Good intentions
​​​​​​​Thank you for keeping everyone updated.
I agree that it is crazy to use mesh for small umbilical hernias. And even more stupid to put the mesh in the abdomen where the intestines can scar to the mesh.
The video also said that 20% of surgeons wanted to repair the hernia with the laparoscope. I wish that there was some common sense in the world.
Regards. ​​​​​​​Bill Brown MD

Thank you for the acknowledgement Dr. Brown. I have thought more about the doctor in the video and realized that she was asked to make a video and to say some good things about mesh. It seems also that Dr.. Towfigh's video was sort of an "equal time" video showing that non-mesh is being considered.

There was really no intellectual value to the first doctor's video. No references or timelines mentioned so that people could learn about these new guidelines. Just some comforting words supporting the use of mesh everywhere possible. No need to think about it, all umbilical hernias should be repaired with "a mesh". I still feel embarrassed for her.

Good intentions
Unfortunately, money and not patient care make many of the decisions.
Regards.
Bill Brown MD

Allow me to provide some background and context to this.

The surgeon being interviewed is well known and respected for her hernia research, which is mostly based on population databases. She is a resident in training. She’s reporting on what data was presented based on her population based research. As you know, the Danish and Swedish hernia databases provide us with robust and longterm patient data that we really don’t have anywhere else.

Note that these databases are government based and objective. They are not influenced by industry or company sponsors.

Most data show superiority in outcome for umbilical hernias when mesh is used, no matter the size of the umbilical hernia. It also shows laparoscopic to provide better outcomes than open, again regardless of the size of the hernia. Outcomes are mostly based on her i recurrence, but also include pain and infection risks , etc.

But that’s not the full story. My belief and that of some others is that we are overusing mesh. That is, the benefit of mesh placement is not as high for smaller umbilical hernias. It is more beneficial for larger hernias.

My analogy to this is driving a car (aka using mesh) Vs walking (aka nonmesh repair). Driving somewhere will always be faster than walking there. But there are risks with Driving (Ie, mesh), such as pollution, car accident, cost of gas. And when needing to visit a neighbor a few houses away (Ie, small umbilical hernia), the Lee really is no need to drive there. Walking (Ie, non mesh repair) is just as good and without the risks of driving, though driving will still be faster to get to your destination.

DrBrown I agree with him because we need to add some logic in interpreting the data. This is one of the problems of database research. It doesn’t account for tailoring to the needs of the individual patient.

Again with the driving analogy: for some people (eg, broken leg, wheelchair-bound) (Ie, patient with high risk factors for recurrence, such as smoker, obese, chronic cough), perhaps the drive for 1 block away (ie, small umbilical hernia) is still better than walking (ie suture only repair).

I am new here and decided to add the following to this discussion.

I had an umbilical hernia repaired without mesh 2 1/2 years ago. I'd had the hernia for over 6 years. When the hernia became difficult to reduce and it was causing me significant pain I realized I needed to have it repaired. At the time I was in my mid 60's and overweight (BMI 27.5). I believe the size of the defect was 2 to 2.5cm. I was told the hernia would be repaired with an open mesh procedure. I was concerned about the potential risks associated with mesh and mentioned this to the surgeon. I said I would prefer a non mesh repair if it was possible.

After the surgery I was told the surgeon was able to repair the hernia without mesh. So far the repair has not failed and the pain associated with the hernia is gone. I do have mid to upper abdominal discomfort and pain but this is related to IBS, something I have had for over 30 years. Fortunately I brought my concerns about mesh to the surgeon and he was willing and able to do the repair without mesh. Hopefully the repair continues to hold confirming that I did not need a mesh repair.

On another note, I also have an inguinal hernia that I have had for almost 8 years. When first diagnosed by a family physician it was recommended not to have it repaired due to the risk of post surgical chronic pain. This hernia is now causing me some discomfort and eventually I will probably have to have it repaired. I'm in Canada in a city where if there are any surgeons still preforming non mesh repairs I will be lucky to be referred to one. I realize my best option is to go to the Shouldice Clinic but at this time I do not feel like traveling and I am still overweight. So for now I will focus on trying to lose weight and hope I don't end up in emergency getting a mesh repair.

drtowfigh Your analogy is very interesting and makes us to understand the situation clearly. Thank you for that.
But I think more discussions about mesh repair and non-mesh repair should be done within the expert group. I have no intention to twist your analogy at all, so allow me to apply it a bit differently.

I agree with you that a small umbilical hernia should definitely be operated on with non-mesh repair. In my experience, however, except for recurrent umbilical hernia or port-site umbilical hernia, all umbilical hernias can be successfully operated without mesh, regardless of size.

Inguinal hernia repair is even more so. I've done nearly 10,000 non-mesh inguinal hernia repairs so far but haven't seen a case where any mesh must ever be needed. Of course, there were rare occasions where mesh would be a good idea, but in less than one in a thousand patients. Even in such cases, the operation was successful with non-mesh.

So I want to add the following few sentences to your analogy.
Almost all inguinal hernia are within a block, so no car is needed. And even if it is a little far away, it is still within walking distance.
As for the umbilical hernia, I would like to add similar sentences. But recurrent or port-site umbilical hernia are crippled ones according to your analogy, so I think you need a mesh for them.

Dr. Towfigh:

I am new to the site, but have read hundreds of posts over the past 36 hours. I am writing you because you have a balanced view of hernia repair.

I am a very fit 56 year old male. I sustained my first hernia (direct left inguinal) 2 years ago while training Brazilian Jiu jitsu (BJJ). It was repaired in May 2018 via a laparoscopic TEP procedure in the hands of a very experienced surgeon with that procedure. i prefer TEP because the peritoneum is not breached. Mesh was polypropylene, but I do not know brand. I experienced the most uneventful and symptom free recovery imaginable. I was up and active as soon as I got home from surgery. Once cleared, I resumed training and put the repair though its paces as BJJ is very hard on the core. It has held up well. My theory is that routinely stretching and stressing the area, tissue ingrowth occurs during all body states, not just static and contracted like you will see in a sedentary person. I have never had any foreign body sensation.

Fast forward, I developed a direct right inguinal hernia, which was repaired on 11/7/19. I'm on day 10 and so far, feeling great. Since I was having occasional dull aches on the original repair, my surgeon and i agreed that he would "scope" that side and check things out. The surgeon told my wife post op that everything looked fine. I have a f/u on 11/19/19 and will get specifics and what type mesh used.

Long winded intro, but here is my question. Some literature suggests that polypropylene is not truly inert in vivo and long term issues can and probably will arise due to oxidative stress, etc..

Regarding my first surgery 1.5 years ago, if I have no infection, chronic pain , adhesions, mesh migration, etc. can I reasonably assume I will most probably be ok in the long term??? Due you know people who have had mesh implants that are still ok 5 yeas post op? 10 years post op?

Please provide some feedback based on your experiences with patients who have had successful long term outcomes with a mesh based repair. I tried to PM you, but it did not work.

Thank you