Episode 143: Importance of Technique in Hernia Repair | Hernia Talk Live Q&A

You can listen to this episode by clicking here.

Speaker 1 (00:10):

Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live. I’m your host, Dr. Shirin Towfigh hernia and laparoscopic surgery specialist. You all are joining me via YouTube, I’m sorry, via Facebook as a Facebook Live. Some of you are here via Zoom. Thank you for coming. So today I plan to answer all your questions and try and focus on specifically hernia surgery techniques and how important it is to have a surgeon who does a good hernia surgery technique to maximize your outcome. The reason why I picked this topic is because this past week and a half, I would say almost two weeks, I’ve had multiple patients who came to me who had, I don’t want to say completely the wrong operation, but it’s an operation I would not have done. And the reason why that surgeon did that technique, I’m not sure of why, but it was the impetus for their complication.


And if you talk to other experts, they would agree with me that probably is not the best choice of surgery. And so I thought we should discuss this because we talk about seeing an expert Mesh versus no Mesh. How do you deal with complications and so on. And we often don’t understand that even if someone is offering quote, let’s say laparoscopic surgery, there’s different techniques in doing those operations. And it’s important that the surgeon do that operation with a good technique because even though if you look at all the literature, it’ll say, oh, shoulder ice is very safe and has good outcomes or laparoscopic surgery is safe and has great outcomes.


The technique is important. So two surgeons can be doing a quote shoulder ice repair or a quote, laparoscopic repair with completely different outcomes because their technique is very different. And that’s what I’ve noticed in the past couple weeks I thought would be a good topic. So I’m here for you. Send me all your questions. Many of you have submitted questions online, so I have those post-its and we’ll go through those as well. But I just want to get, share some stories. So past couple weeks, we’ve had some patients who had laparoscopic repair and now they’re miserable. And many of you who know me online know that I’m a fan of laparoscopic surgery in general because it is less invasive. In other words, less cutting and sewing. It’s actually a bigger operation on the inside for inguinal hernias, but it’s not as much cutting and sewing.


And so the recovery is easier, there’s less incision to heal from. Laparoscopic surgery is also great for the abdominal wall. Again, lower risk of infection and especially with robotic technique, there’s a lot that you can do similar to open without having to open. And so the morbidity and the complications related to laparoscopic surgery are definitely there, but with a good technique, the outcomes are really, really good. So obviously I don’t recommend the same operation for everyone, but for the average patient, laparoscopic surgery is kind of the preferred technique. And I use the term laparoscopic and robotic a little bit interchangeably because often similar in a technique. However, I’ve had three patients in the past week, week and a half, and hello from Houston, thank you, the past week, week and a half that have had a laparoscopic hernia repair groin. Her, the patients had in hernias a little bulge, little pain, and they underwent laparoscopic repair and sounds like the page were super excited because their surgeon offers laparoscopic surgery.


Well, the technique use is what’s called a keyhole technique and it’s highly, highly not recommended. There are different techniques for laparoscopic angle hernia repairs, specifically the keyhole technique is not recommended. It is a technique which replicates the open surgery technique where the Mesh has a keyhole and it’s basically slit. It’s like slit technique is another term for it and is wrapped around the spermatic cord in men or sometimes the round ligament in women, and that’s how the hole is patched. So most of us that do laparoscopic or robotic inguinal hernia repairs, we place the Mesh against the hole as opposed to wrapping the opening of the hole with the Mesh, which implies wrapping the Mesh around the spermatic cord or the round ligament. Why is that different or not a good technique? Well, primarily it’s because it’s kind of like a Goldilocks issue, so it can be made too tight or it can be made too loose.


If it’s wrapped around the hole too loose, then the hole is exposed and then you can get a hernia again, if it’s wrapped around too tight, then you can actually impinge on, erode into into or otherwise, kind of like strangulate the spermatic cord and its contents. What are the contents, blood vessels to and from the testicle, the sperm, the sperm coming from the testicle and the nerves associated with it. So if you obstruct the blood flow, then you can have testicular pain and swelling and bulging. If you impinge the nerves, you can get testicular pain and if you obstruct the spermatic kind of flow, you can have testicular pain and pain with orgasms and pain with ejaculation. So none of those are good options. And how does the surgeon know if it’s too tight or too loose? You can’t make it too tight initially because all these meshes shrink.


So the lightest weight meshes shrink about 10%. The heavier weight meshes shrink about 25%. So how the surgeons know exactly how tight or loose to make it initially so that in six weeks when it’s shrunken, it’ll be perfect, hard to do. So that’s the reason why we don’t like the keyhole technique. Another reason also is the muscle that protects a lot of these things from happening doesn’t exist in the laparoscopic space. It does with the open space, not the laparoscopic space. So it’s completely bare to the Mesh and something that is not a good idea. So I’ve, like I said, three patients in the past week, week and a half that had the keyhole technique and now they have testicular pain, they have obstruction of their testicular blood flow, they have groin pain, very uncomfortable for them sitting. Some of them can’t work anymore. It’s just not cool.


