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Speaker 1 (00:00:10):
Hi everyone, it’s Dr. Towfigh. Welcome to another episode of Hernia Talk Live. We are here with you every Tuesday as hernia talk Tuesdays. I am your host, Dr. Shirin Towfigh, hernia and laparoscopic surgery specialist. Thank you for everyone who’s logging in on Facebook and joining us live as a Facebook Live. And those of you that are also on Zoom welcome, thank you also for following me on Twitter and Instagram at hernia doc. As always, you can watch this episode and all other prior episodes after the end of the show on my YouTube channel at Hernia Doc. I’m super excited about it because I feel like the YouTube channel is doing really, really well and it’s one of those things that I didn’t think I’d be doing. And here I am with my own YouTube channel and I’m really excited about it because many of you’re actually even speaking with me through the YouTube, I answer all my messages as you may know.
Speaker 1 (00:01:08):
So it’s been great. I really enjoy my interaction with you all. So thank you for all of you who follow me. I had a patient today who flew in from a different state and then he watches all of my hernia talk episodes, which is great. And his wife would say that she would run errands or whatever and then come back and there he would be on his phone or laptop, I don’t know, listening to a Hernia Talk episode of mine live on Tuesdays. So thank you for all of you who enjoy this as much as I do. As we started this during the pandemic right as it started, I think it was April, March or April, I think April of 2020, and now we are approaching our third year and it’s going to be super exciting and I love that you all find it as exciting as I do.
Speaker 1 (00:02:02):
So thank you very much. What we’ve done is we’ve had a lot of different topics and we’ve talked about hernia repairs and non hernia related stuff that may be mistaken as hernias, like gynecologic problems, urologic problems, we talked about pain management, complications and so on. So what we haven’t discussed, which I think is very important, and I feel that a lot of surgeons also don’t really think about when they do hernia surgeries, is the future of the patient after they’ve had their hernia surgery. So today we will talk about what happens if you’ve had a hernia repair. How does that affect future operations you may need? So most people, actually, I don’t know if that’s true, most people have, will have one operation, but a very large of the population will have had at least one operation during their lifetime. That could be the hernia repair, but it could be things that are also very common like appendix surgery for appendicitis or gallbladder surgery for a gallbladder problem, gallstones, acute cystitis, gallstone, pancreatitis.
Speaker 1 (00:03:20):
As you grow older, you may need a colon surgery for colon cancer, men may need their prostate removed. Women may need a ovarian removal, they may need a hysterectomy where they take out their uterus. So there’s a lot of commonly performed operations that involve the abdomen in the abdominal wall, and therefore it’s possible that your hernia surgery may adversely affect that operation. And that’s why when I do surgery on patients, I try not to go for the most extreme end stage operation because I understand that you have decades of life to go move forward and who knows what your future may be and therefore that I don’t want your hernia repair to any way adversely affect your future operations if that’s the situation. So for example, I see one of you’ve already said yes, I had gallbladder removal only a few months before the hernia occurred, so that’s when the surgery was before the hernia, right?
Speaker 1 (00:04:33):
So you need gallbladder surgery and now you have a hernia at your belly button. That’s the most common situation because your belly button was the source of the gallbladder removal or the specimen removal pro procedure, and you’re at higher risk to have a hernia at that site. So that I’m not too worried about that is what other operations affect your risk for having a hernia. And we’ve talked about incisional hernias before. We can do another episode on it in the future about specifically on incisional hernias. Mine is the reverse, which is today’s topic is the reverse. That means what happens if you commit to a hernia repair and then now you need another operation for another procedure, let’s say colon cancer or let’s say you have ruptured appendix. How is that affected by your prior hernia surgery? So I’ll tell you my tips on this because it’s something I bring up in a lot of the surgical meetings because I feel that it’s really not appropriate for the hernia surgeon to operate in a tunnel. No, we shouldn’t have tunnel vision and say, I’m going to do the best hernia repair ever, and if they need another surgery and my hernia repair is going to adversely affect another surgeon going in the belly. While it sucks to be you, I don’t believe in that and I think that’s the wrong way to think about it. I think a hernia surgeon should be more holistic and understand what they’re doing for the patient and how that affects their global kind of health, including the need for future operations. So I’ll give you an example.
Speaker 1 (00:06:33):
My pet peeve is using Mesh in really, really small hernias in the belly button. So one millimeter hernia, sorry, not one millimeter, that would be horrible. One set. Let’s do one centimeter hernia. So that’s about what’s one centimeter. It’s about less than than half an inch, right? So maybe two fifths of an inch. So if you have a small umbilical hernia, so one centimeter or less, I usually recommend a non Mesh tissue-based repair. Why? Because I feel that it’s small enough that it’s not worth the risk of putting in Mesh for the benefit of having a lower recurrence rate with Mesh. The larger the hernia, the more the risk of hernia recurrence if you don’t use Mesh. So larger hernias for sure need Mesh in almost everyone. The smaller hernias also studies show that Mesh repair is superior to non Mesh repair in terms of recurrence.
