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Speaker 1 (00:00:00):
Good evening everyone. It’s Dr. Towfigh. Welcome to Hernia Talk Live, our weekly Q&A discussing all things hernia related. I’m your host, Dr. Shirin Towfigh hernia and laparoscopic surgery specialist. Many of you’re joining me on Facebook live at Dr. Towfigh or via Zoom. You may also follow me on Twitter and Instagram at hernia doc. And as always, at the end of this session, our hour will be uploaded to my YouTube channel. You can watch that and all 109 other episodes. So today we have a great guest, Dr. Jeffrey Blatnik. Many of you have been eagerly waiting to hear from him. We’ve actually heard a lot of emails like really eager Jeff. So Dr. Jeffrey Blatnik is from Washington University in St. Louis, Missouri. He is also a hernia and laparoscopic surgery specialist, very talented. You can follow him on Twitter at Jeffrey at Jeff Blatnik. And so please welcome Dr. Blatnik. How are you?
Speaker 2 (00:00:58):
Great. Sound great. Thanks for having me. I feel like I have a high bar to hold up if people are looking forward to hearing me talk, so hopefully we can.
Speaker 1 (00:01:07):
No, I’ve literally had emails waiting for you. When’s this going to happen? So this is for real.
Speaker 2 (00:01:15):
Perfect. Well I’m happy to be here. Thanks for having me.
Speaker 1 (00:01:18):
Oh, well thank you. Thank you for coming. I know it’s always, you’re volunteering your time, so I’m very appreciative of that. And I know that our audience is doing the same. So maybe I can have you first introduce yourself. Where are you in your career? How much hernia surgery do you do? What part of hernia, the hernia world do you enjoy the most?
Speaker 2 (00:01:43):
Yeah, so as you mentioned, I’m at Washington University in St. Louis. I came here straight out of training. And so we’ve been in St. Louis since 2015, so about seven years into my practice. And as you mentioned, I would say 95% of what I do is hernia in one form or another, whether it’s inguinal or incisional and in all different aspects of it. And I think that’s what I really like about what I do mean every day is a little bit different. You kind of go in with a plan of knowing what to do, but every case has its own unique aspects, whether it’s a five time recurrent or something straightforward. And so it provides a challenge and a unique experience every time you step into the operating room. And what I really like is that can, the vast majority of the time you leave the operating room and you fixed a problem, the patients came in with a problem, you do a good operation and they leave with a problem fixed ideally. And I think that’s the best part of it.
Speaker 1 (00:02:42):
Yeah, I think my impressions are weekly session has improved the kind of press about a hernia surgery, but there’s a lot of negative press about it because people who have bad outcomes, which can happen with any operation, are very vocal. And I actually wrote a paper on this where we show that a lot of the negative interaction is kind of promoted by law firms that are profiting from that negative sentiment. But the reality is the majority of patients, vast majority of patients, do really, really well. And that’s always been the case since we were in medical school all the way up to now. And it’s a high, but of course there are complications. And I think part of the problem is like let’s say you have a appendicitis and there’s a complication from appendicitis, the average surgeon should know how to handle that. But I feel that the complication with hernias, if it’s not a recurrence, there’s a lot of other intricacies that maybe at the average surgeon maybe is not able to handle this. And that’s where the frustration comes with patients. What do you think?
Speaker 2 (00:03:54):
No, I totally agree. I mean probably similar to you e C patients who’ve been to five, six different surgeons or have had four or five different repairs along the way, and they’re frustrated. And understandably, I think with those people, patients, our goals are always to try and understand the problem and just have an honest discussion. What can we accomplish? What are goals for this visit? And can we accomplish those, whether it’s with surgery or with other modalities. And I think that’s always a good way to step back from the emotional side of it and really have an informed discussion about yes, we’re surgeons, yes, we fix hernias very frequently, but there’s some things we can do and there’s some things we can’t. And I think just being upfront and honest is really critical.
Speaker 1 (00:04:42):
Yeah, I agree. And what I say is do your research, especially if you have a, I always say for any surgery, any procedure, whether it’s dental or surgical or whatever, always get a second opinion. That’s just a good way of doing things. When I buy, what did I need to buy last week, it was some odd thing my mom wanted me to buy. I did some research on that. I don’t know if it’s a screwdriver or it was something simple from Amazon. I do research on that. And I think for surgery you should do the same. It can be life altering if things go bad. And in the United States, we have a luxury of seeing other doctors. We don’t have socialized medicine and you’re free to travel wherever you want. And now with telehealth it’s even more accessible. You offer telehealth, I assume
Speaker 2 (00:05:30):
We do, yeah.
Speaker 1 (00:05:32):
So you know can be another state potentially. Although state to state difficult in the United States. I do want to say that
Speaker 2 (00:05:42):
That’s
Speaker 1 (00:05:42):
Not easy.
Speaker 2 (00:05:44):
We have to be licensed in that state to That’s correct. But
Speaker 1 (00:05:48):
There’s
Speaker 2 (00:05:49):
Some workarounds.
Speaker 1 (00:05:50):
There’s workarounds. Exactly. So I thought the topic we would choose, because you do all different types of hernia repairs, would to discuss the different types of meshes that are out there. Because in your career since you’ve been in practice, you’ve already seen a wide variety of meshes come and go and newer types of families of meshes coming. So we have some questions related to that. But if you could maybe give a very brief what are the different categories of Mesh is, and then I’ll move into the questions.
Speaker 2 (00:06:27):
So I mean, think Mesh is a critical point of hernia repair. I mean it’s kind of become both a hot button issue, but something that, as you mentioned at the beginning, we use pretty frequently and the majority of patients do well. But as you said, we’re learning more and more about Mesh, the kind of meshes we use and how we use ’em that have greatly expanded the options that are available for patients. So at least for me when I talk to patients about Mesh, I kind of lump ’em into three general categories. And I think that’s an important way to think about it. There’s the kind of traditional Mesh we’ve known for years and years, which is permanent synthetic Mesh nowadays that’s typically made of different kinds of plastics in different manners, but it’s Mesh that’s meant to be there forever. The next generation that kind of came around was what we call biologic meshes. These are usually made from a biologically derived tissue, whether that’s human skin or porcine skin and pretty much every other thing you could imagine along the way. Yeah,
Speaker 1 (00:07:27):
I think they’ve had cow rabbit.
