Episode 128: ACNES & Abdominal Wall Pain | Hernia Talk Live Q&A

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Speaker 1 (00:00:10):

Hello everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live. I’m your host, Dr. Shirin Towfigh hernia and laparoscopic surgery specialist at the Beverly Hills Hernia Center. We join you every week. We call Hernia Talk Tuesdays. Many of you are joining me via Facebook, so thank you to all of those at Dr. Towfigh. And then for those of you joining me via Zoom, I appreciate that as well. Let me just say that I enjoy these. Thank you so much. I hope you all enjoyed your Valentine’s Day break last week and spend it with your loved ones. But today we’re back. So our topic today is going to be on abdominal wall pain. So specifically it has to do with patients that have pain, not necessarily from hernias, but the actual abdominal wall is the issue.

Speaker 1 (00:01:09):

Because I do hernia surgery, I also see people with various types of abdominal pain that could be pain, let’s say from their hernia, or it could be pain from any other abdominal process. So intestinal, gynecologic, urologic. It could be let’s say ovarian cyst. It could be diverticulitis. People can have abdominal pain due to their gallbladder appendix, any type of, let’s say like an abdominal ulcer, like a stomach ulcer. So I try and figure out why they have the pain, if it’s really internal organ related or if it’s related to a hernia, which would be a muscle related. But every so often it’s none of those. And really what patients have is an abdominal wall pain. And for those patients I find it really, really helpful to really tune in to see what the different abdominal wall pain options can be and then go through a very, very simple but detailed protocol or algorithm to figure it out.

Speaker 1 (00:02:19):

The one type of abdominal wall pain I wanted to highlight for today’s talk is called ACNES. It’s spelled A C N E S, kind of like acne scar, but it’s unrelated to anything dermatologic, but it’s an acronym, A C N E S, and it stands for anterior cutaneous nerve entrapment syndrome. So it’s a series of pain syndromes or symptoms related to entrapment of the anterior cutaneous nerve. I want to talk about it because as surgeons we see abdominal pain all the time, but most surgeons actually don’t know about this process or this problem. They don’t even know it exists. If you tell ’em, do you know ACNES, they’ll be like, no. And what’s even more important is people who deal with pain. So pain management specialists, most of them even don’t even know about ACNES and therefore there’s a lot of patients out there with abdominal wall pain that are misdiagnosed, underdiagnosed, or not correctly diagnosed with different problems, but they’re really underlying problem is ACNES.

Speaker 1 (00:03:34):

So what makes ACNES so special? First of all, we don’t know how common it is. It’s probably uncommon because even I don’t see as many of them as like, let’s say hernias, hernias are much, much more common. So it’s not very common and we also don’t know much about it. So it seems that an equal number of men get it as women, I’ve seen it in young people, old people there, people who’ve had surgery who have it. There are people who haven’t had surgery that have it. There are people that have had some type of trauma and others who had no trauma at all. They’re just totally healthy. All of a sudden they get this abdominal wall pain. So as far as we know, there’s no specific characteristic of the type of person that’s prone to getting ACNES or anterior cutaneous nerve entrapment syndrome. However, what is similar among all the different patients is they have pain in one specific area, sometimes two, but usually one, it’s either on the left side or on the right side.

Speaker 1 (00:04:45):

It’s usually below the level of the belly button, but I have treat a handful of patients that have ACNES or nerve entrapment above the level of the belly button. It is almost always either, well, it’s always either over the middle of the rectus muscle or along the outer edge or lateral edge of the rectus muscle, which is why I put that beautiful picture of the abs on this gentleman because you can actually see his rectus muscles and you can tell where the lateral edge or the outer edge of the rectus muscle is. So there are two areas where the anterior cutaneous nerve can get entrapped and one area is at the lateral border of the rectus muscle and the other is in the midpoint of the rectus muscle. It all has to do about how this nerve travels and moves around into your tissues. And it’s c unclear why this nerve nerve gets entrapped, but when it gets entrapped, it is painful and classically, patients say, I have pain right here, and take their finger and they press push right over the abdominal wall and they point to one very specific area. It’s not a generalized abdominal pain. The pain is superficial, it’s not deep and it can be sharpened or dull, but it’s always in the same area. And if they’re doing a normal day, usually they’re pain free, but if they do anything to engage their abdominal muscles, which means anything that contracts the abdominal muscles, that’s what kinks this nerve and then causes the pain and the kinking is because the nerve is running from the outer edge of the rectus muscles and then underneath and then makes a sharp right angle.

Speaker 1 (00:06:48):

And so when the muscle contracts, it then moves the nerve with it and the nerve kind of goes through these little tiny tunnels and if it’s being contracted by the muscle, it’s kinking or so to speak through its pathway and causes pain. And there’s two main areas where it can kink either the outer edge of the rectus muscle or your six pack or within the middle edge of the rectus muscle. So if you’ve had pain, that only happens when you contract your muscles. So for example, I had a patient every time he twisted over to pick up some from something from behind his car seat behind the passenger seat, that would hurt getting up out of bed, coughing, doing a six pack, sorry, doing sit-ups. Those are contracting your muscles and can cause the pain. Coughing can doesn’t necessarily have to, you can have it without coughing because not everyone engages their muscles when they cough.

