Episode 144: How Important is Closing an Abdominal Hernia? | Hernia Talk Live Q&A

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Speaker 1 (00:00:10):

Why Hello everyone. It’s Dr. Towfigh. Welcome to Hernia Talk Live, your weekly Q&A. My name is Dr. Shirin Towfigh. I am your hernia and laparoscopic surgery specialist. Many of you’re joining me currently as a Facebook Live or via a Zoom channel, but you always know after this and all our prior sessions have always been archived on my YouTube channel at Hernia Doc. Thanks for everyone who follows me on Twitter or now X and Instagram at Hernia Doc. We haven’t really made to threads yet. I don’t think it’s, it’s too instagramy for me right now. So we’re going to keep away from threads because you can’t even do, I heard he came and do hashtags, I’m not sure. But welcome everyone. We have some really great announcements to make. I’ll just make ’em right now in that we have a podcast now. So if you want to catch up on all the earlier episodes, we’re slowly updating them, uploading them to Apple, Spotify, wherever you get your podcast.

Speaker 1 (00:01:20):

So go to Hernia, Talk, Live and you’ll see our podcast. I’m super excited where I think we have the first 25 or so of the 150 or so episodes uploaded and we will keep adding on to them. So those of you who are new to Hernia, Talk, Live, and don’t remember the first several, you can go listen to them. It’s definitely a different experience than now because as many of you know, I did Hernia Talk Live as a way to reach out to you all during the pandemic because I was not able to see patients, I wasn’t able to operate, I wasn’t able to examine patients. Beverly Hills, which is where my office is, was actually shut down to all elective medical care for three weeks. The hospital was shut down. We couldn’t do a lot of the more complicated cases. So multiple times my ability to help treat one patient at a time was affected.

Speaker 1 (00:02:19):

And I kind of took that time to reach out to you all and change, not change, but kind of augment what we’ve been doing since 2013, officially 10 years now on hernia talk.com into a more a live format so that probably many of you’re also at home and would like to maybe ask some questions live and you weren’t able to do that during the pandemic. So it’s kind of continued. But I would like to say that what I was doing, episode one is very different than what I’m doing now, close to 150 episodes because I am not like a radio person. I was never a, I mean, I would do public speaking and that I give talks at surgical meetings. That’s very, very different than a live broadcast podcast, webinar, whatever you want to call it. And I’ve learned a lot. And thanks to some of your feedback, we’ve improved the experience on the YouTube channel and now we’re on a podcast.

Speaker 1 (00:03:25):

Can you believe it? I’m super excited. Okay, so on that note, today’s kind of an interesting topic that I thought I discussed and it really has to do. As you remember last week, two weeks ago, we talked about the importance of technique on your outcome. So many people are focused on, oh, I need to have robotic surgery. I need to have the S Shouldice technique. I need to have non Mesh repair or a certain type of Mesh repair. And in theory, those certain techniques may be important, but your surgeon may not be doing the operation in the same technique as it was originally identified. I’m working with a patient that’s out of country and he had a very awkward kind of technique, which doesn’t make sense. He thought he was getting laparoscopic inguinal hernia repair with mesh. He was, but he wasn’t. There were a lot of things that went wrong.

Speaker 1 (00:04:30):

The techniques were very wrong. They’re not widely accepted by most of us. If you follow me on Twitter, we’ve had discussions about surgical techniques and how some recently there was one where the patient was told they were getting a certain type of operation, but then a certain Mesh was used, which shouldn’t have been, which is kind of like E P T F E Mesh. We don’t really use that for inguinal hernias. It’s considered too harsh, too heavyweight, and also shrinks too much. And then the suture was Mesh was suture all the way around. That’s incorrect for anyone that has been operating since the 1980s. They should know by now that you should not do an open inguinal hernia pair by suturing the Mesh all the way around. Surgeons still do that. It’s incorrect. We’re here to help teach them. But that technique was abandoned, I’m going to say in the early nineties when Dr.

Speaker 1 (00:05:32):

Parviz Amid started talking about the importance of identifying the nerves and not injuring them during the Lichtenstein repair. So if you don’t know how to do that by now, that’s shame on you, surgeon. And unfortunately, shame on… It’s a shame that patients may end up in the hands of those surgeons. And then there was another patient on hernia talk.com. There was a discussion, why don’t we have two layer shouldices? There’s a paper that talks about two layer Shouldice. Well, first of all, a Shouldice is not two layers. It’s four layers. Two layer repairs include things like bassini repair and others. Bassini being the most popular among them. But it’s like saying, why don’t cars have three wheels instead of four wheels? Well, because it’s been pretty much identified that a four wheel car is a better car. There are three wheel cars, there are two wheel cars.

Speaker 1 (00:06:34):

We call those motorcycles. It’s not the same. They can’t say, I’m selling you a car, and people think they’re getting a four wheel car, then they give ’em a motorcycle that’s two wheels. It’s not the same. So even if there was a paper that many years ago, describe the two layer approach for a Shouldice repair, which is technically not a Shouldice, it’s half of a Shouldice, so we can’t call it a Shouldice. That was very few patients, very little, and no one’s been doing it since then. So there’s a reason for that. If a technique was good enough, people would’ve taken upon themselves to promote it. And the fact that it hasn’t been promoted often means that it was not good enough. So I thought that we should talk today about one of the surgical techniques that I see has not been widely adopted among non-experts though among US experts.

