Episode 16: Various Hernia Repair Options | Hernia Talk Live Q&A

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Speaker 1 (00:00:02):

Welcome. My name is Dr. Shirin, we are here on Tuesday. Our Hernia Talk Tuesday is every week we have a live question answer session with favorite doctors of mine who are active in the hernia world and can help you with your hernia questions live. And as you know, I am available on social media for you at Hernia Doc on Twitter and Instagram. I also have a Facebook page, and this is being live posted on Facebook. And later on we’ll be posted on YouTube. Today we have the great Dr. Jonathan Yunis. Dr. Yunis can be found on Twitter at Dr. Yunis. He is head of the Center for Hernia Repair in Sarasota, Florida. So he’s like my East Coast partner in crime. We do share a lot of patients, so welcome Dr. Yunis. How are you?

Speaker 2 (00:01:01):

Thank you for having me. I’m doing very well, thank you.

Speaker 1 (00:01:04):

Well it’s now seven what? Seven 30 your time, so I appreciate you sharing your time with us away from family. I’m still in the office so it’s easier on the West Coast and sometimes Oh, okay. Sometimes we do have people from Australia and we’ve had a lot of Europeans and some in the Middle East that have logged in and their hours are not the best right now. I think it’s around 4:00 AM in the Middle East. So I do appreciate when people come in and log in when it’s off hour. So I do appreciate that. So Dr. Yunis, his practice is in Florida on the east coast. I mentioned earlier we share a lot of patients. Maybe you can give a little kind of blurb on where your practice is. Is it outpatient, inpatient? Do you offer open lab robotic? Are you a hundred percent hernia surgeon like I am? Give them my audience a little bit of a, well, they already kind of know you. Most people know you. But for those who may not know exactly what your practice is, give us a little blurb.

Speaker 2 (00:02:17):

Oh, Shirin, like you, we’ve talked about, you and I are one of the few people that limit our practices to hernia surgery, abdominal wall reconstruction, and that’s all we do. And then the other interesting thing about a practice that we share, which is that we’ve both opened ourselves up to expertise in open, laparoscopic and robotic surgery. And we have the luxury to do that. That’s not to exclude anybody else, but having limited practice to hernia surgery, it’s just fantastic to get that much more experience when that’s all you do. So I do a lot of, on Mondays I’m in a hospital, a tertiary hospital doing tertiary hernia repairs. Like I do a lot of complicated multiply recurrent hernias mostly these days, robotic and then some with abdominalplasties. And then on Wednesdays and Fridays I’m in a surgery center or at another robotic hospital where I’ll do say robotic inguinal. And it’s says also it’s incredibly enjoyable what we do and we help a lot of people. So it’s fantastic to be here. Yeah.

Speaker 1 (00:03:25):

Well thank you. So can we just jump into some questions? We already have so many live questions and I also have some pre-prepared questions from Instagram and some of them are related to exactly what you’re saying, which is this kind of open, laparoscopic, robotic. What are your thoughts on the three? Do you feel like anyone is more superior to the other or how do you decide when you do something open or lap or robotic?

Speaker 2 (00:04:00):

It’s very individual depending on the patient’s hernia, the patient, the patient’s level of activities, their medical comorbidities. And it’s really great. So to, a good answer to that also is that I would say I’m almost in certain types of hernias, 33% of each.

Speaker 1 (00:04:19):

Oh really? That’s cool.

Speaker 2 (00:04:21):

In the groin, maybe? In the groin it’s about 33% of each because we do a lot of, I think you as well do a lot of open non Mesh repairs. So the decision is so great because you get to customize it and individualize about what’s best for that patient. So if somebody is really motivated for a non Mesh groin ill inguinal or femoral hernia repair, then those techniques are historically best done open. Now with a new operation that you’ve described, potentially we’ll be doing more primarily robotic. So that’s a great indication for the open ones. And then in the ventral ones, those big ones in the middle of the abdomen, doing them open allows for a more seamless a place where we can improve the cosmetics within a combined abdominal plastic. And then the robotic thing is fantastic in the sense that for the really big robotic, what we call transverses release for really complicated, there is a clear, it’s not just an opinion, a clear improvement in patient’s ability to recover and their outcomes with the robotic surgery versus the old open surgery. And the other thing I would say is that in my world, I don’t know, I would be curious to hear what you have to say. Yeah, that laparoscopic is still very strong because I think we both do laparoscopic total extra peritoneal repairs. Yes. But I do very few ventrals in the advent of the robot where most of those, I think there’s some advantage to the robot. What do you think about that?

Speaker 1 (00:06:06):

Yeah, I totally agree. I think it’s a misnomer to think one is superior to the other. This whole tailoring approach I feel is the best. That said, there are surgeons that only do open, there are surgeons that actually are more comfortable laparoscopic and can’t do a really good open surgery. Mostly for inguinal although for some ventrals too, they just better lap. And there’s some that just skipped lap altogether and went to robotic and do everything robotically which is fine, but do not really do much lap, which is kind of weird. But that’s been one of the benefits of the robot is more people can do minimally invasive surgery. But yeah, I agree. There’s actually some great questions here. One is about open versus laparoscopic. So how much more painful is the recovery of a lap non Mesh angle hernia repair? So like a Shouldice or a Bassini tissue repair versus a laparoscopic Mesh repair. So a tap or top. How much more painful is the recovery? What do you tell your patients since you offer both?

