Speaker 1 (00:01):
Okay everyone, this is Dr. Towfigh joining you for yet again another hernia talk Tuesday. Today we have a very special guest from Europe and that’s why our timing is a little bit different and we’re not us, we’re usually a little bit later in the day, but I’d like you to say hi to Dr. Barbara East. She is a professor of surgery and highly talented hernia specialist working at a Prague in the Czech Republic and she’s one of the leadership within the European Hernia Society and a very good friend of mine cause I really enjoyed being with her. Welcome Dr. East. How are you?
Speaker 2 (00:42):
Thank you Shirin. I think your words were too kind, half of what you said, but thank you very
Speaker 1 (00:49):
Much. I cannot say enough about you. And the reason is you’re fairly young among our hernia surgeons, there’s a lot of older men with lots of gray hair or no hair in our society, but your trajectory was very fast and I think it’s because it’s a combination of your knowledge and interest and research and your highly, highly active in that, but also your personality. And I think in the next hour people will see your personality. It’s just so warm and yet commanding at the same time. I don’t know, what do you think?
Speaker 2 (01:35):
Oh, thank you. I think my carrier has showed up thanks to the European Hernia Society that has actually given me a boost start in check. As a surgeon and as a female surgeon, you don’t get much of an opportunity to become a cancer surgeon or upper GI surgeon or anything like this. You have to work really, really hard if you want to pursue the career in surgery. And because my PhD topic was related to hernias and research, I sort of got involved with the European Hernia Society and the people around it were so friendly and very supportive and they encourage anybody who actually wants to work and that’s how I got involved and that’s where it all started.
Speaker 1 (02:25):
I think you’re right. I think the hernia surgeons internationally all around the world are very kind and nice people. They enjoy what they do. It’s a relatively low stress specialty compared to trauma or transplant or cardiac surgery. We do affect people’s quality of life very much. And so it’s very satisfying at the same time. So people are happy and they do what they’re doing. No one goes to hernia surgery that doesn’t like what they’re doing. No one would choose to do hernia surgery as a specialty if they didn’t actually enjoy doing it. You agree?
Speaker 2 (03:10):
Absolutely. I have one of my research fellows actually last year and annual event of the European Hernia Society submitted a poster which is the 10 reasons Why to become a hernia surgeon. And it’s actually a really, really nice poster. And he’s only his second year of surgical residency in his surgical training. And he put these 10 reasons together which are really, really sweet. And one of them is that you just don’t watch. People die suffer so much. You do something which is a little bit of a cosmetic surgery, but it sort of makes people more beautiful. You improve people’s quality of life and at the same time I think we’re all a little bit of the underdogs of the surgical field. Yeah, because when you look at average medical graduate who wants to be a surgeon, I think so many of them will just tell you, look, I want to be a cancer surgeon, I want to transplant organs, I want to do this. But not many will tell you I want to fix hernias. But they don’t realize what it is. And one day they realize they’ve spent 50 years or 20 years transplanting organs and actually just watching people die slowly and they actually end up having quite a sad life I think compared to us.
Speaker 1 (04:41):
What was your thesis on and how did you get involved in hernias?
Speaker 2 (04:49):
My thesis came around by accident actually because the university where I was studying and where I ended up teaching as well has a big biophysics department and the guy who is in charge of that owns a patent for some machine that can spin nanofibers out of various polymers and they were trying to make an artificial cartilage to be used for knees for soccer players because he’s also a very passionate soccer player and the only Czech FIFA judge. So he was trying to build this bio-engineered cartilage for the knees of all these soccer players. And one day he was sitting next to my boss at some graduations and he said, look, I have this, I had these fibers but I only have fibroblasts growing on them. They’re like wheat, they grew everywhere. And he said, well this is the cell we actually want in hernia repair and I have this girl and she wants to be a surgeon but I want to give her some topic which is quite unimportant, so let’s just give her these fibers and see if she can figure out anything to do with surgery. So that’s how it started.
Speaker 1 (06:06):
And what was the final topic of your
Speaker 2 (06:09):
Thesis? The topic was the use of biodegradable nano fibers of PolyOne, which is one chemical and operative repair of recurrent incisional hernia. I’m very sorry. We have another person joining us and
Speaker 1 (06:31):
The doctor is a brand new, I’m sorry.
Speaker 2 (06:32):
Speaker 1 (06:34):
Boy is six months old
Speaker 2 (06:38):
That he would be nice. Oh,
Speaker 1 (06:39):
Looks like he really enjoyed being on the zoom. That’s so cute. Six month old little boy. I remember when you were pregnant and you were presenting at the conference, I forget, I think you were like seven or eight months. Six or seven like that.
