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Speaker 1 (00:00):
Welcome to another hernia talk Tuesday. This is Dr. Towfigh. I come to you live from Los Angeles. You can follow me on Twitter and Instagram at hernia doc and my Facebook homepage where we are simulcasting hernia Talk live. And we will later post it also for you on my YouTube channel. So tonight we have the lovely, lovely Dr. Vedra Augenstein. She her is a hernia and laparoscopic surgery specialist working out of Charlotte, North Carolina. You can follow her on Twitter and Instagram at @VedraAugenstein. And I would just like to say welcome Dr. Hello.
Speaker 2 (00:43):
Thank you so much Dr. Towfigh. I am so honored to be one of your panelists and as I was just saying earlier, I don’t think that we have anything like this in the hernia world and I’m just so grateful that you have become such an innovator and came up with something that’s for patience to come up with questions and talk to us. So I’m just so happy. Thank you for having me.
Speaker 1 (01:07):
Thank you. That’s super nice. And thank you for affording us your evening away from family for at least a little bit over an hour. And I think everyone appreciates that. We’ve had a really, really good feedback. Everything’s been kind of fun. And I know we call ourselves hernia nerd. For those of you that follow us on Twitter, we’re hashtag hernia nerds. So we actually love this. We do this on our free time. We talk to each other about hernias and Dr. Augenstein is involved with the American Hernia Society Board and doing a lot of creative things robotically. And she does a lot of ventral hernias that are very complex. When I was much younger, I was doing these big huge complex hernias. I still do a handful, but mostly I do groin stuff. But Dr. Augenstein really, I mean you should listen to our talks. There are very few people that really know how to do it well and have all the different tools in their toolbox to know how to tailor the care to each patient. And you’re definitely in the HUD center in the nation for that at Charlotte. A lot of patients come to you from all over, I assume. Does that sound all?
Speaker 2 (02:31):
I really appreciate it. You’re definitely making me look really good here. I just want say the growing stuff is some of the most complex hernia stuff. I think anybody will take eventual hernia over groin, hernia a complex one, and Mesh, resections, infections and all that. So you have probably maybe a few years ago, I guess when you were doing all of these ventral hernias, now you’ve migrated to something that’s even more complex, which is the way it should be, I think with expertise that’s who should be taking care of these things. But yeah, Charlotte so I trained in Louisville did my residency there, didn’t do a whole lot of minimally invasive surgery and wanted to just do a fellowship so I can do some of the main procedures like hernias laparoscopically. And then came to Carolina’s Medical Center in Charlotte, trained there for a year and then ended up moving to Austin, Texas in private practice for about a year and then came back to Charlotte to join back the mentors that trained me. So it’s been in Charlotte now for another eight years. So a total nine years out in practice.
Speaker 1 (03:43):
Yeah, believe that. That’s such a, I think
Speaker 2 (03:45):
I’m old.
Speaker 1 (03:46):
We first met in Milan, do you remember that? We’re in the same bus in an evening event at Milan, at the European Hernia Society. Actually was the World Hernia Congress. That was amazing. Yeah. And we’ve been friends ever since. I’ve loved kind of following your whole career. I can’t believe it’s been eight years. I know already. Wow.
Speaker 2 (04:10):
It’s amazing. I know.
Speaker 1 (04:12):
Well I think ventral hernia, so I agree that anatomy’s more complex for the groin, lot of nerves and critical vessels, et cetera. But for the ventrals it’s a lot more intensive, like inpatient care, wound care a lot of more pre-operative planning in terms of optimizing the patient. Can you talk a little bit about what you guys do from optimization and what we call eras enhanced recovery after surgery. All of those are new things that have been integrated more in these huge complex ventral hernias. Can you maybe give us a little bit of insight?
Speaker 2 (04:53):
Absolutely. I completely agree with you. I think the ventral hernias especially more recently, I think in the last five or so years we’re, we’re a lot more careful about when to operate on patients. So we’ve realized that good outcomes come from really good preoperative care. So we’re investing a lot of our time now in getting patients ready for surgery cause we also study what went wrong last time. What made that hernia fail? Was it a certain type of technique? Was it something related to the patient? People are on a lot of medications A lot of ventral hernias in general happen. Most people should heal after you have any kind of surgery, you shouldn’t get a hernia. But about 20% of people will actually fail to heal after they have their colon surgery, gallbladder surgery or whatnot. So trying to figure out who those patients are and try to get them pre-operatively optimized.
Speaker 2 (05:55):
So some of those things are patients, for example, who are diabetic. We’re very careful. We check everybody’s hemoglobin A1C number. We try to get everybody under 7.2 because it’s a statistically significant marker for complications, wound complications that then also patients will develop hernia recurrence. Other things obesity just thinking about the abdomen and trying to figure out what a hernia is, it’s just a hole in the abdominal wall. Once you close the muscle if your closure is very, very tight, even if you put Mesh, there’s likelihood that the fascia can basically tear from the suture. So if you just think about it, a suitcase analogy that my mentor Todd Hanford always liked to use with patience and I like to do that. I stole that from him. But if you over pack that suitcase with too many clothes those buckles can come apart. But if you take a few shirts out, a sweater or something like that, then it comes together much nicer. And that’s what I think about when I tell patients 15
Speaker 1 (07:01):
Too.