Speaker 1 (00:07:57):

Certain activities like besides getting up and out of bed or a chair opening a door that’s really heavy or bending to do something, anything that involves contracting, the rectus muscles can kink that nerve and cause pain. So they just kind of learn not to do a lot of activities. The pain is often never severe, so people don’t come in with six out 10, seven out 10, eight out 10 pain. It’s usually two out 10, four out of 10, maybe five or six out of 10. It’s usually not severe, but it’s kind of annoying. I would say it’s annoying pain. And then the question is, so what do you do about it? So I actually posted on my social media some pictures of the nerve and what it looks like. The nerve is a very small nerve. First of all, it’s a cutaneous nerve, which means it only serves function.

Speaker 1 (00:08:50):

Its only function is to give sensation to the skin. Cutaneous nerve it comes from, it starts from the back, the nerve starts from the back, follows your ribs around to your front of your belly, and then it gives sensation to the skin in the front of the belly along a narrow strip. And the most common nerve to be involved is the 11th thoracic rib, although I’ve seen it for t T 10, T 11 and T 12. So thoracic, it’s usually a thoracic nerve, so it often starts as an intercostal nerve and comes forward and branches. It becomes a cutaneous nerve and the nerve is very, very small, so you can’t see it on imaging, even on ultrasound, it’s almost impossible to see it unless you’re a really good and you can’t see it actively kinking, it’s not, there’s no diagnostic imaging for it. It’s mostly story and physical exam.

Speaker 1 (00:09:54):

And when I examine patients, what I see is that they basically have a normal exam except where they push to tell me where the pain is. Other than that, there’s no other kind of examination finding. I can push on the area and it won’t hurt them because I’m not actually kinking that nerve, but when they actually do the sit up or whatever, then that can cause the pain. Then the question is, okay, so now you have this pain, why do you have it? We have no idea. We have absolutely no idea. On rare occasion, it’s not a true acne, but that nerve is injured let’s say by surgery or there’s scar tissue from surgery that kinks the nerve. But true ACNES has never had surgery in that area and we don’t know why it happens or why people get it. Then the question is, okay, how do you know I even have it if you can’t even get imaging and the physical exam is normal and that’s a really good question. So one thing to do is to rule out other things, right? Because you can also get a hernia along this lateral edge of the muscle that’s called a Spigelian hernia. Those of you that follow me, you’ve heard me talking about Spigelian hernias, it’s a rare hernia, but when it happens, it happens right at the lateral border of the rectus muscle. And so it’s best that you first figure out that it’s whether it’s a Spigelian hernia or not, because that’s very treatable.

Speaker 1 (00:11:30):

Then the question is, okay, it’s not a Spigelian hernia. How can you prove that it’s an anterior cutaneous nerve entrapment syndrome? Again, examination’s normal and there’s no good imaging. So what I do in my office is I do a local nerve block. So I take an ultrasound and I identify the different muscle layers of your abdominal wall and I that this nerve travels between the transverses of dominance and the internal O bleak muscle, and you can identify that very clearly by ultrasound. I can’t usually see the nerve itself, but what I do is I put local anesthetic into that space where I know the nerve is living right before it pierces through those two tunnels I told you about where they kink. So it’s upstream from the entrapment area and then I ask the patient a minute or two later, how do you feel? Like I feel fine.

Speaker 1 (00:12:29):

Okay, did you have pain 10 minutes prior to my injecting? Not really doc because I was just sitting here waiting for you in the office. Okay, so let’s do things that would usually would give you pain. So they’ll start doing sits, they’ll start doing crunches, lifting their bag, twisting their abdominal wall, and usually they would expect to feel pain If it’s ACNES and I block that nerve, there should be no pain and therefore that’s how you diagnose it. It’s a be a diagnostic nerve block. Now it’s a nerve. So how do you get rid of nerve pain is you try and reduce its activity. Some people give medications, but medications don’t directly affect that nerve. It can help Gabapentin, Neurontin, Lyrica, these are all medications that can help nerve pain, but I think that’s too much treatment for a local nerve problem. Taking a pill goes through your whole system and also may help that nerve pain, but it can give you drowsiness and sleepiness and brain fog and some people get little hallucinations, so I prefer not to give those medications if I can directly block the nerve and get rid of the pain.

Speaker 1 (00:13:51):

So what I do is I block the nerve and put some steroids in the block, simple needle procedure in the office and it shuts down the nerve activity and in doing so it should get rid of your pain and if the pain goes away, then I say, okay, my nurse, nurse bell, everyone knows her nurse bell’s the best, so Nurse Bell will follow up with you in the next day or two to see how you’re doing. So you’ll talk with Nurse Bell and you’ll say, you know what? I had zero pain leaving. I walked to my car. Sometimes that causes pain. I didn’t have pain doing that. I drove two hours back to my hometown. Usually that causes pain, especially being in traffic and using my abs to drive. I didn’t have pain and I still don’t have pains now one day or two days afterwards, great, that’s a great result because what I did was with that nerve block, I shut down the hyperactivity of that nerve so that even though it may still be kinking, it’s not as reactive to that kinking sensation.

Speaker 1 (00:15:02):

So great, come back in two weeks, we’ll do another block. Most people will have their pain come back during that time and then I block it again. Most people who have ACNES, however their pain level will be less. So instead of being a hundred percent before the block, they’re now at maybe 80% of the pain. So if they used to be at six or five out of 10, they’re maybe like a four out 10. Okay, that’s good. I’ll inject ’em a second time and I’ll continue doing this every two weeks for about three to five cycles. And we actually published a study on this where we described our protocol and we found that about half the patients will have a cure that means zero out of 10 pain after about three to five cycles of nerve blocks. And the purpose of that is you’re just shutting down the activity you’re having the nerves kind of reassess, accumulate their activity and oftentimes they don’t go back to normal in terms of activity. There’s no downsides to it.

