Episode 103: Intraoperative Complications | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

Hello everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live. This is our weekly Q&A session with me your host, Dr. Shirin Towfigh. I’m your hernia and laparoscopic surgery specialist. Thank you for joining me on Zoom and Facebook Live at Dr. Towfigh. I’m here with you every week. Also, I appreciate those of you that follow me on Twitter and Instagram at Hernia doc. As you know, I have compiled all of our hernia talk q and as for the past almost actually I think a little over two years on my YouTube channel. So thanks for everyone who subscribed to that and of course this episode will also be broadcast tonight on my YouTube channel. So thanks everyone for joining me today. I thought we should talk about intraoperative complications. That means what happens when your surgeon tells you you’re going to have surgery X and they go in there and you end up having a different operation.

Speaker 1 (00:01:14):

First of all, this happened to me this week. That’s why it was, or last week, it was impetus for what I want to tell you, which is I went in thinking that I was going to do a certain type of repair called a Shouldice, which is a tissue based inguinal hernia repair. It is a non Mesh repair, very good one, probably the best option for inguinal hernia repairs and it treats all types of inguinal hernias, either direct or indirect or both, and that was what we considered the patient. She for sure did not want a Mesh based repair in the Shouldice is a very good option. There are other options too, but we discussed the Shouldice specifically. The goal is to get to address her hernias once we’re in there, even though she had imaging before, which didn’t show it, she did have what was called a femoral hernia.

Speaker 1 (00:02:11):

Now those of you that have followed me or watch me on my Instagram, you can know that I’ve talked about femoral hernias very often. Femoral hernias are a specific type of groin hernia that we don’t see typically in men. It’s very uncommon, it’s also uncommon in women, but when it does occur, it tends to occur in women and it’s the one hernia that we know of that must be repaired when identified. In other words, watchful waiting, which we’ve discussed before is about a month and a half ago with Dr. Fitzgibbons is not really an option for femoral hernia. In fact, it’s, it’s definitely not an option if you have

Speaker 2 (00:02:58):

a femoral hernia, which is again uncommon even if you have no symptoms and didn’t even know you had it, the recommendations that you repair it. Why? Because a large proportion of patients end up in the emergency room with that hernia if it’s untreated and a fraction of them actually die because of late diagnosis, involvement of intestine, dead intestine, they get sepsis, which is like overwhelming infection of the body and there’s a death rate associated with it many, many, many times higher than any other hernia. And so femoral hernias are considered something that must be repaired. Secondly, since it occurs in women, it is necessary that femoral hernias are always looked for. So in this patient we did not have a suspicion for femoral hernia. She had no symptoms suggested of a femoral hernia. We went in hoping to fix her one inguinal hernia. We found two hernias and because she’s female, we always double check for a femoral hernia, checked for femoral hernia, and there she did actually had an incarcerated femoral hernia and therefore I could not do a Shouldice hernia repair because that would’ve been an inadequate repair.

Speaker 2 (00:04:18):

I then switched to a different technique called a McVay repair. A McVay repair is a tissue-based repair that addresses all her hernias, her femoral hernia in particular, as well as her inguinal indirect and her inguinal direct hernia. So that’s a good thing. She got the right surgery. It wasn’t what she necessarily thought she was going to have going in, but we got more information as we went inside. So that’s kind of one aspect of going in and changing your plan of care, which is why I always stress it’s so important that you get you seen by a knowledgeable doctor that understands a wide range of hernia repairs, hernia options, because every so often you’re going to get a situation where you go in there and you see something unexpected and when you see something unexpected, your surgeon should have the expertise and the experience to then change or pivot and do the right thing within a split second.

Speaker 2 (00:05:28):

So patient very well, but it was something just happened recently. I thought I’d share that with you Now. That turned out very well. We actually had no complication from that. It was mostly a change of plan during surgery, which we have to do, and when you see your surgeon and you consent to an operation as part of the consent for the operation, you allow the surgeon to whatever is necessary at the time to meet your needs. So in this patient, she had to have a femoral hernia repaired at the same time it would be below standard of care, I think, to leave the femoral hernia alone because she wasn’t consented specifically for femoral hernia because we didn’t know about that and to repair the femoral hernia later did because that would a delay in that care would actually put her at harm. Another situation would be when people go in laparoscopically to do a hernia and they see let’s say a mass or a tumor like ovarian mass or ovarian tumor, appendiceal tumor, appendicitis.

Speaker 2 (00:06:39):

Those are things that are unexpected and sometimes you have to address those operations. Now we always, when it’s really far away from what you’re planning to do, for example, there have been situations where you go in there trying to fix a hernia because you think the hernias the cause of pain and lo and behold that right lower abdominal groin pain is really an appendix issue and there’s an appendiceal tumor or a mass or appendicitis, then you have to do appendix surgery, which any general surgeon should be able to do the, we often tell the next of kin, even though they may or may not be necessarily legally the one to make that decision, but we at least alert them in the process to say, Hey, just so you know, we’re in the operating room, this is a problem. We’re going to switch gears and do something else that besides what was planned, take out your appendix or take out the ovaries.

