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Speaker 1 (00:10):
Good evening everyone. It’s Dr. Towfigh. Welcome to Hernia Talk Live. We are here on a Tuesday night. My name is Dr. Shirin Towfigh. Many of you know me as your hernia and laparoscopic surgery specialist. I’m also the host of our weekly Hernia Talk Live question and answer session. Thank you for joining me on Facebook as a Facebook live at Dr. Towfigh. And for those of you who are here via Zoom, I’m super excited to have you again for yet another exciting Hernia Talk Live session. For those of you that want to know more about me or to follow more about hernias, you can follow me on Twitter. I’m sorry, now it is called X, as well as on Instagram at hernia doc. So as you know, a lot of times I get my inspiration for our weekly topics based on personal experience or some of the talks that I give or meetings I go to or patient scenarios.
Speaker 1 (01:08):
And what I’ve noticed is for those of you that are on hernia talk.com as my free patient discussion forum that we’ve been doing since 2013, so over 10 years now, you’ve seen that there’s been a lot of frustrations lately and the frustrations seem to be things that are partially just part of the deal of having a medical problem. But I thought I would spend some time today answering your questions and addressing what I feel are just a hernia frustrations. And this is purely my interpretation of what I’m hearing from you as patients and your frustrations. I can talk about all of my frustrations, but I feel like I do that every week anyway, so maybe that’s not fair to keep talking about. Do you have audio now? Okay, audio is back. Okay, good. Good.
Speaker 1 (02:12):
Thank you. For those of you that are telling me that audio is not here, because if there isn’t, just let me know. Thumbs up, thumbs down. Okay, so what I was saying is that expecting a perfect outcome is expecting never to be in a car accident. And so that’s not reality. It can happen, but you want to make it so that there’s a least likely chance of having a car accident. So also you want to minimize your risk of having a bad outcome such as a complication for your kind of hernia repair. The reality is it’s not going to be zero. So there are a handful of people, especially on herniatalk.com that have had poor outcomes such as a hernia recurrence. I’m not talking about worse outcomes, but hernia recurrence and that poor outcome has completely changed their ability to decipher what’s going on and what kind of treatment they need, and all they can do is just lash out at their surgeon, lash out at the technique that was used, lash out at Mesh, et cetera.
Speaker 1 (03:26):
So that’s some of the frustrations that I see is that people go in expecting surgery to be perfect and they have a complication that is completely expected from a hernia pair, which is like a recurrence or bleeding or swelling or these are all kind of expected complications that the best of surgeons cannot prevent. It’s not going to be 0%. And there are people that text me or talk to me through the hernia talk messaging and say things like, I want to have complication free surgery or I want to, there’s no such thing. So the goal is to go in in the best health with the best surgeon and the best plan, but ultimately you don’t have control. And I feel like the sense of lack of control for your surgery is part of the frustration. And then there are a handful of patients that don’t understand that part of surgery and just medicine in general and then they just go off.
Speaker 1 (04:40):
So that seems to be a frustration by a lot of patients, which is this lack of complete predictability after surgery just isn’t. There’s so much discussion, oh, laparoscopic has more complications. Oh, does open have more complications? Does tissue repair have more complications? And there’s a lot of discussion, but it’s uncertain. For some people, laparoscopic surgery will have a worse outcome than open surgery. For other people, it might be maybe the reverse for women, we have population studies that show laparoscopic repair with Mesh is pretty good. Open repair with Mesh, same exact kind of concept of hernia repair, but different approach, much worse outcomes. So does that mean every woman should have a laparoscopic repair with Mesh? I don’t believe that, but if you look at the population study, that’s what it shows.
Speaker 1 (05:39):
So I was told when I was applying to medical school, this is an undergrad that engineers tend not to be good physicians. I didn’t understand that question or that concept. They say that artists and people that are more creative tend to be better physicians and people that are in the sciences tend to be better physicians. Why is that? Because engineers deal with math and construction. There’s a formula for everything and that formula comes up with an answer. So there’s an answer for everything and the predictability of stuff is very clear. So if you go in to make this kind of roof on a house with these dimensions, the outcome is predictable based on what material you use, what angle you put it in, what the foundation is, et cetera. There’s no like, oh yeah, that roof should be okay, but we never know. That doesn’t occur in engineering.
