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Dr. Towfigh (00:00:09):
Hi everyone, it’s Dr. Towfigh. Welcome back to Hernia Talk Live. I’m your host, Shirin Towfigh, hernia and laparoscopic and robotic surgery specialist. Thanks for everyone who’s been following me and DMing me on social media at Hernia Doc, on Instagram and Twitter or X. Many of you’re joining me live right now on Facebook at Dr. Towfigh. Remember, we’re reaching 200 episodes here and you can watch all of them on my YouTube channel at Hernia Doc. And also if you’re a podcast fanatic like me, I’ve been catching up on a lot of really cool podcasts lately. I have a podcast available as well that’s Hernia Talk Live wherever you listen to podcasts, whether it’s Apple Podcasts or Spotify or whatever. But the purpose of today’s session is to, number one, be available to answer a lot of your questions. Many of you have been reaching out to me on hernia talk.com where it’s 24 7.
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It’s a discussion forum available to all of you to talk about everything you like about hernias, everything you don’t like about hernias, et cetera. However, much more importantly, I’m here for you every Tuesday as much as I can and I’m here to answer your questions. I thought the topic of discussion can be limited, however, somewhat to timing of your hernia repair. And I bring this up because as you know, I often pick my topics based on my experience in the past week or two at the office was seeing patients. And lately I’ve been talking a lot about the importance of timing of your hernia repair and that could be whether you definitely need surgery and when’s the optimum time to repair it, whether you know, have a hernia but you don’t really know when you should repair it or if you know have a hernia and it’s kind of like no symptoms and watchful waiting could be an option.
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So let’s go through this. I’ll share some patient stories with you because I think that most people relate to patient stories and if you have any questions, just type it on the bottom here as part of the chat. Or for those of you on Facebook, you can just put in a comment in the Facebook and I will try and answer that for you. So let’s talk about timing of surgery, and I’ll give you a couple of scenarios that I recently had. So as you know, I’m a big fan of watchful waiting and that means that for either primary, which means you’ve never had surgery before, ventral, which means abdominal wall or inguinal, which means in the groin, depending on those situations, if you have no symptoms, then for most patients it’s perfectly fine to have what’s called watchful waiting, which means let’s see how you do continue on with your life, try and have a healthy lifestyle.
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No constipation, no coughing. If you have asthma, treat it. If you’re morbidly obese, lose weight, but be as active as you can be. Go to the gym, exercise, et cetera, work, live your life. And if you continue to have no symptoms, there’s at least three clinical trials, in fact more of recent in Europe, which have showed that it’s perfectly safe not to have your hernia repaired. What does that mean? Perfectly safe. That means you can have your lifestyle as you are living it with the hernia without the risk of needing to go to the emergency room to have your hernia repaired under emergency circumstances, which is not ideal. You’re not going to die from your hernia and your surgery will not be any worse if you delay your surgery. So these are all kind of how we talk about watchful waiting, and I think it’s a good decision for watchful waiting even though I personally for myself always choose the more aggressive treatment, but I do also believe that sometimes the better treatment is no treatment.
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How do I explain this? It’s not uncommon, and I had a couple patients last week. It’s not uncommon for patients to come to me complaining of their hernia repair, right? They have chronic testicular pain. It hurts when they sit. Some of them lost their job or they can’t do the prior job they wanted to do. Some people have home jobs and they’re sitting like me in front of a computer like I am right now and it just hurts with them sitting or they can’t stretch anymore, their belly hurts, et cetera. So I always say, okay, let’s go backwards. Let me track your symptoms to try and figure out why you have this pain. And the question I always ask is, let’s go to before your hernia surgery. How were you before? Did you have a bulge? Did you have pain? And many patients unfortunately say, had no pain.
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Some people say, I didn’t even know I had a hernia. I went to my physical with my doctor, family, medical doctor, internist, nurse practitioner, and they found a hernia and therefore sent me to a surgeon. That’s a good chunk of patients. Didn’t even know they had a hernia. And because the diagnosis was made during their annual exam, or let’s say they did a physical for insurance or a physical for let’s say they’re a fireman or something, and then they’re told they have a hernia and that starts to cascade of getting it repaired. Other patients like, yeah, I had a hernia, I’ve had it for 20 years, never bothered me. And then the doctor says, oh, well you should go see a surgeon. And then the surgeon offers them surgery and they have surgery. So that’s kind of a very sad story where the patient before the surgery was doing just fine.
