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Speaker 1 (00:00:10):
Hello everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live, our weekly Q&A. I’m your host, Dr. Shirin Towfigh hernia and laparoscopic surgery specialist. Many of you are joining me as a Facebook Live at Dr. Towfigh. Others are with me on Zoom. Thank you for joining us. And also please follow me on Twitter at hernia doc and on Instagram at hernia doc. I would like to say that today’s session is all about hernia repair complications. I know that we’ve had multiple prior sessions where we talked about various complications, Mesh, implant illness, Mesh infections, chronic pain, and we’ve like kind of individually talked about pelvic pain and recurrences and the benefits of lap robotic open surgeries. But today I want to just kind of do a brief overview of just hernia repair complications. And as many of you know, I choose some of my topics based on previous week’s experience.
Speaker 1 (00:01:19):
And I would say that I’ve had several patients this past week reach out to me because they’re very concerned about the symptoms they’re having very early on in their hernia surgery repair, weeks to months, several months at the most. And they’re all afraid they have a complication. They’re afraid that they’re rejecting the Mesh, that the Mesh is migrated, that the Mesh is, they’re reacting to the Mesh, they’re afraid the Mesh has balled up. They’re afraid the nerve has been damaged. All of these worries, and fortunately in almost all of these patients, they were just having a routine recovery from hernia surgery and they did not have any problems. They were just really worried about it. And I would like to say that hernia repair surgery has complications. It’s not very common to have complications fortunately, and when they occur they’re very, very specific and it’s really important to differentiate a normal recovery from a hernia operation with an actual hernia repair complication.
Speaker 1 (00:02:37):
So let’s kind of go through those. I have a whole list of questions that have been submitted to me, which are really, really excellent, many of them, and so I will go through those as well. But let me just start with a brief overview of what’s a complication and what is just normal recovery from a hernia repair. So when a surgeon talks about complications, they mean things like infection, recurrence, chronic pain, nerve damage. These are all related and can be related to hernia surgery. And if we talk about inguinal hernia repairs, so basically a groin hernia operation, there are very well defined risks with the operation of complications. No operation has 0% risk. Now, theoretically, if you are a hernia specialist because you’re aware of all the various risks at a more heightened level than the average hernia surgeon, you will try and determine the best operative decision for the patient to reduce their risks.
Speaker 1 (00:03:54):
So the operative operations include open, laparoscopic or robotic. They can include Mesh or no Mesh. And for the AV average hernia repair, the most common kind of concern that surgeons have is a recurrence. And in all patients there have been reports of recurrences from 1% to 17% and in some studies actually the recurrence seems to be higher in laparoscopic than an open. So about 5% for open in lap, 10% for laparoscopic in expert hands is actually the reverse. And those numbers can vary widely. I usually mention about a 1% recurrence in my patients for open and about a half percent to quarter percent recurrence in laparoscopic for my patients. But if you look at the literature, the numbers vary. Vary from 1% to 17% recurrence. And most studies that talk about specialists believe the recurrence rate should be no more than about one or one to 2% if done by a specialist.
Speaker 1 (00:05:18):
And the American College of Surgeons has a really great database of all different types of operations and they have what’s called a risk calculator. You can go online to the American College of Surgeons, just Google ACS or American College of Surgeons risk a calculator. It’s constantly updated and they can take your specific demographics like your age, your base, your body metabolic index, so basically your height and weight, whether you smoke or not. If you’re a diabetic and what kind of operation you had and based on their database, they can spit out a risk factor. So what most patients are worried about is their chronic pain relate to inguinal hernia repairs and that tends to be accepted to be around 10 to 12% after one year. For all patients who undergo inguinal hernia repairs 10 to 12% by about one year. And the laparoscopic data supports that number being lower than the open surgery.
Speaker 1 (00:06:39):
And if you go to other complications, nerve injury from Inguinal hernia repair, it’s concerned to be higher for open and laparoscopic. We already know that. We’ve discussed that before on this show. There are more nerves that are at risk for injury or entrapment in scar with the open angle hernia repair through the laparoscopic. And if you look at the literature from the last 10 years or so, it’s about 10 or 11% risk of nerve pain after open surgery and it’s less with a laparoscopic closer to 7%. And there are other risks you can have bleeding. So that’s about a 3% risk. It’s higher with larger hernias, you can have fluid collections that may need to be drained or somehow address that’s called a seroma or, and that can range every in the last 10 years. The literature has support anywhere between five and 25% seroma rate, but most of those are not, do not need any attention.
Speaker 1 (00:07:46):
It’s just fluid there. And the larger the hernia, the larger the risk of fluid collection in that area. Now if you go through American College of Surgeons risk calculator, the a c s risk calculator, they look at wound infection rate. That should be very, very low for all surgeons and for sure less than 0.5%. Complications overall should also be low, should be in about less than 2%. That’s things like non-surgical complications like anesthesia, breathing problems, blood clots, et cetera. Pneumonia, very low risk, almost zero with any hernia repair in the groin. Urinary tract infection also almost zero. It’s like 0.2% is what their risk calculator shows, but very, very low risk blood clots, close to zero chance of a blood clot with open or laparoscopic hernia repairs and for sure death less than 1%.