Speaker 1 (00:07:34):

Among we experts, we have adopted it for I would say a little over a decade now, maybe 15, almost 20 years. And that is closure of the hernia defect. I’m talking only about abdominal wall hernias, so not the groin because that’s a totally different situation, but not the groin, the abdominal wall. So belly button, ventral hernias, we call ’em incisional hernias. We call ’em flank hernias sometimes. It is now currently considered best practice if you can close the hole. Now, there are situations when we don’t close the hole, but it used to be that we would say, you shouldn’t close the hole. And the question was, why shouldn’t you close?

Speaker 1 (00:08:20):

Why shouldn’t you close the hole? And back then we said, oh, no, no, no, don’t close the hole because you’re going to make that a tighter repair and causes too much pain. It’s better to patch the hole. So if you have an abdominal wall hernia that needs repair, and let’s say it’s two centimeters or four centimeters or six centimeters back in the day, and I mean 20 years ago we were just patching those and we thought we were doing a good job. Why were we patching? One is it was too hard to close. Number two is we thought by closing it, you’re actually causing too much and you’re tearing it true. But it wasn’t, that was not a good reason not to do it. And the third was we were doing a lot of laparoscopic surgery and it was very hard to close those holes.

Speaker 1 (00:09:05):

So those are multiple reasons why about two decades ago we were not really closing those holes and we thought patching was the right thing and they were being patched either as an Onlay Mesh or underlay Mesh or a sublay Mesh, different terms for it. I still see a lot of patients that were patched. However, what was wrong with that theory? Well, patching is a good idea. In cases where you don’t want to do a good repair, you just want to prevent a problem with the hernia repair and then get out. So perfect case scenario is you’re in there for another reason. Let’s say dead intestine and the patient happened to have had surgery from before with the hernia. You don’t want to complicate the patient’s dead intestine surgery with a perfect hernia repair, the hernia can be delayed for later, but you can’t also leave the patient with a big gaping hernia because that will cause problems too.

Speaker 1 (00:10:03):

You have to be able to close the belly. So in many situations, you patch those holes with the idea that you’ll come back later weeks, months, years later and fix that hernia the way it deserves to be fixed, which is closing the hole. Another situation would be if you are doing bariatric surgery, so you’re in there to do an elective surgery, this is not life or death. This is not like dead bowel situation. This is an elective operation. Let’s say the most common being the bariatric surgery. So patient is morbidly obese body mass index, very high 50, 60, definitely over 40, and you encounter a hernia. a lot of patients that are morbidly obese have hernias. Do you address the hernia? The answer is usually no. But if you have to address the hernia to be able to do the weight loss surgery, then most of us recommend that you do a minor hernia repair, which is just patch the hole and deal with a better hernia repair once they’ve lost their weight.

Speaker 1 (00:11:14):

So those are two scenarios in which patching a abdominal wall hernia is considered good practice and probably the right decision for the patient because you not, your aim is not to do a perfect hernia repair at that time. It’s to do another perfect operation, which is save the patient’s life, let’s say with dead bowel issue or do a great weight loss procedure so that they have a better quality and prolonged life and then later on come back and do the hernia repair or not. But the goal of the operation is not to do a good hernia repair at that first time. In all other situations where you’re in there to do a hernia repair, currently the recommendation is to actually close the hole. Multiple reasons. And I know one of you has a question.

Speaker 1 (00:12:11):

What, let me an answer your question before I move on to the rest of what I’m trying to say because I don’t want to lose you. But this is someone asking what are the four layers of the Shouldice and what are the two layers in Bassini? Okay, so those are questions. You can just look it up on Google or on any medical textbook. I can tell it’s you now, but it’s kind of too much I think for this audience. But basically there’s two layers of closure for the Shouldice and four layers for two layers of two sutures. So four layers of closure with Shouldice and two layers of pretty much the same layers for Bassini. And they all include transversesalis fascia, intra oblique fascia, and then the transversesalis and the Iliopubic tract. So they’re complicated. So knowing those four, two layers doesn’t help you as a patient just understand that you need to go to a surgeon who a surgeon should know those layers.

Speaker 1 (00:13:21):

Oftentimes I read operative reports and I’m reading the opera report and I’m like, this surgeon has no idea what they just did because the report says just jibber jabber. I sewed this to that and then put everything together and voila, hernia was done and it’s, it’s really, really crazy. Outside the United States, there’s not a culture of actually doing very complete operative reports. They’re often handwritten and just maybe a paragraph that says hernia repair was done. And so those are very difficult for me to try and interpret what was actually done to the patient in the US we do have in general much more detailed operative reports. However, even those reports sometimes are like a paragraph and you’re like, and half the paragraph just discusses that the patient, how the patient was positioned in the operating room, which is irrelevant to the operation usually. And so those really piss me off because my operating reports are pages and pages long, every little detail is discussed and yet patients still have complaints about, well, did you really remove all the fat?

