Episode 141: Multidisciplinary Treatment of Postoperative Groin Pain | Hernia Talk Live Q&A

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Speaker 1 (00:00:10):

Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live, your weekly session with me, Dr. Towfigh, your hernia and laparoscopic surgery specialist. Many of you’re joining me on as a Facebook Live. And thank you to the rest of you that are on Zoom. And as you know, you can follow me on Instagram and Twitter via at hernia doc and at the end of this show as well as all previous episodes, you can see them and watch them and listen to them on my YouTube channel at Hernia Doc. So today is really a great session. I love having our European surgeons as part of our Hernia Talk Live sessions. It’s a special session today because it’s earlier in the day because it’s like 10 o’clock at night in the United Kingdom. So I would like you all to very much greet and thank Dr. Pawlak for joining us from the United Kingdom. You can follow him at Twitter on Twitter at Maciej P A W L A K. But let’s just say hi to Maci. Hi.

Speaker 2 (00:01:16):

Hi Shirin. It’s great to be here and good afternoon or good evening to everyone who is joining us. It’s a real pleasure and an honor to join you for hernia talks.

Speaker 1 (00:01:27):

Oh, it’s for sure, my honor. So those of you that are on hernia talk.com, which is the website that started all of this, it’s like a free patient discussion forum. They talk a lot about groin pain, postoperative hernia related surgery, pain. It’s a lot of confusion. It’s because they’re sent to a urologist, pain management doctors, some of their surgeons don’t know what to do with it and then they talk about stuff that we talk about. So just you know Maci, my audience, they go to YouTube, they listen to the talks, they know what’s being, what the lectures are planned for at the European Hernia Society meeting. They’re very educated when it comes to all the stuff that we do. They knew the agenda for the E H S before I knew it, they were posting about it. So you gave a great talk this year, this last year actually your talk at Manchester was really great.

Speaker 1 (00:02:29):

There’s a lot of talk about chronic pain, multidisciplinary treatment. You’ve really been at the forefront of that and brought in your own experts that you use. So I was hoping that we could spend the majority of our hour learning about, first of all, I’m very curious, your story, how did you actually get involved in this? Many people know my story and mine was, it was happenstance. Very happy with my decision to be a hernia surgeon and deal with these complicated situations. But I’m always curious how everyone else got involved in the care. So tell me your story first.

Speaker 2 (00:03:07):

Yeah, well every good story, it starts up with a bit of luck, a lot of commitment, a lot of work and good men mentorship. So I was very lucky that since the beginning of my career I had unbelievable mentors and because I really love abdominal wall reconstruction, I love anatomy, hernia and difficult, those difficult parts that we sometimes have to deal with as surgeons or as doctors. That led me to meeting people who were on the forefront of her hernia surgery, on treating of chronic growing pain and a wall reconstruction. And I had a pleasure to learn from them. And we are here in a family and also patients should know, know that we work as a team. We’re a great team of people from us, yes, from UK, from all over the Europe because we are passionate about what we do and we actually want to deliver that excellent care to our patients. It’s just, and that’s why I’m joining you here because I think we need to get to patients with that message that there are surgeons, that there are people out there who want to help them. They have the ability, they study that it’s their tool in the crown that they can actually figure out what’s going on and offer some support and help

Speaker 1 (00:04:50):

A hundred percent agree with that. Part of the reason why I do this is because I’m trying to bring out to the public all the specialists that I know can help them because they’re like, I live in so such and such place, who can I see? And I say, go to hernia talk.com or look at the episodes and you’ll see surgeons in your area potentially or nearby that can help you. And Europe especially I would say has great hernia surgeons, but in the chronic pain, complicated revisional, especially groin revisional situation, we don’t have that many surgeons. You feel that?

Speaker 2 (00:05:28):

Well that is unfortunately true. I hope it’s changing now. So we’ve started a new collaboration together with my colleagues from Netherlands, from Denmark, from UK. And we are sharing our knowledge, we are thinking about what’s the best protocols, learning from our experience from our mistakes as well. And hopefully we can coin that into better knowledge, better research, and I think it will grow. Obviously in United States you have excellent experts. I learned most of the things from David Chen. So he is my great mentor and I’m very happy for everything that he shared with me. Yes, I’ve spent so much time in LA and it’s just incredible that you can learn from people like yourself, David, and other mentors out there.

Speaker 1 (00:06:36):

Absolutely. And he’s very generous in going around traveling all over the world teaching other surgeons.

Speaker 2 (00:06:44):

Yes. And now with the sessions as you mentioned in Manchester, which was solely dedicated to chronic groin pain with sessions dedicated to patients. We all also, I, I’m part of E H S and I’ve been a part of e H s for more than 10 years now. And we are changing as well. We are more patient oriented. We include more and more patients in our meetings and we find that it’s such an important voice and therefore there are more topics about complication and things that might go wrong and where to seek help them.

