his/her odds of a good result. It seems a shame to just let Patsient make the wrong choice if a better one is known.
Unfortunately, there seem to so many possible choices that even the experts are lumping all of the products in to one big mesh bucket. I think that people come to this site to find answers supported by real-world facts. Which mesh should be avoided and which mesh is supported by real-world results? Even a person who doesn’t believe in “mesh” can get some value from the answer to that question.
And, if a pure tissue repair and a “mesh” repair (whatever “mesh” means) both give equal possibilities of chronic pain, which one is the easiest to solve after the pain manifests? In other words, would you rather work on a patient with pure tissue chronic pain or one with mesh-based chronic pain?
I understand the great pressure to just accept the world as it exists today. But the bulk of the data, including the head to head comparisons, lead to the conclusion that there are very valid reasons to avoid using mesh for inguinal hernia repair. The mesh problem is not getting better. It is, by definition, a chronic problem. It will be here as long as “mesh” is here.
https://herniatalk.com/forums/topic/types-of-mesh-and-their-manufacturers/