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Speaker 1 (00:00:10):
Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live, our weekly Q&A. My name is Dr. Shirin Towfigh. I am your hernia and laparoscopic surgery specialist. Many of you are joining me live on Facebook at Dr. Towfigh or via Zoom. Thank you very much. We have a special guest today and therefore also a special time earlier in the day to accommodate for our lovely friend and surgeon coming to us straight from Germany, Dr. Ralph Lorenz. You can follow Dr. Lorenz on Twitter, but he doesn’t post on Twitter, so there’s not much to follow, but please welcome Ralph. How are you?
Speaker 2 (00:00:52):
I’m fine and thank you so much Shirin for your kind invitation. I’m really happy to talk today about something like of course, pure tissue repair or tissue repair. Yes. And that’s a very, very exciting topic and yeah, I, I’m right now during German hernia conference in Cologne. I’m not at home in Berlin. Yes. My home is in Berlin and I’m in a private practice and as well in the hospital very close by in Berlin. That is my professional address.
Speaker 1 (00:01:31):
Yes, yes. So the German Hernia Society meeting is currently on, as you know, we have multiple hernia society meetings throughout the year all over the world. Germany is one of the foremost countries in terms of advancements in hernia. So many of the hernia techniques were invented by German surgeons. The history there is just really, really strong, and rightfully so, the German hernia society is also very active, very strong. So before we started, you were explaining to me how you have not only just the regular society meeting, but you have a lot of education which includes cadaver labs and something called the hernia compact, which I think is a fantastic course if you want to explain what the hernia compact is. And that’s compact with a K in true German fashion.
Speaker 2 (00:02:27):
Yes. Hernia compact is right now, I think we have the 17th compact course right now already. Yes. With almost 40 to 50 young surgeons participants and wow, this course takes normally three days. The first day is going back to the anatomy, which is crucial for all the hernia surgeons. The anatomy is so important and of course, so it’s definitely opening and eyeopening in every direction and that’s quite good. We do cadaver operation, we do cadaver demonstrations, we do ultrasound, we do simulation training on the first day. The second day is hands-on training with different hospitals or in different hospitals in this area. And the third day is lecturers and the very controversial debate on it for having a wide discussion and white debate with young surgeons to attract them and to make them enthusiastic about this topic.
Speaker 1 (00:03:44):
Yeah, it’s fantastic. I’ve been involved with the hernia compact and in America, in the United States we try to mimic it. So we do have certain compact type courses. You’ve been part of it with the American Hernia Society. Yeah, it’s not the same. I don’t know why. Maybe because we don’t have the history, but importantly you do teach tissue based hernia repairs as part Yes. Of the cadaver part of the lectures and also the cadaver lab.
Speaker 2 (00:04:14):
Yeah, yeah, absolutely. It’s important to stay open-minded in every direction. And of course we have a lot of requests and that’s something what we will talk in the next hour about with concerns against any foreign body and whatever. And of course there are good indications in my mind,
Speaker 1 (00:04:35):
And I think so many people that I see on social media are so concerned that we are not teaching our residents and young surgeons how to do tissue repair in the United States. I know very few surgeons that do tissue repair or at least do it well, I should say enough that I would say, yes, go to this person or that person. Some of them started at the Shouldice clinic and then moved to the United States, so that’s helpful. Others like me just have a special interest and have learned the anatomy over years. But it’s very few of us and my residents get taught it because I teach them. But most residencies in the United States and probably other places in the western world do not teach tissue based repairs as a, like you have to learn about it as part of your board’s examination, but if you ask who’s actually done one, I would say most will say zero.
Speaker 2 (00:05:39):
I think the same in Germany. I think, of course we have the same situation. Of course, I train a lot of residents right now since a couple of years also with the university hospital together. And of course they are enthusiastic about this. And of course they are going a bit back to all these open techniques and to learn the anatomy of course by examples and with getting a routine on it. And that’s really, of course highly motivating them. Yes. Yeah.
Speaker 1 (00:06:15):
I think most people who are watching this probably know what a tissue-based inguinal hernia repair is, but do you want to just clarify what we’re talking about?
Speaker 2 (00:06:26):
I think of course, pure tissue repair avoids the use of any foreign bodies during the surgery. Of course, we are suturing and the most, and in my mind most important thing is, or difference is that we make a reconstruction of the abdominal wall that has of course his benefits. We talk since almost 30, 40 years about tension free repair and that makes a bit the difference. It’s not completely with a lot of tension, but with a minimum and on tension and even more on reconstructing the abdominal. And if you are even younger, if you are even more active, the reconstruction of the abdominal wall matters even more.
Speaker 1 (00:07:23):
So just to clarify, in children, so under, I would say under 14, 15, it’s standard of care to do some type of tissue based repair, but as they get older, mesh seems to be more involved and the techniques for tissue repair change as you get older. Would you agree with that?
Speaker 2 (00:07:44):
Yeah, absolutely. Of course, in the childhood, you dorm normally only do the ligation of the hernia sac. Yes, that’s it. Sometimes you use some resorbable additional stitches to close the defect in this thing. But secondly, in the, of course, elderly or even adult people, we use different techniques. And the most important or the most famous one is the shouldice technique. And that is the technique which is also best evaluated since many, many years. And it’s also included into the guidelines as the best method, which is of course where we have the best scientific research on it
Speaker 1 (00:08:40):
And the guidelines or the European Hernia Society guidelines that you’re talking about, which are very important, they’re updated on a regular basis. You’re part of that team and it’s, it guides a lot of us and I wish that more US surgeons knew about it and understood it and followed it. To be honest, sometimes you wonder why people do what they do because it’s definitely against the guidelines.
