[Good intentions]

Here is a link to Hernia’s order form. Maybe I missed a link again.

https://link.springer.com/article/10.1007/s10029-018-1839-4

[Good intentions]

Thank you Dr. Twofigh. Unfortunately, that article really is a “pay-per-view” article so I am unable to see the results.

My point, as it usually is, is that the means exist to identify and call out the bad materials, methods, and devices. So many people would benefit, even the device makers, in the long-term. Stop selling the bad materials today and there will be fewer lawsuits tomorrow. Their reasons for staying quiet are so short-sighted.

If they won’t do it, that leaves the marketplace. Let us know what the bad materials are so that we can refuse them when they’re offered.

I forgot to mention one more possible correlation – laparoscopy. I don’t think that anyone who has been involved in the filed for 10 years or more can not see the correlation with the increase in laparoscopic methods and the increase in mesh problems. Regardless of the specifics, the broad trends seem to match. More lap = more problems. More lap also means more mesh, they use more and cover more area.

Until somebody shows what, specifically, is going wrong, all mesh will be considered bad, and to be avoided. It’s rational.

[Good intentions]

[USER=”2856″]mitchtom6[/USER] could you get more details about your cousin’s surgery? Many athletes or their trainers and managers seem to know to avoid mesh repairs. There are people on this forum who have described having their athletic careers ruined by mesh repairs. And there are professionals who have had their mesh removed within just a few years, in order to continue their careers.

Professional athletics seems very secretive though about injuries. I assume that they don’t want to seem like damaged goods.

Your cousin’s story would be very interesting to hear. Type of hernia, how it manifested, and the repair method and material. Even where he had it repaired if he would share that.

Good luck with your own situation.

It’s a horribly fascinating topic – https://www.theguardian.com/society/2018/nov/25/hernia-mesh-implants-cost-top-british-athlete-five-years-career-dai-greene

[Good intentions]

There is also no breakout of the symptoms shown correlated with type of mesh. Even though the type of mesh is known. They are grouped in to the reaction and nonreaction groups. That would be the start of valuable information for patients. It’s the only way to make things better, identify the bad and get it out of the market.

Also interesting that the trade names and/or manufacturers of the biologic and hybrid mesh are shown but not the polypropylene and polypropylene with PTFE. Don’t know why that would not be disclosed too. Expanded PTFE is most likely a Gore product, but the polypropylene could be many different manufacturers. If the cause of chronic pain is unknown then it can’t be assumed that all polypropylene or all expanded PTFE is the same. Assumptions can waste a lot of time and effort.

It’s a great start, thank you to the authors, whether they meant us, the patients, as the audience or not.

“In the mesh reaction group, 17 (17%) patients had 27 (23%) mesh specimens removed (Table 1). The specimens included polypropylene (17 of 27 [63%]), polypropylene with expanded polytetrafluoroethylene (3 of 27 [11%]), biologic mesh (Strattice; Lifecell) (2 of 27 [7%]), and hybrid mesh (Zenapro; Cook Medical) (1 of 27 [4%]).

In the mesh nonreaction group, 84 (82%) patients had 88 (77%) mesh specimens removed for a variety of other indications not related to the mesh material itself. These other indications included pain (n = 57 [65%]), infection (n = 17 [19%]), hernia recurrence (n = 32 [36%]), neuropathy (n = 16 [18%]), and/or meshoma (n = 13 [15%]). Some patients had more than one indication for mesh removal, for example, meshoma-related pain and hernia recurrence. The specimens in this group included polypropylene (70 of 88 [80%]), polypropylene with expanded polytetrafluoroethylene (9 of 88 [9%]), expanded polytetrafluoroethylene (3 of 88 [3%]), polyester (4 of 88 [5%]), and biologic mesh (Strattice) (1 of 88 [1%]).”

[Good intentions]

Thank you for that link. I wrote something about the paper itself but it is Unapproved. Hopefully it will be released and the following will make more sense.

Here is the image from the Twitter slide, which does not seem to be in the paper, showing the definitions of “mesh reaction” and “mesh nonreaction”. Basically, in conjunction with the Discussion from the paper, it shows that there is no predictive tool apparent for chronic pain. So, it’s still just a gamble, based on whatever information you can find out there.

From the Twitter slide –

[Good intentions]

Thank you. I misread the “Recommended Article” fees in the sidebar as fees for this one.

I’ve read the article and don’t see a description of who explanted the mesh and/or who characterized the patients’ conditions, as “mesh reaction” or “mesh nonreaction”. It also seems that “chronic pain” is in the “nonreaction” group. Regardless, it’s a nice and simple study.