Speaker 2 (07:01):
Yeah, we can close the suitcase. So I think it makes sense. And other things, just making sure that patients understand how every time you operate on somebody complex, your likelihood of actually getting a failure potentially is high or some of the research shows that. So it’s important to get their diabetes under control, get into quit smoking. We’ve known for a long time and many surgeons orthopedic, plastic surgeons as spine surgeons will just not operate on you if you’re a smoker because we know that you’re much more likely to have a complication you’re going to have a wound infection, your hardware’s going to get infected and that’s just not the right thing to do. So smoking cessation one month before surgery then we’ll usually bring patients in, check their urine cotinine levels, make sure that those levels are negative and then do the surgery. So I think just those three main things, obesity, diabetes, and smoking. If we can get those under control, it really, it’s a huge impact on how you do long term from a honey repair.
Speaker 1 (08:05):
Do you have a hard cutoff as to how obese they can be before surgery?
Speaker 2 (08:10):
No, honestly I think most papers will say if it’s BMI over 40, you should consider some kind of either major weight loss through diets or bariatric surgery. But I think there are patients who went from a BMI of 65 down to a BMI of 45 and that’s a huge weight loss. So I think a lot of those patients just require, they need to have their surgery done and I’m sure we’ll talk about skin flaps and things like that. But yeah, so I don’t think there’s a definite cutoff. I look at CAT scans. If I think after their weight loss I can close the fascia then that’s really important and I think then I’ll give them the surgery. But definitely making sure diabetes, everything is under control. So not a definite cutoff but certainly some weight loss.
Speaker 1 (09:00):
You get a CAT scan for every patient before their surgery.
Speaker 2 (09:03):
I feel like most of them already have one. Most of the time the patients come in with them, but I don’t necessarily get one on everybody if I’m concerned about something else at their abdomen or maybe what kind of meshes they have or what kind of component separations and different repairs they had to make at one. But not always Do you get them all the time?
Speaker 1 (09:29):
I do. I feel like it helps me plan to know what size the defect is and therefore what size Mesh I may need to use because I like to order my Mesh ahead of time, we carry it, but it always prevents any surprise like oh we ran out of that size if I just know it ahead of time. And then it also helps me determine if they’re a good candidate for a component separation or laparoscopic repair. Open repair. For those of you that are listening, BMI is basically a ratio between your height and weight. And so up to a BMI of 25 is considered normal, 25 to 30 is considered overweight over 30 is obese. And then we really don’t like to operate over 40. But like you said, some patients, their immense hernia is preventing them from losing that weight.
Speaker 2 (10:26):
Do
Speaker 1 (10:26):
You do bariatric surgery before the weight loss surgery before their hernia repair as a Yeah,
Speaker 2 (10:31):
So I used to do it. I don’t do it in my practice right now, but I refer to bariatric surgeons quite a bit and I think that’s a really great solution for patients who’ve tried to lose weight for a long time and their BMI is still in the high forties and fifties. One thing that we recently are discovered and are kind of pushing patients more towards weight loss and weight loss surgery is that hernias keep getting bigger cause your lateral muscles are continuing to pull apart that hernia. So where we used to say lose the weight and come back when you’ve lost the weight, now we’re telling patients you got to lose this weight quickly cause pretty soon that hernia is going to be so huge. And then you just think about the size of Mesh you need to place. And really once those muscles are so retracted, it’s very hard to get a good repair. So I think some kind of intervention is really important
Speaker 1 (11:26):
At our big county hospital. I think it’s the largest county hospital in the United States, maybe the second now they did a study looking at all of their ventral hernia repairs that were morbidly obese and they’re all told go lose weight and then come back, we’ll fix your hernia. And something like three fours or four fists just they couldn’t lose their weight or if they did lose any weight they couldn’t maintain it enough. So you were basically denying repair to people that are in the county system that already have poor access to weight loss surgery and good medical health optimization. So it just shows how important it is to have a coordinated effect. We have a question for you already related to that, which does metabolic syndrome or pre-diabetes pose the same risk for bad outcome as actual overt diabetes since there’s insulin resistance in both?
Speaker 2 (12:22):
It’s a good question. I don’t think we truly know that. The best I can tell you is that we know from multiple different studies that the hemoglobin A1C over seven in some studies. And then 7.2 is what our studies have shown is correlated with increased wound complications. But I’m sure, I think for me it’s kind of like the orange light on the stoplight. You really got to this is your warning sign and we got to bring you back to green because over time over people will progress to diabetes and at that point also gain weight potentially. And then your repair may suffer and you actually may develop chronic pain because that Mesh is now being pulled off your abdominal wall. So I think it’s definitely, I talked to my patients about weight loss every day, almost every patient. And I think that’s why it’s important to have that relationship with your surgeon because potentially your primary care Dr. May not realize how important this is for a successful repair
Speaker 1 (13:29):
And you have a cutoff for their hemoglobin a1c, which is there relative insulin resistance.
Speaker 2 (13:36):
Exactly, exactly. Yeah. So we do 7.2 for our patients, but the lower the better.
Speaker 1 (13:45):
Yeah. Okay. That’s very reasonable. We have a question from Facebook which I think was presented before, but I’ll show you. So ventral hernias are coming different sizes. What are your thoughts about tummy tuck as a way to treat a ventral hernia?
Speaker 2 (14:02):
So yeah, I think the question asking about combining these two procedures together. So I actually do a lot of panniculectomy resection of the skin the overlying pannus and fat over hernia sac. I do a lot of those as a combination. I used to do ’em with a plastic surgeon essentially all the time and then he retired and I kind of have been doing most of them myself now. But I think it’s a phenomenal way. And honestly this is when I see my patients basically now either they’re getting a tummy tuck and a hernia repair or they’re getting robotic surgery and I’m basically, that’s the way I look at them and I talk to them about the differences, benefits and things like that. And very often, so these are not your classic tummy tucks these are more for patients who’ve lost a lot of weight and they have to meet standards for panniculectomy that are insurance related. So most of these actually I ask for insurance to approve these and write letters and send pictures. But certainly you could do this with a tummy tuck with a plastic surgeon as well and repair ventral hernia as well at the same time.