Speaker 2 (00:09:06):
Yeah, no, normally, of course, I think in since almost 20 years or something like this, of course the Cochran database make the basis of course the recommendation for using mesh every time. Yes. Right now we are going a bit back and in the actual or right now prepared update of these guidelines or international guidelines, they will be written that of course pure tissue repair is also a possible effort to treat hernias. Mesh reduces a bit the risk to develop a recurrence, but there are other benefits on the other hand for speaking for the use of pure tissue repairs as
Speaker 1 (00:09:55):
Well. And I’m glad they’re moving in that direction because up until now it was a very one-sided view of what’s best for patients. Yeah. Were you there when I gave my kind of analogy of was it at this EHS? I’m not sure, but I gave an analogy where I said, when people talk about Mesh versus non Mesh repairs, every single study shows Mesh is better for recurrence. And that’s true. Every single study will show for whether it’s belly button hernia or it’s a inguinal hernia. If you’d use Mesh and you compare Mesh to no Mesh, Mesh always wins for recurrence. However, that’s like saying if I go from point A to B by car versus walking, it’s always going to be faster by car.
Speaker 1 (00:10:47):
Yeah. But in certain situations you shouldn’t be driving a car to your neighbor’s house. Right. It’ll be faster probably, but you should just probably walk that one. If it’s raining outside, maybe it’s better to use the car and not walk. If you have a lot of heavy luggage to take with you, maybe take a car. But if you’re just walking, maybe even in some people, even a block is better to walk than drive a car. But if you break your leg, you should drive the car. So there’s a nuances to that. But if you always say car versus walk, it’s always faster by car, but car is more expensive. Car you need to, it’s bad for the environment. Yes, you can get killed in a car. It has its risks too.
Speaker 2 (00:11:34):
Then normally, of course, both have be benefits on different areas and that that’s the truth. And
Speaker 1 (00:11:41):
Of course that’s important.
Speaker 2 (00:11:42):
Course we keep a balance even more between of course the big variety of possibilities. And of course we should not make the mistake to mix all the hernias. Yes. I think we have such a big variety of hernias and that matters. Yes. Cause we mix the different types, the different sizes, the different ages of the patients. And so for that reason, we need more than only one technique. Yes. One doesn’t fit all.
Speaker 1 (00:12:19):
So I have a patient that came yesterday. He traveled to see me, he is older, 70 something like 78 I think very fit, very thin. Super thin. He has a very small hernia on one side and a squirrel hernia on the other side. And he’s like, I don’t want Mesh, that’s why I’m coming to you because I, you know, offer that. And I said, okay, for that side with the small hernia, yeah, no Mesh, perfectly fine. The scrotal hernia,
Speaker 2 (00:12:52):
It could be a challenge.
Speaker 1 (00:12:53):
We could discuss it, but it wouldn’t be my first choice. So
Speaker 2 (00:12:58):
No, normally of course I think the scrotal hernias are almost in the majority indirect hernias. Yes. And sometimes the scrotal hernia sac is huge, but the defect is small and so that gives you a chance sometimes because indirect hernias, as we know from the scientific research, have a low risk to develop a recurrence. And that’s of course you should keep it in mind I think, right? Yes. I try to navigate my patients a bit more that I do my previous ultrasound, dynamic ultrasound before I do the operation to navigate what is the content, how big is the size? Is it even an indirect or even a direct, I try to exclude any femoral hernia. Yes. And that’s why I do always, always in all cases the ultrasound too.
Speaker 1 (00:13:57):
Because you do the ultrasound in your office and you also do the ultrasound yourself because other doctors or radiologists are not as good for hernias.
Speaker 2 (00:14:15):
Yes. I think of course when you do the operations, the anatomy very clear and you have of course the best possibility. And the ultrasound is so helpful because you want to know exactly where you should have to look for what details are interesting and you have all possibilities to get more information before you do start with the operation.
Speaker 1 (00:14:43):
Well, the radiologist called me and said, we want to make sure that we’re dictating these correctly when we’re reading the hernia ultrasounds, do you care how big the hernia is or is it really the muscle opening that you’re interested in? I said, yeah, if you want to choose, I really want to know the muscle opening. Cause yeah, how much content goes through it is not as relevant. I can see that. Right. Yeah. And it doesn’t affect me so much in my surgical technique as does the actual neck of the hernia. But most radiologists tell you how big the sac is. I don’t care how big the Yeah, yeah,
Speaker 2 (00:15:19):
Yeah, of course. I think the defect matters even more. Yes. And secondly of course, you get even more information about how thick is the muscle, what proportion do you have? Is there a lot of subcutaneous fat or whatever. You get so much information and you can get even much more and you are much better prepared for the operation with this knowledge.
