MarkT
Forum Replies Created
-
Ah ok, that makes sense…also, I’m suspecting it is not dynamic MRI that is being done, otherwise I don’t see how it could be missed if it is visible standing.
For a non-occult hernia (like yours that is visible standing), even regular MRI could pick it up if they compare images with/without valsalva…though I imagine that still depends upon the person reading the scans to know what they are looking for.
-
Dr. Towfigh has been involved with studies looking at this very topic.
MRI is superior for detecting hidden/occult hernias:
https://doi.org/10.1001/jamasurg.2014.484
But it is important to have someone read scans who knows what they are looking for:
-
Why don’t you consult with Dr. Towfigh and have your MRI sent to her?
If you have read her research on imaging and occult hernias, then you know that people reading the MRI scans need to know what they are looking for.
Please don’t be discouraged by all the stories you read on this forum…there is a grossly disproportionate amount of negativity that does not reflect the actual likelihood of having a successful repair.
-
I would keep the Nov. 1 consult for now and go to Shouldice ASAP first thing one morning to ensure an available slot that day for a free walk-in consult.
Assuming your scenario fits within their narrower patient profile, at worst you will leave with another option to consider, including a clear timeline, and you could have that information virtually immediately. Then you can decide if it is a suitable option for you or if you want to wait and consult elsewhere.
-
How accessible is Shouldice Hospital to you? There is a ‘no appointment or referral required’ policy with their free examination clinic. If you can’t attend, but your doctor will supply a letter confirming the hernia diagnosis, they will schedule surgery in advance.
I’ve had two flawless repairs there (one side 30yrs ago, the other 20yrs ago) and would highly suggest consulting with them:
-
That does seems really weird, so I took a quick look to skim the article.
I don’t know why someone chose that as the summary to be displayed. It is merely the first of five ‘key points’ listed before the article begins…and it is worded rather poorly compared to what is actually written in the article, where part of the intro states:
“Refinement of techniques and mesh-based tension-free repairs has resulted in a decrease of hernia recurrence rates to between 1% and 5% [5]. Chronic postoperative inguinal pain (CPIP) is now the most significant complication and quality of life is the most relevant outcome of inguinal hernia repair [6], [7]. CPIP affects the daily life of 5% to 10% of patients, with downstream effects on patient satisfaction, health care utilization, societal cost, and quality of life [8], [9], [10]”.
The article then talks about the definition of CPIP, different types of pain, relevant anatomy, risk factors, symptoms and diagnosis, treatment and management options, and concludes with a small blurb on future directions.
Just shoddy editing, IMHO.
-
There is no good reason to believe higher-volume surgeons are ‘fatigued’ or bored or less attentive or whatever than anyone else. That idea is based on your subjective opinions without any real evidence to back it up.
Some people are simply very passionate about their work, even if others do not find it exciting or would be bored with it after a while. Some people have a remarkable work ethic and are very diligent even when their work is somewhat tedious or taxing. Some people find repetition desirable and comfortable. Some people will tell you there is enough diversity in what seems like repetitive work that it keeps them on their toes and interested (there is a fair bit of diversity between human bodies and hernias).
Beware projecting your own thoughts and beliefs onto others. If someone does 8-10 surgeries a day, a few days per week (virtually no one is in the the ER all day long, five days a week) and has been doing so for a very long time, maybe ask them what their motivation is and how they stay sharp instead of not only assuming they must be ‘fatigued’ at the end of each day but that this fatigue correlates to some decline in proficiency or increased likelihood of mistakes.
I don’t think I would necessarily choose the ‘highest-volume’ surgeon if it looked they were simply trying to do as many as humanly possible for whatever reason…but I would rather have a high-volume specialist vs. someone only doing a few per week, and possibly doing multiple different things (like a general surgeon) so that they are actually only doing a relatively small frequency of YOUR repair.
-
Hi Peter,
I was just recently wondering how you were doing, but never know if it is ok to reach out. I imagine posting and talking about things might be a little cathartic, but also tedious and painful, so thank you for the update.
Your wanting to make your family proud and to not feel like a burden is completely understandable, but the feelings of shame are troubling (your circumstances are not your fault), as is the suicidal ideation. At the risk of sounding like a broken record, I hope you seek out some psychological support as you continue to navigate all of this.