Speaker 2 (06:54):
Yeah, seven, something like this. But it was actually really wicked because I got given a topic to present on inguinal hernia pregnancy and I became pregnant like two months later. Yes. And <laugh> I
Speaker 1 (07:10):
Pregnant. I remember. Yeah, I totally remember that. Well this is good because based on your experience we have many questions about Mesh and Mesh properties. If we can delve into that. And we’re also going to be talking about pregnancy. There have been those questions, so should we start with some of those already? Yeah. Okay. So the first question is just on the different types of Mesh. There’s polyester, polypropylene, EPTFE and PVDF, which are the most popular synthetic meshes that are non-absorbable. Is there a reason why a surgeon would choose one type of Mesh over the other? And are there any that we should avoid? What are your thoughts on that?
Speaker 2 (07:56):
I can tell you in the czech republic I can only choose polypropylene. I can’t choose any other because we only have our majority of our health system estate and the other, we don’t have Polyester in the market and the other is too expensive for us. But like every material has certain properties. So if you look at polyester and polypropylene, they’re basically equal or used interchangeably. Although in the animal studies, polyester causes little bit more of the foreign body reaction and is a little bit more inflammatory compared to polypropylene. But I’m not aware of any human any study or any paper published on humans with this. But it, it’s quite commonly mentioned on animals. I mean
Speaker 1 (08:52):
The original <inaudible> and the original hernia repairs were all done with polyester. Well after stealing and steel first that didn’t work. That kept breaking and then used polyester and it was very soft. It was very fabricy. Yes. And polypropylene came about. It was much easier to make and cheaper to make and the properties were good at the time and it was monofilament, whereas poly was braided. Braided. So one of the major reasons moving from polypropylene was like you said, the foreign body reaction was lower and because it was monofilament and the infection rate was an issue because if you got the polyester infected, that was a very difficult thing to handle. Whereas with the polypropylene not as much. PTFE is kind of became popular is not as popular anymore. What are your thoughts on PTFE?
Speaker 2 (09:52):
I don’t like it. I’ve never used it, but I don’t like it, especially because of the infection of it and cause the poor size. If you just have something where you can’t treat an infection and then I don’t know, I wouldn’t use it myself. I wouldn’t want to have it end myself.
Speaker 1 (10:14):
So T came about, I think at our hospital was where it became most popular because a surgeon, I believe it was Dr. Amid was looking at a way to put a barrier so you could put Mesh inside the abdomen and he tested a lot of different properties of different products and PTFE was the one and that made laparoscopic ventral hernia repair like a big boom in the early two thousands, which was all PTFE based materials. We know that shrinks much more and it’s very much not resistant at all to infect. So if it gets infected that Mesh must come out because it’s very microporous. So there are still products that are PT based and they use it around because it doesn’t stick to anything. It’s considered to be safe around bowel like colostomies and around the esophagus. Really important structures you don’t want to erode into. So it does have some use but it’s not as popular as it used to be. PP D F is only available, I’m sorry, not only in US in Europe it’s not available in the us it is available in Europe.
Speaker 2 (11:31):
And actually I just realized I do use PTFE Mesh for the laparoscopic groin hernia repair cause Yeah.
Speaker 1 (11:39):
So what do you think of that? Cause from what I understand, the Europeans love PTFE it’s very German
Speaker 2 (11:48):
To it is German. Yeah, <laugh>,
Speaker 1 (11:49):
German German centric. But based on the German experience and of course the German hernia society is I believe the oldest of the hernia societies, the one with the most history. So they’re very proud of their hernia society.
Speaker 2 (12:06):
I think it’s the biggest, not sure if it’s the oldest.
Speaker 1 (12:11):
Oh, biggest not oldest,
Speaker 2 (12:13):
Speaker 1 (12:15):
Speaker 2 (12:16):
Think the French keeps saying theirs is the oldest, but
Speaker 1 (12:20):
I think maybe
Speaker 2 (12:21):
Hope nobody’s listening.
Speaker 1 (12:24):
Yes. So what do you feel is different with PVDF than polypropylene? Why do you use that for the groin
Speaker 2 (12:34):
I use it because the manufacturer who makes the smash just makes it in a shape and form and the properties are just so nice to handle and always fits well. You can use just a polypropylene flat Mesh, but I always felt like with this one there’s a little bit less work while with the 3D meshes, I’m not a big fan of those because they’re like too bulky and I find it quite hard to make them fit. But this one is relatively soft, but it it’s also but it’s also quite easy to handle and it fits really nicely.
Speaker 1 (13:22):
<laugh> the company that sells PVDF in Europe tried to come to the us. From what I understand, the FDA process was two onerous. And we have such huge other companies that are leaders in hernia Mesh that they felt that from a financial standpoint they wouldn’t be able to compete after all the money they had to pour in for the FDA process and then market it in the us. But it’s a braided polypropylene like product. So it’s supposed to be less inflammatory, less shrinkage and lighter weight than polypropylene. Is that right?
