Episode 11: Parastomal Hernias & Hernia Radiology | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

It is time and we’re recording and we’re live. Let’s make sure everything’s on mute. Okay. Ready?

Speaker 2 (00:00:07):

Ready. Let’s do it.

Speaker 1 (00:00:09):

Okay, let’s start with some screen sharing really quick. One second. All right, let’s start this.

Speaker 1 (00:00:29):

So welcome everyone. This is Dr. Towfigh. We are yet doing it another Hernia Talk Tuesday. We are where we take live questions from you all with an expert hernia related surgeon every Tuesday and today we are also simulcast on Facebook. So if you are on Facebook and would like to start asking questions you can do that on my homepage or right here on the Zoom page and you’ll have access to this after the end of this show. Today we are joined by Dr. Eric Pauli. Dr. Pauli is a lovely, lovely, super talented surgeon. He practices at Penn State at the Hershey Medical Center There you can follow him on Twitter at Eric Pauli, MD and in COVID times he almost almost looks like this picture here is Dr. Pauli. Hi.

Speaker 2 (00:01:25):

Hi Shirin. How are you?

Speaker 1 (00:01:27):

I’m good. And so most you can see I’m wearing scrubs cause this has become my daily outfit since COVID. I don’t like dress up for work anymore because this goes straight into the laundry the minute I get home. Yeah, but you are actually in scrubs because you barely finished an operation and ran over here just for this Hernia Talk session time.

Speaker 2 (00:01:48):

I did, yeah. Well the timing worked out. It’s like landing airplanes at La Guardia, you know, got to circle the tower a little bit. You got to know when to land, so we landed right on time. It’s perfect.

Speaker 1 (00:01:57):

So just so you know, for you the audience, it’s Dr. Pauli, finish an operation, had another one still to go before this session himself. He went and helped everyone else in the operating room to clean the room and move the patient and get everything ready just so he can be on time for this her talk session. So I do appreciate it. That’s

Speaker 2 (00:02:20):


Speaker 1 (00:02:21):

Super lovely. Most surgeons don’t do that, but

Speaker 2 (00:02:24):

The patient transport was actually fun because it was me and the anesthesiologist who was one of the other attendings as well, and neither of us could drive that bed at all. It was like, what’s going on? It’s like, don’t worry, sir, we’re paid professionals

Speaker 1 (00:02:35):

You banging the bed here and there or not making

Speaker 2 (00:02:38):

The curb barely through the door. We had to wedge through the door. I I’m, it’s fine. He’s okay.

Speaker 1 (00:02:46):

That’s very funny. So you, how many years you been working at Penn State now?

Speaker 2 (00:02:54):

Well, I started here as faculty in August of 2012. I did residency and training. I did medical school here. I did residency here as well.

Speaker 1 (00:03:06):

Wow. I did not know that.

Speaker 2 (00:03:07):

Yeah, I did with two years of research. So then I moved to Hershey in 2000. Yeah, I moved here in 2000. I was in Cleveland. Cleveland for the year 2011 of 2012. I’ve been back here ever since. In a week I will be promoted to full professor and I will also

Speaker 1 (00:03:27):

That’s super fast track

Speaker 2 (00:03:30):

And I’m actually going to be the division chief starting on July 1st as well. So

Speaker 1 (00:03:33):

Congratulations. Thanks. That’s fantastic. We can use more of you on the west coast, but they’re going to have to keep you over.

Speaker 2 (00:03:40):

Well, such a nice, I mean something, the sun is going down on my window. It’s such a nice place to live. Honestly don’t. It’s going to take a lot to get me out of here. So

Speaker 1 (00:03:48):

Yeah, it is very good. Well you’re, I’ve had the pleasure of knowing you since your fellowship and you’re very well known in our group of hernia friends or hernia nerds for many reasons. One is your super smart, and so your tweets and your responses on Facebook are always on point. Funny, <laugh> all not get it.

Speaker 2 (00:04:18):

It’s all nonsense and sarcasm.

Speaker 1 (00:04:20):

I love your sarcasm. And then in addition, you have some talents that others don’t. One is you’re super, super knowledgeable about imaging to the point where many of us rely on you as our non forwarded radiologist for reviewing things, especially hernia related stuff. MRIs are very difficult to read, ultrasounds are hard. CT scans most of us are able to read, but some of the other ones are more difficult. And I know your story, but maybe you can share the story of how it is. You became so involved in knowledgeable in radiology, which is super helpful in patients like yours that are very complex.

Speaker 2 (00:05:05):

And as you know, I worked as an x-ray file clerk in high school and then part of college my mom actually worked at the same hospital. My mom’s a dietician, but she basically ran a lot of their clinical research trials. She was a trial coordinator and so she got me a job in x-ray files and the radiology folks that I worked with knew that I wanted to go to medical school. So they taught me basically anatomy on CT scans. That’s how we first started just this is the liver, this is the spleen, this is what this is. And the more that I was there, the more I wanted to learn. And so I would do is I would do my work as fast as I could so that I could then go and just hang out in the reading room for a little bit of time. And so then they started taught teaching disease. This is a pneumonia and here’s why this is, it’s a pneumonia and not a C HF. CHF has, this is Apache infiltrate. And so I learned a lot of two-dimensional and three-dimensional stuff that way. So when I went to anatomy lab in the first year of medical school

Speaker 2 (00:06:12):

In my brain, I was just seeing something that I already had an understanding of. I built these three-dimensional pictures in my head of what these things look like off of CT scans.

Speaker 1 (00:06:24):

Oh, that’s very interesting. Yeah, I like it too. I, I’m like an artist at heart, so I like the whole three-dimensional view of things. And when I was an intern throughout my residency, every time there was a film, I wouldn’t just read the report. I would take it to the radiologist, sit down next to them and then have them read it and as they read it, I was learning kind of passively and you kind of learn a little bit like that, but you really have to immerse yourself into that situation. And as you know I have a special interest in imaging because I feel that in my field, which is mostly a cult groin stuff imaging of the pelvis is often misinterpreted from a hernia standpoint. They look for tumors and look for a lot of things like GYN based, but they don’t see or report the hernias even though they’re there. So yeah, you’re like a multiple levels beyond <laugh>, but well in the pelvis I’m good.