Speaker 1 (00:15:47):
Yeah, very good. You know, mentioned shouldice among others. One of the questions that was shared with us is, so we have Bassini, Marcy, McVay, Shouldice, Dasarda. What other techniques for tissue-based inguinal hernia repair repairs are there? There’s a whole book on them that has probably hundreds of techniques, but these are the most common,
Speaker 2 (00:16:10):
I think they’re a lot. Yeah, there’s
Speaker 1 (00:16:14):
The new Condon
Speaker 2 (00:16:17):
Of course, I think show is McVay is something which is definitely even more for the femoral openings. If you have a small gap in the femoral canal, you can close it with the McVay repair. The Dasarda is a quite very interesting technique from India, and I know personally and I have a very close contact to him, and I invited him also to Europe. And so he presented this technique, which seems to be a bit more easy to learn. Comparing to shouldice,
Speaker 1 (00:17:00):
Definitely
Speaker 2 (00:17:01):
You re using a flap, which is interesting and interesting technique. Of course the origin is even much older. But yes, I think this other is a very good alternative. It’s not very well in research represented with long-term follows ups. That is the major concern. That’s why it’s not yet included. But there is a door open already that the desarda seems to be, might be the next technique, Bassini, if you do it even in the original technique, it’s quite good. Definitely. Yes. And Marcy is something do you use normally in the childhood or even in the adolescent patients. And the results are also even good. The marcy repair has some in the last couple of years, some which are definitely optimistic. And the rate of recurrences, its very low, but you don’t use it.
Speaker 1 (00:18:14):
Yeah, we don’t see a lot of adults that have recurrences from their childhood hernias. Absolute. We don’t see it that much. Yeah. And they’re usually primaries. Yeah. And then for women, small hernias of women, sometimes the Marcy works well too.
Speaker 2 (00:18:30):
Yeah, yeah,
Speaker 1 (00:18:31):
Absolutely. And then before, there are
Speaker 2 (00:18:33):
Some more techniques with I think, which are in different areas of this world popular. And secondly of course, one of the most newest technique came from South Korea, the so-called Kang technique. Yes. Might be that you have heard something about this
Speaker 1 (00:18:54):
Already. Yes. Dr. Kang. Yeah, he’s on. He’s on hernia talk, yeah.
Speaker 2 (00:18:58):
Yeah. And what do
Speaker 1 (00:18:59):
You think of his, it seems like a modified Marcy.
Speaker 2 (00:19:02):
Yeah, it’s a modified Marcyy and of course the difference is only that you don’t make in a vertical direction, the sutures, you use it in a horizontal direction and that makes the difference and it’s quite interesting and I’m looking forward for the first three lights, but it’s brand new. Yes,
Speaker 1 (00:19:28):
Yes. I think he’s been saying that he has improving it, so his original Kang repair has changed a little bit. He’s changed the type of sutures he’s used and the directions and so on. But yeah, maybe I should interview Dr. Kang for one of my, just to learn more
Speaker 2 (00:19:48):
No, of course. I think there is some progress on it also, not only some slightly small interest, not the hummingbirds in the hernia world. It looks like it’s getting a growing society which has interest on it.
Speaker 1 (00:20:07):
And the Desarda you would be for non scrotal hernias because the external oblique Aponeurosis is destroyed usually in the larger hernias.
Speaker 2 (00:20:18):
Yeah, yeah. Normally of course I, I just think about the topic, which technique is ideal for which hernia, and that would be of course beneficial for all of us when we choose of course the optimum for I think the type and size of hernia. And I got the impression that the desarda repair is something if you have a posterior wall weakness and a very thin conjoined tendon and then it’s very supportive to use the external oblique. If it’s not tears out or if it’s not tearing out or is divided into different fibers, yes. Then you can use it if it’s eaten strong, the external oblique fascia to cover it on top of the posterior wall, that’s beneficial and it’s very wise,
Speaker 1 (00:21:14):
So it’s a two layer repair.
Speaker 2 (00:21:18):
Of course you close the posterior wall and then you make the flap on top and then you come on top of the spermatic cord or round ligament with the external Oblique again.
Speaker 1 (00:21:33):
Oh, got it. Yes. So it’s like external and then another one like that. Yeah, yeah. Got it, got it. Yeah. Here’s a patient got I guess had multiple surgeries, so he says, I’ve had roughly eight surgeries and I’m trying to fix the pain from my left inguinal hernia. I started having more pain after the initial surgery to fix the hernia and I have since had many different operations to help hernia revision, like hernia revision, hernia revision, and I even took out all the Mesh altogether, but the pain is still there. Any abdominal stress tends to worsen the pain. Also, I know ahead of time when I need to make a bowel movement because the left side tends to get much worse before I do even stronger sharp pain so he can feel the bowel movement before because his left groin pain kicks in. I have been to many doctors, but I’m now at the point where everyone of them tells me all they can do is go in and take a look. So is there any advice you could give to me
Speaker 2 (00:22:37):
Complicated.
Speaker 2 (00:22:38):
It sounds a very complex case. Yes, and normally of course the advice is of course first make a very good or clear diagnostics to exclude all the differential diagnosis, which can happen and have an influence if you have already a Mesh implanted. Of course the change, the physiology of the abdominal wall and also the tendons and the muscles in the hip area. So for that reason, of course please exclude all the other things could be, I think there could be a tendonitis, there could be a muscle related pain, there could be a back pain, which going into the groin and if you have any hip imbalance that makes stress in this area and that’s very important that you make the examination not only concentrating on the hip or even the groin area, you should include the whole body into this examination. So because sometimes you have a problem already in the feet and the knees and you can realize that the problem in the more upper areas might be has a relation to the other parts of the left or something like this. And secondly of course the previous operations are very important. What type of hernias do they have? What size of hernias? How do they fix the yes
Speaker 1 (00:24:19):
Mesh, the details?
Speaker 2 (00:24:21):
Yes, the details. And of course it’s a huge analysis in this thing and to avoid any secondary operation without any of course intention, what could it be and what could help for them?
