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Speaker 1 (00:00:01):
Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live, our weekly Q&A every Tuesday. My name is Dr. Towfigh. I am your hernia and laparoscopic surgery specialist. Thanks for joining me. Many of you’re here via Zoom, but also via Facebook Live following me at Dr. Towfigh. As you know, this will be a one hour of fun and questions, and I have a topic to discuss with you, which is very dear to my heart because it’s fascinating to me. Once we’re done, I will make sure that this is posted on YouTube so you can watch this again and share with your friends, but also look at all the other hernia talk episodes. This is topic number 101, and I thought we had Memorial Day weekend and we, there’s so much for us to be thankful for as we remember and honor those who have served the country and gave their life for this country.
Speaker 1 (00:01:05):
And yet at the same time, there’s so much we need to be grateful for ourselves. And so I thought we should talk about positivity and the benefits of positive thinking as it relates to surgical outcome. Now, many of you may think this is all fufu and we’re to just like say, yeah, it’s great to think positive, be positive, and so on. There’s actually science behind it, and I thought that you would find the science super exciting because I found it super exciting too. And I’ll just give you a couple of examples. As you know, my practice involves a lot of chronic pain patients, patients who’ve had surgery and they either have meshoma, neuromas, different types of pain related to their prior hernia surgery, or they’ve been suffering from pain from their hernia. No one’s really diagnosed it, and so they need surgery. Now the question is, is it safe and okay to just go ahead and fix someone?
Speaker 1 (00:02:07):
And if any of you followed me early on back in 2020, during the early phase of the pandemic, when I started Hernia Talk Live, one of our first few guests was Dr. Bruce Ramshaw. Dr. Ramshaw was a leader in not only hernia surgery and laparoscopic surgery, but also in identifying how it’s so unpredictable to deter, determine or kind of predict each individual person’s outcome. So one surgeon can do the same exact operation on two different patients, same hernia size, same hernia, surgical technique, laparoscopic, open, whatever, same Mesh, whatever the situation is, and come up with completely different outcomes. And the reason for that is not just human error, it’s because each human has a different kind of what’s the right term, like cellular makeup as to how they will react to inflammation and surgery. And also in addition, what he found was that each person has a different psychological makeup in addition to physical makeup.
Speaker 1 (00:03:32):
And so their ability to deal with certain pains and problems is also different. And what he started to do, which was very unique and kind of in some ways also pissed off patients, was in addition to saying, yes, you have a meshoma, I’m going to take out your Mesh and take out the plug and do redo your surgery. And by the way, I’m not going to do that yet. I’m going to send you for cognitive behavioral therapy or some type of treatment or evaluation of your psychological status before I commit you to surgery. Unfortunately, a lot of patients mistook his insistence that they undergo psychological evaluation prior to surgery as him somehow discounting that they needed surgery. That was never true. He actually recommended surgery. And what he noticed was when he started doing this, this, there was a fraction of patients, I think it was like 20%, so it wasn’t a very big number, but it was a significant number in that about one in five patients would undergo some type of psychotherapy, cognitive behavioral therapy, if they had anxiety that was addressed, if they had P T S D from their surgical event that was addressed, their ability to handle pain and understand what pain, what sensations should be suppressed and what others are okay to feel and so on.
Speaker 1 (00:05:05):
And he found that he’d reached back to these people and they’re fine. They’re like, no, I’m good. I don’t need the surgery anymore. I don’t have this debilitating, debilitating pain anymore, et cetera. And it was fascinating because as surgeons we’re not taught that first of all, if you have a broken bone, we fix the bone. We don’t send you to psychotherapy. If you got hit by a car and we deal with your trauma from that accident, we don’t send you the psychotherapy. So as a surgeon, we are used to treating the very obvious mechanical problem that’s wrong with you. The problem is a lot of operations that are elective hernias being one of them, especially revisional surgery, orthopedic and spine surgery being another one, patients often enter the surgical realm with the wrong emotional and psychological state, and that can actually affect their ability to recover perfectly.
Speaker 1 (00:06:16):
Let me give you an example, and I have multiple patients like this. It’s a struggle and I, I’m a very patient person, so I work with them, but it’s a struggle. So I have patients that are highly anxious, they’re just anxious people, they’re anxious about everything. Others hate doctors, hate hospitals, hate surgery. They just can’t handle it. Very normal to be like that. There are patients that are just pessimists in general. They’re always half glass, half full. And so they’re focused on the negative aspects of their operation. I had a lady who had cancer, she had a major, major cancer operation, not by me, and she had a very small hernia from it that was repaired. It wasn’t to her satisfaction. She came to me, I rerepaired it, and because she was very much interested in the best cosmetic outcome, et cetera, I took even more care than I usually do and gave her the most cosmetically amazing repair.
