Episode 136: Hernia Meetings Update 2023 | Hernia Talk Q&A

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Speaker 1 (00:00:04):

Good evening everyone. Hello, it’s Dr. Towfigh. Welcome to Hernia Talk Live. I am your host, Dr. Shirin Towfigh, your hernia and laparoscopic surgery specialist. I join you here almost every week as much as I can to answer your hernia related questions. Thank you for those of you that are here out of Facebook Live or on Zoom. And also I know that many of you have been following me on Twitter because I am there at Hernia Doc. And guess what? I am back. I’ve been on Twitter for the past little over two weeks posting about all we’ve been doing with Hernia Society meetings. So I thought now that I’m back in town and able to do my live shows, we should take it off Twitter and start talking about it with all of you. So thanks everyone. I have been a travel freak this time of year is always a good year all around the world, and so we have a lot of surgical society meetings.

Speaker 1 (00:01:15):

You may recall about a month ago I was in Montreal for the Annual Society of American Gastrointestinal and Endoscopic Surgeons meeting. It’s the largest meeting of the year for those of us who do laparoscopic and robotic surgery. The meeting is called Sages, that’s what it stands for. Sages, S A G E S. I’m very active on Sages. In fact, I’ve been a member of Sages since 1996 when I was a resident, so that’s like a long time. I’ve been very involved with them. I host their official podcasts stories. So if you interviewer in are interested in podcasts and you’d like to besides my own of course, and you’d like to listen to surgeons’ stories, how they got into surgery and some fun stories, background information about how laparoscopy started, how people were mentored into doing let’s say surgery. Then Sage Stories is a great, great podcast.

Speaker 1 (00:02:28):

It’s hosted by me and my co-host, Dr. Kevin l Hayek from Cleveland and we have a lot of fun. So I think we’re up to 12 or 15 episodes on that, so I hope you enjoy that. So I was in Montreal for that. Never been to Montreal before. I love my Canadians. I do see a lot of patients from Canada and it was just kind of nice to be there. And I gave tons. I think I gave like three. No, I gave four talks. I hosted two sessions and I had three research presentations, which my residents did and they did a fantastic job. Fantastic. I was very proud of them. So I hope they all choose to go into surgery or laparoscopic surgery, or not surgery, they are surgeries, but laparoscopic surgery or hernia surgery because they did a really, really good job and really represented Beverly Hills Hernia Center in a very positive way. So fast forward to the last two weeks where I wasn’t able to host because I was not in the country. I flew to two separate continents back to back. My brother joked that I was in three continents in three weeks. This is true. I feel like Secretary of State.

Speaker 1 (00:03:51):

Okay, let’s start with meeting number one. I thought now that I’m back, I will share with you everything that I thought was interesting and innovative and new in these meetings. I have posted a lot. I tend to live tweet when I go to meetings to share everything that I see and learn. So if you want to go to my Twitter feed at hernia doc, you can kind of relive my life for the past two weeks, but I will share that information here with you. So basically, let’s see, where’s our video? There we are. Basically the first one is the European Hernia Society meeting. It was two weeks ago. It was in Spain in Barcelona, actually, not technically in Barcelona. It was in this beautiful little beach side town just I guess it’ll be west of Barcelona on the coast called Sitges. So I got to practice my Spanish even though they mostly speak Catalan there.

Speaker 1 (00:05:02):

But I do speak Spanish somewhat fluently I would say, and I learned medical Spanish in medical school. So I love speaking Spanish and practicing my Spanish. So I chose to speak Spanish as much as possible while I was there in both Barcelona and Sitges. And I gave a talk on indications for robotic surgery in primary ventral hernia repair. So just a standard hernia repair of the abdominal wall and when robotic surgery would be appropriate. And just so you know, this meeting spent an entire full day, which is like 8:00 AM to 6:00 PM on just robotic surgery. So that’s going on in the world right now. I don’t know why they spent so much time on robotic surgery. Of course I enjoy robotic surgery, but I don’t exclusively do robotic surgery. I also offer laparoscopic surgery and open surgery. And in Europe, only 4% of European surgeons, 4% of hernia hernias I think are performed robotically. So it’s kind of weird to be in a European meeting and have such a huge robotic presence.

Speaker 1 (00:06:26):

I personally did not like that part of it, but it is what it is. I was not part of the planning committee, but I talked about robotics and what I said in my talk made a lot of buzz. I always like to make buzz in meetings, but this one in particular, I had multiple people come up to me and say, that was absolutely the best talk of the meeting and thank you for being honest about robotics because this is how I feel about robotic surgery and you guys let me know if you agree or disagree, but I think the same way, there’s no one size fits all. That’s my shtick, right? There are surgeons in town that want to be branded as a robotic surgeon and they do everything robotically. Things that can be done with one simple little scar, they will do with three to four scars.

