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Speaker 1 (00:00:10):
Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live, our weekly Q&A. My name is Dr. Shirin Towfigh. I am your hernia and laparoscopic surgery specialist. Thanks to everyone who’s joining us live on Facebook as well as on YouTube, sorry, excuse me. Also on Zoom and later on you can watch this on YouTube. And thanks for also joining me in the conversations on Twitter and Instagram at Hernia doc. So I’d like you to introduce you, our guest for today. His name is Dr. Salvatore Docimo. We call him Sal. He is a bariatric surgery specialist, but he also treats a lot of hernias. He is based in Tampa, Florida at the University of South Florida. And I’m super excited. We were like talking behind the scenes so much we had to stop it to start our Hernia Talk Live because we were having so much fun just talking back and forth. So we’re going to continue the conversation with you all. So as always, feel free to submit your questions. We have about a dozen questions already submitted beforehand, which we’ll try and go through. But welcome Sal. Thank you very much, so much for joining me. I appreciate it.
Speaker 2 (00:01:18):
Oh, my pleasure. Thank you for the invite and very excited to be here. Excited,
Speaker 1 (00:01:22):
Thanks. Yes. So Dr. Docimo is very well known in our field. He is technically trained in not only minimally invasive surgery, which includes hernias, but also bariatric surgery, which involves weight loss surgery. So that’s why the topic for today’s session is obesity and hernia repair because it’s, as you know, if you’ve followed hernia talk before or done any reading, that obesity is one of the main risk factors for incisional hernias and for actually, is it a risk factor for regular hernias or just incisional hernias?
Speaker 2 (00:02:00):
I would say obesity.
Speaker 1 (00:02:00):
Different studies show different thing, everything.
Speaker 2 (00:02:03):
Obesity’s a risk factor for all types of hernias. Yeah, kind of a, it’s kind of a global disease. And the reality is that any part of your abdominal wall where any really, any hernia that can occur, can really, obesity can have a negative effect on it, whether it’s incisional, even inguinal, even hiatal hernias. We do
Speaker 1 (00:02:22):
Hiatal hernia. Yeah, that’s another one.
Speaker 2 (00:02:24):
Yeah. So I think as we dive deeper into the data, obesity is a global disease that affects every part of your body, every system. Negatively. Negatively. So
Speaker 1 (00:02:34):
What is a definition of obesity? We’ll start with that.
Speaker 2 (00:02:38):
So the easiest way to really, that most people have used or define obesity is really looking at your body mass index. So what is that? That’s really just a ratio between your height and your weight. And the reason why we had to create this ratio is if we think of a great example, I always give because everyone knows who he is. But if you look at Shaquille O’Neal, right? The famous basketball, he weighs over 350 pounds. So if I told you that I have a patient 350 pounds, everyone kind of scoffs. But the reality is because he has such a significant height, he’s over seven feet tall. When you look at his B M I, especially during his playing days, it was actually pretty low. It was actually below 30. But so that’s why we had to create this index to get a better idea of what obesity is. So BMI is again, the ratio between your height and your weight and the reality, and again, there’s a huge spectrum of obesity. So when we start getting to the BMI of 30 fives and forties, when we start entering into the phasix of morbid obesity as bariatric surgeons, our biggest cutoff is 40 because anybody who has a B M I or 40 or more is going to be a candidate for surgery of some type of bariatric surgery, regardless of what their comorbidity is. That’s
Speaker 1 (00:03:53):
About 60, 70, 80 pounds overweight.
Speaker 2 (00:03:56):
Yeah, over their ideal weight. Exactly. Yeah. And then when you start getting down to a B M I of like 35 to 40 is when we started looking for comorbidities, hypertension, diabetes, obstructive sleep apnea, et cetera. So this is kind of our significant cutoffs that we currently use. And what’s really interesting topic, even more so is that now in the world, we know that obesity is a much larger problem than what we currently are using in A S M B S such, which is one of our national organizations for weight, is actually looking to lower the indications for surgery, even lower, going toward a B M I of 30 or higher because we know that it’s such a significant problem that it doesn’t make much sense for us to wait until the problem gets out of hand before we start helping patients. So true. So
Speaker 1 (00:04:50):
Those literature supports the cutoff being 40, which means really after 40 it’s best not to do elective hernia repairs, but you really don’t want to do it on a B M I of 39 either, right?
Speaker 2 (00:05:03):
Yeah. And what’s what, it’s kind of blurring a little bit nowadays, what does that mean? Some of the research I published on previously, we actually looked at component separation and open surgery. So that means making a really big incision. And when we’re doing really complex hernia repairs, component separation repairs, and we actually found that when individuals and patients hit a BMI of 35, that was our cutoff because when the patient’s BMI got 35 or higher, they were at a much higher risk of getting surgical site infections, which is really an indication that you’re probably going to get a hernia back. So for open repairs it was even lower. And our data was even validated by another additional study that came out, I think a year or two later, or even larger study. So 35 in open hernia repairs is probably what’s been kind of hovering around there for quite some time. Okay.
Speaker 1 (00:05:58):
Yeah, I think 30. Yeah, so 34, 35, 36. In that range, we as surgeons feel a bit more comfortable operating and especially some people carry it not necessarily in their belly a lot, so it’s more representative of a safer population. So the first question actually submitted is what is the optimal B M I for a non-emergent ventral hernia repair? So really 35 or below if you want to have a good outcome, no infections and well lower risk of infections and lower risk of wound problems. And a good secure repair under 35 would be much better than 35 to 40.
Speaker 2 (00:06:37):
Agreed. Yeah, agree a hundred percent. And it’s kind of interesting because people was like, well, why? What’s the problem with obesity anyway? Right? Yeah. So the problem is you mentioned that anytime, well, you have such people who are in general, people have higher BMIs start to get a larger abdominal wall or they get a larger panis. So that panis is primarily composed of what? Fat tissue. It goes from the AB wall, then you have the subcutaneous tissue, our belly, and then our skin. So when we make these large incisions through the tissue and we try to get down to the musculature, which is where we do our hernia repair, the problem then arises with two main things, right? Because there’s such a huge distance between the muscle and then the skin. You have all that fat tissue, which is not, doesn’t hardly have good blood supply. When we try to close these areas, they don’t heal very well. They’re prone to infection. And again, even when you get an infection, antibiotics don’t really work that well because it’s hard to get from that blood supply to the skin where the infections, right?
Speaker 1 (00:07:39):
So there’s tissue in between.
Speaker 2 (00:07:41):
So that’s why all this makes sense to us from an anatomy type of perspective and how we think about it.
Speaker 1 (00:07:48):
The next question is, if a person has a hernia repair and then loses weight after the repair, will that help the outcome as well?
Speaker 2 (00:07:58):
I tell my patients any type of weight loss that they get will have a benefit. So it depends on how high your B M I is, but the more weight that you lose even right after a hernia repair, the better your outcome. Because the long-term effects of that, again, you’re going to have less tension on your abdominal wall. In terms of surgical site infections, I think probably doesn’t matter. And the reason why is because the reality is to go from a B of 40 to 35 in such a short period of time after surgery. Yeah, it’s really not possible. You’re talking about 20, 30, 40, 50 pounds. Yeah. So the reality is you, if you’re going to go for a surgery in that media post period, you want to have already have your B M I really low or below 35, I would say. Yeah.
