Episode 120: Hernia Surgery During the Holidays | Hernia Talk Live Q&A

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Speaker 1 (00:10):

All right. Hi everyone. We’re live. How are you doing? Welcome to Hernia Talk Live. I’m Dr. Towfigh, your hernia and laparoscopic surgery specialist. It’s December, end of the month of the last month of the year. We’re very, very busy, as most doctors are in December. But thank you all for joining me on Hernia Talk Live. We’re going to be talking about having surgery in the holidays. December is the busiest of all the months for most doctors. I would say almost everyone, definitely for surgeons, at least in the United States. I don’t know if it’s like that for the rest of the world, but in the United States we have insurance systems where patients can kind of pick up.

Speaker 1 (01:05):

They have sometimes a limit as to how much they have to pay out of pocket with their insurance company. And sometimes as they’ve gone through the year, they’ve had CAT scans, they’ve seen their doctor blood tests, some may have been in the hospital, et cetera. And so they’ve met their, what we call deductible, which means after that, whatever insurance covers would be a hundred percent and they wouldn’t have to pay out of pocket for anything within their network. And so patients decide, oh, well maybe now’s a good time to have my surgery because that’s an expensive cost. And guess what? It usually occurs November, December. So here we are. I’m operating almost every day this month, sometimes a couple times a day. I love it, but no one in the office is allowed to take time off November, December. It’s just the way it is because we’re so busy and we can’t afford to take times off when patients are seeking time for that.

Speaker 1 (02:05):

So why else would people want to have surgery at the end of the year? Well, the primary reason the United States happens to be financial and insurance based, I think because there is a insurance called Medicare, which is a federally sponsored insurance that doesn’t have these deductible issues. And we don’t see a peak in Medicare patients usually in December because they’re happy to have their surgery in January and people with private insurance are not. So we think it’s mostly generated by insurance. The other thing too is many people have December off. They have their school, their kids are out of school, so they don’t have responsibilities to take their kids back in forth from school and meet their needs from school, college students, maybe back home. People that work may have a good two weeks off during the holidays in the United States, or they may have time off between Christmas and New Year.

Speaker 1 (03:11):

And so those are potentially times where they can fit in an operation that they were unable to get to because life happens and there’s there’s time, there’s not enough time for that. So basically for multiple reasons, we have a lot of patients that want surgery in December, which means we don’t get to take time off in December. And that’s just something that we decided is a priority in our office. And I never take time off November, December, Sheila’s my office manager. She almost never takes time off anyway, but definitely not when Isabel is, my nurse. Her birthday’s actually during this time, she can never take it off because if I don’t have Nurse Bel, as many of you know, I am missing a limb. So it’s really hard to take care of all our patients’ needs without my nurse. And then many of you also know Myron.

Speaker 1 (04:12):

Myron can work from anywhere. So even if he’s on vacation, he will be answering emails sometimes. So he’s my scheduler, as many of you guys know. So shout out to my awesome team for always taking care of our patients’ needs on the holiday. But just so that you know, that is how it works. I went to the eyeglasses place where you get your prescriptions filled to get new glasses. And yes, I do need to wear glasses for certain purposes. So the guy said, oh, December’s our worst time too because I guess with something called HSA, which is the health savings account and also certain insurances that cover prescription glasses, you have to use that money before December 31st is over. And he said, people just pile in literally December 31st. They will get inundated with people that need to be seen and examined and prescriptions filled and so on.

Speaker 1 (05:21):

So even the optometrist gets slammed in December. So I love this part of the year. It’s very fun. As many of you have followed me on Instagram at hernia doc or Facebook at Dr. Towfigh, you all know that my office is very holidayed out and we have poinsettias and wreaths and what’s the other one called? Our doorways have the string of not a wreath, forget what it’s called, the string. We have Christmas music playing and we have a Hanukkah area and it smells like Christmas in our office. So if you walk in, please drop by. And even if you don’t have to see me, just drop by to experience it because that’s really beautiful. We have little gifts everywhere and we have a whole wall of stockings. So that’s all posted on my social media post. So you can see what the inside of our office looks like.

Speaker 1 (06:23):

Every door to the exam rooms has a wreath and poinsettia is inside. And like I said, it smells great. Smells like Christmas here. So I love this type, this part of the year. And of course we’re in Beverly Hills, California. Weather is great. I think we’re getting chilly nowadays. It’s around in the fifties, which is unheard of, but usually it’s sixties. So it’s just a beautiful time of year and we like it all. So many of you have sent in questions because you’re concerned about having surgery during the holidays. And I’m here to answer some of your concerns. I hope I relieve some of your concerns, but maybe at least I am able to answer them. So let’s go through some of the questions and we’ll see how many of them I can answer for you. So let’s go to the last question actually that was submitted today because that’s I think gets at the crux of the problem, which is if you decide to have surgery during the holidays, should you opt for a large medical center where you can rely on an acceptable level of service to be maintained at all times?

