Episode 78: Let’s Talk About Mesh | Hernia Talk Live Q&A

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Speaker 1 (00:00:01):

Good morning every Good evening everyone. It’s Shirin Towfigh, your favorite host on Hernia Talk Live every Tuesday. Thank you for following me. Many of you’re joining me on Facebook as a Facebook live at Dr. Towfigh and as well as Zoom. And we got tons of questions for today’s session because our guest today is Dr. Charlot Horne. Dr. Horne is, again, I’m trying to bring in the newest talents so you guys can learn from them. She’s a hernia surgery specialist at Penn State University at Hershey, Pennsylvania, United States. Like me, she has a very, very descriptive and informative handle at Twitter. You can follow her at hernia barbie and on Instagram at the hernia Barbie, which implies there may be more than one. I don’t know, the real hernia Barbie. So welcome.

Speaker 2 (00:00:56):

Thank you so much for having me. I’m so excited.

Speaker 1 (00:00:59):

Me too. So there’s so much we can talk about because your practice, is it exclusively hernia or is it predominantly hernia?

Speaker 2 (00:01:09):

I’m like 90% hernia and hernia related stuff. So yeah, I also do some groin pain, so Mesh in Mesh out, and then Mesh complications associated with hernias. And then I do have small general surgery practice as well.

Speaker 1 (00:01:26):

And you work with Dr. Eric Pauli who was a guest of ours with hernia talk. That was very fun. He is one of my favorite people. He is just so intelligent and you guys make a great match. So anyone lives around Pennsylvania or can fly there. I highly recommend your team.

Speaker 2 (00:01:45):

He is a great senior partner. It’s been awesome to start my career out here.

Speaker 1 (00:01:49):

Yeah, so I told you before the show started, we have highly educated, very dedicated audience. They know so much and they’ve sent a lot of questions. This time we are going to be talking about Mesh, everything that people have questions about, we’ll be very honest about it. One of the things that I like to do is I’m as honest and transparent as possible in what I say, and that means sometimes I don’t know the answer. We are just still in the growth phase and learning phase of things, and we are all human beings, so I can’t answer for other surgeons or medicine is not a perfect science. And we know that we all try our best to do the best for our patients and make decisions based on the information that we have. And I learn a lot from this too. So the whole point of it is to educate others, but I learned so much from my audience and I’m really looking forward to this session with you.

Speaker 2 (00:02:57):

Awesome. Well, I am ready to dive into some questions.

Speaker 1 (00:03:00):

All right. Okay. Oh, we already have questions. So we have live questions and pre pre-prepared questions. I’m really excited about some of the pre-prepared ones because it’s going to be a great discussion. But before we go into the live session, let’s just at least do a very brief discussion so that everyone’s on the same page. What is Mesh as a broad term and why do we use it for hernia repair?

Speaker 2 (00:03:28):

Awesome. So I think those are two great general questions. Number one, Mesh is sort of anything in general. It’s kind of a scaffold that people use to repair hernias because we have data that says when you put Mesh in, it significantly decreases your risk of a recurrence. So in the beginning when we were fixing hernias, a lot of times people were just sewn back together and they had noticed that there was upwards of 50 anywhere to sometimes a hundred percent chance that hernias were coming back. And so when people started to try to figure out how do we decrease this, there was a lot of material that was developed in order to decrease this recurrence. And in general, I’m a huge medical history buff. I love all this stuff.

Speaker 1 (00:04:17):

No, I love it.

Speaker 2 (00:04:20):

So Mesh was actually first used in the late fifties, and so that was kind of the first time we were using synthetic meshes. So that’s kind of the plastic material. And it was actually used in military patients when they had all of these crazy traumatic injuries. There was no way to get the abdomen clothes. So Mesh was originally placed in those patients. And since then we’ve kind of spread into I would say three main categories of Mesh that people now used in a frequent situation. So you have your synthetic meshes, which are Mesh that will never go away. You have your biologic meshes, which are meshes that are derived from animals or human products. So pigs, sheep and human skin is common. And then you have this kind of newer class that’s really kind of maybe becoming a little bit more popular is these bio reabsorbable meshes. So these meshes are derived from chemicals and they don’t stay forever. So you have meshes that last six to eight weeks to meshes that last about almost two years. And so that’s kind of this new category. And so when we talk about Mesh, there’s a whole bunch of things that can be made of, but sort of broken down into those three groups. And in general, meshes used to decrease the risk of your hernia coming back.

Speaker 1 (00:05:44):

And is there a perfect Mesh or one Mesh you should always use?

Speaker 2 (00:05:52):

I think the answer is no. Yeah, I think every situation calls for a certain review of what the patient has had before, what the pathology is of the hernia, why you’re fixing this hernia characteristics, and then you can decide what sort of mess you use. And additionally, the other thing that makes deciding what to use is there are so many places that you can put a piece of Mesh. And so everything kind of depends on why are you fixing the hernia, how are you fixing it, and then what is the goal of the operation? Because sometimes someone has a large hernia, but if you’re operating for cancer, nobody really cares if the hernia comes back, you’re operating because you want the cancer to go away. Sometimes you’re kind of mitigating, yes, they have a hernia, but that’s not why we’re here. And so that’s why different meshes or prosthetics will be used to fix that versus if you were operating for just a hernia.

Speaker 1 (00:06:50):

Yeah, I always say life before Mesh. I mean, sorry, life before hernia. Yes, you teach the residents or you’re at a conference at the hospital and there’s big trauma or there’s like a dead bowel or something and there’s a hernia, and they deal with the life-threatening problem and they’re like, okay, now what do we do with the hernia? I’m like, nothing. Yeah, that’s not important. They need to survive the life-threatening portion of the operation. And then everything goes Well, I can fix a hernia later. You can fix a hernia later. But that is a secondary problem and there’s no need to address that totally time. So life before hernia is my thing to say. I hope that stick sticks in them because every so often you see them adding an extra hour, two hours to surgery to fix a hernia. I’m like, leave it alone.

Speaker 2 (00:07:43):

Well, and I think that that’s a common thing because when you start to interact with people that are exclusively hernia people, a lot of times you find that they’re probably less aggressive than most about putting in Mesh. But it’s simply because at the end of the day, they might have a big hernia, but you’re fine fixing a big hernia. That’s what you do all the time. Things get a lot more complicated when you have a prostatic in there and there is a recurrence. And so that’s why it’s kind of do whatever you need to do to save the patient. The hernia isn’t going to kill them. We can take care of it later.