Speaker 1 (00:08:46):
And I would say most of the real failures occur early after surgery. Yes. That occurred two or three years later. So the highest rate of recurrence occur early. So that’s when you really want to be optimal with your weight loss.
Speaker 2 (00:09:03):
Yeah, that’s the whole reason that we always say we want to optimize the patient as best as possible before they even get to their hernia repair, which includes obviously weight loss.
Speaker 1 (00:09:12):
And then the question that was submitted before is, okay, now that I’ve lost the weight, how long do I have to keep it off after surgery?
Speaker 2 (00:09:20):
The doctor answer to that is forever. Right. Always. I mean, that’s the true and the correct answer. Yeah. Because obviously you’re going to lose all this weight. We want to get you optimized, and then when you go for surgery, and as you just mentioned in the immediate post-operative periods where some of those hernia occurrences do occur. Okay. Yeah. The problem is if you start to gain a significant amount of weight after your surgery, even if you have a small recurrence, we know that as patients start to gain weight, that actually can propagate that little recurrence to grow and grow and grow over time. So it actually even puts you a higher risk of getting that little recurrence increasing over time as well.
Speaker 1 (00:10:02):
And every time you recur, you’re losing tissue in the process. So it’s going to be an even bigger hole usually. Exactly. In the original. Yeah.
Speaker 2 (00:10:11):
And how does all that work is because we know that as time goes on, people start to gain more weight, it actually puts a significant strain and tension on that abdominal kind of abdominal core area, the abdominal wall. So there’s issues there. Yeah.
Speaker 1 (00:10:25):
This is a good live question. How do you adjust BMI for one’s frame, large, medium, big boned, muscular people, and then male versus female? Do you just eyeball them? I mean, is it like an eyeball thing?
Speaker 2 (00:10:41):
No, no. So it’s kind of a great question. Yeah, great question. And the answer to that is we really can’t account for frame. People always like, well, I’m kind of big boned and stuff like that. We unfortunately don’t have, I think
Speaker 1 (00:10:56):
I’m big boned, I attested that.
Speaker 2 (00:10:59):
So we can’t accommodate for it at the moment. So the reality answer to that is B M I is our current indicator that most of us that we use, is it the best one? No. For those reasons you just mentioned, it’s hard to accommodate for where the weight is dispersed, where it is, if people have larger frames or not, things like that. It doesn’t really take into account. What’s even more interesting is that we’re start, we’re kind of rethinking what is the best indicator for obesity. And we’re, what we’re kind of looking at is we’re looking at other things like CAT scans, something called visceral adiposity. Visceral adiposity is just a clever term for basically the fat around your organs. And what we’re starting to see is that visceral adiposity is probably down the line going to become a much better indicator of true obesity than what we’re currently using, which is B M I. So kind of
Speaker 1 (00:11:57):
Interesting. Do you refer that as in terms of obesity, the disease or obesity, the growth which you have to fight to be able to fix the hernia? Do you know what I mean?
Speaker 2 (00:12:06):
Yeah, I I think it goes hand in hand. Right, okay. Because it’s kind of interesting as well. Cause when we look at, some people have done lab studies looking at adipose cells and they’ve actually demonstrated in the lab, so bench work, things like that, that people are doing in a lab, but they’ve actually found that obesity and adipose cells actually cause a significant amount of inflammation. So inflammation, especially when you’re talking about wound healing, when you’re putting an abdominal fall back together. So if you have a big hernia and you’re putting all the tissue back together, the last thing you really want is to have a significant inflammatory process going on because you’re not going to get the proper healing that you’re looking for, which is probably going to weaken your repair. So when we talk about things like fat around the abdomen, when we talk about actually fat inside the belly around the organs, this all has a significant negative effect because it does create this pro-inflammatory environment which you’re trying to allow something to heal.
Speaker 2 (00:13:07):
Obviously when you want wound healing, there’s a little bit, there’s always some level of inflammation with wound healing, but you don’t want it so out of control that it actually prohibits wound healing from happening. So it’s actually really kind of fascinating what happens that people think, well, I’m just heavy and et cetera, but there’s actually a microbiological thing going on with these fat cells. So that’s why we’re saying that even B M I, which is not a good indicator of BMI of fat, when you look at viscera posse, that may be a better indicator because it actually be, it’s a better indicator of more of that proinflammatory state, which again, won’t let your hernia heal very well.
Speaker 1 (00:13:45):
Okay. Really. So this is the next live question is in that same realm. So there are two ways. Fats dis is distributed pear versus apple shape. So pear is where you mostly in the hip, upper body is, is smaller. And then the apple shape is where it’s kind of centrally obese around the belly. Some people with metabolic syndrome have more Intraperitoneal and visceral fat than subcutaneous fat. So fat around your intestines as opposed to how many inches you can pinch. Yep,
Speaker 2 (00:14:15):
Exactly.
Speaker 1 (00:14:16):
What are the different surgical problems and complications between patients with the pair versus the apple, the amount of you carry in your belly versus the amount you carry in your skin?
Speaker 2 (00:14:30):
Fantastic question. Yeah. The answer to that is I don’t think anybody really knows the definitive answer to that. So I think, again, when we talk about doing bariatric surgery, and the reason why is again, is we don’t have a really good, there’s no study saying, Hey, does patient with pear shape versus the other types of shapes of body, body shapes, does that have negative impacts? The reality is that when we do all these studies, the best indicator that we have right now is body mass index. So we just can only go on B M I when we try to figure out what are the complications. My personal experience is it doesn’t really matter in all honesty. And the hon, I’ll give you an honest reason why, is because as we’ve moved on in terms of perfecting our surgical technique, whether it’s laparoscopic, laparoscopic, or even robotic, once we get it, once we get into the abdomen, for the most part, certainly when we’re doing robotic weight loss surgery, that body wall, that body habits doesn’t really affect our outcomes in terms of our surgery or how easy it is for us to do. So the other things that normally come into play, wound healing, the comorbidities of the patient, all the stuff that can affect the healing of staple lines when we do a sleep, all that is really, it’s kind of irrelevant in terms of what your body shape is as far as we know. As far
Speaker 1 (00:15:51):
As we know. As far as we know. I mean, back in the day when I was a medical student, they were saying that it’s better to be payer than apple shaped because from a cardiovascular standpoint, less people have heart attacks or cancers even. I think heart attacks was the thing. If they don’t care if they don’t have central obesity, yes, there’s some people that are super thin, legs are thin, arms are thin, and then they got huge kind of midsection and that seems to be more of a cardiovascular risk factor. Then people with the same B M I that carry it in their hips.
Speaker 2 (00:16:25):
Yeah. Well that kind of goes back to what we’re talking about, right? Yeah. That central obesity, again, when we look a little bit further in detail is probably where when people have central obesity, I think they’re more likely to have the higher level of visceral adiposity. And that’s where all that comes in with how can we better measure obesity. Getting a CAT scan and measuring the volume of frat around an organ is probably going to be a much better indicator of comorbidities than something just that’s kind of generalized as a body mass index. And this is why we’re all trying to work on trying to find a better indicator. Cause we know BMI is not the best measure obesity, so we’re trying to find other ways of doing it, but that’s true. Yeah, central, that central obesity just goes back to what we were just talking about, that visceral adiposity, the fact that’s actually within your abdomen around your organs is a lot more detrimental than somebody who has less visceral adiposity.