Speaker 2 (00:07:23):

Well, as you said, when you immerse yourself in this, the more you do, the better you get at it. Once you understand how or why you miss something once you probably won’t, you’re not going to miss it again. I rely very heavily on imaging for a lot of the other things that I do. As I and I were talking before we started the session, I’ve been closing a couple leaks. So one of the cases I did today was a colovaginal fistula and we did a scope and we closed it. The entire roadmap of where is this connection is a little bit based off of the CT scan ahead of time and built off of the pictures that we get endoscopically. And so in my head when I’m doing maneuvers with the scope, I’m not actually paying attention to what’s on the screen. I kind of understand how the scope is moving in this three dimensional model that I built and it’s a little bit of a cheat, but I’ve just done it so much that I can do that in real life. And I do that in hernia repairs as well. When I’m doing lap or robotic hernia repairs, the ability to build that kind of mental roadmap just helps you figure out how do I get from point A to point B? What am I looking at?

Speaker 1 (00:08:39):

Yeah, yeah, I agree with that. And then in the hernia world you do all types of hernias, ventral abdominal, groin, pelvis. I do people in pain. I’ve referred you many patients of mine that are in your neck of the woods for chronic pain issues, mass issues, but you’re most famous for the Pauli Parastomal hernia repair, which we called the Pauli one. I don’t think you your own name, but parastomal hernias in general are something that you are a bit more well known for. And why is that? What’s the issue with parastomal hernias actually? What are parastomal hernias and then what’s

Speaker 2 (00:09:17):

The issue

Speaker 1 (00:09:18):

With them?

Speaker 2 (00:09:19):

So a stoma is a connection between the skin surface and an internal organ. And so they come in a variety of different shapes and sizes. A feeding tube for example, is a type of a stoma. Some people might have a gastrostomy smaller holes like that, like a tube that goes into the small intestine or the stomach. They rarely get hernias around them, although every, I’ve got a couple fun pictures of hernias around feeding tubes. Whoa. Yeah. Actually one of the very first papers I wrote as a, actually I had a medical student wrote it, medical student named Porsche. When I was in a fellow, we had a persistent fistula, but we also had a hernia around a gastrostomy tube. It said we had a great CT scan of this tube going right through the hernia. But most people, when they say that they have a stoma, they mean that they have a portion of their small or their large bowel attached basically directly through their abdominal wall muscles to the skin surface

Speaker 1 (00:10:17):

On purpose,

Speaker 2 (00:10:19):

On purpose because they have a digestive disease or a process that does not let them have bowel movements the normal way. And so that includes people who have Crohn’s disease or inflammatory bowel disease. People who might have had colon cancer might all have a stoma. The other group are people who have had bladder cancer and so their intestine has been turned into a conduit or a reservoir for their urine and the same thing that is brought out through the abdominal wall muscles and then they urinate into a bag that’s attached to the side of their abdominal wall. Totally

Speaker 1 (00:10:53):

The more complicated,

Speaker 2 (00:10:54):

But because hernias on some level are as simple as we jokingly say, it’s just a hernia, it’s just a hole in the abdominal wall. The reason that parastomals parastomal hernias are hard to manage is that there always needs to be that hole. And so you’re trying to fix a hole, but at the same time you can’t really eliminate the hole entirely. And so that means that they have a tendency to come back. When we think about doing a Mesh based repair of a parastomal hernia, we have to configure the Mesh around the intestines. So there’s going to be some interplay between the two. Oftentimes we have to cut the Mesh or drape it or configure it to fit around the stoma. And so when you cut Mesh, it’s not as effective as if you have a big flat sheet.

Speaker 2 (00:11:45):

I think the final reason they’re hard to fix is that this is a loop of the intestine that is got bacteria in it. And when you’re doing any of these operations, no matter how much you clean or how well you prep, it is officially on paper an operation that involves some bacteria and not all hernia repairs. Most hernia repairs are clean operations. Correct. Once you have some bacteria there, the risk of a wound infection a deep infection or a Mesh infection goes up. So all of those things together give you this complicated parastomal hernia algorithm for how are we going to manage this person’s stoma as opposed to that person’s stoma. All of those things are part of the consideration

Speaker 1 (00:12:29):

And the failure rate, the rate of parastomal hernias is relatively high and the failure rate for the repair is relatively high compared to an average hernia repair.

Speaker 2 (00:12:42):

Because yeah, I mean if you look at people who have had ostomies if you follow them long enough, if you get imaging on them or if you do autopsy studies on people after they’ve died the overwhelming majority of them will have some portion that is probably a parastomal hernia. They don’t all have symptoms. I mean a lot of people do, but they happen very, very commonly. I’m sorry, I lost my train of thought there.

Speaker 1 (00:13:15):

They’re more likely to have hernias and also repairing them is not as successful as a regular hernia.

Speaker 2 (00:13:21):

Yeah, exactly. For all the reasons that I listed, you always need a loop of bowel coming through. If you’re going to use Mesh for the repair, you’ve got to carefully configure it around the intestine, which sometimes means cutting the Mesh. And when you cut Mesh in, the body grows and forms scar tissue, the Mesh shrinks and it shrinks away from those cuts, which means that it may open up the hole around the stoma site.

Speaker 1 (00:13:45):

So we have a couple imaging questions for you. The first one I’m going to read to you and then I’ve actually pre-prepared it because this person also sent it to me ahead of time. Okay. So this is about inguinal hernias. Okay. How do you recognize a spermatic cord lipoma on either a CT scan or MRI of the pelvis and in someone who already has an apple shaped body with central obesity that is probably in a lot of places, can this central obesity cause you to have a false positive appearance or impression of a spermatic cord lipoma even if one is not present and then on the same line of questioning essential obesity closer related or even a cause or contributor to a cord lipoma? Okay,

Speaker 2 (00:14:35):

Yeah, then that’s a great question. So when we talk about a cord lipoma, what we are describing is fat that is coming out from the pelvic side wall and it’s traveling along with spermatic cord. If you’re a male, it can go along the round ligament if you are a female and it tracks down through the inguinal canal in the same area where people get hernias, in order for that fat to go through the abdominal wall, there needs to be a hole at least as big as the fat is located. And so when we look at a CT scan and we ask ourselves is that a cord lipoma? Is there a hernia here? We find fat tracks along the cord good percentage of the time, but fat being there does not necessarily mean that you have a hernia that needs to be fixed. When we think about a traditional hernia, we usually talk about the lining of the abdominal cavity, kind of getting pulled along with it to give you a hernia sac.

