Good intentions
Forum Replies Created
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Don’t take offense, but email is too easy. A paper letter will be unique and show that you’re willing to put the effort in to get what you’re looking for. Anybody can sit down and peck out a few words in an email message, hit “send”, and wait. This message here took me more effort just to log-in than actually write the message.
I know people that barely use email anymore because their inbox gets filled with spam. They only read messages from people that they know.
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Try sending a letter. Front offices deal with a high volume of referrals and little else. They aren’t really trained in how to deal with people like you, and they probably, honestly, have little idea of what you’re talking about. Pure tissue, mesh, Shouldice, Lichtenstein, etc., means nothing to them.
A letter can be passed along to Dr. Chen, and if it’s well-written, will probably be read by him. Include your phone number in the letter so that he can call or text easily if decides to respond. Be polite and don’t insult the people that you’ve been dealing with.
Don’t try to fight the system. Work around it, and make it easy for people to give you the answers that you’re looking for.
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Avoid the Valsava maneuver. Ironically, it is used in strength training, but can lead to weakness. I used it when I had a sore back, to stabilize my core so that I could continue to play sports. It was very effective at stabilizing my core so that my back did not hurt, but I think that it is what caused my hernia.
https://en.wikipedia.org/wiki/Valsalva_maneuver
Excerpt-
“Strength training
The Valsalva maneuver is commonly believed to be the optimal breathing pattern for producing maximal force and is frequently used in powerlifting to stabilize the trunk during exercises such as the squat, deadlift, and bench press, and in both lifts of Olympic weightlifting.[10] Additionally, competitive strongmen often use the Valsalva maneuver in things such as log press, yoke walks, and stone loading, as well as any other strongman movements.” -
Thanks for a current account of dealing with some of the bigger names in the repair field.
I think that there is a lot of stress involved in being a hernia repair surgeon in today’s world. The doctors you talked to probably can’t really give straightforward answers, either because they don’t know or don’t believe that what they’re doing is actually best for the patient. Or they just don’t like being second-guessed, although it’s very reasonable with all that is happening in the field. How does anyone know who to trust?
They know that what they are doing is not perfected by a very long shot, but they don’t have the means to find a better way. They have to use the “standard of care”, which has been defined by the mesh makers through the directed development of “Guidelines” and sponsored conferences. The internal conflict must be intense.
This COVID-19 pandemic seems like a great opportunity for hernia repair surgeons to have some discussions about how to make things better. Business is slow in many states because of restrictions on elective surgeries. Somebody has to step up and lead the effort though, and stick with it.
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It’s not fixation, tacks, that cause problems with the nerves. It’s the tissue growth in to and around the mesh fibers, and the shrinkage that follows that is the problem. The nerves become trapped along with the mesh in a bundle of scar tissue.
The surgeon removing the mesh has to decide how much time to spend trying to peel the nerves free, or if they even have the steadiness of hand to get it done.
“They have installed me ProGrip mesh and that i found is they dont use tacks to fix it. So if they don’t use tacks it can’t affect ilioingluinal and iliohypogasric nerves”
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The device and material are barely three years old.
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I added “retroperitoneal” by mistake, above. Still, my questions remain.
How does anyone know that a mesh is best for the patient, in the long-term? Beyond a two week follow appointment.
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Why? What are your criteria for choosing a mesh? The “large pore” or lightweight concept has flaws, there are several recent paapers showing that lightweight has no real benefit. For inguinal hernias, retropertioneal, tissue ingrowth and incorporation are touted as desirable, so “anti-adhesive” does not seem relevant. I think that Alexander is asking about its use for inguinal hernias. Would you choose this mesh for repairing a typical inguinal hernia?
Most of the sales literature describes properties of the material but there is no description of how it benefits the patient, in the long-run. How would using this material benefit Alexander, many years out, if it was used to repair an inguinal hernia?
I think that is the reason we are all here, to learn more than what the sales brochure describes. No offense intended, but you have not said anything more than what Gore’s sales literature says, which I have linked above. Please add something from your real world experience, ideally with accounts from your patients. Without that, there’s not much value to the comment.
Seriously, we are all just looking for more than what the device makers say.
“Synecor is an excellent mesh and my first choice as a surgeon for IPOM ventral hernia repairs as well as many retro muscular repairs.
It is made with woven PTFE with large pores. The mesh has excellent anti-adhesive properties.” -
Here is a link to Gore’s sales brochure. Not a single word about the #1 problem with synthetic mesh – chronic pain – just laboratory results from old thoughts about what matters with mesh. A brochure from the 80’s, in essence. Seriously, the brochure looks like it was written in the very early days of synthetic mesh.
