Episode 132: Traveling for Surgery | Hernia Talk Live Q&A

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Speaker 1 (00:00:10):

Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live joining you here on a very kind of cloudy and dreary Los Angeles rainy day on a Tuesday. I am your host, Dr. Shirin Towfigh hernia and laparoscopic surgery specialist. Thank you for everyone who’s here via our Facebook live at Dr. Towfigh and also via Zoom. And you can follow me on Twitter and hernia doc at Hernia doc on Twitter and Instagram, excuse me, at Hernia doc. And as always, this podcast as well as all previous ones will be found on my YouTube channel at Hernia Doc. So I’ve been getting a lot of questions about traveling to see me or traveling to see a surgeon or I comments on my YouTube channel saying I’m from Malaysia, or I’m from Niger and I need some help who do in this area? And some of them are complicated operations that these patients may need.

Speaker 1 (00:01:19):

And so I thought maybe it would be good time to talk about what it means to travel for your hernia surgery and really for any surgery. But I would say specifically for hernia surgery because that’s what I do and a lot of my patients travel. So in the past couple weeks we’ve had patients travel from multiple states, Texas, New York, Canada, two from Canada actually in this past month. Interestingly, where else do we have Colorado, Mexico. So it’s been good and we have several patients that have reached out to me because as you know, in order to help people get care, even if they can’t see me, I offer what’s called online consultation where it’s more of a email based communication back and forth where I review your whole chart and your images and try and figure out what was done to you, what needs to be done, what the images show, why you may have certain pains and so on.

Speaker 1 (00:02:27):

And then if possible to try and find you a surgeon near you to be able to handle some of your needs because I know it’s very onerous to want to just run around, just run around hoping that this doctor in this state or this doctor in that country’s going to help you. And then you see them and they’re like, yeah, it’s actually not a urology problem or it’s not a hip problem, or whatever. So I think the online consultation really helps. And now with telehealth, it really helps within states to be able to see doctors without having to travel so much. So I actually like this whole telehealth because I feel that so many patients are helped by it. So let me review what it means to travel for surgery, and if you have any questions, feel free to use the chat function and answer any of your questions with regard to that.

Speaker 1 (00:03:27):

So those of you that are on Facebook Live or Zoom can put in your questions. So let’s talk about traveling. First of all, even though those of us that live in the United States are very blessed because we have pretty advanced surgical care, pretty advanced medical care, there’s still a need to travel sometimes for people. So I would say that the patients who need specialty care still will need to be traveling. And that’s kind of something that even in the best possible scenario in the best world, you need to be able to do that because when you narrow down to a very narrow niche, then the number of surgeons that can offer you the care that you need also dwindle and so on. So give me one second to, I need to handle one thing right now because one of our attendees

Speaker 1 (00:04:49):

Is not being very nice here. Okay, so based on basically what I want to say is even though we have a really great country, we really do need to be able to travel sometimes. Not everything can be done in the actual state or even city that you live in. Even Los Angeles, there are people that need to travel for certain cancers or so so on. It’s really hard to do. I understand that it costs money, but oftentimes what you’re doing, which is the opposite of efficient and also costs money, is potentially seeing a lot of doctors that aren’t helping you. I’ve seen people who’ve keep going to doctors within their system and they constantly are getting CT scans, CT scans, they come with tune with 20, 30 CT scans, which is very, very inefficient and not good for you because you’re starting getting a lot of cancer. And then also,

Speaker 1 (00:06:03):

Also what can happen is they give you the wrong answers or they do the wrong operations. I’ve had a couple patients this past week that got procedure they should not have gotten and that got diagnoses that were completely wrong, and that took them down a path of getting nerves cut and Mesh put in, Mesh taken out half of the Mesh taken out, some of the Mesh taken out a lot more nerves cut really did not need to have, let’s say they had seven operations, they probably did not need five or six of those. And that’s a, that’s expensive. B, it takes a lot of time away from your work and because you’re constantly in recovery, C it, every operation has risks, even the correct operation. So if you have risks based on incorrect like operations, that’s definitely horrible. So my point is this, go see your own doctor, whoever it is for simple things.

Speaker 1 (00:07:06):

If you’re confident with your first doctor surgeon, let’s say he does a hernia, then go see a second surgeon. And if that second surgeon pretty much gives you the same answer, then pick whichever of the two surgeons you feel are a best fit for you by personality, by location, by reputation, and go with that surgeon. However, if you go to your first surgeon and you don’t like that first surgeon, definitely go for a second surgeon. But if you go to that second surgeon regardless, and then now you have two different opposing, then that’s a time where you may want to consider leaving your milieu and seeing other surgeons, I don’t want you to panic and go out there kind of doing too much at one time or feel like every single little lipoma removal needs multiple specialists, but even hernia surgery, which is considered by many to be just a hernia, your best if you can get the right diagnosis and B, the right treatment plan. And lastly, the right surgical technique. So let’s say you go to surgeon number one, they say, yeah, you have a hernia, let’s fix it laparoscopically, great, sounds reasonable. You did your research, you thought that was the right answer. You go to the second surgeon and they’re like, ah, you can maybe not have surgery, but if you do wish to have surgery, you can do it laparoscopically. That’s reasonable too.