Speaker 2 (00:15:43):

And oftentimes these two things, a hernia sac and a cord lipoma, they kind of both go out together. So if you want to know if somebody has a hernia, you have to do a physical exam on ’em. You really can’t just rely solely on imaging studies to say this is or is not a hernia. But you can look at imaging and document that there is fat along the cord pretty easily. CT scans and MRIs are both very good at finding it. And I say the imaging studies are good at finding, it may not be listed in the report because as you said earlier, radiologists oftentimes don’t read hernia related imaging studies a hundred percent the way you’d like them to read it, which is accurately, and that has a lot to do with, they’re looking for more important stuff. They’re looking for tumors, looking for GYN pathology. So lipomas of the cord may get under-reported or totally missed on some reports. So they’re both, those imaging studies are good to look for it. I don’t know of any studies that specifically address whether obese people are more likely to have lipomas of the cord. But the short answer is there are retroperitoneal fat and I think that if you carry a lot of your fat in the abdominal wall you’re probably going to have some cord lipomas as well.

Speaker 1 (00:17:05):

But also, so a normal spermatic cord has fat in it and a cord lipoma is considered additional fat often from the retroperitoneal space that follows a normal cord that has fat in it. So I just want to declare, do you agree with that statement?

Speaker 2 (00:17:22):

Yeah, absolutely. And so there is a normal amount of fat that tracks along with the spermatic cord, the spermatic vessels, it kind of invests all of those things. When we talk about a lipoma, what we’re really talking about is, as you said, an additional portion of retroperitoneal fat that’s fat from the lining of the abdominal cavity that’s getting pulled along with the rest of those cord structures. Right. You do it when we do an inguinal, a laparoscopic inguinal repair and we’re working from the inside, one of the things we have to do is not just look and say, yes, there’s a hole and yes, we pulled the sack back in, but we always want to look and see if there’s that additional lipoma of the cord and if there is, we want to reduce it back into the abdominal cavity. If you look there, it’s not going to specifically lead to a life-threatening complication.

Speaker 2 (00:18:11):

I mean it’s just some fat and it can be there, but many patients will still say that they feel a bulge or they appreciate an impulse there, which is probably that lipoma of the cord moving through the hole in the abdominal wall that the hernia was also tracking through. But every once in a while we look at somebody’s cord structures and we say, oh, is this a cord lipoma? And we start to peel it and we say, Nope, that’s just fat along the cord. So some people carry a good fat and it can be mistaken for a cord lipoma, even laparoscopically when you are in there working on it.

Speaker 1 (00:18:45):

And personally, I don’t think that I’ve been able to correlate someone who’s got central obesity with having a more fatty cord. I mean, there’s been plenty of people where there were normal weight and I make the comment, oh, this is pretty fatty spermatic cord. I think imaging if you really want to dice it, I guess imaging can help determine if there’s a lipoma in addition to a fatty cord. But even in surgery sometimes it’s hard to tell the difference. There are subtle differences though.

Speaker 2 (00:19:19):

When we look at the imaging studies, the easiest way to see if you have fat tracking along the cord with the cord is to do the coronal slices, which slice you kind of from front to back and on a coronal slice, if it’s kind of lined up just right, you can actually watch the bit of fat come from the retroperitoneum come all the way down and out through the cord. If every once in a while you get this really nice kind of coronal view of what that looks like and you say, yep, that’s a pretty clear lipoma. If you’re good enough and you can scroll through, you can also track and follow it at where it goes down and actually watching and see the spot where it officially ends as well because fat inside the cord generally is kind of evenly distributed and will track all the way down the cord, all the way down to the testicle, a lipoma of the cord. Sometimes you can actually see it stops shy of actually the testicle itself and you can make a determination that way.

Speaker 1 (00:20:09):

Yeah, very, very well said. All right, more imaging questions. This is a 45 year old male with bilateral inguinal hernia. The right side is the size of a ping pong ball and easily goes in and out. I’m told it’s an indirect inguinal hernia. However, the left side, there’s a small bulb but always stays out, not soft and does not go back in the right side. What is the best imaging test or tests to confirm if both of these are indirect or direct and how bad they are and is there a way to see additional or other hidden hernias? That’s a good question. That’s

Speaker 2 (00:20:46):

A really good, a good,

Speaker 1 (00:20:47):

Yeah. A lot of people ask about direct versus indirect, and one of the reasons is I think personally for tissue repairs and more people are asking for tissue repairs it’s better for an indirect hernia than a direct hernia. And so if you can determine that ahead of time, that would be able to help the patient. But it’s tricky. So what are your thoughts about that?

Speaker 2 (00:21:07):

Yeah, so I remember as a resident examining people and somebody would, an attending would examine and kind of pontificate, this is an indirect and here’s how you got to go to Bates’ physical exam guide and read them. I got to be honest with you I’ve been doing this for years and I’m still pretty bad at guessing, which I mean sometimes it is clearly obvious, but other times it is not, especially when they’re smaller people have a very short inguinal canal, people have smaller stature. It can be very difficult to say, yes, this is direct or no it’s not. This question though raises a lot of really interesting points, one of which is do you need imaging studies for any inguinal hernia patient at all? If this gentleman were in my clinic and I knew that he had a hernia on one side based on physical exam and maybe a hernia on the other, boy, it’s a little subtle, tiny little bulge. This is a person who is a great candidate for a laparoscopic repair or a robotic, right, because when you’re approaching it from the back, as soon as you put a camera in, you can kind of look at the other side and say, yeah, that’s going to be a hernia on the other side and we will fix it at the same time. So I would not,

Speaker 1 (00:22:18):

And it doesn’t matter if it’s direct or indirect, there will be pair as similar approach and you don’t need to pre-prepare for it when you go in laparoscopically.