Speaker 1 (00:07:37):
I kind of gave her a placation, like a tummy tuck in addition to her hernia repair. It was beautiful. And her scar was gorgeous. And I’m telling you, her focus was on maybe one millimeter, and I’m not exaggerating, maybe one millimeter up and down in one segment, maybe less than a half a centimeter segment of her wound where she felt one side was not perfectly aligned with the other. And I’m not joking, it was brought about a millimeter. I would see it because I’m got this little obsessive compulsiveness going on. So I would see it, but honestly, if anyone else looked at, they’d be like, I don’t understand. I can’t see it.
Speaker 1 (00:08:27):
For months, I would have her massage it and put creams on it and do anything I could to help remodel that scar. So she would have a perfect scar. She had a perfect scar. And let me tell you, the scar she came in with from the cancer was not a perfect scar and she had a life-threatening cancer. And yet her focus after cancer surgery and a big ugly scar for the first surgery was on why my one single one millimeter kind of irregularity in her wound. And she wasn’t young and she wasn’t someone that was in any way going to be wearing a midriff bearing anything. So I did understand it, but my point is her attitude was always very negative. And even when she would come to the office, it was never like, hi, how are you? It’s been a great day. It was always very grumpy. So in my situation, eventually over time she kind of got over it. But it’s a problem where attitude makes a difference. Now it’s not just attitude. Oh yeah, if you’re negative, maybe you’re going to think everything is bad.
Speaker 1 (00:09:48):
It’s actually more than that. If you look at cancer patients, they’ve actually looked at the attitude of a patient going in for cancer, chemotherapy or radiation therapy, surgery, whatever the situation is. Study after study has shown that the optimist, the person that goes in saying, I’m going to beat this. I’m going to be strong, let’s do it, and have a support group and just overall positive actually have not only better cancer outcome, but the longer lifespan by years like this is statistically significant. Literally if you have cancer and you enter it with a positive attitude, your chances of being that cancer is higher than if you don’t.
Speaker 1 (00:10:39):
I mean, it’s mind boggling, but this mind body connection is real. My favorite study that very scientifically points out the benefit of positive thinking and optimism is the following. In 1930, and I think it was Milwaukee in 1930, there is this nunnery. And at that time, if you wanted to enter the head person of that nunnery, this Catholic nun, the Catholic nuns were all asked to write an autobiography, which included their age and why and where they came from, but also included a brief of what brought them to seek God and become, devote themselves to God and become a Catholic nun. No more than two or 300 words, something short. And 60 years later, they took that data and they looked up these people to see if they were still alive or not. The people were between ages 18 and 30 when they originally entered the Catholic to be a Catholic nun.
Speaker 1 (00:11:59):
And then they went off to do their own thing and they took each of these autobiographies, I think there was 180 of them. And they ranked the autobiography based on whether it was positive or negative. And for example, a positive one would be, I’ve had a lovely life. I’m so blessed to be in this world. I come from a family of, I dunno, four children and loving family. And I just feel that I’m so blessed that I would like to devote my life to God and to help others see what a beautiful world it is. Okay, that would be a positive emotion. A negative score would be someone who wrote an autobiography and said, there’s so much badness in this world. We need to help those in need. I come from a broken family and I’m hoping to seek solace by devoting my life to God and doing good in the world. And I hope that by doing so, I help not only the people, but also helps in my own growth as well that will be considered a negative emotion.
Speaker 1 (00:13:18):
And they looked and they found after 60 years, almost everyone was dead because there there was somewhere like 80 to a hundred years old and they found that there was a dramatic difference in death rate based on people with a positive emotion versus a negative emotion. In fact, you were seven years, 6.9 years to be exact, seven years more likely to be alive for seven years longer. If you’re way up on the high scale of positivity, then on the low scale of negativity, that’s just amazing. I mean, that’s my favorite study. I think that’s so cool. They were able to archive, find these archives of these autobiographies, read them, rank them, and then go and find these nuns and see what age they died. And if you can look up the published paper, just look up Catholic, none positive thinking or optimism, something like that.
Speaker 1 (00:14:24):
And the paper will come up and there’s like this graph which shows for each score of positive thinking, being an optimism versus negative emotions, that it kind of dips down faster. The rate of death is faster. Your mortality rate is higher if you basically have a negative emotion than if you have a positive emotion, just fasting. I just find all this very, very fascinating. So I bring this up because I also have several patients that underwent really complicated operations, revisions, whatever, and I’m struggling to get them better, not because there’s anything I can do surgically, the surgery’s fine, MRIs look fine. All those problems are fine. The problem is that their perception of what is wrong with them is very off. So for example, you’re going to have two patients have the same exact Mesh removal and one patient is constantly focusing on, but I have this tugging, I have a tugging sens, I feel swollen inside, but you just had surgery. You should expect some amount of difference between normal and surgery.