Speaker 1 (00:14:36):

Did you really do this and that? But I digress. No good deeded goes unpunished sometimes. So fast forward to nowadays the standard of practice, best practice is to close all the abdominal wall defects specifically related to the abdomen, ventral front of the belly, not the groin and any incisional hernia. And why is that? One main reason is we would like to restore the abdominal, not just contour but the abdominal stability. So we’d like to get you as close to your normal anatomy as possible, and the purpose of a hernia pair is not just to close the hole but to bring you back to normal. So you can do sit-ups and you can go grocery shopping and you can enjoy your life. So one reason for restoring the midline and restoring the abdominal wall back to normal is exactly that, which is closing the defect or bring all your muscles back to where they were.

Speaker 1 (00:15:48):

A second reason for closing the hole is so that the Mesh that you need to buttress that closure is against tissue. You don’t want it flopping in the wind if you’re bridging, which is what we used to do. If you’re bridging and you’re basically having Mesh span an empty space between two muscle areas, muscle edges, you risk the Mesh like below out. And you see that more in thin patients where they still see a bulge even though technically there’s no hole and the bulge is just the weak area where you’re missing muscle and fascia and you just have Mesh, cosmetically, that’s a bad outcome.

Speaker 1 (00:16:38):

Symptomatically also, people can feel that bulge as if it’s like a hernia and some of their quote hernia end quote symptoms are there and they may have also some back pain because they have an unstable core because you never really close the area. So that’s part of another reason why we close the hole and then hold on, very dry weather today. So the third reason for closing the hole is to restore some type of contour. And unfortunately today a lot of the techniques we have that close the hole don’t really help with the contour because we’re still sometimes not closing all the holes.

Speaker 1 (00:17:36):

What do I mean by that? People that have larger hernias, by larger, I mean more than four centimeters often have what’s called a TAR or eTEP. And both of those techniques or even a Rives Stoppa, both in of those techniques, many people close the front layer of the muscle but not the back layer. The thought being that it’ll be too tight of a repair if they close the back layer. So that may be a decision you have to make for you to have a successful hernia repair. However, what’s not good is that if you close the front layer and release the back layer, then what can happen is you don’t have a cinched in abdominal wall, which if you’re morbidly obese doesn’t matter because you won’t notice it. It’s not cinched in. But if you’re thin, you can tell that you have more of a rectangular abdominal wall instead of more of an oval rounded abdominal wall. And I personally don’t like that.

Speaker 1 (00:18:40):

So I’m one of the more vocal surgeons in saying it’s not cool to do tars or eTEPs on every single patient, or we have stoppas on every single patient where you don’t close the posterior aspect. You need to understand that the cosmetic outcome for the patient is just as important as the functional outcome, and we need to be cognizant of that as hernia surgeons. However, what I feel is that a lot of us surgeons kind of just like, oh, the hernias fixed. So that’s good. Okay, let’s see. There’s a question here. However, doesn’t fibrous tissue ingrowth into Mesh have enough strength to prevent below S? Absolutely not. There is zero strength to fibrous tissue and actually what fibrous tissue is there to ingrow into the Mesh? The Mesh is against fat and skin and maybe peritoneum. There’s no strength to any of those. So no, the fibrous tissue ingrowth into Mesh does not have enough strength to prevent owing and those kind of symptoms.

Speaker 1 (00:19:50):

Now, if it’s a small hole and you’re bridging a small hole, usually patients don’t feel the bulging or billowing and don’t know the difference. But the larger the hole and the larger the hole to Mesh ratio, the more billowing you get and the more symptoms you can get. It’s just not ideal. And I tell you these little details, not because I expect you to understand them or go to your surgeon about them, but what really happens is that I really want you to understand how many different facets there are to just even something like an umbilical hernia or an incision hernia. Let’s say you had a gallbladder or appendix surgery and then you had a hernia repair or you got a hernia from it and the hernia needs to be repaired. It’s a lot of little elements that go through it. I’ll give you an example.

Speaker 1 (00:20:51):

I have a friend who’s a really great plastic surgeon. I should bring him on. He’s somewhat entertaining too in a very in your face kind of way. But he was telling me about how he sees patients and the patients feel like, oh, it’s just a nose job or it’s just a abdominoplasty or it’s just this or that, and he doesn’t really like it. If patients kind of discount a surgery, oh, well that’s just an eyelid surgery for example, because the patients don’t understand every single little detail that goes through every operation that we do. Now, I say that as we experts, there are definitely doctors or surgeons that don’t think of all these details and don’t appreciate the planning that needs to be done before surgery. And then the integration of the patient’s risk factors and lifestyle and surgical findings into the type of operation that we plan for them and all the details that go on in our brain every time we do an operation.

Speaker 1 (00:22:11):

Everything from what suture size to use, what instrument to use to grab the tissue, what size Mesh, what kind of Mesh, which technique, there’s so many techniques. So the that’s kind of like what we’re discussing together over dinner once, because we both understand each other very well, he is about as nerdy and kind of obsessive about his job as I am in mine, and he’s a plastic surgeon, so you know, would think they’re not really nerds, but some of the good ones are, oh, here’s another question. As scar tissue and a as scar tissue and a Mesh use for bridging repair thins out with aging, can that make a bridging repair more symptomatic with aging? No, it’s not. No, the bridging occurs and symptoms from bridging occur early. It’s just not something that you’ll notice like years down the line, you may have her recurrence down the line because actually that’s another fourth reason for not doing a bridge repair.

