Episode 107: Which Specialists May See Patients with Hernias? | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

Good evening everyone. It’s Dr. Towfigh every Tuesday we like to call it Hernia Talk Tuesdays. My name is Dr. Shirin Tophi. I’m your hernia and laparoscopic surgery specialist. Many of you are joining me via Zoom, also on Facebook Live at Dr. Towfigh. And thank you for following me on Twitter and Instagram at Hernia doc. I always post about every week’s topics, and as you know towards the end, I will upload this session and you can follow all the other hundred and I think six or seven hernia talk sessions on my YouTube channel. So I wanted to take some time today to talk about a very interesting topic, which I thought got really good reviews last Sunday. So last Sunday I was on a local society meeting. They invited me to give a talk and I was told that the audience is not doctors.

Speaker 1 (00:01:01):

It’s like lay people, some doctors, but mostly like a local society. So I taught them about trying to make my case for why it’s not just a hernia. And I put up this slide and I’m going to show you the slide and I’ll read it for you as well. And it basically was what doctors, which doctors should know about hernias. So when you go to, let’s say your gynecologist or your medical doctor and you say, oh, I got bloating and I got this pain around my belly button, they should know that bloating and belly button pain may be related to a hernia at the belly button. Or if you go to your orthopedic surgeon and you’re like, every time I jump and do all these other physical activities, I get this pain kind of in my groin area wraps around my hip. They should know that it’s not necessarily a hip problem.

Speaker 1 (00:02:04):

The orthopedic surgeon, they should know. There’s also, it could be a groin strain or a hernia. So I was making a list of like, okay, what doctors do I talk to and do I work with who have patients that I share with ’em? And the list got so long it was literally I had to stop because the font was getting too small on my slide to fit all these doctors because certainly a family doctor, internal medicine or pediatrician should be aware of hernias and diagnose them and tell you to go see a hernia doctor or a surgeon, but also your gastroenterologist. I work with rheumatologists, nephrologists, hepatologists, infectious diseases doctors. You’d be surprised how many patients really need to get the right care for let’s say a Mesh infection. But the infectious diseases doctor or wound care doctor, let’s say maybe is just treating it like a wound infection, but really it’s a Mesh infection which needs the Mesh removed almost all the time with some exceptions, and yet they’re never referred to.

Speaker 1 (00:03:10):

I have a lovely lady who’s who I’m planning on operating soon who for years has had this chronically draining wound and her wound care doctor was just kept on treating it and then it would heal. It would open up again because the underlying problem was never addressed. So pulmonologist, oncologist, nutrition, psychiatry, unfortunately, psychiatry, yes, because I have patients that, well, I’ll give you two scenarios. One scenario is the severe depression and suicidal thoughts that run through the minds of patients that have chronic pain related to a hernia related complication. I personally know many patients who have killed themselves as a result of their chronic pain because they just saw no way out of their misery, even though potentially I could have helped them, but it just never got to that point. But also I just learned a while ago, one of my patients is bulimic and I didn’t know it was it.

Speaker 1 (00:04:21):

I don’t ask people, are you bulimic? It’s not part of my history. They didn’t offer it to me and this person kept getting hernia after hernia. Well, of course if you’re vomiting every time you eat and you’re inducing vomit after meals as a form of coping or depression or eating disorder, then yeah, that’s really important information for your hernia surgeon. And once I fix that hernia, there’s no way you should be vomiting afterwards because you’re going to mess up my hernia surgery. So I enlisted the help of a psychiatrist and help my patient because bulimia is a psychiatric disorder more than anything, and it’s not purely like I just want to lose weight. So that’s why I put that one in there. Sports medicine, obviously for reasons of groin strain and so on, we talk about wound care, gynecology, obstetrics, urology, plastic surgeon, orthopedic surgeon, colorectal surgeon, thoracic surgeon, neurosurgeon, liver and kidney transplant, surgeons, surgical trauma, bariatric surgeon, anesthesiologist, pain management, radiologist, vascular surgeons. These are all doctors that somehow interact with me in my life as a hernia surgeon and I hope to educate them about some problem that is related to my hernia surgery world. And

Speaker 2 (00:05:56):

I learned from them about problems that maybe are referred to me because, oh, maybe it’s a hernia, but it’s really not. It’s something in their world. So I thought today we would discuss that because in retrospect it always happens. Every time I have a show and I’m trying to come up with a topic that would be of interest, I look back, I’m like, oh my God. This last week was the perfect scenario of examples. So for example, today alone, actually today and yesterday, I should say today and yesterday I have talked to at least seven or eight of these different specialists. Well, I just got a call from a urologist where the patient had I believe some type of trauma and has testicular pain, but he’s thinking maybe the pain is related to a hernia and not related to the testicle. That’s a urology issue.

Speaker 2 (00:06:59):

I have a lady who had pregnancies and three pregnancies, and so definitely had this disruption of her abdominal wall with a hernia in a diastasis recti. So I referred her to plastic surgeons in my town who I really respect to get her get a tummy tuck because the hernia itself was not the main problem. It was really the diastasis and the loose skin. So work with plastic surgeons there. Sometimes they ask me to come in to do the hernia repair part and they do the tummy tuck part. I had a gentleman who flew in who had hernia surgery and now he’s got horrible, horrible headaches. So he’s been seeing getting MRIs of the brain and working with neurologists. And then he had a rheumatology workup. Of course, I think he’s reacting to the Mesh with Asia syndrome, but it’s rheumatology workup because he’s got joint pains and then neurologist for his headache and tingling in the fingers and these weird rashes.