Speaker 1 (00:15:54):
There will be swelling, there will be a different sensations. You’re going to feel a zap one day you’re going to feel a tug another day. And if you ask him the pain’s like, oh, one out of 10, I literally had a patient come to me, different patient complaining about pain after surgery and I asked him to rate the pain. He said it was one out of 10. And I’m like, you understand that one out of 10 is the lowest rate you can get? He’s like, yeah, my whole life is destroyed. And I kept trying. I thought maybe I was misunderstanding. He thought from a scale of one to 10, 10 is really good. So he’s a one as opposed to 10 being really bad, 10 out of 10 pain is really bad. One out of 10 pain is basically no pain. I probably have one out of 10 pain now because I’m sitting upright and if I focus, I can probably say, maybe I got some neck pain or something, but I don’t really have pain right now. I’m just talking to you guys on a podcast. I wouldn’t go to a doctor saying I have pain. He would just keep coming back. He goes multiple times, I have one, I have pain that I can’t work anymore. And he kept saying one out of 10. Again, I kept trying to explain One is really low. It’s like saying, I have no pain. And he eventually I think figured out that he needs to stop focusing on this one hour tame and move 10 and move on with his life.
Speaker 1 (00:17:35):
Meanwhile, I have patients that have had a complete walk and they have seven out of 10 pain. And you know what? I’m good because I understand I had a huge surgery. I’m very grateful all by pain for which I came to you is, and this is surgical pain. It’ll go away. It’ll take time. If any of you have had surgery, you understand that for most people, pain will go away early. But there’ll be times when you’ll go and be like, Ooh, I just felt a little twinge or I had the surgery. It goes away. Nothing to worry about. But scar tissue or a year goes by and you’re still not a hundred percent, you may be 95%, but you’re not a hundred percent. You’re 98%, but you’re not a hundred percent. And so that should be something should be grateful for and not focused on that one or two or 5% as a negative.
Speaker 1 (00:18:30):
I hope I’m making sense here. I had a patient that, and there’s very few of them unfortunately, but I had one patient where I just could not figure out what was wrong. He had this weird testicular pain. I did a bunch of tests, injections, nothing helps. It wasn’t a hernia. He had had a hernia pair. It was fine. It was different attempt to urology. I have a great urologist you’ve seen on a Hernia, Talk, Live. There’s multiple urologists that I work with and I love. And that urologist saw him and also couldn’t figure it out, ultrasounds, et cetera. And then we stopped hearing from him. Like six months went by.
Speaker 1 (00:19:23):
The urologist called me and said, whatever happened to that patient? I’m like, I don’t know. I stopped calling. Let’s reach out. So he reached out to the patient and he’s like, I’m good. What? Yeah, I’m good. What happened to your pain? I don’t feel it anymore. Did you have surgery? No. Did you have an injection? What did you do? I saw a pain psychiatrist and I underwent cognitive behavioral therapy. What? You’re kidding me. Nope. I’ve learned to shut off my perception of that pain. I don’t feel it anymore. I’m good. And he was so happy. He was absolutely happy. So there’s something called cognitive behavioral therapy, which in layman’s term basically resets the way that you perceive pain. So you can focus on the minutia of your pain and just perseverate on it, or you can choose to have different types of therapies, mindfulness, meditation, treatment of your anxiety disorder, et cetera, so that you don’t, are you not obsessed by the pain?
Speaker 1 (00:20:49):
The pain does not rule you anymore. And he was totally fine. I had another patient who actually had cognitive behavioral therapy in the past before for something different. And it was very, very successful for him. And he came with me and he had this kind of mystery pain and he had had hernia surgery. So he was convinced that he either had a recurrence or his meshoma or Mesh reaction. He had none of that. And I told him, don’t let anyone convince you that you do because you’ll go down this rabbit hole of Mesh removal, triple neurectomy, whatever, you don’t need that. And I sent him to urology to make sure that the findings we saw for testicular stuff was normal and not result of that. And we both came to the same conclusion, which is he really doesn’t have the pain until he starts thinking about it.
Speaker 1 (00:21:47):
So for example, when he’s traveling and he’s working and he’s actually enjoying what he is doing, no pain, the minute he settles down and has nothing else to think about, and he focuses on the area, he has pain. If he touches the area, there’s no pain. If I touch the area, there’s no pain. But he feels that there’s pain in the area. And only when he thinks about it that he has pain, which is classic and really important. That’s like I teased that out of him in terms of him for his history to figure that out. And so I said, have you ever considered cognitive behavioral therapies? Of course, I actually had it once before and it worked another problem. I was like, perfect. We ruled out everything. It’s not your hernia. Take that off your list. Don’t worry that you have mentioned you. It’s not your problem. The urologist who’s a world expert saw you, he doesn’t think that you need any surgery. Go ahead with cognitive behavioral therapy. Let me know how you do. If it doesn’t work, let me know. Cause I don’t want to lose the patient to the follow up. But short of that, let’s do that. And basically that’s the step. I’ll let you know how he does when he, he’s done with that.
