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Speaker 1 (00:00:00):
Hello everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live, our weekly q and a held every Tuesday. My name is Dr. Shirin Towfigh. I am your hernia and laparoscopic surgery specialist. Thanks to everyone who’s joining us as a Facebook Live at Dr. Towfigh and via Zoom. Also, please do follow me on Instagram and Twitter at hernia doc and at the end of this episode, this hour will be posted on my YouTube channel, so please subscribe to that and you’ll get to listen to this week’s as well as all prior weeks. So today is dun dun dun, our 100th episode of Hernia Talk Live and I can’t be more excited and I’m super, super devoted to you all and thankful to all your loyalty for making this happen. When I first started this, you may have heard the story, it was the beginning of the pandemic. The hustle was shut down to elective surgery.
Speaker 1 (00:01:08):
The city shut us down for all medical care and so the city of Beverly Hills. And so I was at home and there are plenty of patients that need my help and I couldn’t help them and there’s so much else going on in the world. And so I’m like, you know what? I had hernia talk.com. It’s been a website that’s been bustling with information since 2013. Why not take advantage of this revolution of online and virtual communication? And let’s do Hernia Talk, Live q and As. That’s like the sister of hernia talk.com. So based on that, I basically just started and if you look back, it was a little bit mom and pop. I’m not sure it was the most technologically advanced thing I had done, but it was early on. I’m I’m a surgeon, I’m not an actress. Even though I do work in Hollywood, I should learn more about lighting and audio and whatever.
Speaker 1 (00:02:15):
I’m, it’s been improving, but you all stuck with me. And April 5th, 2020 marked the very first episode. We talked about hernias. I introduced myself to you all. A fair number of you logged on, which was fantastic. And then we just continued week after week after week, and my first guess was Dr. Brian Jacobs. He has a very similar practice to me but in Manhattan. So we’re like East coast, west coast and he shares the same passion about hernias as I do. He sees complicated patients. He does open laparoscopic robotic surgery and it’s been really great working with him and knowing him in the past 15, 20 years. And so he was my automatic first guest and we’ve had, I have to count how many guests we’ve had, but we’ve had at least I think 40 something, almost 50, a little bit over 40 guests so far.
Speaker 1 (00:03:22):
And they range from gynecologists who talk about female chronic pelvic pain and urologists that talk about male prostatitis and male sexual dysfunction. We’ve had people talk about other urologic disorders like interstitial cystitis. These are all diagnoses that I see I as a hernia and laparoscopic surgery specialists. See, because people are either have those diseases or they’re labeled as having it because no one else can figure out their problems. But the big names who are all colleagues of mine that are part of our hernia world, we’re all have all been part of my guests and I must say that I feel privileged to work amongst them. We share patients, they call me, I call them.
Speaker 1 (00:04:15):
I currently have for example, a patient in Connecticut and so I called Dr. Bittner, he was one of our guests where he does basically laparoscopic hernia repairs. He also does weight loss surgery. And we had a whole episode with Dr. Bittner talking about the importance of weight and hernia repairs and how people who are morbidly obese should get their weight lost down to a certain level before they have hernia surgery. But sometimes you have elective surgery like weight loss surgery and you find a hernia. And we discussed what to do in that time. It’s very controversial whether those hernias should be repaired at the time of weight loss surgery or weight afterwards. And he’s got a great program in Connecticut. So I called him up, I said, listen, I have this very complicated patient. His story has really moved me. I really want to help him.
Speaker 1 (00:05:10):
I’m happy to have him come to California, but if could you’re interested, this is the plan of care I have about him and maybe you can help tag team this with me. And he was very great gracious and agreed and we’re both working with the patient to get him better care. So this is what I love about what I do because not only is my practice not limited to Beverly Hills or even Southern California, it’s international, national, international. On that note, we’ve had multiple international guests. We’ve had guests from Germany, I think two from Germany, one from the two from the UK, one from the Netherlands, and one from Belgium. So I have multiple others lined up. I’m super excited about that because I do have a fair number of international colleagues and if you know of any doctors internationally that you’d like to have me work with, I’m happy to include them among my guests, I only include people who I feel are representative of the values that I share in caring patients. Also, I only include people whose clinical acumen and surgical prowess I believe in and find to be gifted.
Speaker 1 (00:06:41):
So I do feel that oftentimes people email me or text me or direct message me and they say, what do you know about such and such doctor? Or do you have a doctor in such and such state? And it’s really easy now to say go to hernia talk.com or go to to hernia, go to Hernia Talk Live on my YouTube channel and they’re the surgeons that I vouch for. I know them, I’ve worked with them, we’ve shared patients. I can vouch for their skill and I hope that all of you have kind of figured out that I love what I do and I feel very strongly and passionately about what I do, even though it’s hernias, like it’s not the sexiest topic, it’s not the most glamorous, but it is such a common D diagnosis and I feel that you all get me because there’s so many of you out there that either have hernias or have need hernia surgery or want to consider hernia surgery or have had hernia surgery and have had a complication.
