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Dr. Shirin Towfigh (00:03):
Hi everyone. It’s Dr. Towfigh. How are you doing? Welcome to Hernia Talk Live. I am your host, Dr. Shirin Towfigh hernia and laparoscopic surgery specialist coming to you from Beverly Hills and many of you are joining us via Zoom. I appreciate that. I hope some of you’re also able to join us via Facebook Live at Dr. Towfigh. And remember all of these episodes and others from the past have been already archived as a YouTube, so go to my YouTube channel at Hernia doc and also we have a podcast. So I hope you all enjoy podcasts. I’ve been listening to so many of them lately and I’m one of many podcasts available to you and I hope you like that as well. So welcome to our show today, I just want to say that it’s been a lovely week. I was able to go down to San Diego, which is where I went for medical school and I love that city.
(01:11):
And in San Diego we had a huge GI meeting with surgeons, so gastroenterologist surgeons, hepato, biliary surgeons, and a very few hernia surgeons. But I had the chance to give a talk down there at the DDW, which is the Digestive Diseases Week. It’s the largest, it’s like a huge meeting. It’s bigger than any surgical meeting because it involves a lot of medical doctors and gastroenterologists in addition to surgeons. So it’s like I think four or five societies all in one. They could only be held at certain towns that have enormous convention centers. San Diego is fortunately one of them and it’s commonly in San Diego. And specifically I was there representing the American Hernia Society in a joint American Hernia Society, SSAT or Society for the Surgery of the elementary tract group. And then in the fall when we have the American Hernia Society meeting, we will host some SSAT surgical members to kind of share their ideas.
(02:24):
So it was kind of cool because a lot of the surgeons that were at this meeting were surgical oncologists or they worked at MD Anderson, which is a very prominent, highly regarded cancer center cancer with a line through it. It’s kind of a good messaging there. And one of my former fellows who you have met as hosts, one of the guests on hernia talk live, he is a surgeon at MD Anderson and he does hernia surgery, which is unique because he sees a hundred percent of his patients have cancer or had cancer. And so he sees a very unique population of cancer patients who also have hernias. So I was there talking about evaluation of the groin in females. So how do you differentiate groin pain in females from other causes of pain, including the gynecologic causes, causes it from the spine, from the intestines, from autoimmune processes from the hip and so on.
(03:32):
So it was kind of a good talk. I like giving that talk. I gave a similar talk last year in Czech Republic about the evaluation of the female groin and it was one of my better talks that people, I got a lot of good positive feedback from it. So I’m glad to have given something similar to an audience that maybe doesn’t think much about groin pain in general and thinks it all is either a hernia or it’s not a hernia, but I was hoping to provide that ability to differentiate based on history and physical exam, how one versus the other kind of goes on. So thanks for all of you who joined me. I picked a topic today as I usually do based on patient experiences and patient patients that I see in the office. So today’s main talk is called hernias after trauma, and I hope we weren’t too freaked out by the picture that I chose of a patient who had a surgery for a prior surgery.
(04:45):
And usually I’ll tell you this is an important topic because I do get a fair number of patients that have had some type of trauma and this is not psychological trauma, although it may be in addition, but it’s usually physical trauma. So hit by a car, ejected from their motorcycle, ran into a boat, I got stabbed by a forklift. There are these horrible traumas that not only cause injury necessarily to the belly, but also maybe the extremities, but I’m specifically focusing on their belly because they come to me usually with open surgery, so a big scar. Secondly, they come in with usually a very prolonged hospitalization. So they were in the ICU in a coma for a long time. They had their spleen removed, they had maybe their intestines was removed at the time of the trauma. There was lots of spilled guts and bleeding.
(05:49):
All of those are major risk factors for scarring and hernias. So patients that undergo trauma surgery are worn the highest likely to get an incisional hernia. But then you add onto it the additional issue of things such as lack of muscle because a forklift went through them or they ran into the rudder of a boat. You can add things such as a colostomy, ileostomy, other or even what’s called a urostomy, basically disconnection of either their bowel or their bladder from normal. And that’s brought through holes in the abdominal wall. So holes that are manmade to save a life or let’s say you are a motorcycle rider and you are especially the Asian ones where you’re kind of not the American ones where you’re in the Harley and it’s relatively, relatively slow and very wide, but the ones where you crouched down with the face heading forward in both of those motorcycle accidents, you can have a situation where your pelvis just splits open on either side as it straddles the motorcycle.