Speaker 1 (00:08:51):

But even something as simple as that, if you go to a surgeon, that’s not a simple simple hernia surgery or a laparoscopic surgery can cause complications at a higher rate if it’s not done by a specialist. So then you want to say, okay, so how many of these do you do? What are your outcomes? And if they make up numbers or they don’t really follow their outcomes, then in my book, that’s a big no-no. I feel like surgeons need to be constantly interested, constantly improving their outcomes. Every single operation, even if you’re 90 years old, you still want to be that surgeon improving your complications. Not that I recommend any 90 year olds to continue operating, but you know what I mean. Anyway, so that’s my recommendation. Now, travel can mean many things. We live in Beverly Hills, it’s in the county of Los Angeles, its own city, and the majority of my patients, I would say 99% are not from Beverly Hills.

Speaker 1 (00:10:00):

That’s just a fact. However, a good proportion of them are from Los Angeles County. I would say in my practice maybe 10% are from Los Angeles County, which means that 90% of my patients had to travel outside of their county area to come to see me. But southern California’s a very big state, part of the state. California’s a big state. I have a lot of people coming from Northern California that they drive or fly down and so on that I think very reasonable. Some of them actually, most of them come to me because they’ve already learned a lesson the first time they had a complication. Now they want an opinion on now what to do. So they have a hernia recurrence, their Mesh is infected, the Mesh is folded, they have chronic pain that they went to their doctor after they had pain, their doctor said, go see pain management.

Speaker 1 (00:10:53):

They weren’t happy with that plan of care. So those are kind of situations where the patient said, I should really go to a specialist. Those are kind of no-brainers. You should see a specialist once you have a failed operation, whether that’s for your shoulder and knee or it’s your hernia repair. I do not recommend going back to the same surgeon if you have a complication, unless that first surgeon was also a specialist. So I have my own complications. I don’t claim to be a perfect surgeon, but I understand how to treat complications. So let’s say you were my patient. I do recommend you come back to me because it’s important that I help you through that process. If you have any complication, most surgeons who don’t do complicate operations, pref aren’t very skilled at figuring out how to handle complications. Not true for everyone, but that tends to be the truth.

Speaker 1 (00:11:57):

So if you have a complication, you should go to your back to your surgeon to see what they think. But if they kind of recommend not to do anything or discount your problems or kind of metaphorically kick the can down the road, then you should definitely see a specialist. And that would imply often traveling. So many traveled to me from Southern California within southern California, so San Diego County, let’s say Orange County. I had a patient yesterday, they came to see me from Orange County so that those are to drive maybe an hour drive, two hour drive.

Speaker 1 (00:12:40):

In California, we don’t think that’s a big deal. But in other states, if you may think an hour or two drive is long, it’s actually not do take the effort to travel at least that much to see a specialist, especially if you have a complicated problem. And then the question is, what about traveling further out? So now we’re going to go from county to the next door state, right? So in California we see patients from Nevada, a lot, Las Vegas especially, and then some from Arizona and every so often from Colorado. So that involves, involves a full flight. We get many patients from Texas, believe it or not, about half my patients from Texas drive, they drive from Texas. It’s like two days to get here, minimum, minimum two days, sometimes three days. But flying, driving, it’s actually a pleasant drive through the southwest.

Speaker 1 (00:13:40):

But now you are in a situation where it’s not easy to go back home. And therefore the purpose of today’s talk, which is the whole purpose of traveling, and then we have cross-country traveling, right? New York, Pennsylvania, that travel or Florida that come to me. Obviously those people fly. And then lastly, it’s a cross countries. So whether it’s candor Mexico, I’ve had patients from Brazil and Columbia, and then we have Australia, that was really cool, Asia and then Europe and Europe and Middle East. So these are all continents that may or may not have specialists or they have healthcare systems that are not amenable to the needs of the patient and therefore traveling to the United States may be worthwhile. Very important, you figure out how to travel for those and hopefully today’s episode will help open your eyes as to it means to travel. So let’s go through, excuse me, okay, so let’s go through the details.

Speaker 1 (00:15:07):

So typically for my patients, my office is very, very well versed. We have three options for you. If you can come see me in person, that’s a traditional consultation, come see me in person. I can examine you, we can figure things out. My office will work behind the scenes to ask for your medical records. If you see another surgeon, make sure you either send them your medical records ahead of time or bring them with you early to your appointment. And that includes not only operative reports if you had them, but your list of medications and allergies and very importantly, if you’ve had any imaging, I want to see all your imaging preferably on a CD or USB or something and not just the report because as you know, and we’ve done a couple of radiology report sessions, I don’t trust radiologists to read my hernia portion of images.