Speaker 1 (00:07:29):

And I think the more you engage the patient and the patient point of view, the more you understand that maybe the message you’re giving out is not necessarily the right message for, I’ll give you an example. The, I think is it hernia surge or the EHS guidelines which promotes laparoscopic Anglo hernia pair with Mesh as the standard best option for women because it allows you to identify a femoral hernia and treat it at the same time. Sounds very reasonable. But then if you think of from a patient standpoint, that means every single female will get a Mesh based repair. I’m not sure I agree with that. I don’t agree with that. And I understand they’re now because of this feedback, they’re considering tweaking that recommendation saying, you know, should always rule out femoral hernia period. Laparoscopic repair with Mesh would be the ideal way to address it. But not all women need to necessarily have that repair. So if you think of it from a patient standpoint, they kind of say, wait a minute, I don’t want Mesh in me and yet the guidelines say it must have Mesh. Then you start thinking, okay, well our message may not have been the right message even though the intention was to improve care for example.

Speaker 2 (00:08:56):

Yeah. Well now guidelines I is a trick, tricky bit of our work and of our research. I am part of a few guidelines projects and they are dedicated to the majority of surgeons to guide them and it helps to have that discussion with patient to start that discussion because then at least in one place you can point of information about the occurrence of the problem, options of treatment, what are the current standards, what are the evidence and what sort of evidence are out there are out there. Obviously in a lot of topics we don’t have first class evidence unfortunately. And we sometimes need to go with experts opinion and what’s best. And then I think our role is to discuss with patients, those are your options guidelines guide me to offer you laparoscopic surgery. But obviously if for example you can perform an ultrasound scan, exclude femoral hernia and then it’s a patient that could benefit from tissue repair. Oh, exactly. And understands the differences, the risks of both surgeries, you know, make that discussion. Yes. Obviously you have to be dedicated hernia surgeon at that point to offer all those surgeries, right? Yes. And we’re going to guidelines where there are guiding the majority of surgeons, not hernia experts or hernia enthusiast as ourself.

Speaker 1 (00:10:34):

Yes. You did your general surgery training and then how did you fall into hernias and now chronic pain and kind of revisional complex patients.

Speaker 2 (00:10:45):

Yeah, so my history started in Poland actually from Poland. I’ve only immigrated to United Kingdom five years ago for a fellowship. And my career started in Poland where I did a PhD on intradural meshes and I’ve after did randomized control trial that compared physio Mesh with ventral steam. And after that we showed how the results of those surgeries that then triggered to pull out data from Danish and German database and it pushed off physio Mesh out of the market. So that’s started and triggered my career

Speaker 1 (00:11:31):

Historic event.

Speaker 2 (00:11:33):

Yeah, actually it was, yeah. And I went to for a fellowship in Edinburgh with Andrew Debo with optimal wall reconstruction surgeon. And what was missing there in the service was actually chronic growing pain. And because I was considering staying there and in United Kingdom, I wanted to fill out that gap. I had a bit of knowledge before because my boss from Poland did some surgeries and I remember in the beginning I was very young surgeon and I’ve seen preparing to surgeries for the next day that there was G P S, it was called like G P S surgery and it’s like, what’s that? I tried to, it wasn’t the time that you could actually Google those things. I had wanted to look for what sort of surgery? I couldn’t find it because nobody did that. So I asked him like what’s G P S? And he said it’s groin pain syndrome.

Speaker 2 (00:12:29):

At that time that how it was called. So I did few surgeries with him and I’ve seen how difficult it is and how we don’t have established protocol for that. So later on in Edinburgh I really got interested, I’ve started, started to talk about it with David Chen. I’ve went for shorter fellowship to LA I’ve seen Ralph Lawrence, that was her guest as well. Yes. And learned pure tissue repair. I’ve visited in Hamburg, Hennig Berg who taught me how to properly ultrasound scan growing because I knew that if I were to go in that direction, I need to offer the whole package. I can’t say I only do that, I need to know what I’m dealing with. Especially when you talk with those patients and you try to find out what’s going on, have that, if you have that ability to do an ultrasound scan, show them what’s going on and what possibly is not a problem. So helpful and you’re like so ahead, you gain their trust as well because you know how not to trust surgeon who is actually interested, who knows the anatomy, knows what’s going on and can show you this might be a problem. That’s definitely not your problem. You don’t have recurrent. And so step by step, I was gaining all those skills that put me in a position to actually start because I think that’s the most tricky bit from hernia surgery is actually deal with complications. Complicated patient, complicated history,

Speaker 1 (00:14:02):

Especially in groin growing pain, especially in the groin. I enjoy the groin. I think the inguinal fascinating. I learn a lot. I love that I get to work with other specialists as a result, but most people don’t. They do a lot of abdominal wall but the groin is kind of like not their thing. I like it though.

Speaker 2 (00:14:23):

Yeah, I love it. But you have to really have the knowledge to love it because patients, they usually have seen so many people before and they need to trust you and so they can trust you. You actually have to earn that trust and you have to earn that trust by knowledge. But by having that knowledge and being compassionate, understand what’s going on and you can only understand it if you actually do learn. And to understand it,

Speaker 1 (00:14:53):

Our friend Hakan is watching us live, so hi Hakan. He is saying when you’re an expert then the chronic stuff they get attracted to you and then they kind of stick on you. Yeah,

Speaker 2 (00:15:05):

Hakan does. He understands an amazing job in Europe as well. He’s promoting our society but also those talks as you’re doing in us, he’s our guy in Europe. So Hakan, great job. And yes, thank you for joining us.

Speaker 1 (00:15:24):

Okay, here’s a live question. It says, is there any way to distinguish whether chronic post inguinal hernia repair pain is neuropathic or mechanical and does it matter in terms of the management?