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They either didn’t know they had a hernia or they did know they have a hernia and it didn’t bother them and now they had surgery and now they’re in chronic pain. Now, fortunately, the percentage of people that end up in that category, it’s not high. We don’t expect a large percentage of patients to have chronic pain or disasters. We suspect it’s around 12% in patients who undergo groin surgery, which is a large number, but that means 88% of patients do perfectly fine. And for ventral hernias, which is the abdominal wall, belly buns and others, it’s even lower number, a significantly lower number. We see more pain and chronic complications with the groin than we do the abdominal wall. But regardless, it’s still not a good situation to take a patient that has no symptoms and now make them in pain debilitated and miserable after surgery.
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So that’s why in terms of timing of surgery, I always advocate to repair hernias when you are symptomatic when it bothers you, right? So if it doesn’t bother you, I wouldn’t, you know what? Sometimes maybe don’t even see a doctor because surgeons, not all surgeons kind of follow my recommendation. A lot of surgeons say, well Towfigh, you are just delaying these people’s surgery. They’re all going to need surgery at some point. That’s technically not true. About two thirds will need surgery at some point. The best clinical trials, we have a show at about 10 years, about two thirds of people will end up having surgery. That’s not all of the patients. That means a third of the patients end up doing just fine with no surgery and I’m kind of like glass half full versus glass half empty situation where I think it’s important for that one third never to have surgery, then have a hundred percent of patients have surgery and 12% of them have complications.
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You know what I mean? So that’s kind of the way my philosophy is. Now of course if you come and tell me you want surgery, understanding the risks and benefits of the surgery, I’m happy to operate on you. But so that’s where we are with watchful waiting. So for timing of hernia repairs, we’ve never had surgery before. These are called primary hernia repairs and you have basically no symptoms. Then I think the timing should be to delay the surgery until after you start getting symptoms. But what’s important is to be able to delay that time as much as possible. You should have a healthy lifestyle, like I said, get rid of all the potential actions. I guess that can increase your risk for hernia. So don’t try and be as close to your normal way as possible. Exercise. Don’t gain weight, don’t use nicotine. No chronic cough, no constipation, no straining. That’s kind of what I recommend. Okay, so hopefully there’s no questions on watchful waiting on that. There are some people that say, okay, well what about age? Right? So isn’t it better for me to have my hernia at age 60 than age 80?
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Not necessarily it’s better. I would rather you risk whatever the risk is of having your hernia repaired when it’s symptomatic at age 80, then having a perfectly healthy life at age 60 and having it at risk for getting chronic pain before you hit 80. That’s kind of the way I think of it. And actually some of these clinical trials have looked at what happens to patients if they wait. So the one clinical trial out of the I, I know it’s the uk, but I think it’s a certain, I think it may be part of the uk, not England itself focused only on men over age 55 and said, okay, now if you’re over 55, should you just have your hernia paired or is it okay safe to just delay it? And they found that two patients I believe who delayed surgery ended up having either a heart attack or a stroke during the follow-up time and their conclusion was, aha, you do get older.
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You do get more complicated and sicker as you get older and therefore you should get your hernia repaired earlier. But listen, those people that had the stroke and heart attack still did not need their hernia repaired. The fact that now they have a hernia with a history of stroke or heart attack is not to me an indication to have your hernia before your heart attack or stroke, if that makes any sense. Here’s a comment, it’s a high enough incident of chronic pain that the cleaning clinic made an entire practice out of the complications. Groin hernia surgery with no lump and minimal symptoms completely destroyed my quality of life. That’s what I just said, isn’t it? Wish I would’ve done some research instead of listening to the surgeon I went to. Well, thank you for sharing that, number one. Number two, this is exactly my situation that I hope doesn’t happen for my patients and so many patients who watch hernia talk or get on hernia talk.com, our little bit more versed in this idea of watchful waiting.
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We have at least one episode in the past. It’s a hundred percent dedicated to watchful waiting and my guess was the author of the famous watchful waiting trials for both the groin and the Umbilical Hernia with Dr. Fitz Robert Fitzgibbons from Nebraska. So Omaha. So again, I’m the advocate of it, but it was kind of interesting to speak with the author of the trial to see his take of what he recommends for patients having done the trial himself and seen the outcomes at five years and then 10 years. So yeah, it sounds like you went to your surgeon, they said you have a hernia, let’s fix it. Maybe that hernia was noticed on even imaging. I’ve quite a bit of patients that had let’s say, I don’t know appendicitis or belly ache, they get a CAT scan. The CAT scan shows an incidental hernia. They’re told you have a hernia completely unrelated to the reason why they went to the er. By the way, they send ’em to the surgeon, they end up having to hernia surgery and now they have complications from it. That’s not a good luck. It’s not a good outcome. I think it’s not patient-centered unless you went in understanding the risk for it.