Speaker 1 (15:20):
So traditional tummy tuck has two procedures in one is the placation or suturing tight of the abdominal muscles together. And the second is the removal of the extra loose skin. Obviously the majority of tummy tucks are done as a cosmetic procedure for let’s say a loose belly like a mommy makeover. And those are not covered because the cosmetic procedure when I do my open ventral hernias, I kind of do the tuck part of it, the placation, I feel like in order for them to wake up with a flatter repair and also to support the original Mesh closure as a second layer, they get like a placation. And then what are your thoughts about, so most tummy tucks don’t use Mesh, but some surgeons do use Mesh as part of their tummy tuck and then is yours, yours is basically a ventral hernia repair, maybe an extra layer application, and then in addition removing all the extra skin, all the same procedure. Is that right?
Speaker 2 (16:29):
Yeah, and obviously you have to be very careful about patient selection in these because if they don’t have a really big defect, they don’t have a huge hernia and you make a two and a half for three foot incision to cut off all this fat what can happen? Your incision now is much bigger and there’s more likelihood of infection, infection of the incision, infection of the Mesh, and then hernia failure. So I think if you’re going to be combining these two procedures, you have to understand that the risks are higher for a wound complication. But I do think frequently, and we’ve actually shown it in some of our research, that just removal of that extra skin that potentially is kind of draping can actually, it’s beneficial and there’s a long-term decrease in recurrence rate of hernia with a panniculectomy.
Speaker 1 (17:24):
And then there’s the apples in the pears. So some people have a lot of their weight in their abdominal wall or in their omentum deep to it and others don’t have too much abdominal thigh. It’s all of their hips and their thighs. How does that change your recommendation, let’s say the same BMI but different fat distribution, does that change your recommendation as to what they can do?
Speaker 2 (17:48):
Yeah, so I mean it really depends where the hernia is as well and how much, once you fix the hernia what you’re going to have skin you have left. If you really have a pouch below the belly button and the hernia is all contained inside that skin if you just push the hernia back and then close the skin, you’re going to have a cavity that can potentially get a lot of fluid collections and things like that. I think it’s a lot harder when patients are more apple shaped than pear shaped. I think just the way the muscles are thinned out. I think in general those are much more complex hernias to fix.
Speaker 1 (18:33):
I assume you see patients from out of town and out of state. What is your protocol in handling them if they have these very kind of complex hernias for you to address? What’s your
Speaker 2 (18:47):
About 60% of our patients actually come from out of state and not just like North Carolina but from all over the us. A lot of times I don’t even look where the patient’s from and then got get surprised. I’m like, oh my gosh, you came all the way from Alabama. Thank you. But we do have phenomenal nurses. We do have outreach programs where my nurse will help coordinate everything from hospitality, house hotels, whatever is needed. If a patient needs to travel and come in. We have people who specifically work on insurance and things like that to make sure that everything’s covered. And the other really nice thing is that I work at a major hospital. So let’s say for example, this patient also needed to see infectious disease they needed to maybe get seen by a plastic surgeon to go to radiology to get Botox injections in their abdominal wall. We can actually coordinate all of that. So other surgeons will send me maybe a CAT scan or a story about the patient and I’m pretty much able to look at their history, review it and say, okay, we’re going to have a whole agenda for you. So when you walk into Atrium Health, you’re not just going to see me, you’re going to see all these other people and then you just go home and then the next time you see me probably will be in the operating room or in the preoperative holding.
Speaker 1 (20:10):
So we have some people that with massive loss of domain, six hernia surgeries gone wrong a hundred percent disabled from it from Missouri, otherwise nor pretty good hemoglobin a1c, et cetera. How should they contact you? Should they just DM you on Twitter?
Speaker 2 (20:32):
Yeah, and absolutely. I mean if you give me your name, date of birth and a contact number, I will have my nurse reach out to you tomorrow. As long as there’s not a thousand people then I can’t promise I’ll really stress her out. But we’ll be very shortly. So <laugh>,
Speaker 1 (20:51):
Excellent. There have been some concerns. Let me share this screen with you. There have been some concerns about robotic surgery versus laparoscopic. What are your thoughts should people worry about robotic or laparoscopic surgery and the risks associated with it? And I know you do a lot of robotic surgery, you actually teach courses for it. So what are your thoughts about patients concerns about the risks of robotic surgery?
Speaker 2 (21:18):
Well, I think first have to, I mean, think of why we do robotic and laparoscopic surgery. It’s actually to avoid risks when it comes to hernia because we know that patients who have robotic and laparoscopic surgeries, they actually have less wound complications. And if you have less wound complications because they’re smaller incisions then potentially smaller rate of hernia recurrence and things like that. I think it’s always good to find out how experienced your surgeon is with any technique but most hospitals are very thorough as far as making sure that the surgeons are very well prepared. I know when I first started doing robotic surgery, and I still do, I mean I still have our intuitive rep in my room essentially for every case. And it’s great and it’s very helpful because it’s amazing what these machines are capable, the visualization and things like that. So having somebody in there that can help you if you can’t, for example, your arm, you’re kind of in the console and if your arm is bumping and things like that, having somebody experience just to point things out is very helpful.
