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Speaker 1 (00:00:01):
Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live. I am your host every week here on Hernia Talk Tuesdays. My name is Dr. Shirin Towfigh. I am your hernia and laparoscopic surgery specialist. Thank you for joining me. Many of you’re here via Zoom and others through my Facebook page as a Facebook Live at Dr. Towfigh. Thank you also for following me on Twitter and Instagram at hernia doc. As always, this session as well as all prior sessions will be put on my YouTube channel. Please do follow me and subscribe and then you will always know when these sessions are on. So as I’ve mentioned before, I like to kind of use a lot of my weeks worth of patience as inspiration for topics for our weekly Hernia Talk Live sessions. And lately I’ve been having a lot of patients that are referred to me for hernia Mesh removal that may or may not need it actually.
Speaker 1 (00:01:02):
And others I think they need a Mesh removal and some who definitely need Mesh removal and are told they shouldn’t or mustn’t or et cetera. And what’s really interesting to me is this sheer number of kind of misinformation that’s out there about Mesh removal. I must say that it’s a operation that we really were not doing until probably the late, I would say late 1990s. Dr. Parviz Amid was really the main surgeon and he’s actually in Los Angeles and went used to work at my hospital, Cedar Sinai, but it was Dr. Parviz Amid that started talking about the importance of good operations and in doing good operations of getting of sometimes need to redo it and use Mesh removal as a way of redoing things. And he invented the triple neurectomy and a bunch of other things. He is the original surgeon who partnered with Dr.
Speaker 1 (00:02:11):
Lichtenstein Irving Lichtenstein also at my hospital, Cedar Sinai, where they invented the Lichtenstein hernia repair. So there’s a lot of history that kind of is interrelated, but specifically with Mesh removal, it was so important to know your anatomy before you just go in there and remove Mesh. This was for inguinal hernias and now we do these open laparoscopic robotic, we do it for inguinal hernias and abdominal wall hernias. Many of most my surgical cases are revisional cases and many of them are Mesh removals. I posted a picture of some mess that I removed last week, and basically in doing so you kind of gain more experience.
Speaker 2 (00:02:59):
And what’s fascinating to me is so much mythology out there about Mesh removal. I commonly have people come to me saying that they were told not to have their Mesh removed, which may be the right answer, I mean or may not be. But the reason given is because you’ll die. You will lose your leg, you’ll lose a testicle, you will lose all this muscle, you’ll never be able to be put back together again. They’re told it’s impossible to remove the Mesh. All of those are not true basically. So it’s never impossible to remove Mesh. Now there’s risk to it. There’s risk towards different Mesh removals depending on where the Mesh is and the patients like risk for surgery, et cetera. But to say that you cannot actually remove Mesh is not accurate. All Mesh can be removed. There’s just risks associated with each proposed operation.
Speaker 2 (00:04:03):
Next is this whole idea that you’re going to die if you have Mesh removal. Now, Mesh removal is surgery. It typically requires general anesthesia. However, if it’s in the groin and done under open as an open procedure, I don’t use general anesthesia. I usually use IV sedation. But short of that risk and the potential risk of any surgery, including Mesh removal surgery, of having complications, infection, heart attack, blood clots, et cetera, in and of itself, Mesh removal surgery is not considered a highly, more like high an operation with high mortality. People are not expected to die of this operation, which is why we recommend it. Why would you recommend a surgery if people die from it? So that discount doesn’t make sense when people are told, oh, they’re just, it’s very high risk, they will die. That said, I must say that maybe in the hands of a non-specialist, it’s not the safest operation because there are nerves, critical structures like intestines, bladder, major vessels, all of these are in the way potentially of Mesh removal.
Speaker 2 (00:05:24):
And therefore, if you are not the cleanest surgeon with the most delicate hands and the best anatomy knowledge, then you can definitely cause damage. And I’ll review some cases that I’ve had actually this week alone, today’s Tuesday just today that I’ll share with you and some phone calls, I’ve got some from some friends who are like, we don’t do this for a living. Can we send the patient to you? So that’s all really good. Plus I know many of you have questions, so I’m really looking forward to answering your questions. I got about 20 questions sent in for today’s session alone, so we’ll try and get to as many as possible. I really appreciate the fact that you guys do send me questions, so I do appreciate that. So you know what, let’s start with some questions. Here’s a live one. How resorbable is Phasix Mesh?
Speaker 2 (00:06:21):
PH Mesh, first of all, is a synthetic absorbable Mesh. It is considered to be absorbed at about 18 months. Does it disappear completely or do persisting remnants usually remain? Depends on the patient. The expectation is that the Mesh disappears completely. I have operated on patients that have had the Mesh two years prior and there’s this kind of gritty like fiber glassy remnant from it that I saw in some patients. Things that are like, what do you call it? Absorbable, really only absorb if your body decides to choose to absorb it. And infrequently there are absorbable meshes that are so synthetic in nature that the body does not absorb it. It actually encapsulates it. And we’ve seen that with some really poor quality biologic meshes that were out there. Can persisting remnants be removed? Yes, asking because I have an autoimmune condition. So that’s really interesting.
