Episode 115: Incisional Hernias: What, Why, When, and How | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

Hello everyone. This is Dr. Towfigh. Welcome to Hernia Talk Live, our weekly q and a held every Tuesday on hernia talk Tuesdays. My name is Dr. Shirin Towfigh. Welcome. Thanks for everyone joining me live on Zoom as well as Facebook Live at Dr. Towfigh

. Also don’t forget, I am on Twitter and Instagram at hernia doc and every end of this session you’re going to have this episode and all the previous episodes uploaded to my YouTube channel. So please do subscribes to keep up to date with all that we talk about. Last week we had a really, really great session. I saw a lot of discussion on social media about it and people talking on hernia talk as well as some of the other forums, including Facebook and Instagram about our guests last week. So I’m really happy that I was able to provide such excellent kind of discussion.

Speaker 1 (00:01:00):

Today we’re going to talk about incisional hernias. I tend to do a lot of hernias of the inguinal region. It’s kind of like my preferred part of the body. That’s where my specialty is. Most surgeons that do hernia specialty do not like the groin. They tend to focus on the abdominal wall and major abdominal wall reconstruction. I find the challenges of the groin and pelvis really fascinating and I’m especially interested in women’s hernias. So as you know, women’s pelvis is much more complicated than even a male pelvis. Male pelvis is already complicated with the prostate, the bladder, the ureter, and all the nerves in the area. So I do like the groin if I had to choose, but of course I’m a hernia specialist. I repair all hernias with flank hernias, abdominal wall hernias, some very rare lumbar and pelvic hernias. And so I thought we would spend some time today talking about incisional hernias and many of you have sent me questions.

Speaker 1 (00:02:03):

So I have those uploaded. I hope that you all join me and also kind of send in questions that you would like to discuss, but let’s get at it. So let’s first start to talk about what an incisional hernia is. So most hernias out there, people are born with it or they acquire it as part of like an injury. An incisional hernia is very specifically a hernia You get after you’ve had an incision there. Let’s say you had your appendix removed and now you have a hernia where your appendix was removed. Let’s say you had your prostate surgery and they removed the prostate through the belly button. That’s one area where we see a higher rate of belly button hernias, which are actually not primary belly button hernias, but are what we call incisional hernias and so on. So in social hernias are unique in that they are by definition of failure of the original closure of the opening.

Speaker 1 (00:03:11):

So let’s your surgeon had to make an opening in the muscle and the fascia to remove the appendix, the gallbladder, the uterus, the prostate, the spleen, the colon, whatever the situation is. Or they had to make an incision to address what’s inside. Let’s say you had a trauma, were hit by a car and you’re bleeding inside, or you got a gunshot wound or there’s some cancer that need to be addressed. So, or you have a bowel obstruction. So they had to make an incision to get to it, and that incision can be five millimeters or the incision can be five inches. It’s irrelevant to how big the hernia is once you get a hernia from it. It’s by definition an incisional hernia. Why is that important? Well, the treatment algorithm is very different between a regular hernia of any type and what we call an incisional hernia.

Speaker 1 (00:04:05):

Once again, to get to be an incisional hernia, hernia, you should have failed closure of a prior abdominal wall hernia. So that already puts you at some sort of category where just redoing what you did originally, usually doesn’t work. So there was a time when the surgeon made a cut, they sewed you up and it broke open, they took it back and they sewed you up again. That could be months to years later. What repeating the same thing over and over again and getting the same result is what? Definition of insanity. I think that’s according to Albert Einstein, but I think he was quoting someone else. So therefore, the treatment of an incisional hernia is not to just close it up again, usually, usually. And the most famous paper was published by Dr. Johannes Jeekel, which we hope to bring as a guest. He is from the Netherlands, and Professor Jeekel wrote a great paper, actually not so great paper in retrospect, but the first paper to show that if you take an incisional hernia and you close it up like you did last time, the chance of failing is closed to 60%.

Speaker 1 (00:05:22):

So 50 to 60% of patients will have a failure of that and now you’re stuck with a larger hernia, longer convalescence for this problem, have to go stop working again for whatever reason to have yet another surgery. So he then introduced, okay, now let’s put a Mesh in place and let’s see how the Mesh improves. And the result was pretty dramatic. So the recurrence rate in his trial stopped dropped from about 50, 60% down to about 20 to 30%. Now that’s also not perfect, but since this is an older paper, since then we’ve had a lot of advancements in hernia surgery and we’ve improved the type of hernia surgery that is done to reduce that number as low as 10 to 15%, still not excellent, but you’re dealing with damage goes to begin with. So 10 to 15% or 20% recurrence is considered acceptable for an incisional hernia because you’re already dealing with a hernia that occurred because there has been damage or trauma to it. So that’s kind of what we’re going to be talking about. Now, some of you will say, well, Mesh is horrible. We should not be using Mesh. It’s possible to actually perform an incisional hernia pair without Mesh.

