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Speaker 1 (00:00):
Welcome to Hernia Talk Live. This is our weekly session where we have audience participation in a question answer session on everything related to hernias. I’m Dr. Sharon Towfigh. You can follow me on social media at Hernia doc and the We are simulcast on Facebook Live. Once we’re done, I’ll make sure that you have access to this hour on YouTube so there’s archive for you to review. This week we have the lovely Dr. Jeffrey Janis. Dr. Janis is a board certified plastic surgeon. You can follow him at j Janis MD on Twitter. He works at Ohio State University and I’d just like to welcome everyone to Dr. Janis.
Speaker 2 (00:44):
Thank you. Honored to be honored to be here. Thank you for the invitation.
Speaker 1 (00:48):
Thanks for joining us. You are our first non-general surgeon. Everyone else has been a general surgeon but you are as all of us are a hernia specialist. Is that true? How much of your practice is hernias?
Speaker 2 (01:05):
Well, I’m glad that I will be the first plastic surgeon or non-general surgeon. So obviously for the audience, that means that this will be the best episode that has ever been produced in the history and actually the future of hernia live. So thank you again for the honor of being here. Yeah, so exactly
Speaker 1 (01:23):
Why you’re number one. This is exactly
Speaker 2 (01:25):
Why. Hey, I’m Ricky Bobby. If you’re not first, you’re last. Those are the rules we play by. So I am a board certified plastic surgeon, originally trained in Dallas. Spent the first part of my career down there where I was gaining an interest in abdominal wall reconstruction and actually worked in collaboration with my general surgery colleagues, all joking aside and had some really fantastic experiences, great patient outcomes, and translated that when I moved to my hometown of Columbus, Ohio back almost seven years ago now in August of 2013 and here I partnered. What’s that
Speaker 1 (02:04):
Cold? Are you as old as
Speaker 2 (02:05):
I am? Oh, I thought you said cold. I was like, it’s 95 degrees here. Am I as old as you? No, I
Speaker 1 (02:14):
Speaker 2 (02:14):
He’s younger. Nobody is as old as you. So <laugh>. I’m just kidding. No, it’s my skin cream. So I’m a plastic surgeon, actually. 17. So in any event I think it is all about collaboration and just again for your audience I’m a plastic surgeon. I do complex abdominal wall reconstruction and I work as part of a multidisciplinary group. So I work with my general surgery colleagues, colorectal urology, ob gyn anesthesia, pain management nutrition, physical therapy, occupational therapy, and so on and so forth. There’s a great team approach we have here at our center for Abdominal Core Health of which I’m one of the co-directors of that and we pride ourselves.
Speaker 1 (03:02):
Your co-director, Dr. Ben Paulis was our guest a couple weeks ago.
Speaker 2 (03:06):
I’m sure he was distinctly average compared to how this is going to be. So yeah, it’s all right. Is this forever? Is this forever? Are we going to be watching this? It’s all right. It’s all good now actually. It’s a great partnership that Dr. Paulis and I have as well as Dr. Raj Narula. We’re the three co-directors. And actually I think that typifies exactly what I’m saying, which is that we come at this, Dr. Narula, a minimally invasive specialist. Dr. Paulis is a general surgeon. I’m a plastic surgeon. And so we practice what we preach. We take care of patients as a team. So that’s kind of the take home point.
Speaker 1 (03:44):
Well, he was one of our guests president of the American Hernia Society. You’ll be a future president of the American Hernia Society. We’re past president of the American Society of Plastic Surgeons. You’re waiting for presidency, I think 2046 President of the United States. Is that right? 2046
Speaker 2 (04:05):
Actually, the way things are going, it might be this year, but I didn’t say that out loud. I was just thinking have my vote. I was just thinking that and the audience is picking up on that with the s p that they’ve got superpowers. This audience has got superpowers. They can hear things. Yeah,
Speaker 1 (04:20):
They’re awesome. They’re the best audience ever. So I love you so much. Can I just tell you, so just for the audience, I met Dr. Janis on the board of the American Hernia Society. I didn’t know you that well before you came on the board. I think I probably listened to your lectures but I got to know Dr. Janis and I’m kind of a nerd and I really, really love people that are super smart and witty at the same time. I come from a family of satire, so I love anyone that is in that vein in Dr. Janis for sure. I was about
Speaker 2 (05:03):
Say who is there somebody else behind? Am I getting photo bombed right here? Because there must be somebody behind me that you’re talking about because it’s not Uncle Jeff, I’ll tell you that much. So
Speaker 1 (05:16):
Thank you for accepting to come. It’s end of your day. You’ve been on tons of Zoom calls and meetings and taking care of patients and all that, so I appreciate
Speaker 2 (05:25):
Your time. It’s okay. It’s an honor to be here truly. And whatever questions your audience has or the patience or what have you, I’m happy to do my best to answer them.
Speaker 1 (05:34):
All right. Well this is the first one’s an easy question. Let me just show you what it is. So maybe you can explain how different you approach abdominal wall hernias than the typical general surgeon who does abdominal wall hernias. So just for the audience hernias are repaired by general surgeons, primarily plastic surgeons, and every so often there’s a urologist that can do inguinal hernias. That’s pretty much it. I don’t think many other people do hernia repairs. But how is a surgeon and your training, how does that make you look at hernias and maybe even repair them differently?
Speaker 2 (06:19):
Yeah, I’d say that this is a one plus one equals three situation. Anytime you get more perspectives on something, especially when you’re trying to tackle the same problem, I think that leads to a better result because you can share opinions, share skill sets and experiences and expertise and come together and it actually causes you or even challenges you to think about things in a different way and in some ways novel ways that you haven’t really thought of before. So plastic surgeons, I think the public thinks are probably largely cosmetic surgeons. I can tell you when I was recently the president of the American Society of Plastic Surgeons and doing a lot of interviews with media and listening to people and patients that came through loud and clear. And I’m not saying that that’s a bad thing but I am saying that plastic surgeons do not only cosmetic surgery, but they also do reconstructive surgery.
