Good intentions
Forum Replies Created
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quote drtowfigh:The majority of patients fortunately do not clinically react to the mesh.Those that do react must get their needs addressed by a specialist, as it’s an uncommon problem and specialists are the ones who see this problem more often and have an algorithm to address how to manage it (including need for surgery).
Hello Dr. Towfigh. Is using words like “majority” and “manage” really appropriate for this situation? It seems to be justifying the use of mesh, even though there are other hernia repair methods available that seem to give better results. 51% is a majority. That leaves 49% that do have a bad reaction.
What is the fundamental reason that mesh is used for hernia repair? It doesn’t seem to be that it’s best for the patients, on average. The results of a mesh reaction are terrible and tortuous. If you factor that in the situation is even worse. It seems that the industry is trying to save their “investment” in this new technology, forcing patients to “pay” with their own well-being. It’s counter to the reason that people become doctors, to help people, taking the Hippocratic oath at the end of their training. I can’t comprehend what is happening.
If the community of surgeons could start using real numbers, and accepting the fact that mesh might not be the wonder material that it seemed to be in the early days, or that maybe people have gone too far with mesh and need to pull back, there might be fewer patients needing to have their surgeon-caused problem to be managed. There is no mystery.
I really appreciate this forum and how you’re keeping it going. But we need to start using real numbers so that people understand the magnitude of the problem. Planning to manage problems that were created by the use of mesh seems unconscionable, especially when it is used on people that were otherwise very healthy.
If the industry is going to handle the situation by increasing “informed consent’ then the use of real numbers is even more important. Tell people the odds, that there’s a one in six chance that they might wish that they had chosen a non-mesh repair. They might have to have the mesh removed and there’s a chance that they will still feel discomfort and/or pain, for years afterward. That would be true informed consent.
Maybe I just don’t understand what it means to be a physician. Apparently, times are changing, see link below. No offense intended, I mean that sincerely, I know that it’s a difficult field with much happening these days. All the more reason though, to clearly expose these things before they grow.
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quote drtowfigh:The majority of patients fortunately do not clinically react to the mesh.
Those that do react must get their needs addressed by a specialist, as it’s an uncommon problem and specialists are the ones who see this problem more often and have an algorithm to address how to manage it (including need for surgery).
Hello Dr. Towfigh. Is using words like “majority” and “manage” really appropriate for this situation? It seems to be justifying the use of mesh, even though there are other hernia repair methods available that seem to give better results. 51% is a majority. That leaves 49% that do have a bad reaction.
What is the fundamental reason that mesh is used for hernia repair? It doesn’t seem to be that it’s best for the patients, on average. The results of a mesh reaction are terrible and tortuous. If you factor that in the situation is even worse. It seems that the industry is trying to save their “investment” in this new technology, forcing patients to “pay” with their own well-being. It’s counter to the reason that people become doctors, to help people, taking the Hippocratic oath at the end of their training. I can’t comprehend what is happening.
If the community of surgeons could start using real numbers, and accepting the fact that mesh might not be the wonder material that it seemed to be in the early days, or that maybe people have gone too far with mesh and need to pull back, there might be fewer patients needing to have their surgeon-caused problem to be managed. There is no mystery.
I really appreciate this forum and how you’re keeping it going. But we need to start using real numbers so that people understand the magnitude of the problem. Planning to manage problems that were created by the use of mesh seems unconscionable, especially when it is used on people that were otherwise very healthy.
If the industry is going to handle the situation by increasing “informed consent’ then the use of real numbers is even more important. Tell people the odds, that there’s a one in six chance that they might wish that they had chosen a non-mesh repair. They might have to have the mesh removed and there’s a chance that they will still feel discomfort and/or pain, for years afterward. That would be true informed consent.
Maybe I just don’t understand what it means to be a physician. Apparently, times are changing, see link below. No offense intended, I mean that sincerely, I know that it’s a difficult field with much happening these days. All the more reason though, to clearly expose these things before they grow.
https://www.beckershospitalreview.co…ernatives.html
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quote saro:Please Good intention, you can check the first link (http://riskcalculator.facs.org/RiskCalculator/), because I can not open it, while for the second everything is fine
Hello saro. I just clicked on the link and it opened. It opens to a page where you need to check two boxes (“I am not a robot” is one) to get to the next page.
If you use Google and search for “ACS NSQIP Surgical Risk Calculator” it should be the first result. Maybe that will work.
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Those studies are over 14 years old. New devices have been produced since then to combat pain and discomfort, like “light weight” meshes. Unfortunately, there is some evidence that they actually make the problem worse. The device makers seem to be guessing at the cause(s) for discomfort and pain while trying to stay within the 510(k) guidelines, for relatively quick and inexpensive new product introduction, in a battle for market share.
