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Speaker 1 (00:00:07):
Hi everyone. It’s Dr. Towfigh. How are you? Welcome to Hernia Talk Live. I am your host, Dr. Shirin Towfigh hernia and laparoscopic surgery specialist, and I’m super excited to be with you today because it’s another beautiful Tuesday. We used to call it Hernia Talk Tuesdays. We’re switching it up a little bit. Some of you are joining me as a Facebook Live on my Beverly Hills Hernia Center page. As you know, I run the Beverly Hills Hernia Center and it’s according to me, the absolute best hernia center in the world. I would say we are experts. We are amazing at what we do and everything we do every day is to make you better from a hernia or hernia related standpoint. So thank you to everyone who follows me on Beverly Hills Hernia Center on my Facebook page. But as you know, I’ll also have my own Facebook page at Dr.
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Towfigh. If you like to hear about academic stuff, you can go on my Twitter page at hernia doc. That’s really mostly for my doctor audience and we always have fun on Instagram at Hernia doc as well. Remember this episode and all prior episodes, all 202 episodes will be are accessible on my YouTube channel or if you like to listen to Hernia Talk Live as a podcast that’s also available to you, which I think is really cool. I listen to it sometimes myself actually. I try and listen to see how it sounds like as a podcast. I personally love podcasts. I’m listening to one right now. It’s on the Indian Cricket League, which I didn’t know much about, but I was talking with some of my friends in London as you recall. I was in London last month and I was watching Wimbledon, so I kind of said a shout out to them and one of ’em said, oh, I’m watching the Indian Cricket League. I’m like, what? During Wimbledon? That makes no sense. But then I saw this podcast on it, so I’m listening about it, trying to learn more. Apparently it’s a big deal. Fun fact. Second only to the NFL, the greatest amount of advertising money is spent for the Indian Cricket League different than the British Cricket League. By the way. Rules are a little bit different.
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Anyway, we’re talking about hernias. So for those of you that follow me, that I tend to pick my topics based on something that happened that week or a patient that came to see me or something like that. And this week’s topic is called hernias and non-believers, and I’ll help explain to you. So you know the term believers and as I have progressed in my hernia world, hernia expertise, as I’ve become more popular and while respected in this field, I started using term believers and I would say, oh, he’s a believer. She’s a believer. It’s kind of similar to the Justin Bieber followers who are believers. Well, these are hernia believers and that is that people understand people who understand that it’s not just a hernia, that a hernia is beyond just being a hole with a bulge, et cetera. I would say that there’s been kind of a disregard for hernias for centuries because it’s always considered a male disease.
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And if you didn’t have a bulge and if it was painless and we would consider a hernia, but I’m sorry, if you had a bulge and it was painless, it was considered a hernia. It used to be taught if it hurts, it’s not a hernia. It must be some other disease process. Or if there’s no bulge, there’s no hernia. All of that is incorrect. By the way, you can have a hernia with a bulge or without a bulge. You can have hernia that has pain and doesn’t have pain. The fact that the pain is intermittent or sometimes occurs and doesn’t occur, you didn’t have pain before, but now you have pain, it’s completely irrelevant. It can still all be a hernia. So the point is the people that do believe it, the people that do agree that atypical symptoms can occur with hernias, that small size hernias are just as relevant as large size hernias. In fact, in times sometimes more important because they’re more likely to incarcerate or strangulate and more likely to cause pain and symptoms in the larger hernias, people who are believers are the ones that I call believers, but then that implies that there are non-believers, and I had to deal with non-believers this past week.
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It made me angry, it made me frustrated because no matter how many times I would explain to them, they were clearly not, and by they, I mean doctors, they’re clearly not agreeable to relearn what was taught to them 50 years ago when they were in medical school. So the situation goes like this. You have a patient that chose to see you for whatever reason, it could be they’re referred to you by a doctor or colleague or maybe a patient of yours referred them to you, or the patient did their own research online, social media, ai, whatever, and they said, go see Towfigh because you may have a hernia or she could help figure it out for you. They see me. I do a full workup. I’m not someone that stands across the table and says, aha, hernia, let’s go fix it. A, I have to diagnose you with a hernia.
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B. That includes oftentimes a very thorough story and your story is very important. Many of you who follow me know how important it is that you have the right story, right? So if you’re telling me your ear hurts and I have this bulge, I’m not going to say, okay, let’s fix the hernia. I’m going to say, let’s see why your ear hurts. And therefore if your story doesn’t match that for a hernia, I start looking for other causes of pain or symptoms. Physical exam is very important and we know, you know because you’ve been listening to me that not all hernias are the same. Some hernias have an obvious bulge. Some hernias don’t have a bulge. Some of them are very tender on exam, others may not be tender on exam. You can have hernias on both sides. There’s different types of hernias. Different parts of the body can have hernias.