Speaker 2 (00:15:39):

Yeah, obviously it does. It’s actually main part of our job is to find out what sort of pain it might be and then figure out what might be causing that pain. Obviously neuropathic pain is the major issue. Well that’s the issue in most of the patients with chronic pain and it’s due to the nerve damage or nerve involvement in stitches or Mesh, whatever. It’s connected to nerves and there are signs, there are symptoms that help us distinguish that. And the other pain on the other end of spectrum is nociceptive that mechanical pain connected to tissue involvement, tissue damage, Mesh, chronic inflammation connected to Mesh and so on and so on. But usually patients that come to see me, they do have both component of pain. It’s not that simple and because it takes time, so in the beginning it might be just a nerve entrapment, but you have to imagine that with time it, it’s becoming a pain, persistent pain cycle.

Speaker 2 (00:16:55):

So it’s not only that neuropathic pain, all the messaging that comes from that area to your brain that’s being changed because your brain tried and your body’s trying to deal with that situation and obviously you have to deal with the stress, you have to deal with your quality of life, which is to debilitated and so on. So you enter that pain cycle. So it’s not that simple that we find that nerve and we’ll deal with that and everything will be fine. No, it’s need to be holistic approach. We need to obviously find out what was the main issue, but the treatment is of a patient not only of that issue.

Speaker 1 (00:17:39):

Talking about neuropathic pain, do you feel that people get nerve pain after hernia repair because it was somehow injured at the time of surgery or is it later on due to scar entrapment or Mesh related reasons?

Speaker 2 (00:17:55):

It can be both. When you look at the risk factors of developing chronic pain, obviously very high intensity of pain straight after surgery, that’s a huge, huge risk risk factor and should be a red flag for everyone. If somebody’s waking up from surgery and they have horrible pain that you know can’t resolve with any painkillers, the baseline painkillers, that means that something is not okay here and probably that patient should go back to theater and should be explored. And that happens like this is surgery, it happens to every S surgeon no matter how big an expert they are. We can’t see everything and we can’t predict everything and you can’t catch, you can be very careful, careful, but there are main branches of nerves but there are also small branches of nerves and we have to fix it. It is surgery, we are fixing a problem whether it’s with Mesh or with pure tissue does involve stitching it with permanent stitch so that stitch can also catch the nerve. Yes. And can cause a problem. So I want everybody to also remember that it’s not only the Mesh that’s a problem, it’s the problem of surgery and those things can happen and it can

Speaker 1 (00:19:24):

Happen without Mesh. Yeah.

Speaker 2 (00:19:27):

When there is a problem straight after surgery, severe pain, that means that something’s wrong. Obviously later on it, it might happen in a later healing process as you said with treating of scar tissue for example, I’ve noticed in laparoscopic repair we use tuckers. Obviously now we are more cautious with using tuckers, but earlier because we learned, we also learned from our mistake and we need to be honest about that. But earlier we just fixed the Mesh because that was the way to do it and we wanted that to stay in place. And I have a lot of patients that actually develop chronic neuropathic event pain when they, for example, lean over something. Yes. So they’re brushing then the factor is pushing on the nerve and they have this pain only then. And for me it’s then simple. I say yeah, I know exactly what’s going on and what I need to do here. Yes, that’s a simple one.

Speaker 1 (00:20:24):

When they’re leaning against their sink, they brush your

Speaker 2 (00:20:28):

Teeth or Yes, exactly. That’s, yeah, that’s a typical one.

Speaker 1 (00:20:31):

Or washing dishes. Yeah, that’s the one because the groin is right usually where the level of the sink or table or something like that. Yeah. Here’s another live question. It says I have postoperative pain for one and a half years. My pain management specialist says my risk of developing chronic regional pain syndrome even from revision surgery that is remote from previous surgery is prohibitive. Are there ways to predict the effectiveness of a reoperation as opposed to just further aggravating and activating nerves making the pain worse? That’s a very good question. I don’t know if we have the answer to know how to predict that, but what do you tell your patients that have nerve related symptoms and you may want to do something to that nerve.

Speaker 2 (00:21:17):

Yeah, yeah, I agree with you. I agree completely. It’s a very good question and it’s a one that will struggle to answer probably for a long time because we need more data and currently we don’t have that data. What I usually try to do is first of all find out what’s going on and then have a clear plan and discuss it with my patients and also taking into consideration the current quality of life and what they can cannot do and how big the surgery might be. If it’s a simple surgery then it’s a small damage and it should be more or less fine after the surgery, after the healing finish. But if it’s a large surgery with Mesh removal and obviously that’s a huge injury to already injured groin with complex pain syndromes and we now tend to go slightly other way, we try to desensitize the groin first with some physiotherapy, medical therapy injections.