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Another scenario is people who live or travel to exotic or poorly populated places. So if you plan to go to Antarctica Safari in Africa and you have a hernia that should get repaired, let’s say you’re symptomatic, I would repair it before you go to those places. Antarctica for sure. In fact, I had a patient who was a researcher going to Antarctica, so I did his laparoscopic inal hernia pair and usually I say, oh, a couple days, three days or something like that and then you can do whatever you want. So after, I think after two weeks and I was being very conservative after two weeks I’m like, listen, your hernia is fine. You had no complications, you have no pain, your wound is healed enjoying your time in Antarctica, and you know what? They turned him down. They thought I was just being a horrible doctor for clearing the patient to go to Antarctica after two weeks of surgery.
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And I was like, well, what do you think is going to happen? He’s recovered from the surgery and they’re like, well, we don’t know that We are usually at least three months, and Antarctica is just so remote that it costs something like a million dollars to bring in a, you have to basically bring in a private jet with a medical team to airlift someone back to civilization if you get sick in Antarctica and no one has a million dollars to spare over there. So even though he was a researcher and I thought he’ll do fine, they were even more conservative at three months is when they felt comfortable having him go there. I’m like, there’s no way you can have a hernia complication such as a wound infection or something after you’ve been fine for two weeks from a laparoscopic surgery. But that’s interesting, right?
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So same is true if you are one of those adventurous people that likes to go to remote areas or even areas where healthcare may be not optimal. So if you can get your healthcare in the US or with me in Beverly Hills, that’s maybe a better situation. Electively, if you have symptoms, then if you are like, I’m just going to go to, I don’t know, some, let’s say some small country Mongolia, let’s say, which is actually not a small country, but a poorly populated country with poor access to healthcare and then just wing it, you may want to choose to get your elective for a new pair before you go on a trip where access to urgent medical care as well. Now I have friends all over the place. One patient of mine’s going to South Africa. I’m like, I know someone in South Africa, no problem.
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I can hook you up another friend, another patient’s going to Italy. I’m like, oh yeah, Italy’s great. I’ve got great surgeons there. So it’s kind of okay to go to certain countries if there’s a way to access healthcare. Again, unlikely that most people will require emergency surgery for any of their hernias. In general, the more symptomatic you are, the more likely it is you may need it. And then, and people always ask me about air flight, like going in an airplane, is a change in pressure going to affect my hernia? Short answer is no, actually never. The other answer is there’s apparently not that much difference in pressure in most airlines, so that should also not be an issue. Here’s a question I was interested about what you said about two weeks as a cutoff for wound infection. Is there no such thing as subacute or chronic wound infection?
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Can you elaborate on that topic? Okay, so this is specifically, I was talking about a laparoscopic surgery. You have three holes less than an inch each, less than half an inch for a couple of them, and the risk of those getting infected is very close to zero, and if you’re not infected within the first two weeks, you should not get infected, subacute or chronic wound infections. Chronic wound infections are usually, sorry, you meant mesh infection. Yeah, mesh infection is not a thing usually for laparoscopic repairs. Now it can happen very, very, very unlikely and it usually occurs in the first couple weeks to a month or something like that. I think that the Antarctica story, going back to that they were worried that there may be, I know an abscess can brew and so they thought three months was a better situation. That’s like one of those never events for angle hernias.
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I’ve had one patient who had a mesh infection after laparoscopic repair and I am going to presume that was from some type of contamination during their surgery from the operating room because that should never happen. It’s a complete sterile environment in three little holes with no touching of the mesh and we change our gloves every time we touch the mesh. So open surgeries, different story, big hernia surgeries, different story. Usually the infection risk is higher with open repairs and the larger the incision and the longer the hernia operation, the higher the risk of complications. So that’s another thing that we can talk about is the risk of complications and how to minimize it by correctly timing your surgery. I just saw a patient today who has, she is on a lot of steroids and I saw a patient earlier this week also lots of steroids.
