Good intentions
Forum Replies Created
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He said that it was larger than he thought it would be. But he only found a small lipoma on the other side, yet still used the same 6″x 6″ piece of mesh. For a lipoma, a blob of fat stuck to the spermatic cord.
Mesh is viewed as some sort of magical material and they want to cover as much area as possible. It is all about recurrence, still, even after it is shown over and over that mesh can and does cause discomfort and pain. Something is stopping them from believing what they know must be true. It is very much like today’s politics. It’s kind of frightenting.
Here is another thread about Dr. Felix. He, apparently, really wants to be known for pushing laparoscopic hernia repair. He is a true “believer”, but it’s really not clear why he believes. If you watch his presentations it’s almost like he sees the patients as competition, to be subdued, for some larger purpose. What that purpose is, is unclear. “For their own good”, maybe.
https://herniatalk.com/forums/topic/the-state-of-teaching-hernia-repair-dr-felix/#post-26636
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Here is a presentation from one of the surgeons mentioned in that paper, where he describes what to say to a prospective customer, and how to reduce the surgeon’s liability. It is a shocking presentation to watch, but Dr. Felix is a popular presenter, an “expert” in the field. He is training the surgeons of the future.
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Yes. Here is a very recent paper, essentially summarizing the “state-of-the-art” of “minimally invasive” surgery for mesh placement. Once they get in there they try to cover all areas that might herniate in the future. Technically, it is prophylactic mesh placement, which is supposedly not correct or ethical, but it is standard practice now. I had two very large pieces of mesh placed, 6″ x 6″, for a single direct hernia repair.
This paper is from February 2020. Chronic pain is mentioned, but only in vague terms of how to avoid its possibility. The main focus is how to get the mesh in.
Chronic pain is standard practice now also, with pain management clinics and a series of procedures to follow when a patient presents with chronic pain. It’s not the surgeon’s problem anymore, it’s a whole new class of medicine.
https://link.springer.com/article/10.1007/s00464-020-07449-z
Excerpt –
“Rule 8: A large mesh (usually at least 10 cm craniocaudally?×?15 cm medio-laterally) may be placed covering the MPO (Indirect, Direct and Femoral triangles) with overlap of at least 3–4 cm (Fig. 9).”
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Ovitex is only a few years old, with a very limited number of patients. The reported data is shockingly sparse.
Don’t overlook that TelaBio is a new company, one of those high tech “startups”, that just went public. They need to get more people to use their product quickly. It’s just the way things are today. This is not a new product from a big company. TelaBio’s survival depends on getting market share. They have to sell.
TelaBio was founded in 2012. Look through their new web page. Be careful.
https://www.bloomberg.com/profile/company/0747851D:US
https://www.telabio.com/ovitex.html
https://www.telabio.com/assets/download/OviTex%20Published%20Clinical%20Data.pdf
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Where are you? In the States, many surgeons use surgery centers to do their repairs. They can use several different centers, depending on what they need and availability. The surgery center will have more detailed records on what materials were used, since they supply those materials. 2009 is quite a while ago so your records might have been destroyed by now. But if you contact the place that you had your surgery at they might still have them.
Your pain would most likely be from the mesh pulling free from surrounding tissue or tissue close to the mesh getting strained because the mesh has tied up the tissue that it is attached to, making it stiff and inelastic.
Really, the type of mesh probably is irrelevant to finding a solution. You’ll be offered pain management and if you hold out long enough, either neurectomy or mesh removal. Eleven years is not bad, if life has been good for those eleven.
Good luck.
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Here is a recent article about incisional hernias. I don’t know if it wil help you find a surgeon but it might make you think twice about just “giving up” and letting the “system” do what it does. It’s a real mess out there.
Another “wake-up call” in decades of wake-up calls about hernia repair.
” “This should be another wake-up call—not only to hernia surgeons, but also to hospitals, payors and those funding quality improvement and research efforts,” Dr. Poulose said.”
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There is no direct mention of chronic pain or discomfort, just “issues of concern”. IF there is solid data showing benefits, it should be shared. If it’s not shared, it’s reasonable to assume that it does not exist. Chronic pain is the #1 concern for a mesh repair.
The “traditional mesh” touts similar recurrence rates. Two years is a very short time frame. The Tela Bio product was introduced through the 510(k) process which does not really require proof of efficacy just similarity to past products. And Dr. Szotek is a consultant for Tela Bio. Also, I am aware of one person in which the Tela Bio resorbable product had to be removed.
These things should all be considered. There is no way to know if the Tela Bio product is a good long-term choice. It’s only real marketing “advantage” is its newness.