Speaker 2 (00:07:42):

Sometimes even although we that’s a little bit, sometimes if it’s malignant, we take it out, but if it’s not necessarily malignant, we sometimes delay those because people need to be better consented about the ovary appendix you can live without. No one gets pissed off if you take out their appendix unknowingly. So again, it’s a situation where it’s good to have a surgeon with an open mind that goes into understanding that yes, I’m there to fix a hernia, but looks around and understands that there are other reasons for pain that can mimic a hernia pain, let’s say appendiceal problem, appendix problem or an ovarian problem and then know what to do at the time. So then the situation is what happens when there’s an actual complication that you didn’t plan? So fortunately, most people who are undergo inguinal hernia, ventral hernia, abdominal wall hernia repair are the first go around.

Speaker 2 (00:08:47):

So they didn’t have surgery before usually, usually it’s a surgery with very little complications. So things like bleeding, injuries to vessels, it’s very uncommon. It happens, but it’s not a major part of the operation. Bowel injury is a risk if the bowel is involved in the hernia, bladder injury is a risk if the bladder is involved in the hernia. Now, if you have imaging, oftentimes you can kind of prepare for those, but for hernias, if it’s an obvious hernia, there’s really no indication for imaging unless it’s complicated. So most hernias are diagnosed by examination and you don’t need imaging. So the question is, okay, so you go in there, you’re not aware that there’s a bowel in this hernia or there’s a bladder in this hernia and you cut through it and urine comes out. Well, now you’re stuck with a hole in the bladder and you have to fix that or you’re even worse because urine is usually sterile so you can fix it, the bladder will repair very easily.

Speaker 2 (00:10:03):

Low-risk complication to deal with bowel is a different story. Once you have a bowel injury, in most situations we don’t do any more hernia surgery. We leave it alone and we address the bowel and we basically stop any further surgery. And so that would be an intraoperative complication where it significantly affects everything because now you have a patient with injury to the intestine, which they have to heal from a wound that is no longer clean because it’s been contaminated by stool or biles, spillage or whatever from that bowel, which is at risk of getting infected. They still have a hernia, so they still need that operation to be done, which won’t be able to be done until they heal from the wound and the bowel, which may take several months, maybe six, three to six months at the least, and then they need their hernia repaired.

Speaker 2 (00:11:04):

So these situations can significantly affect your plan of care. Maybe you were planning on vacation, maybe there was a wedding you were going to go to and you were trying to get all this done beforehand, that may significantly affect your future plans. Maybe you’re starting a new job or can’t take enough time off from a job. So obviously most surgeons don’t plan on making, causing a complication. Most surgeons are well aware that there are risks and they are technically savvy enough to prevent complications. But what I’d like to say is that most these complications happen and unfortunately since they do happen, the goal is to kind of minimize how much complications there are and more importantly, I think it’s not. So it is very important that you’re surgeon not cause a complication. But we all have complications. I’ve had complications. The best of the best have had complications.

Speaker 2 (00:12:11):

If I referred to you the top person, whatever specialty they have had complications. If what we say in surgery is if you operate, you have complications, if someone claims they have no, no complications, it means they’re just not operating because the two go hand in hand. And so the reason why I highly recommend that you always choose a surgeon who is experienced, talented, thoughtful, inquisitive, careful, and an expert in what they do is because things can happen. You can get thrown curve balls like I did last week, totally different operation had to be changed. And you want a doctor who can handle that. So if you’re in there and the bowel gets injured or the bladder gets injured, you need a surgeon that won’t freak out and knows exactly what to do next and doesn’t like scratch their forehead and make the wrong decision. So the wrong decision would be in the bowel. One is to fix the bowel and then just do the hernia repair anyway and hope for the best, and then you get a Mesh infection or wound infection, then you get a hernia anyway now that they’re, it’s with unhappy tissues, et cetera. So you want someone who’s safe but also has all the necessary skills to address all these hernia repairs, all these complications. I’ll give you another example.

Speaker 2 (00:13:54):

You may have seen my TikTok, which yes, I’m doing TikTok, which was based on a recent article describing, I think it was in Texas, I’m not so sure, Texas or Ohio. There was a kid, four year old kid that underwent a routine inguinal hernia repair and as part of the hernia repair, they injured the vas, they termed it a vasectomy, and now the family is suing for I think a hundred million dollars or something, the surgeon. So okay, first of all, complications happen and my point to the TikTok is complications happen. You can have an injury to above vessel organ. In males, they all have a vas. The vas is a little tube, it’s like a spaghetti that connects the testicle to the prostate and it carries sperm from the testicle to the prostate. And so that tube is super small in a baby and becomes about the size of a thick pasta with the thick pastas, not the regular pastas at the regular spaghetti with the thicker ones when you are an adult.