Speaker 1 (00:07:40):
Just looking straight at, like I fix, if you take two patients with one centimeter hernias in the belly button, you put Mesh in one, don’t put Mesh in the other chances are the recurrence rate risk is higher in the patient that did not get the Mesh. However, that difference is very minimal. It’s very small percentage difference. Whereas if you do the same thing for a four centimeter hernia, you try and close it without Mesh versus with Mesh, you’re talking like multiple times higher risk of recurrence. So I’ll give you an example. Let’s do an easy one three centimeter. With Mesh, the risk should probably be around nine or 10% recurrence, and without Mesh it should be around 40%. So that’s a big difference. Whereas for a one centimeter her that was for a three centimeter hernia. For a one centimeter hernia, you could argue the risk of recurrence would probably be maybe 3% with Mesh and 5% without Mesh, something like that, something very low.
Speaker 1 (00:08:50):
So not that dramatic in terms of the whole number. Now, why is that important? Because the belly button is a very important access port for a lot of operations. Almost every laparoscopic or robotic operation, almost every, so almost all, pretty much all gynecologic operations. Most urology operations, except for a handful, most four get are general surgery operation. Most colon surgeries that are done laparoscopically or robotically go through the belly button as one of their incisions. So if you need a colon cancer or diverticulitis surgery, if you have weight loss surgery or you have a hiatal hernia for acid reflux, all of those typically involve an incision at the belly button. If you need prostate surgery, uterus, hysterectomy, those all require an incision at the belly button.
Speaker 1 (00:09:54):
If you already have a hernia at that site, if you had a hernia at that site before and the surgeon chose to use Mesh, then that complicates your next laparoscopic operation for two reasons. One is you should not be going through that Mesh, so the surgeon has to work around that Mesh. Ideally, unfortunately, most surgeons are not cognizant of that. Patients may not even remember that they had a hernia repair that’s happened to me. They’re like, what’s a scar? Oh yeah, I forgot about that. Yeah, that scars from some surgery, maybe a hernia repair, I don’t remember. Then I’ll ask them, did you have Mesh put in you? I don’t know. So that’s not uncommon, and so that’s going to be important information to share with your surgeon. But let’s say it’s a savvy surgeon and they understand the implication of a hernia repair with Mesh, then when they plan your, let’s say prostatectomy surgery, they should know not to go through that Mesh, which makes your surgery slightly more complicated because now the surgeon has to work around a standard, an otherwise standard operation, and make sure they don’t go through that Mesh.
Speaker 1 (00:11:21):
Alternatively, the surgeon may be completely unaware that you have that Mesh and then they’ll put instruments through the Mesh, which is a bad decision on multiple fronts. Number one, you are now destroying a perfectly good hernia repair. Number two, you’re put punching a hole through Mesh, which will expose parts of the Mesh to the small bowel, which were not meant to be exposed if it were an intact Mesh. Number three, if you have an operation that is not sterile and many of these are not colon surgery, prostate surgery, hysterectomy are not necessarily sterile, gallbladder surgery is same, then you may now infect that Mesh and then two, three weeks later, you’ll start getting pus coming out of your belly button, and that’s the outcome of a poor decision by this newer surgeon, which could have been prevented if your small hernia did not have Mesh in it.
Speaker 1 (00:12:28):
Here’s another example of how hernia repair can affect your future surgery. So if you’ve had, let’s say you had a bad trauma, you actually had a pretty big hernia. We’re not talking small umbilical hernia, we’re talking fairly large hernia that must use Mesh, right? So if you must use Mesh, then for sure that decision will already affect future operations because in that area, because the school, the area of the Mesh should be avoided as much as possible. Now, I’ve done plenty of operations in patients back when I was doing non hernia surgery as well and taking call. I fortunately don’t really do that as much anymore, but I’ve had patients of my own where I’ve fixed their hernias, big abdominal wall hernias, let’s say. So there’s Mesh in the abdominal wall, and now they need their gallbladder out. So I’m happy to do the gallbladder surgery, but because I know where all the Mesh edges are, I specifically change my technique to move the trocars and incisions where there is no Mesh so that I don’t go through the Mesh.
Speaker 1 (00:13:48):
And I’ve taught this to other residents and faculty. And there are patients I’ve had who have had hernias and I fixed their hernias and they required a wide piece of Mesh, and now they need some type of urologic procedure. And I’ve had the urologist call me and say, would you mind coming in? And then I come in and help direct them to where it’s safest to put the trocars. And in one situation, we had to go through the Mesh and there’s ways to do it correctly and ways that to do it incorrectly. And I was there personally to make sure that the Mesh did not get infected. The Mesh, the hernia did not recur, and the whole repair was not at risk while the patient was undergoing a urologic procedure. So what I see a lot in our conferences and so on are surgeons that are really, really doing a lot of abdominal wall reconstruction in the aim of doing a very good hernia repair, let’s say.