Speaker 1 (00:16:07):

So that’s the typical standard come in person consultation. Then there’s, we offer what’s called telehealth, right? Ever since the pandemic telehealth has been considered equivalent to regular appointments. And so if you have use insurance for example, it’s considered a legitimate way to do it. Since I’m licensed in California, your first visit with me if you want it to be a telehealth can only be done within California. Otherwise, I’m not allowed to treat you outside of my state unless you’ve been a prior patient. So telehealth works well. I get to see you just like a zoom that we’re doing right now, and as part of that, hopefully you’ve sent me all of your reports so I can review it. I can’t really examine you, but it’s kind of awkward. But I do ask you like show me your belly or show me the area of your pain, and if I can see something that’s great is often not as helpful as seeing you in person and feeling around, but it is an opportunity. So if you’re within California or for other, if you’re talking to other doctors in with telehealth, if you’re within a state in which they have a L medical license to treat you, then oftentimes nowadays since the COVID pandemic surgeons are offering telehealth.

Speaker 1 (00:17:45):

So that’s kind of a good thing because if you’re living 300 miles away from me, then you really shouldn’t need or have to fly down to see me if we can do everything by telehealth. Now, telehealth cannot replace the benefits of an in-person visit. So if I say, yes, you have X, Y, and Z, and based on what I can tell you need surgery, then I definitely would like to see you in person. What does that mean? That means when you come to see me, we can arrange it and my office very good that arrange it. So let’s say we operate on you on a Wednesday. I want to see you on a Monday or Tuesday to sit down with you, physically examine you and confirm that the plan of care we had is the correct plan of care because I’m physically examining you. I can see, you can see how tall you are, how large you are, how small you are, how you walk, all these things that I can’t get from a telehealth visit.

Speaker 1 (00:18:55):

However, if you’re playing on having surgery and you don’t live nearby, it’s tricky. So what’s tricky about it? Well, actually you know what? Let me not talk about that yet. I’m going to answer that in a second, but let’s do the third option. So first option was a traditional in-person visit consultation. Second option, if you’re in the same state as the state in which your doctor is licensed, for example from you, it’d be California. You have the option of a telehealth visit, otherwise it’s not able to treat you as a patient. The third option is, which is what I offer. I’ve been offering it for years really since 2008 ish, 2008 ish, but really strongly since 2013, which is what I call online consultation. It’s kind of my way of being able to help you without you having physically come here. I think it’s the best deal, honestly, I don’t want to encourage everyone to do it because I really do prefer it to see you in person, but it’s like financially it’s a really good deal because you send me everything, I review everything usually on my days when I’m not physically at work because it’s like a weekend or an evening, and then I write you a very long email explaining everything that I reviewed, what I see on the images and what I think is going on.

Speaker 1 (00:20:32):

Then you email me back and you say, oh, thank you so much. I often hear terms, this is the first time someone’s actually told me I have X, Y or Z, or no one saw this on the imaging. Thanks for reviewing it. And then I may have some questions for you to answer. And there’s a couple emails going back and forth and usually after one or two emails, there’s a plan of care and I can say, oh, you are in such and such state. Who’s really good? I know my buddy Dr. So-and-so, why don’t you go see them for this problem? They should be able to handle it. Or I could say, listen, you’re in a state where there really is no specialist. You have to travel X amount. So many times the patients have to travel outside of their state and maybe even come to see me as part of that, but it’s a nice little package because you get everything written down, you can’t forget it.

Speaker 1 (00:21:29):

You can just go read the email again, some people share my email with their surgeon to help with that, but the key is you’re not really my patient. I’m just trying to help out by reviewing some of your records. There’s no doctor-patient relationship, and so this online consultation is really one where I’m here to kind of provide you with my opinion based on the documents you provide me, but it’s not a doctor physician relationship. So it’s not covered by insurance and that kind of stuff, but I think it’s the best deal honestly. So let’s say all of that happens and now you decide, okay, I need to come travel outside of my county, outside of my state or outside my country to see me or any other surgeon. Then this is important, assuming that that you may want surgery, you need to prepare for an operation to make sure the operation is best performed and you get the best outcomes. The operation itself is not as important as everything else that you do in planning it. So I’ll give you an example.

Speaker 1 (00:22:55):

Had a patient come to me from a different area of the country for an Inguinal hernia. He want a tissue repair. He’s from a different state. He did like a one week road trip, came to see me, lovely, but he brought his spouse, number one, very important, okay? He initiated a lot of the communications before, so I knew what we were trying to figure out for him. I said, based on what you’ve given me, here’s my recommendation. Yes, you’re a good candidate for tissue repair. And he made the trek over to see me. He did all of his blood tests and doctor’s appointments preoperatively at his home. So his own doctor pretended like he’s going to have surgery and did a full history and physical exam, did EKG, whatever was necessary to plan for his simple outpatient procedure. So we’re going to start simple, simple outpatient procedure.

