How to find surgeons with <1% recurrence & chronic pain rates? etc

Digestive health
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Hi, I have an inguinal hernia, right side. I’ve done a lot of research online, & it’s looking like I’ll go for Lichtenstein or Open preperitoneal. Open preperitoneal maybe less pain; Lichtenstein maybe because easier to find an experienced surgeon. There’s a large variation in recurrence & chronic pain rates, but it appears possible to get <1% for both, from published papers. How does one find surgeons with those figures? I don’t see anybody quoting them online. [I live in Northern Ireland; UK or Ireland, even Europe, is ok].

How about long-term absorbable mesh, with long-term absorbable sutures or fibrin glue for fixing the mesh? I’m thinking that if I’m unlucky enough to get chronic pain, maybe it will go in ~3 years, as they dissolve.

PS I get >80k hits for every search I do here – am I missing something?

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Hi Neil,

I am resident in the UK.

I am in a similar situation to you in that I need to gain a layman’s understanding of different techniques and the pros and cons of each so that I may make an informed decision.

If you go to the My NHS website and navigate to “Specialties/Consultants” you can then choose a speciality, in my case I chose “Colorectal Surgery” because that was the department that dealt with my previous surgery (ref below). You can then search using your postcode. Make sure you tick the box titled “Only view consultants with outcome data” you should then get a list of surgeons in the area of your postcode that have published data.

As I am sure you have already discovered the NHS does not seem to consider Hernia Repair as either a major topic in itself or a specialty. My rather jaundiced view is that the NHS sees Hernia Repair as something that works a lot of the time but has an unacceptably high re-occurrence rate and should only be contemplated as a last resort.

My background is: I developed an abdominal incisional hernia after surgery at the end of November 2015 to redact a section of my small intestine that had twisted and kinked. I had an infection at the wound site a few days after the operation and they had to open 50% of the wound and leave it open packing it with a seaweed compound to encourage healing. The wound subsequently healed but some weeks, months later, I’m not sure how long, I felt that something was not quite right since my “spare tyre”, which wasn’t big to start with, seemed to be getting bigger and at times it just felt "odd" in that area.

Eventually an abdominal incisional hernia was diagnosed but my GP refused to consider a repair saying the practice these days is to adopt a “watchful waiting” approach. I was not happy with that so I went for a private consultation where I was told that I had an incisional hernia in my small midline laparotomy measuring 4-5 fingers and divarication of the recti above the wound.

The private consultant recommended a repair as soon as possible as hernias only get worse over time. He said it could be repaired using the open technique with a sublay or onlay mesh or with the benefit of a laparoscopic technique combined with the open approach to remove the sac and reduce the size of the defect, this he called “the hybrid technique”. (I’m not sure I understand all the technical details here.)

As the cost of having the repair done privately was prohibitive I went back to my GP and I have at last convinced him to refer me to the appropriate NHS consultant to explore a possible repair.

I don’t know what this NHS consultant will recommend or what technique he would use but I’ve heard so much on this forum about folk who have had long term chronic pain after having had a repair using a mesh that I am cautious about that approach. On the other hand I know that the use of a mesh decreases the risk of a re-occurrence.

So, what to do? I have heard of a number of different techniques each with different re-occurrence rates, risk of chronic pain, etc. thus need to do some reliable research before my meeting with the NHS consultant on 13/12/16.

Neil, you seem to be some way down the line in your research, is there any way you could share your findings thus far with me? I believe there is a way of taking a discussion offline but I’m not sure how one does that.

Regards,

Phil

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Hi Phil,

Thanks for the info, I’ll check that out. I’m a bit pushed at the moment, but no problem to help you with what I know [a lot of it of course mainly relevant only to groin hernias].

The main thing is there’s such a variation in quoted chronic pain & recurrence rates, from >10% to <1%, which of course makes all the difference! Of the laparoscopic methods, TEP is the preferred one; chronic pain & recurrence are comparable to Lichtenstein [say 5-10%], but I’ve gone off that because of the small risk of serious problems. Getting a good surgeon seems to be important, even for Lichtenstein. There are good results from absorbable mesh & sutures, but details of long-term rates [>=3 years] are hard to find.

Neil 

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I had an incisional hernia repair with mesh (non absorbable) just over 2 years ago should have done more research like the both of you before going ahead.  Do detailed research, I had the very best surgeon in the UK, his success rates are phenomenal, but mesh is not phenomenal, take a look at what is going on in the states and Australia currently, admittedly used for different kind of surgical repairs, but same mesh.  And once it is in it is in, very few surgeons are skilled enough to remove it, one or two in the US but not in this country.  Very controversial subject at the moment, we hernia sufferers are between a rock and a hard place, I seriousy believe more research is needed in to how best we can be helped, so difficult to repair someones adomen, to set in context I had 4 abdominal ops including a bowel perforation before my hernia repair so maybe I am a difficult case.  Hope you find the best treatment which is best for you and serves you well.