Speaker 2 (00:08:07):

So I’m sending him to an allergist immunologist because I need them to do allergy testing to different meshes and sutures so that when I remove his Mesh, I know what kind of sutures to use. So he doesn’t react to that. But interestingly, he’s already had some blood tests and that shows that he has some maybe immunologic problem. So he is going to see an immunologist for that. And interestingly, another patient out of state who had hernia surgery and is reacting to the Mesh locally, so he doesn’t have headache, hair loss, numbness and tingling and feeling hot. He just has a very stiff area where the hernia repair was, and it looks like he’s locally reacting to the Mesh because it’s stiffened up. So he has an abnormally high inflammatory response to the Mesh. And guess what? He was diagnosed with something called M G U S, which is a monoclonal gammopathy of undetermined significance. And I was like, Hmm, you’re a normal healthy person. You had this hernia parent and then all of a sudden you get this weird diagnosis. I wonder if it’s related. So I spoke to his, I called over and spoke to his hematologist and I said, I do this work. I’m a hernia surgeon. You’re a fancy hematologist.

Speaker 2 (00:09:35):

I wonder if the patient is reacting to his Mesh and he’s manifesting this reaction as this new gamma gammopathy, the monoclonal gammopathy of undetermined significance. And the hematologist said, oh my God, you’re absolutely right. What? This is so interesting. Yes, it completely can be. In fact, this specific disease MGUS or MGAS, I think it’s called, is known to be triggered by autoimmune disorders or other kind of inflammatory problems. Yeah, absolutely. So he got all excited, which I love because I got excited and he got excited. So that meant that I was on the right track. And so the plan is we’re going to take out the Mesh and then repeat the labs in three months to see if that is something that maybe will get a cure, maybe removing the Mesh will down get rid of not only the pain he’s having from the Mesh, but also this other second diagnosis. Those are just examples. I have more.

Speaker 2 (00:10:48):

There’s a patient with a potential neuroma, and the MRI is kind of like, he’s very complicated. Anyway, so I’m working with a musculoskeletal radiologist to work and read. I don’t want them to look to say, oh yeah, no hernia. I’m like, no, no, no. I want to specifically look in this one area where there may be a neuroma. And that’s the cause for his chronic pain because there’s been issues like that before. Another patient came to me who was headed toward pain management, and I’m like, why are you going to pain management? I think you have a hernia. Oh, well, I assumed that my pain was because I had a muscle strain and my doctor was going to just do like a P R P injection, which we talked before in sports medicine for groin strains. And so I said, hold on. Let’s see if you don’t just have a simple hernia because surgery will cure that.

Speaker 2 (00:11:44):

And then if that’s true, so I called the pain doctors. Absolutely right. Go ahead, get the imaging. If it’s something that you have handle, then great. If not, we’ll take care of it with the sports injection. So my point is this, there’s so many specialists that we interact with. I have another patient with a Mesh infection, unfortunately, and infectious diseases, I learn a lot from them as to what antibiotics and for how long and so on before they need their Mesh removed. So on that note, let me take some of your questions, but specifically I hope to impart on you this hour. Number one, that hernia surgeons like me and my colleagues who you’ve met on Hernia, Talk, Live, we interact with specialists all the time and it’s more the part of my job that I really love because though a lot of people think hernia surgeons, they just fixed hernias.

Speaker 2 (00:12:55):

I actually really like the multidisciplinary approach to it, and I’ll discuss that in more detail because there’s some questions that were submitted that will review on that note. But also I hope that what I do in terms of giving talks and lectures and answering questions and writing papers, the other specialists also reach out to me, has had a cardiologist call me to yesterday, and we’ve shared some patients, but I’ve never really met the guy and I know he’s a great cardiologist. So I was really honored that he called me saying, Hey, we should meet because I hear so much great things and your reputation is so great, and my patients are so happy, and I do cardiology and he wants to learn more about what I do because every so often we’ll get a patient that maybe I can help. So I love what I do and I don’t feel like it’s a very isolated specialty.

Speaker 2 (00:14:01):

I feel like I talk and work with so many different specialties. Here’s some questions you guys are asking. Oh, the talk about suicide, right? So one question is how common is suicide because of chronic postoperative inguinal hernia pain? And what does someone do if they have these thoughts? And a follow-up question, is suicide more common after hernia surgery, complications and pain than other causes of pain? Well, yeah. So chronic pain is always an issue and it can give people suicidal thoughts. Pain is just a horrible, horrible thing to live with regardless of their reason. It could be back pain. Cancer related pain is a big one. People who are amputees that have pain from their amputations and definitely hernia related complications. So I personally know several patients who have killed themselves. Those of us who do this for a living all know about patients. In fact, I believe Dr.

