Episode 113: Sports Hernia & Minimal Repair Technique | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

Hi everyone, it’s Dr. Towfigh. I am your hernia and laparoscopic surgery specialist. Welcome to Hernia Talk Live. Every Tuesday you join me for Hernia Talk Tuesdays. Thank you for coming on Zoom, many of you are here as a Facebook Live. Thanks for those of you that follow me on social media, on Twitter and Instagram at hernia doc. As always, this session in all prior sessions can be found on my YouTube channel. If you miss ’em, you can kind of watch ’em later. But this will be an especially wonderful session because we have the greatly esteemed Dr. Ulrike Muschaweck. I have known and admired her since I got into hernia surgery in 2002. And of course she has a history much longer than mine and is world renowned from what she does. So I’m very, very honored to have her. It’s an Munich, Germany now, so we did this a bit earlier than usual so that we can make sure that it’s appropriate timing for her. So Dr. Muschaweck, thank you very much for joining us today.

Speaker 2 (00:01:08):

It’s a great honor for me. Thank you so much to invite.

Speaker 1 (00:01:11):

Thank you so much. So I was explaining earlier we have this every week. I’ve been doing it since we started the pandemic and our patients submit questions ahead of time for your session. I have at least 25 questions and we only have an hour to go through it. We’re not going to rush, but it’s something I really look forward to. And those of you that are on, please me, your questions, we’ll go through it. But while you do that, Dr. Michelle, if you can please give us a little bit of a brief. How did you even get into hernia surgery? Everyone has their story.

Speaker 2 (00:01:51):

It was by chance I was the head of the outpatient department in the University Hospital of Munich. And then I got the, yes, I was asked if I would like to do hernia surgery. And so this was 80 19 88 and I went to the Shouldice hospital in the beginning and to Oh, okay. To learn the Toronto in Toronto. And this was the beginning. It was a beginning and a big success from the first moment beginning then. So doing only hernia surgery and I’ve been the first one in Germany to do only hernias, nothing else. So I have done more than 29,000 surgeries in the meantime,

Speaker 1 (00:02:37):


Speaker 2 (00:02:38):

Hernia surgeries and of course as more as you do, as better you are and as more as you do, as more experience you get. And this was the beginning of the development of my own technique, the beginning of the development of special techniques. So because of this, doing so many and yes, every week and every day and learning about doing by yourself. That’s

Speaker 1 (00:03:03):

Fascinating. You must really enjoy how much more popular hernia surgery has become because yes, you’re among the first to even do hernia surgery as a specialty. Yes. When I started in 2002, still there was a handful. It was like Dr. Amid, he was really the person that I looked up to and he’s in Los Angeles. So I got to know him and really admired kind of what he was doing to help promote the specialty. But now the residents really enjoy it. The medical students enjoy it. I feel like there’s a lot more innovation with different technologies and the residents actually want to do hernias now. Not sure they wanted to back like before it didn’t have the same pizzazz to it.

Speaker 2 (00:03:53):

Yes, the same interest and the same. They didn’t like to do hernias. Hernias have been something which nobody didn’t want to do in the beginning. And so I was really the first one and they looked at me if they would be have become crazy. Sure. But I started in 1988 and with a met by own hospital in 1993. And since then I’m doing this only this. And this is a big interest now in all the patients, in the athletes, in the surgeon words of the surgeons is it’s really becoming the big interest has been becoming a big interest has been the beginning. They all thought I have become crazy, but I didn’t. No.

Speaker 1 (00:04:40):

Yeah. And very good. So most of your hernias are your specialty with your specialty within the specialty and then within that specialty is mostly growing groin pain due to hernia, MS hernias, groin pain due to complications from prior hernias and groin pain due to a sports type injury in the groin. Is that fair to say?

Speaker 2 (00:05:08):

The beginning has been have done all the inguinal hernias, small, big, all the types, currencies, everything. But within my patients I get got more and more athletes and then I find out by myself that the regular hernia surgery for hernias is not the right therapy for athletes. So that I developed the special technique for them to do as less as possible because the inguinal hernia is different to a spots hernia, which is the wrong name. Yes. But it’s not like this. So this has been the beginning and in 2002, 20 years ago, I developed this own technique and this was first time published during the hundred year anniversary of they are Madrid in Madrid, Madrid. And since then it was a huge success since then, all the assets did want to become this technique because after 14 days they are able to play soccer again without any problems. And so this has been a long way to find out about this and now it’s really, really common.

Speaker 1 (00:06:27):

So one of the main things is try to even understand what a patient has. So how do you differentiate someone having a sports hernia, which is not really a hernia, a sports injury versus just a really small hernia that you can’t see on examination?

Speaker 2 (00:06:45):

It is really, really easy to let, it sounds difficult but it isn’t, you know, have to do the right diagnostic and the diagnostic is, and to do the so-called dynamic ultrasound and I do it always by myself. You have to ultrasound your wall of the crown canal and then under by you can see all the small changes. You can see everything small her yes no her, yes, you can see the sports hernia, you can see everything, but you must do it correctly. And that is really, it’s, it’s a short way to learn but you have to learn this. I did learn it as well. So I do it by myself at always, I was taught by myself and see, so you

Speaker 1 (00:07:29):

Have ultrasound in your office? Yes,

Speaker 2 (00:07:31):


Speaker 1 (00:07:31):

And you do it yourself. Yes. And I feel that that’s great because United States ultrasound is horrible. So it’s not reliable at all. CT or MRI are much more reliable. Yes. I have one radiologist that loves hernias and he does ultrasounds for me. I do some ultrasound in the office, but I’m not as good as you for those little, like the groin area details. But I feel like radiologists need to learn more about

Speaker 2 (00:08:04):

Pathology, have to do it under and really it, it’s really important to do it right. Otherwise you would see it. And therefore, because the MRI is always negative, sometimes I get patient with seven or eight or eight, 10 MRIs. Okay. Always negative. And the one minute I see the artisan and I see the diagnosis. So it is And what

Speaker 1 (00:08:28):

Do you see? Yes. What do you specifically look for? Yes,

Speaker 2 (00:08:31):

This is important to know about the anatomy. I will only say one sense about this. The groin canal, the flower of the groin canal is a fascia. And if the fascia is in a small area, weak. If it is weak at some point, not the whole area, but some point might be between two and three centimeters. Then you see under bava you see a bing. The typical bio. Yes.

