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Speaker 1 (00:10):
Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live, our weekly Q&A session and now podcast. My name is Dr. Shirin Towfigh. I am your hernia and laparoscopic surgery specialist. Thanks to everyone who’s joining me live on Facebook at Dr. Towfigh and via Zoom. Many of you’re also following me on Twitter and Instagram at hernia doc. As you know, all of this will be available to you immediately after each session on my YouTube channel at Hernia Doc. And then now we have a podcast so you can start watching, actually listening to all of our episodes online via a podcast of much more kind of user-friendly if you’re a busy person as a Hernia Talk Live podcast. So what I do, okay, so first of all, let me just thank everyone for all the warm wishes that you sent me. As you know, I live in Southern California and we got hit with Hurricane Hillary this weekend, Sunday, Monday, and there was a lot of hullabaloo about what’s going to happen, the worst storm since 1939, I believe. So almost 60 years ago or more. We were all very prepared. Fortunately for us, we did not get hit hard. We’ve had worse rains or worse winds in the past. It’s just technically not a tropical storm before because the hurricane tropical storm kind of veered eastward. So it kind of didn’t catch a lot of us, which were on the west side, but I really, really do appreciate everyone who sent their warm wishes. That was really, really very sweet. But we’re good, we’re good. No damages, nothing.
Speaker 1 (02:10):
What I did end up doing is basically sitting I at home all day Sunday and not doing much. I didn’t leave the house hunkered down in the home making sure we don’t get a lot of damages from the tropical storm. And one of the things I did was I watched the standup to cancer, I guess you call it. It’s like a TV special fundraiser. I don’t know, you guys let me know if any of you actually watched it. I’ve watched it before, but it really didn’t hit me hard until this year. So if you don’t know, standup to Cancer is now in its 15th year. It was started by Katie Couric. As you may recall, her husband died really young, I think his forties of colon cancer left her as a widow with some children, very devastating and unexpected death. And then she also herself later on had cancer and her sister died of pancreatic cancer a couple of years after her husband.
Speaker 1 (03:12):
So she got hit multiple times with cancer in her family and herself. And she, along with many of her friends, came up with this standup to cancer fundraiser. And every year there’s a show and it’s a combination of entertainment and awareness. So it’s a fundraiser so you can donate money to it. It is mostly there to provide awareness for cancer and then also improve outcomes as part of that. So the themes were early detection, clinical trials, and promoting specialty care. So I’m sitting there as a hernia surgeon doing hernia talk. And a lot of what I do in terms of what I do with you guys with Hernia Talk Live, but also the research that I do and the papers that I write is related to outreach and improving hernia care. Like my goal is to improve hernia care worldwide. So I also go internationally and give talks and help.
Speaker 1 (04:17):
So I’m sitting there, I’m like, wait a minute, this is exactly what we do or what I would like to do, or I feel like I am trying to do for hernias now. Okay, I’m in no way equating hernias with cancer. Obviously the devastation of cancer or the lifetime effects can be significantly more with cancer. Not always, but can be the risk of death and the stress on people and their families is significantly higher with cancer than hernias. But guys, we have much more hernias out there in the world than cancers. And statistically a small percentage, but a large number of patients have devastating effects to their quality of life, not necessarily death. We don’t really have that much deaths from hernias. I would say percentage wise it’s very low, but there are certain people that die of hernia hernias usually for emergency reasons, rarely due to hernia related complications.
Speaker 1 (05:27):
But it happens. It’s not zero, but definitely your quality of life is affected with hernias. And anyone who’s had a hernia repair understands the difference between life with a hernia and life without a hernia, both good or bad. If you’ve had an excellent outcome, you would say, wow, I’ve had such improved quality of life after my hernia repair and they recommended it to their friends, others, and I hear you online saying, don’t delay surgery, just get it done. And yet there are also those of you who have had bad outcomes that wished you’d never had your hernia repaired and actually were okay having your hernia. And so those of you out there actually had a different change in your quality of life, actually a reduction in quality of life.