It’s really just another variation, with no supporting data.
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Here is the link to more supporting data, from your paper. I have seen the device before.
https://www.sciencedirect.com/science/article/pii/S2405857219300658?via%3Dihub
They said that they followed up “every subsequent year” but I cannot find any discussion about the patients’ satisfaction with the procedure, beyond six months. Only the six month chart is shown.
“Postoperative follow-ups were carried out at 7 days, 15 days,
then at 1, 3, 6, 12, 18 months and every subsequent year.”The paper starts with a very good overview of the problem and some good ideas, in words, about how to address them. But the final product is really just another device made from stiff polypropylene fibers. It should cause the same foreign body response and fibrosis as a flat piece of mesh, over time.
The primary author is the inventor of the device.
“However, a factual limitation of this study arises from possible
bias deriving from the correspondent author, who is the developer
of the implant and the related surgical technique. Nevertheless, the evidence demonstrated and discussed in the report seems to
adequately balance said perception”I think that the overview and ideas used at the start of the paper could be a great foundation for developing new products, if a group of people could get together who can think outside of the 510(k) process.
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Dr. Brown, the Shouldice Hospital, or Dr. Kang. I was very close to taking one of those paths but a friend, who is also a surgeon, recommended the chair of surgery at his practice. He really believed in the materials and method. He had had his own hernia repaired via an open mesh implantation years earlier at a different clinic. He thought that things would be better via the laparoscopic method, I don’t think that he was happy with his repair. After my experience he left the practice and has erased any sign of it from his resume. I was surprised, he was proud of his progress there.
His expertise is in an area that does not use special medical devices, so I think that he was able to maintain his original reason for becoming a doctor. The business pressure was not as great as it is in the mesh-based hernia repair field. As you can see from older Topics on the site, non-mesh methods are not even taught anymore. If you become a surgeon today you will have to implant mesh to repair a hernia, or learn suture methods on your own.
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The shame of it all though, is that the “10 Commandments” or 9 Commandments, from the pioneers of the mesh implantation lead to a 15% or more chronic pain rate.
The conversation about mesh always get diverted away from the numbers. The chronic pain numbers. The one in six chance of having chronic pain/discomfort. Focus on recurrence, and blame past mistakes or the surgeon’s skill for chronic pain, even though the data shows otherwise.
You can find that many of these surgeons that are trying materials and methods outside of the “Guidelines” (which also ignore the 15% pain rate), are best “guesses” at what causes the chronic pain. You will find surgeons using adhesives, thinking that it’s fixation that causes pain, or using the two-sided materials, or new “bio”-materials, thinking that some sort of adhesion is causing the pain. But the people behind the mesh products, the device makers, are not doing anything at all, as long as a product is still selling.
A couple of years ago it was well-accepted, and a major topic of discussion, that chronic pain was the #1 problem with mesh-based hernia repair. People like Dr. Felix ignore the #1 problem and only focus on training more mesh followers. I think that he enjoys the limelight.
Chronic pain is still the #1 problem with mesh repairs. The materials are the same and the new surgeons are being trained to the same Commandments. The use of the word Commandments is almost blasphemous.
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I talked to a urologist when I was having mesh problems (because the “system” says that mesh does not cause urological problems therefore only urologists can consider them. Even though urologists know little about hernia repair with mesh) and he made the comment that they often had to cut through or work around the mesh when they did prostate surgery. I got the impression that it was a problem for them, that they just had to deal with.
Dr. Towfigh is well aware of all of the different methods of hernia repair, but does still use mesh for repair often. That is probably why she was aware of the problems with mesh and prostate surgery.
Of course, the obvious solution is to avoid mesh. If a “pure tissue” repair fails mesh can always be used later. The reverse is not true.
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His method is a variation of other mesh methods. The mesh is pushed through the defect from the front and the device has a ring that causes it to expand and open up once it’s inside. The Kugel method and device. So it is in front of the peritoneum but behind the abdominal wall.
Here is a fairly recent paper about his method. He falls in to the same trap of reporting actual numbers, percentages, when talking about the problems with other methods but falls back on vague terms like “vastly improved” when describing the benefits of his method. Unfortunately, people often do this when the actual numbers do not support what they had hoped to show. Some of his statements are little unclear, but he does not provided a measure of chronic pain from his method. He might not know.
In the end he says that his method has similar outcomes to laparoscopic repair as far as chronic pain is concerned. Earlier in his paper he said that the chronic pain rate could be as high as 17% for any mesh repair. So, therefore, his rate would be about 17% also.