Speaker 2 (14:13):
And on IPO in the Intraperitoneal position of the Mesh, which didn’t actually work that well. But for growing hernia repair I, that’s my favorite Mesh and I just use it because it’s easy to handle. And
Speaker 1 (14:31):
What are your thoughts about Yes,
Speaker 2 (14:35):
Speaker 1 (14:42):
What are your thoughts about biosynthetic meshes? One question specifically asked about the gore synecore Mesh there’s also the tela bio ovitex Mesh. There used to be the cook Mesh called Zenapro been taken off the market. And there’s also the absorbable synthetic Mesh called phasix made by Bard. So what are your thoughts on biologic Mesh and hybrid Mesh and biosynthetic Mesh?
Speaker 2 (15:13):
Well biologic and biosynthetic I think is a little bit different Mesh. And I think we start with biologics and I think it’s a really cool idea and it’s basically the same idea as we were using in our research with the nanofibers because when you <inaudible> some polymer, you end up with something that looks very similar to extracellular matrix. And the idea is that you convince someone’s cells to actually inhabitant that area, turn it into a big house <laugh> for all the fibroblast, and then eventually eat it and reform it into a new tissue. It’s the whole basis of tissue engineering. And I think biological Mesh manufacturers had very same idea and they were thinking that they’re going to do also, if you remember the old advertising for all these biological meshes, they always said it’s regeneration instead of reparation and things like this.
Speaker 2 (16:16):
Yes. And it would’ve been great had it worked, but I think and I can’t tell from my own experience, I can only say from what I’ve heard and read, but because of, I’ve never used a biological Mesh and it’s just way too expensive for the Czech medical system to cover that cost of a biological Mesh. But I can see that the world is sort of sees it as a dead end street and it didn’t quite deliver the results which we were hoping for. So Mesh is like the bio came to the market which cost half price under the microscope. It looks very similar and it in theory should have lot less antigenic properties than something that’s been taken from a cadaver or from cow or pick or, so I think the idea behind it is fantastic, but why it doesn’t work the way it should work.
Speaker 2 (17:21):
I think it’s for the engineers to figure out. But the idea is very good. And with physics, I think it’s too early to say because it’s not on the market for long enough. And if you look at the evidence behind pH and the evidence which allowed it to be bought into the market, there’s very little, and it’s based again on animal studies and I think only the post-market surveillance is going to tell us if it was a good move or bad move. Ideally it’s going to disappear and not harm anybody in the long-term, but who knows.
Speaker 1 (18:04):
Yeah, the kind of mid long-term studies have come out and the long, long-term, I think the recurrence rates around 20%. The Mesh that you’re talking about, the pH Mesh is synthetic product that absorbs much more slowly than most biologic Mesh. The theory is around 18 months is pretty much out of your system but if you continue the study after 18 months, then you start seeing recurrences, that may be fine. A 20% recurrence rate may be okay in someone who has a lot of other issues that you don’t want to add permanent synthetic end or if you want to keep operating on someone over and over
Speaker 2 (18:47):
Again. Yeah, maybe something temporary. If you have whole lot of, I don’t know, you have a stoma, you have some fistula, something that’s going to be reversed in the future, but you also have a big hernia, then I think it’s a good product to use. But again, I don’t think there is much evidence behind it at the moment, so can’t really tell.
Speaker 1 (19:12):
What are your thoughts on, here’s another question then we’ll move on to pregnancy questions which we have multiple. What are your thoughts on tissue versus Mesh? By the way, just to preface US, practice of hernias are different than European practices. Part of it is we’re kind of expensive surgeons. We have tons of different types of Mesh products that are sold to us. We have a lot of options for biologics which are very expensive and typically not covered in a more socialistic healthcare system which a lot of Europe is. And so when we use biologics or these fancy meshes in the US, it’s really good to talk with someone in Europe where you are bound by much more restrictions financially in the healthcare system than we are. And therefore I suspect you also do more tissue repairs than we do. Is that correct?
Speaker 2 (20:15):
Well, when I started for groin hernia and the clinic where I started to work for groin hernia, we hardly ever used mash. We did mainly the tissue repair and we did some of these that you only read about some really historical books now. So we didn’t even do Shouldice, we just did some Bassini and mcvay and some really old fashioned repairs. But you see when you do a high volume of these, first of all you learn the anatomy I think a little bit better than if you never have to handle these tissues. And because you do it repeatedly, you somehow learn what to sew the what and then the recurrence rate drops because it’s not like when you have hold of surgeons who used to use Mesh and then you force them to do a study when they do a repair, which they are used to doing with Mesh versus something which they’re not really trained to do.