Speaker 1 (00:09:00):

And you

Speaker 2 (00:09:01):

See this biology, it’s the cause for the problems because this biology is compressing a nerve, they get into a brain nerve. Correct. Then you see this biology, then he has a spots hernia, sportsman’s groin, however you would call it. It’s not a hernia because there is no intestine in disparaging, but pre effect of the layer behind. And this is the cause for the pain because it’s compressing a nerve.

Speaker 1 (00:09:29):

Okay. So how do you differentiate a direct hernia, which is a weakness as well from a sports type injury of the Yes,

Speaker 2 (00:09:40):

Because the dry turn always is containing intestine and you can see intesine in the ultrasound.

Speaker 1 (00:09:45):

I see, okay.

Speaker 2 (00:09:46):

As soon as you see intestine, it’s a hernia, a direct hernia in the growing canal. But if you don’t see intestine only pre peritoneal fat, then it’s a baring only pushing the nerve forward, doing coughing, laughing, kicking the ball, whatever. Then it’s a spots men’s, groin spots, hernia, athletic pubalgia, all the same name.

Speaker 1 (00:10:13):

Could it just be a small hernia where it’s so small all it’s the initial stage where just pre peritoneal fat is there and no intestine?

Speaker 2 (00:10:21):

Yeah, it can be, but it wouldn’t make a difference in the therapy. If there’s a small hernia within this area, there is no difference in the type of surgery.

Speaker 1 (00:10:31):

Okay. And then you mentioned your repair, which has become very popular for athletes. I believe that’s your minimal repair technique. Can you explain how it’s different than typical tissue repair like Shouldice Bassini?

Speaker 2 (00:10:46):

In shouldice is a very good technique, but more for bigger hernias, not for the small defects. If you imagine that the groin canal is seven to seven to six centimeters, the whole length and the defect in a sportsman’s groin case is around between two and 2.5 centimeters. So I thought in the time when I developed this, why should I open the whole canal for the shouldice technique? Yes to this small defect to destroy the whole fascia, only to do shouldice technique. And so yes, don’t open more than the defect, which you can see in the ultrasound. I prepare a special fascia flap in the area of the ilio pubic tract. So you can do the first line without any tension and then you can do a overlapping fascia surgery. And after two weeks they’re back on the field because there is no tension on this repair, there is no defect in the area of the sound tissue. You only to repair the small defect two to three centimeter, not more.

Speaker 1 (00:12:03):

So how, yeah, I also feel very kind of, especially I see a lot of women and women tend to have small hernias. Yes. And so Shouldice, so appropriate for your typical male hernia because it’s usually larger hernias and it makes sense to open up a defect a little bit more, right. For the whole floor. But if your defect is so small, I feel it’s wrong to completely open up the pelvic floor. Yes. The inguinal floor to address it. So the Marcy repair is a simple closure. How is your repair different than a Marcy repair?

Speaker 2 (00:12:37):

It’s not a simple closure. You have to prepare a special fascia flap to do this. It is closing tangent free. That means that you do a overlapping of the fascia in the area of the defect tend free. Therefore you prepare in the distal area a special flap of fascia of the pubic tract. And then a overlap the transverse fascia to close the defect still without opening the, without enlarging the defect. It’s really not to enlarge. Not to enlarge, to do it tension free. And then you can close the canal without any problem and the recurrency is close to zero because you don’t open sound tissue.

Speaker 1 (00:13:24):

What do you think about just the diagnosis of sports hernia? Do you think it’s overdiagnosed or underdiagnosed?

Speaker 2 (00:13:34):

Do you mean all the questions about the nerve? No,

Speaker 1 (00:13:36):

No, sorry, this one. Do you feel sports hernias are overdiagnosed or underdiagnosed? I feel in my town, if people come and they don’t have a bulge and they have pain, hernia pain, they’re like, oh, you have a sports hernia. But they don’t actually have a typical indirect or direct inguinal hernia. It’s just so small. It’s not a sports injury or tear. And I treat them as a hernia. But I feel that some people, they just call it all sports hernia. What do you think? Do you think are over, over-diagnosing or

Speaker 2 (00:14:16):

I think they overtreated treated yes, because sports hernia doesn’t need any Mesh, sorry to say this because No, you use meshes, they don’t use any Mesh. They don’t use to enlarge the defect. They only use a only lead, the repair of the defect. And you can measure the defect with the ultra ultrasound. If you do it properly, you can measure the whole defect and you see it’s a small defect. Why should you open the whole canal? Why should you do more is necessary for a sports hernia. A real hernia needs more. A real hernia,

Speaker 1 (00:14:58):


Speaker 2 (00:14:58):

Real hernia. Hernia needs more. But this doesn’t need any more it it’s important not to do more, not to destroy anything. And this is so much overtreated, so much, yes. All over the world.

Speaker 1 (00:15:14):

And then do you feel that because the nerve is being pushed that they get nerve pain? Right. Many people, yes. They don’t have the bulge. Right. But they have nerve pain, especially women. I see. They have pain into their vagina, into the inner thigh, clearly nerve neuro neuropathic. What do you do with the nerve? How do you decide in a true sport hernia whether you should touch the nerve or do you just fix the hernia and then the nerve pain goes away?

Speaker 2 (00:15:41):

No, so it’s a easy decision. Easy because I always see all three nerves in the groin canal and one who is responsible for the groin pain because of his hernia is obturator branch of the feral nerve. And you can see this nerve immediately if you know how to look for how to look or where to look for. And if a nerve is sound and without any damage, then a nerve is shiny. With a shiny surface, yes.