Speaker 2 (00:15:03):

Jacob and Dr. Ramshaw have both given public talks about their experience in dealing with the situation where patients are in such high level suicide and chronic pain and even shared stories of their patients who eventually killed themselves. And I believe Dr. Jacob is working on kind of a revolutionary way of trying to change the direction of that because there’s a lot of new medications that are in trials that are related to microdosing of otherwise illicit drugs that have been able to help these patients. The reason why hernia surgery related pain is so hard is usually in the groin. For men, it’s often a male issue because they have testicular pain or sexual pain in addition to the groin hernia pain, and that can augment the severity of the depression associated with it. They lose their loved one. They can’t say they can’t enjoy their life, and that’s kind of part of the problem.

Speaker 2 (00:16:29):

Not to say that I haven’t had patients or known about patients who’ve become suicidal from abdominal wall, but really it’s the pelvis and growing ones that I know of that are in the worst shape and just lose hope. And then they’re afraid to have more surgery because they’re told they may lose a testicle or they’ve already lost a testicle and so on. So I can’t say it’s any W worse than let’s say cancer pain or amputee pain or traumatic pains, like if you’re in bad trauma and you flew through a window or it got hit by a car or something like that, but it’s up there. We don’t see people with let’s say plastic surgery who get suicidal or gynecology don’t. They’re not typically suicidal, but in my field, there is that risk.

Speaker 2 (00:17:26):

All right, let’s ask some more questions. So moving on, here’s another question which is do hernia patients tend to have more comorbidities and benefit more from a multidisciplinary approach than other surgical patients? The answer is absolutely yes. And yet it’s one of the least appreciated aspects of hernia surgery. I always say it’s not just a hernia, and I don’t mean that it’s not just a hernia, but it’s not just a hernia. In other words, everyone in the past used to think, ah, it’s just a hernia. And they operated on everyone. And now we know if you’re morbidly obese, if you’re a nicotine user, if you have a chronic cough, if you’re constipated, if your prostate is enlarged, if you have any wound infect, if any infection in the area, these are all situations where you should not just jump into surgery. And in my patients, your diabetes need to get repair, get dealt with.

Speaker 2 (00:18:29):

You need to have colorectal surgeon evaluate you for something. You may need a colonoscopy prior to your hernia surgery. These are all not to delay your surgery but intended to improve your outcome. And I have a lot of colleagues that don’t believe in that. They, I’ve heard, I’ve literally heard surgeons say, oh, well, my patient just wants a hernia repaired. If I delay that, they’ll just going to go to another surgeon and get their hernia repaired. First of all, neither of you should be operating on a patient who’s diabetic diabetes at a whack, they’re morbidly obese, they have a chronic cough or have anything else that could potentially give a worse outcome.

Speaker 2 (00:19:20):

You have to correct those. And I do that and I do it unapologetically. And if a patient just wants a hernia repair and doesn’t care to go through the process, that’s not appropriate. I don’t think that’s the right attitude and I certainly don’t subscribe to it. But there is a little bit of that, which is there are surgeons, and unfortunately it’s part of the medical system in the United States, especially that hernia surgery is not a very profit making specialty, which means that the reimbursements from insurance, Medicare, et cetera, is very low. So most doctors who do hernia surgery as one of many operations, they do live on a volume based system, and that means they have to see a lot of patients and operate a lot. And if you’re making several hundred dollars per surgery, you do like thousands of operations. So you can’t have a luxury of reducing the volume.

Speaker 2 (00:20:34):

I mean you should, but it’s the system doesn’t help, doesn’t promote that I have pushed myself outside of that system so that I’m not bound by those kind of limitations. And so I do spend more time educating my patient to get their outcomes better. I dunno if that made it what sense to you, but here’s another surgery or another question. What I’ve been told about the risks of corrective or additional surgery is causing more trauma to tissues in a region where the nerves are already angry or hypersensitized and this risk trumps potential benefit of additional surgery.

Speaker 2 (00:21:17):

So I don’t agree with that. I do know that if you have had multiple operations and are in a situation where your chronic pain is out of control, then surgery while your chronic pain is out of control is not a good idea because you need to work with your pain doctor to bring down your pain control issues to a much more manageable state before undergoing any hernia or reconstructive surgery. That’s true for any surgery. However, if you truly would benefit from an operation and you’d happen to have chronic pain, that’s not an indication not to provide the surgery. It’s chronic pain. There’s chronic pain. You need to get the chronic pain under some control and not be completely out of whack. But if the surgery’s going to help you, then it’ll help you. Nerve surgery is different story. I do agree that we should minimize as much surgery we do as we do on the nerve itself.

Speaker 2 (00:22:24):

And if you’re at a heightened level of neuropathic pain, then that should be controlled. Otherwise, you are at risk of being pushed into a CRPS or complex regional pain syndrome situation. But to just tell everyone, oh, you’re in, I’m just going to cause more trauma and you’re going to be in more pain means that you’re not working with pain doctors. Here we go again, other doctors where you got to bring them in, work with other pain doctors in a multidisciplinary manner and say, I need this patient pain better controlled because for that doctor, the pain control may be adequate, but for you as a surgeon, you’re going to be inflicting more pain. And so you need to bring down the baseline pain before you add on to that patient’s pain in the acute early stage of the operation. And that’s a different situation. So when you work with your pain doctors and explain that to them, they should understand that maybe they need extra whatever to get them through the surgical, the surgical hump.