Speaker 2 (00:07:38):
So I’ll give you my answer. In my experience, all synthetic meshes including the synthetic absorbables, which includes phasix, are inflammatory in nature and therefore I do not use them in patients with autoimmune or inflammatory disorders. The more kind of cadaverish-like biologic tissues tend to have lower inflammatory potential than the synthetic products. And even in the biologics, the more processed and syntheticey, the biologic Mesh, the more likely you are to react to it and have an inflammatory reaction. So if you ask the company, they have tons of studies that show that the Mesh actually is low in inflammatory potential and has lower inflammation than it’s other biologics. I’m not a specialist enough to know how to accurately decipher that data. I trust that their scientists are accurate in what they’re saying, but I have used phasix before in a clinical trial only, and the patients are fine. I do not use it in patients with autoimmune disorders yet because I don’t see that there’s any evidence to show that it’s going to be tolerated any better than synthetic Mesh in the short term. And then also I would say that, how should I explain this?
Speaker 2 (00:09:20):
I have had a couple of patients, and maybe you’re one of them as well, who have reacted to phasix Mesh because it does have an inflammatory potential to it and they just feel it. And waiting for that 18 plus months for it to go away is usually not enough because their quality of life is poor during that time. So I hope that’s helpful. So am I saying that I will use true biologic Mesh with autoimmune? Yes, I either do not use pure synthetic meshes. Of course everyone’s a little bit different, but if there’s a good choice, I prefer to either use no Mesh in patients with known autoimmune disorders or to use biologic Mesh or hybrid. So it depends on the type of disorder that the patient may have, but the hybrid meshes, which is autoimmune plus some synthetic dramatically reduces the amount of synthetic exposure and therefore the least amount of inflammatory reaction and potential autoimmune exacerbation.
Speaker 2 (00:10:27):
That said, there’s no real science behind what I’m saying. It’s mostly by experience. And even with the hybrid meshes, I have one patient who we believe did react to that Mesh, so we don’t have great signs to say what’s best. Now, for example, this week I have had a patient autoimmune disorder in her daughter autoimmune disorder in her mom and her aunt. She herself does not have autoimmune disorder and she actually asked for Mesh and she said, what do you think about that? And I explained to her, women thin people, young people, people with known autoimmune disorders are of strong family history of autoimmune disorders and she fits three of those criteria tend to be more likely than the average patient to develop a reaction to synthetic Mesh. Now what’s that higher risk? I don’t know. Is it 10% higher? Is it 200% higher?
Speaker 2 (00:11:26):
Is it 20 times higher? I don’t really know. Nobody knows. We just know it’s a higher risk and once our paper gets published, you’ll read that In our experience, the chances of you reacting to Mesh if you have an autoimmune or inflammatory kind of tendency is significantly higher than not. But there are patients with Mesh in them that have lupus and other autoimmune disorders that are doing just fine. So if a patient wants to have Mesh in them, I don’t think that’s dangerous to do. Understanding that they may have to have the Mesh removed if they react to it. That said, I personally feel that less is more, and so I don’t actively recommend Mesh synthetic Mesh use unless the patient specifically asks for that and understands there was some benefits of it. Okay, next question. What symptoms would warrant a Mesh removal? I have hip pain, no issues with hips on a recent scan and irritation to the general femoral nerve, but no relief from steroid injection into the nerve. Slight benefit from P R P treatment. So sounds like you have an inguinal hernia repair with Mesh and you have hip pain and general femoral nerve irritation.
Speaker 2 (00:12:53):
The question is where is your Mesh? Is it anterior or posterior? Is it done laparoscopically or is it done anteriorly? Because all of these can be actually related to the Mesh interacting like as a fold or her recurrence or an entrapment of the nerve. So if it was done, sounds like it was done laparoscopically, which means that general femoral nerve is at risk of injury and not sure why you would have hip pain, but you may actually have a hernia recurrence. So that’s something that needs to be worked up. If you have a hernia recurrence that’s not a Mesh problem necessarily and does not need Mesh removal, most hernia recurrences do not need Mesh removal. But if it’s a entrapment of the nerve by the Mesh, like the Mesh was placed too low let’s say, or the Mesh was folded and that’s why you’re having hip hip pain, then Mesh removal would help you.
Speaker 2 (00:13:55):
So Mesh removal is only helpful if it’s the Mesh is infected, if the Mesh mechanically is a problem like it’s folded or impinging on something or if you’re reacting to the Mesh. So if your nerve pain and your hip pain is due to a mechanical problem of the Mesh, great. But if you do imaging and the imaging shows that you just have a hernia recurrence and that’s why you would have the hip pain and the general nerve type pain, then I would just fix the hernia recurrence and not deal with the older Mesh. I hope that’s helpful. All right, lots of questions guys, lots and lots and lots of questions. Let’s do some more. So based on your experience, what are the incidents of Mesh complications requiring Mesh removal? Good question. So in general, Mesh removal is not necessary for almost all hernia related complications.
Speaker 2 (00:14:53):
Oh, here’s another question. How would you compare the incidents of Mesh related complications to the incidents of postoperative complications unrelated to Mesh? Right, so most hernia complications are related to hernia recurrence, and so those almost never need Mesh removal. Mesh removal, like I mentioned, is either done because the Mesh is infected because there’s a mechanical problem with the Mesh where it’s folded and impinging or pressing on something. We call that a meshoma or if you’re reacting to the Mesh as an inflammatory or autoimmune reaction, those are the top three reasons to remove Mesh. We actually wrote a paper called Why We Remove Mesh Every so often We have to remove Mesh because there’s a hernia that’s recurred and the Mesh is in the way, but that’s not common, especially for the groin. It may be a little bit more common for ventral or incisional hernias where you want to clean slate. But my point is this. Fortunately, most people do not need Mesh removals when they have a hernia complication and fortunately Mesh complications are not common. They’re the number one cause of pain or problems is usually a hernia recurrence and Mesh complication, maybe the third or fourth reason. So that’s actually good news, fortunately. Let’s see, what are the questions?