Speaker 1 (06:50):
That’s why we have such excellent safe airplanes and rocket ships and so on. It’s still not perfect, but it’s very predictable if something’s going to go wrong. There is no such predictability in medicine. So people may die from hypertension, many do well with hypertension. There are certain medications that work well for high blood pressure and others that don’t work well. There’s a lot of, they say there’s art versus science. There’s a lot of art to medicine and not as much science as you would think. And the more you learn in medicine, the more you appreciate the variability in medicine. Whereas most people think, hope, pray that there’s no variability and they want an actual answer. And when a physician says, I don’t have the perfect answer for you, then now they start saying, well, what kind of doctor are you? So one of the reasons why I was told engineers don’t do as well in medicine, they’re not as comfortable in medicine, they’re not the best people to accept for medical school is because their world of engineering is very concrete, black and white and medicine is absolutely not black and white. There are lots and lots of grays in it. One perfect example is you can take an ultrasound or an MRI and have multiple radiologists read it and multiple radiologists will come with a different diagnosis for the same image, kind of looking at a piece of art and try to interpret it.
Speaker 1 (08:31):
So that’s very frustrating for most patients and I try and kind of give my own perspective to patients, but it’s often not hard. I just got a recent phone call from a patient, a friend of a patient because there was a little piece of their wasn’t completely closed and therefore they thought that this was the worst outcome. How is this possible? This is the worst outcome that can happen after this procedure. Meanwhile, me as a surgeon knew that this patient has problems healing, has a disorder that prevents them from healing, has been on medications that prevent them from healing and is undergoing an operation. There’s fraught with potential complications such as bleeding, fluid, collections, infections and poor healing and therefore did my best to do an operation to prevent problems such as healing, prevent problems such as fluid collection, prevent problems such as infection. And from my perspective, they did really well.
Speaker 1 (09:51):
All they had was a one centimeter opening of their wound. Everything else is healed and there’s no infection, which I’m like, wow, thank God. That’s really great. Patient’s point of view is this is the worst outcome ever. I’ve had multiple operations before, how is it? I’ve never had all this gaping wound. Okay, it’s one centimeter by my view, but from the patient’s view it’s this huge gaping wound. So I had to help explain and remind that I discussed this before surgery, that there are all these potential problems that can happen and I’ll do my best to help prevent them, but nothing is perfect. So this is just an example from this past week, and I say these to give you perspective as to patients’ frustrations because something that I or another surgeon may consider to be a small problem recurrence. I think most surgeons consider recurrence a relatively small problem because it’s fixable and usually fixable with good results. Chronic pain, much more difficult. So if you had to choose between chronic pain, nerve pain and a hernia recurrence, I would always choose a hernia recurrence because that’s very treatable. But in a patient’s standpoint, that may be a huge F. What do you mean hernia recurrence? I just had surgery and now it’s recurred. I need a second surgery. To them that’s like a huge hurdle and a big problem because they’re not necessarily seeing the 50 other problems that the patient has not had complications from.
Speaker 1 (11:38):
So it’s just a different way of looking at things and I can see how patients can get very frustrated. I tell my residents to worry. I was taught by my mentor to be a compulsive pessimist, always worry that something may go wrong and therefore you always have to worry about your patients and that makes you a good doctor because you’re constantly diligent about thinking of all the roadblocks that are in front of you and then making decisions to prevent bad outcomes. And I explained to them that the good residents are the ones that the higher level up they get, the more they worry. They don’t relax more, they actually know more, which means they know more about what can go wrong. So when it’s your first year, you would think that’s when you are the most stressed out. You just started, you just were a medical student the prior month.
Speaker 1 (12:32):
Now you’re a doctor and you’re expected to take care of patients and do a lot of autonomous, make a lot of autonomous decisions, and they get very kind of stressed out and they probably look at the chief resident that’s the resident, the last level of their training before they go out and they probably think, wow, they’re so calm and cool and they know what they’re doing and they’re going to be out in the world right now. Not true. The best residents, the higher up they go in their level, the more complications they’ve seen, the more disasters they’ve seen, the more potentials for injuries they’ve seen, and therefore the more cautious they are, the more their brain is constantly thinking about what goes wrong. If someone has a fever, they don’t think, oh, that’s probably okay. They just need to walk a little bit more. They think of everything possible that can go wrong from an early fever after surgery, let’s say people say, oh, just take some Tylenol, we’ll check you in the morning.
Speaker 1 (13:42):
So that’s also true for surgeons. The good surgeons are the ones that worry about their patients. I worry all the time. I had a dream last night about my patient. I referred a patient to a friend of mine who I respect very much and he is a very gifted specialist in town. I dreamed of the whole experience. I dream and I did speak with the specialist by phone, sent him all my notes and kind of coordinated care. But all that night I dream of going to my friend’s new office, checking out the new place, looking at the new machines they have.
