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Dr. Shirin Towfigh (00:00):
Welcome everyone to Hernia Talk. This is our live weekly session on Sunday nights This week we’re here with a lovely guest panelist, Dr. William Brown, who will be answering questions for us on inal hernias. So just that you know all of you, you can join with a question and answers on this webinar as well as on Facebook Live, which it should be streaming, and then what we’ll do is post it on YouTube if you miss out on anything. And here we have Dr. William Brown. He is a general surgeon and hernia sports specialist. He does a lot of al hernias and works on sports hernias as well. And his practice is north of me, so I’m in Southern California. He’s in Northern California. Welcome Dr. Brown.
Dr. William Brown (01:03):
Thank you for inviting me.
Dr. Shirin Towfigh (01:05):
And what we’ll do is see who’s joined us already on this session and if they have any live questions, we’ll ask ’em of everyone if they have, we already have two questions. Wow. Okay. And I have a series of questions for you as well. Looks like we’re on live on Facebook as well. Okay. Are you ready for some questions, Dr. Brown?
Dr. William Brown (01:32):
Yes.
Dr. Shirin Towfigh (01:33):
I know you have hernias as much as I love hernias, so I know this will be fun and exciting. The last couple ones were super great and everyone had lots of fun and I like inguinal hernias. I think inguinal hernias are much more challenging than abdominal wall hernias. a lot of my friends do the really huge giant ventral hernias, incisional hernias, and they love that it’s very taxing on the surgeon’s body in addition to the patient’s body. But I think in terms of complexity of anatomy, anatomy for sure, the inguinal region is more complex. What are your thoughts on that?
Dr. William Brown (02:14):
There are a lot of things that you need to just be careful of. The local nerves, the various tissue layers, this traumatic cord, there’s a lot of little things that if you are careful of you can get good results, but a little lack of caution can cause some long-term problems.
Dr. Shirin Towfigh (02:32):
And what’s your thought of that? Inguinal hernias are the most common general surgical electro operations performed. We do about 800,000 a year in the United States and there are many more millions of people who have inguinal hernias that don’t get it fixed, and yet, even though it’s such a common operation, I think of all the operations we see a lot more potential for complications. What is your thought, do you think that surgeons are not taking hernias as seriously? They just think it’s a hernia. Just a hernia, fix it, it’s quick and dirty operation, move on. They don’t give it the respect that maybe we give it or is it a training issue? What do you think is going on with inguinal hernias? Why is that such a problem?
Dr. William Brown (03:22):
I agree with you. It’s a complicated anatomy, so it’s something that experience makes a big difference on or with in addition, a lot of surgeons just go and fix ’em, but there’s a lot of things you can do to prepare the patient, get their weight down, make sure they’re off smoking, make sure all the diabetes is well controlled, and then during the operation if all the tissues are handled very gently or very careful with all the nerves and then it requires a lot of care postoperatively in terms of when to get back into activities. So there’s just a lot of little steps that if are taken can get you a very, very good result. On the other hand, the surgeon just fixes anybody and sends ’em on their way, then results aren’t going to be as good.
Dr. Shirin Towfigh (04:17):
Yeah, I would have to agree with that. So you do most of your operations in open fashion, I understand, but you also see a lot of people who come in to see you after laparoscopic surgery, is that correct?
Dr. William Brown (04:33):
Yeah, so I also take care of a lot of patients who have pain after either a laparoscopic mesh repair or an open tine or plug type repair and those patients are difficult to treat. It takes a lot of care and thought and a lot of handholding, both the four and after the operation. And I wish I could say the results were perfect. I don’t think it’s very, very hard to get rid of the pain once they’ve had it for a long period of time and I feel if I can get rid of 80% of the pain that I consider that a good result.
Dr. Shirin Towfigh (05:12):
Yes, definitely. It’s complicated for all of you who are watching and listening right now. Dr. Brown practices in Northern California, he’s a hernia specialist, which really has made his name in her sports hernias and also tissue repair of anal hernias. So we do have some questions rolling in. We already have four questions live on zoom alone and if there are any on Facebook, I will answer them as well. So let’s start with our first question and that is from one of our friends who comes every week to see what each expert says about this question. So he has had a bilateral inal hernia repaired laparoscopically with polypropylene mesh and he did well, was sore from the surgery, but he’s never completely recovered, so he has sought second opinion and has done lots of physical therapy. He’s now 10 months out and he’s still not perfect. He’s still sore in the groins. What is the longest time you’ve seen a patient recover and is it too much time to wait over a year to have it addressed? Does waiting for more than a year make any revision operation more difficult?
Dr. William Brown (06:31):
As a general rule, if the patient has severe pain within a week or two after the operation, then there’s something technically wrong. A nerve has been entrapped by a staple or a suture or there’s been some trauma to the spermatic cord. If the pain comes on three or four months after surgery or longer, then it’s often related to some scarring around the mesh itself and that would often resolve with time. I encourage everybody to wait at least a year if they can put up with the pain for that long because the various studies out there show that if you wait a year, the pain will often go away. If it goes on beyond the year, then there’s various treatment options that can be are available. Nerve blocks can often be beneficial. I often will inject the mesh with some steroids to see if that’ll soften it up. The last resort would be to take the mesh out.
