Speaker 1 (00:00:10):
Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live. Our weekly session here with me, Dr. Shirin Towfigh, your hernia and laparoscopic surgery specialist. Many of you are joining me on Facebook Live at Dr. Towfigh and Zoom. And thanks to everyone for following me on Twitter and Instagram at hernia doc. Like always this and all previous Hernia Talk Live sessions will be available for you to watch on my YouTube channel, which if any of you follow me on YouTube, which I hope you do, I actually spent a lot of time revamping it, so I hope you all like it. So our guest today is Dr. Dina Podolsky. I’m really excited to have her because she is like me, a hernia surgery specialist. She loves hernias. It’s, I believe everything she does. We’ll get to ask her. She is currently in New York out of Columbia University where she has a very busy practice and I’m super excited. She took some time off to devote to us an hour today after work. So I really, really appreciate it. Dina, thank you so much.
Speaker 2 (00:01:17):
Yeah, of course. Thank you for inviting me.
Speaker 1 (00:01:19):
So I guess that’s one of my questions is, is that all you do or do you do other, you take call and do other operations besides hernias?
Speaker 2 (00:01:29):
Yeah, elective hernia surgery is about 95% of my practice and then the rest is ACS call.
Speaker 1 (00:01:36):
I think that’s so wonderful. When I was a resident, definitely hernias was not something people aim to specialize in or operate on, but is that something you were interested in going into residency?
Speaker 2 (00:01:49):
Yeah, I mean, even when I was a resident, which was less than five years ago, I graduated residency in 2018. I mean, the only hernia operation I ever did was a lap IPOM and also an open and laparoscopic hernia repair, but we weren’t doing complex abdominal wall reconstruction at all. That was just a couple of years ago. I think the field is, we are living through the transformation of the field. I mean, it really started with Heniford and that whole crew legitimized the hernia
Speaker 1 (00:02:20):
World. Dr. Todd Heniford, he was a guest on our Hernia Talk and you guys can watch it.
Speaker 2 (00:02:24):
Absolutely. Last year, it’s like
Speaker 1 (00:02:26):
Year and a half ago,
Speaker 2 (00:02:28):
They started legitimizing the field with good researching lap IPOMS. Then the whole Heniford family tree, my partner, Dr. Navitzky, I mean all those folks, they’ve grown the field before our very eyes. And I’m not sure that having a hernia center is something that most academic medical institutions have right now, but I think we are in the process of most academic medical institutions getting something like this.
Speaker 1 (00:03:00):
So what’s interesting is the operations, some of the operations have changed, but an opening of hernia repair really hasn’t changed that much. But I feel like the residents nowadays are much more excited to do it. Whereas when I was a resident, we weren’t that excited to do the same exact operation. And maybe it’s because we as surgeons that are teaching them are excited about it and kind of approached it much more academically than before where it was just a hernia and you just kind of sent the most junior person to cover the operation. And senior people want to do the liver case and the pancreas operation, these big operations and not just
Speaker 2 (00:03:40):
Absolutely hernia. There’s an excitement around the field. Even in the time that I’ve been at Columbia for the last four years, the residents this year, I mean so many of them have said they want to go into AB wall. You never heard that a couple of years ago. If you’re a resident and you have attendings who are excited about stuff and are teaching you new stuff and you have good results and you feel like you’re actually helping patients, I mean, that gets people excited.
Speaker 1 (00:04:07):
That’s true. We have at Cedars Sinai, we have a residency program and an M I S bariatric fellowship and both interviewing for the residency and interviewing candidates for the fellowship. Literally people come in and say, we want to come because you offer abdominal wall excellence in abdominal wall. We want to have that experience. And it’s fascinating. I mean, I love it. I I’m glad that I, I’m in this field because I think it’s fun, but it wasn’t like that as even five years ago almost. Yeah, yeah. No,
Speaker 2 (00:04:42):
Absolutely. But if you think about it, the amount of folks with hernias out there compared to the amount of folks with liver disease, pancreas disease, et cetera, yeah, you’re going to be able to treat a lot more hernias during your career than you are probably most other pathology. So if you go into this field and you do it well, you have the potential to help a lot of people.
Speaker 1 (00:05:04):
That’s very true. And I would say also that the, it’s not the residents that graduate too. They learn very quickly you can do all the fun kind of big Oregon operations, but once you graduate the number one operation you’re going to be doing over and over again, it’s going to be hernia surgery. So
Speaker 2 (00:05:23):
Speaker 1 (00:05:23):
Pay attention and learn how to do it correctly.
Speaker 2 (00:05:26):
Yeah, because I think we have a little bit of a myopic view because we’re at big academic medical centers, but the majority of surgeons in this country are not in giant urban centers, giant medical centers, and there’s a huge need for general surgeons outside of urban centers. And the two things are going to be doing is that type of doctor out there is hernia and endoscopy. Well, endoscopy. Colonoscopy,
Speaker 1 (00:05:53):
Speaker 2 (00:05:55):
Yeah. So yeah, it’s a great thing to learn. I’m happy there’s finally getting some respect put on the hernia name.
Speaker 1 (00:06:04):
Agreed. So on that note, you belong to the Columbia Hernia Center, Columbia Surgery Hernia Center, which I believe maybe the only department, freestanding department that is completely devoted to hernia surgery. Is that right?
Speaker 2 (00:06:23):
The only division we are the first division of a, yeah, we’re the first division of abdominal wall surgery in the country.
Speaker 1 (00:06:29):
Yeah, fascinating. I’m so fascinated by it. I saw Dr. Wiski in Manchester a couple months ago and I just want to learn more. How did you make it happen? How’d you do it? Because from a business standpoint, just so people understand, hospitals have departments department, medicine department surgery, department of gynecology, and then within that department there are divisions and each division is kind of a financial, it’s like a little house within a community, and you have to be able to pay for that house, do your surgeons, your nurses, your office space, whatever. And usually hernia surgery gets bulked into general surgery. So they do everything gallbladders, et cetera. Or if you’re kind of in an advanced situation, you may have hernia surgery bulked into the minimally invasive groups. So they do gastrectomies, cholecystectomies, colectomies, and they do hernias. But to have a freestanding division for hernia of abdominal wall is amazing. I’m just going to be watching you guys and learning. Have you noticed a difference in how it affects your practice?
