Mesh-y Situation

Why are more patients asking their surgeons not to use mesh in their hernia repair? That’s how Sharon L. Bachman, MD, FACS, opened her presentation at the 16th World Congress of Endoscopic Surgery. Dr. Bachman, of Inova Medical Group in Falls Church, Va., and other hernia specialists addressed a growing topic of interest among surgeons and patients alike: no-mesh hernia repair. Here’s a recap.

“It’s not as simple as mesh repair versus non-mesh repair. I think it’s way more complex than that,” says Mohammed Al-Mahroos, MD, FRCSC, a minimally invasive and advanced gastrointestinal surgeon at McGill University in Montreal, Canada.

For patients, there’s a trove of online information about mesh repair — and some of it can be pretty scary. A simple Google search yields millions of results related to possible complications. Hernia mesh lawyers hawk litigation related to previously recalled products, with warnings of post-op pain, infections, recurrence, adhesion, bowel obstruction and perforation. So how does this affect care in 2019? The information patients click through may not always come from scientific sources, and it can be overwhelming for patients to comb through it all, says Dr. Bachman.

“How do you sort through that? How do you decide what’s real and what’s not?” says Dr. Bachman, who has an active research interest in prosthetic materials used in hernia repair.

The U.S. Food and Drug Administration estimates that more than 1 million hernia repairs are performed annually in the United States. With time, mesh has become the commonplace option for many surgeons, who cite reduced recurrence rates and the hope of better recovery times. By 2000, non-mesh repairs accounted for less than 10% of groin hernia repair techniques, according to the FDA.

Here are 3 strategies for surgeons and surgical facility leaders to consider when it comes to educating patients about mesh.

How do you talk to a prospective hernia patient about her treatment options? It’s important to block out the noise and keep the patient front and center.

“The technique you choose influences the patient’s outcome. Things need to be very clear,” says Dr. Al-Mahroos. “Patient counseling is always key. They need to know what you are going to do, what are the available options and what affects your options.”

Your patients need to hear from you about your rationale for care. Dr. Al-Mahroos stresses that it’s not just about the technique, but the factors that can impact patient outcomes, such as the size and site of the hernia and patient characteristics like BMI, diabetes and smoking. You’ll need to cite the available data to support your recommendations while warning patients about the chances for complications with each approach.

Patients look to their doctors for recommendations, but they should still be involved in their own care, says Bruce Ramshaw, MD, FACS. In an era of information overload, decisions should be a shared responsibility. Patients have several different approaches to consider for hernia repair, says Dr. Ramshaw, professor and chair of the department of surgery at the University of Tennessee Graduate School of Medicine in Knoxville. “We want them engaged so we can help figure out what’s best,” says Dr. Ramshaw.

Sometimes, so-called “watchful waiting” is the best approach to make sure the hernia isn’t changing. Laparoscopic and open repairs (with or without mesh) need to be discussed, as well. Patients should learn about the different types of mesh that are available before they settle on a treatment plan.

“Because of the awareness on the internet and through social media, patients are learning about this, and sometimes learning misinformation,” says Dr. Ramshaw. “It’s going to be up to us to try to better describe this with our patients.”

If a patient wants a non-mesh approach, says Dr. Ramshaw, physicians should relay the pros and cons and discuss each of these areas:

• an open groin incision versus a laparoscopic approach;
• the chances of recurrence;
• expectations for recovery with each approach;
• expectations for pain; and
• patient concerns about mesh in the body.

A non-mesh open repair is an option for some patients who have fears about mesh implants, but there’s one key detail.

“That’s a fine choice as long as everyone is understanding again the pros and cons of those choices,” says Dr. Ramshaw.

You never know when a patient will ask you to take a novel approach, particularly when they’ve found a paper online that appears to show great promise. Many times, those studies have caveats and limitations.

During her presentation, Dr. Bachman told the story of a patient with a large hernia who wanted her to perform a Desarda repair, a non-mesh technique she had never done before. The patient even handed her some papers to learn more about the procedure. She declined to perform the operation.

“You always have an option of declining,” she says. “Because what I didn’t want to do is try it out in this patient and not have it work. I think it’s better to educate yourself in other ways.”

The lesson is clear. Doctors shouldn’t try new procedures in real time. If you want to add a new hernia repair to your menu of treatment options, you need to do your homework and training. OSM