Speaker 2 (00:22:26):

Yeah, exactly. And I mean oftentimes say that to the residents as well. When they come out and they tell me that this is a guy with, he’s got a small direct hernia on the right, and I go, okay, I mean what if it was indirect? I mean it, it’s in a laparoscopic, laparoscopic repair. It really doesn’t matter which you have because you’re going to widely cover all three of the spots in the groin or people commonly get hernias with Mesh. But this question also brings up a really interesting point, which is that not every bulge either in the groin or in the abdominal wall is a hernia. And there’s lots of things that show up in my clinic that are bulge that are not officially a hernia and that we sometimes need to get imaging to help us figure out. Some of those things are lipomas, which are fatty tumors that live just under the skin and they can show up all sorts of places.

Speaker 2 (00:23:14):

I actually had a patient show up bulge in groin on exam. There’s clearly a bulge there, not a hernia. It was just a lipoma directly over the inguinal canal. And so we took it out. Wow. It didn’t connect anything. It was, I mean, it was above the fascia, so it was not a hernia. A CT scan would certainly be able to help you figure out which of these hernias it is. Ultrasound also would probably be able to tell you what you’re looking at. I ultrasound, the biggest problem that I have with ultrasounds is that they rely on a technician to take the images correctly of the right area at the right time in the right circumstances, and then relay that information with good pictures to a radiologist. So a radiology report for an ultrasound is really only as good as the technician

Speaker 2 (00:24:07):

Who’s obtaining the images. And if he or she has misses the location or misinterprets where they’re looking, then your imaging report for the ultrasound may not be the best. What I like about CT scans is that regardless of what the report says I can look at the images myself and I can figure out what I’m looking at and we can look, can divide the groin up, where’s the inguinal canal, where’s the epigastric vessels? And we can kind of plot out which of the three hernias in the groin region are we looking at based off of those two landmarks. And then we can talk about a repair. And as you said, if somebody is really not interested in a Mesh based repair but is interested in a suture based repair done open, then as you said, and an indirect hernia works better for those directs because you’re talking about really reinforcing a very weak floor and moving tissue a really far distance together to kind of get it to scar down. I know that might be somebody who does better with a laparoscopic repair in the long term.

Speaker 1 (00:25:12):

Yeah, I’m lucky there’s one group in la, one group that’s actually getting older. I hope they don’t retire, where the radiologists themselves performed the ultrasounds. And it’s awesome because they’re really involved and they move the patient around and really get a good growing hernia ultrasound. And often when you order it elsewhere, when a tech does it, they don’t necessarily follow the right protocol. And a hernia ultrasound is different than a pelvic ultrasound or a abdominal ultrasound. So the semantics is important and the protocol quality is important. But yeah, there are some great, but in the United States it’s not used as often because of this disparity between the tech and the radiologists and the quality of it. It’s not as good.

Speaker 2 (00:26:00):

Have you do any ultrasound based procedures in clinic at all?

Speaker 1 (00:26:05):

Yeah, yeah, I do my own.

Speaker 2 (00:26:07):

Yeah, I mean you do your own groin ultrasounds then as well or Yeah, I do.

Speaker 1 (00:26:11):


Speaker 2 (00:26:12):

We talked about doing it in our own clinic. I simply, I have not have a very good relationship at this point with my ultrasound team and with the folks who do them. And I, I live in a very small part of the country here. It’s not a major city. And so we’ve got a limited number of people who are reading our ultrasounds and performing them on our in-house patients. And so to that end that I never really felt that I needed that. It added a whole lot for me to do it specifically in clinic.

Speaker 1 (00:26:45):

Yeah, it helps. Actually today I had a patient so my fellow is doing a one month, my fellow is doing a one month elective rotation with me because she’s going to be going to Emory in a month for her new job. And part of that is to build a hernia center there and deal with all their chronic groin pain patients. So yeah, the lady came and she woke up this morning with severe left groin pain and a bulge went to her gynecologist or gynecologist center to meet all within less than 24 hours. And I’m feeling this bulge. My patients don’t necessarily have five years of <laugh> pain necessarily. So anyway, so the key was that her pain was, it’s very anatomic, right? Hernias are anatomically, you have no anatomy. So there’s the feel where the inguinal ligament is. Her pain was below the inguinal ligament on exam.

Speaker 1 (00:27:39):

So that rules out a lot of different hernias. It pretty much narrows it down to eph femoral hernia, but it was kind of super tender and a bit wide for a femoral hernia. It’s such a small hole, you don’t expect a wide hernia of it. And I’m like, all right, we got to feel where your pulse is, wherever your femoral vessel is. If this mass is tender, mass is medial to it, then it could be a femoral hernia. But if it’s adder lateral to it, then there’s other things that differential. And I sent her for an ultrasound to differentiate that and she had multiple one centimeter lymph nodes. So now we’re working her up for that painful lymph node issue. So anatomy helps. Ultrasounds are very useful, but imaging I think is a large part of what many of us use for hernias.

Speaker 2 (00:28:35):

Well, we have a huge advantage as well. And I mean actually two huge advantages. One of them is that we physically have the patient in front of us at least in pre-COVID times anyway, they were always in front of us. And the ability to put your hand on the area where they’re having pain to feel what an area feels like when they’re coughing or straining in its dynamic. And then to go back, I mean to look at the patient here and then look over at your CT scan images here and scroll through those images or look at those ultrasounds it gives you an advantage that the radiologist just never has because by the time they’re looking at the film, the patient is already gone, they’re driving home in their car. And so that exam is not possible for a lot of the hernias that I fix are recurrent.

Speaker 2 (00:29:20):

And so getting an old operative note for me as well is kind of part of this tryout of things that I do when I’m examining the patient. I, I’m better at reading the CT scan because I know where they’ve already had Mesh put in and what other surgeries they had. I’m better at reading a CT scan cause I can examine the patient and I can see what they have on their scan and I can feel where they have bulges. Once you have all that information, yes you’re going to be better at reading the CT images that are the MRI or the ultrasound the radiologist ever could be because you’re cheating. You got a lot of extra info that they never got.

