 Gwisiusiw y bydd ar y cyfnodau d responsibilityach ffasiliad yn ddaglennu'r cyffinio llyfrgynodau y 8 pasodol yn fawr 2022. Mae hynny yn y gydigion y gydigion, bydd dess y pethau arbennig, oen nhw y pethau pethaustartaniaeth 1865, o gyfnodd nôl a chyfnoddau i ni oedd yn gallu eu chyfnoddau a ffixasio. Efallai y cyfnoddau o'r eich cyfnoddau. Efallai eithas unrhyw i rhoedd, Ieidwg, Clacken, Lauren MacDougall, Graham Robertson. The petition calls on the Scottish Parliament to urge the Scottish Government to suspend the use of all surgical mesh and fixation devices while our review of all surgical procedures that use polyester, polypropylene or titanium is carried out, while guidelines for the surgical use of mesh are established. We last considered this petition on 2 February, where we agreed to take evidence from Sholders hospital in Canada, following representations that we had received, and where we understand that it is the only licensed hospital in the world dedicated to repairing hernias and has been a supporter of natural tissue hernia repair for over 75 years. Joining us today, I am absolutely delighted to welcome Dr Fernando Spencer Netto, who is the chief surgeon at Sholders hospital, and I am delighted to welcome and thank you, Dr Spencer Netto, on behalf of the committee. Dr Spencer Netto is joining us virtually, although we are all virtual ourselves, but we are collectively all virtual for this particular session. We have a recorded apology from Fergus Ewing MSP, who is unable to join us today. Members have a number of questions that we would like to explore with you, Dr Spencer Netto, so we will probably launch straight into all of that. I begin by saying that Scotland has been very much at the forefront of the international discussion on transvaginal mesh repairs as procedures, and very considerable angst and anxiety and trauma was caused to an incalculable number of women, many of whom were told that they were imagining their suffering and that there was no option but to the mesh that had been fitted. In seeking to remedy that, the Scottish Parliament passed a bill that will facilitate women travelling to wherever, including to the United States, where specialist services are available in Missouri for the removal of that mesh. Consequential to that, we have received a petition that seeks to extend the interest and potential impact of alternative mesh treatments to include that in relation to hernia. I think that the committee was incredibly intrigued and interested in the experience that showed this hospital. I wonder if, by way of an introduction, you would be able just to introduce us and to the many people who are watching that today and who will be interested in the discussion that we are about to have into the work of shoulders hernia hospital so that we can better understand it from the perspective of you as chief surgeon. I think that having me here is a great opportunity to clarify some of your points. The first clarification is that the use of mesh may be very different from one area to the other. Whatever I am going to address today is going to be just related with abdominal and groin hernias. I cannot have any word about vaginal meshes, and I understand that some matter of discussion, lots of gynecologists think that that is related with problems. Yes, we do work at Shodais hospital. At least it was the first one. I don't know if it is still the only one hospital just dedicated to hernias in the US. They start several clinics. I don't know if they are considered hospitals that have also just done hernias. We do about 6,000 procedures per year. A half depends on the year. Covid has decreased a little bit in the last few years, but I would say that 99 per cent of these patients will do the procedures without mesh. We have good results. Most of our hernias are groin hernias in the groin area. For this, the use of mesh is really small, less than one in a thousand for inguinal hernias. Our recurrence rate, given by the orders, not by us, by a review of how the Ontario patients show that we have the lowest recurrence rate in Ontario province by far three times less than the second, smaller recurrence rate. I am intrigued. I fully understand the difference. That is why we are interested in pursuing the hernia. It is quite different to the transvaginal mesh. The use of mesh in hernia repairs has been far more widespread over a much longer period. I am interested in your experience as the leading hospital in Canada, but one of the experiences that we came across in the transvaginal mesh area was that clinicians were very opposed to the idea that there was an alternative to mesh as a treatment. Where you are, you have obviously specialised, have the results and are able to demonstrate that the process that you have undertaken has had excellent results. Is that widely accepted as a clinical practice by clinicians across Canada, or is there any resistance to the idea elsewhere that there is an alternative to mesh as an appropriate route forward with hernia repair? Okay. With some evidence that have a higher complication that they should repair. It is relatively recent to this new discussion. At some time ago, and it is still valid by the European hernia society, they think that the standard technique for growing hernia is using mesh. Even though we do not agree the reasons that they say that, they think that it is easier to teach new residents, new surgeons in this, and that is