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Speaker 1 (00:10):
All right, it’s Dr. Towfigh. Hey, everyone logging in to see you all. Welcome to Hernia Talk Live. My name is Dr. Sharon Towfigh. I am your hernia surgery specialist. Many of you’re joining me here as a Zoom as well as my fan base on Facebook currently through Beverly Hills Hernia Center Facebook page as a Facebook Live. So thank you so much for joining and I see that we’re not, let’s see, are we live on the Beverly Hills Hernia page? Yes, we are. Perfect. I know we talk a lot about evidence and we talk about research and we talk about evidence-based medicine and so on. So I don’t know if many of you understand what it takes to actually do the research, and some of you have shown frustration in trying to figure out what research is valid, what’s not. Many of you come to see me with a whole chat GPT lineup, and I have patients that come in to see me that quote literature and it’s conflicting.
(01:22):
So I feel like when I read the literature, I include that in my 20, 30 years of practice where I’ve had all this kind of background information. However, patients may be reading it for the first time and so they don’t really have the whole big picture and many people are not scientists, and so they feel that research should be very black and white, and we know that medicine is not black and white at all. So that’s an issue that we have that I hope to address today and maybe clear up what we do for research, how research is done, and then also specifically to help show you what we’re doing in improving her knee care through research, how you can help and also how you can use research to your benefit. Let me just double check that we’re, is everyone able to maybe give me a thumbs up if you’re able to watch me live on Facebook, that would be great.
(02:46):
It says live video has ended, but it should not have ended. Yeah, we’re not live on Facebook anymore. Let me double check that really quick. So for those of you that know me, I’m very much a big fan of evidence-based practices, but I also am not a fan of cherry picking data. So I’ll give you a great example. I had a patient today who basically came to see me because she was told she absolutely needs mesh for her hernia repair. And the doctor said, I don’t offer a non mesh repair. Go see Dr. Towfigh. So she did, which is great. She came to see me because she did not want mesh based repair. However, it just didn’t make sense that anyone was offering her mesh repair. And why is that? The reason for that is her hernias were barely a centimeter, barely, and she’s fit, she’s active, she’s young.
(03:59):
There’s really no reason to put mesh in someone with such a small hernia. But what her surgeon told her was, hernias are always better with mesh and therefore I don’t offer non mesh repair. Now, is that true or not? Well, it is and it isn’t. So it is true that you’ll always have a lower recurrence rate with mesh. That’s totally true. In fact, every single study you look at, right, we’re talking evidence-based research is why research is important. Every single study that you look at, if you compare mesh versus no mesh, the recurrence rate is lower with the use of mesh umbilical hernia, anal hernia doesn’t matter. The question is, as a surgeon, do you take that information and interpret that therefore all hernias need to be performed with mesh. That’s where the tricky part is. In other words, if you have mesh versus no mesh, and the risk benefit ratio for recurrence is like 1% difference, but in this specific patient because they’re super thin or a female or morbidly abuse or whatever the risk factor is, and that makes their risk of chronic pain higher with mesh or tissue repair, chronic pain higher without the mesh, then that’s up to the surgeon to figure that out instead of looking at the pure numbers.
(05:36):
Does that make sense? So when you’re making guidelines, for example, the European Hernia Society is great at making guidelines. When they make guidelines, they basically tell everyone based on the evidence that’s out there, we recommend the following types of operations for this hernia, for this size, for this type of patient. So they have to take the data as a consensus group and then take the data and boil it down into what is a guideline to be used so that all surgeons, not just a hernia, surgical experts can figure out what the right thing is for their patient. By the way, we’re having problems with the Facebook group, I think Not sure why not Sure why.
(06:29):
Okay. So the point is this. If you’re making a guideline that says a hundred percent of patients need to have the mesh performed, sorry, the hernia performed by mesh because it has a lower recurrence rate, that discounts the fact that there are people that will have a higher risk of other problems with mesh, and you have to balance other problems with recurrence and do risk benefit ratio. So if you’re going to have a high risk of chronic pain or the benefit ratio is really, really minimal, then that should be some type of shared decision making with the patient to determine if they want as their first product project to have the mesh in place or if they’re willing to accept a 1% difference in outcomes and yet not have mesh. Does it all make sense?