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One had a transplant and so they’re already immune suppressed. The other one has a bad asthma and is really bad. Asthma is on tons of medications. So if there’s a situation like the asthma patient where you can optimize their lung function and their health and reduce the amount of steroids they’re on, both of those will help improve for hernia care because with regard to the asthma, I don’t want her coughing due to asthma while she has fresh stitches or fresh mesh repair or fresh hernia repair. With regard to the lung function in an asthmatic, you want them to have as ideal lung function as possible prior to surgery. Regardless of whether you use general anesthesia or IV sedation, your anesthesiologist will refuse to operate on you if you have poor lung function for an elective repair, especially if it’s at a surgery center. And then there’s a steroids issue, so the patient who is on immune suppression because they have a transplant, that immune suppression is never going to go away, so you kind of understand that you have to modify your surgery to minimize their risk of wound complications and mesh infection, but the patient that’s on tons of steroids because they have acute asthma exacerbation or they have acute secondary adrenal insufficiency or other diseases that require steroids in the short term but not in the long term, you want to wait until their underlying medical problem is addressed so that that medical problem doesn’t affect your ability to do a perfect hernia repair because you need to heal and you need to not pop the stitches.
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So let’s say you have a cough or you have upper respiratory infection, not a good time to have your hernia repaired, you got to get that cleared. From a respiratory standpoint, you want your lungs to be healthy so that the anesthesiologist doesn’t freak out that you are having all these secretions during surgery or coughing during surgery. And then I as a surgeon do not want you to be coughing after surgery. So if you come into my office and you’re coughing throughout the office visit, your surgery will be delayed because I will not be wanting to stitch you together or put the hernia back together again while you’re actively coughing.
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In California, we have a lot of patients that regularly use marijuana and if it’s edible, that’s usually not an issue. It doesn’t affect healing, but for those who smoke the marijuana, that often causes a lot of coughing and so the coughing associated with pot smoking, it can be a bad risk factor for hernia repair and outcome. So highly recommend that that be stopped or put away for a while or switch to edibles unlike nicotine where smoking nicotine does cause the coughing not good for hernias, but in addition, nicotine itself prevents tissue wound healing and the smoking reduces oxygen to your tissues. So from that standpoint, we don’t like nicotine use at all. It’s not good for healing, it’s not good for hernias. You have I think seven x higher risk of hernia recurrence in the most recent studies and it prevents good blood flow, which is what you need for healing. So higher risk of mesh infection, higher risk of hernia recurrence and higher risk of wound complications in people who regularly smoke cigarettes or other use of nicotine.
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Other reasons to delay your surgery. If you come to me and you tell me as a male that you wake up three to four times at night to urinate and you don’t really completely finish your urination because you don’t completely empty your bladder and you have frequent urination and your prostate is the size of a grapefruit, well, I would recommend that you have your prostate addressed before the surgery. Why? This is actually a big deal. My nurse is well aware of this problem. She’s already talking to the patient, but before my whole office is aware, so in general, men have a higher risk of urinary problems after hernia surgery, especially in the groin after any anesthesia, but especially the inal hernias. It’s called POUR, postoperative urinary retention. What does that mean? That means that after surgery you don’t urinate very well. Now when does that happen?
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Usually older patients, usually patients with an enlarged prostate. The way I describe it is the big prostate is kind of like a donut around your urethra where you urinate. So the hole for the urethra, let’s say should be normal like a straw. And then when you have an enlarged prostate, now it’s like one of those coffee stirs in terms of the ability to urinate through the tunnel. And so there’s medications, there’s herbal supplements, saw palmetto, there’s five or six different types of oral medications, Flomax Rapa flow, Vidar Alis, Viagra even. These are all things that can help and there’s surgical ways of addressing an enlarged prostate. There’s terp where it’s a transurethral resection of the prostate, what we call the Roto-Rooter. There’s something called UroLift where it kind of like stents open the prostate. You can do what’s called aqua aqua ablation where you steam it open, you can, what else can you do? You can microwave it. You can do what’s called pro PAE prostate artery embolization. Anyway, you have to go see a urologist and your urologist may say, oh, I mean you’re just waking up like three times a night. That’s okay. No, no, no, no, not okay. First of all, anything over two my spice sense goes up. You should be having a good night’s sleep.
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Secondly, my issue from a hernia surgeon is I’m going to fix your hernia. Best case scenario, you urinate after you go home, but then you’re straining for the rest of your life to try and empty that bladder against enlarged prostate and every strain five, six times a day is putting my surgery at risk of recurrence. Worst case scenario, you wake up from surgery and you can’t pee, you can’t urinate because you have what poor POUR, postoperative urinary retention, which means your bladder is being filled with urine because your kidney function is normal but you can’t empty the urine because your bladder’s kind of still sleepy from the anesthesia and then it’s kind of higher pressure area because you’re trying to pee through a coffee stir kind of straw as opposed to a regular straw because your prostate’s so enlarged. Then what happens? You get a catheter, you got three to five days out a catheter, increased risk of urinary infections.