Speaker 2 (00:07:31):
Yep,
Speaker 1 (00:07:31):
Human. Yeah, there’s
Speaker 2 (00:07:33):
Sheep suppressed liver. Yeah, sheep stomach, like you name it, somebody’s tried to make a material out of it. And I think the intentions for those were really good and trying to find something that wasn’t potentially permanent, something that provided a more natural scaffold, ideally for hernias to or for the repair kind of cellular ingrowth and stuff like that, where those will end up long term I think is to be determined that there’s probably some indications for them. But I think it’s like everything in medicine and in life, there’s a huge pendulum swing one way or the other. And then finding where that ultimately will balance out.
Speaker 2 (00:08:17):
And then I think the last category is the newest ones that are out there, what we kind of call biosynthetics. So they’re kind of biologically derived, but still a synthetic material. And the idea behind that is it has some of the Mesh characteristics of the permanent meshes that we used for decades, but it’s still not a permanent material. And so the Mesh eventually goes away with time. And I think that will see a similar pendulum swing to all the meshes. And I think we learn more every year about which patients and which hernias benefit from which Mesh. And not every patient needs Mesh. Not every patient needs permanent Mesh. So I think it’s an important discussion to have with your surgeon who you trust, what the benefits of Mesh are and what are alternatives if there are any for you specifically.
Speaker 1 (00:09:11):
That’s very true. Again, not everyone needs Mesh depends on the hernia and the circumstance. And then not all meshes are created equal and not every patient would need the same exact Mesh. So the beauty of it is I think people like you who are specialists, understand the different companies, the different Mesh available and can kind of tailor to the needs. I feel that surgeons that are general surgeons that don’t necessarily have an actual hernia interest, they have a match they always use and that’s kind of their thing. And usually that’s fine, but sometimes I think tailoring to the needs of the patient may help benefit them a little bit more. I was looking at our questions and actually the very first question is exactly this question, which is how has Mesh evolved as it was first introduced? Do you want to maybe address that a little? You already talked about the different families of meshes through the years, but do you think we’ve actually evolved towards a certain type of Mesh or weight of Mesh or shape of Mesh or anything like that?
Speaker 2 (00:10:18):
Yeah, I mean this can get very, very technical very quickly, and obviously we don’t want to spend an hour talking about nuances of poor sizes and Mesh densities and all those sorts of things. But yeah, I think it has evolved some, we’ve learned a lot about the construct, how it’s put together as you mentioned the weight or how heavy the material is. We know there’s different types of coatings and things like that. And I think just as much as the type or even the brand specifically of Mesh, that’s changed What what’s changed a lot is how we use it. And I think that’s a big advantage for a lot of people is we’ve learned a lot about how to use Mesh more safely that at least in our experience we’ve seen has been beneficial. So I mean yes, Mesh has evolved. We’ve learned I think just as much as we learned what’s good about Mesh. So those characteristics that are helpful, we’ve learned once to try and avoid. Unfortunately that takes years before those things are vetted out. And so we continue to try and improve the kind of Mesh that we use. And yes, it’s evolved, but I think we’ve evolved a lot too as surgeons and how we use it.
Speaker 1 (00:11:23):
What are some meshes you think we’ve moved away from or techniques we’ve moved away from?
Speaker 2 (00:11:28):
Yeah, I think some of the specific characteristics that we’ve seen is either positioning rings, those got into trouble. I think there’s a balance in weight or densities we’ve learned you can be too dense, you can be too light and that there’s Mesh fractures. I think there’s been a general shift away from some of the hybrid meshes with different types of synthetic coatings due to some different characteristics in how they shrink and those sorts of things. So those I think have improved. And again, that’s come with time and knowledge.
Speaker 1 (00:12:03):
I feel that in general, less is more in general. So back in the day there was three layered Mesh, right? There’s like E P T F E and two layers of polypropylene plus a ring and you put in laparoscopically and the patient was like, I feel like I have armor in me. And they kind of almost did. They couldn’t bend, they couldn’t be active. I had a construction worker like that. It was just too much Mesh and you don’t need something that’s so thick and so heavy, the cardboard being put inside you. And then we flipped the other way and they made it Mesh that was so lightweight and so thin that like you said, it was Mesh fractures. It was actually tear open the same way that if you wore a really tight outfit but it was thin, let’s say silk or something, it’ll just tear.
Speaker 1 (00:12:52):
So yeah, also I think we’re moving away from Mesh. That’s too dense. Plugs a big ball of Mesh. We don’t think a ball of Mesh is good. Maybe a flat Mesh is better than anything that’s has a lot of volume to it or besides just density. So I agree with that. Nothing, it’s kind of like the Goldilocks not too tight, not too, not too heavy, not too lightweight. But then if you have someone who’s say 500 pounds or whatever the situations 200 pounds, that’s going to be a different Mesh choice than a ballerina. Right? Agree with me.
Speaker 2 (00:13:32):
Yeah. And I think just, so yes, there’s patient characteristics that change that. I think there’s also hernia characteristics. So where the hernias located right in the belly button, is it off on the side? Is there other associated injuries that we see? Yeah. Where we’re more reliant on the Mesh to be a strength layer than just a reinforcement scaffold sort of thing? Yeah, I mean the patients make a difference. The hernias make a difference. I completely agree with your comment about moving away from plugs or big pieces of Mesh, jumping them in holes. I mean, back in the day, maybe that made sense, but it’s certainly not what I would want on any of my friends or family, that’s for sure.
