Episode 116: Hernia Repair in Europe vs USA | Hernia Talk Live Q&A

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Speaker 1 (00:10):

Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live. I’m here Tuesday night with you as your host and hernia and laparoscopic surgery specialist. Thank you for coming. We are live on Facebook as well as Twitter. And after all this, make sure you follow me, I’m sorry, as well as on Zoom and thank you for following me on Twitter and Instagram at hernia doc. As always, we will have this shared on my YouTube channel, so please do subscribe. In fact, we’ve been gone for a while. I’ve been traveling. I was in Europe for a couple weeks and been working hard, so thank you for kind of waiting for the next Hernia Talk Live session. So I’m, I’m back. I’m excited. We’ve got tons of new surgeons that have signed up for our future. End of 2022, beginning of 20, 23 sessions. I’m going to have a lot of hernia surgeons, but also some kind of not so hernia surgeons that will be involved.

Speaker 1 (01:20):

So I’m super excited to learn from them. But let’s get started. I mentioned my YouTube channel. It is updated and live and nicer. One of my patients, you got a great YouTube channel, but it’s kind of like the thumbnails are not so pretty. So guess what? I took that to heart and I fixed it. So I hope you like it. Go to my YouTube channel, it’s at Hernia doc as everything is at hernia doc and hopefully you can watch all enjoy watching all of the old videos and so on. So let’s start our session today. Many of you have submitted lots of questions, so we’re going to go through that. Please do type in your chat questions and I will help answer those. But I wanted to share with you what a fantastic month I’ve had. Many of you know that I do travel for meetings.

Speaker 1 (02:22):

Last month was the American Hernia Society meeting. Well, two months ago was a hernia, American Hernia Society meeting. This past month was a European Hernia Society meeting, and this weekend was the Western Surgical Association. So I’m very involved academically. I have research fellows and residents that enjoy working with me. We look at data and we publish and we share our experiences and oftentimes I’m asked to give talks. So I want to share with you what Europe was like. So I love going to the European Hernia Society meeting. First of all, it’s Europe, so it’s like a excuse to go to a country and experience it through the eyes of your friends, also known as my hernia friends. And it’s very unique because in addition to being like a meeting where you give talks and you exchange ideas and you have discussions, you’re actually working and collaborating with people outside of the United States, which is I think is really cool.

Speaker 1 (03:24):

I really enjoy it. So the first day I was involved, I actually, many of you have may have seen I was indicted, indicted, inducted was not indicted. I was inducted as an honorary on, I got an honorary board of the European Board of Surgery. So I’m currently board in the United States by the American Board of Surgery. What was really cool is that they have now an abdominal wall surgery certificate in Europe through the European Board of Surgery. So they gave me an honorary certificate and that means many things. Number one, I’m technically board certified also in Europe. Number two, I decide to pay back that very gracious award by volunteering to serve as an oral board’s examiner. So many of you may know surgery and medicine in general, it’s a very long educational process. What happens is you go through college, you get your bachelor’s, you may get other degrees, then you need to go to medical school and get your medical degree.

Speaker 1 (04:35):

That’s where your MD comes from. But in most states in the United States, you cannot practice medicine or surgery until you’ve gone through formal training. In surgery, it’s minimum five years. My program was seven years because we had to do additional years of research. And then you are certified to do surgery, but you’re not board certified. So the American Board of Surgery then needs to certify you and say, okay, we know you put in the time and your program deems you safe to do surgery, but really are. So you have to do a written exam, which at that time it was two days. Yeah, it was two days of examinations, I think four or six hours a day. I don’t remember. If you pass that then you are eligible to then do the oral board’s examination like six months later. And so I had to fly to Portland, Oregon to take the oral boards where you sit through multiple different situations where they, they’re like, okay, now this patient is coding or this patient comes to you with this problem.

Speaker 1 (05:48):

What do you do? You have to explain how to take care of the patient, what surgery you’ll do, what technique are you going to offer? They’re going to throw a complication at you, you to understand how to address the complication. And then the whole goal is not to make sure the patient survives and has a good outcome. And they throw multiple scenarios at you. And that’s a full, I think it’s a little or more than a half day of being grilled by multiple different teams of surgeons in this kind of hotel. So that was my experience in the oral boards and unfortunately I passed them and therefore became board certified in the United States by the American Board of Surgery and that gives you extra qualifications for hospital privileging and so on. And then I kind of had a really good experience because I love the American Board of Surgery.