Speaker 2 (00:15:17):

So in a four-year-old it’s probably super, super, super tiny. What this surgeon did was they actually cut through the hernia sac. We don’t usually do that, but that was her technique and what she cut, she didn’t understand actually involve the vas, not just the hernia sac. She sent a pathology. Interestingly, we don’t always have to do that. I never send benign stuff that’s unnecessary cost for the patient, but that was sent a pathology. Pathology said, oh yeah, there’s a vas in here, hello and family got pissed off and so on. So it sounds like a vasectomy issue. It’s actually bigger than that in some ways because when you cut a VA, you can now have leakage of sperm and it needs to kind of, usually when you a vasectomy, you don’t just cut, you close off that hole so you don’t get sperm leakage. There’s this question of fertility, the assumption is the other side still works, but what if the other side doesn’t work or he needs another hernia repair on the other side and he’s at higher risk of infertility because the need for surgery on the other side.

Speaker 2 (00:16:29):

So four year old getting a vasectomy by accident by a surgeon, it happens. It’s not the first time it’s happened, but it led to a lawsuit. But it happens in adults as well, but it’s not what we call a never event. So in that it shouldn’t ever, ever happen because especially in revisional surgeries, high risk because there’s more scar tissue, everything looks the same, Mesh is stuck to the vas and so on. But the point is that complications occur, you just need to be able to have a surgeon that A, has a lower risk of complications and B, once they occur makes the right decisions. So some of you have sent some questions to me related to exactly that and I’ll help go through them as you send me more complications. And here it is. One question, very simple is why do intraoperative complications occur and can they be prevented? So they occur for multiple reasons. If it’s a revisional operation, so there’s prior surgery, prior Mesh, that changes the anatomy and increases the risk of injury. So if you have bowel, if you have Mesh and maybe stuck to bowels vessels, bladder and you’re trying to get in the safe plane where those structures are not there, but they’re so stuck to everything that you end up injuring or increase your risk of injury.

Speaker 2 (00:18:06):

Some surgeons have more complications than others. Some surgeons are not as delicate with tissue handling. They rush through operations, they feel that their mind may not be all there. They’re thinking of other things and they inadvertently cause an injury. They want to go fast, fast for whatever reason and they may not be as delicate in their touch and some surgeons are just not as good with anatomy as others, but most surgeons are safe surgeons, they’re del, they try to be delicate. They understand that prior surgery will make it so that it’s not as straightforward of an operation and you go slower and more delicate and you’re always thinking there may be something on the other side. So one of my friends talked about the game battleship. You guys know battleship where you’re kind of making moves on your side but you’re not sure what’s on the other side, whether you’re sinking a battle ship or you’re not.

Speaker 2 (00:19:17):

When you operate in revisional cases or where there’s been scar tissue or Mesh or prior infection, which causes a lot of inflammation, if you were trauma victim, blood causes a lot of inflammation in those situations. Let’s say you have bowel here but you’re operating far away from you, but you’re operating between here and the bowel while you’re go working your way towards some goal or some area. You may not know if the next piece of tissue is muscle or fascia or bowel because there may all be stuck to each other and they’re all kind of mushy and they all kind of have the same color. So you go very slowly. So even if you get close to bowel you can say, oh, okay, so I’m so close, I’m going to stop now and maybe reevaluate to see if this is bowel or not. But for sure there have been situations where you mistake muscle or fascia or whatever with bowel or and vice versa.

Speaker 2 (00:20:29):

And there are injuries. So they occur fortunately, not frequently. They tend to occur in preoperative situations more often than primary situations and they cannot always be prevented in. I’ll give you a story. So as surgeons, every week we sit down and we talk about all the complications of the past week. It’s one of the few specialties in medicine where we actually talk about our complications in an open but in a closed forum, but openly amongst our peers every week it’s called morbidity or mortality conference. Most specialties don’t have that. If a doctor prescribes a wrong medication and you have a weird allergy to it, they’re like, oh yeah, a weird allergy and they move on. Or if you end up in the hospital from a, yeah, I guess we shouldn’t give you that anymore, but they don’t sit around and discuss the fact that their patient got admitted because there was a mistake or whatever with medication.

Speaker 2 (00:21:40):

But in surgery we do every single week we sit around as a group and we discuss the complications for that week and we analyze it and one doctor will present the situation and another doctor will like, why’d you do it this way? And the third doctor will say, well, isn’t it true that if you did it another way you would’ve prevented it and you choose this approach and could you have done it better? Could this have been preventable and if so, how? So we actually do discuss that and it’s a very excellent educational process. It is mandated that all hospitals have a morbidity and mortality conference. Yes, that is correct. To what extent they do it, whether it’s they do all the case or they pick and choose a handful of cases. But yes, for surgery it is pretty much mandated by all HO hospitals to do these morbidity and mortality conferences.

Speaker 2 (00:22:44):

There’s also peer review where if you have a complication and it just seemed like someone had a problem with it, a nurse or another doctor or maybe administration, that patient was just discharged, why are they back in the hospital? That doesn’t seem right after let’s say hernia repair. So that sometimes goes to peer review, which means they take that chart and they gave it to another doctor who looks at that and says, let me see you. Maybe you sent the patient home too early. You choose this technique. Did you call the patient to follow up with them? They end up in the hospital and they query the doctor to make sure that that doctor who has privileges at your hospital is doing the right thing. And if they’re not that they get a little bit of a ding in saying, you know, need to learn more about this.

