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Speaker 1 (00:00):
Good evening everyone. It’s Dr. Towfigh. Welcome to Hernia Talk Live. My weekly session with you all talking about everything related to hernias. My name is Dr. Shirin Towfigh, you know me as your hernia and laparoscopic surgery specialist. Thank you for following me on Twitter and Instagram at hernia doc. Today we’re joined live as a Facebook live at Dr. Towfigh and on Zoom. So thanks everyone for joining me. And as always, at the end of the hour, I will make sure that this session can be found along with all my other hernia talk sessions on my YouTube channel. So I just want to say hi and welcome to everyone. Today’s topic will be to discuss the different online patient resources that are available to you. And in doing so, many of you have kind of shared with me what you like and what you don’t like about different resources and the pros and cons of the other ones.
Speaker 1 (01:06):
So we will be reviewing that and sharing that today was a long or day for me, so it was very highly successful. My did really, really well. But I must say these long operations are really bad on one’s back as a surgeon. So after this I’m going to go stretch out and hydrate because we don’t get to eat or drink during surgery. And I’ve been on my feet since 7:00 AM this morning and it’s already 4:30 PM so I’m happy to be sitting down talking to you guys, answering your questions and reviewing all the different resources that are available to you on hernias. So before I started hernia talk.com, Dr. Goodyear, many of you, we know him. Dr. Goodyear was a surgeon who practiced in Pennsylvania. He’s since retired, but he had a website and the website was very simple. It was, I don’t even remember what it was called.
Speaker 1 (02:13):
I think it was the Pennsylvania Hernia Surgery Center, something like that. And he had a very simple website and whoever made his website added a very basic forum to discuss things. This was before blog blogging and it was before social media, so it became a really, really popular thing to do. And Dr. James Goodyear, great guy, really nice simple surgeries. He didn’t offer laparoscopic surgery, he just did outpatient inguinal hernia repairs. And he was instrumental in taking time and answering patients questions. So I would go on that actually, and I would read about patients questions. And for me as a surgeon, it was very insightful because I never had an opportunity before to ask patients like, oh, what are you interested in? Or what are your question? What? What’s bothering you? But these forums allowed the patients to express that without judgment, without really knowing who you are kind of anonymously.
Speaker 1 (03:29):
And in doing so, a lot of topics came up. There were questions about different surgeons, different surgical techniques, outcomes and so on. And some people became kind of well known in that forum and were well known as advocates in the hernia world, patient advocates. So towards the end of Dr. Goodyear’s tenure and while right before he retired, I worked with him and said, Hey, let’s come up with this new website. It’ll be more modern, more advanced, searchable. You can have multiple threads and posts and so on, and we’ll try and get it to work out. And then he retired. So he was the kind of impetus and a lovely, lovely surgeon who shared patients with me for hernia surgery. And now we have hernia talk.com, which has been in public as a free patient discussion forum on any topic you want. Hernia related since 2013.
Speaker 1 (04:48):
So nine years and thousands and thousands of people have logged on, many are active on it, many are what they call lurks where you’re just kind of hanging out and reading. It’s been a nice forum and I’m hoping to continue to, it’s gone through several stages. I’m hoping to continue to advance it and make it more user friendly as the time goes by. So that’s kind of what I wanted to share with you from my end. I also have my own website, the beverlyhillsherniacenter.com, which is with of information. I’ve had people actually copy paste the stuff on my website, on their website, and some of them I know personally and I’m like, call them up. Hey listen, maybe call up your social media person, whoever made your website because you basically took exactly what I wrote and then paste it into your website.
Speaker 1 (05:51):
That’s not cool. You can be a little bit more innovative. I always talk to you about American Hernia Society website. So it’s americanherniasociety.org. It is a website primarily intended for our surgeons as a society surgeons who are interested in hernias, but they do have what’s called a find a surgeon dropdown. And again, they’re also help planning on improving and updating that their website. But if you go on that website, you can see surgeons who are members of the A H S or the American Attorney Society. Why is that important? Because theoretically, if you are a member, then you’re showing an interest in hernias, which differentiates you from the average general surgeon who dabbles in hernia surgery. So I often say, if you’re looking for a surgeon, let’s say in your town or your country, first, go to my website or hernia talk.com and search your under the search, go search for your country or town or state.
Speaker 1 (07:03):
But in addition, go to the Americanherniasociety.org website under the find a Surgeon tab and search under this your specific state. Know that the American Hernia Society is a American society, which means North America, central America, south America. So all those countries should be included in your search if you wish. And then of course, other things I would recommend when you are seeing a surgeon is to make sure they are qualified at least by the basic standards. So one would be to go the American Board of Medical Specialties websites a abms.org. So the American Board of Medical Specialties website has a check your check to see if your doctor is board certified section. And what you want to do is make sure that your surgeon is board certified in general surgery. You don’t want a cardiac surgeon doing your hernia repair. You don’t want anyone that’s not board certified to do your hernia repair because it implies that they are not meaning the minimum qualifications to be a general surgeon.