And then I’m thinking, okay, well I know that you’re not supposed to do the slit technique anymore, and yet there are surgeons in my town who do it. There are surgeons outside this country who do it, why somebody taught them or they chose to learn it. They’re more comfortable with that technique. Actually easier, you have to do less dissection and the use of that technique because an open surgery technique. But here’s a problem. You as a patient, how do you know if your surgeon’s going to do the keyhole technique or the slit technique as opposed to the typical laparoscopic technique, which is for inguinal hernias, which is an Onlay. So either laparoscopic or robotic. It’s an Onlay technique or underlay technique. So you don’t, and it’s really hard to expect and put the onus on patients to ask those questions. How do you know what questions to ask?


Even I, let’s say I needed an inguinal hernia. Presumably I’ll find a surgeon whose technique I know, but I’m just going to, I might most likely will assume that surgeon is not going to do the slit technique because in my world as a hernia expert, we know not to do that. But you just can’t assume, and I’m hoping to discuss all of this with you all to come up with some type of consensus as to how you as a patient can best protect yourself from bad or wrong technique and get the best rep repair from your surgeon. So here’s a couple things that I recommend and we’ve done a whole episode on what questions to ask your surgeon during your consultation. We did another episode talking about how to find the right surgeon for you and who, who’s like the right, what’s an expert, how do you know your surgeon is an expert? But my thought is this, first of all, you should always do your research. So nothing is just a hernia, even a little belly button hernia. There’s tons of ways of fixing those hernias. So you should kind of read up on it. Go to the forums patient forum hernia talk.com is a excellent one. We talk a lot about everything on that forum.


And what’s really cool about hernia talk.com, which is a website for my podcast here is first of all, it’s free. It’s a free discretion forum, but also we have really smart members who are constantly perusing the web and YouTube and share videos and agendas from surgical meetings and discuss what other surgeons have said and so on. Very openly. I learned a lot from myself to be honest. So do some research, then I would see more than one surgeon, even if you think it is an easy thing. Every time I’ve needed surgery, I’ve definitely seen more than one surgeon, even though I probably know who to go to, I still think it’s important to get another person’s perspective. Everyone’s got a different perspective. So let’s say you see multiple surgeons. How do you know that their technique is good? First of all? I think personally that in general, if a surgeon is a bit obsessive compulsive or well kind of put together, most likely that’s also represented in their surgical technique.


There are surgeons that I know of, they’re always disheveled, their hair’s always messed up. Coat jackets are either dirty or sideways. They tend not to be the best surgeons, I would have to say. I can’t say that for everyone, but usually the surgeons that are well put together, clean nails, clean office, well run office, and they’re asked a lot of questions of you are actually interested to know more about your symptoms and more about your lifestyle and support system and all these other things that are important as part of surgical recovery. Those tend to be better surgeons too because they understand that all those little details will eventually affect the outcome from their surgery. So those are little things that I pick up on. If a surgeon’s dismissive or doesn’t want to answer your questions comes in and kind of talks at you, not with you.


Those are red flags where at least for me personally, I would not want to go to a surgeon who is like that because I feel that they need to kind of treat me like I’m the most important thing at that point and not be distracted or to kind of discount, oh, it’s just a hernia- discount my needs. So that’s one thing where those are little clues, right? Secondly, I would say that you should have a series of questions and surgical technique is one of them. It’s hard to ask, okay, so what Mesh are you going to put in and what technique are you use? What suture you going to use? At some point it starts to become a little bit too intrusive with the surgeon and your kind of prying into their specialty and not trusting them, but you know, who cares? I say who cares?


I say, if you can ask these questions politely, respectfully show that you’re anxious about your outcome and you’ve read that there’s a keyhole technique and the regular technique, what do they think about those two? For example, if they’re like, oh yeah, use a keyhole technique every time I would leave the office. But if they say, yeah, a good question, no, we think the online technique is superior and that’s the technique that I use or something like that, or I use absorbable sutures or attacks or permanent sutures or attacks, whatever the situation may be, then those are good. If you have a surgeon that sits down with you and actually tries to answer as many questions of yours as they can, that’s usually a good sign. And then the question is, how active is this surgeon in the surgical community? Because what I notice is most of these surgeons that I have seen do these poor techniques.