Speaker 1 (06:42):

They’re kind of a really cool group of very esteemed surgeons. So I was involved as a volunteer to be an examiner myself several times with the American Board of Surgery, which is kind of cool. I went to Utah to do that a couple times. And then I was also on the board as an exam writer. So I was the one that wrote with the team, with the wrote the questions for hernias for both the written examination and the oral examination. So I’m really invested in this whole thing. I love the process and I love volunteering my time for this stuff. So when I got this European Board of surgery, I said, wow, I would love to be volunteer as an oral board’s examiner. So that’s what I did the day before the meeting. So the meeting started on Wednesday. On Tuesday I showed up and we had 25, you know what I’m going to do posts about this.

Speaker 1 (07:41):

That’s good information. We had 25 surgeons from all over the world, including mostly Europe, but also Middle East that came and went through the oral boards examination for the abdominal wall surgery. I was hooked up with my friend Franz Meyer, who I think is really cool. He is from Switzerland and Franz and I shared the kind of inguinal hernia room where we grilled them about Inguinal hernias. There was like a abdominal wall hernia. There was a complex Inguinal hernia, complex abdominal hernia. There was a open abdomen trauma, intensive care, critical care. And then there was a research stations. So all these are different stations they have to go through and they have to answer questions. So yeah, I will post that, the pictures from it, cause it was really fun. So that was my Tuesday and then Wednesday, Thursday, Friday was the meeting.

Speaker 1 (08:45):

I gave a couple talks. I talked about women’s hernias. I ran the women’s hernia session. My resident came from, he’s actually going to be a plastic surgeon in Houston. So he flew in and he presented two projects. We had one project which reviewed our non Mesh experience in fixing incisional hernias without Mesh. Many of you who follow me and know that there are guidelines as to what is a best repair and specifically for incisional hernias, that means you’ve had a hernia, sorry, you had a surgery. And that surgery resulted in a hernia. Those hernias can’t just be closed because they were closed, but they fell apart. So the fact that you closed it once and it fell apart means repeating the same, repeating the same procedure will fail again. And that quote is somewhere between 50 and 60% risk of it recurring, which is a exorbitantly high risk. So we don’t do operations that have 50 or 60% complication rate. They’re just not considered valid. So based on data out of the Netherlands, we show that if you use Mesh, the incisional hernia recurrence rate drops by more than 50%. So 50% becomes like 23% or something like that, which is still high, but it’s not as high as over 50%. So the thought I had was, well, okay, fine, but what about smaller hernias?

Speaker 1 (10:29):

What about people that have really lax abdominal walls? Do you really need to put Mesh in them? And I’m always looking at innovation and ways to come up with newer techniques and newer options. So I hooked up with one of our plastic surgeons and we found patients that had incisional hernias but also had a lax abdominal wall, often a diastasis recti. So that’s a unique situation, which means they’re also eligible for a tummy tuck. Now of course, not everyone needs a tummy tuck. Not everyone should get a tummy tuck. We’re not promoting tummy tucks. However, what we showed is in our small population, if you have a small hernia and it’s an incisional hernia, which means you’ve had surgery and that surgery resulted in a hernia, the guidelines show you need to have Mesh in. But if you’re also eligible for a tummy tuck, maybe the tummy tuck can be your hernia Mesh.

Speaker 1 (11:32):

Does that make sense? So a tummy tuck is an operation where you ply Kate or kind of tailor down the abdominal muscles. You basically sew the muscle like you would the taking in the seams of a jacket. So to kind of tailor a jacket, if you want to nip in the waistline, let’s say, or like a dress or something, you actually fold in an extra layer to narrow it. So to narrow the abdominal wall, the plastic surges plicate or do an extra layer of muscle on top of muscle. Well guess what? If you can close that hernia and you do nothing else, that hernia will come back at least 50 or 60% of the time. But if you can close that hernia and put Mesh on it, we know that the recurrence rate will be much, much lower, more than 50% lower. What if you can close that hernia and instead of putting Mesh, you add an extra layer of muscle on top of it, the own patient’s muscle.