Speaker 2 (07:17):
And as a matter of fact, there are actually two sides of the same coin because if you think about it, let’s say you’re repairing a cleft lip in a child clearly there’s a functional problem, there’s a reconstructive problem there, but of course it matters how it looks. And that goes for anything. Look at breast reconstruction after cancer that is a cancer is a functional issue. You’ve got to get rid of that cancer. We need to reconstruct that patient to make them whole again in every way. That is not just a reconstructive procedure, even though it’s called reconstructive, that is clearly also cosmetic because there is an aesthetic component when it comes to abdominal wall reconstruction. If anybody of any gender looks down at their abdomen, of course they’re going to care how it looks, but they’re also going to care how it functions. Plastic surgeons care about both, and that’s when we collaborate with general surgeons.
Speaker 2 (08:11):
Now, the general surgeons with whom I collaborate, we have a great working relationship and I’m going to kind of boil it down to how I say it in my patient clinic is that we have whole diggers and whole fillers, and when general surgeons work together with me, they’re getting back inside the abdomen, they’re cleaning up scar tissue. If there’s repairs to be done on the plumbing so to speak, they’re repairing a lot of the GI tract if there’s issues with that. And that’s when I come in and I rebuild the abdominal wall from the inside out. And that includes moving muscles around in some cases putting Mesh materials in, moving skin around. There’s a lot that goes into it. It’s a complex operation. But again, when you’ve got two heads looking at this and four eyes and in some cases more, to be honest with you, depending on the complexity of the patient, we are all capitalizing on our expertise and bringing that to the table so the patient gets the best outcome possible. And especially we live by the mantra do what you love and love what you do. And I think that really comes through in how we take care of patients.
Speaker 1 (09:24):
So my practice is in Beverly Hills, which is I think we have the highest concentration of plastic surgeons within the three blocks around me.
Speaker 2 (09:35):
I think it’s even greater than the number of Starbucks in Seattle. So I do think you win. I think you win that award.
Speaker 1 (09:41):
I think so. And that said, the majority of them do not do hernias, not do abdominal reconstruction. They may do a tummy tuck and that’s the extent of it. But even a tummy tuck, an umbilical hernia within a tummy tuck because I do a lot of joint procedures. So maybe someone’s had a tummy tuck and now they have a hernia. So I want to use a tummy tuck approach to get to that hernia, but I don’t want to be the one redoing a tummy tuck and because the flap blood flow is important and all that. So I’d like to defer to the plastic surgery for that part of it. But I’ve noticed that at least in my neighborhood, they don’t like to do abdominal wall hernias or they don’t choose to do a lot of it. So I do it and then I train my residents and some of them go into plastic surgery and they interview all around and they say, oh, who does your abdominal wall? And they say, oh, like Dr. Towfigh does <laugh> not a plastic surgeon. So what’s your thought of that? Is it okay that general surgeons are doing some of these huge abdominal wall hernias? Should they be experts doing it in general?
Speaker 2 (10:52):
Yeah, I do think that people should again, play to what their experience level is. Their comfort level is, I mean, we want to do the best by our patients. I am sad to hear that maybe in your area you’re not getting as much interest but certainly you don’t need everybody to be interested. You just need a few people to be interested who are willing to partner together, collaborate, and be part of the team. Even here in Columbus, Ohio, not every plastic surgeon is interested in the same things that I’m in. And I’m sure the converse is true as well. I mean, that’s just kind of the way the world works. But I do think you bring up some very important points, which is plastic surgeons are really good at thinking about things from the angle of blood supply. And that’s very important not only from a patient who’s never had a scar anywhere for any reason, but actually even more importantly for patients who do have scars, maybe from other operations, maybe they’ve had a gallbladder taken out or an appendix taken out, or they’ve had previous surgery of their abdomen.
Speaker 2 (11:58):
Maybe they’ve had actually already a previous tummy tuck or maybe they had a bariatric surgery where they lost a lot of weight and now they have a lot of loose, extra drippy skin that you know can go to 24/7 fitness and work out 24/7. And that’s just not going to do it in some of these patients. It’s not for their lack of drive or energy or desire. It’s just that that’s how the body’s tissues are not going to be able to respond in that situation. So plastic surgeons looking at things from that angle of where are the scars? More importantly, where’s the blood supply coming from? How do we get the best result with the least amount of complications by preserving blood flow? These are some of the contributions actually that plastic surgeons have made to the world of hernia surgery, not just what we’re talking about here tonight, but actually even going back several years and looking at some of the major meetings where people who have these common interests are meeting as a meeting of the minds, exchanging information.
Speaker 2 (12:57):
When I see plastic surgeons up on the podium giving presentations, I hear them talking about blood flow, blood supply, how to manage the previous scars that a patient brings to the table and how to still get really good successful outcomes even despite some of what a patient might have been through in terms of their journey. And so again, I think that we cross pollinate, if you want to use that word. We share information and it makes all of us better. And so I think those are some of the key contributions that plastic surgeons bring to the table.
Speaker 1 (13:29):
I totally agree. I think I’m a better surgeon because I learn from the plastic surgeons how to handle tissue, if you like. For example, I teach my residents as a typical trauma surgeon. They’re just like they’re interested in saving lives and they’re very aggressive about retraction and pulling and suturing really, really aggressively. And I teach the exact opposite because I want my patient to have less swelling, better tissue healing less pain, but also the scar needs to look pretty. I strongly believe that what you do on the outside kind of reflects for the patient release, what you’re probably did on the inside. So I learn a lot from my plastic surgery colleagues when I do these joint operations. I really enjoy it. I stay there for the whole operation. You don’t need to be here for this tummy talk portion. I’m like, no, I’ll be there. I’ll cut your suture.
