NIS

Why do reputable institutions recommend mesh?

Why do reputable institutions advocate mesh hernia repairs? Because mesh hernia repair was established as a standard of care and the art of non-mesh hernia repair was lost to history. Today only a handful of surgeons repair hernias without mesh confidently and with low recurrence rates.
 
Mesh has been around since the 1950’s. Back then most surgeons knew how to do a good non-mesh hernia repair with low recurrence rates. In the 1990’s mesh manufactures sponsored some studies that showed that recurrence rates were even less with mesh. Then a few studies came out saying that non-mesh repairs had incredibly high recurrence rates. Surgeons who knew their own results were better than these reports stayed away from mesh at least for a while. Then the marketing term “Tension Free” was invented. With this and a few other opportunities the manufactures of mesh succeeded in getting mesh established as the “Standard of Care” thereby discouraging surgeons from not using it. So even surgeons who were perfectly satisfied with the results of their non-mesh repairs were pressured by their patients and colleagues to use mesh. Only the most hard headed and experienced surgeons continued to say no.
 
Something like this happened before when another new high tech surgery came out in the1980's. It was called Laser hemorrhoidectomy. It was new, it was cool and patients were demanding it. Surgeons who were doing the procedure loved it for all of the wrong reasons. Insurance companies paid them more for laser surgery than conventional surgery. Patients came to them in droves because of the appeal of new and high tech procedure. But laser hemorrhoidectomy was a terrible operation. Patients had worse pain and frequent complications and the operation was expensive. As a fad it lasted for about five years and then died out. No one now does the laser hemorrhoid surgery. It's still amazing how much appeal the word laser has for the public. We even today get patients who ask for laser hernia repair which is a surgery which does not exist. Patients had their own overblown expectations of what a laser could do. Marketers of medical devices commonly exploit the appeal of high tech and patients misunderstanding how these things really work. In the 1990’s interest in mesh took off like a fad for the same wrong reasons but it had enough advantages that it went further and became established as the standard of care.

Another good example of disfunctional choices is food. Why do we eat food that is not good for us? Highly processed food. Artificial food. Food high in trans fats and chemicals. Because it is cheap and convienient and tastes good. Because the food industry pushes it and knows how to make it appeal to us. Profit margins are high. We should go back to healthy and natural food.
 
The American medical community however was slow to recognize and acknowledge adverse reactions to mesh. It is interesting that the European medical community has been talking about and trying to address the problems with mesh for ten years before we were here. Many expert hernia surgeons now will acknowledge that adverse reactions to mesh are common but believe without mesh the recurrence rate is too high. However it is a fact that hernias can be repaired without mesh with a low recurrence rate by experienced non-mesh hernia surgeons. But most surgeons do not have confidence in their ability to do this, perhaps for good reasons. There are published medical studies which proves hernias can be repaired without mesh with low recurrence rates and there are surgeons who know their own results.
 
A fact in medicine that is a bit of an embarrassment professionally and which medical organizations do not like to talk about is that the quality of surgical results for many operations is highly dependent on the particular skills and talent of a given surgeon. They will talk about institutions as centers of excellence but will not endorse the idea of one surgeon being better than another.  Medical boards are created to certify professional ability but in many respects they elevate standards only to the most acceptable common denominator and disavow higher standards.
 
But how could this be for the most common operation performed in the United States? It is what is wrong with organizing and central planning. There is a lot of pressure to simplify and standardize. We now have standards of care, practice guidelines and evidence based medicine. The organization picks the standards, creates the guidelines and chooses the evidence. Gone is the preeminence of individual professional experience and tradition.
 
Medicine is extremely complicated and the art of it looses a lot when it is simplified and standardized. Take away a master painters oils and mixing pallet and give him four primary color pencils that anyone can draw with and then the work of the master and novice will start to look more the same. Mesh is an equalizer. Low recurrence rates are not so dependent on the skills and experience of the surgeon. Results of non mesh repairs are highly dependent on the skills and experience of the surgeon.
 
In my opinion the best hernia repair is an open non-mesh repair performed by an experienced non-mesh surgeon. But now it is nearly a lost art.