the reason that they consider that that should be the standard or the initial approach for them. Yes, there is a resistance in Canada and in other places of the world about not using mesh. Why mesh became so widely spread? It is difficult to say exactly just one factor. For sure, physicians and other specialties as well, the areas are intrigued or fascinated with new technologies and someone says that, oh, I have this mesh here, this different type of device that is a lot more resistant than human tissues. If you have an opening, it makes intuitively think that potentially if it resists more than the human tissue, probably it is going to be more resistant as a mesh. It is also very hard to at the laboratory studies, the studies of animals and experimental studies, even patient initial studies and follow-ups. It is difficult to pinpoint some of the complications that happen with mesh afterwards, because a few of the complications that happen with the mesh are related with long-term or the mesh retracts and causes. Sometimes, pain at sexual dysfunction and sometimes pain at movement, probably the most important complication is pain related to the inflammatory tissue that is around it. In general, I would say that well done, the hernia repair with mesh would be relatively efficient in regard of holding off the hernia that has other complications. It is a lot simpler to do than tissue repair as show dice. Dice, we do a reconstruction of the growing from the more inner layer to the upper layer, takes longer to train the surgeon and takes longer to the surgeon to perform in comparison with open mesh repair. Although you are not seeking to draw parallels from our experience, I think that that was also one of the things that underpinned the use of mesh in the transvaginal example as well. It was issues of cost of simplicity and of being a much simpler procedure than necessarily the alternative. You referred to European hernia, the British hernia society in its expression of scepticism, I suppose, and justification for mesh as being the principle and preferred route. The sutures that are required for the alternative, the tension-based repair procedure that you pioneer, are not resilient enough. How do you respond to that? What is the nature of the way that you deal with it? It was based on studies from the 1980s and 1990s, where they saw the molecular structure of hernia tissues in patients that had hernias, and yes, these people have a different disposition of the tissues in their collagen. It is a little different, and it is genetically, most of the time, something that is not going to change. It was something that also compelled the use of mesh. My response to that is with our results. There are a few other things happening in the world, as you may know. The world is fighting an obesity surge, and actual dice to come from operation. We ask the patients to prepare themselves. We have the luxury because we have good results, and people want to have good results. We ask them to lose weight, otherwise we cancel the procedures. Smoking suggests them to stop, but not always to stop, and it is not a kind of sine qua non-condition for us. Drugs and alcohol should be reduced to have operation here. We are fairly small hospital in regard of the structure. As we have a well-oiled machine, everything goes fine, but we have some requirements that sometimes a single proctoner does not have. Let's say that a surgeon comes with a patient with a 35 of BMI, mildly obese, etc., and an independent proxy. He asks him to lose weight to the surgery. The patient may go to another patient, to another physician, another surgeon. Here, since we have the structure that results back us up, they know that I want to have the repair here. I am going to do whatever they want. Some few of the basics that we have asked for preparing the patients for surgery, because of many things, including commercial pressures, need to have the patient done. Otherwise, he is going to look for another practitioner. It may entail in this direction. It also counts that we are just to hernia. We are quite familiar with the area. This also may influence. This is one of the things that I always thought. In other areas of trauma surgery, as complex surgeries, as pancreatic cancer surgeries, patients do better if they go to reference centres, the centres that do more cases per year. It is the same thing with hernia. As hernia is the most common surgical procedure around the world for general surgery, we should encourage to have centres of excellence. It is one of the thoughts, because it experiences counterbalance. We have a few requirements for the patient to undergo the operation. All that makes it different, because whenever we compare our results for other centres that do the showdice repair, our results are still better, and that is not said by us, it is said by independent investigators. That is helpful. I am going to go to my colleague David Torrance now for our fourth question, which explores a little bit about the controlled trials and the lower recurrence rates. I will allow him to ask a couple of questions that follow on from what you just said. David Torrance. Thank you, convener, and good afternoon from Scotland, Dr Neto. You have got an impressive result with not having the recurrence, but systematic reviews of randomized controlled trials are a gold standard for robust health intervention evidence. The systematic reviews show that hernia