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16-10-2022, 11:30 PM
Mesh Repair for Hernias
https://harpers.org/archive/2021/03/in-t...rnia-mesh/
Michael Ransford had known he would need surgery for his umbilical hernia. “People said if it ruptured, it could kill me,” the sixty-year-old farmer told me. The pain from a second hernia, on his right testicle, sent him “through the roof.” In 2016, shortly before Christmas, Ransford had an operation to repair both at Columbia Memorial Hospital, near his home in Ghent, New York.
In a postsurgical report, Ransford’s doctor, Gary Pearlstein, noted that he had repaired both hernias with polypropylene mesh, a type of synthetic netting that is commonly used in such surgeries. Pearlstein used an oval mesh patch on the testicular hernia and a circular mesh patch on the umbilical hernia. The hospital’s records identify the circular mesh as the Proceed Ventral Patch, a device consisting of multiple layers of material, produced by Ethicon, a subsidiary of Johnson and Johnson. The mesh provided “a nice solid repair,” Pearlstein wrote.
Solid or not, the repair caused Ransford nothing but trouble. From the moment he got home, he suffered from a sharp, consistent pain. At first, he was able to get on his tractor and work his usual fourteen-hour days, but the discomfort eventually got so bad that he went back to Pearlstein. An ultrasound revealed that he needed a second surgery—just seven months after the first. This time Pearlstein found “multiple adhesions in the right groin area,” which appeared to have developed on the surface of the mesh he had placed in Ransford’s body—the mesh had stuck to his bowel. After the surgery, Ransford said, “The doctor left the impression he had removed some of the mesh but not all of it.”
The pain continued, but it remained tolerable until an October 2018 hunting trip, when it suddenly worsened. “I said, ‘Something is wrong,’ ” Ransford told me. When he got home, he called Pearlstein. Almost exactly two years after his first surgery, Ransford found himself on the operating table for a third time. Pearlstein opened him up and “found a lot of scar tissue and colonic adhesions pulling part of his colon into his groin.”
“When I went in for the last surgery, the mesh had just about closed off the colon,” Ransford said. “Pearlstein told me he got it in the nick of time. He took out every single piece of the mesh he possibly could,” amputating Ransford’s spermatic cord and right testicle in the process.
Ransford doesn’t know whether he’ll ever fully recover. Doctors who perform explant surgery—removal of mesh that has degraded—say that 75 to 80 percent of patients see an improvement, but that some continue to experience intermittent pain. “There’s still some sensitivity as far as having sex,” Ransford told me six months after his third surgery. “Believe it or not, I’m still uncomfortable.”
In the mid-Seventies, a magazine ad for Marlex claimed that the product gave “patients a better chance of recovery” because “it interlaces with body tissue, strengthening it so incisions can heal faster.” Years later, this interlacing of body tissue with mesh was found to be a source of harm for many patients. Once the mesh is implanted, tiny blood vessels and nerves grow through the plastic surface, causing an acute inflammatory reaction. Scar tissue forms, and as it contracts, the mesh squeezes the blood vessels and nerves that surround it. “All of this occurs at the microscopic level,” Dr. John Morrison, a hernia surgeon in Chatham, Ontario, told me. “You’d be able to see the folding and the scar tissue growing through the fold but no blood vessels or nerves with the naked eye. We feel that combination causes the pain.”
“It’s very difficult to go back in and remove every single strand of mesh,” Dr. Robert Bendavid, who performed hernia repairs without using mesh at the Shouldice Hernia Center outside Toronto, told me before he died in 2019. “It breaks up into fibrils. How do you remove it when the fibers spread out and erode into the adjacent tissues?”
A 2018 research paper by Morrison, Bendavid, and others, published in the Annals of Surgery, noted that before the widespread use of mesh, chronic groin pain after hernia surgery was uncommon. Now, the researchers found, patients with mesh implants often suffered from testicular pain and dysejaculation, a burning sensation during sex. When hernias were repaired with tissue—the old-fashioned way—dysejaculation affects 0.04 percent of patients; with mesh it affects 3.1 percent.