Speaker 2 (00:16:20):
Ooh, this is a long one. Lemme read this. I’ve been told by multiple Mesh plant specialists surgeons that my case is extremely complicated that my Mesh cannot be removed and that if it was removed it could cause additional nerve or muscle damage and another extended Mesh would need to be implanted. I mean that may or may not be totally true, depends on, I don’t completely agree with that. Basically I have extended j and j polypropylene prolene Mesh put in via component separation repair with oblique muscles elevated and used to reinforce the Mesh. Okay, so you basically had a component separation, which meth, those are tricky to remove, but it still can be removed if you need it.
Speaker 2 (00:17:08):
Let’s see, the Mesh goes hip to hip and ribcage to pubic bone. Okay, so it sounds like you had what’s called a giant hernia or a loss of domain and you needed component separation and huge Mesh that covers basically your entire abdominal wall. It was put in after abdominal wall denervation that happened because of a diep flap reconstruction surgery causing my rectus muscle to atrophy. I had no autoimmune issues prior to the Mesh. I now have Asia syndrome from the Mesh and multiple autoimmune diseases diagnosed. What can be done in my situation can the Mesh be explained without being replaced? Okay, so here is where the risk benefit ratio is. You’re in a very difficult situation because number one, it’s a large piece of Mesh, but definitely the Mesh can’t be removed. However, the underlying problem for which they put the Mesh sounds like is not so much for like a hernia, but because you lost your abdominal wall function because of a deep flap gone wrong, a deep flap.
Speaker 2 (00:18:06):
It’s spelled D I E P. It’s one of the different types of reconstruction flaps where they use the abdominal wall tissue to reconstruct breast tissue usually. So let’s say a female has breast cancer and they get a mastectomy, which means that their entire breast tissue is removed and then they use their own natural tissue from the abdominal wall to recreate a breast. That’s the most typical scenario for a deep flap reconstruction, deep spelled D I E P. So if that deep flap is performed in a way that the nerves are injured to your abdominal wall, then you can lose function of the abdominal wall. And the operation she had was exactly the right operation. Unfortunately, she reacted to the Mesh. So reacting to the Mesh, you would just have to remove it. I would do allergy testing first to make sure that that’s what you’re having is indeed related to the meshes.
Speaker 2 (00:19:08):
The allergy testing is not perfect, but it is something that can add additional information. So let’s say you do allergy testing and it shows that you kind of have a hyper reaction to let’s say polypropylene. What that means is that you’re not going to do very well with any synthetic Mesh that said in someone that has so much autoimmune disorder, you and the thought is since the Mesh placement, and usually it’s within a year of the Mesh place and when these symptoms start, then removal of the Mesh, maybe what you need and just understand that you’re going to look pregnant and you may have back pain and abdominal wall pain because the belly is going to look really thin walled, but that’s better than having an autoimmune disorder. Understanding also, we don’t know enough about these Mesh implant illnesses and the autoimmune disorders that it may spark.
Speaker 2 (00:20:06):
So are you prone to an autoimmune disorder? And the Mesh kind of brought that up earlier, in which case removing the Mesh may not get rid of your autoimmune disorder. Why are you removing the Mesh? Are you understanding that the Mesh may be removed at high morbidity and complication rate and on top of that you may not feel any better and your autoimmune will be the same. So these are all things to consider where the risks and benefits of the Mesh removal need to be outweighed. The risks need to be outweighed by the benefits. So let’s say you’re having chronic fatigue, joint pain, hair loss, numbness and tingling in the fingers and you remove the Mesh and the pain, all that goes away, great, but if it doesn’t go away because you actually now have lupus, then those you just have to treat the medical problem. It’s a very, very difficult co problem. So I agree with your doctors. It’s not like, oh yeah, I’ll disagree with the Mesh and see how it is. It’s highly, highly morbid, but if your quality of life is such that it deserves that, then it’s still something that I would still offer.
Speaker 2 (00:21:25):
The other option too is to consider putting it in a biologic tissue, but I would not do it in one stage. I would remove all the Mesh, see how you do. If you do, fine, then I would start introducing biologic implant to see if that helps you. And then if you are feeling really good about it, then consider a hybrid Mesh, but you may still react to that. Next question, can you give a percentage of Mesh complications that might occur during an inguinal open procedure? Very low. So Mesh complications, so all complications are kind of in that 10 to 15% range. And then Mesh complications depends on, let’s see, what did you say, Al? Open procedure. Okay, so of all the operations, al open procedure has the highest risk of Mesh complications in laparoscopic or robotic Mesh procedures, and even then it should be a fraction of that. So maybe 10% of 10%, so maybe 1% complication or so. Of course it depends on the type of operation, the surgeon skill, your own risk factors, the type of hurting you had, et cetera.