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Certain parts of the body can never have hernias, and so to call an area painful because of a hernia is not correct. So physical exams very important if you need imaging. Imaging is important. Again, those of you that follow me know that imaging is often misread by radiologists, both ultrasound CT scan and MRI, we’ve published on this. Three out of four CAT scans are misread for hernias. So that’s just a horrible statistic, which means that if you go to a doctor and they get a CAT scan and there’s no sign of a hernia based on the radiology report, 75% of the time that may be incorrect. And therefore they come to me. I look at the imaging myself and I’m like, look at, here’s a hernia. So now I have to convince another doctor who never looked at the imaging themselves, never knew how to read imaging themself, who’s trusting the radiologist who wasn’t skilled enough to understand what a hernia may look like on imaging and believes the non-specialist radiologist over the specialist, her neurosurgeon in imaging.
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And then lastly, I have to take that your story for physical exam and your imaging put it together and say you have a hernia, yes or no, and then the hernia is the cause of your symptoms and therefore surgery for it will help or you don’t have symptoms and watchful waiting is helpful, but the purpose is the two have to be equal. You have to have the findings and symptoms that can be attributed to it for me to recommend hernia care of some sort, whether it’s surgery or otherwise. And then that would be my plan. So today for example, I saw a young, healthy, active fit gentleman who wears a belt for work and when bending down felt like this ripping tearing sensation and was like uhoh.
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So he then noticed what he thought was a bulge and went to a doctor and doctor said, maybe you have a hernia. Go to a surgeon, saw a surgeon. Surgeon offered him surgery. So he says, what are we operating on? He’s like, I mean, I don’t know, maybe you can have a hernia. He says, what do you mean maybe do I have a hernia? And the surgeon says, I dunno, we can find out. I don’t work that way. There’s no way. I would just without any workup, just say, you know what? We’ll operate on you and whatever we find, we’ll figure it out and if we don’t find anything then you never had a hernia. That’s not appropriate in my view.
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So of course the patient also thought maybe that’s not the right approach. So he came to see me and guess what? Yes, he did have a hernia, but that wasn’t the cause of his pain. He had a muscle strain that causes pain. The bulging had nothing to do with the hernia. He had bled from the muscle tearing and he had a little blood clot like clotted blood and swelling, which then eventually went away after his own body resorbed it. So long story short, this patient that was being whisked off to surgery immediately by another surgeon, I did not offer surgery to him. I offered him an injection, physical therapy, rest, anti-inflammatories, typical things for a muscle strain and told him to ignore his hernias because they’re small, asymptomatic and he’s otherwise fit and healthy. So he should do fine without need for surgery anytime soon. So that’s the way I work.
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So when I get a patient who’s had years of pain, years of being given narcotics, by the way, years of allowing him to be now depressed, years of him being at times suicidal, and I very carefully figure out that the cause of his pain, part of it, not all of it, part of it are these hernias and I offer hernia surgery. It really irks me when a doctor who has no expertise in hernias, doesn’t know any other surgeon that has expertise in the hernias is blocking me from helping this patient, blocking me from helping this patient while at the same time giving zero alternative options to help this patient.
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I like to have buy-in by the patient’s doctor. I don’t want to operate on a patient without their medical doctor being part of the decision making. The patient was okay with it. The patient understood. I showed him the imaging, showed the hernia. I showed him, I went through all the different symptoms of hernias. He has many of them. I showed him my examination where I feel the hernia. He agreed we had a plan and then later on what happens, the doctor, all he does is hernia shouldn’t hurt that much. Yes they do. He doesn’t have a big hernia. No he doesn’t, but he does have one. Imaging doesn’t show hernia. Yes it does. Well, I showed this to five other surgeons that I saw sitting at this table and all of them said, it’s not a hernia. Well, those are not hernia expert surgeons. Well, I went to a radiologist and show the imaging and they don’t see a hernia because they’re wrong.
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They’re not hernia specialists or imaging specialists for hernias. So the fact that most doctors, most doctors do not understand that hernias can have symptoms that aren’t classic. So we know for the belly you can have bloating, you can have pain radiant to your back. That’s not taught in textbooks. You can have pain to the side of the belly button and not have it at the belly button can still be a belly button related hernia pain for the groin, you have pain that radiates into your testicle inner thigh around your lower back. You can have bloating, you can have urinary frequency. How is that related to a hernia? Well, those are that know pelvic floor spasm can be a complication of anal hernias and all those symptoms. Clitoral pain can be due due to a hernia. Penile tip pain can due to inguinal hernia, we discussed that last week.