Speaker 2 (00:22:34):

So when actually we go in with surgery, those neuron neurons that are responsible for triggering pain from the area, it’s already numb. And then that surgery itself and the injury that we cause won create even more pain. But we can’t predict it. We can only think that that’s quite reasonable and it works in our patient because we have good results with that. But I say I can’t promise anything to anyone because I don’t know what the future will bring. I have only my ideas based on my examination, based on my findings, discuss it with patients and if they’re happy with the plan I’ll go for forward with the plan. But

Speaker 1 (00:23:31):

Yeah, well yeah, I mean anytime I manipulate or cut a nerve, I numb it first. It seems to help reduce any postoperative nerve related reactions. So we looked at all the nerve transections, done all the neurectomies that I’ve done in the groin actually anywhere in the body, mostly groin. And we went to see the outcomes of it and we found in patients that had nerves cut, incidentally I wasn’t going in there planning on counting the nerve. Let’s say the nerve was stuck in scar or somehow it wasn’t their main problem or was done for some reason prophylactically, they all did okay. I didn’t have any problems with those patients post-op. However, in the patients that had chronic pain, neuropathic pain, maybe a neuroma that I went in there specifically to surgically address the nerve, we had a 4% neuroma rate after that. And that’s pretty much the same as other literature, which is I think 5% in other literature. So that’s about similar. And then these people needed more procedures and so on. So then I’m try to look at the literature to see okay, that’s surgical neurectomy, what’s the neuroma rate from ablation, right? So whether it’s chemical ablation, radiofrequency ablation, chemo ablation, cryoablation, et cetera, there’s no literature on it. What’s your experience? Do you think there’s less neuroma risk or less even complex regional pain syndrome risk with percutaneous procedures than surgically cutting a nerve? I don’t know.

Speaker 2 (00:25:21):

I think we won’t get a good answer for that as yet. What I think is what you mentioned already that the procedures that are we are currently offering are the procedures that are damaging something anyway. So neurectomy be honest, that’s basically damaging the nerve in a different place that it’s been already damaged under control. So we control how we damage that nerve and we know that if we buried that in muscles, it’s probably will be protected. Well we don’t know what will happen. It might develop neuroma, it’s we’ll make the area numb and obviously it shouldn’t trigger all those pain sensation, but it’s like with amputation, we all have phantom pain as such and some patients will need further medications. So yes, we start with less invasive procedures and follow that with more invasive procedures. So yeah, I would start with rather frequency ablation in every single time and it’s good to have different plans and it’s good to discuss it and also make it realize to our patients that we are not doing any magic tricks. It’s not like that your pain is gone. No, no. It is a process and we want to be part of that process, help you guide you, create that individual life plan and follow that and you know might be fine for two months, six months, then something might come back then where to find us, we’ll follow up, we’ll try something different.

Speaker 1 (00:27:11):

Just to clarify, the question here is asking, when you talk about desensitizing nerves before any procedure, is that with medication, physical therapy, what exactly are you offering the patients?

Speaker 2 (00:27:24):

So it’s a combination. So that’s probably the main topic that we’ll discuss today is the M D T approach. So it’s not only me, I’m currently the face of the service, but it’s like all the enthusiastic people that are working with me together with me and we create a team and when I talk about desensitization, definitely it’s physiotherapy and we have an amazing physiotherapist who is a pain physiotherapist. He also had amazing lecture in Manchester. We have our pain specialist that is dedicated to this sort of pain and also looks through the medications that those patients were taking and try to tweak it a bit and also use for example, radio frequency ablation as a part of desensitization. So there are stuff that I don’t even know and don’t understand as a surgeon. Yeah, because there are ice packs, there are different topical agents that you can use for desensitization. So it is multidisciplinary thing. So whenever we come with a plan, it’s from different people coming with different background, different knowledge and that’s the beauty of it.

Speaker 1 (00:28:45):

Okay. There’s some more questions coming in. Before we go to those questions, maybe explain to me your multidisciplinary treatment. Do people first see you and then who are the other specialties that encompass your office or your center?

Speaker 2 (00:29:02):

So again, it’s the enthusiasm and pure luck. So I had that vision in my mind that it would be good to have everybody in one room examining the patient. Ideally

Speaker 2 (00:29:18):

Then we can discuss and we can share our opinions and find out what’s wrong. It’s really, it’s almost being a Cheryl Holmes and having a team of real experts that will look and try to figure out that puzzle because it is a puzzle. Very often you have to have so many information in based on what sort of Mesh was used, what sort of suturing material like hackers, where was it done? And a lot of things will help you and guide you to find the answer. And so I was thinking who should we involve? And usually if any patients are listening to us, where are you usually referred to? Pain specialist, physiotherapist to some sort of physiotherapy or psychologists also to discuss other issues and obviously surgeons. So the core of our multidisciplinary team is surgeon who can help surgically and can actually look at the previous surgeries and gain some sort of understanding what might have being done in the groin, what might have triggered that pain. We have pain specialists that also bring in all the equipment based with pain, special specialization and anesthesia. So medication, radiofrequency ablation, injections and so on.

Speaker 2 (00:31:03):

But I always consider physiotherapies as obviously musculoskeletal is a big part of the problem quite often. So that was my thinking and I was so wrong and that’s what I learned in North Devon from our team, that there are dedicated pain physiotherapists that also discuss the PA with patients, their concerns, expectations, actually find time to discuss what’s important to them, what stress factors are involved. So it’s more like psychologist, but it’s just genuinely nice person, very compassionate person. Whenever we discussed on M D T and I gain knowledge from patient to patient and I think I’m getting there and trying to get more information out, but he will always bring something new to the table and so important, I’m like, oh yeah, I would never ask that. I will never notice that this is the problem and we need to because it’s quality of life. But patients also have expectations that they usually don’t discuss with us because we don’t ask about their expectations because we are so focused of what might go wrong or what we might change that we don’t think about it. And I think that’s the most important questions. What are your expectations from coming out of this office? How can we help you?