(07:17):
And that can cause not only GI issues but bladder tears and definitely pelvic hip fractures. So when that happens, then you have very complex issue down in the pelvis. So they can have pelvic fractures with bones that are missing or requiring plates and other orthopedic things to reconstruct the bony part. And then in addition, you may have, you’re like are basically flying off onto concrete or asphalt and you get burns and the skin is destroyed. You can get traumatic hernias or your belly just pops open with either the airbag or the steering wheel anyway. So it can be very complicated. And of course the first goal is to save a life. So a trauma surgeon is not there thinking, I wonder if I can do this laparoscopically. No, usually it’s a big open incision. Sometimes the belly is already opened because of the gash from whatever the trauma was and the surgeon is there to save a life. So they’ll do whatever is most expeditious to save your life and that would involve stopping the bleeding, stopping the intestinal injuries and so on. So you may be missing organs, some of your organs may not be the same size as they were and that involves a lot of bleeding and infection and all of that can translate into a hernia. Also, the scars are usually very pretty after trauma.
(08:59):
Cosmesis is not the first, second or even third concern of a trauma surgeon usually. And so what happens is they can have very ugly scars and you add infection and scarring and they get very indented scars, thick scars, what we call otr. And in some situations they’re missing tissue, right? They’re either missing muscle from the trauma or they’re missing skin. It was burnt off, scraped off or died because of poor blood flow to it from the trauma. And so they have skin grafts. The skin graft patients are very, very difficult because there’s nothing, I mean if you’re lucky, it’s just your skin and not the tissue underneath it that is destroyed and they put a skin graft over it, graft to help close off the area from infection. But also what can happen is you can lose the muscle and you have a skin graft. So basically you have nothing except a really thin layer of skin between your bowels and the air and that can be a very complicated situation.
(10:11):
Of course, I have a lot of pictures of these, but Instagram and Facebook, they don’t like to see that. And I’ve had friends and family members tell me, please don’t put those pictures on. I don’t want to wake up in the morning, open up my Instagram and get pictures of blood and guts that I wasn’t ready for early in the morning. So I try and be cognizant of my audience when I post pictures and what may be not too gory for me, maybe very gory for you. So that’s all we’ll discuss today and I’ll discuss all the risks of hernias after trauma and then the risks of operating on them. And I’ll share some patient stories so you can relate to them.
(11:03):
Before we go on, we have a question already would acnes, so acnes is an acronym, A-C-N-E-S. It’s not skin acne, it’s A-C-N-E-S. So abdominal cutaneous nerve entrapment syndrome. So does acne’s cause digestive issues? Indirectly it can, yes. Or is this more abdominal adhesions or nerve entrapment within the adhesions? Okay, so acnes is a nerve entrapment syndrome. It’s usually idiopathic. That means no one knows why you get it. You’d haven’t had surgery there, you haven’t been stabbed there. There’s no reason to have this nerve entra otherwise totally normal patients. Usually what happens is the nerve goes to this really tiny hole in your fascia and then in some patients right as it travels through that hole it kinks. And so if you’re using your abdominal muscles, it contracts and it kinks the nerve at that hole through which it travels. When that happens, the patient gets pain at a very specific point, either within the middle of their rectus muscle or just on the outer edge of their rectus muscle, depending on which segment of the muscle this kinking occurs.
(12:27):
Some people have bloating associated with acnes. That is a pain response. It’s not because your intestines are abnormal or there’s any GI problem. It’s usually not related to any digestive disorder. It’s a side effect of pain due to the acnes. And so in some patients you fix the acnes, the pain goes away and the bloating goes away. So in answer to that, would acnes cause digestive issues? Indirectly it can, but it’s not like you have adhesions or kinking of your intestines. Alright, here’s another question, Dr. Towfigh. I had an angle hernia surgery on the left side using sho dice technique. That’s a tissue-based repair. Four layers of tissue sewn together to cover a hole in the groin. Sho dice repair gradually, I’m recovering in the next six weeks, but scrotum got hit and injured. Okay, that’s fine, that should be no problem after that there is a nervous system, sensitization, light touch or pressure to the scrotum and surrounding area will cause pain.
(13:40):
Are there treatments available in which doctors shall I see? It feels like I’m being split in half. The pain is 24/7 level eight pain worse, one bending and leaning over it. It feels crazy tight when leaning back. So number one, your S shouldice hernia surgeon should help figure out if any of what happened to you is either directly related to the hit or not and is that a cause of the, sorry, lemme rephrase this. Is the hernia repair? What’s going on in causing the pain and related to the trauma to the scrotum? Or did you happen to get trauma to the scrotum that’s not causing your pain, that’s coinciding with pain from your hernia repair? Or do you have a perfectly good hernia repair and now you have an independent separate scrotal pain? This is where it’s very important that we get a good history.