Speaker 2 (00:23:34):

Okay, next question is how often and why are other specialists needed for your patients? I tell you, for me, I love working with other specialists. So even if I don’t need to bring them on, I often reach out to them anyway. I’ll give you an example. I saw a lady with a colostomy and she’s concerned she has a colostomy parastomal hernia and it ran through my mind, why are we even dealing with a parastomal hernia? Why don’t we just consider putting her bowels back together and taking down the colostomy? So that’s where the patient may not be open to it initially, but I would like to know, is this a good patient to consider at least discussing a colostomy takedown? So then the hernia repair would be much more straightforward and you don’t have to deal with the colostomy and maybe the patient will be happier not living with a colostomy for the rest of our life, or is this patient high risk and would do poorly with a colostomy down because I don’t do colostomy take downs.

Speaker 2 (00:24:43):

I used to back in the day when I was a general surgeon, saving lives at the county hospital, but I’m a hernia specialist now. So I defer those operations to people who do it for a living and they do a much better job because that’s what they do. And so I also know that there’s new technologies and new ways of thinking, so I’m constantly reaching out to these specialists because I learn from them and they may say, oh yeah, well an elderly patient for example, would not benefit from a colostomy take down if a certain amount of their colon has been removed because their colon lacks the ability to adopt to being shorter. And so now they have looser stools and maybe that lady’s had three or four kids already, so she’s going to be in incontinent. So patients would actually rather have a colostomy than be in incontinent. And so no, let’s not take down the colostomy. Those are thought processes, which I think I love having that thought process and tailoring decision making to the needs of the patient.

Speaker 2 (00:25:50):

Next question. What medications have you seen that are helpful to tamp down post-surgery pain to make the patient a more success, more acceptable candidate for revisional surgery? Could it be a lidocaine patch, capsaicin, Lyrica, Cymbalta, or other maneuvers? Actually, it’s a very wide range. So it could include nerve modulating pain medications, muscle relaxants, local medications, C B D, marijuana can be helpful if it’s legal in your state, a topical arnica creams gels a binder or it could be injections. So I have a patient who is in such severe pain, not from the hernia but from her back, but she wants a hernia repair. There’s no way I’m going to offer a hernia repair to someone who has out of control spinal pain because I’m never going to be able to control her pain after surgery if she’s got 10 out 10 pain from her spine already and then I’m going to add and pain for hernia surgery.

Speaker 2 (00:27:01):

And her hernias not even painful. I know it’s a hernia, but not all hernias need to be repaired. So that’s kind of the situation. But yeah, there are different patches. The lidocaine patches are great. There are some CBD patches and arnica creams, topical anti-inflammatory creams, sometimes different nerve medications could also function as antidepressants to help with the pain control. Anti-anxiety medications can help with pain control. So it’s a wide range, very wide range, and that’s where having a couple of really good pain doctors in your back pocket is really great. So I have my own. So in my town I have my own group of doctors who I really respect, who many of them treat me or my family or my close friends and they are my go-to. So sometimes I refer patients to them, but sometimes I just give them a call and I say, Hey, listen, can I ask you a question?

Speaker 2 (00:28:06):

And they give me great, great information and I learn from them. How painful would you consider abdominal wall reconstruction for vent hernia repair? Depends on the type of surgery. So open, laparoscopic or robotic depends on how large your hernia is. So small, medium, large, extra large, and which area of the body it is and how much you weigh and how much pain you have before surgery. So that’s a very, very hard question. It’s like saying, what card do you recommend I buy? What do you need it for? So sorry, I can’t exactly answer that question. What are the specialists to whom you most offer me for? Okay, so top R are gynecology and urology and some orthopedic surgery and pain, medica, pain management, those are the top four. So orthopedics, pain management, gynecology and urology. And I have amazing doctors who I work with for them, but this week I’ve also spoken to a hematologist, a musculoskeletal radiologist, allergist, immunologist rheumatologist, who else did I talk to this week? Cardiologist, neurologist, and so on. But they’re not as commonly needed. Pulmonologist, that’s another good one. E n t, doctor, gastroenterologist.

Speaker 2 (00:29:45):

It’s pretty interesting, the wide range of doctors that I speak with and I learn so much from them. And let me tell you what I do is I kind of sneak in a little bit of my own information. For example, the hematologist that I spoke to, I guarantee you he never knew that Mesh is can cause a Mesh reaction ever. And yet there’s so many patients I’m sure he’s had who have had hernia repairs with Mesh and as a hematologist dealing with these new kind of autoimmune kind of disorders or gammopathy blood disorders that can be triggered by autoimmune problems, it’s important to know that maybe it’s your Mesh. So the fact that I kind of introduced myself because he’s in a different state and brought up the issue and I said, I kind of brought up as this is what I do. I see patients that react and this is the kind of reaction they get.

