Episode 146: What’s More Important: Surgeon or Technique? | Hernia Talk Live Q&A

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Speaker 1 (00:10):

Good evening everyone. It’s Dr. Towfigh. Welcome to Hernia Talk Live, our weekly session officially now also a podcast. My name is Dr. Shirin Towfigh, your hernia and laparoscopic surgery specialist. Thanks for everyone who’s here on Facebook Live. I’m seeing you, I’m watching you. And also for those of you that are here via Zoom, I see you as well. Don’t forget to follow me. I’m on YouTube at Hernia Doc. All of our prior sessions of Hernia Talk are all archived on YouTube as well as our new podcast, Hernia Talk Live podcast. You can now watch, not watch instead of watching me. Now you can actually just listen to me while you’re driving or whatever it is you’re doing. Washing the car, going to work, brushing your teeth, putting your makeup on. You can listen to me on our podcast and we have over a hundred downloads already, which is great.

Speaker 1 (01:08):

We just launched it and we’re slowly launching all the initial episodes first. So many of you are with me now and you can see we’re close to 150 episodes now. And maybe you want to go back to the original discussions we had episode one, which was way back in the very, very first month of the pandemic in 2020. So we’ve been doing this three years now. Unbelievable, but very enjoyable. And so as you know, every week we have a topic that we discuss. The topics often are related to a meeting I’ve been to or a patient scenario that I encountered or questions that have come up from you all. And last week we had the hernia frustrations talk and I think it was very controversial. Okay, that’s not the right term, not controversial. It very, it sparked a lot of emotion in people because it seemed to me that everyone is actually truly very frustrated.

Speaker 1 (02:18):

And my hope was to address those frustrations and try to explain from my point of view why you’re frustrated and hopefully maybe reduce your frustrations by giving you a little bit of an objective analysis of it. But I feel like it had the reverse effect because many of you wrote to me or posted on hernia talk.com, which is our free discussion forum for anyone that just wants to go online and talk amongst yourselves about hernias and share with your colleagues. But they were frustrated by the frustrations. And my whole point was medicine is the science, but it’s also much an art form and we don’t have exact answers for everything. And then the frustration is that many patients expect perfect answers like a formula. There is no perfect formula for everyone. They’re just kind of like a concept and experience is very important in trying to predict what’s the best.

Speaker 1 (03:22):

But if you go to, I think it’s episode number two, even when I talk with Dr. Bruce Ramshaw, it may not be two, but it’s one of the first handful of episodes. He is like the guru of hernia frustrations because he is the one he was spending all of his time. Now he used to be a very active, very skilled hernia surgical specialist. He still is, except now he’s doing mostly research and innovation and not so much direct patient care, which is not good for our patients, but it’s good for our field. And what he’s teaching everyone is that medicine surgery is a complex system and like all complex systems, there is no right answer. And there are ways of trying to get to the best answer, but there’s no right answer for each scenario. Every patient’s different. You put the same mesh in two different patients by the same mesh, same surgeon, two different patients, you’re going to have two different outcomes, which is frustrating, I understand, but it’s reality.

Speaker 1 (04:34):

And my hope with the podcast last week was to give some insight into the fact that frustrations are real, but there’s nothing we can do about it except for doing maybe more research, but expectations. Our patients are way up here and right now our hernia field is not meeting those expectations. There are certain surgical fields like breast cancer where they have really good data to support a lot of what they do. And even in those specialties where there’s so many clinical trials and carefully curated data, even in those, there’s a lot of debate as to what the right thing would be for each patient, which is why they have weekly tumor boards, which are like tumor based multi-specialty meanings that every breast cancer specialty center has. So we don’t currently have that for hernias. We have hernia meetings, society meetings. We actually have a quarterly multi-institutional hernia rounds meeting, which is spearheaded by Dr.

Speaker 1 (05:47):

Nicole and from Oregon Health Science University, who’s also one of our guests on Hernia Talk. I highly recommend you listen to one of his podcasts with me. But anyway, so that was last week all about hernia frustrations. It’s very frustrating and I hear it from you all the time and you write to me about your frustrations. I thought I’d do a podcast about it, and then here we are. You’re still all very frustrated, which just proves to the fact that I can’t cure everything no matter how much I tried calm people down. It doesn’t work. However, today’s topic has to do with a little bit of what we talked about last couple of weeks, which is this kind of push pull between finding the right surgeon and then finding the right operation to undergo for your hernia repair.

Speaker 1 (06:46):

I have a lot of patients that call the office and say, does Dr. Towfigh do shoulder dice repair? Yes, she does. And then they make an appointment. Does Dr. Towfigh do the starter repair? No, she doesn’t. Then they hang up. Does Dr. Towfigh do robotic surgery? Yes, she does. They make an appointment. Does she do non Mesh repairs or does she remove meshes? Yes, she does. Okay, they make an appointment. Does she offer tummy tuck? No, she doesn’t. Okay, click. So they’re making their decision as to what they need based on the operation and not so much based on the surgeon. And I have a little bit of an issue with that because I don’t believe that that’s the right way of moving forward. So the topic today is what’s more important, the surgeon or the technique when choosing hernia surgery. And I always, always, I’m just going to tell you the answer right now, it’s the surgeon. It’s never the technique. And I say that because not just because I’m a surgeon, but I’ve also been a patient. So I can share with you some of my own experiences, which is it’s so much more important to have the right surgeon than to choose the right technique from the onset. Okay, there’s a couple questions. Let’s see.