(14:50):
Then your surgeon should evaluate you and examine you very carefully. If there are trigger areas where they press and that causes pain that’s in the groin, then that’s related to your hernia repair. If touching the groin causes no pain, then this is a separate issue. You should not get any trauma downstream from your hernia repair. However, you can get swelling, bruising, bleeding into the scrotum from the surgery that goes away after time. You can get scar tissue or nerve entrapment at the hernia level, which will cause radiating pain into the testicle. Usually that’s not reproduced with palpation of the testicle for example. And then when you say scrotum, it’s very important to understand is it scrotum like the skin or is the testicle inside the skin? The scrotum is the genital nerve and if you had this operation done either at the s shouldice clinic or by someone who is s shouldice trained, most likely you have the genital nerve cut as part of the S shouldice repair.
(16:06):
That genital nerve gives you sensation to a scrotal skin and so some men have numbness of the scrotal skin. There is a risk anytime you cut a nerve that the nerve will try to regenerate and cause either gets caught in scar or kind of neuroma when that occurs, you can get phantom pain of scrotal skin sensitivity and that’s called genital neuralgia. So there’s a lot to go through. There’s a lot to try and figure out, tease out what it is you really need. A good hernia specialist, supposedly the surgeon who did your s shouldice hernia repair can help at least initially treat you and figure out if it’s from the hernia repair or not. If not, and they think it’s primarily a testicular problem and not a scrotal problem, then they can refer you to their urologist friends. Supposedly they have friends in urology, usually their sexual health specialists, not just a general urologist that can help understand if there’s a separate problem going on in the scrotum that is causing your pain.
(17:22):
Let’s see. Oh, you know what? I’m sorry. I read two different people’s stories. So one story is about the acne’s nerve entrapment and that person is saying that they feel like they’re being split in half. The pain is 24 7 level eight pain, worse, one bending over. It feels crazy tight while leaning back. That’s not acnes. Acnes is usually not disabling pain. It’s usually not eight out of 10 pain. It’s usually no one that I’ve seen talks about acnes as feeling like they’re splint in half. So unlikely you have acnes, but if you would like a consultation I can look it over. However, this other person is asking the question about the scur pain after shoulder dice and everything that I said as related to that next question. My husband had his mesh removed. Come to find out he never had a hernia with. Will his pain for the mesh ever go away?
(18:31):
Okay, I’m skeptical about this comment just because you had your mesh removed and there was no hernia noted at the time of the mesh. Removal does not mean you not have a hernia before the mesh was placed. Let’s just get that clear. It’s very common to remove mesh and be like I don’t even see a hernia. Now at that point the surgeon should have discussed in advance what to do. So let’s say you believe you have pain from mesh and the surgeon agrees with you and your mesh is the problem. The question is why is the mesh The problem is the mesh the problem because you’re a thin patient with a thick mesh and you feel the mesh is the mesh the problem because it folded up in you and it balled up. So it’s a mechanical problem.
(19:20):
Those are all mechanically a problem with the mesh or is the mesh the problem because it’s an implant that’s too inflammatory and your body is reacting to the mesh. That is not a mechanical problem. That’s more of a functional problem. So depending on which situation it is, the mesh is not the issue, it’s the mechanical way it was placed or how it’s forming. That’s a problem In those situations, you should have a discussion with your surgeon. If the plan is to remove that mesh, is the plan also to put in another mesh, either the same mesh or similar mesh or different mesh at the same time?
(20:11):
The discussion should be you had a hernia for which you had this mesh placed. If I remove this mesh, I may or may not see a hernia at the time because there’s scar tissue. Then the scar tissue can fill in so to speak, the gap that you had before from the hernia or maybe they close the hole and then they put the mesh and so now you have closed hole and scar tissue. That scar tissue is not strong enough to prevent a hernia in the future. And the majority of patients close to a hundred percent, maybe 90 something percent will have a hernia recurrence once the mesh is removed. Now that recurrence may be a week later or it can be two years later, but they will get a hernia. So to claim that you don’t have a hernia because the surgeon who removed the mesh saw no hernia, doesn’t mean you didn’t have a hernia.
(21:09):
To objectively figure out if you had a hernia, you would have to look at any imaging before your first surgery, number one and number two, read the operat report of your first surgery to see what in fact they saw. Now are those situations where there was no hernia and surgeons have put mesh because they thought there was maybe a need for mesh and they’re basically overtreating a situation or over diagnosing a situation? I’m sure there is highly unlikely. It’s usually not that the standard of care or I should say it’s usually not what happens. So if your situation is your husband had his mesh removed and come to find out they never had pain, will the pain from his mesh ever go away? Depends on why the mesh was removed. If the mesh was removed again because of a mechanical situation, mesh was folded, it was balled up, it was too heavy weight for his body habitus if it was stitched in too tight. Those are all situations where the mesh pain should be gone once the mesh is removed because mechanically that problem is gone, number one. Number two, you have to confirm all of the mesh was removed because if there are areas where mesh wasn’t removed, those can be still contributors to pain.