Speaker 1 (00:24:42):
Yeah. I never like it when a surgeon says, I’m just going to go in there and take a look because first of all, that’s not without risk. No. Yeah. So much can be learned by imaging before surgery. Almost everything can be predicted by imaging before surgery. So if you have a surgeon that just wants to take a look, I’m not a fan of that at all. No,
Speaker 2 (00:25:04):
Also, I totally
Speaker 1 (00:25:05):
Agree also. Yeah, and also you notice the people who say they have groin pain right before a bowel movement, they usually have a hernia, so this could just be a simple hernia recurrence or an unstable tissue repair that’s presenting like a little mini hernia. I feel like if they say, I know I have a bowel movement before I have the bowel movement because my left groin pain starts, that usually to me tells me that there’s a hernia recurrence or a weakness in the area. Yeah. What do you think?
Speaker 2 (00:25:36):
Yeah, yeah, I think of course I totally agree. And of course, so we should not only concentrate on the groin, we should exclude or include the diagnostics into different areas and also might be a colonoscopy or something like this. Sure could help in these cases. And of course imaging is important and mapping if you have some pain to get the dermatome where the pain is, where you have a numb this and something like this, that’s important and the preparation gives you already a lot of answers.
Speaker 1 (00:26:17):
I had a patient who had a hernia repair for groin pain and then had chronic pain radiated to his inner thigh, testicle. He had a Mesh removal, triple neurectomy. Didn’t work. He came and saw me and you know what he had? Oh, he had multiple nerve blocks and then they put an implant into his back for pain. What he had, he had an autoimmune sacroiliitis, so it’s also called ankylosing spondylitis, so it was always a sacro, like a back issue, but it caused symptoms in the front and he probably never needed the hernia repair. Definitely didn’t need all these other operations after that. And once he was treated for that, all his pain went away.
Speaker 2 (00:27:06):
I totally agree with you. One of the most common things are even the sacroiliitis. Yes. And also the psoas muscle which is related in the deep groin area, and that could be very easily therapeutic treated and of course, definitely. I think these problems are very, very common and if you have any kind of imbalance and of that’s why I look for them in standing position and lean position and examine the hip as well if they have osteitis or something like this. Such cases you told me are very common. Of course, they have pain in the groin, which seems to be not really related to hernia. Yes. They get a Mesh repair or even something the pain is after the surgery the same before. So they get the second surgery. Yes. Once again, we will only want to have a look on it, but they put another Mesh from outside and then you have two meshes already inside. Yeah,
Speaker 1 (00:28:23):
It’s seen those patients now that’s even worse. Yeah. Now it’s like cardboard. Their whole groin is now cardboard. Yeah. Yeah. I had another patient yesterday probably his growing pain was not from his hernia and he had a vericocele, very large vericocele, so they fixed his hernia. The Mesh actually probably made the varicocele worse, so he had multiple surgeries now for the vericocele and now it’s a disaster. And he came to me, he’s like, I think it’s the Mesh. I’m like, no, no, no. You have a serious urologic problem. The Mesh didn’t help, but the primary problem was all urologic and I set him up with one of our specialists. Here’s another question. Someone’s asking, what are your thoughts about Mesh? Are you still using Mesh as needed for certain patients or are you complete opposed to Mesh and polypropylene versus polyester and P V D F and all your other thoughts on those?
Speaker 2 (00:29:24):
I think of course, I think we use meshes definitely, and I, I’m definitely, I try to navigate my patients into the group which need measures. Yes, because they have any kind of collagen disorder which will never be treated by a pure tissue repair. I think we should select the patients and that is the main address, the main take home message for me. I think not everybody is using or need a match, but we have a group of patients, they have this collagen disorder. They are even older. They have, I think they are in an between 60 and 80 because they have such a, I think collagen disorder or even weakness of the posterior world. They have almost in the majority of cases, direct hernia or even a combined hernia with a direct component and secondly, an indirect or even femoral component and these cases or they have a multi local hernia also on the opposite side and or spigelian, even femoral or obturator, something like this. So I think, of course we have these patient groups, but I really try to concentrate who needs really a meh and who not.
Speaker 1 (00:31:08):
Yeah, very true.
Speaker 2 (00:31:10):
Yeah.
Speaker 1 (00:31:11):
There’s another question that was presented, which is how do you think of the different tissue repairs? Is there one that is maybe less invasive, has less recurrence, less short-term pain, all the studies point to shouldice being superior, all things being equal, and you mentioned you own children. We tend to use more of a Marcy or just a high ligation of the sac, but what are your thoughts on the different tissue based repairs?
Speaker 2 (00:31:45):
I think in the outcome of all these tissue based repairs couldn’t identify a lot of differences. I think they are almost very similar. Also, what is the time to rest after surgery? Seems to be similar. We have patients, of course, they can do whatever they like immediately after surgery. Yes, and like me, but when I got my showed as a repair, I went home on the same day. I went up to a hill on the same day, which is useful because we have used the long term resorbable local anesthesia, additional. Oh
Speaker 1 (00:32:36):
Yes. You didn’t know what you were injuring.
Speaker 2 (00:32:38):
Yes. And normally of course, I think the pain was minimal.
Speaker 1 (00:32:45):
Yeah. Can I ask who did your surgery?
Speaker 2 (00:32:48):
Who did it? Yeah. No, of course. A friend of mine who’s really familiar with showed eyes and I can tell you the story that I fixed his hernia in the other way around in the same way, and he was in the same way. Satisfied.