Speaker 1 (00:07:26):

Things that can be done under local anesthesia, they do with general anesthesia because they, they’re a robotic surgeon, which to me I feel is ridiculous because it’s like saying I only wear a certain pair of shoes or I only drive a certain car. If you do, then that’s fine, but that’s not reasonable to say I will only do one thing one way. So what I said was, yes, there are indications for robotic surgery that I feel make the surgery better. However, there’s absolutely zero. Well, I shouldn’t say zero, very little actual research that’s been done to substantiate what I was claiming. I was claiming based on Mayo and expertise and experience that these certain operations can or are best perform robotically. But there are certainly tons of other operations that I do open or laparoscopically, and that’s kind of the way I left it and I gave it as an analogy.

Speaker 1 (00:08:33):

So here’s my analogy, I hope you like it. I’m kind of reliving my talk from two weeks ago. Okay, so I said obviously I’m in Los Angeles, I drive a car and I tend to two seater cars. That’s like my thing. I think they’re cuter, they’re faster, they’re more compact, and they tend to be more sporty. However, I have had four SUVs in my lifetime, four big SUVs, and I showed the pictures of it. Now, there’s absolutely no reason for me to own an suv. Zero. I don’t camp. I don’t go. I don’t have a boat or a motor home to lug around. I don’t have children. I don’t need all that space, and it’s not even good for the environment. So why did I own four SUVs at different times of my life? And by own I mean lease. I didn’t own any car. Well, I kind of enjoyed it. It was fun. It’s nice to be higher up in the traffic when you’re driving. It’s roomy.

Speaker 1 (00:09:51):

It’s kind of comfortable to sit in. It’s not as hard on your back. But yeah, it was more costly and there’s really no reason for me to drive around town from home to work or to grocery store, maybe to Costco, an suv, absolutely no reason. In fact, parking is horrible. Can you try and find a nice large space to park with a S U V? Very difficult to do. So the robot is the same. There are so many surgeons, they’re like, I want the robot. I need the robot. Or they operate with the robot exclusively. And yes, ergonomically, they feel more comfortable sitting than standing For most of the operation, they’re, it’s a little bit easier on your shoulders and your back, not so much on your wrists and fingers. You still get some stress from repetitive motions that way. It’s bulky. It’s super expensive.

Speaker 1 (00:10:52):

It’s not cost effective at all when you compare it head to head with open or laparoscopic surgery. So why do we do it? We like it. We think it’s fun or safer. It’s never been proven to be safer, better ergonomics, and that’s why we do it. And the hospitals often succumb to that. So that was kind of my analogy and I was telling people that if you live in a farm or you enjoy certain outdoor activities or you have four children, an SUV makes sense. Same way, doing a abdominal wall reconstruction with what we call tar transverses, abdominal release or eTEP, which is called, it’s like a extended totally extra peritoneal repair or some of these other techniques. There’s the tar up, the Trump, the yeah, the, what’s the other one R Tap. All of these that I do, they’re actually done much better robotically, but a simple umbilical hernia, someone without a diastasis, you can do those laparoscopically or open and I don’t like it when people do even those things robotically and kind of overuse technology the same way people may be overusing the technology of A S U V for just driving to work.

Speaker 1 (00:12:25):

So that was my shtick and it went over very well because I was talking to 96% of the surgeons who were not doing any robotics, and many of them come from countries that have socialized medicine and can’t even afford a robot. I was joking, in fact, to some of my friends. So at my hospital we own nine robots. Nine, when I first started Cedars, we had two, we don’t even have nine rooms available to run the robotic church, but we have nine. And I was joking that my hospital has more hospital, more robots than many of the countries that were represented at the European Hernia Society. And that’s a fact. That’s a fact. So here’s a comment about robotics. I see one of you, it says, I personally blame the robotic approach for causing my complications. I had a small unnoticeable hernia, no visible bolt on the right side.

Speaker 1 (00:13:36):

I have since had to have Mesh removal and have been in pain and uncomfortable for over two years. My family doctor said it makes zero sense to make three holes in the abdomen to repair a very small one in the groin. The surgeon made it sound like robotics was the way to go. Well, okay, let me answer that because laparoscopic is the way to go usually for al hernias. All things being equal, even if it’s a small hernia, laparoscopic repair is better than open for a long-term. L least chronic pain, better long-term result that’s been proven over and over again in the right hands. Number one in the right hands. Number two, many people are not comfortable doing these operations laparoscopically. It’s actually technically much more challenging, but they’re more likely to be able to offer you a quote, laparoscopic repair using the assistance of the robotic platform. And that’s why we’re seeing a surge in robotic al hernias.

Speaker 1 (00:14:42):

Therefore, the use of the robot for primary inguinal hernias size is not determined of which technique you use necessarily. Depends on the other factors. So I see that you wrote, I know several people who had the open standard repair and had zero issues. Well, the reverse is also true. There’s tons of people out there that have had complications from open repairs. So if you look at the data, what you’re saying is not accurate. Most issues I hear of come from robotic repairs. That’s actually not. That may be your experience with certain people you’ve spoken to and having had a robotic repair. You may be more in tune with complications from robotics. We are not seeing more complications with robotic surgery, oral laparoscopic surgery. In fact, most complications occur from open surgery and not from laparoscopic or robotics. So I know you feel hurt, but the fact that the repair was performed robotically, it’s not a robotic complication.