Speaker 1 (14:28):
My fellow was in that dream. I was waiting for the patient to show up. I mean, I internalize a lot of stuff of what I do during the day. At night, I slept well. It wasn’t a bad dream, it was actually a good dream, but my point is to this day I’m constantly thinking and worrying about my patients and following up, and fortunately my office does the same. So my nurse bell, which many of you have heard of, is constantly calling, checking, texting with my patients when I’m in the operating room. That’s a lot of what she does when there’s no patients in the office. And then also my staff. I literally have my own staff. My office manager would text me, how’s Mr. So-and-so how’s Ms. So-and-so most offices or office managers don’t ask the surgeons about the patients. My office manager has literally gone to the hospital with flowers for some of my patients.
Speaker 1 (15:27):
That’s the kind of people that work with me and Beverly Hills Hernia Center, we are lovers of hernias and we really take care of our patients anyway, so one of those frustrations is kind of this inability to predict outcome, the inability to say, okay, a hundred percent chance you’ll have no problems. Here’s a question. About how long after surgery does your follow-up continue? Months, years? Well, ideally lifetime. So we belong to a national database where by default the patients get emailed about how they’re doing at three months, six months, a year, and then every year after that till the end of life we also have a research group. And so we have patients that we follow up with for our database to make sure they’re doing well. And then based on that data, we try and analyze how we’re doing and how we can improve.
Speaker 1 (16:36):
So many times our patients are called in addition to see how they’re doing from certain procedures. So ideally, lifetime, there’s no mandate for that. Currently, not for hernias. For cancers, there is. So that’s another frustration I think that I’d like to share is that in the United States, there’s no mandate for any follow-up from most surgeries except for really cancers in a handful of other specialty procedure, definitely not for hernias. The only mandate if you want to maintain your board certification is you have to follow your patients up to 30 days after surgery and minimum, minimum 30 days after surgery. There’s no maximum. And there are a handful of quality assurance programs in the hospital that kind of do that for you. So not every surgeon has to do that themself. They can just belong to the hospital’s quality assurance program and they usually stop at 30 days.
Speaker 1 (17:40):
After 30 days, there’s not as much follow up. Quite expensive to follow up. Certain countries, Germany, Sweden, Denmark, have mandated countrywide databases that include hernia databases that follow their patients for the life of the patient while in that country, and most of those patients don’t really travel outside the country. So the Swedes, the Danes, they tend to kind of stay in their country. They tend not to leave. Immigration’s not big there, and so the quality of their databases is actually really good. Now it’s not very granular. So for example, for my own database, because it’s my own patients, I can tell you exactly if I wanted to, I can tell you exactly what sutures were used and how many were used and how many minutes they were in the operating room. But a lot of, and maybe that’s important at one point, and many of the people that are, many of the databases don’t have that, so they can answer certain questions, but not every single question like a research question based on these databases.
Speaker 1 (18:56):
Here’s a question, two questions. One says, how many surgeries is too many? I know it’s a loaded question. I’ve had six bowel repairs for various issues. Okay, well, six is definitely usually too many. If you’ve had an infection that may be kind of in the realm of what happens anytime you have an infection with the hernia involved, you kind of add two or three more operations minimum as part of it. We don’t usually include injections as surgeries, but it’s not so much the number of operations but the purpose of each operation. So for example, if you’ve had six hernia repairs because you had a recurrence five times and each time you had another recurrence, that’s a problem. That is definitely not a good outcome and you have to at some point, maybe after number two or number three, figure out what’s going on. Why do I keep getting hernia recurrences?
Speaker 1 (20:05):
It’s a technique, is it not? Because I have a chronic cough, I have a enlarged prostate, I’m constipated, I’m overweight, I’m obese, I have C O P D, I have obstructive sleep apnea. My diabetes is poorly controlled. These are all risk factors for hernia recurrences. Do I ignore hernia recurrences and I end up having surgery as a emergency each time. So these are all risk factors or do I have just a genetic problem that no one’s figured out where I don’t heal very well and they’re treating me like a normal hernia patient, but they really need to treat me like a patient that has a healing disorder and change their technique. However, if you had a hernia surgery, let’s say, and for whatever reason you had an infection, let’s say you had a perfectly good hernia repair and then bad luck, you had appendicitis or you had diverticulitis and you needed surgery for it or it caused the fistula or something and then you got your Mesh infected and then that started a whole cascade, well then that’s kind of a horrible unfortunate situation, but you’ve now bought yourself two to four other operations to deal with everything maybe more.
Speaker 1 (21:28):
So that’s kind of the situation. Let’s see the follow-up question. I have a small left inguinal hernia currently the doctor did not want to repair it. My last surgery when they did an umbilical hernia repair, okay, now it’s given me issues and my surgeon is strongly opposed to repair unless it gets worse as there’s currently no bulge.
