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quote drtowfigh:

The European Commission recommendations were made without input from the hernia specialists. *♀️

And what ever went wrong when an under-informed legislative body took a position on medical science and practice?

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quote Alephy:

[USER=”1391″]UhOh![/USER] do you have a direct or indirect hernia? The US report in my case also mentions fat and small intestine…fat from the small intestine? How good is the US in differentiating the type of inguinal hernia btw?

” pure tissue repair involving minimal cutting/sewing “: does this include Shouldice in your opinion? from what I have read the Shouldice procedure is quite “heavy”

I’m honestly not sure, the US report didn’t indicate. I’ve always assumed direct because of how it “behaves” (seems to bulge “away” from scrotum, always quick to go “in” when I lie down and come back “out” when I stand, easy to manually reduce whether sitting, laying or standing), but that’s hardly a medical diagnosis.

US did indicate the size of the hernia defect in centimeters, which I took as an indication that it was direct, but again, that’s not exactly a medical opinion…

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There’s the Hernia Centre Munich that seems to utilize her method; not sure if the price is any different?

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quote Good intentions:

Thank you for that information Dr. Towfigh. It looks like a concession but, since the problem is pain, and animals cannot describe their pain, I don’t see a direct link to making things better. The animal studies will show tissue ingrowth and other things that might or might not be tied to pain and discomfort.

It seems like the giving of something of little value. It’s a start though.

Perhaps measurements of unacceptably high inflammatory reactions would be a proxy for such? But in general, I agree.

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I’ve opted for it thus far and continue to do so. As far as things I’ve had to change:

-No more deadlifts in the gym (but can still squat heavy without issue)
-No pull-ups or climbing in ways that stretch out the whole body
-Use hand to hold hernia in when coughing/sneezing

Occasionally, the bulge will enlarge a bit more than usual (typically when I have upper respiratory tract infection) but it doesn’t seem to do so for more than a day. Pain is rare, and if it happens feels like a mild muscle ache (not nearly as bad as when I pull an actual muscle).

Part of why I’ve felt comfortable waiting is that I, too, had an ultrasound and it showed only fatty tissue in the sac. Had it been intestine, I might have thought more carefully about a repair sooner.

There are two things that would make me consider a repair, besides the obvious strangulation (and I’m guessing one will happen eventually, at some point):

1. Significant increase in size.

2. Local availability of a surgeon performing a pure tissue repair involving minimal cutting/sewing (closest seems to be Dr. Grischkan in OH).

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The only study I’ve seen (and actually once posted) showed that the recurrence rate with wholly absorbable mesh was the same as permanent mesh for *indirect* hernias, but approached 40% for *direct* hernias.

[USER=”2019″]drkang[/USER] has shared some very interesting thoughts on what he considers the shortcomings of different repair methods and how they fail to fix the actual hernia defect. Based on this, my hypothesis about the study is that the real culprit was combining absorbable mesh with a Lichtenstein repair, which does not actually close up the hernia defect, but just lays mesh atop it. It makes perfect sense that indirect hernia repairs with this combination held fine – there isn’t an actual tear in the tissue, just an enlargement of the internal ring.

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So I had a chance to read a little more about this procedure (though there doesn’t seem to be a ton available specific to inguinal hernias) and something interesting occurred to me: it seems to be the only procedure, besides Dr. Kang’s, where imaging is routinely done (since that seems to be how “sports hernias” are typically diagnosed). Like Dr. Kang’s, it also seems to do the least damage to surrounding tissue structures.

From this (admittedly, limited) information, I come to only one conclusion: Preoperative imaging allows for less cutting/sewing because the surgeon already knows the extent of the damage and there’s no need to visually examine the deeper structures during surgery.

How has this not become part of the discussion among doctors? And, more interestingly, how have device makers not picked up on it as a reason to market more ultrasound equipment (and training) specifically for this purpose?

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Personally, I would be cautious in asking: “What do professional athletes do for hernia repairs?” when considering one’s own. Why? Because they are (likely) responding to an entirely different set of incentives than the rest of us, and it stands to reason would be considering an entirely different risk-reward profile.