(07:30):
Let’s see. Sorry guys, but we’re still having problems with getting on the Facebook page. So my goal in performing research, and as you know I do a lot of research. We present every single year at the American Hernia Society meeting, European Hernia Society meeting, American College of Surgeons, which is the largest international meeting sages, the Society of American Gastrointestinal and Endoscopic Surgeons, which is the world’s biggest minimally invasive surgery meeting, Pacific Coast Surgical Association, Western Surgical Association, and the Southern California chapter of the American College of Surgeons, which are really major high-end regional meetings. I’m a member of all of these and I submit my research and it often thank God, thank God often gets accepted, which means that I have an opportunity to share my research with other surgeons, get feedback, and based on that feedback become published and that publication will therefore be passed on to generations of surgeons that are interested in hernias or have hernia questions.
(08:49):
And actually not even surgeons, doctors or any lay person who wants to read can freely read these research publications. And in doing so, you’re sharing your experience, you’re sharing your research question. We always say people that do research are inquisitive. And so if you’re doing research, it implies you’re always questioning. You’re always trying to learn, you’re always trying to improve whatever topic it is that you’re interested in. And so doing, you then share that knowledge and that base with the world. And now that everything is online, it really truly is with the world. You don’t have to necessarily wait for the paper to be published in an actual journal. It’s all online. So what I’m trying to say is you can do research for the purpose of just getting published. I don’t get anything out of getting published. There’s no academic title that I seek my, I don’t have an employer because I’m my own employee.
(09:52):
I don’t have an employer that’s demanding that I publish a certain amount. The reason why I do it is purely out of self-interest in improving and advancing hernia care and making it as globally improved as possible. So when I do research, however, I feel like the questions that I like to get asked and therefore answered are very relevant, clinically relevant questions. I’m not here to think abstractly. It’s things like what’s a good algorithm to safely treat femoral hernias? What’s the best imaging modality for people with small hernias? What kind of symptoms do patients with mesh implant illness present with? Is mesh implant illness even a thing? And if so, in what kind of patients do they present it with? And then if we remove the implant from a patient with mesh implant illness, what’s the chance of actually get better? And how much harm are we inflicting in doing?
(11:00):
So? I feel like the questions that I ask are very relevant from a clinical standpoint, and therefore I’m not a big fan of just analyzing data purely from a scientific standpoint. It has to have a practical standpoint as well. So that’s why I developed ready the Beverly Hills Hernia Foundation. So the foundation is a nonprofit organization. It’s a 5 0 1 C3, and our goal is to continue to fundraise so that we can do as much research as possible without funding being a limitation. So currently for the past so many years, I would say 20 something years, I have self-funded my research. And what have I mean by self-funded? I have done clinical trials that paid money when I was at USC and we used clinical trials, income to fund research for our residents and so on. Then once I was out of Cedar-Sinai and in my own practice, a hundred percent of the resource that I fund is self-funded. I just pay for it myself. What does that mean? That means my time of course is donated. So my time that I spend doing research is part of what I like to do, whether it’s days, weekends, evenings, whatever the situation is.
(12:38):
I have research students, residents. So either it’s a resident from our general surgery service or people applying for residency or students applying for medical school who have an interest to learn how to do research, learn biostatistics, learn how to write a paper scientifically, learn how to give an oral presentation and become inquisitive. I have students that I pay them a small salary so that it’s mostly out of the interest to keep them interested. And these students work with me. We come up with a research question and we start punching data. So I have my own database that I’ve carried on since 2008 patients that I’ve seen over the years. We have a hernia health questionnaire that we maintain very carefully, but also we’re part of a grander national database called the A-C-H-Q-C, the Abdominal Core Health Quality Collaborative. If you go back to my hernia talk live session with Dr.
(13:50):
Ben Paulis of Ohio State University, you can learn all about the A-C-H-Q-C because he’s one of the notable founders of that quality collaborative. So we have asked to thousands and thousands of patient data to help answer certain questions. We then take the data and we clean it up, and then we analyze it based on certain questions that we have. And in doing so, we come up with answers and those answers we try and cohesively write an abstract about. So that usually entails a short abstract, which with maybe some figures or tables that we share with a surgical society, that surgical society, I’ve mentioned many of their names will then review anonymously both my abstract and hundreds of others that are submitted and will determine how many of them are worth their weight in terms of the quality of the research that’s there, the quality of the data that’s presented, the relevance of the question, how important this data and question is to the audience of the surgical society, et cetera.