Speaker 2 (22:30):
But I think all of these are tools that are very sophisticated I think, and they’re just there to help us with visualization. With robotic surgery, I’m able to very comfortably sit down and see better in 3D visualization the hernia, the bowel that’s stuck to the Mesh and things like that. So I think it’s just enabling just like any technology, you always have to worry about it. But I think people that are doing this, they’re all trained surgeons and we’re all worried constantly about any surgery that we do. I mean at the scrub saying we’re all praying and thinking about the what’s best for our patients. So that always goes into account. I never sit down to do a surgery or sit down or stand up to do a surgery that I’m not worried about.
Speaker 1 (23:22):
So I agree. I think the best surgeons are the worriers because you don’t take it for granted. You’re not cavalier. I teach that to my residents. I say a good resident is one that worries more as you go from first year to fifth year. Because what can go wrong And you have to constantly worry. My mentor called it comp being a compulsive pessimist and compulsive worrier
Speaker 2 (23:48):
Or paranoid
Speaker 1 (23:49):
<laugh> on your toys. I mean you don’t want to be paralyzed by it, but the reality is that you have a human life under your hands and a lot of things can go wrong when you’re walking or driving. Can you imagine during surgery things can go wrong too. You have to have the skills to prepare for what may be unexpected and also the caring and compassion to worry and care that you’re not going to cavalier about little things. I see sometimes especially the junior residents don’t appreciate the little things that we do to prevent a future problem. But the seniors really get it and that’s part of your training which I tell them, never lose that compassion, never lose that worry because that’s what makes you a safe and a good surgeon.
Speaker 2 (24:44):
Yeah, it’s our job to worry honestly for us to if the patient’s not feeling well or there’s an issue and we blow it off and oh, it’ll be okay, everything went fine. Sometimes it’s not. And you really even compassion, absolutely important, but sometimes we just don’t know. Things happen and we always have to worry. We can’t blame it on the patient. We can’t blame it on the BMI. It’s in the end. We always blame ourselves. I think that’s part of being a surgeon.
Speaker 1 (25:19):
And I must say you have complex patients. I have complex patients and they’re going through a lot personally. It affects their family life and their disability and their work. And many of them are angry or they’ve had complications and there is a lot of anger in them and I appreciate that. But what I’d like to also kind of share is that we’re all humans too as surgeons and we’re stressed out too when we get it. What affects you personally also affects us deeply as well. I lose sleep over patients. I think about if I’m in a wedding, enjoy my time. I’m still thinking about my patients from yesterday,
Speaker 2 (26:05):
You
Speaker 1 (26:06):
Don’t turn that off. Yeah. And I hope that more and more people, especially as we do hernia talk see the human side of being a surgeon and understand it’s a very stressful job with you all the time. And yeah, I’ve been bullied on Twitter and there’s a lot of angry people out there and I hope that we as surgeons can help address their pain, but they can also have some compassion towards us that we are not taking our job lightly. And it is a very stressful job and we are human too. And the compassion that we put in the amount of our life and love that we put towards our work is not seen in a lot of careers or jobs.
Speaker 2 (26:56):
No, absolutely. Yeah, it really does kind of dominate and hear thoughts and I think you really don’t ever let go of it. And it’s important and every case we worry about every case, worry about every patient but I would never trade it for anything else.
Speaker 1 (27:20):
Yeah. Okay. Let’s go on to another question, which is we did the tummy tuck question. Okay, this is about complications. So ventral hernia, Mesh and adhesions, that’s a scenario. So you got her, you’ve had a prior ventral hernia pair with Mesh, now they’re adhesions. The surgeon goes in there, what are the odds of inadvertent atoms, which means injury to the intestines? Can these intestinal injuries be repaired laparoscopically or robotically? Or does a surgeon have to convert to open and does intestinal injury always require segmental resection of the intestine? These are questions by patient, by the way, this is not a surgeon asking. Can you imagine how,
Speaker 2 (28:01):
Wow, this is what I asked my med students. I know I pined them in the operating room. So we have other jobs too. Not only do we operate and all this stuff, but we also have to teach medical students, residents, and fellows. So these are wonderful questions. So I’ll tell you a little bit. So the first question about the odds of enterotomy we’ve actually done a huge study at our center looking at this specifically. And so if you have Mesh in your belly and you’re having a ventral hernia repair the odds of enterotomy anywhere from 5 to 10%. Okay? So if you don’t never had any type of abdominal surgery, then it’s a lot less than that. So certainly that’s a recurrent hernia repair. The odds really go up. Can they be repaired laparoscopically, robotically? Absolutely. And that’s up to the surgeon to decide. Once they’ve realized that they’ve made a neurotomy, they have to decide if they’re skilled enough if they can see the type of injury and if they can fix the adequately enough.
Speaker 2 (29:10):
Cause certainly you can always convert to open but when you convert to open then other things change as well as risk of wound infections and things like that. So I think most people try to, if it’s a small enough injury to repair it robotically or laparoscopically. And no, we don’t need segmental resections of the intestine always. So it just really depends. You could be injuring the bowel with scissors which is a lot less problematic than if you injure it with cautery if you burn it because that kind of, it’ll spread and that defect can actually become worse. So yeah, I mean I think the most important thing to do is to prevent it. Always be very careful take your time figure out where to get in the belly so you don’t cut into it. But those things do happen. And the amount of surgeries that we do, five to 10% is actually, it’s a pretty high percentage.
Speaker 1 (30:10):
Pretty high number. Yeah. We have a question about umbilical hernias. This patient has had one for years and is wondering if surgery is recommended, the patient has no pain also, based on your answer can the patient do abdominal workouts? And is there anything that you recommend not to do when you have an umbilical hernia? Let’s assume, I’m going to ask this patient to respond as well, but let’s assume it’s a small to hernia like a little Audi.