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There’s a lot of badness, so you must must control your prostate and improve your urination before any hernia surgery. For men, for women, there’s not much to do because our urethra is very short and we don’t have a prostate, so that’s another thing for timing. I will delay your hernia surgery until after you’ve seen a urologist and optimized your urination. I think one of the episodes we had early on, maybe the first 20 or 50 included one with Dr. David Josephson who’s a urologist and he said the prostate is his favorite organ, so it’s all we talked about was the prostate and we talked about this postoperative urinary retention and really important details on everything you need to know about that and your prostate. Go listen to that one. That was a really good episode. I was much younger than several years ago. Let’s see, obesity, we have multiple episodes on obesity, so if you are BMI, which is body mass index greater than 40, you should definitely consider repairing your hernia after you lose weight and be aggressive about it.
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Don’t be like, yeah, I’ll put myself on a diet and that. No, no, no. Go see a medical doctor enroll in a weight loss program. Even consider weight loss surgery before having your hernia repaired. Mostly I’m talking in that situation for the abdominal wall, for the groin, there’s some benefit in losing weight for any surgery, but you don’t absolutely have to be perfect weight for your groin hernia repair, it’s really for the abdominal wall where the massiveness of the abdominal wall kind of really puts your hernia repair at risk, higher risk of wound infection, mesh infection, hernia recurrence. So the more weight you lose, the better those patients. I definitely send for weight loss, even weight loss surgery, if you’re in the 35 to 40 range, I’m usually okay to, or even 45 range. I’m usually okay to fix your inal hernia, your groin hernia repair.
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If you’re above 50, really you should just focus on the weight loss and what you’ll notice is if you lose the weight, the pressure on your hernia is going to dramatically reduce and then you may not want your hernia repaired anymore because now the pain is gone. So that’s a positive. But usually we like to time your surgery until after you’ve lost significant amount of weight. The weight loss, it decreases the pressure on your abdominal wall, it shrinks your liver, it reduces the visceral fat, which is the fat around your intestines, taking the pressure off your abdominal wall. It really benefits everything. It reduces, it reduces cancer. I mean there’s so much benefits to losing weight and nowadays there’s medications for it too. So very little reason to wait.
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I did have a patient recently that came to me and she had multiple problems. One of her problems was she’s had, she told me over a hundred operations and at first I was like, that sounds like a little grandiose. No, no, no, no. I’m willing to bet she had more than a hundred operations. Actually I went through her chart. She is having surgery since she was a baby and it’s been going on. So many of her operations were in the abdomen like hysterectomy, appendectomy, cholecystectomy, colectomy. She did a lot of surgeries, gastrectomy. Every organ it seems has been operated on and people who have abdominal surgery are at risk of having a bowel obstruction after surgery that can happen the same year. It can happen 20 years down the line. So she started having belly aches and pains, bloating, nausea, no vomiting, consistent with a bowel obstruction. Now she never really needed to go to the hospital. She did need to go to the emergency room for this problem. So she now has two problems. She has the hernia from her multiple abdominal surgeries that’s bothering her. It actually starting to hurt and she has the intestinal obstruction where her intestinal is a little bit twisted and not fully so it’s what we call a partial bowel obstruction. So the timing of surgery is important. Here’s what I explained to her.
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I don’t want to fix your hernia and ignore the bowel obstruction. Usually if you had no hernia, if you had no hernia and no symptoms, I would say your bowel obstruction symptoms seem to be under control, but if you start getting more symptoms, come see me, I’ll operate on you. But usually 80% of the time those do not need surgery. And so we try and prevent surgery because surgery alone will also cause more adhesions and more bowel obstructions where your intestines get stuck, but she also has a hernia, so that is a surgical problem. No amount of non-surgical management. We will fix that. And now she has symptoms from it and we discussed this earlier, if you have symptoms from your hernia, that’s a good time to have to have the surgery.
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So what I would now say is, okay, now you have two situations you’ll benefit from the hernia repair because you have pain, but I really don’t need to fix your bowel obstruction if that were the only problem, but I can use the excuse, oh, okay, but I don’t want to fix your hernia and then have you end up a year or two later with a bowel obstruction that does require surgery in that 20% unlucky and then someone has to go through my perfect hernia repair to deal with a bowel obstruction. That would be a bad situation. So in talking about timing of surgery, what I told her is let me use the excuse for fixing your hernia as a way to take you to the operating room. So before I fix your hernia, I’ll be in your belly. I will address the bowel obstruction situation, take that out of the way and then fix your hernia as I’m coming out and I’m done with that intestinal surgery, totally okay to do good plan, kill two birds with one stone.