Speaker 1 (21:56):
My operations were sport hernia slash pelvic floor, nerve clipping, anal hernia, umbilical hernia three times the third was finally repaired with mesh. I did not want the first two surgeries. Okay, so let’s evaluate this. First of all, you’ve had six hernia repairs, but they’re in two different portions of your body, so that doesn’t really count as six hernia repairs because the two are unrelated. The umbilical one you had done three times because it sounds like you didn’t want Mesh the first two times and sounds like in retrospect that was the wrong decision because the first two operations probably should have been done with Mesh to prevent you from having the recurrence. And this is a really good point. It’s one of my frustrations, which is when patients come in and they have a certain demand without really understanding the implications of their demand, and sometimes I agree with them, small one centimeter umbilical hernia in a low risk patient, yeah, I can do that without Mesh. Sure, it’s not a 0% risk of recurrence, maybe five to 7%, and if it recurs, then you need to have Mesh. But if you’re morbidly obese and have any of those other complications, you’re a smoker, you’re diabetic, chronic cough, C O P D, constipated, et cetera, then that same hernia may require a Mesh because now it’s not a five to 7% risk. It’s like a 30% risk of recurrence and that’s considered too high.
Speaker 1 (23:45):
So unfortunately because of your decision with the surgeon to do the first two without Mesh, and finally the third with you bought yourself two extra hernia repairs, you could argue maybe the first of the three was legit without Mesh and you fell into that lower risk of recurrence. Then when that recurs, then really you should be using Mesh, but you didn’t. Okay, then let’s go to the hernia. So you had a sports hernia, pelvic floor surgery, then nerve clipping and then inguinal hernia repair. So I don’t understand why you had to have nerve clipping unless the nerve was injured at the time of your sports hernia, pelvic floor surgery or they mistakenly thought that your pain was due to a nerve, whereas you always had an inguinal hernia repair. That is where my frustration comes into play, which is that for whatever reason, you had a misinterpretation of your symptoms, you had two operations that were performed that if you had the original inguinal hernia diagnosis, you would’ve just had the hernia repaired and not gone through this whole sports hernia, pelvic floor, nerve entrapment kind of scenario. I see it a lot. I don’t know why. I feel like surgeons don’t understand the concept of occult hernias and how painful they can be, and then they take the patient through the sports hernia protocol even though they’re not athletes and it makes no sense to me. So undergoing six different operations for hernias, really you had three pelvic and three umbilical hernias and potentially could have had only one or two.
Speaker 1 (25:31):
Let’s see, so I hope I helped answer that. Oh, it says the doctor did not want to repair. I have a small left ankle hernia the doctor did not want to repair at my last surgery when they did umbilical hernia repair and now it’s giving me issues. I think my surgeon strongly opposed to repair unless it gets worse. Well, the reason for it is people who have surgery can have surgical complications. People who don’t have surgery can’t have surgical complications, they can only have hernia related complications and we know that patients that have minimal symptoms, so zero to minimal symptoms in the groin or even in the abdominal wall for umbilical hernias, that watchful waiting is considered safe because actually what can happen is you have a 0.18% per year risk of some problem requiring surgery for an inguinal hernia and a 0.2% risk for umbilical hernia, and that’s considered significantly lower than any surgical risk that can be implied by surgery.
Speaker 1 (26:38):
And therefore many of us, including myself, encourage to do what’s called watchful waiting if they have a hernia they don’t even know about, but if it’s bothering them and you can improve their quality of life by repairing the hernia. So I hope that makes sense. Alrighty, I wanted to tell you a little bit something else that I think I touched on a couple weeks ago, and I definitely talked about it on hernia talk.com with those of you that are on the platform, and I was surprised that it wasn’t well received. So one of the frustrations was that there’s plenty of studies, for example, that support laparoscopic surgery with Mesh having the lowest risk of Mesh related chronic pain or actually any chronic pain. The recurrences are low, lower, the short-term recovery is faster. Long-term chronic pain rate is lower than open repair with Mesh. That’s pretty well accepted literature, and that’s also found not only in major databases, prospective Danish database we database, but also in smaller studies, expert papers, et cetera. The caveat is the surgeon needs to know what they’re doing. So usually these studies are published by experts, so it’s possible that if you have these done by a non-expert, the outcome would not be the same.
Speaker 1 (28:19):
We often look at the VA study as a measure of what happens when non-expert or what we call community surgeons do hernia repairs versus experts, but then there were patients that came on the forum and said, but look at me. We have so many people on this forum, for example, that have complications with laparoscopic repair or robotic repair with Mesh, which is true even in my practice. I’m seeing a growing number of people that are presenting with complications not from open surgery, which is more expected, but from laparoscopic surgery. But my discussion was this, that even if I tell you, I’ll give you an example. I’m going to tell you that 12% of all hernia repairs in the groin will result in some type of chronic pain or pain after the first three months, and that number drops to under 6% after one year. That’s based on a conglomeration of population studies.