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Rectal pain, coccal pain, all of those can be due to pelvic floor spasm related tolo hernias, pain with defecation, pain with sexual intercourse, pain on even erectile dysfunction can be due to an angle hernia. So all of these are atypical symptoms which when you spend time with a patient and ask the global picture questions and key questions that are high yield, which one day I’ll review those for you, and they say yes, yes, yes, yes to all of those, and the physical exam is suggestive of a hernia and the imaging shows hernias. Well then in that case you have a situation where it’s a hernia unless you have a nonbeliever and a nonbeliever is it has to be a big bulging hernia and it can’t be painful. And that’s how it was taught. I literally went to my very first American Hernia Society meeting. These are hernia specialists by the way, but they were all men and they were all older men and they were all interested in your typical hernias and they, after I got involved with the American her Society over the next three to five years, I would sit on Pannus and they would say, and I quote, if it hurts, it’s not a hernia.
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Literally they would say if the groin pain is severe, got to look for another reason for it. It can’t be a hernia. And I was so junior, these are people in their seventies, sixties, seventies, and I was maybe mid thirties, mid early to mid thirties and I was ballsy back then. I was sitting on the same panel as them. So I didn’t feel intimidated by the fact that these are the gods of hernias spewing out information that I didn’t believe in and that I thought was incorrect. And they’re telling it to an audience of surgeons that are listening. They’re then going to go back and take that information that they learned from the conference to their office. I said, ah, I respectfully disagree is quite natural for hernias to be pinched and hurt for them to be very painful in women, et cetera. And they said, well no, we recommend hernias in general should not be painful.
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Completely incorrect. Why do you have a watchful waiting trial that only includes patients without pain? Implying that there’s the exclusion criteria is patients with pain and the is once you get pain, then you have indication for hernia surgery, but watchful waiting is safe when you don’t have pain. Doesn’t that imply that hernias hurt? It didn’t make any sense to me back then and the older doctors and some of the younger ones, mostly with the older ones nowadays are spewing the same information. So now you have a patient who will not be referred to someone like me or when they are referred to someone like me, I’m telling them let’s do surgery and they’re going back to their doctor saying, I’m not approving surgery. I don’t think it’s the right thing. I think you’re doing making a mistake. And what do they do? They bring in all the back, all the, what’s the right term?
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Not luggage, not baggage, baggage I guess from look at all these people with chronic pain after hernias. Look at all this mesh complications and they scare the patient away from having the surgery that they need because they themselves are a non-believer and they’re importing their bias onto the patient, scaring the patient from getting the care that they need. Here’s a question. Can muscle guarding or stomach bloating hide a hernia during imaging? No, it cannot. So in general, the hernia as the defect is always there and even if you’re not having content go through it, or sorry, push through it such as with a Val Salva, bare down views, coughing, whatever. There’s usually content in it anyway, like a little bit of fat that you may not know. So when hernias reduce, they’re not always empty. The sac may still be there. Remnants of the hernia such as fat may still be there.
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So it is better to get imaging with pushing out of the belly because that can make the hernia look bigger, but if you don’t, it doesn’t mean necessarily that you don’t see the hernia with one major exception. And that’s direct angle hernias with a direct angle hernia when you do the Val Salva because it’s not an actual hole with a punched out hole with content in it, it’s usually a weakness. So when you’re lying flat, that weakness flattens out and then if you’re lying flat and pushing out, then it’ll bulge out. It’s called the Mickey Mouse sign. If you have a bilateral left and right inguinal hernias that are direct inguinal hernias and you push out, these are called the Mickey Mouse sign because we kind of get the Mickey Mouse and some patients, the bladder actually goes into it. That’s a very classic Mickey Mouse sign, which is when the bladder falls left and right, direct inguinal hernias.
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In fact, I had one doctor again staying on topic about the non-believers who told me the patient does not have hernias because the imaging didn’t show it. I had to remind him that imaging is only a supporter of the clinical diagnosis. Hernias are a clinical diagnosis. We don’t operate on people that only have imaging results. With few exceptions, with a few exceptions, femoral hernia being one of them. But in general you have to have symptoms and you have to have an exam finding of some sort before we commit you to surgery. Imaging is just there to support any suspicion or plan for your surgery, et cetera. So the fact that you’re arguing with me already about a patient who clearly has hernias on exam and by symptoms because the imaging didn’t show it, it’s complete BS because imaging doesn’t trump physical exam and symptoms, number one.