Speaker 1 (00:32:35):

Question on Facebook is what percentage of your work is actually surgically removing Mesh as opposed to all the other different ways of helping these patients.

Speaker 2 (00:32:48):

So we haven’t published our data yet, but hopefully we’ll publish them soon. I have my team working on that. We did present our data in Barcelona, Barcelona in HS congress and more recently in A S G B I Congress in Harrogate here in UK. That’s a great

Speaker 1 (00:33:09):

Meeting by the way. Yeah.

Speaker 2 (00:33:11):

And so actually it’s only 25% that will have surgery. And this a comes as a surprise to a lot of people. 25% will only need surgery, 35% will need further non-invasive procedure or less invasive procedure like radio frequency ablation and also medications and therapy with pain specialists. But the majority, which is I think it was 39% or something around that needed support, needed physiotherapy connected with pain medication and need basically needed that understanding that we can offer and that compassion and understanding of what might have happened. And it helps, trust me, it really helps if you’re listened to, if somebody can understand and even hearing that surgery won’t help you or might get you worse, but we can help you get where you want listening to your story that that’s helpful as well.

Speaker 1 (00:34:34):

So how do you handle the patient that comes to you and says, I want my Mesh out, I’ve been miserable since surgery two months ago and I just want my Mesh out. And then you end up switching the discussion to be, let’s make sure we’re treating dealing with this. And it’s not, the Mesh is not your problem.

Speaker 2 (00:34:57):

I’m actually horrible person. I often will argue with my patients, I want to help you. If you come to me and tell me what I need to do, I can’t do my job because if I do it, I know that you’ll come ways off and that’s against my aim, my practice and everything that I believe in. So we have that back and forth and we then start to discussing what, what’s going on, what’s the story behind that? And very often after you peel that first layer of take my Mesh out, you hear the story of seeing multiple specialists, being in horrible pain, debilitating pain, not being able to work, not being able to be active, gaining horrible stories and you just peel another layer, another layer and you come to some sort of consensus what has happened and where are we going? And especially in those complex stories, you have to deal with that story first. Yeah. Before you will deal with the groin. So I’m never saying no, I will never say no to my patient that I want won’t take your Mesh out. I just do it on my terms. I need to find out what’s wrong and what’s the best way to help you. And you came here to me and I hope you appreciate that I have my opinion and I want to share it with you and then we can discuss it. And obviously it’s your body, you’ll need to agree to what I’m offering you.

Speaker 1 (00:36:39):

What kind of patients do you think most benefit from this multidisciplinary approach? Is it for everyone or do you think there’s some personalities or problems that don’t need it?

Speaker 2 (00:36:51):

Yeah, we are. We’re trying to find out. Find out because it puts a stress into the service as well and to everybody involved. You can imagine that we can’t run that clinic every week because we have our busy surgical schedules, we have other patients and so it’s very limited access to that multidisciplinary clinic and therefore we need to triage those patients properly. So we try to find out if it’s not an easy fix because a lot of, a lot of, a lot of those problem problems are easy fix. It’s like just you need to look properly and you’ll find what, what’s wrong that could be just recurrent to our most complex patients where we want that. Solving the puzzle from different angles. We hear from the story, it’s more complex. We see that there were already multiple attempts of doing something nothing where, and basically when I need help, when I see no, I need others also to look at that patient. I need their opinion to make a good plan for that patient.

Speaker 1 (00:38:11):

Question about capsaicin, what are your thoughts? About 8% capsaicin as a way to desensitize the [inaudible]?

Speaker 2 (00:38:20):

Yeah, I know that we use it, I know that our pain specialist does use it and prescribe to some patient by some patient. And I’ll be honest, I’m a surgeon. That’s why we work in multidisciplinary team because that allows not to know everything. And I will ask that question, what do you think about that? Because I asked that question, I can answer. We don’t have good data and it’s the fact there are multiple medications out there that we are trying in combination of other medications and that they somehow work. And I know it’s horrible to be a patient and hear that we will try this or that and we’ll see how it goes. But sometimes it is like that we need to try different things. Some things will work for some patients, some things won’t. And definitely we are using that drug in our day but I can’t answer to which patients will benefit the most from it.

Speaker 1 (00:39:24):

We have access to C B D and T H C which tends to help with some inflammatory pains and a little bit of nerve pains. Is that legal in the United Kingdom to use marijuana

Speaker 2 (00:39:36):

Or to I think, yeah, I don’t know to be honest.

Speaker 1 (00:39:43):

It really

Speaker 2 (00:39:43):

Helps. I’m not sure, I won’t lie. I know that it’s definitely a popular way of treatment in Poland for example. But in United Kingdom I didn’t encounter it. I don’t think it is.

Speaker 1 (00:40:01):

Yeah, I don’t think so either. Here’s another live question. How long do you usually wait before trying triple neurectomy if this patient still has pain?

Speaker 2 (00:40:13):


Speaker 1 (00:40:14):

Lemme ask another

Speaker 2 (00:40:15):

Question. We’re believe

Speaker 1 (00:40:15):

In, do you believe in triple neurectomy or selective?