(15:01):
And then they say yes or no about whether they accepted your abstract research abstract. Then you go one step higher and you take that abstract and you’re invited to present that to a surgical society. That can be a small society. Usually we do it to the larger societies. So you have an audience that now usually I have my students do it. I don’t do my own presentations anymore because it’s a good learning experience for my students. So they usually work with me to develop a very beautiful, cohesive, finely tuned oral presentation of our data, which includes the background question, the methods by which we develop the data. We are very clear about our results, and then we try to analyze the relevance of our results with a conclusion to the data to give you an overview of what we think should happen. And in general, our research is not just observational in general.
(16:02):
Our research ends up with some type of plan of action to help improve or change clinical practices. And I’d love to say that we’ve had multiple really impactful research projects that we’re very well known for, whether it’s about women’s hernias, whether it’s about hidden hernias, imaging protocols, femoral hernia, rare pelvic hernias, et cetera. And then once that is presented and we get some feedback from the audience, we then take that feedback and our old presentation and do a much deeper dive and write a paper about it. Now, what does that entail? So every journal has its own type of readership and is usually available online through let’s say Google Scholar or PubMed to be read, and that’s globally available. So it’s very important that you write a paper that is relevant to the surgical audience or the medical audience of that journal, but also to answer specific questions like for example, I’m going to write a paper on acute femoral hernias and an algorithm for modern day on how to treat it.
(17:29):
Well, not only am I going to share with you how we developed our methods and results, but who else has also talked about it? Why haven’t we been talking about acute femoral hernias and everything we have in terms of data, in terms of guidelines, it’s only about elective femoral hernias. So when a trauma surgeon or an acute care surgeon is called to the emergency room to see a patient with a femoral hernia, they really have no guidelines up until now as to how they should treat this patient. Who do they operate on? Who do they do laparoscopic surgery or robotic surgery? Who needs an open surgery? Who can get meh, who can’t get mesh once? Should you fix the hernia once you just get out and save the life? So patients with femoral hernias who present to the emergency room have a very high likelihood of dying over 5%, which is really high for a hernia.
(18:18):
It’s the highest of all hernias. So how can we help reduce that risk by improving the protocol and the thought process? Because most doctors that are in the emergency room taking call treating acute femoral hernias, whether they’re incarcerated or strangulated, are not hernia surgeons. They’re mostly trauma surgeons or general surgeons. Some of them are just taking call because they’re young and they need extra work. So these are surgeons that may see one femoral hernia all year. I see multiple a week. So I have a little bit more insight and better knowledge base as to how to treat these patients, and then I can share that now with the world. So we publish the first ever algorithm, for example, for the treatment of acute femoral hernias, either strangulate or incarcerated, never been done before. Can you believe that? I was shocked. But when you find an opportunity, then you can do the research.
(19:19):
So you publish the paper and then the paper goes to revisions and it’s not guaranteed. Your paper will get accepted for publication. After all these steps, doing the research, validating the research, getting it accepted as an abstract for a surgical society, presenting it at the surgical site and then writing the paper, you’re still not guaranteed to have that paper accepted. By the way, the cost during this whole time is enormous. So besides just having to help fund the research team, you have to pay to register for the conference that you’re going to be presenting. You have to pay for the hotel and the registration fee and the airfare to go to these meetings. And that’s multiple per year. And it’s not just me, it’s my research student as well, plus all the other costs of travel and food and beverages and whatever. And then if you can believe it, some freaking journals then charge you to publish the paper. I don’t like to publish in journals that charge you to publish your own research. That makes no sense to me. They’re selling the journal, their profiting from the selling of the journal. The quality of my research improves their sellability of their journal, and I have to pay for that. No. So I pick the most reputable of journals and I only publish in journals that I don’t have to pay to get published because I just don’t do that. It’s not a thing.
(20:56):
Anyway, beside the point, the point is all of this takes time. It takes human hours and it takes money. And I’ve been self-funding it gladly doing it. I started getting patients that wanted to help fund these research projects. And as you know, I also helped fund an annual research award at the American Hernia Society, specifically focusing on improving research for women because female patients have very little research done on them for hernias. And as you know, money talks. So I offer an annual research award, which I fund called the Female Factors in Hernia in Hernia Award at the American Hernia Society. And we give an award to anyone, or I shouldn’t say anyone, it used to be anyone to the top person who publishes or presents any research that specifically includes females or something related to females in the research because we really have none for Amal hernias.