(22:41):
And number three, understand that the side effect of that mesh pain may be scar tissue, muscle tearing injury, straining bleeding that will take a while to recover from. Now if the situation is your body quote rejected the mesh, I’d like to know what that means and how that was objectively identified. So there are patients as you know and we’re the first to have published on it who quote reject mesh. It’s not a technically a rejection, it’s usually an inflammatory response, not a antibody response. So the true medical term is not rejection, but we call it an implant illness. So the patient who have the patients who have mesh implant illness where they actually physically respond abnormally to this implant usually do not have any pain in the area of the mesh because it’s not a mechanical problem. It’s a body reacting to you. So for example, if you are allergic to peanuts and you eat peanuts, your whole body’s going to react to it.
(23:56):
You don’t have mouth pain and swallowing pain from the peanut, right? The peanut’s not lodged, you just have pain, you have a reaction like whether it’s anaphylaxis, hives, whatever. Same is true of mesh implant illness. So it’s a body reaction either due to the inflammation from the mesh or as an autoimmune response to the mesh and you need number one, full removal of that mesh. I prefer to do a full workup to make sure there’s no other reason or cause mesh for the patient’s reaction. So they get a dermatology evaluation, rheumatology evaluation, and possibly even an allergy immunology evaluation with allergy testing for example. Now I say that because I’d like to make sure we find any other reason for the patient’s problem aside from mesh removal because mesh removal should not be considered lightly. It is a revision operation with risks. Also note, however, we have no good way to definitively say that the mesh is a problem.
(25:14):
For example, if you do allergy testing 40% of the time it’s false, it’s incorrect. So there’s no such way of saying, okay, well the allergy testing didn’t show anything and therefore it is or is not a mesh implant illness, but at least you should go through the process of figuring it out and the mesh implant illness symptoms vary. It can be hair loss, blurry vision, ringing in the ear, difficulty swallowing, memory loss, brain fog, difficulty sleeping, restlessness, feeling hot, weird tingling in the tips of the fingers and toes, rashes in random areas. Those are all are joint pain. Those are all stories that I hear from patients that may be related to a mesh implant illness.
(26:10):
Okay, going back to the patient with the Shouldice repair that got hit in the scrotum and now has sensitivity to light touch and pressure to the scrotum. The follow-up is Shouldice surgeon said hernia surgery was fine. The testicular pain is okay, so now it’s testicular pain. Sounds like not scrotal problem. The testicular pain is a separate problem caused by the scrotum hit and injury. I had severe pain for about a few weeks after the scrotum hit and went to the emergency room. The ultrasound found a hydrocele. Okay, the hydrocele is either something you had before surgery, which therefore it should have been addressed during the surgery or you have a hydrocele from the surgery. Depends on how big the hernia was. If you had a large scrotal hernia where the contents were within the scrotum, their chance of getting a hydrocele after surgery is pretty common.
(27:10):
The ultrasound found hydrocele pain specialist and urologist could not help. Will it heal by itself? Shall I see a rehab specialist or shall I see? I’m happy to have you see me. You can contact my office directly and if you’re not in California, we can even do an online consultation. So I can at least review your operative report, your preoperative imaging or preoperative finding what they said in the operating report and then look at the imaging to see how big this hydrocele is. Or if they’re making a lot out of nothing. I don’t like that you saw these doctors and they weren’t able to offer you anything because that’s just not right. So you should be able to get some type of pain control. I would recommend some type of imaging to make sure that the hernia repair is adequate. Just feeling it and saying everything’s fine is not enough.
(28:06):
If you’re in so much pain, I usually get an MRI as you know, and we have a hernia protocol that’s available on my website to look for the hernia, look for hernia recurrence or whatever. So it’s still not clear. If you have testicular pain, that’s a different nerve issue than scrotal pain. So this is kind of a trauma issue. I guess you got trauma after your hernia repair, but you can bleed into your scrotum from trauma to the testicle or scrotum and that it can be painful, it should go away, but a urologist should be able to say that. But if it all looks normal, that’s a different story. Okay, let’s go back to the other patient that had digestive issues perhaps due to acnes and feeling like they were split in half.