recurrence rates are lower for mesh repairs than non-mesh repairs. I know that that does not compare to you, so what are you doing different to other hospitals? Most of this is preparation of the patient. We get them to the correct weight, we control the comorbidities before the operation. This is being a matter of publication, because we have been criticised because our results are too different from the other people who show dice repair around the world. We are publishing something in the near future about that. We do something different. We control the patient prior. We do the less aggressive method of anesthesia. We do sedation and local anesthesia for all. We do early ambulation patients start to walk in the same day if they have the conditions to. Early rehabilitation with exercise programme is starting the hospital. All these measures together contribute with the quick recovery of the patient. Besides the surgical technique, it is not just the surgical technique, it is not doing the stitches, it is the things around the preparation of the patient. Also, I do not know if you know about our facilities if you have entered the website. It is a little different from general hospitals. Not everyone has the luxury of having these nice fields outside, green fields in the summer, where the patients can walk around and it stimulates the ambulation that we want to have in the post-op. Dr Neville, in your selection criteria, things such as weight loss are applied before admitting patients at the hospital, what is the rationale behind this? Is that selection criteria really important to your success rate? I think that it is. First, we are a small hospital. We cannot have all comers. If someone requires more medical complex and needs to potentially back up from cardiology, back up from ICU, we cannot take this patient. We are a small hospital. That is one of the things. Having said that, our results, when matched with other places in Ontario by the severity of the disease of the patients, it does not dismiss our population. The results are still valid. In regard of growing hernia sizes, this is the main population that eventually we do not take. If the patients are too obese and still want to undergo weight loss, that is okay. Sometimes in this patient that needs to lose many pounds more than 50 pounds or sometimes we have patients losing 100 pounds or more to come to operation here. Sometimes we change a little bit whatever would be the ideal estimated weight. One of the suitability things is medical condition. If it has chronic conditions, it needs to be stable from the chronic conditions. Obesity, even though it is questionable, when you see the results of hernia repair for growing, it is questionable if it changes for us. Using tissue repair makes a lot more difficult the operation, bigger incision, more infection of the wound, more hematomas and one complication sometimes frequently leads to the following month. We try to always get them to the correct weight, unless some very specific things happen. Most of them go to the correct weight or very close to that. We have the operation done. I am 100 per cent sure that it makes a difference for the final result of that individual patient. I thank you very much for that. I am trying to get on the record that, in a general hospital where we are trying to do the repairs, we have felt that putting that criteria in would not be so successful and non-mesh repairs would not be suitable for them. Is that your sort of... If the patients don't follow the criteria, using mesh or not using mesh may have worse results. Someone that is... Well, I was talking about growing hernia. I'm going to talk a little bit about ventral hernias that include umbilical, epigashic and incisionals. Just because in this group it's proved that weight is the major factor of recurrence in hernias regardless using mesh or not. That's well-defined in this area. Yes, we think that weight control is very important to do hernia operation unless there's an emergency case. I say thank you very much for that. I have no further questions, convener. Thank you very much, David Torrance. Following on from that, as he's been reflecting on what's been said so far, and then moving us into the next set of questions in our thinking starting with number seven, but obviously following on anything that has occurred to him as well, I'd very much like to invite Paul Sweeney to take us forward. Thank you, convener. Thank you very much for taking part in our inquiry into the use of surgical mesh. Chronic post-operative pain is clearly a substantial issue affecting many hernia repair patients regardless of the type of repair that is undertaken. Is what causes post-operative pain in hernia repairs? Yeah. Post-operative pain has changed a little bit the definition now for three months of continuous pain, and it's different from the past that was pain that was working the activities for six or more months, and so we are redoing our statistics that was initially one percent, and we are going to figure out what is our real statistics. There is not well defined all of the variables. One significant variable meaning the mesh repairs is that we have several nerves passing in the area, and fibroses related with the mesh or with the surgery without mesh is one of the causes of the nerve to get a little trapped and causes pain. There are some few cases that we cannot detect the reason of pain, chronic pain. When the nerve