Speaker 1 (08:26):
So that’s abms.org or American Board of Medical Specialties website. There’s also the American College of Surgeons. They’re at facs.org. So the American College of Surgeons is the largest organization of surgeons in the world. We are all members of it. It’s there’s a special designation to be what’s called a fellow of the American College of Surgeons or facs. And so the website is facs.org and you can look up to see if your surgeon is a fellow of the American College of Surgeons. Why is that important? There are a lot of people that are not fellows, but you cannot become a fellow unless you go through a process of applying meeting minimum criteria in terms of your practice and you’re not a criminal, et cetera. And then also you need to have letters from your peers supporting your kind of standing within the community. And then you have to go through an interview to make sure you’re not crazy. And then you can get your F A C S and you can only be eligible for FACS after having been in practice for a couple years. So I think it’s important to find a surgeon who’s F A C S.
Speaker 1 (09:55):
Not all surgeons are F A C S, however, there’s also the Society of American Gastrointestinal and Endoscopic Surgeons or Sages, S A G E s sages.org is the website for that society. Similar to the American College of Surgeons, it is the largest society of laparoscopic or robotic surgeons in the world, which means that the surgeons that are stages members most likely are gifted or at least interested in laparoscopic or minimally invasive surgery. So that involves laparoscopic surgery or robotic surgery. And similar to the other websites, both the facs.org, American College of Surgeon website and the American Hernia Society website. If you go to the sages website, sages.org, then you could also look to see if your surgeon is a member. So in general, if you have a surgeon who is facs, a Sages member, a h s member board certified, then each with each of those, you’re like moving up higher in the rung of surgeons and their interest in quality care, evidence-based care involvement in education and knowledge. What I see sometimes is we have perfectly, perfectly good surgeons in the community that have no interest to learn or advance, and they’re doing the same thing that they’ve done since residency. And that residency may have been 15 years ago or 30 years ago. And we’ve learned a lot in the past 15 to 30 years. So I see mistakes made, not because they’re a bad surgeon, but they just didn’t know that we just don’t do that anymore. I’ll give you an example.
Speaker 1 (11:56):
Mesh plug and patch should not be done anymore. It’s one of those things that we know it’s, it’s too, too much Mesh, too much risk of chronic pain, especially testicular pain in men. And there’s other ways of doing operations. There’s really no need. Laparoscopic repair with a keyhole. Mesh used to be done. And we don’t do it anymore. It’s a different, we do it without a keyhole Mesh anymore, just a flat Mesh. And people that still use the keyhole are older techniques that they should have abandoned because they’re a complication with it. Phasix Mesh, the prolene hernia system or the on step, these are all thick meshes that are likely to are more than average, likely to cause problems. So again, if you go to these meetings, you’ll see that we’re going to be discussing it. And in fact, I just finished the outline for next sage’s meeting, which I’ll be chairing the session on everything you wanted to know about hernia repairs, what you were afraid to ask, and that it’s going to be a great talk because we’re going to go through every one of those little things that you know were taught, but you should be kind of untaught by now.
Speaker 1 (13:19):
So that’s kind of like my 2 cents about doing your research on doctors. I just took out some Mesh today and a lady, and I’m telling you, first of all, she had a Mesh infection. So that Mesh infection went undiagnosed for, I’m going to say three years. Three years. She was having S four out of her belly button. No one thought maybe it’s because your Mesh is infected. She kept getting CAT scan after CAT scan, which showed the Mesh infection, but it was interpreted as just postoperative changes, maybe a fluid collection but not correlate it with the Mesh deep to her. And all she needed was her Mesh remove, which I did today. But in doing so, I found close to 50 tax, and I’m not even exaggerating, I kind of lost count, but each one of the attackers has 20 to 25 tax, so they had to go through at least two different attackers, which is unheard of.
Speaker 1 (14:25):
And even my resident was commenting, what the hell? There’s a tack here and there’s attack right on top of it. What you didn’t trust the first attack. And it’s kind of fun removing Mesh and removing tacks from a surgeons standpoint. And the patients do very, very well. But we were getting tired of how much freaking tax do I have a takeout? This is crazy. And studies have shown that if the tax are safe to use, but overuse is not appropriate, and the more tax you have in place, the higher the risk of chronic pain. So of course she did have a lot of pain and plus she had this Mesh infection. So that’s if you were a surgeon that went to meetings, you would know this. But if you don’t read and you don’t go to societies and you’re not being held to higher standards through all these different societies, board certification, et cetera, then you may not be as inquisitive by nature and not maybe looking to meet a higher standard and therefore maybe offering your patients care that for some reason is not as optimal as it can be.