Speaker 2 (30:43):
Yeah, so we know that you know, should fix these if you want the best outcomes. Actually, I think there’s a paper a few years ago that we wrote from our institution looking at what gives you the optimal out best outcome. So you want to fix these small hernias umbilical or small ventrals, you want to fix them when they’re small and when they’re asymptomatic. So when they’re not hurting you a lot, as they get bigger and start bothering you more your quality of life looking at the data that we have will actually go down because we will likely have to use a bigger Mesh. And for whatever reason, when you have a lot of preoperative pain we have seen that you are much more likely to have chronic pain post-operatively. But if it all depends, you know, may have the tiniest little hernia on earth and most people would say, don’t worry about it.
Speaker 2 (31:36):
At some point you may get your gallbladder out and we’ll fix it at the same time. There’s just a lot of options. Or it may be a couple of centimeters, it’s going to get bigger over time. Depends if you’re healthy. If you’re somebody in your twenties and you’re doing sit-ups actively and things like that depends if you’re a young female who hasn’t had any children yet and we know that putting, if we put a Mesh in there, will you hurt more during the third trimester? So all of those things I think are really important for, you know, talk to your surgeon about,
Speaker 1 (32:10):
Do you do Mesh removals for ventral hernias? And what are the indications for which you remove Mesh?
Speaker 2 (32:17):
Yeah, so most commonly it’s either going to be a Mesh infection or a Mesh fistula which is when bowel has actually eroded through the Mesh. And then sometimes there’s actually intestinal fluid coming out through the skin. So you have bowel Mesh and then most people will wear a bag or something like that. So those are the most common reasons. Mesh infections actually happen pretty quick. Frequently one to 8% of meshes. We don’t really truly know the true enumerator out of meshes that we place that get infected. Cause there’s database that captures that, but it does happen. So just being in the center where I’m at, we see a lot of these Mesh infections and really I think there’s some of the hardest questions about what to do once you remove the Mesh. How do you reconstruct the abdominal wall? What do you put in? But I really enjoy doing those cases quite a bit.
Speaker 1 (33:17):
So a lot of questions about Mesh infection. Mesh infection, does it always have to be removed?
Speaker 2 (33:23):
So I think if you’re not healthy can tolerate surgery then you can be on suppressive antibiotics. And we don’t know the long-term risks of that. There’s potential that having chronic inflammation in your body from this infected Mesh is not good for you. There’s potential that being on antibiotics on and off is not good for you. So I would say when we know that you have a Mesh infection, if you’re healthy enough to get that Mesh shot, I probably would.
Speaker 1 (33:53):
Are there other treatment options? I went through the treatment option. So antibiotics. How quickly can the Mesh be replaced?
Speaker 2 (34:02):
Perfect. So this is a question that we debate about as surgeons all the time. And from the data that we have because we do Mesh, in fact should Mesh in fact or case cases, we do these cases quite a bit. So we actually do a single stage procedure. We optimize the patient, do whatever needs to be done pre-operatively as far as imaging, weight loss, diabetes control. And then what we do is we remove the entire Mesh foreign body completely. If it’s infected, all the sutures, tax, everything that potentially be infected. And then we will actually reconstruct the abdominal wall, but use a biological Mesh at that time. So it’s a single stage procedure. And really the outcomes from what we have seen so far is that the risk of recurrence is very low. It’s less than 10% with multiple year, which if we don’t put a Mesh there is almost than 80, 90% risk of hernia recurrence. So that’s how I usually, that’s my algorithm for treating Mesh infections.
Speaker 1 (35:07):
So going back to my county days at the county at USC, we had a lot of Mesh infection cases that I did and I got all of them. They called them the Towfigh hernias, <laugh>
Speaker 1 (35:20):
With love, I’m sure. But I was doing single stage at the time removing the infected Mesh, cleaning everything up debriding, and then using biologic Mesh. Back then it was AlloDerm and the patients did fine, but it wasn’t perfect. Then I switched to two stage. So it’s the same hospitalization, they get the Mesh removed and then I put an open abdomen back in for at least three days, two to three days. Basically you do everything, you remove the infected Mesh, you clean it out, Deb debris, any disease tissue, you leave the abdomen open, they’re on the wards, but they have the open abdomen, you don’t close the fascia yet. You put the VAC in, which sucks out. And I think what that did was it reduced the overall bacterial load and then they’re taken back to the operating room, same hospitalization now three days later for their second operation.
Speaker 1 (36:18):
If it looks clean, then I do the abdominal wall closure with the biologic. And I found that it dramatically reduced the recurrence rate. Now and I forget the numbers, we presented the Pacific Coast Surgical, but I never actually published the paper. It was back a while ago I think 2005 or six, something like that. But it was basically we didn’t really have a lot of wound infections, but the hernia recurrent treat was much lower when we were able to get a good closure with decreased bacterial load. So that’s what I currently use as mine. I, it’s a staged procedure, but one hospitalization.
Speaker 2 (36:59):
Yeah, no, I, that’s really cool. I mean, because I’ll tell you, not a lot of people talk about that, but I think the concept of this kind of delayed wound closure we actually do in a lot of Mesh infected cases because we just don’t close the skin. We do the biologic reconstruction during the first procedure, wash everything out. And most of the cases, I mean if there’s just stool everywhere and it’s like a horrible infection, then don’t place anything. But if it’s a very contained infection, you can get into clean planes, do your reconstruction. What we do is we don’t close the skin and then we place a wound back and we irrigate some of these fancy new vaccines that can actually do antibiotic irrigation and then we take ’em back to the, and close the wound. So very similar, but I think that’s the key. I mean because everything bad comes from wound infection and if you can minimize those then you get much better recurrence rate or much lower recurrence
Speaker 1 (37:56):
Rate. Yeah. Now can people with me infections have the infection spread to their bloodstream?