(22:10):
There’s no clinical trial ever done on women, and we’re hoping to change that. So in my goal of globally improving hernia care, I have now developed the Beverly Hills Hernia Foundation. That’s where I wanted to talk to you about this. This is a Beverly Hills hernia foundation.org. It is a nonprofit. If you are interested in donating even $1 to promote hernia research that it’s fully tax deductible, I highly recommend you donate to our website to go to beverly hills hernia foundation.org. It’s a free website. We’ll soon be holding courses as well through the website. I’ll make an announcement for it within the next several weeks, but right now it’s an opportunity for you to see what we do in terms of our research and then also help us continue to do this research by providing a tax deductible donation. I want to say as long as you want, even a dollar goes can pay for half of the coffee that I buy for my students to keep them awake while they’re perfecting their talk.
(23:36):
Okay, so I named the title of this hour, the Cost of research notes to talk about the money aspect, but also what is the cost, the virtual cost of doing research? Is it a good thing that we have all these different research projects out there? I say this because some of the research is funded by industry and most of us poo poo that, right? We don’t like to give much weight to research projects that are funded by an industry that has a self-interest to fund whatever makes them look good. So if a company that makes mesh published the paper that says their mesh is the best, usually we don’t like to see that, and those are not highly ranked papers. But at the same time, these research mesh industries companies have a lot of funding available to do research compared to little old me. So it’s a conflict.
(24:49):
There’s a cost to that. There’s a cost to society of flooding journals with papers that have conflicts of interest. A lot of surgeons are paid to be speakers or to do research with industry, and there’s a little bit of a conflict there that needs to be disclosed. There has been papers published that not everyone really discloses it, but that needs to be disclosed. And once it’s disclosed, then there’s a question of the validity of the research. So I’ll give you an example. If someone does research with an industry that, let’s say it’s a legitimate research, right? So the data is exactly as the data is reported to be, is it possible that the industry will either rewrite the paper or edit the paper to slant the wording so that it is more positive towards their mesh, let’s say, than if this were not a funded research?
(25:58):
I’ll give you an example. Robotic surgery, the majority of robotic surgery papers are written by doctors who are funded by the robotic companies, specifically intuitive surgical, saying how great it is to do robotic surgery. There’s a handful of robotic papers, I would say less than five major ones. Mine is one of them that talks about robotic surgery and the pros and cons of it, I’m not paid in any way by intuitive surgical or any robotic company. I’m not paid by any company actually. And so I feel like my research output is very untainted. And some of the research projects that are written by doctors that are not paid or in any way affiliated with financially with a robotics company actually make pretty good statements saying that the robotic technique is not necessarily better. You may like it better, but it doesn’t mean that it’s objectively better. So it’s so interesting because there is a little bit of slanting of the way you word things and the way you present things and how the title is leading or misleading to promote one product or another, which sometimes is related to who is paying for the research, which is why I think it’s so important that an independent foundation like mine, the Beverly Hills Hernia Foundation remain independent and at the most have anonymous funding by followers and people that really want to improve her knee care without having industries hands in the data.
(27:51):
The other cost of research is flooding, flooding the journals with conflicting data. So there used to be papers that say heavyweight mesh is horrible and causes so much chronic pain. We’d have to use lightweight mesh. And then an independent paper came out that looked specifically at lightweight versus heavyweight found actually there’s more chronic pain with lightweight mesh UNK it. So there’s no strong evidence to show that heavyweight mesh is any worse than lightweight mesh. It’s where tailoring comes into place. So if you’re an obese male with a large hernia, you’ll actually do worse with lightweight mesh because your hernia will be less stable. It’s like putting an obese male in a tight silk skirt or tight tight silk shirt and you’re trying to palate tear. So whereas putting a heavyweight mesh in a small hernia or thin patient maybe will increase the risk of chronic pain.
(29:00):
So just because your mesh is heavyweight or lightweight does not in and of itself correlate with having worse outcomes. In fact, there are good post effective randomized clinical trials on weight of mesh that shows that lightweight mesh has a higher risk of chronic pain. It also has a higher risk of cardio recurrence, which may be the cause of the chronic pain. So it’s things like that where the patients get really confused. They’ll look at, look all these papers, let’s say on the dsda technique and then say, look at all these patients. I’m like, yeah, but that paper only looks at das. It doesn’t really objectively compare one technique versus another. So you can’t have a one-sided trial and say how good it is when you’re not comparing it to anyone else, things like that. So it’s confusing out there when we believe that laparoscopic surgery is great and in expert hands, we have data that shows that laparoscopic surgery is the same if not more superior to open repair for inguinal hernias.