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Right now there’s a caveat talking about timing of surgery. If I go in there and she has a disaster belly, right, so everything’s stuck, I cause injury intestine is cut, it’s no longer a sterile clean procedure, it’s now contaminated, then I’m not going to fix your hernia. At the same time I’m going to delay the hernia repair. Another scenario I go in there and you’re actually more obstructed than I thought. I have to do more surgery than I thought, and now as a result you’re going to get very bloated after surgery. Also, I may err on not fixing your hernia at the same setting because if you’re going to get really gassy and bloated after surgery, that’s going to put pressure and tension on my hernia repair and make you uncomfortable and maybe increase your risk of recurrence. So if I go in there and it’s just a very straightforward problem with the intestines and I can focus most of my time on the hernia repair, then I’ll do that.
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So that’s kind of how the timing works out. What I don’t want her to do is to end up getting worse and worse with the bowel obstruction and needing emergency surgery. Emergency surgery is never, ever, ever a good time to fix your hernia. So if you have dead intestine, perforated ulcer, gallbladder infection, appendix infection, anything that needs emergency surgery, do not get your hernia repaired at the same time. I’m just taking it from me. It sounds like good idea. Come on doc, just fix it for me. You’re in there already. Not a good idea. Just don’t do it. Just don’t do it.
(00:38:53):
Yeah, so it, let’s see. Bad situation. Okay, there you go. You can hear me now. Okay, good, good, good. Okay, let’s start with this question. So with regards to Port POUR? Yes, thumbs up. You can hear me now? Yeah, I think it’s working. So what if you have a urethral stricture which requires more complicated surgery than terp transurethral resection of the prostate and the urologist did cystoscopy and said the surgery is not indicated even though you are not perfect. Okay, see another urologist. If you need hernia surgery and you have a urethral stricture, which means there’s a narrowing along the length of your urethra where you pee. Most people who have a urethral structure depends on the extent of it, need to strain to urinate. Many times when you have hernia surgery, in addition to what we talked about, which is the whole idea of not wanting to strain after surgery and having difficulty urinating after surgery, you may also need a catheter like a urinary catheter that’s going to be tough or risky if you have a known urethral stricture.
(00:42:12):
So if it’s mild and your urologist says you’re doing fine, they should be able to put a urinary catheter, just use a pediatric size one and it’s not obstructing your urinary flow fine, but if in any way prevents you from having a urethral catheter and or makes you need to urinate by straining, then you should get that repaired before undergoing any hernia surgery or really any surgery that will require a urinary catheter. So I hope that helps you. Okay, let me share you this story. I had a patient who had perforated diverticulitis. Okay, that means you had these outpouching of your colon and then a perforated and you had an abscess. So this is someone with symptoms. He is got lower abdominal pain and he needs surgery. So for whatever reason, the colorectal surgeon said, we’re going to do this robotically. We’re going to take out your colon, you’re going to have an incision, like a C-section incision through which I’m going to take out your colon that’s diseased.
(00:43:29):
Would you like me to do it with or without a plastic surgeon? And for whatever reason, the patient said Yes, let’s get a plastic surgeon involved. So they sent him to a plastic surgeon. The plastic surgeon who sees him somehow has a discussion of doing more than just being available to make sure that the incision through which the colon is removed is somewhat cosmetically pleasing. They have a whole discussion about tummy tuck and liposuction and so on out of this world. That should never be a discussion when you’re doing colon surgery. So when I’m talking about timing, do not combine. We already said do not combine emergency surgery with elective surgery, but also do not combine a dirty or not clean surgery like colon surgery with a clean surgery like hernia surgery or tummy tuck or something like that. It’s just not the right thing to do.
(00:44:46):
It’s like I said, it sounds great. Get a tummy tuck and at the same can you get rid of these little pockets of fat I have too at the same time as my colon surgery. That sounds amazing. No horrible decision, very bad for you. You’re putting yourself at risk. You’re putting yourself actually at risk of a disaster, not just at risk because what that implies is high risk of wound infection, high risk of needing of mesh infection, high risk of your cosmetic procedure, if that’s what it is, will end up looking really ugly as a result. And this whole, oh, trying to be, I just want one anesthesia. No, you can have multiple anesthesias in your life. It’s better situation than what I just discussed. Here’s a question with a laparoscopic mesh placement, does increased abdominal pressure due to benign prosthetic hypertrophy or cough even merely just push the mesh against the angle of floor not doing any harm to the repair?