Speaker 2 (38:02):
That’s a good in question. I mean, I have not seen it go from Mesh to bloodstream. Most people have the Mesh infection is kind of walled off like an abscess. And they come in when all of a sudden this abscess essentially erupts and they have drainage from their skin. But yeah, I mean it can definitely spread to another Mesh. I think that’s why both Dr. Towfigh and I have been using these biologic meshes that are resistant essentially to Mesh. They either get chewed up by bacteria or they win. They don’t carry infections like some of the synthetic products. But I always worry about having some kind of a foreign body that continues to be infected. So I think most people that can have surgery, I would advocate to go ahead and try to get that Mesh out. And
Speaker 1 (38:58):
What biologics do you use when you replace the infected mesh?
Speaker 2 (39:02):
So I use stratus I guess it’s been about five years. We did a study where we looked at all the biologics that were used at our institution for about 10 year period. And AlloDerm was one of them. Alamax a lot of other biologics. And we actually, and XenMatrix was one of them that was as well in the mix. Cause we used to be a Bard hospital, but we looked at the recurrence rate and Strattice was a clear winner. It really was basically seven times better than the XenMatrix and some of the other ones. So that’s when we asked our hospital if we can have Strattice on the shelves. So more regularly. And now that’s kind of the data that are quoted with these Mesh infected cases where we do these single stage repair, about 10% hernia recurrence. But these are your very infected Mesh fistulas and fistulas, things like that. So 10% recurrence rate for these complex cases is pretty good.
Speaker 1 (40:02):
And then are there for elective cases, are there Mesh that’s less likely to get infected than others?
Speaker 2 (40:09):
Yeah, yeah, I mean that’s a great question. And I get patients all the time who come in and they tell me I’m really scared about Mesh infection. I don’t want a synthetic Mesh. I had a young gentleman whose dad was a cardiothoracic surgeon and he called me the night before and he said, he’s a young kid, he is in his twenties, please, I know he got a hernia, but don’t put a synthetic Mesh in mean, it was a completely clean case, healthy kid, no diabetes doesn’t smoke. Everybody would’ve said put a synthetic in but he’s less likely to have a failure than somebody who’s very high risk. So I didn’t have any problems knowing our recurrence data. I told him the risks and benefits of both types. And I said, yeah, I mean, if that’s what you want me to use, I feel pretty confident. So yeah, I mean I think people like who are maybe going to get pregnant in the future, people who are transplant patients, there’s just a lot of different indications for it and I think we have a lot of different meshes out there. So I think that’s why it’s important to study all of them and figure out which ones to keep and which ones to throw away.
Speaker 1 (41:17):
Yeah. There’s another question also for umbilical hernias. Do you have to use Mesh? And because there’s complications with Mesh, what’s your protocol for use of Mesh for umbilical hernias?
Speaker 2 (41:30):
Yeah, I will try to get everybody to try to convert everybody to using Mesh. And I’ll tell you because there’s a significant increase in hernia recurrence if you don’t use the Mesh. And we now have data that even the really small hernias that are one centimeter do that. But I think it does, if you look at it, the recurrence rate, 10, 15%, well if you look at it, the coin flip still, most patients don’t have a recurrence. So if you’re a young healthy person, you really, really don’t want Mesh and you understand that the risk is increased, but you’re okay with that. I think it’s fine not to use the Mesh. I think it’s just something you have to talk to your surgeon about and make sure that they’re open to that. I’d say I use more meshes than I used to but even now that I’ve been out in practice in nine years some of those maybe healthy young women who had these very small defects have recurred. So I think that’s something that you know, really have to talk about because that is weak tissue. And if you don’t have a scaffold underneath to support the weak tissue we can get creative and cut some of that tissue out. Some of the women that have a little bit of a diastasis in their abdomen try and placate that to take some of the tension out the hernia. But yeah, so it’s a tough question. I worry about that.
Speaker 1 (42:57):
We get that question a lot. We have another question here which it’s hard to explain a dichotomy, but which is why is it that we surgeons remove Mesh and then also use Mesh? How is it that you’re okay moving Mesh and you see the complications with Mesh and then you also as a standard put Mesh in patients? I’ve tried to explain this before maybe I’d like to know what your answer is to that question.
Speaker 2 (43:29):
Well, I wish we had a way to close the abdomen that we didn’t need Mesh and that we had no recurrence traits. But I think in general, people who have hernias it’s a different type of a disease process that you know, don’t have normal tissues for whatever reason, you didn’t heal normally from your last surgery. And as long as you’re optimized and a healthy person in general, and all of these the diabetes and everything is fixed, you’re not smoking. Most patients will do very well with air Mesh. So I think if we just abolish Mesh completely, I think we’re going to see a lot of reoperations. And every reoperation carries a risk of having injuring the intestine and the disability from having a hernia and things like that. So yeah, I think it needs to be studied. We need to continue to investigate and look for products that are going to be the most compatible for patients.
Speaker 1 (44:34):
Do you have a certain protocol in terms of lightweight Mesh, heavyweight Mesh, medium weight, Mesh, berated, monofilament? What’s over?