I don’t want to make you less hopeful but it’s important to be realistic. The suggestion to take psychiatric treatment drugs for a physical problem does not seem right. Especially since they have their own negative side effects. You might seek a second opinion. Your surgeon has an inherent bias and may not be completely objective.
Good luck.
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Search for Chaunce1234’s previous posts. He often includes a list in his responses. Another term used is “pure tissue repair”, or suture repair, instead of no-mesh.
Dr. Towfigh, the site administrator and founder, is in Beverly Hills and could give you good advice also. She offers online consultations. https://twitter.com/Herniadoc
Good luck.
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quote Chaunce1234:More specifically, I meant to ask you if your experience with feeling pain and discomfort impacted you in any mental or psychological fashion, basically as a side effect of experiencing the pain. For example, did you develop any sort of depression or insomnia due to the pain or discomfort you experienced? Or anything of that nature? And if you had, did you find those psychological side effects of dealing with pain to change again after your second procedure to remove the mesh?
I wrote half a page Chaunce but I’ll try to condense it. Before the mesh I was a very active member of society and family, engaged in many ways. With the mesh, my life slowly shrank down to a daily check of the state of the mesh site, and a plan for how I was going to try to make it better, today. I wouldn’t say that I was clinically depressed but I knew that my life was much worse. I was more frustrated and angry than depressed.
Now, with the mesh gone, I am planning weeks, months, and years ahead. I’m getting better, physically, every day, and that allows me to be healthy, mentally and emotionally.
One important thing for me though was that I had resources, money in the bank, and time, to solve my new mesh problem. So I had hope. The problems that you are describing will be made much worse for people who aren’t as lucky as I am. I had the ability to find a solution. Many people don’t, and their symptoms are denied when they seek help, as has been documented in many stories.
I think that if this situation was a project under a single entity, like a large corporation, it might have been halted already, just based on a comparison of the old way of hernia repair versus the new way. The new way is full of problems that never existed before.
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Are you “registered” and able to read the full article? I have not tried to register.
This article shows the same problem of grouping all mesh in to one big blob. At least the teaser does. I don’t know why there aren’t surgeons giving detailed reasons about the best mesh material. Do they all see mesh as one entity? Somebody needs to step up and start defining the good mesh from the bad mesh. I also see the inherent bias “for” mesh. Objectively speaking, the sentence should say “for and against” mesh.
There are companies discontinuing mesh products. Why? Let’s talk about that. Are they bad products or do they just have bad marketing groups?
ANUARY 18, 2019 [h=1]Talking to Patients About Mesh[/h] In Age of Social Media and Lawsuits, Surgeons Offer Advice on How to Communicate With Concerned Patients
By Christina Frangou
Boston—With more public attention on the potential complications of mesh, patients are asking more questions of their surgeons: Is mesh safe? Will I have pain? Can I have a repair without mesh?Surgeons need to take time to listen to patient concerns and talk to them about the state of the evidence for hernia mesh, said B. Todd Heniford, MD, the chief of gastrointestinal and minimally invasive surgery at Carolinas Medical Center, in Charlotte, N.C., at the American To read the full story, Register or Login
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quote Chaunce1234:[USER=”2029″]Good intentions[/USER] do you mind sharing if you had any of the brain-related aspects of chronic pain, and how or if they developed or changed before and after your particular surgery?
I mentioned in the first post, quoted below. I do not have any psych problems that I know of. No treatment, or thoughts of seeking help. I’m lucky. I thought that I would get my simple direct hernia problem fixed and be back to living my full and healthy life.
” My neural wiring was well-developed to have a fantastic outcome when I had mesh implantation. I actually had to overcome that neural wiring to realize that I would have to deal with the real physical problems that the mesh caused.”
By that I meant that I believed that I would be okay. I had the bias that many healthy people have toward others with problems, that they must be unhealthy or out-of-shape, or old, or whatever other rationalization that people use to believe that they’ll be better off than the unlucky ones. I had a friend who was a surgeon who had had his own hernia in the past, who recommended the surgeon who did the repair. The surgeon was accomplished, well-respected, chair of surgery, at a big clinic. I had the state-of-the-art TEP repair using light weight Bard Soft Mesh. Everything said that I should be a poster-person for how to make the right decision and get a good result.
My issues, besides the discomfort and pain, were some that I cannot imagine are psychological. Penis issues, not just ED, bowel issues – bowel movements the size of a cats, physical manifestations like a very tight and flat abdomen, almost like a drum head. Feeling the edges of the mesh poking in to my groin, and irritated at the center where they had originally overlapped.
I even tried to work up some sort of routine where I could do healthy things like biking or running, then wait a few days for the problems to disappear. But the overall trajectory was down, getting less and less healthy, unable to focus on things after exercise, realizing that whole weeks were passing by where I hadn’t really accomplished anything. I was taking care of my mesh, like it was a baby, it was my sole focus.