Speaker 1 (08:08):

Oh boy, that’s a long question. Dr. Towfigh, as you know, we have shared many wonderful conversations. Most of us were never told around the complications of mass true. And they have found themselves in a situation that they’re then gaslighted, disabled, et cetera. Also true. All we want is the truth from day one. Yeah, for sure. Truth is true, but you can argue about what is true and what people think are true versus what do we know as fact? It’s one of the frustrations that we talked about last week. Let’s see, this goes on. We are glad that there are surgeons like you. Without surgeons like you, there would be no hope for anyone. Thank you. Please keep going. There are people here who will work with surgeons like you all over the world. We need us all talking together and sharing information. It protects all I do hope.

Speaker 1 (08:55):

Well, thank you. I do really appreciate that. Love that. Thank you very much. Okay, so why do I think the surgeon is more important than the technique? I have a lot of people that come to me and their intent on, I want a non Mesh repair, I want a shoulder dice repair, I don’t want robotics, and so on. So for me, I usually first figure out the story of the patient and understand who the patient is, what’s their lifestyle, what’s important to them, what kind of risk factors do they have going into hernia surgery? What’s important to them in terms of outcome?

Speaker 1 (09:42):

Someone who works in construction has a different kind of need than a retired person who golfs versus a mother of a newborn baby. So what I help them therefore decide after I then examine them and maybe look at imaging is to help determine the best operation for them. Just because the shouldice, for example, is considered a great hernia repair. If you don’t want mesh or because robotic surgery has had some bad press about its safety, doesn’t mean that the show loss repair is the best repair for you or that I don’t offer robotic surgery. I hope that makes sense.

Speaker 1 (10:28):

But the reason why I say surgeon is the following. I’ll give you an example. I had a very recent situation where a very close friend of mine needed surgery and they asked me who they recommend for surgical repair and I gave some names. Now remember, I get asked about surgeons all the time. I’m a surgeon. I actually know a lot of surgeons, not only in the hernia field but in urology, gynecology, orthopedic surgery, et cetera. And there are certain surgeons I know personally and I’ve operated with ’em and I can vouch for their absolute amazing skills. But there are also surgeons I’ve never really operated with, but they have a good reputation in the community or I’ve had friends who’ve trained with them or something like that. When I was younger, I always thought the best surgeon was the head of the department. So the chairman or the chief of a division or someone who won a bunch of awards is probably the best surgeon, not true.

Speaker 1 (11:32):

Why is that not true? Because just because you hit a certain leadership potential does not mean technically surgically you’re a gifted surgeon or that you always make good clinical decisions. And the reason why it’s important to have the right surgeon is very importantly because of the clinical decision. So anyway, to move forward, this friend of ours needed a surgery, fairly straightforward surgery, nothing too complicated. These operations are done millions a year, not a hernia surgery. So I gave some names and I personally have a very close respect for my own hospital at Cedar-Sinai. I think it’s an amazing hospital. We have amazing surgeons, but we also have a lot of very good hospitals around that are competitors and a lot of my friends work at it. So it’s not uncommon for someone to have a operation, a different hospital, but I have a predilection for my own hospital, very much so.

Speaker 1 (12:38):

However, it just turned out that the surgeons that this patient went and saw some of them that I thought would be good because they’re recently recruited from a different hospital or they have this amazing presence or maybe they have a big presence on social media. Turned out to be not one of ’em was kind of a jerk, very kind of put standoffish and didn’t examine the patient, my family friend, and didn’t really answer a lot of questions, just kind of went in there and said, this is how it’s going to be. And another surgeon, their office wasn’t the cleanest. I’ve never been to their office, I didn’t know. And it turned out the one that I thought maybe would not be the best choice turned out to be the best choice. That surgeon was knowledgeable, intelligent, listened to the patient. All of these surgeons, by the way, are good surgeons. So their surgical technique was not in question.

Speaker 1 (13:41):

And then what was important was this surgeon that my friend, my family friend finally chose was the best surgeon because it was the surgeon that listened to them, answered the questions, was knowledgeable and therefore, regardless of whatever technique was being chosen, because regardless the United States most operations are successful and very well done, that surgeon probably had the best kind of thought process. You know what I mean? So something happens in the operating room where there’s let’s say bleeding or a complication, that surgeon would be the most reliable to make that decision while your patient is under anesthesia. So that’s kind of where I come from, which is decision-making before surgery, during surgery, very important and then after surgery, that cannot be replaced by choosing the right technique. So choosing a surgeon who is not thoughtful or is not someone who has a lot of experience or doesn’t see the patient much, it just kind of gives them to their juniors, doesn’t take personal joy in following their own patients, but knowing that, oh, they do this robotically or they do this shouldice or whatever, doesn’t mean that’s the best decision for you. And of course I always say for surgeons always have multiple consults. I’ve had surgery myself, even though I know these surgeons, I still go and see 2, 3, 4 other opinions just to make sure all my questions are answered. And sometimes another surgeon will bring up a situation where I never even thought about it or other surgeons didn’t think about it. I’m like, oh, that’s a good point.