Speaker 2 (00:23:48):

You got to grow such and such course, or you’re in extreme cases, they’ll actually take doctors off of privileges for that hospital and I’ve seen that happen before. So the hospitals say, do not want doctors that are high risk and make wrong decisions because obviously you want to have a good quality hospital. So in addition to morbidity and mortality conference as surgeons we, which is part of our D N A, we strongly believe in openly discussing our complications and learning from others. Then you could also have a hospital induced peer review system and the ultimate is medical board when the medical board gets a complaint and they look into things, but that’s more punitive, whereas everything else is more in terms of helping to improve people.

Speaker 2 (00:24:50):

Here’s another question, I dunno what to do. I have two incisional hernias, one on a scar. So yeah, that’s an incisional hernia. The other very low, so tax will be used, okay, the hernia is very low. Then the abdominal wall reconstruction, I’m not impressed with the general surgeon. First thing he told me was I was going to be in more pain than I’ve ever been in. Also, I may not have a better life. Okay, so first of all, the whole purpose of getting the hernia repair is to have a better life. Most hernia repairs, most hernia repairs are performed to improve your quality of life. It, it’s usually not a life-saving operation, usually it’s usually improve your quality of life. So if you don’t like your surgeon, change your surgeon. No one is forcing you to be with that surgeon. So get a second opinion. Always say you should always get a second opinion and see what the second surgeon says. And now with telehealth, you can get second opinions anywhere in the nation if you’re from the US actually anywhere in the world because you can just, I think all doctors now offer telehealth all over the world.

Speaker 2 (00:26:08):

Next question. Can you discuss the complication intraoperative of nerve injury and how to recognize it and what the implications are? Good question. Okay, so nerves are super, super thin. They’re thinner than angel hair pasta. We’re going with the Italian pasta analogies today, much thinner than angel hair pasta, maybe a fourth of the size of it. The largest nerves we deal with in hernia repairs are maybe the size of angel hair pasta and they’re the same color

Speaker 3 (00:26:42):

And almost the same consistency as muscle and fascia. So they’re very hard to identify randomly. They often have a little vessel that runs with ’em. And so if you see a whiteish thread, it’s almost like a dental floss. Those thin dental flosses, if you see that glistening with a little vessel going through often, that’s one way to find a nerve and sometimes they’re hidden, they’re hidden within the muscle and you can’t see them. You have to dig for them. So in most ventral hernias, so abdominal wall, abdominal wall hernias, you don’t need to find nerves. There are no nerves that you can injure in the front of the belly on the sides and the flanks, yes, there are nerves that can be injured. You have to identify them and you must identify the nerves prior to cutting or sewing because you can cut or actually so through a Mesh and that will cause chronic pain or nerve injury.

Speaker 3 (00:27:49):

It’s possible in the groin to do the same. So again in the groin you must identify the nerves, don’t touch it, just let ’em be there and in doing so, prevent any injury to the nerve by either cutting it or sewing onto it. So that’s where we are with a nerve. Now let’s say in the process of finding it or in the process of getting of operating or unbeknownst to you, you accidentally injure the nerve and that’s possible and that’s something that can happen with the revisional surgery more often than primary surgery. But sometimes a big hernia can cause a lot of inflammation and scar tissue and those are at higher risk of having complications or intraoperative complications. Specifically talking about complications that occurred during the surgery, not afterwards. So I’m not talking about a wound infection. I’m talking about right now what we’re discussing, which is a nerve injury. So the nerve gets cut. Now first of all, cutting and burning nerves often does not cause a bad injury. You may be numb in the area, but there’s about a 4% to 5% risk of future nerve pain, otherwise you just get numb for these smaller nerves. For the bigger nerves you can cause actual muscle, muscle degradation or weakness. Then the question, but partial in partial cutting or partial burning of the nerve, that definitely almost a hundred percent will cause a problem. So you don’t want a partially injury in the nerve,

Speaker 2 (00:29:41):

You got to completely injure it If you do. Now if you identify it, there are tricks to help reduce the risk of neuroma or nerve complications. One is you numb up the nerve, then you cut it sharply and cleanly. Some people burn it and then you want to bury that end that you cut or injured or burned into a healthy vascularized muscle to prevent it from getting involved in the skull scar tissue. So that’s kind of how we deal with it. When I have patients that need revisional hernia surgery and the nerves in the area are at risk of being injured from my surgery Mesh removal, let’s say, I always tell the patients I may have to find the nerves, oh no, sorry, I will find the nerves. I may have to cut at least one nerve because my operation will injure the nerve even though today you don’t have nerve pain and so I need to prevent future nerve pain by cleanly doing that operation. All right. Okay, so here’s the question. I have five hernias, I’m female, 42 and slim and would exercise regularly until recently. Now I can only walk, I have an umbilical two femorals and two inguinal hernias. I’m trying to avoid surgery until I have to.