So I just gave you an example of one of poor technique, which is the keyhole for inguinal hernias. Other poor techniques would be like they use way too many tacks. I took out, there’s a patient I just operate on, I took out two dozen tacks from this patient, two dozen, and he still had another two dozen tacks left them completely inappropriate use of tacks. You don’t need that many tacks for an abdominal wall. Hernia and tacks are these kind of screwed in fixation devices that we use instead of suturing. It works very well if used sparingly, but to completely shoot the abdominal wall with all these tacks can cause pain. So I had to go in there individually, remove them, and he had several other tacks kind of floating in the belly. That’s just sloppy. So those kind of surgeons, I always want to know who the surgeon is, read the operative report and so on.


But they’re usually surgeons that are not that interested in hernias. They don’t come to the meetings. I go to all the meetings so I know who’s at the meeting and if I don’t see you at the meeting, to me that means you don’t really have an interest in hernias. They may not be reading. We have tons of texts, we textbooks and journals and newspapers that talk about hernias all the time and consensus papers and quote expert papers and so on. All of these are readily available to all surgeons. You just have to have the interest to read it. And yeah, surgeons that I see that these patients have complications from tend to not be the ones I assume that are reading. If they were reading, they would know not to do keyhole. If they were reading, they would know that more than a certain amount of text is inappropriate and can cause pain.


And then lastly, how active are they to publish? So when people publish, I feel that they’re inquisitive. Why do people publish? They look at their data, they have a question, a research question that they want answered, and it shows inquisitiveness. You have a query you’re interested to know more, and people who publish tend to have that kind of personality where they want to learn more, do more, do better, and so on. Also, one detail that most people don’t understand about publishing is you can’t publish without doing research on other people’s publishings. In other words, let’s say I do a paper on Mesh removal, right? I did a paper on laparoscopic versus robotic Mesh removal. It’s, it’s a pretty good paper. I can’t publish that paper without including other literature that has discussed chronic pain, mass removal, laparoscopic surgery, robotic surgery, et cetera. Just the act of me going through the process of finding literature that can support or contradict my findings and including that in my introduction and discussion of my research, that alone makes me a better surgeon because I now have increased my knowledge, I’ve read more, I’ve done more, and I’ve accessed journals that I may not have access before.


So people who publish also tend to be more knowledgeable, and when they’re more knowledgeable, hopefully that translates to being a better surgeon because they won’t do certain things. So here’s a great question by one of the audience, which is a plug and patch method comment, great example of a horrible technique. We used to think this was a good technique. a lot of times techniques come and people get all excited about it. The plugin patch was one of them. It was a way to, the Lichtenstein hernia repair was already considered the gold standard. It involved a scar. It involved a lot of sewing and the plug and patch kit that came originally from Bard, but then also from other companies including Ethibond, and I think I’m not mistaken Atrium as competitors. The whole thing was you don’t need to cut and sew as much. You don’t need to have as big of an incision, just focally focus on the area and just plug the hole and you need very few stitch stitches.


And so the incision smaller and therefore the risk of infection is smaller and the in the surgery involves less cutting and sewing so that it should have less pain afterwards. And it actually worked really well. I got trained in doing the plug and patch my first year out of residency and I started doing it for several years. I don’t do it anymore because I learned and other experts learned that it doesn’t really make a better repair, but it does add to the risks for the surgery because you’re putting in a big globule of Mesh in the patient’s groin. In thin people, in thin people, they can feel that ball of Mesh. We call it meshoma. In larger hernias, the Mesh can flip around In athletes, they can be hindered by their range of motion because of the plug if it’s not sutured incorrectly. Again, technique.


So some surgeons we’re putting in only two sutures instead of three other surgeons were putting in absorbable suture instead of permanent suture. These little changes to the original way of how it was designed came up with poor outcomes. Some surgeons were using small and medium sized hernias for these meshes, larger hernias. Again, the correct technique is to use large for an indirect for most indirects and extra large for most direct hernias, you have to match the size of the plug with it. And then the original way where it was designed was to literally plug the hole, but then it was later revised to kind of be opened up a little bit. So the backside of the Mesh is not poking into your bladder, rather it’s kind of flattened out and gives a little bit of an extra Mesh repair. And the problem with it was they sold this Mesh, it was candy and there wasn’t enough focus on surgeons correctly placing this product.


And so to this day, most people use the plugin patch incorrectly. So they use absorbable suture, they use the wrong size of the plug, they put two little sutures, two instead of three, for example. They don’t open up the posterior patch and they use it in the wrong size patient and therefore they had a lot of complications. So now you have people that were totally okay, they had a little hernia, they got this plug in them, and it’s like their whole world has changed because the plug is now eroding into their bladder, pushing into their psoas muscles so they can’t like bend or sit. It’s migrated and so on. So it’s been one of the worst designs when it was used across the masses. You got to have a Mesh design that every type of surgeon in every type of country with all types of skills can use without causing harm. And this was not one of them. This is one of those meshes where unless you use it as an expert, the chances of doing it incorrectly were high and therefore it’s a bad Mesh design.