Speaker 1 (00:23:13):
What absolutely bothers me a lot is when few doctors appreciate this mind body connection or they poo poo it. And I’ll give you an example. There’s this question here that was sent to me that kind of somewhat related, which is I’m just going to go in there and operate. There’s so many patients I see where they go see their surgeon and the surgeon’s like, well, they’re just going to go in there and take a look to do what you need to plan. You can’t just show up and to surgery and take a look. And there are consequences based on what you plan to do. So here’s one I’m going to share with you a question that was asked, and it’s this. It says, if you had a complex hernia and groin surgery and you have postoperative pain that is not particularly burning or radiating burning, implying nerve radiating, implying hernia, recurrence or nerve, if after a very comprehensive and careful evaluation of the surgery with physical examination MRI with Valsalva diagnostic pain injections, you still cannot pinpoint the cause of the pain.
Speaker 1 (00:24:40):
Is it then reasonable to do selective or triple neurectomy despite the collateral damage in neurectomy can cause? No, it’s not reasonable. Doing something just to do something is complete, in my mind is completely insane. So triple neurectomy or selective neurectomy is intended to treat primary nerve pain. If you’ve had diagnostic pain injections and didn’t get rid of your pain, no amount of neurectomy is going to get rid of the nerve pain. A neurectomy is basically a pain injection that’s permanent. So if the pain injection didn’t work, a neurectomy will not work. Also, there are risks with neurectomy such as denervation and neuromas, which are even worse potentially than the current symptoms you’re having. And if you truly have no other reason true, just going and go in there and it’ll just cut the nerves and see what happens. I’m completely against and I’m not against it because it’s risky surgery.
Speaker 1 (00:25:52):
It’s not that it’s risk, it’s it’s improper surgery. It’s like orchiectomy is another good example. Orchiectomy implies cutting off the testicle. There are people that have testicular pain, can’t figure out what it is. So we’re just going to chop off the testicle. You know what, that doesn’t work because the pain is not from the testicle. Assuming all the workup has been done and they can’t figure out what it’s causing, it’s a different cause of the pain. And not having a testicle doesn’t imply you’re not going to have testicular pain. I know it doesn’t sound logical, but there’s a whole entity of why people get chronic pelvic pain or test chronic testicular pain and the testicle itself is not the problem. And maybe the nerves coming to it, or it could be something deeper. It could be you’ve had P T S D for some reason or you need some type of psychotherapy to address it. This patient that I told you who had the cognitive behavioral therapy that cured his pain, he actually had chronic testicular pain that we couldn’t figure out. So my point is this run away from a surgeon that’s like, we’re just going to go in there and take a look. If they don’t have a good algorithm, like okay, we’re going to take a look. If it’s a hernia, we’re going to do this. If it’s a nerve, we’re going to do that. You need a plan of care, you need a roadmap, an algorithm of some sort.
Speaker 1 (00:27:20):
Let’s see, you’ve got some chats coming in here. Let’s see if fearing nerve damage. I’m fearing nerve damage. I could see the benefit, especially having been there. I do mindfulness meditation because of this pain. I’ve started inner journey and yes, mind body is amazing. Yeah, it’s pretty amazing. There’s this whole thing, well, lemme read some more and then I’ll tell you this month marks two years since my inguinal hernia repair pay level is five. That’s doing nothing. That’s while doing nothing. It’s aggravated and it’s ER and Dilaudid when I have aggravation, the descendant abdomen is a physical symptom of what is causing, that’s true. Bloating is a symptom of pelvic pain or it can be B R t brain reprocessing therapy. Yeah, agree with that. And c P s both physical and mental, but the mental is just as important as a physical. Yes, and I don’t want anyone to think that the physical supersedes the mental because the more we learn about the mental, the more we understand how critical it is and works hand in hand with the physical. And also this idea where, oh, it’s just placebo if effect, just tell a patient they’ll do well. They’ll just do well. Placebo effect, it’s actually not, you can’t claim, for example, that cancer pureness is a placebo effect. That’s must be some mind body connection.
Speaker 1 (00:29:06):
There’s no way that a placebo effect will cure cancer. I’m just saying with regards to this first question. I assume a nerve block will alleviate pain temporarily, whether it is neuropathic or nociceptive. Not true. In that case, if a nerve block relieves nociceptive pain temporarily, and there is no obvious surgical procedure, is it not reasonable to do neurectomy to treat nociceptive pain as suggested by our one of your guests who ablation is reasonable as it avoids reentering the surgical plane and retraumatizes tissues? No, not true. Nerve blocks do not, do not get rid of other pains in that area. There’s very specific nerves that we block. We’re not numbing your entire abdominal wall. We’re doing the ilio inguinal nerve block, we’re doing an ilio hypogastric nerve block, et cetera. There are other nerves that are microscopic and related to the muscles, for example, that are unrelated to the sensory nerves that are brought in by those nerve blocks.