Speaker 1 (00:15:48):

There are complications specifically related to the robot. That is true. There’s bowel, bowel injuries and abdominal wall injuries that can occur with the robot if you’re not careful. But what you went through is not specific to the robot. I just want to put that out there. Okay, so that was Barcelona and you may have said, wait a minute, you just come back from the European Hernia Society meeting in November. I did because the pandemic, the typical spring meeting got pushed the fall last year. So I was in Manchester last year and gave like five talks. They worked me hard last year. This year they were easier on me. I only had one talk at the European Hernia Society meeting in Barcelona and next year it’ll be in Prague. So I’m hoping to get my invitation to give a talk there. I’ve been to Prague, actually.

Speaker 1 (00:16:50):

I was there for the European Hernia Society meeting, actually presenting one of my research projects and it was a day Czechoslovakia became the Czech Czech Republic under as a European Union member. Very cool day to be there. If any of you have been to Czechoslovakia, let me know. Planning on enjoying it next year. Okay, so a finished Spain, then I flew directly from Spain to Brazil. Yes, directly. That was fun. Very long hours. Fortunately I didn’t get any blood clots, all this traveling in these long, long trips. But in Brazil was a second separate international hernia meeting. It’s this time the International Hernia collaboration. Those of you that follow me on Facebook or Twitter understand how the international hernia collaboration is to me. My dear friend, Dr. Brian Jacob, who I interviewed as one of the first of my Hernia Talk Live guests is the founder of the International Hernia Collaboration.

Speaker 1 (00:18:06):

We have 13,000 international members of hernia surgeons from around the world. And as a result, every year we have started doing meetings around the world different than society meetings like the American Hernia Society meeting and European Hernia Society meeting with the International Hernia Collaboration. Our goal is not to go to fancy places, nice places, it’s to actually go to underserved parts of the world. So there are parts of the world, most parts of the world where they can’t afford to come to the United States or to Europe to get educated at certain meetings and hear from the experts and learn from the experts. So what they can do is become a member of the international hernia collaboration for free. Get advice online and learn online. All you need is internet access to the close group. And now every year we go to a certain part of the world where we feel that there’s a need where people can’t afford the air airplane or really can’t even afford the registration for a lot of the meetings that we go to.

Speaker 1 (00:19:29):

If you go to a certain meeting, I think Sage’s meeting was 800, $900 just to register. Plus you had to fly there, you had to stay in a hotel. It’s expensive. So someone in Africa, south America, middle East, certain parts of Asia cannot afford to do that. So our goal with the International Hernia collaboration is to take experts from around the world, fly them to a certain meeting area, provide low cost registration to the local surgeons so that they can learn. And we promote a lot of pertinent topics. We don’t talk about robotics all day. That’s not why we’re there. Most of these countries have zero access to the robot. Many of them actually don’t even have access to laparoscopy. And I’ll share one of those stories with you because it’s really cool. So, oh look, there’s a question. Let me answer that real quick.

Speaker 1 (00:20:35):

I had open surgery inguinal hernia repair. It is norm. Is it normal to have pain after a double inguinal hernia repair in a female with polypropylene used on both sides? The pain is only when I’m doing any activities, walking for long periods of time and can cause severe discomfort and pain. Okay, well first of all depends on when the hernia repair was performed. So it’s not normal to have severe discomfort and pain more than a year after your surgery is also uncommon to have the same severe pain between three and 12 months after surgery within the first three months. Everyone’s a little bit different and the recovery is different for each person. So there are things you can do such as massaging the area and walking more and getting that area moving, but especially massaging that can help you with the recovery. But you need to go back to your surgeon to figure out exactly why you have the pain.

Speaker 1 (00:21:42):

Because if you have pain more than three months after surgery, then there may be something serious like a recurrence or a nerve injury or a bawling up of the Mesh, et cetera, that needs to be addressed. The surgery was 10 21. Is that October, 2021? Regardless, it seems like it’s been it’s far away. So yeah, many years out, you definitely need to be seen by an expert. We’ll see your surgeon first, but you need to be seen by an expert. I’m happy to see you if you want to contact my office or find someone near you who deals with what we call C P I P chronic postal hernia pain so that they understand all the questions they have to ask you. They can order imaging and interpret it correctly. They can examine you and understand what they’re looking for. They may be able to do injections if that’s a nerve issue. And they may provide you with revisional surgery if that’s the problem. I don’t like to use polypropylene in women as an open-inguinal hernia repair except for certain circumstances like someone who’s morbidly obese or a larger hernia because women tend not to do as well and have a higher chronic pain rate than men for the same exact operation.

