UhOh!
Forum Replies Created
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Was the original Bassini repair intended for direct hernias (since indirect wouldn’t have an actual tear to sew together)? I wonder if the corrupt version came about from a desire to develop a one-size-fits-all approach (which would seem rather popular with American teaching institutions).
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[USER=”2019″]drkang[/USER] ,Thank you. So to make sure I understand what you’re saying (since I don’t have a good base of anatomical knowledge), it sounds as though in authentic Bassini several layers of muscle are joined together into one in order to recreate the cumulative barrier effect that the three previously had as separate entities, while Kang sews together only the actual tear, then uses other tissue structures to create the barrier effect?
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Very comprehensive explanation, and very interesting (particularly the part about the ‘two Bassinis’). So is the auxiliary barrier in your repair a four-layer repair as in Shouldice, or more similar to the two-layer Shouldice performed by some surgeons?
This brings up two other questions, partially based on the info here and part on my previous thread (about absorbable mesh):
1. If the original Bassini repair had a 2.7% recurrence rate without an auxiliary barrier, why do an auxiliary barrier at all; is there a true need or is it more about the difference between a 2.7% recurrence and the 0.5% you report? That is, of course, unless the recurrence rate was artificially low compared to today, given how many more people would be eligible for surgery/how many more years they live and need the repair to hold…
2. Is the purpose of the auxiliary barrier to hold the repair in place while the fascia heals, or because the fascia will never be “as good as new” again? If it is the former, what would be the likely result of combining a Kang/Bassini (original) fascia repair with a piece of fully absorbable mesh and no auxiliary barrier?
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quote drtowfigh:It’s considered a tension repair. As far as we know the outcomes are likely to be similar or worse than open repair, but that’s just a hunch. We are studying this next year in a clinical trial. Awaiting funding.
Does it repair from the inside, like lap, or from the outside, like open, and which open repair type does it most compare to (in terms of what structures are affixed to what)?
Also, when you are comparing the outcomes, I’m assuming you’re referring to recurrence rates, as compared to your own open mesh-free recurrence rates (vs. the historically high recurrence rates reported overall during the pre-mesh era)?
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People resist behavior change (it’s hard)
People hate admitting they were wrong (it’s embarrassing)
People can have multiple definitions of “gold standard” (depending on how they define successful outcomes) -
quote drtowfigh:Also, in doing so, we were shocked to see a trend toward more patients requiring mesh removal after laparoscopic repairs and also more patients showing up with systemic mesh reactions.
We will followup wirh an outcomes paper soon.
Does this have to do with the laparoscopic technique in and of itself, and how such meshes are implanted/affixed, or the fact that the mesh is placed inside the abdominal wall, as opposed to outside of it?
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quote drtowfigh:[USER=”2608″]dog[/USER] it wasn’t possible technically possible before synthetic mesh so most lived with their hernias, no matter how disabling, and could not be offered a repair. People were maimed by other techniques and complications of open tissue hernia repair. Use of the darning technique caused fistula and erosions and chronically draining wounds. Surgeons were harvesting fascia from the thigh to treat abdominal wall hernias. This worked about half the time for the hernia, and the fascia harvesting left a disabling set of complications to the leg, including nerve injury. Deformity was more common. Testicle loss was more common. Scars were enormous.
It wasn’t a rosey picture before mesh.
Not to mention, from a purely practical standpoint, it could easily be a decade or more before there could be a sufficient number of surgeons trained in tissue repairs. First, the small number of surgeons proficient in such techniques would have to train other teaching surgeons. Then, those surgeons would have to begin training fellows and residents, who could then begin training the next batch of fellows and residents. Overall, it would require a significant lead time, no?
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quote drkang:
I am afraid that few fellow surgeons will agree with me.
Unfortunately, everyone seems to fear the unknown, and there is a long history of assumption that, at least with a direct hernia, it is not enough to simply stitch the torn fascia back together. Therefore, even once you publish, I think it will be hard to convince surgeons of this, given what they have been taught to believe.
Patients, on the other hand, have the opposite problem: they buy into whatever they want to believe most, whether or not it is right.
That is why I wonder if absorbable mesh becomes a “compromise” when the patient tells the surgeon they want this new repair they read about (yours), but the surgeon says that it won’t work because more reinforcement is necessary (in spite of the evidence). Surgeon agrees to try it, provided they can use some prosthesis to support the repair as it heals; patient agrees because once the mesh has been absorbed, they have exactly what they ask for.
Importantly, perhaps, you will give the device/pharma industry something to “chase” (new absorbable mesh patents) instead of galvanizing them to lobby for use of mesh vs. tissue repairs (as I’m sure they do now).