Speaker 2 (44:44):
Yeah, so we usually use mid weight polypropylene. When I was a fellow, we used a lot of lightweight and there were some studies that were written from Carolinas talking about the decreased kind of foreign body reaction less infection with lightweight Mesh products and it looked great. But when we studied these long-term, the lightweight meshes did great for about a year or two. But then what we started seeing is that they started actually breaking. So whatever happens and what’s interesting, I think what our patients need to know is that we really don’t have really good long-term data on a lot of products. And sometimes you don’t even have to have any data and you can put in thousands of pieces of Mesh without any data whatsoever. So I think it’s important to know about the product that’s being placed in you. And yeah, so the lightweight Mesh is just we don’t use them in our practice anymore. Maybe in the groin. I think that’s an area where I think it’s still safe to use. But in the ventral abdomen, I pretty much always use a mid weight polypropylene.
Speaker 1 (45:50):
Is that something that patients should talk to their surgeon about or just find a surgeon that research with and about and trust and then use the surgeon’s judgment about it?
Speaker 2 (46:04):
Yeah, I think, you know, need to obviously find out how often your surgeon fixes these hernias. Do they attend conferences and things like that. I think those things are very important. But developing a trusting relationship with your surgeon and asking, well, what if this happens? Well, what if that happens? I think it’s important because if they tell you, oh, well that never happens. All my cases do great, then that would be a warning sign. I mean, because that nobody should ever say that. I mean, your surgeon should be pretty humble and say, yeah, I mean, that’s a really good question that can happen. And yeah, this is what we’re going to do. If that happens, I’m not going to send you, not going to make you pack your bags and go all the way. Well, maybe they want to come to California.
Speaker 1 (46:53):
Well, I think for those of you that are watching, the Carolinas Medical Center has really been on the forefront of research. You guys have a fantastic research team. So even though you’re clinically very strong and you have thousands of operations that you do big team effort you take all that information and then you also translate into outcomes. And for you to be able to give me some concrete data. So this is what you guys see and this is why you’ve, you’ve changed. Your practice is based on data, not because you have a hunch or you feel a certain way. And it’s really important for complex hernias to go to centers like yours that do it all the time. They see all the problems and have looked at their data to see if they’re, what they’re doing is good or not. And if it is good to continue that, if it’s not good to tweak it, see how they can do better. I can’t express how important it is to have experience, but also research as part of your hernia specialists work. There’s some surgeons out there that they like to do hernias, but they’ve been doing the same hernia repair since they were residents in 1974. And they’re probably good at it, but everyone I think needs a little bit of tailoring with their procedures. Things
Speaker 2 (48:22):
Are constantly evolving. And I mean, I appreciate you mentioning the research, but it is a team effort and it is really I’m lucky that I’m in a place where all of our data is tracked. We’re constantly, we have fellows and residents who have these amazing CVs because they are constantly tracking and mining our data and pointing out what we’re doing wrong so we can do it better next time and improved outcomes. But it is hard, I think for private practice surgeons who a lot of them are fixing these hernias, it’s hard for you to get these huge databases, statisticians but at least then for those surgeons, it’s important to be informed and go to the meetings and understand. Because if you’re fixing some of these really complex hernias, I think having the knowledge of some of the kind of newer data on optimization, different types of component separations, different type of products I think that’s all really important to get the best outcomes because it does vary. It really does.
Speaker 1 (49:23):
Yeah, it really does. It makes a big difference. Okay. Share with me a little bit about your post-operative recovery. How soon after a complex one would you recommend people go back to activities? And then how about exercises and what’s the expected recovery? Do you use binders? What do you Yeah,
Speaker 2 (49:44):
So do for some of these big complex ones like the Mesh infections and things like that. So the average hospital stay at our institutions anywhere from about five, six days because we usually are discharge criteria, and a lot of these patients don’t live even in the same state. We want to make sure that you’re doing okay, that when we send you out the door that you’re eating regular food, that you’re off of all the IV narcotics and really even your oral narcotics are quite decreased, that you’re able to tolerate all of this without any problems, that you’re able to walk around almost as good as if before your hernia that you know can get up, that you can be pretty independent that you understand things about your drains. And the other thing is that most of our patients actually, we wait for them to have a bowel movement before they go home because some of these big resections people can get pretty constipated and really sometimes you have to be very careful about letting them eat and drink in the hospital.
Speaker 2 (50:48):
So I think advancing the diet and when we figure out that you’re okay to go that’s usually the green light for when patients have met all that criteria. When you do go home most patients will go, I actually use kind of an incisional vac and there’s usually a drain that patients will go home with. We have a book essentially that people go home with that’s over 50 pages of just what you need to know about your hernia from everything, from what number to call if the drain is doing this what everything means. And it’s everything from preoperative to what a Foley catheter is. Are you going to be putting a urinary catheter, what the different blocks are that we maybe use for pain control? So all of those things are on there for patients to use. And then usually, so we will see you in the office probably about a week or two after surgery at that time we will possibly remove the drain depending on how much it’s coming out of it.
Speaker 2 (51:52):
That’s usually if we do these tummy tucks and other skin resections, and then the patients will take staples, drains, things like that. Everything comes out around that first time that we visit video. Abdominal binders I think are great for pain control. I tell everybody that these are awesome, and if you can wear it and you like to wear ’em, absolutely do. If you don’t I that’s, that’s okay as well. But I do think that it helps kind of hold things tight. So as you’re moving around you’re a little bit more comfortable. And then as far as activity, I tell most people after a complex case that you need to take off at least two weeks off from work people who actually have to do any heavy lifting, pulling, things like that. I don’t let anybody do any of that for at least six weeks. And if it’s really, you’re lifting hundreds and hundreds of pounds, you may want to consider taking even a little bit more time off until everything heals. But I think most people say about six weeks. Is that kind of what you do, Dr. Towfigh as well?