Speaker 2 (00:22:37):
Okay, next question. Are the myths of death, maming or other extreme complications after Mesh removal completely fictional, or do they have some truth from the standpoint of an unspecialized surgeon? And how do the odds of being worse after Mesh removal differ with specialized hernia surgeons? Okay, this is kind of why I have Hernia, Talk, Live and hernia talk.com because I feel that hernias don’t get enough specialty attention and therefore people go to their local doctor and get a hernia repaired and then when they have a complications, they stay with that local doctor because they don’t feel like they need to go to a specialist. It’s just a hernia. And B, their hernia surgeon doesn’t feel like any specialty special attention because it’s just a hernia. Those are both false, and I’ll tell you it’s because you keep getting complication after complication. I had a patient today, perfect scenario, she had a surgery, got a hernia, they didn’t understand the hernia was partially due to the fact that she’s pre-diabetic, morbidly obese and uses nicotine.
Speaker 2 (00:23:48):
And then what they do, they did a hernia repair, which was the wrong operation to begin with, used too small of a Mesh and did not overlap the Mesh enough with the defect that she had. And guess what? Hernia recurred, she’s still smoking morbidly obese and pre-diabetic, so she has a second surgery. All these, by the way, non non-specialized surgeons, second surgeon goes in there, tries laparoscopic can, tries open, doesn’t, does again the wrong technique. So instead of suturing the Mesh tax, the Mesh probably uses too many attacks, I’m not sure, but we’ll have to see now she’s in chronic pain and so on. So yes, the truth is in the hands of a specialist, all operations are done better, whether that’s heart surgery or transplant or hernia surgery. And once you have a complication, for sure, the next operation would be better performed by a specialist.
Speaker 2 (00:24:58):
Because specialists like me and others, 80% of what I do is treating other people’s complications, which means that’s my specialty within a specialty. Whereas if you go to your surgery who does gallbladders or breast surgery and colon surgery and hernia surgery on the side and it’s 10%, 20% of their work, they’re not a specialist within that specialty and therefore don’t understand the intricacies and how not to repeat the same mistake. So giving the example of my earlier patient, she still has all the risk factors for hernia recurrence and on top of that, she keeps having non-specialty operations where the technique is not optimal. The size of the Mesh is too small, the technique of the repair is too small, the overlap with the fascia is too small, and these are all little extra bits that add to things. So I’ll give you an example. If you buy a car, you want to buy a car from a manufacturer that sells cars all the time and has gone through the learning curve of knowing like tire pressures and where the engine should be.
Speaker 2 (00:26:15):
And if you put the engine a little bit further back or further front, it makes a difference in a car. Same is true about hernias and why specialty care is so important. And the good news is there are specialty doctors, they’re not in every state. If you go to hernia talk.com, we talk about specialty surgeons all the time. So it’s possible that in your town there or near your town there be a mention of a hernia surgeon that we recommend on this show, the Hernia, Talk, Live, I bring hernia specialists from all over the world who talk about hernia surgery and what they do, and you can kind of learn and about them and see if you like their personality and maybe go see them because everyone that I talk to, I have great faith in and would definitely refer to. You can also go to the American Hernia Society webpage and there’s a find a surgeon section that has surgeons that at least have some interest. They may not necessarily be specials, but at least have some interest in hernias.
Speaker 2 (00:27:28):
So that’s kind of my take on that. Let’s see. Here’s another question. Not sure if there’s time for another question, but if so, yes, there is. What are the conditions left behind after Mesh removal? Is the site seriously scarred, deranged, et cetera? And how does this affect prospects for a successful second surgery? That’s actually a good question because we had a similar question. Let’s see. Yeah, is it true that after Mesh removal you will never be the same as you were before Mesh was implanted? So both of those are a good question. They in intend to say the same thing. So yes, the Mesh is very much stuck to whatever tissue it’s stuck to. Usually that’s muscle, sometimes peritoneum or fascia and sometimes it’s critical structure and those are not considered critical structures usually because you can remove the Mesh and shave it off and have very, very, very little muscle or fascia that gets destroyed.
Speaker 2 (00:28:45):
So for example, I had a patient I think about a month ago, so she is lovely lady. She’s had I think three hernia surgeries and each time they put more Mesh in and more tacks and so on and just so much, so much, what do you call it? Scar tissue and tacks. And I think I took out 50 tacks in her and it’s ridiculous how much Mesh was in there. And the hernia was really, really large and the Mesh was infected. So I had to absolutely remove the Mesh without kind of damaging as much tissue as possible. But at the same time I was like, shoot, she’s got such a huge hernia. If I remove all this Mesh, how much tissue is going to come with it and how much tissue do I have left? And guess what I mean, we were maybe lucky, I don’t know, but we removed so much, much a lot of it infected and we did it in a way to minimize, minimize, minimize how much muscle and fascia was destroyed.
Speaker 2 (00:29:59):
Some was destroyed but not enough to matter because we were still able to put her back together again. And I use a biologic Mesh in her because synthetic Mesh would’ve been not the best choice, I believe in the face of active Mesh infection. So she’s great, she’s all healed and for the first time in two or three years she’s got no puss coming out of her wound and no pain and her hernias repaired and her wound is closed. So really, really happy patient. But that’s a story where you can remove tons of Mesh and still have issues that make it so that some of your tissues will be destroyed.
