Episode 91: Pros & Cons of Mesh vs Tissue Repairs | Hernia Talk Live Q&A

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Speaker 1 (00:00:01):

Good evening everyone. It’s Dr. Towfigh. I hope you’re all well. Thanks for joining me on our weekly Hernia Talk Live Q&A session. My name is Dr. Shirin Towfigh. Many of you know me as a host of the show. We’ve been doing this since the beginning of the pandemic, which is now almost two years ago, and we’re very much closing in on almost our hundredth episodes. I’m super excited about that. Thank you for everyone who joins me on my kind of social media mission of trying to educate you about hernia related issues and answer your questions. I’m on Twitter and Instagram at Hernia doc. Many of you’re joining me on Facebook Live currently at Dr. Towfigh. And then as always, you can watch this and all previous episodes of Hernia Talk Live Q&A on my YouTube channel. So today’s going to be interesting because what I decided to do was a little bit impromptu.

Speaker 1 (00:01:04):

I have had some really interesting events happen in the past couple years, especially the past couple weeks. And so I thought that I would use that kind of recent events to spark some discussion. And usually I have a guest and I was hoping that this time our guest would be all you guys. I’m hoping this will be as interactive as possible. Typically, you all send me your questions before or I answer them during the live episode. I’m hoping that will, some of you have sent me some questions. I’m of course always happy to answer any hernia questions that you want during this hour, but specifically we’re going to try and talk about hernia Mesh lawsuits. I don’t have an expertise in this. I’m hoping that as more lawsuits are moving forward in the process from a multi-district ligation type standpoint, that we do discuss it with a specialist.

Speaker 1 (00:02:10):

We’re kind of still very early in the process for hernia Mesh. But that said, there’s enough kind of things that have happened lately that I want to share with you that I hope will spark some discussion. I hope to hear from all you all as well because I know that there’s definitely many of you that either have sued your surgeons, sued the Mesh industry companies or hospital or whatever and can share your expertise or experience with me. But I’ll just give you something very interesting. So I recently operated on a patient and that patient woke up from surgery and picked up his phone, picked up their phone and checked their email. And there was an email that said, have you had hernia surgery? Have you had any complications from your Mesh? And he didn’t even have Mesh and please click here and we will help you litigate.

Speaker 1 (00:03:23):

And he got really angry actually. He’s like, your office is selling my health information, how dare you? And I was like, wait, hold on. My office doesn’t sell anything. And so we kind of went on this kind of escapade to figure out how it was that this patient got an email, so it could be random, but it’s not random and he is not the first person to have heard about getting these emails. And I know already I’m seeing people going on online saying they get tons of those. They’ve had tons of emails. So I’m curious if any of you have actually looked into seeing how your email was found to then link you to a law firm to initiate, let’s say a initiate some type of ligation for your hernia problems. And I’ve actually called multiple specialists because nationally, nationally we’ve had many, many patients that had hernia surgery and then they had an email or even a phone call that says, have you had hernia surgery or Mesh problems?

Speaker 1 (00:04:46):

Give us a call. And they’re like, wait, how did you even know? But yes I did. And then they follow this kind of pathway. So I had a technology kind of expert review this email. The email came from an unknown email address. It’s like xyz at ppft.com to spam level email from unknown server. It had some reply, all was like some Lululemon reply alls, very weird. And it linked to a website and the website was an actual law firm that said if you would like to be contacted about your hernia mesh ligation opportunities, click here. So I did click because now I’m getting, like where is this coming from? Where does this law firm actually get patients information, et cetera. And so I fill out a form, like a fake form, and now I’m getting phone calls every day mostly by nice people. They call me and they like, can we ask you some questions to see if you’re eligible?

Speaker 1 (00:06:15):

Of course the answer is always yes, you are eligible. And so I started talking to these people and I said, who are you? Where are you from? What is this system? So it’s a call center. The call center is hired by this specific law firm and they’re given a list of people to call that have signed up on this mailing list and said, okay, well how did you even know to email it? Well, they claim, all we know is that you filled out this form. So the link between these call center people and the original email, there’s no link, but supposedly this law firm got medical patient’s information like my patient’s email and emailed them and it cannot be random. No way that this patient woke up from surgery and had a random email from Mesh when he from hernias he’s never had.

Speaker 1 (00:07:20):

So these people that call certain they get paid per person that they sign up, they don’t get paid per phone call, they get paid per person that they sign up. I didn’t ask them how much they get paid, but they work based on volume. It’s a volume based problem because even though I told them I’m not really interested to get involved in the lawsuit, I just want to focus on my health. I still get phone calls every single day in a text, every single day and a follow up email every single day. So I’m now in this horrible series of, my data is somewhere with this law firm and it’s a local law firm. I looked them up. It’s a local law firm of maybe 20, 20 different law firms. So I’m curious, are you all getting emails shortly after or around the time when you have hernia problems? Is that a thing or what I am told, so then I reached out to a techie friend of mine and he said, what’s happening is, and I’m sure this is correct because I know it happens in other situations, there are nefarious law firms that find patients in that work at insurance companies. So someone at the data analysis data base. So this is what happens. My office sends out a request for prior authorization for surgery to this insurance company. It includes the code for hernia repair. Don’t say Mesh, not Mesh, doesn’t know anything.