Speaker 1 (00:07:56):
So because there’s the demand for it, I’m happy to be the person that provides you with that access. I’m totally okay by the way, answering all your questions. So if you want to spend any time of this hour, just ask me questions. I’m totally happy to do that for you. But yes, woo-hoo, episode number 100. Some other specialists that I’ve worked with on Hernia Talk Live include Dr. Belyansky, Dr. Michael Rosen, Vincera Institute. We have a couple coming up that are really interesting. I’ve had Dr. Eunice, Dr several plastic surgeons actually, so that’s going to be helpful to those of you that either need abdominal wall reconstruction or tummy tuck. And we’ve had many discussions with plastic surgeons to kind of get their insight as to a lot of what we are told about different types of procedures. We’ve had Dr. Ben Poulose and Vedra Augenstein, Dr.
Speaker 1 (00:09:12):
Bachman, we did have a surgeon from the Czech Republic, she’s great, Dr. Barbara East and let’s see, gynecology. We’ve had orthopedic surgery. We’ve had I believe two orthopedic surgeons so far that have really given us great insight into hip disorders and so has impingement problems and other problems in the kind of pelvis that can present with complicated kind of pelvic pain or groin pain that are sometimes mistaken for hernia. So what happens is, let’s say you have a bursitis of your hip joint or a impingement of your hip joint or some type of hip disorder and you end up seeing a doctor and that doctor misses the fact that you have a hip problem but they’re like, ah, here’s your hernia. That’s what’s causing your growing pain.
Speaker 1 (00:10:07):
It’s not uncommon to see that scenario because hernias are much more common than hip disorders. So the doctor diagnoses you with a hernia problem as a cause of your groin pain even though it’s not your hernia is technically asymptomatic and your pain is due to your hip disorder, then you get a hernia repair and guess what? Your hip disorder is unchanged and therefore your groin pain is unchanged. But now you have chronic groin pain after a hernia repair and if you see the wrong people they can say, oh no, this hip, this groin pain is due to your hernia repair and it may have been a totally fine hernia, and then they end up taking out Mesh and cutting nerves complete unnecessary. All they had to do was send you to an orthopedic doctor and get like your arthro arthroscopy. Or even worse, what can happen is you can undergo an otherwise routine inguinal hernia repair and then that gets screwed up. So now you have your hip disorder which is untouched and you have a hernia repair that you never need it that is now screwed up and adds to your problem. So that’s kind of sometimes a scenario. So it was really helpful to get the orthopedic surgeons come in, donate some of their time to answer your questions and help evaluate specific questions that can be asked by yourself or by your doctor to help come up with diagnoses to interpret like the groin pain as either a hip disorder or a hernia hernia disorder.
Speaker 2 (00:11:53):
My favorite is groin pain for hernias typically goes away when you lay flat, whereas hip disorder pain does not go away when you lay flat flat. If anything it’s worse and it can give you buttock pain which hernias do not give. Here’s a question. How does Mesh age long term in the body? For instance, if someone has Mesh placed in the groin laparoscopically at age 40, what will the area be like at age 80? That’s a great question. So we actually know that answer because meshes have been in place since the 1980s, so it’s very possible that you did have a repair in the eighties or nineties or year 2000 and you still have your Mesh repair. So the Mesh repairs are considered permanent as are all permanent implants and it’s, it is expected to last a lifetime. That said like if you get a hip or shoulder replacement, usually they give you like 15 years or so. If you get a breast implant, it should be changed out every 10 years for optimal results.
Speaker 2 (00:13:00):
We don’t do that with hernia meshes. The meshes are intended to stay forever and your muscle grows into it and if it fails, we put more Mesh in and we don’t usually take out the old Mesh unless that meshes is a problem. So yes, it does stay in your body, it gets integrated into the muscle or the fascia or wherever the Mesh was placed depending on the thickness and type of Mesh, you can either see it through it or it’s completely overcome with the muscles and tissues that you have. So hope that’s a good question. Here’s another question given that the ilio inguinal nerve and the ilio hypogastric nerves are so close anatomically, can a diagnostic injection discriminate Which nerve is a source of your postoperative pain? Depends on the type of injection. So they’re very close to each other at the hip and kind of your, what you call the ASIS or anterior superior iliac spine, that’s that hip pro, that’s that protruding bone from your pelvis on the sides.
Speaker 2 (00:14:06):
If you inject, they potentially you’re hitting both nerves, not necessarily, but potentially you’re hitting both nerves. Oftentimes we do that or we do it more kind of distally, so closer to the groin area where they do separate and they can be an inch or inch and a half apart and depending on the type of injection your symptoms is really how we figure out which nerve it is. Ilio hypogastric nerve always gives pain or numbness or sensations burning electrical along the groin but does not give anything at the base of the penis or inner thigh ilio does. So we don’t usually use the nerve blocks as the primary way of figuring out which nerve it is. It’s usually the injection to confirm that it is a nerve and it’s the area of the pain that predicts the which nerve it may be. Next question, how do you treat prior patients that suffer from pain due to adhesions following open incisional hernia repairs?