To put it another way, you or I are probably quite concerned about what kind of pain, recurrence likelihood, or other complications we will experience in ten years. But if you get a hernia today, and your team has a realistic chance of going to the Super Bowl next month, all you care about is what ensures your ability to play right here, right now.

Perhaps laparoscopic with mesh is the best long-term solution for someone athletic, I don’t know. But even if it’s not, if it’s what puts the pro (whose career has a very limited shelf life regardless) back on the field the fastest, I’m guessing that’s the main consideration.

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Is this method fairly similar to Dr. Grischkan’s two-layer Shouldice? From the diagram on Dr. Grischkan’s website, it looks like healthy tissue is incised only with an indirect hernia (since that same tissue is already torn with a direct hernia), but I can’t quite tell.

Anyone in the U.S. known for using this method, specifically?

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quote drtowfigh:

We have a lot of experience with absorbable mesh. And we know from that experience that they do not work for definitive hernia repair. The biologic mesh resorbs and hernias recur

Would it be fair to say that part (most?!) of the problem is attempting to use absorbable mesh as a 1:1 substitute (including repair technique) for permanent mesh? It seems obvious (to me, from a product standpoint) that these are fundamentally different products: one is a permanent prosthesis, the other a temporary healing aid, so they should be used differently.

Hypothetically (and only a doctor could tell me if this is a valid example), if tissue quality is an issue, using absorbable mesh in conjunction with a suture repair technique in order to provide structure during healing.

I’ve said this before, but from a pure product development angle, the biggest failure of mesh seems to be an attempt to “be all things to all people” by serving a dual purpose (a permanent prosthetic and a healing aid) without being optimized for either of those purposes.

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quote drtowfigh:

We have a lot of experience with absorbable mesh. And we know from that experience that they do not work for definitive hernia repair. The biologic mesh resorbs and hernias recur

Would it be fair to say that part (most?!) of the problem is attempting to use absorbable mesh as a 1:1 substitute (including repair technique) for permanent mesh? It seems obvious (to me, from a product standpoint) that these are fundamentally different products: one is a permanent prosthesis, the other a temporary healing aid, so they should be used differently.

Hypothetically (and only a doctor could tell me if this is a valid example), if tissue quality is an issue, using absorbable mesh in conjunction with a suture repair technique in order to provide structure during healing.

I’ve said this before, but from a pure product development angle, the biggest failure of mesh seems to be an attempt to “be all things to all people” by serving a dual purpose (a permanent prosthetic and a healing aid) without being optimized for either of those purposes.

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quote DrBrown:

[USER=”1391″]UhOh![/USER]
Mesh is not as flexible nor as elastic as your normal tissues.
It always elicites a foreign body reactions.
It shrinks with time.
It easily becomes infected.
What could go wrong?
Bill Brown MD

Yes, exactly. It sounds like it was engineered (or chosen, from a pile of “stuff”) because it checked some boxes in terms of serving a dual purpose (prosthetic; healing aid) without anyone ever thinking about optimizing it for either purpose.

Huge failing from a product development standpoint (true whether it’s a medical product, or meant for any other industry requiring precision).

What do you think the results of “mesh” repairs would look like if, either:

1. A fully absorbable mesh were used in conjunction with tissue repair techniques, to promote healing, and then go away (like a splint, cast or bandage)

or

2. A true prosthetic, meant to mimic the form and function of the damaged tissue, had been developed (along with the right technique for integration)?

Do you think that it would have led to better overall results, instead of new problems (chronic pain vs. recurrence)?

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quote DrBrown:

I agree completely. Without proper codes and documentation we do not know how often mesh has to be removed.
I have not found any articles in the medical literature that give a real number. Without information we can not calculate the cost in terms of dollars and pain and suffering.
Bill Brown MD

I’ve also wondered from time to time whether there should be separate codes for primary vs. recurrent hernias and a special post-operative groin pain code? For those who don’t return to their original surgeon for a recurrence, or with subsequent pain, this would seem to be the best way to track the incidences of each. Surgeons can only report recurrences they know of, and if their repair failed to fix the problem the first time, it stands to reason patients would subsequently go elsewhere, contributing to an artificially low recurrence rate.

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quote Dill:

Wow! So needed. I called there several times asking about no mesh, and not getting a response.