Speaker 1 (00:08:55):
Death rates really come into play for inguinal hernia repairs and are significant in emergency settings. So emergency operation with maybe even dead intestine and there is an expected death rate from the infection and sepsis that you get for that. So those are like the numbers out there in the literature. If you look at ventral hernia repairs, again, similar to inguinal hernias, ventral, which means abdominal wall hernias could be from an incision from a prior surgery or it could be just a bonafide hernia like in the abdominal wall. We’re talking larger than just a simple umbilical hernia. But those also like any operation have risks similar to. So if you look at the literature, recurrence rate is about 10%. It’s a little bit higher with the open ventral hernia repairs, it’s about 12% for open, 10% with laparoscopic. That’s what the literature shows. And in people that get a non mass repair, it’s about 17%.
Speaker 1 (00:10:08):
So higher than any open or lap laparoscopic repair with Mesh, the larger the hernia, the higher the risk of recurrence. You can have injury to the intestines, that’s a major risk with any type of hernia repair, especially if there’s bowel in the hernia, you can injure, you can injure the bowel, and that risk should be low, less than 10%, sorry, less than 2% for both open and laparoscopic surgery. It’s slightly higher with a laparoscopic repair. In fact, one of my patients this week asked me about that. He said, you know, you’re going to go in there laparoscopically or robotically is what I offered him. And I said, this would be my preferred repair option for your specific type of hernia. And he asked me and he said, well, what about the risk of bowel injury? Is it higher or lower than the open operation? I said, actually, it’s higher.
Speaker 1 (00:11:08):
So the risk of bowel injury during a ventral hernia repair or ADO or abdominal wall hernia repair is higher if done laparoscopically or robotically than with the open repair. It’s mostly because the visualization in the area outside of where you’re looking is is not as good because you’re, you kind of have a little bit of tunnel vision with laparoscopic or robotic surgery. So I was honest, it’s higher. He’s like, then why would you choose to do my hernia repair, laparoscopic or open? And I said, well, because of everything else. So let’s review some of the other complications. We already showed that the open repair has a higher recurrence rate than laparoscopic. There is some risk of urinary retention that can occur usually with general anesthesia, people with older age prostate problems. So I like to always ask about whether you urinate too much at night and if you do urinate more than once an evening, you’re at risk of to wake up to urinate.
Speaker 1 (00:12:21):
You’re at risk of having urinary retention from surgery because your prostate is enlarged for males, obviously women do not have prostates. So again, going back to the ACS risk calculator, if you plug in the average data and looking for, let’s see, let’s talk about wound infection rates. So wound infection rates are significantly higher for ventral hernias. That inguinal hernias, we talked about inguinal hernias wound infection rate is less than half percent. It’s even lower with laparoscopic than with open. Similarly wound infection rates are much lower with laparoscopic surgery for ventral hernia pairs than open by a lot though by a lot. So it’s less than 1% with laparoscopic and then closer to 6% with the open surgeries, and especially if you’re using Mesh, that could be a big deal because the infection from a ventral hernia may be may also cause not just a wound infection but a Mesh infection, which is a disaster.
Speaker 1 (00:13:31):
Or if you don’t even have Mesh, it can just eat away at the healthy fascia tissue and cause a bigger hernia. So that’s a problem. Other complications can occur. You may need to go back to surgery because of let’s say bleeding or pain or whatever. That’s significantly worse with open surgery than laparoscopic. Laparoscopic is less than 1% open surgery is closer to 4% risk of return to surgery. You can get a pneumonia that’s about the same between open and laparoscopic. The larger the hernia, the sicker the patient, the higher the risk of pneumonia. But again, less than 1%, it’s not a major concern of ours. Urinate tract infection also low, less than 1% for ventral hernia operations. Blood clot like a half to less than 1% depends on how sick you are. If you’re a patient from the nursing home that needs a ventral hernia repair or you’re unable to walk around after surgery, that risk of blood clots increases heart issues, heart and lung issues, that’s usually based on how sick you are to have the surgery to begin with.
Speaker 1 (00:14:48):
Kidney failure, again, both of these are less than 1% risk, but known risks for any operation death again, should be less than 1%. We don’t really talk about death rates for ventral hernia repairs unless the patient is coming in as an emergency, very sick and already has probably compromised intestine like dead intestine. So considered to be low, very, very low almost. We don’t really talk about it any elective situation. And then all comers looking at surgical infections and blood clots and everything combined total for laparoscopic it should be two and a half percent and for open about three times that. So 10% risk. So when the patient said, okay, well why are you offering me laparoscopic or robotic surgery knowing that the risk of boundaries higher with the robotic surgery, why don’t you just give me the open surgery? I said, okay, because lower risk of every single other complication, specifically Mesh infection, wound infection, blood clots, hernia recurrence, and nerve injury in that patient’s specific situation.
Speaker 1 (00:16:07):
So that’s why when you come to see me and I give you my impression of what you need, everything is taken into consideration, not just one specific detail. So as a patient you may be like, I don’t want bowel, I don’t want bowel injury. Well, I don’t want bowel injury either. It’s a known risk and of course as a surgeon you do everything you can to prevent that risk. But some people, the Mesh is really stuck in the hernia. I’m sorry, the bowel is really stuck in the hernia, et cetera, et cetera. And so there is still a risk.