Speaker 1 (00:23:17):

The more natural tissue and healthy tissue you have that touches the Mesh, the better the security of that Mesh and therefore the least long-term problems as well as short-term problems. So we talk about short-term of the billowing and maybe symptoms of instability of the repair, but long-term hernia recurrence is lower if you have multiple layers of tissue closure and then the Mesh as well. So that’s kind of my 2 cents about closure. So it’s tricky because some people may not need a closure of their defect. Some people do need a closure of the defect. It has to do with why you’re there to having the surgery and how big the hole is to begin with. But in general, for the average patient with average risk, with the average hernia, the goal is to close as much of that hole as possible and restore your abdominal function as much as possible.

Speaker 1 (00:24:20):

Identify what’s important to you, give you the best repair for long-term reduced recurrences, and then also hopefully get you the best cosmesis as well. Talking about cosmesis, people always joke with me because my practice is in Beverly Hills now most of my patients are not from Beverly Hills. I mean, how many hernias can there be in one town? And most of my patients travel to see me, so they’re not even really in southern California. So this idea that I see just like actors and actresses is not really true. In fact, I see more producers and directors if we want to be honest. I see more producers and directors than actors and actresses, which is fine by me. I like my producers and directors, they’re kind of cool people.

Speaker 1 (00:25:21):

However, even though most of my patients are not from Beverly Hills, I do bring the Beverly Hills aesthetic to how I take care of my patients. And I’ll give you a funny story. So I’ve always been in this area town, and even though I’m not a plastic surgeon, I do appreciate aesthetics of surgery and I never liked it when surgeons did a great job inside the belly. Let’s say they did a perfect pancreas cancer surgery. And then they would take the stapler and they would go staple, staple, staple, staple, staple. And they would do this ugly stapling of the skin, why the patient is judging your operation oftentimes based on what their belly looks like. So why would you do that? And the surgeons were like, I don’t have time to make a good scar. It’ll be just fine. I never liked that and I feel that especially for cancer patients or patients that are dealing with a lot of other issues besides just their operation, it’s a nice touch to provide them with as nice of a wound as possible.

Speaker 1 (00:26:37):

The least amount of bruising, the least amount of pain and the wound, et cetera. And that’s just always been me. I have colleagues that practice in other parts of the United States where the patient population may not be as demanding. The patient population may be mostly morbidly obese. They often have diabetes, they’re smokers, they don’t exercise, they have high blood pressure, sleep apnea, all these risk factors for bad outcomes, wound infections and so on is kind of a unfortunate complication of these operations because people who are obese smoke cigarettes, have sleep apnea and are diabetic are at the highest risk for having wound complications anyway. So some of these surgeons, they really focus on their operation and not so much the patient’s satisfaction.

Speaker 1 (00:27:34):

And oftentimes these surgeons are part of a larger institution that has a lot of medical students and residents and fellows and people in training that help take care of the patient. And so there isn’t that kind of one-on-one interaction with the main surgeon. And I say that because I used to be part of that type of institution. I used to work at the Los Angeles County Hospital, fantastic hospital, one of my best jobs ever. But the reality is I was giving good care in the operating room, but the system is just not meant for me to see 80 patients in a day in the officer clinic. So we had a lot of medical students and residents and fellows and that one-on-one interaction was not there when I was at the county as I do have in my own private practice. And let me tell you, it makes a big difference when you have a patient that’s directly telling you how this little stitch is poking out and why is my scar not straight and why is my belly button to the left and so on. Those are things that are directly coming from the patient and you got to listen to it. But if you’re working in a system where you don’t hear any of those complaints, all is that you’re hurting to not recur. You get it to tap yourself on the back and claim to be a great surgeon, but it’s just a different way of practicing.

Speaker 1 (00:29:06):

So anyway, when I’m at conferences, I always bring up the abdominal contour and the scar and so on and they like Towfigh, you’re so 90210 or not everyone’s in Beverly Hills, and you don’t have to be in Beverly Hills to get excellent care. Why can’t the patient in Kansas or Nebraska get the same care? You, you should be providing that amazing attention to all your patients no matter what zip code they’re from. And that’s just my personality. But surgeons move and they move from town to town, they get promoted to different cities and they build programs and some surgeons come to California or other big states or into neighborhoods that where their work is now more one-on-one with a patient, more sitting down with a patient, less reliance on residents and medical students and fellows in training to provide you with secondhand information. And lemme tell you, their practice is different now they do pay more attention and they now do understand all these years when I’m saying that, yeah, but the abdominal contour, when you do these TARs or these eTEP, if you don’t care to close as much of the posterior sheath as you do the anterior sheath and you’re leaving these people with kind of like a square abdomen, guess what?

Speaker 1 (00:30:45):

Now they agree. Now they agree with me. So I feel like slowly but surely if I just continue on with what I’m saying, people will listen and if people just call me extra, then I don’t care because I’m extra for my patients.