Dr. Shirin Towfigh (07:35):
So this gentleman seems to have soreness, which can be interpreted different ways. If the soreness is not life altering and he’s able to do his job and exercise but it’s distracting, you would allow him to wait a year before you do any extreme measures, correct?
Dr. William Brown (08:00):
That is correct. You can certainly try the injection of the mesh with some steroids. It’s fairly easy to do. You can certainly try nerve blocks that sometimes will help differentiate pain between pain that’s related to the scarring and pain that’s related to nerves. Gabapentin will sometimes help with if it’s related to the nerves, I’ve had mixed results with that, so I’m not enthusiastic with and certainly be trying.
Dr. Shirin Towfigh (08:26):
And then what if it’s more severe? So he is let’s say now 10 months out, can’t sit bending is difficult. He has children. This is a scenario I’m just putting out there that I see a lot and children or the pet wants to jump into his lap and it’s too painful. Would you still wait over a year? You think some of those will get better or do they need some earlier interventions?
Dr. William Brown (08:54):
If it is really affecting their lifestyle, they can’t function, can’t play with the kids, can’t work then I have been talked into going earlier.
Dr. Shirin Towfigh (09:06):
Okay. All right. Let’s go onto our next question with a natural tissue repair for inguinal hernia. Is a surgical technique different if it’s a direct versus an indirect hernia? That’s actually a good question also. Is the likelihood of recurrence different between a direct versus indirect? Specifically I think they’re wondering if you choose a tissue repair, are you expecting worse outcomes if it’s a direct hernia than an indirect? These are great questions.
Dr. William Brown (09:42):
The indirect hernias I find are easier to repair because most of the inguinal floors intact, unless the indirect hernia is very, very large and reducing the sac and closing the defect in the internal ring gives you very, very good results. If you’re a young male and skinny, the recurrence rate for an indirect inguinal hernia with or without meshes is the same. So there’s really no reason to use mesh in both male indirect hernia. The direct hernias, the inal floor is diffusely weakened and so you’re dealing with tissues that have been damaged over time from constipation or work or difficulty with urination. Those hernias are more difficult to repair. The tissues are not nearly as strong, so the results from an pure tissue repair is not as good with direct as it is with an indirect inguinal hernia.
Dr. Shirin Towfigh (10:48):
Yeah, so the way I explain to my patients is an indirect hernia, the hole is completely surrounded by muscle and tissue fascia, so that expands and contracts and it stretches. And so when you bring the tissues together, a tissue repair as opposed to patching the hole, which is what mesh does, that tissue is more able to move. When you go more towards the middle, the middle hernias, that’s the indirects are further out, but the directs which are more in the middle, you get closer to the bones and the ligaments and those are those you can’t move. So the muscles attached to the bone and ligaments more, they’re not as able to move. So if you have a big hole and you’re trying to bring it together with sutures, the part that’s attached to bone for example are ligaments is much harder to move. So the big hernias I think that are direct are a little, I agree that the recurrence rate is higher and I think a bit more difficult to do those with tissue repairs. Not all hernias are the same and not all hernias should be performed by tissue, like femoral hernia is another one. What do you think about tissue repairs for femoral hernias?
Dr. William Brown (12:09):
As you say around a femoral hernia, you have to deal with cooper’s ligament, which doesn’t stretch at all, but you can still get a very good repair for a femoral hernia with pure tissue, but it’s still important to get the person’s skinny. This makes the repair so much easier. So I think it’s very important to get the weight down before any pure tissue repairs, but I still do many femoral hernias with a pure tissue.
Dr. Shirin Towfigh (12:42):
All right, very good. Let’s move on to the next question. This patient has had bilateral hip FAI and labrum repairs. So FAI stands for femoral acetabular impingement. So it’s basically the lining of your hip joint is not completely intact and that hurts and tears and hurts and the bone has been traumatized and so it’s not perfectly spherical. So the patient also has an occult inguinal hernia on the left side. Remember the hip was on both sides, the hernias on the left side for several years, but I’ve not had surgery to address it yet. I also have slight chronic detachment of my rectus abdominus on both sides. That’s something Dr. Brown can definitely discuss. So this is a 31-year-old female, she’s an endurance triathlete. She’s worried about having more surgery since she’s already had her two hip surgeries and it was very difficult to recover from those. She also has swelling in her groin crease and large lymph nodes and the physician thinks this could be lymphedema after a hip surgery. Any thoughts on dealing with hernia and these connective tissue disorders? So in summary, 31-year-old high-end athlete, two hip surgeries, one on each side, and now she has a hernia on one side which is occult and occult means the hernia hurts, but it’s not a big obviously bulking bulging hernia. So small hernia that’s symptomatic. Should she consider surgery and should she be worried about having surgery under the circumstances?
Dr. William Brown (14:25):
In her situation, it’s going to be important to determine what the source of the pain truly is. She has the rectus chair hernia, she’s a distance runner, so osteous pubis can be thrown into the mix. The adductors are very nearby, so all those structures can be a source of the pain. The adductor injuries are often missed on imaging tests, so she needs a very thorough examination by someone who’s familiar with all these injuries. And then I often do what’s called diagnostic injections. So say we’re concerned about the osteous pubis or an adductor or the rectus, I often inject that with a local anesthetic and then have the athlete run around the building and see how she feels. And if she feels significantly better, then I’ll know the rectus is a component of her symptoms. If she doesn’t feel better, then we can inject the external, be around the occult hernia, have her run again and see if she feels better, and then that way localize what the source of pain is and then put together an appropriate treatment regimen for it.