Speaker 1 (00:14:55):
However, what they’re not doing is understanding the implication of this repair on the patient. So they’re moving a lot of tissues, they’re dissecting it, they’re putting much, much bigger meshes that is maybe necessary. Understanding that, not understanding that the end result is an abdominal wall full of Mesh and now this patient needs hysterectomy, colon surgery, has Crohn’s disease, has a perforated intestine or something of the like. And therefore the patient is at risk of now infecting not only where they need, the surgeon needs to go to cut through that Mesh, but also that entire abdominal wall is now at risk because the infection will communicate with the risk with the Mesh. And so my point is this. I think it’s very important that the planning of your hernia surgery be done with the additional little detail that you are a human being that’s going to live for another 10, 20, 30, 40, 50 years and more hopefully. And therefore you may need another operation and let’s not hinder your options in the future. A great one is a C-section. We do hernia repairs with Mesh all the time. Well, guess what? If you’re pregnant female and you need a C-section question I get asked all the time what happens with the Mesh? Fortunately, nothing fortunately, both for laparoscopic and anal hernias, a correctly done C-section where does not involve the Mesh and therefore there should be no risk at all.
Speaker 1 (00:16:58):
But there are situations with crash C-sections with these really large incisions where they feel like the Mesh may be in the way or something. And then now you have a very kind of not necessarily sterile area exposed to the Mesh and there can be risks. So it’s another reason why I’m not a big fan of using a lot of Mesh in women. Here’s a question, a very smart one, which is it the same concern if a meshes biologic, the one that dissolves or the synthetic absorbable? Very, very good question. So when we have biologic meshes or synthetic absorbable, so biologics are absorbable but non-synthetic and then pH is a synthetic absorbable brand of Mesh, theoretically they are both absorbable and assuming your surgery is one year or greater after the Mesh was implanted, it should not be a problem. So the problem with biologic meshes or and absorbable meshes in general is they’re not considered standard of care for any hernia repairs, mostly because they have a much higher recurrence rate than standard synthetic meshes.
Speaker 1 (00:18:22):
However, you’re right to point out that if you’ve had a biologic Mesh in you, then that risk is close to nil. I’ll tell you, I was involved with a clinical trial for Bard on pH Mesh before I came out in the market and they were looking at the benefit of using pH Mesh in high risk patients, so patients at a high risk of Mesh infection or Mesh related complications and what kind of patients I enrolled for that study. I enrolled patients who were at risk of needing more surgery. So perfect example, I had a patient who had small bowel tumor carcinoid tumor. So if you know anything about carcinoid tumor, it’s a very uncommon tumor, but what happens is they need sometimes more than one operation in their future. Another example would be a patient with Crohn’s disease. Unfortunately, there are subsets of patients with Crohn’s disease, which is an inflammatory bowel disease wherein they end up having need for multiple operations throughout their lifetime.
Speaker 1 (00:19:38):
While those are actually the best case cases, the best scenarios under which you should be using absorbable meshes. And that’s why I preferentially enrolled those patients of mine that had small bowel tumors, small bowel obstructions, Crohn’s disease, neuroendocrine tumors, people that would require multiple operations. I enrolled them for the study to see how they would do with this phasic synthetic absorbable Mesh. It’s not an ideal Mesh, I understood that, but I’d much rather have a non-ideal Mesh with a higher risk of recurrence, then put synthetic Mesh in somebody who I know will need another operation and potentially messing up their life because that next set of operations may require cutting through the Mesh, exposing the Mesh to harm, including infection, having the patient be in another operative area where the surgeon’s not aware of these, of how to handle an abdominal wall that has Mesh in it where they’ll just suture it like regular muscle.
Speaker 1 (00:21:00):
That doesn’t work. You have to use permanent suture when you’re closing abdominal wall that has Mesh in it because Mesh will not adhere to Mesh. You have to permanently seal that. So there’s a lot of little details that maybe I would know a general surgeon that is not a hernia specialist may not appreciate. And if you use biologic Mesh or an absorbable Mesh, synthetic absorbable or regular, that is a plus. So thank you for bringing that up. I was just thinking synthetic Mesh the whole time. Cause I so rarely use the biologic meshes, but definitely I do use the biologic meshes or the synthetic absorbables for that purpose. You also know I’ve spoken about ovitex Mesh and it is a synthetic and biologic hybrid. So it has just enough synthetic in it to prevent a high risk of recurrence, but not enough synthetic to act like osteitis for infection.
Speaker 1 (00:22:08):
So in patients that I know may need more surgery, usually these are patients with inflammatory bowel disease because that’s the most common scenario. I do preferentially use hybrid meshes because they will need surgery again in the future. And by using the hybrid Mesh, I can prevent potential risk in the future of Mesh related complications. Cause I don’t want to be that surgeon that is screwing up your future because I was a selfish surgeon that just likes to put a huge piece of Mesh in and have good outcomes in terms of recurrence. Meanwhile, you are screwed because you need now let’s say a trauma surgery and now the surgeons in there can’t deal with your bleeding because there’s all this Mesh stuck to everything. So where the Mesh is placed is also another point, which is where the Mesh is placed has to can complicate future operations.