Speaker 1 (00:14:11):
And that message is slowly making it through. But I still think last year it was at Sage’s, there was a video, was it, I think Sages was a video where they laparoscopically put a plug in and I was like, I had to get up and say something, but I could hear the whole audience say, yeah, how did that get accepted to be presented as a novel technique? Yeah, I have a patient who, so there’s a dilemma because, so he’s a smart guy, really bad car accident or maybe motorcycle accident, really bad accident, lucky to be alive. Anyway, long story short, he now has this huge, what we call traumatic flank hernia repair. The muscle is just completely pulled away and he’s missing muscle. Plus it’s pulled away. So there’s a intense reconstruction. There’s no way I can do it without using something to replace all that missing muscle. So I need Mesh and I have to use a heavier weight Mesh because I can’t just put in something super thin. But he’s reading and he’s like, why can’t we do this tissue repair? I know you do tissue repairs. I’m like, I do but not for you. And okay, I want a lot of weight. Mesh, how about a biologic? I’m like, no, for you, you need intense surgery. It’s very different than someone with a little hernia.
Speaker 2 (00:15:39):
And I think that’s important. I think that’s important for patients to I it’s okay to do some research and have some understanding of those sorts of things. And I think it’s an important subject to talk to your surgeons about and ask them. And if it’s somebody who’s like, well, this is just the way I do it, sorry, I think that warrants some further explanation as opposed to seeing someone like you or myself who’s experts and can describe why and what the alternatives are or maybe may not be for those types of patients. I think that’s an important thing when picking a surgeon.
Speaker 1 (00:16:14):
Here’s another question. What are your feelings about anatomically shaped meshes like the 3D max as opposed to flat Mesh?
Speaker 2 (00:16:21):
I think there’s some benefits to it. The agreed, we think about patients, Mesh is a comes in a square most of the time we are not squares. And obviously the growing I think is a little bit different than the abdominal wall, a 3D contour space. And so I think it’s helpful to allow it to sit in there a little bit flat. And again, not to get too technical, but we know some of the characteristics of why hernias in the groin recur usually along the inferior edge. And we’ve seen some flat meshes when you put ’em in as they fold to that contour, they kind of curl up like that. And so you can be at risk for recurrence underneath. So I think there’s some value in for them, especially in the groin.
Speaker 1 (00:17:04):
The anatomically curved meshes that follow the curve of whatever recreates the anatomy better. I think as always, always good. All right, here’s the next question. And by the way, being technical, you’re going to see these questions. They’re pretty intensely like insightful, so it’s okay to be a little bit more technical. Perfect. This audience is amazing. Okay, so here’s a question. As you previously said, Mesh complications are rare, but when they happen, they can have a high degree of severity and be difficult to fix. Would not classifying all surgical Mesh products as class three high risk devices help in diagnosing and managing those complications by introducing and enforcing lifetime monitoring of patients who had Mesh implanted?
Speaker 2 (00:17:50):
That is a really, really good question. And I think there’s, again, there’s a whole spectrum of that question that you can talk about and that comes from education and knowledge of what’s putting in as surgeons even sometimes we see the surgeons don’t even say what they put in, let alone the patients knowing what they put in. So I think there’s definitely value in having this long term follow up available where we can have a better understanding of what happens with these meshes. And that’s where a lot of the data that we make decisions come from European countries where they have a centralized healthcare system where they can follow these patients more long term. And so we’re a little bit behind in the United States on that one. I think the biggest barrier here I is really just the logistics and the challenges of it. Not to say it’s not important, but I think the funding and all that sort of stuff is always a challenge in anything in healthcare. But I think it’d be really helpful for us as researchers and people who study and put Mesh in to know what’s going on. Yeah, long term.
Speaker 1 (00:18:58):
So currently in the United States, FDA approves or clears meshes as a class two device. They are not currently class three in the European Union. The meshes have now officially all meshes, hernia meshes included, have been upgraded to a class three or high risk device. And that implies additional research and additional human data and post-marketing surveillance, which means it matches in you, but then they have to follow you. And I remember before this became official because they kind of gave a two year warning to the European societies, they’re like, that’s great, but who’s going to do this? Who’s going to follow pay for it? Because it’s very expensive to have prospective follow up. And in Europe it’s now mandated because that two years has gone by that no Mesh can be sold unless there’s human data as opposed to relying on historical data. That has not happened in the United States yet. And I feel like the F D A is kind of watching to see what happens in Europe to see how is this affecting hernia care and access Because for pelvic Mesh, different anatomy, different disease process, they have gone from class two to class three, so they re-categorized pelvic meshes to high risk devices. As a result, almost no company even offers pelvic mes anymore. Maybe that’s some people that’s a good thing. But there are situations where the surgeons have nothing to offer the patients.
Speaker 1 (00:20:49):
So I Do you think they’re going to go for it in the us
Speaker 2 (00:20:52):
I think they’re making some headways in that even though it hasn’t been reclassified, there’s more emphasis on long-term outcomes, there’s more emphasis on patient reports and those sorts of things. So I think we’re starting to get there, but as you mentioned, who, who’s going to do it? Who’s going to pay for it? We have trouble, and you may be similar, just getting patients to come back for their one year visit, for us to check how they’re doing even if we schedule it. And so ultimately I think patients are a partner in this and that we need patients to be engaged and understand, I’m asking you to come back so we can know how you’re doing. And so we can learn. I mean some of it’s social, I like to know that you’re doing well, but patients are a partner in this whole experience. So I think that’s important. I think we’ll getting there, but I think it will take some time. I do think the point you made of potential that we may end up having less and less manufacturers or companies making Mesh for even hernia repair is a potential real thing. And as you mentioned, there are some patients where Mesh is critical to giving them any sort of repair. And I think that’s an important thing to keep in mind as we balance the whole Mesh debate out.
Speaker 1 (00:22:09):
I think all or none, all Mesh is evil and kills people and should be banned is really a disservice. It’s like saying having a bad, we had this debate on Twitter actually the PA past day or two with Eric Polly and some others, and he used the car analogy. I’ve used the car analogy before too, to say that there are issues with cars because you can have car accidents and people die. Doesn’t mean you should get rid of all cars, right? You can have regulations, seat belts, air bags, whatever, better construction or speed bumps and speed control. But the same is true for products that we use as implants. Okay, another question. Can the cut edges of Mesh be sharp and cause pain? That’s a good question.