Speaker 2 (14:28):
Well, that’s why I love you. That’s why I love you and why we get along so well. Because I mean, what the patient sees is important in how they feel is important. And I got to tell you this operation, in my mind, it’s, it’s not meatball surgery. There’s a lot of finesse, there’s a lot of nuances. It’s almost like marriage. If you don’t take care of the small things, the small things become the big things. And so we do need to pay attention to details. I mean, you don’t use the cleft lip example again. Do you want somebody who is not a perfectionist and says, eh, I’m going to get it close enough and I’ll put a couple staples in it and it’ll be fine. That’s not good enough for your kid. That’s not good enough for you. That’s not good enough for anybody that you even remotely care about.
Speaker 2 (15:19):
So it is the details, the attention to details and these finer nuances that really do make the difference between a decent outcome and a really great outcome. And that’s where I think this collaboration across disciplines, we don’t need to work in our own little silos anymore, our own little boxes. I mean, that is an older concept that thankfully is out the door and heading the opposite direction nowadays, us working by building bridges, holding hands, connecting with each other and breaking out of these artificial boxes that we put ourselves in is definitely going to be putting the patient at the center of the universe. So we’re revolving around the patient instead of the other way around. That’s the way it should be, at least in my opinion.
Speaker 1 (16:07):
Totally agree. Absolutely agree. Okay. Maybe you can give a little bit of your thoughts about just hernia as a disease, because you see people with bonafide hernias like belly button hernia, incisional hernia, and you also see people with a diastasis, which we don’t consider hernia, but in many patients it’s a bulging for them but doesn’t have the consequences of a hernia necessarily. Are those two related? Do people with diastasis have a hernia disease or a collagen disorder? Do you combine those operations? If someone has a hernia within a diastasis, do you push to have them both repaired? What are your thoughts on the role of diastasis and that?
Speaker 2 (16:55):
Right, so great question. And the answer is, is it depends. And let me work backwards from that. Okay, so for the listeners out there who are unfamiliar with the term diastasis, you know, have your core muscles, your crunch muscles, the muscles you use to do a sit up with, they’re called your rectus muscles and you have one on the left and one on the right. Yeah, you’re six pack muscles, right? I’ve
Speaker 1 (17:18):
Seen here at six pack,
Speaker 2 (17:19):
I actually have a 12 pack. Oh, I’m sorry. I thought you were talking about what I have under the table. Yeah, six pack here, 12 pack there. I’m just kidding. I’m on state grounds. Anyway the bottom line is, the bottom line is that these look like a number 11 when you’re born. They’re supposed to be one to the left, one to the right, and they’re supposed to be, can pretty much mirror images right next to each other. The problem is that with weight gain or more particularly, or at least more commonly with pregnancy it causes a stretching of the abdominal wall and a rubber band, the abdominal wall wants to snap back after it’s done being stretched. The problem is also a rubber band. Sometimes it gets stretched out too far and it just doesn’t snap back all the way. And so it actually can happen even after one child, if we’re going to use the pregnancy example, if the patient is small or if the child is big or if there’s more than one child, especially happens in twins, triplets whatnot.
Speaker 2 (18:20):
And then of course if you get pregnant again, all you’re doing is stretching again, pulling it back, stretching again, pulling it back. And so if you think about it like bending a credit card, if you keep on bending a credit card, eventually it forms that little white line there and if you keep doing it, keep doing it, then it’s got a weak point that things can break. So a diastasis could be termed one end of the spectrum. It could be a very almost unborn hernia, hernia to be. Now, not all of the diastasis turn into hernias. Some do not all do. Most of them do not. Okay. But what I do as a plastic surgeon is when I treat what’s called a rectus diastasis, I am trying to take these muscles, which used to be an 11 that turned into a V, I’m trying to bring ’em back into a number 11 by stitching those muscles together.
Speaker 2 (19:14):
Now, some of the people, those muscles are just eked out just a little bit, not a big deal. It’s worse than before pregnancy, but it’s not excessive. Some people have very large diastasis, and I would even argue in those patients it actually can be very symptomatic. And we know that we’ve actually studied that these patients feel like they don’t have core strength, they have functional issues like trouble doing crunches. In the worst examples, it’s a problem even getting out of bed depending on the situation. And one of the factors that comes into play is low back pain. People try to compensate for this weakness of their front part of their abdomen by changing their posture and it affects their low back. It puts their muscles in awkward positions and they start to complain of back pain even though the muscle problems on the front. So some of these things can be related.
Speaker 2 (20:07):
So it’s core, right? That’s right. It’s core. That’s why we’re the center for abdominal core health is because it’s a domino effect. One part of the abdomen can actually affect the other part of the abdomen. So you have to look at it from a holistic point of view. So a tummy tuck, again, for the listeners, a traditional tummy tuck, otherwise known as an adominoplasty, is a low hip to hip incision. We also make a little circle incision around the belly button and that’s because we want the belly button to stay at its proper location. If imagine you take a window shake, window shade, that’s a tummy tuck. Now imagine on the window shade that you drew a circle on the window shade and you pulled it down and you cut off the extra window shade. Great. The problem is if that circle is just above the window sill, that’s a pretty funky look and we can get into that some other time, but you don’t want your belly button down in the pubic region.
