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Speaker 1 (00:00:00):
All right everyone. We are live on hernia talk. This is our queue Tuesday queue meaning every Tuesday in medical language hernia talk. Tuesdays we have live question answer session, which is currently broadcast simultaneously on Facebook, which is my Facebook page, Dr. Towfigh, and later on I will archive it on YouTube for y’all to watch and learn from. For those of you that are here live, we are joined by Dr. Sharon Bachman. She is a very gifted laparoscopic surgeon with a specialty in hernia surgery. She currently works in Fairfax, Virginia as part of the Innova Health System. You can follow her on Twitter. Sharon Bachman and I have known her for, shoot, I don’t know how many years I want to say. Hey Sharon, how long have we known each other?
Speaker 2 (00:00:57):
It’s definitely been, I think since one of the hernia meetings in Hollywood, Florida. I think
Speaker 1 (00:01:05):
I would say 2000. I’m four ish. 2003 or 2004,
Speaker 2 (00:01:10):
2005. Around two five. Yeah.
Speaker 1 (00:01:13):
<laugh>, welcome. So welcome. Now you’re on Hernia Talk Live.
Speaker 2 (00:01:16):
I am very happy to be here. Thank you so much for inviting me.
Speaker 1 (00:01:20):
You’re welcome. Are you in your office? I assume
Speaker 2 (00:01:23):
I am in my office, yes, I am at work.
Speaker 1 (00:01:26):
You do work late too. I know that you’re like a hard worker. I feel very lazy compared to what you do.
Speaker 2 (00:01:35):
Don’t because you do my work. I don’t know how you stay as plugged in as you do, but all the patients out there who follow you are lucky that you do
Speaker 1 (00:01:45):
Late at night. You could see the timestamps on my posts. People are like, it’s 2:00 AM Are you posting? So for our audience, as you know, hernia talk live is aimed at a patient audience. Can you please give us a little brief of what you currently do, what you like to do in your practice, what kind of practice you have, how patients can find you, and then I know you most prominently from everything you’ve done back when you were in Missouri, so I would love to hear more about what you did then and how it affects how you treat patients now.
Speaker 2 (00:02:23):
Sure. Okay. Well, right now I am, as you mentioned at the Nova Health System. I’m a general surgeon here and I’m actually have some academic and administrative roles that take up some of my time. So I try to focus most of my clinical practice on hernia surgery, patients with growing pain and then some other things, gallbladders lumps and bumps. There’s some things I’ve given up in my practice to focus on hernia. I think those of us who have the ability to do certain things more often recognize that as you focus on a certain area and you get really good at that one area, maybe you don’t want to do the other things that you do only rarely anymore unless it’s an emergency situation. So there’s cancer surgery and things like that. I don’t particularly do anymore because there are other people who do it all the time. But that lets me focus on the things that I really like. Hernias I do a lot of teaching. So for example, I am the clerkship director for our students on campus here. So that means that we participate in undergraduate medical education. So third year and fourth year medical students come and work with us on the floors. It’s kind of like an apprenticeship, and I do.
Speaker 1 (00:03:40):
Awesome. Which medical school is that?
Speaker 2 (00:03:41):
So right now we’re with Virginia Commonwealth, but we are actually transitioning in 2021 to University of Virginia. Oh, wow. They’re realignments,
Speaker 1 (00:03:50):
VCU and UVA.
Speaker 2 (00:03:51):
Yep, VCU and UVA. Awesome. And I do a lot of work with our residency so that’s what we call graduate medical education. And then doctors have to show that they’re maintaining their education. So there’s something called CME, which is continuing medical education, and I’m currently the medical director for our CME office at anova. So a bunch of different things, and I’m sort of dabbling in some of our EMR physician informatics world too. So lots of different stuff. But as Shirin alluded to, my interest in hernias, well first grew from my senior years in residency when I worked with Abe Daoud when I was a resident, and he is somebody who’s been involved in the hernia world for a long time. And it really piqued my interest. And so when I got to go to the University of Missouri for fellowship and work with Bruce Ramshaw, Steve Eubanks it was a great opportunity and we were able to put together a lab while a group of us were there where we were. Did a lot of interesting studies, both kind of the clinical work that people are used to with outcomes as well as some really interesting materials work that we did with a scientist who was at the university named Sheila Grant and her team. So
Speaker 1 (00:05:08):
No one was doing that back then? Yeah, no one did a lab for hernia, Mesh or hernia products or that those was very unique what you were doing in Missouri.
Speaker 2 (00:05:19):
It was exciting. It was really interesting. I think right now people coming out and looking at the hernia literature don’t realize that we didn’t used to have this rate of publishing in the hernia world. It just wasn’t as I guess popular then. And so the materials work we did was really fascinating. Certainly for me one of the really interesting things about biodesign, the whole process of bringing together engineers, business people and surgeons is that a lot of time we as doctors have problems, but we have no way to solve it. Engineers have all these ideas in cool technology but need applications, and it’s kind of putting everybody together that lets you really start to solve problems. So
Speaker 1 (00:06:11):
That’s one thing I really miss in private practice. When I was at USC, I had a joint position in the USCs Viterbi School of Engineering, and I got to not only teach some courses because very few doctors and surgeons interact. And so once you’re part of that school, they want you to teach and tell them what we’re doing. So that sparks ideas for them, but also got to collaborate and do some really cool lab work and research. So I kind of missed that part, a private practice but I think the whole engineering surgeon combo is fascinating and I wish I could do more of it maybe when I retire.