Speaker 1 (07:34):

And should you decide to have surgery in the holidays only for low risk procedures, is that a better choice? Because it can be performed in an outpatient setting to avoid facing inconveniences due to reduced staff. So the whole concern is, okay, I’m going to take time off because I’m, my work allows me time off or the kids are at no longer at school and I’m going to have surgery during the holidays. Should I be concerned about staffing? Should I be concerned about availability of the right people in the hospital? Yes and no. Mostly no because for sure, in a hospital setting, the main people that are important to take care of you, the surgeon, the doctor, the nursing staff, we are the same in terms of availability. So as long as you’re surgeons in town, then their whole team, including the nursing team, the tech, et cetera will be there.

Speaker 1 (08:33):

So it’s not like we have less nurses in the operating room or nest less anesthesiologists to help you. We have adequate staffing throughout the year 24 7. What is variable is sometimes access to the social worker placement, nursing homes, certain people that help with prosthetics and measurements and so on are not available during the holidays. It’s not as much of a problem for hernia patients. But I have seen in the past where we have patients that need to be discharged from the hospital, we just can’t discharge them because the people that do the discharging and figure out which aftercare facility, for example, the patient needs to be transferred to, they’re just not available or they’re down to half of the number that are usually available. And those people are inundated with twice the work. And so those kind of ancillary staff and ancillary services possibly can be limited in the hospital during the holidays.

Speaker 1 (09:50):

I mean it’s limited during the weekends too. It’s not just holidays. So that’s partially a problem. Usually that’s only for sick patients and the consequences you stay in the hospital longer than you may need to. But in terms of care, actual direct care, whether it’s in the hospital operating room or in the hospital ward, that care should be very, very much the same. It’s possible if you’re very sick and you need a specialist that the specialist that your doctor specifically wants maybe on vacation, but there will be a specialist. In fact, I believe there’s some law, I know there is for surgeons. I think there is also for all doctors when you can’t just leave and not be accessible, which is one of the things you have to deal with when you choose to become a doctor is you have to be available at all times.

Speaker 1 (10:52):

And if you’re not, you have to have someone be available for you. So most large practices have an on-call staff or an on-call doctor when I’m out of town, which can be often because I give a lot of talks, especially outside of this area and out of the country, I still screen all my phone calls, but I always, always have two teams of doctors and surgeons that are available to answer to see any of my pages if they need to be seen personally. But otherwise I’m available 24 7, 365 days a week. My nurse, even more importantly, nurse Bel is available as well. And if I’m out of town, she can often see patients if there’s a wound issue or if they just want to be seen. But I always have another surgeon who’s qualified who takes is available to see my patients in person or in the hospital if necessary when I’m physically not nearby.

Speaker 1 (11:57):

But I mean I’ve canceled vacations before for patients because I just don’t feel right leaving town if I have a sick patient or someone who may need me, which is also why my office is really good about not scheduling any patients before I leave town. So I almost never operate in the leave town because I don’t know, I just don’t feel comfortable doing it. I know other doctors do it and it’s often safe, especially if you have someone covering for you. I don’t know, I’m very possessive, hands-on and controlling, so it’s hard for me to just let go. So take that as you wish. So same with the surgery centers. Is that an outpatient setting that still runs as a surgery center like it does any other day of the week? Usually surgery centers are not open on the weekends, but during the week they should have the same staffing as usual.

Speaker 1 (13:03):

So I wouldn’t be worried too much from a staffing standpoint for the actual care that you need because the staffing the same. What is different is the kind of ancillary stuff and potentially other specialists. So here’s the other question is if you decide to have surgery during the holidays, can you always assume that your surgeon will be available to treat any complications that may arise after surgery? And that is a very good question and that is something that you absolutely should discuss with your surgeon. So if it’s a holiday or even a weekend that’s coming up and you’re having surgery right before it, you should get an idea of how available your surgeon is to you. So how easy is it? Who do you call? Who’s their backup? It’s pretty much a requirement of sorts to announce that you’ll be gone to the patient, but also to the medical records for anyone who is following a patient, let’s say in the hospital that not only will you be gone so and so with this phone number is available as backup for those needs.

Speaker 1 (14:23):

So it’s often okay to have whoever your surgeon trusts to take care of you when they’re out. So the most practices nowadays are not like me, they’re like more normal. So most practices have an on-call surgeon every night and everyone else is off. So that means, let’s say there’s a group practice of five surgeons, they all take call one day week and when they’re on call, the rest of the four surgeons go home, have dinner with their family, watch TV, and someone else answers the calls for that group practice. And then one of them does Friday, Saturday, Sunday let’s say. So that gives four of them a break and they can make plans with their family and get some wellness. And then if there’s patients in the hospital, then that on call surgeon will treat, see and treat everyone’s patience. That’s a very common scenario nowadays.