Speaker 1 (00:06:56):

You can consider it for really, really small hernias like fraction of an inch where you know can maybe consider getting away with not putting much in. Doesn’t always work, but it’s worth trying some in some people. Alternatively, you could consider a major reconstruction of the abdominal wall without Mesh, it tends to burn a lot of bridges. If that fails, which is a higher rate of failure than using Mesh, then you’re kind of stuck with even bigger hernia and now with even thinner muscles and thinner tissues. But in Dr. Ramirez Ramirez is a study where he’s a plastic surgeon and he discussed anterior component separation where you basically take your muscles and separate them apart and then bring everything together. And in doing so, close the gap.

Speaker 1 (00:07:47):

I believe he had about a one third recurrence rate. So one-third is not good, but two, that means two-thirds of the people did fine, but it also implies a lot of complications from that. So I hope this sparks some questions from y’all. We’ll go through many questions. I have about 15 questions to go through today, plus any that you submit live. In fact, here’s one live already. I have a hard ball of Mesh recently removed incisional hernia that went through my appendix. Okay, so it sounds like you had appendix surgery and you had a hernia from that. Lots of bowel loops and adhesions when we postop and I feel very sore. That’s very expected. Any recommendation for pain management? Okay, that’s great. So we discussed pain management after an incisional hernia. We had, I think I’m going to say a year and a half ago, and we talked about binders, ice packs, anti-inflammatory medications, not doing too much narcotic because that’s going to make you constipated, making sure you lose weight, you’re not straining, you don’t have a cough, make sure you’re smoking.

Speaker 1 (00:08:56):

So that improves your outcome, specifically smoking, nicotine or using any sort of nicotine. So the soreness has to do with swelling and bruising in the area of your operation. And so that’s an inflammatory problem. And so anti-inflammatories work, so ibuprofen, naproxen, that includes Motrin, Aleve, Advil, you can also do topical. I think ice is the best and then can, the second reason why people can get pain from such a big operation is the way the abdominal walls close is now a little too tight and in being tight that can cause pain and almost like a tearing sensation so that sometimes a binder helps you take some tension off of the repair while you’re healing. The other option too is just to lose some more weight if you have any weight to lose and that takes some pressure off of the repair and helps you out.

Speaker 1 (00:10:02):

So great question though. Great, great question. All right, next question has to do with the concept of an incisional hernia at an AL hernia. So in general, we don’t call recurrent al hernias, incisional hernias, we call them recurrent al hernias. It’s a coating issue, it’s a it’s, we don’t usually call those incisional because they’re usually not the site of an incision. They’re usually a site like where the surgeon went in there for purpose other than a hernia. It’s usually the site of a hernia repair and that hernia repair occurred. So what is the concept of an incisional hernia occurring at the site of a tissue-based hernia repair? Great question. So the question basically means let’s say I have a tissue-based repair, Shouldice, McVay, Bassini, and now I have a recurrence. So how does that recurrence occur? Well, the way it occurs, the same way you have tears in your clothing, the area where the you were sewn has torn apart.

Speaker 1 (00:11:12):

It could be a big tear like you see in jeans nowadays, or it could be little tear like you may see in a jacket that you’ve worn for a really long time where it tear at the seams. So when you have a tissue based repair, the way the surgeon operates is they take the muscles and they sew them together, and there’s sutures, usually synthetic permanent sutures, sometimes wire classically that holds everything together. If that suture, if that closure tries to pull apart and fall apart, then you’re going to be pulling at the seams, so to speak, and it’s those seams which is an interaction between the suture and the fascia. The muscle that tear the suture almost never tears. Your tissue tears and when your tissue tears, that leaves the hole. And when you have a hole that’s a hernia, so you now have a hole that busts open and you can have holes in it, you can have things to go through it or just have pain.

Speaker 1 (00:12:19):

Just the pain is from the tear itself and not necessarily anything going through the tear. So that’s why tissue based hernia recurrences are very difficult to diagnose because it’s very subtle. You have to somehow put together the exam and the symptoms and the imaging as one conglomerate and figure out what’s going on. So specifically for a growing hernia, sometimes imaging doesn’t show a frank hernia where there’s a hole or the holes are really small, but you can kind of tell based on the way that the tissues are together or are no longer together pulled apart, what happens whether there’s a hernia recurrence or not. So yeah, that’s how it does occur. And the best way to repair a tissue-based failure is a Mesh based repair, regardless of what we’re talking about, whether it’s inguinal or incisional, if you had a tissue-based repair was actually, that’s a good point.

Speaker 1 (00:13:25):

So an incisional hernia is failure of a tissue-based repair. That’s a very easy way to put it. So you had a surgery and they closed it without Mesh because that’s what we do for most abdominal walls that need regular surgery, not hernia surgery, let’s say prostate surgery, hysterectomy, whatever appendix surgery that’s closed, that’s called tissue-based repair. When that fails, regardless of whether it’s a groin or it’s abdominal wall, then the next set of operations should be done with a Mesh in over the vast majority of patients with very few exceptions among the type of surgeries, number of previous surgeries, incision location, incision length. Okay. What factor mostly affects the probability of developing an incisional hernia. Okay, so I understand what you’re saying. You’re saying what factor mostly affects the probability of developing an incisional hernia? Is it the type of the surgery, the number of prior surgeries, location of the incision or the length of the incision?

