UhOh!
Forum Replies Created
-
One topic I rarely see discussed explicitly: metrics of “success” in a hernia operation. I may be cynical, but I’m not so cynical to believe that surgeons are “in the pocket” of industry. Rather, a set of success metrics were established long ago by the medical field, and industry optimized its products accordingly.
Priority seems to be at reducing recurrence rates, immediate postoperative pain/complications and variability/learning curve. That’s followed by cost and operative time. The result has been products that have lots of mesh that can be implanted laparoscopically and can be done by any surgeon because they’re all done the same way. They are a resounding success according to “official” measures of success.
Perhaps the difficulty isn’t really in developing the “right” techniques and materials. Instead, maybe it’s developing the right ones that still meet today’s success metrics. This suggests that we need to reevaluate what is considered a successful surgery, and how surgeons’ performance is evaluated.
Unfortunately, it’s difficult to develop a set of metrics that can be measured in the hours or days after surgery. But this sounds like the type of group that can potentially reevaluate that.
-
If I had to guess, I would guess that its popularity will depend on the desire of the inventing surgeon to evangelize it (and patent the mesh design) and, more importantly, interest from a device maker in licensing the design and manufacturing that specific mesh design.
The problem with popularizing new/rediscovered tissue repairs (like Kang Repair) is that it’s on the surgeon and the surgeon alone to popularize it. That’s not always easy; it takes more than academic publications. But, if there’s something new that can be manufactured and sold, then you have all the resources of some of the largest marketing budgets in the world making sure everyone knows about it.
-
I am in NOOOOOOO way an expert (or even that knowledgeable) in any way, shape or form. However, I can say what it was that made me take notice of this method (as described in the original Italian article):
1. First mesh method I’ve seen specifically identify, acknowledge and address a suspected cause of chronic pain (mesh-nerve contact; folded mesh; migrating plugs). Both the shape of the mesh and the placement are designed to remedy these faults.
2. Issues of recurrence (or, more likely, development of a different type on the same side) seem to typically be addressed with more mesh, but here we see what’s meant to be less, but better designed, mesh. Each part of the design also appears anatomically-specific.
3. Seems to be more emphasis on also closing holes, not just patching over them.
4. Use of absorbable (sutures) or partially absorbable (mesh) materials when/where possible.
At least that’s how I understand this in contrast to other mesh methods, particularly the open ones.
-
I suppose this brings up an entirely separate question: Post-repair, regardless of type, is there anything one can reliably do to improve collagen quality and reduce chances of recurrence/new hernias?
-
Got it, thanks. And I suppose that there’s no way to assess tissue integrity until the actual operation commences?
My (layman’s) theory about how I got it was just putting more pressure on the area than it was designed to handle – I’m a recreational lifter and for a couple of years used a lifting belt. When using it properly (to maximize intra-abdominal pressure) it seems like a perfect storm: pressure increased beyond what one could create on their own, with the belt stopping just above the groin (no protection there). I still lift but have since stopped using the belt.
I’ve also noticed something else interesting: When exercising, prior to doing anything core-engaging (push-ups, planks) I will reduce it/engage the surrounding abdominals to “hold it in” and sometimes it stays in for at least a few hours after. That only happens after working out, though. I don’t know if that says anything at all about surrounding tissue integrity…
FWIW, and of course I’m no expert, it doesn’t seem that the defect is enlarging, rather that the hernia sac and gravity are conspiring (since it’s gotten “longer” but if anything protrudes outward less than it has in past).
-
Thanks, and of course that will determine treatment course. However since different surgeons seem to specialize in different repair types, I want to try and have a clearer idea of exactly what to search for.
Also, out of curiosity, why is Marcy contraindicated for an adult male? Is it not considered strong enough?
-
This reply was modified 3 years, 1 month ago by UhOh!.
-
This reply was modified 3 years, 1 month ago by
-
What other pure tissue repair, more appropriate for an adult male, would involve the least amount of cutting/sewing?