Speaker 2 (21:20):
So then the recurrence rates suddenly on the non Mesh lean non Mesh group is much higher. We didn’t do any systematic follow up at that clinic, but I remember one guy, he was a rubbish man, he was the, do you call them rubbish man? The one who collects rubbish rub. Rub, yeah. And my boss back then, he made me do Marcy repair, which is basically just put two stitches around the internal ring. And I said to him, I said, no, he lifts these very heavy rubbish bins. He needs a Mesh, we have to use a Mesh. And he said, well do what you want. And then I thought, well, he’s 40 years older than me, he knows better. So I did what he said to me. And then the same guy came with perforated stomach ulcer about six years later and he came when I was on call again and I said to him, how’s your groin? He was like dying from stomach pain, but he said, oh my groins good, groins good. So I don’t think Mesh is always needed. And I think you can do on certain patients in the groin hernias, you can do tissue repair, which LA lasts for the life and it could be a good repair for some you need Mesh the same as for umbilical hernias. I think for lots of little umbilical hernias, you can get away with couple stitches in the umbilicus and that’s, that’s it. I don’t think What’s the
Speaker 1 (22:58):
Practice? What is your practice for inguinal hernias? How often do you use Mesh?
Speaker 2 (23:03):
Well, the clinic where I work now majority are done via Lichtenstein. So everybody receives Mesh. And when I started to work there and I started to do these tissue repairs, they were looking at me, I don’t know what I’m doing. They just like, what you doing? You know, don’t know how to use the Mesh, do you? And they do, but I don’t think everybody needs it just because it’s the current gold standard. So they actually didn’t do much laparoscopic repair, which they’re starting to do now. But again, the primary focus of that clinic is lung transplant program and they do hernias just as a tiny little subpart of what they do. So it’s something very unimportant for them.
Speaker 1 (23:57):
And what is your practice for umbilical hernias? How often do you use Mesh for that?
Speaker 2 (24:02):
Me, myself I use Mesh. If the hernia is big or if it’s a patient who is quite large has a diastasis, then I would do it. But I’ve never used any of these patches, like these preformed intrapersonal patches. Again, they’re too expensive for us, so I have no experience with them myself. But if we use Mesh, we just use flat Mesh and try to keep it out of the abdominal. The little ones, I just put couple stitches and I
Speaker 1 (24:39):
Agree with you. I think in the United States we tend to overuse Mesh. There are plenty of patients that would do just fine without Mesh. It may imply a longer recovery time, actually we know that. But that may be okay for some patients in countries that don’t have access to Mesh or have only the very kind of basic Mesh types. I feel like they don’t have as good of outcomes. They have some disasters they have to deal with that are very hard to deal with once they have recurrences. So that’s one drawback. But the other thing is they also don’t have a lot of the chronic pain issues that we have with in the United States with Mesh related overuse. I think there’s overuse
Speaker 2 (25:26):
And I think it’s not just overuse or underuse, I think it’s the correct use. And I think when you use a Mesh and whoever you are, you might not be a hernia dedicated surgeon, you might be any surgeon because we both know that any surgeons operate in hernias. Many surgeons who don’t really have big hernia interest operate in hernias. And unfortunately there are so many cases when the surgeons don’t even know what they’re using, they just passed a product by the scrub nurse and they just use it without knowing what that material is. Quite often you see they use a Mesh that’s too small in my opinion, especially for incisional hernias. They try to patch up tiny bit of that scar, you know, have a long scar and you have incisional hernia and a little bit of it, and then they put a little patch and then six months later the patient has another hernia right underneath it. So they put another patch and then eventually there is a hernia between these two and it ends up with some perforated bowel and infected meshes and then it ends up in a disaster partially because they just didn’t use enough Mesh and they didn’t use technique appropriate to fix that hernia. So I think it’s also correct use not just the type.
Speaker 1 (26:55):
So you’re a member of the European Hernia Society and the EHS has done the best job of all the different societies in trying to work with evidence based and publish guidelines for both inguinal and ventral hernias as to where the evidence is, where should Mesh be placed, where shouldn’t Mesh be placed, what techniques, what decision making and surgery and so on. And I feel that European has done a really good job of that. And it’s so important because obviously important if people read it, but it’s still important that that information is out there and it’s a lot of work because you go through every single possible literature that’s out there to help support these really intense, super detailed guidelines. But my point is similar to building a house or repairing a leak in the house, you have good contractors and bad contractors, good electricians and good plumbers and bad electricians.
Speaker 1 (28:01):
So if you get the good one, they’ll fix it and they’ll plug your leak the first time. But if you get one that just kind of wings it and just does a minimal job, you’re going to leak again. You’re going to have to call another plumber. So surges are kind of like that. We’re all trained similar, but at the same time, slightly different manner. And every country’s different. Every institution has its own kind of system of training. And then if all you do is hernias, you’re probably more likely to do it correctly the first time. What happens is those of us, I’m sure you’re in that same ballpark, which is when you’re the specialist, you get all the ones that failed the first time. You don’t get the first
Speaker 2 (28:48):
Speaker 1 (28:49):
<laugh> first five times. It would be ideal and ideal world, everyone would repair hernias perfectly the first time. I’m not implying that we don’t have complications. I have plenty of my own complications. Anyone who operates will have a bad outcome or a recurrence or something, but we kind of know how to handle those complications. We have some more questions for you about surgical technique. So what kind of technique do you use for your open hernia repair?