Speaker 2 (00:07:12):

I’m at the point where, again, we both have the luxury of doing so many of each and everything we work for is not just safety, but making the whole outcome of a hernia surgery easier for the patient. That the answer to that is I absolutely think it’s the same bell-shaped curve that I think my open Dasarda and should eyes repairs have very little pain, except there’s a certain percentage of people who might at the other end of a curve. So now I don’t think other than issues about recurrence and so on I really would say black and white, that with an ex person, very experienced with both techniques that the more experience you get, the less pain that the average person will have. And I think that has a lot to do with That’s very true. The experience with the anatomy. And I think you probably share that as well in your experience.

Speaker 1 (00:08:08):

That was very true. I just had a patient today that I saw it took him almost five months to recover from an open inguinal hernia pair. Five months he couldn’t work. And he works at, he does a lot of baggage stuff. So that’s just not appropriate when I see patient. No, of course there are different reasons for it, but that’s just generally outside of the norm. And I tell my patients three days for laparoscopic and one week for open Mesh and maybe one to two weeks for open tissue repair in terms of recovery. At least that’s what I see in my practice.

Speaker 1 (00:08:49):

What I do is when I see patients that are revisional, so they have some type of complication from their original repair, what question I ask, I say how was your recovery day one, day two, day three? And if they say, oh, I was blacking blue everywhere and my test like scrotum, was this swollen and I couldn’t walk upright for two weeks, then that was an aggressive, I don’t know, I feel like I can read into it. Maybe the surgeons was more aggressive with the tissue, maybe they weren’t as gentle, therefore with the nerves and with the spermatic cord and with the muscle, and maybe they put the Mesh too tight. So these are all things that go in my mind, if someone tells me they’ve had such a prolonged or very difficult recovery from what should be a straightforward outpatient operation,

Speaker 2 (00:09:46):

I often, it’s just a hernia, meaning the solution to your hernias should be less than the hernia itself. And most hernias, most people are not terribly symptomatic. So yes, we both see those types of patients and it shouldn’t have to be that way. Correct.

Speaker 1 (00:10:07):

Okay. More questions on inguinal hernias. We have some on ventrals too. So another question is, again, regarding non Mesh inguinal hernia pairs, there’s a difference between a patient that has an indirect inguinal hernia, which is the most common type of hernia, versus someone that has a direct hernia, which is more of a laxity of the area, tends to be a wider defect that we’re dealing with. So what approach do you feel is optimal for indirect Anglo hernias and repairing the indirect space versus someone who has a direct hernia, therefore needs a direct space repaired? Very insightful question. Huh?

Speaker 2 (00:10:46):

Very important question. I’m not

Speaker 1 (00:10:48):

Sure my resident would be able to answer that question or even think about that question. It’s

Speaker 2 (00:10:54):

An evolution about you looking at the recovery of your patients, not, it’s not just your gestalt of your sense. Anyway. I definitely have an algorithm. Cause my current practice with someone who doesn’t want Mesh is I used to say maybe we need Mesh. And now I don’t even do that is that I’d like to make the decision between a Shouldice repair and a desarda repair. So there’s a very distinct answer in my practice, which is direct hernias within reason are done with a Shouldice repair and very appropriately so, and I’m getting excellent results and indirect hernias that are not huge just because we don’t want to open the floor as I know you probably feel the same way, the entire floor to just deal with indirect that those patients are doing amazingly well with a Dasarda repair. So indirects, I’m typically doing a Dasarda and directs with shouldice.

Speaker 2 (00:11:47):

And then there’s another interesting thing that I want to digress for a second that you will find interesting since you deal with a lot of female complaints and female hernias, which is that in correspondence with Dr. Dasarda, who’s a very wonderfully nice gentleman, I was talking to him about what is he doing to manage a indirect hernia, excuse me, a femoral hernia, which the typical Dasarda repair does not really address. And in females there’s evidence to say we want to do a posterior repair to make sure they don’t get a future femoral. And I think that’s unanswered right now about that. So with women, I think there’s a potential for the femoral, for a recurrent femoral hernia in which case, whatever I do, if they want no Mesh, I will be doing the medial part of the repair to Cooper’s ligament.

Speaker 1 (00:12:45):

I mean Oh, so it’s like a McVay Dasarda combo?

Speaker 2 (00:12:48):


Speaker 1 (00:12:50):

Oh, that’s interesting. Yeah. Can you explain to me the Dasarda? I, I’m not a Dasarda, I don’t offer the Dasarda repair, so I’ll also offer you my bias. So I’m a big proponent of history and it’s one of the reasons why I came up with the laparoscopic, sorry, the robotic iliopubic tract repair. It’s really a revision of something done in the sixties by Dr. Nyhus and Condon. So surgeons that trained in the fifties were doing a similar procedure as the Dasarda using the external Oblique aponeurosis as their Mesh. And they stopped doing it. They said they had too many recurrences. So maybe you can tell me why today’s start is any different.

Speaker 2 (00:13:38):

I am not familiar with that old data, although I’m aware of the prejudice against using external bleak. I was trained at a time where that shouldn’t work. I’m a relatively trusting person to some degree, and Dr. Dasarda and I have had conversations, and even though he doesn’t do things the way some other people do I tend to believe a lot of his results. At the same time, the patient’s desire for non Mesh repair and the minimalist nature of a desarda repair where we’re not opening the floor, what is it is, I mean, you know what it is. It’s where we expose the hernia and then say for an indirect hernia, we’re going to mobilize the superior leaflet of the external oblique digitally underneath and just free it up a little. And then it’s sewn over the inguinal floor from the pubis closing off the internal ring by sewing it to the shelving edge of the inguinal ligament. And then because of the potential for tension, oh, well there might be tension on it or the external leak is weak, a strip is created about two centimeters cephalad, where then that sticks down. So yes, it’s like a patch of external oblique.