If you are in the Chicago area, perhaps just make an appointment for a consultation with that particular surgeon (rather than trying to have information relayed back and forth by phone)?

Edit: It looks as though appointments with him are available via online booking.

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quote Tino_7:

I could be mistaken, but my response to Ddot14 was based on my recollection of a very brief conversation with Dr. Grischkan – too brief to elaborate further. I hope I haven’t introduced any confusion to this topic. You certainly appear to know far more than do I, as I couldn’t even draw the conclusion you did.

My conclusion (still as much a question as anything) was based more on what I saw on his website than anything discussed here.

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quote Tino_7:

Dr. Grischkan will attempt a tissue repair first, but if it is too large for that, he will use a Gore-Tex mesh. I consulted with him and he said my hernia (Grade 2) can be a tissue repair, but cautioned me that if it grew too much he’d have to use mesh. He did say the quality of his mesh was above that used in all other mesh repairs at hospitals.

Perhaps you can comment, based on your interaction, but reading Grischkan’s website, it sounds as though he’s using mesh for a fundamentally different purpose than the majority of surgeons.

From what I understand, it’s usually used as a “patch” which, when combined with tissue ingrowth, serves the function of a bandage or splint. It sounds, from what I’ve read, that Dr. Grischkan is trying to get the Gore-Tex (which I thought was a bit stretchy) to mimic the form and function of the damaged fascia itself. It would be reasonable to expect different results, no?

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quote kaspa:

That’s it, but how can one explain that simple ligation in adults was that successful in Poland until the 1950’s, including Pope Pius XI in his sixties?

I can think of several potential explanations of such phenomenon, NONE of which I have any actual evidence to support (they are just general ways to explain this type of discrepancy):

1. Population homogeneity. I doubt anyone has ever done a study on different hernia characteristics across demographics (other than, perhaps, sex and age) and perhaps there was something inherent in ethnic Poles making them less susceptible to the dilation Dr. Brown references above. You wouldn’t see that in the U.S. today, given the heterogeneity of the population.

2. General health/nutrition. Not sure how, but they’ve linked dietary changes over the years to all kinds of other health changes, so perhaps it had an impact on muscle elasticity/tissue quality?

3. Recording of statistics. Perhaps there was a 35% recurrence rate, but if there weren’t good records kept, then we wouldn’t know that today.

4. Life expectancy. If it was shorter (and I’m sure it was) people probably retired, and reduced physical activity, earlier, meaning the repair didn’t have to last as long.

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quote DrBrown:

[USER=”2862″]kaspa[/USER]
Thank you for the history lesson.
For infants, simple ligation of the hernia sac is all that is required.
This would be similar to the operation the Pope had.
Regards.
Bill Brown MD

How does this compare to the Marcy repair, as you describe it on your website? Just the fact that the Marcey involves using sutures to narrow the internal ring (instead of leaving it be to develop properly, as in a child)?

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quote tenreasy:

I live in Chicago and I do not think that anyone does open tissue repair. They all use mesh. As far as not letting residents participate not sure how you could enforce. My doctor performed the main surgery and was assisted with residents. Maybe doctors could chime in.

The surest way is to strike that section of the consent form. There’s also a difference between “hold this” and “cut here.” But in reality I think it is imperative to have an honest discussion with the treating physician beforehand, to let them know what you are and are not comfortable with.

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quote pinto:

[USER=”1391″]UhOh![/USER], it seems that docs move the goal posts! I am floored when doctors tell patients in extreme pain 6 mos. post-op that the pain is expected. Or when doctors tell these patients that their pain is impossible. It is egregious particularly with docs who are blind to corporate blunder. Granted that some patient complaints may be groundless, nevertheless other complaints are real. As long as imperfect mesh is considered the ‘gold’ standard, hardly will there be much advancement in our lifetimes.

But that’s my point: as long as recurrence is the only measure of success, every surgeon out there will continue telling patients (and believing themselves) that mesh leads to more “successful” outcomes. This is especially true in a world transitioning to value-based care (vs. fee for service) where a surgeon risks not getting reimbursed by a patient’s insurance company for a “failed” procedure (in this case, a recurrent hernia).