Speaker 2 (00:23:06):
Pain is a hard one. There’s a lot of factors that can or cannot cause pain. And I think to answer that question, can it? Sure, I guess potentially, but there are a lot of things you need to really sort out and investigate Before I would just say, oh yeah, it’s the edge of the Mesh that’s causing pain. The kind of Mesh that was used, where it was placed, how long it’s been there, what other surgeries have happened, was it you had this pain beforehand and now we still have pain and so is it the Mesh that’s actually causing the pain? So I think there are a lot of factors in that question that make it hard to say a yes or no answer that I think you really seem to be cautious with.
Speaker 1 (00:23:50):
There used to be meshes where you weren’t supposed to cut it. Yeah, the triple Mesh, I was talking about the composites, Mesh, you should not cut it. And some surgeons didn’t know that and they cut, there was fistulas and so on because you had sharp edges. But most of the meshes currently in the market. I’m trying to think of any meshes where you can’t cut it. I think almost all of them out there right now you can cut because yeah, I think there’s some of the
Speaker 2 (00:24:18):
Hybrid ones, the biologic, synthetic hybrids, the way that they’re woven together. I think if you cut it, you potentially can undo some of that. But in general, I agree. I think we’re okay cutting meshes. And I think that’s also a good feature because we know, kind of thinking back to that plug comment you made before where Mesh is folded or excess meshes there, that doesn’t as well as we would like it to. So I think it’s a good characteristic
Speaker 1 (00:24:48):
To have. Yeah, agree. Here’s a patient two years out for repair and I still have sharp stabbing pain in my belly button, so sounds like a belly button, hernia repair. And besides it, it’s now leaning down and over to the right ovary. What do you think that could be? It makes me gag to puke and I was in bed all night and all the next day. Other than that, it hurts daily to get very bad. And at times CT scans and labs are normal. So this is, let’s say a two years out for an umbilical hernia repair and they have sharp stabbing pain. That’s not normal.
Speaker 2 (00:25:24):
No, that’s expecting, I totally agree that that is a rare thing happens. Yes. But I think that goes back to the whole trying to get a better understanding of what’s causing that pain, what’s causing those kind of symptoms. And that can be hard. Yeah, there is not a perfect test that you just go like, oh, let’s go do this scan and it’s going to show us exactly what’s going on. And unfortunately these situations, especially when it’s now two years, it’s process of elimination. You kind of rule out one thing and you say, okay, well it wasn’t this, so we’ll put a laparoscope in and make sure there’s no adhesions. Okay, there’s no adhesions. So a lot of these scenarios take some time to sort out, and I can understand it being frustrated as the patient for sure when it’s completely impacting your quality of life and your daily activities. But again, it’s not a simple, oh yeah, I’ll just go do this operation. It’s going to instantly cure everything. It takes some time.
Speaker 1 (00:26:24):
So here’s a detail, what if no Mesh was used for the belly button hernia repair and now they have sharp stabbing pain.
Speaker 2 (00:26:31):
That also changes a lot of things I think in those situations. And even if Mesh was used, you know, want to rule out common sources for paint, did the hernia come back? We know that right, exactly. Happened. Is there some other reason for that sharp stabbing pain and unfortunately as I mentioned earlier, sometimes you just have to start checking things off the box and so if it’s never had Mesh, you can still have that sharp stabbing pain. And whether that’s our tissue around a local nerve or something like that, that can be difficult.
Speaker 1 (00:26:59):
It’s pulling apart, you’re too tight and it’s trying to tear, so you’re actually just feeling a tearing sensation of the abdominal wall, which will may eventually lead to a hernia recurrence. So those are all really good. And then what do you do with those? Do you go straight to imaging first? Do you inject anything?
Speaker 2 (00:27:19):
I usually like to do imaging first. Yeah, I think it’s helpful to rule out those common causes of pain where you can say, okay, we see that the hernias come back, so here’s our algorithm for addressing that. So I like to start with some form of imaging just to give us some baseline and then for me, if that’s negative or doesn’t give us a good answer for pain, again, getting a little better understanding of what’s causing the pain. Sometimes we’ll go partner with our multidisciplinary pain management team who will, we’ll look at involvements of physical therapy and massage therapy and those sorts of stuff. If my level of clinical concern for either it’s come back or there’s something wrong, say there was Mesh put in, we’ll we’ll consider a diagnostic laparoscopy or things like that on occasion, but again, that’s patient by patient specific and really an intense conversation that we have with everybody about why we’re doing these different things. What’s the likelihood we’re going to find an answer and have something to act on.
Speaker 1 (00:28:19):
Yeah, exactly. I would say that if they had her belly bone hernia pair and from the very beginning it was tighten and burning and just never got better, just got worse. And probably it was maybe too tight of a repair without Mesh. And that’s just tearing apart imaging, especially a CT scan with Valsalva where you’re pushing out to recreate any small hernia is the first start and then maybe injecting to see if it gets for the pain. It may or may not. Are this an obese patient, we’re losing weight, maybe we’ll take some attention off of the repair and reduce the pain.
Speaker 1 (00:28:57):
Sometimes you just have to, if the clinical story is good enough and the tear may be so small that they actually do need Mesh in there to take the tension off a primary repair. Sounds like she had injections which didn’t work and they took out her stitches recently and she’s still in pain or she, I’m not sure. I guess she, because they’re over questions, but this is where you can’t just mess around with random doctor that’s never done this before because you’re going to get delaying care and maybe all they’ll say is go to pain management and then maybe something treatable.
Speaker 2 (00:29:42):
Yeah, I think pain management is both, is certainly beneficial. We’re pretty fortunate here that we have a good multi-disciplinary team, and so when we send patients to pain management, it’s not just they’re going to give you narcotics to take all the time. We work together with them to try different regional blocks. We work together with physical therapy, massage therapy and multidisciplinary stuff. Really the intention is not to just give you medications but see if we can find other methods that will help with your pain.
Speaker 1 (00:30:12):
Yeah, totally agree. What I don’t like is a surgeon who says that doesn’t follow up and then sends everything to pain management and then the patient goes down this whole pain management trial to the point where they get like, oh, you need a pain stimulator or what’s it called? Spinal stimulator or a pain pump. And I’m just like, no, your hernia just recurred or something like that I can fix. Right.