Speaker 2 (00:15:01):

And I counsel my patients about how it does it. I don’t think it’s as well time tested as a Shouldice repair. I don’t think the data’s as good but knowing that it’s just a hernia, that there’s potential for recurrence and my risk of injury to a patient with a desarda repair is extremely low. Philosophically, I feel reasonable about doing it as long as people understand that potential. And now with you and I are both in the American, Hernia, Society, Quality Collaborative, my numbers, which are all in there for four years, people come back to me, are showing very good recurrence rates. Now that’s only four years and there’s many years ahead of young people after their hernia surgery. So I also have a belief about old data that’s sometimes not fully understanding the anatomy might adversely affect the validity of the data based on are they really doing the operation correctly?

Speaker 1 (00:16:01):


Speaker 2 (00:16:02):

So I’m hearing you and I’m, I’m not positive that the durability is as good as others and it’s certainly not as good as a posterior repair, but it’s pretty minimal.

Speaker 1 (00:16:18):

The question’s very detailed. I’m not going to go through having you explain exactly how to do a Dasarda Bassini and a Shouldice, but <laugh> part of this question is so tailor a larger hernia versus a director indirect, you may do a Shouldice versus a Dasarda versus Bassini or a Mcvay, right? Is that how you decide which one to offer is the complexity and the size of the defect and the location

Speaker 2 (00:16:49):

And the location, yes.

Speaker 1 (00:16:51):

Okay. And then do you use permanent suture? Always.

Speaker 2 (00:16:56):

I’m mixed on that because the Shouldice clinic, I try to, one of their criticisms is, Hey, you know guys have higher recurrence rates somewhere else in the world because you’re not doing it the same way. And they still stand by their permanent suture, their wire,

Speaker 1 (00:17:12):


Speaker 2 (00:17:13):

So for that reason, without someone bringing it up, I tend to use prolene sutures in a Shouldice repair. Yes.

Speaker 1 (00:17:20):

I mean that’s how it’s reported is to use permanent suture.

Speaker 2 (00:17:24):

But I bet you, so a lot of people appropriately, intuitively say, Hey, I don’t want anything permanent in me. And I think it’s probably the results are going to be the same with a long-term absorbable suture,

Speaker 1 (00:17:40):

Long-term absorbable. Okay. The literature does, the literature for Inguinal hernias does not support use of absorbable sutures. I don’t remember if it was long-term absorbable or short-term absorbable that was compared to the permanent. Right. I just did the classical way exactly as it’s described. And

Speaker 2 (00:18:01):

What suture use

Speaker 1 (00:18:02):

Prolene now if they’re allergic or if they have an inflammatory issue. Nylon has or because I’ve done allergy testing and nylons been at the most inert of the sutures for what it’s worth, if they need a tissue repair I’ve had one person that even reacted to the, I don’t remember if he reacted to the prolene suture, maybe I just took out the sutures and put PDFs in the long-term absorbable. I’m waiting for him to recur. But so far hasn’t, it’s been a couple years. Okay. So another question since you brought up the Shouldice hospital we did have one of the surgeons from the SHE Ice Hospital on hernia talk, I think about a month ago. And that was very, very good to hear. It’s such a interesting, I don’t know if you’ve ever been there. I, I’ve been there as a guest and it’s pretty interesting.

Speaker 1 (00:18:59):

They have an interesting business plan and they do it their own way and you just have to accept it. And so many people try and go to Shouldice but not really do what Shouldice wants you to do and change what they do. I think that’s inappropriate because they have their results, because they pick and choose the right patients and do everything the same way. And to ask them to do it a different way, I think it’s going to Chanel and be like, yeah, but I don’t want that bag. I want this other bag, but I want you to make it. I think, I dunno, do you relate to my Chanel bag? Yeah.

Speaker 2 (00:19:36):

Yeah. I mean, they’re an incredibly successful, fantastic organization. I’ve been there twice and they do beautiful work and they totally understand the anatomy because they have such great experience and I would have nothing bad to say about it. I think it’s fantastic. It’s interesting that they continue to keep people longer than you and I do, right? Meaning there’s still key people three

Speaker 1 (00:20:01):


Speaker 2 (00:20:02):

Three days. And for us, that would be unheard of. But they can pay for it, meaning they, it’s affordable in that situation. So I only have good things to say about them and their criticisms of all the other techniques are valid except for when people gain a lot of experience. We both know laparoscopic and robotic inguinal hernia pair from a posterior approach when done perfectly, which most people try to do should be something that lasts forever and has minimal complications.

Speaker 1 (00:20:38):

Yeah. You said you have been to the Shouldice?

Speaker 2 (00:20:43):

Yes, I’ve been there twice. Yes.

Speaker 1 (00:20:45):

Yeah, yeah. Interesting

Speaker 2 (00:20:47):

Place. Wonderful place. Yeah, they brag about their food cafeteria too.

Speaker 1 (00:20:53):

Oh, they didn’t feed me. Oh, they didn’t? No. I may have gotten a sandwich. They didn’t take me.

Speaker 2 (00:20:57):

That’s a big thing that they have that whole thing where patients have even reunions and they get to know each other and they talk about the food. This homemade food that they have. Yeah. Is nice.

Speaker 1 (00:21:11):

Yeah. Okay. I’m going to move on to some of the pre-prepared, not questions. These are patients that have had hernia pairs before. Let me share my screen here. Okay, next question is how do you approach recurrent hernias effort? Two, prior open anterior approaches.