Speaker 1 (00:16:12):


Speaker 2 (00:16:13):

Damage it’s it’s thicker and it’s sometimes like a pearl pearl chain not so therefore you can immediately see if there is a nerve damage or not. So if there is a nerve damage, you have to remove the piece of nerve damage, otherwise you keep the pain forever. And it’s only if you touch the skin, it’s only a sensitive skin nerve. If you touch the skin for next week’s after surgery, there can be, must not be a bit of numbness for some mix which will disappear because the scar is only a piece of the nerve of the damaged nerve, only a piece, not the her nerve.

Speaker 1 (00:16:52):

Do you think if you don’t touch the nerve and you just remove the hernia, you address the hernia from pushing on it that the body will just heal that nerve?

Speaker 2 (00:17:01):

No. If a nerve is damaged and not shiny any longer, it will never recover.

Speaker 1 (00:17:07):

Got it. Got it, got it. And then since you also treat a lot of groin pain, chronic pain, what are your thoughts on selective neurectomy versus triple?

Speaker 2 (00:17:19):

The triple neurectomy is, in my opinion, about terrible therapy. I too

Speaker 1 (00:17:25):

Much don’t you think?

Speaker 2 (00:17:26):

Yes, much too much. I’ve done this. It’s much too much because there are only sometimes two nerves if so, but mostly only one nerve, which is damaged, three nerves together. It’s much too much. I never would do it.

Speaker 1 (00:17:45):

Yeah, so selective neurectomy. Yeah, I do the same. There’s this thought that I think Dr. Amid was really the head of it where he was saying that nerves talk to each other and so if you don’t cut one then you’ll still have chronic pain. But my feeling is that’s not really what’s going on. If you always cut all three nerves that you’re never wrong in which nerve should have been cut. But if you’re selective then maybe you’re wrong and that’s why you may be missing it. But I feel like

Speaker 2 (00:18:23):

There’s one trick I tell you one trick I cannot miss it because I developed this circle of intraoperative nerve response. If you before surgery, mark the point of pain enduring surgery. Yes. Find out this mark because I don’t do under general anesthesia under local an sedation. Yes.

Speaker 1 (00:18:42):


Speaker 2 (00:18:42):

Patient is for some is a bit more awake and then you find immediately the point you see the nerve. Why should you cut all the three nerves? I never would do it. You find immediately the point when you go with a steroid needle into the marked point down to the nerve, down to the pain point. You ask the patient, is this the point of pain? And the patient is saying yes and they know what it is and you don’t know. You don’t have to cut on the three nerve.

Speaker 1 (00:19:09):

Yeah, yeah, I agree. I also prefer to do the Mesh removals or any kind surgery under IV sedation. Not in local anesthesia, not general. Yeah.

Speaker 2 (00:19:23):

Otherwise you wouldn’t.

Speaker 1 (00:19:25):

So one of the risks with touching nerves is you can instigate something called Crips or CRPS, complex regional pain syndrome. Have you seen that? No. In patients?

Speaker 2 (00:19:36):


Speaker 1 (00:19:37):


Speaker 2 (00:19:38):

No, not yet.

Speaker 1 (00:19:40):

Yeah, it’s always concerned. We looked at our data of neurectomies and what the outcome was. So in our data it was a 4% risk of neuroma. And then we had two patients that ended up with complex regional pain syndrome. And it’s unclear if it can’t be prevented, but it’s a very difficult problem to treat once if a patient kind of falls into that category.

Speaker 2 (00:20:12):

But I think it’s also a question of how to cut in it. How to cut the nerve. If you tie a nerve or if you burn a nerve you can awake, you can wait for pain after neurectomy. I never would, would tie a nerve. I never would burn a nerve. This is only take a knife. Yeah. Shortcut and it slips away. So I never seen a neuroma after cutting this nerve if necessary, you know, only have to do it if necessary because it’s really, it’s a bit for patients frightening to know to think about a nerve which is to be removed. But they even don’t feel it because if you cut it right, the nerve is slipping back back and there is no tissue around, no damaged tissue around. So the possibility of developing a neuroma is depending on the tissue around of scar tissue or whatever,

Speaker 1 (00:21:14):


Speaker 2 (00:21:15):

Is slipping back into sound tissue, there is no risk of a neuroma.

Speaker 1 (00:21:20):

I feel some people just make neuros. I’ve treated a couple where they keep getting neuroma over and over again.

Speaker 2 (00:21:25):


Speaker 1 (00:21:27):

I dunno why. So you just sharp cut and then you as proximal as possible. Yes. And then it gets buried into the muscle. Yes. What about you get bleeding? Do you get, because there’s little vessels that remember with the nerve. Yes.

Speaker 2 (00:21:40):

Cause I separate the vessels before I separate the message and then it can be cut in the slipping back and there is never a problem again.

Speaker 1 (00:21:49):

Yeah. Let’s talk about, let’s see, here’s a question about athletes versus non-athletes. So here’s a question a patient submitted. Can a non-athlete who had a prior tissue repair, actually let me ask you this. Can a non-athlete get an athletic pubalgia or can a non-sports person get a sports hernia?

Speaker 2 (00:22:16):

No. Okay. If you have been right before, you already can get a recurrency.

Speaker 1 (00:22:23):


Speaker 2 (00:22:24):

If the sports hernia is only possible in a sound tissue without surgery before, but if there has been a surgery before, of course you can develop dry pain. Of course you can develop pubic pain because of recurrency, but it’s called medial her media currency or something like this. But it’s not as a primary sports hernia, athletic hernia not. Got it.

Speaker 1 (00:22:51):


Speaker 2 (00:22:52):


Speaker 1 (00:22:52):

So this is a patient, I think he is, let’s just say 70 years old, seven zero. Can a non-athlete with a prior tissue repair of a direct inguinal hernia 40 years ago develop a sportsman’s groin from extreme lifting accident?