Speaker 1 (00:14:36):

It’s actually very multifactorial. The two top reasons for incisional hernias have been shown to be number one, an emergency operation, so trauma and so on. And the reason for that is the patient tends to have blood and or stool contaminating the area and the patient tends to be quite sick for other reasons from the trauma. The second most common reason for an incisional hernia is a wound infection from usually a dirty wound. So let’s say a colon surgery or trauma surgeries can be dirty because of the type of trauma, whether bowel was injured or they were dried onto a asphalt or something, or if they have a wound infection. So wound infections tend to be in operations that are very long operations. They tend to be in operations where the incision’s larger, so less likely in laparoscopic surgeries they tend to be in operations where the patient is sicker.

Speaker 1 (00:15:47):

So diabetic, any immune suppression and the incisional infections tend to be in patients that don’t have healthy tissues. So prior surgery is one, nicotine users and so on. So top two reason for incisional hernia is either emergency surgery or an infection of the wound due to contamination and incision length and prior surgeries and type of surgery. Does affect affect those? Does, oh, let me make a second point on that. It’s super important. I tell my residents all the time, it’s super important that a wound infection is treated very early and aggressively because as I mentioned, it is one of the top two reasons why people get incisional hernias is there was a prior infection in that area or contamination. So if you have a perfectly great operation and your wound starts looking red and then maybe a little painful and then there’s a little bit of drainage, maybe like little yellowish drainage or gray drainage would be horrible, then do you treat that earlier?

Speaker 1 (00:17:08):

Don’t wait it to be so bad you have to go to the emergency room and to my resident, I say don’t wait for it to be so bad. The patient’s like I’m now staining my clothing or my patient gown with fluid. Because the longer you allow that infectious simmer, the more it’s basically infection sitting on top of a perfectly good tissue-based repair and when that happens, the enzymes from the bacteria are just eating away at the tissue, it’s disgusting, it will weaken the tissue repair of the fascia and then months to weeks to months to years later, they will have a

Speaker 1 (00:17:48):

Hernia as a result of the delay in care of a wound type of a wound infection. All right. Next question. Does minimally invasive approach have any impact on reducing the recurrence risk after incisional hernia? Well, yes and no. In general, the answer is no. We have not been able to show that an minimally invasive operation has any better recurrence rate than an open operation. In other words, the outcome should be similar in the hands of similar surgeons. Now, it could be that some surgeons are better at one operation than the other and their outcomes are better. All things being equal minimally invasive operations or laparoscopic or robotic should have the same outcome as an open surgery. What’s different is the only thing that’s different is the risk of wound complications such as surgical site infections, skin infections, Mesh infections, et cetera, is much lower with a laparoscopic or robotic, also known as a minimally invasive surgery and therefore that complication is lower as well. The complication, as I mentioned, when you get a wound infection, your risk of hernia is higher. So that’s a slight contributor in an incisional hernia repair. And so choosing the operation with the least risk of surgical site infection will have a better outcome as well.

Speaker 1 (00:19:34):

Great question. Let’s go to the next one. After incisional hernia repair, does the recurrence risk constantly grow with the years? Does it eventually apply to after a number of years? Okay, another great question. Alright, so we don’t have very good long-term data. The Danish and the Swedes have the best long-term data because their whole country is one major medical database and the Danes and the Swedes tend not to travel outside of their country much. So if you have had surgery in your country, the chances are 20 years later you’re still living in the same country. So based on that information, we do know that we do have 10 year and 20 year data. We don’t really have data beyond 20 years. It kind of becomes not valid anymore, but based on that data, we do know that we have a constant steady increase in incisional hernias.

Speaker 1 (00:20:42):

So if you operate on someone, the maximum number of hernias occurs within the first five years, but that number still increases as you go further out. And the reason for that probably is multifactorial. One is people don’t know they have an interstitial hernia until it’s larger and it just takes longer for the hernia to become large enough for you to notice it. So they’ve had it earlier, they just didn’t know. The other possibility is that they’re now older, sicker, weaker, maybe more obese or a number of other risk factors are now added to their problem making their risk of herniation higher. Also, we don’t really know if in some of these people they’ve had another operation and that other operation is what contribute to an incisional hernia, not the original interstitial hernia. The databases are not so transparent that we can tell that well, but it does not plateau. It slowly continues to increase and that’s based on 20 year data. We don’t really have data beyond that.