Speaker 1 (00:23:04):

Here’s another question I have. Can you have pain from scar tissue seven years later? Usually not. Scar tissue is early and every year the passes scar tissue gets softer and softer. So seven years after any surgery, you should not have scar tissue related pain. Pain is not usually related to scar tissue. Okay, where was I? Right? So I was talking about the international hernia collaboration. So our goal is to bring experts to areas of need. The other part of our meeting, which is unique as well, is that we like to also gain knowledge from the local surgeons. How do they operate? What are their practices? And also take in the culture. So we’ve been to Armenia and Costa Rica this year was in Brazil. Next year it’ll be in Mexico. We have a lot of other countries in the future coming up in Europe and Middle East and so on and Asia.

Speaker 1 (00:24:07):

So we’re really, that’s like an exciting group. It’s not as big of a meeting as the larger society meetings because we’re really focusing on the local surgeons. And it however is much more fun. And I really, really, really enjoy those meetings because in addition to the education and bringing the experts, we have a lot of discussion as part of the meeting. So the discussion part, we build in a lot of discussion because we feel that’s where they can readily go back and forth and ask questions from the experts. We also have a hands-on lab where we teach them how to do certain techniques. Like this year we had a laparoscopic surgery hands-on lab and some people have never done laparoscopic surgery before for hernias. We also do live surgery where we go to a local hospital and help treat patients. And in doing so for free by the way, and in doing so, we live broadcast the surgery to help all the other 13,000 of our members to watch and learn.

Speaker 1 (00:25:16):

We also have a wellness component because surgeons are traveling and working and it’s just a very physical job and we are there to help promote self-care and wellness as well. So it’s a great meeting. That’s all I can say. Here’s another question. I had a right inguinal of hernia surgery with Mesh with a plug in 2015, and I still have horrible pain. Now I have three more hernias in every few surgery because I don’t want more Mesh in me. I think every doctor in Minnesota uses Mesh. That may be true in most states. We don’t have surgeons who are trained or comfortable doing tissue based repairs. You are going to need to travel. So if it’s due to the plug, the plug needs to come out, I always analogize it as like a pebble in your shoe. You got to take it out. And then the other hernias, so she had open surgery, not laparoscopic surgery, that’s where the plug went in.

Speaker 1 (00:26:22):

Laparoscopic surgery, usually we don’t use the plug, but the plug needs to be removed. And you may or may not be a candidate for a non Mesh repair. Just because you had a bad experience with the plug doesn’t mean that necessarily you should not get more Mesh in the future. But that’s a discussion you can have with your surgeon. You don’t want to burn bridges by doing a tissue repair and tearing that and having even more chronic pain. And then you really need to Mesh in that situation. Let’s see. Let’s go back to this question. I was 180 pounds and five foot one, so I think he considers me obese. Well, that is obese. It’s not a consideration. Obesity is a technical term based on your height and weight calculation. You can calculate. There’s a B M I calculator. You can Google. Yes, I would appreciate any doctor information local to Hershey, Pennsylvania.

Speaker 1 (00:27:15):

You have some pretty amazing expert surgeons in Hershey, Pennsylvania. I have interviewed two of them. And so just go to my YouTube page at hernia doc and you can see the Hershey Pennsylvania surgeons and see them because they’re excellent. And actually they were at some of these meetings I went to. So there you go. Let’s see. Okay, so for the international hernia collaboration, we were in Brazil. And let me tell you, I like Brazil more than Spain. I don’t know. Have any of you been to Brazil and Spain? Can you tell me what you like? Because I preferred Brazil. I don’t know. It was more fun, much more beautiful country. Much, much more beautiful country. Brazil. I mean Spain was beautiful. It was nice coastal city, some full new fully nude beaches. I got to visually analyze some hernias out there. The fully nude peaches kind I look like. Is that a hernia? I dunno.

Speaker 1 (00:28:23):

I’m joking by the way. But also I’m not, where was I? Alright, but I did enjoy Brazil much more. So in Brazil we had a lot of Spanish speaking and Portuguese speaking, surgeons from Central and South America. And so we offered trilingual translation. So I would give my talk in English. An Argentinian surgeon would ask me a question in Spanish. I would respond and I understand Spanish, but I didn’t necessarily need translation for that. But then the Brazilian surgeon would ask, answer or ask me a question in Portuguese and were just able to talk in three different languages all at once. It was really, really cool. So the talks that I gave, one of them was on Mesh implant illness. And I’ll just tell you this right now. I was sitting next to one of the surgeons from Brazil and he said he came specifically to this meeting to learn about Mesh implant illness because he knew I would be there.

Speaker 1 (00:29:37):

He knew I’d be talking about it. It was a topic of concern for, because he saw a patient who think he thinks he has Mesh implant illness. No one talks about it or no one knows about it in Brazil. And he knew that I published a bio two. So I gave my talk. He asked some questions, which is great. He shared one of his patient questions with me and then he asked me to share my two papers on Mesh implant illness and allergy testing and Shoenfeld syndrome and so on. So Asia syndrome. So it was really great to meet someone and know that I’ve been talking about Mesh implant illness for years. And people did not believe me, did not think I was, they thought I was just making up a syndrome and it doesn’t exist and meshes a nerve and doesn’t cause any pain or systemic symptoms.