Speaker 1 (00:16:49):
So appreciate that surgery has risks, period. And going to a specialist should reduce that risk. I have patients that come see me and they really regret having been to surgeon X and that’s a great surgeon. I would say the fact that despite going to the specialist you had a complication doesn’t mean you shouldn’t have gone to that surgeon X who’s a specialist. It just means that you were at your specific situation puts you at a higher risk than the average patient. And statistically if you went to a non-specialist, your risk would’ve been higher. Again, we’re not talking 0% or a hundred percent. There’s something in between and everyone’s a little bit different.
Speaker 1 (00:17:38):
So that’s really the gist of what I want to talk about is there’s so many things that goes through our minds as a surgeon when we go into the operating room and we often don’t share all of that. It can be overwhelming for most patients to hear all the things that we’re talking about and we’re thinking about before we operate on someone. I did a couple operations today, every single step I take with any patient in the operating room, I remind myself of the consequence of every single decision, everything from the first incision and where I put it to the suture that I use and to the technique that I use and how much I even put retraction on the tissue and how I handle the tissues. Everything has a consequence. And so the decision that’s made is based on me in my mind already having its own risk calculator so to speak.
Speaker 1 (00:18:41):
And then it’s spinning out kind of okay, this is the best decision for the next step in the patient. All right, well we have some questions that I’ll answer and then we’ll come back to some more discussion about hernia repair complications. So let’s see. Question number one. After a double Spigelian hernia surgery with Mesh four weeks postoperatively, I still cannot stand for longer than one to two minutes without horrible pain. Also, it’s very painful at times when sitting down there is zero pain when I am sitting. Is this considered within normal healing? Yes, it is considered within normal healing. So most ventral hernias or abdominal wall hernias are closing a gap and that closure alone is making your abdominal muscle tighter than when it was before the surgery, when it was splayed open. Now, double Spigelian hernia surgery implies you had Spigelian hernias on the left and right.
Speaker 1 (00:19:42):
That’s not common. Spigelian hernias already are a type of ventral hernia that’s uncommon. And then to have it on both sides is very uncommon. I always teach my residents when you sew tissue, number one, don’t take big bites of the tissue. If the tissue is, let’s say you really want like five millimeter bites and you don’t want the sutures too far out because it’s going to cause more pain for the patient, I always teach them to handle the tissues very, very gently because mishandling or rough handling of patient’s tissues, they can’t tell us it hurts because they’re under general anesthesia. So you have to be their advocate and not pull and tug too much on the abdominal wall tissues because what’s going to happen is though at the time of the general anesthesia operation, they are not going to complain after surgery. They will have more swelling, more bruising, possibly bleeding in that area that they may not have if you had a much more dainty surgical technique.
Speaker 1 (00:20:49):
And therefore what is done in the operating room, even just tissue handling is very important in how the patients do postoperatively. Now if in addition to so suturing close the hole which can cause tightness, often Mesh is used for Spigelian hernias to reduce the risk of hernia recurrence. And in doing so, some people put the Mesh in too tight or the surgeon didn’t put the Mesh in too tight, but the patient feels that it’s too tight for them because Mesh, as you remember in prior shows, Mesh does not stretch muscle stretch. Mesh does not stretch. So if you’re trying to stretch or move or engage your abdominal muscles and you have a specific area where it’s very, very tight, then it’s going to hurt because your muscles want to stretch out but the Mesh will not allow it to stretch with time, this should all go away and your body will get used to it.
Speaker 1 (00:21:53):
And at four weeks it’s still possible that all of this is temporary and it will go away for my patients, sometimes they bring them back into the office, it gives a local anesthetic and in doing so, temporize their pain control until they’re done with their healing. In extreme cases I’ve injected Botox, which is a neurotoxin. We put Botox in the different areas of the face for cosmetic purposes to reduce wrinkles by paralyzing and loosening up those muscles. You can do the same for the abdominal wall as you I inject Botox to temporarily for about four months, relax the abdominal wall muscle until it’s ready to re-accept the fact that it’s now tighter than it was before surgery. And lastly, you can start some type of oral pills, which are muscle relaxant pills and the muscle relaxant pills can help relax those muscles while you’re in that recovery stage. Tizanidine I think is a very good one for that because it muscle relaxes and helps with pain control.
Speaker 1 (00:23:12):
So let’s see, another question. In someone with a recurrence of an open Lichtenstein repair, what are the signs that suggest that in addition to Mesh pulling away from its fixation points, there is also a less visible, harder to differently diagnose pulling away of the Mesh from the inguinal floor. How can this be diagnosed definitively and is it seen on laparoscopic repair or is it assumed without being confirmed visually and more or less prophylactic placement of Mesh? Okay, so it sounds like this patient had a hernia repair in the groin, inguinal hernia repair and it was repaired by the Lichtenstein or Lichtenstein hernia repair technique, which is what we call … It’s open surgery and involves Mesh is what we call Onlay Mesh. So we put the Mesh on top of the muscle. So if you look at it’s on top of the hernia, it’s a great repair.