Speaker 2 (00:23:12):

No. And then

Speaker 1 (00:23:13):

No correct

Speaker 2 (00:23:15):

Noah. And the second, yes, you can differentiate you. So first part of the question is a clear no

Speaker 1 (00:23:23):


Speaker 2 (00:23:24):

Because after 40 years, two nos, you cannot get new hernia because of lifting. So you get a hernia or a recurrency because of the tissue repair, which has perhaps not been really done absolutely perfectly, then you can get a recurrency. But it’s not a question of lifting or sports activities. So that we never would call it like this. [inaudible] is in combination with the sports hernia or sportsman’s crime because in the case of a sports hernia or sportsman’s groin, the groin can now becomes wider. That means that the rectus muscle, rectus abdominus muscle is retracting into the medial side and is causing more tension at the pubic bone. And this is the cause for the pubic pain. So therefore if there is a man he has been operated before and gets a direct recurrency, he can get of course pubic pain. But because of pubic Yes. And the therefore increasing tension at the pubic bone.

Speaker 1 (00:24:35):

Yes. So okay, same situation. Let’s say this is the same patient, his chronic groin pain is from a recurrent inguinal hernia, which is expected, well not unexpected, 40 years after tissue repair to have a recurrence, especially for a direct. Right. So what are your thoughts about a tissue-based inguinal hernia repair after you already have a recurrence from a prior tissue-based repair?

Speaker 2 (00:25:04):

So in my opinion, you can do a second tissue repair as well. You can do it without using a Mesh. But this is not a question of the technique. It’s a question of the quality of the transverse fascia of the dry canal. Yeah. If this layer is with a scar tissue and is not good any longer and shiny with the shiny surface any longer, then you should not use a second tissue repair. This is only depending not on the size, not on the technique before it’s depending on the quality of the posterior wall, of the growing canal.

Speaker 1 (00:25:46):

And can you tell that before surgery?

Speaker 2 (00:25:48):

Yes. Okay. I can, yes, but not for a hundred percent. I can see in the ultrasound the thickness of the deepest layer, which is important for suturing, but the quality can only be seen during surgery, not before. So you cannot promise the patient before surgery that you can do a second suture repair. You have to see the tissue, you have to see the quality. If it is shiny, if the fascia is shiny with a good quality, then you can do a suture repair.

Speaker 1 (00:26:21):

Okay. Yeah, I agree with that. It just seems, maybe I feel that if you tear a tissue repair and I perform a lot of tissue repairs, but if you tear that you’re automatically dealing with less tissue to redo and then the next repair will be even tighter than the first repair and more likely to give either recurrence or chronic pain. What do you think about that?

Speaker 2 (00:26:54):

Always depending on the amount of sound fascia, always depending on the quality is the only question. If there is only a small rest, let me say a small rest of a transverse fasciaafter previous surgery repair, then you should not do a new one again. But it’s not very often, you know, always find that after a tissue repair, if there is recurrence developing, then you see that the quality that the tissue repair has to be done properly because there is still a lot of sound fascia in the deepest floor. And then you can do it still without any Mesh. It’s depending on the amount of sound. Fascia. This is the whole question.

Speaker 1 (00:27:43):

Here’s an interesting story. This is a female, she says she’s had chronic groin pain for several years. Historically she was an endurance triathlete, but now she’s completely sidelined and does not compete. She’s seen multiple hernia specialists in the United States with mixed opinions and diagnoses. She was diagnosed by some with a small occult inguinal hernia based on MRI and dynamic ultrasound. Others say, no, it’s not a hernia, it’s a sports hernia. Or athletic pubalgia with slight detachment of her rectus and her pubic bone. Her pain is in the groin triangle and upper thigh, but she also has pain about an inch below her belly button and straight down for another three inches. And this confuses all the doctors because now she’s got this other pain up near her belly button. So do you ever see pain in the up pain or above the hernia?

Speaker 2 (00:28:48):

Not very often, but I have seen

Speaker 1 (00:28:50):


Speaker 2 (00:28:51):

Yeah, it’s not very often, but sometimes it’s kind kind of irritation of the nerve, which has some branches going upwards. And this is sometimes for the patients feeling like having pain in the umbilicus area because of this nerve radiation. And yeah, important is the type of pain. If there is some burning for nerve pain, you always need burning. Yeah. Electricity shocks, radiation and not a special point, only one point of pain, you know, need a field of radiation of the nerve, the feet of radiation upwards abdominus into the inner thigh of the upper leg. This all these typical areas, these are important to find out. And this lady perhaps has a irritation of because one of these branches is going upwards and pets radiate more, radiates more than in other cases. It’s not very common, not very often, but I’ve seen this. Yes.

Speaker 1 (00:30:00):

Yeah, I always ask that question because sometimes I see people with inguinal hernias, but the pain shoots up towards their belly button. Yes. And I don’t explain why that is, but I I’ve heard it multiple times. Not a lot. Yes. Is definitely not common, but yes. So here’s a very complicated question only for you. Please describe what is the ilio pubic tract and how you use it to create a second supporting layer for the transversesalis fascia repair. And does the non-athlete need that second supportive layer? This is a patient, by the way that said this, so they’re very informed, my viewers.

Speaker 2 (00:30:43):

So ilio pubic tract is the fascia, which is continuing into the leg going down and continuing in the leg and it’s ending or it’s going upwards into the growing canal and ending there with a small edge. When you find this edge and you always can find it, if you clarify fair the growing canal with preparing all these things, then you need this layer for a tender free repair. Therefore, athletes of course needs this supportive layer because otherwise the repair would not be tender fee. There’s no difference between a regular patient and an athlete is part of the technique.

Speaker 1 (00:31:38):

And when you do tissue-based repairs, do you kind of look at your hernias? Okay, this is a larger her a Shouldice, this is a smaller hernia. Do you change based on size and quality of the tissues?