Speaker 2 (00:30:42):

Can it be? And then he is like a light bulb went off. It’s like, yes, so cool. All right. In which setting among diagnosis, pre-surgery, optimization and post-operative management is a multi-disciplinary approach most useful for hernia patients? So I would say definitely pre-operative optimization and sometimes diagnosis. I don’t use them as much post-operatively, mostly because the patients that the type of doctors you need postoperatively are very different than the doctors you need preoperatively. So postoperatively you need pain doctors, maybe a cardiologist or a pulmonologist or a gastroenterologist depending on their maybe a complication or wound care doctor, maybe infectious diseases doctor, because these may all be related to complications after surgery, but before surgery I like to get the other specialists involved to make sure I’m not missing another diagnosis or I optimize an underlying diagnosis and so on.

Speaker 2 (00:31:56):

Next question. How often have you found that problems appearing after hernia surgery are fixed by other specialists without resorting to further surgery? How often do you found that problems appearing after hernia surgery are fixed by other specialists without resorting to further surgery? Not that often. I think the question has to do with, for example, a patient has let’s say nerve pain after hernia surgery and then the pain doctor gives ’em, I don’t know, a pain pump or something like that. But not common. Not common. What is the role of a pain specialist? Okay, let’s discuss that. So there are pain specialists and they’re pain specialists. Some pain specialists are really good at chronic pain, so others are really good at acute pain. Another group of pain doctors is very good at just the spine, but really nothing else. Everything is a nerve pain to them.

Speaker 2 (00:33:09):

Others are really good at physical medicine, rehabilitation related stuff like sports medicine. So they can deal with injecting areas where there’s a strain of a muscle or a torn abductor or something like that. And then some are really good at just procedures. So you want to go to that doctor for your epidural and your implant placement for spinal stimulator, but they’re not necessarily the most gifted in diagnosing your actual problem, but they’re really good technical doctors. So it’s a wide range now, and I have my own kind of group of doctors, so I know there’s one doctor who’s really, really good at procedures, but I don’t send my suicidal patient to ’em. But I have other patients that are super suicidal and everything is negative and the whole world is falling apart. And there’s a group of pain doctors that I specifically send those patients to because man, they’ve had really good success at turning around these patients to treat their patient, to treat their medical and psychological problems at the same time, which is really hard to do. And we’ve had a couple patients that were, I thought, wow, how is this ever going to get fixed? And now they’re like normal, live normal life. So very, very unique qualities. Next question. I have a soccer ball size hernia and abdominal reconstruction will be done too.

Speaker 2 (00:34:49):

What is long? What is the length of recovery and what are the chance of recurrence? Okay, again, very difficult to answer. The chance of recurrence are related to your surgeon, their surgical technique, how much Mesh was put in, how wide of a Mesh, how big your current defect is, how much you weigh, what other risk factors you have. Are you constipated? Do you have a chronic cough? You use nicotine, how much you weigh how tall you are and how many operations you’ve had before. Do you have any other medical disorders, diabetes, autoimmune disorders? Are you on medications that affect your immune system and healing? These are all how old you are. These are all relate like multifactorial reasons for why that will contribute to your recurrence.

Speaker 2 (00:35:41):

The size is soccer ball. Soccer ball is huge. This is a huge, so is that all hernia? That’s what I want to know because what you are seeing as a bulge may not be the actual size of a defect. I estimate what people see is about three times larger than what the actual defect in the muscle is. So if you’re saying soccer ball size, does that mean that’s how you look? And then therefore how do you give imaging? Just tell me exactly how wide the that is. And the recovery typically for abdominal wall reconstruction is a couple weeks for the really, really, really complicated ones. Maybe several months, but typically it’s a couple weeks. Next question, do you do zoom consults for out-of-state patients? So the US law and California state law allows me to take care of new patients in California but not outside of California. So the way I get around that system is within California. Yes, I do offer in-person and virtual consultations. So telehealth, which means like zoom base, I get to see you, I talk to you, I can kind of visually examine you. We have a good discussion back and forth.

Speaker 2 (00:37:03):

Then it can go through your insurance et cetera because you’re, you are treated as a bonafide patient doctor relationship. Unfortunately, since the pandemic is kind of settled down, they have cracked down on the type of care we can give to out of state. So since I’m not licensed to give care outside of California because our medical license are state based, then if you’re outside of California, what I can offer you is my expert opinion on your situation. So I’m not really your doctor, I can’t write you orders or prescribe anything for you that would happen through your own medical doctor. But what we do is what we offer is online consultation. So that’s for anyone outside of California, whether it’s United States or international. And take all your records, your medical records, imaging your story, we have forms to fill out and send those to me by mail.

Speaker 2 (00:38:05):

I’ll sit down on my off time and I’ll review them and I’ll send you a very, very detailed, complete long email, which is kind of my opinion of what’s going on based on the information you provide me understanding that I don’t have the privilege to actually examine you. And many patients find that helpful because they’ll take that to their doctor and they say, Hey, so she saw this, what do you think? Or she recommends that, can you offer me that service? Or they figure out that I brought some insight into their care that they weren’t getting near them and now that they know I can help them, they will make an appointment to physically come in to see me. So there is that option for what we call online consultation.