Speaker 1 (15:46):
And going back to talking about keyhole. So for Mesh repairs, for the inguinal hernia and for some stonewall hernias, parastomal hernias, which I did one today as well, what you do is you cut a hole in the Mesh and you a slit in the Mesh and you wrap either the stoma or the spermatic cord in males for inguinal hernias with the Mesh. You wrap the that area with the Mesh. We do that routinely for open inguinal hernia pairs with Mesh. That’s the only way you can do it. However laparoscopically, when we first went from open to laparoscopic surgery because everyone was doing keyhole meshes open, they assumed they also had to do the keyhole Mesh laparoscopically until it was then proved not necessary and actually more harmful with a high risk of recurrence and a high risk of chronic pain to do it laparoscopically as a keyhole.
Speaker 1 (16:48):
So we don’t even do that anymore. Some people still do, and I think it’s, it’s not the best choice. Here’s a question. Two months ago I had surgery for an incisional hernia. After the surgery, I was extremely bloated, very much happened. I almost look like I swallowed a cantaloupe can’t happen. How long does it take for the swelling to go on? What can I do to help it reduce faster? So the swelling from abdominal wall hernias, especially incisional or umbilical hernia, is related number one to the technique and number two to your body’s reaction to that technique. So it’s not uncommon to feel bloated. Two months seems a bit much. Usually after the first three weeks to a month, all the bloating just go away. So if you want to double check with your doctor that there was no bowel involved or did they put the Mesh against intestine or do you have a seroma, a fluid collection that makes it look like you’re bloated? Those are things to look for at two months. At two months, you should not have that much bloating. There may be other reasons for it.
Speaker 1 (18:03):
All right, couple things that also I want to tell you. So there was also a question about websites to go to learn more. So whenever I want to learn more about hernias, I go to Google Scholar or you can do PubMed. I prefer Google Scholar. And I actually research papers that are peer reviewed, published, and based on my background, I’m really, really good at reading papers and determining if a paper is high quality scientifically. So there are papers that are published that have like 10 patients in it, and then they make these sweeping recommendations for people to change what they’re doing based on 10 patients. And that’s just crazy. You need to be much more restrained when you write papers like that. And when it undergoes peer review, your peer reviewers should be holding you accountable for the conclusions that you make based on your data.
Speaker 1 (19:08):
There’s actually a question here I want to share with you all regarding that because I thought it was very insightful. It was sent in. Here it is. It says, apart from your sessions, hernia talk forum, Google Scholar and PubMed, what online resources would you recommend to patients who want to gain a better understanding of hernia related topics? Okay, so there aren’t that much actual websites dedicated to educating hernias. A handful of us have really educational, have really educational websites. I think mine’s very educational. The Beverly Hills for new center.com, there are books you can read, but I don’t think anyone wants to read a book. Most people prefer a website. The Mayo Clinic and Cleveland Clinic themselves have really good basic websites that discuss hernias. I would say for non hernia stuff like pelvic floor, the Pelvic Guru and the International Pelvic Pain Society, and the Pelvic Pain and Rehabilitation Center. I’ll have really good websites that talk about non hernia stuff, but mostly pelvic floor. Again, that’s Pelvic Guru, the Pelvic Pain and Rehabilitation Center and the International Pelvic Pain Society. But the rest is to go through Google Scholar and PubMed. And let’s go through that question that was presented about that real quick.
Speaker 1 (20:50):
As a patient, how can you evaluate the trustworthiness of a study found online? Are the number of citations, the number of patients involved in the study and the study data reliable indicators? That’s a really good question. So I have friends that you’re like, oh, on TikTok, I read about that. I heard that we should do X, Y, and Z. That’s not usually evidence-based information. When you read Google Scholar or PubMed, then much of what’s on there is peer reviewed articles. That doesn’t mean all of it is true. There is a growing number of non peer reviewed journals where doctors have to pay to get published, which I don’t do, but there’s it. It’s becoming more popular. Some of them are peer reviewed, but they’re not usually as rigorously peer reviewed. If something is published in a highly, what’s the right term? Highly like sought after journal, you usually consider that stronger paper.
Speaker 1 (22:02):
Then one that’s in a lower level her journal. So if you are interested, you can go to on Google for example, and search for impact factor. So every journal has an assigned impact factor and the impact factor is a function of the quality of the papers. So how many of the papers are prospective randomized clinical trials and how often are the papers in that journal cited again by other journals that shows or other studies that shows a strength of the journal and implies the strength of the papers they accept. So for example, some of the journals we submit to, they only accept about seven to 12% of the articles submitted and others it’s higher. So the Journal of the American College of Surgeons are JAMA Surgery very well, very good impact factors, for example, and I like to publish mostly in those. The number of citations of the paper is usually a good idea of how strong the paper is. The number of citations within the article, number of references is not a good idea. And then the number of patients involved in this study is also very important.