Speaker 1 (00:23:18):
So IPOM, it’s an acronym called Intraperitoneal Onlay Mesh IPOM Mesh. We used to do a lot. That was like the first type of laparoscopic Mesh we were placing. We’ve moved away from it more. Nowadays I still use IPOM for some smaller hernias, but for the larger ones I don’t use it. And the reason is it it has a higher tendency for Intraperitoneal adhesions, which means stickiness of the intestine and the fat to the Mesh, which means the next surgeon going in there is going to have a hard problem seeing anything because everything is stuck to the Mesh. Whereas if you put the Mesh away from the insides, then you don’t have that problem. And if a surgeon needs to rapidly go in there to save your life like a trauma surgeon, then the Mesh is not adversely affecting that outcome. Here’s another hard question. Sounds like many variables need to be considered.
Speaker 1 (00:24:13):
Are all the meshes a standard size or can a surgeon cut or adjust the size? Yeah, they’re most meshes can be cut to the appropriate size. They come in various precut sizes and the size is determined by the size of the original her. The size of the Mesh is determined by the original size of the hernia as well as patient factors perhaps that may help with future surgeries. If the Mesh is smaller, well, no, because smaller Mesh is not necessarily better. So the size of the Mesh is directly related by some formula. No one’s ever figured out exactly. It’s directly related to the size of the hernia. So for example, you won’t use a four centimeter Mesh in a five centimeter hernia, right? But you also wouldn’t use a five centimeter Mesh. You’d probably use a 15 centimeter Mesh for a five centimeter hernia. So depending on the size of the defect and the risk factors of the patient, are they obese?
Speaker 1 (00:25:22):
Is this a multiply recurrent hernia? In other words, are they high risk? The higher risk the patient, the larger the size of the Mesh because the higher the recurrence rate, so the higher the size of the Mesh, the lower the recurrence rate. So some people I have seen, I literally have a patient that I’m waiting to remove Mesh on who had I think a two centimeter hernia, if I’m not mistaken, two centimeters, that’s not even one inch, that’s like seven eighths of an inch or something like that. And he has like a 14 or 18 centimeter Mesh, something ridiculous, and he is really sick from the Mesh and there is absolutely no reason to put that huge of a Mesh in a patient with a two centimeter hernia. And so that’s another story. But my point is there is some standard and smaller is not necessarily better.
Speaker 1 (00:26:22):
Let’s see. Next question. What about the consequences of open tissue repairs and how to manage complications, particularly pain for instance, in someone with pain from an open tissue repair, how often is it necessary to undo the open repair with removal of sutures? How can you determine the need to under repair and how feasible it is it to under undo the open repair may be causing pain. Okay, so there’s two different types of tissue repairs. One is for the groin. For inguinal hernias, that’s the most common type. The other one is for the abdominal wall. Usually we don’t do tissue repairs for the abdominal wall unless the hernias are small, so less than one centimeter, in some cases less than two centimeters. If you have pain from an abdominal wall hernia because it’s too tight, then you need a revision of that repair. And usually we don’t undo, sometimes we do undo the repair for the ventral hernias, the abdominal wall hernias, but what you need is like a Mesh based repair or some tissue releases to take the tension off the tissues in the groin.
Speaker 1 (00:27:31):
There’s a different situation in the groin. If you have too tight of a repair because you chose a tissue based repair and it was either done too tightly without a tissue release or you had poor tissues and so it’s tearing through the tissues, then usually a Mesh based repair will take the tension off of that tightness and help with the pain or including with that some type of tissue release. However, we don’t usually take out sutures. That’s not typically the reason, like something that helps because too tight of a tissue repair really is the pain is from it tearing. So if you put a Mesh in there, it’ll help prevent the tear.
Speaker 1 (00:28:23):
Other reasons for the pain could be that it’s entrapping a nerve or something, in which case surgery may be necessary. That’s the next question. How is the surgery to connect the abdominus rectus affected by Mesh that is in there now over one year healed as far as under the skin in the ventral area? Does that all need to be removed? Okay, so it sounds like, and correct me if I’m wrong, sounds like you have a diastasis rec dye, which is a separation of the rectus muscles and you had a typical hernia repair with Mesh in that region. So there’s Mesh there, but now someone wants to address a diastasis recti, which was not addressed with the first hernia repair.
Speaker 1 (00:29:12):
Depends on how big the original Mesh placed was, how thick the Mesh was and where the Mesh was placed. But in general, it’s a good idea to remove that Mesh and just do everything with clean tissue and then put a new Mesh if that’s a situation, especially in men, I’m not a big fan of doing tissue repairs around meshes. What happens is they, it’s too stiff and so it’s not the best. Okay. Next question. Regarding the ease of future operations, is there any difference between open and minimally invasive repair? Yeah, that’s a good question. So one question is, is it better to have a laparoscopic or minimally invasive hernia repair versus open? Does that, which one is less likely to affect future surgeries? And the other question is, should future surgeries be done laparoscopically or open? And which one is more or less affected by hernia?
Speaker 1 (00:30:17):
So let’s tackle the first question first, which is laparoscopic versus open repairs in general. In general, it doesn’t matter. So if you have a laparoscopic repair or an open repair of your hernia, if done optimally, not IPOM for example, for like a big hernia, then that decision in and of itself should not adversely affect future hernia repairs. In general, however, most people who do laparoscopic surgery for hernias are not experts and they do the IPOM and that’s that has the most negative of negative effect of all the different hernia repairs On future abdominal surgeries, we usually don’t do IPOMs for open. All those sub surgeries do that too.