Speaker 2 (00:06:56):
Yeah, I mean you do need a collaborator. I think it’s hard to do as a practicing surgeon, but if you can find an engineer or a biomaterials person who has the interest and has the technical knowledge, then it can be a really fruitful conversation. And so a lot of the work we did then was really interesting because Dr. Grant had this whole biomaterials background and taught us how it works and our assumptions of the materials we used, she kind of questioned and challenged us, and I think we were like, oh, well this is just what we used and that’s awesome. And so it really let us start taking a look at the materials. And I definitely think my experience there has influenced how I practice and the way I think about biomaterials.
Speaker 1 (00:07:47):
Yeah, I agree. So you made a comment earlier about you know, don’t do cancer anymore. Probably cancer surgery, which we’re all trained to do is something that should be done by surgeons who do it every single day. And the flip side is hernias are probably more likely to be sent to you hopefully in the system because that’s what you enjoy doing, and you do more of that every day. So based on that, we do have a question and it has to do exactly that. And I think this is the one that was submitted by one of our patients in Scotland. So in your practice, what percentage of your operations are revisional and do you think specialists should be handling these revisional operations, whether it’s for pain or recurrence or Mesh related problem? And then on Twitter, we’ve had a long discussion the past week or so with some patients from overseas about maybe to reduce complications. The primary hernia surgery should be done by specialists. What’s your take on all these concerns that have come up?
Speaker 2 (00:08:55):
Yeah, these are really good questions. Luckily, the majority of my practice is not revisional. I think the majority is still common things like primary inguinal hernias, umbilical hernias, and incisional hernias. So the most common reasons I think revisional surgery starts getting complicated because you need to look at each person individually, and it depends on your comfort level. And I’ll come back to that in a second. So primary surgery. Should all hernia repairs be performed by specialists? I think that every surgeon is trained to fix hernias. I think if we pay a little bit more attention to the teaching of hernias to residents and to our trainees, hopefully that wouldn’t be necessary. What our data shows is that we were talking about what you do most often if you have high numbers, you have good outcomes. So we have papers that show the best outcomes in terms of recurrence in pain are insurgents who have done more than 250 of whatever that particular procedure is.
Speaker 2 (00:10:14):
And so if you are really doing it frequently and you’re keeping up with the literature, I think it is definitely within the general surgeon’s toolbox. If you’re doing it frequently. We argue about technique all the time. So I think it’s reassuring looking at papers that say whether you do it open or whether you do it laparoscopically. If you have a certain amount of volume and expertise, then the outcomes will be similar. And I don’t think we would have enough hernia specialists across the country to do that, to take care of everybody’s primary hernias. But I also think in training we should emphasize hernias a little bit more. Sometimes they have been looked down upon as, oh, it’s a case for juniors. And I will freely admit, I am still learning things all the time about inguinal and ventral hernias, that it is an ongoing education process. Even somebody who is focused on it like me, there is still more to learn. So I think no one is an expert when they walk out the door, but you can certainly learn the principles and practice them and really try to get your volume up.
Speaker 1 (00:11:25):
So a lot of these discussion was with patients in the NHS system. So in the United States, we tend to have more specialists and I think easier access to specialists. Most countries that either have a socialist healthcare system or a nationalized healthcare system tend to reduce the access to specialists. So that’s a problem when the specialist, and just to update you that the discussion went back and forth, and I completely agree with you in that hernia surgery is still considered bread and butter for the generalist, the general surgeon and they should be able to do pretty much every primary hernia surgery. Now some people may not do it as well lap, they want to do it open, but the studies show that as long as you can do it well, yeah, it’s not that important if you do it open or lap or robotic.
Speaker 1 (00:12:29):
So some people may do really good lap in a horrible open or really could open a horrible lap. And we published a paper and it seems to be pretty common acceptance if you have a complication, which means something really bad like a nerve injury or Mesh infection or meshoma or something simpler like a hernia recurrence in general, those are best treated or a giant hernia, let’s say loss of domain. Those are best treated by a specialist. Even the United States, we don’t have enough hernia specialists for sure in the other countries. There aren’t enough hernia specialists. Those of us that join meetings, we have meetings every year, but we’re not the largest meeting of the cancer doctors have more larger meetings, and a radiologist has a larger meeting than the hernia surgeons by far. So we just don’t have enough specialists. And I would also add that at least in the United States, the financial compensation for hernias does not encourage anyone to be a hernia specialist. You’re like the pediatrician of the medical of
Speaker 2 (00:13:42):
The surgeons. Yes. <laugh> definitely much more motivated to do a bariatrics, let’s say.
Speaker 1 (00:13:47):
Yes, bariatrics thoracic surgery. Hi colorectal. Yeah, no one really chooses to be a hernia surgeon because they’re in it for the money or for sure, something you have to love to en and enjoy. And that’s been something we brought up here over and over again. And it’s not that surgeons out there there’s just not enough specialists. And among the general population also, there’s not enough kind of interest. I think in my, my hospital, and I’m sure in your hospital because of who you are and your passion for hernias, I think those residents really like it. My residents love hernias. They can’t wait to scrub it with me and they look forward to cases with me. I don’t remember that when I was a resident. I don’t remember ever knowing anyone in my residency that was like, oh, hernia, yes. Yeah, I’m going to go scrubbing that. We have that in my hospital because I kind of make it fun and I approach it differently. But I think the average residency program that doesn’t have a hernia specialist on their staff hernias like gallbladder, it’s kind of like what you have to do, but it’s not something that exciting. It’s until that changes, I don’t think we’re able to make it that much of a specialty that can treat every single hernia or every single complication.