Speaker 1 (23:30):
And where do these patients come from? So for example, when I write papers, I talk about my own database of patients and it’s not going to be 10,000 patients because I’m just one surgeon where however, I have really, really good deep dive data for my hundreds of patients for a certain paper. So that’s important is how much data is reliable. But there’s also what we call population studies. So population studies could be like the Swedish hernia database or the Danish database patient database where the entire country has data on everyone who gets care in that country. And most people in Sweden and Denmark don’t travel outside the country, so they don’t tend to lose a lot of patients from their database. So they have 10, 20, 30 years of studies on a lot of these, including hernias. However, the amount of data they have per patient is very minimal.
Speaker 1 (24:31):
They have data birth type of surgery, et cetera, but they may not have, do they have testicular pain as a factor? Whereas in my database they would. So when looking at those population databases, you tend to get larger number of patients, which is good, but not as much depth in data. So for example, we have the ACHQC, the, sorry, abdominal core health quality Collaborative. And you can go, actually that’s a good website. The ACHQC dot org stands for the abdominal core health quality Collaborative dot org. They have a great website where you can learn about different exercise. There’s a patient section. So the patient section explains what they do for you and also has exercises that are found to be safe for people with hernias. But they have about 400 I think surgeons that are members. I’m one of them. And we all input our data into that database and it gets followed for the lifetime of the patient.
Speaker 1 (25:44):
And theoretically you can write papers using those, that patient database. But for example, you may have a patient database that says, okay, like the average pain for a laparoscopic hernia repair two weeks out is let’s say three out of 10, but you can’t tell if that’s three out of 10 pain because they also had hip pain or back pain, or is it three out of 10 pain from actually their hernias like hard to be able to tease those things up. So you know, want to read a lot of these papers with that kind of granularity. Here’s some questions. Can bilateral no meshing or hernia surgery or inguinal recurrent hernia cause urinary and pelvic floor issues in women, of course, when we’ve discussed this multiple, multiple times on hernia talk discussion, live q and a, which is our current weekly session, we’ve had pelvic floor specialists, both surgeons and non-surgeons, pelvic floor physical therapists.
Speaker 1 (26:54):
Come on here and discuss that. If you go into my link tree, which is actually go to my Instagram page, and I have a couple webinars where I’ve discussed this in detail. So yes, inguinal hernias, which are groin hernias in men or women can contribute to pelvic floor spasm. And the pelvic floor spasm can cause testicular pain, vaginal pain, urinary frequency, urinary urgency, painful urination per rectal pain, pudendal, Neuralgia type symptoms, pain with sex, pain with intercourse, pain with orgasm. So those are all pelvic floor related, but your pelvic floor is normal, it’s just in spasm because of the hernia and you fix the hernia and the pelvic floor spasm goes away. And that’s something that I’ve noticed over the years. It’s not very well published. I publish in all the chapters I’ve written about hernias and atypical symptoms, but it’s something that is very, very interesting.
Speaker 1 (28:01):
I think I had one patient from Canada and she would wake up almost 10 times a night just to go to urinate and that was, and I fixed her hernia and then that got cured. That’s an extreme example, but that’s kind of that correlation between hernia and fellow four. Next question. I have a large incisional hernia on my left side and back from a thoracic fusion. Okay, so that’s usually it’s a left-sided x lift or trans psoas approach. And then sounds like also back from a thoracic fusion is debilitating and robs me of my core strength. I’ve seen two surgeons that both say there’s no way to repair this as there’s no place to attach the Mesh in that area. Are there procedures that can help me? And if so, how do I find a doctor that does ’em? Okay, that’s ridiculous. All those, the hernias can be repaired, I repair them. The thoracic is a little bit challenging because you, it’s over the Rives and sometimes they actually remove Rives as part of it in the lower thoracic. But yeah, no, absolutely, we fix it all the time. So I’m happy to see if you want to just contact my office. We actually have the only paper published on incisional hernias after flank approach for spinal surgery.
Speaker 1 (29:38):
Let’s see, I’m a California Kaiser patient. Kaiser two weeks out from surgery after open left Inguinal hernia repair with Mesh. How old are you? Because open repair with Mesh, I tend to do that only for older patients. Otherwise, laparoscopic repair is so much better. What questions or concerns should I be asking? My 31 year experience surgeon two weeks out from open left lung surgery to be done with much. Okay, so in two weeks you’ll be having surgery and you’re a 58 years old. So if you’re a healthy 58 year old and you’re active, you should be asking your surgeon why that surgeon is not offering you laparoscopic surgery with Mesh. Because the recovery, the short-term outcomes, the long-term outcomes would be best for that. Open repair with Mesh is fine. The chronic pain rate is significantly higher than all other options for inguinal hernia repair. The recurrence rates good though if done by a specialist. The other question I would ask is how often and how many of these does a surgeon do? If it’s Kaiser Permanente, it’s a general surgeon, probably a lot. Then the question is, okay, maybe you as a 31 year experienced surgeon do not prefer laparoscopic repair or do not do as much laparoscopic repair. Can I be referred to a surgeon in Kaiser Permanente and which there are plenty to get a consultation for my feasibility to undergo laparoscopic repair?