Speaker 2 (00:07:49):
I don’t know about my practice because I don’t know if folks know what a division versus a department is. Sure. I think patients are coming to us because of me, Phil and Yuri, because of advertising, because of Columbia, because of the center. But I mean, first of all, Dr. Novitzky is leading the charge here, right? He’s an internationally acclaimed hernia surgeon. He had the, he’s a professor of surgery at Columbia. He has the reputation, the experience, and the results to get it done. But to tell you the truth, there was a lot of excitement at Columbia the minute we got there. The other departments and the other surgeons were happy to send us their stuff because the reality is that hernias have just gotten really complex, and if you do one bad hernia operation, it’s going to come back to bite you. Oh, yes. So if you are a liver surgeon and you just spend all this time doing liver transplant and then you have a incisional hernia and then you do the only hernia operation you know how to do, and the patient recurs and recurs, who wants to deal with that? Folks are happy to have us come and fix the problem. So the department was ready and open. There was a lot of excitement behind it. We had a great leader. We have a great team. It seems very seamless right now at Columbia.
Speaker 1 (00:09:15):
I think that’s the dream is for a hospital system to have a dedicated hernia group and just send it all so that if you do, let’s say cancer surgery and your patient gets a hernia, don’t try and feel like you need to be the same surgeon to fix the hernia sent into the hernia group. You have a trauma surgeon that saves lives. Now they have a patient with a hernia sent into the hernia group. Don’t try and kind of keep that patient and you and really focus on that specialty focused repair. Because as we know, specialists always have better outcomes than non-specialists in every field. A
Speaker 2 (00:09:58):
Hundred, a hundred percent. I mean, if you’re lucky, if you’re a private practice surgeon out there and you don’t, you’re not next to some hernia center, go for it. You know what I mean? Do the best job that you can, et cetera. But if you’re lucky enough to work at a place with a dedicated hernia center and specialist, I mean, why not use it? Totally
Speaker 1 (00:10:16):
Agree. Totally agree. So when I advertise that you’re coming, I actually asked you what topic you’d like to kind of focus on. You said, oh, let’s talk about hernia surgery and females, and I was like, that’s a great idea. I always talk about it, but I feel like I have never really devoted it with another surgeon. So I’m really excited. We have tons of questions that have been already submitted. So we’re going to go through that. You may get some questions that come through our audience live, but we have 15 questions of it, so I’m really excited to, let’s do it. So we’re just going to go through them. Is that good?
Speaker 2 (00:10:58):
I love it. Let’s go. All right.
Speaker 1 (00:11:00):
Question number one, why are inguinal hernias more prevalent in males, but other kinds of hernias like femoral umbilical or hiatal, occur more frequently in females?
Speaker 2 (00:11:14):
I don’t know the patho, I don’t the reason behind that pathophysiology of ephemeral being more common than an inguinal, I mean in a female than a male. I don’t know why a defect that would form more commonly in the woman, but what I do know is that one, because women are more likely to have femoral hernias, you’re more likely to have an incarceration in the female in femoral hernia.
Speaker 1 (00:11:41):
Speaker 2 (00:11:43):
Exactly. An incarceration is when something gets stuck in that hernia, and sometimes that could lead to an emergency surgery, which is why the recommendation is, and I support that if a female comes into you with a groin hernia, probably the best approach is laparoscopic. I mean, do, my first approach for inguinal hernias is laparoscopic anyways, but you have to rule out a femoral hernia and a female that comes in with a groin hernia. And unless you’re prepared to do that via an open approach, which I don’t know if a lot of young surgeons of my generation feel comfortable doing that. I do think that women should be offered a laparoscopic or a robotic, a minimally invasive approach for groin hernias for exactly that reason.
Speaker 1 (00:12:29):
Yeah. So European hernia society agrees with you. They say so many women undergo an Inguinal hernia repair, not laparoscopic, and this femoral hernia is missed, and many of them need another surgery, and some of them actually die. That’s the issue, is people can die from femoral hernias, whereas people don’t tend to die from inguinal umbilicals, et cetera, hiatals, et cetera. But the one most dangerous hernia, because it has the highest mortality rate, is a little piece of small intestine stuck in a tight little femoral hernia.
Speaker 2 (00:13:07):
A hundred percent.
Speaker 1 (00:13:08):
Yeah. I read a long time ago, and I don’t even remember where I read it, is that the force vectors are different for female versus male pelvis. So male pelvises tends to be narrow. And so the force is, the vectors are force all focus towards the internal ring, whereas the female pelvis tends to be wider and flatter and broader, and therefore there’s less forces directed specifically at the internal ring. And their femoral space is broader because of that wider space. So there’s more pressure transmitted to the femoral space than the average kind of male pelvis. But I don’t know anyone anyone’s ever actually studied it. But that was like a theory.
Speaker 2 (00:13:58):
Yeah, I would assume, because the one big difference is the shape of the pelvis between a man or a woman that has to play a role. I’m sure the spaces are wider in a woman just Yeah, because men’s pelvis are so narrow
Speaker 1 (00:14:16):
And then belly buttons, I just assume it’s related to mostly pregnancy and
Speaker 2 (00:14:25):
That bring a
Speaker 1 (00:14:25):
Speaker 2 (00:14:26):
Yeah. Yeah. I mean, but that if that’s going to be related to pregnancy, I mean, that’s a great segue to talk about that the forces of the abdominal wall that occur during pregnancy are really significant and they’re well documented. They’re kind of two main things that happen. Rectus diastasis, which is when the middle of your belly, the connective tissue, which is usually one to two centimeters widens, and it’s going to be most pronounced around the belly button area. And that’s the natural accommodation of the abdominal wall to fit a uterus and actually also elongation of the recti. So if we’re talking, we’re comparing populations between all folks, including women who have been pregnant, that’s absolutely a leading factor.
Speaker 1 (00:15:17):
Yeah, because a lot of these belly button hernias are within a diastasis, and they actually probably look even bigger. I watch, I don’t know if you do this, but I go on Instagram and look for belly button hernias,
Speaker 2 (00:15:28):
Just I see these
Speaker 1 (00:15:30):
Models and movie stars or whatever, they’re constantly burying their abdominal wall, and I’m like, that’s a little belly button, hernia. And then they get pregnant, and then I follow that, and then now post-pregnancy bigger, I
Speaker 2 (00:15:46):
Kind of want to fix some I know do. My eyes are drawn. Even when I’m hanging out with friends poolside, I spot an umbilical hernia and I have to tell myself, don’t say anything about that. Just I know let it ride.