Speaker 1 (06:13):
So my point is that in hernia care, every little thing that was being addressed in the Standup to Cancer TV show slash fundraiser on Sunday that I was watching, I was like, I relate to all of this, but from a hernia standpoint, now listen to me because you may think that I’m weird, but just think of this. So their whole goal is for awareness, right? We got to be aware of hernias and everything to know about hernias and early detection, right? Early detection is good. It’s good to know if you have these hernias and whether you have to be wary of them, like if you have a femoral hernia or a small incarcerated ventral hernia and whether you should change your lifestyle because of that. So decrease your constipation, quit smoking, reduce weight, and improve your diabetic care. And if you have enlarged prostate, get that treated and so on.
Speaker 1 (07:13):
It talked about the importance of seeking specialty care in cancer, and of course I promote that all the time. Even if you can’t afford specialty care, at least for the surgery, at least get the consultation so you’re aware of everything that’s important for you when you go to a non-specialist. And then clinical trials, and that’s something that we are so missing with hernias, is good quality clinical trials. We have clinical research, I do clinical research. It’s based on my own patients. We do have some databases. You’ve heard me talk about the Danish, Swedish and German countrywide national databases. We have the ACHQC, which is a US-based non-mandatory hernia database, which has its benefits and its flaws and weaknesses, but we have nothing at all compared to what cancer does in terms of repositories, tissue repositories, clinical research done, cancer research done and clinical trials. So then going back to the standup to cancer kind of show, they had a lot of doctors and scientists and they showcased some doctors and scientists that are leading the way.
Speaker 1 (08:37):
And then they had the advocates. So they had people that are in the industry, a lot of celebrities that are a part of this standup to cancer who either had their own personal story to share or some way involved in this charity. And then they had patients and they would go in and out to show a patient and then the patient would share their story and how much I love stories. I mean, it’s all about the stories as I’ve said so many times. And so I felt like what they were talking was so in parallel with what I say and do for hernias and what many of you may hopefully agree. So some of the common threads in this hour long charity show stand up to cancer was that the patient should take charge of their own care and therefore their destiny. So they were encouraging you to go do research, find specialist care and so on, which is what I always say too.
Speaker 1 (09:45):
Take charge of your healthcare. Healthcare is such a luxury to be healthy and you have to invest in that luxury. And they were saying the same thing, of course for cancer. They were very adamant that you should seek specialist care, very adamant. There was one lady, she was there with her husband sharing her story, and she was like, she got diagnosed with myeloma, not a common cancer, not an uncommon cancer, but definitely not common. And she knew based on her research and outreach out there that she should not get care locally because they just did not have enough resources in terms of specialist expertise where she lived. And she knew she had to travel to seek specialty care. And she knew in order to maximize her lifespan and improve her outcomes, she had to seek specialty care. And she was a mom as well. And they showed the child and her very caring husband and so on, and she was very clear that she knew if she had myeloma care by local oncologist in her town, she would not necessarily be alive right now or she would have worse outcomes than if she went to let’s say MD Anderson or Memorial Sloan Kettering or one of those larger cancer centers that we have and are really, really good in the United States where there are specialists that are experienced and provide even clinical trials to provide you with the best care.
Speaker 1 (11:34):
And that’s something that I also say we have pockets in the United States of really excellent hernia care, but we also have huge areas in the United States where there’s either no good expertise or no expertise, general surgeon who dabbles in hernia repair but is still using technology from 20, 30 years ago. And I always say that you should get expert care in order to maximize your outcomes. And this is exactly what they were saying for cancer. And I believe that hernias should be treated with as much seriousness as cancer. I really don’t like it when people discount hernias and just say, it’s just a hernia. It’s not just a hernia. And if you treat it as it’s just a hernia, you’ll see what, we’ll see what the epidemic we’re seeing now of thousands and thousands of patients that are in chronic pain have recurrences, are disabled by their hernia repair, and so much of it is preventable.