Speaker 2 (00:15:20):
So that’s a good question in that there’s controversy about adhesions causing pain. It’s not common for adhesions to cause pain. Now if an adhesion is entrapping a nerve, that’s possible. If there’s bowel adhesions and you’re getting obstructive symptoms that can be treated laparoscopically. If there’s bowel adhesions because you had surgery that should not be causing pain infrequently there are adhesions into a hernia or against the Mesh that can cause pain. Again, that’s that I would usually treat laparoscopically. You guys also sent me some nice questions via hernia talk.com, which I’m very, very grateful for. So let’s go to some of those. Let’s see, very insightful questions. One is what are the short and long-term benefits and risks of Mesh removal for pain in infection or Mesh implant illness? So we actually looked at this. We published a paper called Why We Removed Mesh and it delineated all the patients that we’ve been removing Mesh in and categorize it as to the reason why it was removed.
Speaker 2 (00:16:40):
Was it removed because it was a Mesh infection? They did they have a meshoma? Was there a nerve entrapment? Was there a hernia recurrence? They have a Mesh implant illness and we found that if you remove the Mesh that was implanted for let’s say infection, that’s how actually has really great outcomes because the infection’s gone, the area will area will scar down. You often don’t need another hernia repair because of all the inflammation from the infection. If you remove it for a meshoma, that’s also really good. That’s like taking a pebble out of a shoe. Just amazing difference. People wake up like, oh, I already feel better because you’ve removed a mass or foreign body that was space occupying and causing pain with bending or the way it was folded and the folded meshes removed. And so that insulting meshes gone and the outcomes are very, very good with that.
Speaker 2 (00:17:43):
The other two problems are not as difficult, not as easy to recover from if you have a lot, lot of nerve injury and nerve entrapment from a Mesh, the downstream effects of that are unpredictable in different patients. And what can happen is we can cut the nerve or release the nerve and take out the Mesh and still you still have some lingering symptoms either from the nerve pain or just your body getting used to having so much pain. It takes longer time for it to recover. Same for Mesh implant illness. People tend to wake up and over the next several months feel better once the offending Mesh is removed. But in some patients, especially those with mass cell activation syndrome and similar disorders or an autoimmune disorder, the effect of the body’s reaction to the Mesh and hope, thankfully this is not a common problem, but it may be a growing problem. The effect of the Mesh on your system of balance and your body’s balance tends to be longer term and it takes months and some people years to get better and many people never fully recover.
Speaker 2 (00:19:06):
Here’s a good question. If you had to guess what will improve an Inguinal hernia repair in the next five to 10 years? Great question. So I have my own biases because I feel that inguinal hernias are part of my specialty within a specialty. A lot of, I would say most of the hernia surgeons out there prefer handling abdominal wall hernias, ventral hernias, which I do repair. I do all those operations. However, I really like the groin. It’s much more complicated, it’s much more sophisticated and it’s evaluation. And so there’s very few of us that really enjoy and are very good at the inguinal anatomy and the inguinal re-operate surgery. And so I’m very hopeful that there’s more technology. As you know, I have my own interests in improving Inguinal hernia care and I have my own biases. I feel that men and women should be treated differently and that technology out there should take that into account.
Speaker 2 (00:20:13):
I also feel that less is more. So we don’t need a lot of Mesh in our bodies. Do we need just enough to overcome the limitations we have with tissue repair and not overdo it? So for example, if you’re going to Palm Springs, which is a very warm area in the desert in California, you just need some very loose out loose clothing at the most. When the desert gets cold, you just take a little thin jacket. There’s absolutely no reason to overdress. When you go to Palm Springs, it’s like unnecessary. You should not bring a park eye. You don’t need wool socks. There’s no just in case or what if it never happens? The same is true for hernias. I believe there’s a minimum amount of support you need. We don’t know exactly what that is, but there’s a minimum amount of technology and support that you need to help support a hernia repair.
Speaker 2 (00:21:12):
And you don’t need to overdo it. You don’t need two or three layers of Mesh. You don’t need extra thick Mesh or extra heavy Mesh. It’s just not necessary. Now sometimes it is necessary and sometimes when you go to the desert it does get cold or if you go to another city it gets cold. But in that situation you should be prepared. Same way, if you have a morbidly obese patient or someone with very wide hernia and that you cannot close, you need to bridge. You can use heavier weight meshes. But typically that’s not the situation. And the more we move away from relying on extra tension, extra Mesh, extra everything, probably the better it is for our patients. So that’s kind of my take at it.
Speaker 2 (00:22:04):
Let’s see. Let’s do another question. So, has awareness in the medical community of Mesh implant illness improved since you started giving your sessions? Actually I think it has. And are there new promising studies on this illness? Yes or no? So I think in general our medical community is more aware that hernia relay complications are a problem, is more aware that Mesh can be a problem and is more aware that Mesh implant illness is an issue. And I say this because I give talks and I’ve been giving these talks for two decades almost. And especially in the past 15 years, I’ve been treating more women. I’ve been treating more people with complications from meshes and I’ve been telling people women are not like men. They present differently. Tell the urologist when you evaluate a female, these are, there’s specific questions you have to ask. And not that they said anything they kind of like, were like, yeah, yeah, Towfigh, you got these fufu Beverly Hills patients at all?