Speaker 1 (00:16:01):
True story. I was at at dinner and David Beckham was at the salad bar right next to me, and I had
Speaker 2 (00:16:11):
Speaker 1 (00:16:13):
I know, but check this out. He was with his family, and I’m like, do I tell him he’s got a little belly button hernia? Because he was, had some milk commercial, I think with his shirt off, and I’m like, that’s a belly button hernia. I’m like, oh, I’ll just leave him alone with family. It’s not cool. But yeah. Yeah,
Speaker 2 (00:16:31):
Almost I’m surprised.
Speaker 1 (00:16:33):
Speaker 2 (00:16:35):
I just can’t imagine David Beckham at a salad bar. Just, yeah, it was
Speaker 1 (00:16:39):
A cheesy restaurant. It wasn’t like a very nice restaurant, but they don’t always dine wine and dine, I guess. Okay. The next question, hiatal hernia, I don’t know about, that’s not my thing. And I don’t know that women have more hiatal hernias, but if they do, I assume that’s from the increased abdominal pressure from pregnancy too, maybe. Yeah, I can’t explain anything else about that. All right, cool. Next question is why do hernias tend to manifest in males? Oh, sorry. This should be in females without obvious bulging. So men tend to have a bulge. Women tend to have pain and less likely to have a bulge than an obvious bulge than men. Any ideas about presentation of her, like groin hernias and male versus female? I feel like it’s just smaller space.
Speaker 2 (00:17:44):
I mean, think about it. In a man, you have the spermatic cord, which contains the entire blood supply to the testicle and the vas deferens running through your internal ring and through your inguinal canal and a female, you’re just going to have a round ligament,
Speaker 1 (00:17:59):
Which is like
Speaker 2 (00:18:01):
Speaker 1 (00:18:01):
Speaker 2 (00:18:02):
Teeny tiny. So I think that that probably contributes to the size of the canal. And remember, the round ligament goes to labia major, whereas the testicular bundle of the vast deference go all the way into your scrotum. So I think you just have much more opportunity for travel in a male than you do in a female.
Speaker 1 (00:18:24):
Good point. And that big ass not being ass testicle went down that pathway at some point when you were a kid.
Speaker 2 (00:18:33):
Absolutely. I mean, that’s why you couldn’t do an entire physical exam on a man through a scrotum and feel the entire inguinal canal. You cannot do that in a female. You cannot access that space.
Speaker 1 (00:18:43):
That’s really correct. Okay. Here’s a question. Lyse, when do you do surgery? When you do surgery on primary al hernias, do you use robotic or laparoscopic sticks approach? And what guides your decision?
Speaker 2 (00:18:59):
So both are perfectly valid options. They’re quite similar in terms of outcomes. I use the laparoscopic approach for no reason other than systemic issues. It’s difficult to get robotic time in my hospital and my ambulatory surgery center doesn’t have a robot, so I keep my robotic time for my complex abdominal wall surgery, and I do all my inguinal hernias laparoscopically. I don’t believe that there is a difference for the patient, both robotic and laparoscopic inguinal hernia repairs. As a patient, you wake up with three little cuts on your belly, the same kind of postoperative pain, quicker postoperative recovery, lower rates of infection, lower rates of chronic pain, all the benefits of an MIS repair. Yeah. What about you?
Speaker 1 (00:19:45):
So I’ll give you my take on it. We currently do not have a robot in the surgery center, but there is a surgery center nearby that has one. So I’m getting privileges there because every so often I just need more operating time and the hospital is not able to give it to me. I like laparoscopic surgery. I think it’s clean and beautiful. And I personally don’t like the eight millimeter scars from the robot. I like the five millimeter scars from the laparoscopy. I mean, we even have a three millimeter pediatric tray. We sometimes use for the thin patients that are maybe, I dunno, models or actresses that need to have their belly exposed. So I like the dinginess of a laparoscopic surgery. So I use that for all the primary hernias with the only exception is that for the, like you said, the complex ones, the ones where you need a lot of sewing, maybe a really, really big scrotal hernia, I would do those robotically because I do feel it’s superior in certain aspects for these complex situations. But I kind of like being able to hide scars with the laparoscopic approach. And you can’t hide scars with the robot you have. There’s very specific areas you have to put them, and I do. Yeah, that’s my shtick.
Speaker 2 (00:21:15):
But I tell you,
Speaker 1 (00:21:17):
People are doing everything robotic now. It’s almost like they forgot laparoscopy.
Speaker 2 (00:21:22):
Yeah. I mean, and robotic surgery is fine. It’s lovely. Yeah, it’s really useful, especially for complex stuff, especially for ventral hernia stuff. Yeah, it’s nice to be able to sew on the ceiling, but first of all, it’s nice to maintain your laparoscopic skills as a surgeon. Yes, I do. Same. Yeah. And the only thing I will say is for an uncomplicated inguinal hernia, I don’t know how you do yours, but I use two s to dissect the whole area. And with robotic surgery, you’re frequently using a scissor in a Maryland. I don’t know if that those are your arms. I just think it’s a little bit almost easier laparoscopically for the really straightforward ones. So I agree with you. Yeah, unless there’s a reason I think laparoscopy is good as gold for straightforward inguinal hernias.
Speaker 1 (00:22:12):
Yeah. But I know a lot of surgeons that even were trained MIS, but they were just never comfortable doing a laparoscopic al hernia repair. I just wasn’t. And there’s a learning curve to it, and the robots, hard robot is here and with the robot, boom, they’re doing it. That’s it. So much easier. Well,
Speaker 2 (00:22:30):
I think part of the reason is at least when I was in training, everybody was very focused on doing a TEP for all the patients out there. There are two ways to do laparoscopic inguinal hernia repairs, TEP or TAPP. And the main difference is do you go into the belly and take down one layer of the abdominal wall to get to where you’re going, or do you just kind of wiggle your way through the abdominal wall? And everyone was obsessed with the TEP, which you wiggle your way through the abdominal wall and you never have to enter the belly and all that stuff. But it is a technically difficult operation and it’s unnecessarily hard. And the cases needed to get good at that are somewhere about 150 to 200, and the cases needed to get good at the other way is about 50. So we kept trying to teach ourselves how to do the harder operation. I think a TAPP is much easier, and I think folks like robotic surgery because it’s always a TAPP. Nobody does roboTEPs. So yeah, I think we made it unnecessarily difficult.