Speaker 1 (00:31:18):
That’s a hard one. This is why it’s so important for people to think before they do hernia repairs and then in for inguinal as well, the laparoscopic and the open should not make a difference. There was a time when robotic surgery was done open, but laparoscopic surgery for the Inguinal hernias was starting to be done laparoscopically not open. So Inguinal hernias were done laparoscopically and prostate surgery was still being done open. There was a time when there was an overlap and there was actually a published article by one of my colleagues who was a UCLA resident prior to him being a urologist in training, I mean in practice where there were patients who could not undergo prostatectomy because there was so much invasion and inflammation of Mesh around the bladder and prostate that they couldn’t do the operation. They had to literally stop the operation or the patient bled a lot.
Speaker 1 (00:32:28):
That doesn’t happen anymore. Fortunately for two reasons. One is we’re probably doing a better job laparoscopically with our inguinal hernia repairs, but more importantly, prostatectomy, about 97% of them in the United States are done robotically and not open. So if you need to have a robotic prostatectomy done and you’ve had a hernia repair before, it’s almost never a problem. Part of the issue may be the lymph node dissection in the area may be challenging for the urologist because they’ll be Mesh overlying the area. But short of that, currently laparoscopic or hernia repairs should not adversely affect the urologist’s ability to take out the prostate usually for prostate cancer because those are done robotically. However, if it’s done in open fashion, it may be a problem because the planes are destroyed, the tissue planes between the bladder and the abdominal wall and the Mesh are all destroyed from her hernia repair.
Speaker 1 (00:33:34):
Okay, let’s go back to the prior, oh, here’s a new question. I had a two centimeter umbilical hernia repair one and a half years ago with pH. pH is the synthetic absorbable Mesh no issues, but in researching all at potential complications, should I get it removed? Oh, no. Or should I remove the remnants if it’s dissolved already? No, there’s zero need to remove any Mesh if it’s not causing any problems. I don’t know what potential complications you’ve been researching, but it’s a synthetic absorbable Mesh. It should be absorbed by 18 months. You’re already that there. Although we do see remnants of it two years or later. So I don’t know why you would even consider that. What potential complications have you been researching? Inquiry minds want to know. Next question. Apart from recurrence, what are the causes that could lead to the need for future surgery in the same area previously involved in inguinal hernia repair?
Speaker 1 (00:34:42):
And what are the chances for it to happen? So in males? So, okay, so the question is you’ve had an inguinal hernia repair, let’s say with Mesh. For males, a prostate surgery may involve the same area because if it’s done for cancer, for prostate cancer, then you need to have lymph node dissection done and the Mesh may be overlapping. The area for women, if you’re still of fertile age, a C-section may adversely be affected by the hernias repaired in the groin. However, it’s very, very uncommon, very, very uncommon, especially unless the surgeon puts way too large of a Mesh and way too much overlap in the midline, which is not considered standard.
Speaker 1 (00:35:36):
Next question one surgeon who specialized in open surgery told me that having a Mesh is not a big issue if you acquire further surgery because the Mesh can be cut and sewn back together. I mean that’s a very simplistic view of it. However, another surgeon who specializes in minimally invasive surgery told me that cutting through Mesh should be avoided whenever possible because a Mesh can easily become infected. That is much more true. So when we put Mesh in place, it’s put in sterilely and then the body grows into it and keeps it sterile. If that space is reopened, you are now exposing bacteria to the Mesh. Mesh does not have blood vessels to it, so you can have bacteria stick to it and then no matter how much antibiotics you give it, antibiotics go through your vessels, not to the Mesh but to the tissue around it, but not to the Mesh itself. So it’s very hard to treat infections.
Speaker 1 (00:36:40):
Now in terms of cutting through Mesh, some meshes you can cut through, most meshes you can cut through. What happens during the operation is you cut through the Mesh, let’s say, but now the Mesh is exposed to everything you’re doing for the next 1, 2, 3, 4, 5 hours. So it’s exposed to air. If you’re doing a bowel surgery, it’s exposed to stool and bacteria and that places an increased risk of infection. Then you close the abdominal wall and you have to close the Mesh. Mesh doesn’t stick to it to Mesh, it has to be sewn to it. So you have to use permanent suture. That’s one trick and that’s closure needs to be sterile. So everything in your power, you have to do everything in your power to prevent that area from getting infected. So the second surgeon has a more correct answer. All right, let’s going back to the viewers.
Speaker 1 (00:37:49):
It said that they have a two centimeter umbilical hernia repaired one and a half years ago with phasix, should I get it removed because of potential complications even though they have no symptoms. So the potential complications she has read about include infection, autoimmune disorders, Mesh moving and causing pain discomfort. So let’s introduce all those. So Mesh infection occurs early if you haven’t had in the first two to four weeks, likelihood is you’ll never get it ever unless you have like a re-operation or something. This is moot in patient with absorbable Mesh because the Mesh will be absorbed after one and a half years, and so there’s no Mesh to get infected, so that’s not a valid concern. Autoimmune disorders occur with synthetic meshes. They can occur with phasix. I have seen it, but they occur early. They all occur within days, weeks to months. And so if you haven’t had any problems by a year and a half, you will not have a problem.