Speaker 1 (00:08:17):

They often get disappointed because they call me as the expert. Okay. Now do you nothing what? We thought you’d have some fancy idea. Nope. Nope. The best idea is not to fix the hernia or Exactly. Be very, very minimalistic. Don’t do a perfect job right now. That’s not the important part. Already have some nice comments thanking you for sharing the history of Mesh. I think it’s so important to understand why we do things because there’s a lot of misinformation out there that we’re putting in Mesh because we make more money. We’re putting in Mesh because companies are paying us to do that. And I mean, are you getting paid

Speaker 2 (00:08:57):


Speaker 1 (00:08:58):

Oh, no. Concussion.

Speaker 2 (00:08:59):

And I will tell you, I am the cheapest surgeon in the world. So everything that I want, I’m like, listen, it’s also this huge misconception of how much Mesh is. So the Mesh that I use on a regular basis is often 50 by 50 centimeters because that’s my practice. And that Mesh is $450. So it’s in general a relatively cheap piece of Mesh. Yeah, I’m super cognizant of or costs actually. And in reality, I think that yes, there is certainly money that people make as doctors to talk about products and stuff like that, but I think for the most part, people are doing what they should do because they think that it’s right. And it’s not any sort of financial benefit at all, to be honest.

Speaker 1 (00:09:52):

And I always tell them for Inguinal hernias, there is no extra payment whether you use Mesh or you don’t use Mesh, in fact. So therefore it’s actually a money loser if you really want to look at it. You can not put in a couple hundred dollars of Mesh and get paid the same. And by paid, I mean the hospital, it’s an exact you and you don’t get paid differently if you put Mesh in or you don’t put Mesh in. And also same with ventral hernia. So don wall hernias, there is a small extra payment if you put Mesh in, it’s really negligible and definitely doesn’t, cost doesn’t cover the cost of the Mesh. And Mesh can be so expensive that the reimbursement that the insurance gives the hospital, not the surgeon, the hospital for that piece of Mesh often doesn’t even cover the cost of the Mesh. So if we were to get rid of all meshes, more people will actually make more money. The doctors and the hospitals for sure. They hate that we have a whole section of the hospital that has 1500 different types of meshes because that’s a drain on their resources. So we definitely don’t get paid extra to put Mesh in. We’re not incentivized to put Mesh in there. It’s actually illegal in the United States. We have a sunshine act and everything that separates us. And it’s a huge misconception that we are part of this machine to promote Mesh.

Speaker 1 (00:11:22):

The companies make money. I mean that’s why they’re there. Yeah. They’re not like, well,

Speaker 2 (00:11:27):

And both you and I are part of a quality Collaborative where we want to know how the Mesh that we are putting in is functioning. Because I think one of the hardest things about being a surgeon and being a hernia surgeon is there’s not a lot of long-term data like five, 10 years down the road. And I’m sure you see a lot of patients that have had hernia repairs years ago. And to be honest, a lot of times if you had a repair and it went great, you’re probably not going back to see your surgeon. And if you had a hernia repair and it went terribly, you’re also probably not going back to see the same surgeon. And so in reality, we don’t have a good idea of how these prosthetics are functioning long term.

Speaker 1 (00:12:07):


Speaker 2 (00:12:08):

That’s why you and I are involved in these quality collaboratives because we want to know who’s putting in, how is it functioning, and we can use all of this repository of data to be like, listen, this Mesh is not doing what we thought it is was a lot of times there are red flags before device companies are willing to pull it off the market so that we could stop using it before it’s starting to hurt our patients when we kind of know that it’s not performing as we thought.

Speaker 1 (00:12:35):

And Ben Poulose from Ohio State University was one of our guests on Hernia Talk. So we did talk about the quality Collaborative and encourage anyone who’s having any surgery that’s hernia related to ask their surgeon whether they are a member and if not, to encourage them to be a member because that helps us learn a lot about what happens to patients after they get any type of hernia repair, whether with Mesh or without Mesh, but any type of hernia repair. So that’s great. The other question that’s up here has to do with the concept of absorbable Mesh is, so why would one use an absorbable Mesh if the whole point is that Mesh is better than not having meshed? Because eventually you will won’t have the Mesh in you. So why even consider absorbable Mesh and does it even work?

Speaker 2 (00:13:24):

So I think there are sometimes when the concern about putting something in there that won’t go away is that if that prostatic gets infected, it has to come out. And so a lot of times when people are operating for infection, if there is an ostomy, so some bowel or fistula or something like that, putting in a prostatic in that situation, so something that doesn’t go away can cause that to become infected. And then it becomes a big problem because you have this infected piece of plastic basically that’s pretty much never going to heal unless you take it out. And so in that situation, people will often put in an absorbable Mesh. And as these meshes kind of last a little bit longer but still go away, the theory is that the Mesh is in there long enough that especially for the ones that last about 18 months, which is phasix at this point, is that it’s in there long enough for your body to form enough scar tissue that once it goes away, you have the strength of your body’s own scar tissue. So you don’t really need the Mesh there.

Speaker 1 (00:14:37):

And has that data been proven? Cause I think they just put out the three-year data at this year’s a h s meeting.

Speaker 2 (00:14:44):

So they actually just looked at this, they looked at the three-year data and they talked about the five-year data and their recurrence rate for their three year data. So the Mesh goes away at 18 months. So this Mesh should have been gone for almost a year by the time they looked at it in clean cases was 17%, which is a little bit higher than what we have for synthetic Mesh, but also not terrible at all.

Speaker 1 (00:15:13):

Yeah. And the thought is that I believe it’s higher, but not that much higher at five years. Yeah.

Speaker 2 (00:15:21):

Well, and the theory is that you also decrease your surgical site infection and then wound complications like a hematoma or seroma. And so that data is a little bit better than some of the other biologic meshes out there in terms of recurrence still not as good as a synthetic Mesh, but it’s not bad actually.

Speaker 1 (00:15:46):

So why did my surgeon choose the Mesh he or she used in me? And by surgeon, I don’t mean necessarily you like your expert, you probably have a very, very kind of tailored approach as to what meshes you choose and so on. But in the average surgeon, the average patient, can you explain how the decisions made as to what meshes placed?