Speaker 2 (29:27):
It depends on the patient. Every patient’s different and every patient has a different wish as well. I think it’s important to speak to them and agree what do they want and what do they expect from it? So a couple days ago I operated on the director of the primary school where my son goes. He went at laparoscopic repair, so he had laparoscopic repair and I think he was very suitable for it. And across the road here, I have a neighbor who had a massive scrotal hernia, which he had for 25 years, and his scrotum was all the way to his knee. So he had open stein repair because I feel that I felt that that was the most appropriate for him. He agreed to have a mash, he wanted one. And it’s kind of nice because I look at his house from my window and I saw him the other day transporting probably a ton of bricks from floating a ton of bricks. So I popped in a couple days later and I said, are you still okay? And he said, yeah, yeah, it’s okay. So I think it all depends on the patient.
Speaker 1 (30:38):
You live on the outskirts of Prague, is that right?
Speaker 2 (30:41):
Speaker 1 (30:43):
How far are you from the center of town?
Speaker 2 (30:45):
About 20 minutes by car, half an hour by public transport. Prague is not that big. So
Speaker 1 (30:53):
That that’s pretty far away then.
Speaker 2 (30:57):
Yeah, I think the bordered official border of Prague is about one kilometer away from our house. The airport is just here, so we always joke that we are in the closest place to wherever we need to go, like America or <laugh>, New Zealand or anywhere. But yeah, Prague is not very big. It’s quite small,
Speaker 1 (31:21):
Very green. It must be so green where you live.
Speaker 2 (31:24):
Yeah, it is actually Prague is the greenest capital.
Speaker 1 (31:31):
Interesting. I did not know that I was in Prague for the EHS back in say 2006 or seven or the EHS, was it pro?
Speaker 2 (31:45):
Yeah, it was like 2003 maybe, or even earlier than that.
Speaker 1 (31:51):
It was the year that you became an EU?
Speaker 2 (31:55):
Yep. I think it was 2003.
Speaker 1 (31:59):
Oh, Dr. G is on, he says it was 2004 <laugh>.
Speaker 2 (32:03):
Thank you. It’s thousand four. How can, thank you.
Speaker 1 (32:08):
Okay, one question technically about Lichtenstein. Do you, your pubic tubercle stitch, where do you put that? Is that into the periosteum or into the rectus fascia or what’s your technique?
Speaker 2 (32:21):
Well, I try to avoid the periosteum because I was told it causes chronic pain, so I try to avoid it, but it’s not always possible, especially in certain patients. And again, if you are, I think we are very lucky in check with the mentality of the patients as well because it, it’s not like us, you can’t or I think you can, but almost nobody sues any doctors or does any damage claims or anything like this. And goes from the history. All the care is free to everybody and people just come with a problem and they don’t expect so much of an individual treatment. And there’s a system works differently. So if you’re a little bit kinder than the average person and you speak to them and you explain it to them and you say, look, you’ve had this operation five times before, we’ve sort of ran out of options, so we are just going to do whatever we can and you may have some pain afterwards. They’re usually very good with accepting this and living with it. I don’t know how with you, maybe your patients would accept it as well had they been explained
Speaker 1 (34:05):
For sure. In the United States there’s much more stressed as a surgeon, as a doctor, I would say in general as a surgeon a little bit more because you’re operating on people and it can cause more damage than a nonsurgical. Malpractice lawsuits are a huge, they’re, we pay a lot of money to have malpractice insurance. A big chunk of what we make is for that and mm-hmm. Pretty much every surgeon get, I think close to a hundred percent of the surgeons. It’s a really high number will get sued at least once. So it’s one of those things that you live with. But it’s stressful. It’s stressful when you get sued because it’s a long process. It’s becomes very personal sometimes. And most surgeons are not out there to hurt anyone. The majority of us do what we do because we like to help people and sometimes it’s not even your fault, but a patient may be angry. It’s, it’s a very complicated situation and I would much rather operate in a world where lawsuits was not part of my daily world.
Speaker 2 (35:17):
Yeah, come here.
Speaker 1 (35:20):
Have you ever used the prolene hernia system?
Speaker 2 (35:24):
No. No. We used to use them when they probably six, seven years ago. We had about a year when they were very fashionable here and we used them and then I’ve taken quite a few out and then we just stopped using them.