Speaker 1 (00:17:19):
I think with the new AI, all this kind of artificial intelligence, they’re probably going to be able to take a picture of you and say, based on your configuration, they’ll give you more input than just the sub BMI. Don’t you think? I feel like we’re going to be heading toward that way.
Speaker 2 (00:17:35):
Definitely. I mean, that’s kind of, these are the things that we’re working on actually with Exactly, with the radiology. So when we have CAT scans of patients, we can just take, if we take the same cross section for every patient, we can actually it in a computer system now, and it’ll actually let us know what is the true volume of fat in that patient’s abdomen compared to the other pictures of all the patients. So it’s happening. I mean, it’s happening. And I think, yeah, I agree. I think surgery has gone through so many evolutions. We went from open surgery to laparoscopic, which we’re probably going through now, you know, can even say robotic, and the next stage of revolution is going to be artificial intelligence. Yeah, yeah. Kind of. Cool.
Speaker 1 (00:18:18):
Very cool. Okay. Keeping all the same topic, does having a large amount of Intraperitoneal fat versus subcutaneous fat complicate laparoscopic access? Either tap or tap? How’s that for a question from an audience?
Speaker 2 (00:18:35):
That’s a great question. That’s kind of a double edge sword. And what do I mean by that? We always talk about, especially when we’re doing a tap repair, like a pre peritoneal, when we try to get into that pre peritoneal plane. Yeah. Surgeons when they see, oh, there’s actually a nice little fat plane here, right? When you
Speaker 1 (00:18:56):
Get, yeah, it’s
Speaker 2 (00:18:56):
A buffer fat you get, it’s a buffer. It’s a buffer from, you know, don’t shred the peritoneum, things like that. So I think for the most part, it’s kind of a balancing act. But the reality is, in my opinion is we want the best optimization is to get you to lose as much weight as you can. Does it make the surgery a little bit more difficult? It’s hard to quantify, but from my perspective, I don’t really think it matters in the long term. So it doesn’t matter. I think once we optimize them, once we get their weight down as low as possible. Yeah. I think for me, I can do the surgery whether the BMI is 30, 32, 33, so haven’t that, this is all kind of just hearsay and our it’s dogma. Yeah. But quantifi answer to that, that’s a great question. I mean, it’s a fascinating question.
Speaker 1 (00:19:46):
So lap, we in general, laparoscopic or robotic is favored over open for patients that are obese, right? Definitely less wounds, definitely less. Definitely less to heal externally, less infection rates. Do you find that robotic is superior to lap for the morbid obese or vice versa?
Speaker 2 (00:20:06):
So let’s talk, we’ll separate that into two questions, right? Yeah. Two parts. Okay. First part, bariatric surgery, and again, this is my opinion. I know our poly anger some people by saying this, but in my opinion, I would never want to go back and do laparoscopic, laparoscopic weight loss surgery ever again.
Speaker 1 (00:20:23):
Oh,
Speaker 2 (00:20:24):
Really? So my entire practice from a bariatric perspective is all robotic.
Speaker 1 (00:20:28):
Wow. Okay. I haven’t
Speaker 2 (00:20:30):
Done, I really haven’t done a lot of, I have
Speaker 1 (00:20:31):
Questions about that.
Speaker 2 (00:20:33):
I haven’t done a lap robotic bariatrics procedure in probably almost going on well over a year now. So I’ve completely converted to all robotic. And I’ll tell you why. Because when, once you get your ports into the abdominal, once you get your reports in position, yeah. The robot, it’s irrelevant in terms of how thick the abdominal wall is, what the strain is on the robot. The robot is what gives you the benefit to be extremely precise. And let’s be honest, right? We are human beings. As a day goes on, when you’re working against a BMI of 50 60,
Speaker 1 (00:21:08):
So hard on your body,
Speaker 2 (00:21:09):
Get that right. By the time you get to the end of your day, you are physically exhausted. Yeah.
Speaker 1 (00:21:14):
So shoulder, neck, horrible back. Exactly
Speaker 2 (00:21:17):
Right. So when you talk about the robot, once supports are in position, it, it’s almost irrelevant what the B M I is in terms of me doing my work. The only negative drawback is it goes into the fact that as the B M I, in some patients, as your B M I goes up the visceral adiposity increases, which makes things a little bit more difficult. But at the end of the day, I told you I would never go back and do a lap weight loss.
Speaker 1 (00:21:41):
You were never trained during the open bariatric surgery, I assume?
Speaker 2 (00:21:44):
No,
Speaker 1 (00:21:44):
No. I was,
Speaker 2 (00:21:46):
Yeah, exactly.
Speaker 1 (00:21:47):
That was really bad on your body. Cause
Speaker 2 (00:21:50):
I could imagine not
Speaker 1 (00:21:51):
Only did you have to be able to reach the wound, which is much further away from you than normal, but they didn’t have the beds that they have now. So operate on a normal patient bed, which is twice or three times wider than a typical bed for the operating room. So you’re even further away. And I’m telling you, as a resident, finally, and we were such high volume for these open surgeries, I finally told my attending, I’m like, Chris doing a lot of work and it’s really hard on our body. He’s like, well, I appreciate you. I said, could you appreciate us some more? He’s like, how can I help? I said, maybe a massage certificate
Speaker 2 (00:22:30):
Or something.
Speaker 1 (00:22:32):
And I was joking, but I wasn’t joking. And he actually gave us massage certificates because it was so hard on our body, so hard, even
Speaker 2 (00:22:41):
Though just I could just imagine retracting. I mean, it probably took a couple hours to do the case. So if you can imagine just pulling out a system wall. That’s right. I
Speaker 1 (00:22:51):
Mean, yeah, we had a system, but it was very hard on our body. So I’m going to push back on you a little bit. So yeah, the issue I have with robotics is the robot is very strong. Very strong. And some surgeons move those arms much more violently than others.
Speaker 1 (00:23:14):
Yes. When you are doing an operation on a bariatric patient, a hundred percent agree on the surgeon’s body, it’s so much easier because you don’t feel it anymore. You’re just on the robot. But I feel that maybe the risk is when you’re the surgeon doing it laparoscopically. Two things. One is you can move the instruments to be in line with how you need to operate as opposed to perpendicular, and that’s less torque on the abdominal wall. You can also use smaller instruments if you wish to, not necessarily eight millimeter, but if you do it robotically, the way the trocars are placed and the amount of torque the robot is placing on the patient’s abdominal wall, I feel is a lot of injury. No,
Speaker 2 (00:24:06):
I think you’re No, I, you’re, you’re definitely correct. So why do we know this? How do we know this to be fact? Because what we saw initially, especially in robotic surgery, I’ll give you an example. We use these different sized robotic ports. So you have most commonly, nowadays we use an eight millimeter robotic port and then use a 12 millimeter robotic port. Right. So what we see is that an eight millimeter robotic port, you have to be careful exactly what you said when you put these ports in on the robot, when you’re working on it, I really cannot feel, you can’t feel the tension, you can’t feel how much torque is on the AB wall at the end of the case. You have to be really diligent to go back and actually look at the ports because as time throughout the case, as this port is moving up and down left and and you are twerking, pulling
Speaker 1 (00:24:51):
On the tissue,
Speaker 2 (00:24:52):
Yeah, pulling on it, you are causing local damage there. And sometimes that eight millimeter port can increase in size to a 12 meter port, which can put you at risk for additional hernias. Yeah, this is very true. So
Speaker 1 (00:25:04):
Has that been shown to have more cord site hernias?