Otherwise, what’s currently happening with fully absorbable mesh on indirect hernias? I seem to recall that the one study out there showed about 40% recurrence on direct but near zero on indirect.
-
One thing, and one thing only, will affect change here: an evolution of how a “successful” surgical outcome is defined. Right now, “success” means no recurrence, meaning this is THE outcome surgeons are incentivized (and no, not just economically) to achieve and therefore that residency programs are incentivized to teach.
If consensus was reached that there should be more allowance for recurrence, with less allowance for chronic pain, you’d see the repair methods change. If zero recurrence were still the goal, but low-to-no pain was an equal goal, you’d see changes in how carefully surgeons are taught.
But, as I’ve said before and will say again: People respond to incentives, and the criteria on which they are judged at the end of the day matter. As long as those remain unchanged, so too will this situation.
This has way more to do with learned behavior and resistance to change than anything drug/device companies could ever do (they’ll always find something else to sell to surgeons, since that is their incentive).
-
I think it’s easy to see “doctors consulting for industry” and have a negative view. As I see it, much of the origin of such skepticism comes from two places, neither malicious (as hocking products because there is a profit motive would be):
1. Confirmation bias. When people work really hard to develop something they see it as superior and want the world to adopt it. So they look for evidence that it is working. It doesn’t have to be for profit motive, but can come from believing they’ve truly discovered a better way (because who would work really hard to develop the second best way to do something…). In the hernia repair field, probably no better example than the Millikan plug and patch (which seems retrospectively to be one helluva lot more ego-driven than anything @pszotek has said above!).
2. Incentives. People respond to incentives, and behavior change only comes from changes to the incentives. Surgeons are no different; they are judged by certain metrics and tailor their practices accordingly. Now, I’m not talking about monetary or economic incentives necessarily. For a hundred years, the metric by which hernia surgeons have been judged is recurrence. So, hernia repairs were designed to minimize recurrence (or formation of a new hernia of a different type in the same location). Surgeons did exactly what they were incentivized to do. Now, that’s starting to change, and methods and materials must change, too.
All that said, I’d be most interested in talking to doctors using procedures and/or materials that they developed. Because that’s where innovation comes from, and innovation is how we move away from inferior approaches to everything.
-
Not to hijack this thread, but I’m curious, Dr. Szotek, for a non-robotic tissue repair of a direct hernia, which method do you use for repair? Haven’t made a decision on whether to have mine repaired, but am very curious what options I have within a few hours of Chicago if/when that day comes.
Pretty sure I would prefer tissue repair, and believe mine is a direct hernia.
Thanks.
-
Is it possible that the “got hernia repaired only to get one on the other side” phenomenon is actually:
-Weakness exists on both sides, with greater weakness on side with original hernia.
-The “stuff” that would fill a hernia sac ends up concentrated on the side with the hernia, protruding through it and leaving less “stuff” (and pressure) to create one on the other side.
-Hernia gets fixed, that side becomes a strong point, not a weak one, so contents begin protruding through the next weakest point (the already weakened, but not quite broken, other side).In other words, it’s not a cause and effect relationship (repair = tear on other side) but more a question of a hernia on one side providing less opportunity for one to form on the other side?
-
Respectfully, I don’t think that, for the most part, economic interest (of physicians) or incompetence play that big a role. It’s entirely about how a successful surgery has been defined, and therefore the results surgeons are incentivized (in terms of “success rate” not $$) to achieve.
At some point, a successful repair was defined as one that does not lead to recurrence. Therefore, the incentive is to achieve the lowest possible recurrence rate, which is done through use of mesh. Were the incentives to change, and long-term comfort were prioritized over recurrence rate, then the methods of repair would change accordingly.
-
Personally, when I found out I had a hernia, I gave up the weight belt the next day for that exact reason: maximizing intra-abdominal pressure while having nothing to protect the inguinal area seemed like a recipe for it to get worse quickly.