Speaker 1 (00:33:07):
Very good.
Speaker 2 (00:33:08):
Yes.
Speaker 1 (00:33:09):
I feel I don’t have hernias, but I did get imaging and there is a little bit of fat in my inguinal canal. I don’t have any symptoms, but I know it’s there, so I’m always, it’s bilateral, so I’m always thinking it’s bilateral. What if I need a hernia? Who would do it and what type? Of
Speaker 2 (00:33:30):
Course, if you have only some fatty tissue, this is something which is definitely almost common that you have a long round ligament or Yes, a long to spermatic cord. Yes. Some slightly small tissue. Small, yeah. Some petty tissue normally, of course. Is it a hernia, a real hernia? No, they have no peritoneal.
Speaker 1 (00:33:52):
No, not yet.
Speaker 2 (00:33:53):
Nothing. Yes.
Speaker 1 (00:33:55):
Yeah. Okay. Here’s another question about weightlifters. So I’ve had this question come a couple times. What are your thoughts on hernias in weightlifters? Oh, stop share, hold on. What are your thoughts about hernias and weightlifters and do you think there’s this preferred technique to repair them?
Speaker 2 (00:34:20):
No, I think what really matters is I think the size and the type of hernia at the age of the patient. Once again, I have one example, which is definitely famous because he was the winner of the Olympic gains in weightlifting, and he has a kind of course remaining pediatric hernia,
Speaker 1 (00:34:50):
And for
Speaker 2 (00:34:50):
This reason, he got only a pure tissue repair. Great. Which was I, and finally, of course he, he’s still active.
Speaker 1 (00:35:03):
I mean don’t see, I’ve had maybe one not or had a wrestler, but I’ve never had a weight, like a professional weightlifter. I don’t think they get hernias disproportionately. They may actually have less hernias. What do you think?
Speaker 2 (00:35:17):
Yeah, I strongly believe I have to switch on the lights. Sorry, put this
Speaker 1 (00:35:25):
Well, because you’re in Cologne, Germany and it’s like 9:30 PM
Speaker 2 (00:35:29):
Yes, it’s getting darkness.
Speaker 1 (00:35:30):
I appreciate it.
Speaker 2 (00:35:33):
So I think of course, I think we try, there is no difference between the different techniques in regarding sports activities. If you are even more sports active, a runner or triad lead or whatever, I would avoid any foreign body. I think I know all the sportsmen are much more sensitive to, they
Speaker 1 (00:36:02):
Can feel everything
Speaker 2 (00:36:04):
They feel normally, of course all the foreign bodies and that makes a slightly difference.
Speaker 1 (00:36:12):
Yeah, I feel the more athletic you are, any little imbalance tightness on one side more or a hernia on one side more, they absolutely feel the imbalance. It’s so interesting. Yeah.
Speaker 2 (00:36:25):
Yeah, absolutely.
Speaker 1 (00:36:27):
So for inguinal hernias, you’re, you think a tissue repair for a weight weightlifter or mass repair or it depends. You don’t think it makes a difference that they’re weightlifter? I
Speaker 2 (00:36:40):
Think the weightlifting doesn’t matter. Yeah, I agree. I would look for the age at the type in size of hernia, and that would be help me in regarding the decision. Yeah, how to treat, fix this hernia.
Speaker 1 (00:36:57):
I agree. What about the belly button? That’s a different story.
Speaker 2 (00:37:01):
The belly button is something which is different. Of course, the pressure in the abdominal wall in the lyse or epigastric area is much higher than in the groin. So for that reason, of course there is slightly depending on the size of the hernia, both possibilities are of course possible. Normally, of course, in a very tiny small hernia of one centimeter, the majority of surgeons would fix it by suture.
Speaker 1 (00:37:41):
Yeah, agreed.
Speaker 2 (00:37:42):
That’s it. But if you have a rectus [inaudble], and that is something
Speaker 1 (00:37:47):
That’s a problem, which better
Speaker 2 (00:37:48):
Even more than the size of the hernia. Yeah. Then you should choose a Mesh. Yes.
Speaker 1 (00:37:58):
Yeah, agreed. This is the question I get asked a lot, which is, let’s say you had a tissue repair and now it’s recurred, so is Mesh always the next step?
Speaker 2 (00:38:12):
That’s wise? That’s an interesting questions because these are
Speaker 1 (00:38:16):
All my audience. These are all audience. I had nothing to do with these questions. Audience submitted.
Speaker 2 (00:38:22):
No. Normally, of course, I would be very critical for the first repair, if it’s not done by an expert, yes. The quality is very different. And so for that reason, my first choice or my first recommendation would be, please send me the operation note, yes, that you have get any information. What have they used? How do they made it, how do they follow any standard protocol of these techniques or not? And sometimes I can read already, of course, they have used resolvable sutures. They have used only two layer repair instead of a four layer repair. Then I know, okay, we should look intraoperatively. What is the quality? And if you have done previously might be, for instance, a show as repair and it’s a recurrence. After that you have one option with the disorder. That could be one option. True.
Speaker 1 (00:39:33):
That’s actually a good option for disorder. That’s
Speaker 2 (00:39:35):
Very good option if you want to avoid any foreign body. That is one main thing. Sometimes we have also a lot of recurrences after previous or index operation with mesh, and then it’s definitely also an option to use a pure tissue.