Speaker 1 (31:33):
What about the Mesh? Yeah, the Mesh is appropriate usually for our 58 year old male. For Inguinal hernia, Mesh is typically appropriate. I prefer non Mesh repair for patients such as women or really, really young or really really thin patients. So if they do laparoscopic, you have to ask them why they’re not offering you the laparoscopic approach because that’s, that would be a better repair for you. I would ask them specifically why they recommended open surgery and not laparoscopic. It may be because that’s what they do and that’s a preferred operation, in which case a laparoscopic a surgeon whose preferred operations laparoscopic would be better.
Speaker 1 (32:29):
Okay, thank you Doctor, you have brought tears of happiness my eye. I will contact your office. Oh, with about the flying hernia? Oh yeah, yeah, yeah. We have the largest experience in that, unfortunately, mostly because of the large number of spine surgery that’s done in Los Angeles. It’s ridiculous. Going back to the Inguinal hernia repair with Mesh, anyone who tells you that an open repair with Mesh has less complications, is not doing a lot of laparoscopic hernia repairs. So now there may be certain circumstances where you’re not a good candidate for lap laparoscopic surgery. Maybe you have bad heart or bad lungs, maybe general anesthesia is not good for you. We have end stage liver disease or open prostatectomy. Those are all relative contraindications to doing laparoscopic surgery for inguinal hernias. But if they’re telling you there’s less complications in open surgery, compare laparoscopic, then maybe in their hands it’s less complications.
Speaker 1 (33:37):
But in an expert’s hand there should not be. And there are definitely great surgeons in the Kaiser Permanente system that offer excellent laparoscopic hernia pairs with mush. And that’s what I would recommend for you if it were me. Let’s see. Can you discuss the concept of closing the external superficial ring of the inguinal canal in an open hernia repair? What would the symptoms and clinical consequences be of not adequately closing this ring? Okay, so we don’t close the external ring. It’s not part of the hernia repair. We do close the internal ring. So the internal ring is the actual ring. Sorry, I’m, I’m going to restate what I said because everything I said was incorrect. Okay, rephrasing, it’s been a long day regarding closing the external ring. So the inguinal canal is like a tunnel and the tunnel has an opening on one end and an opening, like an entry and exit point.
Speaker 1 (34:38):
So for your hernia and enters the internal ring and exits to the external ring, if that makes sense. The internal ring is the only area of importance. So what we do for hernia repairs for patients is in is patch for males. We patch the internal ring with Mesh for tissue repairs. We close the internal ring as much as possible around this spermatic cord for men and for women. We close the internal ring in tissue repairs or patch it for Mesh repairs. So that’s the internal ring. The external ring is of zero consequence, so, so the external ring is never closed. It’s technically no longer kind of an external ring If you patch it with Mesh because that canal is basically closed off at the entrance, it doesn’t matter if you close the entrance, it doesn’t matter if the exit is open. Does that make sense?
Speaker 1 (35:44):
So there’s no consequences toward adequate external ring closure. I hope that’s helpful. It’s kind of a weird question. I’m curious why anyone would talk to you about external ring. Let’s see. Do the patient with a rare flank hernia contact Dr. Toy’s office for sure. They will give you hope and offer you the best chance of fixing your rare problem. Thank you very much. That was very nice of you to say. Okay, let’s go to your next question. Regarding hernias, what are for a patient the most dangerous kinds of misinformation found online and how do you identify them? Okay, that’s really, really good. So I’m mostly an optimist and a positive thinker. And we had a great hernia talk session several months ago where we talked about the power of positivity to the point where patients actually who have cancer diagnoses are more likely to live longer if they’re positive about their approach to life and lifespan is considered to be longer in those that are positive thinkers.
Speaker 1 (36:59):
So what I don’t like is a lot of negativity online and there on hernia talk, there’s currently a handful of contributors that are very, very negative to the point of name calling, which I don’t like. And sometime I have to moderate because something happened to them and now they feel like everyone is at fault and everyone is a horrible doctor because they had a poor outcome. The same is true for the Facebook groups for the most part, the majority of the Facebook groups are excellent for patients who require help. Almost every Facebook group is somehow focused on patients who need support. It’s more of a support group, which implies that there’s something wrong. Either you have pain from your hernia, you need guidance or you had a bad complication. Most people do not go on the support group to say how wonderful their hernia repair was.