(00:45:55):
No, that’s actually not correct. All increases in abdominal pressure are considered bad for hernias and for hernia repairs regardless of the type of hernia. Now, if you have a laparoscopic repair and the mesh is placed behind the muscle, you can argue that it’s more resistant to increases an abdominal pressure. That is true. However, by pushing into the mesh, you can push the mesh into the defect or you can shift the mesh away from the defect even laparoscopically, even if there’s T or fixation used. So we don’t recommend that that happen and in rare cases you can actually tear the mesh okay with the next hernia pair. Oh, my next hernia pair is for a spa hernia and I’m doing a pen colectomy at the same time. Does this sound okay? Pan colectomy technically is not a tummy talk. Now that said, all studies show that doing a hernia repair at the same time as the pan colectomy has shown a higher risk of wound complication with the pan colectomy.
(00:47:19):
However, if your surgeon is gifted and you have your low risk for complications, if the mesh is placed deep to the muscle and not near your pen colectomy, and if the purpose of the pen colectomy is to reduce your risk of seroma hematoma after surgery, you could argue it’s a good idea. That’s not necessarily a cosmetic reason to do something. It’s more of like a decision to improve your outcome. But if you’re doing it because you want to get rid of your extra fat, I personally and for no other reason, I personally would stage it and have your spa gillion hernia repaired on its own, usually laparoscopically and let that heal and then bring you back and do a much better pan colectomy or whatever surgery at the same time. That would be my preference. There are surgeons that do enormous hernia repairs and do add a pen colectomy, you’re already doing a very high risk operation and the pen colectomy doesn’t increase your risk that much more. But spa gallian hernia is not a high risk operation and I personally would not add a pen colectomy at the same time.
(00:48:44):
Let’s see, I had left as opposed to right al hernia surgery using Shouldice technique in April, 2024. Sounds good. Ultrasound in January, 2025 found a one centimeter, 1.3 centimeter indirect inguinal hernia recurrence. The surgeon said the hernia repair is fine after examination. Is the ultrasound accurate? What shall I do the following? Is the ultrasound report indirect anular hernia, lateral to inferior epigastrics? Okay, well the question is why did you have the ultrasound performed? If you have symptoms and the symptoms are consistent with a hernia recurrence, usually chronic pain, dull achy pain, pain with activity, the fact that your surgeon doesn’t feel the hernia, hernia recurrence is not as important as the fact that the ultrasound showed a recurrence because you want your symptoms to match the findings. And in general, a hernia recurrence from a shouldice is not easy to palpate. There’s four layers of suture that it has to kind of push through, and so they’re often small. They’re often not obviously bulging, but you get, that’s where the chronic pain comes in with tissue repairs is it’s kind of unknown reason for chronic pain. And so a laparoscopic repair with mesh should address your pain and if you have, sounds like you have chronic pain and pain with sitting, yeah, that’s a hernia recurrence. So yes, I would discount the examination findings and put more weight on the ultrasound findings, which is consistent with your story.
(00:50:42):
I can’t have any more laparoscopic surgeries. The incisions being used for both. Okay. Yeah, everyone’s a little bit different if you’re using, okay, so basically what they’re doing is instead of making an incision directly over your spigelian hernia, they’re using a big wide low transverse incision to make a flap, get to your spigelian hernia, fix that, and then do the panniculectomy. If you need the panniculectomy because it’s a low hanging panis, there’s lots of maybe even fungal infections or bacterial infections because of it. We call that panniculitis, then yeah, you should consider it. But in general, combining those two has a higher risk of complications than staging it.
(00:51:33):
A year and a half ago I had diastasis recti and incisional hernia repair, loss of weight brought on the apron. Okay, that’s your pannus. Some same surgeon is doing this new repair and has worked with plastic surgeon before, not an intense pan colectomy. Well, I would love to hear how you do. I think if it’s thoughtfully performed with a plastic surgeon, you’re okay having an extra long operation. Again, mesh is placed away from the pan colectomy so deep to the muscle, not as an onlay. You don’t want to do an onlay. That’s a disaster because you will have drains because of the pan colectomy. You will have fluid collections or even bleeding in the area and there’s a risk of your panniculectomy scar breaking down and if that happens, you’re putting your mesh at risk of infection. So the mesh should ideally be placed deep to the muscle so that the panniculectomy any complications from the panniculectomy will not result in a mesh infection even if you have an infection under your pannus surgery if you’re diabetic.