Speaker 1 (00:29:52):

Totally agree. I totally agree. All right. More questions on imaging. This is a patient with a unilateral inguinal hernia. He’s holding out he or she? Oh he, he’s holding off of repairing it for now because he has a possible enlarged prostate. It

Speaker 2 (00:30:08):

Sounds like it’s a guy.

Speaker 1 (00:30:09):

Yeah. <laugh>, a lot of prostatic hypertrophy. He has not done any imaging yet for the hernia. And what and is the most effective imaging to suggest for the hernia and the prostate? Can you do them both directly with you? That’s something that you would like to see and have, I think you already answered that, but do you have in-house imaging ct, MRI, ultrasound, what’s available at your center? But yeah, this is a common problem for males, especially those over 50 is kind of when those symptoms start, right? Yep. Prostate symptoms and a hernia. What’s your protocol for that?

Speaker 2 (00:30:47):

To be honest the BPH stuff is super common. We know that most males over the course of their lifetime will have some amount of prosthetic enlargement. The important thing is that it’s followed to make sure that it’s not a becoming more obstructive and B is not becoming a cancer, a prostate cancer. Most people do not require specific imaging just because they have BPH unless they’re having other symptoms that are not BPH. So in a physical examination is generally enough to document the size of the BPH and then follow it over the course of time to make sure that the prostate feels normal. The same thing, not everybody who has an inguinal hernia needs an image. There’s not really a role if you are able to get a good physical exam on somebody. And so I would not specifically recommend imaging for either of these things unless something on the physical exam when I’m looking at the patient makes me say, Hey, what if I got imaging this would be helpful for reason X, Y or Z? But for the most part, these two problems are just physical examination alone and a little bit of history taking. Our facility has all of those things. We have CT and MRI and ultrasound and PET scan so they’re all available, but I would not specifically use them without physically seeing this patient first.

Speaker 1 (00:32:19):

Agreed. Now, symptoms of prosthetic hypertrophy, which includes straining to urinate and kind of increase the flow of your urine or if you’re unable to empty or bladder completely in your straining those can hurt, can make a hernia worse. And if you repair your hernia can contribute to a poor outcome. So people should get their prostatism addressed before surgery, but that doesn’t necessarily need imaging. I agree, I

Speaker 2 (00:32:48):

Agree with that. One of the areas where there’s a little bit of new literature I’m not sure if this is published, I feel like I reviewed it somewhere was the question of do you do anything different if a patient’s inguinal hernia has a urinary bladder in it? And so when I meet somebody and we’re examining them for a hernia, we ask some questions about when is the hernia the worst? And sometimes people report that their hernia is the worst in the morning time when they wake up and then after they urinate, the ball just kind of gone and it feels better. And that suggests that if the bladder is full and the hernia is out, that the bladder may be involved in the hernia.

Speaker 2 (00:33:33):

I don’t specifically do anything different in terms of imaging of those patients because the way that I do my laparoscopic repairs as a, I mean I do laparoscopic transabdominal repairs, which means I’m in the abdominal cavity and I peel the lining of the abdominal cavity down. I’m working from the inside out. But people who do balloon based repairs might have a concern that when they’re blowing the balloon up, if the bladder is out in the hernia that could actually injure it. There could be a role for imaging to document yes there is or is not urinary bladder in this hernia.

Speaker 1 (00:34:07):

So rare.

Speaker 2 (00:34:09):

Yeah, they’re very uncommon. And I think that from my perspective, I would not specifically order imaging because of that. But what I would say is if I’m concerned that somebody has those symptoms I’m, I’m going to be a lot more cautious as I’m approaching the hernia in the operating room. Cause if the bladder’s in there, we definitely don’t want to injure it even though it is uncommon.

Speaker 1 (00:34:30):

Do you do offer laparoscopic surgery and someone who’s already had prostate surgery?

Speaker 2 (00:34:36):

Oh gosh. If there is no other good alternative, I will. So if somebody’s already had, for example, an open inguinal hernia repair and they have a recurrence and they’ve also already had a prostate surgery, then yeah, I will offer them a laparoscopic or robotic repair. But that’s not super common. I mean it happens every once in a while. My personal philosophy is that as much as I believe that I do a better job laparoscopically with inguinal hernia repairs and as much as I like the idea that widely covering the defects with laparoscopic Mesh, it’s kind of tension-free wide coverage, no tax. It’s kind of hard to beat a well done open, old fashioned inguinal repair If you have someone who knows how to do that operation, well it can be done under local it can be done with minimal pain, it can be done with as a same day surgical procedure with a pretty short recovery time. And so when I think about the risks of a laparoscopic repair like injury to the urinary bladder versus the benefit of it as opposed to a well done open repair in that circumstance, the risk benefit ratio for me and for most patients who I talk to falls in favor of doing it open.

Speaker 1 (00:36:00):

For those of you you’re watching, the question is how much scar tissue in the pelvis is too much and before you consider a laparoscopic surgery, that can be, usually that’s a prostate surgery that adds a lot of, not only adds a lot of scar tissue but the bladder is involved in that scar tissue you can and can’t be thinned in that area and you can tear the bladder in trying to get to the hernia part if that’s a risk. I’m just more careful. I still offer it and the appropriate candidate and then it’s not so much for people that have had C-sections like that hasn’t been that big of a problem. The scar tissue there is usually not in the way to prevent you from doing a safe laparoscopic surgery, but it is for the prostate. Okay. Here, here’s a question for you. I’ve had four failed abdominal hernia repair. Sounds like one of your patients. This week my surgeon is now considering a reconstructive surgery putting a diamond size Mesh from pubic area to top of the ribs and to my flanks on both sides, cutting every other flank on both sides. I’m 49 years old, five foot, 349 pounds. Are there other options to repair the current hernia?