Speaker 1 (12:41):

So technically it’s not Mesh, it’s your own muscle. So it’s like a biologic, you can think of it, but most biologics are off the shelf and they absorb this is your own body’s biologic or autologous tissue. So that was our theory. Maybe in this handful of patients that have a loose abdominal wall, maybe extra skin, good candidates for tummy tuck and have an incisional hernia, maybe those people do not need Mesh because it’s always better if you can do an operation without Mesh, with just as good of a result as with Mesh. And guess what? They all did great. We’ve walked, we’ve followed our patients more than four years now and none of them have had recurrence. There’s no handful. It was only four, four patients because this is not a large population of people we’re talking about. But it kind of gives you a little inkling as to what can happen if you’re innovative and don’t just blindly follow guidelines.

Speaker 1 (13:42):

And that’s kind of where we at. So I thought that was really cool. Everyone loved it. They’re like, this is awesome, this is great. The meeting itself was very, very innovative to begin with and coming up with a lot of great discussions on techniques that are not necessarily standard and analyzing it. So that was one of the talks that we gave. The other one had to do with tailoring of care. So as you know, I talk about tailoring, tailoring care a lot. So if you are tall, athletic, obese, super thin, I would provide a different or old or super young, I would offer a different plan of care for the same problem. I’ll give you an example. inguinal hernia. In a patient who’s a ballerina, I would not use Mesh in a female with autoimmune disorder. I would prefer not to use Mesh in an obese male who’s a smoker.

Speaker 1 (14:44):

I would definitely use Mesh in a MBA athlete, probably I would use Mesh. But I would do that laparoscopically in a 80 year old patient on blood thinners. I would do it open with Mesh. So depending on the type of patient, I would offer a different surgical plan to tailor to their needs. So we kind of looked at that. I’ve been doing that since 2008. So we looked at that and we looked at how my practice has changed. And we shared that as if you are tailoring to the needs of your patient, this is what you should expect. You should be doing less open surgery, more laparoscopic surgery. You should be doing less Mesh in women and more laparoscopic surgery in women than we were doing in 2008. So that was kind of enlightening and people enjoyed learning about that.

Speaker 1 (15:51):

I gave four talks. I think they had me working. I worked all day Tuesday and then Wednesday, Thursday, Friday. So I gave the keynote lecturer, which was about the legal system and why we’re seeing talks about Mesh on television. Remember this is Europe. So in Europe it’s typically socialized medicine. There are countries like England, maybe a little bit of France, maybe a little bit of Germany that have a private practice option for medical care. But they’re almost all socialized medicine, which means you’re paying extra taxes and in return you’re getting basically free or very low expense medical care. And what I learned is, I mean I kind of knew it, but I learned it more is it’s very different than the United States. United States. It’s a lot of it’s, well first of all, we’re not socialized medicine. We do have care that is sponsored by the state called Medicaid or by the government called Medicare.

Speaker 1 (17:04):

And that’s to a limited population of patients and pretty much everyone else is in a private system which makes it so that care, the care, the technology involved in the care, the wait lists are all so different in the United States than it is in Europe. Most people are on wait list In Europe, not so much in the United States. Most people get low technology surgery. So not laparoscopic surgery. Mostly open, much more tissue-based repair than mesh repair in Europe, definitely virtually no robotic surgery, very little. It’s growing, but it’s very little. My hospital, Cedar Sinai has more robots than almost every country in Europe.

Speaker 1 (17:57):

The number’s nine by the way, which I think is crazy, but also really interesting. So yeah, robotic technology is virtually non-existent in Europe except in various small situations. And definitely those are the private situations. And then finally the legal system. So there are no class action lawsuits that you see widely throughout the Europe. There are patient groups that are fighting for their needs with their government, but they are not led by class action law firms. Whereas United States, you can listen to the radio, watch TV or be on cable and you will see ads all the time, whether you have a hernia or not. You’ll be inundated with pelvic and hernia Mesh lawsuit kind of ads. So that was my keynote lecture because it’s fascinating to them that this even exists and that lawyers are involved in patient care decisions.