is causing pain, we call neuropathic pain. It's relatively, it's not easy, but a little bit easier to treat, and the odd is not susceptible pain. We don't know exactly the reason for the not susceptible pain. We think that those are small nervous terminals that are damaged and that are not possible to see in the naked eye, and sometimes it's very debility. Well, thank you very much for that overview. Systematic reviews comparing mesh and non-mesh repairs have found that post-operative complications, including the chronic pain that you define, are generally lower for mesh repairs. Should the shoulder ice hospital's written submission indicate an alternative view of the evidence, can you explain why the shoulder ice hospital's written submission to us varies with systematic reviews that we have observed about mesh and non-mesh repairs? Usually, tissue repairs are related with less chronic pain. Other side, in the other hand, they are related in general with more recurrence. Recently, you had a publication for the umbilical hernia that was very interesting several thousand patients. They had 2 per cent of recurrence with tissue mesh with small hernias, 2 per cent of recurrence with tissue repair, but just 1 per cent of chronic pain when they had 1 per cent of recurrence with mesh, but 3 per cent of chronic pain. For some places, it's a trade-off, incurring a little bit more pain with the use of mesh. This is for umbilical hernias. The incidence of chronic pain with mesh in the groin is a little bit higher because you have mirrors passing there, as they mentioned. It's hard to control the pain. It's a matter of that still needs more research and understanding from the physicians. We know that remodelling of the area and modulation of inflammation in the area takes a role, but it's difficult to actually do that. Ways that we do that, we do the range of motion very early with the mobilisation of the patients and some specific exercise that makes them mobilise the joints for groin hernias, but this is not a still a perfect method. We need to understand more about that to do a formal recommendation. I think range of motion, yes, helps a lot guys that are related with that. Protecting the nerves is our policy. We don't cut the nerves. Some people do cut the nerves to avoid chronic pain. Again, a trade-off, low incidence of chronic pain, or have no sensitivity, no sensation in that area. We think that's better to preserve the nerve. We don't want to take something that's unnecessary to do in the operation. However, some people that use mesh use a strategy to not have pain cutting the nerves that are one in the area. One of the issues that we faced here in Scotland in relation to the potential removal of mesh in the transvaginal example was that it was a hugely technically skilled operational procedure. Rather of the libb view before all this was examined properly, it was that it might be possible for some clinicians from Scotland to simply sit in a few procedures and they would have the necessary skillsets. That just didn't prove to be the case, which is what led to the act here in Scotland, which is facilitating the transfer of women to wherever the skills actually exist. Alexander Stewart is going to explore now the potential transferability. We will be meeting with the Scottish Government minister responsible for all this in due course, but he's going to explore the potential transferability of the skills and experience and preferred model of shoulders to hear in Scotland. Alexander Stewart. Thank you very much, convener. Good afternoon, Dr Spencer-Metall. As the convener has indicated, the skills, training and the techniques that are used and what you do in the shoulders hospital, how could surgeons in Scotland learn from the techniques that you have put in place? What additional training and support would be required for them to fully understand and facilitate what you are doing in your hospital that could benefit patients across the city of Scotland? Alexander Stewart Okay. It's a difficult question because there are some cultural things on that. One of the things that, if it's possible, could select the group of surgeons that are interested in doing hernia repairs or being the leaders of hernia repair but then to talk and eventually to train and come here. Potentially, there are some conversations to be done and etc, but yes, potentially they can watch here and we can eventually send someone to do some guidance over there if this is tiring the future. Can be done, potentially could. But mainly, as I mentioned prior, if you develop policies to patients to undergo hernia operation as we do have here, it may facilitate because if surgeon A says that you need to lose weight, it goes to surgeon B and surgeon B does the operation and eventually has a complication. That doesn't help too much. Again, based on the thing that if you do a lot of procedures, the same procedure, you're going to improve. That's no brains. That would be some potential areas of development. It's possible that other techniques then show that this could be employed as well according with the local training or eventually they can visit us to have a look at what we are doing, see if it's possible to incorporate the whole technique. Some of the suggestions in this regard, if you guys are interested in doing the show-dice technique, are more of us can sometime there and try to help on this. Leading on from that, in a general hospital