The genius of using pigskin for hernia repair… so why does the NHS often refuse to pay for this remarkable treatment
Hernia repair is one of the most commonly performed operations in the world. Cricketer Kevin Pietersen went into hospital for one last March, and Madonna has had three. The Prince of Wales and footballer Frank Lampard are other well-known names to have had it done – along with about 180,000 other Britons each year.
Standard inguinal hernias – small lumps in the groin pushing through a hole in the abdomen wall – may develop in a quarter of all men and one in eight women. They are easily repaired by patching the hole with a piece of synthetic mesh. But the latest research shows that very large hernias can be most effectively repaired using biological mesh made from pig tissue – dubbed ‘pigskin’ by some doctors.
Consultant general and colorectal surgeon Pasquale Giordano, who specialises in treating complex hernias at Whipps Cross University Hospital in East London, has been pioneering repairs using mesh made from pig tissue for nine years.
Pigskin has been used for more than 20 years and there is less risk of infection when using it
However, as pigskin mesh costs ten times more than its synthetic counterpart, whether patients get it is a postcode lottery – some Primary Care Trusts (PCTs) are reluctant to pay for it. And some sufferers are likely to face a wait of many months for the operation as other conditions such as cancer take priority. Since Mr Giordano’s PCT – Waltham Forest, North-East London – decided not to fund the biological mesh a year ago, he can do it only on a private basis.
The mesh costs about 8.50 for a section around half an inch square. Given that about 8in by 12in is needed for many larger hernias, that works out as costing as much as 5,000, compared with about 400 using the synthetic mesh.
‘Biological [pig] mesh has been available for more than 20 years,’ says Mr Giordano. ‘In more complex cases there is an increased risk of synthetic mesh becoming infected as the structure allows in bacteria, but not immune system cells. Ultimately the body will reject it.
‘Should it become infected, removal is inevitable, which of course makes it difficult to repair the area again. The biological mesh is made predominantly of collagen, which occurs naturally in our bodies, and the structure of the pig collagen is very similar to a human’s. The patient’s cells will grow and integrate naturally into the graft and the body won’t reject the patch.’
He adds: ‘All PCTs should take the long-term view. Biological mesh may be more expensive, but complex hernias can’t be repaired using synthetic mesh so patients on my waiting list are turned away and told there is nothing to be done. Their lives are made miserable by the condition – they cannot walk properly and can’t work and they are doomed to claim benefits for the rest of their days. That ends up being far more costly to the taxpayer.’
Smaller hernias develop spontaneously at a point of muscle weakness in the abdomen wall after heavy lifting, coughing fits or other forms of strain. Larger and more complex hernias usually result from trauma, accidents, being left open after an operation to clear out infection or post-operative complications.
The Department of Health has said it is up to PCT's to decide local policies on the use of biological or synthetic mesh in the use of hernia treatment
Timothy George, a 47-year-old tourism consultant from Ilford, East London, is a good example. At the end of 2008 he began suffering severe stomach pains and, after being diagnosed with a hole in his intestine that was leaking toxins into his system, had a 12-hour operation at the King George Hospital in Ilford.
Three weeks later, Timothy’s post-operative scar developed an infection and he had to be restitched. In July he noticed his stomach had distended. He was diagnosed with a large and complex hernia (about 8in by 12in), and in October had an operation to repair it using synthetic mesh. But after two months the mesh became infected and the hernia returned. ‘My stomach protrusion was so large I looked as if I was nine months pregnant,’ he says.
‘I became depressed, turned down work and stayed inside like a recluse. I was so embarrassed – people would stare at me if I went out.’
Timothy was seen by Mr Giordano in November 2009, but the case he made to his PCT for a piece of biological mesh costing 4,000 was refused because a similar-size synthetic mesh cost just 400.
Eventually the manufacturers of the mesh agreed to let Mr Giordano have the material for Timothy’s operation free, for compassionate reasons. The operation went ahead in April this year. Timothy says he feels he has gained his life back – he can go to the gym and wear ordinary clothes.
Consultant plastic surgeon Kevin Hancock, who has worked with both types of mesh, says in the past few years there has been an explosion of the mesh market and estimates that pieces can cost up to 10,000.
‘In many situations the synthetic mesh is adequate, but in others the biological mesh is unquestionably superior – if the hernia has resulted from an infection, for example.
‘In such cases, the ongoing care of the patients is such that the cost of the biological mesh can be clearly justified.’
The Department of Health says it is up to PCTs to decide local policies on the use of biological or synthetic mesh for hernia repair – though PCTs are not allowed to operate a blanket ban and they must have a mechanism for considering individual cases as potential exceptions to the local policy.
‘I know of many more examples where it’s madness not to use the biological mesh,’ says Mr Giordano. ‘I’ve seen a woman with terrible infections and who is on intravenous antibiotics for six months. That treatment alone costs significantly more than one piece of equipment.’