Speaker 2 (00:37:30):

Well, it’s a little challenging to answer that specific question without some additional information such as what were the other hernia operations that were done? Were other muscles already cut? But the operation that it sounds like that person described is an operation that I do pretty regularly called a transverses abdominal release. It’s a type of abdominal wall, a complex abdominal wall hernia surgery, which has the advantage of covering the entire abdominal wall really from top to bottom and from side to side with a big piece of Mesh. That diamond shaped piece of Mesh is generally one square foot of Mesh kind of turned on its side. So it’s basically about a foot and a half by a foot and a half when you make it into a diamond. I’ve done that operation twice so far this week. I did one on Monday and I finished one earlier in the day today.

Speaker 2 (00:38:32):

And so I definitely use it as a go-to operation for people who have failed other types of hernia surgery. But there are also people who are not very good candidates for that. That’s thing one, I would say. Thing two is there are some surgeons who maybe should not be doing that operation. It is a challenging surgery and if it’s not something that your hernia surgeon does regularly, you might want to ask him how often ask him or her, how often have you done this operation? Very good point. How many years ago did you learn it? How did you learn how to do it?

Speaker 2 (00:39:10):

It’s in 2020 operations where we divide the abdominal wall muscles are commonly done. And I don’t know that we still have a full 100% understanding of what the long-term consequences of that are. I’ll tell you, I do those operations a lot and my patients are universally better in the long-term than they were before we fix their hernias. But I can also tell you it takes a long time to learn how to do those surgeries correctly to pick the right patient for that operation. And if it’s not something that your surgeon has done before or does regularly, you might want to find somebody who does it regularly. And there’s folks all over the country who specialize in these sorts of operations. When people come to me and they just have a straightforward inguinal hernia, I mean it’s fun and I like doing them definitely. I definitely get a little confused, a little bit too simple

Speaker 1 (00:40:09):


Speaker 2 (00:40:10):

People who have had three or four or four repairs who have other problems and complications and Mesh already in place. That’s kind of the thing that I do regularly. And so there are certainly other folks around the country and around the world who do it regularly. Just ask the questions.

Speaker 1 (00:40:28):

Yeah, I totally agree. So she said all other repairs were abdominal hernias and no muscles have, no muscles have been cut before and she’s in the LA area. Sounds like someone that I’m happy to see. We have a couple of us here who can handle that but I totally agree. First of all, these are very complex. If you failed four times, your surgeon needs to figure out why you failed. I kind of do a forensics of the prior operative reports to see if the Mesh was too small, the wrong technique. It was they use absorbable sutures in certain areas that whatever the situation is try and figure out why you failed. Maybe the patient’s morbidly obese and they have severe constipation or chronic cough. So those are all factors that can be controlled before the surgery. And then imaging, you would use imaging, especially someone who’s had four hernias before.

Speaker 2 (00:41:24):

No, absolutely. The planning and the timing of the surgery after four failures needs to be spot on. Perfect. People like that. I usually say you have one kind of legitimate chance to get this fixed and have it gone for forever. And so we’re not going to do that operation until they are optimized, weight controlled diabetes, controlled infections controlled, and until we have a good understanding of what’s already been done. And so that’s imaging and that’s also getting and reading all of those old notes. So I have a medical assistant who is like a hound dog, she can track down an note from anywhere, anytime.

Speaker 1 (00:42:03):

<laugh> really helpful because sometimes you have to do a lot of detective work and correlate what was said in the opera report with what you see on imaging because sometimes what was said and what was done may not be exactly accurate and the imaging gives you a little bit of insight into that.

Speaker 2 (00:42:23):

Yeah, that’s a really good point. A lot of times I read a report that describes abdominal wall muscles having been cut but what they really did was just kind of raise up some skin flaps and really did not cut any muscle. And if you look at the CT scan, the muscles are pretty much in the same spot where they they’re supposed to be. And so I know that muscles were not specifically divided in a way that allowed them to be released. And so that concern that I might have had, oh my gosh, this person already had muscles released. I have to be very careful doing it the next time around, suddenly you get some images and you say, Nope, that’s not what happened. Yeah,

Speaker 1 (00:43:03):

And that’s helpful because now you have more options available for the patient because

Speaker 2 (00:43:06):

Absolutely. And fewer and fewer fears. Fewer fears and

Speaker 1 (00:43:11):

Fewer fierce. Yeah, I agree. We’ve got a very nice comment about how we’re awesome for doing this, so thank you very much for that comment. Okay. Can you discuss some challenges about imaging and using that to diagnose athletic pubalgia or what we call like pre pubic AP neurotic plate disruption?

Speaker 2 (00:43:38):

Yeah, so I’ll start by saying that hernia surgeons as a group and general surgeons who do hernia repairs do not do this disease process very well. A lot of that is because again, as I said earlier, the Luddite view of the world is that hernias are just holes in things and my Twitter feed literally says I fix holes in things. I mean that’s kind of what I do. This is different. This is a musculoskeletal injury that comes in a variety of different flavors, all of which present as an unusual symptom of pain. And since pain is different for everybody and there’s a variety of different things that can be torn or injured in athletic pubalgia or what we call a sportsman’s hernia, which it’s not really a hernia imaging can also be a challenge. So if you were to get a CT scan, there’s a couple points.

Speaker 2 (00:44:37):

One is did the injury just happen? Is it an acute injury or is it a chronic injury? And so you’re thinking about the phases of things. In general, MRIs are very helpful for this. And the reason for that is MRIs are very good at getting detailed images of areas that have ongoing inflammation, small amounts of fluid that are easily missed on CT scans. T2 sequences can really show you small amounts of fluid and they can also show you the exact area where a muscle or tendon may have been disrupted. And so for somebody who comes in who has a story that is concerning for a sports type injury that is clearly not got a hernia on physical exam, I will universally go to an MRI for the evaluation of that patient.

Speaker 1 (00:45:32):

Along the same line let me share that screen with you is, can you tell based on MRI if it’s a rectus muscle insertion or abduct or tendon that’s involved in this injury?