Speaker 1 (00:24:15):
It’s considered a gold standard for internationally. The question is I that this patient has a recurrence. So how do you know that the Mesh pulled away from the sutures or did it pull away from the inguinal floor? So it depends on what the imaging shows. It doesn’t really matter because if it’s a recurrence then a laparoscopic repair with Mesh is indicated. But on imaging, if the imaging is done with Valsalva or with pushing out, so like an MRI pelvis with Valsalva, what can show is if it’s a true recurrence where the keyhole has opened up, then you will see a full thickness hernia go through the Mesh through the hole keyhole in the Mesh and out. However, if the Mesh has pulled away from the hole, then what happens is it’s a partial thickness hernia in that the Mesh, sorry, the content from the hernia goes through the hernia and touches the Mesh and pulls the Mesh away from the repair but it doesn’t go through the Mesh.
Speaker 1 (00:25:40):
I hope that makes sense. I dunno if that makes sense, but imaging is how you diagnose it, definitively. And then laparoscopic repair is the next best option to move forward with it. We have some other great questions I’d like to go through because they’re really insightful that were presented and if you have any more questions to submit to me live, let me know. So here’s a great question. It says, what are the hernia repair complications that you consider most worrying about? So I personally don’t like hernia recurrences because I take them very personally. Even if I was not the reason for the hernia recurrence, let’s say as a patient who gained weight or had a COVID cough, they recur, but then now I have to rerepair the patient. I don’t like to have recurrences in my patients, but what I’m most about are infections because though very rare it, any infection of a hernia has such long-term consequences with scar tissue and Mesh infection and Mesh removal and you basically buy two, maybe three other operations and with all that scarring, the nerves are hard to find and the hernia can’t be repaired correctly the first time because now you have inflammation from the infection and so on.
Speaker 1 (00:27:11):
So it’s really, I worry most about infection knowing that that’s like the worst complication, but it’s definitely not the most common complication. It’s actually quite rare, especially for laparoscopic cases. I don’t really worry about infection with my laparoscopic cases actually. I mostly worry about pain and then also recurrence. I do just worry in general. That’s just my thing is I worry a lot about all my patients. I may have told you this story. Dr. Thomas Burns very famous surgeon at a USC and he was my mentor when I worked there as my first job out of residency. He was very senior, I was very junior and he really took me under his wing and he said A good surgeon is a compulsive compulsive pessimist and you have to worry about your patients all the time. You have to be a warrior. And I’m like warrior, no warrior. You have to be a worrier. And I worry, and if I have a resident or a trainee that doesn’t worry. I worry about that because you want your doctor to always worry about, you always think what can go wrong? You double check, triple check. If you’ve been patient of mind, you know that I’ll email you and have or call you. My nurse will call you constantly. Are you okay? Everything good? Not that we think everything’s going to be bad, I was just constantly thinking about you.
Speaker 1 (00:28:47):
So I don’t know if you relate to that. It’s, it’s a unique thing with medicine, especially surgery. You’re so personally involved in the patient’s care that you want it always to be perfect knowing that it can never be perfect but you worry about all the time anyway. Because I worry about things like what if the patient’s wound is not healing perfectly, but they never care to tell me I want to know these things. I don’t know if the patient knows that drainage is not normal after from their wound and they’re just watching the drainage and not doing anything about it, things like that. Let’s see. Question. Is an MRI the only test that will show my Mesh and Mesh plug for Inguinal hernia surgery? No. A CT or an ultrasound will definitely show a Mesh plug and possibly the Mesh as well. The Mesh plug is very easy to see on all imaging.
Speaker 1 (00:29:51):
Well I like to use the MRI to plan for surgery because I like to see if you have a Mesh plug and you think it’s the cause of your pain and it needs to be removed, what do I need to know about that Mesh plug? How big is it? Where was it placed? How close is it specifically to the external iliac artery and vein? Most likely the vein because by and where is the bladder in relationship to that Mesh plug? Because once you plan for surgery, you have to make sure you remove that Mesh without causing more injury. And that usually involves the nerves, the vessels and the bladder. And with imaging such as the MRI, it’s much easier to identify those and plan for it than with the other ones. Here’s another question. I had an occult femoral hernia on the left side repaired laparoscopically with Mesh three weeks ago.
Speaker 1 (00:30:45):
I’m still feeling pain at about the same level as pre-op along the left thigh, groin and hip. Is this to be expected and at what point will I know whether I should go back to the surgeon? So if you had surgery three weeks ago, I assume you’ve already seen your surgeon at least once. We like to see our patients within the first two weeks after surgery. So that’s number one. And what did you tell your surgeon at the time? The key question is how is your current pain three weeks after surgery different than your pain before surgery? Now if you’ve had an AC since you had a call hernia, so that means you didn’t know you had a femoral hernia and it was repaired or that you had pain and they thought it was from a hernia but it wasn’t obvious and then they found a hernia and they fixed it.
