[pszotek]

We are already discussing our experience with this through our secure system AP. Hopefully someone here can relate a similar experience as we have discussed.

Dr. Szotek

[pszotek]

Alephy,

Working on getting the contacts. Reached out to them to make sure they are ok with me giving out their email. As soon as I hear back will get their email addresses to you.

Dr. S

[pszotek]

Alephy,

Maria Bergmeister – Universitat Innsbruck

Or

Al Windsor – UK

They have the most experience with the product there and are open to using alternative products such as this. If you want me to email them and introduce you just shoot me an email and I will put you in contact.

[email protected]

Let me know if you need anything
Dr. S

[pszotek]

Alephy,

Ofcourse. Happy to reach out and find out your best option for discussion. Everyone has the right and should do their own research and make their own decisions. Part of that process is gathering information so that you can make the decision that is right for you. This is why I related our experiences with Ovitex as there is not a lot of data out there on it so I was just trying to help give you more information. I believe in a model of patient choice so much that I recently discussed this very same issue with a participant from this very website who had researched Synecore and was interested in that repair with the robot. I did not hesitate to let them know I know surgeons using it and would be happy to use it for their repair if they desired. This is exactly how we started using Ovitex in robotic Inguinals. A patient did their research and asked me to do the repair with it so we agreed as he felt that was best for him and he understood the long term risks of recurrence with a product that had not been around for very long. Needless to say he did great and so I began offering patients a choice who desire alternative products and our data has been at least equivalent to any synthetic data at this point. Since we use text messaging directly to my patients I am always available to them and alway in contact with them. As a result if we were having problems I would know about it better than at anytime in my career or any surgeon that does not directly communicate with his patients 24/7. Let me see best location for you and get back to you. If you want to do a telehealth visit with me just let me know as another option for information.

Dr. S

[pszotek]

Alephy,

1) persistent pain can be a result of any surgery but in hernia surgery it is believe that at least some percentage of it is due to the amount of FBR to the mesh/inflammation

2) less foreign body reaction is better for any surgical implant

3) most biologic materials tend to have less FBR (they are collagen and protein based) and less severe complications as they are tissue but historically they have suffered from a higher recurrence rate – reherniation

4) it stands to reason if we can lower the FBR using more natural materials and not increase the recurrence rate this is heading in the right direction and that’s what I’m trying to do

5) I have a number of patients who have had hernias at different times and now have synthetic in one side and OviTex in the other and they say they notice a difference in the implants from a soreness/tightness perspective

Lastly, every patient is free to live with their hernia but when they choose not to (or it is dangerous for them to do so) that’s when they have to weigh the risks and benefits. Risks and benefits should be weighed anytime someone has surgery. And it should be noted that by far the large majority of patients heal well and have an improved quality of life after hernia surgery regardless of the material choice. We’re all striving to improve the procedure and outcomes for our patients.

Hope that helps!
Dr. S

[pszotek]

Thanks again for your reply good intentions. No offense taken. The point was merely that I was providing a reply to this topic and made the mistake of not completely explaining everything. I was trying to help out while picking my son up from swim practice and should have more fully elaborated. This is an open forum and you have the right to post and question as you did which gives the integrity of the feed. At the end of the day though this was merely a Paul Harvey scenario where you needed to know the rest of the story…

I am sorry that you had your experience with Soft mesh. Traditionally it has performed well and I used to use it prior to switching to ProGrip and then ultimately giving folks the choice more recently. I think the mere fact that anyone is willing to sit down and discuss it with a patient and give them a choice is far above the norm of what someone will experience in this country when referred for hernia surgery. I actually wish everyone did as you and others are doing by getting the information fully before proceeding. I think one thing that needs to come to light is surgeons being forced to use products such as Bard Soft Mesh without giving the patient or surgeon a choice by hospital administrators who choose it for us based on big contracts and kick backs that are not reported to any database. It is most likely that you received Soft Mesh because that was what the surgeon was told they were going to use by someone with zero medical background because it is the cheapest mesh by cost out there.

I participate here and I use these alternative products because of my belief that we can provide more value to patients through a shared decision than a paternalistic model of telling them this is the best product and this is how I am going to do it. At the end of the day most of the data out there is tainted somehow. The only way to really know is forums like this where patients are being open and honest. I actually love your reply but wish you would make them less of an attack on the surgeons as we are here to help and not getting a dime for merely trying to help folks make an informed decision on here.