Speaker 2 (00:15:19):
But on the positive side, I think groups like the American and European Hernia Society and sages, and we’ve even seen courses at the American College of Surgeons, there are so many more courses now focused on hernias and offering alternative methods for trainees to learn. And even some of the social media groups focused on hernias. So there’s a lot more opportunity for people who realize they’re not getting that richness of education in their training, supplement their training with it, or when they graduate to find additional resources. So
Speaker 1 (00:15:59):
Yeah, I totally agree. And that has
Speaker 2 (00:16:01):
Changed a lot.
Speaker 1 (00:16:02):
So for our audience, SAGE is the largest laparoscopic large, and probably the most respected laparoscopic society in the world. It’s based out of United States but has become very international even more and more every year. Dr. Bachman has always had some leadership role within the society, especially in certain sub-specialties, including hernias. I’ve been under her wings many times for the hernia task force and other hernia kind of endeavors that sages has taken on. And you’re right, like Sage didn’t used to be a big hernia meeting. And now I don’t want to say 50%, but I would say majority, it’s really high up there lot how much hernia courses and hernia talks there are.
Speaker 2 (00:16:58):
And I mean part of that has been the development of laparoscopic and then the addition of robotics to the minimally invasive armamentarium. But there’s still a decent amount of discussion about open hernias there
Speaker 1 (00:17:08):
As well. Yeah, yeah, exactly. They still do open hernias in basically a laparoscopic meeting.
Speaker 2 (00:17:13):
And I mean, you’re an American College of Surgeons governor, so that there are a lot of hernia talks at the American College of Surgeons meeting, which is a big meeting for general surgeons all across the
Speaker 1 (00:17:23):
Country. So yeah, huge, a huge interest. I don’t think the interest was there as much when the American Hernia Society wasn’t as strong. And I think those of us that got involved and then also got involved in leadership elsewhere, it kind of validated hernias as a very academic topic and something that should be seen as more than just a get got lot of surgery or something. But
Speaker 2 (00:17:47):
Going back again to that question of should you see a specialist? I think
Speaker 2 (00:17:53):
People who have some kind of complication after their surgery, and I’m especially thinking about pain those are the patients who I think really sometimes struggle with finding a surgeon who will talk to them about their complication because it’s an uncomfortable, very true topic. Very true. And you really need to have some experience with it to define an algorithm for yourself and how you manage it. And I think having trained with somebody who that was one of their areas of specialty kind of helped me be more comfortable managing that kind of care when I came out, it’s still not easy, and there’s still always very
Speaker 1 (00:18:37):
Complicated
Speaker 2 (00:18:37):
Not right answers, but it makes you more comfortable in the unknown. So you know, can say, here’s potential ways I can help you. We cannot say this will work 100%, but here’s how we will work together. And for some surgeons, that’s a really uncomfortable conversation.
Speaker 1 (00:18:59):
Oh, absolutely. For many surgeons, the algorithm is very complicated and it’s easier just to refer to a pain doctor or tell the patient there’s nothing wrong with you because they just don’t know. And we have a fellowship where we train laparoscopic surgeons in both minimally invasive surgery and bariatrics. And then in the minimally invasive side, we’ve now offered a month, one month elective. And now the last couple of fellows that we’ve graduated have all gone to do an academic job with chronic growing pain and hernias as part of how they got recruited, and now they’re doing their one month elective. With me going through all the nitty gritty it’s kind of cool to see that interest and proud of their life should
Speaker 2 (00:19:56):
Be, I mean, you have one of the most comprehensive patient intakes I’ve ever seen on that. So I was, you’ve very kindly shared it with me. Oh,
Speaker 1 (00:20:05):
Have you read my notes? <laugh>
Speaker 2 (00:20:08):
IED
Speaker 1 (00:20:08):
Of
Speaker 2 (00:20:09):
Notes and your patient intake forms? Yeah, no, they’re very thorough. I’m very specific, and again, it doesn’t always 100% tell us what’s wrong, but it’s certainly a good way to start. So,
Speaker 1 (00:20:19):
So we have some live questions about Mesh choices. One is about synthetic Mesh, ones about hybrid meshes. This come up before. So as you know, there are two types of, hi. There used to be three types of hybrid meshes. There’s the gore synecore mesh, the tela bio ovitex and the cook. The zenapro cook is no longer selling the zenapro Mesh, and then there’s the absorbable synthetics. So we used to have biologics, but now we have absorbable synthetics like phasix Mesh by bard. What are your thoughts on these newer meshes compared to the typical, let’s say polypropylene Mesh?
Speaker 2 (00:21:03):
So the underpinning of my thought about Mesh is number one, if we’re using Mesh to keep people from having a recurrence, how long do you need to protect that person? And we don’t know, although we suspect forever, because when we look at right long-term studies that look at recurrence rates of hernias, the slope is always going up. There’s always more people every year if you have a good follow up who present with a recurrence. So that would suggest that people are always at risk for recurrence because there was probably a reason they developed a hernia to begin with, whether it’s collagen, nutrition, infection, or just technique. It’s hard to know. But there was some reason somebody got a hernia, and the data shows there is always a recurrence rate. It never goes to zero. Now, in this country, most of our studies only do follow up for one to two years because it’s very hard to track patients in the United States and the Scandinavian countries, countries with a smaller socialized healthcare have really been the best ones at showing us that this outcome.