(30:17):
And then you have the classic VA trial, which did not include expert surgeons and found that the recurrence rate was significantly higher with laparoscopic surgery than open because most of the surgeons that were forced to do laparoscopic surgery never even knew how to do laparoscopic surgery. And it was only the experts that did more than 250 laparoscopic repairs prior to the trial that did show that they had improved outcomes. So I guess it’s like politics. You have to read everything with a critical view. And sometimes I feel like I’m here as part of this hernia talk to answer your questions, but also provide you with the global view of things. So when someone says, I don’t want meh because I don’t want chronic pain. And then if you look at the data, there’s actually the same amount of chronic pain with mesh repair as with tissue repair.
(31:22):
Well, how’s that possible? How could you have chronic pain if there’s no mesh there? Well, if you’re tearing through the muscle from the tissue repair, that’s pretty painful. And if you have a higher recurrence rate with a tissue repair, that is painful because why are you recurring from a tissue-based repair? You have to tear something. What are you tearing? You’re tearing not to stitch, you’re tearing the muscle. So that’s how the data shows up where chronic pain is actually not higher with mass repair. It’s the same, but it’s a different type of chronic pain, the way the questions are asked and all that. So my point is there’s a cost of doing research and the cost of doing bad research where you’re flooding the Google, let’s say with all these different conflicting data points, and there’s no standard by which a researchers project is done or no standard by which a repair is performed.
(32:22):
There are people who do research and if you look at their patient population, it’s all different surgeons doing all different types of repairs. And just because of an hernia repair or abdominal wall repair doesn’t mean they’re all done the same way and therefore the outcomes are very different from one paper or another. One paper always has a retrorectus mesh place for the ventral hernia pair. Other ones had combination of non mesh or smaller hernias. We have papers out of the Danish and Swedish population studies because they have a nationwide database. But have you seen a Dana or Swede? They’re gorgeous, they’re tall, they’re never obese, they’re fit, they bicycle everywhere. They have a healthy diet. That data doesn’t necessarily jive with the US population where we unfortunately are mostly more obese and we’re not necessarily the tallest either. So these are kind of ways of interpreting data, which it’s important and the cost of just going to touch GPT where information is not always often correct, but not always correct can be a problem.
(33:41):
Here’s some questions. When should I get my Anglo hernia fixed? What are the chances that the hernia will not get bigger or worse? Is it better to fix the hernia when it’s still small? So no, depends on the type of hernia and your lifestyle. So if you are fit and have a small hernia and it’s not affecting your lifestyle in any way, you’re able to exercise and you’re a male, watchful waiting is considered totally safe as 0.2% per year risk of incarceration and needing emergency surgery. And about five years, about one third of patients will start becoming symptomatic and want their hernia repaired at 10 years, about two thirds the patients start getting symptomatic and want their hernia repaired. So is it better to get your hernia fixed when it’s small? Not necessarily. Some will say yes and interpret the watchful waiting data, which I just quoted to you as saying, well, the majority of patients are going to need surgery anyway, so I’m just going to offer it to them now and not wait until they’re more symptomatic.
(34:46):
Well, that statement is technically true majority, but it’s not a hundred percent. I just told you it’s one third of five years and two thirds at 10 years, which during the watchful waiting trial will start getting symptomatic and want hernia repair. That means one third of patients at 10 years will not need surgery. So if you offer surgery routinely to a hundred percent of patients and only two thirds of them would’ve needed it in 10 years, are you really over-treating a third of the patients? And who are those third? We don’t know who those third we don’t know.
(35:19):
So surgeons don’t. Here’s a question. Surgeons don’t typically make recommendations for surgery just based on ultrasound for a few reasons. One, small hernias, ultrasound are often not hernias at all and just a small amount of fat sitting in the inguinal canal and two small hernias and ultrasound that cause little to no symptoms, don’t always need surgery and can often be watched for many years. So number two is correct. Number one is not correct. So small hernias, synod ultrasound are often not hernias at all. That’s not true. That is by definition a hernia. Fat. Fat in the inguinal canal is a hernia if you don’t have fat in the angle canal, it’s not a hernia. Now is it a symptomatic hernia that depends on your story. So symptomatic hernias, we do recommend repair because the symptoms imply something’s being pinched and therefore you’re higher risk of incarceration or strangulation.
(36:16):
If you don’t have any pain, then that’s an asymptomatic hernia and it means nothing’s been getting pinched or at risk of incarceration. So you can wait until you have symptoms. So your statement is incorrect in that you say small hernias seen on ultrasound are often not hernias at all and just a small amount of fat sitting in the val canal. That is by definition of hernia. And that’s a false statement what you said. However, number two, small hernia senal ultrasound that cause little to no symptoms don’t always need surgery and can often be watched for many years. That is true and that is true of the watchful waiting trial. Just because there is a hernia found on imaging does not mean that hernia needs to be repaired with one major exception and that’s the femoral hernia.