Speaker 1 (38:09):
And so they tend to be a bit on the negative side. And actually I published on this because we surveyed all the public Facebook opportunities and Twitter discussions on hernias and it’s mostly very negative. So what I don’t like is for people to go on social media, typically Facebook support groups, and sometimes on Twitter to give out misinformation. So I’ll give you an example on Twitter, most of the active people are either lawyers or law firms that are affiliated with these class action lawsuits against Mesh or they are Mesh victims groups, Mesh v Mesh, victim groups. They tend to be very angry and very negative and it’s very difficult to have a conversation focused on just facts because there’s so much emotion involved in it.
Speaker 1 (39:17):
I’ve engaged multiple times and often regretted doing so because most of the people that are there unfortunately are not interested in discussing alternatives or providing advice. It, it’s mostly intended for them as an outlet to express their frustration, which is fine, but just know that in doing so, there’s a lot of misinformation. And so I think similar to reading the news, you should read it from different outlets. And so regarding hernias, you should also research and read different outlets. So it should be websites, books, discussion forums, support groups, your doctor wide variety of voids to do that. Okay, going back to the external ring again, what about if it was pure tissue based repair with no Mesh? Same. So the tissue repair is also based on closing or narrowing the internal ring, not the external ring. The external ring has to do with the external oblique epi neurosis. And that is always closed as part of either an open Mesh or an open or a laparoscopic, sorry, open Mesh or open non Mesh angle hernia repair, mostly to reduce swelling and bleeding has nothing to do with the hernia repair itself. Alright, what is your fee for laparoscopic or hernia repair? You’d have to call my office for that because it depends on the actual surgery, different codes as well as your insurer, whether you’re cashed and so on. So we work with our biller for that.
Speaker 1 (41:25):
Alright, for Kaiser Permanente, we actually have a contract with them, but it’s only to repair or rerepair. Undo revise patients who’ve undergone hernia repair after they’ve exhausted all opportunities to get care in the Kaiser Permanente system. So for a simple, straightforward al hernia repair, most likely you would not be a candidate for that. So you can contact my office directly to get all that information. Okay, here’s another one. You previously said that regarding Mesh, the number of complaints found on social media is not representative of the magnitude of the problem as only the very strict minority of patients i e those who experience a Mesh complication are more inclined to post. That’s true. However, would not these complaints still be representative of the severity of the Mesh complications and of the difficulties of fixing them when they do happen? Yes, absolutely. So I’ve never been a surgeon that says, oh, like there’s no Mesh is great.
Speaker 1 (42:26):
There’s no complication because that’s not true. And the large volumes of patients that are on social media that are expressing their frustration is exactly against these surgeons who are denying the fact that they have Mesh related complications. So yes, all surgery has complications. Mesh related complications are an additional complication with Mesh related her hernia repairs, the percentage of patients that have complications is much lower than what it seems to be based on just social media posts. So that’s what I like to kind of explain because there have been a handful of patients that come on hernia talk and man, the amount of anxiety that they have for their hernia repair is so high, they think that it’s like a hundred percent chance that they won’t be able to walk again. They’ll never have sex again. They’re going to have their testicle, they’re going to lose their testicle, they’re going to be infertile.
Speaker 1 (43:34):
I mean, it’s intense and that’s just not reality. I mean, I operate on patients every week and they do very well. The expectations should not be to see me or a hernia specialist somewhere else and to have a bad outcome. As surgeons, we just don’t operate. If there’s not a bad outcome expected, that’s not what we do. Electively emergency situations at different situations, you’re saving a life. But when it’s elective, all elective surgeries are performed in a manner to improve your quality of life for the vast majority of patients. And so we don’t offer operations to mame you.
Speaker 1 (44:20):
And anyway, so I just want to express that. Yes, absolutely. The fact that there are so many complaints is definitely representative of the risks that are intrinsic to hernia repairs, including mushroom related complications and we cannot discount it. And I feel that actually it’s because of all these patients that have gone online that have expressed their concern that finally surgeons and the Mesh industry are listening to them and changing how they approach patients and what they offer. So I think it’s a good thing that that’s what they’re doing. But I don’t like that so many people are being kind of scared or frightened of having hernia surgery. Surgical Mesh products indicated for the transvaginal repair of pelvic organ prolapse are classified as class three high risk devices and are no longer sold in the us. Why are surgical Mesh products indicate for hernia repairs still classified as class two, low to moderate risk devices.