Speaker 1 (00:30:31):

And now I have surgeons from all over the world specifically tuning in to learn more about Mesh implant illness. And you may recall last year after the European Hernia Society meeting in Manchester, I told you I also gave a talk on Mesh implant illness. Then I had more information to share this year. But when I spoke then it was a full house with people standing and lining the entire back of the full house room. So I was like, wow. First of all, to include that in a meeting where we’re discussing Asia syndrome, systemic problems to meshes, Mesh related complications. A whole session on Mesh was a big deal. I know you patients will love that. We do it more, but we weren’t. So the fact that we are doing more is great. It shows a general interest. And then for them to be so interested in learning about Asia syndrome, Dr. Travert was there. You may know him. You can go back to one of my earlier sessions where I interviewed him about Asia syndrome or Shoenfeld syndrome or this kind of autoimmune reaction to meshes.

Speaker 1 (00:31:50):

Oh, here’s a question. Oh, this is the lady from Minnesota. I’m 81 years old, my husband is almost 85, and we both have other health issues. I was going to come to see you two years ago, but we were snowbirds, but some druggies burned our house to the ground. I want you to come to Minnesota to treat me. I can come to Minnesota to treat you. I don’t have a license in Minnesota to treat you surgically. But if you have pain, see a doctor there and have them take out the Mesh, go to the University of Minnesota and have ’em take out the Mesh. And if they have to put more on Mesh in you, it’ll be fine. It’s not the Mesh itself, it’s the plug that needs attention. So it’s like saying you have a pebble in your shoe, so you want the shoe removed.

Speaker 1 (00:32:43):

It’s not the shoe, it’s the pebble. So that’s the best analogy I can give to you for that. The second talk I gave in Brazil was on tissue repair performed robotically. So minimally invasive tissue repair of an inguinal hernia in the groin. So we know about the open options, right? Shouldice, McVay, Bassini, Marcy, now Dasarda, those are all tissue-based hernia repairs. There’s never really been a widely accepted or understanding of doing it open, I’m sorry, a laparoscopic tissue repair. It’s really hard to do. But robotic is what we took in. So we talked about robotic tissue repair and people were interested. They’re like, maybe we can just use this for people that are known to have hernias. Let’s say you have a, one guy asked me a question. He said, what if you’re in there and you’re doing a prostatectomy? The urologist says, oh, there’s a hernia here.

Speaker 1 (00:33:48):

What do you do in those situations? Because you can be more prone to inguinal hernias after pro prostate surgery, then not. And the reason for that is when they do prostate surgery, they remove a lot of lymph nodes and they take down the layer that protects the hernia, which is called the peritoneum. And the combination of those two procedures increases the risk of exposing the hernia. Whereas before it was kind of hidden. And then you wake up and now you have a hernia. So my urologist, who I work with know to look for hernias both by examination and by symptoms and let me know so I can come and fix the hernia at the same time as their robotic surgery. And in some situations I’ve taught them to do this tissue repair so that they can do a tissue repair and they don’t necessarily need to call me.

Speaker 1 (00:34:45):

So that’s about it. But here’s a question. How about Long Island? Did I interview anyone from Long Island? I’ve definitely interviewed people from New York, at least two surgeons in new, no, yeah, two surgeons and one radiologist from New York that I’ve interviewed on hernia talk. Long Island, not so sure. You may have to drive to Manhattan, which is not that much of a drive. Okay, where was I? Right? So those were my two talks and I really enjoyed the Brazilian everything. It’s not as safe as Spain didn’t feel as safe, but we had really good protection during the meeting and it was fantastic. Again, I got to practice my Spanish because we had surgeons for Argentina, Costa Rica, Chile, Peru, we had a lot of women’s surgeons that were involved. Mexico, where else?

Speaker 1 (00:35:57):

El Salvador, Colombia. And of course Brazil. Brazil’s a huge country. I believe the surface area is as larger than US minus Alaska or larger than the US minus Alaska, something like that. Got to learn a lot of interesting things about Brazil. Oh, this is the story I wanted to tell you. So we also have a women in surgery dinner at these international meetings specifically to encourage women surgeons to be more involved with societies and meetings more in view, and also to empower them to do really good hernia surgery. Most Latin American countries are not promoting the women’s surgeons, so we take it upon ourselves to give them a platform. So we had 41 females of which 30 showed up to a women in surgery dinner. It was awesome. But let me tell you this, this is a great story. So I was surrounded by some of the younger ones. Let’s see, they’re all Brazilian. Yeah, they’re all Brazilian. And they were telling me their stories. So first of all, 95% of the inguinal groin hernias done is open Mesh and non Mesh. That’s very different than most English speaking countries such as us, Canada and UK and Australia where there’s a good amount of laparoscopic and now robotic inguinal hernia repair, dent gallbladder surgery, which in the United States is almost exclusively laparoscopic. The amount of open gallbladder surgery that’s done is especially electively is minimal. Less than 5%, maybe less than that.