Speaker 2 (00:38:52):

I also want to take a little moment and to give a shout out to all my patients from today. Almost every patient today told me that they watch hernia talk and they will be going home and watching me after their visit. In fact, one search, one doc, one patient I believe is driving home now like to another state and maybe listening to me online while they are driving. So I do really appreciate that. I’m very impressed that you all find this valuable and I do appreciate that extra little push to have me do this every single week. Okay, what is the role of an interventional musculoskeletal radiologist? So you may recall a couple months ago, many months ago that I interviewed Dr. Jan Fritz from NYU, New York University. He used to work at Johns Hopkins. So he is an interventional musculoskeletal radiologist, which means he is really good at looking at imaging from a muscle and nerve standpoint.

Speaker 2 (00:40:04):

And in doing so he diagnoses things and then he under MRI or CAT scan or ultrasound guidance, he will inject or ablate nerves that a typical pain doctor, for example, would not be able to do. I also have a really talented musculoskeletal radiologist at Cedar Sinai, my hospital who is so good with the hip, he’ll do injections and specifically aim at certain areas to inject. And then I went, I reached out to him for a patient. I said, listen, I have this patient, this is exactly what’s wrong with her and there’s this one nerve, the genital femoral nerve got injured from her spine surgery approach from the side and I can’t inject that area because it’s way back and there’s so as to her back, but if I show it to you on the imaging, can you inject it? He’s like, never done that before.

Speaker 2 (00:41:06):

But sure. So this one was in so much pain. She had a spine surgery and the spine surgery was fine. Her spine pain got, but now she’s got this new horrible pain that radiates into her kind of labia and basically, basically she had an either injury or more likely scar tissue from her spine surgery the originated way back in her back at this, but not at the spine. So I marked the area where he needs to enter and then he went and looked at the imaging and I told him exactly where the point is at the imaging. And then so I was two centimeters over here, one centimeter over there. Anyway, he went in and injected it based on my collaboration. So now I’m collaborating with a radiologist and oh my god, that woman was so happy she was on cloud nine, her pain was completely gone, she only needed two injections and it was gone completely healed.

Speaker 2 (00:42:07):

And he was so excited because first of all he, he’d never done that before. Second of all, he was collaborating with me so he learned something new. And third, as a radiologist, you almost never cure anyone. You’re basically helping diagnose but you’re not really treating as much. And he was able to completely change the life of this woman. So those are stories that I absolutely love and that’s where the role of a musculoskeletal radiologist is very important because they really understand that part of kind of life and the part of the anatomy really well. And sometimes someone like me will bring in the clinical aspect. I believe this is the diagnosis and then I work with a radiologist, let’s say, that understands the anatomical approach since you bring clinical and anatomical together and then you can get this lovely relationship where we’re able to treat patients together.

Speaker 2 (00:43:16):

And the great thing about my practice, which I see that it’s kind of harder to do when you’re in a kind of high volume institution based practice is I have a cell phone that I have not erased phone numbers since I was a resident and that was over 20 years ago. Many of these residents that I was with are attending surgeons that I was with are now doctors that I work with. So I have their cell phone, I have people’s cell phones from across the United States or even out outside the United States. And I call them and I talk to them and I refer to them or I just kind of discuss with them when you don’t see sometimes as at night I may be on Twitter or Instagram and I may be direct messaging with colleagues of mine about situations, clinical situations, questions, et cetera.

Speaker 2 (00:44:19):

So I love that part of it and I feel that in general people think that hernias, oh, which is a hernia. But the Collaborative part is so important. And I, today’s topic was an offshoot from my talk on Sunday, which was basically exactly this where I went through every specialist I went through gastroenterology, allergy, gynecology, obstetrics, urology, et cetera, infectious diseases, pulmonology, hepatology, trans liver transplant surgeon. And I explain how each of those specialists need to know about hernia surgery hernias because we interlay for example, did you know that as a rheumatologist there are certain autoimmune disorders that affect the joints. You know that rheumatoid arthritis, there’s a diagnosis called ankylosing spondylitis and that is where your sacro iliac joint in the back of your pelvis in the back on the left and right side gets inflamed. It’s often seen in people of Northern European like Norway, Sweden, kind of Scandinavian genetics, if you do a blood test, they tend to be H L A B 27 positive.

Speaker 2 (00:45:45):

And when you get that lower back pain left and right, it radiates to the groin. So I have literally treated patients that were incorrectly diagnosed with hernia pain because they had groin pain and shoot it down to their inner thigh and maybe their testicle and then they had hernia surgery and guess what? The pain was still there. So now they’re labeled as post inguinal hernia, chronic pain and they had Mesh removals and spermatic cord denervation surgery and they were told they have to get their testicle chopped off and all that. And it was always an ankylosing spondylitis. All you need to do is put them on these autoimmune autoimmune medication, not surgery, medication and maybe some injections into the joint and that treats your pain.

Speaker 2 (00:46:42):

We talked about the monoclonal, monoclonal gammopathy, which was another one which was kind of unique. The other one was bloating. So did you know that hernias cause bloating? So most people who have bloating go see their medical doctor or their gastroenterologist and I just saw a patient this week, just tons and tons and tons of surgeries and endoscopy, colonoscopy, hydrogen, hydrogen breath test, h pylori, bacterial testing and treatment, different types of diet controls. She was told she’s got I B S, which is irritable bowel syndrome, which is kind of like everyone is labeled somehow that way.