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quote drkang:Your last question is not easy to answer. If they follow the principle of closuring the hernia defect, then as you mentioned, it could be helpful to use prosthesis until they get familiar with and confident of their new trial of tissue-based repair. However, I believe there is no point in using prosthesis if the principle is not followed. Tissue repair that does not close the defect directly is in effect the same as existing tissue repair which, in my point of view, is not type-specific repair closing the hernia defect directly.[/FONT][/SIZE]
In addition to becoming familiar with the technique, would the absorbable prosthesis be helpful in cases where tissue quality is questionable, and it is determined that some additional support is necessary in helping the repair (of the defect) heal completely?
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I think the difference is that the “autologous” prosthetic in Desarda isn’t absorbed, mirroring non-absorbable mesh in that regard, no?
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quote drkang:Hi Jnomesh,
I feel strong companionship with some people on this forum. It is the job of doctors like me who know the seriousness of mesh to pose issues concerning mesh. But you all on this forum are taking the trouble to do so. As a doctor, I am regretful of this.
I am actually more fundamental than you think. Through the 15,000 inguinal hernia surgeries that I have performed, I have gained firm conviction that mesh is not required for successful inguinal hernia repairs. By successful, I mean minimizing recurrence and complication.
Doctors that support mesh hernia repair always reiterate “evidence-based medicine’. But why is it that only a portion of published studies can be called “evidence”? Not only are there many “evidence” on this forum, mesh pain stories frequently appear in actual clinical fields. I do not understand why these cannot be called “evidence”.
Some emphasize that there are people who get good results through mesh repair. This is true. 80-90% of patients that underwent mesh inguinal hernia repair are satisfied with successful results. However, this also means that 10-20% of patients awaiting mesh repair will encounter issues post-surgery. This is not a risk that can be overlooked.
The most effective way to make doctors realize the seriousness of mesh complication is to have them personally remove the problematic mesh that they have implanted. Once this is done, no doctor will be able to disregard the gravity of mesh complication. The problem is, many doctors avoid personally removing the mesh that they have implanted. Their reason is that they are not capable of performing such removal surgery. This is merely an excuse. Doctors who perform mesh removal were not born with the skills to do so. Also, this surgery is not something that can be learned from someone else. It is a surgical process that has to be carried out personally and requires familiarizing and mastering of the process. So, doctors that claim they do not know how to remove mesh implants and direct patients to another doctor are really saying that they do not want to perform such a laborious surgery. Therefore, patients suffering from mesh pain have to persistently request for the doctor that implanted the mesh to remove it personally.I have conducted mesh removal on more than 50 patients and for every one of them, one thing always came to my mind. It is that the doctor that implanted the mesh would be able to remove it the most safely. This is because each doctor has a distinct method of mesh repair and thus naturally, would know the inserted state better than anyone else. Therefore, if suffering from mesh complications, patients should continuously complain to the doctor that performed the hernia repair and if mesh removal is decided, patients should persistently demand that doctor to personally remove it. If many patients do this, the number of doctors performing mesh repair will rapidly decrease.
It will be interesting to see how the push here in the States towards Value Based Care (where insurance reimburses physicians based on the outcome), vs. Fee For Service, will impact hernia surgeries. It will undoubtedly depend on how those insurers define “success” when it comes to outcomes; if chronic pain is considered a “failure” then there will be a bigger push towards improving techniques and materials. However, if recurrence is the only basis for judging success or failure, then I think we will find surgeons even more reluctant to return to non-mesh methods, since it is somewhat of an unknown for them, when their mesh repairs yield virtually no recurrence.
If chronic pain necessitating removal is considered a failure, and there is at least a partial clawback of compensation paid by the insurers to the surgeons, then that will certainly help push them in the direction of basing decisions solely on the likelihood of recurrence.
Personally, I don’t consider life with a hernia that bad (granted, mine is confirmed by ultrasound to contain only fat), and if I were to have it repaired, I would gladly take an increased recurrence risk over the risk of new pain. Worst case scenario, I’m back where I started but with a new scar…
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quote drkang:Hi UhOh!,
I have searched about the Guarnieri technique to answer your question on whether it is similar to my repair method.
The only similarity is that direct inguinal hernia and indirect inguinal hernia are treated in separate ways. I have read that this technique is no longer used even in that hospital, and I can guess why. In my opinion, it is because this technique is too complicated. On picture, it looks like a very detailed and delicate method but not only is it extremely difficult to carry it out the way it is on picture, it would not be easy to get successful results. Reason being, surgery in reality, is like a battle so it does not proceed as planned or pictured. This is why surgeries have to be as simple as it can be. That way, the possibility of errors or unforeseen situations will be minimized and increase in the possibility of a successful surgery will follow. Furthermore, the simpler the method, more doctors will be able to provide equal quality of the surgery, which leads to its generalization.