Speaker 1 (00:23:28):
True. Yeah, I agree with it. Although I really like the TEP.
Speaker 2 (00:23:32):
Yeah, it’s lovely, but it’s also not a, I don’t consider it a failure to do a TAPP.
Speaker 1 (00:23:39):
Agreed. Yeah, totally agree. All right. Here’s a complicated question. I got incisional and ventral and bilateral indirect hernias after a deep flap for breast cancer reconstruction surgery. So deep flap, for those you don’t know, it’s a plastic reconstructive surgery where they take the skin and fat from your lower abdomen and they make a breast. It’s kind of like a reconstructive operation. It has some abdominal wall implications if there’s injury to the abdominal wall. In doing that, the hernia repair surgery is via a low incision across my abdomen, goes to the right and left groin area. Question number one, could the bilateral indirect al hernias have been caused from the incision from my deep flap?
Speaker 2 (00:24:30):
Speaker 1 (00:24:31):
No agree. Yeah. Now, if you had a trans flap, you get kind of like a tummy tuck as part of that. And the increased abdominal or tension by pulling a really tight reconstruction from a tram flap potentially can open up the hole of the groin a little bit bigger and give your hernias. I’ve seen that, but not from a diep flap. I’ve had all of these hernias repaired with sutures and Mesh. I’m now suffering from chronic autoimmune inflammatory syndrome from the polypropylene Mesh, and I have a recurrent right inguinal hernia and a hiatal hernia due to private prior abdominal surgery. What are my options to get the Mesh removed and have these recurrent hernias repaired without any Mesh since my immune system cannot tolerate any foreign body implants. This is a growing problem. I feel that we’re dealing with that. We’re seeing
Speaker 2 (00:25:33):
It’s, that’s a tough situation. You can’t fix any of those hernias without synthetic Mesh. I agree. So if you have true autoimmune disorders, you don’t have many options because if you were to take out all that Mesh, which would be an extremely destructive process, because when you take Mesh out, you take the tissue that has integrated into it, which is part of your abdominal wall, you have to fix it then. And if you try to fix it with a non-synthetic Mesh, either a biologic Mesh or a bioabsorbable Mesh, when that Mesh goes away, you’re going to be in trouble. So if you are trying to seek a non-synthetic option here, there are no good ones. And that’s just the reality because the problem with the flaps is that they have taken a part of your body and put it someplace else to reconstruct, which is completely valid. But that part of your abdominal wall now is missing and you can’t bring it back. So it’s a really tough problem.
Speaker 1 (00:26:31):
It’s a really tough, so often, so often I have to remove Mesh and do a tissue repair. It’s doable, but it’s not ideal because you’re going backwards. Right? You’re like, take, instead of taking fresh tissue and doing tissue repair, you now have destroyed tissue doing tissue repair. So it’s a much worse situation than reading a book about how great the Shouldice is. But here’s a thing. What if I told you she has a plugin patch and that’s why she has pain?
Speaker 2 (00:27:06):
Oh, well’s. Actually, the plugin patch,
Speaker 1 (00:27:09):
Speaker 2 (00:27:11):
I love taking out plugin patches. If you have a plugin patch and you have pain because of that, that’s a fixable issue. That’s a fixable issue. So I take those out, not infrequently. Folks really feel that plug. It’s almost like they describe it like a rock in their groin. And for people that present with pain after that surgery, I offer them to take that Mesh out and then either do a primary repair if the tissue’s adequate or I do a posterior repair at that same time.
Speaker 1 (00:27:40):
What if she’s 80 years old?
Speaker 2 (00:27:44):
Then I ask, what is your quality of life? You know what I mean? If you can live your life and you have some pain that’s treated with some Tylenol or ibuprofen and otherwise you’re okay, then I would say just leave it. If you can’t live your life, if you’re not happy, if it’s stopping you from doing the things that you love to do, that’s when I offer folks surgery.
Speaker 1 (00:28:06):
The last comment she makes is, my doctor wants me to try a nerve injection for my pain from the left Anglo hernia surgery. I would like to say I am so tired of everyone treating all of the groin pain as a nerve injection. A plug pain will not get better from nerve injection or hernia recurrence will not get better from a hernia nerve injection. A laparoscopic repair will, doesn’t indicate like a nerve injection usually. So I feel like so many doctors that don’t understand what we do or what’s been done to the patient, see hernia pain equals nerve injection. Do you see that too? It just really bugs me. I’m sorry.
Speaker 2 (00:28:50):
No, it’s true. It just requires to not do that requires a real level of understanding about groin pain and inguinal that I’d say if you’re not a hernia specialist, you probably don’t have. So I understand why it happens, but I agree with you. It’s unnecessary. You know, need to have signs and symptoms of neuropathic pain, of nerve pain for nerve injections to help. If it’s nociceptive, it’s from, if it’s from the actual Mesh, the nerve injections are probably not going to do much.
Speaker 1 (00:29:20):
Yeah, okay. Usually the question, does Columbia have expertise in managing sports hernias or athletic pubalgia and other non hernia related groin disruptions?
Speaker 2 (00:29:32):
Yeah, absolutely. So I take care of those all the time. With sports hernias, we actually have a team. Dr. Christian is our hip specialist, because I mean, sports hernias first of all is not the correct term, but it’s the term that’s been used. Athletic pubalgia, groin pain, the groin is multifactorial. You’ve got to rule out any kind of hip issues. Core issues I take care of if folks need adductor tenotomies, if there’s something wrong with their aductors or rectus abdominus complexes, if there’s inflammation around their pubic synthesis, getting mini repairs in the groin. These are all things I do. But we also have a Dr. Christian who’s our hip specialist to make sure that the hip isn’t contributing. We have Dr. Desai who does a lot of ultrasound guidance interventions, will do P R P injections into the adductors and things like that. So the short answer to the question is absolutely, I love our team. I think we kind of attack athletic pubalgia from all fronts. That’s great. Yeah, it’s great. It’s a growing business.
Speaker 1 (00:30:44):
And I had a patient today who thought he had a hernia. It’s clearly her hip. In other words, my nurse came and said, oh, this is a hip, but go ahead and see him anyway. But yeah, it’s a lot of overlap with orthopedics, pain management, sports medicine, so on As a follow up, they’re asking, what operations do you do for athletic pubalgia?