Speaker 1 (00:23:58):

He came to see me. I confirmed the diagnosis. I actually gave him more diagnosis than he had because I was able to physically exam, examine him. However, the plan of surgery was unchanged and he had tissue based repair like one or two days after he physically saw me. That was all pre-coordinated. But here’s what happens. You need to wake up early to get to surgery. It helps if someone’s there for you. When you’re done with surgery, you absolutely must have some type of arrangement for someone to take you home or to your hotel or your Airbnb. You can’t drive yourself home, you can’t walk home. You can’t get an Uber, you cannot get a taxi driver. You can’t get a private driver. You just can’t. The standard is you have to have someone available to pick you up and physically take you inside the house or apartment or hotel, make sure you’re comfortable and safe and then leave you alone.

Speaker 1 (00:25:13):

Oftentimes that’s a friend or spouse. So I highly, highly recommend that’s how it is, and you come either with your family or friend or whomever to do that. So do not travel alone if you plan on having surgery. However, there are nursing private nurses that can provide you with care. Let’s say one day not doesn’t have to be too expensive, but that nurse can pick you up, take you to your house and stay with you for a couple hours and you pay for that service. Otherwise, I may have to drive you home and I don’t want, and I may have other surgeries to do, so we can’t just send you up.

Speaker 1 (00:26:07):

I’ve had in extreme situations where I’d have to put them in the hospital overnight and have them leave overnight, but I just don’t like that. I don’t like that at all. Before we go on, let’s see what questions there are. Hey, hey, here’s another amen. Outcomes are pertinent to any profession. Very true. Here’s another one. I’m still hoping to get my medical records mailed to you, but both my husband and I and I have been having health issues. I’m sorry, I had left angular hernia surgery in 2015, have been in horrible pain since I have three more hernias but won’t have surgery because I’ve heard even the doctor in Minnesota uses Mesh. Well, that’s true, but you can travel. I was going to come see you two years ago, but when we wintered in Arizona, some drug use burned our house to the ground.

Speaker 1 (00:27:03):

I remember this story. So I can’t come to California because my husband’s 84 and I’m 80. Aw. So I’m hoping one day to send you all my records so I could talk to you. I’m very happy to talk to you. I hope you do the online consultation. I really hope that travel notes, oh, here’s my friend, okay, I’m going to read this to you because I know this person and I’m sure that they have a lot to offer. So Inguinal hernia, travel notes. I’m going to read this off of Facebook right now. Driving 1600 miles. This is for real driving 1600 mile. This is why I love him. 1600 miles from California back to east Texas was good at day five post-surgery, I would not have wanted to do it sooner. I drove 400 miles each day, which is crazy by the way. That’s a lot of driving.

Speaker 1 (00:28:01):

I stopped every one and a half hours maximum, which was good for stretching, and I walked for 20 to 25 minutes. I kept the area cold while driving with disposable ice packs. I actually recommend those non disposable ice packs where you put ice in it because they stay cold, longer. Stiffness, pain was a lot less. Even by day four of driving, which was now nine days post-surgery, new pains started surgery wear is very sensitive to touch and clothes are rubbing on it. I noticed on last day of driving and still not home, 12 days post-surgery, ibuprofen, acetaminophen did not help like it did with the immediate post-op pain. Would this be nerve related? Usually it’s swelling related, but we can talk. Ice makes it worse. I can’t massage the incisional area at this time due to pain when touching the skin. Walking is difficult due to rubbing.

Speaker 1 (00:29:00):

Thanks for taking care of me. Okay. All right, so here’s a great scenario. So this is a gentleman who drove for four days after surgery. So number one, if you have four days of travel, do not do it immediately after surgery. Give yourself some days. So this patient waited five days for a surgery. That’s great. Five days for a simple operation is pretty good for the more complicated the operation, the longer you should plan to be in the area where you’re a surgeon to the operation. So big abdominal wall reconstruction, one month minimum two weeks, minimum two weeks for really large complication. Complicated abdominal walls up to one month, but definitely minimum two weeks for simple operations like laparoscopic angular hernia repair. Fly back the next day for open tissue repairs. I would say five days. Five days minimum to travel. But now you have a problem.

Speaker 1 (00:30:03):

You have pain burning, unexpected, what do you do? Well, that’s where it’s very important to make sure you understand how easy it is to contact your original surgeon. Do they have their cell phone number? Do you have their email address? How quickly does the office respond to phone calls? Very, very important. If you have an office that’s dysfunctional, they don’t respond, the doctor doesn’t, doesn’t return your phone calls, they don’t offer an email. I would not go to that doctor if to travel because you’re going to need to speak with someone. You’re going to need to ask them for pain medications. You may have new findings that you need to talk to a doctor with. They can’t ghost you, right? That’s a new term for the generation ghosting. You can’t have a doctor’s office that ghost you. So you must make sure if you’re choosing to travel for surgery that you choose a doctor that’s responsive because it may be great while you’re there, but once you go back to your home, you need to be able to reach that doctor and ask them for questions, prescriptions, follow-ups, whatever, and they need to be responsive.