Speaker 1 (00:31:39):
So in those situations what I always question is, okay, we didn’t really know why you had the pain. We found this femoral hernia. We’re thinking that’s the cause of your pain. Let’s fix, fix it. You fix the hernia. Then the question after surgery is how is your pain? If they’re like, oh, I got so much pain doc. I say, okay, what is the quality of that pain? I understand you have pain. Is it the same exact pain, completely unchanged from before surgery? In which case most situations imply that the hernia was not the cause of your pain. If you’ve had thigh, groin and hip pain, you may actually have a hip disorder like F A I if femero acetabular impingement or some type of arthritis or bursitis of the hip or impingement syndrome. So I would say that the quality of the pain, if it’s the same may imply that the femoral hernia was never the cause of your pain and you have to look for something else at three weeks.
Speaker 1 (00:32:45):
It’s hard to tell you’re still recovering. I would give it a little bit more time if it’s not too severe. One thing I would say for some hernias, people feel like their hernia came back early after surgery and it didn’t. It’s just there’s fluid there. So where your hernia used to be is now empty, right? You had a hernia repair. Now with that emptiness, what you have is fluid will fill that space because your body doesn’t like empty spaces. So it will temporarily fill with fluid and when it fills with fluid or blood and it’s going to feel sometimes like you have another hernia either because it’s bulging or because the symptoms of the fluid now in that space are recreating the symptoms you had when you had a hernia in that space. And therefore if you have fluid in this space and that’s why your symptoms are back then I would massage the area and with massage help absorb, help your body absorb the fluid faster, in which case that will get you to a better recovery. I hope that makes sense. I don’t know if that makes sense a lot, but that’s the way I think about it. Here’s a comment. As with any profession, there are those with your level of concern. And then there are those cavalier cowboys who aggressively offer large meshes for small hernias. Don’t call, they don’t, don’t inquire about the healing process. And so on. A six week checkup was all that I had. Yeah, that’s not good. Or at least that’s not how I run my practice. We sometimes call too much.
Speaker 1 (00:34:31):
All right, next question. I’m the patient from the previous question. With the recurrence of the Lichtenstein hernia repair with Mesh, that was merely repaired by rerepaired by merely suturing Mesh back down to its fixation point where to come loose. That does not work, my friend. That’s not how Mesh repairs work. In this case. Can you still see abnormal findings on MRI? They can indicate the second surgery you discussed, ie pulling of the Mesh away from the Inguinal floor to confirm need for laparoscopic repair as a third operation. Okay, first of all, the repair option for someone who’s had a recurrence from a lichtenstein hernia repair shall be a laparoscopic repair. If your surgeon does not offer laparoscopic repair, they shall tell you to go to an expert who does offer laparoscopic repair. Going in open after a prior open repair with Mesh has a higher risk of recurrence and chronic pain.
Speaker 1 (00:35:31):
That’s number one. So based on what you’re telling me, I don’t understand the logic. And going back again, open number two, Mesh works by causing inflammation. And that inflammation starts a cascade of healing, which includes scar formation and growing into the Mesh to make it so that it’s now a stronger floor once that inflammatory cascade is gone. So usually three weeks, six weeks, maybe nine weeks, once you’re done with that inflammatory cascade, that Mesh is like paper it, you can put paper against the wall as much as you want. It’s not going to stick. It’s just flat cardboard. Okay? So suturing cardboard back in place in a fake way puts it back in place. However, the rest of the area of the Mesh that’s not stuck to your tissues will never stick again because there’s no, the inflammatory stage is gone and there’s no rein inflammation from the ad operation.
Speaker 1 (00:36:45):
So I have seen on multiple occasions surgeons who just take the old Mesh and they suture it back in place. It does not work. That is not how Mesh works. That is not how Mesh heals. That’s not how a Mesh repair can be successful because you’re basically putting cardboard over something you need to glue it in and it’s not with glue either. You need to have inflammatory properties of the Mesh for it to work. And once that property is done gone, it’s no longer useful to you. So you need a revisional repair. So in your situation, I would not go back in open, I would do a laparoscopic repair assuming what you have is a recurrence. So this is kind of what I’m talking about where you’re kind of going in surgery, you have to plan everything before understanding what you’re dealing with is very important.
Speaker 1 (00:37:49):
What is Mesh? What is the property of the Mesh? What am I dealing with? And then how am I going to handle it? So knowing when I teach my residents, I talk about how important it is to know when you’re reading the operative report from the prior surgeon, okay, the patient had Ventralex St Mesh, what is that? Do you know what St meshes? Do you know what size it is? Do you know what it looks like? Did you know that it has a tail to it that’s different than other types of meshes? So you have to deal with the tail in addition to the Mesh and the tail has consequences. And so when you’re evaluating a patient, it’s not just, oh, they had a hernia to redo it, understand the properties of what was done to them in advance. Okay, here’s another question. Is there evidence that the coating on Mesh that prevents adhesions has caused more of the foreign body reactions?