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Number two, this other non-believer we’re talking about here didn’t know what a direct hernia is or indirect hernia is. Those of you that follow me know the difference. Indirect hernia in the groin is a very common punched out hole, often with fat through it, sometimes intestine if it’s large enough, sometimes bladder infrequently. A direct inguinal hernia is medial inwards from that. Also in the groin that is usually not a punch down hole. It’s usually a thinning and stretching out of a layer of muscle called the transverse fascia. When that happens, when you stand, it boulders out. When you lie flat, it goes flat because it’s just a weakness. It’s like the way I used describe it is like when you wear sweatpants for a long time and the knee starts to stretch out, that’s what a direct inguinal hernia is.
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So if you look at imaging, the radiologist often does not call a direct anular hernia only calls an indirect inguinal hernia because the direct hernia in their eyes is not a hernia. They don’t know about it, but mostly because it’s not a hole with something going through, it’s just a thinning. So then the same non-believer calls me and says, no, I reread the imaging with the radiologist and they said there’s no hernia. There’s quote, just a thinning of the fascia with fat protruding into it. You just described it directing a hernia, what do you mean there’s no hernia? So this is what drove me nuts last week is when I had to deal with these hernia nonbelievers and they’re like an obstructionist wall. All they’ve heard about is hernia repair has gone bad, mesh gone bad, and therefore what is their idea? Everyone with hernia should never get surgery ever. I mean this guy, one of ’em ones that I was dealing with, the patient has had chronic pain for years and I’m offering a solution and I’m not just like some random Joe Schmoe he thought I was. Maybe he didn’t know who I was. I don’t know. He should know because we’ve shared patients before, but I don’t know.
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I feel like sometimes her attack live is just a way from me to vent a little bit because you’ll get me and you understand me and many of you have suffered through the same situations and stories and hopefully you understand and many of you have had doctors that are hernia, they don’t think you have the right hernia. I’ve had patients drive down from Canada for days to come to see me against the will of their medical doctor because the medical doctor said, you don’t have hernias, you’re just going to go down there and quote Beverly Hills and you’re going to see this quack doctor, which is what they were told. She’s going to quote, take your money and mam you, which of course is not correct and of course I didn’t take it personally, but how horrible for a doctor to do that. Of course I diagnosed the patient correctly.
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They got their hernia repair first time ever that they were pain-free to the point where the patient driving was driven by, I don’t know if it was boyfriend or husband, from way, way up north in the upper province, one of the upper provinces in Canada all the way down south to California and she was in so much pain through the drive. She was in the back of the car on the passengers lying flat because of the pain and driving back up, no pain driving back up. We were able to pit stop here and there to enjoy the scenery and have a lunch or something. So all delayed because she had a doctor that didn’t believe non-believer. Okay, let’s go through your questions again. If a hernia is not causing the defect, how does it cause pain and how can it lead to strangulation? Good question.
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So direct hernias usually do not lead to strangulation. I always explain to my patients that of all the hernias, it’s one of the more safe hernias because you see the bulging, the bulging can usually cause not severe pain, but like a dull aching pain. Some people describe it as a heaviness, it’s like having a sack of water hanging. So that’s usually the type of symptoms of a direct hernia. If it gets very big, it can follow the same trajectory down with the indirect hernia that goes down to the scrotum. Those would be really big and so that if it stretches out so far out that it’s essentially like a punched out hole, then so thinned out the neck of the hernia can cause obstruction and that’s very uncommon in the first world. May be more common in a situation where people don’t get access to care.
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Can a small umbilical hernia asymptomatic be repaired during the same laparoscopic tap surgery for bilateral ular hernias? Absolutely. If so, hold on. If so, will the umbilical hernia also be repaired with mesh? Unlikely. Unlikely. So I actually offer this very commonly because patients either know or don’t know that they have an umbilical hernia, but they are seeing me for their ular hernia. Then when they do, so I diagnose ’em with an umbilical hernia like, hey, you have an outage, you know that, oh, I didn’t know that. Or yeah, it’s been bothering me, whatever the situation is, and then I offer repair because I still need an incision. I still need to do an incision in the belly button for the laparoscopic repair, so why not use that thing like a coughing, not sure why. So I can still get access to the belly button in that incision for the tub to fix the hernia repair, fix the umbilical hernia repair.
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Yeah, so yeah, totally doable. Usually those are small hernias, less than one centimeter and they do not need a mesh repair infrequently. They do need mesh if it’s two centimeters or more or if they’re high risk patients and it’s between one to two centimeters and you can, I have at least one episode where I talk only about umbilical and ventral hernias and we go through the algorithm for that. But basically it’s great to be able to do a laparoscopic repair and if there’s a hernia at the belly button, use the incision for the laparoscopic repair to also gain access to the belly button to get it done. To get it repaired.