Speaker 1 (00:38:52):
In terms of autoimmune disorders, the Mesh moves, Mesh does not move. There’s this whole thing on the internet about Mesh migration. There’s only one type of Mesh that quote migrates, and that is the phasix, sorry, that’s the Mesh plug. And the Mesh plug has been known to migrate because it’s placed in an area where things move and it’s kind of bulky and surges. Were not suturing it with permanent sutures and therefore it would move around. No other Mesh migrates. Once the Mesh is in place, it’s stuck in place. So all flat Mesh does not migrate. So that’s not a legitimate cause. It’s mostly to scare you out there. Lawsuits are all about Mesh migration, which is not a thing, and then it causes pain, discomfort. Well, if you haven’t had pain discomfort now, you will not have it in the future. Pain and discomfort usually occurs because the Mesh is folded.
Speaker 1 (00:39:53):
Sorry, let me rephrase that. Mesh related pain and discomfort occurs usually because the Mesh is folded or inappropriately placed. That happens early on weeks to months after surgery, not a year and a half because why Mesh doesn’t move. So once it’s put in, it’s put in. But if it’s put in a folded manner, that’s how it’s going to act. So again, that’s not a problem either. So please, please do not become a slave to these law firms and groups where they scare you about all these problems with the meshes. Yes, there are problems with Mesh. No, we don’t have a perfect hernia repair. Yes, you can have problems with non non Mesh repairs, but if you’re doing well, the chances are you will continue to do well because most of these complications occur early.
Speaker 1 (00:40:48):
Okay, here’s the next question. I apologize, I’m having some trouble following in the mail with prostate cancer and prior Mesh, how would you recommend fixing the Mesh if it is necessary to cut through the Mesh to access the prostate cancer for surgery? So in a patient with Mesh, okay, there’s two places where Mesh may be. If the patient, the male patient that has Mesh in the groin is there should be no issues with your prostate surgery. If it’s done robotically, which in the United States 97% are done robotically. If you do need open surgery and you have retroperitoneal like laparoscopic Mesh in you, that’s going to be issue. And you haven’t discussed that with your surgeon or your surgeon needs to be aware of that. If you’ve had open Ingle hernia Mesh, it doesn’t affect any type of surgery, whether it’s laparoscopic or robotic. Now what if you have belly button Mesh? So if you have belly button Mesh, then your surgeon should, and your surgeon’s doing robotic prostate surgery, then your surgeon needs to make sure they don’t go through that Mesh. They can put their trocars higher up or to the side, but not through the Mesh. That would be my recommendation.
Speaker 1 (00:42:10):
Every so often surgeons go through the damn Mesh. That’s not good. It’s not ideal because you’re tearing through Mesh and that just destroys the repair and exposes the Mesh to bowel and everything else inside. It’s not preferable. So they should get a hernia surgeon or general surgeon involved to clean up the area. Once the urologist is done with their problem, I’m referring to a large ventral hernia pair in the setting of prostate cancer recently diagnosed. Okay, so again, that’s like umbilical hernia Mesh. So if you had a large ventral hernia repair and you have prostate cancer recently diagnosed, first of all, fortunately with prostate cancer, surgery is not necessarily the only option. There’s a lot of hormonal therapies or radiation that can be used. You also have an ability to have an open surgery. However, if you plan to have a robotic surgery, let’s say that seemed to be the best and you want to have the best prostate surgery, your surgeon should approach the abdomen.
Speaker 1 (00:43:29):
First of all, they should figure out where the Mesh really is. You can see it on imaging. They should also understand where the Mesh was placed with respect to the muscle versus the intestines. So was it placed in within the muscles on top of the muscles or inside the abdomen exposed to the bowel? Worst case scenario is if this large ventral hernia was replaced with Mesh, put inside the abdominal wall because surgery will be complicated, not just because you have to go through the Mesh, but the Mesh is also stuck to everything else in the abdominal wall. You have to address that first and then go into then address the prostate. So it’s like two surgeries in one.
Speaker 1 (00:44:16):
In either situation, I would recommend that you have a hernia surgeon talk with your urologist to explain to them the importance of planning before surgery. In my situation, my colleagues, they just let me know. I figure out all these details for them and then I either say, oh, this is easy, just do X, Y and Z. Or I am part of the surgical team and I’m there when they put their trocars in. And sometimes I’m also there when they need to take out the specimen. So those are kind of scenarios that may be good for you.
Speaker 1 (00:45:02):
Next question. How likely is it for an incisional hernia to recur after an open surgery? Not related to the hernia, but that uses the same incision where the hernia was? Yeah, that’s the problem. Does preventive use of resorbable Mesh have a role in that scenario? No. So if you had an incision, hold on, incisional hernia after open surgery, not related to hernia, but that uses incision when, okay, so you had a hernia before, let’s say a belly bone hernia that was repaired and now let’s say you had no Mesh in you, right? Typical small umbilical hernia or epigastric hernia, no Mesh, then you need another and that was fixed. No Mesh. Now you ha need another surgery. Let’s say gallbladder surgery. What are the risks that hernia repair will fail? It’s a pretty high risk. It’s about 50% risk if they don’t treat it appropriately.