Speaker 1 (00:09:15):

My patient is now flagged as having undergone or wanting to undergo or planning to undergo a hernia repair. And someone within the insurance company, unbeknownst to the insurance company, supposedly then takes that email or by patient’s information and there’s hundreds of them and get or thousands of them. And then the law firm pays per address, totally illegal by the way, not considered good practice or safe practice. It violates every possible law related to HIPAA as well as that person’s probable like security level of dealing with patient information at the insurance company and also the law firm is illegally getting this information and then they take that information, you’re now in a database and you start calling. So interesting. I’m getting a lot of people responding. So one person said they’ve never received emails, texts, or phone calls about hernias. Okay, well that’s good. Another one says, I can’t get any lawyer to take my case.

Speaker 1 (00:10:38):

I wrote to 10 firms and have not heard from any of them. I had a really bad reaction to Ultrapro. Okay, so Ultrapro is an ultra lightweight polypropylene and Vicryl, which is absorbable suture Mesh made by Ethibond. So if it’s not recalled, then they don’t want you. Yes, Ultrapro is not recalled. In fact very few Mesh is are recalled and most of the meshes that are involved in lawsuits are not recalled meshes the doctor did not, did nothing wrong. My body rejected it. Okay, let’s see. Never received an email nor a text. I do get innumerable Facebook ads for it though. So that’s another thing is that if you go on a website to search for these terms and you leave your computer on long enough, it’s possible that someone can kind of track that and then take your information off the net and start emailing you. That said Facebook makes sense. So if you’re on Facebook and you are talking about your hernia experience or someone had a hernia or you are on a hernia group, especially a public one, then it’s possible that someone like a law firm is paying to place ads on your feed because they specifically targeted words like hernia, Mesh, chronic pain, something like that. So that is true. Most likely that’s how Facebook functions. So that that’s, and that’s basically legal.

Speaker 1 (00:12:18):

I wish I could have a lawsuit on my Mesh, but I can’t sue the army. Are you in the army when you had your Mesh put in? Yeah, I had it taken out and feel amazing now. Okay, well that’s great news. Let’s see. More comments coming in. Yeah, so that’s the issue with Facebook and it seems that if your computer’s hacked or you’re on some website that can kind of trap your information. Just the act O of searching can tag you. So I asked my patient, I’m like, were you searching other? He said, yeah, I was, but I didn’t give my email to anyone. But it’s possible if you leave your computer on and it gets, I don’t know the right terms, but somehow they can get some of your information just by staying on on those sites where you talk about it.

Speaker 1 (00:13:18):

What do you think of Doc, the late Dr. Robert Ben David’s many criticism of Mesh. He was a famous surgeon researcher, not a lawyer. True. So I know Dr. Ben David, he passed away several years ago, I believe 2019. He was an Israeli doctor. He was a surgeon both in Israel and at the Shouldice clinic and very active prolific writer, written reading books. I’ve written chapters in his book know him personally and he was very active in the hernia societies. So Dr. Ben David did not when he spoke with me, and I’ve spoken to him multiple, multiple times, it’s not correct that he was anti Mesh. He did believe that there were, and I have this in writing from him because we used to communicate about this, he did believe that there are times when Mesh is absolutely necessary and had been proven to be better than tissue repair.

Speaker 1 (00:14:25):

Femoral hernias is a perfect example. Recurrent al hernias, another example, larger abdominal wall hernias. So he had no issue with the fact that hernias, many of them actually should be repaired by with Mesh. His message, however, was that tissue repair should not be underused and more people should learn tissue repairs, understand anatomy. He also felt that meshes can be improved to reduce inflammation. He had several papers where he looked at the nerves and how the nerves and Mesh could interact. So yes, I know Dr. Ben David very well. And the question specifically is what do you think of his many criticisms? His criticism was not that Mesh should never be used. It was that it should not be overused. Number one, that surgeons need to appreciate anatomy and perform Mesh repairs correctly and accurately. And then also that Mesh products need to be improved to reduce complications that are preventable from to it.

Speaker 1 (00:15:46):

Alright, so let’s go back. Let’s see. Saying hello. My case is still ligation. The lawyer’s calling me tomorrow. I was told I they had five years to pay. Well, it’s been five years. So yes, usually it’s a three to five year process. For a lot of these litigations you have to kind of add two years because of COVID and the pandemic. So unfortunately that’s the situation we are in. What are the odds that a Mesh placed laparoscopically for Inguinal hernia results in bowel adhesion close to zero, in other words, less than 1%. So laparoscopically placed Mesh for inguinal hernias is not placed anywhere near the bowel. It’s placed extra peritoneal, which means between the peritoneum and the muscle. The peritoneum is superficial to the bowels, so it goes bowel, peritoneum, Mesh muscle and therefore there should be close to zero risk. Now why don’t I just say 0% because every so often there’s a hole in the peritoneum and that hole in the peritoneum can expose the Mesh to the bowel and have the bowel stuck to the Mesh. So that risk is possible. It happens more with tap T A P P than tap T eTEP. So potentially that may be increased with a robotic explosion for Inguinal hernias because those are always tap. It’s hasn’t been shown. That’s just like a theory that I have. But what are the odds that a Mesh placed laparoscopically result in bowel adhesion Close to zero and the adhesion would not be bowel to bowel, it would be bowel to Mesh.