The Discussion seems to confirm even more though, that it’s just a straight-up gamble to get a mesh implantation. No way to predict if you’ll have chronic pain, according to its categorization in the “nonreaction” group. No preemptive allergy tests or similar that will show a predisposition to chronic pain. It seems to confirm how hopeless things are. Even indirectly, the fact that this study was necessary, shows that the problem is real and significant, enough so that it needs to be included in the financial planning of the medical industry. It all seems sort of crazy, like “how did we get to this point?” Putting mesh in, even though there are alternatives, and now planning how to reduce the cost of taking it out. Maybe, after the math becomes more clear, financial incentives will drive a solution for the patients.

From the paper –

“In summary, we confirm that findings of foreign-body reaction, fibrosis, and chronic inflammation are ubiquitous to explanted mesh and do not correlate with patients’ clinical symptoms. No clinical deductions can be made from the pathology findings and pathology findings would not change clinical management of the patient.”

[Good intentions]

First, you need to know if it’s a recurrence or a different problem. If it’s a mesh reaction problem then more mesh will not help. You’ll still have the problems from the Lichtenstein procedure mesh, plus, possibly, new problems from the laparoscopic mesh placed on the other side.

The chromic discomfort and pain from mesh commonly comes from the irritation of approximate tissues by the mesh itself. Oftentimes the mesh is still “perfectly” placed, but it is inflamed and edemateous. Not rubbing on things it’s not supposed to. It’s where it should be, no recurrence. No fixation to cause problems. But the discomfort and pain exists. That is the problem that many surgeons can not get past – where is the cause of the pain? “It can’t be the mesh.” Even though the evidence is right in front of them, they can’t see it.

You should try to get more details on the actual material used and the procedure, if you can. I think that some doctors describe any anterior placement via anterior approach a “Lichtenstein” procedure. You might have a plug and patch in actuality.

[Good intentions]

quote localCivilian:

It seems like most mesh related complications occur because of surgical technique.

The evidence does not really support that. It’s the meme that supports the use of mesh but there is no proven correlation. It’s a hope, the hope that allows people to keep using mesh, the hope that with practice mesh will work. But the vast majority of the data available shows that the mesh itself is the problem. The best, most experienced surgeons have patients with mesh problems. The fallacy that surgical technique can “guarantee” a good mesh repair is something that the device makers love to hear.

[Good intentions]

quote mitchtom6:

Nov 2014 Original hernia surgery.. Healed and was more or less problem-free w/ occasional discomfort. Maintained a generally active lifestyle (jogging, limited weight lifting, rowing, caving, etc).

Dec 2018- Regretfully started an intense stair-running workout routine which I did for several weeks. One night I crossed my legs on the couch and felt a lower abdominal “tearing” sensation, near my pubic bone / surgical site, which was alarming. However, there was no immediate pain at that time. I called off exercise for a while. A few weeks went by with no real issues.

Your previous posts must have got held up, I hadn’t seen them until now. I see that you added some detail. You say “more or less problem-free”, then describe starting intense exercise. Were you holding back over those four years? Why? The activities you mentioned are not very intense. Jogging, light weights, etc.

I don’t want to discount Dr. Towfigh’s advice but your situation is very familiar, even down to the date of hernia repair.

Your situation is similar to mine except that I started intense activity, playing competitive soccer, as soon as the surgeon said I could, three weeks after surgery. I also had bilateral implantation of Bard Soft Mesh, two 6×6″ pieces, via the TEP procedure. I also had pain at the pubic bone when I did things that stressed that area, like pullups and pushups. In TEP they like to place the mesh all the way down on to the pubic bone, to bond to the pubic bone to hold it in place, as I understand things. The lower abdomen ends up completely coated in mesh, internally, and becomes very stiff and inflexible, like a plastic bowl.

Good luck. Supply more details if you have them. You didn’t say specifically but I’ll bet that both surgeons checked for a recurrence via the manual method, and maybe ultrasound, but did not find anything.

[USER=”2856″]mitchtom6[/USER]

[Good intentions]

“Dr. Bisgaard said ….. Even so, he still believes mesh is the best choice for hernia repair. “I do not think it’s a question of using mesh or not. I think it’s a question of furthering the evidence to show which meshes we should use and where should we place it.”

What he seems to miss is that, in the meantime, we, the patients, are essentially lab animals. Except that nobody is collecting the data from the lab animals. His words say, indirectly, that the product is unproven, as a whole. But he seems okay with continuing to do what he doesn’t fully understand. With the patients paying the price.