Speaker 2 (00:23:30):
No, that is no longer how my talks are interpreted. In fact, I see other people that were not believers being believers and it’s taken five years, maybe close to 10 years in some cases it’s taken, some surgeons change a change in their practice, they change cities, they move from a a Midwestern city to a metropolitan city or vice versa, and they’re seeing a different population of patients and different types of complications. So now their eyes are opening up and I’m like, I’ve been telling you guys as most of my patients do not come from Beverly Hills. And so I do see a very wide range of people, but more importantly I see a very narrow problem within a very wide field. And so that’s why I feel that the more I keep repeating, repeating, repeating, giving more talks, people are starting to listen more.
Speaker 2 (00:24:32):
So now they want to hear about women’s hernias now they want to hear about Mesh and implant illness, chronic pain, selective neurectomy instead of triple neurectomy, robotic Mesh removals and other kind of advancements use of hybrid me Mesh. So these are all topics that I think are unique to me and what I like, which is different from other surgeons. And finally they’re asking for it. Many of you may follow me on Twitter. I just reposted a video when I was in Costa Rica at the I H C meeting, the international Hernia collaboration meeting, general Surgery News was there. It’s the number one most read news by surgeons and they’re great set of writers. And I was interviewed by Dr. Eric Pauli who is a former guest on Hernia Talk Live, very, very smart men at a Penn State in Hershey, Pennsylvania. And the topic was about women’s hernias and how they’re different and how could you tell and what do you need to know?
Speaker 2 (00:25:40):
And I’ll try and download that video to put it on my other social media posts. But do go to my Twitter feed and you’ll see from general surgery news, it’s kind of a cute little, actually it’s on Facebook too, I think I put it on Facebook to go to my Facebook page at Dr. Towfigh. But what’s what I was asked to talk about, I almost never used to get asked. It was one of those topics like, oh, way back in the corner, we’re going to have a little discussion on women’s hernias, not part of the main sessions. And now it’s definitely something that people are interested in to hear has become a topic of interest. Next question. Some of your colleagues who deal with chronic postoperative pain recommend waiting 12 months before doing another intervention. Do you agree? Absolutely not. I do not agree with that.
Speaker 2 (00:26:37):
Given that the inflammation resolves earlier, what is the logic of waiting 12 months rather than six months and what physiology could be changing in the interval between six and 12 months? That’s a good question. So the reason why 12 months came into play is the studies that the initial studies that started looking at chronic pain saw a very high rate of chronic pain at three months, I think 20% and at 12 months it dropped to like 9% or 6%, something like that. So therefore they’re like, if you just ignore most of those people, then they’ll be fine by a year. Now I don’t think that way because every patient’s different. When you do these population based studies, you’re talking about a population, but each individual patient needs attention. So let’s take those numbers 20% and 6%. So if 20% of patients have chronic pain at three months, you don’t know of that 20%, which individual patient will end up being pain free at 12 months and you don’t know what it took for them to become pain free at 12 months.
Speaker 2 (00:27:52):
So why ignore all those people when you could be helping someone that needed help 12 months prior? I hope that makes sense. So I’ll give you an example. If you have a patient that had an open abdominal wall hernia repair and many of you have come on here and said, I just had surgery, I’m in so much pain, what do I do? Oh, anti-inflammatories, ice packs, wear a binder, those are all help you. Okay, I’m now two months, I still have a lot of pain. What do I do? Make sure you don’t gain weight, make sure you’re not constipated. Ice packs, anti-inflammatories binder, it’s now three months. No difference. So now you got to start thinking, okay, what’s going on? It’s got imaging. Maybe there’s a seroma or fluid collection that I can help address. Now most aromas will go away, but why do you want to wait eight months for it to go away when I can suck it out right now and make you feel better?
Speaker 2 (00:28:58):
Maybe the Mesh is too tight, you need to lose weight or we can add Botox to the air until you, your body gets used to it. These are all things that can be addressed early on. You don’t have to wait until patient kind of gets better on their own necessarily. Now what if the patient had a groin removal, sorry, groin, groin, a hernia repair and the nerve wasn’t trapped. That patient should not be waiting a year because by a year they’re screwed up, their life is at risk, their psychological situations at risk, their family life is at risk, their job is at risk because nerve entrapment is very, very painful and should not be ignored. They can get a nerve injection the next day or maybe even taken back to surgery. So the problem I have with interpretation of population based studies is it doesn’t take into consideration the individual needs of a patient. So if you see a patient at three months that has pain and it’s clearly not nerve entrapment, it’s clearly not a Mesh repair gone wrong or an infection or a seroma, then it’s okay that you go forward and do whatever needs to be done over give it time.