So none of us really use them that Mesh anymore because it’s unnecessary. The Lichtenstein repair open is a perfectly good open repair and there’s no need to use that. But again, technique is important. I put in tons of plug and patches early on. I don’t recall having, I had one patient who had a problem with it and he was morbidly obese. The hernia was really big and I probably never should have used that plug on him to begin with, but most patients did very well. And the surgeon who was kind of the leader in it from Rush University, really good surgeon, Dr. Milliken, he had really great outcomes. The patients did really well. But then you had this Mesh sold everywhere with very little education, understanding about the phasix of how this Mesh works. And then now all we do is take out the plugs because it’s considered just unnecessary Mesh and that Mesh is still being sold.


In fact, I think it’s dropped in the amount of being sold, but at one point it was the highest volume Mesh being sold by any company in the world, and that may have been its downfall because of the way that it’s designed is puts the patient at risk of using the wrong technique and therefore having a poor outcome. So a lot of these meshes that come out, the technique of putting it in is important and because of the way that it’s designed, if you don’t do it correctly, you can actually cause harm. And that’s usually a bad Mesh design. The P H SS or pearling hernia system is another type. It’s a bilayer or not bilayer, it’s two layered Mesh, which when placed by the original surgeon, Dr. Gilbert who designed it, art Gilbert or other experts who do it really well, it worked really well.


But then you had surgeons using it thinking they just kind of shove that Mesh in there and then the Mesh would ball up like a plug. That was not the intention of the Mesh. And patients would have similar pain problems as did people who had plugs in. So technique is very, very important. And I must say it’s not just Mesh related technique, it’s also tissue related technique. So shoulder dice repairs, perfect example. a lot of surgeons don’t offer the Shouldice because the technique is actually quite complicated. You have to understand your anatomy very well, and if you don’t, you can have a higher risk of chronic pain, hernia recurrence and damage to the nerves. So with tissue repairs, you have to know what you’re doing. There’s a marcy repair for example. It’s a very simple tissue repair used on children and small hernias on women.


It’s just simply closing the hole. There are other surgeons that have come up with different techniques. They’re constantly helping improve it, but unless you’re showing me your data and saying, here’s how the technique I did from January of this year to the January of next year, and then I saw I was getting recurrences and therefore I improved it and made it, and now for another year I did this other technique and here are my results. Unless you do something like that, it’s not cool to just randomly make up a technique on your own and hope that it’ll work because you think it’s going to work. You need to as a surgeon, I would say as a surgeon, you need to do to be very upfront, and let me tell you, if you’re experimenting with different techniques, at some point your patient kind of needs to know that the technique you’re using is not the real Shouldice or the real marcy or the real Bassini or whatever the technique is, but a modified version of it.


Because the studies that are out there that say, let’s say Shouldice is a great technique, it’s because everyone who’s in that study has performed that technique perfectly, exactly how Dr. Shouldice intended exactly how the technique has been perfected and they’re not messing around by changing the type of suture or doing two layers instead of four layers and so on. I’ve, I’ve seen so many operative reports. I mean, it kind of pisses me off. I see so many operative reports of by surgeons who tell this patient, oh, I did a shoulder dice repair on you, and you’re reading the report and either the surgeon has no idea what the anatomy is or they have no idea what a shoulder repair is because it’s completely wrong in the way that they’re documenting what they did. And then the patient has either chronic pain or hernia recurrence, nerve injury or something in that realm, and that’s just not cool.


So when you talk, let’s say you want a tissue repair or you’ve been told you should get a tissue repair and you go to a surgeon, well, it’s important that they explain to you are you doing what kind of technique they plan to use? It’s okay to ask, is it permanent suture or not, or is this the original technique as described? How do you, oh no, we modify it. Oh, how do you modify it? Again, be very respectful with your surgeon, but at some point you don’t want to be the one telling the surgeon what to do. That’s I think, inappropriate because you need to find a surgeon that you trust and at the end of the day know that they’re doing going to do a good job, but prior to that, during a consultation, at least get some feedback from them to prove to you how they’re going to do the best job.


Does that make sense? I hope that makes sense. It’s a fine line. It’s a fine line. A patient of mine, her name, she wrote a book called, what’s the name of the book? The it’s a patient help book. I posted a before. It’s really a great book book, which it tells you the take charge patient. That’s the name of the book, the Take Charge patient. It’s a great book. I give it as gifts sometimes during Christmas, but it takes you as a patient through all the different steps on how you can access the right care without being that patient that no one wants to take care of because you’re just kind of asking questions for without a purpose and being really disrespectful about it. So it is a little bit of a fine line, but the right surgeon would be the one that is okay being questioned respectfully and is there to make sure that you feel confident in their practice and technique because at the end of the day, on the day of surgery, you want to show up, all your questions are answered, complete confidence in the surgeon, know that they’ll do the right thing and then have an excellent surgical outcome.