Speaker 2 (21:12):
That doesn’t look great. So we do make a circle cut around the belly button not to move the belly button, but actually to keep it there so that it stays in its proper position. So that’s a tummy tuck. Now when you lift the skin up, when you take that window shade and pull it a wet away from the window before you pull it down, that’s where we kind of look under the hood and look at those muscles. And if those muscles are spread apart and you have this diastasis that we’re talking about, that’s where we repair those most often with just stitches. Okay, stitches that either can go away with time called resorbable sutures or sometimes permanent sutures where they don’t go away with time. So that’s a standard tummy tuck. Now on occasion, either expectedly or sometimes by surprise, we do see hernias even in our cosmetic patients that’s called an incidental hernia because we didn’t expect it.
Speaker 2 (22:05):
Even on a good thorough physical exam, sometimes it can be missed. And in those situations, to your earlier question about whether those are repaired at the same time, yes, we’re already there, patient is under anesthesia, we already have what’s called great exposure because we’re looking right at the engine basically under the hood. There’s no reason why that shouldn’t be repaired at that time in an otherwise healthy patient who didn’t have something else going on that’s making this a more complicated situation. Matter of fact, we do cover that in our informed consent. When we have patients authorize our ability to do surgery, we say we may find something unexpected. And a matter of fact, in my tummy tuck patients, I do tell ’em it is possible we find something like this. Are you okay with me repairing it if I find it? And to date, I have not found one patient who doesn’t say Yes, of course while you’re there please, I don’t want another operation, another general anesthesia or another recovery period. So in those situations they may be combined.
Speaker 1 (23:04):
So a tummy tuck is a two process procedure, one is to address the extra skin and one is to tighten the muscles.
Speaker 2 (23:15):
That’s right. There’s the inside and the outside basically.
Speaker 1 (23:18):
Do you ever use a tummy tuck to repair a hernia, like visual hernia? Do you ever do that as part of your hernia? The primary plan is a hernia repair, but you involve a tummy tuck as part of it.
Speaker 2 (23:34):
Yeah, I’ll give you an example. I just saw a patient two days ago that came to me because she has got a hernia that’s just up until the left of her belly button. She’s got three kids and her youngest is three and a half months, her oldest is six. She’s not planning on having any other kids which is important because if you think about it, if you’re going to try to take away all the extra tissue and tighten everything up you pretty much wanted to be sure, as sure as you can be that you’re not planning, at least you’re not actively planning on having another child because that’s just going to stretch everything out again. And you just went through everything that you went through for nothing. Plus in a tummy tuck situation, you actually paid for it, by the way, because that’s not covered by insurance.
Speaker 2 (24:18):
So that’s a double dip on that you don’t want. So after making sure that she’s lost all the weight that she needs to lose after her pregnancy and she feels like she’s down to goal after confirming that she’s got no efforts towards increasing the number of people in her family through childbirth then that’s a situation where she had all three kids by C-section. She’s already got a scar. And so now she’s actually asking me, okay, well I need to get this hernia fixed and that’s kind of the reason why I’m coming to see you, but while I’m here, is there anything that we can do to address that hernia in a way that makes the scar as inconspicuous as possible? And also, I don’t really love my C-section scar because somebody’s cut on it three times now. So I’d love that to be revised. And my answer is the answer to your question, perfect opportunity.
Speaker 2 (25:16):
Let’s revise that C-section scar, which is actually part of the low smiley face incision that’s part of a tummy tuck incision. And while we’re there, we’re also going to repair your hernia. You’re going to get basically an all in one. It’s safe, it’s not adding a ton of extra time to the operation, which of course we wouldn’t want to do. It’s not adding a ton of excessive risk to the operation, which again, we wouldn’t want to do, and that’s not adding substantial recovery to the operation. So that’s one of these, why wouldn’t you in that situation go ahead and do both at the same time. And we have plenty of patients like that.
Speaker 1 (25:50):
We have a question from Facebook Live, which is how can you tell if you have a diastasis and concerned x-rays help diagnose that or is it a clinical diagnosis?
Speaker 2 (26:02):
Yeah, so x-rays, no CT scans, yes, but almost never necessary unless you’re getting a CAT scan for some other reason. Usually it is able to be detected on physical exam. And so the way ways that I do it is that I’ll have a patient life flat on their back. I will put my hands on their abdomen of course with permission, and I always have a chaperone in the room. And so we’re doing this physical exam where I’m pressing on the middle of their abdomen and I’m trying almost like walking along a cliff and then falling off. There’s this center part where you literally can just walk off the muscle and fall into a little crevice there. And the other way that we do it is we have patients lift their head up off the bed again, they’re lying flat, and we lift their head up to maybe above their shoulders.
Speaker 2 (26:57):
And then in some cases you can make this even more apparent by asking them to strain as if they were trying to do a crunch or having a bowel movement, even just something to apply pressure inside their abdomen that pushes out the center part in between the muscles and makes it obvious. And then in some cases, especially in thinner patients, you could take a ruler and you could measure what that looks like. Now, a key difference here when we’re talking about a diastasis versus a hernia is that a hernia is nothing more than a hole. A diastasis is a stretch, so it’s a stretch but not a break. So if I’m feeling along this crevice, and actually I feel there, there’s a rip in this tissue that’s stretched almost like the taffy’s been pulled and actually it broke. That’s a different story. That’s a hernia. And the issue there is not, no, not so much the hole, but if something gets stuck in the hole, of course that’s why we are repairing hernias because you want to get that done during the day, not in the middle of the night as an emergency.
Speaker 1 (28:01):
So you discussed the reasons why people get diastasis pregnancy being the most common reason in men may be an increase in weight. It is also genetic though, isn’t it
Speaker 2 (28:16):
Previous? Yeah. Yeah, it’s about three or 4% is congenital meaning that you’re born with it, you didn’t do anything, nothing happened to you. It’s just the way that things happened. But by and large, that is the vast minority of occasions that is responsible for a diastasis. Most often it’s the things that you mentioned most often related to weight changes that are significant in pregnancy.