Speaker 1 (19:15):

And what else did I give a talk on? I give a talk on, oh, the female anatomy and how it kind of relates is different than males for hernias. Gave a talk on imaging and its use. So it was kind of fun. I gave a lot of really good talks. I thought they were very good. Interestingly, the female hernias section. So we had a section dedicated. We had six or seven talks solely on growing anatomy in women. And we had a great, great discussion on that. We were packed, had, I mean the good thing there’s no fire marshal issue in Europe. Standing room only. Literally people were standing all around the walls. We had great talks. I helped moderate that session and I gave a talk at that session. It was really, really great. The whole women’s section. The other one that was really innovative for hernia surgery meeting was we talked about Mesh reactions, Mesh complications, Mesh reactions, Asia syndrome.

Speaker 1 (20:26):

I gave the Asia syndrome talk. We had Dr. Jan Willem Cohen Tervaert who was a guest of mine early on in hernia talk. You can watch his videos. One of the most watched videos. He talked about his experience with autoimmune reactions to meshes. We had a biologist who talked about how implants can trigger Mesh reactions and so on. So it was really, really good and interesting. a lot of people showed up to that one too. So even though it’s not a big topic in Europe, it was really great. So that was kind of my experience. I really enjoyed it. We had great evenings. I got to go to a Manchester United soccer game, which I thought was really cool and very different experience than soccer games in the United States. I’ve been to the L A F C, the Los Angeles Football Club and they’re great.

Speaker 1 (21:27):

I think they won. They were like US champion at least one year. Very family friendly Manchester United soccer game, not so family friendly. That’s all I that’s, I’m going to say it was quite a memorable experience and lots of great food, great Indian food. Oh they took me to this all you can eat, literally all you can eat. Indian restaurant buffet was called the Royal Nawab. Guys, 50 to 70 various meals available to choose from. I had maybe 15 or 20 of ’em and I was like, I can’t say more, I’m full. But if you guys think the Las Vegas all you can eat buffet is a lot, this beat it by so much. And it was relatively cheap. It was like $25, really, really delicious Indian food and huge, huge banquet hall in Manchester. So Manchester was the city in which the meeting was in a very good foodie kind of place. The Brits are super fun. I loved it. I got to visit London. That was kind of one of the highlights cause I’d never been there before and everyone’s super nice and London’s just beautiful, absolutely beautiful.

Speaker 1 (22:51):

I will do a show coming up, I think it’s next week, talking about patient advocacy because I got a chance to meet with some patients while I was in Europe and patients and patient advocates that are fighting for improved hernia care in the UK and the rest of Europe. And they have partnered with a lot of US based groups. Many of them run really successful Facebook groups. I I think next week is when we’re going to focus on that. I won’t kind of give up the details, but just to say it was one of the highlights of my time there was meeting these patients, getting to know them, hearing their stories, understanding how their system works. Again, it’s a socialized system so by definition your kind of insurance carrier is the government. So if you want to basically ask for better coverage, like you’re on a wait list or you want to be able to see a specialist outside your system, you have to go to your member of parliament.

Speaker 1 (24:09):

And that’s kind of interesting because I would not go to my senator or my congressperson if I couldn’t get hernia care. That’s just not a thing. You’d go to your insurance carrier maybe or a appeal somehow to a doctor, but in Europe is different. So I learned a lot about that system and kind of how they are trying to navigate improve care. Here’s a question someone said can you share any of you the presentations you gave or others gave to your social media? I can share the titles. These were not recorded in any way. So you know what I can do, which I haven’t done, is I can technically, I have all my slides so technically I can give the lecture and narrate my slides again and posted on my YouTube channel. And I have so many talks I’ve given. I think since you’re asking, I should probably do that.

Speaker 1 (25:11):

I appreciate that comment because I spent a lot of hours, like hours and hours and hours working on my talks to make them fully full of information for the audience. And so I will maybe over Christmas break, which I don’t really have Christmas break because I operate through all through New Year’s and only take New Year’s day off and Christmas day off. So at some point I will try and make time to redo my talks and basically narrate the slides because except for sages, which is a meeting that actually videotapes their talks and post it on YouTube, none of the other meetings videotape. So I cannot share with you the actual talk or you won’t be able to have the experience of what questions were asked because I think the question answer session is the best part because it gives you an idea of what the audience is thinking and how they are interpreting what you’re saying. And it also helps identify the problems that the audience may have in like digesting what you’re saying. So I will try my best.