“Even when you remove mesh, twenty-five percent of patients never get better,” said Petersen. “They are doomed to live with horrible pain the rest of their lives or live on medication that makes them nonfunctional.”
“Many of my patients are not able to work,” Morrison told me. “They develop psychological problems, lose their jobs and families, become divorced, declare bankruptcy. They have nothing. These poor people have a hell of a time.”
Forty-year-old Michael Younger is one of them. He was forced to quit his job at Sun Life, a major Canadian insurance company, because the pain resulting from mesh implants he received in 2008 was so intense that it was impossible to spend all day crunching numbers. For the next eleven years, Younger went from doctor to doctor seeking relief. He got none until Morrison removed the offending mesh in November 2019. “I would tell the doctors that it’s the mesh causing pain, and they’d say, ‘You’re crazy, you’re a lunatic,’ and recommend antidepressants,” he told me. “Nobody believed the mesh could do this. What you’re telling them, in their minds, can’t happen.” Since the removal surgery, the pain is “getting a little tiny bit better each day. If this is as good as it gets, I’m a happy customer.”
Doctors who use mesh say it reduces the chance of hernia recurrence, but many think the difference is not especially significant. Dr. Bill Brown, a Bay Area surgeon who performed mesh procedures for a brief period in the Eighties, explained it this way: The chance of a recurrence after a mesh repair is probably about 3 percent; the chance after a non-mesh repair is about 4 percent. To achieve the 1 percentage-point decrease, around 15 percent of mesh patients are likely to experience long-lasting pain. “I said, this is really stupid,” Brown told me, and he went back to doing traditional repairs. But unfortunately, he said, “Younger doctors don’t know how to do it the classic way.”
Data from a large randomized trial published in the Annals of Surgery showed that lightweight mesh “has no significant benefit over heavyweight mesh for inguinal hernia repairs and was associated with greater pain and higher risk of recurrence.”
https://harpers.org/archive/2021/03/in-t...rnia-mesh/
Michael Ransford had known he would need surgery for his umbilical hernia. “People said if it ruptured, it could kill me,” the sixty-year-old farmer told me. The pain from a second hernia, on his right testicle, sent him “through the roof.” In 2016, shortly before Christmas, Ransford had an operation to repair both at Columbia Memorial Hospital, near his home in Ghent, New York.
In a postsurgical report, Ransford’s doctor, Gary Pearlstein, noted that he had repaired both hernias with polypropylene mesh, a type of synthetic netting that is commonly used in such surgeries. Pearlstein used an oval mesh patch on the testicular hernia and a circular mesh patch on the umbilical hernia. The hospital’s records identify the circular mesh as the Proceed Ventral Patch, a device consisting of multiple layers of material, produced by Ethicon, a subsidiary of Johnson and Johnson. The mesh provided “a nice solid repair,” Pearlstein wrote.
Solid or not, the repair caused Ransford nothing but trouble. From the moment he got home, he suffered from a sharp, consistent pain. At first, he was able to get on his tractor and work his usual fourteen-hour days, but the discomfort eventually got so bad that he went back to Pearlstein. An ultrasound revealed that he needed a second surgery—just seven months after the first. This time Pearlstein found “multiple adhesions in the right groin area,” which appeared to have developed on the surface of the mesh he had placed in Ransford’s body—the mesh had stuck to his bowel. After the surgery, Ransford said, “The doctor left the impression he had removed some of the mesh but not all of it.”
The pain continued, but it remained tolerable until an October 2018 hunting trip, when it suddenly worsened. “I said, ‘Something is wrong,’ ” Ransford told me. When he got home, he called Pearlstein. Almost exactly two years after his first surgery, Ransford found himself on the operating table for a third time. Pearlstein opened him up and “found a lot of scar tissue and colonic adhesions pulling part of his colon into his groin.”