Speaker 2 (00:16:10):

So I think a couple of things are what are you fixing? So an inguinal hernia might be managed a little bit differently than a incisional or an umbilical hernia. So where you’re putting the Mesh in, and then another layer to that question is what layer of your abdominal wall is the Mesh being put in? So if the Mesh is touching the bowel, then that Mesh needs a barrier coating to it that prevents it from sticking and adhering to the bowel. But if it’s not going to touch the bowel, then they don’t need that barrier coating on the Mesh. And then a little bit of the decision making is what they’ve used before in the past and have had good outcomes with. And so they’ll probably continue to use that Mesh in future patients.

Speaker 1 (00:16:55):

And it’s also partially a business decision by the hospital. There are different contracts that are made with different companies and depending on how much the surgeons involved, surgeons are often not very involved in those contracts. Then that company has a cadre of Mesh options available to the surgeon and they tend to use what’s available to them, and they’re not actively involved in that. So you’ve heard about recalled Mesh. We haven’t really had many recalled recently and by recently in the past couple years, but I get this a lot that I have recalled Mesh in me. We get a lot of phone calls to our office that does Dr. Towfigh take out recalled Mesh I or I see a patient and they’re said, they tell me. I was told my Mesh was recalled. So what are your thoughts on recalled Mesh?

Speaker 2 (00:17:51):

So I think that’s a tricky question. I think the first off, those people obviously need to be seen examined, and I think in these situations imaged because if you have a recalled piece of Mesh that is doing exactly what it should do and you have no recurrence at all, then you’re kind of operating for something that you don’t even have a problem with right now. And so in those situations, if you said, Hey, I have a recalled piece of Mesh in, but the Mesh lies flat, you have no recurrence, I would say, okay, we know you have a recalled piece of Mesh in, but I would leave it in that situation until you’re like, okay, I I’ve noticed a bulge. Because a lot of times the meshes have been recalled because they’re breaking. And so a lot of times people will have a recurrence. That’s how I know the only one caveat I would say or would be a little bit nervous about is there was the Atrium C cure Mesh that had that plastic ring that broke. You’d have to obviously weigh the risks, benefits to taking out the Mesh, but that’s probably one Mesh I’d be a little bit more aggressive about because it has that hard plastic ring. When people have problems, it’s because that ring is stabbing into the bowel and you obviously want to avoid that situation. But I think in general, if the Mesh is functioning as it should, even if it is recalled, I’d probably leave it in unless I was concerned that they’re at a high risk with a low morbidity of surgery to take it out.

Speaker 1 (00:19:24):

One thing that I’ve noticed is a lot of patients are led to believe they may have recalled Mesh. If you actually look at the Mesh implant log itself, that Mesh has never been recalled, but it’s a ploy I’ve seen by the Mesh lawsuit companies. The law firms are doing these clashing lawsuits, these class action lawsuits to kind of lure in patients thinking that they may have recalled and they’re under the impression that they do have recalled Mesh. We really haven’t had any recalled Mesh of late. The ones that were recalled were all due to packaging issues. They never made it into patients. There was some delamination issues that were recalled. The physio Mesh that you kind of alluded to where there’s, it actually tears in the middle that was just too light of a Mesh actually it wasn’t as effective of a Mesh. And so that was removed for the market by the company. It was never recalled because there’s a higher recurrence rate because it would kind of tear in the middle because it was so thin. The composites kugel Mesh back then, I think it was called composites.

Speaker 2 (00:20:37):

Yeah, yeah, yeah. The

Speaker 1 (00:20:38):

Composites, kugel Mesh had the ring, and I actually had several patients that were injured by that.

Speaker 2 (00:20:45):

So it’s

Speaker 1 (00:20:46):

Terrible. It was the larger ones and you had to roll it in to put it in, and the ring was not pliable. So the ring would break. It became if you break a toothpick, how that becomes very sharp, or if you break a Q-tip, a wooden, it becomes really sharp and then it perforates about. But that was in 2002, three or 2005 in that range of dates. So if you haven’t had an injury since then, you’re probably fine. As far as I know, there’s no Mesh that demands recall. I’m sorry, demands removal. If it was been recalled, that was a big question, especially the one that was hurting patients. They redesigned the ring now, so it’s more pliable and it’s actually, I think absorbable, it’s like a P d S based ring. But it’s scary if you have a park and you like if your car has a recalled part or something, you take it to the dealer and then they change it.

Speaker 1 (00:21:45):

But we don’t do that because up until now, there hasn’t been any product that demands removal. And even that composites a thing back in the early two thousands did not demand removal. You just wait until someone had a complication. And we haven’t had any recalls that were dangerous to the patient. It was always a packaging thing or there was a too hot of the packaging would open up and so that it wouldn’t be sterile. But those were all recalled before they were replaced in patients. And patients need to know whenever anything’s recalled, it’s removed off the shelf immediately.

Speaker 2 (00:22:27):

Oh yeah.

Speaker 1 (00:22:27):

So you can’t claim to have a recalled Mesh years after it’s been recalled because that should not even be around. And to date, I have not seen any patients that truly had recalled Mesh in that was placed in them after it was recalled. So I’m pretty sure that doesn’t happen. Okay. We got a lot of, a lot of, a lot of live questions. So here we go. One question has to do with allergy testing. So do you guys do allergy testing for

Speaker 2 (00:22:58):

I actually just did it this week.

Speaker 1 (00:23:01):

Oh, tell me about it.

Speaker 2 (00:23:03):

So here’s the thing. I certainly believe that people can have this systemic response to Mesh. We see it a little bit more in other prosthetics, like the breast implant illness. So there are a select group of people. Yeah, yeah. And I’m saying very select group of people,

Speaker 1 (00:23:23):

Fraction of a fraction of percent. Yeah,

Speaker 2 (00:23:25):

Exactly. That have there’s response to a prostatic. I think it’s super hard to predict. Yeah. I think even if you were in a situation, you probably are going into the, OR with a maybe likelihood that it’s the Mesh that that’s the problem. Because you know, and I talked about this, the allergy testing, the skin sensitivity testing isn’t great. It’s not very specific. Correct. The data that came out of the University of Alberta, which is my alma mater, oh, is also again maybe 30 to 50% sensitive for picking this up. We don’t really have a lot of good data. And so I actually was thinking about this as I saw a patient that has had multiple surgeries where she has spit every suture, she has a ton of problems. And she was like, I’m nervous to have this surgery. Sure. Because I don’t want Mesh in me because I’m so concerned that I’m going to have some sort of reaction to it.