(37:01):
Okay, here’s another question. Would you consider going back into academics if offered significant position? No, and I have been offered multiple significant positions, I’ll never do it again. I hate to say that because at one point in my life I did have aspirations of becoming a department residency, program director, department chair, dean of a medical school. I have zero aspirations for that right now. What I’m able to do in terms of improving my career and also in improving my impact on global hernia care is beyond what I would ever be able to do at an institution. Unfortunately that’s the reality. So whereas before I cared if I were tenure track or associate professor and now professor of surgery, those titles don’t move me. Although I do have those titles, but I don’t like, doesn’t rule me. What I do love are these kinds of things and being able to travel.
(38:13):
So I mentioned to you earlier all the different society meetings I go to and I find the travel myself while at my prior job they were unhappy that I was going to these society meetings, which duh, that’s academics. But as you probably know, many of academic surgery is no longer as academic as it used to be and it’s all about throughput and how many patients you see. So they were not happy that I was spending so much time academically even though they were academically or academic institution by name only. And secondly, there are restrictions as to how much of your time you can spend doing what you want to do. And for me, I did not like my career being affected by that direction because ultimately, regardless of how high up you go in the academic ladder, you always have someone above you who’s your boss. And I don’t like having your boss tell me what to do because ultimately it’s not because, well, they’re not telling me what to do because it’s in my favor. It’s in the institution’s favor or usually in their own personal favor. So not my thing anymore, but thank you for asking. I think I would be a really good division chief or a chair or dean of a medical school, but that ship has sailed my friend.
(39:37):
Next question. Hi Dr. Towfigh. I live in Australia and have laparoscopic mesh repair on my left inguinal and femoral hernia five months ago they later discovered right direct al hernia and a small femoral hernia. I’m still getting sporadic pain that comes and goes each day of the left groin. That’s a side where he had surgery after five months after surgery that is different from pre-surgery pain. Various scans have not found any problems with the left repair, but my right hernia pain is starting to get worse. I have one top. Okay, so you had to repair left side, still bothering you, but it’s different than before surgery, which means you may have a mesh folded or retained cord lipoma or some problem on the left side. And then on the right side your virgin inguinal hernia and femoral hernia are now becoming more symptomatic. Okay, moving on.
(40:30):
I have one top surgeon recommending that I have another laparoscopic mesh repair for the right two hernias and thinks the previous surgeon had made some poor decision with left repair possible. Another top surgeon is recommending the Maloney technique for right direct inguinal hernia. He claimed the 2% recurrence rate and the standard tissue repair for the femoral yet that would be, I would have to see who you are, but usually I would not recommend that. Of these two ops available, which one would you lean towards? I would lean towards the first one. I haven’t found anyone in Sydney that offers a shouldice repair. Yeah, there’s no one in Sydney that offers this suppress. Sorry, I had cord lipomas and inguinal hernia mesh repair. It’s another patient. The post-op report says the cord lipomas were reduced tack to the outside of the mesh. Isn’t it better to fully remove lipomas?
(41:26):
No. So laparoscopically, we don’t fully remove lipomas, we just take ’em out of the hole because those lipomas belong to fat that naturally lays in the pre peritoneal space. So we do not cut that out, we just push it back in place with mesh implant illness. Do the rashes tend to come and go or are they all there all the time? They usually come and go. Does MII cause hives? It can. Would love to know all things MII related that you have to offer. So thank you for that. I’ve actually published now two papers on me. Implant illness, you can read those. It’s free online in the journal of, I think it’s the Journal of Abdominal Wall Surgery Jaws, JAWS. So you can read about mesh implant illness there. And secondly, I’ve had multiple mesh implant illness podcasts and on YouTube and wherever you look at the podcast. So definitely look those up. Very, very detailed information for you.
(42:35):
Okay, we have some questions that were submitted. Let’s go to those. Are there any ongoing researches for hernia treatments that do not involve implanting any kind of foreign body material? Good question. So at this year’s American Hernia Society meeting, the Ohio State University is doing some really interesting research projects looking at questions that mostly patients ask about microplastics after mesh placement and so on. There is one paper that I saw in mice where they use some type of foam to and another one where they use some type of stem cell therapy to regenerate tissue to fix the hernia. So maybe one day we’ll have something like that. That’ll be great. Next question. How can you tell the difference between chronic nerve mesh related pain and hip label tear physical symptoms? So hip labeled tears usually affect weight bearing and have buttock pain and are not better with your lying flat on your back, whereas chronic nerve mesh related pain do not have those specific symptoms.