Speaker 1 (29:25):
However, I cannot say that for you personally, you’re going to have a 12% recurrence problem because you’re going to come to me potentially. Can you guys hear me okay? You’re going to come to me potentially and say, I had a bad outcome, or yeah, you going to say I had a bad outcome. It’s true that and a population, that number may be 12%, but in someone who’s super thin, that number may be higher for open surgery or the difference between laparoscopic and robotic and openly higher or someone who’s morbidly obese will be different. So from an individual standpoint, we don’t have any data where I can plug in your gender at birth, your B M I, your lifestyle, all your risk factors, your blood sugar level, et cetera. I cannot plug that in and then have you have it say, okay for you you’re going to have a 3% risk.
Speaker 1 (30:49):
We just don’t have that data. Now, if you had breast cancer or if you had some type of lung cancer, we actually had that data. Breast cancer of almost all the other, has very excellent long-term prospective database data where they can tell you exactly what is good or bad with each technique and help you make choices. We do not have that granularity for hernias. And another frustration that I see patients have, which is completely legit is I may give you one number and then you can go to Nebraska and have your surgery there and the expected outcome there is completely different. And that’s true of every surgery, which is the surgeon makes different choices, has a different technique, has different skill, makes different recommendations, and those are all factors that are going to affect your outcome. So it’s very frustrating for patients to hear me, for example, saying, oh, laparoscopic surgery is so much better than open for the population. I don’t see that to each patient. I see. I have patients in my office that come and they’re like, I’ve used this example before. They’re like a ballerina type or a model. I may not recommend laparoscopic surgery with Mesh. I may recommend open surgery, which is completely not supported by most population studies, but for that specific patient in my experience, I feel that’s a better decision.
Speaker 1 (32:31):
But you may go to some doctor that’s in a small town that only does maybe 20 to 50 laparoscopic repairs a year, which is not enough, and you’re not going to get the same outcome as an expert and just going there and saying, oh, I’m getting laparoscopic surgery, thinking that’s the right decision, may not be the right decision for that specific surgeon, which is why many of us say the best decision is for the surgeons to do their operation they’re best at, because some people do really good open surgery and they have good outcomes with that, and they’re horrible laparoscopic surgeons. We have a bunch of them in Los Angeles. I would not want them to do laparoscopic surgery on me because I know that they’re not as skilled in it. They don’t understand that and vice versa. There are a handful that probably should just do laparoscopic and don’t do any open surgery because you don’t know what you’re doing and you’re going to cause problems.
Speaker 1 (33:30):
So that inability to come up with the perfect answer for your hernia repair and there’s no database you can go to that can give you personalized outcomes data and there’s no way to say, okay, there’s a hundred surgeons that do this operation, they’re ranked. There’s no ranking of us surgeons to say who’s the best currently. There are some efforts to do that. I’m actually part of one of those efforts to try and help rank surgeons based on their outcomes through a population database of outcomes, but that requires a lot of patient feedback. It’s frustrating If I were to have a hernia repair and I didn’t have the personal knowledge of people that I know, it would be very frustrating to know who to go to because you may be limited geographically, you may be limited financially, you may be limited in terms of time. These are all factors.
Speaker 1 (34:46):
So that’s very frustrating and I see that frustration a lot in my patients and they express it online. Oh, they say, well, Dr. Towfigh, that’s easy for you to say blah, blah, blah. How do we know what is the actual best surgeon or best technique or whatever? And I don’t have a good answer for that. All I can say is always get a second opinion. And when you do get that second opinion, or maybe third or fourth, I’ve had operations myself, I’ll see six doctors and I would know them all personally, and I would still go and go through the motions, be their patient, have them examine me and come up with an actual plan of care and then I’ll make a decision. And I’ve had situations where either for myself or for my family members, I’ve helped them make a decision that was against what my original thought was because then I went and saw the surgeon and we talked and discussed, and everyone should really do that even if they think they don’t have the resources they should because it’s an investment. It’s a luxury investment in your health.
Speaker 1 (36:03):
You must invest in your health. We are not in a system where you can get the same care everywhere across the us. It’s just a reality that’s true for everywhere, anywhere in the world. There’s a are some questions that were submitted. I’d like to be able to get to that. If I had a hernia, I would have you operate on me. Oh, thank you. And if I needed a nose job, maybe I’d come to you. I don’t think I need a nose job. If I do, I don’t plan on getting it. Okay, let’s see. There’s some questions that I can, yeah, there’s lack of certainty and this variability, variability among surgeons, variability about what they recommend. Patients will come to me and I’ll spend an hour with them and they will come out with a very concrete plan and I’ll explain to ’em exactly my reasons for everything and then they’ll go to another surgeon and they’ll say, yeah, sign another hernia expert.