Speaker 2 (00:24:26):

So I gave her a piece of the Mesh that I would use so that she can put it on her skin to see if she has a reaction to it. But this is where we were talking about this bioabsorbable phasix Mesh, if it is something that’s quite different from the stuff that we normally use, it’s around long enough that it would probably be effective at fixing a hernia. But it’s also not something that’s going to be there forever. So heaven forbid she has allergic reaction, it should go away with time, albeit two years is a long time. So yes, I think it’s a thing. It’s very, very infrequent that it actually happens. And it’s really hard for us to tell despite all of the testing that we can do, whether or not you’re actually allergic or sensitive or have some autoimmune reaction to the Mesh.

Speaker 1 (00:25:19):

Yeah, I’m impressed that you’re starting to do it. So yeah, I’ve seen people that with real reactions, you put the Mesh in, there’s a big redness on the skin, exactly where the Mesh was placed deep to it. Those were real reactions I’ve given, I’ve told this story before, but it was a guy that actually has a polyester allergy. He can’t wear polyester socks. He used to work in a shipyard where those little polyester resins are in the air and his eyes would get all red and watery and blow up. He literally is allergic to polyester. And then he had a polyester Mesh put in him. Poor guy. So that was a true allergy. And then there’s this whole kind of autoimmune or autoinflammatory reaction, we call it Asia syndrome. So from University of Alberta, we did have Dr. Professor Traver as one of our guests.

Speaker 1 (00:26:10):

I do work with him. His data is from the Netherlands, so he’s Dutch, and he used to work in the Netherlands and he got I think 40 patients that had some type of, because I believe he’s a rheumatologist. So they had some type of rheumatic disorder, [inaudible] Mesh. And so he, he’s really the first to report it for hernia Mesh. And we also had a plastic surgeon who’s very interested in breast implant illness come on, and kind of help us understand they’re doing on the plastic surgery side and kind of learn from that. But our data, we did, we did quite a bit of allergy testing and I do it with an allergist. They get a full allergic workup, blood tests and skin test, skin allergy testing. She has samples of all different types of meshes and sutures. And like you said, it is very hit and miss. It’s 40% false negative rate. So if you test negative, there’s a 40% chance you may actually be positive. And the test is just not adequate. Blood tests have not been shown to demonstrate any validity in predicting any of this either.

Speaker 1 (00:27:27):

So here’s a question is after hearing you speak of allergy testing prior to the use of Mesh, I asked a well-known surgeon also on hernia Talk about this when I had my appointment. And I was told that he did not think testing on the outside will be beneficial for use on the inside. I’ve had allergies since the seventies and do have concern about Mesh, which I know is needed. So to you, I would say having allergies, I have allergies, nose runs, ears inside the ears, itches. Having allergies and being allergic to an implant are two different things. What I’ve noticed is that if you have tons of allergies, and I’ll share with you this one patient and tons of autoimmune problems and reactions to everything, then yes, that would be probably something that would be a red flag. But having allergies alone is not enough to predict, at least in my experience. So this patient wrote, I have POTS, which is a postural orthostatic tachycardia syndrome, which is considered an autoimmune problem, which is an autoimmune and inflammatory disorder and rheumatoid arthritis, which is an autoimmune and inflammatory disorder. I also have various food and other allergies. What are my choices for hernia repair?

Speaker 2 (00:28:55):

Well, I think it’s obviously a very challenging situation. And I think going into that and trying to, as you said, do some sort of allergy testing or skin sensitive testing may be beneficial in these patients. There are other things. The interesting thing is polypropylene, which is what most of the Mesh is made out of, is something that people are often in contact with in a fairly regular basis. And so while some of those are autoimmune things, I think the other thing that I get a little bit nervous about are people that have had surgeries that are spitting sutures quite a bit. And it seems to be, can

Speaker 1 (00:29:34):

You explain what spitting sutures

Speaker 2 (00:29:35):

Is? So if you notice that whenever you have surgery at sites where they’ve put sewed things closed, you have drainage or that place gets infected and it’s kind of continually happening, your body obviously doesn’t like that material. And so often when you say spit is because you can kind of see the suture as your body tries to get rid of it actually. And so I think working with an allergist, but honestly I think the Mesh in general is fairly safe and you would probably be okay. And this is where I’m a little bit curious about. And again, this is no data about how these longer acting bile reabsorbable Mesh dysfunction, because I think there is a lot of concern about Mesh out there, which is reasonable. I think in general, Mesh is actually fairly safe, but we also are now practicing a world where patients are educated and they know themselves.

Speaker 2 (00:30:38):

And honestly, we don’t have a lot of data to say, Hey, I have put in a synthetic Mesh in someone that has multiple allergies, has autoimmune diseases, that Mesh is going to be just fine. So you’re kind of operating with all of the information you have, but is there data to guide your practice in that specific patient? Actually, no. And so it will be interesting to see how these meshes perform. And at the end of the day, what we do know is they’re probably safe, but your risk of recurrence is a little bit higher. So if you’re like, listen, I sit down with your patient counsel and say, listen, I can, I think a synthetic Mesh is safe, this might be an option for you. I would be more than happy to do any allergy testing or skin sensitivity testing at the end of the day, if we do put in a prostatic that isn’t permanent, you might have a recurrent hernia, albeit risk is 15%, and at the end of the day you can say there’s a 15% that this is kind of come back or an 85% chance that you’re going to be totally fine.

Speaker 2 (00:31:41):

And it’s just the numbers and how you look at them.

Speaker 1 (00:31:45):

Yeah, I think up until now we’re not discussing this with the patients. We promised a perfect repair and now we are spending more time weighing the risks and benefits and saying maybe recurrence is not as important to you. You’re happy with a 70% success rate, which in our society is horrible. We want a 95% or better, and I’ll accept a 20%, 30% recurrence rate knowing that you’ve done your best to try and reduce your risk of let’s say, Mesh allergy or some recurrence or fistulas or drainage, chronic drainage or just feeling melons because you have an implant in you that’s not suited to your Mesh. Okay. Next question. How can you distinguish allergy versus infection from the Mesh?