Speaker 1 (15:32):

It didn’t used to be when I was a resident, no one covered for each other. And that kind of old school mentality is pretty much gone now and we’re encouraging doctors to take time off and not be overworked and burnout. So I’m not burnout burnt out. I feel like I’m, I’ve got pretty good balance, but I also don’t really do that much emergency surgeries anymore. I used to do it a lot and every Friday night I was on call and operate all day until Sunday morning, Saturday morning and often many times a week I’d be on call. So if I continued that, I would’ve burned out. But currently I’m happy to take care of everyone’s needs throughout the week at any time. And when I am gone, I still continue that practice. But do understand that’s not typical anymore and it’s very common to common to have doctors cover for each other and just know that most doctors choose someone they trust to cover for them.

Speaker 1 (16:46):

So I don’t feel necessarily that you’re getting different care because you are being treated by a different surgeon. Here’s a question live, do you have any advice on tracking Mesh in the UK when notes have been lost? Is there the equivalent of the Iron Mountain dating back 2014? I don’t know what Iron Mountain is, but in the United States you’re, you’re mandated to keep records I think seven years, seven or 10 years. And so large hospital systems often just throw away all the records. So if you had care in 2014 and you are unable to find the records, it’s pretty much impossible to find. So when a patient comes to see us, we always look for old records, whether it’s imaging or it’s their operative report, et cetera, and we first go to the area of service unless they had surgery at a certain hospital, we’ll call the hospital or the surgery center. If they don’t have it, then we hope to find the surgeon and call the surgeon’s office directly because the surgeon’s office may still hold those records in their system, whereas the hospital may have purged it. So we then ask the surgeon if they have access to those medical records to send to us. And if they don’t, then that’s pretty much it, which is why I highly recommend that people maintain their own medical records for all that. So that is something else like a fallback, you should maintain your own medical records.

Speaker 1 (18:27):

That said, I had access to my kid, my childhood records, my parents still have still held my vaccination records from when I was four. That stuff you could probably throw away. I don’t think that’s necessary. And then the next thing is I Mesh injured and the surgeon is denying using the Mesh. I never consented that I knew about it and my legal is investigating. Okay, I understand. So you’re trying to get records to, I guess to show you actually had an implant put in. So when you can do is to see if the hospital maintains implant records separate from the hospital records of your operation to see if you had an implant put in and what type of implant because that’s a mandated man that is mandated to be kept. But of course I think still after seven to 10 years they purged those as well.

Speaker 1 (19:28):

But if you feel that you think you have Mesh in you but your surgeon says you don’t, then imaging should be able to help figure that out. I actually had a patient that saw me. She came from another country I think pretty sure she had surgery. She had a tummy tuck and she is saying how she’s having these weird seizures and headaches and double vision and she wants her Mesh out. And I’m like, how do you know you have Mesh in you? And she said, yeah, the surgeon told me that I have Mesh in me. So we had to do some digging because it’s not common to have Mesh as part of a tummy tuck. It’s possible but not common. So already the story was a little bit didn’t make sense. And then we looked at her opera report and of course it was one of those situations 20 years ago she had this.

Speaker 1 (20:21):

So we called the hospital, they didn’t have it. We called the patient surgeon, he did not have it, but I spoke with the surgeon. He said he has only put Mesh in for a tummy tuck twice in his lifetime. And she was not one of it, one of them. So that kind of confirmed my suspicion that she did not have Mesh, but she was still adamant that she had Mesh in her and it needed to come out. So I offered her imaging specifically an MRI because MRI can show stitches, it can show Mesh. And so we did that. And of course it also confirmed that she does not have Mesh in her. So that’s kind of the process we had to go through to help this patient.

Speaker 1 (21:03):

Same patient saying, I’ve had sepsis and lost anatomy tears when Mesh was found. I don’t know what that means. I don’t know what that means. I have had sepsis. So you can have sepsis but not have it be due to a Mesh and lost anatomy tears when Mesh was found. I don’t know what that means. Which imaging is best specifically to look for a Mesh? MRI is best, but if you’re looking for evaluation of a hernia for the abdominal wall, it’s CT scan, and for the groin it can be ultrasound, CT or MRI. Let’s see, same patient, mine was an abdominalplasty and prolapse I something I definitely have 15 by 15 centimeter Mesh incidentally found I, I’m going to have you rewrite this. I don’t understand any of the writing of the question because it just doesn’t make sense. If you could rewrite that. Here it is. I had substance and needed it to be removed and lost part of my bladder and umbilicus. Okay, so you had your Mesh removed.

Speaker 1 (22:29):

So the surgeon that did the opera report for the Mesh removal can help recreate history and figure out what you had in you and how big and what size and which location and why aren’t all surgeons taught non Mesh repair along with Mesh repair. I’ll tell you why. So I trained in the late nineties, early thousands, and let me see, did I get trained in tissue repair? I know we’re taught how to do tissue repair for sure. And to this day, everyone has to know how to do tissue repair fundamentally, not physically, but fundamentally because it’s part of your board examinations. I’m trying to think if we ever did a tissue. I think we did maybe a Bassini repair in residency.