Dr. Shirin Towfigh (15:37):
So I think assuming that the hip surgery was done and addressed, the hip pain, if there’s an occult hernia with no symptoms, I would leave that alone and do what we call watchful waiting. You agree?
Dr. William Brown (15:53):
Yeah. So I don’t think you need to fix anything that’s not symptomatic.
Dr. Shirin Towfigh (16:00):
And then what about if it were symptomatic? Well, you answered that the symptomatic we would repair it. So I think having had hip repair doesn’t make you a poor candidate to have or poor outcomes for inguinal hernia surgery. I think they’re unrelated understanding that hip problems can give groin pain. So what Dr. Brown said was exactly right, really we have to figure out as hernia specialists, is that pain coming from your hernia or from your hip if it’s coming from your hernia repair should be done if it’s not coming from your hernia, the fact that you just have a hernia is not reasoning enough to get a repair. Does that sound like a good summary?
Dr. William Brown (16:45):
Yeah, so it is just very important to determine what the source of the pain is and then treat that so the hernia may not be giving her any trouble. The hip certainly could still be giving her trouble. So sometimes I encourage ’em to get hip injected with the local anesthetic and then run around the building again and see how the athlete feels.
Dr. Shirin Towfigh (17:04):
And then there’s a concern that she has maybe a connective tissue disorder or a connected disorder. I don’t think these are necessarily connected. The swelling in the groin crease may or may not be from the hernia enlarged lymph nodes. We don’t really consider them enlarged, but more than one centimeter. So if you’re thin, you can feel your own lymph nodes sometimes even though they’re not abnormally enlarged and then lymphedema after hip surgery, that’s kind of stretching it. That’s a lot of lymphatic disruption and most hip surgery doesn’t involve the lymphatics.
Dr. William Brown (17:44):
I agree with you.
Dr. Shirin Towfigh (17:45):
Okay, awesome. Alright, these questions are rolling in. Let’s see, next one. This patient has had bilateral inguinal hernia repair with mesh only on one side. That side recurred, he had a shoulder ice repair with mesh still in there. Okay, so you had a hernia repair with mesh, it recurred, then he had a shouldice repair. After that the mesh is behind the rectus muscle rather than on top. Can this still be safely removed and if so, can I still have a pure tissue repair after? So this is an indirect inguinal. Hernia had a mesh repair that recurred had a shouldice on top of that and now he’s wondering if he can or should safely have the mesh removed, the retro rectus mesh. Why do you want it removed?
Dr. William Brown (18:43):
Yeah, it’d have to be removed if it’s giving trouble,
Dr. Shirin Towfigh (18:48):
Right?
Dr. William Brown (18:50):
So if the mesh has become fibrotic or one of the local nerves are involved, then the mesh can be treated. But if it’s not given any trouble, I definitely leave it in place.
Dr. Shirin Towfigh (19:05):
So I’ll just say it’s uncommon to fix a hernia recurrence from a mesh repair. It’s uncommon to fix that recurrence with a tissue repair. Does that sound right? That’s not considered. I know we do it sometimes, but it’s not considered standard.
Dr. William Brown (19:25):
Well, if it’s an indirect hernia, I certainly wouldn’t hesitate to do a pure tissue repair.
Dr. Shirin Towfigh (19:30):
So if someone had a laparoscopic hernia repair with mesh for an indirect hernia and it recurred, what options would you offer that patient?
Dr. William Brown (19:40):
So if it’s an indirect hernia and I actually did one of those last week where had a mesh repair and they must’ve missed indirect hernia, I just go back and fix it, this pure tissue repair and then if there’s mesh in there and they came back with a direct hernia, then I agree with you, it’d be which type of repair would, which require careful consideration. Occasionally I’ll put mesh in occasionally if it’s really small I might just do pure tissue repair, but having the mesh in there makes the decision making a little more difficult.
Dr. Shirin Towfigh (20:15):
Okay. I’m curious why this gentleman wants the mesh removed. If the mesh is there and not hurting you in any way, I would leave that alone. So his response is, the reason I want the mesh removed is due to pain, scratching, stiffness, burning, and a lot of inflammation.
Dr. William Brown (20:35):
So again, I certainly try conservative measures first nerve blocks if there’s a nerve component injecting the mesh with steroids. And then the last choice would be to remove the mesh either with an open incision or laparoscopic approach if the symptoms can’t be controlled with conservative measures.
Dr. Shirin Towfigh (20:59):
I agree. So if for sure those are symptoms related to the mesh and some of them do sound like it, that kind of scratchiness, we hear a lot like sandpaper inside feeling of stiffness, which can happen with the heavier weight meshes, especially in a thin patient. Then mesh removal will be something to consider. And since you already have a tissue repair anteriorly and this was meshed put in posteriorly laparoscopically, I would offer a laparoscopic or robotic mesh removal and not touch the hernia itself.