Speaker 1 (12:42):
We had an episode last week where we talked about whether it’s important to get the right technique done or have the right surgeon. And of course the answer is it’s always the surgeon. You need the expertise and the specialty care to get the best outcome because that’s where the surgeon has the expertise, understands the big picture, knows what meshes are available, knows if you should even get mesh knows multiple different techniques, has the clinical skills to decide what’s the best option based on your risk factors and your lifestyle, and also will do the right thing in the operating room. Let’s say they go in there and they find something they didn’t expect that surgeon based on their experience and skill will make the right decision. Whereas if you choose someone without experience and skill, you may not get the right choice made. So they talked about what’s called dream teams, and I think I have the dream team. Many of you who have sought care at my office have met Nurse Bell. She is the world’s premier hernia expert as a nurse. There are very few nurses that specialize in her hernia care and she’s one of them. She’s probably the best one.
Speaker 1 (14:08):
It’s all she does, and she really actually does a lot of patient care. And then of course I have Sheila, who’s my office manager, knows everything about hernias as well and understands the needs of the patients and Myron, who’s just so key in making sure that my patients get expedited care in the operating room. So that’s my team and that’s my dream team, the Beverly Hills Hernia Center dream team, hopefully coming to a city near you. Let me know if that’s of interest to you guys for me to expand my care because that’s something I’m seriously considering. But other common threads through this standup to cancer show was the importance of innovation. And I talk about innovation and about how it’s so important to keep thinking outside the box and coming up with new techniques. You may know that I have this robotic tissue repair for angle hernias never really been studied before, and I kind of took what I knew from techniques from the 1960s that were open and now we can do it minimally invasively as a tissue repair without mesh for certain patients that are eligible.
Speaker 1 (15:23):
They talked about patients working together to get excellent outcomes from their cancer care. And that’s because as a forum, you all can share your expertise and what you learned, and there are patients that have had hernia repairs and can talk to each other. And those of you that are on hernia talk.com as a free patient discussion forum, you have learned how important it is to get that patient feedback from your peers because they’ve been through it before. There’s a couple really good posts by the way, on hernia talk.com. One patient posted all the things they learned about what to do, what to pack, what to get prepared for before surgery, what to have in your house for after surgery, what to do not to do, how to take showers, how to prevent constipation and best use of ice packs and everything. So go search for it in there is a really, really good post.
Speaker 1 (16:27):
Other thing that was a common thread throughout this hour was importance of bringing in new insights and thinking outside the box. Those of us that go to meetings, I just went through my calendar because I am so overwhelmed with how many meetings I’m going to between now, which is August and December alone, I think I’m giving 10, 12 talks over a span of several months. Many of them I have to travel around the nation for. I don’t have any international travels until next year. I am giving some talks in Turkey, but fortunately they were able to allow me to do that virtually. I’m just not ready to travel to another continent again. I did enough of that earlier this year. But that’s what we do. We go around and then when we go to these meetings and we talk amongst ourselves, we’re also exchanging ideas and patient scenarios, and then we encourage thinking outside the box.
Speaker 1 (17:34):
Another thing they were talking about stand up to cancer was the importance of promoting less invasive therapies. Of course in surgery that includes laparoscopy, robotic surgery, and in some cases non Mesh as opposed to Mesh repair may be less invasive in someone, let’s say, who’s got Mesh type Mesh problems in the past. So that’s something that we promote for hernias as well. Evolution, the evolution of different treatments we do today is very different than what we were doing in the fifties and sixties and definitely for the better. There’s some horror stories and pictures of hernias that you may not have seen that people used to just deal with. There was no surgical options. And now we have great surgical options. And one thing that they mentioned was going back to the need to travel to get specialty care and therefore improved outcomes, is that they actually published a paper.
Speaker 1 (18:45):
It’s also true for hernias, but it’s never really been published for hernias, which is certain zip codes in the United States have worse outcomes for the same exact cancer. So whether it’s breast or it’s pancreas or lung cancer, colon cancer, depending on the zip code where you get your care, you’re more likely to have a good or bad outcome. So what they said is these zip codes where there’s lesser care is because there’s less clinics, there’s less doctors, less specialists, and therefore less experienced. And that combination can be deadly for patients with cancer. So when we say the outcomes are poor, that means actually more people die or their cancer recurs than should if they went to a specialty place.