Speaker 1 (35:43):
Speaker 2 (35:46):
Some I took out for recurrence and some just because people came kept and they said they have a feeling that they have a bulk of something and they’re groin and they did have a bulk of something in their groin. They were absolutely correct but again, I think it was because they weren’t used properly. They were designed for certain type of hernia and certain type of patient and if you suddenly start using something like this for all your patients, you’re going to have a significant part of those who are not suitable for it. So I don’t think it was necessarily just the problem of that match. But yeah, also of the abuse of it
Speaker 1 (36:31):
Was a good design idea. I think most surgeons were not able to use it perfectly because it’s got two layers. So most hernia repairs one layer, so you have to make sure that one layer is perfectly placed. And this one you have two layers, so now you have to have two layers perfectly placed, which doubles your chances of it not being perfectly placed. And it is more, and
Speaker 2 (36:58):
I’ve seen actually a lot of surgeons trying to use it for indirect hernias and sort of using that cone part to wrap around the cord, the spermatic cord because they thought that’s what it’s for. And things like this and
Speaker 1 (37:14):
Oh, like a,
Speaker 2 (37:17):
Speaker 1 (37:18):
No, that’s not, yeah, okay. I know that it, it’s already done as pink. It’s kind of on the other side. Most hernia specialists do not use it anymore. There’s a handful that still use it, but they’re probably doing very well with it. Do you do parastomal hernia repairs?
Speaker 2 (37:41):
Very rarely. The most colorectal surgeons do them themselves in check, and I did it again on the clinic where I worked before. I have calculated our parastomal hernia patients and I think it came to something silly like that. 25% of them died within one year of the operation and the 75% had a recurrence. So the results were really, really bad. And where the clinic where at work now actually have one person hernia scheduled for later this year and I think it’s the only one I’m going to do this year.
Speaker 1 (38:27):
And what technique do you use for that? Is it the sugar baker?
Speaker 2 (38:30):
No or no? Most of my colleagues would use just an online Mesh and they would relocate the seroma. That’s still pretty much the standard here, which I don’t fancy. So for this one I would like to try this technique that Anetta Montgomery is promoting is lopa where she does it from, actually from the orifice of the seroma, she does sort of retro muscular repair with a Mesh, but from the stoma side,
Speaker 1 (39:10):
Up until I think almost 10 years ago, just a little bit, maybe less than that, seven years ago, if you’re a colorectal surgeon, you had to take the colorectal board exam. When they asked you about parastomal hernia, the correct answer was what you said, recite the stoma and then repair the former parastomal hernia as a incisional hernia. That is no longer the case in the hernia world. We recommend the sugar baker repair. There’s also the keyhole repair, there’s the poly repair, which we discussed last week with Dr. Paul Parastomal hernia repair but the reciting is no longer considered the best anymore. It’s an option, but I feel that the whole world encouraged the colorectal surgery world to change their practices because we both repair those hernias. And now the answer to the colorectal surgery boards is it’s exactly that. Either you just primarily repair the hernia either as a sugar baker or a keyhole technique. That’s the most common.
Speaker 2 (40:20):
The problem I have with sugar baker is again, it leaves a Mesh in the peroneal cavity and I don’t know, maybe it’s just me, but I have a problem with it. So yeah, if I can, I’ll try to avoid it.
Speaker 1 (40:35):
One more question about Mesh and then I’m going to move on to the pregnancy. So I really want to get your opinion on all of that. What’s your opinion on the best method to secure Mesh, especially in the groin? Do you use glue, stitching, tacks
Speaker 2 (40:52):
Laparoscopic repair or open?
Speaker 1 (40:54):
Speaker 2 (40:57):
And most patients, I don’t fix mesh at all. And if I have to, I use glue. And the glue I use, I don’t know if I’m allowed to say any brand name, but we use really cheap historical glue, which only costs equivalent of about $4. Do you get a very fancy applicator, which costs another a hundred dollars. But <inaudible> has taught us a method how to use just the pipe from an infusion set and apply it through that. So then for four or $5 you have a glue with an applicator that you can use perfectly. I
Speaker 1 (41:41):
Think yours is Cyanoacrylate. I don’t know that we have, I don’t think our FD or approved Cyanoacrylate for inside the body. So ours is much more expensive glue. It’s like hundreds of dollars just for the glue
Speaker 2 (41:57):
Speaker 1 (42:01):
Okay, so let’s move on to some pregnancy questions. Okay, easy one. Should I have a hernia repaired before or after pregnancy? inguinal
Speaker 2 (42:15):
Speaker 1 (42:17):
Tell me your or ventral.
Speaker 2 (42:21):
Oh, ventral. If you mean like primary ventral, like umbilical hernia, then sure. Even if you read the guidelines and we have written the patient friendly version of the guidelines that anybody can see on the European Hernia Society website, then we recommend as a group that you should wait after your pregnancy with after your last pregnancy. Ideally if you can with groin hernias. There is not that many women, young women with inguinal hernias that I know of. So I think if you have one, I would just get it repaired. If you have a femoral hernia, definitely get it repaired, but there is no need to wait because when you become pregnant, nothing happens to your groin. It’s not like the belly button that sort of ends up being somewhere else but not your groin.