Speaker 1 (28:40):
And another question is, can laparoscopic surgery? The insufflation of the abdominal wall for laparoscopic surgery can that cause a diastasis,
Speaker 2 (28:50):
Not that I’ve seen, heard or read laparoscopic surgery is it’s only going to last a very short period of time. Think about a pregnancy that’s L lasts nine months. I mean, that would be a heck of a long laparoscopic surgery to actually stretch the balloon. And I mean that would be a huge bill from anesthesia, just a huge bill. But if you had laparoscopic surgery that does stretch your abdomen, I mean that is a true statement. It just doesn’t stretch it long enough to make a difference versus some of these other things that we’re talking about that are kind of longstanding, that’s what creates the problem.
Speaker 1 (29:30):
Yeah, there have been doctors that, or patients that have come to me that have been told it was because they had laparoscopic surgery, and I’m like, that’s just due to and they don’t want laparoscopic because they think it’s going to cause a hernia, which we know it doesn’t. Here’s a patient who developed a diastasis after their inguinal hernia surgery. Are those two related?
Speaker 2 (29:55):
I can’t think of a reason why they would be related because those two are not usually intertwined in terms of their causes. So I would say, again, patient specific, I would need to know more details, but in general, the answer would be no.
Speaker 1 (30:14):
Right. Okay. Next question. Let’s see is what about weight? What’s the role of weight and do you think weight can make a hernia more? Or if you lose weight, will the hernia look smaller or feel smaller? What do you tell your patients about weight gain and weight
Speaker 2 (30:35):
Loss? That’s a great question. So believe it or not you ever seen those stories where people don’t know that they’re pregnant and then one day they sit down on the toilet and then there’s a baby?
Speaker 1 (30:48):
My own office manager almost
Speaker 2 (30:50):
Really? Okay, so I mean these are real stories. These are real stories. But I have the re, and let me connect the dots here because you got to follow my thought process here. I promise you I’ll get to the end. But there are some people who when they lose weight, had a hernia the whole time that they either ignored or didn’t pay attention to, that didn’t really become visible or visibly obvious to them anyway until they dropped some weight. And so in some cases, the answer to the question is, so will losing weight also affect your hernia? Well, it may actually make it more visible but this hernia that the hole that we’re talking about, this is not like you fell on the sidewalk, scraped your knee, got a scab on your kneecap, and eventually that scab fell off and there’s fresh new pink skin underneath it and everything’s healed.
Speaker 2 (31:49):
The hernias, once you have one, they’re not going to heal on their own. The only time where I know that that happens is in some kids with their umbilical hernia when they’re newborns, and that just naturally closes over the first few weeks or so. But in the adult, once you get one of these holes, it’s either going to stay the same size if you’re lucky or it’s going to get bigger. And if you gain weight, then the tendency is for those holes to get bigger. Now, we know that when we repair hernias that if you are overweight or even extremely overweight that actually can make your outcomes worse. So what we do ask is that if our patients are in that situation before their surgery, that there are some of these things that are not under their control. If they’ve had five other operations, well, I wish we could turn back the hands of time and undo, wave the magic wand and pretend like none of that happened.
Speaker 2 (32:43):
There’s nothing that anybody could do about that situation. But some of these other factors like weight, if you’re overweight and you have a hernia your chances of having another hernia go up the more you weigh. So it is in your best interest if you want to have one operation and get rid of this hernia and hopefully keep it away without the need for another operation to get back to more towards your ideal weight. We all, and there’s science behind that, obviously there’s good data, there’s also good data that says that if you gain weight after your hernia repair, that you also are increasing your chances of having a problem like a recurrent hernia. So it’s really on both ends. You got to get it off and keep it off in order to have the best outcome possible from a weight perspective. So hopefully that
Speaker 1 (33:30):
That’s an intersystem line. It,
Speaker 2 (33:32):
I think I just made it up right now for the first time. You can write it down. It’s in my book.
Speaker 1 (33:38):
So the next question is on component separation. So for the audience, component separation is kind of manipulating the abdominal wall components, the muscle and the fascia to be able to close and close a hole like a hernia. And I believe that operation has always been under the auspices of plastic surgery. The original descri description was by a plastic surgeon, and up until recently, it’s really been something that has been taught in plastic surgery training and not so much in general surgery training. Is that correct?
Speaker 2 (34:14):
Yeah, so the original person who coined the term component separation or separation of parts was a doctor named a surgeon named Oscar Ramirez, who published on it in 1990 and he’s still around friend and colleague see him usually once a year at a meeting. Great person and obviously a pioneer in an innovator. Now the original concept actually predated that there was a general surgeon from the UK, last name is young who had the concept actually back in the forties but this actually crystallized it Ramirez did. And you’re right, plastic surgeons have who are used to moving muscles around, moving skin around. I mean, that’s what we do. That’s the name of the game to be a plastic surgeon. That is why component separation is usually a plastic related to a plastic surgeon. That being said, over the last, I’d say maybe eight to 10 years, as we’ve related to the earlier parts of this conversation where we say that we get together and exchange ideas and experience and come up with new techniques or perfect old techniques, that’s where general surgeons have started to get more and more into component separation than they were in the past.
Speaker 1 (35:36):
And the original component separation was a tissue repair, right? And the goal was to be able to close without needing to bridge correct with some type of implant. But we’ve kind of moved on to combining the component separation with Mesh which I think is a general surgery kind of way of thinking. A lot of plastic surgeons are not comfortable with Mesh and often do, at least in my town every plastic surgeon I’ve worked with, they’re like, oh, this looks fine. We’ll just tissue repair. I’m like, no. Our studies show that it’s going to fail without Mesh or higher. I think the number is about a third for a Ramirez repair without Mesh, and then with Mesh, that drops down to single digits. So that’s how we’re trained is to always use Mesh to support that tissue repair. But in plastic surgeons, they strongly believe in the tissue. What’s your thought about that? Is anyone right or wrong?