Speaker 1 (00:21:56):

Are incisional hernia repairs characterized by higher chronic pain rates compared to other kinds of hernias? Fortunately, no. So in terms of chronic pain, patients who undergo pelvic surgery, so usually growing ankle surgeries, they are much more likely to have chronic pain than a patient that undergoes abdominal wall surgery. That’s good news because it’s good to have hernia operation where you don’t have to discuss too much about chronic pain. That said, the chronic pain profile with abdominal wall hernias is often due to tearing recurrence and less of a nerve issue. So nerves tend not to be that predominant on the abdominal wall, especially in the midline compared to let’s say the pelvis and the groin. And really people have pain if it’s there’s a hernia that’s recurred or torn or if the hernia is repaired too tightly. Now that’s not to say that that people don’t have complications from abdominal bowel surgery. They do besides recurrence and wound infections, they can actually have really devastating complications that we don’t typically see with inguinal and groin pelvic hernias, and that’s Mesh erosions into the bowel and bowel related complications such as fistulas and fistula means basically the bowel eroded. So what happens is you have a piece of bowel that’s stuck or somehow touching some Mesh,

Speaker 1 (00:23:44):

And if the Mesh is not flat, that’s a higher risk of a fistula and then that bowel kind of erodes into the, sorry, that yeah, the Mesh erodes into the bowel kind of like sandpaper over time and erodes into it until eventually there’s a hole in the bowel and then that becomes a devastating complication. Fortunately it’s not common, but of course many of you that are on this webinar already know that that happens. So it’s a problem. It tends to occur not with flat meshes but with meshes that are placed and for some reason are folded or at the edges of meshes. There used to be these meshes that you couldn’t cut and the surgeons for some reason they didn’t know that or didn’t think about it, I don’t know what the process is, and they would cut meshes and they would put it in and literally I had a situation where I was asked to help with a patient who had already had surgery and the patient already had some surgery and was in the hospital and there’s poop coming out of the wound and they knew that I was there, so they asked me to help.

Speaker 1 (00:24:55):

So I go in there and see the patient, I’m like, ah, shit. Literally there was stool coming out of the wound, excuse me, and I knew there was Mesh. I’m like, guys, you got to take this patient back. Okay, can you help us? Yes. So I take it back with a surgeon and I look at the Mesh and I’m like, did you cut this Mesh? He’s like, yeah, not thinking twice a while. I said, you can’t cut this Mesh. Oh, well it need to be smaller. Yeah, so you have to use a smaller Mesh. These meshes you cannot cut because the way the Mesh is made is to protect exactly what’s happening. The edges are softened and protected from being exposed to any me exposing any bowel to any Mesh. If you cut that, all the safety precautions that were part of the Mesh designed are now taken away, you now have fresh Mesh edge like a knife cutting through the bowel.

Speaker 1 (00:25:55):

Of course you would have a bowel perforation within days of the Mesh that you can put in. So unfortunately, the not all surgeons are aware of what Mesh should we use for what purpose and not for others and are not aware of the different intricacies of different Mesh products. It’s quite, quite interesting how little doctors know about instruments and products and devices that they actually are using on a daily basis. And it’s like when you drive your car, do you really know how to address one of the error signs on the car? Not everyone how to use everything in their car to its maximum benefit and the fact that they don’t imply they’re not using their car necessarily to its maximum benefit, but then when you’re dealing with humans, I believe you need to know your devices much better. So sad story for that patient, but good teaching point for future generations.

Speaker 1 (00:27:11):

What percentage is the difference in chronic pain rate between pure tissue and Mesh repair for incisional hernias? Is there any difference in chronic pain rate between permanent and absorbable Mesh? Okay, well this is a very different answer than if I were to give it to you for groin inguinal hernias. So the chronic pain rate is actually much higher with pure tissue repairs than Mesh repairs for incisional hernias. The reason is there tends to be a higher tension to the closure when done as a tissue repair, whereas the Mesh tends to take the pressure off like an internal girdle off of the suturing and it’s a suturing that hurts with incisional hernias. So suturing hurts if you add Mesh, it tends to take the tension off of the suturing and doesn’t hurt as much anymore. So interestingly, the chronic pain raise is differ, is better with Mesh than without Mesh and a pure tissue for abdominal wall incisional hernias. Is there a difference? Is there any difference in chronic pain rate between permanent and absorbable meshes?

Speaker 1 (00:28:27):

Yes, as far as we know, absorbable meshes have a lower chronic pain rate than a permanent Mesh, mostly because it has a lower inflammatory potential. Now the caveat is that absorbable Mesh must be a low inflammatory Mesh. There are absorbable meshes that are more inflammatory and more synthetic than your typical absorbable Mesh and there are meshes that have a are thicker, heavier or have a higher inflammatory reaction than other meshes. So the higher the inflammatory reaction, the stiffer the Mesh, the higher the chronic pain rate, the more kind of natural I’m using quotes, the more natural the feel of the Mesh. So the bo, it’s more like your own body’s tissue, the less of your chronic pain rate. And that is why all of these companies are super interested to help develop a product that adds closely mimics this abdominal wall of the patient as like details as possible.

Speaker 1 (00:29:39):

So it may stretch a little bit, it may be very pliable, it should have low inflammation, you shouldn’t reject it. We don’t really have a great product like that. We have some products that are good in part, well some parts but not good in other parts. So hopefully over time technology will get us to a point where we can have fascia like meshes to help support the patient’s own natural fascia, but to today there’s nothing good enough. Thanks for your question. For a patient with ventral hernia repair with abdominal wall reconstruction component separation done robotically, what would you say is a typical recovery time? Okay, so there’s a difference between robotic and open surgery. In my experience and the experience of most surgeons that do robotic and open surgeries, we noticed that the robotic repair recovery is much, much, much better than the open recovery.