Speaker 2 (00:40:19):

So I believe in both. It’s funny, I like to find out what’s going on and then discuss the options. Okay, sure. So the protocol that we have is we wouldn’t go straight after surgery before the whole inflammatory process and healing process finishes and that that’s like three to six months and usually after three months you should start on something. But that would be usually medications because you want to aid the natural response of your body, of your immune system and because probably something is going wrong if you have pain for more than three months, but first you just aid your own. Our body’s amazing, it can deal with most of the problems. If pain persists for more than six months, that’s probably when we should assess what’s what, what’s going on and find for a different way. So I wouldn’t do neurectomies definitely before six months and before a proper assessment. So it’s not that it’s not elective surgery, somebody will send me somebody for triple negative. No, no, it’s a dedicated surgery for the patient who understand the risks and benefits and actually had a proper assessment.

Speaker 1 (00:41:44):

When people come to me and they say, I don’t want meshing because I don’t want chronic pain and I explain to them that that’s not necessarily the right answer, it depends on the patient, but if you want to take all hernia repairs put together, probably the laparoscopic approach would give you the least chance of chronic pain than in any open approach with mesh or without Mesh. But in my area of town, we’re seeing a lot more people offering not just laparoscopic but specifically robotic hernia repairs. And I feel like they’re doing it because the robotic technology is being pushed a lot and they don’t want, it’s a fear of missing out and they never really did laparoscopic before. So I’m seeing a lot more MIS robotic mass repair has gone wrong. So I can’t in good faith say go anywhere and get it done. The outcomes are not the same. So I’m getting a lot more chronic pain. Even a lot of spermatic cord injuries, et cetera from laparoscopic or technically robotic repairs. Are you seeing that as well?

Speaker 2 (00:42:58):

Only catching up and I know not probably good, it’s

Speaker 1 (00:43:01):

Not pretty. Don’t catch up too fast

Speaker 2 (00:43:04):

And it’s not easy to use the robot in or gain access to robot in Europe. Colorectal surgery, obviously urology where we know that there are clear benefits of that aid because let’s be honest, that’s an aid to your surgical knowledge into your skills. It just helps you do the things that you wouldn’t be able to do otherwise. Yeah, and we can do laparoscopic inguinal hernia repair. That’s a simple procedure in most of the cases. If you know what they are doing, like T A P P R T P, you know just need to know 10 commandments of how to create M P O. Yeah. At Felix ya colatta, you have the experts, you have EHS, A H S, you have places where you can learn proper surgery and you can do it laparoscopically. Obviously robotic does allow you to do more difficult cases. So for example, if I were to choose Mesh removal, which is in posterior posteriorly, so that was implanted laparoscopic, that’s easier to, for me to remove that with a robot because that aids me to be very, very meticulous about the surgery, about the layers see very well or it’s cellular layers that you can see. So yes for that, love it. And that’s where probably it should be used but it shouldn’t be used as an elective. I

Speaker 1 (00:44:46):

Mean they’re doing gallbladder surgery robotically and now mastectomies are being studied for robotics.

Speaker 2 (00:44:53):

Too much money. Too much money. I know,

Speaker 1 (00:44:57):

I so agree with you. Yeah, we looked at our data of laparoscopic versus robotic Mesh removals. The outcomes were exactly the same. We didn’t find any benefit. There is slightly more blood loss and vascular injury with laparoscopic than robotic, but it wasn’t statistically significant and I do prefer robotic over that. But during the pandemic I didn’t have access to the robot. The hospitals were shut down to elective care and so I was doing it laparoscopically. The patients also used to doing it robotically. I had to go backwards and do it lab. But it’s doable. I agree with you. I prefer the robot. It’s a much danger operation with a robot. A couple more live questions. You got a lot of live questions today. What is an article reviewing pain management in which David Chen was a senior author, describe pain burnout where basically a spontaneous pain improvement at about five years in a substantial number of patients. What do you think of that? Is that for real? Does the body just give up? I dunno.

Speaker 2 (00:46:08):

I have to admit that I’ve read most of the articles that David Chen written. I haven’t seen this one. So you caught me here.

Speaker 1 (00:46:18):

That’s my audience. They read everything.

Speaker 2 (00:46:21):

Yeah, you told me in the beginning that they’re probably well more better informed than I am. And that’s true here. So if I think it’s all in your brain, whatever happens to your body and how you feel your body is happening to your brain and it’s all the stimuli that are going, it’s neurotransmitters. It can modulate and we know that and it can change. And we know about persistent pain cycle, we know about pain connected to trauma and that persistent pain that is related trauma that happened in the past. So all those things can modulate then and can change. I haven’t encountered that in my practice years probably because I’m not practicing that long to have those patients. But yeah, I think probably not spontaneous probably if they’ve seen already David Chan, he definitely did something and did help them. So it might be, it’s just a longer way for some patient and after long-term treatment, the pain just subsides not a one. As I said, it’s not the one off that we do something and it’s gone. No, no, no. It is a journey. Yeah,

Speaker 1 (00:47:49):

Yeah, for sure. I mean I don’t know if you’ve ever had surgery, but I’ve had surgery before and you’re not the same. I mean it could be the perfect surgery, it’s still not the same. And then five years later you’re like, it’s better. Whatever symptoms you had the first year or two or three. Oh yeah, about five years. You’re just kind of, I don’t know if

Speaker 2 (00:48:11):

Our body is incredible and when as doctors we often say that we are here only to aid your body to help you. It’s like robotic surgeries for us. We are for your body because in the end we change something and actually you’ll heal that. That’s why we for example, we’re so strict about smoking because when you smoke you kill your own ability to heal. And that’s stupid. Good way to put it. You shouldn’t be doing that because how can I help you if you lost that ability? No, you need to have that ability so I can help you. Yeah. So if I do something, I know that you’ll heal it.