Speaker 1 (00:31:06):

Okay, here’s a question. How do you avoid putting too much tension when closing the hole to avoid pain? Do you have to release or undermine tissue more associated with more dissection? Yes, that’s the caveat. So up until two centimeters you don’t have to do any special releases in some patients up to four centimeters. You can close the hole and not do any specific extra work that involves releasing tissues, but right around four centimeters of what width of your hernia defect, at that point, the surgeon should take extra steps to release the fascia and release the muscle and so on from each other into multiple components to allow for closure of those pole without too much tension. The fear that we had 20 years ago about closing was that it would be too much tension and therefore everything would just fall apart. Now we are less reluctant to just close primarily and we’re more apt to open up the abdominal wall into different layers and close those different layers individually giving a multi-layered effect.

Speaker 1 (00:32:17):

I’ll give you a good example. I just came up with this right now, so bear with me. I don’t know if how many of you are into fashion, but if you have a tailored jacket, you can go to the store and you can buy different types of jackets. The cheapest jackets are those single layer jackets. There’s no lining to it and there’s no extra layer. It’s a single piece of fabric that’s sewn into a jacket. It’s usually lightweight, it usually doesn’t have very good form to it. They tend not to last very long and they’re the cheapest form of jacket.

Speaker 1 (00:32:56):

The most expensive jackets have actually multiple layers to them. They have structure to them. They have an inner lining, they have a lining in between the inner lining and the main jacket, and each of those are independent. It’s like, it’s like sewing three jackets and each of those are independent layers of each other so that from the outside you look like you’re wearing a perfectly tailored jacket from the inside it’s hugging your body in a different way, and whatever tension is on the inner part of the jacket is not translated to the outer part of the jacket. It’s a well tailored, oftentimes designer or personally made jacket is multiple layers of jacket and different layers of fabric. Each of the fabrics have their own specific weights and give to them, and those jackets last forever. You’ll not get snags, it will not. After wearing ’em for 10 years, it’ll still look great on you.

Speaker 1 (00:33:59):

It won’t have snags or areas where it starts stretching out or lose its form. So the simple closures like the cheap jackets, it’s like a one layer. It’s all you have. It lasts pretty good for small hernias, but if you need to wear it, yeah, if you need long-term results in someone with high risk, for example, or if it’s a larger hernia, you can’t apply that for small. For larger hernias, you need to take the extra effort and do multiple layers. And when you pull out the muscle against the fascia, you close the posterior fascia, which is the back layer closer to the intestines. Then you add the Mesh, that’s your second layer. Then you close the anterior layer, which is the front layer, and then you do the fat in the skin to give you a nice cosmetic look. And that’s like a typical open surgery.

Speaker 1 (00:34:47):

There’s similar techniques for robotic or laparoscopic surgery. The point is multiple layers. Each layer takes tension off the next layer. Each layer is its own repair on its own, but it’s supported by each subsequent repair layer. It’s going to now the groin or the inguinal region. One of the reasons why shouldice is considered superior to Bassini, McVay, Nyhus and all the other types of Condon, all the other types of repairs out there, Dasarda is because it is a multiple layer repair, it’s four layers, but each layer can act on its own and each subsequent layer helps take the tension off the first layer. So recurrences from Shouldice repairs are slightly lower than all other repairs, and when you’re talking about two layer Shouldice versus a four layer Shouldice, you’re basically saying it’s good enough to have two layers. You don’t need the extra two layers. That’s not always true and that’s why it’s not called a shouldice when it’s two layers. So those are kind of where I am with that. I kind of like my analogy. I don’t know how many of you get it. I hope you give me some feedback.

Speaker 1 (00:36:06):

If you’ve never experienced a very well tailored jacket or women’s, I highly recommend you go to a store and just check it out. It is a work of art. Or even go on YouTube and just Google like tailoring a men’s jacket. There’s a lot to it and there’s multiple layers to them. And depending on which part, whether it’s a shoulder, whatever, there may be more than two layers, sometimes three layers. But that’s why certain jackets you’ve seen, like let’s say celebrities or someone who’s very high in the political world wears it and you’re like, wow, that’s a nice looking jacket. Those are not single layer jackets. Those are not your linen jacket that just has a single layer. Those are multiple layers. And hernia surgery or surgery in general is very much like a tailor. So if you understand tailoring, I think you’ll be a better surgeon than people who don’t do tailoring. Maybe that’s why sometimes women are a little bit better at surgery because at some point we’ve been exposed a little bit to tailoring that more commonly than men. That’s not always true, but something to consider.

Speaker 1 (00:37:27):

I’ll tell you one analogy I used to use a lot was the you choice of sutures. So the most common way that people close fascia, any surgeon who needs to operate has to know how to close fascia. Whether you’re a gynecologist, urologist, hernia surgeon used to be use really thick suture because you don’t want the suture to break and to hold it together and you do these kind of big bites to kind of hold everything together completely wrong. Multiple, multiple studies show that you don’t should not use a very thick suture because if it’s too thick and actually stronger than the patient’s muscle, it’s not the suture that tears, it’s the muscle that tears and that’s how you get hernias. So you should use a suture that is most similar to the tensile strength of the patient’s own abdominal wall and not do what we used to do back in the day, which we used to use two layers of sutures at the same time, even if you can believe it. Just unbelievable.