The main reason that I am more active here is because the mesh is gone.
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quote drtowfigh:As you know, many undergo what we believe is the right approach to address their chronic pain but they are not cured of their symptoms. Dr Ramshaw has shown that that negative result may be related to the unaddressed neural wiring side effect of chronic pain that is not addressed by the operation.
Are the symptoms new symptoms, from the surgery and/or the mesh, or are they the old symptoms from the hernia?, would be a clarifying question.
I think that much of this problem gets lost in the description and definition of “pain”, maybe assuming that the pain is from the original problem. A cognitive bias toward believing that the mesh should not cause pain. My problems were definitely tied to the mesh. I was better before the mesh, and am better after its removal. Time with the mesh implant was the worst.
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Here is the TAPP presentation from the “Perfect Repair” series. Shows how it’s done, says it as “just as good” as any other method. At the end he just says “pick what you’re good at”. He did not really address long-term complications at all.
One thing I realized as I watched this one was that none of the presentations addressed pure tissue repairs, except Dr. Ramshaw’s, whose presentation was not actually in the “Perfect Repair” session. They are just comparing the mesh procedures. The title of the session should have been “Perfect Mesh-Based Hernia Repair”. And, as in the others, time and money are major concerns. The economics of health care are driving much of what is happening.
TAPP repair: Who, when, how & why? – YouTube
https://www.youtube.com
This talk was presented at the 2018 SAGES Meeting/16th World Congress of Endoscopic Surgery by Jacob Andrew Greenberg during the The Great Video Debate: Perf… -
quote drtowfigh:Dr Ramshaw’s discussion abaiut neural wiring is based on his research and that of others:
Patients with chronic pain suffer from somatic and neuropathic pain in their body. They also suffer psychologically from the chronic pain. This manifests in depression, PTSD, anxiety, insomnia, etc.
he he has shown that patients who can get attention to the brain-related negative effects of chronic pain will have a better outcome from the surgical approach to treating the chronic pain (eg, by mesh removal). As you know, many undergo what we believe is the right approach to address their chronic pain but they are not cured of their symptoms. Dr Ramshaw has shown that that negative result may be related to the unaddressed neural wiring side effect of chronic pain that is not addressed by the operation.
Actually, the start of his comment was “influence from outside of healthcare, the lawyers” as the source of that “misinformation”. He didn’t explain clearly that he meant that the patient had inherent psychological problems. He almost explicitly blamed other people for putting ideas in to patients’ heads.
Looked at alongside his other comment “Let me be clear: mesh does not cause chronic pain”, he seems like somebody struggling to know what to believe himself. You can find him on both sides of the debate.
He seems like a great guy, and hard-working. But there does seem to be some internal conflict and bias to his comments. I wish him well with whatever his new situation is.
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Here is the TEP video from the “Perfect Repair” series. The presenter shows how she does her TEP repair, but at the end, even though she says it’s not a competition, it’s a debate, she “bashes” the other methods. Maybe trying to be funny, but there was no pros versus cons comparison to the other methods. I assume that it happened in the discussion.
The video also shows the dramatic difference in amount of dissection, between TEP and open mesh implantation. TEP splits open a very large are in the abdomen, side-to-side and top-to-bottom, then places mesh in that space. Very large pieces, she says “at least” 4 x 6″ pieces should be placed You can imagine a voice in the surgeon’s head saying “I really really hope this person does not have a mesh reaction”. Open repair is very focused on only the defect, TEP is a big exploration.
TEP really is a go-for-broke approach, huge dissection, peeling apart tissues in the most sensitive area of the body, and large placement of a potentially dangerous material. It looks so clean and neat but when you really look at what’s happening, it seems like a very drastic approach. I appreciate even more the time that Dr. Billing took to remove all of the two 6×6″ pieces that were placed in me. It takes much more time to undo a TEP placement than the few minutes it takes to put it in there.
TEP repair – YouTube
https://www.youtube.com
This talk was presented at the 2018 SAGES Meeting/16th World Congress of Endoscopic Surgery by Archana Ramaswamy during the The Great Video Debate: Perfect I… -
quote Chaunce1234:It is curious to me that this particular subject seems to defy all laws of supply and demand. You’d think given the large number of consumers (patients) interested in pure tissue repairs, that the market would respond and there would be a significant supply of surgeons growing to meet that demand for non-mesh repairs, but that does not appear to be happening.
Dr. Ramshaw talks often about the business aspects of medicine. Much of what’s happening now is due to pressure to standardize health care. One common solution covering all of the patient variations. It’s not really a free market supply/demand situation. It’s like the old joke about Henry Ford’s first cars, and choice of color – you can have any color you want as long as it’s black.
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Dr. Ponsky presented at the recent SAGES meeting, in the “Perfect Repair” session.