Speaker 1 (15:52):

I do believe choosing the right surgeon is most important and you should definitely seek more than one consult for any operation you’re having and then make a choice based on the surgeon and how comfortable you feel from with the surgeon because that’s surgeon will ultimately do the right thing for you and will ultimately have your best interests providing you with the best opportunity for surgery and not you dictating what surgery you want and then trying to find the surgeon that you find who will fit that puzzle for you. Alright, a lot of questions coming up. Let me help answer those real quick. Is knowing if I have a direct or indirect or inguinal hernia important in selecting a surgeon or a technique? Absolutely. I’ll give you an example.

Speaker 1 (16:40):

First of all, we know that well for indirect inguinal hernias, my personal bent is if it’s a normal inguinal hernia, most techniques do really well. Yeah, you can’t go wrong with any technique for the average patient if your hernia is huge, inguinal hernia, so size does matter. If it’s really huge, I tend not to do tissue repairs and if it’s really small I tend not to do Mesh repairs. So that’s kind of one thing. And then a direct hernia. The main thing with a direct hernia is it’s an important variation of a hernia. Why is it important? It is considered a thinning of the tissue and a weakness of the tissue as opposed to a punched out hole. And so just putting Mesh on, thinned out tissue doesn’t work. It’s like, how should I explain it? It’s like having a ground that it’s like putting a rug over a ground that’s not stable, right? You got to stabilize the floor and then you put the rug on top of it. So that’s what a direct hernia is. A direct is a very thinned out loose tissue. So for open surgery you have to plicate or tighten that hole. And for laparoscopic or robotic surgery also you have to kind of reduce that thinned out, redundant thinned out tissue.

Speaker 1 (18:11):

So a tissue repair for someone who has a direct hernia is usually not the best option because why? I just told you it’s very thinned out loose tissue and you want nice healthy, bulky tissue for a good tissue repair. If you have poor quality tissue, a non-mesh tissue-based inguinal hernia pair is not your best option usually. And so knowing if you have a direct or hernia can help differentiate about whether you should choose a direct or indirect hernia, sorry, tissue or non tissue-based mesh repair. I’ll give you a good example. I had a patient that came to me was like a fourth maybe fifth opinion.

Speaker 1 (18:59):

One surgeon said Your hernia’s not that big, it’s not bothering you so much watchful rating. Another surgeon said you have a hernia, you must get it repaired. Third surgeon said, I do non Mesh repairs. Let’s try this without Mesh, you don’t need Mesh. So I was the fourth surgeon and what the patient didn’t like was the watchful waiting. He is like, I don’t want it to get bigger. Someone told me it won’t get bigger. Well yeah, if it gets bigger, that’s maybe restricts some of your options but not so much. Hold on guys, I’m afraid I’m going to run out of batteries pretty soon and then you guys, give me one second. I need to get a charger. If I lose your feed, you’re going to hate me. Give me one second. All right. Sorry everyone, can you hear me okay? Unbelievable. I went from 34% to 9% in like 20 minutes.

Speaker 1 (20:11):

Okay, going back. Okay, so I was surgeon number four and what I noticed was this patient actually had a direct hernia and not just an indirect hernia. And I said, listen, I agree with some of your surgeons, I don’t agree with you have to have your hernia repaired immediately, but I do agree that laparoscopic or open without Mesh are both options, but what’s different in you is you have a direct angle hernia. No one had told ’em that. I knew it based on its imaging, you have a direct inguinal hernia and what happens with the direct inguinal hernia is tissue repair is not the best. It tends to be tighter, more chronic pain, higher recurrence rate. So I would personally recommend a mesh based repair on you, whether open or laparoscopic because of your direct hernia. Now this is exactly where it’s more important to choose your surgeon than it is to choose the technique.

Speaker 1 (21:19):

Why? Because as a surgeon I was able to tell him that the technique that he was hoping to get, which is the shouldice, was maybe not the best technique for him. Anyway, we have ongoing conversations with this patient, but that’s kind of where I’m going. Now, this patient could have very well had the shouldice repair or the laparoscopic repair and done just fine. But as an expert I know that I treat direct inguinal hernias differently than indirects because they have a higher chance of failure. You have to take certain steps that you don’t take with an indirect inguinal hernia. And these are like little tidbits that we experts know and that’s why it’s, I always say even if you don’t necessarily have surgery by an expert, at least run the case by an expert so that you can get some of your questions answered in some details answered that you can then take to another surgeon. I hope. I don’t know if that makes sense, but I hope that makes sense. Very informative, thank you.