Speaker 1 (00:16:09):

The only downside is using the steroids, which some people don’t like or it can cause fat necrosis if you put it into superficially, I have a SP special technique to make sure that doesn’t happen and you’re done. So that’s half the patients don’t need surgery, they just need three to five cycles of nerve blocks about every two weeks and every time they see me, their pain is a little bit less, a little bit less, a little bit less, and the duration of the nerve block is longer and longer and longer until eventually they don’t need a nerve block anymore. The other half of the patients still have the pain and even if the pain level is lower, it never goes away and it still bothersome. And in those patients, classically what I’ve done is I’ve gone in and I’ve cut that nerve, so it’s called a surgical neurectomy or just neurectomy and you go in, you find the nerve, but sometimes it’s not easy, but oftentimes like the picture I sent you guys, you can see the nerve as this big bulging nerve because it gets bigger as if it’s obstructed or something downstream and then you cut that nerve and by cutting that nerve you may not everyone, you may get numb along that strip of skin over your abs.

Speaker 1 (00:17:28):

On that one side, the nerve has no function other than giving your skin skin sensation and that is how you treat ACNES.

Speaker 1 (00:17:42):

Some patients that have opted to do what’s called ablation, so radiofrequency ablation or cryoablation that burns the nerve. The problem is the nerve is so small it’s really hard to identify by ultrasound guidance to accurately burn that nerve. So it just seems that there’s a little bit of a hit and miss when it comes to ablation. So here’s some questions. I understand how the anesthetic shuts down the nerve, but how does a steroid portion of the injections shut down the nerve? Very good question. So part of the reason why the nerve is active is because it’s being entrapped and that causes inflammation. Steroids are very strong anti-inflammatory and it prolongs the effect of the shutting down by the nerve. It also reduces any inflammation coming back so that you don’t get the pain back again. What levels of the abdomen are involved from the pubis sternum or more limited anatomy?

Speaker 1 (00:18:44):

So the majority of them are below the level of the belly button, so T 11, T 12, almost I would say three-fourths of them are in that region, maybe more sometimes T 10, which is level of the belly button and then a minority of them are higher at the level of like T 7, T 8, T 9, those are uncommon and having it on both sides also uncommon, but I have seen it in my patients and we don’t know why it’s in the lower abdomen mostly. We actually dunno that much about it. Can ACNES be located lower than the ABS on one side but closer to the groin? Yes and no. So ACNES technically is a anterior cutaneous nerve entrapment syndrome and the anterior cutaneous nerve stops at the 12th nerve. The next set of nerves, sorry, the 12th thoracic nerve. The next set of nerves are lumbar nerves, L one, L two, and those include the ilio inguinal nerve, I hypogastric nerve, so those are closer to the groin.

Speaker 1 (00:19:48):

However, everyone’s anatomy is a little bit different. So what you may think is the groin may technically not be the groin but is low enough that you consider it the groin and that would be T 12. So if you’re wearing jeans that kind of ride low, that would be kind of T 12 area and so that is possible. Ooh, here’s a very long question. Let read it to you. Hi there. I recently had an open Mesh removal procedure that involved an entrapped ilio inguinal nerve that was in scar tissue and the Mesh. Okay, very possible the surgery was done by a well known and respected surgeon who has been on your show. Great. I trust his work. I do too. That’s why he is on my show. His post-op diagnosis indicate ACNES along with Mesh failure. Original hernia is repaired again during Mesh removal. The nerve needed resection.

Speaker 1 (00:20:46):

Wait, hold on. Open Mesh removal during Mesh removal, the nerve needed resection. I handled the procedure well and had immediate improvements. Sadly, after four weeks the nerve pain has slowly creed back. It also causes headaches and sleep interruption. Okay, this is a good point. I’m going to talk about that. It is aggravated by the lying supine, which means lying flat, and also by the waistline of my pants and discomfort builds with activity. Still, I’m only in six weeks post-op today and will follow up again with the surgeon in a few weeks. I’m using gabapentin to help for now. Would there be an indication for neurectomy? Would this be an indication that the neurectomy might have failed? Is there’s some hope that this just needs some time to settle down? What would be the next steps if it doesn’t settle down after three months post-op? Great question.

Speaker 1 (00:21:31):

Very sophisticated question, but very great question. Okay, so here’s a situation. What you had was not truly ACNES because that involves anti cutaneous nerve, but you probably had ilio inguinal nerve entrapped either by scar from your prior surgery or by the nerve by the Mesh itself or some combination thereof or the Mesh removal process alone sometimes indicates need to have the nerve cut because the nerve Mesh, the Mesh removal process can injure the nerve itself. So based on that you had the nerve transected. Now there’s different ways of transecting the nerve. Every surgeon surgeon is a little bit different, but most of us who do this for a living, we cut the nerve sharply or we burn the nerve and then we dunk that end of the cut or burn nerve into the muscle where there’s no scar tissue but a lot of really good blood vessels and in doing so what happens is that nerve ending is then kind of hidden away from other scar tissue.