Speaker 2 (36:37):
Well, so no, nobody’s right or wrong, but obviously you know, want to be familiar with at least the existing evidence. In some cases, a tissue repair alone is fine. Okay, but let me explain this from a wound healing perspective. One of my areas of expertise is wound healing. And so when you get cut you heal. And when you heal, you regain the strength of your tissues over time, and that is called tensile strength. So if you’re born and you start at a hundred percent strength, then you get cut, whether that’s by a surgeon’s knife or you get into an accident, God forbid, or anything like that, that causes a break in the skin or the tissues and you get cut and then you have to repair. It takes about 90 days on average. And again, that varies. That’s just an average to get back up to your max strength.
Speaker 2 (37:34):
But your max strength is not a hundred percent, it’s 80%. Okay? 80% is the max recovery of your tensile strength. Now imagine in the case of let’s say, let’s apply this to hernias where you maybe have multiple operations that are all in the same place. Okay, first time a hundred percent, you get cut, you heal to 80. Next time you go through that same thing, except you heal to 80% of 80%, the next time it’s 80% of 80% of 80% as long as all of this is in the same place. So when I say to my patients that the more hernias you get, the more hernias you get is because your tissue strength over time, especially in the face of multiple operations, is just a downward slant like this. And it gets to the point where the tissues are just not capable of withstanding the average forces that you put on them by doing your daily activities.
Speaker 2 (38:39):
You want to go running, jogging, you want to exercise. I mean, even honestly jumping, which puts pressure on your abdomen or straining to start doing bodily functions these all require the development of pressure inside your abdomen. And if your tissues are not capable of handling that, especially if you really drive them hard, they tear. So at some point, we need to supplement the strength of this tissue, and that’s where people turn to Mesh materials and that’s where the science has been published to say that depending on what you read, in some cases it decreases reoperation rates. David Flum looked at this in the retrospective study from University of Washington, looking out over 4,500 days and found like a 23/24% decrease in reoperation rate for all points in time. We have one of the most often quoted papers in hernia literature from the Netherlands from a surgeon, Lewin Dyke who says that basically, you know, reduce your recurrence rates by half versus doing a suture repair alone in hernias that are six centimeters or less.
Speaker 2 (39:52):
So we do have evidence that we apply to patient care. Ultimately, is the patient’s decision though on whether they want to accept Mesh or not? That is always the patient’s, right, and always the patient’s decision and something that we discuss with our patients. If they want us to do a tissue repair alone, that’s fine. Just understand that we’re not God and we’re not mother nature and there’s nothing we can do about some of these things that we just talked about. I wish I could invent scarless healing. I wouldn’t be on hernia live tonight. I would be off on my own island somewhere or maybe a different planet that I bought with my spare change, but that just doesn’t happen. That’s not real life, not yet. Anyway.
Speaker 1 (40:36):
So do you think it’s legit to offer a component separation without Mesh?
Speaker 2 (40:42):
I think that if you had a hernia, that’s big enough because for the audience, just so you know, component separation, in other words, moving muscles around in an advanced way, that’s not something that needs to be done on every hernia. As a matter of fact, I like to do, and don’t get me wrong here, I do my best, but I like to do the least amount that’s required, and that’s not corner cutting, okay? That’s not burning bridges is what it is. I don’t like to play every card in the deck. I don’t like to shoot every bullet out of the gun, so to speak in order to solve a patient’s problem because you don’t know if they’re going to get another problem down the line. You want to hold some stuff back but only when necessary, if it’s indicated to move muscles around, I’ll do it at the very first operation. Okay? I’m not trying to get more business by generating more. However, if you have a hole that’s big enough, a hernia that’s big enough that it requires manipulating these muscles in a fancy way to put things back together, that’s usually a sign that there’s going to be tension on that repair and you’re going to want to support that. So with Mesh materials it just depends on the situation. So you really can’t put a cookie cutter on this.
Speaker 1 (41:58):
Do you think that someone that’s older, over age 70 can heal from a component separation or big abdominal wall reconstruction? It’s age a factor when you discuss these options.
Speaker 2 (42:11):
Age is not a factor in my discussions because as long as they’ve been able to heal well and they have their health conditions under control we’ve actually shown this in plastic surgery because again, we’re reconstructive specialists. We’ve looked at age, we’ve looked at whether age is a problem when doing advanced reconstructive surgery, including things like head and neck cancer, et cetera. And we have not found that beyond a certain age that there’s like a limit. You can only operate on somebody until they’re 80, and then you can’t operate on them after that just because the juice isn’t worth the squeeze, so to speak, or the complication rate is too high, that doesn’t exist in plastic surgery. As long as you don’t have a disease that is impairing your ability to heal, and the older that people get, the more likely they are to get some other diseases. As long as we control for that, then age is not a problem for me.
Speaker 1 (43:10):
Okay, cool. That’s another question. What are some complications that patients should be aware of if they are told they need a component separation? Is it wound dehiscence? Is it, are the vessels at risk, the nerves in the area?
Speaker 2 (43:27):
So component separation involves cutting muscles. So you do have to let patients know that, especially if they’re on the active side, they may notice a functional deficit depending on which muscles you’re cutting. Most patients don’t, to be honest with you, but it depends on are you a bodybuilder or a couch potato or somewhere in between. And again, I’m just kind of using generic terms here but that’s what you’re doing now. Usually doing muscle work like component separation is a sign that it’s a more complicated surgery and with more complicated surgeries is usually a longer surgery and sometimes a longer length of stay in the hospital. And oftentimes maybe a longer recovery that may in involve more activity restrictions or pain management or what have you. Certainly if you’re cutting muscles, it’s going to hurt more than if you’re not. So there are some things that patients need to be aware of on the front end.