Speaker 1 (22:28):

Let’s see, I’m 100% with you. When I had Mesh removal surgery, I had visited a few surgeons. I settled with Dr. Wick simply because of her knowledge and the way that the surgery was going to be approached. But what sealed the deal was trust. I trusted that doctor and would do the utmost best for me in my circumstance. Yes, so huge trust is huge. So performance, there’s performance and there’s trust. And the trust is even more important because there may be something that happens during surgery. You have to trust that your surgery will make the right decision during surgery, you’re under anesthesia, you’re not going to be able to intervene there. You can’t control every aspect of your care. And then secondly, what about after surgery? You can have complications after your operation. If your surgeon is unaware, what kind of is unaware of the ways in which they can help you with a complication?

Speaker 1 (23:26):

Not the best situation. Alright, here’s the next question. How do you and your practice decide between performing robotics and tap for recurrence following open repair after repair included stitches between the rectus muscle and the pubic plate. What are the factors you use in this decision and can you decide pre-op or only once patient’s asleep? How do you in your practice decide between performing robotics and tap for recurrence falling open, it doesn’t matter. Robotics which is tap or laparoscopic, which is tap or tap for recurrence are both equally fine and the stitches of the rectus do not affect that decision. Here’s another question actually had a couple questions submitted before that I promised I would answer. Okay. Can you speak to the technique and the operative preservation of nerve function and sexual health related to a femoral hernia awaiting repair? Is there data in this area?

Speaker 1 (24:28):

So there are no major nerves involved in femoral hernia repairs. If it’s approached laparoscopically, which is the preferred technique, there’s the general femoral nerve and the lateral femoral cutaneous nerve both should be untouched and not disturbed and not injured. If you are having the femoral hernia performed open, which is uncommon, it’s called the McVay repair, a tissue-based repair, then all three nerves, the ileo inguinal, ileal hypogastric and genital branch of the genital femoral nerve are at risk for injury as they are for any open hernia repair. And as a female, I would not recommend any of those nerves be cut. I personally, I’m not someone who cuts any of those nerves, so all the nerve functions should be preserved with any operation for a femoral hernia.

Speaker 1 (25:32):

Sexual health also is unrelated to any hernia repair. There are men who have erection issues after hernia repairs, mostly due to pain from the hernia or the hernia repair, not so much related to the hernia repair itself. There are ejaculatory pain that can happen again in men if Mesh used is somehow impinging on or eroding into the vas deferens as part of the repair. Again, surgical technique is super important with these in females, there’s no real sexual health related issues for femoral hernia repair. We do know that there is pelvic floor spasm associated with hernias including femoral hernias, pelvic floor spasm can present as pain with orgasm or pain with ejaculation or pain with sexual intercourse for women. But that’s not a sexual, how can I say this? It’s an indirect problem. It’s not directly affecting sexual health. I hope that helps. We have another question.

Speaker 1 (26:47):

Let’s see here that was presented. Please discuss surgeon versus technique when it comes to hernias in difficult locations. Oh, that’s a good one. I have a low midline supra pubic incisional hernia that has a minimal inferior landing zone from Mesh. Okay, very unique. So this is a hernia in the lower abdomen just above that pubic bone in the middle. It’s a very unique area. It’s called a suprapubic hernia. It can be from any urologic or gynecologic operation, usually uncommonly from a C-section, but it can be from let’s say an open hysterectomy or some prostate operation. The technique that’s used with that is almost always laparoscopic or robotic and not open and almost always with Mesh, this issue that there’s not enough inferior landing zone for Mesh is incorrect. What you have to do is take the bladder down and allow the Mesh to go between the bladder and the lower pelvis to allow for that landing zone for the Mesh.

Speaker 1 (27:58):

So you need a surgeon who understands how to do these hernias in difficult locations. Hernias in difficult locations include hernias that are not in the middle of the abdomen, so flank hernias, back hernias, hernias in the low midline and hernias in the upper midline. Those are all considered difficult locations because you have organs and nerves in those areas that we typically don’t need to address. And they’re also uncommon hernias because most surgeons also don’t do many of those. So yes, super important that you have the right surgeon who’s known how to do these before and also understands how to do laparoscopic and or robotic surgery. I’ve seen a lot of doctors who send hernias to plastic surgeons because they don’t do complex hernia repairs and this would be a complex repair.

Speaker 1 (28:57):

The issue with plastic surgeons during hernia repairs is they are not surgeons who do anything laparoscopic or robotic. So the only options they offer you are open repair options. And for this specific operation, that’s the incorrect, I shouldn’t say incorrect, it’s the least favorable decision is to do this open. So laparoscopic or robotic, definitely with Mesh and you need to find a surgeon who does this for a living and has done multiple of these operations. Next question. Is an ultrasound identified inguinal hernia with a finding of no definite reducibility a cause for concern? No. Or simply an indication that it was not clear on the ultrasound of the hernia could be reduced? Well, first of all, not all hernias are reducible and not all components of a hernia are reducible. Part of it may be and part of it may not be. So the fact that an ultrasound or imaging says the defect, sorry, the contents of a hernia are reducible or not reducible is not that important to me. What’s more important is the content and the size of the hernia and the symptoms of the patient. So if your symptoms are unchanged and you just happen to have an unreducible or non reducible hernia, that’s not important. But if your symptoms are all of a sudden much more painful than it was and I cannot reduce your hernia, that’s a much more important detail than what the imaging shows. a lot of questions guys. Here’s another one.