Speaker 2 (00:25:09):
Yeah, I don’t, don’t know. Not that I, none that’s shown
Speaker 1 (00:25:11):
Interest, not that I’m aware of.
Speaker 2 (00:25:12):
Interesting study that we could do.
Speaker 1 (00:25:13):
Has it been shown to have more pain?
Speaker 2 (00:25:16):
No, as far as I know, no. I mean, we all pretty much, but I’ll give you an example. Like I said, I always look at the ports at the end of the case. I will kind of gauge them. I personally close all my 12 millimeter robotic ports. I’ll put a suture through it. I will close that port. I’m obviously a little bit more paranoid probably than most about hernias, so I close all of them. We
Speaker 1 (00:25:38):
Like paranoid
Speaker 2 (00:25:39):
Surgery. Exactly. That’s what we like. Right. And the fact that I do hernia, I’m well kind of aware of it. Yes. So eight millimeter, eight millimeter robotic ports, you have to look at the port, you have to understand what it looks like before and after. So if I see that the eight millimeter robotic port is increased in size, I will also close that. And I’ve unfortunately, we’ve seen that. We’ve seen some patients come in with portside hernias and they’re always like, oh, well I was using an eight mill report, I don’t understand. You’re not supposed to get hernias. But the reality is, probably throughout the case, it increased in size and upward hernia.
Speaker 1 (00:26:13):
So this is pre robotic, but we looked at all of our patients who had portside hernias after bariatric surgery. And one really interesting thing we found was if they presented to the ER within 21 days of the surgery, it was always an incarcerated or a strangulated hernia. Whereas after 21 days, it was just like, yeah, I have a hernia. But it wasn’t an emergency. So
Speaker 2 (00:26:36):
Oh, I believe early.
Speaker 1 (00:26:37):
Yeah.
Speaker 2 (00:26:38):
Yeah, definitely. Definitely.
Speaker 1 (00:26:40):
Okay, this question’s about tissue repair. So what is the optimal BMI for hernia surgery? We kind of discussed that. And what is the maximum BMI you should have if you want to maximize the changes of the, we’ll maximize the opportunity of getting a tissue-based repair?
Speaker 2 (00:26:58):
Excellent question. So those are a couple things on that. So probably the most common and probably the most utilized tissue repair. Now again, tissue repair is a small, very small percentage of my own practice. But yeah, tissue repair repair, yeah,
Speaker 1 (00:27:13):
Umbilical hernias, right?
Speaker 2 (00:27:15):
Yeah, yeah. Umbilical hernias. And then even when you talk about inguinal or hernias, right? Yeah. So hernias probably the most common one that’s performed now, that’s probably a Shouldice repair. And again, it’s a tissue-based repair. You have overlapping tissue, overlapping suture lines. So a Shouldice repair has been probably one of the most studied by a center called, literally called the Shouldice Center. Shouldice Clinic. That’s where it originally from. Okay. Yeah. So they have excellent outcomes, very good outcomes. They do a great job. This is all they do at their hospital, but they are very particular in terms of who they choose to undergo the surgery. Yes, correct. What does that mean? That means that they
Speaker 1 (00:27:54):
Refuse to operate on anyone that’s obese.
Speaker 2 (00:27:56):
Exactly right. So now their BMI cutoff, I’m not intimately aware with it, but I can tell you well under 30 most likely, just from, I can see the patients that have the repair. So yeah, so when you’re talking about tissue-based repairs, you know, have to have a BMI that’s significantly low, probably well below 30 in order to have a positive outcome. So in patients, so anybody who comes to my clinic who says, and they say, Hey, listen, I have an inguinal hernia repair. I want to get it repaired. I don’t want Mesh, I want a tissue repair. They have to have a B M I below 30. They have to be pretty skinny to get that because the reality is I can probably do a tissue repair and a higher BMI, but it’s going to fail.
Speaker 1 (00:28:39):
And then you’re stuck with even worse problem.
Speaker 2 (00:28:41):
Exactly. So we do know that, and anybody with a higher BMI, let’s say if they have a BMI of 33 and they have hernia, they’re going to get a Mesh repair all day long. I won’t do a tissue repair because I don’t think it’s the right thing to do. And again, the Shouldice clinic who are the world experts in this tissue-based repair, they know that and they understand, and that’s why they’re very particular in who they operate, which is always a low B M I. So yeah.
Speaker 1 (00:29:04):
What is the maximum BMI you consider safe for performing hernia surgery? Well, that’s a hard question. That’s
Speaker 2 (00:29:11):
A hard question. And why is it? Because there’s so many variables that go into, but if
Speaker 1 (00:29:15):
You have a B M I of 60 and they’re with incarcerated hernia or strangulated hernia,
Speaker 2 (00:29:22):
You have to, in those situations where, so let’s say a patient has a B M I of 55 or 60, and they come through the emergency room and significant incarceration obstructions or even strangulation where the bowel is dying. In those situations, as a surgeon, you got to do your best. You have to go in there, you have fix the bowel injuries. In terms of the hernia. In that specific situation, what I would probably do is just, you know, want to live in, to fight in, you want to live another day, you want to fight another day. So what do you do? There’s a couple options you could do, just do a tissue repair. Maybe you can put some type of prophylactic Mesh and something absorbable maybe in nature, but you don’t want to burn any bridges. I would never do a formal repair on A B M I in that situation, like a component. I just would never do that. We know you’re probably going to have a complication, so you just temporize as best if possible, and you let the patient know you’re probably going to get a hernia in the next six months to a year. And then hopefully in the meantime you’re going to optimize ’em, get them to lose weight, and then eventually bring them back and do a formal repair. Now
Speaker 1 (00:30:26):
If so, am I 50 or 60? Let’s say you save their life, right? You do with life-saving operations, you deal with the bowel incarceration or strangulation, but you don’t give them a perfect hernia repair because that’s, it’s going to fail a hundred percent pretty much. Right?
Speaker 2 (00:30:41):
Exactly.
Speaker 1 (00:30:43):
Or like 99%, basically almost every situation, if you do a good repair, it’s going to fail. Yeah. So then do you talk to ’em about weight loss surgery?
Speaker 2 (00:30:54):
Yeah, I mean, okay. Exactly. So in my specific practice, so my training, I got additional training in weight loss surgery, as well as complex hernia repair. What does that mean? Probably component separation, those sorts of things. So in our practice, someone comes in with a much higher B m, let’s exam, same thing. We use that, I’ll give you an example of a B M I 50. So if they come
Speaker 1 (00:31:17):
In, so that’s like a 400 pound patient.
Speaker 2 (00:31:20):
It depends on what their height is. So a BMI of 50, like 400, maybe 5′ 10″, 5′ 6″, something like that. So if they come in with that B M I with a large ventral hernia, again, we know that any type of repair, you’re probably going to have an issue. So we have to move them toward some type of weight loss solution. In my particular practice, that means Bariatric Sur weight loss surgery. So I talk to ’em about the risk and benefits of weight loss surgery, and then we enroll them in our program, which on average is somewhere between four and six months. We get them squared away for their weight loss, their bariatric surgery. Once they get their bariatric surgery, then we have to wait somewhere between six months and a year for them to lose weight to meet their goals and for their weight to stabilize. Then we actually start talking about doing a complex hernia repair. So it’s a staged approach. And I would say probably in probably a hundred percent of these situations, the weight loss surgery that we’re going to do on them is going to be what’s called the sleeve gastrectomy. We try to avoid, we don’t want to do a bypass in those patients because the way that we organ reorganize the bound of bypass, they still have this hernia, which if the bowel incarcerates or strangulate, now you got a massive problem. You have a lifeguard bowel.