Speaker 2 (00:47:34):

What else? Anyway, long story short, the bloating may be from the hernia. Let me fix the hernia and the bloating can go away. Did you know that endometriosis can cause bloating? So this patient I saw, I think I figured out her problem, she was down to 80 pounds. Can you believe that? Eight zero, no one who’s an adult should be 80 pounds. And she was tall too. She just so much pain eating you can’t eat. And unfortunately when you fall into this situation where you’ve got bloating, these kind of non-specific abdominal pains, et cetera, and all the studies come back normal or you’re not, you get labeled therefore with like I IBS and you’re get put on all these medications for IBS which don’t really like, I mean if you have true IBS, it’ll work, but it doesn’t work otherwise. And then it doesn’t work.

Speaker 2 (00:48:39):

So then she becomes labeled as difficult patient and meanwhile she’s kind of going downhill, downhill, downhill because she has kind of bloating and now she’s 80 pounds. So what happened was the, I looked at her imaging and I said, you got this big ovarian cyst. Oh yeah, we know about that. They just told me it’s a simple cyst, not big enough to cause my pain. I said, but hold on, you’ve had this pain since age 17. Guess what? That’s kind of when the menses started and you’ve had endometriosis. Why is this an ovarian cyst and not endometrial mass and this huge colon that’s sitting on top of your ovarian cyst, which is probably endometriosis, is very abnormal. It’s like really wide dilated, not stool is not moving through it. I said, this is your endometriosis, we just need to treat, it’s not a hernia. Thanks for coming to see me but I can’t help you because it’s not a hernia, but I can help you try and get through to the right specialist. So maybe this bloating and this GI problem is from a gynecologic problem, so let’s go down that route. And in fact it’s been worse since she’s been off for medication for endometriosis. So put two and two together and maybe that was a problem.

Speaker 2 (00:50:09):

Another question. My doctor wants to use a Mesh from my epigastric hernia. I heard using Mesh is not good for us. I don’t know what that means. Not good for us. If you need Mesh then you should have discussion with your doctor as to the pros and cons of using Mesh in you. And you know how that can help. There are patients where I prefer not to use Mesh, but the majority of patients do well with Mesh. And if you have a larger hernia you may need Mesh. If it’s a smaller epigastric hernia, like one centimeter, I don’t use Mesh even one and a half centimeters. But if it’s two centimeters or more, I usually use Mesh because there’s no good treatment for that.

Speaker 2 (00:50:51):

Do epigastric hernias cause bloating too? Yes, they can. These specialists you call need to know how Mesh is can interfere with our diagnosis. Yes. So this whole hematologist was so excited about it. And then who was it? There’s another one recently where, oh okay. So this other patient, normal healthy guy flew in from out state to see me today. So he doing fine, gets Mesh in, wakes up with all these problems, he’s got ringing in the ear, hair loss, tingling in the fingers, rashes around his back, twitching of his body all over the place, things like that. So to me that sounds like a Mesh reaction but of course it can be other things potentially. We got to rule it out. Oh, headache, major major headache. Headache top of his head. So he is had MRI brain, CT brain, more MRI brain neurologists, they’re all looking for a head thing. Not linking the fact that it could be related to the surgery he just had because he was fine before that. Got allergy testing and immunology testing finally, which is good that very, very helpful. He’s got ringing in the ear so he is going to go see an E N T doctor, but I hope his E N T doctor first of all rules out a bonafide ear reason for the ringing in the ear, which very well may be.

Speaker 2 (00:52:29):

However, if not that E N T I hope is then told. Okay, so it’s not that. But do know that people that get Mesh put in can get this weird reaction where they get ringing in the ear. So you’re absolutely right, we need to kind of close that loop and that’s why I give these talks and try and educate people including doctors, how much kind of Mesh and hernia can interfere with other, I got a phone call today, another patient of mine I operate on 10 years ago and she had had a lot of complicated surgeries before me and I fixed her hernia and she’s been doing great but now she’s another hospital, they want to operate on her for another reason and the doctor was concerned. So the patient was cursing, don’t touch my Mesh. Dr. Towfigh said if I ever need surgery, call me because call her because she did a painstaking operation and put this Mesh in me and don’t want to get messed up.

Speaker 2 (00:53:37):

So the doctor called me, very nice surgeon, he’s like, listen, I don’t think I need to operate on her, but if I do I need your advice. Now she has Mesh Anders. So I kind of gave him advice as to what needs to be done and I sent him my operative report of hers so that he has a roadmap a little bit to understand what was done and what’s there. But you may need to have a surgery through someone’s Mesh. You need to understand what that means. What does that imply? Can you just cut through the Mesh will that Mesh can affect it? What suture do I use to close the, do I use the same? Do I close the fascia the same way I close regular fascia or is the fact that there’s Mesh is there is different. So that’s very important. There are some other topics like low back pain.