Speaker 1 (00:31:18):

And if they’re not, then that’s a good option. So that’s another thing with traveling for surgery. So if you go on hernia talk.com, there was a great post, and I forget who did it, but it’s a great post when they told you exactly what to prepare for because there is a Korean surgeon that’s active on hernia talk.com and there are patients that are considering traveling to Asia for their hernia surgery, which is fine. I think we have, I don’t think it’s necessary to travel to Asia, but it’s definitely doable if you wish to do that. And this patient did a really nice job of putting down all the tips on what to travel, which as a physician I may not be as good at telling you, but as a patient was really good. So go to hernia talk.com to read about that. But he made certain comments like for example, pack in a way so that your luggage has wheels and that work and your luggage isn’t heavy. You don’t have a lot of bags you have to put on your shoulder. Everything can be rolled away. Second, you want to wear really soft and clean and loose clothing. It’s just more comfortable. You don’t want to be in jeans or anything that’s constrictive. You want to wear comfortable shoes, you want to stay warm in the area and so on.

Speaker 1 (00:32:58):

It also talked about food to be prepared. If you are traveling, make sure that after the day of your surgery that you have a refrigerator stock with juices and foods and water and all your pain medication is filled out before you return to your hotel or home because those are things you don’t want to have to deal with in the first 24 hours after surgery. You don’t want to be like, okay, I’m really hungry. Where can I go? Or I don’t have any water or I have the or I want to just, what is it take where I need to fill my prescription At the pharmacy, you don’t want to do all that within the first 24 hours because you just had surgery. So of course if you have a friend or spouse, they can help you with that, but it’s better that you get all that prepared ahead of time. Ice packs are very important, so I highly recommend the non disposable ice packs, but the disposable ones work as well. They just last very last 20 minutes, whereas the other ones last six to six hours.

Speaker 1 (00:34:19):

So that’s kind of the gist of it. Here’s another question. I have polypropylene Mesh in my abdominal wall muscles that is definitely causing me problems, but because it’s complicated to remove the Mesh, the Mesh, my local sort of doesn’t want to even attempt it. Also, he’s given me no other options to repair the area with other, the Mesh because quite frankly, he has hardly any experience removing Mesh. Okay? This is a very, very common scenario. Almost every general surgeon, with the exception of few of us, which are specialists, will give you this answer. Is it possible to get my own tissue repair from my abdominal wall? Also, if I try or lose weight, will this make the pain in my abdominal wall worse? So the question is, what are your risk factors? All Mesh can be removed. That’s not an issue. I don’t know if a Mesh that I’ve ever not been able to remove no matter where it is.

Speaker 1 (00:35:19):

The question is then what do you do once the Mesh is removed? And you need to first of all, be a very low risk patient, which means what? Normal to low weight, no nicotine use, no straining to have a bowel, no straining to urinate because of an prostate, no chronic cough. If you can fit all those criteria, you’re considered low risk patient. What do I mean by low risk? Low risk for hernia recurrence? Because as you know, tissue repair has a higher recurrence rate than a Mesh repair. So the lower your risk for recurrence to begin with, the lower your risk of recurrence with a tissue repair. So then when we take out the Mesh, we can consider doing a tissue-based repair. Now, the expected tissue-based repair for a Mesh removal for the abdominal wall, not the groin, but for the abdominal is 50 to 60% risk.

Speaker 1 (00:36:18):

That’s a horrible outcome. That means more than likely it’ll fall apart again. Then what do you do? However, we need to do risk benefit analysis. Why do you need the Mesh removed? Do you just want the Mesh removed? That’s not good enough. Is it causing you pain? Maybe it’s not because of the Mesh, it’s because you have a hernia recurrence or the Mesh is folded or the repair was incorrect. So a lot of discussion needs to go as to the indications for Mesh removal, whether that’s even going to help you and then reduce your risk for tissue-based poor outcomes. Basically. That’s kind of what I want you to get out of it. Okay, so going back to traveling for surgery, many of the larger institutions have hotels within the hospital even or adjacent to the hospital. So traveling or needing to drive out after surgery is not an issue because the hotel is right there.

Speaker 1 (00:37:27):

Cleveland Clinic does that. UCLA does that at the main hospital, not the Santa Monica branch, other or Cedar Sinai. The hotels really literally across the street. Other places like myself, we have relationships with local hotels. Some of the hotels, the really fancy ones, have their own physician in-house in the hospital. I mean in the hotel, there are hotels that function as nursing care after care that we can use. They will come pick you up from as nurses. They will come pick you up from the operating room when you’re done and take you to the hotel and help take care of you. And we also have relationships with local hotels that give you good deals or they provide shuttle service. But again, after surgery, you definitely need someone with you. So unless you want to pay extra to have a nurse, a private nurse, you should bring a spouse or a partner or friend or a neighbor or anyone who’s willing to provide you with a ride that’s not like a taxi driver so they can come into your house and help you with all that. So that’s kind of what it’s with travel care. There’s a couple questions that have been provided ahead of time. I want to review with you, is it reasonable to consider traveling for a first time uncomplicated hernia repair? I think it is, and I’ll tell you why.