It might be a shot in the dark, but I’ll chat with a couple of people I have recently been working with in a sports medicine clinic to see if they can point to any potential resources.
Consulting with Dr. Conze sounds like a good idea, do it! Did you ever try to contact Dr. Kang in Korea to see if he might know anyone? Seeking diverse perspectives outside of our ‘local’ systems can be helpful. Keep spreading your story, keep talking to doctors…the networks that people have are extraordinary and you never know when one of these connections might lead to the right person.
– Mark
-
Thanks for sharing a detailed update, Ivan. We need to hear more of these positive experiences to help offset the unfortunate perception that the probability of negative outcomes is higher than it actually is, and to reduce the hysteria perpetuated by some louder voices around here.
Glad to hear you are at the 1yr mark with no complications and enjoying a normal recovery. You account of feeling fine, but then getting a little ‘reminder’ sometimes after making sudden movements mirrors my experience in the short-term after my Shouldice repairs. Every once in a while, your body reminds you of your limits and that full healing takes time.
I agree with your advice regarding exercise. Everyone’s surgery, recovery, pain tolerance, etc. will be somewhat different…some will feel comfortable doing light exercise very soon after their surgery while others may struggle to walk…but barring different instructions from their surgeon, everyone should try to walk as much (and as soon as) possible to restore mobility and promote healing. Generally speaking, resting completely is not helpful.
Hopefully you will check-in periodically. I think that having more longer-term updates will be helpful for some current and future forum members.
-
The purpose of the study was to (retrospectively) compare outcomes between the Bard and Dextile meshes.
The background section talks about some ideas and research about mesh and the potential reasons behind complications of pain and recurrence (incl. inflammatory response, light-weight vs. heavy-weight, flat vs. 3d shape, and fixation vs. non-fixation). They point to a systematic review finding no improvement on chronic pain or foreign-body sensation with light-weight mesh, but increased recurrence rates. Also, that flat mesh is more likely to fold or migrate, and that fixation efforts to reduce that problem can result in more chronic pain. Avoiding fixation with 3D anatomically shaped heavyweight mesh has been identified as a ‘safe and effective’ solution.
They don’t explicitly talk about the decision process behind the hospital switching meshes (which would be nice to know, but isn’t the purpose of this paper), only stating the following:
“The hospital where the current study was conducted has switched from the 3DMax mesh (Bard) to a relatively new 3D mesh, the Dextile Anatomical mesh (Medtronic) since July 2020 for all laparoscopic hernia repairs. This new mesh has a 3D patented anatomical shape and conforms even more to the contours of the groin region in comparison to other 3D meshes. It is made of non-absorbable macroporous monofilament polypropylene textile and is heavyweight. The shape allows wider coverage of the hernia defects and potentially further reduces the risk of hernia recurrence.”
On their attempts to distinguish between reasons for recurrences so that mesh isn’t implicated as the sole/main reason in all of them: “The 2-year recurrences in the 3DMax Mesh group and the Dextile Anatomical Mesh group were due to a lipoma in 8.0% and 13.6%, due to a “true” recurrent hernia in 72.0% and 68.2% and unknown (e.g., when only physical examination was done) in 20.0% and 18.2%, respectively”.
I’m not quite sure how they distinguished between “true” recurrences and those due to “unknown” reasons…and it is unclear to me if those are mutually exclusive categories or if some proportion of the “unknown” are actually “true” (however “true” is defined)?
So we have a product for which this one study found no real clinical utility: “Even though the surgeons who used the Dextile Anatomical mesh were satisfied with the features and handling of the new product, the results of this study suggest that there were no substantial clinical advantages over the 3DMax mesh with regard to the studied outcomes.”
If there is a silver lining, at least a study with non-significant findings did not get buried (which was too common in the past)…and if I can be idealistic for a moment, we can hope that this helps to shift attention away from mesh shape and towards other reasons behind the troubling recurrence and pain rates we continue to observe…i.e., maybe we are seeing a plateau with how mesh product design can address these issues…?
As with most studies, I would love to see longer-term follow up data…as noted, those recurrence and pain rates are surely understated with only a 2yr post-op timeline passively relying upon patient reports.