Speaker 1 (00:30:36):

Now of course, I think all my patients do well, but I do know with the robotic repair there tends to be less tension, less manipulation of the tissues and wider dissections without as much tissue trauma and therefore recovery is much easier. So for example, whereas a typical open incisional hernia repair would involve three to five days minimum of hospital state only for pain control, the patient who undergoes a robotic operation of the same type goes home the same day, which is remarkable. Absolutely, absolutely remarkable. And once you’re home, I would say that typical abdominal wall reconstruction with component separation needs a minimum two weeks to really feel like they’re up to going back to work maybe or being more active at home, whereas the robotic patient maybe within days to weeks they can go back to work. That’s a typical scenario that I see. Thanks for that question.

Speaker 1 (00:31:49):

We should talk about robotic surgery, huh? Yeah, I think we got a question coming up on that. Do you see Mesh implant illness cases more often among incisional hernia patients? And if so, what do you think are the causes? In fact, we don’t. So I have had multiple patients with Mesh implant illness from an abdominal incisional hernia. The thought is that there’s so much Mesh use for these that that’s one of the instigators. However, for some reason there, at least in my study, we actually saw a large number of people undergoing pelvic surgery or surgery with Mesh implant illness, and perhaps it’s because there’s more nerves and more sensitivities in the pelvis than there are in the abdominal wall.

Speaker 1 (00:32:45):

So here’s a patient who’s undergone both open and robotic surgery. She reports that she’s never felt good after any of her open abdominal wall reconstructions and the robotic surgery was so much easier to recover from. So thank you very much for that comment. Yeah, it’s pretty remarkable. You can do an operation three or four times bigger in terms of complexity with the robot and have a third of the recovery. It’s so interesting. Alrighty, next question for incisional hernias, are the advantages of using Mesh partially offset by short and long term Mesh complications are the advantages? Yeah, so yes, so there are Mesh related complications. Short term they include some inflammation, maybe a pulling sensation, tingling swelling, maybe flu collection and then wound infection and long-term it would be tearing maybe erosions. There aren’t that many long-term risks. Mesh implant illness would be very uncommon, whereas the benefit is significant.

Speaker 1 (00:33:57):

So if the majority of patients who want to undergo tissue repair have a recurrence, that’s a horrible outcome. If you can reduce that number with Mesh, then that’s a really good benefit and that’s why we use meshes. Now again, you have to use the products appropriately. I have so many patients that I hear about or that I see who come to see me and I read and I’m like, what? Huh? You did what? That’s like, that’s like the wrong operation. Yeah, you had an incisional hernia repair, but it should have been done laparoscopically, not open. You should have put the Mesh under the muscle, not on top of the muscle. You should have used this type of Mesh, not that type of Mesh. And I can poke so many holes into why the patient had their recurrence.

Speaker 1 (00:34:51):

Let me give you a shout out to one of my colleagues, Dr. Napoleon in Oregon Health Sciences University. So he’s done a great job in trying to address all of these issues. So he has a national multi-institutional educational program. Every quarter we all kind of log in. I’m always there with my residents and it’s an institutional educational program where we talk about hernias all the time and what we do is with the residents and the fellows, they present an operation and we tear it apart. Why’d you do it this way? Why couldn’t you do it that way? Tell us about this part. What was this technique, et cetera. And it gets to people to talking because you know what I do is different than what happens in Alabama, which is different than what happens in New York possibly, or maybe what I say. The surgeon from Florida agrees that the surgeon from Washington state’s like, no, no, no, no, this is what, what’s going on?

Speaker 1 (00:35:48):

This was my reasoning. So it’s a very intellectually stimulating quarterly meeting. I love it. We pick a, or he picks a topic, let’s say pelvic hernias, let’s say incisional hernia, robotic surgery, inguinal recurrences, something like that. And then we submit multiple patient case scenarios and we use that as a teaching point. So I think it’s very well done. It’s been rooming and growing throughout the nation. Okay, next question. You mentioned it’s that it’s the width and not the length of an incisional hernia that determines a necessity of using Mesh true but not then repairing an incisional hernia as soon as it is found. Help in keeping the hernia small and thus allow for a pure tissue repair. Interesting concept. So here’s how I’m going to answer it. If you have a 10 inch incision and you have a quarter inch hernia on the top edge of it, and it’s usually like at the top edge where we see the hernias and you fix that quarter inch, that’s maybe all you need, great.

Speaker 1 (00:37:07):

You can maybe even get away with just putting a couple stitches in it and not having it fall apart. However, that entire 10 inches is at risk for herniation at some point. So the logic doesn’t hold. In other words, if you have a 10 inch incision and a quarter inch on the top has a hole in it at year one, and you go in there and you close the hole in the upper part, maybe at that level you have prevented the hernia from progressing, but the entire hernia is still at risk for herniation down the line. Remember, one of the questions was when do you stop having incisional hernias? Does it kind of continue annually percentage wise or does it plateau? And it does not plateau, it kind of continues. It’s at a slower rate, but it still continues. And so it is not correct that by operating earlier you could prevent new use of Mesh.