Speaker 2 (00:32:35):

So a lot of times when we talk about allergies, it’s kind of the skin redness that you have. And then we are talking about this autoimmune reaction. So people often feel like they have, they’re fatigued all the time. They have changes to their bowel or bladder habits that are new, the chronic pain, the migraines, new rashes and stuff like that. So that’s kind of the very much allergic or autoimmune reaction to the Mesh. When we talk about infection, a lot of times you’ll see, we get imaging there is fluid on top of the Mesh. The Mesh is there’s stuff draining that looks like puss or you know, can tell the difference between red. That’s an allergy where it’s like, well demarcated where the Mesh is versus this is infected, it’s hot, right? It’s angry, it’s draining. That is an infected piece of Mesh.

Speaker 1 (00:33:33):

Have you ever dealt with a low grade Mesh infection? So these are people that probably have their body’s constantly fighting a very low grade infection. I’ve seen that people, they have joint pains and just my legs really nothing else. And they probably have a risk for having it. So it was placed maybe in a not necessarily clean situation. Have you seen that? And is there anything that you’ve noticed in that patient population that’s predictive that maybe that’s what they have?

Speaker 2 (00:34:08):

Well, I think I was operating on a patient that had a seroma that was drained. He was totally fine. And then it came back and on the ski CT scan, it looked like simple fluid. He had no fevers, he had no chills. He noticed a bulge where the seroma was no skin redness. And I’m like, okay, this is sitting right on top of your Mesh. We should probably go in, take your Mesh out. And I was like, we’ll do put a new piece piece of Mesh and do something nice and definitive for you because it is just a seroma, nothing but puss.

Speaker 1 (00:34:44):


Speaker 2 (00:34:45):

So much puss. Wow. It was insane. And I was like, I had to close him primarily because I was like, I can’t put a Mesh in this situation. But I think I have always, your body is so clever at kind of walling off the chronic infections. It doesn’t want there to be bacteria everywhere. And I think it’s pretty common when you’re operating for these persistently infected meshes or these low grade infections that when you get in, you find something that is way more than you ever thought it was. Because your done a pretty good job of walling stuff off.

Speaker 1 (00:35:24):

Have you seen anyone react to the Sepra film or the barrier used? I guess secure Mesh had that kind of fish oil, omega fatty acid. Have you seen allergies to that?

Speaker 2 (00:35:36):

I, not actually.

Speaker 1 (00:35:39):

Yeah, on the I H C, there’s been some discussion of reports that some surgeons had where they felt the Sepra film reacted. I’m not so sure that it wasn’t just the Mesh itself at the time.

Speaker 2 (00:35:54):

Well, I’m convinced that again, no data to support this, that the barrier coded meshes, although so in reality, so these meshes are meshes that we place touching the bowel and the film that is on the bottom of them, the separate film goes away. So it doesn’t last forever. And in reality it’s sort of built to a

Speaker 1 (00:36:19):

Week. Yeah,

Speaker 2 (00:36:21):

Do the, prevent the bowel from adhering to it and then have the strength on the side that interacts with the abdominal wall so that you don’t get the current. But I find that those meshes must be processed a little bit differently because I’m sure as you notice, these people have had, let’s say if you’ve had an intraabdominal piece of Mesh place and then you have diverticulitis or cholescystitis and they spill some those meshes, something happens to them. And heaven forbid there’s any sort of bacteria, albeit it doesn’t really make sense why that happens because if you put, there’s no, again, no barrier coating at this point that Mesh in the retro rectus space would be totally fine if something happened. But those meshes just don’t function well. And we do have data that said that salvage in of those meshes in situations is like zero, so that’s correct. So yeah, I don’t

Speaker 1 (00:37:15):

To remove it. All infected Mesh needs to be removed. There was a surgeon that reached out and was like, I have this infected Mesh, but I was going to go in there and just kind of take out as much as I could. I said, no, no, no. You got to take out all of it. Oh, but is it really necessary? Yes. He’s like, but there’s this little voice in me that says it’ll be fun. I said, we’ve all had that little voice, my friend. It’s been proven over and over. Do not listen to that voice. It’s an incorrect voice. So yeah, at least we have, again, we try and do as much evidence-based surgery as possible. We’re often the ones that are coming up with the data because through experience, and there’s a comment about do you have any true data on polypropylene and link with autoimmune disease? Everything is a correlation right now. We don’t have true data that says this caused that. We can just say the patient was totally normal, they got meshed, now they’re abnormal. We took out the Mesh, now they’re normal again. And so we’re kind of correlating it and they may or may not have an allergy test or any other kind of objective manner of approving that correlation. So no, we currently do not have any fancy studies to support a lot of what we say. And we’re still learning. We’re still learning. It

Speaker 2 (00:38:35):

Would be great to have that data, but in reality, I think most hernia studies sort of end at two years and after that we have no idea how the Mesh is performing and what’s going on,

Speaker 1 (00:38:46):

Which is why this ACHQC, our quality Collaborative is so important because that’s follows the patient through their lifetime. One patient wrote, thinking back to some oral surgery I had 20 years ago, I spit out the stitches several times and I never connected that to my issues with hernia Mesh reaction. So that’s interesting to hear that correlation. Now, I did react to some of the Mesh samples when I had allergy testing, but it turns out I react to really any foreign body implant, not just alerted to a particular type. Is there any way to predict form body reaction?

Speaker 2 (00:39:20):

No. No, not really.

Speaker 1 (00:39:23):

Have you had patients that have infections complain of a burning pain? I have allergies form body reactions and autoimmune response. And I’m wondering if the constant burning is a low grade or encapsulated infection.

Speaker 2 (00:39:37):

I think it’s hard. A burning is I think a lot of times like a very much a nerve related complaint. And so I wonder if the reason that you’re having the burning sensation is that your infection may or may not be close to a nerve that’s causing you that sensation. Yeah.

Speaker 1 (00:39:54):

Here’s an interesting question. I had a hysterectomy recently and the adhesions on my ventral Mesh repair were so thick they couldn’t view the upper abdomen. I had endometriosis everywhere. Is it possible that endo could spread to that Mesh?

Speaker 2 (00:40:10):

I don’t see why not. Actually.