Speaker 2 (00:30:22):
And that’s what the study shows. If you give it time, the majority of those people will get better. But if you have pain from nerve entrapment or an infection or something that’s very treatable and should not be delayed, then that’s not where the studies need to be followed. You should get that addressed early on. Sounds like my audio’s not matching my video, but there’s nothing I can do about that. I’m sorry about that. I think it’s because I started Facebook after I started Zoom. Sorry. Okay. I’m undergoing diagnostic surgery to see what’s going on. I have no Mesh anything. I have no Mesh anything to tell the surgeon to look out for. Well, depends on which part of the body your pain is. If you let me know, we’ll help you. Our dynamic ultrasounds and MRIs equally effective at diagnosing Mesh related issues in the oral region. Is it all user dependent? So dynamic ultrasounds are helpful if you do not have Mesh. Once you have Mesh and it’s very difficult to evaluate the groin. There are certain very few handful of highly talented 3D ultrasonographer that maybe can help, but the average ultrasonographer will not be able to give you any information if you’ve already had surgery or a Mesh, which is why MRI is very helpful.
Speaker 2 (00:31:48):
Also, MRI is less user dependent than an ultrasound. That’s why I rely much more on an ultrasound. Let’s see. I had left inguinal hernia surgery in 2015. I’ve had pain since day one. I’ve tried multiple things to try to relieve the pain. Two weeks ago, my pain doctor wanted to try the DRG pain stimulator on me. I had it in for seven days and then removed it. My pain has been more severe and now also my upper buttock and hip pain and now the pain doctor wants to hold on, do a steroid injection in my lower spine. That doesn’t make sense to me. Should I try it?
Speaker 2 (00:32:38):
No, I think you need a better doctor. I don’t know the specific specifics, but as I’ve told you before, pain doctors are not all the same. They’re usually used to spine disorders. They just do spine injections. That’s what they’re comfortable with. Most of ’em are not even comfortable with peripheral nerve pain. They have no idea what we do in the region. And just dealing with your average pain Dr. May not be adequate. So no, don’t do it. All right. Let’s see. I’m having treated so many post-surgery pain patients and having explanted routinely, do you find yourself leaning more into tissue repairs than laparoscopic for primary growing hernias in your practice? Yes, very true. I have a study that I did.
Speaker 2 (00:33:40):
The study looked at the evolution of my work over time based on the operations I’ve been doing and what it shows is I’m relying more on tissue repair, less on Mesh. I’m relying more on laparoscopic and robotic, especially robotic than on open. And you’re right, I’m using more tissue based repairs, especially for thin patients, people with chronic pain. When I remove meshes, I’m more likely not to put Mesh back in depending on the situation. Absolutely true. Let’s see, I’m getting suicidal from being in pain for almost a year, stabbing pain with no answers. Okay, first of all, you’re not alone because suicide is a major, major issue when it comes to chronic pain and especially if you have chronic pain from groin surgery that especially in men, that’s a lot of sexual dysfunction that also gets added to it, which adds even more to your chronic pain and to your depression.
Speaker 2 (00:34:56):
I highly recommend that you reach out to your peers to get some help, but I don’t know why you’re not getting the care that you need because there’s plenty of us that can help you. And if one doesn’t help you just go to the second one, you go to the third one and go to the fourth one. So we had multiple episodes talking about how you have to be your own advocate up until a certain point. The average doctor can help you. Once you get into chronic pain and complications, the average doctor usually cannot help you. You have to be your own advocate and move or change doctors or ask for a second opinions. We all offer zoom meanings. We all offer online consultations. Now you even have to travel to get better care and in the United States, you’re free to get care with whoever you want.
Speaker 2 (00:35:46):
There’s no limitation. So I highly recommend that you be your own advocate and get to find the doctor that can help you best. So this is regarding a ventral hernia repair on the right side along the belly button on the bottom left of the belly button. So this a ventral hernia repair. Let’s go back to the original question, which is I’m undergoing diagnostic surgery to see what’s going on. I have no Mesh. Okay, so if you have abdominal wall pain after a ventral hernia repair without Mesh, oftentimes it’s either too tight of repair or you are tearing the repair. A lot of that can be diagnosed without surgery. You need imaging. You may need an injection on ultrasound or a CT scan should be all that you need and you may need an injection to the area. Just going in there to take a look with no plan is absolutely the wrong idea. If you ever have a surgeon that’s like, I don’t know what’s going on, let’s just go in there and take a look. Without good interpretation of imaging or whatever is a waste of your time, you could potentially get hurt. So I’m not an advocate of just going in blindly and seeing what, what’s figure it out.
Speaker 2 (00:37:09):
That’s not how I roll it. That’s not what I recommend. Who’s an expert for acne’s? A C N E S, which stands for many of you already know because we reviewed this anterior cutaneous nerve entrapment syndrome who is an expert for acnes and constant lasting nerve pain from surgery, which caused a lot of scar tissue making the whole surgery not worth it. So if you have pain from an area of surgery, it’s not acnes. Acnes occurs independent of having any procedure in the area. It’s an actually anatomical problem, has nothing to do with surgery. So if you are trying to seek out an acnes, so I’m an acnes expert. I actually wrote the only paper by a surgeon regarding acnes because I see enough of it of patients that really have it and it’s abdominal wall pain that no one can figure out. My point is this, you don’t have acnes if you had surgery and now you have pain in the area of your surgery. Acnes is an independent diagnosis separate from any operation.