Speaker 2 (00:21:35):

I typically approach it posteriorly, which would puts the surgeon and the patient in a place of less risk of injury because it’s virgin territory. And often you’d be even unaffected, even with two previous anterior operations that when you go in laparoscopically or robotically from the backside or maybe with a ripped procedure that you can be in virgin territories, see everything perfectly and usually solve the problem. This most durable and safest and comfortable way likely. What do you think about that?

Speaker 1 (00:22:18):

Yeah, I mean after the first recurrence from anterior approach, the gold standard is to go posterior with laparoscopic or robotic approach. I’m surprised they had two that’s not considered standard. Okay. Next question. If I failed an open tissue repair for anal hernia, is my only option a laparoscopic repair with Mesh or what are my options? What would you offer?

Speaker 2 (00:22:46):

It depends a lot about on the patient’s motivations and how much pain they had from their first operation. I would be typically recommending a posterior repair, which is a laparoscopic or robotic repair. And I know this is a question where now we’re just starting to be offering a robotic repair without Mesh from the inside. And most of my, I know you have more experience than I do with that, but most of my experience with that is the frequency with which I remove Mesh. So I’m doing that very same operation as you described. So that question is, that’s not your only option. And in fact, it’s very possible with a failed open tissue repair, that one could go in and the anatomy could be reasonable to do another open tissue repair. Yes, it’s a possibility. It wouldn’t be my first choice, but depending on the desires of the patient and so on that is a possibility. Yes,

Speaker 1 (00:23:50):

I agree. So the standard is if you fail an open tissue repair, you should have a posterior laparoscopic repair with Mesh. That’s a standard. The non-standard would be either a small hernia can be done laparoscopically or robotically without Mesh or do your second open Inguinal hernia pair either with Mesh or without Mesh. Those would be non-standard options that I typically would prefer not to do. But maybe there are circumstances where you can’t do one or the other for whatever reason. So those options are all available. I think the way I tell my patients is we recommend choice A, B, and C based on the best recovery, the lowest recurrence rate, the least likely for chronic pain and injury to you. So for example, if you have some condition where I can’t go retroperitoneal, maybe that’s been destroyed from other surgeries or radiation, I don’t know, making up things but whatever the situation is, we have to take our standard recommendation and then identify whether there’s certain risks or benefits that prevent you from doing the standard repair. Maybe a Mesh reaction, right? Yeah. Okay. This patient, I feel so bad. This patient had in her eighth or her eighth hernia repair, they found scar tissue and adhesions. Actually, this may be a ventral hernia. It wasn’t clear. So what’s going wrong when you see someone in your office with their eight hernia repair, let’s say it’s ventral, that’s a more likely a ventral situation.

Speaker 1 (00:25:40):

And they said, oh yeah, we just found some scar tissue and adhesions. We fixed you up. How do you approach those patients and what do you think is going wrong? <laugh>,

Speaker 2 (00:25:54):

You and I both say

Speaker 1 (00:25:57):

You’ve had this.

Speaker 2 (00:25:58):

Yeah, this is not uncommon. This is, or a number that ranges from four to eight every day in my office. Your office. It’s tough to talk about it, but there’s many reasons mean one of them from the patient perspective is potentially related to obesity. But the most common thing is that general is people need to understand that general surgeons are well trained, brilliant, wonderful, well intended people, and they are responsible for doing many different types of surgery. And they are responsible for doing gallbladder surgery, complicated liver surgery, colon bowel and hernia surgery and breath surgery. And there’s so many areas that depending on the community and the town that their experience with more complicated hernias from previous recurrences might not lead to that perfect operation. So in terms of what’s going wrong, I don’t want to blame somebody else, but usually the right operation, done the right way hasn’t been done, but I am sympathetic to whoever that surgeon was. And usually these patients, I’m sure you’re the same experience when they go to someone that doesn’t have to be me or you, but someone who is a hernia specialist, it’s rare for this chain to continue. We can stop that I think. What do you think about that?

Speaker 1 (00:27:25):

Yeah, I agree. So I do a forensic evaluation of their medical records to see did they use too small of a Mesh? Did they make it too tight? How was the recovery? And then you also look at the patient factors. So do they have some intrinsic healing problem that hasn’t been diagnosed or is known like they’re on steroids or something? Do they have a chronic cough? Are they constipated and pushing against the repair? And that’s a chronic problem. Patients with ulcerative colitis who’ve had colectomies and they have a J pouch, they actually have to exert a lot of abdominal pressure just to empty their rectum because they don’t have a real rectum anymore. Those patients are different than the average patient because every day they have multiple bowel movements and they have to push. Obesity is a big one, right? The BMI or the body mass index, which is your ratio of your height to your weight, that is used as a marker.

Speaker 1 (00:28:38):

Every study has shown worse outcomes in people with higher BMIs. Normal is up to 25 and then up to 30 is overweight, 30 to 40 is obese and then over 40 is morbidly obese. So we typically do not operate on patients with a BMI over 40. It’s really a disservice when you do. There’s so many things that can go wrong. So maybe that’s the problem. So yeah, these are complicated. And what you don’t want to do is to repeat the same question, the same problem over and over again and be the ninth surgeon, the tongue surgeon, because each time they’re probably ripping through. If you have a hole in your outfit, you really can’t use the same string and the same hole. It’s always a little tighter because you have frayed ends. So same thing happens with a muscle each time you have less muscle to work with. And then you get to these horrendous abdominal wall issues that many of us have seen are what we call loss of domain, which I don’t treat as much anymore because I see so many people with groin issues. But I get maybe a handful a year of these loss of domain PA patients. They’re tough. Yeah. Yeah. Okay. Ready for the next one? Okay. Do you order ultrasound, CT and or MRI are routinely, and do you interpret them yourself?