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Hi Shirley,

Thanks for the reply & info. There do seem to be lots of developments regarding mesh. I do consider myself quite lucky that I wasn’t among the early pioneers of mesh, from what I’ve read, lots of people ending up with chronic pain, & it still happens as you say.

Can you tell me who your surgeon was? Does he do inguinal hernias?

Thanks, Neil 

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Hello Neil he is a colorectal surgeon in Edinburgh, if you do not live in his area you would have to go private I suspect, dont know if he does inguinal hernias you would need to ask, he is Andrew de Beaux chalr of the British and European Hernia society.  His contact details are readily available.  Not sure what type of repairs he offers, again worth doing your research.. look up the group Hernia Surgeons Edinburgh.  

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Thanks Shirley, I’ll look him up. Hope things work out for you. Neil 

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I had mine repaired privately at london hernia (hospital of st john and st elizabeth) by Martin Kurzer who is a hernia specialist. They do a great package cost wise. It's been nearly 3 months now since my op and while it's been a rocky road healing wise I now feel almost back to 100%. Not quite but almost. The 1st few days are tough but I took two weeks off work and it was six weeks before I felt much better. From there the healing process is slower to notice but progess is definately in the right direction, just slower to actually notice. The hospital and staff that take care of you are absolutely fantastic.

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Hi Folks,

At long last I had my consultation with the local (Cheltenham) NHS colorectal consultant (Mr Borley) who my GP referred me to for repair of the abdominal incisional hernia that ensued after I suffered a volvulus of my small intestine in late November 2015.

I had done a certain amount of research but as I am sure you know a lot of the available data out there relates to inguinal hernias. I had already been for a private consultation with Mr Hakky at St Mary’s, Paddington as part of the British Hernia Centre and he had advised using a hybrid technique of using an inlaid mesh (part absorbable part, polypropylene) laparoscopically and open to close the wound.

Mr Borley advised me that he would recommend using a technique known as “Component Release” technique and not use a mesh at all. [Actually he said he didn’t think many surgeons were still using mesh – what he meant by that I am not sure since a lot of people on this forum have recently had procedures using mesh. Maybe he meant for abdominal incisional hernias. ] I was mightily relieved to hear this as I was getting somewhat concerned about the prospect of having a mesh inserted.

I have done some small research on this technique and I think it is known under a different name in the states as “Component Separation” technique (CST). This was first described by Ramirez et al in 1990 and is used to repair midline abdominal wall defects such as a large ventral hernia. [Search for “Indications and Outcomes of the Components Separation Technique in the Repair of Complex Abdominal Wall Hernias”.] Essentially it involves releasing one of the muscle layers of the abdomen by severing it’s anchor point in the area of the flank. This means that the muscle can then be pulled over the hernia and used to cover the hernia thus forming a tensionless closure. I think it comes under the banner of “abdominal reconstruction” which is probably why it is not appropriate for inguinal hernias. I note that some surgeons still go on to use a mesh as well but Mr Borley is not advocating that in my case. Phew! However this is no “magic bullet” reoccurrence of the hernia is not ruled out.

It was also brought to my attention by my partner that NHS Scotland suspended the use of mesh and tape implants in 2014, albeit for the treatment of pelvic organ prolapse and incontinence in women, conditions that can commonly occur after childbirth – search for “mesh implants NHS Scotland”. Apparently there has been a high incidence of painful and debilitating complications as a result of this procedure.

I am now on Mr Borley’s waiting list which is considerable but I think given, the very competent impression I have formed of him, that I want him to do the procedure despite that fact that he doesn’t do 100’s of them per year (he is really in demand for his colorectal experience) but he has used this technique for some time.

All this must, I know, be of no solace to you Neil since it is a technique that is not applicable to inguinal hernia repair … as far as I can see … after all the foregoing is just a layman’s view.

Good luck for the future and do let us know how you are getting on.

Regards,

Phil

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Hi,

Thanks for the reply. That’s actually where I’m going I think, getting booked in for a couple of weeks from now. It won’t be Martin Kurzer, but I’m told they’re all equally good. I’ll post it up when I’ve had the op.

That’s quite a bit longer of a recovery than I expected; but I suppose 3 months is not all that long. Did you have to go back in that period?

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Hi Phil,

I got a bit obsessed with the research – every answer leads to more questions! The Lichtenstein [mesh] repair still seems to be at the top of the list for inguinal hernias though. I think Mr Hakky was one of the surgeons mentioned for me. Hope it goes well for you.