Speaker 1 (43:20):
The current hernias get repaired whenever you want. It doesn’t affect pregnancy. And then umbilical hernias wait
Speaker 2 (43:26):
Until, I would wait
Speaker 1 (43:27):
Until you’re done with all pregnancies. But otherwise the recurrence rate in chronic pain rates higher.
Speaker 2 (43:32):
Speaker 1 (43:34):
Okay. So on that note, is it safe to get pregnant if you already have an umbilical hernia?
Speaker 2 (43:43):
I have an umbilical hernia and I was pregnant twice and I believe it’s perfectly safe.
Speaker 1 (43:51):
You have a 0% problem. Right. All right. This was a funny one. Does an umbilical hernia affect your period?
Speaker 2 (44:02):
You mean the strength of it or <laugh>? Not sure I understand the question. I don’t think so.
Speaker 1 (44:15):
Yeah, I think the pretty definitive, no, it does not affect your period, but I must say umbilical hernias can get bloating and the pain from the hernia may be worse during your period. Right, okay. The hormonal changes can make it worse, but that’s about it. This is someone that reached out to me on Instagram. I told this patient to join us today. So incisional hernia was repaired, it recurred, and this patient is morbidly obese with a large pan is they want to come to see you. They live in your part of the world. So what would you recommend to them?
Speaker 2 (45:01):
Well if they came to see me, I would sign them up for our program. We have developed with our sports mat medicine department, we have developed a program about five years ago, which is completely free for all the patients as most healthcare in check. And they get a physio and they get three times a week access to a gym where they have a physio present there and they have a dietician and for three months they’re trying to lose weight or at least lose a little bit of weight and improve their muscle strength and work on their diaphragm motions and on lots of other things. And after three months, most of them decide to continue another three months. And in these six months time, most people are usually able to lose about five to 10% of their body weight if they’re more the D obese. And that’s enough for us to get a little bit more space in the abdomen to operate on them this little bit safer and with slightly higher chance of succeeding and then taking the pannus away. I think it’s a standard part of the incisional hernia repair nowadays. Please, for me it should be.
Speaker 1 (46:19):
Yeah, we were with Dr. Paula, yes last week and that week for him was just filled with morbidly obese patients that have had weight loss of some sort and a recurrent incisional hernia that required a combination procedure. In fact, within an hour before his <laugh> talk with me at a hernia talk, he texted me and said, I’m starting a case. I hope I won’t be late. So heated his portion and then while he was talking with us, then the plastic surgeons were doing their portion of the operation, which is the pannus and so on. So yeah, that combination procedure seems to work very well on patients even though there’s a higher risk of wound complications in that population.
Speaker 1 (47:08):
I’d like to you to share with me a little bit your experience. Many of you who follow you on Twitter and Facebook know that you’re very interested to learn more about what it is that patients want us to work on in hernias and kind of gear the surgical efforts towards that. I’m sorry to hear that even though you had very generous and bonafide interests to get to know more from the patients, you got a lot of backlash for asking that question. You had a survey that you sent out for anyone who’s had a hernia repair to answer give me a little bit of background what the purpose of your survey was and how it’s gone so far. And what I can do is in addition to the patient friendly European hernia site guidelines, I will also post your survey if it’s still open for people
Speaker 2 (48:10):
To Yeah, it is.
Speaker 1 (48:12):
Tell me more.
Speaker 2 (48:13):
Actually the survey started because I was writing a guideline document for our guideline group how to write guidelines properly and the methodology we are using is called grade and it dictates that if you are writing a guideline for surgeons which operate on patients, you have to ask the patients what do they expect? They’re the most important stakeholders and I think it’s something that surgeons still not all surgeons are absolutely aware of this, that it’s the patient’s body and it’s their health. And I was looking through the literature and there isn’t much published on what actually patients would like because we as surgeons, we measure recurrence. That’s it’s something we can measure, we can pain, but again, think how many surgeons would deny that the patient has a chronic pain or because they don’t want to see it and it’s something which is not so easy objectively proven as the recurrence.
Speaker 2 (49:21):
So recurrence has become something we all focus at the most, but I wanted to know is it the recurrence that the patients actually fear and how important is it that they can choose between Mesh and non Mesh technique and are they happily happy to accept maybe slightly higher rate of recurrence but avoid the Mesh? Is chronic pain something that they really don’t want or are they again, happy to live with some pain if they don’t have a recurrence or the cosmic is the most important? And so I put the survey with very kind help of two our patients, which come to our meetings and they have helped me a lot and they put some more people in contact and actually really lovely lady joined us through Twitter who’ve never seen and she has done enormous job on the survey and helped us enormously and we put it out and the results been quite it.