Speaker 2 (00:30:14):

That’s a very good question. Those are the imaging modalities for many of the things that we deal with. And most cases the experienced surgeon’s hand, as you would agree, is probably the most accurate of everything. But we definitely need these a lot. We need for complicated recurrent hernias. We need the CAT scan to give us the information about how big the hernia is and the amount of muscle and the quality of the muscle around it. So I order a lot of CAT scans and I order a lot of MRIs and am very interested in ultrasound, especially as a form of vascular surgeon. It’s in the back of my mind to get that project going. We all know it’s operator dependent. So in my local area, I haven’t done very well getting quality results from ultrasound so CAT scan and then MRI. I use a lot also to evaluate, especially for groin pain, other orthopedic causes of groin pain and so on. And I do interpret them myself for sure, because we know as another paper that you wrote that our ability to put the two together is, even though the radiologists are wonderful, brilliant people, our ability to interpret the studies in front of our patient is actually much more accurate. Oh yeah. See a lot of inaccuracies with that. So you have to get into it.

Speaker 1 (00:31:43):

We cheat because we get to talk to the patient and touch their belly and do their exam. The radiologist don’t have that luxury.

Speaker 2 (00:31:52):

But then over time you gain experience matching those two up, which adds to your ability to be good at reading them.

Speaker 1 (00:31:59):

Right. Okay. Let’s move on to some ventral hernias. You ready for those? Sure. Because you do all of them, right?

Speaker 2 (00:32:05):

Yes, absolutely.

Speaker 1 (00:32:08):

Okay. Can a non Mesh repair be done for a ventral her for an incisional hernia of the abdominal wall? Above the belly button? So from the bottom of the chest wall to the belly button. Can non Mesh repair be done for those?

Speaker 2 (00:32:26):

It can be. And I have many patients that will ask for that, again because of patient individual concerns about Mesh problems of their own or other. But that’s where there’s a lot data in our world about how Mesh is the use of Mesh in the right way helps to reduce the risk of the hernia coming back again. And depending on the transverse diameter of how big the hernia is right across the, no matter how well we do it, I do believe that the risk of the hernia coming back again is extremely high. You and I both see people that not only want a non Mesh repair but have had terrible allergies to Mesh and so on. And so I ultimately, unless I don’t want to burn any bridges or do an operation that can be destructive knowing that the hernia can come back again. But if I can do a minimal robotic repair from the inside where we’re closing the hernia and it came back, I don’t, and I don’t think I burned a bridge. I think that was a reasonable attempt for this patient who’s motivated to not have hernia surgery with Mesh. And then we both know that we also can be discussing with them options of absorbable meshes. Not that answers the question for them, but at least knowing that the Mesh would absorb in anywhere from six to nine months is sometimes, oh,

Speaker 1 (00:33:50):

We have

Speaker 2 (00:33:50):

A happy for patients.

Speaker 1 (00:33:52):

We have an absorbable Mesh question. Let’s continue with this then we’ll move on to that question. So one question is, what’s the recurrence rate for incisional hernias repaired without Mesh and is it hard to fix again if it comes back? So Yel and his group out of the Netherlands looked at this back in early, I want to say early two thousands where the landmark paper was published. So incisional hernia is a hernia after you’ve already had surgery, let’s say you had colon surgery and you get an incision from that and then the hernia occurs at that incision. If you repair those without Mesh there, they should over 50% recurrence rate. And with anyone that has a slight complication or risk factor, maybe a cough, constipation, it’s like 60 70% recurrence rate. So we do not recommend incisional hernia pairs without Mesh because of those numbers.

Speaker 1 (00:34:56):

Now again, the size of the hernia matters. So if you’re incisional hernia repair is like five millimeters. <laugh> a different process than a true huge laparotomy trauma, trauma surgery incisional hernia. But what do you offer if someone doesn’t want Mesh? And I hate to spend so much of our hour on non Mesh issues, but because it really isn’t considered standard, at least not in the United States, but as our audience is very interested in it. And I hope that our objective way of addressing kind of gives them some reality as to understanding that what’s standard, what’s not standard, and why is it not standard?

Speaker 2 (00:35:46):

Well, I mean you’ve made it very clear that the data shows this much higher recurrence rate. And I also obviously agree with you that very small hernias and to me, the size that I choose is not so much based on the literature. A lot of it has to do with pliability or how much someone’s abdominal wall can move together. That again, if I feel confident and the patient feels confident that we’re going to do an operation that doesn’t burn a bridge, that’s not going to hurt the patient, that’s not going to make the next operation worse, which is what that question, part of that question, then I’d be often be willing to do it. And I do many small two centimeter, say port site hernias from a previous laparoscopy or robotic surgery. I do them very frequently without Mesh. And at the same time I don’t recommend it.

Speaker 2 (00:36:40):

I don’t usually tell people in the other important concept, when I talk to people that have these Mesh concerns and wouldn’t want say a Mesh, they come in with a seven centimeter hernia. Where typically we would be using Mesh is to really, people need to understand that the Mesh that we use as hernia specialists is really not the Mesh or the position of the Mesh that is often implicated in Mesh problems from other than patients that you’ve spoken to or lawsuits or so on. So when we use Mesh in venture hernia repairs experts or people like Dr. Towfigh, we will put the Mesh in a very safe place within the abdominal wall usually. And also a very lightweight Mesh where the incidence of Mesh related complications in these hernia operations, even when not perfectly performed, is close to zero. So I make sure they’re enlightened about that. Mesh is not the same as other Mesh.