Speaker 1 (23:18):

I don’t even remember honestly. But at that time there was a huge push towards Lichtenstein repair and Mesh based repair because the outcomes from tissue repair were so poor. So people used to be in the hospital for a week, very debilitated. They often couldn’t go back to a lot of their exercising and so on. Chronic pain was definitely an issue, but even more of a problem was recurrence. So the issue with tissue repair was if you don’t do it right, it’s a horrible problem. And so when Mesh came about, you can be a kind of mediocre surgeon and still do a good Mesh repair and not have recurrences because a Mesh took care of things. Whereas if you do a mediocre tissue repair, then that would fall apart. So that is why people started moving towards Mesh. Dramatically reduced recovery at dramatically reduced recurrence rates.

Speaker 1 (24:13):

I’m saying we went from like 15% recurrence rates down to one, and we went from one week hospitalizations to outpatient. So those were dramatic changes that the introduction of Mesh had for inguinal hernias. We’re just talking inguinal hernias because that’s where really tissue repair comes into play. So once we did that, people stopped teaching tissue repair except in situations where you couldn’t do a Mesh repair. So that would usually mean a strangulate hernia or any other kind of contaminated or dirty wound where you had to fix the hernia, but you couldn’t put Mesh in. So that’s the only time when a tissue repair was considered indicated was when you were not able to do a Mesh repair and therefore most people did Mesh repairs. Now we’re in a situation where people are having chronic pain and poor outcomes from Mesh repair at a rate that seems unacceptable. And it’s not necessarily the Mesh, although in many situations it is the Mesh. So the plug, the phs, some of the ptfe, very thick meshes, those have been known to be inferior meshes on their own because the chance of doing a good repair by an average surgeon is not excellent.

Speaker 1 (25:41):

And as time goes by, if you don’t do a tissue repair and you do a Mesh repair, you don’t really need to know your anatomy that well. So over time, as we’re not teaching it and focusing on Mesh based repair, the appreciation of the anatomy is gone. So now I teach my resident’s tissue repair. We do McVay, Bassini, Shouldice, Marcy and Nyhus repairs. They each have their own specific technique and the anatomy is so detailed. I mean I put my glasses on and I encourage the residents to wear their loops or their glasses and really focus. We go over the anatomy before so that they understand everything we’re doing during the surgery and specifically what they all say. And what I love is that, oh my god, this is a beautiful operation. The anatomy is so cool, and it’s like no other general surgery because there’s so much anatomy there that you happy, careful of, and you just don’t see or do that for the average Mesh based repair.

Speaker 1 (26:57):

And so they really appreciate that and they like it, but it takes time and it takes patience to learn it and do a good job of it. And I’m seeing, and I discussed with the patients today that I saw he had a similar question and he’s like, why aren’t they aren’t enough people doing tissue repairs? He came from area, town, that area of the state where we literally have no one that does it. So many people from that area just come in to see me for tissue repairs. And I said, the good news is I’m starting to teach my residents. There are a handful of surgeon around the war nation that are doing more and more tissue-based repairs and they are teaching their residents. And those residents hopefully will go on and use that experience and apply to their patients. So we’re slowly improving it.

Speaker 1 (27:54):

We have courses now where we hands on teach tissue-based hernia pairs with experts on cadavers to actually teach them this is the specific area, this is the anatomy, this is the what you sew to what cause very complicated. So this pendulum is swinging back, not fully. We’re not going to fully abandon all match repairs, but we’re going to, I do see that slowly we’re moving to a situation where at the very least surgeons appreciate that a tissue repair should be considered and therefore refer to another surgeon if they themselves can’t do it. And secondarily, more surgeons are interested in offering tissue-based repairs. Hope that it helps explain it. Okay, going back to imaging, do CT and MRI need to be with contrast? No, they do not.

Speaker 1 (28:57):

Let’s see, the Mesh was not removed as it was too big to removed and they wouldn’t risk it in case of complications. Well, I don’t believe that statement if a Mesh needs to removed, has removed, especially if it’s an infection, the infection was removed, hence I lost my belly button and part of my bladder, but the surgeon said there was too much risk to remove as it didn’t actually know what type of Mesh was in there. All this is documented, but I need to know what Mesh was used in a clear case manager plan. In case of reoccurring infections, it’s causing me chronic pain anxiety. So you don’t need to know exactly what meshed back. If it was 2014, it was polypropylene based Mesh, we didn’t really have any other type of meshes. And that’s all you need to know. You don’t really need to know that.

Speaker 1 (29:51):

But if you had an infection, then all of the Mesh should be removed. Maybe I can get your details and explore if you could help if I can get my MRI abdominal CT scans too. Is this an option? Yes, absolutely. I offer online consultation if you’re, you’re not in California. If you’re in California, we can see you in person. Lemme rephrase this. I can see anyone in person, but if you choose not to come in person for whatever reason and you live within California, I do offer telehealth consultations, which is similar to in person. It’s just video based. Or if you’re outside of California, I can offer you an online consultation where I can help review your situation. So if you’re in the United Kingdom, just contact my office directly, all the information is in my social media bios and initiating an online consultation and my nurse Bel will walk you through the process.