Speaker 1 (00:40:01):
So I think the typical scenario would be they had, let’s say a strangulated hernia. They went to the emergency room, the surgeon did bowel resection, et cetera. They did a tissue repair. So not an ideal tissue repair, but still that two plane is destroyed in some ways. Then if that recurs, which is probably the highest chance of it, you’re saying that you may take these patients for a tissue period in some cases? In some cases cases, you won’t always say no cases. Yes. Yes. And do Mesh. Yeah,
Speaker 2 (00:40:35):
No, I would not generally answer that. They need always a match. Yeah. I would look for the details. I would look for the quality of the index operation. I would look for what do they have used, what is the quality of tissue and something like this. And then you get might be interoperatively decision, which is of course experience based even more. But normally I think I don’t exclude it only by the data that yeah, it was a recurrence.
Speaker 1 (00:41:17):
Agreed. Yeah. It’s actually a good option for it to start. I never thought of that. Those of you who follow me know that I’ve never been a big fan of Desarda. Part of it is that the way it’s been rolled out has been not without much strong evidence. And the second reason is because my mentor, when I used to work at U S C, he trained in the fifties, 1950s, and he remembers a similar repair that was being done and they abandoned it because they had a high recurrence rate. So those two, that data made it so that I never really took upon the Desarda technique, but I think in this situation it sounds like the ideal tissue repair option. Yeah. Yeah.
Speaker 2 (00:42:08):
I think, of course, I give you an example because yesterday we have in the cadaver workshop here in Yes. In Cologne, a case one side was originally there was no previous operation, but the, and we did open pre perineal on top, we do show lies and SEC as a third layer of third stability for training issues. Yes. We did a Lichtenstein on one side. On the other side, we could identify during the surgery that there was already a Lichtenstein made. Oh, before we did, we didn’t know it. And of course they opened the floor and there was a Mesh already. And so for demonstrating we tried to make a desire repair on this side. Brilliant.
Speaker 1 (00:43:02):
It worked. So you were able to lift the extra oblique off. Yes, yes. And preserve it enough to bring it down. Yeah, I can see that. Yeah. Yeah, yeah.
Speaker 2 (00:43:12):
I think of course Desarda is something which is a bit more upcoming. I think there are even more studies right now and in the last five years and also in the last one year or two years, yes, we get even more publications on this topic and they compare not only Liechtenstein with disorder and there are even very comparative. And so I think there is not a huge difference. And so for that reason, you can avoid with this auto look Mesh any foreign body
Speaker 1 (00:43:52):
Question about stainless steel sutures. So the original shouldice repair is stain described stainless steel. Yeah. What are your thoughts on that? I know currently even the shouldice hospital is agreeable to using proline suture. Yes. Instead of stainless steel. But what are your thoughts on that? Is it a good idea, not a good idea. Does it break? Does it prevent you from having an MRI? What’s
Speaker 2 (00:44:25):
No, no. I think of course the stainless steel is historically, of course the original technique from shouldice. Yes. We did in 2019, this consensus meeting in Hamburg, and invited also the son of shouldice. Yes. And also different important persons from the shouldice hospital. And they agree on this issue that we use permanent suture, which is a polypropylene suture, which is a non-resorbable. It should be a non-resorbable,
Speaker 1 (00:45:03):
Non suture resorbable. Yes.
Speaker 2 (00:45:05):
Yes. And you should stick on four layers of repair. That is something which we explain as a key point of this technique, and to show that as hospital, make a publication this year about the modification or also a consensus on it. And they allowed to use the polypropylene suture instead of the wire or even stainless steel. Okay. I’ve spoken a couple of weeks ago with the actual or current head of the Shouldice department and his opinion.
Speaker 1 (00:45:46):
Yes.
Speaker 2 (00:45:47):
To be honest, yes. And he totally agree with the polypropylene suture, which is same stability, which it gives you the same results as if the stainless steel. So I think the stainless steel is might be something what you should of course replace with the polypropylene sutures.
Speaker 1 (00:46:10):
Yeah. Yeah. That’s Dr. Spencer Netto, who was a guest on Hernia Talk before.
Speaker 2 (00:46:16):
Yeah. Yeah. I think
Speaker 1 (00:46:17):
Two years ago almost. Yeah. You see patients like I do who react to foreign bodies more than usual. Have you seen anyone react to stainless steel suture?
Speaker 2 (00:46:33):
N no. Of course. It’s very unusual that I think there’s nobody using in central Europe. Yeah. Stainless steel. And that’s why we don’t see anything might be there is a slightly difference, but I have never seen any patient with this. And you call it, and you have made this beautiful publication about Mesh implant illness. Yes, thank and thank you. In the Asia, Shoenfeld syndrome, yes. By the origin, and of course there is slightly in the majority of these patients have a bigger size of Mesh and not, yes, only a suture line, which is only one 70 centimeter long or 50 centimeter long suture. Yes. That’s a huge difference. And I haven’t seen might be that you have seen anybody with this reaction also.
Speaker 1 (00:47:32):
No, and I think so. The only risk would be if you are nickel allergic, and I have to check, I think the stainless steel suture does not have nickel in it. There are other stainless steel products on the market that do include a certain percentage of nickel. I have not looked into it to see if it includes nickel in the stainless steel suture. I think that would be the only thing, because I have had people
Speaker 2 (00:48:01):
React. No, we should to be aware of. That’s something of course, I think, but I strongly believe that the mass of material is so low that the influence is also very low on the whole body. And normally, of course, these allergies or even Shoenfeld syndrome is something of course there you need even more material.