Speaker 1 (00:38:16):

Now that also implies that when you do go in there to repair an incisional hernia, we usually do not just repair the area that’s herniated, we repair the entire length of that hernia because again, at the lifetime of that incision, you’re at risk for herniation. If you’ve already shown one area, it’s like in your house, you’re not going to just, I don’t know, fertilize like one pot. Let’s say if you have a field of flowers, you’re not just going to fertilize one flower, you’re going to fertilize all the flowers because they all share kind of the same soil and doesn’t make sense to just improve the outcome from one rose and then not prevent the de deterioration of another rose. That was a bad analogy, but I dunno. I think that was a bad analogy, but if you don’t understand gardening, maybe you’ll get it.

Speaker 1 (00:39:14):

Okay, here’s a question live. Let’s go to that real quickly. So have you heard of complications from intubations such as dry cough? I had a squirrel hernia repair in August and the repair seems to be a good job, but I had a dry cough and irritated throat a day or so after and it becomes and goes, but it is weird. My surgeon said, make an appointment with the anesthesiologist. Actually should, the anesthesiologist will not see you. They don’t have offices. Usually make an appointment with a head and neck surgeon. So couple things, if you have a tube down your throat called intubation for general anesthesia, which I don’t usually do for anal hernias, but for this very reason because you can have a cough let’s say, and throat irritation afterwards. But if you do get, have that the first day or two, you’re going to have a sore throat and maybe even irritation and inflammation and then you cough. So obviously I’m anti cough, so I don’t want people coughing after my hernia repairs.

Speaker 1 (00:40:20):

I always minimize how much, I always minimize how much general anesthesia I use. But let’s say you need a gen needed general anesthesia. What you do is just have cough drops for the first two days. Now if you have a dry cough or irritation or a horse voice constantly clearing your throat days to weeks after an intubation or longer, then there’s something wrong. It may just be that you have acid reflux and what happened is you had an irritation of the vocal cords from the intubation because it goes through your vocal cords and then you also are doing acid reflux, so that inflammation never healed because you’re constantly bathing it with acid and so you need anti acids. That’s a very simple reason. It’s also possible that you had an injury of the back of your throat or an injury to your uvula, that little baby tongue that hangs or an injury to your vocal cord that can cause a polyp or any other problems which is causing to have a constant dry cough or itchy throat and so on.

Speaker 1 (00:41:41):

The best person to see that is a head and neck surgeon or E N T doctor. They’ll basically take a look, say, tell you, say, ah, look at your mouth, look at your uvula, and they’ll stick a camera down to look at your local cord and see what’s going on. If it’s red, then that means you’re having acid reflux constantly burning that tissue and not healing the original inflammation from the endotracheal tube. If there’s a polyp, they can see the polyps. So there are specialists within E N T that are auto, that are laryngologists. They’re technically, they’re auto laryngologists. They do ear, nose, throat, but there’s those that only do throat that are called laryngologists or voice specialists. If your town has a laryngologist, that would be the best person to see because they see injuries from endotracheal tubes all the time. Do not go see your anesthesiologist. That’s a waste time because they’ll be like, I don’t have an office unless you’re having surgery, you’re not my patient.

Speaker 1 (00:42:49):

Okay, going back to the incisional hernia question, therefore, should you not avoid watchful waiting for an incisional hernia if you want to maximize your chances of getting pure tissue repair, again, no, not relevant. That will not necessarily get you there necessarily it’s it’s an option, but not necessarily, okay, going back to the gentleman with the throat issue, I’ve had more pronounced acid reflux since then. Okay, so you must be on a very strong anti-reflux medication because you’re constantly burning that vocal cord until that heals, you’re going to still be coughing. I assume that’s a problem, but again, a laryngologist should be able to help you.

Speaker 1 (00:43:42):

All right. Condensed adhesions help prevent an incisional hernia or its recurrence? No, it does not, unfortunately to separate problems. The adhesions, the thought process seems to be can the adhesions kind of sock everything in and prevent the fascia from opening up because it’s included in that and they’re not. The adhesions don’t have strength to hold your abdominal wall together. Can adhesions be caused by an incisional hernia also? No. So well, in some ways you can have adhesions within the hernia, so what we call hernia sac adhesions and people can have bowel obstructions within the hernia because of adhesions within the hernia of the hernia sac. But that’s kind of like slicing the bologna too thin. You need to, maybe I shouldn’t say bologna salami, you should slicing the salami too thin because either way it’s still considered a hernia related adhesion and bowel obstruction.