Speaker 1 (30:48):

Oh, you guys are interested in MRI. Now look at this question. What do sutures look like on an MRI? Are prolene and ethibond similar on MRI? So sutures look like a foreign body and they like little circles. So the bigger the suture, the bigger the circle. Basically it distorts what the MRI sees. So sutures, and tacks or any other implant will look black and in case of suture, they look like a circle. So you can tell where knots are basically. Sorry if I joined late and if this topic has already been addressed, when does one use phasix Mesh and what are the chances of recurrence for bioabsorbable Mesh like phasix Mesh? Good question. So for those of you who don’t know if there’s a trend towards absorbable meshes, because so many people are complaining about their Mesh, it gets infected, it causes chronic pain. So the thought is if we use Mesh that is absorbable, then you can’t have a chronic problem because due to the Mesh, because the Mesh will go away.

Speaker 1 (31:56):

Well, we know that with the early versions of absorbable meshes called Vicryl Mesh or dexon Mesh, they absorb in three weeks and those don’t work as any type of hernia repair. It just causes scar and scars not, and the scars very thin. So we know at three weeks if a Mesh absorbs is not good enough. So you synthetic Mesh is superior. Then they started dabbling. Industry started dabbling in biologics. So cadavers of animals or cadavers of humans, they use different parts of their body to make Mesh. So usually it’s the dermis, sometimes the stomach lining or the intestinal lining, even the heart pericardium. So animal or human cadaver tissues absorb as well. The cells are removed, so you can’t react to it from an immune standpoint.

Speaker 1 (32:59):

And then that’s implanted and most of them them absorb at around eight months. So at around eight to nine months, you expect the biologic tissue to be gone. And what you’re left behind is whatever tissue repair you did. And they used to say that the biologic tissue was like a platform. It was like a scaffold and then whatever the tissue was sewn to it would grow into that platform. So they used to put it in the brain, like dura. So if you patch a piece of brain with this biologic Mesh, it becomes dura. If you put it on the abdominal wall, you patch the Mesh to your muscle, it becomes muscle or fascia. Well, it turned out that’s not true. It just turned out to be some more scar tissue, maybe a little of a thicker scar tissue than the dexon or vicryl meshes. And it turned out you cannot use it like you do regular synthetic Mesh because it has no long term strength to it.

Speaker 1 (34:06):

You can only use it as a buttress to a tissue repair. And it actually works that way. Not very well, not as good as synthetic Mesh, but it does. And the recurrence rate was about 30 to 40% with those. Then then more recently is what’s called phasix. So phasix is made by Bard or now BD is the company that owns Bard. They make what’s called phasix. It’s some type of synthetic material similar to polypropylene, let’s say. Not technically, but let’s say, but it’s an absorbable product. So it’s weaved similar to all other meshes. It’s like a sheet. It absorbs around 18 months. So we went from three weeks to eight months now 18 months. And the question is, wow, let’s use something that lasts a little bit longer. So maybe we can reduce that recurrence rate from 30 to 40% to something lower. So I believe the most recent data shows the recurrence rates around 17 to 20%.

Speaker 1 (35:18):

It’s again, like all other meshes that are not since that, that are not permanent. It cannot be used like a permanent Mesh. It can’t bridge it. You have to have a good tissue repair for any of these to work. There’s some questions that I have about the Mesh that I think because it’s synthetic, it also has an inflammatory component and an autoimmune component that is risky. The scientists that work at the company believe they’ve been able to show tissue studies that show doesn’t have that much inflammation. I have had patients that have reacted to that Mesh, but they’ve reacted to everything else too. So it’s yet another opportunity to be innovative and come up with newer meshes. But what we know is that regardless of how long these absorb, they eventually absorb. And what you’re left behind with is some scar tissue and your original tissue repair and a lesser tissue repair is a good one. No amount of absorbable Mesh is going to make it better.

Speaker 1 (36:24):

Next question, are sutures a Mesh equally likely to be the cause of postoperative chronic pain or is one of them more likely than the other? That’s a really good question because actually I don’t know that anyone’s looked at that, but I’m going to say sutures are more likely to cause postoperative chronic pain than meshes. So why do I say that? If you have a Mesh in the abdominal wall and you suture it in more likely that the patient will complain of that one suture that’s poking and too tight and tearing than of complaining of the entire Mesh. That’s definitely true for the abdominal wall. With regard to the groin, sometimes the suture is placed incorrectly, so against the nerve, it’s not the Mesh issue, it’s a suture issue. Sometimes the meshes are placed too tight and the sutures are tearing through. So that’s a suture issue, not a Mesh issue. It is a Mesh repair technique issue, but not specifically a Mesh issue. But the Mesh could be folded or get infected, and those can be Mesh related problems. So I’m going to say for the abdominal wall, it’s more a suture problem than a Mesh problem.