Speaker 2 (00:31:11):

Okay? The fact that you have a femoral hernia means you should not delay your surgery. And I’ll tell you a fact, I just heard today that a very close friend of mine had a complication from a delay in surgery. So yeah, you don’t want to delay your surgery with e femoral hernia. I’m trying to avoid surgery until I have to. The surgeon I spoke with would like to use Mesh. Is it foolish of me to want to avoid Mesh? Yes and no because of the femoral hernia. The best hernia repair is a for a femoral hernia is Mesh based. Now like I explained earlier, I just last week did a tissue-based repair for a femoral hernia In thin patients, it actually is not a bad repair. It’s called a McVay repair. You have to find a surgeon who knows how to do it. There aren’t that many of us that that know how to do it. If you’re very active physically, tissue repair is not ideal. A Mesh repair would be better if you’re not super thin, not super young. 42 unfortunately is not considered young in my discussion of this problem, if you have no autoimmune

Speaker 4 (00:32:38):

Diseases, then I would pick the Mesh repair, a nice laparoscopic repair with a lightweight Mesh. Is it most likely the best option for you? You can go back to your exercises early. I have some discomfort in my right side. I’m concerned so much Mesh in me will cause more pain and discomfort as I hear many people discuss this. Would stitches be better for me? Let’s see, this is the same patient. Okay, so first of all, stitches do not cause less pain than Mesh or less discomfort than Mesh. That is a myth. We discussed this in many of the myth. I did do more myth once. You know good idea, I haven’t had a MythBusters in over a year. You guys want another MythBuster session? I think I’ll do a MythBuster session because that is one. People think that stitch are better. It’s actually not in terms of chronic pain for two reasons.

Speaker 4 (00:33:41):

One is you’re actually sewing so much sewing hurts more than the Mesh. Secondly, it’s a tension repair whereas Mesh is not tension and so if the Mesh is under the repair is under tension, you’re constantly trying to pull it apart and that’s very painful. And one of the reasons why people with tissue repairs cause chronic pain. Now you may be a good candidate for tissue repair, but I wouldn’t choose tissue repair because you think it’s a better repair or because it’s less painful because it’s not. I would only choose a Mesh, sorry, a tissue based repair for the groin if your hernia is small, if you’re relatively thin and if your activity level is not extreme.

Speaker 4 (00:34:30):

All right, next question. My husband has just had double hernia Mesh surgery. No Mesh. Hold on. My husband has just had double Mesh, double hernia. Mesh surgery. No Mesh removed from previous surgery. Mom, about size of a grape moving around causing pain. You are so right Regarding early discharge, he’s 81 years old. Surgeon is booking him in saying overnight I overheard he was in for overnight and three days due to conservation. If I didn’t speak up, shuffled out. I’m sorry. I have no idea what your question is. Maybe you can rewrite that for me. Next question. Hi Dr. Towfigh. As you’re aware, all Mesh X plans have chronic inflammation present. That’s correct. I actually published on that if polypropylene and polyester are causing inflammation, I question why an organic

Speaker 2 (00:35:37):

Material hasn’t been considered to reduce its inflammation. Do you know of any studies on this? Yes I do actually. So the biologic meshes also have chronic inflammation. Any implant that is not human and your own will cause chronic inflammation. So synthetic meshes, non-synthetic meshes, biologic hybrid, all of them when they’re removed will have what’s called a chronic inflammation on pathology. Now that doesn’t mean that your body is feeling that inflammation. So in a fraction of patients, people with synthetic meshes, polyester, polypropylene, whatever it is, may feel prolonged inflammatory pain as part of that Asia syndrome, autoimmune autoinflammatory syndrome induced by adjuvants Asia, there are biologic absorbable products that induce much less inflammation. They’re usually the higher quality ones, but they’re also biologic absorbable products that are highly synthesized and act like a synthetic that cause inflammation still. So I don’t usually recommend those and there are synthetic absorbables that can cause inflammation.

Speaker 2 (00:37:01):

So all of the products cause inflammation, otherwise it’s too inert and it will never induce in growth. But you do want some inflammation. You just don’t want so much information that your body starts reacting abnormally to and causing chronic total body inflammation or pain. Next question. What would be a large nerve in a lap ankle hernia that could cause denervation? Okay, so none the only nerves that are visible with a laparoscopic inguinal, yeah, laparoscopic inguinal hernia repair is the genital femoral nerve and cutting the genital femoral nerve should cause no denervation injury. In infrequent situations the cremasteric muscle may lose its function. Infrequent it happens but is infrequent. There’s also the lateral femoral cutaneous femoral cutaneous nerve, which is a purely sensory nerve. So cutting that will also cause no denervation. However, if you go further up the flank from a typical inguinal hernia and you see the ilio inguinal or the ilio hypogastric nerves that are branches off of L one, L two, then in end you cut any of those, you’re at risk of having degradation of the lower abdominal wall, which especially if you cut both of them, which is why we don’t recommend that on except in very dire circumstances.