Speaker 1 (00:37:45):

Correct. And also it is harder to fix when it comes back because your defect is now either larger or more complicated or both. And so the larger the defect from an incisional hernia, the less muscle we have that’s normal and healthy to work with. The worse your outcome, the more likely you need synthetic Mesh. And the more likely you need what’s called some type of complex abdominal wall reconstruction, which we discussed with Dr. Janice a couple actually last week. And that is that not everyone can offer you that procedure and you, you may have to travel and your recovery’s going to be longer. And if that recurs, then there’s this whole what we call vicious cycle where you end up having this loss of domain. So yes, there are serious repercussions with not following standard. The reason why we talk about the gold standard repair is because the data shows that’s the best outcome for all patients.

Speaker 1 (00:38:48):

But maybe for this subset of patients, that’s not the best outcome. Population studies don’t tease out the tailoring. That’s where we come into play, or at least we try to <laugh> but we have to do some surgery that’s considered standard. Going back to the Shouldice, there’s a question about patient who doesn’t know if he has a direct or indirect angle hernia. And he’s concerned that a Shouldice may be too invasive for an indirect. And so he’s desperate to figure out if he has a direct or indirect to therefore determine if he should go to Shouldice clinic or not. What do you think of that?

Speaker 2 (00:39:32):

Well, I think that if they feel that strongly about that level of detail that the Shouldice clinic does have the most experience in the world, and that’s not a terrible idea. But we went through my algorithm where I feel very comfortable with the Shouldice repair as you do. And my patients are doing very well. And I’m not that worried going in as long as I’ve communicated with my patient about that I might be tailoring the repair when I’m in there still with a non Mesh repair. What is it? So you asked me that earlier. So again, for typically a direct hernia, unless it’s extreme, is quite amenable and does very well. And it’s very appropriate for Shouldice repair and indirect hernia also could be done with the Shouldice, but is where I tend to use the desarda. What is your organ algorithm for that?

Speaker 1 (00:40:28):

I think that, so I offer the Shouldice or the Bassini or the McVay for tissue repairs open. And the way I gauge it is based on the size. So it could be a small direct or a big indirect. I think the larger the defect, the more difficult it is to get a good Shouldice I think is too tight. So I go for a Bassini with those. And the reverse is also true. The smaller, more delicate ones, I think the Shouldice. And for women with really small, you could just do what’s called a Marcy, which is a single stitch.

Speaker 2 (00:41:04):

Oh good. I’m glad you brought that up. So that’s something that I’m, I do. I’m also doing them laparoscopically, but I’m glad to hear that that’s what you do. Cause I think that’s very minimal and very appropriate because they tend not to get direct hernia.

Speaker 1 (00:41:21):

Yeah, I just did one today. You know what I saw today? It’s so weird. It’s not the first time I’ve seen it either. Open repair with Mesh, the Mesh was placed between the fat and the external oblique aponeurosis. They never got to the hernia. And it’s not the first time I’ve seen this.

Speaker 2 (00:41:41):

Interesting. Have you

Speaker 1 (00:41:41):

Ever heard of that? Is that a common thing or something that’s ever taught? Because I don’t know where that comes from.

Speaker 2 (00:41:48):

I’ve never seen that in the groin. I mean, I’ve seen that in ventral hernias. But speaking of your approach to the female hernia that’s small when you’re doing it anteriorly, meaning an open repair, open marshal repair, do you divide the round ligament for those

Speaker 1 (00:42:04):

Always? Yeah. Yeah. Round ligament’s always gone. And every time I see someone who’s a female urologist or gynecologist, I ask them about the round ligament and every single one. So far I was like, take it. Just don’t injure the nerve, but take it. So really good. Okay. So next patient had an inguinal hernia repair and I, I’ve noticed tightness over the years and bothers me enough that I’m considering Mesh removal. I believe this patient is multiple years after the repair. Is when they notice the tightness. Is Mesh removal way too invasive and risky to consider without substantially ongoing pain? Or is it completely subjective and if removing mush robotically and not doing any further repair, can scar tissue and the scar plate be enough to prevent future hernias? That’s a really good question. The original repair was done robotically and moderate soreness and pain for two years.

Speaker 2 (00:43:12):

And if the patient developed the pain or the discomfort, they have that in their mind that their symptoms developed after the operation, soon after the operation that it clearly wasn’t symptoms they had before the surgery then that’s much more suspicious over time of a related problem. So Mesh removal’s an option, but in consideration where I’m not hearing disabling symptoms, I typically am very conservative as I’m sure you are with removing that without disabling symptoms it often wouldn’t be indicated. But the other thing to be considering is other causes of the pain. So you and I both would be working up examining the patient to look for an iliopsoas muscle strain. I mean, not over two years, but that would be shorter or hip joint problems like a labral tear arthritis or abductor muscle strain or rectus muscle strain, which can be very chronic. And just to make sure that it’s not other causes of pain.

Speaker 2 (00:44:23):

And then ultimately, if all that’s ruled out and somebody can’t live with the pain, I think you and I both are at a point where there’s incredible safety now for me in both open and robotic Mesh removal that if somebody can’t live with those symptoms, we take the Mesh out and we’re doing very well. The issue, it was a good question with when you take the Mesh out, you’re going to be dealing maybe with a recurrent hernia that we often see a scar plate where there’s not an obvious hernia or there wasn’t a big hernia or significant hernia at the original surgery, which is a possibility, but I don’t think it known historically. We would doubt that the scar would be good enough to repair the hernia for the long term. But it’s my personal philosophy when I take Mesh out and some of our expert colleagues that are excellent surgeons, they have the confidence that they will do a robotic or an open Mesh approval removal and they will put another Mesh in where they are doing, they’re putting the Mesh in appropriately and choosing an appropriate Mesh and they feel good about it.