Speaker 1 (00:22:41):

I also, in addition to cutting, I also or I tie the end of the nerve that’s also been shown to maybe reduce the risk of scar tissue entering the nerve endings. However, we actually published this study and there’s another, there’s some other studies prior to us that support the same claim, which is if you had nerve pain and you had nerve neurectomy in our study, it was 4% and nationally it’s 5%, you have a risk of getting a neuroma. What’s a neuroma? A neuroma means a balling up of the nerve ending causing same exact pain again, now six weeks is kind of early for a neuroma, four weeks, six weeks, it’s kind of the early time of when a neuroma may happen. It doesn’t happen early for sure. So if you have your nerve cut now we’re talking ilio, inguinal, ilio hypogastric, usually not the acne’s nerve because those are much smaller nerves, but in the groin when you have a nerve cut I usually lo put local anesthetic in it because you can have this rebound pain from just the neurectomy part or the surgery and if patients have some type of nerve pain after a neurectomy early like the first few days or a week I cough, have them come back and I just inject more local anesthetic to help ease the healing of from the side once it’s healed that should be all.

Speaker 1 (00:24:12):

However, in four to 5% of patients what you’ll happen is you that healing is not perfect and then you get scar tissue at the healing. So that’s layman’s term of explaining how a neuroma forms and your nerve gets hyperactive. Again, the treatment for that is another neurectomy. However, what you’re doing is right, the gabapentin is good. You can also have local injections to calm down that nerve again and see how that works. But if the pain continues it’s clearly a nerve pain and the N and then nerve block helps and the gabapentin helps but not a cure, then you may need another surgery which is a neurectomy again. Could you share the link to the study of patients with ACNES? I have shared it and actually if you go to my, you just Google Towfigh ACNES, it’ll show up. But if you go to my link tree or Instagram where the link tree link is, there’s a bar that shows all my publications or he can go to Google Scholar and look at all my publications and it’ll be there.

Speaker 1 (00:25:27):

It’s actually a cute little study. All right, you can also email my office. We can send you a copy of the article. That may be easier. All right, next question. Is the damage caused by nerve compression permanent and result in chronic pain? It can be. It can be. So usually the damage from ACNES is not severe because you’re not, those muscles are not entrapping the nerves too much. It happens only intermittently and therefore the nerve compression doesn’t cause ischemia. The muscle doesn’t cause ischemia. However, I had a patient who liked to wear like his lee jeans with a really big cowboy belt and really tightly, he liked to have the belt really tight and he tucked in his shirt so you can get that pictorial right lee jeans tight belt, big belt buckle and what would happen was he actually actually would get got ischemia, which means poor blood flow to the nerve that at that level of his waistband and because of that, yes he had permanent damage to that superficial nerve and we need to cut that nerve. He got better but that’s uncommon, very uncommon. Usually ACNES does not cause permanent nerve damage resulting in chronic pain.

Speaker 1 (00:26:56):

Let’s see, I’ve seen lots of sports and medicine and general surgeons and hernia specialists for abdominal pain that I’ve had for five plus years. My pain started a few months after a difficult hip femoral acetabular impingement surgery recovery. I can pinpoint the tender spot on my rectus abdominus around T 10 per my doctor T 10 is like around the belly button level. My pain comes and goes and it’s worse when I engage my core. Okay, this is sounding a little familiar. I’ve had ultrasounds, MRIs, ruling out a hernia. Okay, that’s good because you can get a Spigelian hernia sometimes in that area. My question is can that nerve pain eye experience at the tender spot when it’s bad feel more diffuse and radiate straight down the rectus into the pubic area? No literally a straight down line down the rectus from the tender spot into the pubic or labia area?

Speaker 1 (00:27:50):

No. If anything it may radiate outwards around to your lower back or the upper lower back, but never at least never that I’ve seen goes down. Now the treatment for that or the diagnostic test would be to do the nerve block that I just mentioned and in doing so, if your pain is gone then maybe the person who happens to feel that pain going down. That said if you think about FAI surgery, I’m not familiar how they place you in the bed to do the surgery but sometimes the way they place you in the bed during the anesthesia where you’re not aware can cause pressure points or injuries and possibly if you want to relate it to your hip surgery, maybe that’s where it is, but it’s very possible that it’s completely unrelated from a physiologic standpoint because I had a patient who had bariatric surgery and they ended up in the hospital with a severe pain and they asked me to see the patient and it was ACNES and acne is completely unrelated to their bariatric surgery.

Speaker 1 (00:29:11):

It just happened to be around the same time. So do the nerve block and if the nerve block cures your pain and you’ve already ruled out any hernias, then you have ACNES and just do a bunch of nerve blocks until the pain goes away. Hopefully you’ll fall into that 50%. Let’s see, next question. How can you recognize postoperative neuropathic pain and can the symptoms overlap with those of nociceptive somatic pain prior to doing injections? Okay, that’s complicated procedures. So how do you recognize postoperative neuroma? Okay, so postoperative neuropathic pain is usually like a burning hot poker sharp sometimes, sometimes radiating pain whereas a somatic pain is usually related to the surgery. It’s not like an actual along an actual nerve dermatome, it’s more diffuse. It often doesn’t follow, it follows where the surgery was but doesn’t follow like the actual nerve pathways.

Speaker 1 (00:30:15):

If it’s very unclear you can do a nerve block and then what the nerve block may do. If it’s nerve pain it will reduce the pain. If it’s not nerve pain it may increase the pain and that will help differentiate it too. But it’s often just a puzzle solving what surgery did you have done? Where is the pain? What makes it better or worse? Exactly where is it located and then based on that it can help figure out the puzzle, you know what I mean? How long will nerves continue regenerating and causing zaps of pain after open surgery along the midline? It could be years. Years. I still get zaps from my prior surgery and it’s been many, many years in fact touching the area gets a little bit nervy nerve pain. So everyone’s a little bit different. Depends on what you had done and it can be definitely years.