Speaker 1 (00:39:03):

If you’re in a situation where you have been watching Hernia, Talk, Live and you say, oh, I’m one of those people that has rheumatoid arthritis or lupus or psoriasis or some autoimmune disorder, I’m allergic to a bunch of things. I’m a thin female, let’s say, and I know based on what I’ve learned from Dr. Towfigh that my best outcome is to, the best outcome is to not have Mesh in me. If you’re like this gentleman who’s in Min or this, I think female who’s in Minnesota and can’t find any patient surgeon in Minnesota to do a tissue based repair, you need to travel. You don’t necessarily need to travel for the consultation because some of us do offer these online consultations, but for those who don’t, you do have to travel for your consultation. And then if that’s the only surgeon who can offer it and it’s deemed the appropriate.

Speaker 1 (00:40:11):

For example, if you’re 80 years old or 84 years old, I usually would recommend Mesh based repair because your tissues are usually not adequate for a non Mesh tissue based repair. However, have I performed tissue-based repairs? An 80 plus year old patients? Yes, I have. They were healthy and the hernias were not huge and they’re doing very, very well. But it’s all part of the risk benefit ratio of operating. So going back to traveling for uncomplicated hernias, yes, I have a fair number of people that come to me that travel to me, and I’m kind of surprised. I’m like, oh, why are you here? Because you don’t have a hernia that’s complicated. You don’t have, you’re not a revisional patient, you don’t have a prior history. You’re just like a regular patient with an inguinal hernia. Why’d you travel to see me? And it’s because for them, they were able to do their research and they decided I would be the best surgeon for them.

Speaker 1 (00:41:17):

I probably could have sent them to a local surgeon. They probably would’ve done fine, but for some patients probably is not good enough. And so they feel that they should kind of come see me, those patients, because I don’t get too many simple uncomplicated hernias to repair. It’s a very small fraction of what I do. So when I do get the straightforward hernias, I’m going to live because low stress, I can do a good job and know that I’m not dealing with scar tissue and nerves and meshes and all that. Okay, next question is what are the hernia complications that are most difficult to treat and for which you should even consider traveling outside of your state or internationally and to see a specialized hernia surgeon who has experience in treating them? Very good question. And I have a couple patients, one from Turkey, one from Spain, and one from, I think it’s Saudi Arabia.

Speaker 1 (00:42:26):

So those are patients that are unable to get the care they need. Almost all of them are Mesh removal patients. I’m a great person from Italy that I helped with as well, and many from the UK that are in the process. So here’s what happens. The repair is complicated because the Mesh is folded or the nerve isn’t trapped and so on. Those are straightforward operations in that the problem is you have to remove the Mesh. The technique though, is complicated. And so those are the ones that you should travel for because you don’t can cause a lot of damage By doing a Mesh removal, you can damage the vessels, you can damage the bladder, you can damage the nerves, and the higher, the more experience the surgeon, the lower the chances that those damages will occur. It’s not zero, but it’s much, much lower. So what hernia complications are the most difficult to treat? Usually the Mesh removals, usually the ones in the groin.

Speaker 1 (00:43:42):

What’s hard to do with a traveling patient is chronic pain that’s nerve related. Those are really hard. Those are very hard because you need injections, come back in two to three weeks for another injection, come back another two to three weeks for another injection. You may need pain medication, pain management. If there’s a Mesh involved or a repair that’s involved, you may still have pain afterwards, which needs more injections and epidurals or whatever. So it’s like a three to six month dedication to the patient. Whereas, which is fine if you live locally, but if you’re living from a different country, I’ve had a couple patients that are like, I’m just going to come here, coming to the United States, I’ve saved up some money. Just going to get a little hotel or residence in the area and just do what you need to do that. That’s happened. It’s just hard for most people to dedicate living in a different city for months. But that if you have a chronic pain nerve related and not Mesh related, those are the most difficult to treat if you’re out of state or out of country.

Speaker 1 (00:45:05):

Next question. How important is the facility where your surgeon works and where you will go to have your hernia complicated treated? Oh, excellent question. Very, very important. I’ll give you an example. I work at a Cedar Sinai Hospital. It’s number one in California and number two in the nation. So why is it so such that that first of all, in GI surgery, it’s also number one in the nation. So general surgery is part of GI surgery. We have the most amazing nurses, and I’ve worked at different hospitals throughout my training and prior jobs, even the top other top hospitals or world famous, I think Cedar Sinai is even better, mostly because the nursing is superior. And we have really, really smart group of specialty doctors that I work with, whether it’s a cardiologist, urologist, gynecologist, pain doctors, et cetera.