Speaker 1 (45:40):
And what is the rationale behind this decision? So the transvaginal Mesh as well as the hernia Mesh were both classified as class two until about six or seven years ago. They’re both considered low to moderate risk class two devices because of the, basically they went to the FDA and said, look at all these complications we’re having where we’re explanting meshes, the transvaginal Mesh device as a whole, they came in, kits were considered high risk because of the place where the hernia Mesh was placed, sorry, the place where the pelvic Mesh was placed, it was against the urethra and the vagina and it was done trans vaginal through the vagina. And these are organs that are constantly moving and are very thin and delicate. And the people that chose to put these meshes in unlike general surgeons, did not seem to understand how meshes work versus the organs against, we’re putting it like for example, in general surgery.
Speaker 1 (47:00):
We don’t put it against directly against intestine and yet they were putting it directly against other organs in the pelvis. So it’s possible that hernia Mesh will be reclassified in the future as a class three or high-risk device that FDA is considering it as a possibility. And still looking into it, the European Union, the European Commission has indeed changed their classification of hernia Mesh to a high risk device. And therefore, number one, all hernia Mesh that’s implanted must be followed for the lifetime of the patient and only meshes that have prospective human data can be sold. So currently there are plenty of companies that sell Mesh that don’t have robust human data. And although they’re currently being sold in the US they cannot be sold in European in Europe. And so I believe what’s happening is the F D A in the United States is observing how this new change of the past year or two by the European Union is being rolled out and how it’s affected care.
Speaker 1 (48:24):
Because what they saw happen with the pelvic organ prolapse Mesh, the transvaginal Mesh is they did not ban it. You can still sell it, but it became such a high risk thing to do, it wasn’t worth selling anymore. So almost, almost all companies pulled out of the pelvic Mesh market, which is horrible for patients. And could you imagine if you had zero hernia meshes available in the United States? I couldn’t be able to take care of half my patients. So the problem is by changing it to a class three high risk device, there are implications as to care for patients. And if that makes it so that the patients, sorry, the companies are find at too high risk to sell hernia Mesh, they will never sell it again like they did with the pelvic Mesh. And that can put patient care in jeopardy in situations where you absolutely need Mesh.
Speaker 1 (49:30):
What are the causes of post-surgery pain and laparoscopic repair? Are the ilio inguinal ilio hypogastric and genital femoral nerves at risk? Or is it the smaller no-name nerve? Also, if there’s no fixation, what causes the pain? Is it fibrosis that encroaches the nerve? Great question. So post-surgery pain and laparoscopic repair is often related to folding of the Mesh or hernia recurrence or inappropriate placement of fixation that could be attack or suture. The ilio inguinal and ilio hypogastric nerve is almost never involved in this problem because you can’t see it from the inside. You have to, it’s on the other side of the muscle, you’re on the inside of the belly, the nerves are on the other side of the abdominal wall muscle. If you’re unlucky and you’re super thin and your surgeon pacification so deep that it goes through the full length of the muscle and catches a nerve on the other side, then you can injure the nerve. But we often don’t see that.
Speaker 1 (50:34):
So it’s not nerve related pain. Usually the general femoral nerve and the lateral femoral cutaneous nerves are both exposed as part of the dissection, but it’s often deep to a fascial layer and not injured. So unless your surgeon was very cavalier or placed the Mesh too low or dissected too deep, or put tax in inappropriate places, which is not common, those nerves also should not be injured. So in infrequent situations, the Mesh can actually get really stiff or be too thick for the patient and that’s why they have the pain. Or it can be involved with the bladder, that’s why they can have the pain. It can be too stuck to the spermatic cord or it can be placed too low and overlap with a so ass muscle and make going uphill and stairs difficult. So that’s a part of what I do, guys. I try and figure out why you have your pain and how I can help you address it.
Speaker 1 (51:36):
So for example, last week I had a gentleman who had pain. No one could figure out why he had the pain because they’re like, you don’t have a hernia. But what had happened was the Mesh was tucked in place with too many tacks. He had nine tacks, you should get maybe three or four maximum five tacks. He had nine that were inappropriately placed or replaced in areas near the lateral femoral cutaneous nerve near the [inaudible] iliac vein through the epigastric vessels, which is horrible and just shows being kind of sloppy of the surgeon. And one of the tacks had pulled away and unwound itself and it became like a sphere. And that’s probably what was causing his pain. So a lot of what we do to try to figure out your pain is problem solving. We try and figure things out. Can a recurrent inguinal hernia be repaired without Mesh again?
Speaker 1 (52:35):
And can this be done laparoscopically? Typically? No. So if you’ve already failed a tissue repair, assuming it was an appropriately done tissue repair, then a second tissue repair is not prudent because you’ll just tear even more and each time you tear, you have less and less tissue. There are some special circumstances, maybe your first repair was a tissue repair as a child and now you’re an adult. Theoretically you can have another repair done tissue or your first repair was a Marcy and now you can get a Shouldice as a follow-up. Can this be done laparoscopically? So I do offer robotic, not laparoscopic, but robotic ilio pubic tract repair, which is called ripped, R I P T. And it is a tissue repair. It is only only appropriate for small super small hernias in thin patients. So do not attempt to have it as a standard routine.