Speaker 1 (37:44):

And for the groin is probably equal, but very, very good question. Then the question is, okay, well then when you’re doing a tissue repair, isn’t that basically a suture issue as well? And the question is yes. That’s why most good studies show that chronic pain is the same whether you use Mesh or you use sutures alone. There is no vanishing of chronic pain because we don’t use Mesh anymore. It’s just we don’t have Mesh related chronic pain. Alright, I hope that helps people clarify their questions. Okay, going back to the patient in the UK who had the infected Mesh and had the loss of belly button and also had sepsis, the surgeons of the Mesh looked like porcine Mesh. Okay, so porcine Mesh, we did not have, let’s see, 2014. 2014, we had porcine Mesh, but that porcine Mesh should be absorbed again at eight months. So hard to believe that Mesh, porcine Mesh would be able to be seen that far out from surgery.

Speaker 1 (38:56):

The surgeon said that the Mesh would, but would that have absorbed? Yes, it would have. He said that it was smooth but very tough. He struggled to cut through it and repair it. So the smooth and very tough meshes are usually P T F E. If you get a CAT scan, you can see those meshes very, very clearly on a CT scan. And it was common to use those meshes before 2014. Not as common nowadays. Okay. Well those are really great questions. I’m really, I’m lucky the thought process thinking we’re not talking about holidays anymore. I’m okay with that, but good question. Okay, what is the longest duration of absorbable sutures to retain function and is there any role of absorbable sutures? Okay, so P D S or Maxon are the two names for absorbable sutures. They last about eight months, so that’s about as long as they last.

Speaker 1 (39:54):

And what we mean by last is they do lose their strength over time. And kind of eight months is when it no longer really functions as a suture. If inguinal hernia is caused by omentum infraction, infraction or infection, in a relatively healthy young patient, B M I less than 22, would you recommend the omentum removal? Would Mesh still be required? So I do not recommend omentum removal unless the omentum is diseased like part of an infection or dead. So usually for most hernias, whether it’s inguinal or ventral, we just replace the content back to where it belongs because that content belonged somewhere and now it found this hole and it worked its way through. So usually, especially for omentum, we push it back in place, if possible. Would Mesh still be required? That’s whether or not use Mesh is a private discussion between you and your surgeon and it’s dependent on type of hernia, size of hernia, your own tissue quality, your own risk factors.

Speaker 1 (41:06):

I had a patient last month that he was a french horn player. I’m not going to do tissue repair on a patient with french horn player because the amount of abdominal pressure they have to generate every single day for how many hours is going to bust open those sutures. And so the best repair would be a Mesh based repair for that patient. So there’s a lot of factors to consider. And then also like your surgeon, your surgeon’s technique, what they’re most comfortable offering because you don’t want to force your surgeon to do a tissue repair if that’s not the repair that they’re best at.

Speaker 1 (41:42):

Is there a scenario where you could use absorbable sutures in a tissue inguinal hernia repair and is it known whether they decrease incidence of postoperative pain? So there have been scenarios where people have used absorbable sutures in a tissue based inguinal hernia repair is not considered standard because all of the tissue repairs that were described by Dr. McVay, Dr. Bassini, Dr. Shouldice, have always, Dr. Yeah. Nyhus have always been described with permanent sutures. There are surgeons that offer it with absorbable sutures. Those hernias have a higher likelihood of recurring that has been shown in the literature to have a higher risk of recurrence. And guess what? Recurrence is one reason for postoperative chronic pain, but in some patients you have to do it. I had a patient that did I do the patient? I know I removed his sutures because he was reacting to it. I don’t remember if I put in absorbables. I think on the other side we needed hernia surgery because I knew that he reacted not only to Mesh but also to permanent sutures. I used absorbable sutures in him, but that was a severe compromise. He was not a typical patient.

Speaker 1 (42:59):

Would E P T F E Mesh be there eight years later? Yes. E P T F E Mesh is completely permanent. Mesh is E P T F E message to remove. It was suggested last October. The amount used was at risk of rupturing. I was incidentally found and the surgeon wasn’t competent to start removing, has never seen it or used it as it was. Was this a general surgeon or a gynecologist? Sounds like a UR urologist or gynecologist was involved in this because most general servers know what E P T F E Mesh is. It’s gortex Mesh.

Speaker 1 (43:39):

It was very commonly used before 2014 and it is permanent. It’s relatively easy to remove. It’s quite stiff and firm. Yeah, urologist. That’s why because you had a urologist. Urologists don’t use meshes especially E P T F E. And that’s why they were unfamiliar with it. If they had a general surgeon. See, I predicted exactly what’s going on. I don’t even know. Look at that. Yeah, E P T F E Mesh is highly, highly resistant to any treatment. When it gets infected, you have to remove that and you can’t leave parts of it in. All of it needs to come up because that Mesh, it’s like, I don’t know how to explain it, but of all the meshes that has to be removed, if there’s an infection, even staring at it because it gets infected. So if there’s infection nearby, so if that has become infected for whatever reason, then you have to remove all of that, that Mesh.