Dr. William Brown (21:35):
I agree.
Dr. Shirin Towfigh (21:36):
Alright. Here’s a question about imaging. Do you do a lot of imaging? Dr. Brown?
Dr. William Brown (21:44):
I order a lot of imaging. I don’t have an ultrasound machine or an MRI in the office.
Dr. Shirin Towfigh (21:49):
Okay. I do ultrasound in the office too. Do you order CT scans or MRIs ever for inguinal patients?
Dr. William Brown (21:58):
In most patients you can feel the hernia. a lot of people like to have imaging for documentation or they don’t trust my fingers. And then for sports hernias, I almost always order an MRI because it’s often an hip component, often an adductor component. So I want to get all the information I can before making a decision. A sports hernia, the classic hernia, I don’t necessarily do any imaging.
Dr. Shirin Towfigh (22:25):
Yeah, sports hernias are an entity on their own. They’re very complicated, so many different dimensions to look at. And a non-contrast MRI with a sports protocol, which most institutions have can really identify areas of the hip joint or the rectus abdominis or adductor muscles and where there may be associated inflammation or tears in those regions. So the question for you is, would an MRI show mesh problems? Is there a certain type of MRI that you would recommend to give the best results? I know my answer.
Dr. William Brown (23:02):
Okay. The MRI often doesn’t even see the mesh. So if there’s a big fluid collection around the mesh or an infection around the mesh, the MRI can identify those. But the MRI often is not particularly helpful in evaluating mesh. Doesn’t mean I don’t order one occasionally, but I depend on the diagnostic injections more injecting the mesh, see if the pain goes away, then I think the mesh is a source of pain. If I do nerve block in the office and the pain goes away, then I think the nerves are a major component. So I depend more on physical examination and diagnostic in the MRI.
Dr. Shirin Towfigh (23:48):
So imaging for hernias is actually something that I’m very interested in. We published a couple papers on it for MRIs. The issue with the MRIs, you need someone to be able to read it correctly. Most radiologists are not trained to read MRIs for mesh related problems. I read my own MRIs. So a non-contrast MRI with a hernia protocol or a dynamic protocol where you push out can give you a lot of information. If you have groin pain, you think it may be a hernia, it’s more likely to catch a small occult hernia than a CT scan or ultrasound by a lot. I think in our study the ultrasound was about 50/50 and CT scan it was incorrect. It was about 20-25% of the time. And then the next is if you have a mesh in place, if you do an ultrasound, often the mesh distorts your vision of what’s going on and there’s too much artifact.
(24:55):
CT scan, everything looks gray so if the groin, it’s okay for the abdominal wall but for the groin it’s such a complicated anatomy there that you really want to know how the mesh interacts with the soft tissue and the muscles and on CT it all looks the same color so it’s hard to differentiate what’s mesh and what’s not. With MRI, you can actually tweak it so that you see the mesh separate from the muscle. So usually the mesh comes out dark black and then the fat is bright white and then the soft tissue is more of a grayish color, so therefore you can tell if the mesh is folded, if it’s falling into the hernia, if there’s flu collection around it, if it’s displaced, if it’s too low, too high, too medial if it’s affecting the bladder. Those are all little things that an MRI can demonstrate.
(25:46):
So we actually have a hernia protocol for MRIs. You can go on hernia talk.com and look up hernia. Our MRI protocol or MRI hernia protocol, you can search on that website and I’ve uploaded our protocol. You can just download it and share it with any doctor or radiologist. I also have it posted on all my social media platforms. You just have to search for it. And then the protocol I believe is also on my website. If not it should be, but we published on it. So you have to do the MRI with val salvo. It’s a bare down view where you push out and I think it gives a lot of information, but I am a minimalist so I need to know exactly what’s wrong and address that problem instead of undo and redo everything. And so I really rely a lot on imaging to figure out where exactly I can figure out the problem and address it there. That’s my take on imaging.
Dr. William Brown (26:59):
Okay. No, I’ll take advantage of your protocol. I’ll download that.
Dr. Shirin Towfigh (27:03):
Yeah, it’s great. So the way we did is we wrote it as if you’re a radiologist or radiology tech. So if you just show it to the radiology tech, they can put those codes in there and give you exactly what you need because the hospitals around me, Cedar-Sinai, and a lot of the imaging centers around me already have that protocol, which is great, but the minute you drive 10 minutes out, they may look at you like, I don’t know what you’re talking about. But if you offer that additional information about the MRI hernia protocol, which again is on hernia talk.com, that’s the easiest way to find it.
(27:40):
Then you’re kind of communicating with the radiologists within their own language and it makes sense. Okay. Question about pregnant patients. There’s a lot of concern about hernias in pregnancies. I think it’s a bit more than what really is reality in pregnancy, but here is a question. What are some tips for pregnant people who have pain after femoral and inal hernia pair with mesh? As a baby grows, the pressure is getting worse. Okay, so this sounds like a lovely lady who’s already pregnant and she’s already had a mesh based femoral and inguinal hernia repair, which I’m going to presume was a retro muscular mesh, like a laparoscopic, correct me if I’m wrong. So as the baby’s growing, the pressure in the groin is getting worse for her, what do you recommend?
