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  • Surgeons with hernias - what would they do?

    I've wondered about this. At times I've thought that the best thing that could happen for the hernia mesh situation is for one of the top vocal influencers, the surgeons with strong opinions about "mesh", to get their own hernia, have it fixed via the most popular mesh technique, then be one of the 1 in 6 mesh-induced chronic pain sufferers. Then they might understand. Suffer for the greater good. I can't decide if thinking this way is wrong or not. But I think that it could have a very large impact on the way other surgeons think. If the surgeon with the "mesh" repair and "mesh" problems maintained their energy and influence. Which is unlikely, because energy and focus is what diminishes, as the new problem occupies all of your thinking.


    But, in the meantime, some tweets from the recent SAGES meeting are very interesting, asking what surgeons would choose for their own repair. The proper questions to generate new thinking are being asked. The audience is an audience of surgeons. There's not much out there about the meeting. https://www.sages.org/meetings/etabstracts/ SAGES 2019 Annual Meeting
    April 3-6, 2019, Baltimore Convention Center, Baltimore, MD

    Interesting stuff. Thank you Dr. Towfigh for sharing. I think that this type of discussion is what will really get surgeons to empathize with their patients. What if it was me... I wonder how big the audience was (they should put the number of replies on the data bars).


    Apparently, most of them would not choose immediate surgery despite the risk of incarceration and death. They call it watchful waiting, but, of course, it's really avoiding surgery. But why would they avoid? I don't think that they recommend watchful waiting to over 1/2 of their patients. Something is off...

    https://twitter.com/Herniadoc/status...46402950012930

    They are fully on board the lap mesh train. 80% would get lap, and that means mesh, large pieces. Still, 7% would choose open without mesh. So there are a few holdouts.

    https://twitter.com/Herniadoc/status...46679191007233

    But this last one really shows the heart of the problem I think. They believe that the problems can be avoided by surgical skills. Choosing the right surgeon. It's not the materials or the method, it's the surgeon's skills. They don't know though, because nobody tracks success or failure, of materials, method, or surgeon. I think that it's more hope than knowledge, for this last question. Trying harder to develop skills will overcome materials and/or method. No supporting data either way.

    https://twitter.com/Herniadoc/status...47139624988674





  • #2
    Interesting answers, right?

    The data shows risk of watchful waiting to be 0.18%/yr and most of us (should) include that as part of our consent to the patient. Or, itís safe to wait.

    We also know that that the risk of complications, including chronic pain is lowest with laparoscopic repair with mesh done by an expert surgeon. That includes comparators of open with mesh and without mesh.

    We also know that surgeon skill is directly related to outcome, including recurrence and chronic pain.
    #ItsNotJustAHernia
    www.BeverlyHillsHerniaCenter.com

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    • #3
      Originally posted by drtowfigh View Post
      Interesting answers, right?

      The data shows risk of watchful waiting to be 0.18%/yr and most of us (should) include that as part of our consent to the patient. Or, itís safe to wait.

      We also know that that the risk of complications, including chronic pain is lowest with laparoscopic repair with mesh done by an expert surgeon. That includes comparators of open with mesh and without mesh.

      We also know that surgeon skill is directly related to outcome, including recurrence and chronic pain.
      Most surprising to me was the waiting part. It was my understanding that if you're going to bother getting a repair at all, the sooner the better.

      Comment


      • #4
        Originally posted by ajm222 View Post
        Most surprising to me was the waiting part. It was my understanding that if you're going to bother getting a repair at all, the sooner the better.
        Yes, it doesn't seem to fit what most surgeons tell their patients. Very few seem to recommend waiting. The message the patients receive is that bad things can happen, emergency rooms and death, so you should get it fixed soon.

        Also, I didn't mean to give the impression that I agree with what the surgeons would do. I posted to show the mismatch with what is recommended to the public, but also how their other thoughts follow the Guidelines. The typical surgeon today will recommend lap with "mesh". But, in the end, the surgeons know as much as us, which is not much, about what really works well to avoid chronic pain, which appears to be at about a 10 - 30% level, today.


        A follow-up survey that might be very informative would be one asking surgeons who had had their own hernias repaired to report on the results. How do they feel about it? Would they recommend what they got to friends and family? Not talking from the Guidelines but from something that they've actually experienced.