where surgeons aren't as skilled in non-mesh techniques, and would you expect the curtains rates following non-mesh to be higher than you would have at your previous hospital itself? Yes. I would expect if they don't follow the guidelines that we are doing. If they don't get the patients to lose weight, I expect them to be higher. We just do that so that it increases a little bit the skill. If you have a different situation, the growing we have done or we have a colleague in the other room that has done, we call and discuss and etc. On from that, do you think that a ban on mesh in periode of care would be a good thing? Do you think that that would change some of the dynamics? There are some situations that there is no water possibility of closing the opening without a mesh. I would say that that is along the time that the hernias themselves improved and the knowledge of the surgeons about the hernias and how to place the hernias also improved. If we make our stats from today, it is probably very different from the stats that we currently see in frontations that operate five to ten years ago. For hernia repair, it is not possible to do a ban because, in some situations, it is the only way to do a good repair. Paul Sweeney, you would like to come in on the back of that evidence that we have just heard. Thank you, convener. I am just intrigued, because a previous evidence session on this matter, Dr Terrio Kelly, a senior medical adviser to the Scottish Government, advised us to quote him, that the shoulder repair technique would not be applicable to non-enguinal hernias, and it might also not be appropriate for patients with larger defects or for very degenerative tissues. Do you agree with Dr Kelly's assessment of that? Yes. The shoulder repair technique specifically is just for the growing hernias, just for inguinal hernias, not even femoral hernias. That comprises 85 per cent of our patients, but our general policies and methods of losing weight, early mobilisation, and the listing of the anesthesia that is for everyone. I agree with what he is saying about that. That is helpful. Thank you. I suppose that one thing that just occurred to me, because you just referred to the situation where mesh might still be appropriate. The reason mesh has been relied on by some is because the hernias suggests that the tissue walls are not sufficiently strong to withstand the subsequent pressure. You have explained the preparatory criteria in terms of the people that you think it would be appropriate to operate on. How can I put this? What you find internally is that, are there times when you look and you think that this might not, even though the patient has taken all the necessary action, might not be that looking at it now, we think that they will be sufficiently strong. The wall will be sufficiently strong to withstand that. Does that not happen from time to time? You have to call back on an alternative. Yes, it happens. It is not common. Recently, two years ago, we have one patient that with no indication, a young man 30s to 40s, and the tissues were just melting with the stitches. We need to use a mesh. This is for inguinos. For the others, it is not common. It is a little bit more common, you do not call for inguinos. It is really uncommon. Sometimes we find that it has a large mesh, inguinos, but it has associated the femoral hernia. Some of the femoral hernias, because of the anatomy, is a little hard to do in the association. Sometimes we use mesh as well for the area. Just out of interest, is there any difference in the application, the success rate, the outcomes, based on sex? Does it matter whether it is a man or a woman, or is it equally effective? It is easier to do in females. Any repair of the inguinos hernias is easier to do in females, because we cannot have a wrong ligament that we can section without problems. We cannot do in males because then we are going to kill the testicle. If we come for a new repair and losing the testicle, we may not lack the best approach. There is still an opening that we need to leave. There is a potential problem or a potential site of reference, and we know that. In relation to that rather uncomfortable final thought that you had there in relation to men, that must happen from time to time. Is it a risk to the testicle? In any hernia operation, the biggest hernia is the worst risk. That is between 1 to 800 cases and 1 to 1,000 cases. That is a lot of testing. Gael, on the use of mesh. Consequential to the procedure, the issue that we have reported by so many people—in addition to the whole question of mesh—is that I have sat on the cross-party group here in Scotland on chronic pain. One of the obvious consequences that we have seen with mesh is the number of people who have subsequently presented post-procedure. With life-crippling pain, which has been intolerable, the post-operative experience of patients—the post-life experience of those who undertake the procedure that you promulgate at shoulders—what is that, essentially? Yes. It happens that we still have some patients with chronic pain. It is about 1 per cent, as I mentioned before. It is really hard to pinpoint exactly what the cause is. Sometimes we clearly see by the characteristics related to the nerve. There are some specific medications, sometimes some procedures that we do for that, but sometimes it looks like just not a receptive thing related to the cut. We do not know exactly. Some of the times