Speaker 1 (00:46:13):

The anesthesiologists, superb anesthesiologists at Cedar Sinai. So that’s all really important. And that all comes with that all comes with superiority of the facility. When I see patients as an outpatient, then it’s also a Cedar Sinai Affiliated Surgery Center. But fortunately for me, it’s in my building. So wherever you see me in the office, different floor, there’s a surgery center, which is great because not only do I work here often and therefore they know me, but many of you know Nurse Bell. Nurse Bell is my nurse. She is a full-time hernia nurse specialist. She often is the nurse who will be with you in the operating room as a circulating nurse and will help recover you in the operating room. She plays multiple roles. So in doing so, she knows exactly what I need, what my protocols are for the patients, what kind of pain medication I like them on when I think it’s appropriate for them to go home, et cetera. And so it’s really great to be taken care of in a facility where the doctor has their own team. It’s the same team every time. That’s really, really key.

Speaker 1 (00:47:42):

I really prefer that and it’s really, really great. Okay, next question. I’ll give you another example of what I’ve heard. There are some doctors out there that belong to really inferior surgery centers and I’ve heard just horror stories by the patients and they went there for that surgeon, but then they went to the hernia cent, the surgery center, and it was dirty. It was kind of weird. It was dark, dreary. It was kind a weird part of the town. I don’t want to judge. But there surgeons have options as to where they can practice. So sometimes if you see a surgeon working at kind of a dreary hospital, you want to kind of question why they don’t take you to a better hospital. I don’t know. I’m sometimes judgemental about that. I’m very picky about which hospital I have privileges at and where I take my patients.

Speaker 1 (00:48:43):

And I feel that surgeons that don’t, like aren’t picky like that to them, it’s just like they’re just operating to them. The whole perioperative care is not as important. After complex operations such as me removal, how long should you plan to stay near the hospital to treat possible complications? So for outpatient surgery, laparoscopic, I let my patients go home the next day including travel by airplane for open repairs. If you’re local, obviously you can drive a couple hours, I’m okay with that. But if you are not local and have to fly, I prefer maybe one to five days depending on the situation before you fly. If you have to drive for days or hours, I would say it’s okay for laparoscopic kind of, I don’t know. Those are more difficult because I don’t like you just sitting, I want you walking around. So the earlier patient said every hour and a half, he started walking around and that helped him a lot.

Speaker 1 (00:49:52):

And therefore, I would delay. If you had to drive, I would delay three to five days before doing that. Abdominal wall’s, totally different situation. If you have a simple belly bio hernia repair, then treat it like a laparoscopic anal hernia repair. You can travel the next day. However, if you have a more complicated abdominal wall reconstruction, which includes component separation, you may have drains, et cetera, then those patients, I recommend you stay around for two weeks to make sure your wound is well healed and then up to four weeks. Next question. If you’re traveling alone and facing a complex operation such as abdominal wall reconstruction or Mesh removal, how long should you wait before we return home? Okay, we already discussed that.

Speaker 1 (00:50:47):

Let’s see what other questions we have here. Okay, it’s a thank you. So let’s just kind of recap what we discussed here. Before you travel, you have to have a plan of care. Are you traveling simply for the consultation or do you intend to have a consultation and surgery? Usually you need some type of advanced notice before you plan for surgery. So you can’t just show up and say, Hey, how about tomorrow for surgery? I’ve had patients do that. I get very frazzled because I don’t like to have things. Surgery kind sprung on me. If it’s straightforward, I may offer it, but I really like patients to ponder on what it means to have surgery, what it takes to recover and implications, and get some time to think about surgery and not just jump into it. So we highly encourage, if you’re traveling, if you wish to travel for surgery, that you have a good amount of time before surgery that you either talk with a surgeon or communicate with a surgeon or you see the surgeon via either telehealth or in person or in my case, what I offer is the online consultation to figure everything out.

Speaker 1 (00:52:06):

Because if you have, okay, let me say it this way. All hernia repairs need planning. I was saying this to one of my residents last week where we were doing a small belly button hernia, small, really small belly button hernia, but the patient was having another operation at the same time and she had a diastasis. And that was a perfect opportunity for me to teach the resident that what this patient went through. And basically, if you have a small little belly bone hernia and you go to a surgeon like, oh, yep, I’ll fix it too in the operating room, I don’t think that’s good enough for her. I planned it out. First of all, she has a small belly bone hernia, so there’s no need to put Mesh in. Second of all, it’s within a diastasis. So just primary closure alone is not adequate. And you need to do something in addition.

Speaker 1 (00:53:10):

Usually a two layer may repair or some type of diastasis recti, placation procedure. And thirdly, she is thin and she’s very interested in the cosmetic outcome. So where I place the incision is important for her. So we have to have that time to discuss it. Those three things, I guarantee you a good proportion of surgeons may not even discuss with the patient. They say, yep, you got a hernia, we’ll fix it. See you in the operating room. I don’t believe in that. I think even the simplest of operations can benefit from some type of planning because what if you put permission that’s in my mind, adding extra risk to a small hernia that doesn’t need it. What if they didn’t understand you had a diocese? Well, then you’re going to have either a bulge or because you didn’t repair the diastasis locally or a hernia recurrence because you didn’t take care of the fact that there’s a diastasis, which means a thinning of tissues at the same place as the hernia as where you plan to do the hernia repair.