Speaker 2 (00:30:35):
Yeah, and I completely agree. And that’s usually for when we see them directly, it’s rule out the common things that you can intervene upon before you go down the rabbit holes of some of those other alternatives.
Speaker 1 (00:30:49):
The next question is relatively straightforward. Can you safely fixate Mesh place laparoscopically to the Cooper’s ligament?
Speaker 2 (00:30:58):
I would say yes. Whether that’s with sutures, if you’re doing things robotically, if you’re tacking, I don’t necessarily put a tack directly into Cooper’s if we use that sort of fixation. Yes,
Speaker 1 (00:31:11):
Agreed.
Speaker 2 (00:31:12):
But usually just in the tissue above, and to be honest, for smaller inguinal hernias, there’s good European data that you may not even need much fixation at all if you have adequate Mesh overlap, which I think is probably more critical than any fixation method. Right. Getting an adequate repair and overlap. So I would say yes, but lots of variables, everything.
Speaker 1 (00:31:35):
There’s a question about that very specific thing, but let’s do this question and then we’ll do the next one. So the question is, I had a small recurrent, I think inguinal hernia due to flipping up of a Mesh implanted 20 years ago. It was repaired using a 2.5 centimeter by one centimeter piece of ultrapro Mesh to bridge the gap. That’s not even an inch.
Speaker 2 (00:31:59):
I know. I was going to say that is tiny.
Speaker 1 (00:32:01):
That’s like the thumb size of my thumb. The new ultrapro Mesh will suture to the original Mesh which had been fully incorporated. Is this an appropriate and safe way to treat this type of recurrence?
Speaker 2 (00:32:15):
I think we need a little bit more information to know for sure. Yes. Kind of like where the hernia was, kind of how it recurred, what happened, those sorts of things to say for sure. Without knowing that information, it’s a little bit hard to say as far as the safety and all that sort of stuff. But as far as I’d
Speaker 1 (00:32:33):
Say not effective, I would say it would not be effective.
Speaker 2 (00:32:36):
That would not be my first choice. I think that’s a safe way to put it. And again, that goes back to the comment when we feel Mesh is appropriate, when we decide that Mesh is appropriate for a patient, I think what’s critical is to make sure that you’re using again, the right Mesh that’s the right size and the right indication. And I can’t honestly say that I’ve ever put a 2.5 by one centimeter piece of Mesh in anybody and felt that that was met all those requirements.
Speaker 1 (00:33:07):
Have you ever used a two and a half by one centimeter piece of Mesh for anything?
Speaker 2 (00:33:11):
I don’t think so. No. I
Speaker 1 (00:33:12):
Don’t remember either.
Speaker 2 (00:33:13):
It’s pretty small.
Speaker 1 (00:33:16):
Okay. So let’s break this down a bit. What are your thoughts about Mesh to Mesh bridging, like old Mesh is there and you just use a new Mesh to bridge the recurrence on the side of the old Mesh?
Speaker 2 (00:33:29):
So the way I talk to patients about this is I use the analogy of shingles. You talked about cars before. I use shingles in this situation and that if you get new shingles on your house, most of the time they’ll take the old shingles off before they start with new shingles. And so my preference in these situations is to try and take the old Mesh out, kind of start from scratch. There are certainly some, again, some caveats to that statement is taking the old Mesh out going to be more dangerous than leaving it in that situation if it’s on or near critical blood vessels or different things like that where taking the old Mesh out may make you worse Also, where it was, is it in between different muscle layers previously? Were now going to cause muscle trauma trying to take all that old Mesh out. So there’s certainly some situations where I will not, but my preference if I can safely do it, is to take the old Mesh out before I put any sort of new Mesh back in.
Speaker 1 (00:34:27):
Very good. So the way I describe it is the way Mesh works, once you put it in, it’s not neutral. It starts an inflammatory reaction and that reaction is what allows the Mesh to kind of incorporate with the muscle. But 20 years later that Mesh is piece of paper. I can put a piece of paper against the wall, it’s always going to fall. It’s not going to stick. It’s like an old sticky, the glue is gone. So the new Mesh, however, will have that, we’ll restart the process, the inflammatory process, but to think that Mesh is going to somehow stick to Mesh or you can kind of force to be together, I think it’s not an effective way of treating. Most I do, I’m I’m more of a purist like you are, and I take out the old Mesh almost always and kind of put in the new Mesh or at least take it out where I need the old Mesh, the new Mesh to be because it doesn’t work otherwise.
Speaker 2 (00:35:28):
Yeah, I agree. Plastic is not going to heal in or
Speaker 1 (00:35:32):
That doesn’t grow into plastic plastic. So the other point of the question was, but that first Mesh was already fully integrated into the external bleak. I take out grow Mesh all the time. They’re always fully integrated. I think that’s an irrelevant kind of reasoning to do this patch approach. But what do you think?
Speaker 2 (00:35:57):
Yeah, again, I think it comes back to why you’re going there, but is if it’s somebody who had a say an opening inguinal hernia repair done 20 years ago with Mesh, yeah, did fine for 20 years and now has a small symptomatic recurrence or a symptomatic recurrence where it’s not a Mesh problem, it’s not a pain problem, it’s a recurrence problem. I think in those situations I’d consider going in minimally invasively and fixing it from the exactly out and probably not touching the old Mesh because if they’re not having problems with it, your risk for injury to, if it’s a male, the testicular vessels, the vas deference surrounding tissues, the risks of that happening don’t outweigh the benefits of taking it out. So I think in those situations, I try to think of all if it’s a groin hernia, alternative methods for repair. Now if it’s somebody who’s having pain and you think the Mesh is one of the features or one of the culprits for it, and I think that’s a different situation. But if you’re strictly operating for recurrence, then I think you have to decide are the risks and benefits balanced out?