Speaker 1 (00:17:38):

Let’s see. a lot of questions guys. Yeah, so this patient first had Mesh in Afghanistan while they were in the service. This newer Mesh has been in for 12 years. No rupture, but the pain is definitely getting worse. Plain to see you sometime in the future. Okay, happy to see you. Let’s figure out if it’s the Mesh or if it’s something else. Hi doctor. I do not know how I missed the beginning because I had been waiting for the live to start for the last half hour. I’m here now. Okay, well, I kind of gave you a little bit of a new experience that I had, so you can probably listen to it on demand on YouTube. All right. What is the timeline following a Mesh and plan her angioplasty for the various complications, including pressure on a nerve fibrosis leading to nerve entrapment, meshoma migration, clam shelling, et cetera.

Speaker 1 (00:18:37):

I may have some of these terms incorrect. Apologies and thank you. Oh, well, first of all, I’m very impressed that you know any of these terms, but Mesh implant, so her neoplasia implies hernia repair with Mesh. Then the question is what’s the timeline where you may have fibrosis, nerve entrapment, meshoma, migration, et cetera. So it’s within days to weeks to months. If you have no nerve entrapment, no folding of the Mesh, no shifting of the Mesh Mesh doesn’t really migrate. So I would take that term out. It’s very uncommon for Mesh to migrate, although I see that term a lot. I think people understand migration, but it’s not really a thing as much as some of the other complications you can see with meshes. But that happens very early on. So if the Mesh didn’t fold within the first few weeks, or if the nerve is not entrapped in the first, like I’m going to say months, definitely less than one year, then the risk of that happening years later is zero.

Speaker 1 (00:19:52):

These are all early signs of problems, early problems. So people don’t come in with meshoma or mesh folding years later. It happens early. The fibrosis occurs in the first three months and can lead to injuries within the first three to six to nine months, maybe a year. The one exception is neuroma. So if a nerve is injured, it may take years before a small injury will present with nerve pain. The other late form of complication is a Mesh infection. So it’s possible that there was some break in sterility at the time of surgery, and then several bacteria got involved in an otherwise sterile field sitting, hanging out with the Mesh, and then two bacteria becomes five, five bacteria becomes 500, 500 becomes 5 million, and finally you get a Mesh infection years later, or you had a perfectly good hernia pair and then unfortunately had perforated diverticulitis, perforated appendicitis, rectal abscess, tooth abscess, and you got bacteria in your blood and that bacteria as it’s flowing through your blood system, sits on the Mesh and hits the Mesh and sits on there.

Speaker 1 (00:21:18):

In those cases, the infection of the Mesh can occur many years after surgery, but there’s really only three reasons why you would get a delayed problem. The number one reason after a hernia repair, the number one reason is recurrence. So if you come in saying, I was doing fine for five years, now I have pain, my hernia repair, it’s almost always a hernia recurrence. Number two is neuroma. Number three is infection. From your experience as a revisional surgeon, what are those surgical mistakes that you see and think should be prosecuted? How often is Mesh involved? Okay, very interesting question because I am seeing a pension by the law firms to sue industry. I’m not seeing them go after surgeons as often as maybe the damages seem to be. So for example, I see I do a lot of revisional surgery. The majority of revisional surgery that I do allows me to kind of like forensically relive and figure out what went wrong.

Speaker 1 (00:22:37):

Why did this patient need Mesh removal? Why did this patient have nerve injury? Why did this Mesh fold? Why is there a recurrence? So all of these kind of go through my mind as I’m evaluating a patient. It also makes me learn. So I learned from other people’s problems. So I must say the majority of problems that I see are surgical technical. So they use too small of a Mesh or too big of a Mesh for the space that they created. They put suture where there shouldn’t be suture, they put tax where there shouldn’t be taxed. They put a heavyweight Mesh in a lightweight patient or lightweight Mesh in a heavyweight patient, these are or they put Mesh that should be placed Intraperitoneal, Onlay against the bowel, extra peritoneal against the muscle. These are all mistakes that are made as a result of the decision made by the surgeon and not really a Mesh problem. Are there Mesh problems? For sure. Are there designs that can be improved for meshes? Absolutely. I am huge advocate to help change our Mesh products so that complications that can occur from meshes, like how it gets stuck to the spermatic cord and can involve nerve entrapment and nerve kind of erosions erosions and to bowel, those should all be designs of the Mesh that can be improved.