Speaker 1 (00:31:11):

Thank you so much for these hernia talks. Exclamation point. Thank you. They’re incredibly helpful. My questions related to T 10 or T 11 cutaneous nerves. Okay, those are usually the nerves, the entry cutaneous nerve that I mentioned. My doctor is going to do the diagnostic injections to see which one is bothering me. Great. I’m sensing that my rectus abdominus and my deeper core muscles like my transverses abdominus are struggling to properly engage because of this nerve irritation. You sound like an athlete. Only athletes know if they’re a transverse abdominus is engaging. I can never tell you if my transverse abdominus is engaging and it’s making me overcompensate by using my psoas and hip flexors when I should be using my core. So my pain is even worse than just the nerve pain at the tender spot. Could this theory be right?

Speaker 1 (00:32:08):

Possibly my psoas is regularly irritate or inflamed and is worse when my nerve pain or core pain is worse? Well I do believe that and many, many believe it’s not just me that the body talks like the different parts of the body talk to each other. So even though technically anatomically one area of the bi, let’s say the psoas may not be actually related to another part of the bi, like your transverse of dominance, it’s all part of your core and when one is misaligned or misfiring or not optimally functioning, then the other one starts to act up. So yes, it’s very possible and I think I guessed right you are at least were an athlete and hope to be against soon. See I knew it. I know my abdominal wall people.

Speaker 1 (00:33:00):

Let’s see, next one you mentioned with a diagnostic nerve block, a steroid is included but follow up nerve blocks, you said you’ll do those every two weeks three to five times. Are steroids also included? Yes. It’s not a lot of steroids but yes, I had a physiatrist do a diagnostic nerve block for I nerve and he said I can only have three per year. Definitely not true. I don’t use that much steroids. I don’t know how much steroids I use. I use maybe like 30 milligrams of kilo to at the most, maybe 50 milligrams but you can only have three per year. Yeah, that’s a hundred percent not true.

Speaker 1 (00:33:40):

Maybe for epidural but even epidurals you can have more than that. Are there any concerns with leaving ACNES untreated while you’re pregnant? No. Assume the pain can get worse. It usually doesn’t get worse. It just doesn’t get better. Would you recommend addressing this prior to getting pregnant? I don’t know about pregnancy and ACNES. I’ve never had a pregnant lady with ACNES. I’m just thinking, I wonder if as the abdominal wall stretches, if you’re less likely to entrap it because you’re actually stretching it out instead of contracting the muscles. I don’t know the answer to that. I think it should be okay. Do you believe that there are connections or communications between the three main inguinal nerves which may explain why single nerve injection and hysterectomies fail? I do not. I actually don’t believe that. I think that’s BS. I’m sorry to say. I will say that it’s possible that triple neurectomy is better than single neurectomy in terms of success rate of dealing with pain because if you are wrong about which nerve is the problem then cutting all three nerves all the time, you’ll never be wrong.

Speaker 1 (00:34:57):

I personally think that’s overkill. I don’t like doing triple, I do what’s called selective. So if I think it’s your ilio inguinal nerve, I’m not going to cut your ilio hypogastric nerve. If I’m in there and I’m removing Mesh and the ilioinguinal nerve is involved and the ilio hypogastric nerve is nowhere to be found, I don’t cut it and I never almost never cut any nerves during laparoscopic or robotic surgery. I have learned that there are some surgeons that routinely cut it and they feel they must cut it because of this theory that nerves can talk to each other. But I’ve never done it and all I do is deal with patients with complications and nerve pain and they’re all doing fine. So I think my theory is correct in that yes, theoretically all nerves can talk to each other, but triple neurectomy is not the solution for all patients.

Speaker 1 (00:35:51):

There are downsides with triple neurectomy. Every nerve you cut has a risk of getting a neuroma, so you’re tripling that risk if you only need one nerve addressed if that nerve was cut and now that’s the nerve pain that they never had before, that’s an unfortunate side effect that you shouldn’t kind of prevent and so on. So I’m I’m not a big fan of that and I have a feeling that theory came about because when triple neurectomy was initially discussed, the studies done by Dr. Harvey’s amid showed that Triple Neurectomy patients did better overall than selective neurectomy patients. But I think it’s because the, it’s important you spend a lot of time with the patients getting a history and physical and really figuring out which nerves are at risk or need to be addressed and that will help get your results just as good as a triple neurectomy.

Speaker 1 (00:36:52):

What is a recovery like for ACNES surgery? It’s actually very, very good. It’s a superficial surgery. It’s done under a local anesthetic. With some IV sedation you don’t need general anesthesia, you have a bandage over the abdominal wall. There’s no hernia repair so there’s no risk of busting opening any sutures to your activity level is not limited after surgery and recoveries work very well and you do not need general anesthesia for it. Can the general branch of the general femoral nerve be excised with an open procedure or only laparoscopic? Yes, it can be done with open or laparoscopic. Absolutely depends on whether you plan on cutting through the Inguinal floor or not. So if you’re there for a hernia repair and it depends on where you have to cut the nerve, so laparoscopically is the most aggressive way of cutting that nerve and the easiest way open surgery, you often don’t have to cut it so far back and if you do you can still cut it with the open approach too.