Dr. William Brown (28:35):
I’d like her to get through the pregnancy if she can, and then there’s a good chance that pain will resolve once the intraabdominal pressure resolves. Again, conservative measures, maybe an abdominal binder, something that provides a little bit of external support, Advil, some analgesics, heat injecting the mesh with local anesthetic would help, but it’s going to be just very temporary, so I wouldn’t put that high in my list, but I do everything I can to try to avoid removing the mesh until after the baby delivers.
Dr. Shirin Towfigh (29:14):
So I agree these are not things that would alter your pregnancy and so we usually don’t like to operate on women that are pregnant unless it’s going to either improve their lifespan, make the pregnancy go better if you have gallbladder surgery or it would improve your quality of life. Some women have so much pain that you take narcotics and then that’s not good for the baby. So that would be one indication to operate. But it sounds like in this situation, so in general, if you have any type of groin hernia repair mesh or no mesh pregnancy should not negatively affect that in that you should have a normal pregnancy with no pain. I think that’s the expectation. Do you agree Dr. Brown?
Dr. William Brown (30:04):
Yes.
Dr. Shirin Towfigh (30:05):
So if you are having pressure and it’s getting worse, you either have a hernia recurrence, your mesh is, it could be your mesh is too tight, but that area of the groin doesn’t really stretch that much. Belly button’s different but down in the groin the belly doesn’t stretch as much during pregnancy, so I would get it looked at as possible. You have other pregnancy related problems. You can have basically venous congestion, which is a well-known reason for groin pain and groin pressure during pregnancy, which is mistaken for hernias or hernia related problems. A standing ultrasound will help show any labial varis, which are basically varicose veins that you get the same way you get varicose veins in your leg. You can get it in the groin area during pregnancy because the pressure of the baby and that can mimic groin pain or groin pressure. It really shouldn’t be from your hernia repair if the hernia repair is fine. And then lastly, I’m a big fan as Dr. Brown mentioned of pregnancy belts. So pregnancy belt is made to lift the grave abdomen off of your pelvis and that helps a little bit with groin pain, groin pressure, maybe even release some of the pressure on your lymph nodes. You don’t get the swollen legs. So that’s my 2 cents on pregnancy and women.
(31:34):
Okay, these questions just come right in. Yeah, so just going back on the last patient, it was a laparoscopic tap repair, so my answers are the same. So this patient has concerns about having surgery for pain producing indirect inguinal hernia as a woman in her low thirties, a woman who wants to have children in two to five years. So there’s a young lady who’s in her fertile years, she has an indirect inguinal hernia. Should she get repaired before the kids or after the kids? She wants to have kids in about two to five years. Does it matter? What are your recommendations for the timing of inguinal hernia pair and someone who’s considering pregnancy in two to five years?
Dr. William Brown (32:25):
If the hernia is symptomatic now, then I definitely would get it repaired whenever convenient and if it’s completely asymptomatic, if she’s planning to have children, I’d probably go ahead and still repair it just so she doesn’t have trouble during the pregnancy. Once repaired the pregnancy, it shouldn’t be any complication from the pregnancy and in terms of recurrence of the hernia or anything like that.
Dr. Shirin Towfigh (32:53):
Yeah, I agree with if it’s symptomatic, you should get your hernia repaired, your inguinal hernia repaired. In general, patients who have any type of inguinal hernia repair do not have any problems during their pregnancy from that hernia repair, that part of the body does not stretch as much as the abdomen does. And so mesh or non mesh repairs do fine and if you plan on having a c-section also that doesn’t get in any way affect the c-section, the ability to them for them to do a c-section. So go ahead and do what’s best for you in terms of the hernia if you don’t have any symptoms. The reality is if you have no symptoms and you are pregnant, you probably will also not have symptoms during pregnancy either. There’s one great published study in the past five years that looked at big population study in the rate of hernia need for inguinal hernia surgery during pregnancy. I think the number was zero. If it’s not zero, it’s very close to zero. So even though people are worried about it in general for inguinal hernias, it’s I would just focus on being pregnant, having your baby. Do you have children? Dr. Brown?
Dr. William Brown (34:15):
Three and three grandchildren
Dr. Shirin Towfigh (34:18):
And two grandchildren. Oh, and do you get to see them during this pandemic?
Dr. William Brown (34:23):
Yeah, two of them live in my guest house, so I see them every day.
Dr. Shirin Towfigh (34:30):
Okay, well that’s very nice. I know so many that are disconnected from their parents or their grandparents because of this pandemic and it’s kind of sad, which is why we have zoom and FaceTime and all those things. Okay. I hope that answered your question. Here’s a question from a lovely lady who I know very dearly. So if mesh isn’t inserted robotically, does it also have to be removed robotically? Let’s talk about inguinal hernias, Dr. Brown, what’s your take on that?
Dr. William Brown (35:05):
If it’s put in robotically or any sort of laparoscopic, then removing it laparoscopically is a very, very good way to go. If there’s a hernia associated hernia recurrence, then the laparoscopic report removal and it can be repaired the same time laparoscopically or a hybrid operation where incisions made on the outside and an open repair is performed, it could also be removed openly. That’s a little more complicated. You have to go through all the abdominal wall to get to the mesh, but that also is very doable.