Speaker 1 (37:16):
And I’m like, who is that? And they’ll give me the name and I’ll be like, okay. To be honest, they’re not a hernia expert, but okay, what do they recommend? They said they completely disagreed with you. Okay, based on what? I don’t know. They basically said they would not do what I recommended. Fine, everyone has a right to their own opinion. I strongly disagree. I mean, I’ve had people go to surgeons where the surgeon said, the Shouldice is just a sham operation. I’m like, are you kidding me? How could you say Shouldice is sham?
Speaker 1 (37:50):
That doesn’t sound very legit to me. But there are surgeons that may say that to a patient because they don’t know how to do a Shouldice for knee repair and therefore that’s not even part of their list of operations they would recommend, and I think that patient I recommended or we discussed. Here’s another comment. I always learn something new from you about hernias. Keep up the outstanding work. Thank very much appreciate it. Thanks for watching. Here’s a question. Why does being thin increase the risk of having pain? Because your nerves are more exposed. There’s not enough fat to buffer. You’re, if there’s Mesh to be used, the Mesh, you may be able to feel the Mesh more because whereas someone who’s got some fat on them may not feel the Mesh and it all causes inflammation, so you may feel the inflammation more because you don’t have the fat to buffer.
Speaker 1 (38:51):
Most studies show that being extremely thin is not your friend. There’s another question. I have a small inguinal indirect hernia, less than one centimeter with five centimeter fatty lesion or lipoma along this spermatic cord. One surgeon said to have watchful waiting, but the other said the earlier the better. Can I delay the surgery as long as I can stand the discomfort? So the studies only look at people that have no symptoms or are minimally symptomatic. Minimally symptomatic is defined as having minimal symptoms that do not affect the quality of life. So you can still work, exercise, sleep, do your daily activities be on your feet a lot, go to parties without the hernia affecting it. If you fall into that category, then you have a 0.18% chance per year that you will need emergency surgery for an incarceration or where the hernia gets stuck. Other than that, that’s all the data that we have to say. Can I predict that you’re going to fall into that 0.18% likely not. Like if you were going to bet probably not. The size of the hernia is not a reason to operate. It’s the symptoms. So you can have a five centimeter hernia or a one centimeter hernia, and my recommendation would be the same in terms of the safety of what’s called watchful waiting. The surgeon that said earlier is better.
Speaker 1 (40:25):
That is not necessarily a hundred percent accurate. So if you want to have a tissue repair and Foregut hernia Mesh, then the smaller the hernia, the better the tissue repair. That is true. If you want to have the best recovery with the least amount of bleeding and seroma and hematoma and fluid collections and so on, then the smaller the hernia repair, the less risk of those things. But those are all short-term problems. It’s easier to repair smaller hernias than larger hernias. But is it better usually, not necessarily. So I hope that helps clarify because I do hear that a lot. Oh, it’s better to do it early, better for whom? Is it easier for the surgeon? That’s important to make sure that, but is it lower recurrence rate for ventral hernias? Small. That’s true. You don’t want to operate on bigger ones, but for inguinal hernias, that’s not that much true.
Speaker 1 (41:30):
If you’re okay having Mesh in you. Here’s another question, Dr. Towfigh, why do doctors feel that a Mesh is a go-to when repairing a hernia? Again, this is based on very widely accepted population-based data, looking at outcomes and by outcomes, they usually talk about recurrence. So all hernias, every single hernia that has ever been studied has been shown to have a lower recurrence rate and better long-term outcomes with regard to recurrence, if you use Mesh and surgeons are often evaluated by their outcomes. In other words, their recurrence rates and therefore Mesh has been shown just lowest recurrence rate. It could be a one centimeter belly body hernia or it can be a 20 centimeter abdominal hernia.
Speaker 1 (42:28):
You have to use Mesh if you want to have the lowest recurrence rate. Now, there are other ways to look at outcomes. Let’s look at serious complications. Long-term problems such as bowel obstructions, infection rates, those are all higher with Mesh, not large numbers. These we’re not talking large numbers, but they are higher. Let’s look at chronic pain rates for the groin. There’s conflicting data unless you add laparoscopic surgery in there, open Mesh and open tissue repairs tend to have similar chronic pain rates for the belly button hernias, usually non Mesh repairs have more chronic pain than Mesh repairs usually. And then again, technique. It depends on technique and your personal risk factors and so on. But the reason why Mesh has been a go-to has been it has dramatically reduced hernia recurrence rates. And if you guys go to, they never have a chance to volunteer south of our border or in Africa. These people, there are people that have hernias you’ve never seen before. It is humongous. And that is because they either don’t use Mesh or they don’t get early care and these hernias don’t do well.