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All right. Sorry for all the coughing you guys. I’m so sorry. So let’s see, we had some questions submitted as well this time actually almost every week, but often we don’t get time for it. So when should you seek consultation with an expert hernia surgeon after other doctors dismiss your symptoms as not hernia related? Well, I would say nowadays that’s a very easy question because social media, ai, those are all great resources with the web. Those are all great resources to look at to do your research, right? There was an ability to do research back then everyone would just go to Mayo Clinic or something or they would ask their neighbor or ask their friend. It was like a referral base, but you should do your own research. We are really good right now at being our own patient advocate. I have patients from all over the world. We had Singapore, Malaysia, multiple Middle Eastern countries, South Africa, Algeria, a lot of the South American countries, Canary Islands, jersey. Do you guys know where Jersey is? Pretty cool place. Beautiful island in the English channel. I think it’s kind of British but it’s not part of the United Kingdom.
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Russia even they do research the same way you do research. Their web access is the same as your web access. If you’re, I’m talking about you as in the United States, and so you can do your own research. I offer online consultations so you don’t even have to fly in to see me. If you want to just run your situation by me, you can say, listen, I have a non-believer, but every time I do my own research it shows that I probably have a hernia or I read an article by you and I felt like I was reading about myself, everything this patient was going through, I’m going through these symptoms, I have those symptoms. So researching and being your own patient advocate is great and many of us, Cleveland Clinic I think does the same, I’m not sure, offer online consultation. So you basically contact my office, send in all your information, some people send in pictures of themselves, then they mark on the picture where their paint is, some people send of where their pain is. I love getting a full diary of your symptoms and overview of things. I must have any imaging that you’ve had. I want to see the prior notes and reports and all that. We have our own hernia health questionnaire, which is a detailed questionnaire asking very key high yield questions. So you go through all of those, send them to me. Then when I’m not working in the office, usually on a weekend or at night, I have no life.
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I will review that and send you an email. So if you get an email from me on a Sunday night, don’t be surprised. That’s often when I do my online consultations, so I enjoy that. It’s like a little puzzle. How many of you guys do the New York Times puzzle? So you know how there’s the wordle, right? Like Wordle, but there’s also the, what’s it called? I’m blanking on it. I just did one. Today’s it called the one to four groups. Oh, connections. There’s connections, right? Very difficult. Usually the last one or the second to last one is very difficult or strands where you go look for the hidden words. I love doing that stuff. So when I get an online consultation, I’ve got multiple on my desk right now, one with a big yellow sign that says expedite please so you know who you are. If you ask for expedition of your online consult, I usually take those home and I work on them. So if I don’t have you talk about in work, then I do a wordle or two. So that’s how I roll.
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Where were we? Let’s see. Question. Okay, question With regards to the symptoms and findings you’re talking about today, what clinical history, physical examination and other tools can be used to differentiate pain originating from a pubic plate disruption, athletic myalgia from that coming from either a direct or indirect hernia inpatient diagnosed with both conditions but in whom the hernia defect may be an asymptomatic result of the same athletic injury. So angle hernias are usually not a result of athletic injury. Athletic injury is more common with a tear. It’s usually not an inguinal hernia, although there is something called a gilbert’s hernia, which is really usually not even a sports injury. And in order to have an athletic injury, you have be an athlete. So if you are not an athlete, it’s unlikely you’ll ever get an athletic injury. The physical exam findings are definitely different. Like the patient that I saw earlier today, he has point tenderness on his pubic bone where the rectus muscle attaches and can’t do a situp. When I pressed on it, he was yelping in pain whereas his inguinal canal area was not tender at all. It had no bulging at all.
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He also had imaging findings, which shows some swelling in the area of the rectus muscle insertion onto the bone. You can have a tear of your fascia, in which case a nerve may go through it. You can have nerve pain and physical exam will be pretty much normal and imaging will also be normal if your pain is often activity related and a pain goes away when you’re lying flat, that’s usually a hernia and not a sports injury. If the pain radiates the inner thigh or the testicle around your lower back, that’s usually a hernia related and not a sports injury.
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And sports injuries will tend to respond to injections, whereas hernias would tend to be more painful after an injection. So there’s all these little nuances, but it’s really that trifecta of triple concordance. So story physical exam and imaging, all three supporting the same diagnosis and not being thwarted by one finding versus the other. So let’s say you have a hernia on imaging, doesn’t mean your pain is from imaging like we saw in this patient that I saw earlier today. Next question, what kind of hernias or associated complications present the most complex differential diagnosis? So good question. I would say two types. One would be the rare ones, right, and next week we’re going to talk about rare hernias. If you have a rare hernia, most people will not be thinking about that in your differential diagnosis. I just repaired my second sciatic notch hernia. Sciatic notch hernias are the most rare hernia you will ever see of any hernia.