Dr. Shirin Towfigh (35:47):
One of the questions is we use the word mesh so widely. What are your all mesh the same and can you discuss all the different types of mesh that are out there and how they may be different and how we as surgeons think about it?
Dr. William Brown (36:06):
The one that I deal with the most is probably the plugs, which is a bolded up piece of mesh that’s kind of shoved through the hernia defect, either direct or indirect, and then it’s supposed to expand underneath, but that multiple layers of nest that make up the plug, you just get scar tissue between all those sleeves of the plug and then it turns into this big lump that is very, very painful or it can be very painful. I would advise not using the plugs at all if people can avoid people that there’s a hernia, I forgot what it’s called, but it’s a two layer mesh. That one component is foot deep to the ular ring and the other is left over the floor. And I found that that is also one is very difficult to remove and cause a lot of scar tissue
Dr. Shirin Towfigh (37:04):
PH the prolene hernia system.
Dr. William Brown (37:05):
That’s correct. So those two, if not that, most people are going to be asked what type of mesh their surgeon’s going to use. But those two, the ones that I see very commonly as giving trouble, otherwise most of the low weight meshes, the results are pretty much equal I think as far as I can tell between most of those.
Dr. Shirin Towfigh (37:30):
So what do you think about biologic mesh? Because most of the time when we say mesh, we really are talking about synthetic mesh permit, synthetic mesh. What do you think of biologic mesh and what do you think of hybrid mesh? Do you have any opinion about those two
Dr. William Brown (37:48):
Options? I’ve never had to take out a biologic mesh, so I don’t know if that’s good or bad or it just means that not too many have been put in yet and they’re relatively recent, so I don’t know anything about the long-term results of biologic meshes, but I’m hoping someday that a mesh will be developed. That doesn’t give any trouble. I just don’t know enough about the biologic meshes yet. The hybrid meshes are usually a proline mesh with some sort of absorbable surface on those and those are supposed to cause less trouble. But I have taken out several of those so I know that it’s not perfectly trouble free.
Dr. Shirin Towfigh (38:31):
Yeah, I think in the early two thousands when the first biologic mesh came out, I think it came out in 2000 AlloDerm, that was the first mesh approved for any type of hernia repair and they were marketing it as basically like stem cells for hernias. So you put this in and then your normal tissue sees this, gets all excited and transforms the biologic mesh into whatever tissue you sew it to. So if you sew it to muscle, if you sew it to fascia, it’ll be fascia. If you sew it to your brain dura, it’ll be brain dura. That was okay in the lab and that didn’t really turn out to be true in real life. It is absorbable. All biologics are absorbable and so they’ll be gone now, they may be gone in several weeks to months to years depending on the type of mesh, but because they’re gone then what we see are recurrences once they’re gone and now they even have synthetic absorbables like phasix mesh, which is cheaper to make, but they still sell it just as expensively to compete with the other biologics and that takes about two and a half years to absorb.
(39:53):
And then the hernia recurrences show up then so long-term studies on all of those are not productive. I’m a big fan of the concept of hybrid mesh, which is it’s biologic plus synthetic. So we know the good thing about synthetic is it’s permanent and so the recurrence rates are low. The bad thing is that it’s permanent and the material, it’s not common, but it could be too stiff, it’s stiff, it could be cause inflammation, et cetera. And then the biologic mesh, we know that the good thing about it is that it’s very low in inflammatory potential. So it’s basically comes from human cadaver or some type of animal cadaver tissue and it’s biologic, it’s like organic mesh, so it goes away, which is not good, but it has low inflammation. So the pain, there’s no pain or feeling of foreign body sensation with those meshes. So you put the two together, you have the low inflammatory potential of the biologic mesh and the permanence of the synthetic mesh. There’s a product that I use called oex, which is 96% biologic, 4% synthetic. And we’ve looked at our data, which hopefully will be published soon, which shows that if you’re reacting to synthetic mesh should do well with a hybrid mesh. But that’s my take on it. The common thing is there’s no perfect mesh out there
Dr. William Brown (41:45):
For sure.
Dr. Shirin Towfigh (41:46):
We’re still looking. We need something that acts just like the vascular normal muscle or fascia and don’t have that. This is a question for me. Do you offer MRI reading as a service? I do. So I have what we call an online consultation. Before this whole telehealth, I was doing a lot of online consultations. I know not everyone can fly in to Beverly Hills to see me. So if you just contact my office or DM me on any platform, I’ll get you in touch with my office. We have a whole protocol, you send us all your images, all your op reports and medical records and questionnaires, and I read all of your images again. And that’s kind of how it all started. I was doing these online consultations and then I saw that people’s images were showing hernias, but it was reported by the radiologist, normal and no hernias.
(42:43):
So they’ve like got moved on to, okay, not a hernia, let’s figure out why we have this pain. And the reality was it was just a misread imaging. So that’s why I got involved in imaging. So yes, please do contact my office and I’m happy to, I really actually, I don’t know about you, Dr. Brown. I’m like a puzzle solver. I’ve always solved puzzles. Even as a kid I would get those books with the puzzles. So I really enjoy these online consoles. It’s kind of my talk.com. But I really enjoy them because I’m trying to solve a puzzle for someone I don’t know. That’s my thing.