Speaker 1 (00:38:44):
Not that I know of. To date, there has been no overwhelming evidence in any way that the adhesion barrier of Meshes is promoting foreign body reactions. In fact, most of those barriers are gone within one to three weeks and so it should not. Now there are people that are allergic to those barriers to the chemical form and the barrier and that is not allergy to the material is not the same as having an autoimmune reaction. So people who have allergies get like redness over the area. Same way if you have a bee sting allergy, you have a bee sting redness over that area. It’s an allergic reaction to that portion of the adhesive barrier, anti-adhesive barrier. And usually as the anti-adhesive barrier dissolves, the allergic reaction also goes away. And it’s usually just a redness and swelling like you would a be sting in some patients but not a foreign body reaction. Foreign body reaction occurred to foreign bodies and the adhesive barrier is usually not the foreign body that we talk about. Here’s another question. How can chronic pain at 15 months caused by nerve injury during an open repair be managed and does nerve pain usually become worse over time? So fortunately nerve pain does not necessarily become worse over time. In fact, it may become better as the nerve heals, but it’s unpredictable how nerve pain progresses.
Speaker 1 (00:40:30):
In some patients it’s a small injury, the nerve will heal that injury and they’re better over time. In other patients, it’s a severe injury, they never get over it and they actually become more severe over time. And on average people just don’t change. They have the nerve pain just never goes away or gets better usually. So if you have chronic pain at 50 months caused by nerve injury during an open repair, it’s managed in a multimodal manner. Number one, you have to identify the type of nerve involved. And what is the injury? Is it a suture through it? Was it cut or damaged during surgery? Is it involved in scar tissue? There was no injury during surgery, but once scar tissue hit in, now it’s entrapped in scar tissue, is there a neuroma and therefore more resistant to typical management? And the first line of treatment is to do a nerve block and determine how much better you get with a nerve block and then that can followed up with more nerve blocks or nerve ablations or surgical neurectomy.
Speaker 1 (00:41:38):
And if you go to my visit with Dr. Payam Vahedifar, we had a great discussion about nerve pain and how to handle nerve injuries. In one of my very earlier podcasts, I think it was my first year I was doing this. So we really discussed this in depth about how to handle it. Of course there’s also medications you can use that tame the nerve and can help with the nerve pain. The medications usually do not cure the nerve pain, but it can keep it under some control. And then lastly, you can have topicals. So Salon Pas is a brand that makes lidocaine patches and the salon Pas patches can help with numbing the area locally. There’s other kind of patches that you can buy or creams. C B D cream tends to work for some nerve pains. So it’s multimodal pills, topicals, injections, and then potentially in procedures with an ablation or a surgical neurectomy after Mesh removal for an inguinal lipoma and lots of scar tissue.
Speaker 1 (00:42:57):
Do you have to be careful with lifting forever? So not repaired? Oh yeah. If you haven’t had a hernia repair and you have a hernia, it’s going to recur over a year postal just working out with lightweights. So a healthy core which may be based on exercise and so on is great. So if you want to reduce your risk of getting a hernia, don’t gain weight, don’t use nicotine. Correct. Any cough and exercise including weightlifting. All right, let’s go to some more questions. Is there anything that a patient can do to prevent or at least help spot complicated early on? So yeah, so if you’re diabetic, your sugars must be under good control. That will dramatically reduce your risk of infection. If you’re obese, you should lose weight before surgery and continue to lose weight and do not gain weight after surgery to reduce your risk of complications.
Speaker 1 (00:44:04):
If you use nicotine, you should stop nicotine before surgery and do not restart nicotine after surgery because that could impair healing and increase the risk of infection and recurrence. Both are major complications. If you have a cough, you should reduce the length of how long your coughing is. If you have constipation that should be treated before surgery and you should prevent constipation after surgery because the straining from the coughing can cause hernia, recurrences or chronic pain. But pulling on the sutures, if you have an enlarged prostate and you’re straining to urinate, that should be treated before surgery. That will reduce your risk of urinary retention after surgery and then also provide less risk of recurrence because you’re not going to be straining against a hernia repair. So there’s a lot that a patient can do. It’s not normal to have wound drainage. If you do have wound drainages, you’re run it by your surgeon to make sure that’s okay.
Speaker 1 (00:45:09):
It’s not normal to have a lot of redness over the wound. Another thing to review with your surgeon. Here’s a question. What are the odds for an athlete to tear a hernia repair, low risk. Will Mesh prevent or reduce tearing? Yes it does. Are there any other binders besides Carin that you recommend for flank hernia or denervation? Cause after hernia repair surgery gone wrong, I do like cared the, there’s another brand starts with an M, what is it called? I’ll try and find it for you. If you can email me, I’ll try and find it for you. That a lot of the other surgeons also like that’s really good for ventral hernias. And then maiden form has good compression garments as does yummy tummy. I think they’re really good. Let’s see more questions.
Speaker 1 (00:46:14):
How would you rate different hernia repair complications according to their dependency on the skill and experience of the surgeon performing the repair? Okay, well I think hernia recurrence is number one. So the more experienced the surgeon, the lower their recurrence rate, that’s for sure. Chronic pain may be number two. So the more experienced your surgeon, the lower the risk of chronic pain after their repair. Everything else is very much patient dependent and not so much surgeon dependent. Are there any hernia repair complications that require a multidisciplinary surgical approach to treat them? Great question. So yes, I would say that I tend to work with plastic surgeons. If there are complications that are addressed in someone who’s had a tummy tuck before or if they have a lot of extra skin, I work very closely with urologists If there’s any involvement of Mesh with the bladder or with the spermatic cord where a vasectomy may be necessary.