Speaker 2 (00:31:51):

Yes, of course. Yeah, I call it tailored approach. And of course actually Lichtenstein repair, which I learned also with this Parvez Amid in Los Angeles, who was a good friend of ours. So I, I’ve seen all the techniques in the original places and of course necessary do this and if necessary, do your shoulders as well. But you know, have to make the decision be between the different types of hernias. You cannot do the same technique for all the hernias. And this is the main point why a lot of hernia repairs are failing? No, because you have

Speaker 1 (00:32:31):

To. They do only one type. Yeah. Yes,

Speaker 2 (00:32:33):

Agreed. But they do all the same for everybody. Everything work.

Speaker 1 (00:32:37):

I hate it.

Speaker 2 (00:32:39):


Speaker 1 (00:32:39):

Hate it. What about women? Do you change your technique based on whether that’s male or female?

Speaker 2 (00:32:46):

No, no, because they have the same growing canal, they have the same tissue layers. I even more try to avoid to use a Mesh in case of women. But of course, of course in case of a big hernia, big direct hernia, if it’s a complete weak tissue, of course I use the Lichtenstein technique, Lichtenstein technique it. It’s always depending on the findings, intraoperative findings.

Speaker 1 (00:33:14):

Okay. Well thank you for bringing up Lichtenstein because there’s a question about that. Dr. Amid, when he teaches the Lichtenstein, he says very important not to put a suture into the periosteum for that medial stitch over the pubic bone because he feels they can cause osteitis and chronic pain. Do you think that’s true? Is that Yes. Okay, but don’t orthopedic surgeons put sutures in periosteum all the time?

Speaker 2 (00:33:44):

Yes, unfortunately, yes.

Speaker 1 (00:33:49):


Speaker 2 (00:33:49):

Completely right with his whole opinion. Yes. I only can agree.

Speaker 1 (00:33:55):

I feel like I do the same, I follow his directions. But if you think about it, orthopedic doctors are putting sutures for disruption. When you have a disruption of your rectus muscle or a tear for abductor, they’re putting sutures full thickness into the periosteum. So why is it wrong for Lichtenstein?

Speaker 2 (00:34:18):

Yes. So why should you do it? I don’t know. Any consequences or

Speaker 1 (00:34:24):

No, I agree we don’t have to do it. I agree. But orthopedic doctors do it all the time. I just wonder if that’s not the reason why people have

Speaker 2 (00:34:31):

Orthopedic are no real, in my opinion, it’s no real hernia surgeons. They have [inaudible] and various means that you can get chronic pain, that you can get infection and really chronic pain. And if we remove then the measure, which I do a hundred times a year, then this pain is consisting because the perio is damaged forever. So I never would do

Speaker 1 (00:35:01):

It. No question about pregnancy. Do you feel that any of the operations that you do, whether it’s for Inguinal hernia or a sportsman hernia, that pregnancy would put it at risk afterwards or no,

Speaker 2 (00:35:15):

No, no. Yeah, if you do a tension free- never ever. It’s only a question. The pregnancy, if you would do a hernia surgery and the lady would become pregnant afterwards and you say, oh, if you become pregnant, you get a recurrency, it would really be terrible. Now you have to do a Tension free still and then he can become pregnant a lot of times. No problem.

Speaker 1 (00:35:42):

Yeah. Okay. a lot of questions coming in. This is great. I’m trying to feel, I’m getting questions from Facebook and Zoom. They’re all coming in and then they’re also coming in from what I, what’s been referred, oh, what are the typical symptoms, let’s go to before even surgery, what are the typical symptoms for diagnosing a sportsman hernia that’s different than a typical angle Hernia?

Speaker 2 (00:36:11):

They are extremely typical. Typical pain is pain during moving, sneezing, coughing, sometimes burning, sometimes sending electric shocks radiating to the inner thigh of the upper leg, sometimes to the testicle. So if you hear this about this symptoms, then you nearly can say, okay, I don’t have to, I trans you, I know the diagnosis and you see immediately the bunch. So it’s absolutely typical for sportsmans groin, sports, hernia, all these symptoms, they must not be all the same. Sometimes only related to the inner side, sometimes only related to the testicle. But altogether they are typical for a sports hernia.

Speaker 1 (00:36:59):

But are those also typical for inguinal hernia?

Speaker 2 (00:37:03):

Sometimes yes, but not what’s, what is sometimes different is they don’t have pain. Inguinal hernia don’t have pain perhaps in the pubic bone area. Why not? Because yeah, the tissue is much weaker and the hernia is going through the tissue downwards in the direction to the testicle. And there is no pubic bone any longer. The sportsman’s groin is getting a wider canal without developing a hernia and therefore causing tension at the pubic bone. Because the of rectal muscles, and that’s such around this area, around is weak, is not weak but strong. Therefore the tend is increasing. And this is the main That’s correct. Yeah, because the rectus muscle is in the area of a strong fascia and not in case of hernia around surrounded by a weak tissue and the hernia sac, which is going down and avoiding tension at the pubic bone.

Speaker 1 (00:38:09):

So a sports injury often is not surgical. So how do you determine when it’s a surgical problem or when just physical therapy and rest and injections and anti-inflammatories can help.

Speaker 2 (00:38:24):

So there is a frame of six to eight weeks of conservative treatment in case of a sports hernia. And if this doesn’t work, you have to change to the surgery surgical technique because then you waste time. Yeah. So six weeks, six to eight weeks is the frame for us.

Speaker 1 (00:38:46):

Six to eight weeks. Okay, very good. Next question. Let me reread this. Okay, so is there a role for Mesh in treating, let’s say you have a disruption from soccer player. Is there a role for Mesh in treating sport attorneys?

Speaker 2 (00:39:08):

Never. Never, ever. Two. Cause one is still that there’s only a small defect if it is really a sports hernia. But the second one is if you use a Mesh, then you lose a lot of elasticity of the wall layers. Yes

Speaker 1 (00:39:30):

You do.