Laparoscopic inguinal hernia repair (Based on Patkowski’s technique – YouTube
https://www.youtube.com
This talk was presented at the 2018 SAGES Meeting/16th World Congress of Endoscopic Surgery by Todd Ponsky during the The Great Video Debate: Perfect Inguina… -
Here is a video titled “Inguinal hernia-Open mesh repair” in the “Perfect Inguinal Hernia Repair” sub-category. It’s really just a collection of “state-of-the-art” techniques, I believe. No actual measurement of “perfection”.
It doesn’t really instill confidence. The presenter makes an off-hand comment that if the patient has a non-painful hernia when they come in that they will certainly not have pain afterward. “They’ll be fine” at 4:00. He cites a one year study. This does not fit with many stories on this forum and around the internet. People who got their hernia repaired to be safe, and ended up with more pain afterward. Anecdotal, of course. The pain discussion starts at 2:50.
Inguinal hernia-Open mesh repair – YouTube
https://www.youtube.com
This talk was presented at the 2018 SAGES Meeting/16th World Congress of Endoscopic Surgery by Matthew I Goldblatt during the The Great Video Debate: Perfect… -
Here is a link to the whole 2018 “playlist”. There are a few more hernia, and mesh, presentations.
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quote Good intentions:Dr. Bruce Ramshaw even can’t resist defending what’s happening and seems in denial. His statement from the article is surprising. I can’t see a reason for making such a blunt statement except to defend the industry.
“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.”
That’s the same logic as “the fall doesn’t kill you, it’s the sudden stop at the end”.
I wrote the comment above then went back over what I knew about Dr. Ramshaw. He seems to undecided about the whole “mesh” situation. He has written quite a bit about post-repair pain, and does remove mesh. But sometimes he seems to imply that the problem is psychological. It’s hard to tell what to think about his comment, it might be one of those Freudian slips, from wishful thinking. I don’t know.
Here is a link to his UT page, and a recent video from the last SAGES meeting. He seems like a guy you would want repairing your hernia.
https://www.youtube.com/watch?v=Pffj-GAEMRs
Bruce Ramshaw, MD, FACS | The Department of Surgery
http://gsm.utmck.edu
The University of Tennessee, Graduate School of Medicine is located in Knoxville at the University of Tennessee Medical Center. The Graduate School of Medicine is part of the University of Tennessee Health Science Center and offers residency programs, fellowships, and opportunities for medical students. -
The American College of Surgeons does pretty well but still implies that chronic pain is a short-term issue, “pain one year after surgery”, not really exploring what happens after that. But they do give a value of 10-12% and address it directly. More promising. They also show that the recurrence rate is higher for laparoscopic than open, which is surprising. Overall, they seem to have compiled current study results and are facing them directly. Just not going far enough with chronic pain. “Pain” is the original reason for going to the doctor. It should be of the highest priority.
https://www.facs.org/~/media/files/education/patient%20ed/groin_hernia.ashx
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The US FDA tries to address the issue but still falls back on the lack of understanding, thereby perpetuating the problem. Blaming chronic pain on previously recalled products. Still making very vague statements, “many complications”, and taking no action. At least they’re getting closer.
“Many complications related to hernia repair with surgical mesh that have been reported to the FDA have been associated with recalled mesh products that are no longer on the market. ”
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These two links illustrate the huge disconnect between some hernia repair surgeons and general surgeons, at least in Great Britain. Even though supposedly they are the same type of surgeon, and hernia repair is a skill within general surgery skills, somehow the hernia specialists in Great Britain are on a completely separate page from the rest of the surgical community. I say apparently, I haven’t read the whole article, it’s a pay-per-view article.
It seems that the hernia mesh repair surgeons in Great Britain, or at least their representative, are using the “no firm relationship” view to keep on doing what they do. It’s shocking to see it in print. The first article is about caring for your patients, the second one is about caring for your business. Some of these surgeons must know each other, it’s hard to see how they can coexist. And this is after many years of published studies showing that there is a correlation between mesh hernia repair and chronic pain, higher than pure tissue repairs, where chronic pain was so low that it was not an issue. The chronic pain issue has developed in step with mesh repair.
Hate to be so negative but these are recent results. Strange how the industry seems to be paralleling American politics.
From the article – “Around 570 0000 hernia mesh operations have taken place in England over the past six years, figures from NHS Digital show. Leading surgeons think that the complication rate is between 12% and 30%, meaning that between 68 000 and 170 000 patients could have been adversely affected in this period.”
Hernia mesh complications may have affected up to 170 000 patients, investigation finds
BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k4104 (Published 27 September 2018)https://www.bmj.com/content/362/bmj.k4104.full
From the British Hernia Society – “Some patients can develop chronic pain after surgery. There is no firm relationship with the use of mesh and chronic pain, and non-mesh repairs can equally result in this problem.”
Mesh and your Hernia Repair “helping you to make an informed choice”