I wish you the best and appreciate you pointing out my consultant work. We will all continue to work together to inform patients of the dangers of hernia surgery. At the end of the day we are all in this together and I am just trying to help folks with our experiences and my patient’s experiences. I am the only surgeon I know right now that has a direct HIPAA secure text messaging system that allows patients direct Texting access to me 24/7 so I would say my finger is on the pulse of patient experience better than it has ever been in my career. If there is a problem I actually know about it as my patients text me directly at 1pm or 1am. This is a free service that they can use forever. There is no better way to actually know what truly is or is not working than give someone your direct cellphone texting capability.

For example when I say there is less chronic pain with Ovitex it’s because I literally text my patients nearly everyday post-op for two weeks asking them and getting their responses. Then we follow them through the system every 3 months for 2 years and then yearly after that. In addition they can text me anytime in between. I tailor the repairs to the hernia. For giant indirects I feel the Velcro of ProGip is more secure as the mesh will not slide. I had this discussion with a patient and fixed him last week. We did ProGrip on the left and a small direct on the right with a combo robotic tissue repair/Ovitex reinforcement. Several days later he texted me saying he was having more discomfort on the left where the synthetic mesh was placed. This is a very common scenario and folks tend to report more soreness for the first two weeks with the synthetic yet at 6-12 months its seems to be similar. This is insight that no surgeon who does not provide direct to his cell phone texting capability 24/7 could ever provide you because they do not know what they do not know. There has been no better learning experience or influence on my practice then texting directly with my patients 24/7.

Have a great weekend and keep making sure we all provide the rest of the story for those depending on this site.

Dr. S

[pszotek]

Thanks for pointing this out “Good Intentions” as you are correct that I am a consultant with TelaBio and it is cute how you went and pulled the Sunshine Act numbers however I can only wish that my 1099 matched your numbers. I know you also meant to add that I am a consultant for Medtronic, Bard, and have been for other companies over the years. I also know that you meant to add all the surgeons partaking in these discussions are also consultants for various companies at some level. This is how we improve things for patients. If we did not work with companies to improve the products you would be left with the same plastic synthetic products that we are all concerned with. How do you suggest we make things better for our patients if we cannot or do not work with companies to improve the techniques/materials available for repair?

Since you seem to know everything about my practice and recommendations for patients, I also know that you forgot to add that 30 out of my last 35 patients received ProGrip synthetic mesh for their inguinal hernia repairs because I felt it was a better repair in those patients and I tailor all my repairs to each patient and each patient’s desires. Each and every patient gets a choice of their repair using a shared decision making model. I also know that you meant to mention that this past Tuesday I did an abdominal wall reconstruction explanting a Biologic and implanting ProGrip mesh. I use a model of care delivery that is tailored to each patient and they are allowed to decide what is best for them. I offer all types of products and have done repairs with them all. If patients want 100% absorbable we use Bard Phasix. If patients want no product at all we discuss risks and benefits and perform the repair with a tissue repair. I would be happy to hear your proposed better model of patient care as we are all striving to do what is right for our patients?

As far as your reference of a chronic pain patient with Ovitex from one of the surgeons on that list clearly we cannot discuss when hiding behind generalizations and each individual case which would be impossible on a forum like this secondary to HIPAA laws. You are welcome to reach out and discuss this anytime you like personally with me so that you know that I do have good intentions for my patients and the folks on this forum. I follow all my patients indefinitely and we have not had one that has reported chronic pain related to the Ovitex implant so I guess your input in how to define that or better report it would be appreciated?

Have a nice weekend and it was my mistake not to add the disclosure of being a consultant for TelaBio as that was not the good intention of my reply above. It was merely to report my experience and I should have clarified that I actually use ProGrip also in cases that have indications and patients are ok with it. In fact, I use it more often currently.

[pszotek]

Alephy,

The majority of the use has been in the US but they are available in Europe also. There is a surgeon in Germany that I trained last year in use of them and several throughout Europe. Alistair Windsor in/near London has been using it for over a year since I visited and introduced him to it the spring of 2019. Shoot me an email and I can put you in touch with the closest to you depending on where you are located.

Dr. S

[pszotek]

Thanks for inquiring about this early work. As part of our practice we are offering reinforced Biologic repairs using TelaBio Ovitex. I placed the first implant ever in a human in 2015 and have done extensive work along with Dr. Towfigh, Dr. DeNoto, Dr. Sawyer, and Dr. Ferzoco to name a few on the use of this product. We currently have about 400 cases overall and have done approximately 175 robotic inguinal hernia repairs using Ovitex over the past 2-3 years. Our experience shows a 1.8% recurrence rate at >2 yrs for robotic inguinals (not significantly different than our synthetic recurrence rate) and less than 1% overall for all hernia repairs in this series of about 400 cases. The one thing we have noted is the improved comfort and no question reduced inflammatory response with the use of Ovitex. We have not observed any chronic groin pain and we suspect that these implants will continue to perform at the highest level. I give patients the choice to decide and we tailor the repair to their desires using a product of your choice or even open tissue repairs. One thing that we always recommend is not to sell yourself short and avoid the benefits of robotic repair because of a fear of classic synthetic mesh as the retained foreign body/permanent suture is likely equivalent in weight or even less than what we would used for tissue repair using Ovitex. Since we are seeing exactly the same outcomes with the reinforced Biologic Ovitex with minimal retained foreign body I feel you can have the best of both worlds and be safe from chronic groin pain while having a low recurrence rate.