[Good intentions]

I saw your other question, that Dr. Towfigh answered. It looks like you didn’t give all of the facts though.

There’s a lot not quite right in the situation that you describe. As Dr. Towfigh said mesh is not a solution for a “sports hernia”. So either your surgeon told you something wrong or you misheard what they said.

Also, if you’ve had a plug and patch already, it might be that that is the source of your problem, and that you don’t really have athletic pubalgia. It might be that you really have a mesh plug and patch problem and it needs removal. Se the tweet I attached below. Athletic pubalgia has distinct symptoms. Have read the “sticky” from the first page?

Seems like a second opinion with a hernia specialist would be in order. If you give your general location somebody might have a recommendation.

Also, can you give more details on your old repair? How long ago, what type of plug and patch, etc. Good luck.

https://www.herniatalk.com/6882-in-depth-sports-hernia-guide-infographic

https://twitter.com/Herniadoc/status/1021561699290116097

What do you see?

This is a medium size Perfix #plug #mesh that has balled up, aka #meshoma . It was causing chronic groin & nerve #pain due to erosion into the spermatic cord, so I excised it. He is now #pain free!🙏🏻#meshcomplication #hernia #chronicpain #itsnotjustahernia pic.twitter.com/EgnLh0ULXR

— Dr. Shirin Towfigh (@Herniadoc) July 24, 2018

[Good intentions]

quote kaspa:

So I’ll try to have it done in Europe. USA or Canada are too far away for that.

The Hernia Centre in Germany has much experience with hernia repair. They work on top level athletes, who generally avoid mesh if at all possible. If I was in Europe it would be my first place to visit. I won’t be surprised if I end up there in later years anyway. I still have a piece of mesh in me and both groins are still adjusting to the damage done.

https://www.hernia-centre.com/

[Good intentions]

quote kaspa:

Hi. I’m new here.

I’m 51 and had my inguinal right hernia since less than 3 months ago. Something I thought it could never happen to me.

My option is a Desarda repair. I’d like to have it done by Dr. Desarda of course. But he charges a lot of money and only operates in India, and I wouldn’t like to have surgery there.

So I’ll try to have it done in Europe. USA or Canada are too far away for that. Unfortunately there are few surgeons using Desarda repair.

A good alternative would be Kugel mesh, as it only incises skin minimally, no muscle incisions of spermatic cord handling but there were quite serious side ettects in the past and I’m not sure it’s safe now.
.[/I]

Hello kaspa. Try hard not conflate the methods with the materials. At this point in time there is little evidence than any mesh is any different from any other. The only fairly strong opinion you might see is that some doctors recommend against the plug.

I think that your first decision is mesh or no mesh. Then the type of repair. “Kugel” mesh is a Bard trade name, for a mesh that has a ring of of more sold material around its perimeter, to stop the mesh from folding, in principle, or to let it spring open to the desired flat shape after pushing through the incison. But, many people have mesh problems with mesh that is perfectly fine, no folds or creases. I had two pieces of Bard Soft Mesh implanted and one had a fold and the other didn’t. But they both were inflamed and surrounded by edema (fluids) when they were removed.

The Kugel method is a method to implant mesh, and the Kugel mesh is a mesh design meant to work well with the Kugel method. But, in the end, you still have mesh in your abdomen. That is the key. It’s just another polypropylene mesh in the end.

https://akinglobal.com.tr/uploads/subdir-182-4/BARD_catalogue.pdf

[Good intentions]

quote Spanish:

In Holland, the most corrupted country in the EU and having one of the most underdevolped health system, I am offered to have a laparoscopy in weeks by the expert in hernias in the hospital, i.e. a student. Go figure.

Thanks again for the help!!

That is disturbing that you think that.

The HerniaSurge group is based in Holland, and they are behind the big push to promote a new set of “International Guidelines for Groin Hernia Management”. There is some question abut how they decided to designate themselves as the global authority on hernia repair but they have a growing following. Odd that they would come from the situation you describe..

http://herniasurge.com/

If I were in your situation I would go to Germany. I almost flew over there myself when I was having problems.

Good luck.

[Good intentions]

Here is a link to the Gallini Medical products site, I think. No mesh products shown.

http://herniatome.com/about/

[Good intentions]

quote Stonehood:

Hi,
I am new to this forum and I appreciate all the useful contribution on this site.
I live in Denmark and my hernia story is described in the following:

Male,
Age: 37
Weight: 67kg
Height: 180cm
Trying to stay in shape via running.

This mostly because in my opinion (but also the surgeon),I do not display the typical pain characteristics; stabbing, burning etc. + I think the 15% risk of worsening is a lot.