Speaker 1 (44:41):

Please contact me directly. I’m happy to help figure this out for you. And for those of the U in the UK. Me, I don’t know if you saw my posts this past month or two. I was in the UK last month and let me tell you highlight of my life. I am in love with England. I haven’t seen Wales or Scotland, but London was amazing. Manchester was great. I met so many great patients there as well. I kind of want to move to London. I don’t know if you guys know of a way where I can penetrate the medical system there. I would love to come to the UK. That was an amazing trip. I’m definitely going back again. Could you please offer more guidance on the infection issues please? Yeah. So all surgery areas are at risk for infection. It’s just a relative risk.

Speaker 1 (45:40):

So a clean elective operation in a thin healthy patient that’s not diabetic and doesn’t smoke cigarettes, likely will not get infected by an obese patient. Emergency operation, large hernia use of Mesh, diabetic smoker, higher risk of infection. So let’s say you got an infection and the Mesh is therefore infected for whatever reason. If it’s a low profile thin Mesh every so often you can save those because you can clear the infection off of it. That’s one ex extreme. The other extreme is E P T F E Mesh. That is a heavyweight non-porous Mesh. You cannot salvage E P T F E ever. That must be removed. And if it’s not fully removed, you’re at risk of leaving infected Mesh behind because once one piece is infected, the bacteria will walk all over the rest and you may have what’s called a chronic infection. So you may not have an acute infection when there’s pus pouring out, but you may have a chronic infection when you’re tired and you get headaches and weird joint pains and you just don’t feel well.

Speaker 1 (46:55):

And you may have feel hot but not really have a fever. And that’s because you have a piece of Mesh in you that’s an implant that has bacteria on it that your body is constantly attacking and trying to prevent from growing. But it’s a constant battle between bacteria and your body. And that can cause like a chronic fatigue syndrome, difficulty sleeping, et cetera. What is the metric for large hernia? Is there a size and centimeters or inches that surgeons follow to? Well, most large hernias are hernias that have completely distorted the anatomy in the area. So you can have a hole with stuff going through it, but the rest of the anatomy is fairly maintained. But once it distorts the anatomy, then that’s concerned large. So in my book, a large Inguinal hernia would be one that goes down into the scrotum. A large abdominal wall hernia would be one that’s not only visible but has skin changes over it or measures well over six centimeters. But there’s also extra large and giant, in which case it’s like, you know, don’t need explanation for those. But that’s how I explain it. There’s no standard by which we use the word large, what I think is large may not be large to some other person.

Speaker 1 (48:21):

I know a plastic surgery friend of mine was like, oh my god, the largest hernia repair. I know he showed me a picture who was like, besides maybe a golf ball at the most. I’m like, we don’t consider that large, but okay. All right. What is the data on long-term use of P T F E Mesh? Is it safe a decade from placement? Yes or two, is there any data on what happens long term? It actually works really well when it goes well. What does one do if this fails 10 years from the placement, you have another hernia repair. What do the surgeons do in those cases? So P T F E Mesh became all the rage and was specifically invented in order to be able to do laparoscopic her repairs specifically in the abdominal wall because it was the only Mesh that could be placed where it would not stick to the intestines.

Speaker 1 (49:16):

That’s the IPOM or Intraperitoneal Onlay, Mesh technique, I P O M, Intraperitoneal Onlay Mesh. So the laparoscopic boom for the abdominal hernia repairs was made possible because of the company Gore, W L Gore inventing this E P T F E Mesh. It worked very well. The issues with it were number one, very heavyweight number two, highly Rives resist resistant or susceptible to infection number three, it shrink a lot of some studies show up to 40%. So if you put in a match that you think is the right size, it’ll shrink. And then when it shrinks, it now is too small of a size, so recurrence rates can occur. So if you have a recurrence at let’s say 10 years in this patient’s situation, then you have to go in there, have the IT repaired. We usually do not remove Mesh if it’s not in the way of a rerepair, but sometimes the Mesh is in the way and we remove that Mesh and replace it with a new one.

Speaker 1 (50:19):

We really don’t use E P T F E Mesh that much anymore. I know that it’s used in the chest because you don’t want Mesh sticking to the lung. So if you have a chest wall hernia or a diaphragm hernia is often repaired with E P T F E Mesh. Some surgeons still use it. It’s really not considered a high volume situation. Does a chronic indolent leukemia that has not progressed over many years and is not associated with anemia or decrease in granulocytes increase infection risk to a large degree? No, it does not. If you don’t have any obvious abnormalities in how well your white blood cells work and you’re not on medications to suppress leukemia, which would affect your healing, then you should be fine. There are patients there that have leukemia that’s just like they’re just observed and they usually do well, I have a diagnosis of autoimmune chronic fatigue syndrome, myogenic encephalitis.

Speaker 1 (51:29):

Yeah, that can be due to your Mesh possibly, or it can make you more likely to react to your Mesh. I’ve never had a hernia though. It wasn’t of the abdominal pasty and prolapse operation together. So prolapse is considered in the hernia world and the, I’m not sure why you had the abdominal pasty that’s usually not hernia related. Is a 15 by 15 centimeter Mesh large? I would say it’s a medium to large. I’m petrified not knowing what I have inside me. Well, you need to see a specialist to help you with that. Was P T F E the only type of Mesh from W L Gore or were there other similar? No, they only made P T F E based meshes at that time. They now have a wider area of meshes currently. As far as I know, they only had ptfe. They had different sizes and they had different shapes and they also had oval versus rectangle.

