Dr. Petersen recently attend the 1st World Conference on Abdominal Wall Hernia Surgery held in Milan, Italy April 2015 as faculty presenting Results of Hernia Mesh Removal for Pain. The conference covered nearly every aspect hernia surgery prominently among them the problem of severe chronic pain after hernia surgery, it's prevention and treatment.
Vendors by the dozens displayed their latest iterations of mesh improvements based on increasing scientific knowledge of how mesh interacts with the human body in an effort to reduce the incidence of chronic pain.
Of particular interest to me was a new product by Davol called Phasix™ Mesh made of poly-4-hydroxybutyrate. The unique properties of this mesh is that it is fully resorbable over a long period of time(18 months) and it weakly provokes acute inflammatory response from the host. Microscopic studies demonstrate rare M1 macrophages relative to a prominence of M2 macrophages. M1 macrophages are mediators of the acute inflammatory response of the human body to mesh and M2 macrophages are mediators of the remodeling phase of healing. Phasix is less susceptible to bacterial colonization than other mesh products. It acts as a scaffold for the build up of functional collagen with gradual stress bearing transfer to health collagen as the mesh dissolves.
Poly-4-hydroxxybutyrate mesh looks very interesting and may be a game changer in hernia surgery. I suspect however it will not replace pure tissue repairs for patients who do not need mesh for hernia repair. Along those lines there was a lot of discussion about who does and who does not need mesh for hernia repairs. Also, the successful pure tissue repairs, such at the Shouldice and Bassinni were demonstrated and explained by prominent experts.
There was considerable interest and discussion about neuropathic versus nociceptive mesh pain the point being that neuropathic responds better to neurectomy. My experience has been that most patients have a mixture of neuropathic and nociceptive pain. Patients can be very unhappy exchanging pain for and deafferentation hyperesthesia and abdominal wall laxity can make a patient feel severely compromised. It is not a good outcome. I say take the mesh out and preform only a limited and reversible neurectomy. Then the patients who fail that may be a candidate for a proximal neurectomy.
An important question that I have been trying to answer is how long a patient should endure the pain before his mesh is removed. My first guess was three months. There appears to be consensus that post operative pain lasting more than 3 months is abnormal and that is the basis for my presumption. At the meeting in Milan I asked one prominent Australian surgeon who said the proper amount of time was one year. I did not like the answer and I am afraid I may have offended this surgeon when I blurted out "One year of severe pain is enough to ruin a life!"
Along those lines I think we should challenge the standard protocol of pain management, neurectomies and local steroid injections for patients with severe disabling mesh pain. These therapies are marginally effective and cover up the problem at best and do not address the true problem. Why would we ask a patients to endure their pain or treatment side effects when we know we are not going to make anything better in the long run. Mesh removal is safe and effective.
Edited 6/18/2015. Please visit this page again soon. My experience in Milan provided a wealth of new information, perspective and new friends. As I glean the pearls I found in Milan I will add them to this page.
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"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