Speaker 2 (00:39:31):

If you have a Mesh between these layers, you get a kind of stiffness. And this is not good for an athlete. He needs his electricity whole, the free movement of layers to do all these spots types, which he wants to do. So never ever a Mesh for.

Speaker 1 (00:39:52):

Yeah. What about, let’s, lemme push you on that a little bit. What about laparoscopic repair? That’s less of a,

Speaker 2 (00:40:05):


Speaker 1 (00:40:05):

Doesn’t limit the athlete as much than an open Mesh based repair. What about a laparoscopic repair with Mesh?

Speaker 2 (00:40:11):

Why should you put a Mesh size to 10 to 20 centimeter, something like this, nine to 15, 10 to 15 to the growing canal because of a two centimeter defect? I never would understand this. Why it’s not a question of the finding and why should you treat a two centimeter, two centimeter defect with a big Mesh? There is no sense for me at all. And you know can do it properly, you can do it perfect and no, you do it perfect. I know everything but not fun ethnic. Why?

Speaker 1 (00:40:55):


Speaker 2 (00:40:56):

You want to Mesh. If you only have a sports hernia, I think you never would want to get one. There is always the risk of Mesh migrating, Mesh shrinkage, Mesh pain. This is still not 0%. Why?

Speaker 1 (00:41:11):

Yeah, so the European Union, the European Commission has already changed the market for meshes. It’s considered a high risk device and you’re not allowed to actually sell Mesh unless there’s human testing that’s that’s been tracked. So that’s completely changed. We have not done that yet. In the United States there’s talk about it. But in the United States for hernia Mesh, it’s still the same. Yeah. What have you seen in your practice or your colleagues’ practices that has changed in the past year since this new kind of restriction on meshes for hers?

Speaker 2 (00:41:53):

I didn’t see any change. They only see that more and more doctors are using Mesh for all the cases, sports, hernias, everything without, I think it’s a question how to do the diagnosis and how to know what you want to, what would have to see with the diagnosis. With the diagnostics you can do, if you understand the anatomy, if you see the small defect, I think they would really change the technique. They would not do it. But nobody is doing the dynamic ultrasound. Nobody or I don’t know. And if you go to other cities, nobody is doing this. And if so, they do it only and don’t see anything. You know what you have to see what you have to find. You have to look, especially for this. And still I see, don’t any sense for a Mesh in case of an ethic or in case of a small hernia or in case of a young man with a sound tissue. This is for me still no need.

Speaker 1 (00:42:55):

Do you think that the standard should be changed? So as much as possible, sometimes we can’t do a good tissue-based repair, put those aside. But if a tissue repair can be performed, do you think our teaching should change? And we should say do a tissue repair first. If all is well, great, if it recurs, then use Mesh. What do you think about that?

Speaker 2 (00:43:22):

I think the problem is that these tissue repair surgeries are not really, really shown in the hospitals. They don’t learn it. The surgeons don’t learn it properly. They learn by surgery is saying, ah, let us do a mesh. It’s much faster. Let us do this. Others, the surgical technique with a suture repair is demanding. If you don’t do it tension free, then you get a recurrency. If you don’t do it right, you also get a recurrence. They’re afraid. Part of this. And then the second point is that they’re talking about chronic pain. I can tell you I don’t have not even one patient with chronic pain. So this is a question how to handle the nurse. You

Speaker 1 (00:44:07):

Haven’t had any patient with chronic pain. I want to give you a prize.

Speaker 2 (00:44:13):

Really? I don’t have not even one. I did do a lot of surgeries with patient with chronic pain after mesh repairs with mesh removals. But in my patients, I don’t have one patient. This is two, I have of course recurrences 0.2%, but not one patient with chronic pain.

Speaker 1 (00:44:33):

And in that 0.2% of your recurrences, how do you treat them?

Speaker 2 (00:44:40):

Then they get a lichtenstein repair because I have done then the repair with using the whole fascia. Fascia. But it is only 0.2. It’s not too much. If one would say, I have 0%, I think you would lie, there’s no surgeon in the word zero. But then add the lichtenstein repair and this is, it’s fine then and there’s no problem.

Speaker 1 (00:45:08):

Okay. Question for you. What are the outcomes for surgical treatment for – I guess we kind of discussed that. So the expectation is if you have a tissue-based repair for sports hernia, which sound, it sounds to me that any early hernia too, that’s not big, no intestines evolved. You would also consider that a sports hernia. Does that sound right?

Speaker 2 (00:45:33):

I didn’t get the first part of the question, but is it with the,

Speaker 1 (00:45:38):

Yeah, so if it’s a small hernia, not no obvious bulging, you do an ultrasound and you just see fat there, but it’s a direct type hernia or even indirect with a small lipoma. Would you call that a sports hernia? Because it’s not like there’s no intestine involved. No hernia sac.

Speaker 2 (00:45:55):

I would only know, I would only call a sports hernia. It would be in the medial part of a growing canal with the bio wall. Okay,

Speaker 1 (00:46:04):

So like a direct type?

Speaker 2 (00:46:06):

Yes. Other ones would be indirect hernia or direct hernia, but not a spot hernia.

Speaker 1 (00:46:14):

And then the expectation is that they don’t tear. Again, low risk of that because that’s part of the chronic pain after tissue repairs is it’s too tight and they’re constantly in the state of trying to tear through the sutures. Right.

Speaker 2 (00:46:30):

If you do it tension, don’t do a tension fee. Of course you can get a feeling of tension. This should be avoided. It should be avoided. And also is not only a question of tension, it’s also a question of how to handle the nerve. To be honest.