Speaker 2 (00:22:20):
So if we suspect that people need that buttressing, that support of the tissues forever, then you know have to kind of say in your head, meshes that are absorbable, what will the true long-term outcome rates of those be? Now, there’s some situations where I think an absorbable Mesh is a good option. If you’re getting out of a bad situation, if there’s somebody who you’re worried about pain, you’re worried about infection and the patient acknowledge that this may increase the recurrence rate down the line, but it deals with your situation in the here and now. And whether that is some kind of a biologic, whether it’s porcine dermis or porcine small intestine or bovine pericardium, whatever that is, we know that is at some point going to be incorporated and reabsorbed by the tissues, the truly biologic meshes, and then the synthetic absorbable meshes the same. Now we can tinker with those a little more to affect the rate of reabsorption. So the phasix, for example, we know it takes about two years to reabsorb. I’m not sure about the synecore. And now some people even have hybrids where there’s some of it is absorbable and then there’s a lightweight permanent Mesh left behind.
Speaker 2 (00:23:43):
But again, I don’t know that anybody has really shown us in a true long-term outcome study that resorbable meshes over the long-term have the same rate of recurrences, synthetics. So I think each situation is unique, but a medium weight synthetic with larger pores would probably be my first choice for a patient unless there was a reason that I was uncomfortable putting a synthetic in somebody.
Speaker 1 (00:24:18):
I agree. I think so. I think we are overusing Mesh in the United States. What do you think of that?
Speaker 2 (00:24:26):
I don’t know. Again, looking at those charts and seeing those recurrence rates even for small umbilical hernias, now we’re really seeing data that shows increased recurrence rates in primary repair. So I am not sure about overuse. I wish we had a different option, a better option. I wish we had some way to genetically knit people back together, but we don’t have that. So if our goal is to prevent someone from coming back to the OR and to allow them to have a life where they don’t have to restrict themselves, I mean Mesh is pretty much what we have right now.
Speaker 1 (00:25:10):
I agree. So let me ask you this. I, I’ve come up with this analogy, I’m kind of proud of it, but I’m testing it on people. So I agree. Every single study PR that’s worth anything has shown that Mesh is better than Mesh for recurrence. The non Mesh for recurrence, so small belly bone, hernia, big belly bone, hernia, both of those, if you put Mesh to repair that hernia, you’re going to have a lower recurrence rate than if you don’t. Of course there’s pros and cons with open, I’m sorry, there’s pros and cons with non Mesh and there’s pros and cons with Mesh. So the way I think of it is, in my practice for under 1.5 centimeters, I don’t put Mesh in for a belly button hernia over 1.5 to about two. I would determine the benefit and then over to for sure, they need Mesh. And that’s the way I interpret the data because to me, I think it’s acceptable to have a 5% recurrence rate. Do I really need to bring a 5% down to a 0.5% with Mesh and then a risk like a possible Mesh problem now 20%, 15% down to 0.5. That’s good. So the way, this is the way my analogy, so if you go from A to B and you have a choice of walking or driving, you’re always going to go faster. You’re always going to get to from a B with the car.
Speaker 1 (00:26:45):
Now there risk with the car, right? It’s more expensive. You have to put gas in you make it accident. But if you want to go from A to B, and if your only metric is how fast you get there, it’s always going to be a car. But if you’re going to your neighbor’s house, do you really need to drive there, you know, can walk there. Now of course there’s risk with walking. You can break your leg, you can get hit by a car depends on your health, et cetera. Maybe the weather is bad, but their risk with both. If I had to go to a grocery store seven miles away, I will probably drive, but if I go to my neighbor’s house one block away, I’ll probably walk. Either way the car is going to, if you test them head to head, the car will always win. And I feel like the car is the Mesh and the walking is the non Mesh, and they both have their risks and benefits, but do we need to be in a society where everyone drives? I don’t know. Is that a good or bad analogy?
Speaker 2 (00:27:48):
I mean, what you’re saying is it’s situational and I agree. Yes. So I would agree mean for me around that 1.5, it’s about 1.2 centimeters and below. I cannot fit a Mesh prostatic into that hole, and I’m not going to make that whole larger to put a prostatic in there. That patient gets a primary repair. Yes, I figure if the defect is large enough for me to get a small 4.3 round underlay Mesh there, great. Then as long as that patient is low risk for Mesh and an open situation, I will do that. And if it’s somebody who is high risk, and I mean our studies pretty conclusively show that that includes people with BMIs greater than 35 or 40 and smokers and other immunocompromised reasons then I consider a laparoscopic approach because they’re high risk for recurrence and they’re high risk for Mesh problems. Absolutely. Yeah, I think that’s very reasonable. I like your analogy, but I think we got to the same place.
Speaker 1 (00:28:51):
Okay. Are there any specific meshes you tend to prefer lightweight or macropores or shaped or precut or coated? There’s one question about titanium coating and omega-3 coating and how that changes the Mesh or cutting it changes the Mesh. What’s your thought about the synthetic meshes and is polyester better than polypropylene or polypropylene better than polyester? What are your grand thoughts about
Speaker 2 (00:29:23):
Sure.
Speaker 1 (00:29:24):
Mesh properties.
Speaker 2 (00:29:26):
Okay, complex questions here. First of all, one thing that’s interesting to know that maybe a lot of patients don’t realize is that as surgeons, we don’t necessarily have access to any Mesh we want. Yes. So a lot of participate in what they call these group purchasing organizations and companies will negotiate with your GPO to get materials for a lower cost. So essentially you’re doing bulk purchasing, so it can be really expensive sometimes to get a Mesh that’s outside of that availability. So when I teach residents about Mesh, what I teach them more about is the building blocks of Mesh and how Mesh is put together. And then if they, within the limitations that they might have at their institution can try to match up with what we think is kind of the best option. So we talked about my time at the University of Missouri, and one of the things we learned at that point was for a long time we thought the more Mesh, the better, the heavier.