Speaker 1 (30:32):

How can I know as a patient if I have a direct or indirect hernia? Oftentimes during surgery there’s no perfect way of predicting it preoperatively. Are there signs I can identify myself or findings on an ultrasound report that I can use to understand it? If it does not say directly, say that is direct or indirect, almost no hernia imaging will say direct or indirect. It’s just not something that radiologists say. As a surgeon, I know that that detail is important and I can read in. So some of the larger hernias, you can tell the difference between direct and indirect on all terms of imaging, ultrasound, CT scan and MRI. However, most surgeons don’t read their own imaging and so that’s another issue. Physical exam is also not perfectly predictive of whether you have a direct or indirect inguinal hernia. Typically, if a hernia goes down into the scrotum, then you know is indirect, but a large direct can do that too.

Speaker 1 (31:39):

Typically a direct hernia is wide base and more medial. It fans out when you are lying flat and it bulges out when you’re standing up. But that can happen with an indirect in or hernia two, typically indirect hernias can include bile, but direct hernias do not include bowel. But I recently took out fixed a very large direct inguinal hernia that had colon in it and went down to the scrotum. So it basically violated all rules of what a direct hernia is as opposed to an indirect. So reliably you cannot certain images if read by a surgeon who understands the anatomy really well can help you find that like the one patient I just explained where I was able to demonstrated them that they in fact have both a direct and indirect. And for those of you that follow me, you may know that’s called the pantaloon hernia and the treatment that is a little bit different than the average hernia because there’s more defects, more weakness, more tissue loss, and therefore tissue repair alone is usually not the best if you had a choice. Let’s see.

Speaker 1 (32:56):

Okay, here’s another question. What is considered a large inguinal hernia? So small means I can’t see it when you’re standing. I can feel it, but I can’t see it. Large means it’s very visible down to the scrotum. That’s kind of the way I explain it. Maybe there’s a different way of how other people like to explain it to more questions. Let’s see. Regarding chronic pain, long-term discomfort and recurrence risk are the results of the different hernia repair techniques, Mesh versus no Mesh similar after the choice of technique is tailored to the needs of the specific patient regarding chronic pain long the results? No. So the surgeon, okay, so basically what the question is, let’s say you figured out that you need, let’s say all the surgeons say, okay, you need a tissue repair or you need a Mesh repair. Doesn’t matter which surgeon you go to. Yes, we discussed this last week, which was about hernia frustrations, which is each patient will have a different outcome and each surgeon will have a different outcome for the same operation.

Speaker 1 (34:13):

That’s why I do what I do is because I have a lot of patients that come to me and have what seems to be a perfectly good repair, but certain decisions were maybe not the right decision by the surgeon that did the hernia repair. Maybe they picked a too heavyweight of a Mesh for a thin patient or they put too many attacks for their hernia repair where they probably shouldn’t have put tuck in those areas, or perhaps they cut a nerve when they shouldn’t have cut a nerve and now the patient has a aroma. So these are all decisions during surgery that make a difference. So the question is this, let’s say the decision-making up until the time of surgery has been done and is deemed to be validated by everyone that you need, let’s say a laparoscopic angle hernia repair, does it matter then after that, what surgeon you go to?

Speaker 1 (35:10):

And the answer is yes. So every operation we know has a learning curve with laparoscopic repair. It’s about 500 cases we believe is where you start evening out in terms of your complications, your outcomes start being about the same after 500 cases. So you shouldn’t go to a surgeon who does maybe 10 cases a year because they’re still in their learning curve and you don’t want to be that patient. Were the wrong decisions are made. But also there are surgeons that could care less if they did a hernia pair, they might as well do a butt abscess surgery or appendectomy or a cholecystectomy. It doesn’t matter to them. Hernias are not top on their list. Well, those surgeons likely are not going to have as good of an outcome. Then the surgeon that goes to the American Hernia Society meeting every year reads the journals is on the international hernia collaboration talks to friends to make sure that their hernia repair, that they’re up to date with hernias.

Speaker 1 (36:09):

So all of those make a difference and again, that’s why picking the right surgeon is much more important than picking the right technique. Here’s another question. What do you do if there is postoperative hernia pain and no local surgeons who can manage pain If you have to travel including to your practice, how long would a patient have to stay in a hotel to allow completion of workup? Okay, that’s a legit question. In most places in the United States, there is no hernia specialist and no pain management specialist that understands hernia patients. That’s just reality. And so yes, you may need to travel now, you may not have to travel out of your state, you may just have a need to travel to a different county.