Speaker 1 (00:47:30):
So those are the two ones where I work with closely. I do work with gynecologists because endometriosis may be contributing to patients chronic pain in the pelvis after hernia repair and that’s the most of it. What were the most unexpected intraoperative complications that you encountered when performing a hernia repair? I would say the one that pisses me off the most is when the patient was told that they’ve had Mesh removed and there’s tons of Mesh still in them and they’re being told, well we removed the Mesh, we don’t see why you’re having any problems. And you go in there and some I’ve had situations where I really don’t know how much Mesh was removed, maybe 10% and the other 90% is still in them. So I would say that’s one. I recently saw women that had essure or Essure Coils that were supposedly removed and she had chronic pain still and basically was told that she’s nuts because, well we took out the Essure Coils. Well in fact they did not. And what happened was the gynecologist went inside and noticed coils sticking out of the uterus, little like sharp points coming out of the uterus that could have injured intestine and so on. So that was kind of crazy.
Speaker 1 (00:48:58):
Let’s see. Here’s another question. Live. Is it only injury to major nerves that results in chronic post-operative pain or can cutting small nerves to access angle floor in open procedure also cause chronic pain? As far as we know, it’s the injury to named nerves which are visible that causes chronic pain and not so much injury. Cause there’s nerves everywhere. Your entire body’s a nerve map. So yeah, let’s see, I had a Spigelian repair a week ago. I’m still in pain but always see these called rare. Okay, so Spigelian hernias are rare because there aren’t that many people that get Spigelian hernias. I repair several a year, but there are surgeons out there that have never seen a Spigelian hernia. That’s how rare it is.
Speaker 1 (00:49:56):
How much and why does core strengthening help in preventing a recurrence after hernia repair? Because it provides a good strong platform where there’s engagement of the muscles as opposed to when you gain weight where your muscles just display open and the more you gain weight and the looser your abdominal wall, the more abdominal pressure to these hernias. Whereas the more strength you have in your core and the more stable it is, the less tension on the hernia repairs. Let’s see. Can core strengthening compensate to some extent other risk factors such as smoking or being overweight, no smoking and being overweight are independent risk factors for complications regardless of other positive factors that you have given that Mesh, unlike tissues is not able to stretch. How common is pain or discomfort when exercising? So that’s a good point in that when I teach my residents, I say Mesh will does not stretch number one.
Speaker 1 (00:51:08):
And number two, Mesh shrinks. So when they put the Mesh in, not only should it not be put in tight, but if you put it in a little bit loose. So it allows for the patient to stretch and bend, cough and exercise. How soon a for laparoscopic operation should you begin working on core strengthening? That’s a very specific question for your surgeon and the type of repair that you had. For inguinal hernia repairs, I say now, tomorrow, I don’t care when you do your exercises for inguinals. For ventrals, it depends on the size and the risk factors for the repair, how often it’s been recurred. For example, could using the same trocar site three times for surgical procedures cause chronic nerve pain? Usually not. But trocar sites can be painful because you can get hernias at those laparoscopic trocar sites or depending on the location of that trocar, there may be nerve damage. Sorry, yes, nerve damage. Usually the Ilio hypogastric nerve or an anterior cutaneous nerve. Why after a tissue-based hernia pair does the hernia grow in size? If there’s a recurrence?
Speaker 1 (00:52:34):
Oh because you’re, you’re tearing, you’re basically tearing through the tissue. Is the body not able to regenerate a healthy tissue around the area of the original repair? Not healthy tissue. I would say their scar tissue, but scar tissue is different than healthy tissue depending on different hernia types and sizes. And assuming that the repair is performed by a specialized hernia surgeon using permanent or hybrid Mesh, what are the typical rates of recurrence rate and Mesh? Okay, so we already reviewed that earlier in the beginning of the talk. Does reduction in recurrence rate by using Mesh always justify the added risk of Mesh related Complications? This is a great question because I discuss this with my patients all the time and I also talk about this with my surgeon friends because they sometimes disagree. So in a 100% of situations using Mesh will result in a lower recurrence rate than not using Mesh every single time.
Speaker 1 (00:53:36):
If you have a contest between Mesh repair and non Mesh repair, the Mesh repair will always win for based on recurrence rate alone. So why do we offer non Mesh repairs? Well, some people have had an infection in the area already or there is currently an infection in the area. Can’t use Mesh in those patients because they’ll get a Mesh infection and that Mesh infection risk is much higher than the worry about a recurrence rate. Maybe in some patient they actually have a known problem that will make them allergic to or react to the Mesh. They may have mast cell activation syndrome as one of my patients had yesterday. So in that situation, best not to use Mesh, understanding that you’re giving them a repair with a higher recurrence rate than if they use Mesh. Some patients the difference in benefit of Mesh versus non Mesh is very small.