(43:24):
Okay, here’s a question about ventral hernias, which I’m going to skip because we have a lot of other questions and if you wish to come back next week when we have Dr. Adrales who does a lot of ventral hernias and a lot of women on hernias on women, we can answer that one. So I’m going to save this question for next week. Okay. So thank you for that question on the robotic mesh, what are the increased risks with a second mesh removal required for systemic foreign body reaction? So this patient, very complicated situation, complic, it reacts to every product that’s ever been put in her. So she has put in, meh, put, meh put in, mesh, put out. What are the risks of just having this constant cycle of mesh being removed like in the second mesh, removal more complicated than the first?
Dr. William Brown (44:24):
Well, yes, the more times you have to take on mesh out, the more difficult becomes that tissue planes are destroyed, almost impossible to find the nerves again, unless you get really retroperitoneal, it’s a little bit easier in women because you don’t have to worry about this matic cord. So the fact that she’s female’s a little bit of a plus, but still more times that she has the operation done, the more difficult it’s going to become. If she can get a pure tissue repair the next time around once the mesh is removed, that would be what I would suggest as soon as she’s seen it removed again. Is that
Dr. Shirin Towfigh (45:10):
Yeah, I think so. I think so. All. I’m going to share my screen because we have some more questions that were turned into us through Instagram and I think these are questions you’ll enjoy answering Dr. Brown. So I’m curious to know the symptoms and diagnostic process of an occult hernia as well as repairs for a cold hernias in patient in someone with a known connective tissue disorder. Okay, let me ask you this, Dr. Brown, if you have someone who has a known connective tissue disorder, let’s go extreme. As someone with Ehlers Danlos, would you offer them a tissue repair?
Dr. William Brown (45:52):
It really depends on physical examination. If the Aerus, the tissues are usually stretchy and tear very easily, but there’s various degrees. If the tissues look pretty good, I still could offer pure tissue repair. If everything is torn and every other operation they’ve had done has had trouble, then I’d probably put a mesh in.
Dr. Shirin Towfigh (46:16):
And what are the symptoms that you see in someone that may have a hernia but it’s not palpable?
Dr. William Brown (46:24):
Well, they usually have pain with any sort of activities that increase the intra-abdominal pressure. They may have some swelling. Sometimes the pain will radiate down towards the spermatic cord or testicle if there’s been some pressure on the spermatic cord. And again, ultrasound with Valsalva or your CAT scan with Valsalva, pardon me, the MRI with Valsalva might be able to evaluate, identify the occult hernia if physical examination hasn’t been successful.
Dr. Shirin Towfigh (47:03):
Okay. We are actually looking at all of that ourselves. I’m very interested in occult hernias. I’m hoping to have a very defined scoring system of different symptoms that people have that will lead you to thinking in hernias a cause of chronic pelvic pain. So stay tuned on that one. Des, if you’re on and you’re listening, you’re being held to a very high standard on this one. Okay. We already discussed imaging. Dr. Brown, do you see femoral hernias in men and is it more likely to be seen during laparoscopic or robotic surgery?
Dr. William Brown (47:41):
Femoral hernias do occur in males. It’s been several years since I’ve identified one in a male. Definitely more common in women, but inguinal hernias are more common than fal hernias in women. In terms of identifying it should be easily identified during laparoscopic or robotic operation. I think that answers the question.
Dr. Shirin Towfigh (48:10):
Yeah, I think so. In women, the international hernia guidelines are that you should always look for a femoral hernia at the time of inguinal hernia repair because of the higher incidence of femoral hernias among women. And what’s been shown is the reason why many of these women don’t do well after hernia repair is they actually had a femoral hernia that was missed. And so then they have chronic pain and no one can figure out why. And femoral hernias are risky hernias. So for women, because it’s higher risk of having femoral hernias in women than men, that hernia should always be ruled out, not so in men, when we do laparoscopic or robotic surgery, the femoral space is very easily identified and we have these nine commandments of how to have a critical view of the inguinal space. And one of ’em is to make sure we identify the femoral space and rule out a femoral hernia. So it’s much more commonly and easily identified during laparoscopic and robotic surgery. And therefore also the gold standard for a femoral hernia para is currently laparoscopic or now robotic surgery with mesh because of the, this one, I would love for you to answer Dr. Brown because we get this asked every single week, and it’s a very important question. Everyone wants to know, is it okay to work out six weeks after hernia surgery and that workout can be squats, planks, three kilogram weights, et cetera. Do you allow your patients to work out after hernia surgery?
Dr. William Brown (49:53):
Yeah, I do allow ’em to. Very easy aerobic exercise pretty much right away. If you measure tissue strength, you get about 70% of the final strength at three weeks and about 95% of the final tissue strength at six weeks. So three weeks is a good start time to start exercises and usually right around six weeks you can start pushing yourself pretty hard. I encourage everybody to listen to their body. Everybody heals at different rates. So if six weeks after surgery you’re still going upstairs, slowly have a little trouble rolling out of bed and stuff, then it just makes sense to wait longer. But if it’s six weeks, you’re bouncing out of bed and picking up all the grandkids and moving around, fine, then just go ahead and start pushing yourself.