Speaker 2 (00:38:18):
The trade off of having chronic pain from minor pain from a small hernia, it’s just not worth it. And I wish doctors were upfront about this with patients that there is a risk of scar tissue and heat is a nerve pain and they don’t tell you this. That’s true for the groin, not as true for the abdominal wall. But yeah, chronic pain is a potential risk of any operation and therefore one of the reasons why I brought Dr. Fitzgibbons in, so another of one of our episodes dealt with watchful waiting and the benefits of watchful waiting versus not. And in patients that have no symptoms or are minimally symptomatic, which means they have a little bit of pain but not too much, it is definitely worth discussing, watchful waiting and it’s concerned to be safe for groin hernias and abdominal wall belly bone hernias. That’s been studied and I agree with you and Dr.
Speaker 2 (00:39:12):
Fitzgibbons agrees with you and he was also not a proponent of operating because most of you will, 80% of you will require surgery and because you will have pain anyway because what about the other 20%? It’s really not fair. And so that’s also my take on it. So many questions you guys. I love it. Let’s see. Have you mentioned that doing a surgical intervention to address chronic postoperative, her pain including open tissue repair, can further traumatize the tissues of make a patient’s pain worse. How do you balance risk of further tissue trauma and therefore worse pain versus undoing a tissue hernia repair to improve postoperative pain? Great question. Yes, it is a balance, but at least in my hands, 80% of patients are cured, 20% are not better and need more intervention and very, very few, I would say less than 1% are maimed or worse. So we do have that discussion, but it’s usually not the scenario regarding your answer. Why would those patients get better? Why would they get better? They would get better because you’re undoing the original problem. Maybe I don’t understand the question.
Speaker 2 (00:40:40):
Oh, this is okay. The question is at three months versus 12 months, why do people get better? Because the three month pain is inflammatory. Pain from surgery, tissue trauma, inflammation from the Mesh. If the Mesh is used, tightness in the area, et cetera, muscles loosen Mesh, inflammation goes away, the body get, the body gets rid of inflammation and that’s why they get better on their own over 12 months. Understanding that inflammation and fluid collections can all cause symptoms that will eventually resolve hope. That helps answer it. It’s scary that removal from Mesh and plant illness with autoimmune issues and nerve entrapments doesn’t have the same results as removal for infection or meshoma. That’s true. However, even if the improvement takes longer, it may not be a total improvement. That’s okay. Any improvement is a step in the right direction. That’s a very glass full half full positive look.
Speaker 2 (00:41:49):
And it’s also the best way to ensure you will have a better outcome is to be positive. And that’s been scientifically proven positive thinking improves outcome even in cancer patients and that’s been proven. So definitely it will help in hernia patients. I guess there’s no way to know the risk of things getting worse or is there? Is there any data on the chance of that happening asking for a friend. Thank you. Okay. No, currently we have zero ability on an individual basis to identify if you will do better or worse with a revisional operation. Now there is something called the C E Q O L is an app. You can download the app. Dr. Heniford who again, prior guest of ours, one of our 100 episodes from the Carolinas, he looked at data that was gathered from a clinical trial and use that data, which is only applies to males by the way, undergoing inguinal hernia to provide risk factors for chronic pain.
Speaker 2 (00:43:07):
And if you put in your data, it’ll give you a expected individual risk of chronic pain. It’s a great app. It may overestimate your chronic pain rate or may it underestimates. That’s unclear. We don’t really know, but it’s pretty scary because you’ll put in your diet, you’ll be like, I have a 13% risk of chronic pain. What the hell or 40% risk? And so that’s a very good way of doing it. We don’t really have that in any other form. We definitely don’t have it for women and we definitely don’t have it for other operations. So that’s the only, for example, revisional surgery. I may be able to come up with one if we have enough patients from my database. I’ll have to look into that. That’s something to think about.
Speaker 2 (00:43:59):
You’ve mentioned that doing a surgical intervention to address chronic postoperative inguinal hernia pain including open tissue repair, can further traumatize the tissues and make the patient’s pain worse. How do you balance the risk of further trauma and therefore worse pain versus doing a tissue repair to improve postoperative pain? I think I answered that, but basically it has to be worthwhile. a lot of people are like, I just want the Mesh up, but that’s not, that’s a risky, so if I’m going to make you worse than you are now and you’re doing fine now, you just don’t want to have the psychological aspect of having Mesh in you. That’s not a reason for Mesh removal or we’re not plumbers or just kind of technicians where you come and tell us what to do and we just do it. There has to be a medical implication and need for what we do.
Speaker 2 (00:44:58):
That said, I personally feel that a very technically gifted surgeon, someone that’s very careful with their technique, tissue handles a tissues very lightly, uses the least amount of tension when operating causes the least bruising causes the least amount of tissue injury will offer the best outcomes. And that’s kind of how I do my own practice. What would you say is a cause of pain for a patient who had abdominalplasty with hernia repair? The location of the pain is approximately two inches left and right of the original incision. Mesh was used in surgery. Usually we don’t use Mesh during an abdominalplasty. That’s not typical. It is part of what many do. I’m not a fan of it. In fact, we’re we’re looking at our own data to show the benefits of non Mesh hernia pairs if it’s included with an abdominalplasty. But most likely what you have is a suture that is under tension and trying to tear through the muscle and probably right there where the pain is, is where the suture is and therefore going in there and maybe removing the suture is probably an option.