Speaker 2 (00:30:37):
That’s great. The hernia isn’t going to recur super well. That’s not necessarily the case. More is not necessarily better. Anything that we put into the body, whether it’s an hip implant, a cardiac pacemaker, a piece of Mesh, our bodies are so smart, our immune systems are amazing. They know these things are not supposed to be there. And so there’s always going to be an interface between the implant and our tissues where our cells are trying to destroy it. Anything we put in, right? Nothing is truly inert. Nothing is truly hidden from our immune system. What we noticed with Mesh was that when we looked at materials that had more density, so there were for example, thicker fibers, they were knit closer together without pores in between the fibers. When there was overall a greater amount of foreign material, that inflammatory reaction was greater. So there’s a dose dependent response, and the more of the material you have, the more of these cells that kind of get together in these really big cells that try to attack the Mesh. And it’s that reaction that causes really some of the scar tissue and the inflammatory changes that can get patients in trouble.
Speaker 2 (00:32:02):
Materials that have larger interstices between the fibers. So pores, materials that are maybe have thinner fibers but are still stronger than the breaking point essentially of the abdominal wall. So they’re still stronger than the muscles. They provide support and they’re still a foreign body response, but that response doesn’t usually cause those big kind of sheets of scar tissue and inflammation. So you have more limited foreign body response to just around the fibers, but in between the fibers and poor, there’s kind of more normal scar tissue there.
Speaker 2 (00:32:43):
So in my mind, I want to use just enough, I want to use a material that isn’t going to fracture or break, and there are some materials that we’ve found that have done that because maybe they’re a little bit too light, but I want one that’s not so dense that it’s going to cause that inflammatory response. So I tend to use what we classify as a medium weight material. Mesh classification is a whole different story. People have worked on that, but there’s still no true standard on how we classify Mesh. But I would say what most people would define as a medium weight Mesh is what I try to use. And that’s to again, try to prevent some of the contraction embrittlement changes to the material that we can see. I also try to use materials that are pretty simple. There’s some materials that we need to have a coding if they’re in contact with the viscera, we really want to have at least a barrier temporarily between the intestines and the Mesh so that they don’t grow into each other and cause holes or fistulas.
Speaker 2 (00:33:48):
But what we’ve seen too many times is that when you, with the best of intentions, try to put together two different kinds of plastic where one is a real barrier to meshing growth and one is kind of lets the body grow into the Mesh, they react to that foreign body response in different ways, and the meshes then can twist and really do things that you did not anticipate and wouldn’t necessarily want to happen. So I try to stick to pretty simple materials. There are three main kinds of plastic that Mesh is made out of at this point. Now there’s some other ones in Europe, but in the United States it tends to be polypropylene polyester and PTFE, which is what most people call goretex. They have some polyvinyl chloride, I think, or what is it? I think it’s poly. Yeah, in Europe. I think essentially the body’s reactions to these are similar. Some surgeons really do not the idea of using the polyester because they’ve had some bad experiences with it. But I think again, some of it comes down to how the fiber is extruded and what the reaction is. So I think if you had a one-to-one head-to-head mono filament of polyester versus polypropylene versus goretex it, I suspect they would behave very similarly.
Speaker 1 (00:35:17):
Yeah, we talked with Dr. East last week and what you said is exactly right. She said, that’s all great. You guys are talking about all these different hybrid meshes and coated mesh. We don’t have any of that. We have straight polypropylene. Yeah, that’s it. You’re lucky to get anything beyond that. It’s socialized medicine. We’re not a rich country. That’s all I have. So everything else is like you, your rich Americans basically are, you talk about, I mean, we have a lot of different Mesh options and then oh, let me share this with you. This was actually a question. This is these all look like I planted them, but I didn’t. These are actual real questions. So one of our viewers submitted this and basically the question is this, last August, my surgeon repaired a large incisional hernia with suture only. I don’t know what large is. Maybe if you’re on, you can tell us what definition of large was my hernia has pushed through and now will need Mesh, which is what happens when you fail suture repair. Is there a tried and tested formula to determine size, thickness and of Mesh to be used in the repair of a large incisional hernia?
Speaker 2 (00:36:36):
No. Next question. No, just kidding. So it is not surprising to either me or Dr. Towfigh that you had a recurrence. In fact, the number we state is that 20% of incisions will develop a hernia. And our classic data is that over 10 years, an incisional hernia repaired just with stitches 60% of those will recur. So more than half recur over 10 years
Speaker 1 (00:37:12):
Based on a first major study in the Netherlands. Yeah, and
Speaker 2 (00:37:15):
That’s why we use Mesh. That’s why we accept this risk of putting plastic in people. The type of Mesh depends on the type of repair. So if you’re going to have Mesh, as I mentioned, that is in contact with the intestines, as with some of the laparoscopic repairs, we would want there to be some kind of a barrier between the Mesh and the viscera. And a lot of the Mesh is now have an absorbable barrier. So once your body has encapsulated the Mesh, that barrier goes away in the absorbable. Some of them have a permanent barrier, as we discussed, and for the open Mesh or for an open repair where the Mesh is not in contact with the viscera, then I think a medium weight simple Mesh is appropriate.