Speaker 2 (00:45:45):

Yeah, I mean that it can be a challenge. And again, this is an area where MRIs are much less familiar to everybody, myself included, because the rectus inserts on the pubic and the abductor tendon also inserts at roughly the same spot on the pubic. If the injury is located at the pubic, it can be hard to tell which of those two things is actually the thing that has been injured. If it’s clearly above the pubic bone in the DR tendon or in the BTU tendon, then they get the report can give you details at that level. But for some people the injury is located directly at the pubic and it’s hard to tell exactly what’s inserting on what,

Speaker 1 (00:46:30):

And that’s where the story and the physical exam come into play

Speaker 2 (00:46:35):

For sure. The repair of a lot of these is similar. So as we said earlier, is it direct? Is it indirect while I’m doing a lap? So it doesn’t really make a difference to me. When you are exploring somebody for a sports type injury like this and you’re working over the pubis, you’re going to inspect both of those tendons for disruption. And if they need to be managed, they can be managed.

Speaker 1 (00:47:05):

I have a Mesh question for you. What is your understanding of the rate of Mesh shrinkage? This patient was told that his may up to 40% risk of shrinkage up to 40% of the area.

Speaker 2 (00:47:22):

Yeah. So numbers,

Speaker 1 (00:47:24):

Do you quote your patients or do you agree to

Speaker 2 (00:47:27):

I have never had anybody ask me that question. That’s a very, I mean that’s

Speaker 1 (00:47:31):

Up to my audience <laugh>

Speaker 2 (00:47:33):

A high level question. What I describe for patients as something much more simple than that, which is all Mesh shrinks as the body forms scar tissue around it. And my job is to make sure that I have widely overlapped enough to accommodate for that shrinkage. Mesh shrinkage is a product of the type of Mesh that you’re putting in somebody the weave of the Mesh or the knit of the Mesh depending on whether it’s woven or knitted, and ultimately the pore size. So the spaces between those pores. When the Mesh is a tight weave, think of that as a high thread count sheet, and there’s really only small holes between the Mesh fibers. What happens is as the body forms scar tissue around the Mesh, the scar tissue from one fiber of the Mesh becomes confluent or joins the next Mesh fiber. And what you get is a process called bridging fibrosis.

Speaker 2 (00:48:42):

And that bridging fibrosis results in more shrinkage and contracture of the Mesh because you have effectively very small pores in the Mesh. My Mesh of choice for the majority of procedures that I do is a very wide poor Mesh. And the reason I choose the wide pour Mesh is it handles very well, and B, it conforms to the abdominal wall. It’s not really thick and heavy where people might feel stiffness from the Mesh, but more importantly it does not shrink or contract as much because of those that wide pour configuration. And so I can’t tell you exactly what your Mesh contracture rate is because I don’t know what Mesh, you have in you and obviously everybody’s inflammatory response to Mesh is a little bit different. That’s why we can put Mesh in thousands of people and most of them will do just fine. But some people will have a problem related to the Mesh that we don’t have a very good understanding.

Speaker 2 (00:49:42):

We can’t look at one person and say, oh yeah, obviously that’s why you have this response to the Mesh because we know they interact with these materials on a daily basis. And so some people are going to have more inflammation around their Mesh just because they will. And those people may ultimately form more fibrosis and may ultimately have more shrinkage of the Mesh. So understanding that we don’t know who’s going to respond exactly in what way means that my job is to oversize the Mesh a bit to make sure that that shrinkage is never a reason why someone gets a hernia back

Speaker 1 (00:50:19):

Oversize and not put it in perfectly tau because it will shrink a little bit. So you got to take into consideration a little bit of that shrinkage factor

Speaker 2 (00:50:33):

If you, no matter how tight or how loose you put it in the tissue remodeling that happens around these meshes is very slow. And I liken it to how can I have crooked teeth and go to the orthodontist and over the course of time they can mold my face and pull my teeth in different directions. How does that work? And the answer is, it works because the body is very plastic and slowly over the course of time these things can happen. So when you think about how did somebody’s Mesh, that was a nice flat sheet when it went in, how does it wind up as a wrinkled up ball in the corner? And the answer is slowly and over the course of time because the body is really good at doing those things.

Speaker 1 (00:51:20):

So the numbers, as you said, are all over the place and very dependent on the type of Mesh, the porosity and the patient’s reaction to the healing process. The numbers that I quote from what I’ve read over time and also what the reps also kind of agreed to for each of their products is for the lightweight Mesh, it’s up to 10% shrinkage. For the heavier weight Mesh, it’s up to 25% shrinkage. And I believe for the E P T F fee or goretex Mesh, it’s up to 40% shrinkage. I think this patient is important, has that cortex Mesh. Okay. Are you familiar with the Shouldice method and what’s your opinion on them? For this question, I just to remind everyone, two weeks ago we had a Shouldice surgeon on for the hour and it was a very insightful and fun hour on hernia talk, but do you perform the Shouldice? What do you think it’s the best surgical technique for tissue repair? What is your thought on Shouldice?

Speaker 2 (00:52:26):

Yeah, so I am familiar with it. I have done some but not as an attending. And the reason that I don’t do ’em as an attending is as I said to the person earlier who was looking for who is going to get their fourth hernia repair. And I said, find somebody who does that all day long and can do it in their sleep. You kind of need to do that with Shouldice as well. That’s kind of my personal opinion. Why is the Shouldice clinic able to get the results that they get? Well, because it’s a factory, they heavily screen people to pick people who are very good candidates for an operation that they know well. And then you show up, you have people who, this is all they do all day long, every day is fixed groin hernias and it’s a factory. I mean, if you are getting an operation done, you want it done by somebody who does that version of the surgery all the time.

Speaker 2 (00:53:17):

And so I don’t do it because I’m not going to be able to give somebody the results that they would get at the Shouldice clinic because I’m not the Shouldice clinic and I don’t do it every day. So I mean, I can open up a book and I understand the steps and I know how to do the operation, but I also know how to do a pancreatic cancer operation. I know how to do it, but you do not want me doing that because I don’t do that every day. Okay. Right. I think that there are lots of things that the Shouldice Clinic excludes people for the most notable one being weight and also recurrence after another operation. And every once in a while I get somebody who asks me about this operation. In fact, I had a guy who called me and he said, Hey, I’d like you to do a Shouldice on me. And I said, if you want a Shouldice, I’m going to recommend you go to the Shouldice clinic. And he said, oh, well, I called them and they told me I wasn’t a candidate for it. And I said, if the place that named the thing that you want says you shouldn’t get it, why on earth are you asking me to do it? That’s a pretty good response that makes me say, maybe you shouldn’t have this done.