Speaker 1 (00:40:13):

Yeah, endo can go anywhere, but I would highly recommend if someone has had a major abdominal wall reconstruction or Mesh and they’re planning on having another abdominal wall, another surgery that uses the abdominal wall, whether it’s urology, gynecology, colorectal, reach out to your hernia surgeon or to a surgeon specialist in that same PR neighborhood to help out because I don’t like it when they call me later on infection or our wound opened up and now your meds is exposed. And I’m like, wait, you went in a belly and didn’t tell me. I want the me patient to tell me and I want the surgeons to tell me. And in my hospital they already know. So they call me, they’re like, Hey, so this patient now has such and such cancer, we’re going to go in there. We want to make sure we don’t screw up the repair you did. So I go in there and I help them enter because I know where the Mesh is, I know how to handle that. Whereas the specialties don’t necessarily, and then what I try and do is to make sure that my repair is not disrupted by whatever they’re doing. Someone need a stoma, they need a urostomy. And they’re like, they knew enough to know that they shouldn’t put stoma through, but they also don’t want to screw up the hernia repair. So I was there to help with that, that Do you have that Collaborative?

Speaker 2 (00:41:42):

We do. Yeah. And I think whenever I see patients, especially when I do these complex abdominal wall reconstructions, I’m like, listen, nobody goes into your abdomen without me knowing. And if we can make it happen, I will be in there when they go into your abdomen because once you have done coded someone’s abdominal wall with Mesh hernias that come back after that situation can be very challenging to fix. And while there is a lot of people that are fixing hernias and doing conflicts, abdominal wall in general, the number of people that need that thank goodness is small in relation to the whole population. And so it’s not something that people will commonly other surgeons of subspecialties commonly handle or deal with. And so I think especially when you’re kind of like, listen, this is what I’ve done. I know where my Mesh is, I know what type of Mesh I have. I know how to mitigate any recurrences or complications with what you’re doing. It’s essential that if you’ve had hernia surgery, even as a patient, I would say try to get ahold of your notes so that heaven forbid you need surgery again. People know where your Mesh is and what Mesh you have. Yes, that’s for sure. That’s really even hard for us to hunt down sometimes. That makes a huge difference.

Speaker 1 (00:43:04):

Let’s move on to more like pain questions. How does Mesh cause pain in either an open or tap or tap inguinal hernia repair? That’s a big hand

Speaker 2 (00:43:14):

Question. Oh my gosh. We could talk all night about that. So this make a brief, my spiel, I’ll make it quick. I think the biggest thing is, especially in the inguinal realm, people have been told that their Mesh is the source of their pain when reality, I think there was probably something like the Mesh is doing something that’s causing pain. It’s not the Mesh that is the problem. It’s like the location of the Mesh. And so obviously when you’re doing a tap or tap inguinal hernia repair, I was just with Dr. Chenin ehs and the only safe place to put any fixation is basically on cooper’s. Everything else is battleship in terms of hitting nerves. And so the best you can do is make sure that you are not putting any sort of fixation below the myopectineal orifice. Stay away from the nerves. The surgeon should carefully dissect out the cord.

Speaker 2 (00:44:13):

But in reality, there are so many reasons that your tap or tap Mesh may be causing pain, recurrence, any sort of nerve or inadvertent injury to nerves that are there, tax fixation, all of that stuff. And so I think I have this conversation every single day in clinic. It’s not the Mesh that’s causing you the pain, it’s how the Mesh was put in that causing you the pain that Mesh truly has never been recalled. It’s a very, very safe piece of Mesh. But I think we are starting to understand all of the nuances to inguinal hernia surgery that we people were unaware of before and how challenging it can be to have a nice durable inguinal hernia. And I think the trickiest things with this population of patients is oftentimes you’re dealing with young, active healthy males. And so you’re going from a, I want to be completely functional, no restrictions, feel nothing, and you have to do a surgery that allows people to do that. And so everything matters. You have to be very careful in the or, but in reality, it’s probably not the Mesh that’s the problem. But the Mesh is irritating something that is the reason you’re having pain.

Speaker 1 (00:45:33):

And I want to say if you go to a doctor and they don’t understand your problem, you just very nicely explain where there’s many facets of pain and they just say all pain is Mesh pain. I would run away because that is a horrible way you overtreat patients you often don’t do right by them. And I’ve heard that said before and I was just floored when I’m like, all Mesh, all pain is Mesh pain. What if there’s a recurrence? Nope, that’s Mesh pain. What if it’s a nerve problem? No, that’s Mesh pain. I’m like that. You’re just not thinking right now. This makes no sense to me. Okay, we have a comment here. After having this polypropylene hernia Mesh inside my body for almost 20 years, it went really bad.

Speaker 1 (00:46:21):

No testing was ever done by the F D A. This just floors me. It doesn’t matter if the Mesh was recalled or not. Polypropylene Mesh is garbage. Well, I’ll just make the comment that if you’ve had the Mesh you for 20 years, then the likelihood that whatever problem you have now is related to the mag is to zero. Okay. There’s more about this. I got terrible skin rashes. I never knew why I came to find out the polypropylene hernia. Mesh was more than likely causing these terrible skin rashes. I was diagnosed with multiple sclerosis and I had all of this BS hernia problems at the time. Nobody wants to look into the facts though. It’s a big nightmare. So we are to our look at the facts. I would say if your allergies started 20 years later, it’s probably not the Mesh. That’s just not how allergies work. But if you need the Mesh out and it’s a low risk procedure, we’re not God. We do not. We don’t know everything. So we’re happy to consider taking that out. This is a good question. There are no long-term studies on the degradation byproducts within the body from these implants. The chemical process involved caused so many other reaction that’s not just cut and dry CO2 and H and H two. Have any other absorbable measures been evaluated for longer periods?

Speaker 2 (00:47:39):

I think the answer is no. Actually a lot of the bioabsorbables are very new and I think the biologics are also something that people put in very commonly. I actually very infrequently use biologic slash never use biologics because I find that the predictability. And so I think that’s why some of these bioabsorbable meshes became are becoming a lot more popular because they degrade through a particular fashion. Whereas some of the biologic meshes really how they’re interacting. Nobody really knows. I’ve had situations where the Mesh has been there and looks fine. I’ve had situations where the Mesh has just become putty almost sitting there. And then I’ve had situations where we’ve actually had to use a sternal saw to cut through biologic Mesh because the patient ossified their whole abdominal wall. Wow. So it was, it’s

Speaker 1 (00:48:41):

An absorbable Mesh, which obviously hasn’t.