Speaker 1 (00:44:48):

What can cause back pain months after midline incisional hernia pair? Well, it depends on the reason for the incisional hernia pair. So one reason for back pain after hernia pair is your hernia recurred and that’s making a core unstable. The other possibility is that you already have a weak core because you’ve had an incisional hernia and you have an abdominal wall hernia repaired and through this whole process you’ve kind of lost your core strength and stability and that can cause back pain in both situations. The more you strengthen your abdominal core, the better the back pain may be. And you can also work on your back core muscles too, and both of those should be totally safe to do even though you have a hernia.

Speaker 1 (00:45:39):

Given that minimally invasive surgery is becoming more common, how often do you encounter complex incisional hernias that require advanced techniques such as roboTAR? Great question because I am a minimalist, so if I can do an operation with less incisions, better recovery, less kind of something like more dainty, I will do it. So for example, there are people that would use do robotic surgery and put like four, maybe five incisions. I prefer use three or some people use robotic technology for every single type of hernia pair, and I don’t do that. However, I do sim. I must say that for really large complicated hernias, the robotic technology has really improved outcomes for my patients. So I do rely on it. I used to never do these big ones laparoscopically because it’s just too complicated. But with the open robotic technology, I’m offering a lot of minimally invasive options to patients that before I would’ve done open because it wasn’t going to be a good laparoscopic option.

Speaker 1 (00:46:55):

So yes, I’m happy to say there’s more minimally invasive surgery being offered. They tend to be more robotic than laparoscopic nationally because it’s just easier and if there’s a higher penetration of robots in the US, it’s probably not so true outside the us including Europe. Europe because it’s just so expensive to have robotic technology outside of the US. But unfortunately in the US medical care can be as expensive as we want it to be. Are trocar hernias still classified as incisional hernias? Yes. Can you repair them without using Mesh? Yes, you can. That should not be your first option, but if there’s a trocar site hernia and it’s really small like five millimeters, you may want to consider a bonafide tissue repair in one or two layers with permanent suture to help. However, the correct answer if you’re being given the oral board examination and so on is you know, you should be using Mesh for any incisional hernia including small ones from trocar site.

Speaker 1 (00:48:13):

Great. Next question. What is the best test to check if Mesh from a large incisional hernia is still intact? So if you mean intact like the Mesh is flat, not torn, not wrinkled for the abdominal wall, a CAT scan with IV contrast should be adequate oral and IV contrast. In some situations, if you really want to be very specific about the Mesh, you can get an MRI. Those are much more difficult to interpret for the abdomen because of the shape of the abdomen. The MRI is an option. You’d have to get a soft tissue. MRI that said imaging, yeah, if you could find a really good ultrasonographer, they may be able to give you an idea of how the Mesh is, but it’s so hard to do that in the United States. Outside the United States, we have much better access to good ultras sonographers.

Speaker 1 (00:49:18):

And let’s see. I feel like those are all the questions that were sent out to me. This has been great. I really like talking about this. I did want to make a comment about robotic surgery. So there’s a question about robotic tar. T A R TAR stands for transverse abdominal release. It’s basically a posterior component separation. You may have heard of an anterior component separation. These are all different tools in the box, and I must say that I think it’s a great operation. It’s an operation that has done an excellent job in providing relief to patients that have large hernias. I do feel it’s maybe sometimes overused and it doesn’t offer the best cosmetic outcome because what you’re doing is just closing a hole, but you’re not tightening the abdominal wall. So from a purely cosmetic standpoint, if you have a big hernia, it’ll make you look not protuberant, but your belly will not be flat and therefore I do not offer a robotic hernia repairs to everyone.

Speaker 1 (00:50:30):

I do offer it to the really small and the really large hernias, but the medium sized hernias where you can really get a good flat repair for some people and get them to look even better than they did before. I do those often open because I think cosmetically it’s, it’s nicer. a lot of surgeons don’t care about the cos music like your hernia fixed, go home and the patient, but I still look like round. And the reason for that is there’s no hole, but your muscles are still not pulled together and I feel that in the right patient they should have that outcome. I’ll come next question. I’ve had two failed prior text Mesh repairs, which wrapped around my bowels. Oh boy. I’ve lost 24 kilos now and I’m being offered a myocutaneous flap. Okay, it’s a very large hernia loss operations four years ago and it was a laparotomy. I’m now waiting for a CT scan. Okay, let me give you my 2 cents on this. So if you’ve had bowels wrapped around Mesh, I don’t know if you’ve had this complication, but one of the major complications is erosion into the Mesh.

Speaker 1 (00:51:42):

If you’re lucky, the Mesh eroded, it just caused an obstruction and the obstruction can be dealt with in kind of an elective way by removing the meshes and then cutting bowel and putting it back together again. However, if you have a full on fistula where you have stool leakage, then that’s much more complicated. Obviously all the Mesh needs to be removed, but all the infected tissue needs to be removed. The bowel that’s causing the fistula needs to be eventually closed at some point, and then you’re left with this big hole to close, given that you’ve already done poorly with Mesh and been infected and now have a hernia. So myocutaneous flaps depends on what kind of flap if you are having a component separation, so not a free flap. Free flap is a different situation. Component separation, that’s a good choice usually for hernias, 10 centimeters are wider. We have to use a component separation of some sort and if that’s being offered to you, it sounds like the surgeon knows what they’re doc talking about. If you’re being offered a free flap or a flap like a latisimus flap or a like gluteal flap or some type of flap where they take tissue distant from your abdominal wall and bring it over to cover the abdominal wall, that works to fix an opening, but it’s not a very good long-term problem because that muscle will stretch because it’s not really healthy.