Speaker 1 (00:32:32):
Okay, sure. So
Speaker 2 (00:32:33):
Yeah,
Speaker 1 (00:32:34):
I’ve had patients that come to me and they say they’ve had, let’s say one or two or three failures, and part of the failure is because they, they’re morbidly obese and no one’s really addressed that part of it. And maybe some of them were emergency surgeries, so they really didn’t have a choice. And I say, okay, well there were stages you, I say, be patient with me, we’ll get you there, but you’re going to need multiple surgeries. One’s going to be a weight loss surgery, one’s going to be the hernia repair, blah, blah. And some of them tell me, oh, I’ve had so much surgery, I can’t imagine having another surgery. Yeah. How do you explain that to a patient that they need the weight loss surgery?
Speaker 2 (00:33:18):
So you have to have to just be honest with them. Yeah. I think that’s the most important thing. You’re just honest with the patient. You say, Hey, listen, obesity also along with this hernia, this is a life-threatening situation. So I think you explained in, let’s say the patient, let’s say the patient is having chest pain, they get a cath, right? The cardiologist takes some pictures of your vessels and they find that they have blocked arteries. I would say probably the majority of people will say, okay, I want you to fix my blocked arteries because that can probably kill me. I want to bypass or stents or whatever it may be. We have to basically talking to them on the same level with obesity in these hernia repairs, right? Yes. So because the reality is, this is probably in the same level in terms of how dangerous this is. Walking around with a significant hernia where they already had complications in a abdomen that is completely kind of distorted, and they have all this obesity. So we have to talk to ’em on the same level and say, listen, we can’t go in and do your hernia repair. Because if you have a major complication along with the fact that you’re obese, you’re probably going to have a, we’re talking about significant morbidity and even a mortality, a death
Speaker 1 (00:34:27):
Anesthesia’s not even safe each time when you’re morbidly obese.
Speaker 2 (00:34:31):
No, no, exactly. So we explain to ’em, say, listen, this weight loss surgery, it’s not aesthetic. It’s not a cosmetic, it’s a lifesaving procedure. We have to get you to the point where you are healthy again to get a surgery safely. So, and that’s the reality. I mean, it’s the honest truth, what
Speaker 1 (00:34:53):
We’re trying, and a lot of patients are like, no, I can do it. Yeah, I’ll do it medically. But to lose, let’s say a hundred or more pounds medically, it’s going to take years,
Speaker 2 (00:35:03):
Years,
Speaker 1 (00:35:03):
Years. Whereas with surgery, it’ll take within one year maybe.
Speaker 2 (00:35:07):
Yeah. There’s three, really three main options for these patients. So one obviously we kind of touched upon, which was weight loss surgery. The other option is going to be a really, really strict diet. We’ve some published publication, I think from, I want to kind of top of my brain here, but I think Cleveland Clinic published some material on very strict liquid protein diet for a couple of months where they just try to get their BMI down. So you’re basically talking about almost like a semi starvation, a super calorie restricted diet. That’s another option. And then your third option is going to be weight loss medications. Weight loss medications. Normally for me, I’ll refer these patients to a medical doctor who special
Speaker 1 (00:35:52):
Specializes,
Speaker 2 (00:35:53):
Who specialize in it, because every day, there’s so many medications out there. Right now it’s the
Speaker 1 (00:35:59):
Fad. Now
Speaker 2 (00:36:00):
It
Speaker 1 (00:36:01):
Is. I dunno about Florida.
Speaker 2 (00:36:02):
Yeah, it’s all,
Speaker 1 (00:36:03):
Everyone in LA it seems is on a medication, weight loss medication, ozempic, manjaro, everyone, all of a sudden you’re like, you saw him last week, you saw him this week. You’re like, are you taking that medication?
Speaker 2 (00:36:17):
I know, exactly.
Speaker 1 (00:36:18):
It’s pretty crazy.
Speaker 2 (00:36:19):
It’s crazy. And so I think for that reason, if you’re going to be on these medications, especially, you have to work closely with your medical doctor. So for us, luckily we have a medical doctor who’s in our practice, our bariatric practice, to who I can refer directly to, and I can tell ’em, Hey, listen, they don’t want to do surgery. They’re refusing surgery. Which is okay, I can’t force anything on anybody, but I still want to help ’em as best as possible. So I’ll put in my notes, I’ll say, Hey, listen, I need them to get to this B M I goal. Do your best, see if you can get them down there. If you can’t, send them back and then want conversation. But the problem with me, they’re medications, they are meds, so they can have negative interaction. They give contraindications or other cross cross contamination with other medications that you’re taking. So that’s why if you
Speaker 1 (00:37:06):
Were a BMI, if you were a B M I of 60, yes. Did you do the medication or would you do surgery?
Speaker 2 (00:37:13):
Oh, I would recommend surgery all day long.
Speaker 1 (00:37:16):
And if you were a BMI of 40 40, would you do surgery or do medication?
Speaker 2 (00:37:25):
That’s a tough question. Yeah. Obviously I’m a hammer and the patient, a obese patient is a nail. I’m being honest. So I’m a surgeon, so I, I’m going to operate. Right. But the reality, let’s talk, we can answer this question probably in a little bit more. So if we do the surgery, the long-term weight loss is probably better with the weight loss surgery. With
Speaker 1 (00:37:50):
The surgery
Speaker 2 (00:37:51):
For the medication. And I’m probably will anger some people saying this, but the reality is what a medication, when you stop the medication, there’s always a high risk of gaining all that weight back and maybe some more
Speaker 1 (00:38:05):
Okay. Within the first year. Right? That’s what I read. Yeah,
Speaker 2 (00:38:07):
Exactly. So I think that’s the conversation I have with patients when they say, well, can I just try the mental, it’s like, you can always try them. But the reality is for me as a physician, I think it’s better if you can lose the weight and keep it off as long as possible. With bariatric surgery, that is probably the way to go because do you really want to be on a weight loss medication indefinitely for the rest of your life?
Speaker 1 (00:38:27):
Plus if you have a hernia, and that’s why I need to lose the weight. Could you imagine if you lose the weight medically, then you have beautiful abdominal wall repair, then you gain the weight, then someone starts talking about surgery, but then they have to go through your Mesh or something. That would be horrible.
Speaker 2 (00:38:43):
Oh, definitely. Definitely. So this is the conversation I have with them. But if they totally refuse surgery, which again is their, I can only advise ’em as best as possible, but if they totally refuse surgery, I recommend them either to a strict diet along with some type of weight loss medications.
Speaker 1 (00:39:00):
Okay. How do you supplement the B M I value to keep into account for other factors? Oh, we kind of discussed this. I guess let’s go to the next question. Is surgery the only way to repair hernias or can it be fixed via diet or exercise?