Speaker 1 (00:30:18):
So no, just because you’re doing in nerve block doesn’t mean you’re going to block all pain. And the triple neurectomy only deals with nerves that you can see that are named. It doesn’t mean that you’re cutting all nerves to your back. Let’s say. I hope that makes more sense. My last procedure was ilio hypogastric nerve block. It made things way worse. Okay, that’s a very good point. Sometimes a nerve block makes your pain worse. The way I explain that, because it sounds counterintuitive again, why would a nerve block which numbs you up make your pain worse? Think of it as music or sound. If you have nerve pain or nerve sound right, that is going to get it to the point where you’re going to have pain from that nerve. But you may also have pain in other areas unrelated to the nerve block and the nerve.
Speaker 1 (00:31:27):
Lemme explain it better. You may have pain and then you try and get a nerve block. The nerve block will shut down any pain symptoms that you may have separate from the pain, the underlying pain. So let’s say your pain is at a level five, right? And you have background normal sensation from the other nerves. If you block those nerves, then your underlying pain will sound actually louder. So if you block the background noise, your baseline pain will sound louder and nerve block blocks the background nose. So that’s kind of the way that I explain it. So some people will get heightened pain from a nerve block because that nerve is not the issue. So if you get worse pain with a nerve block, then for sure that nerve is not the issue and you should not get a nerve block. Here’s another question with regards to this question. I assume a nerve block will alleviate pain temporarily. Oh, I answered that question. All right, let’s go on to more questions. We’ve got some really good questions.
Speaker 1 (00:32:58):
All right, next question. Let’s share screen. All right, in a previous Hernia Talk Live, you mentioned your MRI…Ooh, this is a very intense question. In a previous Hernia Talk Live, you mentioned your MRI protocol to include single sliced sagittal plane dynamic Valsalva acquisitions, typically about five individual acquisitions. What is involve in this and how does it differ from other protocols at merely to a Valsalva maneuver? If they do a Valsalva maneuver in typical MRI, they usually do exactly what I said. So what they’re supposed to do is they’re supposed to mark the area of your pain, they get a normal MRI, they’re supposed to mark the area of your pain, and then take a bunch of slices to the left and a slices to the right with Valsalva to get the most benefit. Some people don’t do that, they just do a valsalva without having it specifically focused on the area of your groin pain. That was a very specific question.
Speaker 1 (00:34:11):
Yeah. So this one, what’s the difference between a T2 weighted fast suppressed, fast se spin echo MRI sequence and the T2 haste MRI sequence acquisition that you described? They’re both similar. They’re both very fast single pictures of the MRI single sequences. But I think it has to do with whether it’s what kind of MRI you have. So each MRI has a different brand or trademark type of name. Okay. These are crushes I like. Can hypnosis and homeopathy have a rule in controlling pain after surgery? Yes. And are there any other alternative approaches proven to be effective? Yes. Yes, yes, yes, yes. Okay. So hypnosis in patients that are good candidates is actually a great idea. And to the point where some people undergo surgery under hypnosis, it’s insane to be cut by someone while you’re under hypnosis, but it actually works and homeopathy is very interesting. So I actually believe in homeopathy in the sense that there are homeopathic regimens like arnica that have been shown in scientific studies to help, for example, in the case of arnica, help reduce swelling, bruising, and therefore pain. So I include arnica in kind of what I like to do for my patients. That said, a lot of people think homeopathy is quack medicine.
Speaker 1 (00:35:58):
I go by the evidence and I’ve shown it in my own patients. We’ve published it that it works. A lot of plastic surgeons believe in it as well and use it. But homeopathy is kind of this idea that if you somehow dilute medication it works better, I don’t understand that part of it. But there are herbal and homeopathic ways of treating pain, which I highly recommend. We publish a paper on it where we use arnica, bromelain, turmeric, ginger alpha-lipoic acid, super B complex, and in that regimen basically help reduce your need for narcotics after surgery. And then the question is, are there any other alternative approaches proven to be effective? So I would like to discuss a very controversial and extreme method. So there are patients that are, it’s very, very, very, very difficult to get their pain under control. And by pain, I mean chronic pain, not acute pain, not the pain in the first weeks of surgery, but they’re 2, 3, 5, 10 years down line, their life is, life is turned upside down.
Speaker 1 (00:37:20):
They’re suicidal, their wife left them, their children hate them. They’re alone, they’re depressed. They’re constantly considering killing themselves because life has no meaning. They’re always in pain and they’ve lost their job. They’re bankrupt. It’s just a horrible cycle. So in these patients, in my case that they may be post-operative and they’re very, very complicated patients. In other situations, they may have had a trauma, they may have been victims of violence or sexual abuse. They may have P T S D from any of these traumas. And there’s new evidence that microdosing psychedelics, yes, I said it. Microdosing psychedelics, L S D has been shown to somehow reset the brain and get patients to a point where they can live a normal life, no longer be suicidal, find a job, become functional members of the society. It’s crazy because it’s not considered very western medicine, but there are multiple prospective randomized clinical trials. And if you’re interested, you can still enroll in them. You just go to clinical trials.gov to enroll in these trials because it’s technically illegal in the United States to take L S D in any form or M D M A or there’s all these other ecstasy basically and other forms of illicit drugs. But under the right circumstances, a very small fraction of patients have been shown to benefit.