“When I went in for the last surgery, the mesh had just about closed off the colon,” Ransford said. “Pearlstein told me he got it in the nick of time. He took out every single piece of the mesh he possibly could,” amputating Ransford’s spermatic cord and right testicle in the process.
Ransford doesn’t know whether he’ll ever fully recover. Doctors who perform explant surgery—removal of mesh that has degraded—say that 75 to 80 percent of patients see an improvement, but that some continue to experience intermittent pain. “There’s still some sensitivity as far as having sex,” Ransford told me six months after his third surgery. “Believe it or not, I’m still uncomfortable.”
In the mid-Seventies, a magazine ad for Marlex claimed that the product gave “patients a better chance of recovery” because “it interlaces with body tissue, strengthening it so incisions can heal faster.” Years later, this interlacing of body tissue with mesh was found to be a source of harm for many patients. Once the mesh is implanted, tiny blood vessels and nerves grow through the plastic surface, causing an acute inflammatory reaction. Scar tissue forms, and as it contracts, the mesh squeezes the blood vessels and nerves that surround it. “All of this occurs at the microscopic level,” Dr. John Morrison, a hernia surgeon in Chatham, Ontario, told me. “You’d be able to see the folding and the scar tissue growing through the fold but no blood vessels or nerves with the naked eye. We feel that combination causes the pain.”
“It’s very difficult to go back in and remove every single strand of mesh,” Dr. Robert Bendavid, who performed hernia repairs without using mesh at the Shouldice Hernia Center outside Toronto, told me before he died in 2019. “It breaks up into fibrils. How do you remove it when the fibers spread out and erode into the adjacent tissues?”
A 2018 research paper by Morrison, Bendavid, and others, published in the Annals of Surgery, noted that before the widespread use of mesh, chronic groin pain after hernia surgery was uncommon. Now, the researchers found, patients with mesh implants often suffered from testicular pain and dysejaculation, a burning sensation during sex. When hernias were repaired with tissue—the old-fashioned way—dysejaculation affects 0.04 percent of patients; with mesh it affects 3.1 percent.
“Even when you remove mesh, twenty-five percent of patients never get better,” said Petersen. “They are doomed to live with horrible pain the rest of their lives or live on medication that makes them nonfunctional.”
“Many of my patients are not able to work,” Morrison told me. “They develop psychological problems, lose their jobs and families, become divorced, declare bankruptcy. They have nothing. These poor people have a hell of a time.”
Forty-year-old Michael Younger is one of them. He was forced to quit his job at Sun Life, a major Canadian insurance company, because the pain resulting from mesh implants he received in 2008 was so intense that it was impossible to spend all day crunching numbers. For the next eleven years, Younger went from doctor to doctor seeking relief. He got none until Morrison removed the offending mesh in November 2019. “I would tell the doctors that it’s the mesh causing pain, and they’d say, ‘You’re crazy, you’re a lunatic,’ and recommend antidepressants,” he told me. “Nobody believed the mesh could do this. What you’re telling them, in their minds, can’t happen.” Since the removal surgery, the pain is “getting a little tiny bit better each day. If this is as good as it gets, I’m a happy customer.”
Doctors who use mesh say it reduces the chance of hernia recurrence, but many think the difference is not especially significant. Dr. Bill Brown, a Bay Area surgeon who performed mesh procedures for a brief period in the Eighties, explained it this way: The chance of a recurrence after a mesh repair is probably about 3 percent; the chance after a non-mesh repair is about 4 percent. To achieve the 1 percentage-point decrease, around 15 percent of mesh patients are likely to experience long-lasting pain. “I said, this is really stupid,” Brown told me, and he went back to doing traditional repairs. But unfortunately, he said, “Younger doctors don’t know how to do it the classic way.”
Data from a large randomized trial published in the Annals of Surgery showed that lightweight mesh “has no significant benefit over heavyweight mesh for inguinal hernia repairs and was associated with greater pain and higher risk of recurrence.”