Speaker 1 (52:32):

And then they also had, some of them had a one side that stuck more to the muscle better the other side that was less likely to stick to organ. So if you had a prolapse surgery, it’s possible that you had that in you so that your organs, like your rectum and bladder and maybe uterus, usually uterus is gone with that surgery. Do not stick to that. And do you have contacts over in UK Manchester? Yeah, look at the British Hernia Society. The British Hernia Society is online. You can look at those people and you can go to hernia talk.com and see what surgeons specifically in Manchester or nearby, just Google, just search for the words on hernia talk and see who can help you for that. Wow. We’re really running through a lot of questions, guys. Like my mouth is getting dry. This is crazy.

Speaker 1 (53:36):

All right, let’s go back to some more questions. Let’s see. All right, next question. Apart from the advantage of not taking too much time off from work and the disadvantage of ruining your holiday because you’re in recovery, are there any hidden pros or cons of having surgery during the holidays? Good question. So I think the pros of operating in the holidays is purely a scheduling issue, like family’s available. Maybe your responsibilities are less and potentially it’s financially more feasible to do it during the holidays. Other than that, I don’t see a benefit of doing any surgery during the holidays because like you mentioned, your surgeon may not be available, your medical Dr. may not be available. Some specialist you may need may not be available. So I’m not a big fan of specifically aiming to have your surgery during the holidays. I know it’s, it’s got it’s pros, but if you can find another time in your schedule to do it, I would just do it.

Speaker 1 (54:52):

Then when you know your surgeon’s in town and you know that your medical doctor, for example, is available and definitely need to have surgery when you have a support system around you. So what you don’t want happen is delay in care because one aspect of your care, whether it’s social worker, the nurse, the pharmacy, sometimes pharmacy’s not available. You don’t want any of them not available. What is the best synthetic Mesh for inguinal hernia in your opinion and experience? I can’t say there’s any best synthetic Mesh. We are heading towards lower profile, lower weight meshes, but two low weight is also not good. So we used to have what’s called ultra low weight that we don’t use anymore. So we kind of use low weight meshes.

Speaker 1 (55:53):

The shape is important. I’m a big fan of making sure the shape is appropriate to the patient’s anatomy and you want to make sure it’s doesn’t shrink too much. So usually the lesser weight meshes don’t shrink as much as the heavier weight meshes. And ideally one day we’ll have a Mesh that isn’t stiff and can stretch a little bit with your own tissues. We don’t have that right now. Ideally we’ll have a Mesh that doesn’t leave that much of a inflammatory potential. We don’t really have that right now. So we’re still making better meshes. Definitely today’s meshes in general are better than yesterday’s meshes, but there’s some concern that some companies have chosen a cheaper route and that’s been to the detriment of the patients. So we don’t know. It’s one of those things where I always ask for a lot of patients from our patients because you think that everything’s perfect now we know everything, but we don’t know everything.

Speaker 1 (57:03):

And the reality is we’re constantly improving. We don’t know everything. And I feel some patients want to hold us accountable for not knowing things and we just don’t know. Goodnight from the UK. Thank you very much. Goodnight to you. Maybe I can visit UK again. Definitely. That’s something in my horizon I hope. What weight restrictions do you give to your patients for ventral hernia? So diastasis repair and abdominal wall reconstruction long term, the lower the weight, the better to an extent. So we go by B M I, which is body mass index, definitely under 40 kilograms per meter squared, ideally under 35 kilograms per meter squared. And if you can be normal weight, which is under 30 kilograms, you will have the best outcome. And specifically if you’re looking for diastasis recti, that will dramatically slim your waistline, which means you have to lose so much weight to be able to tighten that up because you’re competing with the fat inside your abdomen around your intestines if you don’t.

Speaker 1 (58:15):

So if you can lose the weight to get your fascia loose enough to be able to tighten it, then that’s the ideal. And that’s usually a BMI under 30. And that’s a lot of questions, guys. I love it. I love it, love it, love it. And I’m really enjoying today’s today’s session because it’s all these great questions. All right, so that’s the end of it. Thanks everyone for joining me. It was a great Tuesday night. Let’s see, the other question, I meant lift restrictions. Oh, I don’t restrict anyone. No lifting restrictions, but if you’re having a diastasis repair, your plastic surgeon may have restrictions at up to six weeks of no lifting till six weeks, like five pounds or more. All right. That’s it. Thanks everyone. Trying Hernia Talk Tuesdays. We’ll have another fantastic guest next week. You’ll love him. He’s great. Thanks for following me at Hernia Doc on Twitter and Instagram. Please subscribe to my YouTube channel. This and all the others will be posted up there every week so you can watch it and share. And thanks for following me on Facebook at Dr Towfigh. And if you’re on Facebook Live, I’m going to say goodbye now. Take care.