people even need to change the profession because they cannot have lifting anymore. We do have yet just the incidences a little bit lower than the people that use mesh. That is very interesting. It is challenging for me and for the people that work here. A lot worse than having a recurrence. A recurrence that we can fix. Chronic pain is a lot harder to fix. Sometimes we can, sometimes we can't. I suppose that there are a couple of things that I was trying to understand, just with different healthcare systems and places. First of all, how big a department is this particular facility that you have? And how many procedures are you routinely expecting to undertake? We are around 10 surgeons full-time, so we may have a little bit more because some are part-time, and together we are 10 full-time. The hospital has 89 beds, and the patients don't go home immediately at the same day as in the other hospitals. They have one or two days after surgery to do this rehab and pain control. Another point that I need to mention in our experience is that most of our pain control is with inflammatory and analgesics, non-opioid analgesics. 5 per cent of our patients receive opioids during the admission after surgery, and less than 1 per cent have a script of opioids when leaving the hospital. Again, this is because of all the measures that we do together. Thank you. Just one final thing so that I can understand is that the healthcare system in Canada, how is the procedure financed just so that I understand that? Obviously, we have a national health service here, so everything is part of the national healthcare plan. The patients who present to you, what is the financial underpinning of the process that is undertaken? Here, we are a private administrative hospital, but we work mostly with patients from the provincial health insurance, which is called the HIP, Ontario health insurance plan. We receive it for the hernia procedure as the Ontario health insurance space. The provincial plan is a public state, so they refer it. Sometimes they come from other provinces in Canada, and we receive it from their provincial governments. If there is a difference, they pay the difference. Sometimes it is more expensive or cheaper than here, so they pay the difference. When they come from outside the ward, they pay for the surgery. They buy the pocket and they may receive or not based on their experiences. You very generously, in response to an earlier question that might have come from Alexander Stewart, said that, potentially, conversations could take place in the event that there was an interest here in Scotland in trying to gain the experience of all that. If we, in our evidence session with the Scottish Government Minister responsible for this area of healthcare, are able to introduce into the conversation that potential, what would be the appropriate way for that to be explored further? Would that be for the Scottish Government to perhaps make contact with the shoulders hospital to see if a conversation could be initiated? Yes, it could be, and this will be through Mr John Hughes. I don't know, because it was never done. You need to figure out how it's going to do. Just in regard of your previous question that I kind of missed and I got now, we do around 25 to 30 patients per day in the regular days. That means around 500 to 600 per month, and around that 6,500 per year. 85 per cent are in general. That's a very considerable compliment. Colleagues, are there any further questions that any colleague would like to explore just at this point? Are we all content? In which case, I'd really like to thank you incredibly for what's been an absolutely fascinating opportunity. It's amazing what the world's worst pandemic has led us all into being able to explore across the world more easily as we've become familiar with this kind of virtual technology, because otherwise it's probably not a conversation that we would have thought to have or would have been used to having. I think that, on behalf of the committee, it's been fascinating to talk with you, and I'm incredibly grateful to the time that you've given us today and to the evidence that you've presented to us. Thank you very much. Is there anything that you would like to say that we might not have touched upon? No, thanks for the opportunity. My big home messages are that a centre in hernia repair makes sense and makes, because it's the most frequent disease. It may vary a little bit from what we do here because of local characteristics, and that's okay. You need to see what's better for you, and not always having the complete recipe that we do is good for you. Probably the easiest way is to try to find some leadership in hernia repair and try to start talking with them. Eventually, having a unit or a hospital or part of the hospital service is just completely dedicated to hernia repair. I thank you again and for your good humour in dealing with wee amateurs when it comes to this field of experience. We're very grateful to you, and so thank you again. That concludes our question session. I, of course, thank Dr Spencer Neto again for joining us. At the next consideration of this petition, we will be hearing from the chief medical officer and the Minister for Public Health, Women's Health and Sport. Beyond that, our next meeting will be on Wednesday, 18 May, and I formally close this session of the Citizens' Participation and Public Petitions Committee. Thank you all very much.