Speaker 1 (26:31):

I should be just good about it and record like a talk or something. I have the slides, but I posted some slides without narration and people didn’t like that they wanted me to talk through it. So on my YouTube channel. So what I’ll do is I’ll try and give the talks through narration. You guys are making me work more. Okay. That would be amazing. Thank you. You could even do them as hernia talks and share the q and a that you remember. But narrowing slides is amazing. Appreciate, okay, yeah, I’ll try. I’m working hard you guys. So November, December is the busiest time for me. My office and I are not allowed to take any time off during November and December. You can’t take holidays off, you can’t be off on vacation. Many of us have birthdays in November. Too bad you’re going to have to do your birthday trip if you want to take time off our vacation either before November or after January or after December.

Speaker 1 (27:33):

So it is our busiest clinical day clinical, sorry, two months. So you know guys have me working hard. That said, I’m going to try and do as many hernia talks through the holidays as possible because I do enjoy them and people seem to be okay taking an hour off. Okay, let’s go through some questions that were submitted because they were related to to a little bit of what we discussed. So we talked about the healthcare system. Oh, one thing I didn’t talk about. So another thing I learned was unlike the United States, they don’t have as many hernia specialists in the UK. Now there are plenty of surgeons that are interested in hernias for sure, no doubt. Germany, Sweden, Denmark, England kind of, but the Belgium and Switzerland kind of. But Germany for sure, and some of the other countries that I mentioned, they have surgeons very much interested in hernia surgery.

Speaker 1 (28:51):

What they don’t have are dedicate specialists. That’s all they do. So because it’s socialized medicine, most of these surgeons either do everything but they really like hernias and therefore most of their research and so on is based on hernias or they’re just involved in hernias, but it’s not necessarily everything that they do. Whereas for me it’s everything I do. As many of the specialists that I brought on hernia talk, at least 50% of their practice is hernia surgery. Whereas in Europe, that’s not necessarily true. So the one thing that of the surgeons told me is we really enjoy having Americans at our meeting because your volume is so much higher than ours. Partially because they’re a bit capped in terms of their volume. There’s no incentive to work after hours or weekends because it’s basically like a socialized system. Whereas in the US will do extra work because usually extra work implies extra pay because we have a capitalist system. So there’s that incentivization to have a higher volume.

Speaker 1 (30:08):

And then also we have more hernia specialists per capita than they do in Europe. And then we talked about that legal system and the technology access. So here’s some questions that were presented online to me, what type of hernias do not have complete healing? So I’m not clear what that really means, but I’ll tell you one thing. Healing has to do, mostly not with the hernia but with the patient. So for example, if you’re a smoker or diabetic, you have a significantly lower rate of healing than a non-smoker or someone who’s not diabetic or their sugar is not better controlled and therefore you are not going to completely heal. And your risk of surgical site infection as well as surgical in hernia recurrence is significantly higher. 5, 7, 10, 10 times higher. So the healing is mostly related to your own ability to heal. There are people, for example that have collagen disorders.

Speaker 1 (31:21):

Ehlors Danlos syndrome is the classic one. If you have this problem, the chances that you will not heal as well is the same as someone who’s a smoker because they also have a collagen problem. And knowing that we kind of change what we do, we’re usually more likely to use Mesh and other implants that bring in external help to help you heal. In diabetics, we usually take extra caution to pick the type of operation to reduce the risk of infection. So laparoscopy or robotic surgeries preferred over open surgery in the typical diabetic patient or the obese patient specifically to answer the question of whether what kind of hernia has the best or the worst healing, I would say it’s very technique dependent too. So bridging was something we used to do a lot. There are many surgeons that still do bridging, but what bridging implies is if you have a hole which is your hernia, we don’t want to leave the hole open and just patch it with Mesh because that implies that you’re just fixing, you’re just patching the hole, but you’re not restoring core function.

Speaker 1 (32:34):

This is for abdominal wall hernias. So all you have in the middle of hole is Mesh and you don’t have tissue to grow into it or kind of replace that hole with something viable like muscle or fascia. So I would propose that the hernia repairs that are bridged are the worst in terms of complete healing because there’s not much healing to do because there’s no tissue there. You kind of have Mesh just against fat and maybe peritoneum or muscle or sorry, or intestines, which is not the best option. So that’ll be the only answer I would give.