Speaker 2 (00:45:33):

It’s my personal philosophy to not put Mesh back in. So

Speaker 1 (00:45:37):

What if it’s just a recurrence?

Speaker 2 (00:45:39):

I’m sorry,

Speaker 1 (00:45:40):

What if it’s just a recurrence?

Speaker 2 (00:45:43):

Oh, if it’s a recurrent hernia, then that’s different. Then I might have to take Mesh out robotically to get it out of the way and then I could put a better Mesh in. But if I’m operating just for pain and I’m removing Mesh for systemic or local symptoms from the Mesh, even if I, and I see a residual hernia at the end of the operation, it’s my feeling that I just want to get rid of that person’s pain and I’m going to do your operation, a robotic ilio pubic tract repair, and then the long term results we’ll see. But I give them information to possibly expect a future hernia, which again, by a specialist, could be fixed, usually a minimal way, maybe from the other side.

Speaker 1 (00:46:29):

Okay. So sounds like the pain is aside, but there’s still heaviness and tightness. I’ve noticed in some patients that the repair is fine. So you do imaging, one of the questions is do you use imaging to determine Mesh problems and which imaging is best? So the best imaging, and someone’s already had surgery in the groin, we’re talking about growing only is an MRI because it not only shows the muscles and the hernia better, but the Mesh is very easily seen on MRI. Whereas a CAT scan, it’s hard to see the Mesh separate from the muscles. Everything looks gray. And the ultrasound, the Mesh often asks acts as it, what’s the right term for it? It distorts the image. And so you can’t see beyond the Mesh plus MRI will show you other reasons for pain whether it’s a hip problem or something new that can be identified.

Speaker 1 (00:47:29):

So the answer to that question is for me is MRI. but what this patient said is that now they have a heaviness and tightness whereas the pain is gone. So it’s possible, I’ve seen this and it works really well for me, is people can have either too tight of repair or they could have had too many attacks or sutures. Those need to be addressed. But sometimes a Mesh is on the vas, the spermatic cord, and that interaction then has a Mesh kind of eroding is too strong of a term, but stuck to the nerves of the Vas. And so I release that connection and put anti-adhesive and in doing so, releases the Mesh interaction with the spermatic cord, that pain goes away. So Mesh removal alone is not necessarily the only option for any groin pain after her repair. One is to rule out a recurrence.

Speaker 1 (00:48:32):

Second is to rule out the Mesh being folded. Both of those can be done with MRI pelvis. And then the third is to determine if there’s any testicular or groin pain. Related to that, while we have so many questions, I think you hit the jackpot in that you are the most active of all the surgeons we’ve had so far. I’m not sure we’re going to get to all the questions. The next 10 minutes complex patients or the obese, do you feel that laparoscopic surgery is more beneficial, robotic would be the same, and is it more difficult to do in these patients?

Speaker 2 (00:49:15):

Well the answer is variable and many of those patients need an open or a laparoscopic or robotic approach. But typically for complex patients that are obese, robotic surgery has brought amazingly improved outcomes versus open repairs. But it depends on the case and and I both know that it depends on how big the hernia is, where it is, what the previous Mesh if there’s previous Mesh and what it looks like. So I’m always looking for the safest, simplest option with the least risk of complications. And it often not always is robotic these days for ventral hernias and laparoscopic or robotic for inguinal.

Speaker 1 (00:50:09):

What are your thoughts on biologic Mesh for either open or laparoscopic surgery and what do you know about oex, the hybrid Mesh?

Speaker 2 (00:50:19):

I think, I mean I don’t use that much biological Mesh anymore. We, I’ve been through it overtax. Mesh is a brilliant concept that I’ve had a lot of experience with and have had excellent results with because as we both agree it is a biological Mesh with a very small amount of permanent or absorbable material woven within it. So a lot of these things, the use of that is pushed more with what the patient wants. Getting back to something we talked about earlier that I think an experienced hernia specialist with a ventral hernia that’s of a certain size when the technique is done properly or the proper technique is chosen, which is often advanced, that a lightweight or medium weight polypropylene meshes all you need and can perform very well. So I think of biological meshes, I really do overtax what I answer that. And then biological Mesh for me is really only used when I’m planning to use it for a very complicated surgery where bowel has been injured or at the time of some type of contamination.

Speaker 1 (00:51:41):


Speaker 2 (00:51:42):

I agree. Even then some of our colleagues still use permanent meshes. You and I both care.

Speaker 1 (00:51:48):

Do you treat sports injuries or groin tears in addition to a standard inguinal hernia?

Speaker 2 (00:51:53):

I help diagnose them. And when they are truly musculoskeletal injuries and not just a transversesalis or external oblique injury I send them to other places because I’m very interested in them and I’m acted in diagnosing them. But not a lot of experience with repairing them other than I think in the realm of sports journey is still potentially an external oblique tear, which I may find and fix.

Speaker 1 (00:52:28):

Sounds good. Let’s move on to some more questions here. Okay. I’d like to answer this question because it comes up often on a lot of the forums. So the question, it’s a real one real meaning like legit question to ask <laugh> opposed to fake questions. Why is Mesh, we’re talking inguinal hernias because that’s what this is referring to. Why is Mesh still the gold standard when it causes 13% or more chronic pain after surgery? It seems like the desarda repair should be the new gold standard according to the few studies available out there. I have my answer to that. What is your answer to that?