Speaker 1 (00:37:01):
Right? Cause the safest, most effective and appropriate using the terms of this question for hernia recurrence from an open surgery 20 years ago would be to go in laparoscopically and not do it the same way as a first one. Yeah, totally agree with that. All right. Next question is related to what you were mentioning earlier. So in Europe, the syndrome of sports hernia or athletic pubalgia is at times treated by laparoscopically placed Mesh in a Manchester repair fashion. I don’t know if you’re familiar with this term, but Dr. Ali Sheen has term the Manchester repair. It’s basically a laparoscopic repair without fixation and sometimes using fibrin glue as your only fixation, but no mechanical fixation. In your opinion, is this a valid way to treat this and how does it address the pubic plate instability associated with athletic pubalgia?
Speaker 2 (00:37:55):
Ooh.
Speaker 1 (00:37:56):
Right.
Speaker 2 (00:37:57):
Yeah. Is a, yeah, I take back my technical comments told you. So I think sports, hernia, athletic pubalgia, whatever kind of term you want to put on it, yeah, it’s a difficult subject in that some people are pure believers. Some people say it’s not a real thing. Some people say surgery from everybody, some people say no surgery. So it really depends who you see and who you ask. And so my suggestion to patients in these situations is find somebody who does this a lot. Not somebody who’s like, oh yeah, sure, I can some Mesh in there and see and get their input. So I think it’s a balance. I certainly think that if you believe this is a muscular instability sort of thing as the culprit of the pain and you’re trying to provide some strengthening or reinforcement to some of that stability, I think there is potential value in that sort of repair. But I think that’s where, again, it’s important to see somebody who has expertise in this, who studies who follows their patients. I think those are all really important things as you’re looking for a surgeon to take care of this.
Speaker 1 (00:39:17):
And those that do a lot of athletic pubalgia in two camps. One is that everything has to be done open and kind of reconstruct the pelvic floor and the attachments of the rectus and adductor and so on. And there are others that are like, no, we can do this retro muscularly just put in a Mesh that can kind of support and take tension off the other muscles. But I feel that a lot of times those are just people that have hernias and it is not really a athletic pubalgia and it’s therefore the hernia repair works. I don’t know. I haven’t not in either camp.
Speaker 2 (00:40:03):
And I think it can even go the other way. And that there’s patients who have athletic pubalgia who are told they have a hernia and get surgery in one form or another and still have their pain syndrome. And now all of a sudden then you’re left talking about like, well wait, is it the Mesh that’s causing it? The pain? Was it pain? Was it the pain you had before surgery? And so that’s where they can get really challenging.
Speaker 1 (00:40:27):
This question’s a good one because I think it’ll give some good kind of addressing some misinformation that’s out there. So the question is this, my hernia recurrence manifested itself 25 years after my plugin patch. So we already talked about plugin patch. It was very common in the, I would say very late nineties, early two thousands. That’s when it kind of peaked and then people still do it. Also, I have a feeling that some problems that arise never get attributed to Mesh when they should. Although link is the undoubtedly hard to find in many cases. For example, I have a tumor in the neck of my bladder. And after studying the literature, I learned that there are a number of cases where shards of decomposing Mesh can cross anatomical plains and even end up in the bladder. And that sometimes these growths are the result of calcifications building up around the irritant, which in this case is the shard of the Mesh. Do you want to address this?
Speaker 2 (00:41:32):
I think they make a very good comment in that statement in that it’s a hard thing to isolate and differentiate on one patient or another. Did that happen? Did that not happen? And so I think it can be very difficult to know for sure in one patient versus another to clearly say, oh, it’s this microscopic fiber of Mesh that has or has not migrated. And so I think just as hard as it is to prove it, it’s also probably equally as hard to definitively say, Nope, this didn’t have anything to do with it at all. Right? And so I think that it’s a challenging situation and I don’t have a good answer for that to be honest, to say yes no. But I think it’s a difficult situation and certainly there are things that happen that we can’t explain no matter how much we’d like to look it up in a textbook or in a paper and say, oh, this is why this happened. This is why you’re hernia camera, this is why you have a tumor. It can be very difficult to put any sort of definitive answer on it.
Speaker 1 (00:42:33):
So there’s a lot of talk online about Mesh migration and it really comes out of the lawsuits. Yeah, but can you address, do all meshes migrate? The short answer is no. But can you explain Mesh migration and why people are so hung up on like, oh, my Mesh migrated and I have migration. What if I have migration of the Mesh?
Speaker 2 (00:43:00):
I think it, so I agree. Does all Mesh migrate? Not necessarily. I think it really comes down, the first thing you need to answer is what does migration mean to you? Yeah. Because what migration means to me may be different than what a patient who says, my Mesh migrated what that means to them, or another physician or anybody. So I think that’s an important definition to put out. So when I hear migrate, I think of it’s moved, it’s come loose and now it’s migrated to someplace else. And so can that happen? Yes. Does all Mesh migrate? No. Correct. If somebody has a recurrent hernia, for example, and it recurs off the side of the Mesh, their hernia was here, they put a Mesh in like this, and now they have a recurrence off the side of the Mesh. Yeah,
Speaker 2 (00:43:43):
I don’t think that’s because the Mesh had little feet and migrated off to the side. I think it comes down to the characteristics of the hernia repair and the patient characteristics and all that sort of stuff. So in that situation, I would say that’s not a Mesh migration problem. There’s multiple factors. Why or why not that hernia may have come back? And the things I really [inaudible] about migration is yes, Mesh that’s either broken loose from the abdominal wall of its attachments or wasn’t adequately attached to begin with, whether that’s a plug or a ventral hernia Mesh and now it’s located someplace else. That’s what I think of for migration.
Speaker 1 (00:44:17):
Yeah, I think the term migration was mostly used with the plug. We keep bringing up the plug this hour, but the plug and patch, and if people were not fixing the Mesh in at least three areas, it would flip around and or move. This whole issue of migration, erosion penetration, the way that plug was, depending on where it was placed and how it was placed, there were situations when it eroded into bladder, it eroded into the intestines and it migrated, was found somewhere else deeper in the pelvis than where it was originally placed. I don’t know that most other flat meshes migrate. They can fold, they can shift maybe, but to migrate actually physically move to a different part of the body, I think that’s classically a Mesh plug issue. And then in terms of these shards, I don’t know about shards. I don’t know anything about shards making its way into another tissue plane. That’s not something that we experience or see. Yeah, I feel like a lot of this discussion sometimes is in forums and they become real. But if you ask someone who does it for a living, we’re like, no, that doesn’t happen.
