Good intentions
Forum Replies Created
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I don’t know how much it costs to put on one of these meetings. The corporations have the opportunity to help out, apparently. $10,000.
I wish I could understand why students coming directly from medical school say that they were not taught pure tissue hernia repair. Maybe a change of topic to something like that would shed light from a different direction.
Corporations are going to try to influence technology. It’s what they do. Share price does not rise if product revenue is shrinking. Corporations are not focused on healthcare, they are focused on money. If you leave a dog alone with food on the table and the dog eats it, whose fault is it?
https://e4n9e9m2.rocketcdn.me/wp-content/uploads/2020/09/2020-AHS-Virtual-Mtg-Prospectus-3.pdf
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It’s just hard to believe Dr. Towfigh. The evidence implies otherwise, in the hernia repair field itself, and just in society overall. The IHMR study (Ethicon, publication delayed regularly), the development of the International Guidelines (sponsored by Johnson & Johnson and Bard, linked on the AHS site as a “resource”), Dr. Voeller presiding over the AHS Foundation while also being employed as a Professor at UT Knoxville, these things are all signs of the problem. Tennessee does not require disclosure of funding for their universities. I only choose Dr. Voeller as an example because he is so “pro mesh” and his potential conflict seems obvious.
When I was in school, we got a very expensive piece of equipment donated to us. The manufacturer knew that if we learned on their equipment that we would be more likely to specify that equipment in the future, if we got in to positions with that authority. It reminded me of Intuitive Surgical and their robotic systems. https://centennial.ncsu.edu/partners-directory/intuitive-surgical/
The “blocking” is not direct. It is insidious and indirect. Fill the curricula with one technology so the other gets starved and dies. Mesh techniques wins over pure tissue techniques. No time to teach pure tissue when the Guidelines say that it is irrelevant. It seems well known that pure tissue methods are not being taught at all in the medical universities, beyond comparing them to mesh methods, as inferior.
Here is a broad overview of the problem, from 2017. Considering the last four years I doubt that things are better now. https://www.theatlantic.com/education/archive/2017/04/public-universities-get-an-education-in-private-industry/521379/
I was in school at the tail end of the “golden age of research”, when funding was primarily from government sources, to advance science for the good of society in whole. Today’s funding comes primarily from industry sources, for the good of the universities and industries first, as business entities, both public and private. It’s just the way things are today.
I think that if the sources of university funding were fully disclosed, it would be a shock to many people. Universities aren’t what they used to be.
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The author hit all of the key points, very well-written. A person could bookmark it and use it to answer most of the questions that are discussed on the forum. She could have gone deeper in to the relationship between university funding, at the colleges where the new surgeons are produced, and what the students are taught. I think that the device makers are deeply influential there, and are the ones blocking, probably indirectly, the teaching of pure tissue techniques.
Welcome back.
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JamesDoncaster, and others, I’m at just over three years since mesh removal and still improving. I think that the reason I’m improving is the same reason that the mesh did not work. The body is continuously working to get to a certain state, determined by your DNA. When the mesh is in, the body keeps working to get rid of it. When it’s out, the body keeps working to repair the damage that was caused. I cut off the tip of my finger when I was young and it took about ten years before feeling came back and probably another ten before it softened up enough that it felt normal. The time frame won’t make you happy but the continuous improvement is something to look forward to.
Here is an official document from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). There are a lot of words but they’re not really very filling. I went through it a few times to try to tease something substantial from it, but in the end it seems like the authors were conflicted and kind of lost their way, talking themselves in to circles and contradictions. Ethics discussions are usually difficult. I get the feeling of someone explaining away the deviation from the Hippocratic oath and the focus on the patient, and, instead, justifying the use of all of the new technological “advancements”.
It’s worth reading just to realize that this is the official position paper, regarding hernia mesh among other devices and procedures, of one of the premier medical societies for abdominal surgeons. The “Informing Patients…” section is worth reading at least.
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Here is the start of the Guidelines summary. Seems worded to imply that mesh is better and that Shouldice results are unknown, when anyone who follows the field knows that the opposite is true. Disingenuous, but, look at the sponsors.
“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. ….”“RECOMMENDATIONS
STRONG: The Shouldice technique is recommended in non-mesh inguinal
hernia repair.MESH REPAIR
Mesh is recommended as first choice, either by an open procedure or a
laparo-endoscopic repair technique. One standard repair technique for all
groin hernias does not exist…” -
Yes, I had a direct hernia and have not had any signs or symptoms of recurrence since having the Bard Soft Mesh removed three years ago. There is still a small piece of mesh remaining though, near the site of the hernia. It was too entangled with critical structures to risk removing. The stiffening and thickening of surrounding tissue that the mesh caused seems to stop any new hernia formation.