Speaker 2 (00:38:55):

Thanks for your questions guys. How is the nerves are damaged? Are they not visible in either open incision or laparoscopic or No they are not. So the nerves, like I explained earlier, they look like that thin. If you’re lucky, they look like that thin dental floss and they’re often the same color or similar color as the muscle or fascia. So it’s very hard to identify. You have to know your anatomy very well and if you’ve had surgery before, there’s scar tissue that looks exactly like nerves. So that’s why they’re not very easily visible. You have to go looking for them and oftentimes they’re hidden in muscle.

Speaker 2 (00:39:43):

Okay, here’s another question. Is it difficult for the doctor to know what she’s getting into because the doctor cannot see the Mesh and adhesions on x-rays? Yes. I’m scheduled for a four hour surgery tomorrow with Dr. Mary Hana, Stanford. Great. I think surgery will be at three o’clock because she doesn’t know what she is getting into. Already have had large Mesh and many adhesions. So if you’ve already had surgery before, first of all the Mesh can be seen on MRI and some CAT scans usually and you often can identify nearby structures to at least have a little bit of a path to seek what’s nearby. So in these revisions I’m almost always get imaging for revisional hernias because you don’t want to be surprised. What if there’s bowel nearby bladder nearby, some weird structure. You want to know what a little bit of a roadmap before you proceed.

Speaker 2 (00:40:47):

It’s like when I travel I always get a roadmap first. I don’t just like punch, I don’t usually punch it into ways or Google maps and just drive. I need to see the whole map and I understand where I’m going and what direction before I proceed. I don’t know if I want, does everyone do that? Do you just put in the Google maps and start driving it and follow directions or do you look at ahead of time and analyze the recommended like roadmap before you go? Cause I always look ahead of time and that’s what I do for surgery too is I plan ahead of time. But yeah, it four hour surgery sounds like it’s revisional. If you have prior match, probably Dr. Hong will be removing the Mesh. It will be stuck to bowel and fat and then you have to figure out how to put everything back together again.

Speaker 2 (00:41:40):

So yeah, that’s why revisional surgery is not done by a lot of surgeons and there are higher complications with it. Next question, can the nerve damage reverse or does it become worse? Not sure what you mean by that question, but in general, if the nerve is damaged it can often self-repair in about 4% of situations. It doesn’t and it cause a permanent neuroma, which is very difficult to manage with that physically cutting that nerve out. And I just did one, I did two in the past 10 days. Both were neuromas, one was last week, one was the week before the pathology from the week before confirmed neuroma, which was from a prior surgery. And then the pathology last week was also a neuroma from a prior surgery. So both of them had nerve injury from prior surgeries and both of them, the pathology confirmed neuroma pain is gone. Okay.

Speaker 2 (00:42:47):

Is postoperative nerve pain only a consequence of nerve injury from the ilio inguinal ile hypogastric and general nerve branch or can also the lower level branches also cause pain? So those three nerves are the lower level branches, so it has to be L1 to L2, L3 is down, is not involved in the groin and T 12 is too high up to involve the groin. So groin pain is always L one, L two, ilio hypogastric or genital branch or the genital femoral nerve. There aren’t any other nerves that can be injured in that region that would cause groin pain.

Speaker 2 (00:43:30):

If a patient has preexisting pain, will a Mesh repair reduce the pain or increase the pain in your opinion? And should Mesh be used in a tiny hernia? So every patient’s different. I can’t answer that for all patients, but if you’re a low risk patient then I don’t usually use hernia, use Mesh in small like umbilical hernias. But if you’re an obese patient and you have a small umbilical hernia, the same hernia, I would use Mesh because you have higher risk factors for recurrence than a lower risk patient. That’s just an example. And if you have preexisting preexisting pain, yes, I would still consider using Mesh. It all depends. Why do you have pain? Do you have fibromyalgia then? No, I wouldn’t use Mesh in you. Do you have pain because you have a hernia then? Yeah, I would consider using meshing because that will address the pain.

Speaker 2 (00:44:24):

Do I take insurance? Yes, I am out of network for all insurances, but I do accept insurances that allow out of network benefits. You’re welcome. If the pain from a lap procedure extends up into the space near the hip muscle, will that be in a space where the ilio inguinal and iliohypogastric can affect be affected with removal… if pain from a lap procedure extends up into the space near the hip muscle? Okay, so it used to be that people were getting ilio inguinal and iliohypogastric nerve pain from tacks placed too deep during their laparoscopic or hernia repair and injuring the nerve ilio I hypogastric nerves on the other side of the muscle. You have to be very thin for that to happen and then tack has to go in very deep. It’s not common but it can happen. But that’s the only time when you can injure those nerves once if you wish to remove the Mesh, no, you should not be getting any injury of the ilioinguinal or iliohypogastric nerves. Do you find patients developing fibrosis after Mesh repair or fibrosis in the Mesh upon explanation. So yes, all the Mesh that’s removed also has fibrosis on pathology. That’s just the body’s reaction to a foreign body. But in the body they get scar tissue but I would not call that fibrosis.