Speaker 1 (44:01):
We don’t see those kind of recurrences here, and part of the reason is because we do use Mesh. Here’s another question. Thank you for the great session. I have chronic pain on left testicle, four to five out of 10, dull pain reading around to the bottom after open surgery five months ago. Anything I can do to deal with the pain? Yeah, so if you’re five months after surgery, you should not have testicular pain. The question is, did you have Mesh or not? And why do you have testicle pain? Is it because you need to get ultrasound to look at your testicle itself? Do you have a fluid collection? What’s called spermatic seal epididymitis, which is very common after hernia repairs, which is kind of an inflammatory or an infectious problem or poor blood flow to your testicle. If those have been ruled out, then you should then evaluate the groin, put the good physical examination by your surgeon and figure out why you have the pain. Is this a nerve issue? Is this too tight of a repair around your spermatic cord and so on? And then the history is important. Were you doing fine for five months and all of a sudden now you’re having pain or not? So there’s like you need an hour with your surgeon or a surgeon expert to go through all of these and tick off all the boxes to help figure out what’s wrong. But it’s not normal to have four to five out of 10 pain five months after hernia repair.
Speaker 1 (45:29):
You need to figure out why that is. That’s almost always treatable. So there’s no reason to prevent seeking help or to be told that it’s all in your head or there’s nothing to do or give it a year. I’m not one of those people that does that. Let’s see. Oh, here’s another one. Another frustration that I hear a lot is, yeah, that’s easy for you to say, Dr. Towfigh, you’re an expert and you say, go see experts, but there aren’t that many experts. Or I live in a state with no expert or I don’t have the finances for an expert. That is a real problem. We do not have enough hernia specialists in the United States, although we have much more than any other country, including all of Europe and the hernia experts that we have. There’s only a handful of us. We are trying to encourage our residents to go into hernia surgery, and I would say both on my side and my colleague’s sides, we have been able to increase interest in hernias and more people are doing hernia specialties than before.
Speaker 1 (46:41):
So that’s a good thing. And more people are eager to do a good hernia pair and are spending a bit more time learning how to do a good hernia pair than they were during my generation. So that’s a good thing. But yeah, it is quite frustrating for patients that they don’t have access to, or I would say they don’t have ready access to a hernia specialist. It’s why I started what’s called an online consultation. So if you live anywhere in the united, actually anywhere in the world and you’re not near me, you can initiate what’s called an online consultation, which is just send me all your information, well talk with my nurse, she’ll work with you to get all your information, imaging, whatever your history or medical history, your symptoms, any operations you’ve done. I’ll review those and give you a report as to what I think is going on, and then maybe I can help you find someone near you who can help you or maybe you’ll say, oh, okay, this is helpful.
Speaker 1 (47:48):
I’m just going to come to you. So here’s one question. Do you have any referrals around Western Pennsylvania or Pittsburgh? Yeah, so that’s why I made hernia talk.com. Just go to herniatalk.com and put in Pennsylvania or Pittsburgh or something like that. I have had guests on hernia talk that are from Pennsylvania that are hernia experts, at least two hernia experts and one plastic surgeon. So there’s no reason for you not to be able to go into hernia talk.com in the search section and search for states, and then those names will come up. You can also ask other people that are on the forum for their recommendations.
Speaker 1 (48:33):
Let’s see. I have a recurrence of, this is another question. I have a recurrence of an indirect hernia after open hernia repair for recurrence. So this is your second recurrence. I do not have spontaneous testicular pain, but rather pain if I do not wear supportive underwear, i e traction on testicle causes pain. Any thoughts? That usually means that you’re upstream where the hernia repair was performed. There’s some type of adherence of the Mesh or the repair with your spermatic cord, and sometimes massage helps to reduce that scar tissue. If so, great. If not, you have to release the scar tissue and the Mesh from your spermatic cord. That’s usually the situation.
Speaker 1 (49:21):
But yeah, if dangling of the testicle is painful, it means because usually there’s something holding it at the level of the Mesh repair that’s preventing it from being more mobile. Another question, Dr. Towfigh, is there a difference between hernia specialist and a general surgeon? Yeah, general surgeon is a general surgeon. Hernia specialist is a specialist. So in terms of training, everyone’s a general surgeon. First and general surgeons learn to do a bunch of operations including hernia repairs, and they may or may not choose to do more or less hernia repairs in their practice. Hernia specialists tend to do more than 50% of their operations on hernias, and I believe a true hernia specialist should be able to offer a variety of care for patients with hernias, including open, laparoscopic, robotic with Mesh without Mesh hernia repairs, including revisional hernia surgery, including the ability to figure out if you have nerve pain, including the ability to understand a wide variety of reasons why people have pains that are outside of the hernia world, which may be urologic, gynecologic or orthopedic neurologic, et cetera.