Speaker 1 (00:38:34):

And then the analogy I would use is if you have a silk jacket, like a silk shirt, you would never use leather string or a leather thread to sew the seams of a silk shirt. That’s just common sense. But somehow in surgery we were kind of doing that using these really thick sutures for some people’s really thin fascia muscles. So yeah, the current discussion is to match the suture strength and size the patient on tissue, which tends to be in most people what we call two oh oh or two oh sutures. Whereas back in the day we used to use sutures like three to four times larger, which is in retrospect ridiculous. But at that time we thought we were doing a good thing and I am willing to bet 80% of the operations that are out there are still using the same extra large sutures and causing hernias, which I know is ridiculous.

Speaker 1 (00:39:45):

I just dunno how to teach these people anything more than what we’re trying to do. Okay, here’s another question. Can this principle of the additive support effect of multiple layers be applied to an angle hernia repair that is painful, maybe due to too much tension by applied, be applied in a revision using Mesh? And can the Mesh have this effect if not fixated, or does it have to be fixated? Okay, sorry, that’s a very poorly written question, but I think I understand what you’re saying. You’re in a situation where you’re worried or currently have a situation where you had a groin hernia repair and it’s too painful because it’s too tight. So any repair that’s too tight will be painful. The same way. Again, going back to our tailoring, if I have a too tight of a clothing, it’s going to be painful to walk around in it. If I give you pants that are two sides is too tight, or a shirt button down shirt or zip shirt, that’s too tight, you can’t sit, you can’t bend, you can’t breathe. It’s going to be very uncomfortable. Same with the hernia pair. If it’s too tight, it’ll be painful. So what happens? Why is it painful? It’s too tight. What happens when it’s too tight? It tears.

Speaker 1 (00:41:06):

And guess what? Tearing of muscle hurts. The sutures don’t tear. The sutures are much stronger than the tissue, but the muscle will tear and that’s very painful. Usually for a lot of these tissue repairs, we do what’s called a fascial release because the release allows for some of the tension to be taken away. We kind of have to do that, but in some situations, you know, try and do that and it’s still too tight for patients. Okay, so the question is can you then, well, you can undo the tissue repair or you can support the tearing tissue repair with the Mesh repair, and when you have Mesh, you don’t need extra tissue layers. That’s basically it.

Speaker 1 (00:42:12):

In other words, the Mesh is one of those layers. When you have a tissue repair and you’re doing multiple layers, you can take off a layer or two because you can add Mesh as one of those layers. I hope that makes sense. The Mesh is stronger than your own tissue, so you don’t need multiple tissue layers when you have the Mesh repair. So yes, and you don’t have to fixate Mesh depends on the situation. You can fixate Mesh sometimes if you think it’s necessary or you can leave the Mesh in an envelope type situation or you have a perfect space where the Mesh can stay and not move around because within three days most synthetic meshes are kind of stuck where they were meant to be and they don’t move. So a good repair can help that.

Speaker 1 (00:43:04):

Okay, let’s see. Got some questions that I wanted to share with you. There’s a question about umbilical hernia. Actually, let me show it to you. That was sent in Instagram. Okay, here we go. The question is this, does a fat containing umbilical hernia need to be fixed or does it usually get worse if it’s not fixed? So we’ve discussed this in our umbilical hernia repair situation session. We also discussed this on our watchful waiting session, so if you want to go through the back questions, the back sessions of Hernia, Talk, Live where we talked about umbilical hernias, and we also talked about watchful waiting. This was discussed in great detail, but small fat containing umbilical hernias, so small means usually under one centimeter or under two centimeters at the most, and then a fat containing meaning there’s no intestine in it if you have no symptoms, so asymptomatic or you have minimal symptoms.

Speaker 1 (00:44:16):

So minimally symptomatic, Dr. Fitzgibbons and his group has actually looked at this long term and found that they don’t get worse typically, but they do get worse at about 0.2% per year. So of all the patients, 0.2% of them get worse per year, and then by worse it means it either gets bigger or it gets more symptomatic. And so that’s a point where you’d want to get it repaired. So that’s the answer to short question. If it’s symptomatic, you really should repair it because it’s important to have your life’s like quality of life improve, but again, making it worse, like causing emergency surgery or getting incarceration where it’s kind of gets stuck and causes too much pain. That happens at 0.2% per year and we recommend that if you don’t need to have it repaired or don’t want to have it repaired, as long as you understand that risk, then it’s totally okay to watch it. And that’s typically in a patient that has very little risk factors. Also for women, it’s important to know that we prefer that you don’t get your umbilical hernia repaired until after you’re done with pregnancies and females. Here’s another question. Did you say two or two oh or oh, proline is usually not too thick relative to what was used previously. Yeah, yeah. Right now the consensus is most people would benefit from two O or what we call sutures.