Speaker 1 (00:38:01):

But if the plan is only to do a general femoral nerve and nothing else, then laparoscopic is a better option. Do general surgeons with work with a nerve surgeon during the surgery? Some people do. I’ll tell you at my hospital we have plenty of very talented neurosurgeons. They don’t want to do nerve surgery per, sorry, peripheral nerve surgery like what I do. So they actually send me those patients. We also recently hired a plastic surgeon who has a specialty in peripheral nerve surgery. So he’s an interesting surgeon to work with but maybe some surgeons use a neurosurgeon. I have not. What I haven’t discussed, which I think maybe of interest to you are other causes of the abdominal wall pain for women. A common one is endometriosis or what we call endometrial ma endometrioma is a ball or cyst filled with endometrial with endometrial cells and it grows during your menses and it shrinks when you don’t have your menses and it’s basically a hormonally activated massive tissue which was originally in your uterus and eventually made its way out.

Speaker 1 (00:39:24):

So a common scenario is a patient had a female patient had a C-section or some other uterus type surgery where the uterus had to be opened up let’s say fibroid surgery and then they incised your abdominal wall, they did the C-section, baby is out, they closed the uterus, then they closed the abdominal wall. In doing so there may be some leakage of endometrial cells, so cells from your inlining of the uterus into the abdominal wall and then you have your next period and your lining of the abdominal wall sloughs off and guess what? Those cells that were leaked onto your abdominal wall are also hormonally activated and start bleeding and you get this ball of painful ball in the abdominal wall called endometriosis. It is not a cancer and therefore it does not to be removed like cancer. I have patients who have massive abdominal wall surgery as if this is a tumor and they cut out so much muscle and now they’re left with an abdominal wall with missing muscle all for endometrioma and that’s horrible because it should not happen and then I’m stuck trying to fix them and becomes very complicated because you’re missing muscle.

Speaker 1 (00:40:51):

But that’s one reason to have abdominal wall pain. It’s usually cyclical and you get bulging pain and it goes away with your menses. Another abdominal wall cause of pain could just be a nerve pain from your spine. So like a disc, let’s say you have a disc at T 10 or T 9 or L 1, you have a disc and that disc is at your level of your spine in the back and it’s pushing on the nerve. That nerve happens to give sensory and motor a function to your abdominal wall. So just like sciatic nerve where the sciatic nerve is L five S one, let’s say it’s being pinched by a disc and it gives you pain in your buttock going down the back of your leg towards your feet. The nerves in your lower thoracic and upper lumbar which feed your torso can be pinched by a disc.

Speaker 1 (00:41:47):

And then now you have abdominal wall pain, no one can figure it out. You get colonoscopies, endoscopies, you have patches, et cetera, nothing works and you get epidural because there’s imaging that shows maybe there’s a nerve entrapment, I mean a nerve impingement and your pain goes away and then that’s really where your spine doctor comes in place. It’s not common to have discs in the upper, upper lumbar or lower thoracic regions, but if you do then that’s definitely the reason why you have the abdominal wall pain. And the question is does L 4-5 disc herniation ever cause groin pain? It does not because L 4 and L 5 and or L 4 goes down to your upper thigh or kind of thigh I should say. And so that is doesn’t have any sensory or motor innovation of the groin. The groin is L 1, L 2, little bit of L 3.

Speaker 1 (00:42:50):

So upper lumbar. How do you repair the endometriosis bought surgeries? Well, depends on what you’re talking about. If you’re talking about what I just mentioned which is patients had endometriosis removed from their abdominal wall and now they have a gaping hole that was maybe tried to be closed kind of sorta they didn’t do a good job. Those are hard. So you have to do a full abdominal wall reconstruction, you have to bring muscles from elsewhere to recruit and sometimes in really extreme situations you’re just relying on Mesh to function as like a scaffold to prevent the abdominal wall from being very, very lax and give you back pain.

Speaker 1 (00:43:35):

Does laparoscopic genital nerve resection cut motor fibers as well as sensory fibers even if done as proximal as possible? So you mean as distal as possible? The more proximal, which means the more closer to your spine, the more motor function is lost. So the main muscle that the genital nerve branch feeds is the cream hysteric muscle for men and really nothing for women because we don’t really have cream hysteric muscles. So it’s possible that a gentle nerve branch being cut can cause cream hysteric muscle weakness and your testicle therefore will be hanging much lower, not a little bit lower, much lower than on one side than the other. That’s possible. It doesn’t happen to everyone. Often if you had a hernia surgery, that alone helps prevent dropping of the testicle because of the scar tissue from that surgery. But it’s mostly sensory. There’s some motor, yes. So let’s see what else can cause abdominal wall pain. We talked about spinal disorders, ACNES endometriosis, there aren’t too many tumors of the abdominal wall. There are desmoid tumors that can occur. Those usually are not painful. You can see a bulge but it’s often not painful. Zoster is another good one.

Speaker 1 (00:45:09):

Typically the pain starts first and then several days later you get the shingles kind of little shingles the source along a dermatome of the abdominal wall. So those fall the nerves and you could be an abdominal wall nerve that is involved in your shingles. Shingles occurs in people that have had chickenpox before, so it’s the herpes zoster virus. It kind of sticks around in your body and then maybe during a stress time or some type of usually a stress, those kind of wake up and those can cause pain. So there’s a question of whether pelvic congestion syndrome can cause abdominal wall pain. It does not. So pelvic congestion syndrome is another one of those kind of hard to diagnose problems that women may have. It’s really a female issue, not a male issue. And what we see is that you can have hypertension or think of it like varicose veins of your pelvis. That’s not the best way to describe it or most accurate, but that’s kind of the easiest way to think about it. So that usually gives pelvic pain and it’s usually a deep dull achiness in the pelvis. Same way you would get a dull pain of your feet if you have varicose veins and the blood is pulling in your feet. However it doesn’t actually give true abdominal wall pain. There are very few other things that give abdominal wall pain.