Speaker 1 (36:57):

And with telehealth you can initiate a lot of your care via telehealth. So if you’re in California, you can do telehealth with me. I have patients, a lot of patients from Northern California where there really aren’t surgeons who are interested in treating chronic postoperative pain. So I encourage them to initiate telehealth. They don’t need to travel to see me for their first visit. I’m happy to see them, but I’m also happy to do telehealth. So send me all your information and we’ll figure it out. And maybe I can say you don’t need a surgeon yet. You need a pain doctor or you need a physical therapist and we’ll try to find someone near you or no, absolutely you need to come see me. I know I can help you. And then based on that, my office knows which hotels you can stay in and we can figure out how to keep your stay short, et cetera. They’re usually hospital or medical rates around where I live to give you a little bit less charges for your hotel stay or they’re Airbnbs, et cetera.

Speaker 1 (38:10):

So that’s what I recommend, which is initiate a telehealth. And for people who don’t live in California, at least for me, I do offer what’s called online consultation. So let me help you figure out what’s the problem and then I will, so you contact my office, I’ll review everything, your imaging, your CDs, your operative report, your story, et cetera, and help figure out what’s going on. And I’ll say, okay, now what you need is X, Y, and Z. If you can get it near you or if I have a friend or colleague near you, I’ll even call my friends that are nearby and I’ll say, who’s the best physical therapist near you? Who is the best pain management doctor or urologist near you that you can refer so you can get as much of your care near you as possible that I’ll help coordinate? And if that doesn’t work, then you can come see me and I’ll do your nerve blocks or schedule you for surgery or whatever is needed.

Speaker 1 (39:12):

So everyone’s a little bit different, but you have a lot of options and for those of you that are on here from the United States, you really do have a lot of options. I can’t say that about most other countries. There are some hernia specialists in Europe, not as many as in the United States and not as many per country than as we have in our country of the United States. And then I’m sorry, outside of the US and Europe, there really aren’t surgeons who do chronic pain. There are really good surgeons and there are a lot of great hernias, surgery friends of mine, but chronic pain and dealing with complicated patients, I get asked to give the most international talks about that because they just don’t see it as much and when they do, they really don’t know what to do and it takes a fair amount of experience and a lot of time and energy and interest for surgeons to offer these services. So interest I think is the most important. It’s you really have to be very patient and spend a lot of time with your patients if you want to go into this chronic pain world, and that’s really how it is. Okay, more questions. Let’s read these for you.

Speaker 1 (40:43):

Can the optimal technique to repair hernia always be chosen before surgery? I think the term always is not the best, but typically, yes, at least I believe that. I have a lot of patients that come to me and they’ve seen other surgeons and the surgeons say, oh, well, we’re just going to go in there and take a look or we’re going to just go find out in the operating room. And I’m like, absolutely not run away. If your surgeon is saying, we’re just going to go into your abdomen, operate on you with no plan, and whatever we see, we’ll deal with it, then first of all, the fact that your surgeon’s saying that and really has no plan means when they’re in there, they’re not going to make the right decision either because you really need a plan of attack, you need to plan a, plan B, a plan C, whatever the situation is.

Speaker 1 (41:38):

And when I teach my residents, I tell ’em, okay, here’s a patient story. This is what we’re planning on doing. If we find X, we’re going to do something else. If we find Y, we’re going to do something else. We’re there’s a plan and I have imaging and I’ve examined the patient and I know their story and I’ve marked their abdomen, all the specific areas of their pain before surgery, the day of surgery. So those are all very important key practices, especially in revisional operations or when you’re operating on patients who’ve already had surgery. So therefore it is super important that there is a plan and oftentimes you know exactly what’s going to happen during surgery, whereas that’s not necessarily true in situations where the surgeon says, oh yeah, we’re just going to take a look and see what we see and we’ll deal with it, then run away. I strongly recommend you run away from those because that is absolutely not the right thing to do completely. I’m absolutely completely against that. Let’s see. Do you agree with the idea that young active patients with normal B M I mesh is not generally advisable? No, I don’t agree with that, especially in athletes, depending on the athletic activity, laparoscopic repair with Mesh is the best option for them, and that’s coming from me. I’ve operated on N F L N B A N H L, golfer, soccer player, M M A wrestler.

Speaker 1 (43:23):

Each person has their own needs, but they do really well with Mesh. It’s the surgical technique that’s important. You mentioned the need to plicate direct hernia and it can be done laparoscopically. How do you do that laparoscopically? How do you access all the layers that need to plicate? First of all, it’s just one layer. It’s not all layers and it’s not a plication. When you do it laparoscopically, it’s an implication, which means you take the redundant tissue and you bring it back in. So you go from concave to convex, and that allows the Mesh to be attached to as much tissue as possible instead of bridging a hole. Bridging in general is not a good idea and direct inal hernias tend to be wide mouth and you don’t want to bridge a wide mouth hernia. Let’s see.