Speaker 1 (00:24:12):

Do I blame the Mesh industry because the Mesh folded or the patients got the wrong Mesh? No. So I do believe that surgeons are not perfect. I for sure have had my own complications. I’ve also been sued, and that’s part of being a surgeon. The complications that I see that I revise are almost always, I would say at least 80% of it, maybe 90% of it is technical in nature and not something related to the Mesh itself, but something related to the technique in which the Mesh was or the hernia pair was performed, the decisions that were made by the surgeon, and I learned from that. I think it’s really gratifying to be a revisional surgeon because not only do you get to help the patients, but also you get to learn so that you don’t do the same mistake that was made.

Speaker 1 (00:25:23):

Oh, here’s a good question. I just thought I would update you on the reclassification of hernia mesh in Australia. Manufacturers now have to go through more stringent criteria to have their Mesh approved through the T G A. That’s true. There are no currently no law firms in Australia taking on hernia mesh cases. Oh, that’s interesting. Well, United States is much more litigious than any other country. With the T G A reclassifying these measures. I believe that the meshes that have been removed from the TGA’s approved devices should spark something in the way of compensation. Okay, interesting discussion. So here’s a situation. The Australia and the European Union have both decided that the European Commission has decided that this whole argument about the five 10 [inaudible] process is completely legit. In other words, if you are selling a Mesh product and you have zero human studies on it or even animal studies on it and you’re completely basing it on past meshes, then that is no longer adequate.

Speaker 1 (00:26:36):

So the European Union, European Commission has decided that, I think it’s this year in May, I’m pretty sure all meshes will be taken off the market unless they can show human or animal studies. Australia has already done that. So Australia has already removed Mesh pod. These are products that we’re currently using that may be perfectly fine, but they don’t fit the criteria, which is if you want to get a stamp of approval from the European Commission or the T in Australia, then you’d better be able to show some data. And it’s not cool to just have products out there without data. Even if you’re a great Mesh, sorry, you got to follow the rules, which I think is great, I think is definitely very good. It will definitely get a lot of products off the market for sure. The other caveat too, which has been a sticking point, is once the Mesh is in the market, you need to as a company, assure that there’s post-marketing, post-marketing surveillance.

Speaker 1 (00:27:49):

We call that phase four clinical trial, which is post-marketing. That means after you’ve had the Mesh put in, it’s not one and done. They need to follow and track the outcomes from these products after the Mesh has been put in. So phase one, two and three trials are, it’s very strict. You’re followed with regard to your Mesh and often that’s it. Once it’s the market, no one follows these pages anymore. Now it’s required to do phase four. The question that we’re trying to figure out is the stumbling block is who pays for that? It’s not cheap to do follow up and follow through for clinical trials. It’s so expensive. Consider similar expenses to continue after you’ve sold this, these meshes. So does the patient pay for it? Does the government pay for it? Does each company have to pay for it? Does the hospital have to pay for it or the surgeon?

Speaker 1 (00:28:49):

No one knows. No one’s figured that out. They’re just like, you got to do it. So should there be a database, a mandatory country-based surveillance form? We don’t know. Definitely. We’re not there yet in the United States, but I believe the F D A will follow the lead of the Europeans and the Australians. And I actually published on this. I wrote a great paper, I think it was a great paper about the fate of hernia Mesh and learning from the fate of what happened with pelvic Mesh and how the F D A will really need to be able to get their act together to further regulate hernia Mesh products so that patients feel that they’re getting vetted products and that surgeons are not just experimenting on them, but whatever product comes out and also that safety measures are maintained. So F D A is falling behind the other countries, but I think what they’re doing is they are, they’re just watching to see how the EU and Australia are handling this and then learning from them in similar way how they went after the pelvic Mesh.

Speaker 1 (00:30:07):

I believe they’ll also go after some type of regulation and restrictions on hernia meshes. Let’s see. Got more questions coming in. Sorry for jumping around a little bit. If the Mesh is buckled, does that mean it has been buckled since implantation or is it a design flop? Both. So when Mesh is buckled, the instigator is the initial procedure. Often it’s because the area for the Mesh has not been adequately opened up to make space for the Mesh. So consider this. I’ve used this envelope letter example before, this analogy before. If you have an envelope, the letter you put in it has to fit the envelope. It can’t be too high or too wide because then you can’t close the envelope or it will wrinkle if you put it in the envelope. So if you put a piece of paper that’s too wide into an envelope that’s not wide enough, that letter will wrinkle and will not fit in the envelope.

Speaker 1 (00:31:16):

The same is true for inguinal hernias and ventral hernias. If you’re putting in Mesh that’s not perfectly flat when you’re done because you haven’t made the space perfect, then that will be buckled either immediately or over a matter of days to weeks as is trying to fit into that space. So yes, the answer is yes, it is at the time of surgery. Now is it a failure of the Mesh? You know, really should make meshes that are less likely to buckle. So the very lightweight meshes actually have that problem because they’re more likely to kind of fold and wrinkle. And also these kind of two layer meshes, the, what do you call it, the PHS prolene hernia system really is a bit floppy and really, really have to make a good space to fit it. It’s a perfectly good Mesh if you put it in perfectly, but the average surgeon doesn’t have the skills to do that. That’s the problem. The kugel Mesh was made so stiff that it wouldn’t buckle, and if you didn’t put it in perfectly, now you had something like cardboard stiffness, buckling. So that’s where the kugel kind of lawsuits came about. So that’s kind of my answer to that question about whether Mesh buckling happens at the time of surgery or later, and whether that’s a Mesh flaw or a surgical flaw.