Speaker 2 (00:48:43):

Yeah. And so I think that’s

Speaker 1 (00:48:47):

Everybody is different.

Speaker 2 (00:48:51):

Impossible to predict what is going on. I think in general, technique matters more than probably the Mesh that’s being put in. Yes,

Speaker 1 (00:49:00):

I agree.

Speaker 2 (00:49:01):

And in general, this is kind of the sad thing, and we actually had a ground rounds here by a urologist that does the female urology that talked about the whole Mesh problem with pelvic organ prolapse. And that’s actually a polypropylene piece of Mesh. Yes, it is something that we use every day, but in that situation was absolutely terrible and caused a ton of problems. And so I can only imagine as a patient how confusing it is to be when you’re like, okay, there’s this Mesh that’s the same message that my hernia surgeon is putting in, but it shouldn’t be used here, but they’re going to use it here. It’s so confusing. And in reality, honestly, when you think of the total numbers, we probably do about 300,000 plus hernia repairs every year in the us. The overwhelming majority of those people are getting 1 million.

Speaker 1 (00:49:53):

I’m going to correct that number. It’s 1 million.

Speaker 2 (00:49:55):

Yeah, a million hernia surgeries every year. The majority of those people are getting Mesh. So in general, Mesh is fairly safe and it’s actually pretty good. Yes, there are some nuances to putting Mesh in and where to put it and what Mesh to use.

Speaker 1 (00:50:10):

Yes. And

Speaker 2 (00:50:10):

We do need a lot more data, but I think there is this overwhelming fear that meshes terrible and shouldn’t be used in reality. Probably not as bad. a lot of people do just fine. But you certainly need to sit down with your surgeon and talk about risks, benefits, alternatives, all of these things that can help you have a great outcome

Speaker 1 (00:50:29):

After your surgery. You’re so right. So well said. Next question. I had left inguinal hernia surgery six years ago with a plugin patch and have since had horrible pain. No. One doctor said, I have a left inguinal hernia, and he, oh, now one doctor said, I have a left al hernia and he found three other hernias, which he wants to fix with Mesh. How could I have a left al hernia repaired? Well, you want to talk about the plugin patch.

Speaker 2 (00:50:59):

I was going to ask you how do you feel about the plugin patch? I think we feel the same way.

Speaker 1 (00:51:04):

Yeah. So the plugin patch, let’s talk some history here, was introduced as a way to fix a hernia without doing a big incision, without doing a lot of dissection, and therefore a shorter recovery time. And it was developed by one set of surgeons and then improved by another set by another surgeon as to how to put it. In retrospect, that was not a good idea for two reasons. One is it’s way too much Mesh. We’re putting in a ball of Mesh, and now many people have literally feel like they have a ball of Mesh in them. And so I explain it and we call those meshoma. I explain it having a pebble in your shoe and now you have to walk. So unfortunately, that needs to be removed. It may still be one of the more common meshes that are sold by the company, but at the time, it was the number one selling Mesh.

Speaker 1 (00:51:57):

And so now we have a lot of people around, again, most people did well, but of all the meshes that are put in, it seems that the Mesh plug and patch has the most. But we actually looked at our data and looked at all the meshes we removed, and to see if there was a preponderance of one style of Mesh versus the other. And actually the plug was number two, regular flat Mesh had more problems than the plug, believe it or not. But the second issue is it kind of forced surgeons not to understand anatomy and be really delicate with what they were doing. They just kind of jammed something into a hole and called it a day. And that was kind of this kind of horrible way that Mesh was tried to be made easier. And so over time, people were not really appreciating anatomy, which back in the day when they were doing tissue repairs, you really had to know your anatomy to know what you’re doing. Whereas it’s really hard to screw up a Mesh repair because the Mesh does so much of the scarring and so on in addition to it. So yeah, if you do have Mesh plug problems that just needs to removed, there’s no way for that.

Speaker 2 (00:53:08):

This is Mesh. I often bring this stuff to clinic because people want to know what it is. Yes. Got my little Mesh package I bring to

Speaker 1 (00:53:16):

Clinic. That’s a large Mesh plug.

Speaker 2 (00:53:18):

This is a Mesh plug. It’s literally a badminton birdie.

Speaker 1 (00:53:22):

Yeah, yeah. Or birdie. Yeah. Yeah. It’s a lot of, a lot of, I mean, some people won’t feel it, but if you’re a ballerina or someone’s thin or have, God forbid, a propensity towards reacting to implant, that’s a lot of implant.

Speaker 2 (00:53:39):

Well, and I think the question was asked, how can you have other hernias? Yeah. So a lot of times the Mesh plug was placed in the indirect space. There are multiple places that you can develop hernias in the inguinal area, and it’s not impossible to have a recurrence after a plug placement. So if your surgeon says you have a plug and you have more hernias, that is something that exists. And so you know, probably need your plug out as well as sounds like maybe some other hernias fixed.

Speaker 1 (00:54:11):

Yeah. The other comment is, isn’t it time that we move forward with a hundred percent certainty about what we’re doing? What’s your thought on that? Why are we doing all this when we don’t have a hundred percent certainty in every action that we do?

Speaker 2 (00:54:25):

I think it would be impossible to get a hundred percent certainty because you’re asking for a hundred percent certainty for one person, and not everybody is the same. And so the best we can say is for this patient population, number one, just to get enough people to say we know a hundred percent certainly that this is going to be okay, is almost a never event because there’s so many things that people can have. There’s so many autoimmune diseases, sensitivities, allergies, to actually get a good number of patients with that. And that had the same sort of hernia characteristics. I mean, we can only get as close. And I think there are a whole bunch of people that are really invested in trying to examine exactly how things are performing the best we can. But just the sheer statistics of trying to get to a hundred percent is just it’ll take some time. And a lot of people,

Speaker 1 (00:55:22):

I think one of the frustrations that there is in medicine is nothing we do is a hundred percent nothing. Zero. Okay, I can give you aspirin for, I can give you an Advil for your pain and it won’t deal with a hundred percent of your pain. I can give you a blood pressure medication and not a hundred percent of people will have a good response to that blood pressure medication. I can take out a breast tumor or do breast surgery and we won’t have a hundred percent results in that surgery or a knee surgery or knee implant. Nothing that we do is a hundred percent. It’s kind of the world we live in and it’s a risk benefit ratio. And that’s why we have a lot of regulation to make sure that we are aiming to be as close to a hundred percent as possible and that we’re not doing operations like Dr.