Speaker 1 (44:15):

Oh, I wanted to also make a comment to those of you in the United States, we really are blessed to have a lot of great surgeons. Our general kind of cadre of surgeons are really high level. I know everyone has problems and complaints and complications and so on, but I’ve traveled around the world. I’ve been to countries in Asia Middle East, I’ve been to, I haven’t been to Africa yet, and I haven’t given talks in Africa yet. I’ve been to Europe, obviously South America, central America, and oftentimes I am invited as an expert surgeon to kind of review. I also have a big social media presence and not only do patients reach out to me, but surgeons reach out to me and I get a lot of interesting videos and comments that are sent to me like, Hey, what do you think of this? Look at this great technique I found, and I just want to tell you, US surgeons are really good.

Speaker 1 (45:19):

I say this because the countries that I’ve been to that are maybe typically second and third world, and even some European countries, but mostly non-European, the surgeons are technically really good surgeons, but their knowledge base is limited. It’s one of the reasons why we go to these countries is to help them learn from us, but it’s not uncommon for them to be about 20 years behind us. In the US technology comes to the US first training comes to the US first. Our training system is much more intense and in depth than most other countries. I was just recently in Brazil, they only need two to three years of training, and that’s it for surgery.

Speaker 1 (46:15):

It used to be two. They thought maybe we should increase it to three. We have five minimums sometimes up to eight, so it’s two to three times longer just in training the number of hours the US trainees work or longer, the breadth of training is wider, and the technology that we incorporate is more so even though I have colleagues in other countries and there’s superb surgeons, there are also a lot of surgeons in other countries out there that really, we were making these mistakes 20 years ago and now they’re making those same mistakes now. So they don’t necessarily have a lot of access to today’s knowledge bases. So my point is this, we’re very blessed in the United States, and I know we have complications and I know we have unhappy patients.

Speaker 1 (47:13):

It’s significantly better situation than in most other countries. Let me see the questions here. What types of Mesh are you currently using? Biological, dissolvable, synthetic. Is Mesh drinking a concern? Concern Mesh shrinking is a reality. It’s not a concern. It’s a reality that we work around, and I don’t usually use biologic or dissolvable meshes unless I don’t plan on doing a definitive hernia repair and I’m trying to just prevent a major disaster while the patient is recovering from whatever life-threatening problem they may have. That’s not hernia related. It’s almost always synthetic Mesh or what I call hybrid Mesh, which is a combination of biologic and synthetic meshes. Have you ever recommended spinal cord or dorsal root ganglion stimulation to a patient whose pain was refractory to all surgery and drug treatments, and how are the results of neuromodulation helping pain? I’m not a big fan of spinal cord or dorsal root ganglion stimulation because most of the patients that come to see me have not had an exhaustive approach to treating their pain. I mean, I’ve had people with hernia recurrences that were told there’s nothing to do for them, and they were given a spinal cord nerve stimulator and all they need was a hernia repair or they had a hernia and they were offered that. So I’m not a big fan of it because most of the patients that I see in the United States are offered that too early or without exhaustive approach to reduce their chronic pain.

Speaker 1 (49:00):

Let’s see. Some more questions. Good day. What I would like to know, what is the difference between hernia, plastic, Mesh material and vaginal plastic Mesh material? There is always this division. Okay, so happy to answer that. From my understanding, the Mesh that was used for transvaginal hernia repairs were all polypropylene based, and it’s unclear if they were all what we call lightweight polypropylene or medium weight polypropylene. I believe they were not heavyweight for hernia repairs. We do have polypropylene meshes. They come in lightweight, medium weight heavyweight and ultra lightweight. We also have polyester meshes, E P T F E meshes, hybrid meshes, et cetera. But the Mesh itself is pretty much the same in concept. The companies that distribute them were different. So companies like Boston Scientific and others were never in the hernia Mesh industry, and there’s been some understanding that the Mesh that we used that they were making was not as pure as the original hernia meshes. However, there’s also some information coming out from lawsuits that perhaps the hernia meshes that are being used are also now not as pure as they were before. So the Mesh itself were very similar, but the size of the meshes and possibly the weight of the meshes were definitely different, and for sure, the space in which the meshes were placed were different.

Speaker 1 (50:51):

What is your go-to if a patient is allergic to Mesh? Depends on the allergy. If a patient is allergic to Mesh, then I don’t use Mesh. If they can have a non Mesh repair, that would my ideal option. If they absolutely need Mesh, then I would either use a biologic Mesh that is very low in inflammatory state or a hybrid Mesh, which is also low in inflammatory state. Depends on the severity and the importance of the perfectness of the hernia para in some ways, how much they actually need some type of permanency to their meshes. So many questions. I love it. I love it. Is consulting with a specialized hernia surgeon who offers multiple techniques and then choosing another surgeon who specializes in the technique that the first surgeon recommended. Always a good choice. That’s actually not a bad choice.