Speaker 1 (00:46:07):

The next level thicker is O, and the next level thicker is number one. That number thicker is number two. And we used to use O or even number one sutures back in the day and they still do sometimes or they use a double layer, which I don’t understand. I never double layer. Alright, let’s go through more of your questions. What effect does a planned open abdomen have on the difficulty of a following abdominal wall closure? Oh, good, good, good question. So what is an open abdomen? That is when you’re so sick that you need some type of abdominal surgery. Let’s say you got shot in the belly or you have dead intestine that the surgeon was able to take care of everything inside the belly and you’re just too sick or too swollen from all the trauma to be able to close the abdominal wall.

Speaker 1 (00:47:08):

That happens infrequently, but more often in emergency situations or trauma. And then the situation is, okay, now we have a patient with what we call open abdomen. We eventually need to close this in situations where it’s an acute problem like trauma, like you were healthy and then you got shot or got in a bad car accident and those patients usually within the week, they can close that abdominal wall and they don’t need Mesh, they don’t need a hernia pair, they just need to wait for the patient to get a little bit less sick and a little bit less swollen in situations where the patients are sicker alike, really bad infection, intestinal obstruction, dead intestine and so on, where the process is not acute, they were, it’s been going on for days, hours to days to weeks. Those patients are much more difficult to close because their abdominal wall is, their whole body is just filled with let’s say infection and fluid.

Speaker 1 (00:48:08):

And in those patients what we do is we delay the surgery and maybe even just bridge because you can’t really do her repair. You bridge those people and bring ’em back three to six months later, closer to six months later and try and close their abdominal hernia. Then difficult situation, very difficult situation. I’m giving a talk in Boston in a couple months for the American College of Surgeons for one of these courses that deals with emergency surgeries. And one of the questions that I’m there to help answer is all the different ways in fixing hernias in those situations and the open abdomen will definitely be on my list.

Speaker 1 (00:48:54):

Asia question. Asia meaning autoimmune syndrome induced by adjuvants or like a Mesh implant illness. How do you manage Asia patients or Mesh implant illness patients with a late abdominal wall hernia recurrence after Mesh removal? Hopefully those patients have not already had too much disruption of their abdominal wall in terms of the different layers, and so you would either fix them with a multiple layer repair without putting Mesh in, or you would put an absorbable Mesh in like a Vicryl or something and hope they don’t react to that. But something absorbable, but definitely not something synthetic. They’ve already been shown that they react to meshes.

Speaker 1 (00:49:43):

Another live question, let’s see. Does the pain associated with suture tearing through the muscle have a particular quality that have you noticed in your patients you see for pain falling hernia? They tend to be burning pain, hypersensitivity burning or sharp. It’s usually not a dull pain unless there’s a hernia already torn. Okay, more questions. I love the questions like the rapid fire questions at the end. Does a position in which, hold on. Does a position in which the Mesh is placed have an effect on the maximum size of the abdominal wall defect that can be repaired?

Speaker 1 (00:50:27):

No, not for the midline hernias. For the hernias on the side, yes. So if you have a flank hernia, an open Onlay Mesh is usually less optimal. You should do like a robotic or laparoscopic sublay Mesh because you have more space for the Mesh for those people. How often and after what amount of time on average do abdominal hernia occur after Mesh removal? Almost always. I mean it’s just a matter of time. I don’t know. I feel like if you’re removing Mesh and there is no hernia at the time, but there was a hernia originally, then all you’re doing is exposing that hernia. Again, right now, scar tissue, but scar tissue like we just discussed earlier, is not strong enough to overcome any hernia repair. The only exception is if the Mesh was removed in at the time of an infection in those patients when there’s been an infection and the Mesh was removed at the time of infection, the inflammatory process from the Mesh infection is so huge that patients actually do really well and almost never have a hernia recurrence because that amount of tissue regeneration from the infection is huge.

Speaker 1 (00:51:53):

But if it’s not an infected situation, it’s almost never, I would say 80% at least I will recur. What are the effects of repairing a large abdominal hernia on intraabdominal pressure? Oh, very good question. We actually have never discussed this before. What this is insightful. We’ve never discussed abdominal wall hypertension or increases in abdominal pressure from a hernia repair. What a great question. Okay, let’s focus on this one. I’m kind of excited. So the question is, I have a big hernia and you’re going to close me up now, isn’t that going to be pushing all this hernia contents back inside the belly and try and close it doesn’t That in and of itself cause a lot of pressure. It’s like it’s wearing a, what’s a good example? Like wearing a scuba diving suit that’s too small for me and try and push my belly inside the scuba dive and then zip it all up.

Speaker 1 (00:53:04):

Sometimes it’s not even possible. So what do you do? So this is actually an important point. Only in large hernias and large hernias have to do with what we call loss of domain. If 50% or more of your abdominal contents, intestines, et cetera, outside of your abdominal cavity into the sack of hernia, which is only preventing prevented from the outside exposure by skin, then you have what’s called loss of domain. And in patients with loss of domain, it is a problem because you have to be able to close the abdominal wall over this enormous amount of intestine that doesn’t live inside the abdominal wall anymore without causing so much abdominal pressure that the patient becomes completely stuck in this armor of abdominal wall and they can’t even breathe and can’t sit or bend. That is a horrible situation. Fortunately, that doesn’t happen really much anymore. There’s so many techniques to release abdominal pressure, and in the worst case scenario where you actually cannot completely close the abdominal wall because there’s too much pressure generated by that, you can bridge, you’re allowed to bridge because that’s a situation where the patient needs to be able to breathe.