Speaker 1 (00:38:07):

It’s the exact reverse there. They said something like 90% of gallbladder surgery is done open. Dude, that is unheard of in the us. In fact, yeah, like there’s zero indication to do a gallbladder surgery electively open in the United States, the standard of care is laparoscopic, not true in Brazil. And part of the reason it’s not that they don’t know how to do it, there’s just no laparoscopic instruments, there’s no laparoscopic tower, there’s no laparoscopic scope and camera and video monitor and everything that goes into laparoscopy. You actually need instruments. Whereas for open surgery you don’t need special instruments. So I found that fascinating. One lady was there, a young beautiful surgeon. Her father is a general surgeon. His hospital did not have laparoscopic anything. So her father actually bought a laparoscopic tower for the hospital. I mean, how many surgeons do you know that buy instruments for the hospital?

Speaker 1 (00:39:21):

Usually the hospital supplies the instruments to recruit the surgeons to operate there. So she wants to do laparoscopic surgery and the hospital that she’s in, the area where she trained, there was no laparoscopic surgery. So check this out, she enlisted in the military. She became a member of the Brazilian army because the Brazilian army hospital had laparoscopic towers and laparoscopic opportunity and she wanted to learn laparoscopy. So she enlisted in the military that my friends is dedication to enlist in the army so that you can have a better surgical training and learn laparoscopic surgery. I mean when she told me that, I was like, get out of here. That is amazing the amount of dedication you have to have to your career to enlist in the army so that you can be a better surgeon and get exposure, laparoscopic surgery because they want to do laparoscopic surgery.

Speaker 1 (00:40:37):

That just blows my mind. Another surge. So that was Brazilian. Another surgeon is Costa Rican. And she also would like to improve what she offers and become a more dominant player in the Costa Rican surgical field. She is self-funding a trip for a year in the United States so she can learn from the best and take all everything that she learns back to her country. I mean the amount of dedication that we see, we really take for granted in the United States that we have so much available to us both in terms of technology and resources. I mean no one listens in the army so that they can get better surgical training. You can get surgical training really well outside of the army. And like I said, my hospital has nine robots. There’s no lack of technology in the educational facilities in the United States, not so much in Brazil.

Speaker 1 (00:41:35):

Oh, I learned something else. So in the United States, many of, in order to be a surgeon, you have to do get your college degree, that’s four years. You have to get your medical degree. That’s four years, that’s eight so far. And then you have to do residency hands-on training for minimum five years. So that’s eight plus five, 13 years. And then many do an additional one to two years of laparoscopic training and hernia surgery training. And that’s, so that takes you up to 15 years. So that’s a lot of training. So the interesting is the five years in Brazil, how long it is for surgical training?

Speaker 1 (00:42:21):

Two years. And they recently increased it to three years. What there is no way that a United States resident within three years is can go out there and be an independent surgical practitioner. That’s the reason why after five years, we still do an extra year of specialty training because we don’t feel it’s enough and yet there because there’s such a need. I assume that’s why, I don’t know what else. I assume it’s because there’s such a need to have practitioners and specialists. They only two, sometimes three years of training to be a surgeon. And during that training they have to learn hernias, gallbladder surgery and everything else. Colon cancer removals, stomach surgery, liver surgery, spleen, lymph nodes, skin cancers, breast surgery, like that’s intense. And their work hours are limited. So in the United States, the training, when I was a resident, there was no work hour limitations.

Speaker 1 (00:43:34):

We average a hundred, 120 hours a week of work. They change that to 80 hours maximum. In the United States, you can’t work more than 80 hours a week. In Brazil, it’s 60 hours a week. So you are working less hours for less number of years. So total number of hours of training is significantly lower than the United States, and that’s the level of their surgical training. It’s crazy to me. And so the ones that are really motivated then go and enroll in the military to get more experience and access to laparoscopy. That just blows my mind. And I just find it absolutely fascinating and I hope you like that story because part of the reason why I do a lot of these international meetings, besides the fact that I’m invited to them, I say yes to them because

Speaker 2 (00:44:31):

I like to educate and share my knowledge. But I also think it’s very humbling to understand how my peers in other countries work and the obstacles they have to be able to provide excellent care to their patients and how thirsty they are to learn more and do more and advance more and how dedicated they are to their career. And I absolutely love it. Unfortunately, I’m too busy to go to more of them. I was invited to present my results from the work I do with the Mesh implant illness to Dr. Schoenfeld meeting next year in Slovenia. But I also already have a conflict and I can’t go. So I’m kind of unhappy about that. A, I want to check out Slovenia and B, how cool would it be to be on the same stages, Dr. Schoenfeld, the god of Asia syndrome and Schoenfeld syndrome and talk about my Mesh implant illness kind of experience. And then also be there for the whole meeting to learn from rheumatologists and allergists and immunologists about implant illnesses. So unfortunately it’s not going to happen. I’m kind of sad by that.