Speaker 1 (00:48:30):
Yes, yes. Correct. Correct. Here’s a question. A 70 year old female, seven zero, I got a hernia doing leg presses eight years ago. We could argue whether it was due to leg press or not, but she has a hernia just below her belly button. It’s large. And I would like to know if it can be repaired without using Mesh as I’m afraid of Mesh related side effects. Actually, let me ask you this. Of course. I think there’s no argument at least between us two, that there are side effects with Mesh including reaction to Mesh. But in your experience, how common do you think that problem is? Is it 50%? Is it 1%? Is it fraction of 1%? Because I tell my patients we don’t really know, but based on my experience, it’s a fraction of a fraction of 1%. We don’t have people running around having a lot of that. I think it’s, but what are you thinking?
Speaker 2 (00:49:31):
No, of course might be that you and I have a very selected group of patients. Yes, I’m sure. Yes. That we have because we offer some alternatives and that makes a difference. Yes. I have in my patient series almost. I think it’s a fraction of 1% not, yes. Not a fraction of fraction, but Okay. A fraction of 1%. Yes. So I strongly believe it’s open 5% of any issue with the Mesh. Yes, of course. They come into my practice, into my office for get any recommendation, any tip, any trick or any treatment, any recommendation, how to solve this problem. And yes, of course you get since some years, even more, of course, if you are even more dedicated on this issue, the old 70 years old lady, I think it seems to be she has an hypogastric hernia. Yeah.
Speaker 1 (00:50:42):
Is it correct? Below the belly button?
Speaker 2 (00:50:44):
Below the belly button. And that is something which is definitely a very rare condition of hernias. If it’s on the left or right side. That could be a Spigelian hernia. Yes. Yeah. But in the, I think suprapubic area or even in the hypogastric area is a very rare condition. Might be It’s a port side hernia.
Speaker 1 (00:51:10):
Yeah, port side or incisional. Yeah.
Speaker 2 (00:51:12):
Yeah. That could be one option. And of course, once again, it depends on the size on quality of tissue. And then you can make a recommendation. For that reason, I would always recommend to do a ultrasound or something like this that would help to get even more information to that.
Speaker 1 (00:51:34):
But in general, large abdominal hernias, not inguinal, large abdominal hernias don’t do well without Mesh.
Speaker 2 (00:51:41):
No, yeah, I’m sure. Yeah. Yeah. I think of course there is a big difference. I think. Of course, the abdominal wall has much more pressure. Yes. Secondly, of course, if the size of the hernia is even not only one centimeter or one and a half centimeter or even almost two centimeters, but that’s the
Speaker 1 (00:52:01):
Limitation. That’s about the maximum one and a half
Speaker 2 (00:52:04):
To two. Yeah, one and a half, and almost in some selected patients might be two centimeters, but that is the limitation. But large hernias, I think, I don’t believe that they can be fixed without any measure.
Speaker 1 (00:52:22):
When you see people that maybe are concerned that they’re reacting to their implant fibromyalgia type symptoms, et cetera, are there any tests that you submit them to or is it purely clinical, your
Speaker 2 (00:52:36):
Diagnosis? I think almost, almost. Of course, the diagnosis is, I think you can make some blood tests for sure, to look for, of course, this immunologic reaction on this, you can make a testing definitely, of course, a skin test with all these, if you get the informations about the used material, you can make a skin test by a dermatologist or you do it by yourself, allergist.
Speaker 1 (00:53:10):
Yeah, yeah. Or
Speaker 2 (00:53:11):
I have an allergist. Yes. Normally, of course, it’s wise to make a consultation with a dedicated electric allergic doctor or electric cost. Yeah.
Speaker 1 (00:53:27):
Yeah. Our experience with allergy testing is still in its infancy, and so far has not been very, how should I say it? The false negative rate’s pretty high still, so it’s not very diagnostic. Have you used other sutures besides polypropylene for your tissue-based repairs?
Speaker 2 (00:53:49):
We use also some PBS or even
Speaker 1 (00:53:53):
PBF suture. We don’t have that. Yeah.
Speaker 2 (00:53:55):
Yeah. I think of course it’s a German brand. And then secondly, of course, we have almost some,
Speaker 1 (00:54:05):
Have you ever used nylon?
Speaker 2 (00:54:06):
No, not yet. Not anymore. I think we use some long term resorbable sutures, which have a very good elasticity like this from brown mono max, which is very, very elastic. That could be an option. I think. Of course, we are looking for some comparative studies practicing showed with a long term resorbable. I think short term that’s works. Yes. Yes. PS or something like this, which is resorbable after half a year is too early. And normally I need some material which is, lasts a bit longer. I think there is some progress might be we wait for some new sutures. That
Speaker 1 (00:54:57):
Would be great.
Speaker 2 (00:54:57):
I think. Yeah. The same with the resorbable meshes
Speaker 1 (00:55:04):
Like the phasix, like a phasix suture,
Speaker 2 (00:55:06):
Like phasix suture or even phasix Mesh. We have used them also and we have used the tiger matrix and something like this. Yes, there are some resorbable measures on the market. I’m not very optimistic that they will fix the problem or even the problem is, of course, you make a reconstruction and you add a match, and if, do you get a recurrence afterwards, you don’t know. What was the failure? Was it the match? Yeah. Or was it your suture? I don’t know. Have
Speaker 1 (00:55:51):
You done that where you do a tissue repair but you buttress it with a layer of absorbable Mesh, like a biologic
Speaker 2 (00:55:59):
Done that we have? Yeah. We have done some cases, not very frequently. I tried to avoid it, but of course we did some cases with resorbable, biological meshes.