Speaker 1 (33:20):

Other hernias that don’t heal well are the ones that don’t have good blood flow to it. So again, diabetics, people that are smokers have less blood flow to their area of surgery because of those two diseases. People with really bad heart disease probably also have bad arterial disease elsewhere in their body and are not getting good blood flow. So they are at higher risk for failure of surgery because of poor blood flow. Another way of getting poor blood flow is if the surgeon performs an operation that significantly destroys the blood flow to your area. So I see this more often with really, really, really large abdominal wall hernias because what happens is they do, the surgeon will go out of their way to do very wide dissections, but the further out you go in terms of your dissection, the more blood flow you’re cutting off to what you’re dissecting.

Speaker 1 (34:24):

Does that make sense? And so similar to a tummy tuck where it’s very critical that you get excellent blood flow to get great cosmetic healing and you want that belly button to heal with really big hernias as well. You want to be very cognizant of the blood flow to the area. So general surgeons are not as cognizant of this important aspect as our plastic surgeons because it’s usually not an issue for us. We don’t usually do plastic surgery level operations where blood flow can be affected. However, in really large hernias you can go extremely wide and disrupt the blood flow to where you’re trying to operate and you can get what’s called skin necrosis or kind of necrosis of the skin area and even the fat. And that becomes a very, very bad and difficult wound to care for. And if you have exposed Mesh to that, that’s even disaster because then you’re going to have a Mesh infection and it’s, it’s just a horrible situation.

Speaker 1 (35:28):

So that’s, what else do I have to say about poor healing? Oh, nerves. So if you have an operation that is performed that destroys the nerve, that feeds the muscle, we’re not talking about sensory nerves where yet numb, we’re talking about motor nerves, then that can also affect healing because the way the muscle gets its nutrition is through the nerve. So if you destroy the nerve, then that’s going to be a problem in terms of healing of the muscle. So that’s the most I’m going to say about that question. Is the Medtronic anatomical groin Mesh just a patch or is it somehow woven in? So all meshes are patches, nothing is physically woven into the person’s body. Although sutures, I guess you could say sutures are all meshes are patches. And then depending on the patch, they have openings or interstices where it’s basically like a woven patch.

Speaker 1 (36:36):

So those holes within the patch allow for the muscle to grow into the Mesh and basically take over the Mesh, grow into it and prevent it from moving around and also allowing it to integrate with the muscle, make it stronger. So I hope that makes sense. So all meshes Medtronic and others are patches of woven material. There used to be or there still is, there is a Mesh called Gore Goretex Mesh or E P T F E. And these meshes are not really woven, it’s more like a sheet. They tend not to integrate as well as the woven patches or meshes. a lot of the biologics are not woven, they’re sheets. So they are not as well integrated and so therefore they’re not really considered the first line of care for most hernia surgeries. But it is an option because we have lots of options for care for those. Next question has to do with Mesh removal. Where is it?

Speaker 1 (37:50):

Oh no, I missed that. Okay, I’ll tell you what the question is. So the question had to do with the TEP procedure. So it was basically the question was, is a laparoscopic TEP procedure easier to remove? Then let me rephrase this. The question specifically was, you know what, I’m going to bring it up so that I don’t misspeak looking into my Instagram because that’s where it was shared. Here it is. Can a mesh placed laparoscopically via TEP be removed safely even though it’s a large Mesh? Okay, so first of all, there’s large and there’s large. So inguinal hernia meshes or TEP meshes are not considered large if you compare them to meshes that we use for the abdominal wall like incisional hernia or ventral hernia or something like that. So my answer to you would be can a Mesh be safely removed even though it’s a large Mesh?

Speaker 1 (39:11):

Yes, it is not considered large by in comparison to other meshes. It is large in that that’s a designation. You can get the small, medium, large, extra large meshes and usually we use the large size. So that’s just a term we use that is actually a designation by that manufacturer that this is the large component size of the same Mesh in which they have small, medium, large, extra large. But is it a large Mesh? Is it like huge? It is not. And yes, pretty much all laparoscopic TEP hernia meshes can be removed safely. And by safely, I mean you won’t die from it. However, there are risks to the operation. It is not an unsafe operation, but it’s a risky operation, which means you may get damage from the removal, especially if it’s performed by a surgeon that’s not very comfortable with the anatomy in the area.