Speaker 1 (51:54):

Let’s say you come to me and I’m like, yeah, shouldice technique would be great, and then you go to the shouldice going to have your hernia repair. Yeah, that’s not a bad choice at all. Good question. Very, very good question. Next one. Apart from recurrences and Mesh reactions, what are the most evident cases that you have seen where a one size fits all approach determine a bad outcome that could have been avoided by tailoring the repair technique? Oh, so many of these. So basically the question is this. How often have you seen it when a surgeon does same operation over and over again on everyone, and if they had just tailored the situation for a patient, it would’ve been better. Okay, I mean, do we have all day? Basically, there are the majority of general surgeons out there. The majority of general surgeons that are not hernia specialists that do hernia repairs, 10, 15, 20% of their practice, the majority of them usually offer one type of hernia repair.

Speaker 1 (53:10):

It’s either open Lichtenstein with Mesh or it’s a laparoscopic or robotic Anglo hernia repair with Mesh or for ventral, they may just use, they have a certain technique, a certain Mesh that they use, and they’d use it for everyone. Let’s say IPOM technique, not the best choice. I’ll give you an example. Some surgeons always do what’s called IPOM. They put Mesh inside the abdomen. They do it laparoscopically. They don’t close the hole, not the best repair. If you have, let’s say Crohn’s disease or some type of inflammatory bowel disease because you don’t want Mesh there with your bowel, that’s not good thinking and not good planning because a patient with Crohn’s disease is different situation than a patient without Crohn’s disease. You can have inflammation of your intestine erosion fistulas and infections as a result of placing Mesh inside the abdomen that you would not have if you did not have Crohn’s disease. That’s a perfect example.

Speaker 1 (54:09):

So that’s kind of where I’m at. There’s a lot of surgeons that offer the same operation for everyone. I would say the majority, I want to say maybe over 75% of surgeons will do that, which is why I say you need to see more than one surgeon. There are reasons why I tell you this, people, I’m not just making your life more difficult. Most general surgeons do the same operation and they’ve probably been doing the same operation for years and have not changed it. The majority of their patients do well. There’s no indication they have to change what they’re doing. If a patient doesn’t do well, they blame the patient, and that’s the way it is. And we don’t have data to say that you must for sure tailor it to X, Y, and Z for this certain type of patient. We just don’t have that kind of data.

Speaker 1 (54:59):

So there’s no impetus for these surgeons to change what they’re doing. We don’t have the data to support it, and they can claim that their patients do just fine, which is why you need to see more than one surgeon and more than one area and go from there. Here’s another question. Did many of the many athletes you mentioned have sports hernia misnomer rather than traditional hernia? And did you treat them right? So they all had actual hernias. a lot of people where their hernias are not visible are told they have sports hernia because people don’t understand you can have a hernia without it being a big bulging mass. And so if the patient has pain without the bulge in the groin, people call it a S sports hernia completely wrong. It’s an actual angle hernia, and I treat them that way, but some of them, okay, who here’s the N B A fan? Because as you know, LeBron James, one of my favorite, just lives down the street here.

Speaker 1 (56:09):

Lakers, one of my favorite Lakers players. He’s been having a lot of growing pain and it comes and goes, and he’s getting injections and physical therapy for it, has not had surgery for it. My gut feeling is he probably just does have a sports hernia, which is just a misnomer. It’s really an athletic injury. However, I really do want to see if he has a hernia, like a real occult hernia that I can fix because if he does, then he may not need all these times off while he’s playing. I can just fix his hernia like I fixed other teammates of his and have them back at the game and winning championships. So LeBron James, if you’re watching this, just send me your MRI. I don’t even have to see you. Send me your MRI. Let me look at it. Let me see if you have a hernia that’s been missed by all of the specialists around you, because I mean, of course, I would love to meet you in person. I would love to be able to examine you and hear your story. I’ll wear my Lakers outfit for you, but it would be great to know if there’s a component of an occult inguinal hernia in his situation in addition to his, well, he probably has, which is a sports hernia. So yeah, I’m sure LeBron is watching this. He’s probably a big fan and has watched all hundred 50th.

Speaker 1 (57:42):

If he has, he knows this is not the first time I’ve mentioned him because I do want to help my Lakers team. I do want to help my Lakers team. You understand? I’ve been watching the Lakers since I was a kid, since Kareem Abdul-Jabbar time. I go to Lakers games. I have Lakers outfits. I’m a big fan and I love my team and I love LeBron and what he’s doing for our team, and I hope they win championship this year, but if they don’t, I still love them. Anyway, that’s a little bit insight into me, my personal life.

Speaker 1 (58:25):

On that note, someone said I should do one of those, like sit down with Towfigh and get to know her situations. So if you think that’ll be fun, I’m happy to share some of my life with you, but I’m usually someone that just likes to talk about hernias. So on that note, welcome and thank you everyone for watching and asking all your questions on Hernia, Talk. Live. We had a great hour with you. Thank you for joining me. My name is Dr. Shirin Towfigh. Please do follow me on Twitter and Instagram at hernia doc. Facebook at Dr. Towfigh YouTube at Hernia doc. And don’t forget, subscribe, subscribe, subscribe to the Hernia Talk Live podcast. It’s called Hernia Talk Live podcast. It’s on Apple Podcast, Spotify, wherever you listen to your podcast. And on that note, I will see you all next week. Thanks everyone. Have a great rest of your evening. Bye.

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