Speaker 1 (00:46:49):

Really? Yes. Well anatomy, right? Anatomy, yes. You have to know your anatomy. Yeah, I think when I teach, teach my residents tissue repair, they do McVay, Bassini, Marcy, Shouldice, Nyhus. I do posterior sometimes as needed. So they love it. And mostly it’s because they get to see anatomy and it’s so important to understand the anatomy and they love it because it’s more involved in the re repair. Absolutely. Your typical Mesh based repair. Yeah, I agree with that. These are so many questions. I love it. Let’s see. Can a sports hernia and other groin injuries recur like a true hernia would

Speaker 2 (00:47:38):

Sofa, I don’t have recurrency, but of course it can develop. There is a risk of 0.1%. The risk never is zero. But most of the problems after the sports hernia surgery is the adductor pain because they have had pain before because of the compression of the gen branch nerve, which is causing pain in the groin and inner thigh. So they need of for sometimes longer treatment of the adductors. And this is for the patients if they would have a currency, but they have still adductor pain because of the rest of the nerve compression. So this is the combination of adductor pain and groin pain. Because this nerve if compressed is sending the pain downwards. But real re I never have seen no, because I don’t don’t open sound tissue. It’s the main Cause I don’t open, I don’t cut sound tissue. This is a the secret. Yeah,

Speaker 1 (00:48:42):

I have an issue with that too. I agree. So you’re familiar with Dr. Bill Myers. We’ve had his associates on this show before. What are your thoughts on his types of repairs for ad for rectus adductors and fascia tears, et so et cetera?

Speaker 2 (00:49:02):

I would love no comment.

Speaker 1 (00:49:05):

Okay. There’s so many different well known. There’s a handful of, I would say maybe four or five in the world that are very well known in sports hernia repairs. And they all treat, have a different technique.

Speaker 2 (00:49:21):

Yes. Interesting technique. Yes, I know. So I don’t love this kind of technique and I know him personally and I don’t want to say anything about this.

Speaker 1 (00:49:33):

Yeah. We also talked about the Lloyd’s repair or sorry, Lloyd release. What if you can explain what that is and

Speaker 2 (00:49:41):

Yes, in my opinion is terrible because he’s doing this laparoscopically, but there’s not a point he’s cutting the ligament because in his opinion, the I inguinal ligament is causing tension. So to cut the groin ligament means to cut one of the most important structures of the groin canal, which need for any repair. And if you cut it, you can get so much different pain afterwards. So no, it’s not my favorite.

Speaker 1 (00:50:27):

Yeah, we haven’t discussed Mesh removal. It’s a lot of what you do. You don’t put in too much Mesh, but I’m sure you remove more Mesh than you put in. Yes. So tell me a little bit about how you do it. You go it’s It’s done outpatient, correct. Or do they stay in the hospital?

Speaker 2 (00:50:43):

No, you mean it’s Mesh repair, removal. Removal. They should stay for one night. I do measure near four times a week, measure removals and they stay for one night because they get a drainage for one night then. But they can walk around the next, the same day. They can walk around immediately. The beginning of training is the same fast and short time as without removing it because you have to do it very carefully, not destroying the whole internal OB leak muscle, but to find out immediately about the pain cart, that means the damaged nerve. And then they do a Mesh free repair. So this is the whole secret. So one night because of a drainage and possible pain treatment if necessary.

Speaker 1 (00:51:42):

And how often do you have to cut a nerve with Mesh removal?

Speaker 2 (00:51:46):

The Mesh removals after the lit iron repair, we are talking about these Mesh removals. The nerve

Speaker 1 (00:51:53):

Maybe prolene hernia system or plug sometimes

Speaker 2 (00:51:56):


Speaker 1 (00:51:57):

Yeah, but not laparoscopic Mesh removal. Right. I mean,

Speaker 2 (00:52:01):

No, I don’t do this because then it’s much more difficult. You have to do a laparoscopic again. That’s good. It’s difficult. That’s good.

Speaker 1 (00:52:08):


Speaker 2 (00:52:09):

But I do a lot of second surgery after laparoscopic repair because the nerves are involved because of the Mesh behind. So yes, chronic pain, yes. I don’t remove these meshes. So in case of an open Mesh Mesh removal, the nerve, it is always the nerve. And this is always a question of a wrong technique in my opinion, because this Mesh is directly sutured onto the nerve and asking me if I remove the Mesh, the nerve. You cannot separate the Mesh from the nerve any longer. The Mesh and the nerve are one package grown together. And after removal, they don’t even have a bit, a lot of numbness. The pain immediately is disappearing. They have to follow.

Speaker 1 (00:53:02):

I’ve seen that They’re not numb and yet the pain is gone. Yes. There are many people who have done Mies as part of the Mesh removal, like you said, the nerve and the Mesh. It’s like Velcro together.

Speaker 2 (00:53:14):

One layer.

Speaker 1 (00:53:15):

I tell the patient, even if you don’t have nerve pain, just the act of me removing the Mesh will be injuring the nerve. Yes. So if that’s the situation, I’m obliged to cut the nerve. Okay. And you do under sedation and local anesthesia, is that correct? Yes.

Speaker 2 (00:53:30):

Yes, correct.

Speaker 1 (00:53:31):

And then one

Speaker 2 (00:53:32):

Day miss, the main point of pain,

Speaker 1 (00:53:36):

And I love that you go all over the world actually to do these operations. So what I struggle with would be the follow up because these are patients that need a lot of handholding because their recovery is not typical. So how do you follow up with when you’ve operated on someone in different country?

Speaker 2 (00:53:57):

So I always stay in this country for one week and do these surgeries in the beginning of my stay. And then I have almost a surgeon on the hospitals who are supporting me and taking care for the patients after this one week. Yeah. And basic question, we are mailing of sending pictures from the possible problems but the are not. After one week the main problem has gone. Yeah. If there is a problem,

Speaker 1 (00:54:24):

What if you need someone to do a nerve block or something? You have people to do that for you there.

Speaker 2 (00:54:31):

Yes. But it’s not necessary very often though. Yeah. If so, of course they would do it. Yes, yes. But we

Speaker 1 (00:54:40):

Have a question. We have a question about recovery. We haven’t talked about recovery. What is your post-surgical protocol for sports hernia or pubalgia and occult hernia repairs? And do you do physical therapy? What does that look like? And how long until these people are fully recovered?