Eventually, I also gave up deadlifting, too, since that was the one exercise where I could feel pressure on the hernia (that I don’t want to get bigger). I still squat heavy, though, and have for the four years I’ve had a hernia. For some reason, that’s the one thing that’s never seemed to bother it (in terms of pain; not sure whether it has contributed to it increasing in size any).
Not sure how that has impacted it to be honest. On the one hand, there is an increase in pressure, but on the other, perhaps the increase in core strength has helped compensate for the damaged tissue. I can only guess…
Other things I have changed/given up in terms of gym: No more twisting (like medicine ball, or kettlebell twists), no more “hanging” core exercises (knee raises) and no more pull-ups (I would feel a “stretch” in the area as well as pressure on it). Also, when I do push-ups or planks I first reduce it and then keep the surrounding muscles as tense as possible during the exercise. Just my personal experience; absolutely no part of which should be construed as advice or expertise.
-
Thanks. What caught my attention was the statement that mesh was not used in all cases. Which I had understood to be an absolute requirement of successful lap surgery. That’s what made me wonder whether this was something new(ish).
-
This, to me, is a great lesson in being careful what behaviors we incentivize, and what the unintended consequences might be. Long ago, it was determined, somehow, somewhere, that the primary determinant for successful hernia surgery was recurrence rate. Therefore, every surgeon’s primary incentive was to prevent recurrence (as that is the primary metric of a “successful” operation).
Unfortunately, an occult hernia on the same side would still appear as a recurrence, even if its origins were entirely different. So, what do you do, in order to prevent such “recurrences”? Check for hidden hernias, or insert enough prosthetic to cover every possible site of another hernia, of course!
That’s why, in my (completely non-medical, non-professional!!!) opinion, Dr. Kang’s greatest innovation is the use of ultrasound imaging preoperatively. Having that information, of what type you’re dealing with, and whether there are others lurking, ensures that only necessary cutting and sewing be done.
-
As someone who markets innovations professionally (albeit software, not medical devices), all I can say is that if this is the case, this needs a different story. So, doctors here won’t acknowledge the problem… but there are other issues which they are more than willing to acknowledge. Like time it takes to train surgeons, or the need to stock different materials for different repairs. Saying “one piece, suited to any hernia, left or right, direct or indirect, with the same repair technique for all” will get attention even without the pain issue coming up. The question is whether this is a sound repair – the marketing is easy.
-
Here’s something I’ve wondered about for some time: Do the behaviors of different hernia types (direct and indirect) differ depending on whether they contain fat or intestine? I ask because I’ve experienced the following:
1. My hernia is reducible, but immediately comes back out when not holding in (either with my finger, or by flexing the surrounding muscles).
2. It goes back in when lying down, and immediately protrudes upon coughing.
Both suggest direct, but…
3. The end of it protrudes into the top of the scrotum (suggesting indirect).
The ultrasound from a few years ago said mine is fat-containing.
I’m wondering whether fat, given its consistency, will behave differently and either come out more easily (in the case of indirect) or drop down into the scrotum (in the case of direct) even though atypical. Unfortunately, that ultrasound didn’t specify type.
-
The theory is at least interesting: X amount of mesh is needed to promote healing and tissue growth, but only Y (small fraction of X) is really needed to provide long-term support as a prosthetic.
What I find even more interesting is that Dr. Szotek seems to perform a tissue repair first, theoretically addressing one of the key concerns that led Dr. Kang’s criticisms of mesh (that the defect itself is never repaired).
-
The valsalva maneuver is typically combined with the use of a weight belt to achieve maximal intra-abdominal pressure during lifts. That IAP is where the stability comes from. I don’t use it to the degree I used to (when I used a belt), for that very reason. I still actively breathe into my stomach instead of my chest but concentrate on locking my lower back in place, not bracing against my abdominals, for stability/to keep from flopping over.
-
Out of curiosity, Dr. Szotek, when doing pure tissue repairs, which repair techniques do you specialize in?