And that’s the goal. But you got to put the time into it before surgery to get all those questions answered.


Let’s see. I’ll give you another example of what happened. The patient, I feel so bad. These stories are horrible because I get all these stories sent to me and I’m trying to help patients. Some of them I can’t help anymore because they’re kind of already had the damage. But there’s so many patients out there where I’m kind of like when I read their story, it’s kind of forensic to me. In other words, I’m trying to figure out what I would’ve done differently or how I would’ve interpreted this pain differently. And there’s this one patient that had completely wrong diagnosis and they had a hernia pair with this keyhole technique, right? Then they had a completely wrong diagnosis for why they have the pain. But the doctor who was treating him was so confident in saying, oh, this is your problem, but was completely wrong and took this patient down this completely wrong pathway, got the wrong procedure, the wrong procedures to help with his pain, pain.


And now it is like has had multiple spinal cord stimulators. I mean it, it’s just ridiculous how much misinformation and mistreatment he’s had since that one failure by his surgeon. And I’ll preface this and I, let me tell you, I’ve had my own complications, so I’m not claiming that experts or others don’t have complications. However, once you do have a complication, it’s almost like this rolling ball of you’re at risk for more complications or more delaying treatment and more procedures necessary to kind of get to the end of it. So this poor patient had keyhole Mesh technique, which is a no-no laparoscopically, no one can figure out why he had the pains that he did. He’s all, he’s now being told he is got nerve pain, which he doesn’t really have because you can’t even have ileal nerve pain after laparoscopic inguinal hernia repair because the nerve is not there to injure. Anyway, it’s, it’s complicated, but he is being told all these different things that eventually I’ve seen patients that were told, oh, you need your testicle chopped off. Yeah, no, you do not. You almost never, almost never. 99 point something percentage of patients will never need their testicle removed as a complication of hernia period. If they tell you that, you got to get a second, third opinion. Okay, sorry. Let’s move on.


Okay, here’s a question from, all right, it says I had left, Ooh, it’s long. I had left anal hernia surgery with Mesh and a plug in Minnesota in 2015. Yeah, there we go. The plug issue, the minute I hear plug, I think meshoma where you can’t sit or kind of erosion into adjacent structures. When we went to Arizona for the winter, six months later I saw a surgeon in Arizona. He said he was going to exploratory surgery to see what was causing my pain. Wrong answer. Exploratory surgery is almost never necessary. The combination of history, physical exam and imaging should be able to answer why you have the problem in the majority of patients, I’m going to say more than 90% of the patients, you do not need to go in there and just take a look or see what’s what’s going on. That’s completely wrong.


It means that surgeon does not understand what’s going on. Okay, sorry, let’s move on. He said he was going do exploratory surgery to see what was causing my pain. He removed the Mesh and plug, but replaced it with the new Mesh plug. What? Wait a minute, are you serious? What they took out the Mesh plug and patch and then put another one back in that makes absolutely no sense, no sense at all. It’s like, oh, you have pain in your foot. Lemme take a, I’m just going to look in your shoes, see what’s wrong. Oh, look at there’s a pebble in your shoe. I’m going to take out the pebble and I’m going to put another new pebble inside that makes absolutely no sense. I’m sorry. This is stuff that pisses me off. Okay, he removed the Mesh plug but replaced it with a new Mesh plug.


I’m still in horrible pain. Of course you are because you had the wrong operation. Plus I have three more hernias and I refused surgery because they used Mesh. Mesh is not your problem. It’s the plug and the technique. It’s going back to technique. Don’t blame the Mesh quality itself. The actual fact that there is Mesh is not the problem you probably do need Mesh. It’s the technique and the decision making. Okay? I was going to come see you two years ago when we wintered in Arizona, but some druggies burned our house to the ground in the summer, so we didn’t return to Arizona. I wish you were here in Minnesota. I wish you were here in California because I can help you for sure. The plug and patch operations are one of the most satisfying Mesh removal operations because it’s literally removing a pebble from the shoe and the patient’s like, oh, so much lighter, better.


They don’t have whatever it is from the Mesh plug. Okay, next patient. The question, I went into surgery exploratory and woke up with six hernias repaired with Mesh. Never was asked if this was okay. Okay. I don’t know why people are getting all these exploratory surgeries. I assume you’re being consented to have a certain operation. Maybe you have a hernia, we’re going to fix it. I don’t understand this exploratory. I went to surgery looking for adhesions. Oh, okay. Just had my new CAT scan and I have more hernias. I’m not sure if I will use a new surgeon. That makes no sense. So you had exploratory surgery and hernias repaired, although they were looking for adhesions, just had my new CAT scan and I have more hernias. I’m not sure if I will use the new surgery. Yeah, get another opinion please. Please. And remember, I offer online consultations, so even if you can’t like travel for surgery, sometimes it’s good to get a second opinion even virtually.