Speaker 1 (40:16):

I’ll give you example. So when I do Inguinal hernia repairs, I’ve done so many that I can map out to you exactly where everything is in a patient’s body without even looking. I know comparatively where the vessels would be, where the bladder would be, where the spermatic cord would be, where the nerves would be, where the direct space, indirect space of femoral space, obturator space, I can point ’em out without having to do much dissection at all because I kind of know. In fact, a lot of times when I’m teaching the resident, I take the Mesh and I kind of draw on the Mesh where everything will be covered on the Mesh and you put it inside there and I say, I’m like, okay, approximately here is where the vessels will be approximately. Here is where the indirect space is going to be and all that.

Speaker 1 (41:07):

And they put it in there and it’s exactly the anatomy inside. So it helps the resident understand it. But also more importantly, it kind of shows that I know what the hell I’m doing. So there’s a relative kind of understanding of where each structure is compared to everything else, which is very important when removing Mesh or doing any type of revisional surgery because with revisional surgery now you have possibly Mesh and also scar tissue that’s going to distort that anatomy. So you have to really know your anatomy first and then you’re going to have to be able to navigate a distorted anatomy. The Mesh may move the bladder and pull it towards itself. The Mesh may twist the spermatic cord in a manner that the vast deference is where it shouldn’t normally be. And if you don’t understand that, you can accidentally injure the bladder or injure the vast deference because the anatomy has been distorted. Same with nerves. So yes, all TEP, and by TEP we mean T E P, which stands for totally extra peritoneal. It has to do with inguinal hernia specifically. We don’t usually talk about TEP for abdominal walls, Al although we do have TEP type procedures for abdominal walls, we usually call those eTEP for extended eTEP because it’s much more than a typical inguinal tap.

Speaker 1 (42:41):

But yes, if you need it removed, we do remove it. It’s not such a safe operation that we would remove it in people where it’s not indicating. So I have patients that come to me and they say, I want my Mesh out, and lately I’ve had several and there’s zero reason for them to have the Mesh out. The repair is perfectly fine. The Mesh is in good place, the hernia has not recurred, they have actually no pain from the hernia repair at all. They’re not reacting to the Mesh, they just want the Mesh out. And that is not a good reason to have a revisional Mesh removal surgery because there are risks with the operation and you don’t want to do harm as a surgeon. So I’m not a technician. You can’t just come to me and say, I want this to work to happen and I’ll just do it.

Speaker 1 (43:28):

I need to use my surgical knowledge and sense to understand the indication for the operation and then provide the best option for your operation. So those patients were not happy when I told ’em I would not remove their Mesh because they specifically came to me thinking that they could just tell me to remove the Mesh and that I would remove the Mesh. Unfortunately, I don’t work that way because that’s just not the way medicine should be practiced anyway. So if there’s indication and the risk benefit ratio of removing the Mesh is in favor of the benefits, then yes, laparoscopic mesh removal can be done. If the Mesh was put in T E P or T A P P, I usually use the robot for that. You don’t have to. I used to do it laparoscopically and during the pandemic when I had poor access to the robot because the hospitals were all shut down.

Speaker 1 (44:32):

We were doing it laparoscopically. But both options are available more on that. So in Europe, not as many surgeons do Mesh removals because they’re inundated with patients that just have hernias. And this is what I saw when I used to work at USC, which is the largest LA county USC, which is the largest county hospital in the United States. And we had a five-year waiting list just for Inguinal hernias to the point where by a time we got to certain people, they had moved or changed numbers or something like there’s, it was really a horrible system of tracking and we just couldn’t operate on enough patients that needed hernia repairs. So many of them already had their surgeries in the private SEC sector, and that’s more of a system that you see in UK. There’s thousands of people on the wait list for hernia repairs and therefore people that have complications or need Mesh removal or those are very highly specialized procedures, are unable to get it because the wait list is long and the surgeons just don’t have the time or energy to devote to these highly specialized systems of care that require hours and hours of surgical care, which means four or five patients will not be getting their elective care and in the office they need to spend hours with the patient.