Speaker 1 (00:39:13):
And I’ve met people that do this for a living. It’s somewhat underground and hopefully it will be legal one one day because there’s a lot of evidence growing. Very strong scientific peer-reviewed, prospective randomized clinical trials where this works. And I have a handful of patients that I share with many of my colleagues, pain management doctors mostly that have had scores of operations and they’re not getting better. And some of them kind of self-medicate often with just marijuana in California. That’s legal and seems to help them a lot, but it does reduce their anxiety a little bit. And it does help with some pain control, but still not perfect. And I’m hoping that their ability to reach out to some of these opportunities to get some type of, it’s not really homeopathic, it’s herbal in some ways, but these drugs microdosing under a supervised situation and get them. So that’s kind of like maybe an answer to this question, which is are there any other alternative approaches proven to be effective?
Speaker 1 (00:40:37):
A lot of people are depressed and treating their depression will help. That could include something as severe as electrical convulsive therapy when medications don’t help or this kind of microdosing of psychedelics. There’s ketamine that’s been something that’s been become popular, which is ketamine IV therapies under the direction of a pain management specialist who understands it can help reset the brain pathways so that the pain that you’re sensing is no longer taking over your life. Let’s go there. Some questions. Hello. I recently had inguinal Mesh removal, and now I have this sense of pressure and pain that feels like gas pain in the area. This pain is only one sitting, whether it’s be in a car or a chair, it’s an unbearable feeling, one sitting, there’s no visible bulge, and the pain subsides upon standing. I’m at loss. So sometimes this can be from a stiff Mesh. The Mesh can be stiff because it’s a heavyweight Mesh that was used. It can be stiff because it was put into tightly, or it can be stiff because you’re thin and you can feel the foreign body, or it could be stiff because your body reacted to this Mesh in a way that made it stiffer than it is.
Speaker 1 (00:42:10):
Good history and exam and review of your imaging can help figure out what the problem is. Sometimes you just have to remove the Mesh in those situations. Dear Dr. Towfigh, you have described me to a tee. I use a small amount of cap cannabis. I hate the taste in the stone feeling, but pain, I’m pain free for 12 hours, 10 to 12 hours. Fortunately in California, cannabis is very widely available as it is in many other states. Oral cannabis as opposed to smoking tends to be a little bit stronger. There’s also the oils and oral oils and smoking it, but they come in pill form too if you don’t like the taste of it. There’s wide variety of ways of getting the cannabis. But cannabis, the CBD B part itself is just a anti-inflammatory, so it’s not really does much, but the THC part, which gives you the high different manufacturers make different ratios of THC to C B D and depending on how much your anxiety level is and how you may need more THC to help you sleep, for example. And so there, there’s all these different alter ways to figure it out. Can oral cannabinol, canna oil, can oral can be the oil or can mean work in the same way as L S D due to a reset. So we don’t think cannabis resets. I think cannabis is mostly a anxiolytic and it helps with inflammatory pain.
Speaker 1 (00:43:51):
There’s more research being done now that it’s legal to help us understand how cannabis works. I’m not sure it resets, but yes, ketamine does work in the same way as L S D to do a reset. And so the easiest way to get access is to go to pain doctor and get ketamine IV infusions and see if that therapy works for you. However, there are some people who do offer microdosing lsd, some of them in a controlled clinical trial and others not. What are your thoughts on LDN? Okay, what is LDN? You guys need to enlighten me. You’re like too fancy.
Speaker 1 (00:44:40):
So what is LDN? Everyone tell me. Let’s see. I need to Google that. LDN meaning, oh, the drug low-dose naltrexone. Okay, so low-dose, thank you. Yeah, low-dose naltrexone. Again, I’m not a specialist in this, but from what I understand, because I do have patients on low-dose naltrexone, that seems to help patients that are in chronic pain. It’s in some ways an alternative to chronic opioid use. So if opioids work, then low dose naltrexone should also work a different pathway. Actually almost a reverse pathway, but it works. So no, it’s different. It is a pain medication alternative. It does not give you a reset of the brain pathways. It just treats it. It doesn’t go to, it doesn’t reset the brain waves like ketamine and LSD does, for example.
Speaker 1 (00:45:57):
Yeah, mushrooms. Mushrooms are another one. I can’t believe I’m talking about all this, but I think we’ll be ahead of the wave. I’m just going to say I’m, we’re ahead of the wave and honestly, I’m open to any treatment that will help patients to kind of judge or make it so that you shouldn’t be talking about certain things I’m totally against. If it helps you, we should help you. Yes, I’ll be doing this in clinical environment using mushrooms. I also use cannabis dabs are strong, but fast acting. I also have tried ketamine with no effect. Yeah, everyone’s a little bit different.