-
I suppose I could also summarize the discussion points instead of copy-paste if that is a copyright issue…I was feeling lazy, and it won’t let me edit the post anymore :/
-
This is a retrospective study, not a randomized control trial. Patients just gave the standard informed consent that covered future use of their data.
Also, there was no choice in what mesh was received because the “hospital where the current study was conducted has switched from the 3DMax mesh (Bard) to a relatively new 3D mesh, the Dextile Anatomical mesh (Medtronic) since July 2020 for all laparoscopic hernia repairs”.
Given that the study covered all repairs (with some exclusions) done between Jan. 2019 to Jan. 2022, it seems that which mesh each patient received simply depended upon their surgery date.
No statistically significant differences in ‘long-term’ outcomes:
Chronic pain 1yr out: 3.4% (Dextile) vs. 3.0% (Bard)
Recurrence within 1yr: 3.8% (Dextile) vs. 3.0% (Bard)
Recurrence-free probability after two years: ~94% (Dextile) vs. ~97% (Bard)Some discussion:
“Despite the fact that the anatomical shape of the Dextile Anatomical mesh potentially allows wider coverage of the hernia defects and thus potentially lowers the recurrence rate, this was not found to be the case in this study. When the Dextile Anatomical meshes were first used, several early recurrences were seen after using the small mesh (13?×?9 cm). Therefore, the standard policy was changed to using the medium mesh (15?×?10 cm), which was also the standard policy during the current study period. Overall, the Dextile Anatomical mesh had a low hernia recurrence rate but did not differ significantly from the 3DMax mesh. As described in the results section, not all recurrences were “true” recurrences but also lipomas, although these lipomas may have formed in the interim, others have described recurrences due to missed lipomas [23]. This would suggest that these particular recurrences are not necessarily related to the mesh but to the technical execution of the surgery.
…
Another reason for the development of an anatomical three-dimensional hernia mesh was the assumption that this could reduce the risk on early- and chronic post-operative inguinal pain. This is thought to be the result of to the mesh adapting to the contours of the inguinal region and avoiding the need for mesh fixation, thereby minimizing injury to nerves. The present study confirms the previous reported low chronic post-operative inguinal pain rates in laparoscopic inguinal hernia repair using a three-dimensional hernia mesh [18, 19]. However, no significant difference was found in early post-operative pain at 8 weeks or chronic post-operative groin pain between the Dextile Anatomical mesh and the 3DMax mesh.Even though the surgeons who used the Dextile Anatomical mesh were satisfied with the features and handling of the new product, the results of this study suggest that there were no substantial clinical advantages over the 3DMax mesh with regard to the studied outcomes.
…
One limitation is that only one follow-up at 8 weeks post-operative was conducted. Previous studies with telephone contact showed that most recurrent hernias are referred by general practitioners. All patients were instructed to report when they had reappearing symptoms. However, late recurrences may have been missed since not all the patients were investigated after 1 year. In addition, there was no randomization of patients due to the retrospective design of this study, which may have led to selection bias”.It is worth noting that the purpose was to compare the two meshes over the shorter-term…but the limitations they mention are important, because they suggest that the pain and recurrence rates may be understated (IMHO, they surely are).
They only pro-actively followed-up once with patients 8-weeks afterwards and then just told patients to contact them with subsequent problems. So the longer-term chronic pain (pain > three months) and recurrence data relied upon patients contacting the hospital. Further, we know that 2yrs is an insufficient follow-up period to accurately measure chronic pain and recurrence. Their own graphic shows a number of recurrences being reported near the tail-end of the 2yr period and there is no reason to believe that suddenly drops off to zero.
-
ABSOLUTELY go to a hernia specialist, if possible.
Regardless of the repair method, it is better to have a hernia specialist handle the repair, rather than a general surgeon…and that is particularly true for less ‘ordinary’ or higher risk cases.
-
Your hernia is small, you’re relatively young, and you’re active/fit. It seems likely you would be a good candidate for a tissue repair and I would thus consider a Shouldice repair with Dr. Sbayi (who was trained in the repair at Shouldice Hospital).