From the original post –
“For patients not wanting traditional mesh and a robotic repair I utilize a reinforced biologic repair on top of the tissue repair with a 95% resorbable product called Ovitex. We have done over 160 of these in the last 24 months with a 1.8% recurrence. This rivals synthetic robotic repair without the issues of concern around the traditional synthetics.”
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The foreign body response is an inflammatory process. In “theory” it leads to “incorporation” of the mesh, which is really just encapsulation of individual mesh fibers. Chemistry is a molecular process, the fibers are huge in comparison.
Inflammation is a process that breaks down tissues to make room for rebuilding tissue. If you study the process as a whole you can understand how the mesh manages to move, and why recurrences happen. Also, in my case, why the mesh was surrounded by edematous tissue.
Here is one reference and an excerpt, below. The fact that Lucas supposedly has a recurrence from a procedure with a supposed 0.5% recurrence rate suggests that his inflammatory response is stronger than the patients who have supposedly “good” results. An educated doctor will already know all of this. A surgeon that removes mesh will know this. I think that he when he finally talks to a mesh removal surgeon that they will say what I’m saying. His body is rejecting the mesh and it wil need to come out. If he talks to a surgeon like Dr. Brown they will also offer a pure tissue repair that will have better odds of success, both recurrence and pain, than any mesh repair, based on his individual characteristics.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5805548/
“At the tissue level, inflammation is characterized by redness, swelling, heat, pain, and loss of tissue function, which result from local immune, vascular and inflammatory cell responses to infection or injury [5]. Important microcirculatory events that occur during the inflammatory process include vascular permeability changes, leukocyte recruitment and accumulation, and inflammatory mediator release “
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One more thought for you Lucas. The mesh surgeons will put much effort in to making some sort of mesh work for you. Where “work” means no recurrence. You can see that they are already planning to cut nerves (I assume that’s what “infiltrate” means, destroying the nerve), to remove the pain, even though the hernia itself should be the source of the pain. They want to change your body so that it will accept the mesh, instead of using what’s best for your body.
The inflammation from the mesh will weaken the tissue. So, the mesh itself becomes the reason to use mesh. It’s a circular argument that just leads back to mesh. More mesh. If the mesh is removed the tissue will get stronger. Only then, after a period of healing, can they assess tissue quality properly. But that takes time and mesh is about speed.
My main point is that once these surgeons become mesh surgeons they, apparently, feel the need to defend the mesh. Find a mesh removal surgeon and talk to them before making a decision.
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You don’t really need to go outside of this forum to learn about laparoscopic mesh problems. Most of the bad stories are about that method.
As this COVID-19 crisis continues the parallels between the two situations just seem more and more clear. The industry ignores the bad that’s happening and keeps pushing toward what it wants – profitable business. Ignoring the science, and the clear set of facts in front of it.
Seriously Lucas, just read the posts on this forum. Nothing has changed, there is no “best” mesh implantation method. There are stories from people who had mesh implanted 20 years ago and from people who had it done 20 weeks ago. If you’re having problems with an open repair mesh you’ll probably have problems with a laparoscopic repair, except they will make the mesh much much more difficult to remove. Your body is not “incorporating” the mesh, it’s rejecting it. It won’t matter how it’s implanted.
Good luck. Don’t be swayed by the white coat or the position in the practice. My surgeon was the head of surgery at a very large clinic. But he was run-of-the-mill as far as results.
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Dr. Brown has written about how there is a certain level of knowledge and skill required to understand how to do diagnostic injections and how to interpret the results.
Related to my first post – if the surgeon is not inclined to remove the mesh if it is determined to be the problem then they will not have mesh removal in mind as an option. When Dr. Brown says “the mesh itself can be injected” he means to do that as a way to see if mesh removal will help. When you have mesh problems it’s almost a waste of time to talk to surgeons that do not accept mesh removal as a potential cure. The “vast majority” of surgeons that implant mesh do not want to be involved with mesh removal, at all. They will keep working on you but will avoid the most likely cure if it turns out to be mesh removal. They have been trained that mesh is never the source of the pain.
I hate to always be the negative commenter but it’s just the reality of today’s healthcare.
Here are some of Dr. Brown’s past posts about injections.
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Sorry for the extra commentary alephy. It does look though like they have not made much progress with that material. If I’m reading Google Scholar correctly it hasn’t even been cited.
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Here is their web page. The paper you showed was published in 2012. It doesn’t look like they’ve done much with it.
It wouldn’t be a surprise if they just could not compete with the big synthetic mesh companies. Johnson & Johnson, and BD, and the others. Plastic mesh is much cheaper than anything else out there. It’s basically just repurposed fishnet material. There are reports of the poorer countries using mosquito netting for hernia repair, and seeing essentially the same results, as far as recurrence, as the expensive meshes. Many of the mesh variations are designed to make it easier for the surgeon to get the mesh in and reopened.