Speaker 1 (53:41):
I love your weekly show on here. Oh, thank you. Your honesty and forthcoming abundance of information is a godsend for many who tune in. Oh, I do appreciate that you tune in. I I’m actually very surprised every week anyone tunes in, but I do appreciate it. Thank you so much. I’ve had my repair, but continue to tune in because of your unbiased opinion and plethora of information really. That’s so lovely. Aw, I’m glad that you’re, I assume your hurting, your repair went fine. So I hope that maybe something that I taught led you to have a good repair. How many Mesh related longitudinal studies have been done? Many. The perception of synthetic like thousands, the perception of synthetic Mesh being the golden standard for repair is misconstrued. Not enough. People with Mesh problems share their outcomes with the F D A. That’s true. And because of that, surgeons have not been given accurate information about the efficacy of the Mesh is used.
Speaker 1 (54:41):
This is my understanding. Well, I’ll tell you this, doctor, don’t care too much about the FDA reports because anyone can report anything to the FDA. So if you have a sore throat after your hernia repair, you can report that to the FDA and say, that I think is related to the Mesh. And there’s zero follow up to say, yeah, well maybe the sore throat’s really because you have a sore throat from the surgery or from your cold and it’s not the Mesh. So just because you have a report to the FDA doesn’t really imply that it’s, it’s a real report that’s a problem with the FDA. But we have tons of research on Mesh. The best is done in, like I mentioned earlier, Denmark and Sweden because they have a, and actually Germany, because they have countrywide hernia repair database and they all use Mesh there.
Speaker 1 (55:37):
And you can see what happens at five years, 10 years, 20 years, how often do patients need Mesh removed? How many of them have chronic pain? How many of them have Mesh infections or need a second surgery? So the, that’s the best data. The data we have in the United States actually is not that good because we don’t have a nationwide database that’s mandated for hernia surgery. But even the ones we have from clinical trials, let’s say are they’re very good. So I know that people don’t want to hear that, but I’m very evidence-based. So what I’m telling you is don’t read about it. Okay, follow up from my previous question on my incisional hernia. I see this in the surgeon’s note, the patient will likely have a bulge from this large defect and a tar T A R might need to be performed if it causes him pain.
Speaker 1 (56:31):
This was discussed before the case. If this something is this end quote, is this something I should consider? I’m not in pain, just very uncomfortable. So the bulging hernia after a flank operation is going to just get worse. And even if you’re not, unless you’re old, sorry, I don’t want to be mean, but unless you’re not a good candidate to have another surgery, I do recommend you get that repaired because it’s just going to get bigger. And the bigger it gets, the more difficult it is to repair. And these are already hernias that are very difficult to repair and the outcomes are the worst, worst of all the hernia repairs that we do because of the area and the nerves and the muscles are weak there and so on. So if you’re very uncomfortable currently, you should be wearing either a binder or a compression tank top and make sure that you’re not smoking, you’re not constipated, you don’t have a chronic cough, you’re not overweight and you’re not straining for constipation, and that you’re not straining for an enlarged prostate if you’re a male, male.
Speaker 1 (57:41):
And get the hernia repaired is what I recommend because it’ll just get bigger and will actually interfere with your life more and will have, will be much more difficult operation to be performed like that. And final is, thank you for your answer. So is the alternative Mesh? Yes. Yes. If you have a hernia recurrence from tissue repair, the second alternative is a Mesh. By the way, my bilateral hernias were repaired with Bassini 18 months ago. Very good. My recurring hernias are very small and my weight is 132 pounds. Okay, so you had a hernia recurrence within 18 months. That’s the problem with tissue repairs is that you get a hernia recurrence. So our recurrence within 18 months is actually not good. So we need to make sure that every reason for why you have the recurrence besides surgical technique is controlled for cough, nicotine, weight, lifestyle, constipation and straining. And so there we go. That was a really great session, guys. I so appreciate it. That was fun. I hope you all had fun. Oh yes. And collagen disorder. Thank you. Love that. All right everyone, thank you for joining me. It was fun. We had a lot of good discussions. I forgot to talk to you
Speaker 2 (59:20):
Guys YouTube, but maybe next time on that note, go to my YouTube channel where you can watch my videos and discussions on hernia talk as a session. The links are on all my social media channels, both Twitter and Instagram and Facebook. So I’ll see you next week. We have a great guest next week, Dr. Blatnik. Can’t wait to speak with him from Washington University in St. Louis. On that note, have a great evening. Talk to you later. Bye.