Speaker 2 (00:45:43):
Yeah, I agree. I think, can we see Mesh erosion in the tissue? Sure, we can see that. Yes. Again, not common, but we can see that. But to have these microscopic pieces of it migrate into other places, it’s just hard to prove. It’s very, very hard to prove.
Speaker 1 (00:46:00):
What are your thoughts on hybrid Mesh? So part synthetic, part absorbable biologic,
Speaker 2 (00:46:10):
I think the argument for those is you get the best of both worlds. You can have some material and then it goes away. You get the benefits of biologic and you get the be benefits of permanent synthetics. But I think the flip side of that is you get some of the downsides of both, you know have permanent material that’s left forever. So is there value over using a traditional just permanent material to begin with? And same thing with some of the different biologic materials that we know, whether it’s poor ingrowth or poor fluid penetration or things like that. So I think the idea was you get the benefits of both, but I think the trade off is you get some of the downsides of both. So it’s not a common part of my practice for those reasons.
Speaker 1 (00:46:55):
Okay. Here’s another question for you. For incisional hernia patients, are there any new studies aimed at improving wound healing? To the point there that non-absorbable permanent materials and the patient’s own long-term immune system activation can come with them that come with these non-absorbable permanent materials, can be avoided while minimizing recurrence rates at the same time. So he is talking about is there a Mesh or are there meshes out there potentially in the future where you’re putting it in there, it will heal without necessarily messing up someone’s like inflammatory response or autoimmune response risk and not recur?
Speaker 2 (00:47:44):
I think ideal Mesh, yeah, I don’t know of any active studies, but I think it’s a really interesting question. And so this goes back to what I said at the beginning, kind of these different styles of meshes and some of the absorbable ones that are more prevalent now. And there’s a big push of saying, well, we should use those for the high risk patients, whether it’s concerns for infection because of smoking or obesity or diabetes. So there’s been a big push. Those patients that are at high risk for infection, which is one of the things we worry about with Mesh, should have non-permanent Mesh fine. But I think there’s a whole other subgroup of patients where those actually may be beneficial. And that may be the overall healthy patient who’s a normal BMI who will probably heal but needs some temporary support and reinforcement to get them over the healing learning curve. And so I do think it’s something that as a practice as a group, we probably need to start looking in that should we start using non-permanent meshes in the healthy patients in the mid-sized hernias as opposed to saying, oh, well they’re low risk, so we’ll just use permanent material. But I don’t know any of those active studies going on right now.
Speaker 1 (00:48:58):
Yeah, I’m not there yet. I don’t know that we have enough data to support using absorbable products, whether synthetic or biologic as standard of care. I don’t know how you feel about that.
Speaker 2 (00:49:14):
I agree. I think there are a lot of things to take into consideration there. Not that cost should be a factor that decides the care we provide patients, but it’s part of the whole equation. So knowing that some of these meshes can cost tens of times more than other Mesh options, I think is an important part as we try to be good stewards of healthcare costs, especially if there’s no clear clinical benefit, I think it’s an important conversation to have with patients. And again, I go back to that term I used earlier and I use a lot of goals. What are your goals for the operation and what are the risks of different Mesh choices? Some people who maybe had a Mesh infection in the past for whatever reason, and they’re now come back down the road, they may say, listen, I would rather take a higher risk for my hernia to come back if I had a lower risk for another Mesh infection. And you may get another patient who’s had three repairs and three recurrences and they’re like, listen, I just do what’s going to give you the best long-term repair. That’s the risk that’s more important to me or the benefit that’s more important to me. So that’s where goals of the operation are different for everybody. And so it’s not a universal statement.
Speaker 1 (00:50:25):
It’s like the car analogy. Do you need a car to take your kids to school or for grocery shopping or to have fun on the weekend as a two-seater? I can’t say there’s one perfect car. Yeah, exactly right. It all depends on the person. So what do you think we we’re moving towards? You think that, are we moving towards less synthetic permanent Mesh? Are we moving towards less inflammatory components to the Mesh? What do you think we’re moving towards?
Speaker 2 (00:51:07):
I think it’s, again, it’s a pendulum swing. And I think it’s different for every hernia. It’s different for every patient along the way. So I think as we get a better understanding of Mesh in how we use it, we’ll find patients that maybe don’t need permanent synthetic Mesh that we historically would’ve just said, oh, here’s a Mesh we have, we’re going to use it. But I think that that is still very much in its infancy, as you mentioned just recently. Yeah. So I don’t envision permanent Mesh going away. Yeah, I think there are patients that clearly provides the best clinical benefit for them based off of their hernia and their characteristics and all that sort of stuff. I think we’ll probably see less of the traditional biologics as we’ve always kind of known them again as we learn a little bit more about how Meshes interact in the body. But I think a lot that’s changed is again, that how we use it part just as much as the kind of Mesh we use for hopefully the benefit of patients.
Speaker 1 (00:52:11):
I go back to the year 2002, I think 2000, 2003. Yeah, 2002. And I had this lady, she had 15 hernia repairs and then massive infections, massive and obese. And it was just a horrible situation where I had to take out all the infected Mesh. And I don’t know how wide her defect was. It was well over 20 centimeters. And she was obese lady and diabetic. And I’m like, how am I supposed to put her back together again with infection with this huge, I couldn’t close it. There’s no way. And at the time I worked at the county hospital, so we were a big burn center. So we had access to AlloDerm like there was no tomorrow. It was like we were probably the world’s largest user of AlloDerm, mostly as a cadaveric skin replacement for burn victims. Yeah. But I had access to a lot of AlloDerm.