Speaker 1 (00:32:58):

Next comment. Yes, post-market surveillance with medical implant is a recipe for disaster. Yeah, I mean it’s great in concept, but then who regulates it and who pays for it? pH Mesh is not one under mass tort case, although it in the surgery as a whole has completed disabled me, no attorney would look further into my case. I’ve met a dozen or so others who’ve had similar issues with this Mesh. All right, well that’s very interesting. I would like to know what you mean in terms of issues. Are you reacting to it? Theoretically, the pH Mesh is gone within two years. So by the time the lawsuits go through, the patient should no longer have the Mesh in them. Maybe that’s why these absorbable meshes have much less likely chance of surviving any type of lawsuit. What are the wrong anatomical structures in which sutures and tax may be placed?

Speaker 1 (00:34:03):

So sounds like you’re for Inguinal hernias, sutures and intact should not be placed where the nerves are and should not be placed where the vessels are. Cooper’s ligament is perfectly a good place for Inguinal hernias, for cooper’s, the inguinal ligament, the pubic tubercle, the rectus muscle, the transverses abdominus. Those are all places where sutures are measure placed for the abdominal wall. Pretty much don’t put it anywhere that could injure the heart and the diaphragm, the epigastric vessels ilio, inguinal, orally hypogastric nerves, but everything else is fair game for the abdominal wall. Hi, I am from Australia and had a bar 3D max Mesh put in my al canal last August. I didn’t have a hernia but had pain in my groin and my doctor thought it was from a small lipoma I had in the area and recommended I had Mesh insert in my inguinal canal.

Speaker 1 (00:35:05):

Since the operation, I feel pulling on my right side wherever, whenever I move around I can no longer do any leg exercises. I get pain in my groin and an intense knee to urinate all the time. I now don’t think I should have had the surgery. Do you think this will eventually go away? I can’t find anyone here to help me. I really want the Mesh removed. Is it too risky? I’ve been thinking about contacting you about my other options. I also wanted to thank you for all the information you have online, which has helped me so much. Oh, thank you very much. Well, first of all, sounds like you had two pieces of Mesh. So my question is, what do those meshes look like? Are they flat? Are they folded? When I hear people saying that they’re urinating a lot, they either have pelvic floor spasm because they have a hernia recurrence or their Mesh is buckled and is pushing on the bladder.

Speaker 1 (00:35:56):

So all of these are treatable. What you’re telling me is absolutely treatable. I would love to be able to help you if you can call my office and make an appointment. Or actually if you’re not in California, you should do an online consult and then we can kind of at least review your imaging and I can give you a full plan of care. As you can tell, very OCD and I actually think the online counsel’s a great, great value because you get a very, very detailed analysis and plan of care from me and I’m happy to treat you afterwards. Or you can take it to your doctor and convince them to follow my lead or at least consider what I think. So it’s been really, really helpful to a lot of patients that I cannot see in person under US laws. In what amount is a surgeon accountable for failing to diagnose or misdiagnose a per surgery complication?

Speaker 1 (00:36:48):

So there’s no actual law specific to this. However, delay in care is considered a potential lawsuit worthy problem. If that delay results in significant quality of life, like you may die, but let’s say you have a hernia and it’s the cause of your pelvic pain and you had surgeons that didn’t diagnose a hernia until 10 years later, that’s not something you can sue for. That’s just trying to find the right specialist. But if you had a hernia and they injured bowel with it and they didn’t know they injured bowel with it and you die three days later from the bowel injury, then that you know can potentially sue for that if there was negligence on the surgeon trying to figure out why you’re getting so sick after hernia repair, which is the Mesh that your speaker spoke about on the 15th. I don’t know. He said it creates its own collagen. Oh, okay. So Dr. Heifer, well, I think he spoke about biologic meshes in general and I think he uses stratus. He was also perhaps talked about ovitex, I think it was stratus that he was talking about, which is made by life cell, which is a subsidiary of Allergan, which is a subsidiary of AbbVie. You’re welcome. Can open tissue repair be done after robotic Mesh removal if recurrence happens? I’ve been told that it is virgin tissue, but also heard that removal damages some of that tissue.