Dr. Shirin Towfigh (50:43):
Is that true for both tissue repairs and mesh repairs for you?
Dr. William Brown (50:49):
Yes.
Dr. Shirin Towfigh (50:50):
Okay. And just to clarify, it’s a question on Facebook. I’ve been ignoring my Facebook group. I’m so sorry. Answer those questions. Do you do more natural repairs or tissue repairs than mesh repairs or what’s your practice look like?
Dr. William Brown (51:08):
Yeah, I do mostly pure tissue repairs just because I’ve mesh out so often that it just scares me to put it in. I’d hate to put it in and then had to take it out six months later or a year later. So I do mostly pure tissue repairs. I know you like the meh repairs for the femoral hernias, but I usually do a pure tissue repair for those also.
Dr. Shirin Towfigh (51:31):
Is that the McVay repair you do for those?
Dr. William Brown (51:34):
Yes.
Dr. Shirin Towfigh (51:35):
What are your thoughts on the desta? We’ve had questions about that.
Dr. William Brown (51:41):
The desarda I use is a flap of the external bleak to reinforce or usage as the only method to fix the hernia. In other words, it takes a piece of the external bleak, a neurosis and comes down and covers the hole. I don’t think that’s strong enough. So what I usually do is often do be for a direct attorney, often will do a bassini or shouldice for the floor and then use it as started on top of that to reinforce it. So I combine the two.
Dr. Shirin Towfigh (52:12):
I had a professor, he was my mentor when I was on my first job as faculty at USC. His name is Dr. Can’t believe I can recount it. So he actually trained in the fifties
(52:34):
Back when NI con and then were doing surgeries as well. And there was a technique very similar to the Desarda technique that they were employing then where we use external oblique aqua neurosis as your patch and the failure rate DR by I can’t believe Dr by who has since passed away. I’m sorry to say. So I asked him about the, and he said, oh, we did that when he was a resident and we abandoned it because the recurrence rates were so high. So from what I understand of the Desarda, historically that technique was named something else before and was abandoned because of high recurrence rate. What are your thoughts about the Desarda in terms of recurrence rates?
Dr. William Brown (53:21):
Yeah, I wouldn’t do it just to Desarda. So I usually combine it with some other tissue repair.
Dr. Shirin Towfigh (53:26):
Got it. Okay. Some patients, so one question on Facebook is what’s the consensus on using a thin strip of goretex mesh? So it’s a goretex pro light ultra mesh to help patch it as if it’s a daar, but you don’t have enough tissue for a daar. So you use a patch of goretex. Have you heard of that?
Dr. William Brown (53:51):
Yeah, there’s various goretex meshes. I haven’t been fond of the goretex meshes, they just don’t get incorporated very well, so they just kind of float around in there, even if you sew it in there. So if you’re going to get put mesh in, put prolene mesh in or something like that, I’m sure go Tex works occasionally, but I’m not a fan.
Dr. Shirin Towfigh (54:15):
So Gore-Tex mesh has been shown to shrink by 40%. So it was used for ventral hernia repairs because we didn’t have better mesh to put around bowel and then we stopped using it because there’s better products out there, but it shrinks by 40%. So it doesn’t incorporate well like Dr. Brown mentioned. So it doesn’t stick very well to the tissues partially because it doesn’t really cause much of an inflammatory reaction either. So maybe there’s a benefit there with pain, but it does shrink 40%. So if you think if I give you a shirt today and say it’ll be shrunk by 40% in six weeks, you may want to buy an exercise larger and two sizes higher because, so the same is with the mesh. So some of the shrinking complications with mesh can cause chronic pain. That’s my take on that. Everyone’s so excited about these questions.
(55:19):
Thank you so much. So we have two more minutes. I would just like to thank Dr. Brown very much. These questions are very difficult to answer if you’re not a specialist. And it kind of stumps a lot of surgeons because hernias are done by most general surgeons. But in terms of specialty, there’s maybe two dozen of us that do this as a specialty and Dr. Brown is one of them. So we’re really, really happy to have you, Dr. Brown, thank you for accepting my invitation and just as a partying, I’m going to share the screen again. This webinar will be posted on YouTube later this evening. And I will share the, share that with you on all the different social media. So you could follow me on Twitter and Instagram and Hernia Doc. Many of you’re watching me on Facebook Live. So just follow me on Facebook. I will post the YouTube extension of this if you want to watch it again, re-review it, share with wherever you wish on my YouTube channel. And just so you know, this started not only because of the pandemic and we’re all sitting at home and don’t have access to doctors readily, but I have a free patient discussion forum called www.herniatalk.com. Dr. Brown is one of the lovely surgeons that does respond to your questions and give his expertise on that forum. So please go on Hernia Talk and talk to other patients that are suffering or have questions just like you and many of us surgeons that are also on it that help answer your questions. Thank you, Dr. Brown.
Dr. William Brown (57:13):
Thank you Dr. Towfigh. I appreciate the invitation.
Dr. Shirin Towfigh (57:16):
Thank you and we will see you again next week. Dr. Gina Adrales of Johns Hopkins will be our specialist there. And thank you very much and goodbye.