Speaker 2 (00:31:10):
So if I think that there’s, there’s a slam duck abductor pathology. Let’s say you love to play tennis, you’re playing tennis, you go for a lateral move, you feel a sharp pain in your groin, you get an MRI. I see a big tear in your abductor. We try physical therapy, that doesn’t help. We try rest. That doesn’t help. And you can’t get back on the court. I would offer you an adductor tenotomy where we actually just shave that adductor off the pubic synthesis. I like to pair that with a little mini groin repair where I would actually go into your inguinal canal and tighten up the floor as well. No Mesh, nothing like that. Sometimes if I see obvious rectus abdominus pathology, I could also look at the RA tenderness insertion into your pubic synthesis. Yeah, that’s what I can offer you for sports hernias.
Speaker 1 (00:32:03):
Right. Here’s a question about patients with chronic pain after surgery. How do you know if it’s nerve related or adhesions?
Speaker 2 (00:32:15):
It’s probably not adhesions. No. If you have an open inguinal hernia repair, we’re not even in the belly. So it’s probably not adhesions. If you have a laparoscopic inguinal hernia repair maybe, but it’s probably not going to be adhesions for folks that have inguinal hernia repair and then have pain after as a hernia surgeon, you got to map them to figure out what’s going on. So basically I look at somebody’s groin, I take a little Q-tip and I poke around and I say, does it hurt here? Does it hurt here? Does it hurt here? And then you tell me where it hurts. And if the distribution of your pain seems like it might even vaguely follow a nerve and you tell me it burns and tell me I woke up like this. Then I say, okay, maybe there’s a nerve involved and the surgery has to make sense.
Speaker 2 (00:32:56):
If you get a laparoscopic inguinal hernia repair, you’re not really interacting with the nerves, which is why the rates of chronic pain are lower for a laparoscopic, uncommon inguinal hernia. Yeah. Very uncommon. Something has had to folks still get into the wrong planes. It could happen. But if you have an open inguinal hernia repair, that makes more sense. If I ask you where the pain is and all you’re showing me is where the scar is, or you take one finger and you’re saying right there, and then you’ve had an open plug, that’s when we start thinking, okay, this is probably from either inflammation from the surgery or the actual Mesh itself.
Speaker 1 (00:33:34):
Now you do a lot of abdominal wall as opposed to growing. What percentage of your practice do you think is ventral abdominal wall flank compared to growing pelvis?
Speaker 2 (00:33:46):
It’s like 50 50 this week. For instance, I have four inguinal and four apples. Yeah. Well, inguinal hernias are just so common, but in terms of complex stuff, probably more complex alcohol than complex groin.
Speaker 1 (00:34:07):
So do you see much nerve injury with abdominal wall? One of the questions about I think the nerve versus adhesions is a chronic abdominal wall pain after abdominal wall surgery.
Speaker 2 (00:34:19):
Oh, I see. Neurologists, like folks that have had a lot of abdominal surgery will come in with either numbness in their abdominal wall even after, sometimes before I fix their hernia, sometimes after my complex. Yeah. Or hypersensitivity too. Yeah, those are kind of the main things I see.
Speaker 1 (00:34:43):
And this other question has to do with denervation of the abdominal wall. After abdominal wall surgery, how do you repair a denervated abdominal wall that was caused after Mesh implantation surgery and was noted once the Mesh was removed. This is very complicated. This patient’s been on this forum before. Sounds like she had some type of abdominal wall hernia repair or maybe even tummy tuck. Anyway, the Mesh was removed and now she has a denervation injury. How do you treat regeneration injuries of the abdominal wall? Or do you
Speaker 2 (00:35:22):
Well, you can’t ever regenerate the nerve. Yeah. What’s been denied has been denied. So I always can counsel folks. That’ll never be back to the way it was. But I can help folks with obvious bulging or laxity and I would do a complex abdominal wall reconstruction on them and reinforce the repair with a heavyweight Mesh to give them a bit more support and contour. And that’s, I think, the best that we can offer for denervation injuries.
Speaker 1 (00:35:50):
And if this patient had the Mesh removed specifically because she was reacting normally to the Mesh
Speaker 2 (00:35:58):
Situation, yeah, not many options. Maybe some plications if it’s kind of like a semi lunar line issue. But eventually, once enough damage has been done, there’s only so much we can do.
Speaker 1 (00:36:14):
Yeah. Yeah. Agreed. Question, what do you as surgeons think will be different and better five to 10 years from now for inguinal hernia surgery? That’s a good question.
Speaker 2 (00:36:26):
Ooh, that’s a good question. Yeah. Well, the first thing you got to always consider is Mesh technology. Yes. mesh technology’s always changing for
Speaker 1 (00:36:35):
Patients, these couple that are already on this forum.
Speaker 2 (00:36:39):
Yeah, absolutely. They need to be
Speaker 1 (00:36:40):
Speaker 2 (00:36:42):
Absolutely. I think robotics will open the way for a lot more minimally invasive options for folks that even have complex hernia Hernia options. Yeah. I think that tissue repairs are going to be join the armamentarium. Yeah. I think for a long time, especially after Lichtenstein described his Mesh repair in the nineties, the odds of
Speaker 1 (00:37:11):
My hospital, by the way.
Speaker 2 (00:37:14):
Yeah, absolutely. West Coast. But I think now we’re going back to understanding that a Mesh repair, I mean a tissue repair is suitable for certain patients and we should get good at that. So I think that’s also going to get back into vogue.
Speaker 1 (00:37:33):
Yeah, I totally agree with that. Going back to the whole male female thing, are there any differences in difficulty between male and female hernia surgery? Anywhere in the body?
Speaker 2 (00:37:44):
Yeah. I mean in the grime, men are more difficult because we have to protect the spermatic cord and the vast deference. Whereas in a female, we can just take the round ligament. So I would say for a pelvic surgery, men are more complicated than women. For ventral hernia surgery, women become more complicated because of the prevalence of diastasis and also because you have to consider if they’re going to have children or not.
Speaker 1 (00:38:15):
Most people, patients, about the effect of pregnancy.