Speaker 2 (00:54:27):

Did you know that hernias can cause back pain? Belly bone, hernia can cause back pain. Groin hernias for sure can cause back pain. So I have literally had patients that have known back problems. So they go to their doctor, oh sending you to a spine surgeon. They go to a science surgeon. Oh yeah, you’ve, it’s not that bad but yeah, we should do surgery for your spine. They come to me, I said, okay, hold on your groin hernia may have may or your belly bone hernia may be causing this mac pain. Let me fix the hernia first. And back pain goes away. So they didn’t need spine surgery after all. But very important that doctors stop sending patients to physical therapy and spine surgery because of back pain if they have a hernia because it could all be from the hernia, not all the time, but it helps.

Speaker 2 (00:55:24):

What else did we discuss on Sunday? It was a pretty good talk. I talked about constipation and chronic cough. a lot of these doctors who treat cough and constipation, it’s all they see. And so it’s good for them to understand that by treating the constipation or the cough, they’re actually helping the patient from a hernia standpoint. What I don’t like is when doctors are not open to feedback. So I would call the spine surgeon and say, listen, the patient flew in from Canada to see me. They have a bulge in their abdominal wall. It’s not a hernia, it’s likely a disc problem. And they’ll say, oh that never happens. What do you mean abdominal wall bulge? I said, well, kind of like the nerve to the abdominal wall is pinched somewhere in the spine

Speaker 1 (00:56:23):

And so that nerve that feeds the muscle is now injured. So they have a bulging abdominal wall, so let’s send them to you, the spine surgeon, take a look at the spine and then if there’s impinged nerve, you can fix that and the abdominal wall will get better. He’s like, that’s ridiculous. The pain, no then that’s not it really. So I get imaging, I prove that there’s a disc, send it back to the doctor, doesn’t believe me. So I sent another doctor who believed me, operated on the patient, the patient was normal. Another spine surgeon was looking at imaging that granted very, very, very, very, very rare hernia. A sciatic notch hernia is the rarest of all hernias. Sciatic notch hernia. I’ve treated one so far.

Speaker 1 (00:57:15):

They didn’t know there was such a thing. There was a loop of intestine going through the area where the sciatic nerve goes through and it was causing sciatic pain. So they got imaging, oh you probably have a disc. And they saw this mass next to the nerve which was a bowel. They didn’t think it was bowel, they thought it was a tumor. So they said, oh shoot, you got a nerve tumor. So for I don’t know, a year or two they kept getting imaging after, I mean let’s watch this tumor and see if it grows or how bad it is. And then someone sent her to me and said, there’s bowel this. And I said, oh yeah, that’s a sciatic notch hernia, I’ll fix it. And of course that’s all she needed. So these are all little tidbits that I have a lot of stories like this, a lot of stories.

Speaker 1 (00:58:12):

So that’s why I kind of enjoyed giving this talk on Sunday because I just shared story after story after story and had pictures of patients of mine before and after and it was really great talk and hopefully if I do believe they recorded it. So if they can share with me the recording then I will share it with you guys to, cause I thought was a good talk. I’ll post it on YouTube and I’ll let you guys know when that happens. But it was kind of cool. There was a talk about a hepatologist. I had a patient who has a hernia and has really, really bad liver disease. Her belly is out to here, huge, huge. She looks like she’s 20 months pregnant and thin lady as most liver failure patients are. And what happened is she got hernia. Well listen, I can fix all hernias, a hernia

Speaker 2 (00:59:20):

In someone who is end stage liver disease. A hernia repair can kill you. So she needs to be better controlled with her liver disease so that the liver disease is under control and then that can fix the hernia. But if you have out of control liver disease, the hernia surgery may kill you. So that was like an issue I’m working coordinating with her hepatologist saying listen, I know you sent this patient to me, but you do know that she’s got like decompensated liver disease. He said, actually I do know that and I knew that if I send her to you that you would do the right thing and tell her exactly what we’ve been trying to tell her, which is you need better control of your liver, you’d be more compliant with your medical treatment of the liver disease. And so thank you first of all, I hope, I wish they had told me that to begin with and not tested me, but it was kind of nice that they said that’s exactly why we specifically sent her to you because we knew that you would do the right thing and educate her how important it is to be medically compliant for your liver failure before submitting to any hernia surgery.

Speaker 2 (01:00:53):

And we knew that you would not just willy-nilly offer her hernia surgery. So on that note, I want to thank you everyone for being with me. Oh, quick question. Is triple neurectomy for chronic postoperative hernia repair pain ever available? A viable alternative as a last resort? Only if it’s nerve problem. How does it compare to dorsal ganglion stimulant implant? Totally different disease process. Totally different disease process.

Speaker 2 (01:01:26):

If someone’s trying to tell you that’s equivalent, it’s not a triple neurectomy or any neurectomy is purely intended to deal with nerve pain and not chronic pain. That’s not nerve related. Alright, that was fantastic. Thank you everyone. I enjoyed it. I hope you enjoyed it too. We have a great guest next week. I’m really excited. In the meantime, enjoy your evening. I’m peace out. Dr. Towfigh here. Follow me on Twitter and Instagram and hernia doc on Facebook at Dr. Towfigh. Many of you are here already on Facebook. Do tune in on my YouTube channel and subscribe so that every week you get an announcement of when I post new episodes of Hernia Talk Live. And I will see you again next week. Thanks everyone. Always a pleasure. Bye.