Speaker 1 (00:38:42):

Yeah, you can absolutely have open Inguinal hernia repair or open any hernia repair after robotic Mesh removal. What they mean by virgin tissue is the open approach is approaching the muscle in a space where no one else has been because the laparoscopic or robotic Mesh removal process was done on the backside of the Mesh, I’m sorry, on the backside of the muscle. And the open tissue repair was done, is done on the front side of the muscle, different area, different space. Virgin tissue meaning there’s no scar tissue in that space. Removal damages tissue, but only the area where the tissue was removed and not that much actually. Whereas the open tissue based repair is done in a different space where tissue has not been damaged, it’s virgin tissue. What are your thoughts on metal versus absorbable tax with Mesh or self gripping Mesh instead? They’re all good.

Speaker 1 (00:39:57):

They’re all have, so self gripping Mesh is pretty good. You can’t use it for everything. It doesn’t come in all different sizes. So it’s not perfect for every hernia. It doesn’t work for hernias where you don’t close the hole. If it’s a big hole, it can’t fall into it because it’s not a permanent fixation. So it’s a great prop, great Mesh, but you need to be able to close a hole. So you don’t want it bridging any hole tax help, bridge tissues. And there are metal tax, plastic tax, suture type tax screw on tax absorbable and non-absorbable tax. So I personally do not like absorbable tax because I also don’t use absorbable sutures. There’s no proof that they’re any better, that there’s better, in fact, they’re worse than non-absorbable products. So other surgeons think it’s fine to use absorbable tax for sutures. So metal versus non-metal, I’ve moved away from the metal tax. I still use ’em if it’s the other ones are not available, but I’ve moved away and I like these suture type suture fixations.

Speaker 1 (00:41:18):

All right. What are some of the potential problems of operating through non-virgin tissue and an open repair for recurrent hernias originally done open? Yeah, so if you are having a redo, redo, so redo surgery in an area that’s already been done at this, if it’s, let’s say you’re removing Mesh, you want to do the suture repair at the same time, that’s fine, but if it’s been open before, now you’re dealing with scar tissue and fibrosis from before, then that really makes the tissues difficult to safely identify critical structures like nerves. That’s my issue with that is that risk of nerve damage is much higher also because the fibrosis and the scarring from the prior surgery before, not the same time, but prior, then you can have stiffness of the tissues and it’s much more difficult to sew stiff tissue than healthy non-stiff non-scar tissue. So if it’s done at the same time, I’m totally okay with that. Let’s say someone had an open surgery, they need the Mesh removed and then a tissue repair or another Mesh repair. You can do all that in one setting, but if you’re going to stage it, so you take out the Mesh, let’s say, and then two years later fix a hernia there, you’d rather go in an area where there is what we call virgin tissue, which is non scarred tissue.

Speaker 1 (00:42:57):

Let’s see. Do you find that a lot of patients are developing medical P T S D? Oh, interesting concept and loss of trust in the medical profession because of their experiences with both the denial, denial of the matches problem and the lack of support when there are complications. Should hernia repair surgery ultimately be performed by specialists and not by general surgeons? Okay, very good question because that’s another impetus of why I wanted to do this show today on hernia Mesh lawsuits. So I have another patient that was operate on by three different surgeons. First surgeon did a perfectly good hernia repair and IT rec recurred. Second surgeon, no, didn’t recur, sorry. First surgeon put a perfect, did a perfectly good inguinal hernia repair and for some reason the patient started getting pain like 10, 15 years later, I think it probably recurred. There’s no objective evidence that it recurred.

Speaker 1 (00:44:07):

It may have been given away because he gained like 60, 70 pounds and he had a direct hernia. So probably the Mesh was pulling the Mesh was no longer was pulling over a weakened area, whereas before when he was lighter it wasn’t as bad. So the next surgeon, number two, took out the Mesh, but now the patient’s fixated that it’s the Mesh, that’s a problem. Meanwhile, he was fine for almost 10 or 15 years with the Mesh, which means the Mesh is really not the problem. And yet having read and done his research online, he is convinced the Mesh is the problem. That’s a very dangerous situation because now you have a patient that believes one thing, reality is different and you still want to be able to provide care to the patient and not piss them off. But you also need to get their buy-in as to the care you want to provide them.

Speaker 1 (00:45:08):

Let me explain this better. 15 years after his first hernia repair with Mesh in the groin, he has pain. And based on his research on his own, he’s convinced the pain is because he has Mesh in him. It is not because he has Mesh in him. He’s had that Mesh for 15 years, but I can’t or whatever. The second surgeon could not convince him otherwise, but so therefore the decision was made to remove that Mesh and not put more Mesh in. So now you have an obese patient that had Mesh in him, doesn’t want Mesh put back in him and convince a surgeon to remove that Mesh and do a tissue repair. Completely wrong decision by the way, in my opinion, retrospectively because he had a direct hernia. Direct hernias don’t do best with tissue repairs. He’s a big guy and chronic pain still occurs with tissue repair. So to think that the removing the me magically cure his problems is a fallacy. What he really needed and what the surgeon originally recommended was, let’s just take out the old Mesh cause it’s pulling and tearing, but do a good laparoscopic Mesh repair. Patient refused. That would’ve been the right idea. So now he has a tissue repair that is tighter than his Mesh repair. He’s gained so much weight and now he’s convinced that that surgeon screwed up not the case actually, and he wants his sutures removed. So how do you handle that?