Speaker 1 (00:53:10):
And back then, you don’t remember this cause you were too young. Four by six, that was the largest piece available. I sewed, and I’m very embarrassed to say this, but I think I sewed 20 pieces together. Not joking. She was like a quilt, a patchwork that said she closed, no more infection, was able to go home. She was in and out of the hospital for three years before that with infections. And no one would tr, which I, and I saw her, I want to say three years later, where supposedly all that AlloDerm is gone and all she has is like skin. Yeah. Yep. But she was morbidly obese and she didn’t look bad. She didn’t look like she had a massive problem, but in retrospect, I don’t know what else I would’ve done, but in retrospect, that was not the right thing to use that much biologic. Oh. And I couldn’t close skin, so I backed it. She wouldn’t grew tissue over it. So I was able to watch AlloDerm become vascular and grow blood vessels. It was the most unique experience ever. We don’t do that anymore. No, we don’t overuse biologics like that anymore.
Speaker 2 (00:54:31):
Yeah.
Speaker 2 (00:54:33):
I think in that infections that the setting of either active infection or past infection really changes the discussion a lot. Especially if it’s M R S A and for that patient. So they may have a recurrent hernia, but you’ve fixed a problem that they came in with a chronic infection in and out of the hospital, all that sort of stuff. So I think if you think about what your goals were for walking out of the operating room on that day, you knew you weren’t going to give him a permanent hernia repair. Or maybe at that time we thought the biologics would be a permanent hernia.
Speaker 1 (00:55:07):
At that time we thought whatever you sew it to, it’ll be that. Right. You sew it to fascia will be fascia.
Speaker 2 (00:55:11):
Yeah. It just turns into fashion. But nowadays we know that’s not the case, but wasn’t what you were trying to accomplish for that.
Speaker 1 (00:55:17):
We didn’t know back then. We didn’t know back then. There’s a comment right now where someone’s really unhappy that we’re saying a lot of, we don’t know. I don’t know. And we’re not talking in very definitive statements like, this is the right Mesh, this is good, that’s bad. And that’s the reality. I know patients want us to be able to give them definitive question answers, but listen, I thought I was doing the best thing for this lady, and maybe I did because she no longer had infections. This is 20 years ago. But I know so much more now and many of the patients I treated back in 2002, I would not do the same in 2020.
Speaker 2 (00:55:56):
Well, and I think to the commenter’s point, it’s a little bit hard in these non-specific scenarios to say here’s the right one, but, and I don’t want to speak for you, but I would say for most patients, when we see them one off, we will leave the office visit with a pre definitive plan and a very definitive discussion about what we’re going to do and how we’re going to do it and those sorts of things. So on a patient by patient basis, I feel very confident in telling ’em what we’re going to do and why we’re going to do it. It may not have all the answers, but I’ll be able to give them a definitive plan. But in these general scenarios, there’s so many things that you just can’t take into consideration that make it hard to say it the best Mesh is.
Speaker 1 (00:56:43):
Yeah. Whatever
Speaker 2 (00:56:44):
Brand you want to say.
Speaker 1 (00:56:45):
Yeah. We don’t know. Is polypropylene better or polyester is there’s, there’s P V D F in Europe that we don’t have here. Is that a better implant use? We just discussed hybrid meshes and synthetic absorbables and biologic absorbables. Like they’re all these ranges of products. There’s no proof that anyone is superior. We know some don’t work as well as others, but maybe for one patient, the one that doesn’t work as well is actually the better choice. Yep. Yeah. I think people who feel that medicine is an exact science are very pissed off when we can’t give them definitive answers for things because they think it makes us look like wishy-washy. Like we don’t know what we’re talking about. But it’s actually the opposite. The surgeon that is like knows everything exactly, is usually the one that under doesn’t see the full picture.
Speaker 2 (00:57:44):
Yeah, no, I didn’t. And I describe that to patients and some of these really complex things is, and first of all, I apologize right to being wishy-washy because sometimes you are, but that’s what I say, it’s the art of surgery much more than the science of surgery. And that’s where you want somebody who has the experience and has seen lots of things to be able to make adjustments, you know, get in the operating room and you see something that’s different. All of a sudden you need a screw and all you have is a hammer. Yeah. That’s not ideal. So you want somebody who’s able to adjust to different situations as they arise throughout the course of an operation.
Speaker 1 (00:58:17):
And we’re all watching what’s happening in Europe. So many companies cannot sell any of their meshes in Europe. And they’re either bankrupt or they have just decided that they’re just never going to enter the European market, which in some ways is not good for patient care because you’re reducing innovation and so on. So I don’t want that to happen in the United States necessarily, but we all speak with companies and talk about the future and so on, and many of them are like, we’re just not going to be in Europe. Our Mesh will not be in Europe, and they have no ambitions because it’s, at the end of the day, they are for-profit companies and there’s no nonprofit Mesh company out there. So it is what it is.
Speaker 2 (00:59:06):
Yeah, I agree.
Speaker 1 (00:59:08):
All right. I think I answered a lot of these questions. We had some other comments, but I’m going to thank you for your time because it’s been great.
Speaker 2 (00:59:19):
This was all fun. Thanks for having me.
Speaker 1 (00:59:21):
I haven’t been able to see you and interact with you for so long because of, I guess, COVID and meetings and this and that. So I’m always grateful and I can see my friends and colleagues at least virtually like this and kind of talk about things we like to talk about and so on. So thank you very much for your time. I do really appreciate it.
Speaker 2 (00:59:41):
Thank you for having me, and thanks for all the questions and comments along the way. It certainly makes the discussion very insightful.
Speaker 1 (00:59:48):
Thanks and fun. Every week. We do this every week.
Speaker 2 (00:59:51):
I love it.
Speaker 1 (00:59:53):
All right, everyone. Thank you for joining me on Hernia Talk Live. This concludes our hundred and ninth episode. Can you believe that of Hernia Talk Live Q&A? I’m Dr. Shirin Towfigh. Thank you, Dr. Jeffrey Blatnik. You can follow him at Jeff Blatnik on Twitter and stay tuned to watch this and share it with your friends on my YouTube channel. And thanks everyone for joining me, and thank you again for your time. Bye.
Speaker 2 (01:00:20):
Take care.