Speaker 2 (00:39:15):
Good question. The easy answer to that is no. I tell patients, when I tell patients when they have a hernia, one of two things is going to happen with the hernia one, either it’s going to stay exactly the same, which is kind of unlikely, or two, it’s going to get bigger. So that’s the easy answer to that. Yeah,
Speaker 1 (00:39:33):
It’s like a sweater. It’ll either not lose shape or it’ll lose shape, but it’ll never get smaller.
Speaker 2 (00:39:40):
Exactly.
Speaker 1 (00:39:41):
Like a knit sweater.
Speaker 2 (00:39:43):
Exactly. Yeah. Yeah, exactly. So yeah, unfortunately hernias are, you know, got to fix them for the most part.
Speaker 1 (00:39:50):
I will say though, there are some patients that are very symptomatic because they just have been told, don’t exercise, don’t lift any weights, et cetera. And so they’ve actually lost their tone and they’ve gained weight, and now they’re more symptomatic from their hernias, whether it’s umbilical or inguinal. And sometimes I say, you know what? Go back, become more fit, et cetera. And then their symptoms are not as much or they go away. So the hernia’s still there. It doesn’t cure anything. But in terms of symptoms, sometimes being more fit may improve their
Speaker 2 (00:40:20):
Absolutely. I mean, I always tell patients this, when they come in and they’ve lost, let’s say we see them a couple weeks after surgery and they come in and they’ve already lost 20, 25 pounds and they’re kind of like, oh. But they’re always like, oh, I wish I want to lose more. Oh, I wish I had lost more already. I’m like, listen, it takes almost up to a year to lose kind of level out where you’re going to be. But I always tell ’em this, I was like, go and find 25 something that weighs 25 pounds. Hold it in your arms and walk around for 20 minutes, 30 minutes. That’s a good one. And just feel how exhaust, you can’t even do that for five minutes. Right? Good one. Think about how exhausting that is. That’s what you were physically carrying on your back, on your knees, your hips, everywhere. And when they put that in perspective, then they get it. Because I’m think of a bag of flowers like five pounds. Imagine carrying five of those around. Yeah. So do
Speaker 1 (00:41:16):
You as a bariatric surgeon, feel like it could never be obese? You, there’s like a stigma that as the surgeon, you could never be overweight.
Speaker 2 (00:41:25):
Oh my gosh. Stress on your shoulder. I’m sure there’s huge, I’m sure huge amount of my surgeon friends are going to start texting me and making fun of me. I’m like, I’m so paranoid about my, is my weight always, I mean,
Speaker 1 (00:41:36):
Right.
Speaker 2 (00:41:36):
The most self-conscious thing ever. Yeah,
Speaker 1 (00:41:38):
Being a hairstylist and having the worst hair.
Speaker 2 (00:41:43):
Exactly right. You can never, I don’t know. You can never really be in, I guess you could always be in better shape. Everyone could always be in better shape. Okay. The most self-conscious field, besides probably being a plastic surgeon, right?
Speaker 1 (00:42:01):
Yeah, exactly. Can you imagine being a plastic surgeon with a really huge crooked nose? I don’t know. Or lots of wrinkles on your face.
Speaker 2 (00:42:12):
I see this question. This is a good one. Yeah.
Speaker 1 (00:42:15):
So how much weight should I lose before surgery? I’m 260 pounds and five two, I did the math for you. It’s 7.5 kilograms per meter square. Perfect. With an abdominal hernia.
Speaker 2 (00:42:25):
So let’s say, okay, if we’re going to do a open hernia repair and you have a big ventral hernia, it’s going to be open. Yeah. The answer to that is you want to get down to a BMI of 35 or less, and the patient, so I know what the next question’s going to be. Well, how many pounds is that? So let’s say, I have a calculator up here right now. Okay. So we’re going to put 200 pounds, 5’2″, that’s going to bring you to a BMI. I’m a little off. So 36.6. So let’s do, let’s say 175 pounds.
Speaker 1 (00:42:51):
Yeah,
Speaker 2 (00:42:52):
That’s too low. So let’s do 190, 34.7. So you would have at a height of 5’2″ using a BMI calculator, which anyone can Google. There’s a hundred of them online. At 5’2″, you’d have to get your weight down to 190 pounds, which is going to be into a BMI 35. So luckily I can do this,
Speaker 1 (00:43:13):
Man, that’s 90 pounds.
Speaker 2 (00:43:15):
So that’s a good amount of weight, right? No, that’s
Speaker 1 (00:43:16):
70
Speaker 2 (00:43:17):
Pounds. 70 pounds. So you’d have to lose 70 pounds in order to become a candidate for an open hernia repair
Speaker 1 (00:43:23):
And keep it. And you have to keep
Speaker 2 (00:43:25):
It and keep that off.
Speaker 1 (00:43:27):
So 70 pounds may be reasonable for some people. Do you recommend them to be in a medically, medically overseen weight loss program, or do you send them to noom or Weight Watchers?
Speaker 2 (00:43:40):
I would still recommend bariatric surgery for this patient. Okay. They’re going to do bariatrics. Yeah. I mean, again, they’re going to have more long-term weight loss over time. If they have any other, if they have any other issues like diabetes, hypertension, they’re going to have a great resolution with it as well. Good. And you said I can almost control, I can control the whole narrative behind the whole thing. What does that mean? That means that I can say, Hey, listen, I’m going to enroll in the program today. In about six months, you’re going to get weight loss surgery in about 6 to 12 months after that, you’re going to have a complex formal hernia repair. So I can give them a timeframe. I can control the narrative. Whereas if I just say, Hey, listen, go to a medical doctor, take some weight loss meds, come back to me whenever you lose this amount of weight that could happen in three or four months, probably not. Or they can just be lost to follow up indefinitely and never, nothing ever happens. Then they end up having a major issue down the line. So I feel
Speaker 1 (00:44:42):
It’s like planning a vacation. Yeah. You find the day, you get the hotel, the reservation, all that. But if you’re just like, maybe summer will do something, that’s the more than medical way.
Speaker 2 (00:44:53):
Exactly. So I think from that perspective, if you are a candidate for bariatric surgery, you should probably get weight loss surgery and it’s going to be the best solution for you in the longest. Especially with the hernia
Speaker 1 (00:45:05):
With the BMI 47.5. That’s automatic candidate. Right,
Speaker 2 (00:45:09):
Exactly. Pretty much.
Speaker 1 (00:45:11):
How and why does obesity affect your chances of getting a hernia recurrence? Is it always only a mechanical problem? That’s a good question.
Speaker 2 (00:45:18):
Great question. It’s a combination of everything. So it’s a combination. As we talked about the stress on the abdominal war, the physiologic stress of that large pan is pulling on the abdominal muscular, the skin,
Speaker 1 (00:45:31):
Even the skin, right? Yeah,
Speaker 2 (00:45:32):
Exactly. The skin, the inflammatory process of having the significant amount of adipose tissue that obviously comes into play. The high risk of infections. We know that in a wound that gets an infection after hernia repair, that’s almost like your risk of it recurring is dramatically high. So all of these come to play. And then other things that we talked about, if get, get a small little localized wound infection that could normally be treated with antibiotics, an obese patient, those antibiotics can’t penetrate to the skin area. It’s really hard to treat. And then the worst, so
Speaker 1 (00:46:09):
Primarily it’s mechanical and also gravity, and then the rest is infection, diabetes, poor healing,
Speaker 2 (00:46:17):
All these things
Speaker 1 (00:46:17):
Aren’t obese patients already malnutrition by definition.