Speaker 2 (00:30:48):
Let’s see. Where would a patient feel pain related to fixation to Cooper’s ligament? Usually that it’s not painful. Can you use thigh crease or pubic bones to help a patient localize that type of pain? I mean, Cooper’s ligament is on the bone and usually fixation to the bone does not cause pain. Can Mesh be fixated safely to Cooper’s ligament without causing pain? Yes. How long does it take for fibrous ingrowth into the Mesh to acquire a hundred percent unexpected strike? So that’s a good question. We believe for most meshes within the first three months is the strongest it gets and kind of maximizes at about one year. So the maximum it peaks at three months and then between three months to a year is when your strength is the best. How long does it take for Mesh to incorporate into surrounding tissues? So within the first three days, so this is synthetic Mesh we’re talking about not biologic Mesh because that takes about eight months, but to completely incorporate a three months to be incorporate enough that I don’t stress out about you, but for synthetic Mesh, it’s usually within the first three days it starts to incorporate into the surrounding tissue.
Speaker 2 (00:32:03):
Can Mesh ever be removed without resulting in immediate or delayed hernia? Yes. So usually if Mesh is removed in the face of an infection, so there’s a Mesh infection, then when you remove the Mesh, there’s so much inflammation and scar tissue that’s laid down as a reaction to the infection that you’re not going to see a hernia. Often that’s the case and because of that, we usually just remove infected Mesh and don’t need to fix a hernia. In the case of the most inguinal hernias and most small hernias in the larger hernias, that’s not usually the situation because there’s a huge gap, but that’s the most common situation. Also, if you have a small hernia and for whatever reason need to have the Mesh removed that there may be enough scar tissue to fill that. In both cases, however, eventually you’re going to get a hernia less likely with the infection situation because the amount of scar tissue late is so thick and angry.
Speaker 2 (00:33:06):
But in the situation where you just remove Mesh without infection and it’s a small hernia, that scar tissue that fills a hernia is not enough to last you. So in the next year or two, you may expect a hernia to recur. Oh, here’s my patient who follower from England says I’m in England, which by the way, I will be in England next month. So October, I can’t wait. I’m in England and I lost 23 kilos for my operation and now they moved the goalpost swimming two miles a day. I’ve had Mesh stuck to my bowels twice nearly killing me and having tax et cetera in my hernia is huge. Well, congratulations on your weight loss. 23 kilos is a lot. That’s like 50 pounds or more, which is a lot, a lot, a lot. I regularly refer my patients to surgical weight loss because it’s just so hard to lose that much weight. It takes a long, long time, which means your quality of life is diminished during the time when you’re trying to lose the weight. So surgical weight loss is often the best choice.
Speaker 2 (00:34:18):
But yeah, if the Mesh is stuck to your intestines and tacks and so on, that all should be removed and the best thing to do is to reduce all your risk factors before surgery. So stop your nicotine, no constipation, lose the weight, make sure you’re not, don’t have infections. If you have chronic cough, fix that, get your diabetes under control and then have your Mesh removal surgery. How can you check if your Mesh is infected? Usually there’s a fluid collection associated with it. You have fevers, you’re sick that may be drainage or a non-healing wound underneath it. The one patient that I was talking to you about, no one told her her Mesh was infected. They kept treating this like non-healing wound and draining wound. They kept calling a draining sinus. Yeah, it’s draining sinus because there’s bacteria there and the reason why there’s bacteria there is because the Mesh, which is synthetic, is constantly harboring disinfection. Unless you remove it, it’s not going to go away.
Speaker 2 (00:35:20):
Can you explain why the American Hernia Society makes recommendations to not fixate Mesh and Lichtenstein repair to the pubic periosteum? And what is it that makes the pubic periosteum unique as a pain generator given that the orthopedist suture periosteum in other sides commonly? Very good question. So this was really Dr. Parviz Amid’s thing. He was dealing with a lot of patients that were coming to him with chronic pain, and one of the things he noticed is that there’s suture into the periosteum and the bone, and he felt that and they had a lot of pain specifically over that area and they were getting osteitis pubis, so he felt that that was a technique that was causing problems. And therefore most of us and the European and international consensus papers recommend that we don’t put sutures into the bone. We can just use the periosteum or the rectus insertion on the periosteum on the bone to hold our sutures.
Speaker 2 (00:36:33):
Now if you talk, you’re exactly right. If you talk to orthopedic doctors, they suture the periosteum all the time. So it’s unclear if what he was recommending has any validity to it. It was based on his observations and I must say it’s a better technique not to go through the periosteum, but we go to Cooper’s ligament all the time and no one cares. So you pick up on a very, very interesting detail. Most doctors would not be able to figure out that detail, and I agree with you, it doesn’t make sense, and I do feel it’s a better operation. It’s cleaner not to go to the periosteum, but the fact is that tons of people will have it go through and it’s probably not an issue. Next question.
Speaker 2 (00:37:25):
What is the threshold for the pain scale one to 10 where you’d consider removing Anglo hernia mush? Oh, well, it would have to affect your quality of life. If it’s not affecting your quality of life, then depends on what you do for a living and what kind of quality of life you have and what you’re willing to undergo before committing to surgery. Next. I had Mesh removal from diastasis rectocele umbilical hernia repair over two and a half years ago. There’s no recurrent hernia, but I do have intermittent pain that can be debilitating. What can be the cause? So oh, you had Mesh removal, but if the Mesh was removed, I wonder if they put sutures in because if you have sutures in, the pain can be pulling of the sutures.