Speaker 1 (00:46:38):
Sounds like cannabis is illegal in New Zealand. Medical cannabis is $300 a month. That’s actually not bad. My inguinal hernia Mesh gives a constant base level two pain, like a donkey bite, donkey bite on the knee. I don’t know what it’s like to be, oh, you must be from New Zealand. Donkey bite. We didn’t talk about donkeys in the US. Okay. It’s a New Zealand thing, like a donkey bite on the knee. The nerve damage is periodic nerve blocks have been unsuccessful, so you probably don’t have nerve damage if nerve blocks are not successful. It’s not a neuropathic problem, but definitely it’s something that can be hopefully treated.
Speaker 1 (00:47:22):
Let’s see. I wanted to give you guys some insight. Oh, you know what? We have more questions. Let’s keep on with the questions. Is it true that subconscious behavior patterns are so powerful that by using hypnosis to access them, you can even undergo minor surgery without any kind of essay? Yes, there’s, there’s a lot of reports. I mean, even when I was in medical school, which was over 20 years ago, maybe 25 years ago, we learned about surgery under hypnosis and it was offered by our hospital in San Diego. So yeah, absolutely mind body connection.
Speaker 1 (00:48:06):
Does stress before surgery have any effect on surgery outcome? And can stress after surgery cause or contribute to chronic pain? I don’t know the literature on that, but I think the answer is yes. If yes, is chronic inflammation caused by stress the cause? Okay, good question. So I don’t believe it’s an inflammatory process caused by stress. I think the stress has to do with hormonal and or other chemical imbalances in the brain that affect your surgery outcome. So your surgery itself is fine and you don’t necessarily have more inflammation because you are under stress under prior to going surgery. But your ability to process the different actions and activities as part of your recovery process is different than someone that has ease of mind. In fact, let me tell you this great story. I had a patient, he flew in from another country. His elderly patients flew in from far away and he came the day before his surgery simply to tell me that he hasn’t been sleeping well and is very stressed and feels he shouldn’t have surgery yet because he is not in the right mental state.
Speaker 1 (00:49:31):
Now you could say, really, you couldn’t just call me and say that, and really you waited years to have the surgery and now you haven’t had good sleep and you’re just going to, I mean, I’ll give you good sleep during surgery, but that’s the wrong attitude. He chose his own psychological state to supersede any calendar or surgery planning or whatever, and took priority up for his psychological and mental state and felt that he needs to be in a better position mentally before he undergoes a revisional hernia operation. He already had surgery with me once for a different, different procedure and it went very well. He wanted make sure this one also goes very well because the first one was revisional and he didn’t want the same outcome that he had from the first surgery before me. That was a mess up. So good for him, good for him and his parents were very supportive.
Speaker 1 (00:50:35):
And I think that needs to happen more often where people don’t rush, rush, rush into surgery. They don’t go into surgery thinking, oh, we’ll just take a look. They don’t find a surgeon to do an operation that they want. They find a surgeon that does an operation that they need or maybe doesn’t do an operation because they don’t feel you need it yet. And that’s kind of like something I want you guys to kind of leave with question. If a nerve block I had made it worse and yet I do have edema, allodynia, allodynia is pain, allodynia is pain in areas where you shouldn’t have pain and burning, searing, radiating cold sensation of my spine is indicative of nerve damage. No, not necessarily. Not necessarily. Are diagnostic nerve blocks with lidocaine dangerous? Nope. Almost never. Unless you’re allergic to the lidocaine. Can it make the pain worse permanently? Nope. Or can damage the nerve? No.
Speaker 1 (00:51:46):
In predicting C P I H P pain catastrophizing hypervigilance, psychosocial vulnerabilities such as depression, anxiety, are reported to predisposed to post heart pain. That’s correct. So this is talking about chronic postal hernia pain, which they’re calling C P I H P. We usually call it C P I H P or just chronic pain CPIP or CP. The action of pain, catastrophizing, hypervigilance and depression or anxiety also referred to as psychosocial vulnerability are reported to predisposed to postoperative pain. Completely correct. Let’s go over this a little bit. Pain catastrophizing. That means like my patient what not 10 pain, my life is over. He said, now maybe he does feel his life is over, but with one out of 10 pain, your life should not be over. So that’s the perception and the catastrophizing that needs to be addressed. Hyper vigilance, hypervigilance implies being super like every little thing that you feel needs to be addressed and focused on. So I have a patient who fortunately agrees that he needs to treat his anxiety and as soon as he has all of his pain symptoms have reduced. But initially was off the charts. Every little twinge burn, push, pull bubble feeling was like, that means that my hurt repair has failed and I’m going to be stuck with chronic pain forever. Not true is actually better, but that hyper vigilance was very counterproductive. And of course, depression and anxiety as a baseline kind of makes you more likely to undergo these types of reactions.