Speaker 1 (00:47:06):

How do you handle someone who has an idea of what they need to have done? Completely wrong idea. So the question here is, do you find that a lot of patients are developing medical P, this patient was in my office for two hours arguing his case about how I should go in there and take out his sutures because that’s his problem. But he doesn’t want a hernia repair because he has medical. P T S D doesn’t want hernia repairs, doesn’t want Mesh put in, doesn’t want sutures done. In fact, he, he convinced another surgeon to go in on the other side, take out the fat from his hernia, but don’t fix the hernia, just take the fat out. Which of course doesn’t work if I, there’s a hole. I told him, I said, if there’s a hole on the ground and a little cat fell in it and I just pick the cat out of the hole and don’t cover the hole, some other cat or someone’s going to fall into the hole.

Speaker 1 (00:48:08):

Same with your hernia. He would convince that no, no, he can close the hole on his own with physical therapy, which of course doesn’t happen. So because of his medical PTSD and his reading online and his poor communication with the second surgeon, he’s now screwed because he’s got chronic pain. He’s asking doctors to do things that are not correct. He has complete mistrust. He was claiming that all his surgeons, all the surgeons lied on their reports and made up data and never spoke to him. And I’m like, doctors don’t lie on their op reports. I mean, I have had doctors lie on their reports, at least one that I know of, but it’s not a very reputable surgeon and is a horrible situation that we figured out. The surgeon completely lied on its op report, but that’s not a thing usually. And these are reputable surgeons he actually went to.

Speaker 1 (00:49:14):

So because of his P T S D, he was so angry in my office, not disrespectful, but just angry. He was so mistrusting of excellent surgeons. He went to actually very reputable surgeons that he was claiming that they were lying on their opera reports. And now he’s going from doctor to doctor to doctor and how do I say this? They’re, they’re dismissing him because his demeanor is so aggressive, but so is aggressive because over years he’s just had chronic pain and has an idea of what the right answer is and kind of won’t have the trust to allow someone who knows what they’re talking about to lead him the way. And basically, I’m trying to help this gentleman, but I have a feeling that it’s just not going to be, never going to be able to find the right treatment because he’s refusing to believe in a doctor.

Speaker 1 (00:50:31):

There’s just so much mistrust. It’s just a very, very difficult situation. I’d love to hear more about how you guys think I should handled this situation. But you are absolutely right. There’s definitely medical P s D, there’s definitely a lot of mistrust. I have a lot of patients that come to me with already a lot of mistrust. So unfortunately a lot of my time is spent trying to regain that trust and so on. So I would love to hear your thoughts about how surgeons can regain that trust because I for sure try my best. I spend so much time in the office, emails, call, phone calls, telehealth, follow ups, trying to gain patients trust to allow me to treat them, knowing that every so often there’ll be a patient that will just, I could just never kind of salvage and I don’t know what else to do.

Speaker 1 (00:51:37):

And I have friends that tell me, you can’t create world peace, you can’t save everyone. I agree with that, but I want to. But I feel like I’m getting PTSD honestly, I have a couple patients that give me PTSD every time I open up. There were a couple patients every time I opened up my email and I got email from them, I would get this little rush of P T S D because they were just so kind of angry and upset and not necessarily at me, but it was just too much. So there’s also surgeon PTSD, which I think less surgeons get than patients, but I get it and I hope that, I hope to God that what I’m doing is helping people and that I don’t get burnt out by it. But I’ll tell you very honestly that patients, I totally understand their PTSD and their burnout because I feel it too, just on a different in position because it’s tough. It’s tough dealing with patients with chronic pain and mistrust and all that as well.

Speaker 1 (00:53:00):

Let’s move on. Let’s see. Not only P T S D and mistrust, but our own ignorance and lack of education on our own situations. Yeah, so that’s right. You go into a situation where you didn’t go to medical school or surgery residency, so you kind of like, okay, inguinal hernia repair, fine. And now I have patients that are focused on cremasteric muscle internal ring and all these terms that are not really familiar to them, but now they’re finally learning things and now they feel bad that they didn’t know more when they first decided to do all this.

Speaker 1 (00:53:39):

I get it, I get it. It’s a bad situation. Do you think lawsuits against Mesh manufacturers actually result in improved Mesh products and better patient outcomes in the long run? Excellent question. That’s a great question. Do I think the lawsuits are doing good for the patients in the long term by helping improve products? Well, I’ll give you my stick. Yes and no. I think there are companies out there that truly want to be innovative in a manner that helps improve patients, and those companies will come up with Mesh products that are helpful. Now, the pelvic Mesh industry has been so negative that as far as I know, I think really maybe one company sells Mesh products for pelvic Mesh, but really there’s none. They’re all off the market. And there are companies that I know of that should be using their excellent product for pelvic transvaginal repairs because actually good doesn’t have all those complications that we’ve seen. And they, they’re like, we’re not going there. We’re not going to try and expose ourselves to so much ligation. So they’re actually good products out there for the pelvic Mesh, transvaginal stress, urinary incontinence patients, rectal prolapse patients that can help them. But companies are not investing in that industry because there’s so much ligation and hate and negativity that they can’t afford to enter that market.