Speaker 2 (00:54:58):

So day of surgery is day zero, beginning from day two after surgery. They can start with fast walking. Yeah. Day five or six, they can start with jogging day eight to 10. They can start with sprinting and whatever. And they fighting. They can kick the boring can go back to the field. And this is the only limit which I have in the days before is if they feel pain, they would perhaps do it two or three days later, then they two or three. But the main protocol is after day two or three, fast walking, running day five, six or seven depending on the pain, sprinting. So it’s after within 14 days they’re back to full recovery. 14 days.

Speaker 1 (00:55:49):

And then my last question for you is what are your thoughts on Mesh? There’s a big movement, oh, I call it anti Mesh movement. They’re actually calling for Mesh to be banned. They say it’s a toxic substance, et cetera. As you know, there’s certain operations we cannot do without Mesh. Now Mesh means there’s a thousand different types of Mesh. It can be biologic, absorbable, synthetic.

Speaker 2 (00:56:16):


Speaker 1 (00:56:17):

Polypropylene, polyester, ptfe. Mesh can mean a lot of things, but not all hernias can be repaired with Mesh. And oftentimes making the wrong decision of doing something tissue based actually makes the situation even worse. So that’s my thought. What’s your thought on Mesh and what’s your answer to people that say all Mesh must be banned?

Speaker 2 (00:56:48):

It is difficult. Yeah. I absolutely would not use some special type of mesh. For example, Plex or this PHS or whatever. I never would use because imagine about the amount of Mesh in the groin. Yes. About the lack of elasticity, about the feeling of foreign body. This have to respect this before you put these meshes. Yeah. But I don’t want to say I never would use a Mesh. I use meshes for big hernias and wheat tissue. I use meshes as well, but I don’t use all these plugs and whatever. And this with a frame and all this bath hernia system, and I don’t use this. But if you use a Mesh properly, it is a big help. And it can remove the hernia forever. But you have to do it properly as well without stitching the pubic bone.

Speaker 1 (00:57:47):

Yes, correct. Thank you. Yeah, I think it’s the surgical technique is super important. Anatomy and then tailoring what you said, pick and choose. Yes. Which patient gets what type of hernia repair. Even in tissue repair, not all tissue repairs are the same.

Speaker 2 (00:58:05):

Yes, that’s true.

Speaker 1 (00:58:07):

What do you think of a Dasarda technique? Have you heard of Dasarda?

Speaker 2 (00:58:12):

Yes, of course.

Speaker 1 (00:58:14):

So I was trained, I had a mentor. He was trained, I think in the 1950s. Yeah. When he did residency. And when I told him about Dasarda, he said, oh yeah, we need to do something similar. But we stopped doing it. There were so many recurrences. But what do you think about Dasarda?

Speaker 2 (00:58:37):

I don’t like it. Yeah. I can’t tell you why. Because you take the external oblique to reinforce or to strengthen the posterior wall. You pull it down and fix it in the groin canal. Yeah. You take the excel optic, which is a very important layer to close the, as a upper layer of the gray canal. Yes. Why should you take it when you can take the posterior wall at the best take, at the best fascia, the best structure to reinforce. That’s

Speaker 1 (00:59:10):

The most important layer. Yeah.

Speaker 2 (00:59:11):

Yes. And also if you pull it down, there is your on earth is the ilio epigastric nerve, which can come, which can get under tension. And if you think about all this, I wouldn’t use the desarda

Speaker 1 (00:59:25):

Technique. Yeah, I agree. And I think history doesn’t, we can’t repeat history. Right. It’s been done before. Yes. And no one remembers. But if it was done back in the fifties and they stopped doing it, there’s a reason for that.

Speaker 2 (00:59:40):

Yes. I think this is the reason I do. Yes.

Speaker 1 (00:59:45):

Well, thank you so much. That was a full hour. Everything went by so quickly. Can you believe it? We went through almost all the questions, so that was great. Right. So patients would like to contact you from out of country. How do you do that? Do you do video? Do they have to come to see you? Is it by email?

Speaker 2 (01:00:08):

Everything. We do it by email. We do it by video. I have international office for all the patients from abroad, and they handle all these questions with the possible day to see the patients and to answer other MAs to organize a video or conference, do everything.

Speaker 1 (01:00:27):

Okay. Good to know. And then when you decide to operate on patients, how does that work? So you do all the decision making before you see them probably Yes. And then you go to their country.

Speaker 2 (01:00:41):


Speaker 1 (01:00:42):

See them, we

Speaker 2 (01:00:43):

Make no a so-called combined, combined date. That means he comes, the patient comes for examination and ultrasound and to say the indication for surgery or not. Then the next day would be surgery the day after I see the patient again and then they fly back and we are always in contact until the suture has been removed, which they’re do by themselves. It’s only running suture. And then we are in contact with maze or pictures, whatever necessary.

Speaker 1 (01:01:15):

Yeah. Very good. Well, thank you very much. That was a fantastic hour. I really appreciate it in middle of my day and end of your evening. So I appreciate the time that you afford us and I hope that if you have any patients, you’d forward them to hernia talk because we have lots of videos with specialists like yourself. And we have a full website, hernia talk.com, where patients just discuss everything about hernias. So thank you Dr. Muschaweck. I appreciate your time. Hope you have a good evening. Thank you

Speaker 2 (01:01:49):

So much. Thank you so much for inviting me. It was a big honor for me to do so

Speaker 1 (01:01:55):

I appreciate that. And thank you everyone for joining me. It was different earlier hour than usual, but that’s what we do for our European friends and colleagues. Join me next week. We’ll have another episode of Hernia Talk Live and see you then. Thanks everyone.

Speaker 2 (01:02:13):

You then have a great day. Thank

Speaker 1 (01:02:15):

You. Bye-bye. Good night.