One big reason behind the widespread implementation of mesh repair is that it is simple and easy for doctors to repeat the process. Thus, I believe that simplicity and easy-to-follow are important conditions for new tissue repair methods in the future.
[USER=”2019″]drkang[/USER] Thank you! It’s impossible for someone like me (not a doctor of any kind) to understand based on diagrams/descriptions what constitutes a “simple” or “complex” surgery. Looking forward to the day (hopefully soon) that your team publishes and there is the possibility of bringing a more effective technique to market.
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Thanks for the clarification. My gut (no pun intended) feeling when I read these cases is that if it were truly revolutionary I’d be seeing more than one report of it.
To a layman, it sounded like an autologous prosthesis. Would that be possible if the sac had a layer of stretched fascia?
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Thanks! So is it particularly likely that, when bearing down, one would feel a slight protrusion when pressing on the inguinal triangle that is NOT a tiny hernia of some sort? With a finger in the right place I definitely feel a slight expansion, but there’s never any visible bulge either when bearing down or not.
I dont have much sense of how much “stretch” that fascia would have and remain intact.
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Guess someone has tried this after all. Any other studies out there about its efficacy? Note: I’m almost certain the “20%” recurrence cited in the abstract is a typo; other parts of the article refer to “2%”
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quote Good intentions:Here is a web page describing the mechanism, or working action, of the inguinal canal. Easy to see how placing a piece of mesh over all of its complexity is an easier choice than working with the fine details and repairing it to resume normal function.
This is just one, I’ve seen others.
http://inguinalhernias.weebly.com/31-mechanisms-of-the-inguinal-canal.html
This made for a very interesting read. It’s one of the reasons I’ve been so hesitant to seek a repair of any kind; the mesh ones come with many potential complications, and the tissue ones seem to try and create barriers out of structures not intended for that purpose (and which won’t function like the original).
In theory, for a direct hernia, the idea of a prosthetic only slightly larger than the original defect, used in conjunction with defect closure, does make sense because it manages to leave other structures undisturbed. The problems would seem to be:
-Resistance to customizing the prosthetic size for each patient
-Finding the right material that didn’t create unwanted inflammation
-Proving that it will, in fact, be “enough” to prevent recurrence
-Getting people to look at a prosthetic in a wholly different way (make it as small as possible, not as large as tolerable; mimic the original structure as much as possible, not reinforce entire area)Someone will become very famous one day when they introduce a protocol for promoting tissue regeneration/healing that allows a surgeon to simply sew the fascia of a direct hernia back together with the confidence that it will regain an appropriate level of tensile strength
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So you’re saying that the current generation of surgeons at that center have abandoned the mesh-free version of the founder’s signature technique entirely?
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Bumping this old guy, too…
To better clarify my earlier question (having taken a little more time to look at some anatomy diagrams): If the fascia covering the inguinal triangle feels as though it is “expanding” slightly upon bearing down/coughing, does that necessarily mean a small hernia is present, or is there some natural “give” in it that would cause this phenomenon?
This is on the right side (obvious hernia on left), there is no bulge, and the doctor I saw recently about the real hernia felt nothing in the righthand inguinal canal (pushing up through canal starting from scrotum).
I feel this when standing, bearing down, and pressing on the area that approximates to the inguinal triangle.
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Bumping this older thread… Still curious whether any of the docs on here are familiar with this technique (or, in fact, set of techniques)? Looks like they’ve presented at several hernia society conferences, and the co-author of the book is a past president of the AHS.
[USER=”2019″]drkang[/USER] : I’m curious whether there are any similarities with your repair technique, given the way it’s described (less tension than Shouldice, more targeted than Desarda, different for direct/indirect)?
[USER=”935″]drtowfigh[/USER] : Do you know if the co-author, Dr. Nicolo, who is in the U.S. uses this technique himself (or if he just translated the materials to English, which it looks like he’s done elsewhere)? Figured you might be familiar through AHS…Is there a good reason its use never became widespread, or is it more a victim of circumstance, like many other innovations released at just the wrong time? It seems they published at a time when mesh was gaining significant popularity, without many of its complications having been brought to light, so possible nobody would have been paying attention to a new non-mesh technique?
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Isn’t it premature to discuss repair types without knowing for certain the hernia type (direct vs. indirect)? Based on what Drs. Kang and Brown say about repair types, it sounds as though the majority of non-mesh techniques are best suited to direct hernias. At the same time, I’ve seen multiple sources suggest that the majority of hernias reaching the scrotum are indirect…