Speaker 2 (00:38:22):
So there are two things that we know can happen. If a woman gets pregnant after having a ventral hernia repaired Mesh, she can experience pain and discomfort when she’s pregnant because as the abdominal wall stretches, the Mesh doesn’t. And that can cause discomfort and it increases the risk of the hernia coming back. So if you have a 30 something year old who wants to get pregnant, has an incisional hernia, you have to think about it a little bit harder than you do with a man. You have to consider whether you want to burn bridges in terms of offering hernia repairs. And you want to consider maybe using bioabsorbable, Mesh like pH. That gives folks better repair than a biologic. Mesh a little bit of a worse repair than the synthetic Mesh, but can do the trick for people in that age group. And I don’t know if a lot of folks out there know that. So that’s conversations they should be having. And then for belly button hernias, if you have a diastasis, you usually have to address that. So which
Speaker 1 (00:39:22):
Is what we’re learning more and more. It used to be that a lot of the stuff was not addressed. And I feel like, I don’t know, maybe I’m biased, but it’s more of a female thing. And so it’s kind of like, okay, whatever. We’re just going to fix your belly button hernia. Whereas in men, it’s usually a simple operation. Women, you need a little bit more thought into it. Are they potentially going to get pregnant? And is there a diastasis involved as part of this? Very simple, otherwise belly button, hernia repair.
Speaker 2 (00:39:51):
Yeah, absolutely. Yeah. There are differences in gendered care. We know that. Yeah. Yeah. I’m happy we’re talking about, I’d love to
Speaker 1 (00:39:59):
Learn more. There’s some questions here about gender differences. Okay. Here’s another one. Regarding recurrence and complications after hernia treatment, are there any differences between males and females?
Speaker 2 (00:40:12):
Interestingly enough, the female gender has been associated with worse pain following hernia repair. Yes. And yeah, that’s been in a couple studies. I think that is
Speaker 1 (00:40:26):
For al hernias. I have my own theory. What’s your theory?
Speaker 2 (00:40:30):
I don’t know. I don’t think I have a good one. What’s your theory?
Speaker 1 (00:40:34):
My theory is, correct me if I’m wrong, male and female pelvis are very different. The size is different. The shape is different. Apparently the concentration of nerves is also different, much higher in women. So partially, I think it’s because we do the same exact operation for men and women for Inguinal hernias, same size, Mesh, same techniques, everything’s the same. But we know that the incidence of hernias is different. Inguinal, direct, indirect, and the anatomy is different. So I think part of it is that, and the other part I think is these women don’t necessarily have hernias. They have endometriosis or ovarian cyst or hip disorder or something else that is a bit more complicated. Pelvic pain in women is a little bit more complicated in men. And just because they have a hernia doesn’t mean that’s the cause of their pain. Cause I see to men too, they have, let’s say a hernia. They go to their doctor and they complain of some type of pelvic pain that’s not due to the hernia, but the hernias the obvious thing. They’re like, okay, we’ll fix a hernia. So now they have the same preoperative pain, plus they have possibly a complication from the hernia repair. So I feel that’s just more common in women. I don’t know.
Speaker 2 (00:41:57):
I think that’s a great idea. Brings up the question of should there be gendered Mesh, right. If the form of the pelvis is different, should we be using the same type of Mesh in men or women?
Speaker 1 (00:42:10):
What do you think about that?
Speaker 2 (00:42:12):
Who knows? I can see it being different in the future, which is great if it works better nozzle. But I agree with everything that you said. Growing pain is complicated. The reality is that growing pain is complicated and men are women because it could be multifactorial. And sometimes the hernia, even when it’s there, is not the reason for the growing pain. So it just takes some work.
Speaker 1 (00:42:42):
The guy that came today, it was completely a hip issue. He was limping, he had difficulty sleeping and had to go frog legged. He couldn’t cross his legs. He had a hernia. But that was, yeah, I agree. Yeah. Do the factors that affect the decision to use Mesh and the kind of Mesh used, differ between males and females?
Speaker 2 (00:43:07):
Do the factors to use Mesh?
Speaker 1 (00:43:12):
Another good question. I
Speaker 2 (00:43:12):
Would, that is a good question. Don’t, when there’s, if male or a female presents with a significant direct hernia, which is the type of inguinal hernia, I’m using a regular weight Mesh. The only difference that I would do is I find myself using a large sized Mesh in women and an extra large in men. And I think that’s just the space that’s down there.
Speaker 1 (00:43:41):
Yeah. Yeah. I mean, women tend to be thinner. They tend to be more like, I had a ballerina last two weeks, weeks ago. I treat ballerinas differently than football players. You know what I mean? So yeah, there’s a little bit of difference in that. Here’s another question. Does Dr. Podolsky perform tissue repairs? And if so, which one does she prefer?
Speaker 2 (00:44:09):
Yeah, I like a tissue repair. Cause I think where usually
Speaker 1 (00:44:12):
Speaker 2 (00:44:16):
Well, I did my fellowship in hernia surgery. So Yuri and I, yes, I did some tissue repairs. But then I’ve been able to do a lot of courses through URI over the years, through AHS, the hernia summit. And I learned through some folks that I got to do real life tissue repairs with David Chen and those people. I love a tissue repair because I think it actually requires technical expertise above a laparoscopic
Speaker 1 (00:44:45):
Speaker 2 (00:44:47):
You really got to know your anatomy to do a tissue repair. And I don’t think a lot of people know how to do it. So it makes me feel like I really have something to offer people. I like a tissue repair for thin people who are younger with good, good passion. Yeah, I have no problem offering it to them. If you do a good tissue repair, you got good results. Interestingly enough, rates of pain are the same with or without Mesh, which is really fascinating. I had a patient the other day ask me if I use steel sutures like they do at the Shouldice clinic in Canada. I do not. I use prolene sutures.
Speaker 1 (00:45:22):
Do you know why they use steel sutures?
Speaker 2 (00:45:25):
No. Tell me.
Speaker 1 (00:45:26):
It’s expensive to have the pre-made non-steel. That’s the only reason why. So they actually, if you go to the shouldice clinic in the back, there’s like a sterile room and there’s some women that are putting steel rods into the swedged on needles and making, they make their own sutures. They don’t pay brand name sutures because it’s a government sponsored clinic and they get paid a certain amount per resident, Canadian resident. I mean, this was back in the day. They’re doing much better now financially because there’s so much hype about the clinic that Americans and non Canadians go there. But they pay premium for that. But yeah, it’s a financial, it was completely a financial decision. At least that’s what they told me.