Speaker 2 (00:46:21):
Yes. So
Speaker 1 (00:46:22):
That healing too, right?
Speaker 2 (00:46:23):
Yeah. So they’re all these other markers for nutrition, like albumin, pre albumin, all these labs that we get in, all these obese patients are all majority of them, they’re kind of out of whack. Yeah. So it’s a complex, obesity is a, obesity is a disease and it’s a disease. And the fact that it affects so many organ systems negatively. Again, there’s issues with mental issue, central nervous system, nervous system, muscle scale cancer,
Speaker 1 (00:46:56):
Doesn’t it affect cancer?
Speaker 2 (00:46:58):
I mean, we publish data looking on the cancer rates after bariatric surgery. And even cancer rates are reduced after you lose weight, which is kind of, wow, that’s a big deal. Cancers like colorectal cancer, I believe breast ca as well are really directly effective with this. So yeah, so it’s a bad disease and we’re fighting it more than ever, unfortunately. Wow. Yeah.
Speaker 1 (00:47:23):
All right. Let’s see. How would you rate obesity among other risk factors like chronic cough, constipation, or smoking in terms of causing a hernia or its recurrence?
Speaker 2 (00:47:37):
Are I those all pretty, I mean, they’re all bad things pretty bad. Yeah. So chronic,
Speaker 1 (00:47:44):
Would you rather have an morbidly obese patient or someone who coughs is constipated or smokes? I would rather have the coughing constipated smoker
Speaker 2 (00:47:51):
Probably. Or I can at least say I’d rather have the obese patient cause I can at least help them, right?
Speaker 1 (00:47:57):
Oh, that’s true. Yeah.
Speaker 2 (00:47:58):
But all these are, I mean, probably obesity is up there. It probably is number one, right? So
Speaker 1 (00:48:04):
Yeah, I would say number one,
Speaker 2 (00:48:06):
I think the reason why is a chronic cough. There’s probably some underlying issue that we have to be able to fix and figure out. Most people shouldn’t have a chronic cough, so we have to figure that out. Constipation, I can probably fix with a routine medications, some type of stool softener, well hydrated, change your diet a little bit. That’s kind of easy. Smoking. You just got to say, listen, if I want to be doing a complex hernia repair, I got to get you to quit smoking. So that’s like either you quit or you don’t. Yeah, it’s kind of an easier conversation. So I think overall, probably B M I is probably number one for those reasons.
Speaker 1 (00:48:40):
Why do bariatric patients have a higher rate of an infection and poor wound healing?
Speaker 2 (00:48:46):
So I think all the reasons that we talked about before to
Speaker 1 (00:48:50):
Diabetes and malnutrition. Yeah,
Speaker 2 (00:48:52):
Everything. So diabetes, malnutrition and
Speaker 1 (00:48:55):
Poor blood flow,
Speaker 2 (00:48:56):
Poor blood flow, the all the physiologic reason, anatomical reasons. Like I said, it’s so hard. Like adipose tissue to get in order to, for the blood flow to get to the skin is just so decreased. So all these reasons come into play.
Speaker 1 (00:49:09):
Yeah. How has bariatric surgery changed recently and what are currently the surgical options to treat obesity? And when do you recommend them before at the same time or after hernia surgery? Do you ever recommended during
Speaker 2 (00:49:25):
That is a, that’s a tough question to answer. The answer to that is probably overall no, and actually, lemme rephrase that. We are actually, we’re actually kind of revising or currently working on a newer study that we’re going to hopefully publish here in a little bit of time. But when we looked at some of the data, because, so what they’re asking is when, let’s say someone has a hernia and they go for weight loss surgery. Yeah. Should you fix the hernia at the same time along when you’re doing bariatric surgery? The easy answer to that is what we’re finding now, and the most stuff recent stuff that we’re working on is if you need to put a Mesh in, so if you’re doing a weight loss surgery and you have a hernia that will require some type of Mesh, the answer to that question is, no, you shouldn’t fix the hernia.
Speaker 2 (00:50:07):
Okay. That’s why before we were always like, it’s all, or it’s like, yes, you should fix it. No, you should fix it. I think this probably gives a little bit better guided. So if you get in and you have a hernia that is going to need an ideal world. If you are going in just to fix a hernia and you need a Mesh, the answer is no. Don’t fix it. During the time of weight loss surgery, and a couple reasons, again, if the Mesh, there’s a higher rate of infection when you put the Mesh in obese patient, when we’re doing weight loss surgery, we are cutting bowel, especially in a bypass. We’re cutting the bowel. There’s always a chance of contamination of the Mesh, et cetera. So some people, what they do is if they have a very small, let’s say, belly button hernia, what they’ll do is they’ll reduce the hernia, maybe put a couple stitches in there, but they won’t put a Mesh. So I think that’s probably where now the guidance is going is that if you need a Mesh at the time of that surgery, just don’t fix the hernia.
Speaker 1 (00:50:58):
So one thing was surgically, if you go in to do obesity surgery and you notice there’s a hernia, there’s maybe some little piece of fat stuck in it from the omentum. You’re supposed to leave that, right? You’re not supposed to. I leave. I leave it. Leave it. Yeah. But if it’s, let’s say the belly button and it’s just a punched out hole, you do put a Stitcher in there, wouldn’t that potentially tear make it a bigger hole?
Speaker 2 (00:51:24):
I’m going to do my, my honest answer, I try to not touch any of this stuff.
Speaker 1 (00:51:28):
Yeah. Don’t touch anything.
Speaker 2 (00:51:29):
I leave it as is because my mindset is whatever I do at that moment in time is not going to be the best solution for the patient. Right? Yeah,
Speaker 2 (00:51:36):
I agree. So if I’m in there doing weight loss surgery, I’m going to tell ’em, Hey, listen, I saw the X, Y, and Z. After you lose your surgery, we’re going to take you back and fix it. Yeah. The great, what you mentioned before was that fat that’s stuck in this little hernia, it’s almost like a cork. And even if the fat gets in strangulated at some point, or likely it’s not going to be a life or anything, but if I pull the fat out and then a piece of bowel pops in there and gets strangulated, now we’re talking about a significant problem. So yeah, I try avoid touching anything of the abdominal wall at the time of a weight loss surgery. I want to fix it once they lose weight and give ’em blood. And
Speaker 1 (00:52:13):
Is there a risk of a bowel obstruction early after surgery for the rapid weight loss falling into the hernia?
Speaker 2 (00:52:22):
There’s some data that suggests that. So I think that kind of where option of just leaving fat in there and not touching the hernia, because hopefully, yeah, that’s going to be act as a blockage or a cork for bowel. Getting in. There is some data to suggest that. Yeah.
Speaker 1 (00:52:39):
Here’s a great live question. I’ve always wondered this too. So we know that sleep apnea is a risk factor for hernias. Yes. Is it because sleep apnea is related to obesity or obesity leads an and obesity leads to a hernia? Or is it a oxygenation thing at the tissue level? Do we know why sleep apnea is associated?