(29:11):
Brief history. 2019 gallbladder was okay until October, 2022. Then two failed lysis of adhesions. Appendectomy. Brief history, 2019 gallbladder was okay until October 20. Then two failed lysis of adhesions appendectomy, no improvement. 24/7, level eight. Abdominal pain, not intermittent. Pain is always there. Severe digestive issues, can’t pass gas. Constipation, practically bedridden. What do you think is a problem? All I do is suffer all day every day. Okay, this doesn’t make sense. Why is the gallbladder an issue here? Did you have gallbladder surgery? Two failed license of adhesions? I don’t know what that means. By failed like they weren’t able to do the license of adhesions or they did ly of adhesions and that didn’t address your pain. So abdominal pain can come from your back. Has your back been evaluated to see if you have a nerve impingement in the thoracic or lumbar? And do you have any hernias that have been addressed?
(30:23):
Adhesions will not usually show up on CAT scan or MRI, so that’s not something that can usually be used as imaging for adhesions. If you’re bedridden, have you had colonoscopy and endoscopy an intestinal issue like inflammatory bowel disease? There’s so much that we can review to see what workup has been done to have an open mind and help figure out the causes of paint in patients. It could be sibo. Do you have severe bloating? For example? Do you have a dismotility issue? That’s a very difficult one, but a good GI doctor can help you. There are medications that can promote better, more coordinated movement of the intestines so that you do have normal bowel movements. You’re not bloated that you’re able to eat and not have nausea, et cetera.
(31:24):
Let’s see. Question. Okay, what if I can’t have mesh? Oh, let’s see. This is a follow-up again too. No, not a follow. What if I can’t have mesh and I get mine removed? Can a new hernia be repaired without? It depends on the type of hernia. It’s all based on risk factors, right? So if you are thin fit as a small hernia, likelihood is you’ll do okay, not perfect, but okay with that mesh, if you’re obese, diabetic use nicotine, your hernia is big, then yeah, you will not be able to have a non mesh repair. You may not even be able to be performed without mesh. So the answer is we don’t know. Depends on your type of hernia. In general, if you had mesh before and you’re now have a hernia again, the second time is best performed with mesh because now you have scar tissue, you have weakened tissues and probably less tissue as a result of the procedure.
(32:46):
Okay, going back to the patient who has the severe abdominal pain issues, abdominal pain is worse after bowel movement, endoscopy, colonoscopy I assume is normal maybe, but yeah, if it’s worse after bowel movement, you have to see if you have a pelvic floor disorder and why you have the pelvic floor disorder. Could that be because you have a hernia that’s not diagnosed or you have some type of pelvic floor trauma that needs to be addressed? Or do you have some back issue that is causing you to have either pelvic floor spasm or dysfunction? Do you have a collagen disorder? Do you have let’s say aler delo syndrome where there’s a syndrome of problems that can affect your collagen and therefore your muscles and all that? So there’s a lot that can be discussed there. I’m happy to take it offline and have you sign up for a consultation and see if that will help you. Okay, going back to the hernia after trauma topic.
(33:57):
So I’ve had a couple patients recently, some I’ve operated on, some we’re discussing operations. When you plan for hernia surgery after trauma, the discussion’s very different than a typical hernia surgery after no trauma. So most patients either had, they just have a hernia, what we call primary hernia. Those usually have a lot of options laparoscopic, open, depending on the size you can do mesh or no mesh, robotic, et cetera. There’s another category of patients that have hernias from a prior surgery, but let’s say elective surgery, colon cancer, liver transplant, what do you call it? Pancreatic surgery, cancer surgery, let’s say. So those are patients that can be more complicated than the primary hernias, almost always. And there’s a consideration as to what is the best option based on outcome recovery and cosmesis. So we want to be able to get you back to your normal life but also look good. So sometimes that’s an open procedure, sometimes that’s a robotic procedure, depends on what your priorities are.
(35:27):
Then you have the trauma patient. That trauma patient is basically similar to the incisional hernia patient where they have a hernia with a prior history of a surgery. But that surgery implies more scar tissue, more adhesions, and therefore much more of a disaster in the abdomen than the typical patient that has had, let’s say elective surgery. Why? Because there’s either blood involved, which is very caustic and causes a lot of adhesions or there is guts involved and that contamination can cause a lot of inflammation. Reaction and adhesions usually. Usually the typical laparoscopic or robotic procedure is not as easy to do and more challenging and also in some cases more higher risk in a patient who’s had a trauma before than your typical patient who either has a primary hernia or even in someone who’s had a prior surgery, but elective surgery. So let’s say you had a hysterectomy, now you have scar tissue, I mean you have a hernia. Usually we can do that laparoscopically or robotically, but if you had a perforation of your bladder or a perforation of your intestines and your liver was cut in half from a car accident, that’s usually not a place where I want to go back inside the abdomen laparoscopically or robotically usually.