Thanks for inquiring on the Ovitex product and if you have any interest in learning more about it or about our repairs feel free to reach out and I would be happy to help you as I currently have the largest series of repairs using this product in the country and offer it regularly. In fact we used it two times yesterday.

Thanks!
Dr. Paul Szotek
Indiana Hernia Center
[email protected]
http://www.indianhernia.com

[pszotek]

This is very common. Not surprising. You could even be my non-steel suture Shouldice hernia repair from last week that sent me pictures of the exact scenario you are describing.

Dr. Szotek

[pszotek]

All your points are valid. I would say there is the option of also doing it on the robot with a product called Ovitex that is 95% absorbable and we do quite frequently with excellent results. If the surgeon telling you that he is going to do an open repair with say a size 0 permanent suture the total residual foreign body may be no different than using a product like Ovitex. In addition, there is really no need to use a fully permanent synthetic mesh for a robotic repair of an umbilical hernia that is close to 1cm. That being said the more important question is whether or not you have been imaged to ensure no significant associate diastais Recti?

The presence of diastasis can change the equation regardless of the actual defect size. If you have a 1.5cm hernia with an associated 3-4 cm diastasis this will function more like a 3-4 cm “hernia” and should be repaired with robotic plication or open plication plus hernia repair in many instances.

I would say you only received part of the story. Happy to discuss with you via a telehealth visit and give you all the options and information that will help you make your decision

Hope that helps a bit,

Dr. Szotek
Indiana Hernia Center
http://www.indianahernia.com

[pszotek]

Thanks for your question. We use a significant amount of reinforced biologic mesh in the groin since I give patients a choice for this type of repair. The experience is somewhat limited but I likely have one of the largest, if not the largest series of prospectively collected data in the use of reinforced biologics for robotic inguinal repair. We have performed >160 of these repairs in the last 2+ years with zero chronic groin pain and 1.8% recurrence. I think however when looking at chronic groin pain related to hernia mesh you should realize that it is often the person placing the mesh that plays a pivotal roll in the resultant chronic groin pain as we have not seen it with our series of ProGrip synthetic mesh either. Technique is of utmost importance.

In our experience there seems to be less pain initially with the reinforced biologics and long term they seem to be about the same though.

I do not see a true indication that the recurrence rate will be higher with the reinforced biologics.

The concept behind Ovitex is that like Concrete scar tissue maximally compressed and then expands/stretches. If you place the biologic with reinforcement it is remodeled into your own tissue (a component of which will be scar) and when the tissue starts to stretch it has reinforcement like rebar in concrete.

Hope that helps a bit.

If you would like to discuss in detail and see images of the repairs, etc feel free to schedule a telehealth appointment and I will go through with you.

Dr. Paul Szotek
Indiana Hernia Center
http://www.indianahernia.com
317-868-1305

[pszotek]

Thanks for the question. Robotic tissue repairs are something newer and Dr. Towfigh just publishes a paper on it. I have been doing them also for a couple years now I’m very select hernias. In most cases I have found it actually easier to do them in direct hernias unless the entire floor blown out. Indirect is also doable but have to be very careful and often the tissue quality is not the best. 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. In cases like you are describing if the direct is small and has good tissue associated with it we would just do tissue repair. If the floor is blown out up to the inferior epigastric then I usually do a safe tissue repair plus the reinforcement. Hope that helps. Happy to discuss with you anytime through a telehealth visit and show you images of options.
Dr. Paul Szotek
Indiana Hernia Center
http://www.indianahernia.com

[pszotek]

Alephy,

The answer for your question is different depending on where you are now but here is some general knowledge that we have:

1) Tissue repairs are dependent on the tissue you are repairing for durability. In many of the cases I do tissue quality for repair is proportional or at least related to the size of the hernia but not always. As hernias get bigger the tissue quality surrounding them often diminishes and the feasibility of long term success with a tissue repair may decrease. So in this sense the sooner you get it repaired the more likely you will have a successful tissue repair. In the instance where the tissue is weak or even there is no good tissue we often use a reinforced biologic material to help augment and support the tissue after performing the tissue repair. That being said we are also able to offer the robotic approach using the reinforced biologic with excellent results. When discussing these options with my patients I spend a lot of time going through the pros and cons of all types of repairs from mesh to no mesh open raptors to robotic repairs. There are benefits to each approach.