Speaker 2 (00:53:05):
Interesting question. It’s like a chicken or the egg type of question, right? Yes. So there’s a different components. There are individuals who are thin, skinny, whatever word you want to use, non-obese who have sleep apnea, and it’s a genetic problem. But we do know that when people gain weight, majority of people don’t just gain it in one little area. They do gain it throughout their whole body. And also that also affects what’s called your oral pharynx or the back of your throat and your mouth. So when I go and before I do weight loss surgery, I go in and do what’s called a screening, endoscopy, do an upper endoscopy, make sure the stomach is okay. When I put the scope in, I mean, it’s pretty dramatic the amount of tissue that’s in the back of the throat. I mean, it’s hard to even get into the esophagus, the swallow tube. So as you gain weight, that’s where all that obstructive sleep apnea comes in, comes into play. So that puts you at a lot of, that also puts you at a lot of risk, even in the, let’s say the patient has sleep apnea, you go for a big hernia repair that’s going to affect you in the recovery phase. You’re going to have more issues getting extubated, you may have coughing fits, you may have to get reintubated. So all of this really comes into play. So
Speaker 1 (00:54:21):
Very scary. Yeah. Is it safe to do outpatient bariatric surgeon and someone who has a sleep apnea or is that considered not safe?
Speaker 2 (00:54:32):
At the moment, I say the majority of bariatric surgeons are, it’s inpatient. So for us it’s about a less than a 24 hour stay. So if I do surgery, bariatric surgery on a Monday, every patient’s going to be going home as long as everything goes according to plan on Tuesday. So they’re there for one night’s stay. There is some individuals that are starting to look at doing same day surgery for sleeve gastrectomies, things like that. So I think maybe over time we would move toward that. I’m not a huge fan of that, to be honest with you. I think the one night, the observation stay, the overnight stay is probably the safest thing because like I said, these are bariatric surgeries become so safe. If you look at just the statistics behind it, weight loss surgeries actually safer than a doing a gallbladder removal.
Speaker 1 (00:55:20):
Really?
Speaker 2 (00:55:21):
Yes. Yeah. Oh wow. So bariatric surgery has less morbidity and mortality than gallbladders. So it’s become really safe. But we still have to remember, and that’s because you know, have very specific surgeons in centers of excellence. Not
Speaker 1 (00:55:36):
Everyone does those surgeries.
Speaker 2 (00:55:37):
Right, exactly. But we still have to remember that these are really sick, complicated patients. So I’m a fan of the overnight stay. Observation is probably for me, the way to go, but who knows what the future holds.
Speaker 1 (00:55:50):
Okay. Question about the practical difficulties that a surgeon encounters operating on overweight or obese patients. One was there’s a lot of torque lap laparoscopically. There’s a lot of torques. So it really affects your wrists, your thumbs, your elbow, your shoulder, your neck, everything. Your upper body and your back is horrible.
Speaker 2 (00:56:12):
Exactly.
Speaker 1 (00:56:13):
So much.
Speaker 2 (00:56:14):
Yeah. Mean it is obesity just makes everything more difficult. So even if you’re doing an open hernia repair, just retracting, seeing the tissues, getting really healthy bites on tissues, all these things, maneuvering the tissues, all this becomes a much more difficult, it’s not ideal situation. Even in lap and robotic, the same thing. The amount of torque sometimes just a body habit alone makes a laparoscopic case maneuverability almost impossible in some situations. Mean every surgeon always says, oh, it was a really hard abdominal wall. It was large. I bent my instrument, et cetera. Yes. Things like that. Robotically though, I have to say this is that probably, again, I use that cutoff at 35, but I always kind of been stressing this whole talk about in open cases. Yes. I think as now what we’re seeing is that the data suggests that we could probably push the B M I cutoff for complex hernia repair in a a robotic patient, probably closer to 40. And that’s because of we mentioned the wound site infection. Healing processes when you’re having tiny little incision is obviously much easier than when you have a huge incision that goes through your entire abdomen. So there is definitely significant benefits to the lap and the robotic repairs.
Speaker 1 (00:57:32):
And do you see any complications related to their obesity just laying on the bed for during the surgery? Do people get decubitus pressure ulcers or anything like that?
Speaker 2 (00:57:44):
We’ve gotten pretty good about understanding where all the pressure points are. So we are really diligent about making sure that all the pressure points, the hips, the ankles, the knees, all the stuff is really well cushioned during surgery. Because like I said, even if you’re doing a robotic tar, I mean you’re probably going to be in the OR for a few hours. The same thing with a bypass. They’re going to be on the table for quite some time, for a little bit of time. So we try to do our best. We get proper, we try to prevent it as best as possible. Definitely.
Speaker 1 (00:58:15):
The next question, we pretty much answered, how do you handle emergency hernia surgery in bariatric patients? Do you do anything special if it’s open? Do you use special wound protectors or you close the skin or a certain way?
Speaker 2 (00:58:31):
No, honestly, I try to keep nothing out of the extraordinary. I try not to. I guess the best answer is try be a hero in the situation. Try to get in, do your best, make sure, get the patient out of the life threatening situation that they’re in. Yes. That’s the number one key. That’s
Speaker 1 (00:58:51):
The key to all emergency surgery.
Speaker 2 (00:58:53):
Exactly right. And then the second thing is then you start thinking about, okay, I want to temporize the hernia, the abdominal wall that the issue that they’re having. And then after that, then get ’em to the point where we could do a great solid formal repair.
Speaker 1 (00:59:06):
That’s great. Yeah. Well, we’re almost towards the end of our hour. Did that go fast?
Speaker 2 (00:59:12):
How is that an hour felt like? Exactly. Yeah.
Speaker 1 (00:59:15):
And then we still have more questions, but we did cover those other questions a little bit already, so I think we’ll, they’ll be happy that it was answered. So how do patients find you? Do you see patients outside of Florida or
Speaker 2 (00:59:30):
Anybody who, I mean, if anybody wants to come and visit me in sunny Florida, they’re more than certainly take a flight, come on down and visit. But we’re in the Tampa, Florida region area, so we kind of serve anybody kind of down in the southwest part of Florida. And we, I mean, I have patients in some situations where they’ll drive three, four hours to come and see us. So yeah, it’s actually obviously really kind them to do that. And it’s nice that they put their trust in us, but I think for us, we have a very localized center where we could do the weight loss and the hernia repair kind of all in one spot.
Speaker 1 (01:00:04):
So that’s very
Speaker 2 (01:00:04):
Unique. Patients like that. Patients like that.
Speaker 1 (01:00:06):
Yeah. Most of the time we have to kind of partner up with a bariatric surgeon. Yeah, very few kind of hybrid surgeons that do bariatrics and hernia as well. You’re welcome.
Speaker 2 (01:00:17):
I let them know. I let them know. I said, you’re going to be stuck with me for 2 years of your life. So sorry.
Speaker 1 (01:00:23):
That’s great. I’m sure that’s very happy. Well, that’s the end of it guys. Thank you everyone for joining us. This finishes yet another wonderful Hernia Talk Live session. I enjoy every single one of these and I’m so appreciative of everyone who joins us every week. We have another great guest next week getting close to the holidays. So I hope you enjoy that. And thank you everyone. Remember this episode and all previous episodes will be on my YouTube channel at Hernia Doc and also on Facebook. It’s currently available. So follow me, subscribe and we’ll see you all next week. And thanks again, Sal. I really appreciate
Speaker 2 (01:01:00):
It. Thank you. And thank you for doing this and being a wonderful patient advocate. I think everyone appreciates it. Appreciate it.
Speaker 1 (01:01:06):
Appreciate thanks to all you to help me.