Speaker 2 (44:26):
This is not to be surprised on the back end, but you have to educate your patients on the front end that this may impact some of these things that I just discussed. But then again, these are modern techniques that we have in order to restore function. And maybe a counterpoint to this that your patients need to understand is that we’re not just trying to avoid complications, we’re trying to improve quality of life. We are trying to give back the ability for patients to do more after their surgery than what they felt they were capable of doing beforehand. And so if we have to move muscles around, that may add some risk and some time and some recovery, but ultimately it can improve function. And we actually know this, there was a study published by Ken Chest in 2000 out of Pittsburgh where he tested patients who had hernias.
Speaker 2 (45:19):
So they had holes in their abdomen and obviously their muscles were separated, not like how they were born. And he had ’em do a sit-up against weighted resistance like in a Nautilus machine and then put their muscles back together where they belonged after a hernia repair. And had the patients go through another exercise like that after they were repaired and found a 40% increase in what’s called truncal flexion force. So their ability to crunch, do a sit-up generate force by flexing their abdomen when you put their muscles back in their natural native position improves function. And so if you have to move muscles around in order
Speaker 1 (45:57):
To do, that’s like, that’s a good thing. Yes, the factors in line with it. So another question, this is actually more of a technical question because it was from one of our colleagues but it’s worth asking is the role of Botox. So as a plastic surgeon, you guys love your Botox, it’s become a big part of some plastic surgeon’s practice, but specifically for abdominal wall reconstruction, do you think that Botox can change the type of operation you provide, for example, not require component separation or major reconstruction? Maybe you can give us a little.
Speaker 2 (46:39):
Yeah, so again, for the audience to understand what we’re talking about most people associate botulinum toxin or the brand name in this case Botox with wrinkle reduction. And certainly for cosmetic purposes, that is usually one of the main reasons that it is used. I actually use it not only for cosmetic purposes in my patients, but I also do migraine surgery. So I do surgery of the nerves around the head and neck in order to decompress them in order to relieve somebody’s migraine headaches. That’s another big part of my practice. Interestingly enough that, and I use Botox in that situation, which by the way, in that situation, that’s an on-label indication that’s approved by the FDA for patients who have chronic headaches. And so we can talk more about that maybe on a non hernia talk headache talk segment, headache talk, headache talk, headache talk live <laugh> live from red rocks.
Speaker 2 (47:37):
So what we’re talking about here is can we use the relaxing properties of Botox in order to relax the muscles enough so that you can scoot them together and close the abdomen and close that hole without having to cut them, which in other words, avoid a component separation. Or maybe in certain situations with the biggest of big holes in hernias where we pretty much have little to no hope of putting the horses back in the barn and shutting and locking the barn door, how do we actually generate an increased chance of success? Well, one of the ways to do that is to loosen or weaken the muscles. And this is temporary. There hasn’t been a permanent Botox invented, so this is temporary. But in this window of time that we have, while the muscles are more loosey-goosey, can we scoot them together and use that to our advantage?
Speaker 2 (48:46):
So that is the nature of the question, and the answer to that is yes. And that’s again, not just my guess that has been shown with evidence that has come actually from around the world, a lot of it from Mexico. But I know that there’s some good work coming out of Carolina’s Medical Center as well where they’ve looked at this and it actually in some cases is avoiding the need for component separation and in the largest of hernias is generating the ability to get this closed. I also use it in my practice, not for everyone, but in occasions what I just described and I am seeing success with it. So this is another technique that is, it’s not prime time I would say, but it’s definitely another tool in the toolbox that we can use on patient’s behalf.
Speaker 1 (49:34):
We had a whole discussion about the importance of seeing a hernia specialist when it comes to secondary third for second time, third time, fourth time hernia repairs. We don’t have enough specials to go around for the first hernia repair, but for sure, once it gets complicated, people need to come to patients, to physicians like you who have knowledge of the anatomy and all these different tools to be able to give the best outcome because you really want that hernia parent to be the last one. You don’t want that to recur. And I strongly agree as well with you about not burning bridges. I have a serious issue about doing tars on everyone. The transverse release, it’s become very in style and everyone seems like, oh, the tar is the answer to all hernias. And I feel like that’s for end stage. That should be the last thing that you go to because you really, there’s no more bridges after that. I think if you fail atar, that’s pretty much then you start patching up after that. There’s not much good stuff to do after that. Just to clarify, there’s a question. What’s the difference between component separation and compartment release? And is that term used interchangeably?
Speaker 2 (50:44):
Yeah, so those are totally different. They are not used. Operation is moving muscles around, and this is related specifically to abdominal wall reconstruction or hernia repair in order to get those barn doors closed. But the muscles back where they belong, compartment release is usually used it could be used in the abdomen, but it’s more commonly used in the arms and legs where you have a trauma. Let’s say you broke a bone in an accident or a fall or some, or maybe an electrical burn or something like that and you’re generating pressure from swelling of the muscles and your muscles live in a compartment. Think of it wrapped in a tight piece of strong saran wrap and your muscles live in there. And normally there’s plenty of space in there to live and breathe and do what the muscles need to do. But if the muscles are swollen or jammed up against this tight saran wrap it actually can choke the muscles off.