        The pool of respondents would be small but the answers should be of very high quality, a surgeon's perspective, from inside. With anonymity the answers could be very honest. With presentation at the bigger meetings like this one, their thoughts could spread much farther. Everybody wins.

        Comment


        • #5
          Most studies show surgeons are less likely to choose surgical options (for anything, not just hernia) than the average person. We know risks occur and are often willing to delay risk potentials.

          If surgeons are promoting early or urgent elective inguinal hernia repairs, thatís not supported by level 1 evidence.
          #ItsNotJustAHernia
          www.BeverlyHillsHerniaCenter.com

          Comment


          • #6
            Very interesting to see the survey among surgeons. We need to remember that all the respondents were lap surgeons and the hypothetical condition was a minimally symptomatic hernia. Yet if memory serves me, those choosing surgery all chose lap. Very curious! Not only they would not wait but they would rush to have lap. How was the survey conducted? Within a conference of lap surgery or within the privacy of one's home? Even hernia surgeons are not immune from social influences, so the survey results are only as good as the method employed. [Game changer: meaning of "minimally symptomatic hernia." If that translates to small hernia hole, then absolutely immediate surgery would be called for, as small herniae have much higher chance of incarceration. Again another concern about method.]

            GoodIntentions makes a worthwhile point: some surgeons oversell surgery. I echo his report: surgeons I spoke with pushed rushing to surgery while at least one internist told me I need not fear incarceration, that I was not in a dangerous condition.
            Last edited by pinto; 04-13-2019, 06:31 AM.

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            • #7
              Method: Audience survey via text-in polling. So basically anonymous.
              #ItsNotJustAHernia
              www.BeverlyHillsHerniaCenter.com

              Comment


              • #8
                Perhaps but the respondents were presumably in close proximity even sitting next to each other. Then again they also may have assumed a higher chance of incarceration, encouraging them to favor early surgery. They are also likely to be enthusiastic about lap by virtue of their conference attendance, so their choice of personally getting lap isn't surprising. In this regard it doesn't necessarily show lap superiority if some readers might conclude so. Polling/surveying isn't always what it appears.

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                • #9
                  They werenít in close proximity. And most chose watchful waiting. Laparoscopic repair with mesh was choice of operative option. And they felt choice of surgeon was more important than choice of technique.
                  #ItsNotJustAHernia
                  www.BeverlyHillsHerniaCenter.com

                  Comment


                  • #10
                    All of that quite true I am sure but subtle social reinforcers could have been present. The "conference" has been a subject of sociological study and hardly absent social factors or elements. Even within the sparse commentary available by the lap conference attendees, one can readily see their thinking influenced socially by their medical collective or association. That's natural of course, for as much as a medical society is medical, it is social at the same time!

                    Comment


                    • #11
                      Originally posted by drtowfigh View Post
                      If surgeons are promoting early or urgent elective inguinal hernia repairs, thatís not supported by level 1 evidence.
                      What about the notion that the longer you wait, the larger the hernia will become over time, which could increase the chances of complications or recurrences after repair?

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                      • #12
                        The evidence is for asymptomatic or minimally symptomatic inguinal hernias. It is strong in showing that watchful waiting is safe.

                        Indication for hernia repair is not based on size, but primarily based on symptoms.

                        I recommend that that if a hernia is getting larger, then one should consider repair, as itís an easier operation with better outcomes. But that doesnít mean Iím saving a life by recommending that. Itís a discussion to have with the patient and their needs.
                        #ItsNotJustAHernia
                        www.BeverlyHillsHerniaCenter.com

                        Comment


                        • #13
                          "Indication for hernia repair is not based on size, but primarily based on symptoms."
                          Surely, but only if the surgeon does mesh repair. If suture repair, then wouldn't the factor of size loom large?

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                          • #14
                            Great question

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                            • #15
                              Nice topic here. Of course, Dr Towfigh must be right as an inside trader and surgeon's wouldn't rush for a repair. But when they do, I think they'll use same surgery they do. If they do a mesh, they'll prefer so. If they're non-mesh, they'll prefer tissue repair.

                              But there must be lots of variation here. If I was a surgeon who does mesh repair because that's what they taught me and anyone thinking otherwise is crazy inside institution, anyway I think I'd take a non-mesh repair elsewhere...

                              Comment

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