Speaker 1 (00:38:13):
And I’m sure people come to you for your expertise in hernias sometimes for complicated problems where you need to remove Mesh. What are your thoughts about Mesh removal? I see a lot of patient, well, I do a lot of Mesh removal. I do a lot of Mesh or basically revisional surgery is a big portion of what I do. I have a lot of patients that come to me and saying, oh, I was told I can’t get this Mesh removed ever is unsafe to remove Mesh. What are your thoughts on that? You think it’s unsafe? Do you think it’s Mesh that you could never remove? What is your take
Speaker 2 (00:38:53):
On? Well, I mean probably I have had patients who had complications for Mesh removal. Yeah, I mean absolutely. There can be bowel injuries, there can be complications. It depends on where the Mesh is and what type it is. I also remove a fair amount of Mesh. So I think patients need to understand the potential consequences of taking Mesh out. Obviously getting a hernia back is a big consequence of that. Sometimes you just want to talk it through. So there are people who, for example, had an open groin repair and have chronic pain. And we talk about, all right, if we take this out and your hernia recurs, what are we going to do? Let’s talk about that. Now. I try to at least raise the subject with people at the beginning before we do something irreversible. And there are some patients who they had pain with an open Mesh, they recur, we do a laparoscopic, and they feel fine. There’s some people who have chronic pain, we take out their Mesh, they still have chronic pain. So it’s tough to predict and you know, just have to be very open and honest with people and say, look, my goal is to at least make you feel better. I cannot promise you’re going to be pain free, but to try to make you better. But there’s the chance won’t and we’ll have more issues to deal with.
Speaker 1 (00:40:16):
Yeah, I agree. But I’ve, I’ve had patients that have been told, your testicle’s going to get chopped off. You may lose a leg. You can’t lose a leg. I mean, <laugh> really hard to do. Yeah. Anyway,
Speaker 2 (00:40:31):
I mean, I’ve done surgeries where you keep finding little pieces of Mesh in different places. You’re like, where did this come from?
Speaker 1 (00:40:37):
Yeah, absolutely, absolutely. But for sure, I would say if you need Mesh removed and it’s an elective procedure where you can find time to see second opinion or something, then there’s a list of specialists that are on hernia talk.com watch, which is our site as well as the American Hernia Society has a list of members seek a specialist and get 1, 2, 3 consults, whatever it takes before you’re comfortable going through a procedure that can potentially cause harm if it’s done, not done by someone who knows their anatomy really well and it’s technically a good surgeon. Things like that.
Speaker 2 (00:41:20):
Yeah, they’re not easy, they’re not easy cases. And it is always easier to put pet mission than take it out. Let me put it that way.
Speaker 1 (00:41:30):
For the groin, we have a laparoscopically, we have a lot of different meshes. There’s the flat Mesh, there’s a sticky Mesh, there’s the anatomic Mesh. Do you have any preference for one versus the other?
Speaker 2 (00:41:43):
Again, some of it is situational. In my mind, overlap matters more than shape. So the analogy I would use is they’re a couple, depending on your experience, if you ride bicycles and you pop a hole and you need to patch it, you don’t just cut out something for just the hole. You want to get onto the tire. For those who have home repair experience, if you’ve got a big hole in your drywall and you can’t just spackle it, you have to put one of those screens across. You don’t cut the screen to just a little hole. You cut the screen to go around onto the normal wall to help hold it in place and
Speaker 1 (00:42:26):
Exactly.
Speaker 2 (00:42:27):
And that’s the way we think about Mesh overlap, or at least the way I think about Mesh overlap. So some meshes are shaped, some are not. But as long as you have a material which I think conforms to the groin and gives you decent overlap, it’s a reasonable Mesh.
Speaker 1 (00:42:47):
Here’s a fun question. How big can a scrotal hernia become?
Speaker 2 (00:42:51):
Oh, it can get really
Speaker 1 (00:42:53):
Messy. Should I show pictures?
Speaker 2 (00:42:55):
You can. I will. Let’s see. I had one patient who had most of the left side of their colon in the scrotum. I’ve had other patients, yeah, who’ve had their right colon, their appendix, some of the small intestine. They can be large. They can be large. I would say a football size scrotum every once in a while comes my way.
Speaker 1 (00:43:23):
Yeah, I, I’ll tell you a funny story. I was a chief resident and at the VA as a chief resident, you were like the boss, you know, kind of walked around, you were the boss and did teaching rounds and acted very academic and you know, got veterans. And I think there was one patient that came in, I had not seen the patient I was doing teaching rounds and he had a sheet covering him and you could see a stump, kind of an amputation stump. He was there because something happened to his face, not related to anything below the waist. And I was just chit-chatting, you know, like to get to know people’s stories. If there are veterans, they’re a lot of amputees. As part of the VA system, it’s not uncommon to see someone who’s had an amputation whether it was from war or a vascular disease.
Speaker 1 (00:44:22):
So <laugh> there with my team, and they already knew the patient. They knew why the patient was here. They had examined him from head to toe and I saw just the sheet was covered and you could see one leg and the other one was a stump, like an amputation. So I kind of grabbed it and I said, which ward this happened, sir, tell me your story or something of that. And my team was like, no, <laugh>, like don’t go there. So I pulled down the sheet and it was a hernia. Wow. Down to his knees, like a log. And it was callous. The skin of the scrotum was callous. And so then I said, okay, do you want to get this fixed? He’s like, no, the girls like it. And I was just like, really? You don’t want to get this fixed? No, that’s a big operation. That’s not just a hernia repair. But he was good. He was okay having this enormous callous down to his knee, basically like like an amputation stomp. Oh, I dunno.