Speaker 2 (00:46:18):
Did you go up there? Have you spent time in this? Yeah.
Speaker 1 (00:46:21):
Yeah. Long time ago. 2005 maybe.
Speaker 2 (00:46:30):
Yeah. And that you just went to learn?
Speaker 1 (00:46:35):
I think I saw their head. I think I saw ’em at a meeting. He’s like, oh, you should come by. I’m like, I will. And I was in Toronto for something, I don’t remember what, and I call up, I’m like, they’re like, yeah, come on over. So I just went over and they gave me a tour. I got to watch a bunch of operations and check out their whole process. It’s a very fascinating process. They don’t have anesthesiologist.
Speaker 2 (00:47:04):
I didn’t know that.
Speaker 1 (00:47:04):
So the nurse, the patient sits in the pre-op area. The nurse gives the patient some pills. I think it’s like, don’t quote me on this. It’s like let’s say Vicodin and maybe a Xanax or something at Ativan, something like that. And the patient walks into the operating room, puts himself on the operating room table. I was standing where the anesthesiologist would have been. There’s no anesthesiologist. They just are of in this days from the pill that they took. And then there’s two surgeons, two qualified surgeons. There’s no like PA or assistant. So two surgeons operate together and they use tons of locals. They have a bucket of local that’s very diluted, and they have this syringe system and you know, usually get the syringe, the nerve. Yeah, no, they have this two-way valve. There’s like a tube in this bucket that drains onto this syringe. Every time you go like this, it fills a syringe and you inject and you go, you open. It fills the syringe, the I love it. They don’t use a cautery pen. There’s no Bovie. That’s expensive. Wow. So
Speaker 2 (00:48:17):
Everything is a knife and Tietze.
Speaker 1 (00:48:20):
Huh? Knife and Tietze. It
Speaker 2 (00:48:22):
Knife and Tietze. I love it.
Speaker 1 (00:48:24):
They don’t close the skin. They have these little metal disposal, not disposal, reusable little metal clips. The patient stays their three days. Day two, they take off half the clips. And day three they take off the other half and then they go home.
Speaker 2 (00:48:40):
But think about that. Patients
Speaker 1 (00:48:41):
Speaker 2 (00:48:43):
I know. I mean, look, obviously what they’re doing is working. Yeah, I think it’s great. Three days in the hospital after an opening inguinal hernia repair. I don’t think you can get that in this country anymore. But they did popularize and legitimize a nice tissue-based repair. Yes. And that’s important too.
Speaker 1 (00:49:03):
Very good. Regarding inguinal hernias in women, do you routinely sacrifice the round ligament?
Speaker 2 (00:49:10):
I do not a hundred percent of the time. Sometimes you’ll find a rare case where you could really personalize it off the round ligament, but almost always the peritoneum and the round ligament are so adhered that you can’t pull that peritoneum back enough. Yeah. And by the way, yes, I have talked to a gynecologist. I asked, do we sacrifice the round ligament because surgery was invented by men or is it actually okay? And they gave me confirmation that you can sacrifice the round ligament and it’s fine.
Speaker 1 (00:49:46):
Okay, I’m going to add to that. I need to publish this data because I’ve talked to every single urogynecologist and gynecologist that I could find and have asked ’em the same question. They’re like, cut it. They talk to a general surgeon and they’re like sweating like, oh no, don’t cut the round ligament. What if the uterine prolapses or retroverts and all the gynecologists, who cares?
Speaker 2 (00:50:12):
Yeah, the gynecologist, they’re not worried about it. If they’re not worried about it, I’m not worried
Speaker 1 (00:50:16):
About it. So please spread the word. I have a very quick survey asking surgeons what they do about how they handle around the round ligament. It’s pinned on my Twitter page. So if you haven’t filled it out, please fill it out for me. I would like to know your answer. And it’s been sent to all the different GYN and urology, urogyn societies to get their input too, because we need to put an end to this round ligament controversy.
Speaker 2 (00:50:50):
Speaker 1 (00:50:51):
I love it. Also, a recent study showed people who routinely sacrificed around ligament, those patients had less chronic pain than when the round ligament was kept.
Speaker 2 (00:51:09):
I’m not surprised,
Speaker 1 (00:51:10):
Speaker 2 (00:51:11):
Because I’m, I’m worried about that inferior border of your Mesh if you don’t sacrifice the round ligament. Yes,
Speaker 1 (00:51:17):
Agreed. Agreed. How do you identify a Spigelian hernia and can it be repaired during a tummy tuck
Speaker 2 (00:51:27):
Physical exam? If I can’t do a physical exam and I’m an ultrasound handy, I’ll pop an ultrasound in the belly. And if I don’t have that and I can’t feel anything, I’ll get a CAT scan. Those are three easy ways to identify spagelian and hernia. It can be repaired during a tummy tuck if it goes through all three layers of the abdominal wall. Sometimes it’s only through the transversesalis and the internal. But if it goes through all three layers of the abdominal wall, and you can see it externally during a tummy tuck, a surgeon could just use a simple suture to close it primarily. Probably wouldn’t be a Mesh based repair or anything like that.
Speaker 1 (00:52:06):
Agreed. You’ve given several talks about in-office ultrasound use. See people are watching you. Dina, can you believe this? How do you use ultrasound in your practice? So you just mentioned that you would’ve ultrasound for a spigelian. Yeah. So you just have one in the office?
Speaker 2 (00:52:26):
Yeah. So unfortunately we have two offices. One has an ultrasound, one doesn’t. Okay. So I only have access to it 50% of the time. But I love it for a couple of things. Somebody comes in with an umbilical hernia, I’ll just look at their abdominal wall to see if they have a diastasis. That’s a super simple thing for things like spigelian hernias and little incisional hernias. I just pop it on the abdominal wall. I do like a physical exam for inguinal hernias. I try to use it for ones that are equivocal, but if I really can’t feel it, I’ll send it out to the radiologist because doing an ultrasound in the groin can get a little difficult. And then in terms of injections, I do do my own nerve injections, Ilio gastric, ilio hypogastric, right? Ilio inguinal ilio hypogastric. And I’ve started to do some adductor injections. I have one coming up for folks that have adductor pathology, but the picture’s not clear. Then they don’t really qualify to undergo a tenotomy. But I want to rule out adductor related pain. I will inject where the adductor lands on the pubic synthesis with some marcain to see if they get relief. So those are a couple of quick and easy things I do.