Speaker 1 (00:54:32):

So it’s adding a little extra layer of a little extra fabric to your outfit. Let’s say you’re trying to get back into your wedding dress and you’ve gained a hundred pounds since your wedding 20 years ago. Well, technically you can wear that wedding dress if you don’t zip it up or if you kind of patch that little area. So that’s kind of the situation. Here’s another comment. Thank you Dr. Towfigh for that information about ASIA after Mesh removal. I have a recurrent hernia after car accident a month after my month after the my removal. Yeah, it’s unfortunate that you had a car accident.

Speaker 1 (00:55:19):

Yeah, that sucks. That you basically may have been destined to have had a hernia recurrence, but the car accident really pushed through that. Can we grow or use our own stem cells to grow tissue before hernia repair to avoid the use of Mesh? Dr. Fiona Wood in Western Australia grows tissue for burned victims. Do you think this could be done in the future for repairs? So the problem with growing muscle tissue, which has been done and can be done, or you can get muscle fascia tissue from other parts of your body, is it doesn’t have the ability to contract because you need nerves for that. And we haven’t been able to basically do kind of like a grow muscle that’s innervated and works. Otherwise it just is like abridged piece of tissue. So, so far, no. Maybe one day probably will be so expensive that it can’t be used on a regular set of patients, but interesting that you guys kind of think of that really, really interesting. Okay. And more questions.

Speaker 1 (00:56:33):

Would you define Mesh bridging as a proper abdominal wall closure? Yeah. Well, I mean not for most elective operations, but yes, as we discussed earlier for emergency situations and the morbidly obese or in situations where there’s loss of domain and we cannot do any more release of tissues, yes. Have you ever seen abdominal bowel hernias that cannot be repaired? Yes. Well, you just bridge them. Can primary closure of the abdominal wall always be achieved? No, I have patients where I haven’t been able to primarily close them. But you know what? Some of those patients you do that you kind of train the abdominal wall to be more lax, you give them Botox, they lose weight and then they can come back for another repair to actually try and get to closure.

Speaker 1 (00:57:33):

Oh, good question. Is watchful waiting a viable strategy for large abdominal wall hernias? This has actually been looked into. Again, go back to my talk with Dr. Fitzgibbons. We had a great Hernia Talk Live with him. So he actually looked at watchful waiting for small hernias and large hernias, and he found for nine centimeter hernias or larger. So these are considered large hernias. The quality of life of the patient was dramatically improved if you repaired them. And therefore watchful waiting was not considered superior to repair. Repair was encouraged in larger hernias because of the dramatic improvement in quality of life. And quality of life was measured by not just pain, but also ability to go back to work and have a functional social life and deal with your daily activities, which may include things as simple as showering or going to work or having a good relationship with your partner.

Speaker 1 (00:58:37):

Here’s a question about minimally invasive surgery. Let me share this with you. Says, is minimally invasive surgery effective and minimizing the risk of getting an incisional hernia? Yes. As a patient, should you pursue a minimally invasive approach whenever possible if you need surgery? From a hernia standpoint, yes, from a recovery standpoint, it depends on the operation and from an outcome standpoint, depends on what your surgeon says. So in the United States, we’re doing more and more laparoscopic and robotic operations. Most of the experts out there are really providing a lot of minimally invasive operations operations that we thought would never be able to be performed laparoscopically or robotically. They’re now doing it. These are lung operations, pancreas operations, even heart surgery.

Speaker 1 (00:59:34):

They’re often done at places like my own hospital at Cedar-Sinai where we just have just amazing experts. And a lot of the older surgeons that never really got into laparoscopic or robotic surgery are still great surgeons and they have their use. But if you have a choice, often you want to choose the robotic approach. So again, depends on why you’re having the surgery, but in general, the more we do minimally invasive, the less incisional hernias are made. But we still see incisional hernias from robotic surgery, robotic neurectomies, colon surgeries, kidney repair, kidney removals. I fix all those hernias, gallbladder removals.

Speaker 1 (01:00:24):

I haven’t seen much from gynecology to be honest. They’re doing pretty well from the hernia standpoint and a lot of questions. But I love it because you guys have done a great job. It’s been a great, great kind of interactive, I would say nice interactive, Hernia Talk Live. We’ll do this again next week. Please go on YouTube and subscribe to my YouTube channel at Hernia Doc. And now while you’re driving, traveling, putting your makeup on, getting dressed for work, you can go and listen to my podcast and they can choose whatever episodes you like. There are a lot of them, and see how much we’ve evolved in the past two and a half, almost three years. And that’s it for everyone. Thanks you guys. It’s been a great Hernia Talk, Live session. Go to my YouTube channel at Hernia Doc. Thanks for my followers on Facebook at Dr. Towfigh and on Twitter X and Instagram at Hernia doc. See you all next week. Talk to you later. Bye.

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