Speaker 2 (00:45:36):
The girls liked it. Sure. The girls
Speaker 1 (00:45:38):
Liked it. Girls must like it. Yeah. I dunno. Okay, here’s a question. What is your opinion about fixation methods? Can a suture replaced in the pubic tubercle as described for our original Lichtenstein?
Speaker 2 (00:45:57):
It can I, well mean we can do anything. So some people have described stitches going into the bone as a possible cause of pain after surgeries. Now what a lot of people don’t realize is that you can’t really hard to put a stitch into bone. What we’re actually sewing to is, it’s kind of a tough collagen covering on the bone. But I think that as a technique that’s probably low risk for chronic pain on having a monofilament fixation suture there as long as you’re putting it through the periosteum. Now again, some people maybe a small group might have some kind of unusual reaction to polypropylene but that we can’t really predict who that might be.
Speaker 1 (00:46:54):
I teach the residents, there’s the bone and the periosteum over it, which is the thick layer encasing the soft bone. And then there’s the muscle tenderness insertion on top of that. I would try aim for that tenderness insertion. But as you mentioned, there’s different techniques for everything and there’s no good solid evidence to support the little differences in the more questions for you. Let’s see. Do you feel like there’s been major advancements in hernia treatment and Mesh choices? And what’s your prediction of the future also for hernia treatment? Which direction are we going in, you think?
Speaker 2 (00:47:45):
So I think in terms of major advancement in hernia treatment the recognition that bringing the tissues back together in the midline is really important. For a while there we were focusing on that as much. We were kind of just covering the holes with Mesh. And I think in the past five years we’ve really seen people develop techniques and learn techniques to try to get the midline truly reapproximated. And it’s really interesting when you do that for people aches and pains, they didn’t realize they had from their hernia go away. Things like back pain and especially if you get people some physical therapy to help strengthen the core afterwards. So I really think that’s one of the biggest advancements. I mean, we see fancy stuff now, we see the robot, but really what the robot does let us do that technique minimally invasively. And it’s really getting the midline back together. That I think has really become a focus for a lot of hernia surgeons. We can’t do that in every situation, but I think it’s our goal in most situations. How much of
Speaker 1 (00:49:01):
Your practices with a laparoscope or robot and how much of your hernia practice is not with a laparoscope or robot?
Speaker 2 (00:49:09):
I do a lot laparoscopically. I use the robot for very specific indications. There’s some surgeons who have decided to do all of their minimally invasive surgery on the robot and just for a couple reasons, I don’t do that. I still really think that for me in my hands for an uncomplicated initial inguinal hernia, the old preperitoneal repair is what I prefer.
Speaker 1 (00:49:38):
I agree.
Speaker 2 (00:49:40):
But the robot has allowed us to do more especially in some of the ventral hernia repairs and it’s actually made laparoscopic repair and complicated inguinal hernia is a lot easier for me. I think the robot if you’re going to do the abdominal technique, has just changed the game as far as I’m concerned.
Speaker 1 (00:50:02):
Oh, totally. Yeah, I agree. I’m also one that does not do a hundred percent robotic. I really like the simplicity and smaller scars of the laparoscope as much as possible. But for sure robotics has changed the hernia world in a very good and big way.
Speaker 2 (00:50:20):
Yeah, no, it has. In terms of Mesh, I mean if we looked at Mesh use across the country, we would probably find that the most common materials being used in the United States are still straightforward polypropylene. There are people who are publishing some interesting things about how can we modify that polypropylene. So there’s some groups who are looking at changing the surface of the material. There’s some people who are looking at different coatings and spinning it in different ways. So there’s some interesting research on ways to try to make Mesh a little more biocompatible. And I think by that they mean less hydrophobic. So we’re made out of water, plastic doesn’t like water so much. So people trying to make that interface be a little more natural. But again, I don’t think we’re ever going to fool the immune system that this stuff isn’t supposed to be there. But there are some interesting things being done. For example, if you wanted to put Mesh into a contaminated field, could you spray in a gel some people published about spraying a gel with antibiotics in versus just dunking your Mesh in an antibiotic solution. So a lot of different interesting research being done now that people are kind of recognizing this problem.
Speaker 2 (00:51:46):
One day we’d be able to inject stem cells that can knit people back together. Man, I hope so. Cause that would be the best option of all. But I don’t think we’re anywhere near close to that.
Speaker 1 (00:51:58):
Yeah, I, yeah, I totally agree with that. The whole idea of advancement. I think surgeons are critical to lead the way as to what we need. I think patients are critical to kind of voice their interest or non-interest in the directions that we’re going. And of course we need industry to, and the engineers that they employ and the scientific labs that they run to help make all this happen. What else do you do in your practice? I feel like I send you a lot of women. I see a lot of women. Half of my women, half of my patients are female. Whereas I think if I were to see a proportionate number of patients as hernias, I think it should be more like a seven to one or 10 to one ratio of males to females. But about, it’s to me, do you also tend to see more women or what is, or it just
Speaker 2 (00:53:01):
No, I mean think more people definitely seek you out. But you have definitely raised the importance of evaluating women for brain pain and looking for hernias in those patients. And I actually learned very early on from Dr. Ramshaw, from Bruce that women, and I think sometimes even men, don’t necessarily present as a classical appearance for hernia, that for a lot of people having fat in the inguinal canal is the source of their pain. And that doesn’t necessarily look like a hernia. I have a nice video, I think of a woman of you don’t see anything and you push on the groin from the outside, it’s a laparoscopic video and you see the cord lipoma bulge back out at you. And so you’ve like, oh yeah, if you didn’t think to look for that, you would write something off. So I think that has been really a great service you have done for many women. And you’ve definitely some have come to see me based on your referral, so thank you. But I think I still see more men than women. Inguinal hernias are absolutely the most common hernia in women as well, but the prevalence in men is still much higher.