For anyone trying to understand the reasoning behind what’s happening, they need to keep in mind that a “market” has been firmly established in medical devices for hernia repair, with a very large revenue stream, flowing out to all of the device manufacturers. These studies in to new products are funded by device makers trying to gain market share or improve their products enough to maintain market share, or, possibly, to deflect from their responsibility and show that they are trying to solve a problem. But, as shown by the International Guidelines document, there is no focus on the best hernia repair for the patient that does not include a device, a mesh-like product. “International Guidelines for Groin Hernia Management” is actually a deceptive title. An honest title would be “International Guidelines for Mesh-Based Hernia Repair”. The group that put the Guidelines together, HerniaSurge, was funded by the mesh makers and they state clearly that non-mesh repairs would not be considered. It’s all about expanding the market for mesh.
All of this work is designed to maintain the billion dollar revenue stream. So, there might eventually be a “best” mesh device, but if pure tissue repairs are actually best for the patient, this type of work will never define that. The device makers would lose revenue and their stock prices would drop. Follow the money.
The people using the Danish hernia registry to quantify things like chronic pain and recurrence are the only ones that really seem to be showing how bad things are. If the medical industry eventually turns toward a long-term results focus instead of short-term their work might become more relevant.
Sorry to bring doom to the discussion again. The business side of things is really in firm control right now though. Marketing and advertising are their tools for influencing.
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Here is a post about a recent study using data from a “real” registry, not a company created and promoted pseudo-registry.
https://herniatalk.com/forums/topic/lightweight-vs-heavyweight-mesh/
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Here is the Ultrapro link to what I posted above.
https://www.jnjmedicaldevices.com/en-US/product/ultrapro-mesh-ethicon
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Ethicon has delayed the publication of the report again, to December 2023. But they’re still using the suggestion that the study supports their products.
“Estimated Study Completion Date : December 31, 2023”
https://clinicaltrials.gov/ct2/show/NCT00622583
“ULTRAPRO Partially Absorbable Lightweight Mesh offers strength with reduced foreign body mass1** and may reduce the risk of patient complications compared with heavyweight mesh.† In a study of patients from the International Mesh Hernia Registry (IHMR), patients demonstrated low rates of intra- and postoperative complications, such as seromas, and recurrence (<1%) after 1 year.2* In the same study, patients reported improvement in pain and movement limitations from baseline at 1 year postsurgery.2*”
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Thank you for the reply Dr. Towfigh. Can you tell me what happened to my other post? It was more critical and detailed and pointed the blame at the device makers, like Ethicon, for promoting unproven ideas in order to sell more product. I thought that it was very rational and reasonable and I supported my comments with links to relevant websites.
If we’re not allowed to post about certain companies, maybe you could create some guidelines to follow so that we know what’s allowed and what’s not. It is frustrating trying to guess at what will be allowed through the filter, whatever the filter is.
Thanks again for allowing this never-ending topic to be discussed somewhat freely.
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To be clear, my point about mesh being developed for situations like yours, should really say it’s meant for the situation that you might end up in because of your condition. Mesh is meant for use AFTER the pure tissue attempt fails.
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I had written a long post that said essentially the same things that alephy said. The surgeon that you talked to sounded like a very common run-of-the-mill laparoscopic mesh repair surgeon. Everything you wrote is what the training of the day is. The “eye” shaped mesh sounds like a 3D product, which seems to be more prone to folding, from anecdotal evidence. “Thin” probably means lightweight mesh, an idea that was introduced to the market through the 510(k) process, but several studies have shown does not have the benefits that it was proposed to have. It’s the same or even worse than the older stiffer mesh. Small entry points (incisions) and quick “healing” are the selling points of laparoscopy, but lap also lets the surgeon insert a much larger piece of mesh than an open implantation. In short, the surgeon did not say anything special, therefore the one in six probability still applies. He’s the same as the other ones.
Your situation still fits the “pure tissue first then mesh if there’s a recurrence” approach that I think should be the standard for all hernia repairs. I would bet that from a patients’ welfare standpoint that the logic supports that approach. There would be less chronic pain and discomfort in the hernia repair population, fewer patients waiting to get a hernia repair (because of the lower pain rate), less pain management necessary, and even a healthier population of surgeons, because they would know they are doing what’s best for the patient instead of best for business. Their patients would be happier and forums like this would go back to what they were intended to be, full of confidence inspiring success stories.
If your tissue is weak and the sutures pull free, or a new hernia forms, then you can still get mesh. That is why mesh was developed, for cases like yours. It has spread like it has due to efforts from the medical device makers. It is a money-maker, much more revenue generated from today’s large mesh implants than selling a few feet of suture material per repair.