Then, change of plans. The latest visit to this unit the surgeon suddenly said that the mesh needed to come out. …..I am not sure what has triggered the surgeon. Apart from that, I trust this surgeon – I asked how many meshes he has taken out, he said about 25-30. I don’t know if that is a lot?

Don’t be afraid to ask the surgeon the hard questions. The fact that he changed his mind means that what he thought he was right about yesterday he does not feel is right today. He should be able to explain why. The world needs more surgeons to accept that fact that maybe they’ve been wrong or led astray. Holding on to the wrongness just delays the inevitable and harms more people along the way.

You probably have your own feeling of what needs to be done. We all know, generally, how nerves work and can tell when a specific part of our body is affected, or a more general area. In my case I could tell that everywhere that the mesh contacted my body was a problem, and that every day it was there was causing more damage.

One thing that you want to consider is if the surgeon plans to perform neurectomies during the mesh removal. Just because he recommends removal doesn’t mean he won’t still do neurectomies. There are surgeons out here who perform neurectomies during mesh implantation, as a preventive measure. It seems unethical and probably is but one posted so on a different forum.

You might consider the clinic in Germany. They do many mesh removals and have a focus on athletes. Many professional athletes travel there, apparently.

Get more details from your surgeon. Good luck.

[Good intentions]

Hello briby. I wrote a whole page about what “invasive” might mean but decided to not to post it.

You can look at the actual procedures via video and make your own determination. There is a topic on the site showing four different methods. I think that for hernia repair the word almost doesn’t really matter. It’s really a pointless word. Lap repair is called minimally invasive even though the instruments and dissection areas are actually inside your abdomen, and a very large area of peritoneum is dissected from the abdominal wall. I think that the word is a holdover from things like appendectomy and gall bladder removal. Not really the same as inguinal hernia repair.

But, your main concern should be the long-term results of the surgery, for you and what you plan to do with the rest of your life. This is not a broken bone repair or a gall bladder removal. The methods are fairly simple but the effect on your life can be very dramatic. Don’t worry about those odd details. Worry about the results and put the time effort and money in to getting the results you want.

Ambulatory, one-hour, scarless surgery is a complete waste if you don’t get the results that you expected. It really is. None of that will matter if the repair is bad, and/or you have a bad reaction to the mesh. It can ruin your life. You’ll wish that they had taken days or weeks to fix your hernia instead of minutes. It really will affect the rest of your life and the other people in it.

Good luck.

[Good intentions]

Here is a more reasoned response, a rebuttal, to the Guidelines. I hope that it is okay for approval. It is from the HerniaLetter site that I had posted in a different topic. It’s not as extreme as some of his writing, but seems relevant. If the Professor Emeritus and Chair of Surgery at Harvard is involved, one would think that it’s worth considering.

A proper debate requires a look at both sides. If an idea is good it will get stronger with more discussion.

Rebuttal to the “International Guidelines”
By R. Bendavid MD | June 25, 2018 | 1

The original “rebuttal” (of 2500 words) as suggested by the invited guest-editor was rejected by Drs Miserez, Fitzgibbons and Montgomery, Editors. The following is the version which was shortened to 1011 words and still rejected by the same editors of HERNIA.

The release of the proposed “International Guidelines for Groin Hernia Management in Adults” will no doubt instigate a gamut of responses. The document will be a testament to a considerable effort on the part of the steering and working committees but, regrettably, the outcome falls far too short of the exegesis which it purports to be.

In response to this attempt at an “International Guidelines”, the Boston Consensus Group was formed which expressed a deep concern about the methods leading up to the conclusions and how these translated into recommendations. This group gathered in Boston at the behest of Josef Fischer, emeritus professor and chair of surgery at Harvard. There were ten people involved and an additional nine who were not listed, nor were they actually present because of their delicate positions within the AHS, EHS and the steering/working committees of the said guidelines! These unlisted members did register objections to aspects of the guidelines to the steering committee and were rebuffed without further consideration by the leadership of HerniaSurge. We must respect the wish of these unlisted members to remain incognito as it is not anyone’s aim to create a state of subversion within the sister societies. The situation whereby members of societies seek anonymity reflects upon an unsavory political nature which these societies have evolved into and promulgated.

Because of the limitations of space and time we will simply list the major objections to the HerniaSurge recommendations which the Boston Consensus Group felt were academically pertinent and significant. The following grievances must be looked at constructively and not as a gratuitous attempt to disconcert or confuse those members who labored at it.