(43:57):
Okay, next question. Is there a possibility of equipping meshes with sensors to detect complications and monitor healing being explored? Yes there is. So there have been some meshes that have been implied to have sensors that tell you if the pH has changed and therefore if that implies an infection in the area. These are all great research projects. The problem is they don’t make it to market because it’s too expensive, you’re going to pay for a $25,000 piece of mesh. But yes, there have been projects of implanting nanosensors nanotechnology in meshes to help determine changes in the local environment. There’s even been studies of using the mesh implant as a way to monitor your own blood, whether it’s your glucose or whatever using nanotechnology. So there’s some interesting stuff out there that will make hernia repair. Really interesting question. Can you describe in detail where exactly they placed mesh for inguinal hernias?
(45:21):
I’m confused where it goes. Yes, of course. So inguinal hernia mesh is placed over the inguinal region. So the borders of that are just above your groin crease and to midway between below your belly. But at some point the middle part is to at your pubic bone and then the upper part is towards your hip bone. So the mesh is either on the muscle or behind the muscle. And the size of mesh depends on your size of hernia, but usually it’s 10 10 x 15 or 12 x 16 centimeters, which is about three x six or four x six inches. So the size of an index card let’s say, and hopefully that answers it regarding Sydney Australia. Thank you for your answer, Dr. Towfigh follow up question about getting my right hernia repair with meh while still having pain with previous left repair. Excuse me.
(46:24):
If done by a better surgeon, does that reduce risk of getting pain on the right side too? Which is my only hesitation? Yes. So if you have repaired by an expert surgeon, your risk of complications including chronic pain should be lower number one. Number two, they may use that opportunity to review what’s going on on the left side to see if your mesh is folded. Now I’ve operated recently on a patient where I did not suspect the mesh to be folded based on imaging, but the patient had persistent pain and everything we did to alleviate their pain did not work. So I did offer surgical exploration because she was in so much pain and I had just looking at it inside the abdomen with a camera laparoscope showed no problems.
(47:16):
However, when we took down the peritoneum, just look at the mesh itself, it was completely folded. So that may be your situation. It’s folded in certain area and that’s why you’re having symptoms. In which case you may want to consider revising the left side either at the same time as your right side repair or separately. Next question. After a failed shouldice, no meshing or her tissue repair, I think a laparoscopic posterior mesh repair is a preferred option. That’s correct. I do not wish to have mesh. That’s not a good idea. Do I have any options? I would rather have recurrence again than having mesh. Well, you already have a recurrence, so if you’re trying to treat a recurrence and you’re okay having another recurrence, that doesn’t make sense. If you have a recurrence live with your recurrence or you should choose mesh. Now there are various options for mesh, but I don’t believe that once you fail a shouldice, another tissue repair was moving on.
Speaker 2 (48:21):
But there are various mesh options that you can choose, but I’m, unless you have a life-threatening disease, that would make me worse. That would be worse. With mesh you should submit to having mesh compared otherwise. Let’s see. Next question. The pre that biological meshes alone cannot prevent short-term recurrence for some species offering types. Correct. Are there any studies in progress to address this limitation? Well, yes and no. There are a couple of clinical trials of newer biologic meshes that are prospective randomized clinical trials. Most biologic nurses do not have prospective randomized clinical trials. They just have either have observational studies or they have single arm studies. They’re not being compared to other competitor. But there’s one newer biologic insurance has a clinical trial that’s ongoing.