Since you have learned so much I think that your odds of having a successful tissue repair are higher than most. Many people, I think, can’t resist the urge to “test” their repair and do things that they know they shouldn’t be doing. You have already learned that your body has weaknesses and have learned to live with them. You’ll probably do the same after a tissue repair and get good results, would be my bet. But, if not, mesh is always ready and there are thousands of surgeons waiting to put it in.
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Here is a typical mesh repair opinion, drgephys (his doctorate is in physics, not medicine), post #1687. This person was very “pro mesh” right after he had his surgery, convinced that he had done his research and chosen the best possible repair method. But you can see that he’s not super enthusiastic about it today. He deals with it, apparently, but he’s not jumping for joy.
https://forum.bodybuilding.com/showthread.php?t=133353003&page=57
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Thanks for posting this. You didn’t state it explicitly, but this is an example of a successful pure tissue repair. Since you’re at one year and healed, there is no reason to expect chronic pain to crop up in the future. If you do have a recurrence, you can always get a mesh repair in the future.
The only similar enthusiasm I’ve seen for a mesh repair is in the body builder forums, because they can go back to lifting heavy weights. Most mesh repair opinions are about how they are better after mesh implantation than when they had the hernia. But not the same as they were before the hernia.
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I had an odd dysfunction wherein the corpus cavernosa would not fill with blood but the glans, and I assume the corpus spongiosum (hard to tell but I think it’s the pathway to the glans) would. I had normal sensation but no erection, just a swollen glans. The problem got worse and worse over the months of the third year of having implanted mesh. After having the mesh removed all functions returned to normal, including the odd pulling sensations that I used to get in the first year of mesh, before things really started going downhill in the third year.
I tried to describe this to my first surgeon, who said “that’s not my area” and referred me to a urologist, after getting angry and asking “can’t you just take a pill?”. The urologist was clueless about it and couldn’t even make a guess, even though, supposedly, he was a urologist. Right before I had the mesh removed I had to see another urologist to have my bladder examined for mesh intrusion/erosion, via internal camera. Her expertise was in women’s issues and she proposed that pelvic tightness might be a cause.
Unfortunately, it’s just the nature of the area that people don’t really want to break things down in to the nerves and hydraulics and how it works. Even the pros don’t really want to talk about it, in-depth. They ignore it or pass it off to someone else or give you a prescription for one of the pills.
My basic point is that I had correct function before mesh, slowly degraded performance with very specific anomalies compared to the usual “fix it with a pill” dysfunction when I had mesh, and that all of the correct function came back once the mesh was removed. I had had bilateral implantation of Bard Soft Mesh using the 2014 “state of the art” TEPP procedure, done by the chair of surgery at a large clinic who also was part of a group that taught laparoscopic methods and certified the students who completed the course as “trained”. I did all of the things I was supposed to do to get a good result, finding an expert surgeon who had done many procedures, and used the latest greatest material (lightweight mesh) but got a three year nightmare instead.
Just one true story to consider. My problem was either due to nerve’s getting “numbed” so that they couldn’t control the vessels that control blood flow or because there was an actual physical blockage occurring, I think. It’s the only explanation that makes sense. But the fact that I could get 1/4 of an erection shows that the impetus was there but the work just could not be completed. Mesh can cause erectile dysfunction. What the odds are is not defined.
Good luck. I would think twice or more about the Desarda surgeon’s comments about Shouldice. The number of Shouldice operations performance is probably thousands or even millions of times more than Desarda. I think he was talking his book, as they say. Making a sale. If they don’t have actual numbers, then they don’t really know.
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“Chronic pain” is a term that didn’t really exist for hernia repair until mesh was introduced. So I don’t know about its association with any of the pure tissue methods.
It looks like your meeting with the Houston surgeon actually went very well. I don’t see the horrible manner described that you mentioned. And I don’t think that any doctor can guarantee a successful result or no pain. The best that they can do is to improve the odds, based on up-to-date high quality information. That is the main problem with medicine today I think, there are more powerful organizations controlling the information for the purpose of generating revenue or profit. Medicine is being controlled by business entities.
Your connective tissue disorder seems like one of the original reasons that mesh was developed. For extreme and specific instances. But because mesh had other business related benefits it has expanded in to the mess that it is today. It might actually be that mesh would be the best for your condition, if you could find a surgeon who knows how to use it properly. But doctors have to stick to the “standard of care” so that they don’t get sued for “malpractice”, so most surgeons use it in a way that makes the organizations safe and healthy, not the patients. If all practice is bad then malpractice is invisible to a jury. “Everybody does it this way”.