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It’s a very rare pelvic hernia. Most people don’t even know what it is and therefore a radiologist would not necessarily know to look for it or find it or diagnose it. A neurosurgeon may see someone with sciatic pain or a spine surgeon or a pain management doctor and treat them as it was for sciatic pain where truly a sciatic notch hernia where the hernia is irritating the sciatic nerve causing the sciatic pain, which is very common to have sciatic pain, very uncommon to have a sciatic notch hernia as a cause of the pain. So the rare hernias are one, you can have lower back lumbar hernia is very, very uncommon. Opterator hernia pretty uncommon. All of these rare hernias, a parametal hernia, it’s over the pubis. That can be another problem. The others are the groin. The groin is very complex. The pelvis in general is complex.
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You have nerves, you have sexual function, you have various types of muscles, plus you got the genital urinary system for, you have the GI system for the rectum and anus and then you have the sexual system in both men and women. Then you have the musculoskeletal system with the pubic bone and the sacrum and the SI joint and the coy. All of those involve orthopedic surgeon, gynecologists, pain management specialist, spine surgeon, urologist, GI doctor, general surgeon, so colorectal surgeons. So all of those areas can have overlapping symptoms due to a non hernia diagnosis or a hernia diagnosis. So I think chronic pelvic pain and groin pain in general is very difficult and then diagnosing a really rare hernia, you don’t know what you don’t know. If you don’t know that there’s such a thing called a petit hernia or a grin felt hernia, which are these two rare lumbar hernias and the patient’s got lower back pain and if they’re not super thin you’re not going to be able to feel these hernias.
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Then they may never get these diagnoses or it’ll take a decade or so. Or if you don’t know that women present differently than men and you have a situation where you just allow women to have chronic pain, just give ’em narcotics, which is a very common situation. Then you have a situation where you have decades of chronic pain and they don’t have sex and they don’t have children and they lose their spouse and they can’t keep down a job all because there was misdiagnosis. And what really irks me though, going back to today’s topic, what really irks me is not so much the difficult ones, right, the difficult where no one knows what’s going on. I just got a referral, I got a phone call before this. There’s a doctor who called me and says, I heard that you actually enjoy solving problems. I said, yeah.
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I said, well, I have this patient, he’s actually a colleague, he’s a doctor and he’s got this medical problem no one can figure out and it’s been plaguing him for years, so would you mind seeing him? By the way, it’s not a hernia. It’s not a hernia at all. It’s like an abdominal issue. And I said, yeah, for sure, absolutely, why not? I’ll try and figure it out. My point is those the zebras I can understand, but when you have a situation, when you have a diagnosis, it’s made you literally have the patient see a specialist, let’s say me hernia specialist and the hernia specialist who does this for a living, diagnoses the problem and you’re trying to disprove the specialist by showing her all these non-specialists who disagree. That really irks me because there’s a potential to cure this patient and I have the patient eager to have the surgery but also hesitant because their medical doctor is claiming that I’m incorrect and I may hurt him.
(00:43:11):
He has so many patients with mesh problems. By the way, doctor, if you have so many patients that you know with mesh problems, complications, you should send them to me so I can fix them. My success rate’s pretty good. It’s been published, so why are you hesitant to trust a colleague of yours and yet at the same time you’re not offering any treatment to your patient. These non-believers really working because I’m a very logical person. I’m a Scorpio so people understand logic is I’m very logical, which means sometimes it really bothers me when people are very emotional about things because I’m like, well, where’s a logic in that? So if I’m giving you two plus two equals four and you’re like, yeah, but is it really four? I mean, do we really know that it’s four who told you it’s four? I talked to five other people and they didn’t believe two plus two equals four. And I’m like literally, I’m a math expert. I’m telling you two plus two is four. And it just bothers me that they don’t believe it and I don’t think it’s because I’m female. I think it’s truly that. It’s not that they don’t believe me because of like me, I think they just truly have never been exposed to a situation where there’s new information since he was a medical student. I don’t know.
(00:44:58):
Whatever suggestion you guys have, I’m happy to hear about it. Okay, next question. While growing disruption is more common athletes, is it impossible for a non-athlete to disrupt the pubic plate by lifting something too heavy with poor form using a deadlift technique rather than bending knees? Yeah, it’s pretty much impossible. You need to have, okay, so what is a disruption? You have a muscle attached to a bone. If your muscle is so strong, excuse me, if your muscle is so strong that when it was contracted it pulled off the bone and pulled some bone off of it or a tour, then that’s athletic level. If you’re not an athlete, how are you going to disrupt that? How are you going to tear? Okay, incredible Hulk, right? You guys all remember incredible Hulk? Incredible Hulk.