Speaker 1 (00:46:59):

Some hernias obviously, but we’re talking about non hernia related stuff. There’s really not much else. I guess technically if you have a foreign body in there, I mean I used to work at the county hospital and there were people that had a psychiatric disorder where they liked to insert things into their skin and that would be random pencils and pens and paper clips and sharp nails and so on. And so you would be called for abdominal wall painting but it was literally a foreign object was inside them. Of course surgery helps, but the real treatment for that is psychiatric medications because I forget the actual diagnosis for why people do that, but it’s some type of psychosis where you’re basically, your brain promotes you to do that as a thing that gives you happiness. Very interesting. There are also people that like to eat things that shouldn’t be eaten.

Speaker 1 (00:48:14):

And I remember we had a patient that had, they like to eat specifically pens but really anything that was on at the nursing station, paperclips money, dirty gloves, whatever was available, he would eat it. And you can imagine how hard it is for a long pen to make it through the intestines. But surprisingly most of it did and some of them didn’t. Yeah, pubica pubica it. Some of it is pubica, some of it’s it’s not pubica, some other disorder and because it’s not before the taste, it’s for the, there’s some kind of self-gratification with it and one patient had a pen tip sticking out of the skin literally. And all we did was like pull it out and for some reason that connection between the intestine and the skin just closed up. I think because they were so scarred and they had so much scar tissue from prior operations that it just healed. It was just the most interesting thing. How about pain due to or abdominal organ weight on bulging atrophied flank?

Speaker 1 (00:49:30):

I mean technically that’s not an abdominal wall pain disorder. That’s maybe a degradation problem or a herniation, which is the main problem. It wouldn’t be a primary abdominal wall pain disorder. Let’s see, next question. I had diagnostic laparoscopy for a suspected hernia two weeks ago and a femoral hernia was found and repaired with Mesh. I’m feeling better from surgery but I still have the same exact pain in the ilio inguinal or femoral area. How do I know if the occult hernia was not the, if the occult hernia wasn’t the cause of the pain, maybe it was instead peripheral nerve pain. An MRI showed femoral edema and a diagnostic ilio inguinal nerve block was helpful. Okay, good question. So you had a hernia repair but your pain is not better. So you’re questioning whether you even needed the hernia. Maybe that was a red herring and you actually had another problem.

Speaker 1 (00:50:32):

So it’s not normal to just wake up one day and have ilio inguinal nerve pain. That doesn’t happen unless you’ve had surgery, let’s say a C-section or a appendectomy or some type of laparoscopic pelvic surgery where it’s possible the ilio inguinal nerve could have been injured from that operation unrelated to the hernia and now they’re like, oh you have a hernia, they’ll fix a hernia. But that’s not really the problem. If the ilio inguinal nerve block was helpful, it could have been because your nerve was being irritated by the hernia and when you blocked it, the hernia could no longer irritate the nerve because it was blocked in which case fixing the hernia is the right thing to do because it’s not a nerve problem or the other reason why the I nerve block was helpful.

Speaker 1 (00:51:41):

Oh actually I have a question for you. Is this pre-op or post-op was the ilio inguinal nerve block done before your hernia surgery or after your hernia surgery? Cause if it was done before your hernia surgery and it helped you, that doesn’t necessarily mean it was a nerve problem. It could be that your hernia was pushing on the nerve and yeah, it looks like it was preoperative nerve block. So it could be you had a small hernia that was pushing on the ilioinguinal nerve every time it was protruding. So when you numb that nerve, the pain goes away. Doesn’t necessarily mean it was a nerve issue, it just means that it could be supported by the fact that you had a hernia. If your hernias not didn’t get better, one of two things can happen. One is that the fat from the hernia was never really addressed.

Speaker 1 (00:52:38):

I see that not uncommonly in women because it’s such a small piece of fat that when you go in laparoscopically you don’t remove, some surgeons do not remove all the fat because they don’t really see that much and they think they’re done, but there’s really more fat. So now you have entrapment of the fat with the Mesh. So a repeat MRI will help identify why, maybe one reason why the pain didn’t go away. However, if you’ve had surgery in the area, so a C-section commonly or a laparoscopic pelvic surgery or an appendectomy, if you’ve had any of those operation or a kidney transplant, if you had any of those operations, those could have injured the ilioinguinal nerve and that’s your primary problem. But to just one day wake up and have illioinguinal nerve pain, that doesn’t happen as a primary disease. I’m curious what this femoral edema means. Unless it’s it was edema in the femoral space due to a femoral hernia, then that would make sense. I’m trying to think what other abdominal wall pains there could be.

Speaker 1 (00:53:55):

That’s pretty much it. There are pains that cause abdominal pain. You can have a kidney stone get abdominal pain, you can have gallstones, appendicitis, et cetera that gives abdominal pain. But actual abdominal wall pain is very different and it’s very important. We discuss with the your surgeon that you’re clear whether the pain is superficial or if it is deeper. And you’ve sent me a lot of great questions and I hate to not go through them, but here’s some we’ll go through quickly towards the end of this session. So how rare is ACNES? We don’t know. We just know that it’s not common, but it’s also not uncommon.