Speaker 1 (00:48:54):

That’s very true. Dr. Pawlak, does your team ever recommend spinal cord stimulation or dorsal root ganglion stimulation for refractory pain?

Speaker 2 (00:49:04):

Yeah, I’ve seen that question in Q and I was hoping that maybe we’ll skip that. It’s another one that I’ve discussed with my pain specialists. Currently we’re not offering, my understanding is it’s quite invasive as well and it’s a very, very last resort because it’s, it send stimulus all the time. So it’s it just a mechanism those your

Speaker 1 (00:49:39):

Nerve to look the other way basically.

Speaker 2 (00:49:41):

Yeah, it’s

Speaker 1 (00:49:42):

Here. Look that way.

Speaker 2 (00:49:44):

That’s what I’m, I’m not talking here from expertise on profound knowledge. I left it with of my pain specialist and they said for some really refractory patients at the end of the spectrum of we can offer yes, but most of the patients will won’t benefit from that. There are other better ways to deal with pain.

Speaker 1 (00:50:12):

Well I think that’s the right answer. In the United States, putting in nerve root stimulators and dorsal ganglion spinal stimulators, it’s quite a profitable procedure. And so it’s used sometimes some can argue overused. I’ve had patients with a hernia recurrence that went through the whole pain cycle and injections, which of course don’t work. You have a hernia and then they get pain pills and then they’re put on a trial for this nerve stimulator, which doesn’t work. We’ll put it in you anyway. I’ve pretty crazy what we see here with nerve root, any type of spinal stimulator, et cetera. Because our pain doctors, I mean unless they work with me and they understand me and I think the beauty of your pain doctors is they understand pain and symptoms related to hernia surgery and hernia repair as opposed to otherwise in the doctor, the patients that I see, they will have ileal Neuralgia probably due to a small hernia, irritating it.

Speaker 1 (00:51:23):

And they’re told you have to cut the nerve, we have to burn the nerve that we’re going to do a epidurals spinal stimulator for a little hernia. And not understanding that some small hernias can primarily present with ileal inguinal type symptoms. And you don’t just wake up one day have ilu like isolated, I inguinal Neuralgia. That doesn’t happen unless someone stabbed you there, there’s no reason for you to just have that problem. Whereas your patients that come to you and your group, those pain doctors understand surgically what happened, what can happen postoperatively and correctly, don’t overuse spinal stimulators. Yeah,

Speaker 2 (00:52:12):

Okay. Similar with I think those stimulators are more invasive than surgery. And even with surgery, and I think you mentioned that as well, sometimes we do something because we really truly believe that it’ll help and some of patients will come back and will say, no, it might be slightly better, but I still have pain and you know, kill yourself over that. And we are people as well. I had multiple sleepless night and trying to find out if maybe I should have done something differently. Maybe I just judged it incorrectly. But then with time, and again I’m going back to our bodies with time, our body deals with that because we gave that chance to the body and reorganize everything how it should be. And it’s just taking more time I think. And again, it’s maybe a research. I think the some patients had chronic pain, the longer their recovery will be.

Speaker 1 (00:53:23):

Yes. Yeah, true. Here’s another question. I have multiple full thickness periosteal sutures as part of a complex groin surgery. Dr. Pavlik, have you ever removed pubic periosteal sutures because you thought they were causing pain?

Speaker 2 (00:53:41):

Yeah, they definitely are causing pain. Yeah, we know that. And whenever we teach on our courses where to play stitches, you just don’t put them there. You don’t put them anywhere close to the pole. So on the other hand, for example, also I deal with complex a wall reconstruction and we have those complex hernias close to the bone structures, you know, don’t have sufficient overlap and actually you need to fix it to the bone. And we have in our team, dedicated trauma surgeon and trauma surgeons put all sort of things in the bone. So there was a phasix surgeons and they help us, they put stitches through the bone to fix the Mesh. And so far from the group that we did, I had only one patient that came back and said, I have complex pain here around that bone. And I don’t know if it’s from those sutures, it’s very, very likely, but his quality of life is quite good and he’s happy with the abnormal wall reconstruction and what he does now, that’s his only complaint. But actually if I compare it to how it was before, perfect. I don’t want you to touch it, I just want you to know about it, but I don’t want you to touch it. And sometimes it is like that. Sometimes we do things that we say we shouldn’t do, but we do them for the reason. So again, it’s only question of looking at that specific case, what has been done, why it has been done, that makes sense. What’s the quality of life and what we can achieve by taking those stitches out.