Speaker 2 (50:25):
It’s been a big eye-opener for me. And I guess I came from a little bit naive environment and it was taking a cold shower for me. I realized that there is very little trust between patients and surgeons and they see us as something evil. And I didn’t mean anything evil and I didn’t mean to hurt anybody with that survey. All I wanted to do was give patients voice and it’s very hard to publish a paper in a good journal to make other surgeons read it. If you publish it in tiny little journal, nobody’s going to read it and nobody will give up. Think about what it says and nobody will take it seriously. So I thought if I want to publish it, so the surgeons, and it’s not the hernia surgeons I was targeting, but all the general surgeons who operate in hernias to make them read it, I knew I need to read certain number of people to respond to that study.
Speaker 2 (51:26):
So the reviewers of the magazines where I would send it will not say back to me, oh, you don’t have enough numbers, so it’s not important enough and we are not going to publish it. So I was trying to get as many patients as I could and I posted the survey on all these Mesh Mesh groups and patient support groups and I actually have written a little editorial which is called Entering the Lions then and it got rejected from one magazine So far I don’t think maybe I’ll just put it on I h C one day and <laugh> let my friends read it. But it’s very hard to sort of defend someone’s rights if they see you as one of something they’re fighting against
Speaker 1 (52:24):
If they don’t see you as their advocate. That’s a problem that I’ve experienced as well in this specialty United States. Is that a lot of mistrust? It may be why there’s also so much lawsuits or maybe the lawsuits lawyers are promoting more of mistrust. I’m not sure. But yeah, it is stressful. And we’ve discussed this in different hernia talk live sessions. I know that I posted your survey on hernia talk. I hope some of the members of hernia talk who are very involved in online on the discussion forum, the free discussion forum probably filled it out for you. Thank you. I will for you all the other platforms and hopefully get a little bit more feedback and not so much hate mail <laugh> for trying to do good. You’re getting a lot of thank yous from in the question and answers for graciously and generously sharing your vast experience. Question from. And by the way, we have people from the UK, Italy quirky, you’ve got a nice international group joining us
Speaker 2 (53:45):
Speaker 1 (53:48):
So one question is about these patient groups, did they direct their mistrust or anger? Do they make derogatory comments against you personally and what they actually are curious about what examples in general youth experienced?
Speaker 2 (54:08):
Well some reactions varied and there were some people who were extremely helpful and grateful and very, very nice in these groups. But there was always somebody who’s one or two people who were very angry and to begin with, they did actually have some very derogatory comments to me and sending me back to medical school and things like this. And lot of people, there’s lots and lots of patients who believed that the Mesh hurt them and they don’t see that there’s somebody who put the Mesh in them. The Mesh didn’t just unpack itself, it didn’t climb into their bodies while they were asleep. They believed that some Mesh is made of some toxic materials and they might be right and in some certain extent they might be right. But I sometimes felt like that there are certain members of these groups that are almost like blindly believing something and then anybody who has a different opinion is Satan to them. And that’s what I’ve become in some of these groups and some, we actually got engaged in very good conversation and I was approached by some people asking for help. I tried to do my best. Again, I’m sitting in Prague, Czech Republic, so it’s very hard for me to help somebody who’s in Australia, but I try to do my best.
Speaker 2 (55:53):
But I think there needs to be more dialogue between patients and surgeons and that’s why we do the patient info page on the EHS website and we’re hoping to again provide a little bit more valid information to the patient population.
Speaker 1 (56:13):
I will provide a link to that for our viewers so that they can use always there online. I think it’s time for us to let you go back to your family, your little baby, and it’s almost 10 o’clock at night at your time. So bedtime, maybe <laugh> working tomorrow I assume. What’s your day looking like tomorrow?
Speaker 2 (56:37):
You don’t want to know. I’m taking my grandmother to the dentist, so <laugh>. Okay. She lost her front tooth. She tripped over and lost her front tooth, so it’s going to be our fourth trip to the dentist and she’s getting a new one, but I don’t work, no, I don’t actually have any work scheduled until October, really when I start working again. Excellent. I only go to the hospital when I want to now. Yes. This is quite nice.
Speaker 1 (57:07):
Okay, well it was so lovely for you to share all that and a lot of your friends are on here. Thank you very much. I’m going to leave everyone here. As a big thank you all of you know that this broadcast is being simucast on Facebook Live. I will also edit it and put it on YouTube so that you can watch it all on YouTube. I will post the link to that. It was basically on my YouTube channel and on Twitter and Instagram. I will also link those. I also owe you three things. I will put up the link to the EHS Patient Guide guidelines to the European Hernia Society Patient Information page and also to Dr. E’s survey. Is that survey only for people who have had hernia repair?
Speaker 2 (58:00):
No. It’s also for those who have hernias and are thinking about repair or just don’t want repair for whatever reason. And it has plenty of space to give your personal views and opinions.
Speaker 1 (58:15):
I’m grateful for those. And thank you so much. Hope to see you. Thank you so much. You’re such a wonderful person and I’m so glad to know you. Thank you very much and thanks for spending time with us today.
Speaker 2 (58:30):
Thank you, Sharon.
Speaker 1 (58:32):
Thank you. Bye everyone.