Here is why you get them fixed in my opinion:
1) Getting bigger.
Sooner it’s fixed the more likely to ge the repair you desire as when they get too big there is just not enough tissue without reinforcement.

2) Pain/Increasing Discomfort.

3) Risk of bowel entrapment.

I do virtual consultations and would be happy to discuss your options with you. What I would say in relation to you question about who to see is that make sure your surgeon does all the operations and will offer you a choice. If you are not offered a choice of repair that you feel meets your value then move on and seek another opinion.

Thanks for your post!
Dr. Szotek
Office: 317-868-1305
Email: [email protected]
http://www.indianahernia.com

If you want to set up virtual visit to discuss options let me know.

[pszotek]

Brunog

There are a lot of factors that go into it as why someone might recur after mesh removal. In my experience we have not had issues with recurrence after removal. Most often we remove the mesh and reconstruct with a tissue repair plus or minus a reinforced biologic augmentation. We have not seen this repair recur to date.

Dr. Szotek

[pszotek]

Alephy,

In my experience patients should be able to return to normal activity with either open or MIS (lap/robo) repair. That being said I have not seen a correlation between type of activity and developing chronic pain. Return to normal activity can often take longer in some patients with open repairs in our experience. If you are concerned there are other options for reinforcement materials that allow you the choice and can be more comfortable in our experience for activity.

Dr. Szotek

[pszotek]

Brunog

Thanks for your question. I often remove mesh open and via the DaVinci robot. Can you elaborate further on “nerve damage”?

Often when we remove mesh anteriorly through open incision a neurectomy is performed. When we remove mesh that was place laparoscopic or via the DaVinci robot neurectomy can be variable depending on the specific case. In addition there are different levels of neurectomy as if a nerve is involved with a mesh it will usually come out with that mesh removal. To add formal robotic neurectomy proximal to the mesh is dependent on the situation.

Thanks!
Dr. Paul Szotek
Indiana Hernia Center
http://www.indianahernia.com

[pszotek]

Damien10,
Thanks for contacting us here at HerniaTalk. Will try to answer your questions in order but have to ask exactly where the pain is located and where the “tension feeling” is located (above the base of the penis, slightly more lateral toward the hip bone, halfway to the hip bone, or much more lateral) and does it hurt when you push on it with your hand?. Also what were you doing in the gym? (lunges, squats, etc with your lower body/core)

1. Your hernia could have recurred but impossible to know for sure without exam/imaging. You could have athletic pubalgia also.
2. Recurring hernia surgery can be challenging. I would recommend Dr. Towfigh, Dr. Orenstein, Dr. Chen, Dr. Jacob, myself or someone who specializes in it to get the best results.

3. Stretch scar tissue: Yes it is possible. IF you would like to consider an online rehab program for this we are currently beta testing one and I would be glad to work with you to arrange this and go over your issue more in depth via a telehealth visit. You can find us at http://www.indianahernia.com, fill out your information and we will get things set up.

4. Ultrasound, CT, MRI all can work to confirm. It can come through the mesh or most often an area that was not covered by the mesh completely. It could descend into the scrotum but unlikely at this point as that usually takes a bit of time.

5. Usually I would not recommend a second open repair unless you have chronic groin pain that I suspect the mesh is causing the problem and needs to come out. We would approach these Laparoscopic/Robotic.

Thanks!
Dr. Szotek
[email protected]
http://www.indianahernia.com

[pszotek]

How long can I wait?

CKBUZZ,

Thanks for finding us here and posting your question. I think it is an interesting one. There is data that suggests it would be safe to wait for a period of time. However, if you are unable to push it back in, pain is increasing, and your scrotum is enlarging then I would suggest getting re-evaluated. Although you are correct about it becoming an emergency there are mechanisms in place to deal with things that are becoming an urgency. Would be happy to discuss in more detail if you desire over the phone or our telehealth platform. You can signup at http://www.indianahernia.com and we will be in touch.

Hope that helps a bit. In general though if you are not incarcerated or strangulated you can wait a reasonable period of time before repair but it is impossible to estimate this without further discussion and exam.

Thanks
Dr. Szotek

[pszotek]

Newagehernia,

Having performed over 260 Ovitex robotic inguinals I would say that option is technically easier but I have done 4 TEP procedures. That was my pre-robot era operation with ProGrip. Although doable I think it’s technically more difficult in my hands. Dr. S