Speaker 2 (00:46:06):

Oh boy. Partner with questions today, but I love that we’re all focusing on the complications, which is great. We’re the most common intraoperative complications specific to Mesh removal? Good question. So bleeding is a common one because you are taking Mesh off of, you’re shaving it off of a surface and so you can injure a vessel or that area can be ripe for bleeding. If there’s a nerve underneath that Mesh, then for sure that nerve is at risk for injury and then you have to see what’s near. So if there’s bowel nearby bladder, nearby vessels or nerves, those are the top four. And then in men, if it’s in the groin, there’s the spermatic cord. So those are at risk for injury.

Speaker 2 (00:47:01):

Are there factors depending on the patient that may raise the risk of intraoperative complications? Not really. The main factor that increases the risk is how many times you’ve had surgery and if you’re one of those kind of patients that are what we call, what do we call them, scar forms. So some patients make an intense fibrotic scar reaction to a simple surgery and some patients just like they heal very, very perfectly. So that would be the only main kind of patient risk factor that would make it more common to have a complication. I will share a panel meeting meeting with you held in Melbourne Mesh. I was wondering if you could watch it and possibly do a video on what you think of that discussion. This panel included the head of the T G A and many medical specialists as well as pa. Ooh, I would like that actually. Yeah, send me the video I because Australia is definitely on the forefront of a lot of the kind of Mesh panels and then Europe and then the USA. So yeah, I would love to watch it and I will have my own take on it and I’ll do some fact fact checking and myth bus myth busting of my own. Yeah, that’d be a good one. I would like that. I would like that.

Speaker 2 (00:48:44):

With regard to the last question about the three nerves in the groin, I was referring to smaller branches of the three main branches. So we don’t have names for the branches of those, of the ilioinguinal iliohypogastric or general branch of the general femoral nerve. We just refer them as the same nerve. So when I say ilioinguinal nerve injury, it could be a branch of it or it could be the whole nerve. Everyone’s different as to when they branch out. What questions should I ask my surgeon for a large ventral hernia with an umbilical hernia? What do I need to be aware of? So go to one of my prior earlier episodes or all on YouTube so you can watch it where I specifically said how to prepare what questions to ask your surgeon prior to surgery, like how to prepare for your hernia surgery consult. I forget which one it was, but it was in the first I think 50. I think you’ll find that helpful. Okay, great. So in Facebook live is the YouTube video of this Melbourne Mesh panel, which sounds really interesting. I’m curious when it was performed probably recently and so I will watch it and the next available pretty talk live, we’ll discuss it. What is done if nerve damage occurs that causes denervation.

Speaker 2 (00:50:24):

Okay, good question. So here your situation is you had a normal abdominal wall, a nerve was damaged, that nerve happened to be responsible for muscle strength in one area and now that nerve is damaged, the muscle is no longer healthy. What happens usually is that fun? What are our function? That nerve, that muscle supplied it can no longer do. Usually it’s abdominal wall so you get a bulging of the abdominal wall. Rarely is the cremasteric muscles, so the testicle light lays lower than the other side. If it’s a cremasteric muscle, it’s simple surgery, you just pull up a testicle and so the cremasteric muscle up. However, if it’s in the abdominal wall, it’s very complicated. I do offer the surgery because I see the nerve damage mostly from spine surgery because you really have to damage a big chunk of the nerve for this damage to occur, but you have to get what’s what I refer to as a tummy tuck of that muscle.

Speaker 2 (00:51:30):

So what’s a tummy tuck? They take the muscle and they kind of sew it onto itself and make it tighter. The same way when you have a tailored jacket where the seamstress or seamster kind of tailors it to get, give you like a nice cinched look, so you get the same, you do the same thing with the abdominal wall muscle. In other words, you take that loose muscle and you sew it together. Now that’s unhealthy muscle. So muscle suturing alone will not work. You need to have a permanent synthetic tough Mesh on top of that to hold it in place. It’s a very big operation. It works fairly well. It’s not a perfect operation. It has worse outcomes than typical hernia repair in that some people are still kind of look a little bit not as symmetric of the other side, but it’s the only option. The other option is where a binder for the rest of your life and if you are unhealthy and cannot undergo surgery, then that is unfortunately what needs to be done.

Speaker 2 (00:52:40):

Let’s see. Oh, all these questions. Okay, should I get my Mesh removed? It has been 18 months and I still struggle to bend over. My Mesh is four by six and I have fibromyalgia, which has greatly intensified. Yeah, it sounds like you should definitely see a hernia specialist to consider it. Yeah, I would consider it as an option. Let’s see, I’ve had laparoscopic open robotic multilayer Mesh on the right side and the original was bilateral. I’ve had laparoscopic open robotic, well that that’s like all three options. Multilayer Mesh on the right side and original was bilateral, so the original hernia sounds like it was left and right. Groin. I have contacted surgeons who specialize in hernia, Mesh, et cetera. All tests have never shown anything. I’ve had three recurrences in the same place. I’ve chronic inflammation, the joints, et cetera. The robotic 2019 made things worse.