Speaker 2 (00:53:15):

To me, the gold standard may be evolving and changing and it depends on who you ask, what the gold standard is. And so I think potentially, I do think that there’s a chance that for many patients, an open non Mesh repair could be, again, proven to be as effective as a Mesh repair, I think. But I just don’t think that there, we have the data yet to really say that. And that’s how I would answer that. What do you think?

Speaker 1 (00:53:48):

So here’s my thought on it. So the 13%, 12%, 15% chronic pain rate is for open, Mesh based ankle hernia repairs at three months. That number dramatically reduces at one year and is supposed to reduce after that as well by a little bit. So the reason why it’s still considered the gold standard is the hernia recurrence rate is in the, depends on who’s doing it, but an expert hands is about half a percent, less than 1% recurrence rate. And nationally I think it’s under 5% recurrence rate. That number is dramatically less than tissue repair. So people need to understand, again, surgical history. So historically we’re doing tissue repairs, people were in the hospital for a week, and the surgeon that that initiate the Lichtenstein on lane Mesh repair for inguinal hernias is from my hospital, Cedar Sinai. He was kicked off the privileging because he was offering tissue Mesh repair as an outpatient.

Speaker 1 (00:54:55):

And they said, there is absolutely no way that we would allow you to perform outpatient surgery. This is malpractice. And he had to leave the hospital. So that’s his history behind it in that people were in the hospital for a week. There are studies that have compared directly in Europe directly open and tissue repairs and the chronic pain rate at three months, it’s exactly the same. Now with an open repair, it’s less tension, more risk for Mesh related problems with tissue repair. It’s more tension and nerve injury risks with no Mesh to blame it on. So re to think that because you’re not going to use Mesh, that chronic pain goes away completely, completely not correct. And we have good large number of patient populations to prove that. And to say that all hernias by all surgeons will have a 10, 15% chronic pain is also not correct.

Speaker 1 (00:55:58):

Laparoscopic repair, much lower robotic, probably also very low experts, much lower risk of chronic pain. So if there’s a standard, everyone has kids, there’s a standard of how much you have to teach at grade one, grade two, grade three, that’s for all comers. Now you may go to some fancy private school and they’ll a level grade five when you’re in second grade, or you can go to a poorly funded school where you can barely learn the alpha by the time you graduate from high school. So there’s a standard and then there’s also reality. And when we say gold standard, it means for all comers, the Mesh based repair sure is considered gold. And in fact, the open repair is considered gold standard. In the United States, we still have barely 20% offering any type of lap or robotic repair, even though we know that it’s less recovery, lower recurrence rate, less chronic pain, but we don’t have enough surgeons that even perform it, even with the robot, that numbers is increasing, but we just don’t have that number.

Speaker 1 (00:57:12):

So unless you’re willing to reduce the number of surgeons that offer this surgery and that will drive up the cost, right? Supply and demand with all comers, we’re doing a million hernia pairs. I just hope that people understand that it’s not a simple, well, why don’t you just offer lap? Most surgeons don’t offer laparoscopic surgery. Why don’t you just offer tissue repair? We don’t even teach it anymore because it’s not easy. And they’re a lot of complications with that as well, which we know if we follow our surgical history. So that’s my 2 cents. I’m not saying the world is perfect and unfortunately it’s not. And if you come to see me or Dr.Yunis, we will look at all your risk factors and decide give our recommendations for what’s best. And maybe Mesh repair is better for you. Maybe lap or open is better for you or non Mesh. It all depends on your situation. But if you’re working at the airport and doing luggage and you’re obese, I’m not going to offer you a tissue repair. I think that’s poor. But if you’re in ballerina with a little hernia, you’re not going to get a Mesh repair.

Speaker 2 (00:58:29):

I agree.

Speaker 1 (00:58:30):

These numbers are like population based numbers, all comers, all sizes, all types. So I think that tailored approach is better. And that’s my answer and I hope it doesn’t offend anyone, but I think it’s really not a good thing to look at one data set and say, therefore Mesh should never be used or Mesh is wrong. Understand where that data came from. It’s based on open repair at three months, and the definition of chronic pain is any pain. It could be two out of 10, it could be 10 out 10. Do you have anything to add to that <laugh> before we say

Speaker 2 (00:59:10):

Goodbye? Well, I just would highlight part of what you said, that there’s a misconception. I, I totally agree with what you said, but there’s a misconception that there’s a lot of Mesh related complications and both you and I see it, but in the groin, most of those Mesh complications are pain and they’re mostly a high percentage of open repairs. So the point is Mesh is not Mesh. So for the patient that’s afraid of Mesh and you’re saying that you might need Mesh, it’s not so much that you need Mesh, it’s that if we put it in laparoscopically or robotically on the backside, your risk of complications from what you fear is extremely low and not the same as it is from an open repair. So that is something that’s not typically known or out there.

Speaker 1 (01:00:03):

I mean, there’s just less nerves there, right? Yeah. So we still have tons of other questions that need to be answered. We will have to take that on maybe next week or weeks to follow. Thank you, Dr. Yunis. I really, really appreciate all the time that you’ve shared with us. And that is the end of our session. Thank you for all of you that come so diligently every week to Hernia Talk live. You can get a, watch this again if you wish or share it with your friends on Facebook at Dr. Towfigh, or I will also post it on the rest of my social media and on hernia talk.com a link to the YouTube video for that. Thank you, Dr. Yunis, and thank you everyone for sharing your questions and participating and making this really, really great session. And have a great night.

Speaker 2 (01:01:06):

Take care. Thank you for having me. Appreciate it. Thank

Speaker 1 (01:01:08):

You. Thank you. Bye

Speaker 2 (01:01:09):