Speaker 1 (00:56:12):
Yeah. I had a soccer player who, young healthy guy. He had a Lichtenstein, and it was just a bad experience. He had chronic pain from it, nerve entrapment, and I took out the Mesh, did whatever I had to do with the nerves and then did it. He didn’t want any more Mesh. He’s like, I don’t want any more Mesh. So I said, fine, but you’re a soccer player and you have a recurrence already. Let’s like two hits. Yeah. So I said, let’s compromise on this. Let’s do a tissue repair, but I need, in the short term, I need some extra buttressing to help scar in that tissue repair. He had fine for I think eight years, and then he came, he’s like, I don’t know, I have this little pain here. And the imaging showed a little tear in the tissue repair. It wasn’t a complete recurrence, but by then he was okay putting Mesh in, so I laparoscopically repaired it, and he’s like, fine. It’s like, it’s the best I’ve ever felt. But that’s my main long-term follow up in someone where I did tissue repair plus a buttress. Biologic scar tissues is not strong
Speaker 2 (00:57:32):
Enough. I do remember one case, which was really impressive cause he got, of course, he don’t like the idea to get a Mesh. Yeah. He got a previous shouldice repair, and after one year already, he developed a recurrence.
Speaker 1 (00:57:54):
Oh boy. So
Speaker 2 (00:57:55):
It was really, really early. And at that time there was a new brand, the Tigr Matrix on the market. And he agree using this Mesh in case of course, any kind of instability.
Speaker 1 (00:58:16):
Yes.
Speaker 2 (00:58:17):
He got this Tigr Matrix. Three years later he develops again a recurrence. And once again, he tried to avoid any foreign body. And of course, though, I think, yeah, so it was already very narrow for me. And I choose finally a disorder repair and it works.
Speaker 1 (00:58:42):
Okay. Yeah. I mean, disorder is an online Mesh. It’s an online biologic. You can think of it as online biologic. Yeah. It’s permanent biologic. It’s not an absorbable biologic. Yes.
Speaker 2 (00:58:54):
A permanent
Speaker 1 (00:58:55):
Biologic.
Speaker 2 (00:58:55):
Yes. And it’s a outlook flap of your own material. And of course, I think the very good thing is that when the data explain the mechanism, if you pull tension on this flap, then you narrow a bit the internal ring,
Speaker 1 (00:59:19):
And
Speaker 2 (00:59:19):
You make it a bit
Speaker 1 (00:59:21):
Like plication. You almost plicate it. Yeah, yeah. Just a little plication. Yeah. Yeah.
Speaker 2 (00:59:26):
And that’s quite interesting. I think. Of course, he’s using the crossing fibers to understand this technique. He visualized these fibers of the abdominal wall and the external oblique as fibers in different directions. Yes. And they are crossing almost. Yes. And this principle, he used to develop this technique. Got it. And that makes sense in my mind.
Speaker 1 (01:00:02):
I need to go visit Dr. Desarda.
Speaker 2 (01:00:07):
You’re
Speaker 1 (01:00:07):
Making me no, rethink my thoughts about it.
Speaker 2 (01:00:11):
No, of course. I think he’s might be very extreme because he strongly believes that we never use any, or we don’t need any measures. I’m, I’m not convinced about this. I think we need measures, but we don’t need measures in all patients. Yes. That’s the important take home message.
Speaker 1 (01:00:35):
Well, can you believe the hour is over? And that’s going to be our take home message.
Speaker 2 (01:00:42):
It’s really, oh, wow. Yes.
Speaker 1 (01:00:44):
Yes. Can you believe it? It’s 10:00 PM your time. Can’t
Speaker 2 (01:00:47):
Believe it. No, it was very, very short.
Speaker 1 (01:00:50):
Very short. Because, so Dr. Lorenz, I always enjoy speaking with you because I can talk to you forever when I see you at the meetings, which is the only time I ever see you, unfortunately. I just can’t stop talking with, I feel like we share so much and our brainwaves are similar. And it’s always nice to find someone that you kind of share similar thoughts and practices with. And I always learn something from you too. So yeah, it’s my pleasure to have you take time away from all the work you’re doing at the German Hernia Society teaching and talking and spending an evening with me and my audience on.
Speaker 2 (01:01:32):
I really appreciate, I’m really thankful for this kind invitation. And definitely we will continue this communication and this yes debate on these topics. And it’s quite interesting. And of course my enthusiasm about this topic, and of course there will be some progress.
Speaker 1 (01:01:53):
I do, I do. And I feel everything we do at a Hernia Talk Live is a reflection of cutting edge. And we follow guidelines and we try to teach patients about what is the best level of care. And it’s people like you that help push the quality of our weekly sessions. And for that, I thank you very much.
Speaker 2 (01:02:21):
Thank you so much for this invitation.
Speaker 1 (01:02:23):
Thank you. And thank you everyone else for your questions and your participation. This and all prior Hernia Talk Live sessions are all available on my YouTube channel at Hernia Doc. You can listen to it again, share it with your friends. I will see you next week with yet another lovely guest. And on that note, thank you and good night.
Speaker 2 (01:02:45):
Have a good night too. Or Evening, have a good day. Good. Thanks much earlier. This is true. Okay.
Speaker 1 (01:02:55):
Thank you Byebye.