Speaker 1 (00:46:02):
So if they go through that hernia and don’t close it as if knowing that it was a prior hernia, so they use absorbable sutures for example, instead of permanent sutures, then the risk of recurrence is like 50% or more. And that push, that puts a patient at risk. That’s why it’s important that you as a patient for sure, explain to your all the operations you’ve had. Don’t just be like, oh, that was just a hernia repair. No, no, no, no. That hernia repair has implications for future operations that you’ve had. If you’ve had a prior hernia repair with Mesh and they have to go through that same incision to access whatever surgery you need, then you will get a hernia recurrence if that surgeon doesn’t treat that area, especially the Mesh with care. So the standard traditional closure of the abdominal wall is with long-term, slowly absorbing suture. You cannot use that in someone who’s had a hernia before. It has to be permanent suture. Mesh to Mesh needs to be sewn with permanent suture. I hope that’s clear.
Speaker 1 (00:47:26):
Let’s see, what complications, here’s a question. What complications can arise if Mesh was implanted later? Explanted and both through the midline. If a third surgery is needed. I had pH also, but my body rejected it from day one. Four months later it was implanted. So pH can be cause an autoimmune reactions, highly inflammatory, although the company has data to show otherwise, but other companies have data to show that it truly is one of the most inflammatory meshes. So it’s a competing data. I’m not an expert to know which one’s correct, but I’m going to assume when I see patients with severe reaction to phasix, it’s because it’s a highly inflammatory Mesh.
Speaker 1 (00:48:18):
These are reactions we tend not to see in biologic Mesh as and more often in synthetic. So the more often you have an incision to the same area, the higher the risk of incision incisional hernias. So if you had a hernia, then you had a hernia repair with Mesh, then you had that Mesh removed and now you need that incision redone reentered, then you’re, your risk of that hernia recurring if it’s not treated correctly is about 50 to 60%. If your surgeon is savvy and they use a good surgical technique and they use permanent suture and you’re not a high risk patient, so you’re not diabetic, you’re not obese, you’re don’t use nicotine, you don’t have a chronic cough, you’re otherwise low risk, then your risk of recurrence without and from that incision is about half. So it’s about 30%. So it’s still not zero or close to zero, but it is higher than if you had a regular open and close where the risk is considered around 11%. Here’s another question. In a trauma surgery for the small intestine done open, of course trauma surgeons almost always done open. Does the Mesh adhere to the abdominal wall or the peritoneal tissue? Depends on where they put it. If they put it Intraperitoneal, so IP Intraperitoneal, that’s where I P comes from I P O M. Then it does stick to the peritoneal tissue and the on one side and the abdominal contents the other side. But if the Mesh was placed more superficial than that, then it sticks to muscle or wherever it was put in.
Speaker 1 (00:50:20):
I’m questioning whether that Mesh will be involved to close or rectus to close the abdominal defect. Not closed after the internal surgery, but I can’t imagine having layers of Mesh. I know they used ovitex and put supra SDRM on top of it over it. What’s Supra SDRM. That sounds like a dermal matrix of some sort. SDRM, lemme look that up. I think it’s a, oh, it’s a synthetic wound Closure meters. Yeah, it’s a dermal matrix. So it sounds like they put in an absorbable biologic. I don’t know if they used the absorbable or the permanent of text, but they put in a biologic with minimal either no or minimal amount of synthetic in it. And then they use some type of other dermal matrix because you had a trauma, they want to make sure that you healed well from that.
Speaker 1 (00:51:22):
So if now you’re doing rectus closure, depends on how many years out you are from the ovitex and see if that’s involved. But ovitex leaves like a little layer of scar and that may make, let’s say a tummy tuck or kind of a rectus closure, a little bit more difficult. But if it’s purely absorbable, then it’s possible that if it’s been a year and a half, ovitex should be gone at about nine months to a year. I’ve been in patients where two years later and it’s still kind of, the Mesh is gone, but the scar from it is behind. So I would say that doing an abdominal wall placation or closure of the rectus muscles having had scar tissue from a prior operation where everything is absorbable may require some scar releases before he can get a good closure. Is it normal to feel a tingling or pinching sensation?
Speaker 1 (00:52:31):
One and a half years of getting the Mesh, is it perhaps nerves growing or the Mesh dissolving? It happens occasionally. So tingling or pinching can occur with healing. It can occur with your hernia trying to recur, especially if you are a year and a half out from the phasix mesh, that’s kind of when the recurrence start. Or it can just be scar tissue. So it’s hard to know until it gets worse. There’s no perfect way of figuring that out compared to tissue-based repair. Can you say that permanent Mesh both increases your risk of needing further surgery due to mesh complications and makes these co surgeries more complicated due to the presence of Mesh? Yes, that is correct. The use of Mesh will always complicate a future operation. It is what it is. So I can’t, we’re not in a situation where non-permanent Mesh is of any standard use.