1. The EHS-HerniaSurge does not have a data base to corroborate any recommendations. As famed pharmacologist and teacher, Mark Nickerson once stated … ”If it cannot be measured, I am not interested”!

2. The search for publications which use RCTs and Metanalyses may be dubious retrospectively. Many of the articles did not have the statistical power for the intended conclusions. Ioannidis, Barbour and Steen have warned us about the unreliability, fabrications and retractions of articles which have become instruments of lobbies. (1,2,3). Most reliable instead would have been Random Registered Trials (Registered Clinical Trials) and Propensity Score Matching which would depend on the availability of a very large data base. Consistency and transparency of a clearly defined, pre-specified primary outcome would improve by accuracy by 10-60% (4).

3. The elimination of pure tissue repairs is a blot which tarnishes the history of hernia surgery. Only twenty years ago, such names as Stoppa, Nyhus, Shouldice, Schumpelick, Flament, Berliner etc. reported recurrence rates of less than 1-2%! Pure tissue would have been an ideal recommendation whenever meshes are removed because of a chronic pain syndrome! Where is the wisdom of removing a mesh and replacing with another albeit lighter mesh?!

4. A major objection to the Guidelines is the recommendation of mesh, laparoscopically for all women! This recommendation would never be accepted by many surgeons. It is a recommendation which, in the eyes of five national hernia societies which expressed themselves in Cancun at the annual AHS meeting, has stripped much of the credibility in the Guidelines. Certainly, such a recommendation is far from being compatible with the findings of the Shouldice Hospital and the data base Herniamed, both bodies having each 400 000 case histories in their records.

5. It is safe to say that the issue of mesh being used on everyone aged 18 years and older has been most controversial and has been generously rejected by everyone but the members of the steering and working committees of the EHS-HerniaSurge. Mesh complications become more evident with time and we have recorded complications as late as 20 years later. The Shouldice Hospital as well as Herniamed easily confirm this serious objection on each of our part.

6. The experience of a surgeon is a major contributory factor in many surgical endeavours. Is it wise to eliminate it altogether to impose a Guideline which does not have approval of an immensely knowledgeable surgical public?

7. It must be clarified unconditionally that Guidelines are not immutable laws. The appearance of a recommendation may be translated as a commandment by licensing bodies and may put (as it has already been in Nevada) many surgeons at risk unless the individual surgeon toes the mesh line! That would be unfortunate.

8. The most worrisome aspect of the Guidelines is that it exonerates all manufacturers of meshes and devices from any fault, wrongdoing, inadequate research and testing before marketing, responsibility, or any obligation towards surgeons and patients. The industry would hide behind a security screen and claim (as they already have) that mesh is safe, does not degrade so that any problems lie with the incompetence of the surgeon! These are well hackneyed tactics which have been used in court proceedings. Another court defense by the industry is the fact that the industry only supplies what the surgeons are demanding!

It is our hope that HerniaSurge will lend an ear in the hope of reconsidering many of the ill-conceived recommendations. The evidence is there, it is available, let us include it!

References:

1. Ioannidis John. Why most published research findings are false. PLoS Medicine 2005; 2(8):e124. doi10.1371/journal.pmed.0020124. (10/19/2010).

2. Barbour, V et al. An Unbiased Scientific Record Should Be Everyone’s Agenda. PLoS Medicine. 2009;6(2). doi: 10.1371/journal.pmed. 1000038.http://wwwncbi.nlm.nih.gov/pmc/articles/PMC2646782 (last accessed 10/19/2010).

3. Steen, R. Grant. Retractions in the scientific literature: Do authors Deliberately commit Research fraud? Medical Ethics: Nov 15-2010:doi:10.1136/jme.2010.038125.

4. Christopher W. Jones, Lukas G. Keil, Lukas G. Keil, et al. Comparison of registered and published outcomes in randomized controlled trials: a systematic review. BMC Medicine201513:282. DOI: 1186/s12916-015-0520-3.

5. Jones CW, Keil Lo, Holland WC, Caughey MC, Platts-Mills TF. Comparison of registered and published outcomes in randomized controlled trials: a systematic review. BMC Med, 2015 Nov 18; 13:282.

[Good intentions]

Very difficult to realize that this was published four years ago, 4/15/2014. Yet, the supertanker plows forward. Much of what he writes is much worse today. I am aware of three mainstream TV channels that have mesh lawsuit commercials on, on a daily basis, where just one year ago, you only saw them on the fringe channels. Mesh problems are so commonplace that they are becoming background noise.

[Good intentions]

I got flagged as Unapproved again. Not sure what is going on, nothing seems to be getting through.

https://thehernialetter.org/category/issue-one/