Speaker 1 (00:55:30):

So that’s one thing. The second is there are also companies that are so put off now by these Mesh lawsuits that they want to go completely the other way and let’s just try makeup as brand new product as brand new thing and promote a product that’s so dislike what’s currently out there that they can’t any be associated with. This gets stuck with this, all these Mesh lawsuits, and that’s not necessarily better. I mean, innovation is good, but trying to push a product because it’s so different and not necessarily better for the patient, let’s say higher recurrence rates or more inflammation than, I don’t think that’s good either. I think we can tweak things and improve it, find what’s wrong and improve it and show that. I think companies need to show that they hear the voice of the patient, that they actually care to make better products, that their goal is to reduce chronic pain.

Speaker 1 (00:56:45):

I don’t hear a single, well, maybe one company pretty much all but one company, sorry, none but one company, no company except for maybe one exception, has expressed any interest to make a product that they can market to reduce chronic pain. Have you heard anyone, has anyone said in the past 20 years, use our Mesh product and we will have less chronic pain, less inflammation, less nerve entrapment, lower meshoma? No, they haven’t. And yet they can develop that. I don’t know why they don’t. I just don’t get it. I really don’t get it. What is defensive medicine and how can you spot it if your surgeon is practicing that on you? So defensive medicine relates to doing so much that no one can say you didn’t do enough. So let’s say you have shoulder pain, right? Shoulder pain. So you say, I have shoulder pain. It only occurs when I reach up to grab something from the top of the cabinets and your doctor does a full cardiac workup to make sure this is not referred pain from your heart going to your shoulder.

Speaker 1 (00:58:11):

That’s defensive medicine because what if there’s always cardiac angina and there’s always a heart problem and I missed it and I’m going to get sued for missing it. So I’m going to get chest ct, heart echocardiogram, cardiology consult in addition to orthopedic surgery. That’s defensive medicine. It’s one of the reasons why care in the United States is so expensive because something like shoulder pain, and I’m just making this up as an example that maybe you will understand if you go to any other country, will be treated with probably physical therapy and a brace. You go to the United States, you’ll get an MRI and just make sure, what if it’s a tumor? You never know. And what if it’s your heart? Let’s go all a E K G and cardiology and chest CT scan and echocardiogram and stress test. And what if it’s your neck, your spine referring to your shoulder?

Speaker 1 (00:59:14):

Let’s do a MRI of your spine. So that’s defensive medicine and it increases healthcare, but it’s often spawned by the risk that we as surgeons and doctors feel when we care for patients and then get sued for doing perfectly good care that you thought was perfect. You don’t, doctors typically don’t intend to hurt patients. They don’t intend to inflict pain. They don’t intend to kill patients, and yet patients have pain or have complications or die. So when the consequences will then get sued, then that’s a problem because you start practice and defensive medicine, it’s kind of like a system where that’s how we kind of protect ourselves because we all have health, what do you call it? Malpractice insurance. We all pay tons of money. I pay tons of money for malpractice insurance because we live in a life where that’s reality. Last comment, I hear you.

Speaker 1 (01:00:31):

I totally resonate highly with that patient just because at no point did the surgeons consider the Mesh to be the cause or any cause of the pain I was having and I was given up on by the local system, but was coached by a surgeon’s assistant on how to get the next surgeon I saw to remove the Mesh against their advice using my right to a quality of life, which I had none. While I had the Mesh in me, I know that I took a huge risk. The surgeon approached me a second time and asked if I was sure if I wanted to go ahead with the removal because he didn’t believe that he could fix what was wrong with me. But I wanted it out that bad. I had lost over 30 kilograms of resembled a cancer patient knocking on death’s door, and I actually felt tortured by the system’s denial. Now when I go to the hospital, I feel like I have to bring the Health Ombudsman Ombudsman Report stating that my treatment was below the Expected level of Care. Yeah, I mean there’s so much inequity. I totally get it.

Speaker 1 (01:01:29):

And this was great discussion, guys. I appreciate it. I know where this would go when I first started. I don’t like to talk about lawsuits and stuff, but let’s see where some of these other lawsuits go. Hopefully people will focus on their health. That’s always a message I give focus on your health and not ensuing. The first goal should be to get better because no lawsuit will fix what’s wrong with your health. And on that note, I thank you all for joining me for another Hernia Talk, Live q and a. We have a lot of cool specialists coming up in the weeks to come, and I will be traveling to many, many meetings. So I’ll share with you where I learn

Speaker 2 (01:02:19):

A lot of travel this year. I’m hoping to be able to share everything at the different meetings I go to. I have at least four or five that I’ve already talking at or running. So super excited. Thank you for your help, and thank you for all your questions and interactions. It was super awesome. I appreciate you all, and I’ll see you next week. Bye everyone.

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