Speaker 1 (00:53:36):
I discuss how I use it sometimes in patients where I know they’re going to need multiple operations and I’d rather the patient not have synthetic permanent Mesh in them when these future operations. But those are far very few, few subset of patients. Does inflammation from Mesh contribute to adhesions formation after surgery? Yes. Can these adhesions complicate future operations? Yes. Is there a point where you cannot perform surgery at all due to excessive adhesions? Yes. So this was a situation with the open al hernias and, sorry, the laparoscopic al hernia repairs with Mesh and the open prostatectomy surgery. There was so much inflammation from the Mesh that it made surges unable to identify the bladder because the bladder and the Mesh were stuck to each other. But you have to be able to get into that space to get down to the prostate. So there were operations that were aborted, too much bleeding than it was aborted.
Speaker 1 (00:54:45):
I think we’ve learned more since those early experiences, but it is a problem. And then if the Mesh is placed Intraperitoneal, so against the abdominal wall and the inside where it’s exposed to small intestine or other organs, then there will be almost always adhesions and scar tissue between the Mesh and the bowels. Depending on the patient, the type of Mesh used and the technique used, there may be so much adhesions that you can’t have any other operation. That operation has to be aborted and it can’t be done. Let’s see. Next question. Apart from the presence of adhesions, does open or minimally invasive tissue-based repair have any effect on the future?
Speaker 1 (00:55:38):
On the difficulty of future operations? No, not really. All right. Let’s see. Do multiple open operations increase your chances of developing an incisional hernia? Yes. If it goes to the same incision, yes. Assuming body weight, smoking, cough, constipation, and other risk factors are under control. Good for you. You were just right on all those risk factors really well. Does the age at which you get the operations matter for the purpose of minimizing your chance of getting an incisional hernia? Yes. The higher your age, theoretically, the lower your collagen level in the tissues, even if you’re really fit as a, let’s say 80 year old very fit person and therefore the higher the risk of incisional hernia. How are incisional hernias managed in patients who, because of their illnesses, require frequent operation? Yeah, so that’s what I was talking about earlier, which is if I know I have a patient that’s going to need frequent operations, then what I recommend is use of these hybrid meshes where there’s enough synthetic in them to prevent a hernia recurrence, but not so much to interfere with future meshes. That’s the way that I do it. What happens to the Mesh that the suture together with permanent sutures after another surgery?
Speaker 1 (00:57:03):
Nothing. So you just have to suture it together with permanent sutures to prevent a hernia where you cut at the Mesh. Cause otherwise you’re basically splitting the Mesh. It doesn’t grow to each other. It just is as held together by that suture as if it’s part of the Mesh procedure. So let’s see if the Mesh, oh, thank you very much for all the information I learned much from everyone’s questions and you calming some of the internet ideas and worries that we read about. Yeah, I feel like, so me, can I just give you a little bit, so somebody kept coming on my Facebook claiming that I’m just like making everyone be suicidal because I’m telling everyone Mesh is bad and every podcast and every post is about how bad Mesh is and there’s no hope for you and you just need to go die. I mean, I hope that’s not the message I’m giving out because I’m definitely not Mesh or anti Mesh.
Speaker 1 (00:58:08):
I feel there’s a need for Mesh in some patients and there’s definitely should not be use of Mesh in other patients. And then there’s a middle ground. So that’s what I talk about a lot, which is tailoring. And I also believe patients when they tell me they have certain ailments, and that’s why we had our paper on Mesh implant illness and coming up with even more research to try and educate my own colleagues about Mesh related complications because many of them don’t believe, don’t believe in it. But I really hope that a lot of what I do is debunk some of the highly anxiety-provoking misinformation out there that wants everyone to go to a surgeon to get their Mesh out even if they have no symptoms. I hope that’s my role and that I’m not adding to the anxiety. I’m hoping that my Hernia Talk Live Q&A are calming everyone down, but heightening your knowledge base.
Speaker 1 (00:59:16):
Last question. If the Mesh was implanted laparoscopically in the peritoneal space would be IPOM? Should there be many adhesions? Yeah, that’s the highest level of adhesion. Now, if it’s extra peritoneal, which is away from the peritoneal space, then it should be fine and there should be no issues there. But usually the problem is that it’s in the Intraperitoneal space and that has the highest risk of complications. All right. Well that was another fast hour that went by. Unbelievable. I really enjoy these. I hope you enjoy them too. Thank you all for your questions. I hope I am reassuring you and calming your nerves. Thank you for that comment. And let’s see, March is just rolling right through. It’s unbelievable. We are now March of 2023 and by next year, I think we’re going to have to celebrate our, I think it’ll be our third year. This is ridiculously crazy. However, this has been such an amazing journey with you all and therefore the end of today’s podcast. So thanks everyone for joining me. Come back next week for another Hernia Talk Live Hernia Talk Tuesday. Don’t forget, follow me on Facebook at Dr. Towfigh and YouTube at Hernia doc, and if you care to watch me on hernia on Instagram or Twitter, I’m also at Hernia Doc there. Thanks everyone.