Speaker 2 (00:45:50):

Okay, here’s a question. I’m going to send my stuff to you. Is it better to fly there to see you? It’s always better to fly, but if it’s too much, we do offer what’s called online consultation. So send everything. I’ll review it and I’ll give you my feedback. If you think that feedback is enough to say, oh, okay, maybe therefore now I should come and see you, then you can come see me. But it’s a little bit longer process that way it’s more efficient just to come to see me. But if you want to take the other route because you’re busy, that’s fine too. I had six hernias in 2002, femoral and incisional. I haven’t been the same. I’m better when I’m not mobile and laying down helps. Last week I decide to walk. It wasn’t good. I had a lot of pain. I went to two surgeons in New Jersey.

Speaker 2 (00:46:42):

First one said I had a hernia based on an old CT from four months postoperatively. The second opinion wasn’t very kind. He said My muscle is separated, but he didn’t see a hernia from the old ct. I don’t know if my pain is from hernia Mesh and my muscle issues in the abdomen. I’m afraid if I fix more of my hernia, I will get more. I’m complicated. Well, doesn’t sound too complicated, but you definitely need an updated CAT scan because this one’s already a year old and it’s important to understand your opera report. So what does the opera report say? What hernias, how big were they approached? Did they close the hernias? Did they use Mesh? Where is the Mesh? How large is the Mesh? What sutures did they use to sew your clothes, if at all? And what sutures they use to put in the Mesh.

Speaker 2 (00:47:36):

Basically surgical technique. I also need to know how healthy are you? Are you obese? Do you use nicotine? Do you have a job that involves a lot of heavy lifting? Are you diabetic? Do you have any immunologic disorders or healing problems? Are you hyperflexible. These are all risk factors for hernia formation. And also on top of that, I need to look at your imaging. So your report gives me a visual as to what you had before surgery and what they did during surgery. And so I have an expectation of what everything should look like. And then I’ll look at your updated CAT scan, which your doctor can order for you. It’s a abdominal and pelvic CAT scan. It’s very simple. You just drink the contrast and that’s it. You may want to get it with your belly pushed out or bare down views or what we call a Valsalva.

Speaker 2 (00:48:32):

That’s usually a better CAT scan for these problems. And then based on that I can assess where are your muscles? Where’s the Mesh, how big are the hernias? How much weight do you carry inside the abdomen versus outside the abdomen? And all those are kind of clues to me as to why you may have pain. And then of course I need to know where is your pain? It sounds to be activity related. Oftentimes activity related pain is due to either too tight up a repair or a recurrence from the repair. And if you have a recurrence, you need more surgery. Simple as that. So that’s kind of where I’m at. But if for those of you, if you’d like, oh, the pains of the groin, but you said femoral and incisional, so you had incisional hernias, but that’s repaired with no issues. It’s the groin. So then the question is how was a femoral hernia repaired? Was it used to plug? Did they use a flat Mesh? Did they do tissue repair? And so on.

Speaker 2 (00:49:40):

So then I, I’d also want to know, okay, in the past year and a half, what have you done for it? Have you taken medications? Have you done certain exercises, massages, physical therapy? Has anyone injected you? And then what are the results of that? It’s a very long process. So doing this by email works as an online consultation. If you want to fly in, I can examine you, which is a very important part of the evaluation. And then we’ll spend up to an hour going through all of these details to figure out exactly what your pain is.

Speaker 2 (00:50:20):

I’ll give you, in this Brazil meeting, one of the best parts of the meeting were all the, so I would give my talk, 3, 4, 5. Other surgeons would give their talks and then we all sit as a panel and the audience will ask us questions or the moderator of this session would ask us questions and we would talk, right? And they would ask questions a lot in the chronic pain portion of the meeting. And what was interesting is in Brazil, in most Latin and South American countries, there’s really no expert that deals with chronic pain. But there are surgeons interested to do it. They’re a little afraid to. So they were asking us, okay, Dr. Towfigh, I want to maybe help these people because they come to me and I don’t know what to do. What do you recommend? So we were talking about what our recommendations were.

Speaker 2 (00:51:28):

We said, first of all, just call us. Don’t try and work on this on your own as a surgeon. Second of all, come to all these meetings. Third of all, you need to be a certain personality to handle a chronic pain surgical practice as surgeons we’re used to operating. So to sit to slow it down, not go straight to surgery, to slow everything down, listen to the patient, review all the old medical records, have a good eye for radiology, have touchy fingers for a good physical examination, and really understand the nuances of different types of reasons that people get chronic pain. That’s what it takes to be a surgeon that deals with chronic pain, complications after hernia repair. It is not for everyone. And we do not recommend that any surgeon just willy-nilly gets involved with these operations. And I do not recommend that you seek consultation from a general surgeon that does not have experience in these because they can cause more problems.

Speaker 2 (00:52:39):

I’ll tell you in my town, there are surgeons that tell me, oh, I’m just going to go in there and take a look. Absolutely the wrong answer. Most chronic pains, situations do not need surgery. In fact, operating will cause more pain potentially and more damage potentially. So what I recommend is if someone says, oh, we’re just going to take a look and figure it out. No, no, no, no. You can figure it out by a history physical exam and imaging. You don’t need to go in there and take a look to figure things out. The fact that you can’t figure it out before surgery means you don’t know what you’re doing. So what you need to find is that surgeon that’s very much enjoys the process of puzzle solving and doesn’t just want to go straight to surgery. When we take the oral board’s examination as surgeons to be board certified, you’re taught to, most patients will need surgery.