Speaker 2 (00:38:22):
All right, great. Great questions, everybody. Okay, we answer that question. Is it correct to say that since the immune system activation always Mesh implantation and always involves some amount of inflammation, Asia patients, so autoimmune or autoinflammatory symptoms induced by adjuvants patients are just those patients where the degree of immune system activation and associated inflammation is enough to cause systemic symptoms. I e all Mesh patients have Asia to some extent, but only a few have symptoms. Okay, so here this is talking about patients who undergo hernia Mesh implantation and react to that implant in a severe enough way that they get an autoimmune or inflammatory systemic response, hair loss, tingling in the fingers and toes, joint pain, joint swelling, bloating, nausea, vertigo, ringing in the ear, visual changes, problem sleeping, chronic fatigue, brain fog. These are all inflammatory systems symptoms, excuse me, that we believe are part of the Mesh implant illness syndrome.
Speaker 2 (00:39:58):
Now the question is does everyone really get some type of inflammatory response in the body and others are just, it’s just so extreme. I don’t think so. We do know that all hernia Mesh implants cause inflammation, but it’s local inflammation. It’s like cutting yourself. If you cut your hand, you’re going to get inflammation locally, but your head to toe body’s not going to have an inflammatory response necessarily, and that and your normal body should compartmentalize that inflammation strictly to the area where the implant is and not have your whole body go into some extreme inflammatory state. Now some people feel bloated after surgery. That may be from the anesthesia, it can be from the medications, it can be from the IV hydration, they may be constipated, who knows? But in general, no, I don’t agree with that statement. That said here, I’m super excited because this Friday I’ll be presenting my results and experience with hernia mush implant illness and allergy testing in that realm to Dr.
Speaker 2 (00:41:23):
Shoenfeld and his group in Israel, which I’m super excited about because he is the inventor of the Asia syndrome and he has a weekly autoimmune autoimmunity kind of conference. And I attended it last week. It was really great and I hope to present my data this week and have a discussion about it. I hope and learn some more and then maybe collaborate with Dr. Schoenfeld on hernia meshes because we need much more, much, much more data than we currently have. So I’m super, super excited about that. Next question. I live in the central part of the United States. Awesome. Every doc tells me the same thing. We cannot operate because it may or will kill you. Yes, but what I say earlier, I believe it’s because they are not specialists and they feel they will kill you. Maybe that’s true, but you shouldn’t be killed in general. I always use the analogy like why would you die from a hernia surgery? We do heart transplants and people don’t die. Why would you die from a hernia repair or meshable? Anyway, I got it Late to your podcast when you were talking about finding a surgeon. Do you know of any surgeons close to the middle of the US I could call? Yes. So first of all, last week we talked to was last week, two weeks ago, we talked to Dr.
Speaker 2 (00:42:51):
Dr from Washington University in St. Louis. So I highly recommend you go there. Why am I blanking on his name? Blatnik, Jeffrey Blatnick. There’s two surgeons, doctors, Jeffrey, actually three surgeons in that group. I’ve interviewed two of them, Dr. Michael Brunt and Dr. Jeffrey Blatnick, they’re in St. Louis, Missouri. Missouri’s in the middle and great surgeon knows a lot about hernias, a lot about meshes, and we talked about different types of meshes. So if you want to watch that YouTube on my YouTube channel from two weeks ago, you may be able to, maybe you’ll like him and you can call him. What else in the middle we’ve talked to, let’s see, in Tennessee, Dr. Dr Guy Voeller can consider him very knowledgeable. I believe he’s in Memphis, I believe. And so at University of Tennessee, or you can just go to hernia talk.com and search for different states and see if they were mentioned in different discussions. I would recommend traveling if you have the means to travel for your care because that’s very, very important.
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And then American Hernia Society, the webpage has a list, find a surgeon. So just go to the american hernia society.org and then there’s a list called find a surgeon. You can put in your state and see if anyone in your state at least has an interest in it. But yes, if people are telling you you will die, do not go to them for your hernia meshoma surgery. Let’s see. So are you saying that a second surgery after Mesh removal will always be another Mesh surgery? No, I’m not saying that at all. In general, if you have a hernia recurrence after a hernia repair with Mesh, then the hernia recurrence should definitely be with Mesh, otherwise it’s going to fail. However, if you need Mesh removed for a certain purpose, let’s say infection, let’s say chronic pain from the Mesh or Mesh implant illness, then you may undergo a redo hernia repair without Mesh understanding that it’s a lesser repair in terms of hernia recurrence, but your situation may be such that it is.
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Here’s a comment. I have found that many surgeons, even hernia surgeons shy away from Mesh removal due to concern over in outcomes, true lack of appropriate compensation based on the complexity of surgery of the surgery possible or the fact that a surgeon can perform a great number of simple repairs per day. That’s very true actually. So the compensation per time unit for a complex operation is much less for a complex operation than for a simple operation. So if I did five or six inguinal or umbilical hernias in one day, I would make more money than if I did one or two complicate operations. That’s just the way that insurance companies work.
Speaker 2 (00:46:19):
That said, I’d admire your willingness to take on these tough cases and your wonderful forum to help those of us that need bravo. Thank you very much. I do appreciate that. I actually enjoy the mental kind of process you have to go through to figure out exactly what’s wrong with someone and what’s the best operation for them. Is it Mesh removal? Is it nerve block? Is it medications? I had a lady who came in today and she was thought for sure she needed hernia surgery. I was like, no, I think you have a GI problem. So I have another patient’s online consult also thought that she’s got like a hernia, but she doesn’t. It’s actually a GI problem. So I like that kind of opportunity to figure things out and problem solve. Everyone knows I’m a huge, huge, huge problem solving fan, and the way that my office works is different.