“Traditional hernia surgery carries a high risk of chronic pain. As many as 17% of patients can have significant pain for years after traditional hernia surgery. This high incidence is likely secondary to the location of the mesh used for this kind of surgery. ”
“vastly improved” below…
“With this surgery, three hernia defects are repaired every time: direct, indirect and femoral. Our series of Kugel repairs now extends to over a thousand hernia patients. In our experience, the recurrence rates are similar to that of published series of anterior approaches, with vastly improved postoperative recovery times, including time to return to work, use of pain medication, and chronic pain complaints. This is in line with findings regarding outcomes after laparoscopic hernia repair for primary hernias6, 7 of which our approach is a variation.”
https://www.jomi.com/article/8/minimally-invasive-open-inguinal-hernia-repair/
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Hi alephy, I’ve mentioned this before, but what does “biomesh” mean? What are you referring to when you write that?
It means many different things to different doctors, let alone patients. It almost doesn’t really mean anything, unless you add details. No offense intended, I know that you’re struggling with finding a solution.
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p.s. could you give some details on the type of surgery (Lichtenstein, Onstep, etc) and the mesh that was used? There are many many possibilities and variations. It might offer some clues and also give advice for future patients.
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Start browsing through the Topics on the site. Your problem is not uncommon, and the future is somewhat predictable. Your surgeon will examine you for a recurrence, he or she will very likely not find one and will report that everything is “as planned”. He/she will suggest taking NSAIDs like ibuprofen, acetaminophen, or naproxen.
Your best hope is that you just strained the new tissue around the mesh. It’s trying to shrink and you stretched it. It’s best for you if you don’t aggravate it more, you can’t power through it or work it out like a normal injury. More stretching and tearing will cause more tissue buildup and more shrinkage. It’s just waiting and hoping that it will settle down that seems to work best.
Start reading, the site is full of stories, but don’t get disheartened. About 85% of people with a mesh repair do okay.
Good luck.
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Thank you for that link alephy. I located the full paper and have linked it below.
The results do look good, in their paper. But, like many research reports, it ends with “more work needs to be done”. At the long-term interviews they apparently just relied on someone to ask the patients some questions. And ended up with “All patients seemed satisfied with the operation, the recovery and the final result.” All of that work and the end result is “seemed satisfied”. Hard to know what to think about that.
Also, they only interviewed less than half of the original group at 24 months. 104 patients out of 240 starting. “24 months (104 patients)”. It is common for disappointed patients to avoid the surgeon who performed the first procedure. It could well be that the other 146 patients were disappointed. It’s unknown.
It is not a terrible research paper though, they just weren’t very diligent at the end. It could be much much better. It’s unclear how or why a surgeon would choose that method over any other mesh-based method. They all say that they are good.
I see also that the average age of the study group is 61.7 years old.
Here are some excerpts:
” From September 2012 to August 2015, we treated 250 adult patients for primary inguinal hernia, 241 males and 9 females with an average age of 61.7 years (range: 22–90). Hernias were classified according to the European Hernia Society criteria ”
“Patients underwent to planned follow-up at 3 months (50 patients), 6 months (35 patients), 12 months (25 patients), 18 months (35 patients + 1 patient lost) and 24 months (104 patients). Average follow up 15 months. None of our patients suffered from postoperative neuralgia, sensation of foreign bodies or even simply discomfort. One recurrence was seen. The patient was re-operated by laparoscopic approach (TAPP). All patients seemed satisfied with the operation, the recovery and the final result.”
“A multicentre study, with long term follow-up, is needed to compare this new procedure with the most common techniques.”
https://www.sciencedirect.com/science/article/pii/S1015958417301628?via%3Dihub
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It’s just another surgeon’s best guess at the source of chronic pain, proposing that direct interaction of mesh with primary nerves is the cause, avoiding the idea that the mesh itself causes pain no matter where is located. By “all-in-one” I think that he means “combined”. He is combining suturing methods with mesh implantation.
At the end of it all though, there is no data supporting his premise, or his new method. It’s just another cobbled together way to do a hernia repair, no evidence shown at all that it works, let alone does not create a whole new set of complications. It’s how new products are developed today, around the world.
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Who removed the mesh? Just like the many different kinds of mesh and the multitude of repair methods, there are many different ways to remove mesh.
Hopefully things will get better for you over time. I’ve found that staying physically active helps a lot. The opposite of when I had the mesh implanted. And change is very slow, but it is constant. There is no immediate relief once you get in to the chronic pain arena.
Good luck.
@droppain