Speaker 2 (00:46:16):
Oh my Lord. Look at all these questions. See if we can get through all of them. I’m going to go fast you guys. I hope you’re okay with that. Let’s see. They keep saying they don’t see anything on the CAT scan, even though I’m in so much pain, I would love to see you, but I live in Ohio. Again, online consultation. As long as you have access to mail and email, you can get a consultation with me. So just contact my office, send me all your reports, I’ll review it. I’ll review that CAT scan that everyone says is normal. I’ll look at it based on your information, I’ll try. I’ll give you feedback as to what you should do. There’s a again, zero reason for you not to be able to get the care that you deserve. I had several hernia repairs done with Mesh put in each time.
Speaker 2 (00:47:07):
I am a repeated cycle of hernias returning. I had two bowel obstructs as well. What is another alternative than me Mesh or a safer solution? First of all, you got to stop having so many operations and figure out what’s wrong. Are you morbidly obese? Is your B M I greater than 30 or 35? Do you use nicotine to have chronic constipation or chronic cough? Do you use marijuana in your coughing? Do you have a healing disorder? Do you have Ehlors Danlos syndrome, which is a collagen disorder? These are all things that need to be looked at and tailored and therefore the next care should be tailored to your needs.
Speaker 2 (00:47:48):
Yes, there are Mesh alternatives. There’s absorbable meshes that are synthetic. There are hybrid meshes that have less total permanent Mesh in them, but usually if we have to figure out why you have so many her hernia problems before embarking on the next repair because you’ll be a disaster. I’ll post a picture of patients that have had this cycle where they have repair after repair after repair, and at the end of the day they end up having no abdominal wall and it’s just a horrible way to live. So if it’s not ACNES, what is the likely cause of chronic tissue pain after surgery? Usually it’s a suture that’s too tight or it’s tearing through the muscle.
Speaker 2 (00:48:35):
Does inguinal or femoral hernia pair and women affect pregnancy and birthing children? No. Someone I know with a belly body hernia was told she couldn’t have more children. False. Wondering if this inguinal is the same? Not true. If it does not, how long is delay? Does it delay in recommending to becoming pregnant after surgery, usually three months. I’m having an MRI on my groin area and hip area. As soon as I get the reports I’m sending you all my medical reports. Great. I had surgery in 2015 with pain and doctoring. Since how many reports do you need? I needing, if I scan you over here to the side, you’ll see my desk. People send me literally boxes of stuff or you can just scan it and email it. That’s much better. Why does weather change like rainy and cloudy days Cause more inflammatory pain? Good question. We don’t know the answer to that, but it has something to do with, I guess the body’s inflammation related to temperature and humidity. I really don’t know. I’m having my sutures removed on June 9th. Fingers are crossed. Okay, good. I hope that’s a reason for your pain.
Speaker 2 (00:49:55):
Next question, what if it was dissolvable suture? What if they were dissolvable sutures though? So dissolvable sutures, first of all, what kind of dissolvable does they dissolve a three month weeks or they dissolve at eight months. It could still tear during the time when it’s, it’s not fully dissolved. So during the process it’s tearing and now you have a tear in your muscle. Same way that let’s say a soccer player has a growing tear and that can be very, very painful. Also though the suture is gone, there may be adhesions in the area that are still pulling and the area is too tight. Doesn’t mean that the area can’t be too tight. And if it’s too tight, it’s trying to tear. And if the process of trying to tear all the time, what can be very painful.
Speaker 2 (00:50:44):
Next question. Oh, are there promising studies on Mesh implant illness? Not really. Not really. Have you ever encountered any revisional surgeries involving Mesh scenarios where a lifetime chronic pain is an unavoidable outcome only in patients that have severe psychological consequences to their pain and those patients must undergo extensive psychotherapy. Cognitive behavioral therapy? I mean, I’m referring people even to microdosing of psychedelics because that’s how extreme their situation is. And those are patients that absolutely are very difficult to deal with because their mechanical surgical functional pain is gone. But their psychological trauma, the P T S D from it, the depression from it, the cyclical centralization of pain is not gone. And that is very difficult to treat.
Speaker 2 (00:52:02):
But that’s usually the situation. How often and why are intestines evolve in your revisional surgeries? Not often. Fortunately for ventrals it’s more of an issue than for inguinal hernias. The ventral being abdominal wall hernias, parastomal hernias. But yeah, the fistula is obviously. So if you have a fistula, which is basically an adhesion, scarring of an open piece of intestine to the abdominal wall, those definitely, we do a lot of bowel surgery for it. In some patients, the hernia Mesh kind of causes intestinal involvement in tissue and so on. But it’s usually a ventral hernia issue and not so much a inguinal hernia issue. If Mesh is and sutures removed, what are the tissues healing? Eventually get better. Why would it continue to hurt a year and a half out from Mesh removal? Okay, so Mesh removal’s a different situation because potentially you’re missing, you have a hernia, now you have a tissue repair under tension because it’s too tight of a repair In those patients, I actually recommend Botox injections into the muscle to see how much of the repair tightness is contributing to the pain.
