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.
Search:
"Milan—Chronic groin pain after hernia surgery is now considered the most important issue facing inguinal hernia surgeons and their patients. Yet, there is still much uncertainty surrounding what causes the pain and how to prevent it." - Victoria Stern, General Surgery News