(00:46:11):
When he got pissed off, he was like a normal man and then when he got irked by something, he would just get so pissed off and then he would turn green, he would gain all these humongous muscles and then his shirt would tear. But lemme tell you, if you’re not the incredible halt, you can’t tear your shirt. It’s really hard If you’re trying to tear a shirt apart, you have to tear through it. It’s really hard. So an athletic disruption is a similar situation. If you’re just a normal bodied person, it’s going to be very hard to tear your shirt. You have to be the incredible Hulk or Luo to be able to tear a shirt and I’m sure they gave him a shirt. That’s terrible by the way, and by terrible, I mean tear able to be torn. That’s my point is I’ve had so many people, I’ll give you an example. The sports hernia type patient that I had last week, she had a tear in her fascia with a nerve going through it. Now classically that’s a S sports hernia, but she had surgery there before, so technically that tear was a disruption of her surgical repair, not a athletic injury. Now we’ll still call it a sports hernia or sportsmen hernia. It’s really not.
(00:47:49):
We don’t really have, we have other, it wasn’t pelvic plate disruption. It was a tear of the external oblique fascia. Usually I see it in gymnasts, ice skaters, a soccer players and so on, not in a lady who is in her seventies. So basically don’t let people because they don’t know any better, tell you you have a sports hernia when you don’t even are involved in sports. All you have is a hernia that doesn’t have an obvious bulge because either a direct hernia because it’s just a weakness or it’s a small indirect hernia, and classically that’s dull achy pain. When you stand worse, better when you lie flat, et cetera, that’s usually not the situation with sports injuries. They’re usually not better when you’re lying flat. If you rest, they’re better, but specifically lying flat is not a thing with most sports hers.
(00:49:08):
So that’s kind of my 2 cents about it. Let’s go to the next question. Is that of a ventral hernia always an obvious diagnosis? Oh, is a diagnosis of an ventral hernia always obvious? Maybe that’s the better way to put it. Yes and no. So there’s types of ventral hernias, also called spigelian hernias which are not full thickness hernias. We had a whole episode on spigelian hernias I believe. So spigelian hernia is a hernia through the oblique. There’s three layers of obliques. There are internal oblique, oblique, sorry, external oblique, internal oblique and trans transverse abdominis. And if you have a hernia through the transverse abdominis and the internal oblique, but the external oblique is preserved, that is a spigelian hernia. Those hernias are usually hard to diagnose because they’re not obvious. They just may cause pain or a very slight fullness, not an actual bulge, and they’re often missed on imaging.
(00:50:27):
People misread the imaging. Another hernia very often misdiagnosed until you go in there surgically. RQ at line hernia, more commonly seen in women, most commonly in someone who’s had a hysterectomy or C-section in open fashion where they do a fan steel incision. The way that they close it, it can disrupt the arcuate line and then you can get what’s called an arcuate line hernia. If you’re lucky on imaging you’ll see bowel that kind of falls into the space between the rectus muscle and the posterior rectus sheath. There should be no herniation there. I recently treated one of those about a month ago. It’s laparoscopic. You don’t necessarily need mesh for these. You just close off the space.
(00:51:24):
Typically uncommon ventral hernia and hard to diagnose. There are a couple of diaphragmatic hernias that are hard to diagnose. What else is a ventral hernia that’s hard to diagnose? Most of ’em are pretty easy. The incisional hernias are very easy usually because you had an incision and so if you have bulging or pain in the area, you should always think incisional hernia before anything else. Is it necessary for a surgeon to know whether an ular hernia is direct or indirect before laparoscopic surgery or do they find out during the surgery with bilateral ular hernias, are they usually both either indirect or direct? Do ultrasound reports usually indicate the type of inguinal hernia? Great questions. Okay, I’ll do one at a time. It would be helpful to know if you have a direct or indirect inguinal hernia before surgery because direct hernias tend not to do as well as indirect for tissue repairs. So open non mesh repairs, it doesn’t really matter for open mesh repairs if it’s direct or indirect for laparoscopic repairs. If they’re both, if either hernia is small to medium size, it usually doesn’t matter if it’s direct or indirect. I personally prefer to change my technique away from laparoscopy if it’s a really big direct anular hernia because I feel like it’s not as good of a repair as an open repair or maybe even a robotic repair.
(00:53:01):
But it’s perfectly fine and common for a surgeon to figure out if it’s a direct or indirect during the surgery. And it’s often difficult. The ultrasound images and reports usually do not mention direct or indirect because the radiologists usually do not know what the difference is themselves and it’s for them to differentiate and there’s no standard by which they need to follow to differentiate one versus the other. For bilateral inguinal hernias, you can have a direct on one side, indirect on the other, or they could be similar. Most patients are symmetric, so if you have a direct on one side, expect a direct on the other. If you have an indirect on one side, expect an indirect on the other typically, but it’s so random, it doesn’t necessarily mean that you’re going to be symmetric in all patients. There’s no rule about that. So I hope that’s really helpful for you. Let’s go to the next question.