Speaker 1 (00:54:22):
So we’re actually coming up with a formula you can stick in, you can stick, it’s like a might as well make an app out of it, but it’s not currently an app. You stick in all your different symptoms and it’ll predict whether your chronic pelvic pain is due to an A called al hernia versus endometriosis or a hip tear or something like that based on our,
Speaker 2 (00:54:48):
I would use that app 100%.
Speaker 1 (00:54:51):
Isn’t that cool? Yes. If you score above a certain number, the chance of you having an occult al hernia as a cause of your groin pain is X.
Speaker 2 (00:55:02):
And interestingly, some of the patients you’ve sent to me who do have a hernia have also had endometriosis. I mean they’ve gotten multiple pelvic issues, so well
Speaker 1 (00:55:09):
It colors their clinical picture a little bit because yeah, it’s pelvic pain and then you really have to delve into what exactly is causing their symptoms. We did a really, really great webinar, actually two hour one which will be up on YouTube shortly with the pelvic guru. She’s like a great pt pelvic floor PT lady with great online presence and a lot of educational stuff. And that’s all we talked about was women’s chronic pelvic pain, how to determine if it’s an ingle hernia the pros and cons of repair. And this kind of going through all the different symptoms and how important history is more than the exam, and specifically on the exam, how important it’s to actually feel for tenderness as opposed to looking for a big bulge.
Speaker 2 (00:56:01):
I look forward to that video. Like I said, I am still learning just like everybody else, and sometimes we tend to get really focused on our area. Yeah, if you’re the hammer, everything’s a nail, but it might be a bicycle, who knows. Yeah.
Speaker 1 (00:56:16):
Do you use glue sutures tax? What are your thoughts about that whole world of fixation?
Speaker 2 (00:56:24):
Yeah, first of all, data is very inconclusive, I think, in these areas. So one big change we’ve seen, and I think the European recommendations kind of helped put that all together, was in laparoscopic inguinal hernias. If it’s not a large forward facing direct hernia, we don’t need to fixate anymore. And so I haven’t used tax for the majority of my laparoscopic inguinal hernia repairs in several years. And I would say at this point I prescribe people five pain pills afterwards. They use ibuprofen and Tylenol and and a lot of the time they don’t even want it. Or I’m like, it’s there if you need it, but if you don’t need to take ’em, take them. And it’s very few patients who take all five and I would say the majority take either none or they’re like, well, the first or the second night I took one or two and that’s it. So it’s really made outpatient inguinal hernia surgery even less painful than going to the dentist I think.
Speaker 2 (00:57:32):
But for the direct hernias, I will still fixate because I think you have the risk of Mesh eventration into the defect using fixation in different situations. For ventral hernia repairs really depends on the technique. So for example, now in a retrorectus if it’s robotic, I’m not fixing it at all. I’m leaving a drain, but not fixing it. If it’s an open repair where we’re doing a retrorectus repair or a tar, I’ll put in a couple of absorbable stitches like a Vicryl just to help hold the Mesh in place while we close. But I am not putting trans fascial fixation stitches in for that anymore because we’ve realized the Mesh has nowhere to go, it just has to stay in that space. But for laparoscopic repairs, and I still do Intraperitoneal onlays there’s argument both ways and there’s no data to definitely say one versus the other. But I still like several permanent sutures to help hold the Mesh in place. So for me, I usually do four. Now can you beat those four sutures? You sure. We can see, I’ve seen patients with hernias from where or Mesh has pulled and moved. But again, I think that comes down to picking the right technique for the right patient. So yeah, totally agree. It is really situational for me.
Speaker 1 (00:58:56):
Totally agree. Well I just want to thank you so much for giving me your time. It’s always a pleasure to talk to you. You’re so far from me. You’re on the other side of the coast and
Speaker 2 (00:59:07):
We usually, we haven’t been able to meet up this year cause we’ve had no meetings.
Speaker 1 (00:59:11):
I know meetings we have so much fun with that. But we will see each other soon hopefully. I hope so. I know we’ll be on Sages giving some talks in August together. Virtually. Virtually, yes. Looking forward to seeing you there.
Speaker 2 (00:59:27):
Well, I just want to say this was delightful and thank you so much for inviting me and thank you again for really, I mean you truly have been a leader in hernia and your work has helped. Thank you so much.
Speaker 1 (00:59:40):
Okay, your check is in the mail. Oh,
Speaker 2 (00:59:43):
<laugh>. No reimbursement was received for this webinar.
Speaker 1 (00:59:47):
<laugh>. Okay. I’m going to say goodbye. And we’re going to end with just a big thank you to Dr. Sharon Bachman. you can follow her on Twitter and just know that once we’re done with this session in a few seconds I will post the link to it so you can watch it on YouTube. Of course you can follow it on my Facebook page but also on Twitter, Instagram and LinkedIn. I will add the link so you can all watch it. If those of you are the take advantage of the free discussion hernia discussion form on hernias called hernia talk.com, it will be there as well. And I will see you again next week. And thank you again Dr. Bachman. Thank you so much. Hope you have a lovely, lovely evening.
Speaker 2 (01:00:31):
And you as well, doctor, thank you.