So send me your stuff. I’ll review it and give you kind of my advice about it. And sometimes you can take that and move on to get the best kind of plan of care from by someone near you, but at least there’s some guidance. Okay, next patient. I had open surgery without Mesh for my left inguinal hernia four months ago. Now I have another inguinal hernia on my right side. Is it okay to have laparoscopic with Mesh on the right side? Yes. Is there any chance, chance that laparoscopic surgery on the right side will increase the possibility of recurrence on the left side? No. Okay, so that was easy.


Oh, in response to that plug out plugin situation, wow, my story is similar with the first part. I had plug and patch and pain from day one back in 2014 with chronic pain over six months. The surgeon then acted like I was crazy and was not in pain. Unbelievable. That’s a red flag by the way. If your surgeon is blaming you for your pain, move on. This is like your girlfriend or B boyfriend saying I’m just not that into you. Don’t try and force ’em to date you or be into you. They’re not. Cut it off and move on. The surgeon that acted like I was crazy and was not in pain. Now over nine years, I am back in chronic pain and with bad nerve pain in the groin testicle and lower abdomen, I’ll bet you have a hernia recurrence. I think that’s what’s going on from you for you.


Oh, did you have the Mesh removed? If you had the Mesh removed, you probably had chronic pain, recurrent her, but if your pain went away and came back, that’s a hernia recurrence. These are easily treatable, by the way, guys. You don’t need to suffer. Yeah, sorry. It’s complicated. I never knew I had hernias in the past. Yeah, this whole idea of exploratory surgery really kind of pisses me off too. I’m kind of pissed off today. Sorry guys. It’s kind of the reason why I chose this topic was because patient after patient came to me with this damn keyhole technique, which would never be used, and I would just bombarded with people wondering why they had problems with their laparoscopic hernia surgery. And there are people online, many of them are on hernia talk.com, which are poo-pooing laparoscopic surgery, not understanding that there’s different techniques, right?


There’s the keyhole, the non keyhole, there’s the right technique and how you handle the meshes and so on. So just because an expert says the laparoscopic repair is the best, doesn’t mean that every laparoscopic hernia repair out there is perfectly and that or that you as a individual would do best with laparoscopic surgery. So that’s kind of a distinction that I hope people understand because there’s a lot of negativity out there and they’re saying, oh, laparoscopic surgery is horrible or Mesh is horrible. Never have that. It’s not true. Just each individual patient has their own. I’ll give you an example. It’s like saying cars are horrible because people die in car crashes and look all the gas guzzling and so on. But you know what? Some people cars allow them to go to work every day, transport them here and there, or they make money off of their car.


Other people maybe shouldn’t, are like 90 years old and shouldn’t be driving a car because it’s dangerous. So anyway, okay, so the person who had the Mesh plug and patch is afraid to move forward or anything you should not be afraid of. There’s a handful of us that treat people like you for a living, and it’s very good to know, at least know your options. What is my diagnosis? Is it the Mesh? Is it the plug? Is it the technique? Is it, do I just have a hernia recurrence? And then at least you’ll know and then we can discuss the pros and cons of what will make you better. Okay, one more question. I have a confirmed early groin, indirect hernia with fat in the sac and was recommended watchful waiting. My question is this, is it okay to delay the surgery with the fat?


Yes. And have the moderate discomfort? Isn’t the fat stuck in the sac making the surgery even harder when I come to have it? No, it’s totally okay to sit around with a hernia. That’s what we call minimally symptomatic, that has fat content in it. Totally. Okay. The fact that there’s fat in it or not or does not change how difficult the hernia recur, the hernia repair will be, and having a hernia for one day or one year or 10 years doesn’t necessarily make the hernia repair any more difficult. So don’t worry about that, which is why we have what’s called watchful waiting and they watch patients from zero to 10 years and the patients that were 10 years out and needed surgery did just fine. So there’s no need to worry. What I hope is the more you educate yourself and ask these questions, whether it’s here on Hernia, Talk, Live or it’s on hernia talk.com or it’s with your surgeon that education is power, information is power, knowledge is power, and therefore this fear goes away.


I see so many people online that are fearful and it’s their fear that prevents them from getting the care they need and they have a horrible quality of life. And then some of them end up having surgery, let’s say with me, and then they’re like, oh, that was it. Oh, well, I should have done this so much earlier. Yes, you should have done it much earlier. I can’t force you to do much earlier. It’s your choice, your life. But at some point it’s important to just educate yourself, get all your questions answered, and then do whatever it takes to improve your quality of life. I’m a big advocate of that. I wanted to also talk about surgical technique as it relates to the how busy the surgeon is. So some people think that a busy surgeon is a good surgeon and a not so busy surgeon is a not good surgeon, not necessarily true.