Speaker 2 (51:52):
It decreases blood flow to the point where the muscles get no blood at all, and if you don’t get blood, you’re going to die as in the muscles are going to die. And a compartment release is where you go in and you put a hole in the saran wrap so that you give more space for the muscles. And sometimes, I mean, when you cut a tight compartment, those muscles can come out like a mushroom because they’re under tight pressure. So that’s a big difference. The other thing I should mention about Botox is that for those patients that really don’t like their hernias but don’t want to undergo surgery, we can also just give them cosmetic Botox and they become so enamored with their new appearance of their face that they completely forget that they had a hernia. And that’s called a distraction. It’s called a distraction separation. So I don’t know if you’ve read about it. It’s in a book about to come out.
Speaker 1 (52:47):
Well, those are the tricks of your trade. I don’t have the tricks.
Speaker 2 (52:50):
Right. That’s right.
Speaker 1 (52:52):
Another question about insulin resistance and the metabolic syndrome. Does any of that affect healing and does it affect what operations you do or offer patients if they come in with not overt diabetes, but metabolic syndrome and maybe insulin resistant, kind of what we call?
Speaker 2 (53:13):
Yeah, so basically elevated blood glucose levels beyond a certain range, especially over time, can cause problems and they cause problems in a couple of different ways. The most common way is that people think about anyway is that it impairs blood flow because it hardens the blood vessels. It’s what it contributes to what’s called calcification of the blood vessels. And that’s not really good. So that’s one way. The second way is that the body heals, and we talked about this earlier with tensile strength and whatnot. The body heals by, and let me paint a picture for you. It throws down a bunch of bricks, it saves the good ones. Some of the bricks are broken, and it throws those away, and then it takes the good bricks and it builds ’em into a nice wall that looks really good. It’s nice and strong, but then over time, some of the bricks get older or start to crumble.
Speaker 2 (54:13):
And so the body actually takes those bricks out that are older and replaces them with new bricks. That’s how the body heals. It’s a collagen recovery cycle. You got to lay down the collagen, you got to remodel it, you got to actually disintegrate it and then lay down new one. It’s got this cycle. When you have elevate elevated blood glucose levels, it actually impairs the body’s ability to break down old collagen like it normally does. And instead you get this weak old collagen that kind of sticks around and that leads to poor wound healing. It can lead to wounds coming apart. It can lead to increased incidence of infection because also white cells love to drink sugar water, and if they’re drinking sugar water, they don’t want to get up off the couch and do their job, which is guard against invaders and kill germs and bacteria and whatnot.
Speaker 2 (55:06):
They like to hang out and drink basically beer, sugar beer. They’re just hanging out. They’re not getting off the couch. Okay. So if you have pre-diabetes, not a huge problem, but if you start to get into a chronic condition where your blood sugars are elevated, you can have complications with wound healing and with hernia repair. We actually know in the plastic surgery literature where they studied what’s called diabetic limb salvage, they did this study, it was published by Matt and Dara and Chris Adder out of Georgetown. They have a wonderful diabetic limb salvage center there that if you have one blood glucose level above 200 in the perioperative period, it significantly increases your risk of complications. So yeah, this was in the diabetic limb salvage literature, but again, you can extrapolate that to what we’re talking about. I like when we’re operating on these patients or others, we really want to control those blood sugars. We don’t want to make ’em too high or too low. We got to hit that sweet spot, but there’s a problem if it gets out of control.
Speaker 1 (56:09):
Well, thank you for your time. Our hour is almost up, so you’re in your office right now. It looks like you have a beautiful office. This is at Ohio State?
Speaker 2 (56:17):
It is. This is at Ohio State. This is my office where I actually almost never am. But for you. But for me, you’re For you. I mean, you can’t spare any expense, right? So I tried to make it look fancy.
Speaker 1 (56:33):
What’s the story with the statue behind you?
Speaker 2 (56:37):
The quick story behind that is that when I was a resident back in the 18 hundreds, again, it’s my face cream go online jeffreyjanis.com. Anyway, I’m just kidding. I,
Speaker 1 (56:52):
It’s actually, I think dr janis md.com or something
Speaker 2 (56:54):
Like that. I don’t even know what it is actually. But I went to a meeting and in the meeting I met a sculptor who’s not with us anymore his wife is but he died a few years ago and his work was incredible. And he does medical sculpting if there is such a thing. And I was just so impressed by him. And I sat there and talked with him for a long time and learned about him and his family and the work that he’s done, and I was so impressed, but I couldn’t afford it. So I said, can I put like $50 down and then could I come back to it in five or 10 years when I have a, because again, I was a resident. I mean, I was making a buck 86 an hour if you amortize it. I actually made more as a bus boy when I was a junior in high school. I calculated that out. And so he let me lay it away for eight years with 50 bucks down or whatever it was, and then I ended up making monthly payments on it later on. But it was just a beautiful piece of work that he does. Renardo is his name.
Speaker 1 (58:00):
That’s a great story. Yeah, medical sculpting is like, it was really in the 1940s, I think. So, yeah, right about that time.
Speaker 2 (58:07):
He does a ton of great work. I mean his pieces live on but it’s beautiful. So it gives me inspiration. That’s very
Speaker 1 (58:15):
Nice. That’s a great one. Well, thank you very much. I’m going to leave you and say goodbye also to our audience. So basically this is it. Every week on Tuesday night, we’re joined by an expert. Not all of them can be as witty and funny and intelligent as Dr. Janis, but we try
Speaker 2 (58:37):
Venmo. Send me your Venmo.
Speaker 1 (58:40):
This will be on Facebook Live, and I’ll also post it on YouTube and you can follow me on social media. I’ll at the links for you all to watch it. Thank you, Dr. Janis. It was a fantastic hour. I hope you get to go home and rest. And thanks for affording your time to me and I hope to f see you soon in person. Yep,
Speaker 2 (59:00):
Absolutely. I hope we see everybody soon after all this hopefully Subsides. Thank you again. It’s
Speaker 1 (59:05):
Been an honor. Have a great, great night. Take care. Bye-bye. You.