Speaker 2 (00:47:21):
We don’t really contract with much with most insurance companies. We can still bill for you, but we don’t contract with them because I think that the type of reimbursement that they believe in is totally against what I believe in. So don’t not a fan of working with insurance companies because they don’t agree that I should be spending my time sitting down and figuring out your problem. They just feel like I should just be going. Hernia surgery, hernia surgery, no hernia, no surgery. That’s not how I work. Pain never went away since inguinal surgery from the incision, I feel like it never healed terrible to the touch. Any advice? So very good problem to help figure out for you. Basically if someone has had pain before inguinal surgery, then they have surgery and now they have pain, the question is tell me exactly what the pain is and how is it different, not just in quantity, but in quality be from prior to your surgery.
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So you had certain quality of pain before surgery, then you had surgery, now you have this other pain. Is it exactly the same? That means your hernia was not the cause of the pain, most likely is it different quality? So I still have pain, but it’s different than was before surgery. Then that may be a hernia surgery complication which can be addressed. That’s where this kind of back and forth goes to where we question. And then your physical exam is also very important and in reduced situation. I think it’s so important that you have a imaging. I think imaging’s a big deal when it comes to revisional surgery. All right, let’s go through some more questions. Is acute inflammation that occurs immediately after Mesh implant local or systemic? Local? After what amount of time does it subside? Depends on the patient. Usually within days, two weeks, usually less than six weeks.
Speaker 2 (00:49:30):
Is there any residual long-term local or systemic systemic chronic inflammation at the level of the implant? Yes, because of the implant, you’ll always have a local chronic inflammation. We showed that in our paper that we published on Mesh pathology and we showed every single Mesh that we removed had chronic inflammation. That’s expected. And if you talk to the pathologist, they will say, oh, well yeah, duh. Even if I remove a pacemaker or if I remove a hip implant, the pathology will always show local chronic inflammation, but it should not be having have a systemic reaction. Okay, let’s go back to the other question about the pain after hernia surgery. It hurts to shave feels worse afterwards. So if it hurts to shave, you have a nerve problem. So it’s neuropathic pain, and that may be because of just swelling in the area or it may be because you have nerve entrapment or nerve injury from the hernia repair. So that’s something that your doctor needs to figure out which nerve to nerve blocks and give you nerve medication to see if it goes away and determine if it’s a reversible problem.
Speaker 2 (00:50:51):
In other words, is the nerve entrapped in scar tissue and can they release scar tissue or is a nerve injured or eroded by the Mesh, in which case a nerve should be perhaps destroyed? Okay, if pain post-surgery is similar in location and quality, but much more severe constant and easier to provoke than pre-op and not related to the surgical intervention sutures, hold on. If pain post-surgery is similar in location and quality, but much more severe constant and easier to provoke within pre-op, not related to the surgical invention in sutures and or Mesh. Okay, so So exactly. If you have certain amount of pain and you have a surgery, hernia, Mesh sutures, whatever, and post-op, you have the same quality of pain, but it may be worse, let’s say, then you must consider alternative reasons for your pain like a hip problem. Okay? Now, is it possible that the pain can be worse because you had a hernia and you had an inadequate hernia pair where the hernia was never really fixed?
Speaker 2 (00:52:08):
That’s also possible. That’s why imaging is so important. But you must always be open to the fact that maybe it was never your hernia to begin with because so now you have the original pain plus surgical pain on top of that in the area I have had, okay, going back to the pa, okay, you’re giving me a little bit of, you’re not giving me the whole story. This is what is important. You need to tell me the whole story. So now it turns out this patient who had pain after hernia surgery, did have nerve surgery as well, had neurectomy before surgery, nothing helped. So we need much more much, much more information. You had neurectomy before your hernia surgery. So why do you think that it’s your hernia surgery that caused your pain? Why couldn’t it have been the neurectomy that went wrong and caused neuropathic pain?
Speaker 2 (00:53:09):
Or maybe it’s another nerve that was missed. But if you’re hypersensitive in the area, that’s usually a nerve pain problem. So if you want more help, please feel free to call my office directly. I do offer online consultations if you don’t want to come in to see me in person or do it or you’re not in California, which is where I do where I licensed to practice, and I’ll try and figure it out for you, but I need a little bit more information. I’m getting a little bits from you and I need a little bit more information, but I do like solving puzzles, like I said, so happy to help in retro muscular or extra peritoneal Mesh placement. What is the thickness of the tissue that separate Mesh from the bowel? Oh, I don’t know, millimeters. Is that maybe one millimeter? Depends on, depends on how much fat you have. So the peritoneum itself is super thin. It’s like a piece of paper. So that’s how thin the peritoneum is, but if there’s also fat there, so if you have fat in addition to the peritoneum, then depends on how thick your fat is. Is that thick? This always enough to shield the intestines from the inflammation caused by Mesh?