Speaker 1 (00:54:23):

Yeah, we discussed all that. The Laura, those came out a couple weeks ago. A lot of restrictions which is fine because their goal is to make their model’s very unique. There’s very little preoperative workup. If you have a visible reducible hernia, they’ll fix it. So my patients can’t go there because they rarely perform it on women and they don’t perform it on women unless there’s a very obvious bold. And some women, they have inguinal hernias. And I actually reached out to their head and said, I’ve diagnosed her, she’s Canadian. Can’t she just come and have it dealt with you? And they said specifically, they won’t repair on cult inguinal hernias because they have looked at their data and their outcomes are not as good. I think because they don’t really do much of a pre-operative workup but teach their own. Each person has their own way of running their business and their practice, and that’s fine. But yeah, very restrictive. They do very well with the patients that they do, but very restrictive.

Speaker 2 (00:55:31):

Yeah, I mean, the other issue is a lot of folks travel there to get their hernias fixed. When they get a recurrence, they don’t travel back because they’re not a candidate anymore, so they get it fixed somewhere else. And so there is always this question in the literature about is this the real recurrence rate? And these are folks who have traveled and how long is the follow up? I mean, I’ve had one or two patients in my time here who had had a Shouldice done. Two of them had it done at the Shouldice clinic and they had recurrences. But again, they’re cranking out. I mean, they do many, many, many hernias there. And they do well obviously, even though I do hernia as well, I have recurrences too. So recurrences do not a bad surgeon make.

Speaker 1 (00:56:10):

Before we end, I’d like to give you a little shout on your pair of stoma hernia repair which I have done based on your reports. It works really, really well. And actually know a friend of ours I went to proctor her on robotics, and it was basically to do the Shouldice repair so it went really well. Let’s see if

Speaker 2 (00:56:35):

I can You mean to do a parastomal?

Speaker 1 (00:56:39):

Yeah, it was a parastomal with an incisional hernia and she basically like a robo robotic tar with the poly repair. So this is based on your, let’s see. This is, I think it’s the original paper, right? How I do

Speaker 2 (00:56:56):

It? Yeah, it’s the original paper. Yeah,

Speaker 1 (00:56:58):

Your original paper that discussed your initial results in taking care of these types of patients. Not easy. And what I just want to show is the progression. So here’s the inside of the belly, and I think a lot of people enjoy looking at this inside the belly. And here’s bowel going up into a hole as a colostomy or ileostomy. What is this?

Speaker 2 (00:57:23):

That’s a colostomy. It’s a sigmoid, colostomy,

Speaker 1 (00:57:25):

Sigmoid colon. And it has to go through the hole. And the question is, how do you fix this hernia while still mean you don’t touch this? Right. You don’t touch the actual stoma, you let it be where it is. You

Speaker 2 (00:57:40):

Just hole around it. Exactly. So one of the advantages is if the stoma is situated in a good position, we don’t need to move it and we just leave it where it is.

Speaker 1 (00:57:49):

So you leave it where it is on top, you leave it where it is on the bottom, but you need to do some releases. So here’s the release from here to here, which kind of displaces where the stoma is, right from where it’s or origin was. So you basically then push it backwards. You make this hole bigger, here’s your original hole, you make it, put it backwards, make that the new hole and close. Here’s the stitches close in front of it. And now you have this front repaired and this front repaired and the final is you put Mesh in and it’s basically a sugar baker after that. Right, because you kind of follow this kind of smooth like tract up.

Speaker 2 (00:58:37):

Yeah. I mean is you mean the shape of the Mesh is a sugar baker configuration?

Speaker 1 (00:58:43):


Speaker 2 (00:58:44):

Ultimately just a TAR operation that we do commonly. I mean honestly I live in Hershey, Pennsylvania where we have Reese’s Peanut butter cups. Remember the commercial where the guy with the peanut butter bumps into the girl with the chocolate and they, they’re like, you got your peanut butter in my chocolate. This is all I did was take two operations that I had seen before. And one day while doing a dissection, I realized that if I cut the back layer of the tar dissection, which we tell everybody, don’t make holes in it, if you do the thing that we tell not to do, suddenly we could configure the Mesh the way that we like it to be configured. And so, honestly, you

Speaker 1 (00:59:21):

Covered it. You covered it. Yeah. I mean, where it works, because you make the new hole, the old hole, you close and you cover it.

Speaker 2 (00:59:29):

Correct. Yep. Yeah.

Speaker 1 (00:59:32):


Speaker 2 (00:59:32):

Is just stuff that Dr. Sugar Baker and Dr. Navitzky kind of taught me, and I just put ’em together into one. So

Speaker 1 (00:59:40):

Yeah. Sounds great. Okay, well that is all we have for today.

Speaker 2 (00:59:46):

Awesome. That was great. Thank you for having me. That was

Speaker 1 (00:59:48):

Pretty fast, right?

Speaker 2 (00:59:49):

That was real fast.

Speaker 1 (00:59:51):

Okay. <laugh>.

Speaker 2 (00:59:52):

All right, guys,

Speaker 1 (00:59:53):

You have to go back to surgery now?

Speaker 2 (00:59:55):

No, I’m all done. I’m going to pack up and go eat some dinner.

Speaker 1 (00:59:58):

Yeah. Oh, okay. That sounds really good. Yeah, so I’m going to leave you and thank you very much. And just to finish off, once again, Dr. Pauli is here with us for the full hour. Learned a lot, answered all your questions. You can watch this on reruns again on my Facebook page. I will also post links to it to my YouTube channel on Twitter and Instagram for you all to follow. And we will have yet another guest next week. Thanks everyone, and hope you have a pleasant night and I hope you get to rest. And have a good dinner, Dr. Pauli, with some great thanks. Bye guys. Okay. Bye

Speaker 2 (01:00:35):