Speaker 1 (00:54:41):
So we reviewed the data early on. Mesh versus non Mesh for recurrence rates. Recurrence rates are two to three times higher. If you don’t use Mesh can be. However, that’s for all hernias, especially the larger ones. For the small, like if you have a one millimeter hernia, putting in Mesh is virtually the same as not putting in Mesh. So let’s just not add the extra risk and cost of adding Mesh. So that’s a discussion I have with my colleagues. Many of them don’t agree with me because again, Mesh always reduces recurrence rate compared with non Mesh always. And so they’re like, why would you do that? And I said, it’s up to the patient. If the patient understands that the non Mesh repair has a higher recurrence rate and they’re willing to accept that higher recurrence rate in my hands, laparoscopic repair with Mesh open repair with Mesh it’s 1% or lower risk. And with a tissue-based repair it’s about five to 7% risk.
Speaker 1 (00:55:53):
To me, that’s a big difference. Five to seven next to the patient they’re hearing, oh, I have a 95% chance of doing just fine without Mesh. That’s not bad, I’ll take it. So it’s how you, what’s important to the patient, what is their goal with the hernia repair? And so that’s a discretion that I have with the patient. I allow the patient to help make that decision with me as opposed to telling them that, oh, you must have Mesh. And that’s kind of the way that I approach these things. Let’s see. Can you share your thoughts on the use of recumbent bike after abdominal Mesh removal? Very good option. What procedure would you recommend to a patient who has a recurrent inguinal hernia and a family history of mass cell disorders and autoimmune disorders?
Speaker 1 (00:56:48):
Okay, that’s a difficult situation because you’re, you put in that recurrent word in there. So if you had a Inguinal hernia and you have known family history of mast cell activation and or autoimmune disorders, I could understand how a tissue-based repair without Mesh would be ideal. If that recurs, then you’re stuck because now the gap between Mesh and non Mesh gets even wider. Where a recurrent hernia repaired, again without Mesh is almost a disaster going to happen. Maybe greater than 50% risk of recurrence for ventral for sure and maybe 20% risk of recurrence for inguinal. Whereas with the Mesh, that could be all be brought down to 10%, 11% for ventral, and 1% with inguinal. So I do like hybrid Mesh. TelaBio is a company that makes ovitex. There are other hybrid meshes planning on coming into the market. It’s basically a combination of absorbable biologic Mesh and a sliver of permanent suture run through it.
Speaker 1 (00:58:15):
So it’s not absorbable cadaveric, biologic Mesh, which we know does not work and will result in a recurrent hernia eventually. Two-thirds of the time. It is, it’s that plus a little bit of extra permanent suture to provide that synthetic permanent scaffold and thus reduce the risk of recurrence. So I’m a big fan of Telabios ovitex Mesh for patients with high risk for Mesh reaction or Mesh and plant illness or known risk known history. I tend to prefer that Mesh, I’m not claiming you can’t react to that Mesh, but in my experience that’s been the best go-to Mesh for patients at higher than average risk of Mesh reaction.
Speaker 1 (00:59:13):
Ooh, we’re almost done guys. Let’s do a couple more questions, see if we can fit some in. Is there a significant amount of scarring left after you remove Mesh? There is scarring. I don’t know about the word significant. Does it eventually go away? Yes. Or to the contrary, it can worsen with time. No, all scarring, remodels and reduces overtime. Can fistulas excessive intraabdominal adhesions or erosion occur after Mesh implantation even when the Mesh is placed extra peritoneal? No. How rare are these complications? Are some patients more at risk than others? So people with known inflammatory disorders, especially inflammatory bowel disease such as Crohn’s or ulcerative colitis, are at significantly higher risk of fistulas and Mesh related complications. And therefore we either don’t use Mesh in them or when we do use Mesh in them, we place it far away from the intestines. I will never place synthetic Mesh on like a Crohn’s bowel just asking for disaster.
Speaker 1 (01:00:30):
Is there, oh, here’s a question. Is there a significant amount of muscle tissue excavate with Mesh removal? No, actually there should not be. Should be infinitesimal amount of that. And let’s see. Can adhesions develop or increase in severity during watchful waiting? No. Making the hernia repair more difficult? No. What may make it more difficult is a larger hernia if you’re watching it over time, but no it does not. A ADA is not a factor in making hernia repairs more difficult, especially femoral hernias. Okay, let’s see. That is it my friends. You guys have been great. Back to back Every week we’re having more and more questions. What do we go through? 40, I think 30, 40 questions today, maybe more. That was amazing. So I hope that helped you a little bit about getting a little bit of a grip on what we as surgeons consider to be complications just because you have a difficult recovery that’s not usually considered a complication from a hernia repair because time will heal that and there are other ways of fixing that.
Speaker 1 (01:01:54):
And that was our topic for today. Thanks for all the information. I love you guys. You’ve been the great, I do appreciate you very much. So. Remember on my YouTube channel at Hernia Doc this and all prior Hernia Talk Live lives are archived. So you can go through all of ’em. I did allude to a couple of them today that you can look at to give yourself more information. Thank you for following me on Facebook at Dr. Towfigh and on Twitter and Instagram at her doc and that my friends, is the conclusion of another Hernia Talk Tuesday. Thanks everyone.