Speaker 1 (00:54:47):

How can ACNES you get ACNES if you’ve never had abdominal surgery? That’s the most common situation. It’s not related to any abdominal wall surgery. What nerves are involved? So I mentioned that it’s mostly the lower nerves are involved. Is there a specific patient’s demographic? No, we found no difference in young and old male or female obese or thin. And yes, it’s frequently misdiagnosed. So I went through my algorithm to diagnose ACNES. It’s usually physical. It’s usually identifying the area, ruling out a hernia and then doing a diagnostic nerve block. Does scar tissue from a previous midline laparotomy or from Mesh use to repair an abdominal wall hernia make you higher risk for ACNES? It does not, but know that some nerve pains from surgery in the area can be because whatever you put in there, let’s say a stitch is entrapping that nerve know that there are nerves to entrap surgically. How important is precise positioning when treating ACNES by administering a local injection? That’s very important because the nerve has a very specific pathway and so by ultrasound guidance you can identify that pathway and inject exactly where the nerve would be. Can you still have ACNES if you have non localized pain on one side of your abdomen and a local injection relieves the pain only partially? That’s a good question.

Speaker 1 (00:56:29):

I don’t want to oversell ACNES. It’s definitely an abdominal wall pain, but it’s not common. And I would say that it’s kind of a diagnosis of, you know, have to rule everything out first. So if you ruled everything out and you feel that the injection helped a little bit, you could argue that there’s something going on in that area. It doesn’t necessarily have to be ACNES. It may be, let’s say a fascial tear or something like that.

Speaker 1 (00:57:08):

Let’s see. Can one or more, oh, lipoma guys. Lipoma forgot to tell you guys about that. Lipoma is the most common reason for abdominal wall pain. Everyone’s, not everyone, but there’s a large number of people that have lipomas. It’s basically a benign non-cancerous fatty tumor. It’s just overgrowth of fat. And it is one of those things that if you have a lipoma, it’s causing direct pain and you touch it and it hurts and you feel it and there’s a little bulging. And sometimes by ultrasound you can show that there’s a lipoma there. Your surgeon just cuts out that little piece of fat and the pain goes away. So yes, that’s definitely, definitely a reason for pain. Okay, let’s go to the next question. Let’s see, what do you do for fascial tears? Okay, good question. So fascial tear, the history is usually it’s either in some type of athlete.

Speaker 1 (00:58:15):

So let’s say the ones I’ve had recently, the fascial tears were like in a ballerina and I had a skate, I had a ice skating champion and I had one of these people that does hiking. What do you call it when you’re, it’s hiking but it’s running while you’re hiking. I forget what it’s called, but it’s intense hiking. So they all got fascial tears. So fascial tear can tear over a nerve where it may mimic nerve pain or it’s actually just painful because it, there’s a tear and the treatment for that initially is not surgery unless it’s a huge tear. So initially it’s steroids encourage that tear to heal and if it does, great, if it doesn’t, some people also do P R P injections to again encourage it to heal. And if it does, then the last thing is you go in there, you just sew the tear. And can you see fascial tears on MRI?

Speaker 1 (00:59:15):

Not typically. I have seen it. You see a little wisp of fascia that shouldn’t be there. I have seen it. But even on ultrasound it’s very, very hard to diagnose. It’s mostly a diagnosis based on history and where the pain is can one or more injections. Yes. We talked about that. If local aesthetic injections fail, is surgery the only treatment, surgery or nerve ablation, what kind of procedures performed and are there any changes chances for the pain to get worse as a result of surgery? Almost never. I would say it’s one of those safest operations we do. And I have yet to see a neuroma from an acne’s neurectomy as a result of the neurectomy. Can you get a bulging adamant due to abdominal wall, abdominal wall denervation or other long-term problems? That’s a very good question and a concern of many patients. The answer fortunately is no. These are sensory nerves. It’s very distal, small nerves cutting. It will not cause any denervation or bulging of the abdominal wall. You said in the past that abdominal wall is less innervated than the inguinal inguinal region. Correct. Leading to a lesser risk of nerve damage and neuropathic pain when performing procedures like Mesh removal for incisional hernia. Yes. But does not ACNES involve abdominal wall nerves? It does, but the nerves are hidden within the various muscle.

Speaker 1 (01:00:54):

Muscle layers which are not involved in Mesh removal, number one. And number two, they’re very small nerves and at the most they may cause numbness of the abdominal wall, but it doesn’t cause pain. Usually. Can you have ACNES even if coughing doesn’t make it worse? Correct. Yeah, that’s very correct. Let’s see. I think that’s it my friends, that’s a lot of questions. We went through so many questions. This is great. I love it. Thank you everyone. So for those of you that maybe join us late. Yes, absolutely. As always, this will be another episode on my YouTube channel, so please do subscribe to my YouTube channel and every week we’ll post the new week’s worth of hernia talks. And also if you follow me on Facebook, they’re just always on Facebook, so you can just scroll through and find the Facebook post that correlates with this.

Speaker 1 (01:02:13):

But the most kind of reliable is the YouTube. So going to my YouTube channel, it’s at Dr. Towfigh. So follow me there. And that’s going to, that’s going to be it. That’s the end of our lovely Hernia Talk Live sessions. I know you guys love it because I really enjoy it myself and I hear from you and you all DM me and send me messages both on YouTube and my social media platforms, which is at Hernia Doc on Twitter and Instagram and at Dr. Towfigh on Facebook. So keep those questions coming. I love how you engage. Thanks for all your questions live and those that were submitted ahead of time. And I will see you again next week of questions. This is true. This is true. Thank you everyone. Bye.