So up to a point, you want to have your surgeon to have a lot of experience doing things, but once they’ve done, let’s say a thousand hernias or more, doing 2000 or 5,000 is not necessarily going to make them that much better of a surgeon. However, the quality of the surgery now is very important. So you want them to have that experience under their belt. 500 to a thousand hernias will be excellent if you can get, find someone with that much experience. But there’s a balance between quantity and quality. There are some surgeons that pride themselves in doing thousands of hernia repairs and they’re just horrible surgeons. They’re just don’t care. It’s another hernia to them. They don’t sit down with the patient. Everyone’s treated exactly the same. It’s like a factory. And they’ve do done it the same way their entire life. They’ve made no improvement.


Many of them are open technique surgeons. They only do one type of hernia repair and the patients go see them. They only offer them that one type of hernia repair. And so that may not necessarily be the best for you. So my suggestion is this, at least see two surgeons and figure out what technique will best be tailored for your needs. And then if you want to stay local or so within your network, let’s say you have insurance problems or you want to go to a higher volume surgeon, then know that whatever that surgeon’s offering you was the right decision because you talked to other surgeons about it. I hope that makes sense. Let’s see. More questions. Thanks everyone. Okay, I’m seeing a surgeon to have surgery in September. She looked at the CAT scan and did not see a hernia recurrence. I’m just seeing her again now because I have right pain and burning.


She reviewed the CAT scan again, examined and said it could be possibly a small hernia on the right side. My issue is very complex and it’s a long story. I even have been to a pain clinic that was recommended by my first surgeon. I found out she’s a general surgeon but specializes in breast surgery. I never had a block in my area of my first surgery and now pain is all the way down my leg and now limping at times. Okay? Limping is almost never a hernia related problem. And pain below the knee is almost never a hernia related problem. So if you have new onset pain or problems that go below your knee or you’re limping, you have to look at things like your back or your hip. Limping is often because of the hip. Oh, the first surgery was on the left side in 2014 with the plugin patch. So in general, if you’ve had a hernia repair and you had problems but it got better and then you had a period of time where you were without problems, and then now you have problems. Again, usually when there’s a period of time when there’s fine and then you have pain, that’s usually a hernia recurrence until proven otherwise.


Oh, here it is. New patient. Hi, I am just out of the hospital. Hi. Just out of hospital. And the fear, the absolute fear you’re talking about is very real to me. I have abdominal wall, polypropylene, Mesh, and now appendix problems, and the surgeon surgeons are not willing to operate because of the Mesh. Okay, that’s bss. There’s tons of ways to fix to get rid of an appendix in someone who’s had Mesh because it’s not like a hundred percent of your abdominal wall has Mesh in it, number one. And number two, surgeons have to deal with issues. So if you now hold on, if you can get better with just antibiotics, that would be ideal. Get and antibiotics are considered a good treatment for most people with appendicitis. So if you have appendicitis and it’s an infection and you can get antibiotics and Foregut surgery because you have Mesh in your nearby, that’s fine. However, you can have Mesh in your abdominal wall and still have surgery including appendiceal surgery. So I don’t know why your surgeons are so scared. I would be scared if they’re scared. See that it’s never good when your surgeon is scared because then you should try and find a surgeon that’s not scared.


Limping happened from the nerve block. Nerve block limping relate to nerve block only lasts about six hours at the most. So if you have permanent limping, then that’s not from the nerve block. Okay, let’s see. We talked about quantity versus quality. So last thing I want to share is another story. I had a patient who’s very particular and very knowledgeable about what they need and the problem, the surgeon who addressed the patient didn’t come prepared. So the patient did their job, they did all their research, they sat down and had all their questions answered by the surgeon, but the surgeon showed up that morning, didn’t look at their notes, didn’t clarify all the little things that were discussed during that he would or she would do during the surgery. And then that surgeon didn’t do everything that was planned. That is not ideal. It’s usually not a problem.


Most people don’t have complicated situations. But for me, I try and write all these things down because if I see you on day one and your surgery’s three months from now, I’m not going to remember all those little details that we discussed, especially if it’s a complicated situation. So I write those down because then three months from now when I see you for surgery, I need to look at my notes and kind of review the little details that we found. And that is why I say an obsessive compulsive doctor surgeon is actually good. I’m a little O C d. I think about things a lot and I try and perfect things. I’m not so bad where I’m turning lights on and off and not stepping on cracks and stuff and not like that. But I am very detail oriented and I feel that you really need, I think that’s a good thing for a surgeon.