(00:52:47):
Also, major risk for complications from panniculectomy, and that’s kind of my biggest tip would be to a hundred percent. Make sure your mesh is deep to the muscle and not as what we call onlay because onlay would put it on top of the muscle and then any fluid collection, drain placement or wound complication will put that mesh at risk and then you’re in a much worse place than you are today. What shall I do an MRI using your MRI protocol for occult inal hernia to confirm the ultrasound findings? So usually I don’t recommend any more imaging if the ultrasound finding is consistent with your physical exam. I’m sorry, with your symptoms, right? However, if you’re trying to convince your surgeon to operate, you may want to get an MRI. The problem with MRI is a lot of the people, even if they use my Val Salva protocol, which I a hundred percent recommend you do, that’s available free on my website.
(00:54:06):
If you do the MRI and it’s misinterpreted and it says no hernia where you actually have a hernia, just because people don’t understand what a hernia looks like after a shouldice repair, it’s very different than a typical hernia. Then that may push you back and your surgeon may say, aha, I told you because your surgeon may not be someone who reads MRIs themselves and just reads the report and then the report. So already you have someone who’s somewhat gaslighting you by telling you your symptoms are not because of a hernia, even though an ultrasound shows a hernia and your symptoms are classic for a hernia. So that’s my concern for you. I would say you can get the MRI, but just be careful. The report may mistakenly say there’s no hernia and then you’ve kind of kicked yourself for getting it because now you have a study that supports what the surgeon wants you to have, even though it’s an incorrect report. You know what I mean?
(00:55:15):
Yeah. So that’s kind of my 2 cents about that. Okay. Let’s see. We talked about combination procedures with plastic surgery. Oh, open repairs left and right. Some people have left and right angle hernias, groin hernias, and they want both repaired at the same time. If you have a laparoscopic or robotic repair, you can get them both repaired at the same time. It’s actually the perfect scenario for it. Same incision, same anesthesia. Great. If you don’t want laparoscopic or robotic surgery or you can’t get laparoscopic or robotic surgery, but you have left and right groin hernias, the timing is usually best to stage them. So you fix one side, heal from that, give yourself at least three weeks and then fix the other side. What you don’t want to do is to fix both because it sounds like a good idea because all the studies show that the risk of recurrence is higher if you fix them at the same time than if you stage them. So in my practice, I follow the data. I don’t usually offer simultaneous open by left and right inguinal hernia repairs with mesh or without mesh. Either of those. I don’t do them. At the same time, I believe the Shouldice Clinic also does not offer bilateral at the same time. They just do them one at a time. I don’t know how long they allow for healing in between. I think it’s also three weeks.
(00:56:57):
There are exceptions. There are patients who it is really hard for them to come to see me. They may be from a different country already. It’s difficult to fly in to see me, and therefore they want all of the surgery done At the same time, the reason why we think that the recurrence is higher, we’d have to come up with a reason. We don’t know. That’s just what the studies show is you never really heal either side. You don’t have one side to rely on while the other side is healing when it comes to walking stairs, bending, et cetera, and therefore there’s pressure on both sides for the healing. That’s the only way that I can answer that question. Oh, we were talking about pan colectomy. So pan colectomy is removal of a pannus and a pannus is that apron of skin that some people have either because they’re morbidly obese or because they lost a lot of weight and that stretched out skin kind of hangs every so often.
(00:58:01):
It’s in a woman who’s had multiple children and then that is just loose skin. So what you have is skin hanging over your mom’s or even your upper thigh and that is prone to infection. It gets very moist in there. It’s a hard area to keep cleaned and then when you have surgery, it kind of gets in the way. So it sounds like a really great idea to remove it at the time of surgery. But all the studies that I’ve seen have shown that that actually increases, increases your operating time and increases your risk of wound complications and infections. So if it’s done, it should be done thoughtfully with the understanding that the risk of wound complications and infection is higher and therefore if you’re using mesh for the hernia repair, the mesh should be as far away and deep to any risk of infection as possible.
(00:58:54):
So that’s kind of, those are my two cents, my friends. So this was fun. I kind of missed you guys because out of, I was out of town and then I had the Sages meeting. I got an award there that was kind of cool. And then I had patients scheduled at the same time as Hernia Talk Live. So there was multiple times when I had another podcast I was on. It was busy month. So missed you guys. I’ll see you as much weekly as I can. I’ll keep you up to date with what’s going on on my social media. Please do follow me on Facebook at Dr. Towfigh on Instagram and X at Hernia doc on YouTube as on my channel at Hernia Doc. Please do subscribe to my podcast. I think we had 7,500 downloads already of Hernia Talk Live. Can you believe that? That’s to me just absolutely amazing and I hope to reach 10,000 pretty soon. I will let you know. So see you all next week and have a great night. I will talk to you later. Bye.