Speaker 2 (00:53:48):

So sounds, I’m happy to see you or review your situation if I can help you. I don’t know what the question is. I think it’s a question of the chronic inflammation, the joints induced by meshes. Maybe that’s, I just recently wrote a paper, we call it Mesh Implant Illness and it seems to be something that we definitely need to address in our patients. All right, next question. Are there intraoperative complications that are specific to revisional surgery? Oh, very good. Yeah, so yes there are because when you have revisional surgery, in addition to anatomy that may be in the way, you have scar tissue, you have prior surgeries such as like a Mesh and you may have things, the anatomy may be completely distorted by both of those two. And so yes, in higher risk of intestinal injury, bowel injury and vascular injury, are there intraoperative complications tied to the use of general anesthesia? Not usually regarding intraoperative complications. Is open surgery riskier safer or the same as minimally invasive surgery? I would say it’s the same. They each have their own profile of intraoperative complications and sometimes we choose open surgery because we think that it’s absolutely unsafe to do minimally invasive surgery. We almost never choose minimally invasive surgery because we think it’s safer than open surgery. It may have better outcomes, but in terms of pure safety, usually the reverse is true.

Speaker 2 (00:55:41):

Let’s see. I saw another question. Okay, now psych. Next question. Do laparoscopic and robotic surgery have the same risk of intraoperative questions? Highly dependent on the skill of the surgeon. I tell you this because more and more surgeons are adopting robotic surgery and a large percentage of these surgeons don’t really do good and safe laparoscopic surgery, many of them don’t even do much laparoscopic surgery outside of simples. They don’t do advanced laparoscopic surgery because it’s too advanced and complicated for them. inguinal hernia is considered advanced laparoscopic surgery. Appendix and gallbladder surgery is not considered advanced laparoscopic surgery. So they may dabble in laparoscopic surgery with the gallbladder surgeries, sometimes appendix surgery, but they don’t do advanced surgeries. And now the robot comes by. Currently it’s, it is the intuitive surgical DaVinci robot. The robot comes by and it makes it so much easier. So now you can do advanced laparoscopic surgery, but with the robot, however, you have lo haven’t really had the whole learning curve that you need with lap that you’ve many of us have had with laparoscopic surgery. And so it’s possible that your robotic surgeon is actually not as safe because they’re not as skilled laparoscopically. Or it could be your robotic surgeon is more safe because you can do so much more with robotic surgery than laparoscopic surgery. So that’s a hard question to answer, but in general, in general, they should be equally safe. We don’t have data that proves otherwise, but it’s really the skill of the surgeon that determines safety for those operations.

Speaker 2 (00:57:52):

For example, I think I do both equally safely. And I would say that I do choose robotic surgery for my most complicated operations because I do feel it has less complications, especially the revisional nurse removal patients. However, I rely on laparoscopic surgery to gain access to a lot of the patients that have had so many operations as too dangerous to start robotically. So I’m sorry it’s a little bit complicated, but it’s where it’s, oh, here’s a good question. Can severe diverticulitis diverticulosis affect the outcome of bilateral lingual Mesh explanation? No, diverticulosis cannot. But if you have diverticulitis or a history of diverticulitis, that means you have had prior infection or inflammation that can induce scarring in the vicinity. And so yes, it’d be nice for your surgeon to be aware, which I am aware in this specific situation to be aware that of that history.

Speaker 2 (00:59:07):

And therefore when they do the surgery, they don’t accidentally injure the bowel or something. I’ll give you a good story because we’re almost done. This is a publicly known, so one of my colleagues who’s a very good surgeon operate on a colleague, another surgeon who had I think not diverticulitis but a bad peripheral appendicitis, similar in concept prior infection, lots of inflammation but never had surgery to address. It just medically was treated and I’m not, maybe it was diverticulitis, I’m not sure. Let’s say it was diverticulitis and he underwent a very routine laparoscopic hernia repair and something like a week later he got sick and all this stool started coming out of his wound. This is a colleague, a surgeon operating another surgeon in the same hospital.

Speaker 2 (01:00:09):

I mean, okay, first of all, that’s a horrendous complication. Second of all, the situation is this. The surgeon that was operating was unaware of this history of diverticulitis, let’s say, and there was so much scarring to the area of the hernia. And then he basically like didn’t know because he was doing his tap or totally extra peritoneal approach was also what I do. And then doing so was basically moving the hernia around, not understanding that this, he’s actually on colon because the colon was inflamed and now it’s stuck to the hernia and put Mesh in, got out, thought everything was fine, everything was great, and then there was an inadvertent injury to the colon during that surgery and the patient got sick and had stool come out. So that’s a majorly bad intraoperative complication. Hopefully it doesn’t happen to end of you all, but just goes to show you even the best of hand.

Speaker 2 (01:01:10):

This is a very, very skilled colleague of mine who I would choose to have my hernia repaired if I ever needed one and that happen. So complications can happen. They happen less often with careful surgeons with a lot of expertise and experience. So do choose your surgeons wisely. Do know that even the best of us, we have count complications. The goal is understanding how to help prevent them and when they occur, how to address them safely. And on that note, I bid you all farewell, you’ve been awesome. Been a great, great group. So many questions. There was like another five or six or seven questions that I couldn’t get to. I’m sorry about that. We will get to hopefully answer some next time. And on that note, have a good day. See you all next week on Hernia Talk Live. Bye-bye.

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