Speaker 2 (00:53:23):
So first I do local into the area where the pain is to see if there’s a tear. If you inject the tear and the pain goes away, then it’s the tear that’s causing the pain. And that may be too, then you can do Botox injection to see if the Botox relaxes the muscles and gets rid of the pain. If it does, then it’s too tight of a repair. You need to more Botox in the area. That’s my secret sauce that I’m sharing with y’all. Have you ever encountered in your revisional, okay, we already discussed that. What has robotic surgery brought to hernia treatment apart from intolerance to pneumoperitoneum insufflation, are there any contraindications to robotic surgery? Great question. So on that note, we have had two separate surgeons that specifically talked about robotic surgery and robotic hernia surgery. So look at our prior episodes for that.
Speaker 2 (00:54:23):
But I would like to say that robotic surgery has revolutionized hernia surgery because up until robotic surgery you either did surgery open or you did it laparoscopically. And everyone loved laparoscopic surgery because it involves small scars. And so the healing was better, but the pain was not necessarily less, especially for ventral hernias because we were not sewing, we were not operating like open surgery. We were kind of reinventing a way to do things laparoscopically with the robot. We are basically doing open surgery through little scars, not as little as laparoscopic scars, but little scars compared to open scars. So the recovery time is dramatically less, complications are much less, and the outcomes are pretty good. So we are now shifting to doing even less open surgery than we were in the past. And it’s gotten to the point where the outcomes are so much better with robotic surgery in most situations than open surgery.
Speaker 2 (00:55:32):
And oftentimes you cannot do it laparoscopically. And so it has definitely revolutionized hernia repair. Have you ever referred anyone for ketamine infusion therapy for C R P S complex regional pain syndrome or had a patient who was helped by a vein? Yes, absolutely. Ketamine kind of resets it. It’s actually one of the mainstay of C R P S. Absolutely. There’s a clinic at George Washington University in Washington dc Yes, there are multiple ketamine clinics, at least in Los Angeles. There’s multiple, some are shady. So make sure you have a pain doctor that really knows what they’re doing and not just giving out ketamine, but yeah, absolutely. Ketamine is a great one. Let’s see. Can stretching or deep tissue massage, loosen scar tissue and the muscles to improve pain related to two-time repair and continue tearing the tissues. Deep tissue massage? Yes. Stretching a little bit. If you don’t have Mesh involved, if there’s no Mesh involved, that tissue can stretch.
Speaker 2 (00:56:38):
You do very careful deep tissue massage breaks up scar tissue in addition to stretching more than stretching alone. And I do like that if it’s done carefully by a practitioner that knows what they’re doing. So yes. And let’s see. We have one more question, I think, oh, nope, that was our last question, guys. Wow. That was great. That was our hundredth episode. Woo-hoo. I’m super excited. You think we’ll make it to 200? I’m not sure. It took us two almost exactly two years. A little over two years to get to a hundred, if that makes sense. Because 52 weeks in a year we took some time off for certain meetings. And I think that if we, so, okay, let’s just talk about the next several weeks. I have some pretty amazing people will set up for you. I’ve got specialists in niches that you never thought of. I personally want to hear a lot of their answers to my own questions. So I really can’t be happier to have them. I’m super excited.
Speaker 2 (00:58:03):
I’m kind of personally very proud and excited about number 100. I for sure did not think we would do a hundred episodes. It’s crazy in two years and I enjoy it. I don’t know. I feel like you guys enjoy it too. I’m, I’m always amazed that you all would spend your evening talking about hernias. I will be making this into a podcast official one. So I love your support and if anyone has any advice and kind of pointers that my way, let me know. And let’s see. Question about P R P stem cells for pain and tissue repair. Yeah, so if you have a muscle tear, then P R P and stem cell therapy directly into that area will help you heal that tear. But if you have a too tight of a tissue repair, no matter of PRP, we’ll we’ll help that area. You need Botox and that, my friends is a wrap. I really love this. Thank you so much. I hope you guys
Speaker 3 (00:59:21):
Come back next week. Why not? Should do this every week. Oh yes, we do. Do it every week. Thank you everyone. That’s been wonderful. Please, please, please subscribe to my YouTube channel. We hit 5,500 supporters and subscribers. I’d love to have more so that every week that I post these, you get to watch on my YouTube channel. Thank you for following me on Facebook at Dr. Towfigh Twitter. I use mostly for my academic discussions, a little bit higher level than my other platforms. So if you’re interested in that, go to Twitter at Hernia doc. Otherwise, Instagram and Facebook is probably more appropriate for my discussions about educating about hernias. You can find me at Hernia doc on Instagram and thanks for following me. Love you all. See you next week. Bye.