Overall, looking back ten to twenty years, there really has been no advancement of the materials used for mesh repair. The same problems exist as back then. Only a few products have been discontinued. Efforts to define the problems have been stymied.
Very similar to what’s happening with COVID-19, in the United States at least, just a different time-scale.
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Neurectomy is supposed to be a last resort. There is quite a bit on the site about the topic. I searched Google to find the herniatalk threads, link below. Going directly to triple neurectomy seems like malpractice but that’s how things are today. Your surgeon will say they tried and send you off to pain management with your new problems.
Avoid the run-of-the-mill mesh repair surgeons. They are all reading from the same playbook. Trying to make mesh work. It’s a high volume business so the low number of patients that actually report problems barely registers compared to the number of patients who never come back.
https://www.google.com/search?q=site%3Aherniatalk.com+neurectomy&rlz=1C1SQJL_enUS862US862&oq=site%3Aherniatalk.com+neurectomy&aqs=chrome..69i57j69i58.13630j0j8&sourceid=chrome&ie=UTF-8
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Here’s the view on the psychosomatic angle. My mesh removal surgeon found that the mesh was surrounded by edematous tissue. I don’t think that my brain produced it. I felt great before surgery and expected a good outcome.
https://medicalxpress.com/news/2020-02-team-hernia-surgery-recovery-outcomes.html
“The predictive model suggests that the emotional status of the patient prior to surgery—levels of depression, anxiety, grief, or anger—influence recovery outcomes. Patients may experience less pain if their fears or emotional issues are addressed before surgery.
“If we begin prehabilitation, which includes a holistic assessment—not limited to physical and emotional condition—of the person prior to the intervention, then we may be able to affect outcomes,” Koszalinski said.”
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And there is this. I have not watched it but it is probably informative. It’s the Herniatalk Q and A with Dr. Ramshaw from May 3rd.
https://www.youtube.com/watch?v=cvmLowkvg3Y&feature=youtu.be
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Here are a couple more articles with his comments.
“The relationship between mesh and chronic pain is poorly understood, Dr. Ramshaw said. “Let me be clear: Mesh doesn’t cause chronic pain but it may be a contributing factor as part of the many factors that can contribute to chronic disabling pain.”
Register for this newsletter and you can read this one –
https://www.generalsurgerynews.com/Opinions-and-Letters/Article/03-20/Value-Over-Volume/57512
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Dr. Ramshaw is a proponent of mesh repairs. In some ways, he is a denier of the premise that mesh itself causes pain or discomfort. He has stated explicitly that “mash does not cause pain”. His arguments on that topic are kind of convoluted and weak. He has his patients take a psychological exam before surgery, I believe, to see if they will be able to deal with the foreign body feeling.
He’s an interesting person in the field, very popular and active. But he is firmly in the mesh repair camp, I think.
Here is a video from a couple of years ago.
https://herniatalk.com/forums/topic/mesh-must-avoid-or-must-have-2018-sages-meeting/
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You’ll find quite a bit out there also, about surgeons who say they do the Shouldice procedure but actually do something different. Different sutures or a “modified” procedure. You might not actually be getting the procedure that gives the excellent results.
And, it’s not uncommon to go under general anesthesia expecting one thing and wake up finding that you got something else. Your surgeon will probably tell you that they will do their Shouldice procedure unless they think that mesh will give a better result.
Finally, your surgeon is probably “gung-ho” because business has dried up and he/she needs to catch up. No patients means no cash flow. Hernia repair is the cash cow of the general surgery practice. High volume and a steady supply of patients.
Be very careful of the things that you would normally be careful of even without the COVID problem. If I wanted Shouldice I’d go to Canada, to the Shouldice hospital.
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The “sac” is the stretched out fascia and peritoneum. It can contain intestine, or fat, or omentum. The contents of the sac can be pushed back in to the abdominal cavity before the sac is ligated. Meaning tied off, so that the “stuff” can’t get back in to it.
Don’t get drawn in to trying to translate comments about mesh repairs to pure tissue repairs. That’s one reason mesh is popular. It removes the need for things like ligation. With mesh the surgeon can just push everything back in to the abdominal cavity, plop the piece of mesh over the defect and all potential future defect sites, with lots of overlap in to areas that had no problems so that the defect will still be covered when/if the mesh moves and/or shrinks.
Mesh is designed to be quick, easy, “anybody can do it”, get-’em-in-get-’em-out. Pure tissue repair requires a higher skill level and more advanced knowledge of anatomy. I think that that is one reason surgeons don’t like to talk about mesh repairs. A surgeon can take pride in learning how to do a good pure tissue repair. With mesh, they usually talk about how fast they can get it done.