(00:54:12):
Can hernia, hold on. Can a hernia manifest with symptoms that do not include bulging or pain and still be worthy of prompt surgical attention? The only hernia, well there’s a couple. The main hernia that can have no symptoms, no pain, no bulging and should still also be repaired is a femoral hernia. Femoral hernia is one of the deadliest of all hernias because if you do show up in the emergency room with incarceration, strangulation need for bowel surgery, you have a 5% risk of dying from that admission. So it’s a serious problem, mostly because people don’t know they have a hernia. There is no bulging, there is no pain until a loop of intestine gets stuck and then you end up in the emergency room. Another similar story is with the opterator hernia. Those are even more rare than a femoral hernia. An opterator hernia classically is seen in a very thin C connected, constipated patient, usually elderly, usually nursing home patient.
(00:55:20):
That’s the classic situation. It doesn’t have to be, but it’s more often thin people than robust people because the opterator space already has a muscle there. So your muscle needs to kind of thin out and to accommodate for this herniation usually. So yes, an ator hernia also can be one of those where you never knew you had a hernia. Classically, the patient shows up with a bowel obstruction and the majority of bowel obstructions are in people who’ve had surgery before. But let’s say this patient’s never had surgery, so an opt rate or hernia or femoral hernia should be, or any hernia should be in a differential diagnosis of someone who shows up to the hospital with a bowel obstruction and oftentimes they never even knew they had a hernia. So that’s where imaging is very important.
(00:56:20):
Maybe a sciatic notch hernia of the different pelvic hernias. You may not have bulging or pain, but if they do usually involve intestine, there’s not much fat to be in the area and therefore what can happen is the patient can have an imaging finding no bulge, maybe some pain, and then there’s bowel in there. So if bowels involve, we usually recommend surgery, even if it’s asymptomatic. Does pain at rest but not after physical activity always exclude a hernia or its complications? That is a great question. So pain at rest but not after physical activity. I would say that is typically not a hernia pain at rest, but not after physical activity. I’m trying to think. So for those of you’re watching hernias have pain with physical activity and less likely to have pain at rest. In fact, you may say, yeah, every time I go for a walk, if I’m working a long shift, if I’m at a party, I feel the hernia, but if I lay flat, I’m fine, hernia goes away, pain goes away. But the reverse, what situation? Whether it be pain at rest but not after physical activity, I can’t imagine one. I would say you’re stumping me here. I cannot think of a situation no matter how rare, where the patient will have pain at rest but not after physical activity. Yeah, good one. Very, very good one. Let’s see, another question.
(00:58:25):
Why is open repair better for direct hernias? Does data not show less pain with laparoscopic? Yeah, I’m not talking about pain, I’m talking about recurrence. So with a open repair with mesh, you can plicate the direct space. That means you have a redundant thinned out transfer salus fascia and you can sew it in a manner that makes it flat but not tight and then you place mesh on top of it with a laparoscopic repair, you can’t sew it, you can reduce it and maybe tack it up or sew it up or robotically. You can reduce it and put it up. It’s just not as good, I would say as you would think it would be. And therefore the relative benefit laparoscopy or robotics is reduced when you have a large, not a small, but a large direct angle hernia. Okay. Do am MRIs with Val Salva help diagnose femoral hernias or just inguinal?
(00:59:40):
Yes. All hernias. All hernias are benefited from Val Salva in femoral hernias. You may argue it actually is better because they’re so hard to diagnose and they’re so small typically. But yeah, all hernias would benefit from Salva. So usually whether it’s a CAT scan or MRI or ultrasound, we prefer that there’s a dynamic component to it where there’s bulging, what do you call it? There’s a Valsalva or bear down and that will give a little bit more information than if you did it. In fact, I have a collection of images that I give. It talks where I show before and after imaging with and without Val Salva. And it’s really helpful to show the difference and why it’s important to add that little extra, extra bit. Contrast is not important. IV contrast not important in MRI or CAT scan and yet Val Salva, very important. Alright everyone, that was a great hour. Enjoyed speaking with you all.
(01:00:52):
Thank you so much for joining me on Hernia Talk Live. Do follow me on Facebook at Dr. Towfigh and also at Beverly Hills Hernia Center. I look forward to seeing you next week. We’re going to talk about rare hernias and if you have any special topics, let me know. I’m going to have a patient come up soon as a guest and I got some international surgeons as guests, some friends that I met in London who I’m going to being in as guests. So really very much looking forward to, I would say the next half of the year. Aren’t we just past the 50% mark of the year. Yeah. Thanks everyone. Bye.