Speaker 1 (00:56:10):

Death, the neurosurgeon, where he had all these horrible complications. Because there is a lot of oversight in our practices that maybe people aren’t aware of. And a lot of this issue with the current vaccine and is we don’t have vaccines that work a hundred percent and people are very frustrating. How could you recommend that everyone get this vaccine as a mandate when it doesn’t work? 100%. So it is frustrating. That’s what science is. Science is not a hundred percent engineering is we don’t build homes that if done correctly, they all do. Well, when we put sinks in, it’s pretty much guaranteed that the sink will function. But yeah, medicine is not like that. And it’s very frustrating for patients to grasp that, especially when they’re in that portion of the fail the failure portion. So I dunno if you have any more to add to that comment.

Speaker 2 (00:57:11):

Well, yeah. And it’s very much, people don’t say I do medicine. They say, I practice medicine. And it truly is a situation where people are constantly learning, we’re constantly trying to make things better. And at the end of the day, it is the evidence that we have, the experience that we have to put forward our best practice recommendations for a patient. And I said to a patient today, she was nervous. She had Mesh in and was getting a colonoscopy. She says, I worried that they might perforate my colon because I have this smash. And I say, you’re going to be totally fine. Everything looks and feels okay. But at the end of the day when you say, well, your risk of having a perforation with a colonoscopy is one in a thousand percent or whatever it is, if it happens to them, it’s a hundred percent.

Speaker 2 (00:57:59):

And so yeah, while risks and ratios do matter, if you’re the person that’s in the one to 5% that has a recurrence or higher percent that has a complication, it doesn’t matter. You are a hundred percent. And so people on the medicine as a whole is really trying to do what’s best for the patient population, but obviously we don’t have all the answers and we’re trying to make things better every can every day that we can. And when we kind of notice that things aren’t going as we thought, we invest in getting more data and figuring out why. And really, as you had mentioned with the Mesh companies like advocating to say, Hey, listen, like your Mesh isn’t performing how we thought maybe we should investigate this so that we can do the safest thing for our patients.

Speaker 1 (00:58:49):

So we have a lot of positive comments. I appreciate your focus on collecting data and considering every variable such as technique allergy, Mesh type, et cetera, to avoid harm in your patients, both of your amazing doctors. That’s very kind. Here’s another question. Well, you know what? We have one minute. Wow. We didn’t even go through the over 20 questions that were submitted. Oh, I’m going to save these because some of them were really, really good. We may have to come back if you’re agreeable to come back and oh, for these, so many great questions. Wow, what can I say? I’m very impressed you guys. This was a very quick bam, bam, bam, going through lots of questions, lots of really fantastic, we fantastic like insight. And I love that the fact that everyone was so interested in what we have to say. I appreciate that. I say this every week. I love that people tune in and then they do again. So, oh, before we leave. So you may know a nice gentleman, Mr. Aphm Onyema.

Speaker 2 (01:00:04):

Oh my gosh.

Speaker 1 (01:00:07):

So I went to the Geanco Foundation charity event last Friday. It was fabulous. I was there with Kevin. You went to Nigeria and volunteer your time. I know we’re we’re going over, I never go over, but I want you to just give us a little blurb of what you did and maybe I’ll do it.

Speaker 2 (01:00:35):

Well, yeah, it was awesome. So Dr. Al Hayek, who was a friend of yours Yes. Was a surgeon that trained me actually. And when I was a chief resident, we went to Nigeria with the Geanco Foundation. So it is a family. Then his dad, he was a ob gyn in Nigeria, and he had noticed that there was just a huge deficit of healthcare in Nigeria itself. And so Aphum has fundraised a ton of money to help educate women there. Yes, they did schools for a ton of work with helping pregnant women get the appropriate testing. They’re building schools for children there. They go down and do some orthopedic surgery. And what our goal was, was to teach some of the surgeons there how to do some minimally invasive, so laparoscopic surgery. Because in the general surgery world, it’s not very common and especially when these people need to return to work sooner because their families rely on their income. They can’t have big wounds because obviously those are hard to heal. We were there to teach a couple of the surgeons there how to do laparoscopic surgery, and so it was awesome. Speaking of Mesh and device companies, one of the companies we work with donated like $50,000 worth of medical equipment for the company there or for the hospital. It was awesome. It was

Speaker 1 (01:02:15):

Amazing. These surgical missions, most of the patients need hernia repairs. Yep. It’s a thing. It’s the most commonly needed operation for these people, and often because they have it as a child, really, it doesn’t get addressed until they’re, they’re unable to work and it affects their ability to help their family. So yeah. Kevin, I think is going next week, this week or next week for another mission in Nigeria, and I help sponsor some work at the foundation. I got this beautiful little letter handwriting. He’s got this craziest handwriting. He’s this gentleman. Yeah, quite the gentleman. Just as a thank you note today, actually, I got the letter, so I was like, oh, I’m going to talk to Charlotte about it because yeah, that’s something that she’s done and hopefully I will do as well. All right everyone. You guys been great. I don’t know how to thank you all. It’s been a fantastic event. Thank you Charlotte, for your fantastic insight. I love that. I think I love it most because I agree with everything you say.

Speaker 1 (01:03:29):

It’s kind of frustrating sometimes when a guest comes in, I’m like, no, not really, but we’re like, I feel like we’re on the same page. We’re parallel. Which it just confirms that maybe the thoughts that I’m having are al also pretty correct if you have similar thoughts about these patients. So thank you everyone for coming. Thank you, Dr. Horne, for your time. I hope you can get back to your family. A S A P. It’s kind of getting late on your side of the world. I’m tuning out. This is Hernia Talk Live question, answer session. We’ll be back again next week for another Hernia Talk Live session. Make sure you follow me on YouTube because this will be shared there. And Charlotte, if you ever need to share it with anyone, feel free to and we will call it a day. Thanks guys.