Speaker 1 (00:53:25):

It doesn’t have nerves that go to it, and so the muscle just stretches and you become really deformed by it. Those are very extreme salvage situations, but it is the problem that some patients have very infrequently and it is what it is. Okay, looks like there’s a question again about the incisional hernias and inguinal hernias. I discussed this at length early on and I hope that you can listen to it later either on Facebook live or on YouTube because we discussed what happens with inguinal hernias that tear apart or recur. Next question, talking about cosmetic outcome of robotic tar, is that the same case with reconstruction component separation? Also closing diastasis?

Speaker 1 (00:54:26):

It can be depends on your surgeon and what they plan to do. So if you have an abdominal wall operation and the plan is to close all layers, not just, so usually what they do is they break you into two layers, top layer, bottom layer, and a lot of times they close the top layer, but they leave the bottom layer not closed. It’s not just hanging there, it’s just not completely returned to back to normal. In those situations, the bellies tends to be not as perfectly flat. They tend to kind of look like a square, like a table as a and not flat. And that’s because the front is closed, but the deep one is not are the deep muscles are pulled away and you end up the size tend to pooch out more than you wish. I don’t like that and I don’t really offer that unless the patient is really, really complicated and cosmetic because the last thing on their list, they just want their hernia repair so they can go back to normal lifestyle.

Speaker 1 (00:55:25):

If you are having the diastasis addressed and the hernia is not so big, then you can close the top and the bottom layers, then that’s great. But if you’re going to close the top and the bottom layers and you have a huge hernia, then it’s, what I’m trying to say is not everyone can have both layers closed. The larger the hernia, the less likely it is that both layers can be closed. The goal of a hernia pair is to close a layer and often that’s a top layer and the bottom layer’s kind of left to be, I don’t like that and I tend to push the limits and I tend to close that bottom layer more than most surgeons because I want to get a flatter cosmetic look in addition, but I’m not willing to give that cosmetic look if it’s going to hurt the hernia pair and make it a tear again. So it’s a decision. If your hernia is wide and huge, then it is what it is. You should be able to get the hernia fixed. But understand you’re not going to have a flat belly necessarily, but if you kind of have a medium size hernia, then you know potentially they can close the back layer and give you a little bit better cosmetic outcome than a typical robotic tar.

Speaker 1 (00:56:53):

A lot of patients, they end up, a lot of patients that end up having these large robotic tars are not thin patients. And so to be fair with the extra fat they have between their skin and their fascia layer, you can’t really tell what their abdominal contour is, whereas the thin muscular patient can. So that’s kind of where you want to have that discussion with the surgeon as to what your plan of care is. Going back to this patient who had the Mesh wrapped around her bowels, they removed some of the Mesh four years ago. Some they did not remove all the Mesh. Okay, don’t get me started. They removed some of the Mesh four years ago. This new surgeon said I wouldn’t have a flat stomach. I looked nine months pregnant on my appendix site. Oh, your appendix site, okay, we didn’t discuss this, but the best outcomes are from the midline or kind of middle hernias.

Speaker 1 (00:58:00):

If you have hernias on the sides, that’s very, very complicated because the muscles on the sides are very weak and therefore what you want to do, which is repair the muscles, it’s very hard in that the tissues don’t come together very well. It’s thinner. There’s a lot of the nerves in the area you can and so on. So big hernias in the flank area are much, much more difficult to repair. Now you can potentially get a flatter look. I don’t know how big your hernia is or how complicated the operation is, how big and how much fat is in the area. But my recommendation is if you’ve already had so many complications, the goal is to get you to be pain free and hopefully hernia free. And the cosmetic part unfortunately is going to have to be less of a priority because you don’t want them to do extra work to make you look prettier at the belly, at the risk of hurting the hernia repair. And then you’re going to have another hernia repair which needs more surgery or you’re going to tear or you’re going to have a bad

Speaker 1 (00:59:20):

Outcome. So focus on getting a good hernia repair outcome and then the flatness part can be dealt with later. That’s kind of my 2 cents. So I don’t know if you guys think the way I do. I always think quality of life is great and cosmic is a very important part of what I do and how I operate, but it cannot hurt the quality of the operation and the repair that I provide. And that’s it my friends. Thank you for another great hernia talk. I’m going to be taking some time off, so please follow me on Twitter to get some more education. I’ll be live tweeting at some different society meetings and give you some feedback that way. I will see you in three weeks. Actually, no, I’ll see you next week and then I’ll be missing two sessions two weeks after that. So I will see you next week, join me, get your questions ready, and then I’ll be live tweeting at some of these surgical society meetings that I’ll be attending the weeks to follow. So thank you very much for joining me.