Speaker 1 (46:07):

I spend every consultation, we block off one hour for a patient and sometimes we need more. So in a non-private system, it just doesn’t work as well for patients that need specialty care. And so what I learned from these patients, trying to circle back to what I was saying earlier in Europe, there’s a huge need for surgeons like me to come in and kind of sweep in and help them out. The problem is I’m not part of their socialized medicine NHS, the National Health Services, I’m not part of that in France. I’m not certified to take care of patients in France. So it’s an issue and I’m trying to figure out what’s best for these patients because I certainly have people fly in from Europe to have care by me, but there’s not aren’t that many and most of the patients either can’t afford to do it or just, it’s just not part of their culture to leave the country or the continent for medical care.

Speaker 1 (47:23):

They’re so used to just being cared for, not only within their system but within their town. So it’s a cultural thing. I found it quite interesting, but I must say that it was eye-opening and I really enjoyed the camaraderie with the surgeons, but I also felt a lot for the patients because it’s really hard to penetrate. That’s kind of how I felt when I worked at the county hospital here, which is I can do so much, but I can’t save the world. I can’t do everything. And one of the reasons why I’m in the practice that I am, my own practice is I have full control. I can do whatever I want and there’s no system that’s really stopping me. Whereas when you’re working in a system where there’s limitations, whether it’s financial or social, then it, it’s really difficult. And I hope I’m able to figure this out a little bit next week when we talk about patient advocacy.

Speaker 1 (48:31):

And I’m going to have one of our guests, she’s very influential in the Facebook groups to kind of talk about all this. And I met several others that are doing the same in Europe. And it’s a battle they have to kind of navigate a system often alone. And I was just, I’ll give you a little bit more of my story. So when I showed up there, I had about three hours before I had to go in for the oral boards examination on Tuesday. And I spent that time meeting with the patients and patient advocates that were in the UK and none of them were from Manchester. So they’re coming from Liverpool and other parts of Channel Islands, hours and hours. One person drove four hours, they took the train for many, many hours just to kind of come and meet with me, which I found to be endearing and loving and I really loved that.

Speaker 1 (49:38):

And we talked for hours and hours. I’m going to do a post on it. We talked for hours and hours to talk about the system, how they deal with it, how many patients are in need, how I can help per perhaps many of them were invited to the meeting, which is really unique. By the way, the European Hernia Society meeting is in a different country every year. The way it works is the Hernia Society for that country sponsors it. So because this was in Manchester, the British Hernia Society sponsored the European Hernia Society meeting and the British Hernia Society, unlike almost all other hernia societies, with the exception of the American Hernia Society has a patient arm to it. So there are patients that are part of committees with the British Hernia Society, which I thought was fascinating and even more fascinating is we actually had, among the talks I gave was the patient side and how social media can help surgeons and patients interact.

Speaker 1 (50:50):

But that session was a patient session. We had tons of patients that presented themselves their story, what they’re doing, their advocacy, the system, as well as surgeons that are explaining how they’re navigating the system to improve informed consent for patients. And we discuss a lot of issues that are pertinent to patients. Again, that was not recorded. I wish it were because that would’ve been a really, really great meeting session for you guys to watch. But I hooked up with, we’ll discuss this next week, but I hooked up with one of the patients. I gave a great talk I thought on social media and how it can help patients navigate the system. Sometimes it can hurt, but usually it helps. And I gave a little plug for hernia talk, hoping more surgeons sign on to be members of hernia talk.com so that they can help answer questions and so on.

Speaker 1 (51:55):

So that’s all I have to say for today. I have a big case tomorrow I’m going to go have some dinner and get some rust, big revisional, redo, redo, redo hernia repair in a patient that had a very complex history from a different state from the east coast. So I’m really excited to help her. I’m super excited. I did a Zoom with her last week as a follow up in preparation for today, for tomorrow. She was excited. I got to meet her husband. So I’m super excited about tomorrow’s case. And I will be popping some protein shakes and wearing my compression hose because it’s going to be at least a four to six hour, probably closer to six hour operation, and I will hopefully improve her quality of life. So that’s all I have to say. I do want you all to show up and go to my hernia. Go, sorry, go to my YouTube page because it’s brand new and I update everything. And we’re going to have really fun sessions on YouTube. Please share subscribe. I’m going to do my best to update it with my previous talks, including the talks from the hernia, from the European Hernia Society. So I appreciate your following. Thanks for watching. I will see you next week. I have a great, great patient advocate coming on next week and I hope to see you soon. Thanks everyone.