(49:39):
However, it’s so far we’ve never found a biologic, so it’s worth switching from standardized measurements. Next question. Have studies ever focused on detecting any eventually collecting genetic factors? Great question. Answer is yes. So far there’s single genetic, there’s no single gene that has been associated with corneas. There are multiple connective tissue disorder and collagen disorder genes that have been associated with hernias. None of them very specific. So having that gene doesn’t necessarily mean that you are going to get hernia. So so far no. But local use of stem cells have been looked into in mice to treat brain. Next question. Thank you for your answer from Sydney Australia, I’m led to discussion and so grateful that you’re sharing your expertise through pa. Thank you. Next question. Does there tend to be a pattern of where pain would be if you are having
Speaker 1 (50:52):
Problems with hernia mesh? Not a hernia recurrence specifically with the mesh? Right. So there’s something. So people with mesh infant illness tend not to have localized pain. It’s a systemic like body reaction to having an implant. It’s like saying if I’m allergic to peanuts and I eat a peanut that my mouth won’t get the sore. No, you actually, your whole blood pressure drops and you stop breathing and your, you get a rash. So that’s the way mesh plant illnesses, the whole body, the area where the mesh is placed is usually not painful. However, there are specific pains associated with meshes such as inflammatory pain or pain related to how the mesh is interacting with local structures, whether it’s the intestines, the bladder nerves or the muscles and the bone. So it could be feeling of tightness, it could be feeling of swelling in the area. You can have feeling of sandpaper in the area. It could be tugging on a nerve and therefore giving you nerve pain. It could be mostly an inflammatory process local to the area. So there’s no one specific data point. And so there is no way to say you have to or don’t have to have any of these symptoms to have a mesh related
Speaker 2 (52:29):
Pain for example.
Speaker 1 (52:32):
Okay. Last question. Has there been any significant progress on developing
Speaker 2 (52:35):
Certain diagnosis criteria for
Speaker 1 (52:37):
MII or mesh S? Okay, that’s exactly what I was talking about. No, we have a series of questions that we ask without really weighing one question’s forms versus the other as to different symptoms we may have, sorry, from top to bottom, the headaches or vision, bringing in the ear problem, sleeping, problem concentrating, brain fog, acid reflux, hi, joint pain, swelling, nerve tingling, loading, nausea and so on, hair loss. So those are all brain fog. Those are all questions to ask whether one symptom is more suggestive than the other is not. We don’t know. The timing is mostly early. I would say days, two weeks to maybe six to eight months, usually not more than a year after the batch was implanted. So there is that. However, at some point as we learn more and we can add blood tests that are more diagnostic, we can have a much more objective way of analyzing me plant illness. It hasn’t been done for breast and implant illness. It certainly hasn’t been done for me implant illness. And we’re still in the very early stages of learning about
Speaker 2 (54:19):
That. Okay, next question. After a failed shouldice, no meshing or hernia tissue repair instead of laparoscopic test. Can I do the following one, Dr. Phis, no mesh laparoscopic repair. No, that’s not intended for hernia recurrence and it’s not intended for more than very small. Endorphines two, Dr. King,
Speaker 1 (54:46):
Dr. King’s tissue repair is basically a marcy repair and it is not as
Speaker 2 (54:54):
Clinically secure as shouldice repair. So I would not recommend it. Three desarda
Speaker 1 (55:00):
Maybe the desarda repair usually imply the tissue repair with an onlay of a flap of extra oblique. So possibly I recommend you listen to
Speaker 2 (55:14):
the podcast I did with Dr. Ralph Lorenz
Speaker 1 (55:17):
about tissue repairs
Speaker 2 (55:19):
And see what you think.
Speaker 1 (55:22):
Four. Basini repair, no. Bassini repair is basically half of a shouldice repair. No, Dr. Dr. Ulrike Muschaweck’s repair. No. That’s also like a miniature bassini type repair. Another shouldice repair, no, which will be better. None. I don’t recommend any of those. So
Speaker 2 (55:52):
I’ve said this before, choose
Speaker 1 (55:56):
The right surgeon and follow the expertise. If you’re trying to force a
Speaker 2 (56:01):
surgeon do a procedure that you should not be having done, especially if they don’t really do that themselves, then you’re going to run into trouble and then you’re going to have nerve damage. You’re going to lose your testicle. You’re going to have a huge early recurrence that no amount of mesh is going to make better and
Speaker 1 (56:27):
Then you’re going to kick yourself in the butt for having forced yourself to move in that direction. So I don’t understand this fear of mesh in a patient that requires it. Perhaps what better education about what they really fear about the mesh and what they understand mesh to be, that can be better addressed.
Speaker 2 (56:52):
But at this point, I don’t support any type of tissue repair after a failed shouldice repair. That’s just my opinion. If you find another surgeon that would,
Speaker 1 (57:10):
You can make that decision with it. So to wrap it up, if you’re interested to donate any money, it’s tax deductible to that money will go towards supporting the research team led by me. Go to beverly hills hernia foundation.org and I would love to get some funding that will go towards helping us improve hernia care globally. And that’s my
Speaker 2 (57:43):
Final statement before I sign off to you guys next week and hope you have a great night. Thanks for all your questions. Bye.