Speaker 1 (50:47):
So that’s my bent. There aren’t that many of us that actually can do that specifically and can do Mesh removals and replacements and so on. However, there are fair number of general surgeons that do spend their time doing about 50% hernia repairs. I personally don’t consider all of them hernia specialists, but those that can handle revision surgery are probably, so you should just ask ’em what percentage of your practice is hernia repairs? They say, oh, at least 25%. Okay, well, they’re just a general surgeon and that means they don’t have a special interest in hernias. But if they say, oh, over half of my patients are for hernias and I really enjoy the complicated ones like where I have to do revisional surgery, that it’s getting closer to being a hernia specialist. Here’s another question with regards to previous testicular question. It was a tissue repair.
Speaker 1 (51:48):
Could simply scar be causing traction related to testicular or spermatic cord pain? And does that require reoperation? So depends on the technique. So some people during their tissue repair actually put a stitch at the spermatic cord at the cremasteric muscle, and that can cause testicular pain or, but less frequently they can make it too tight or change the angle of the direction of the blood vessels and spermatic cord that goes down the testicle and that change in angle can be painful. All of those are situations where you need revision surgery. Short of that, if it’s just scar tissue, then deep tissue massage and massaging of the spermatic cord may help. It may help. That’s one way of helping get some of that care. Oh boy, that was a lot. Let’s see. Are there any questions that I missed? I’m just going to look through this really quickly.
Speaker 1 (52:48):
We talked about lack of specialists, population studies. Oh, okay. Let’s talk about this last frustration. It’s all of this. Who do you trust? Do you go on Facebook and trust the people that are saying that Mesh is toxic and leach is cancer into you? Do you trust the industry that says, oh, Mesh is perfectly safe and inert and we don’t know what you’re talking about. Do we trust physicians or that say, I’ve never had a complication before. Do you trust the patient advocates that telling you to go one surgeon versus another? It’s really hard to be able to navigate the system, and I feel that it not only causes frustration for my patients, but it adds a sense of anxiety and adds to their mistrust of the medical field. And it’s really hard for me to talk people down from their anxiety when they’ve already come to my office having done tons of research and have gone, some of ’em have gone through this whole rabbit hole where they believe, let’s say Mesh is bad and they should never have Mesh in them.
Speaker 1 (54:06):
And they come to you with this big scrotal hernia. And I say literally, for you personally, that is a horrible decision and I would not offer you non Mesh repair even though I would offer it to someone else with a different situation. And then now they don’t know what to do because they just spent two months trying to figure out, what do you call it, trying to figure out the best option. They came up with one option. I came, then they come to me hoping that I would validate them, and some of these people have traveled from afar and I just knock it down. So it’s really, really frustrating for patients because they don’t really have that perfect guidance. It’s one of the reasons why I built hernia talk.com to hopefully have a unifying discussion forum where people can discuss their frustrations and get some type of help from their peers and also from doctors and surgeons like me.
Speaker 1 (55:07):
It’s also why I started Hernia Talk, Live this q and a, which is a weekly webinar. And for those of you that enjoy watching or listening to podcasts, guess what? We have started Hernia Talk as a podcast. So all of there are close to 150 episodes so far are being uploaded sequentially. If you want to start listening to the podcast in your car while you’re traveling, while you’re doing your job, while you’re walking your dog, while you’re gardening, Hernia Talk Live is currently live on Apple Podcasts, Spotify, and anywhere else where you listen to podcasts. And I’m super excited about it because it’s really the next step. I wanted to take this, and I know that many of you join us on YouTube and watch this on YouTube, which I love. You don’t have to see me or look at my face. You can just listen to me.
Speaker 1 (56:12):
And if you do do the podcast, you’ll notice the first several episodes, audio not so good. I was just playing around during the pandemic and I think the audio is much better now and the production value is much better now. So thank you everyone for joining me. I hope I adequately represented your frustrations because I share your frustrations with you. It’s definitely something that I understand and get. And please go ahead and go to my YouTube channel and watch this at Hernia Doc and go back to my older episodes on Hernia Talk Live as a podcast and subscribe, subscribe, tell your friends, and hope it becomes an even bigger reach since it’s going to be a podcast. All right, everyone. See you next week. Talk to you later. Bye everyone.