(37:02):
Then you have a look at the scars too, right? So if you had an operation and it was let’s say laparoscopic or robotic, let’s say a prostatectomy or colon surgery and they had to remove an organ, let’s say your prostate or your colon, and they had to make an incision for that. And so now you have not a big incision, but now a visible hernia, usually those are very easily, not easily, but relatively easily performed laparoscopically or robotically. And the scars usually not ugly in a trauma patient, usually their scars are quite ugly. Often with staple lines instead of a cosmetic plastic surgery closure, maybe a prior infection of their wounds, their scars very thickened and widened, maybe skin grafting. Those we do not do laparoscopically or robotically. I’ve had a patients with, they almost died and there’s surgeons like, oh yeah, we’ll just go laparoscopically, not thinking hello to go inside this patient’s bladder.
(38:22):
I mean abdomen laparoscopically or robotically though it makes you sound like a cool surgeon and so on is not necessarily the best. First of all, they already have a scar, right? So you’re not buying them less scarring. In fact, you’re adding extra little holes in areas where they didn’t have holes. So cosmetically we’re not making it more cosmetic. Secondly, you’re implying you have to wade through so much scarring and potentially can injure intestine and bowel before getting to the hernia to do the hernia repair. And often the abdominal mal is stiff because there’s so much scarring and retraction since the hernia that it’s not a good repair. You’re not releasing enough tissues to take tension off of the tissues to be able to close it. And I even had one guy, not one guy, actually multiple people have gone to surgeons where the surgeon’s like, yeah, we’re going to do this hybrid approach.
(39:29):
We’re going to go in there laparoscopically and we’re going to take down the adhesion laparoscopically, then we’re going to open you up and close the whole open. Then we’re going to go in laparoscopically and put the mesh in. No, there are risks and benefits with laparoscopic or robotic and there are risks and benefits with open. If you do both at the same time as a hybrid approach, it may make you sound cool, but you’re actually now doubling their risks. You’re not really doubling their benefits because you’re buying the risk of the other procedures. So for example, if I tell you less to this laparoscopically or robotically that implies small little holes and therefore less risk of wound infections and therefore mesh infections because it’s a small hole, how can that get infected? Very low risk.
(40:24):
But if I add an open surgery to it, I’m now taking the one major benefit from laparoscopic and robotic, which is lower risk of surgical site infection and I’m adding that one benefit, I’m adding that as a risk because I’m adding the open. It makes no sense to me and I feel like I don’t want to bash on surgeons, but I feel like if you go to a surgeon and they want to do this very complicated, open robotic laparoscopic combination procedure, it usually is not the right thing because it just makes no sense. You can either do it laparoscopically or robotic or you can’t. And if you’re trying to do this hybrid procedure to me tells me that you’re not thinking. Alright, here’s some more questions.
(41:15):
In someone with a deficient bulging AL floor causing discomfort in whom you recommend a laparoscopic mesh to buttress or scaffold or support the bulging, we can al floor. Can you describe where you place your non-absorbable tax? Which structures are landing zones for tax? So you don’t want to put tax where there’s nerves, obviously there’s areas where you don’t want to put those. So there’s the triangle of pain where we don’t putt. There’s also the triangle of doom, which are where the vessels are where we don’t put tax. So the attacks tend to be inferiorly along Cooper’s ligament medially onto the rectus muscle as it inserts onto the pubic bone and superiorly either just medial or just lateral to the epigastric vessels. Okay, going to MII suspicion. So MI sounds like, I mean spells out mesh implant illness. I’m here for MII suspicion my doctor says because my blood work shows nothing.
(42:22):
I am having MS-like symptoms with a high heart rate and blood pressure all over. Neurological and cardiovascular problems have been ruled out through a hospital stay. I left that doctor and will be seeing someone else. I did address a quick failed endometrial ablation due to scar tissue and previous problems with app episiotomy stitch issues prior to the ventral hernia repair in which he said he never in 12 years had an issue. Okay, first of all, it’s impossible not to have any issues in 12 years unless you only do one or two cases in 12 years. So it doesn’t make sense for surgeons, and I really don’t like it when surgeons say, oh, I never have complications, I have complications and I’m considered an expert in my field. So for someone who claims never to have complications, then either they’re not following up on their patients or their patients are choosing not to follow up with their doctor.
(43:23):
So runaway, if people say, oh, I’ve never had a complication, I actually published my complication because I feel like others should learn from, it sounds like you had endometrial ablation and app episiotomy stitch issues and then a ventral hernia repair. I mean, if those procedures were done at the same time, there’s a slight risk of actually infecting your mesh because those vaginal surgery is not considered clean. But I’m not seeing MII cause blood pressure and only blood pressure and heart rate issues going back to the laparoscopic repair. Oh, however, in people with pots postural orthostatic tachycardia syndrome pots, patients with POTS have a higher risk of MII than the average population. And we’ve seen that in our population. And I published on going back to the laparoscopic repair of a weakened inal floor. Can a self adhesive don’t even go there? No, I’m not going to talk about this.