Speaker 1 (00:54:18):

And then if they didn’t discuss where the scar will be, you may end up with a really ugly scar. I have a patient that came to me, male went to, let’s see, who did he go to? I think he went to a pretty reputable surgeon. I’m pretty sure reputable surgeon. But he wasn’t told where his scar would be. And he got this huge scar in a very ugly area and it healed ugly. So now he has these weird indentation and he is male. So maybe surgeons don’t think that a male could be considering cosmesis, but men are out with their shirts all the time. And even if you have hair, it’s important that you always provide a good cosmetic outcome to your patients. So he wasn’t happy. And I think if I remember correctly, I think the repair was just fine, but the fact that that scar was so ugly just bothered him.

Speaker 1 (00:55:15):

And that’s just an outcome I don’t want for my patients. And so I always teach my residents even the smallest hernias need planning. Here’s another question. Oh yes. I also need to ask this. With every Mesh implants, do you need to replace every 10 years? What is a normal amount of time that Mesh lasts inside the body? Very good question. So I was listening to a plastic surgeon on Instagram because I like plastic surgery. I follow a lot of plastic surgeons on Instagram. So I was listening to him and he was talking about breast implants and how he was saying every I think 10 years, 10 or 15 years, you should replace your breast implants because they scar in, they get crunchy, they start moving in the wrong directions, and they don’t look or feel as normal as they should. And the analogy he had was a really good analogy.

Speaker 1 (00:56:09):

He said, any implant you use, whether it’s your tires for your car, the oil in your car, the oh, the shoes you wear, anything that is used needs to be replaced at some point. You can’t wear the same shoes for 20 years that’s going to get a hold of it. You can’t. You need to change your tires so often your oil needs to be changed depending on your car every so often. So similarly, when an implant is placed in your body, that should also be replaced every so often. So for hip, shoulder, knees, there’s a certain number of years that they last, I think like 15 years or something for a knee, a knee, 10 or 15 for a shoulder, something like that. Interestingly, for hernia, Mesh, we don’t recommend change taking it out or changing it. In fact, we, it’s made so that you don’t take it out.

Speaker 1 (00:57:25):

And I, I’ve always wondered how interesting it is that when we talk to patients after putting an implant, we say, oh, this is for life. And there’s an expectation that this Mesh will last for lifetime. In fact, it does. Unlike breast implants and hips and so on, it, we don’t see the Mesh degrading and causing hernia recurrences at a rate that’s relevant. And therefore we don’t recommend Mesh as meshes be like interchanged. But this notion that it should never be revised is also not probably a good one that we surgeons tell patients, we said, oh no, you should expect a lifetime’s worth of hernia repairs of hernia repair. So no, you do not need to replace it every 10 years like a breast implant. Yes, the expectation is that the Mesh stays in you forever. In a fraction of patients, the Mesh may need to be removed in a larger fraction.

Speaker 1 (00:58:32):

The hernia repair may need to be redone, but that’s kind of the gist of it with hernia meshes. So I hope this was helpful. I hope any of you do consider out working outside. What we didn’t talk about was cost, but I must say at some point it needs to be worth it to you to travel. And there are many people that take their health very seriously and they understand that need. They may need to pay a little bit extra or save up money to get the quality care they need. Many patients end up not doing that and end up disabled or in the long run paying more because they’ve lost work and they’ve had multiple operations and unnecessary imaging, which will cost them more in the long run.

Speaker 1 (00:59:32):

But it needs to be worth your while. So do invest in your health. Traveling is becoming more and more common because of the internet. You can understand more about your disease and learn more about your specialist near you. And I hope that a little bit of what I explain today entices you to consider traveling for surgery. And if you do to be very prepared for it, don’t just show up. There’s nothing worse than me having a very complicated patient show up without telling me and nothing at hand, which despite what my office tries to do, still happens. Quick question. Do they still use Mesh plugs for Inguinal hernia pairs? Yes, they do. And that is the end. Thanks everyone. See you next week. Actually, do not see you next week. I will be at sages in Montreal. That’s our annual laparoscopic meeting. Very, very busy meeting for me. Lots of talks. My residents are giving talks.

Speaker 1 (01:00:45):

I belong to a bunch of committees. I have a podcast with them. So basically a lot of things going on next week. I will see you in two weeks. And until then, thanks for joining me on Hernia Talk Live. Please do follow me on Facebook at Dr. Towfigh and subscribe to my YouTube channel so you don’t miss any of the shows at Hernia Doc. And actually, if you want to know what I’m doing at sages, go to Twitter. I always live tweet on my journeys to all the different societies. And I live tweet on Twitter at Hernia doc. So if you want to see what I do and what I learn, go there. See everyone. Bye.