And the surgeons that I admire a lot often tend to be the ones that are super smart, but really understand the details of the crux of it and not the ones that are just flippant and cavalier and just kind of wing it. What I hate the most are the ones that just want to operate and not think. And I think that’s not a good trait for a surgeon because you want to be that surgeon that is a thinker. And I’m a big fan of thinkers and doers are good. If you’re saving a life, you want to be a doer, you just go in there and save a life. So trauma surgeons, they got to be doers. It’s good to be a thinker too, but that comes secondary. But when it comes to elective surgery, you want to be a thinker. And then not everyone needs surgery. For example, one question that was asked was submitted was a kind of very simple question, which is doesn’t everyone follow the same technique? Is it the Shouldice? Like everyone does the S Shouldice the same technique or that when they say laparoscopic hernia repair, it’s the same technique. The answer is no.


Same way. Does everyone tie their shoelaces the same? No. Does everyone hold their pencil the same? No. Does everyone put on even put on their socks the same way? They don’t. So that is why when people say, oh, you’re going to have open surgery, you’re going to have Lichtenstein, you’re going to have laparoscopic inguinal, you’re going to have a laparoscopic IPO or tar, whatever, they may or may not be talking the same language as what is considered standard. So for those of you that are interested in the online consultation, all you have to do is just contact my office. All my information is online, but just email me info I N F O at beverly hills hernia center.com. It’s a mouthful. I know info@beverlyhillsherniacenter.com. My nurse, you all know her nurse Bell. She’s the best. She’s the best hernia nurse specialist in the world.


There are very few. Her nurse specialists. There are maybe less than five and she’s definitely one of them. But just contact my office directly and they’ll take you through the whole process of getting all your records and setting up an online consultation and getting your images and your story. I need to know your story. Pictures will be good. I have a hernia health questionnaire you have to fill out, which is very kind of directed towards hernia, hernia stuff. And it’s for those of you who can’t come in to see me and don’t live in California, we have to do this as what we call online. So I don’t have the ability to practice medicine outside of California, so I don’t feign to be your doctor. I’m just there to give you advice and have all your care taken by your doctors wherever you are. So it’s more of a advisory thing. I’m not treating you in any way. So that was a mouthful. That was a really, really exciting hour I just spent with you guys. I’m sorry. Sometimes I get into these kind of hangups because I see back to back two or three, four episodes or examples of things that go wrong. And I wish that I could help this poor patient that I told you about that have the wrong technique, operation, and then the wrong procedures to help him with his pain. And now it’s been five years, seven years, something like that, six years.


I so wish that I could have been there to help him from day one because what he had initially was actually not that difficult of a problem. It’s a little complicated. Not everyone can do a Mesh removal after a keyhole. It’s actually the most difficult. Keyhole Mesh removal after keyhole technique for laparoscopic angle hernias is probably the most difficult and challenging of all the Mesh removal procedures. But it works really well because you’re like being strangled and then you release the choke hold. It’s that impressive in some patients. Oh, here’s another question. Are McVay and Bassini techniques good? Yeah, all the techniques are good. It’s just a matter of whether your specific situation warrants it. And again, technique. So does your surgeon really know how to do a Bassini or McVay technique? Don’t ever go to a surgeon and say, oh, I want a Bassini.


And they’ll be like, what’s a Bassini? You never, don’t ever want to tell the surgeon to do an operation that they don’t know or are not comfortable doing or aren’t very skilled in doing. Don’t ever force your surgeon to do something they can’t do. That’s a horrible situation. But yes, McVay, Bassini, Shouldice, Marcy, Nyhus, these are all techniques that have aged well and are very, very well good techniques. But it depends on the type of patient, the type of hernia, and also the skill of the surgeon. And you may or may not be a good candidate for any of those operations if you have a femoral hernia. But sitting doesn’t work. For example, McVay and McVay is a little bit of a tight repair. So if you have big, you’re morbidly obese. McVay is not a good technique. These are all little details that a good surgeon who’s done these operations before understands the whole menu of hernia operations that can be performed, which one is best for you, can kind of go.


So that’s all I have for you all. I hope that was helpful. Had a lot of questions submitted, but I didn’t get through most of them, but we always have another week. So thanks everyone for joining me. We have a lot of guests coming up, some international. I’m really excited about those, the international ones, if they’re too far away time zone wise, I try and change the time so that they’re not obliged to be up in the middle of the morning. So be very careful about the time zones that I send you the invites for. Do subscribe to my YouTube channel. We’ve got tons of subscribers. I want you to be one of them because all of these Hernia, Talk, Live episodes and all the prior ones, over 140 of them are archived there. You can watch them. You can search for keywords to see what specifically you want to look up. If you want to look up Bassini, look up Bassini. The episode where we talk about Bassini comes up. So hope to see you again at the next Talk live. It’s every Tuesdays. Hope to see you soon and have a great evening and thanks everyone for all your questions. Take care. Bye.

Leave a Comment

Your email address will not be published. Required fields are marked *