(44:40):
We’ve discussed this before. Self adhesive mesh does not provide any support. No. Nope, nope, nope, nope, nope. Let’s see. Going back to laparoscopic repair, how much does placement attacks increase the chance of chronic postal coronary pain related to a non fixated med? So fixation is always higher risk of chronic pain than non fixation. But non fixating in a situation where you need fixation is more likely to cause chronic pain than not as well. So you have to take it into consideration, into context, I should say. So you can’t read a paper and say, oh look, this paper says there’s higher risk of fixation pain with fixation. Well actually that paper, if it’s one that actually talks about the number of fixation tax, will tell you if you have more than five tax. That is a predictor, not having tax alone. And then also there’s very few papers that have looked into the lack of fixation in specific categories such as large direct hernias or weak can ingle floors where you do need the fixation to prevent the mesh from falling into the hole. And by using Velcro like mesh, you’re not necessarily preventing that.
(46:08):
Let’s see, in someone with a deficient, okay, we already answered that. Oh, I have a beautiful comment. You are a great doctor. Well, thank you. Okay. Totally something funny talking about you’re a great doctor. So when I was a resident, they came up with this robot and the robot was voice activated and then by the surgeon. The surgeon had to, this is a long time ago, this is like late nineties, early two thousands, the robot was activated by voice. So the surgeon would operate with a little microphone and it would hold the camera for laparoscopic surgery and move it around. So you’d say, I think the name was Hercules. So Hercules, go left Hercules, go right up, down, et cetera, built into this robotic computerized robot to move the camera. So it’s basically a robotic assistant. You can ask for compliments. So this is too funny. So you can finish the case and say, oh, Hermes, it was a Hercules, it was Hermes, Hermes compliment. And then in a deep, sexy, breathy female voice, the robot would say, you’re a great surgeon. And I was like, are you kidding me?
(47:42):
That’ll never fly nowadays, especially with female surgeons increasing. But listen, the male surgeons loved it, I guess, and often asked for a compliment at the end of their operation. Just hilarious. Whoever decided to come up with that little extra little tweak at the end of the operation was hilarious. But thank you. When you said you were a great doctor, that’s the first thing I thought about. You’re a great surgeon. Okay, thank you. Shall I do an MRI with your special protocol before consulting with you any other imaging I can do to diagnose testicular pain and nervous system sensitization? So yes, the MRI will be helpful with my protocol to help identify a hernia recurrence. It will also show any abnormal fluid collections. And then in terms of the testicular pain and nervous system sensitization, a good pain doctor should offer you a genital nerve block.
(48:42):
And a good urologist should offer you a spermatic cord block. So genital nerve block, spermatic cord block should be part of the workup to help figure out what is causing your pain. So you can narrow it down. You have to be very patient. I’m sorry to say. Having all of these potential pain triggers, you have to be very patient. I handhold a lot. Go through all the different differential diagnoses. Okay, next one. Are indirect inal hernias less likely to reoccur compared to direct? Yes. Usually based on your surgery experience with many patients, yes. The higher recurrence rate is with the wider thinner hernias, which is the direct hernia.
(49:31):
No, please bash on them. I don’t like to bash on surgeons because they’re like my people. I just need, I prefer that they would learn or something. Maybe they should be watching hernia thought. What do you think? Okay. Shall I also see a neurologist for testicular pain and nervous system sensation? My experience is neurologists are not helpful. There’s a handful of interventional neurologists that will do your nerve block for you, but usually neurologists are not very hands-on and don’t deal with chronic pain. Unfortunately, a lot of surgeons get angry when you ask them if they had complications because they feel like you offended them, then you shouldn’t go to the surgeon. So as surgeons, we are trained to learn from mistakes. We are the only specialty that mandates what’s called m and m, morbidity and mortality conference where you meet weekly or monthly to go over all the complications.
(50:30):
It’s kind of mandated by every hospital to have a morbidity and mortality conference. So get over it. If you have complication, own it, learn from it, and don’t do it again. And if your doctor gets pissed off, then don’t give ’em the business Mesh are problematic, non mesh or ultra problematic? Yes. Good point. In conclusion, there’s no real treatment yet. Excellent. Very well said. Completely true. There’s no perfect hernia mesh. There’s no perfect hernia repair. Women especially are not being treated well because everything that we do have that’s pretty good is based on male anatomy and not meant for the women. So women actually have worse outcomes than men. Sounds like tars from Interstellar movie. Yeah, yeah, yeah. Great surgeon. Okay, let’s see. Next comment. My third last recent surgery, the surgeon used seprafilm barrier as a slurry. I’m way worse now when doing lysis, adhesion laparoscopically.