Speaker 1 (52:57):
Right. So it depends on how strong their tissue was at the time. The risk of the operation. So small hernias, I don’t restrict anyone. The big complex ones. I do the two weeks and then I’m a big advocate of binders. I think it reminds them to be careful. It makes the incision heal nicer, less fluid collections. I think overall I like binders if they’re worn correctly. Do you give antibiotics after surgery?
Speaker 2 (53:27):
So if they have a Mesh infection, I’ll keep ’em on antibiotics until the eye close, their incision. Usually I don’t send them home on antibiotics. But there are some people, and I know a lot of plastic surgeons, they send patients home. If you have a drain, they’ll send you on antibiotics. What do you do?
Speaker 1 (53:44):
No,
Speaker 2 (53:45):
No, I don’t.
Speaker 1 (53:47):
Well,
Speaker 2 (53:48):
There’s really no data for, I think there’s no data. There may be plastic surgery data for other things, but I think for hernias there, there’s not, well,
Speaker 1 (53:55):
Plastic surgeons are very conservative. I think many of them, most of the tummy tucks have drains and many of them be patients on antibiotics while the drain is in place. That’s a very old school way of handling things. I don’t like c diff and colitis, even
Speaker 2 (54:15):
Simple antibiotic when people are just give me an antibiotic, I’m like, everything has a risk. You can die from an antibiotic. So
Speaker 1 (54:25):
I agree. Well, we are almost done. Let’s see. There’s a few more questions about the biologic Mesh we already discussed. Well, maybe you can discuss what are the shortcomings of biologically derived Mesh for complex hernia repairs? And then do you think it would be a good idea to use biologic Mesh to reduce chronic pain associated with synthetic Mesh?
Speaker 2 (54:50):
Yeah, so I think sure. The shortcomings for biologic meshes we really don’t know because most of the time most surgeons use these meshes and only the most complex cases. So we only have data in patients who really they’re set out to have really poor outcomes. So people will say, biologic really don’t work because the Mesh has disappeared it. But what happened is that there was an infection and the bacteria ate the Mesh, and we should only be so lucky that the Mesh is gone because if you had a synthetic Mesh, it would be infected. So I think it would be great for us to be able to study biologic meshes in completely low grade low class patients who don’t have a lot of infections and complications and see how they do. I think as far as chronic pain with synthetic Mesh a lot of times patients heard because of how the Mesh is attached.
Speaker 2 (55:49):
So if you have tacks or sutures that are holding this Mesh in place and many of us are going to absorbable sutures and kind of moving away from ta, that’s why robotics is very helpful cause we’re able to kind of suture the Mesh with an absorbable suture. So I think that helps with pain. I think also biologic meshes may help with that as well, because a synthetic Mesh kind of takes a grab of the abdominal wall and it actually shrinks a little bit. Most of these synthetics will shrink while a biologic Mesh tends to kind of stretch with the abdominal wall. So I think that also makes a lot of sense and I think it needs to be studied more.
Speaker 1 (56:26):
And do you use any glues in your repairs?
Speaker 2 (56:29):
Occasionally I do for more for hemostasis, but I’ve not actually done a whole lot as far as gluing the meshes. I think for inguinal hernia sometimes it helps to use a little bit of Episeal and things like that to get it to stick to the vessels and everything. How about, yeah, yeah.
Speaker 1 (56:51):
So my first job was at USC with Namir Kakuta and he, he’s the one that started the whole glue of Mesh protocol. And so this is kind of cool. Okay, I’ll glue the Mesh in. And then with time I stopped even gluing Mesh at all. For inguinal hernias you don’t even have, with some of the meshes, you don’t even have to use any type of fixation. And then for ventral hernias, I don’t typically glue, but I like the Dr. Veler kind of chevrel technique where he uses a very wide coverage and then glues, the Mesh on that works really well for situations like onlays. So not commonly, but it’s definitely one of the tools in our material.
Speaker 2 (57:37):
Absolutely.
Speaker 1 (57:38):
Yeah. Well, we are done. I can’t believe that. No <laugh> time flew.
Speaker 2 (57:45):
Chad Tuesdays. <laugh>
Speaker 1 (57:50):
Time Tuesdays. Yes. Yes. It’s the thing. It’s a thing.
Speaker 2 (57:55):
You’re having fun, Dr.
Speaker 1 (57:57):
I know. Time flies when having fun. I didn’t cough as much this time, so that’s good. Okay, well, I will say goodbye. And for all of you, this will be posted. You can watch it on the Facebook page. Please share it. I will share with you the link to the YouTube channel. Once it goes up, please share it, watch it again. So much amazing information. Dr. Augenstein is a wealth of information. She’s a prolific researcher, amazingly talented surgeon. So glad that you offered one of your Tuesday nights with us. Thank you so much. I love your background. You’re the chicest surgeon we’ve had so far. Aw,
Speaker 2 (58:38):
<laugh>.
Speaker 1 (58:40):
This is always true. You’re always the most fashionable at this. No,
Speaker 2 (58:43):
No. You’re the most fashionable one.
Speaker 1 (58:46):
I love that.
Speaker 2 (58:48):
Thank you so much for such an honor. I really
Speaker 1 (58:51):
Appreciate
Speaker 2 (58:52):
Thank you. And thank you for what you’re doing for patient advocacy. So appreciate
Speaker 1 (58:56):
It. Thank you. And I hope to see you at meeting soon.
Speaker 2 (58:59):
Yay. Live <laugh>.
Speaker 1 (59:01):
All right. Thank you everyone. Peace out. We’ll See you next Tuesday. Thanks, Dr. I can see. Bye-Bye. Thank you.