Speaker 2 (00:54:29):
Yes and no. If you have a lot of fat, then yes, that’s usually enough to prevent a lot of inflammation transmitted from the Mesh onto the intestines. Okay, next question. We’re running out of time guys. I’ll try and do as many as you can. Do you agree with Dr. David Chen that the three inguinal nerves intercommunicate and therefore triple neurectomy is necessary for pain relief despite risks of abdominal wall denervation? I do not agree with that. And we’ve actually discussed this. I am a proponent of selective neurectomy and not triple. I do not feel that the nerves necessarily intercommunicate. Now, is there science behind the fact that they intercommunicate? Yes, they do. But does that mean everyone needs a triple no. Is that putting you at risk for abdominal wall generation? Absolutely, especially if it’s done laparoscopically or retro. So no, I do not automatically perform triple neurectomy for everyone with pain.
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I only perform neurectomy if that nerve is injured or part of the problem. And even then, I don’t like to do neurectomies. If I can do other forms of pain control such as direct nerve blocks or percutaneous ablation of the nerves. I have published a paper on outcomes from neurectomy and in the greater literature it’s about 5% risk of neuroma. In ours, we had 4% risk of neuroma, so very similar, slightly less, but very similar. And a certain fraction of patients will have C R P S. We ha we’re going to have a specialist come soon to talk to us about CRPS, but CRPS stands for complex regional pain syndrome. Very, very difficult problem, very complicated. You do not want anyone to get C R P S and it is a problem and a risk factor after any type of neurosurgery. So I’m very judicious about neurectomy and I do not believe that triple neurectomy is the answer to all chronic pain.
Speaker 2 (00:56:49):
Let’s see, I have my Mesh removed and then it was sutured up and feeling started and the feeling started after the first surgery, which is still the same. So the question is, is you’re feeling all neuropathic? In which case it’s not a hernia issue, it’s a nerve issue. You got to figure out which nerve and then what the problem is. Is there a neuroma? And if it’s a neuroma, then that should be addressed surgically or with ablation. Oh, here’s another question. Do you know of any hernia specialists in Texas? Of course, and I had my first hernia surgery in 2015 where they attacked a six by six Mesh, sorry, they attacked a six by six Mesh to my pubic bone and two months later had to have another surgery because the Mesh came undone. I have been in constant pain ever since. I’ve been told I would have to live with it.
Speaker 2 (00:57:47):
I also have been see sent to a psychologist because I think I’m crazy. I’ve heard that before because I keep telling them I’m in pain. I’ve had one other hernia surgery since those two. I’m not crazy. I hurt and I have had to quit work due to all the pain. Okay, so Dr. Kent Van Sickle, I believe he’s in San Antonio, is a great surgeon in Texas. There aren’t that many other specialists in Texas, unfortunately. So he’s the one he’s that I often refer to in Texas because he’s a great guy. Going back to the neurectomy patient, the doctor did neurectomy, it numbed my leg with a broken Mesh. Later I found out.
Speaker 2 (00:58:38):
I don’t know what that means, but if the area of your neurectomy is a different area than where you’re currently hypersensitive, then there’s a different nerve. That’s the issue. Let’s see. After Mesh implantation, is it only scar tissue that grows through the Mesh so that when you remove the Mesh, you only remove scar tissue? Or do those tissues grow back? No, actually your muscle fascia center will ingrow into the Mesh, and so when you remove Mesh, whatever structure is close to it may also grow into it. So for example, if the Mesh is placed against a vessel, then the vessel will not grow into the Mesh, let’s say your extra iliac vessel. However, if it was, okay, another example, if it was the Mesh was placed against your bladder, the Mesh will not necessarily grow into the bladder, but if the bladder was invaded and the Mesh was placed against the muscle within the bladder wall, then yes, that muscle will grow into it. Same with the abdominal wall. If it’s placed against muscle or fascia, then yes, that muscle will grow into the Mesh. The fascia does necessarily grow into it. It’s mostly stuck to it.
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I had a neuroma removed. Do they come back? Yes, they come back. So now you’re telling me you have a neuroma. These little details are so important. Yeah. So yes, if you had a neuroma and depending on how that was addressed, that neuroma can come back. Like I mentioned, neurosurgery has about 4-5% risk of neuroma. Is it true that after measurement you will never be the same as you were before Mesh implant? Oh, we already asked answer that question and about the death question. Oh, that’s all your questions. Oh, no, no. There’s one more question. Let me go back to this. This was on Instagram and I promised them that I would answer it. So here’s the question. It says, I am five months with my Mesh and I want to have another baby by the end of the year. Should I first remove it? No. No, no, no. If you have Mesh in you and you want to get pregnant, just get pregnant. Do not first remove the Mesh. That would be a horrible situation. Now, if the Mesh is in the groin, you should have no problem if the Mesh the belly. It’s possible that you’re going to have pain from it, but that’s not an indication to proactively remove the Mesh.
Speaker 2 (01:01:22):
Thank you so much, Dr. Towfigh. These sessions are almost always appreciated. Thank you for joining me. I do appreciate that you all spend your Tuesday evening, afternoon, wherever you are following me, and also, I do appreciate the fact that you all find this highly valuable. So thank you very much. I would like to say you guys are amazing people, and I do love that you love what I do because I love what I do and it’s kind of nerdy but fun that I like hernias and I thought the mesh removal topic went really well today because you guys asked way too many questions. On that note, thank you everyone. Thank you for joining me. Come back again next week
Speaker 3 (01:02:18):
And we will have another great topic to talk about. We got some guests that I signed up for two weeks from now, which it’s going to be super, super, super VIP. And hope that you guys join me then too. See you all later and take care. Bye.