(51:38):
Do use anti adhesion barriers if you ask which one? So the separate film barrier only lasts like a week. So the fact that the use of slurry was a good idea, I would’ve used it as well. I do recommend it because if your problem is you are just adhesion maker, then adding an anti-adhesive barrier is helpful. It’s like seaweed, not even it’s cellulose. So it’s completely biodegradable and lasts at most a week, five days to a week. So I would not blame the Spro film or the seprafilm slurry from it. But if you’re, the question is, is this all abdominal wall paint or this is intestinal problem? I feel like based on what you were telling me, I haven’t figured out exactly what you’re saying or doing. All right. So I’m happy to answer any more questions. But oh, here’s another one.
(52:36):
Surgery was January. Can match implant illness cause neurological lightheadedness and brain fog type symptoms if they started about 10 days after surgery and became more frequent consistent and consistent over time. Absolutely. So the majority of our patients had symptoms within the first few weeks to months after surgery and then decreases as you get closer to a year and less likely after the first year. So yes, it’s a pretty rapid response. You may have pots, neurological lightheadedness, and brain fog are definitely something that can happen within the first 10 days. So you need a full workup to make sure you don’t have a medical problem that’s predisposing you to it.
(53:24):
We’re potentially learning about some genetic predispositions towards having mesh implant illness. And it may also be if you have an autoimmune disorder yourself or in your family or if you’re generally allergic to things or react to things, then I would say you’re at higher risk for mesh implant illness. And depending on the type of mesh you had, where it was placed and your risk factors, you may want to consider allergy testing just to help me learn more about how allergy testing and may have a role in all this. Get imaging to make sure there’s nothing else that’s being missed. See a good rheumatologist and cardiologist. And once that workup is done, then you may have to commit to having the mesh removed. And in our study, 60% of the people who did better or got better, but there’s a good 40% that still had lingering problems. So it’s a problem. We don’t know if a mesh implant illness is just not real in those other 40% or if it triggers some type of autoimmune response that you may not have had triggered otherwise. And now that autoimmune response, whether it’s MS like or lupus or whatever, whether that just continues on once the trigger is gone.
(54:51):
Let’s see. Another beautiful comment. Thank you for these comments. I wish there were more surgeons like you in the hernia world. Thank you. But I’m telling you, it’s not easy. I don’t sleep. I worry about my patients all the time. It’s a little bit of a curse to care a lot about your patients and it’s kind of old school how we’re taught the newer generation. We try and encourage them to be as empathetic as possible, but generationally, many of them are more interested in lifestyle and are less physically and emotionally involved with their career. And so I mean, I would love my own doctor to always be a thinker and I only refer to and work with doctors that I think are also thinkers. And I immediately reject anyone who I feel is just a one and done surgeon. I can’t deal with you.
(55:57):
My third abdominal surgery was lysis of adhesion with spro film, abdominal pain with severe digestive issues. Okay, we heard that my indirect hernia that I had recently repaired came from hanging leg raises. Should I stay away from such exercises now after surgery and young, I’m young and was physically too active maybe. Well, we don’t know. Sit-ups, pushups, pull-ups, bench press deadlifts have all been studied and there’s been no increase in abdominal pressure. And therefore we don’t believe that they should be at a risk factor for hernias. And in fact we highly encourage them. Do we specifically look at hanging leg raises? No. Do we think that hanging leg raises increase abdominal pressure? No. You usually have to engage your muscles to do that. So I’m not your surgeon. If I were, I would say go ahead and do it after your hernia repair, but I am reluctant to blame that type of activity on hernias.
(57:11):
Exercise is almost never the cause of someone’s hernia. Okay, well that was fantastic and very fast. I feel like we went really quickly this time. I had so much more to say about hernias after trauma because it’s crazy. But at the very least, let’s just say that you should be very thoughtful about the type of hernia that you have repaired and make sure your surgeon considers your past surgical history, including trauma in your decision making when looking for the right hernia repair to have performed. I personally want to bring you back number one as close to normal anatomy as possible so you have your core function restored. And number two, I love giving a good cosmetic outcome. So that’s the way I approach it. Some people don’t care about the cosmetics, but that’s just kind of my bent. Anyway, it was lovely. I hope to see you all next week. We’re going to do a lot of Hernia Talks this month and then we got some conferences coming up in June that I’ll be at where I will be missing you guys. So until then, see you next week. Bye.