Speaker 1 (00:55:29):

Yeah, I’ve always wondered this because Parviz Amid was the first to say don’t put periosteal sutures it’s part of the chronic pain after open inguinal hernia pair with on the Mesh. So yeah, I teach my residents, you know, put it in the rectus insertion, not onto the bone, et cetera. However, like you mentioned for posteriorly, like supra pubic hernias, we tack it to the bone. With laparoscopics, you’re putting attackers into the bone Cooper’s ligament, but it’s really, you’re into the bone too with attackers. Orthopedic surgeons puts sutures in periosteum all the time. So why is this different? I’ve never been able to answer that question.

Speaker 2 (00:56:10):

Yeah, it’s a tricky one. It is. I think EV every case is very individual and we have to look at everything and what we can offer and quality of life. That’s that. That’s the end game. If we can improve it, yes, let’s do something. Sure. If the quality of life is okay, then we should go with that. And that’s a funny one because even every person, every nation will distinguish a different aspects of quality of life that are important. And we discussed that in numerous conferences that in some cultures there is less chronic pain than in some

Speaker 1 (00:56:54):

Oh yes, for

Speaker 2 (00:56:55):

Sure. Because the quality of life and what is the quality of life and how it’s being perceived.

Speaker 1 (00:57:03):

Listen, India and China are the two largest countries in the world in terms of population and they have tons of hernia repairs, not as much Mesh based, but numbers wise, a lot of Mesh based used. And there are a handful of patients that I get from India, really none from China and yet in the United States, Canada, UK, Australia, the English speaking countries, it’s a huge problem. I haven’t figured that one out either.

Speaker 2 (00:57:35):

Yeah, it’s also a huge, huge problem in the United Kingdom and it’s real problem. I see those patients and I know that it is a problem and I didn’t figure it out that neither, I just discussed it. I remember the funny anecdote on that, I think it was Jorge has, I don’t want to put words in his mouth, but he said my patients are more focused on Fiesta and at spending their life to the full drinking wine and then just having fun. They don’t think about chronic discomfort, pain and so on. Maybe it’s true, maybe it is a process that develops, I

Speaker 1 (00:58:20):

Don’t know, maybe they’re selling different meshes to the English speaking countries. Yeah, we dunno. So are you part of the N H S system or it’s a different system and how do people find you?

Speaker 2 (00:58:34):

So I’m a part of N H S system. I’m moving jobs. So actually very recently there was a number of publications, if there are any patients from United Kingdom. You probably know that there was a, a lot of, a lot of documentaries and articles about Mesh, about Mesh related problems. And especially some of those were in Scotland where I did my fellowship. So we are currently establishing a dedicated optimal wall reconstruction and hernia center in Scotland where I’ll move in September and yeah, it’ll N H S based. So if anyone wishes to contact me or see me, I’ll be happy to see them. Obviously it will take time now to establish the service there. So you know, need to be patient if you need to see someone now. Definitely the team that I was leading in north Devon in southwest of United Kingdom is an excellent team and you’ll find some help, some good help there. And I’m sad to leave, but we developed that service there. It’s working perfectly. So in that sense I’m very proud of it and I’m leaving it in very good hands of my colleagues and I’m moving on and trying to establish something similar in Scotland.

Speaker 1 (01:00:07):

That’s a really great plan because Scotland has been on the forefront of addressing patient related problems with Mesh, probably more than any other state I would say. I mean more than the United States

Speaker 2 (01:00:23):


Speaker 1 (01:00:24):


Speaker 2 (01:00:26):

In a sense. I was obviously applied for the job, interviewed and have the abilities to develop that, but definitely they were searching for someone who could develop that there. And I’m happy that I got so many recommendations and so many good surgeons and people are believing in that and that’s necessary and I’m always happy to help.

Speaker 1 (01:00:54):

Yeah, that’s really fun. Fantastic. It’s

Speaker 2 (01:00:55):

Called in Glasgow where you’ll find me starting September.

Speaker 1 (01:01:01):

That’s fantastic. And actually one of the current viewers that’s been asking some of the questions is in Scotland. So you may be getting a new patient the minute you open your doors there.

Speaker 2 (01:01:13):


Speaker 1 (01:01:16):

I’m just here to help.

Speaker 2 (01:01:19):

Yeah, me too, me too. And I love what I’m doing and I live for hernia surgery, for optimal wall reconstruction and actually developing knowledge and educating because I got fantastic education and I love to share it. And again, another a advertisement if I may, e h s. If you’re a patient looking for any information in Europe, it’s EHS. You’re been here in a society that you need to look into. If you’re a doctor looking for some knowledge, good courses, learn how to do a proper surgery and so on. Again, European Hair Society.

Speaker 1 (01:02:02):

Perfect. Sounds amazing. And on that note, we are going to end our session. That was a full hour. Thank you. I really appreciate that.

Speaker 2 (01:02:09):

Thank you, Shirin, it was a pleasure.

Speaker 1 (01:02:12):

Thank you. And thank you to everyone who came in live and a prospective thank you to those of you that are going to be watching this and sharing it and learning from it. And hopefully if you have any needs, this has helped you get better information and get access to the specialist that you need. Thank you everyone for joining me on another great episode of Hernia Talk Live. I will see you again next week with another great guest and I want to thank you again. You can go sleep now. Thank you.

Speaker 3 (01:02:43):

Thank you. Bye-bye.

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