I would just keep searching and reading and thinking. One benefit of finding this Houston surgeon, an opportunity that you didn’t take advantage of, would be to ask him if thinks a pure tissue repair or mesh would be best for you. Also ask him what type of mesh he would use and how he would use it. There are so many different types of mesh and so many different ways to use it that any good attributes of mesh are overshadowed by the bad. It is chaos that is protecting the companies that profit from mesh.
Anyway, here is Dr. Kang explaining his views on the original Bassini procedure, and what he calls the corrupt Bassini procedure, linked below. I wish I had better answers. I can say that when I had mesh implanted I didn’t really feel comfortable with the surgeon that did it, he didn’t really seem confident in what he was proposing. I don’t think that he believed in the material or the procedure but it was “how it’s done”. Standard of care for hernia repair. But I trusted a surgeon friend who vouched for him and went ahead with it. On the other hand, when I had the mesh removed three years later, I trusted Dr. Billing just through talking to him over the phone. He was confident and understood the problem and felt that he could help, and he did. So, your own personal feelings come in to play I think, if you feel that you’re a good judge of character and ability. I should have trusted myself when I had doubts about the surgeon who was doing the mesh repair.
Here is that link to Dr. Kang’s thoughts – https://herniatalk.com/forums/topic/kang-repair-question/
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You could just try to push through his bad manners and contact him again. You might end up surprised. At least ask him if he knows the difference between the modified Bassini and the original Bassini. You could also pose the question to his staff and ask if they can relay a reply back to you. I always tell people to write their questions down before their visit so that they don’t get the stage fright that you got and leave without answers. You could even write him a letter so that he can respond in his own time. Doctors have to limit the time of their visits because they have a day’s worth of appointments to get through.
He’ll either get angry, maybe defensive, and cut your questions short, or he’ll realize that he’s talking to somebody that has done their home work and change his tone. I am sure that most doctors get simple nonsensical questions on a regular basis. It must be tedious.
Good luck. You don’t have anything to lose, really. He’s not going to refuse to operate because you ask too many questions, I’d guess.
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Dr. Kang has written about the Bassini and the “modified” Bassini procedures. His impression was, if I recall correctly, that the modification actually made the results worse and that’s part of what gave pure tissue repairs a bad reputation. It was, apparently, a simplified version, not taking the extra care needed to get a good result. Remember, hernia repair is a high volume procedure. The simpler the better. Get ’em in, get ’em out.
Does the surgeon still prefer the Bassini method or does he only do it if asked? His manner might have been brusque because he doesn’t really want to use that method. He might already be a mesh convert and would rather do a mesh implantation.
If you post his name there might be info out on the web. Of course, if he found out he might not be happy.
Really though, the fact that you think his manner was horrible is enough isn’t it? I would just move on and find someone you can trust. If he doesn’t have empathy for your concerns about mesh then he probably does not believe that there are problems with mesh. Subconsciously he’ll even have a reason for you to have a poor result. Because he believes in mesh for hernia repair.
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The damage that the mesh does can never be undone. The tissue that is left behind when the mesh is tediously peeled back out is not the virgin tissue that was there before the mesh was implanted. There is a new layer of “scar” tissue, thicker and stiffer than what was there before. That was my point.
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Here is a link to Dr. Kang’s hospital. There are testimonials and maybe more of the information that you’re looking for.
http://www.gibbeum.com/main/main.html
You have probably read about Peter C’s bad result from Dr. Brown’s attempt to fix his problems from prior surgeries. But you might also read dog’s account, and others, of Dr. Brown’s hernia repair results. He seems to know how to repair a hernia.
The one thing that you should consider is that if a pure tissue repair fails, you can get essentially the same results from a mesh repair afterward. No matter the method, the surgeon will just lay down a piece of mesh that covers all possible future hernia sites, including recurrences from pure tissue repairs.
But if you have mesh problems you can never go back to a pure tissue repair.
Your hernia sounds like my direct hernia in the early stages. Direct hernias form what looks like a small pyramid, that disappears when you lie down. Indirect hernias work their way down to the scrotum through the inguinal canal. I was very physically active, going to the gym, playing soccer, running, and working around the house. I tried to learn to live with it but playing soccer made it bigger. If I was starting over with what I know now, from my personal experience, I would get it fixed via a pure tissue repair, as soon as possible. I almost did that for mine but a surgeon friend convinced me that I would be okay with a laparoscopic mesh repair.
Don’t try to work out or lose weight, beyond changing your diet and doing more walking or light running or biking. Avoid any exertion that causes you to hold your breath to generate power. Avoid twisting and lifting at the same time also, that seems to cause abdominal pressure and uneven load on the abdominal wall.
I would let Dr. Brown repair mine, if I was starting over. Or Dr. Kang, if we weren’t in the middle of this mess.
Good luck.