NIS

A note to hernia surgeons

This website receives about 2,000 visitors per day. I know for a fact that many of our visitors are physicians and hernia surgeons. If you are a hernia surgeon, first of all, thank you for visiting. But now that I have your attention please read and carefully consider the following. You have been misled by a powerful industry whose number one objective is to sell a product.

The very first standard of care that we physicians are taught and learn to hold above all others is Primum non nocere.The second is to put the patient’s interests above all else. The third is to treat a patient to the best of our ability assuming full responsibility for our choices of treatment. There are more and this is not exactly the Hippocratic Oath but these are the most essential. It is these principles that distinguish a physician from a peddler.

So how does this apply to the standard of care in hernia surgery?

We repair hernias to prevent the inevitable progression of the hernia and hernia complications. No recurrence after hernia surgery has been held out as the most important end point and outcome of hernia surgery. But according to our first standard of care we have to make sure that we are not harming patients.

When we do the standard of care we find comfort for ourselves no matter the outcome of our treatment because we preformed the “Standard of Care”. What else could be expected of us. Are we putting our interests above those of our patients? Are we abrogating responsibility for our therapeutic choices.

Hernia mesh causes chronic pain in 10% to 30% of patients. It causes crippling, life destroying pain in 2%-5%. Only considering recurrences is likely leading to a violation of our first obligation. Consider crippling pain. How many recurrences is one case of crippling pain worth? Remember this crippling pain responds to no treatment and will be life long. It is almost as bad as a death.

If the only way to repair a hernia was to use mesh then calling it the standard of care would be appropriate. But in the tradition of Basinni and those who followed low recurrence rates are achievable without the risk of severe crippling chronic pain. But not every surgeon can do a good Basinni. Is that why mesh was designated as the standard of care? Why should a surgeon who can do a good Bassini or Shouldice repair have to contend with this self serving notion of standard of care. Does it really benefit the patient?

I have spoken with thousands of mesh victims and have operated on hundreds. It’s enough to make me think that hernia surgeons are mesh peddlers. Before surgery patients are not being told of the risk of chronic pain and they are not being told that there are alternatives to mesh hernia surgery. After surgery patients with mesh pain are being told that nothing is wrong and that the pain is all in their head. This violates all of the principles that are the heart and soul of our profession.

I do not believe that hernia surgeons know that they are participating in peddling mesh. The industry has infiltrated every aspect of the hernia surgeons world. Manufacturers support research, society meetings, education and marketing. This is sealed and stamped with a label of approval by calling mesh the standard of care.

This is the problem with accepting anything as the standard of care. Who ever is promoting this is telling you to stop thinking.

A very common problem that I see every day is hernia surgeons misinterpreting chronic pain after hernia surgery as being a sign of a hernia recurrence and treating it as such. The risk of chronic pain after mesh hernia surgery is 20%. The risk of a hernia recurrence is 2.5%. It makes no sense for a surgeon to put recurrence on the top of his differential diagnosis list for a patient who presents with chronic pain after mesh hernia surgery. This bias is a consequence of the coercive nature of the designation standard of care.

Mesh is not the standard of care. It is one of the tools that you have for fixing hernias. It has advantages and disadvantages. There are good alternatives. No recurrence is not the only important end point of hernia surgery.