Speaker 2 (00:53:48):

And that’s the right answer for most situations that they’re going to throw at you. That’s not the right answer. However, if you’re dealing with chronic growing pain, chronic pain after surgery, et cetera, and so if you have had these problems and you’re having difficulty getting the answer, please reach out. There’s a handful of us in the nation that are willing that love this. If you’re in the United States, you’re blessed because there’s like zero outside of the United States. And most countries, a handful of countries have specialists and they’re not seeing as many patients as we do. So you’re blessed if you can travel, you’re even more blessed because you can actually come to see us in person and get the answer that you need.

Speaker 2 (00:54:38):

But run away from any surgeon that doesn’t do any imaging, barely examines you or touches you, is interested in categorizing your quality and quantity of pain and just says, we’re just going to go in there and take a look because that’s not the right answer. And I see it a lot and it’s part of what really irks me because I try and tell these surgeons, listen, that’s not the right, and like, well, I’m just going to take a look and it’s just going to figure it out. And oh, look at more answers. Yeah, the first surgeon was nice but didn’t touch me. What did I say? It’s not the first time I’ve heard this story. That is completely inappropriate for a very complicated situation such as groin pain.

Speaker 2 (00:55:34):

Oh, here’s another answer. Thank you so much. I have a surgeon now that says he wants to take a look, but warned it could get worse. Wrong answer. I can’t imagine Worse. I’m heading back to Cleveland. Thanks again. Cleveland is great. Cleveland has a very good series of surgeons actually dedicated to chronic groin pain, and we interviewed the main one and two others in Cleveland Clinic. So lots of Cleveland representation on Hernia Talk Live. So if they say they’re just going to take a look, dont. And if they say, oh, you may get worse. Listen, I understand a disclaimer, right? I’m going to try my best, but it may make you worse. You should say, wait a minute, how would you make me worse? Be very specific. So if I tell you, you may get worse, what I really mean is by going in there to address a specific problem, let’s say remove Mesh, there may be nerves that I don’t see that I need to address because the nerve looks like scar tissue, but it doesn’t mean I’m going to make you worse.

Speaker 2 (00:56:45):

Why would I ever operate on you to make you worse? That’s the wrong operation. If I go in there, I may have to cut a nerve that I wasn’t planning on cutting because otherwise healthy nerve, but I may be the one causing the nerve injury as part of the revisional exploration. But if a surgeon is telling you it may make it worse, they plan just going in there and not addressing any potential complications. So I have a serious issue with that. I’m kind of getting pissed off already because I hear this so often and just such the wrong answer. Here’s another one. I had inguinal hernia surgery in Minnesota in June. I had pain from day one when I went to Arizona. Six months later, the surgeon there went in to take a look. Ugh, he removed my Mesh plug and replaced with new Mesh and plug, oh my God, I’m stressing out already.

Speaker 2 (00:57:37):

So I’m afraid to see anyone but you. Listen, this is a discussion you’re supposed to have with your surgery before surgery. Okay, surgeon, what are your plans? What do you plan to see? What do you plan to do? You shouldn’t wake up with another Mesh plug that makes absolutely no sense to me. It’s like, okay, I’m going to take a look. I found a pebble. I’m going to take out that pebble from your shoe, and then I’m going to put another pebble. What I mean, I don’t know what to say to that. That drives me crazy. It really does. I dunno how to express myself better, but I’m sorry. It’s just one of those things where I keep hearing this story and I’m hoping by repeating it to you guys, the surgeon will stop saying it, but they don’t. Okay, that’s been an hour of excellent talk with you guys. Everyone. Thanks. Oh, here it is. Your talks are very helpful. I hope you continue them for a long time. Thank you. Hopefully until I am alive, I’ll keep doing this because I’m enjoying it. And I do like to give hope because I think hope is very important for everyone to have.

Speaker 2 (00:59:03):

I really don’t like it when surgeons remove hope and make you hopeless by saying there’s nothing to do because there’s often something to do, almost always. And I usually figure that out, which is why I like what I do. And then my friends is the end of a fantastic hour. We talked about catching up on all the hernia meetings I’ve been to lately, and then also some stories about surgery done outside the US and what the surgeons do, and it just fascinates me. Well, on that note, we have many amazing guests coming up. Do join me next week. Some of my guests will be out of the country. So in Middle East and Europe and South America, specifically the South Americans, their time zone is fine. But the Europeans, the Middle Easterners, I’m going to change a time of Hernia Talk Live to be more midday instead of afternoon in order to accommodate the time zones in those countries. So do subscribe to me on Facebook or just go to hernia talk.com. I will update you as to what the time will be for the next session. And I’m super excited because I’ve got some really great guests. See you next week. Bye.