I don’t see the value in assuming even the relatively small unique risks associated with mesh, unless there is good reason to do so. I also see little benefit in waiting too long to get it fixed, given that your hernia is symptomatic and you lead an active lifestyle. I certainly agree that it is important to learn more and not rush into a decision…but getting too bogged down into the drama on this forum will likely only raise your anxiety level. There is a lot of ‘muck’ to sort through here, unfortunately.
I had two repairs at Shouldice hospital (one side just over 30 years ago, the other about 20), with zero post-op complications or restrictions on activity since, but that is just my experience. It is a strong, proven tissue repair with many decades of history behind it…but also a comparatively complex/nuanced one that you want done by a skilled, experienced, high-volume expert in THAT repair (and that advice really still applies for any type repair).
I would recommended at least consulting with Dr. Sbayi as you contemplate your options.
-
I think I’m ready for a break…just tired of the hysteria, hyperbole, disrespect, and irresponsible misrepresentation.
Whether it is a case of ‘sock puppets’ (entirely possible) or perhaps like-minded imports from an echo chamber somewhere (my other theory), it doesn’t really matter. I feel very badly for people who come here looking for good information and have to wade through endless muck.
I’m not sure what the solution is…perhaps some more active moderation.
-
miner, if yours was visible, why were MRI and CT done? Were there other potential issues they were looking for in addition to the hernia?
-
Dynamic imaging entails capturing a series of quick time-lapsed images in succession vs. static imaging that capture snapshots in time.
I copied the MRI protocol she has posted in the past, along with some of her notes about it, but I’m not sure if anything has since changed, so I would definitely confirm it with her:
1. For all of our groin pain MR studies, we have the patient place a fiducial marker on the site of the pain.
2. We prefer 3Tesla MRIs, though 1.5T is acceptable. Open MRIs are not acceptable, as they lose resolution for the pelvis.
3. The following are then acquired:– Axial, sagittal, and coronal T2 HASTE with breath hold.
– Axial, sagittal, and coronal T2 HASTE with valsalva.
– Single-slice saggital plane dynamic valsalva acquisitions- typically about 5 individual acquisitions, both through and on either side of the fiducial marker.
– Axial T1 gradient echo.
– Axial T2 fat sat (either fast-spin echo or STIR depending on the machine).Note that some call it a sports hernia protocol, but it is a bit different (most sport hernia protocols don’t do valsalva components).
No reason to use any contrast with MRI (usually oral contrast for CT, can help show bowel and hernia…or IV for inflammation issues).
Important to do dynamic…yes, more labour-intensive, can take 45 min. or more to get everything…the video aspect is key to showing small hernias.
-
That’s not a ‘routine’ surgery though…a 12yr surgery would very much be an exceptional case.
-
Interesting vid.
There is no doubt that long surgeries are taxing, but just as Dr. Towfigh states in that clip:
“You go into, like, your zen mode…I forget everything, I have no bladder, sensation, my thirst sensation is gone, everything is gone, I’m just focusing on surgery…(her guest then says “I’m the same way”)…I kind of like it, it’s kind of like our little country club, the surgery, operating room, and so on…’
This speaks to the attentional focus, the motivation, etc. that characterizes expert surgeons. She noted that she once had a 12yr surgery! No doubt that is quite physically and psychologically demanding and doing that every day would be challenging, but that is not the norm. I think we can imagine how comparatively ‘easier’ (still not ‘easy’!) it is to do a series of short, routine repairs where you do have some sort of natural break in between.
Note her guest mentions his ‘clinic day’ and how he ‘dreads’ it because he would much rather be in the OR. From that we know that he’s not in the OR five days a week, all day long…and two, he wishes he was, which again speaks to motivation. If he were unduly fatigued by his work, he would probably look forward to those clinic days 🙂
I do agree with your point that I’m looking for some reasonable middle ground though…although not really the ‘middle’, as I’m still tending towards high-volume specialists.
Unfortunately, we don’t know the magic number in terms of frequency and volume required to achieve a level of proficiency that correlates with the highest odds of having complication-free outcomes. I don’t doubt there is a point of diminishing returns that is below what the highest-volume folks are doing…but I would still err on the side of a high-volume specialist, because the skill/experience they have accrued is logically a positive, rather than a negative, in comparison to a generalist or someone who simply does have the same number of ‘reps’.
-
temporarily.