Speaker 1 (00:53:37):
Yeah, I think the local is a great one because they’re in your office instead of setting the page of pain management. It’s like it’s several weeks and it just delays their care. The other thing I don’t understand about pain management is they put the patients under often for these local I just do in the office. Do you? You’re okay doing it awake, right? I’m not weird.
Speaker 2 (00:53:57):
No, no. I mean, once you get good at it, a nerve injection takes five minutes
Speaker 1 (00:54:06):
And you’re there. So you can get good feedback from the patient when they say, oh yeah, my pain’s like a hundred percent gone, or 20% gone, or something like that. Right.
Speaker 2 (00:54:16):
Yeah, a hundred percent. Besides I feel like as a hernia surgeon, if I weren’t able to do my own injections, yeah, I don’t know. I’m trying to get that street cred out there.
Speaker 1 (00:54:29):
Yeah, exactly. You do have street cred for sure.
Speaker 2 (00:54:34):
Speaker 1 (00:54:36):
At Columbia, do they ever recommend single or triple neurectomy? Okay, so what they mean is do you do selective or triple neurectomy for chronic postal hernia pain? And the second part of the question is, do you prefer instead to send them for either spinal cord or dorsal ganglion?
Speaker 2 (00:55:02):
I’ve only had one patient that I was trying to treat for chronic pain. I wasn’t able to help, and they eventually went to pain management and got the dorsal stimulation. I’m not sure that helped either. I would sent, if I’ve done everything I can for somebody and patients have horrible pain, that’s when I would refer out to pain management. I believe everybody in our practice. Does triple neurectomies kind of leave no nerve behind philosophy on that? Yeah, the only time we would do a selective neurectomy is if we do a posterior Mesh removal. If somebody’s had a lap or a robo Mesh repair and has pain, when we take the Mesh out, we do usually pair it with a GFN neurectomy. The general femoral nerve will be right there. That’s the only time we do a selective.
Speaker 1 (00:55:54):
Do you always do that with Mesh removal laparoscopically or robotically?
Speaker 2 (00:55:57):
Not a hundred usually, but not a hundred percent. I had a patient who had fibromyalgia that I didn’t do it on because there’s some consideration that those folks do worse when you cut their nerves. If there’s an obvious interaction between the Mesh and the nerve, I would definitely take it.
Speaker 1 (00:56:17):
So we interestingly looked at all of the neurectomies I’ve ever done and we stratified it based on elective or well therapeutic and kind of like incidental. So therapeutic was we knew before surgery we had to go in there to address a nerve related problem, Neuralgia, neuroma, whatever. And incidental was, we were in there, let’s say removing Mesh. And we saw that the process of removing Mesh, for example, would injure a nerve. So we cut that nerve or we’re in there doing an elective hernia repair and for whatever reason the nerve is either damage looks horrible, it’s in the way, make it injured. So we cut it. And what we noticed, which I did not expect, is first of all, our neuroma rate was 4%, which is about the same. I think literature says 5%. So it’s about the same as expected. But those who had the incidental neuroma all did fine.
Speaker 1 (00:57:17):
No neuromas, no chronic pain, really no issues, which is interesting to me. I thought for sure it would be a risky operation at least. But so far, not that we could show in our data. The people who had the therapeutic neuromas, a good percentage of them after surgery, I think was like 17% in that range. One out of five needed subsequent therapy. So another nerve block to kind of medication to calm down that nerve. And 3% of those ended up with even more complications, including complex regional pain syndrome, which as you know is a very devastating complication of basically the nerves of your whole body are going haywire, is very, very difficult to treat. So I think what you mean, for example with the fibromyalgia patient, maybe those that kind of patient is more prone to going down that difficult path of recurrent pain and nerve pain and then it overwhelming the body and so on. But isn’t that interesting? We found 0% pain with the incidentals, but a good amount of difficulty in needing more therapies for these more complicated patients that already have nerve pain to begin with.
Speaker 2 (00:58:47):
I’m not surprised. The data confirms that higher rates of preoperative pain lead to higher rates of postoperative pain. So if you come in already in pain, it’s hard to get you to a hundred percent pain free. Yeah, that has, because pain is so complex, sometimes it’s not a physical problem. The pain cycle, the nerves that are triggered might still be going on even after you cut a nerve. The regional inflammation, I mean, think about how interesting phantom limb syndrome is, right? For the folks out there who lost a limb and were in horrible pain, and when you showed the body a mirror where the body saw the limb in place, the pain went away. Pain is cerebral, it’s physical, it’s complex.
Speaker 1 (00:59:40):
Yeah. I’m going to give you one more question because that was submitted and I’d like to be able to help answer her question and then sure. This will be the end. So I carry weight in my abdomen and my hernia is getting worse. Should I lose weight first? I’m age 59 and weight 260 pounds.
Speaker 2 (00:59:59):
Yeah, absolutely. We know all complications following hernia surgery increase at a BMI of 35 and up. BMI’s body mass index. That’s how we figure out your weight compared to your height. Lower weight in hernia surgery leads to lower recurrences, better outcomes as it does in a lot of different surgery. So if there’s an opportunity for weight loss before a hernia operation, absolutely go for it.
Speaker 1 (01:00:26):
So thank you. That was it. I’m so happy to have you as my guest. We went through tons of questions and you can’t see, but we have about another 10 questions that have been submitted live. And I didn’t go through about three or four other questions that were submitted before. So obviously very important topic. Everyone wants to hear about you. So I do appreciate so much that you volunteered your time to help educate us and help advocate. Thank you so much for better sex-based, gender-based care.
Speaker 2 (01:01:00):
Absolutely. Thank you for inviting me. This was fantastic. Thanks for all the folks listening and the questions. I love this platform. Platform. You’ve done a great job.
Speaker 1 (01:01:08):
Thank you. And that ends us for Hernia Talk Live. Thanks everyone for joining me. I love that you joined and asked so many questions. Please go to my YouTube channel and watch all the other episodes. Share the one that we did today, and I will see you next week on her Talk Tuesdays. Bye everyone, and thanks again, Dina, really appreciate it.
Speaker 2 (01:01:31):
Have a good night.
Speaker 1 (01:01:32):