Speaker 1 (00:53:46):
However, is it a chicken versus egg? Which first, which ca came first scenario true? Can these psychological emotional factors merely be the result of severe preoperative pain? And can it be the severity of the preoperative pain and therefore the nature of the injury that predisposes to postoperative pain rather than negativity and psychological frailty? Very good point. So there’s a lot of surgeons who say you operate on pain, you get pain. I don’t operate on people with pain and I disagree. I’m like, but they have pain because they have a hernia or because they have an obstruction or they have, I don’t know, meshoma, nope, won’t operate on them. You operate on pain, you get pain. So I don’t necessarily agree with that, but almost every study that looks at outcomes after inguinal hernia or ventral hernia repairs has been able to correlate preoperative pain with postoperative pain. So the higher your preoperative pain, so the higher the pain going into surgery, the higher your reported pain after surgery. Now, can that be because you’re just someone that is hypervigilant about pain or you’re depressed or anxious? Or is it that the preoperative pain itself has kind of trained your body to always feel pain?
Speaker 1 (00:55:22):
I don’t know because I operate on a lot of people with pain and I cure them and I pick my patients carefully so I don’t operate on them just because they want surgery. It’s always indicated and a lot of people can operate on for their pain and it’s from hip pain, but they get a hernia repair because they’re also diagnosed with a hernia and they can’t figure out why their hip pain is gone. So that’s just a misdiagnosis. So this is where we’re going back to what we talked about earlier on in the show. Dr. Bruce Ramshaw said, you know what? I don’t know if your preoperative pain will commit you to postoperative pain because you are negative or because you are depressed and anxious. I don’t know. So let’s not put it up to fate. Let’s figure it out. You have preoperative pain, you’re going to go see a psychologist.
Speaker 1 (00:56:26):
I want them to evaluate you. If you’re depressed, you’ll be treated. If you are anxious, you’ll be treated If you need psychotherapy, let’s do it. If you need cognitive behavioral therapy, let’s try that. And he committed people to preoperative treatment of their social psychological ailment, whether it’s negativity, psychological, frailty, whatever it is. And then he operated on them. He never said no to surgery, but then he operated on them. And like I said, about 20% didn’t even need surgery anymore. So they’re like, we’re good. No more surgery for me. I’m good. And he found the other 80% that he did operate on had a much better outcome than before he was doing this. This pre-operative optimization is what he called it, or pre-hab. It was called pre-hab preoperative rehabilitation.
Speaker 1 (00:57:31):
And that was something that was revolutionary in our world. And now even more surgeons are working on prehab and that prehab can be psychological. So let’s make sure we address all your psychological needs or it can be you’re a smoker, let’s get rid of the smoking habit, or let’s deal with your obesity. As we know, those are risk factors for hernia, poor hernia outcomes. So that was kind of a cool thing. That’s where the next question, when chronic pain or other problems arise after surgery, especially after Mesh implant and your recommended alternative therapies such as cognitive behavioral therapy, how can you tell that you are not gas lit gaslit by your surgeon into believing palliative remedies would have any effect. That’s where trust comes into play. It’s very, very true. Like I said, when Dr. Ramshaw was doing these therapies, a handful of patients thought, this is great. I definitely need this. I wish I did it earlier, and this doctor really cares. He cares that I have a good outcome. He doesn’t want to just operate on me.
Speaker 1 (00:58:50):
Another handful of patients were like, seriously, you think it’s all my brain? I’m just making this up. I’m just kind of faking it. Why aren’t you believing me? Give me the surgery that I need. I have a meshoma take out my Mesh. And so it took a while before and after he got the data to help support what he was doing. And there’s other surgeons that are now doing it. No one was doing it to the extreme that Dr. Ramshaw was doing it, but at some point, someone has to be a pioneer in these things. So yes, if you do not have trust in your doctor and you think what they’re actually saying is go do this C B T, which is called cognitive behavioral therapy, and don’t come back to me, that’s where you’re being gaslit, that’s saying, it’s not my problem. Might hurt your repairs, fine.
Speaker 1 (00:59:46):
It’s all on your head. Go to your psychotherapist and don’t ever come back to me. That is the wrong one. What if they’re saying, listen, what you’re feeling is way out of proportion to what I’m seeing. I’m not discounting your pain. You may very well need surgery, but you should not be having your life topple over with one out of 10 pain. I’m not going to operate on someone with one out of 10 pain because they feel their life is upside down. So let’s get you into therapy and figure out how else we can at least reduce your pain perception and then we’ll reevaluate you. That is a right answer, and that’s the way that I kind of hope that that message gets around. And on that note, we are done. Thanks everyone. It’s been great. This was a great topic, and I’d like to say, by the way, that I’m definitely not a specialist in any of this.
Speaker 1 (01:00:43):
I’m just telling you stuff based on my own experience and what I learned from my pain doctors. But I do have specialists exactly in this coming up in the weeks coming forward. So I’m really excited to have them join us. Until then, see you guys later. Please do go to my YouTube channel and subscribe so that every time we’re done with one of these Hernia, Talk, Live Q&As, you get a notification to watch it. And thanks also for following me on Twitter at Hernia Doc, on Instagram, at Hernia doc, and on Facebook, Dr. Towfigh. Thanks everyone. I’ll, I’ll see you next week.