Speaker 1 (19:40):
But the same thing is true for hernias. Depending on the specialty center you go to versus a non-specialty, you should expect better outcomes, lower recurrence rates, less chronic pain, better quality of life, improved recovery if you go to a specialist. So higher volume, higher experience usually equals better outcomes. And that’s just kind of a statistic thing. So I do want to kind of bring that up because I just was so impressed by I’m watching a cancer show show and everything they were talking about like, yep, hernias. Yep, hernia, yep. All of these are definitely things that I definitely want to bring up to today’s Hernia, Talk, Live, because it’s so, so relevant. And I never thought cancer will be relevant to hernias. And I was trying to figure out a good title for today’s talk because I don’t want to equate hernias with cancer for sure.
Speaker 1 (20:50):
That would be weird. And I also don’t want people to think that I’m discounting cancer in anyway. But guys, everything they were saying in this one hour, I was glued to this TV show, by the way. It was great. They had entertainment, they had celebrity showings. These stories were amazing. They talked to the doctors. They were giving out awards, but so okay, going back to stand up to cancer. So it seemed like what they do, and correct me if I’m wrong, is their goal is to improve outcomes. And by doing that, they address, in addition to outreach and encouraging people to seek specialists, they’re also actively addressing disparities in care by promoting not only outreach to educate patients, but also funding. So what they’re doing is they’re funding clinical trials, right? That’s very important. More clinical trials the more you learn in cancer and their therapies, but they’re mandating that their funding goes toward funding clinical trials that specifically include patients from underserved communities. Fascinating.
Speaker 1 (22:14):
Let me tell you about funding for clinical trials for hernias almost zero. I personally, not personally, through the Beverly Hills Hernia Center, I fund an annual award every year at the American Hernia Society to promote trials and research for gender-based studies because we have virtually nothing about women for hernias. That’s kind of my thing, the National Institutes of Health. So N I H is the government’s largest entity to fund major clinical trials. Do you know how many hernia trials that they funded? Seriously, think about it, how many clinical trials? There was one back in the nineties, which was the watchful waiting trial for hernias. And there was one also around the same time for laparoscopic versus open through the VA trial, but pretty much that was it until talking eighties, nineties, now until this century, last couple years through the University of Michigan where they funded clinical trials and looking at disparities in care for hernias.
Speaker 1 (23:49):
And if you stay tuned in the next several weeks to months, we will have those specific surgeons on our show as guests to talk about their research and advocacy for hernias because we need funding for national studies, not just me on my handful of patients national studies, looking on disparities in care and improvements in care for hernias. And right now it’s being done through the University of Michigan. There’s also, I believe, a trial from Ohio State University. We already spoke to the head of that university department of Surgery, Dr. Ben Paulose in the past to go ahead and go look in the past for that. But honestly, there’s not much funding for hernia research and it’s kind of pathetic. There’s five or something like that in the history of the NIH and it’s horrible.
Speaker 1 (24:50):
Meanwhile, hernias are the number one operation done by general surgeons. It makes no sense to me, but it’s because people think, oh, it’s just a hernia. So they don’t really consider it valuable. I’m not saying you should take money away from cancer research that’s also saving lives, but it’s kind of sad that sometimes there’s so much research on a disease that is affecting 0.001% of the population and yet virtually almost zero money for hernias. Not cool, not cool at all. Okay, let’s see. Sorry, I was kind of got into my zen mode. Let’s see what you’re saying. Here we are. I want you to come to Minnesota.
Speaker 1 (25:42):
I had left hernia surgery, meh. I had left inguinal hernia surgery with mesh and plug in 2015 and have had chronic pain since. I have three more hernias, but refuse surgery because of my pain. I need you in Virginia, Minnesota. Oh, is Virginia a town in Minnesota? Kind of interesting. I’ve actually never been to Minnesota. I mean, you guys have the Mayo Clinic there and you have University of Minnesota, so you guys have a lot of excellent, excellent surgeons. I’ve interviewed at least one of your surgeons for the Mayo Clinic, Dr. Megan, and she’s great. But to be fair, they don’t really have a chronic pain group for hernias. So outside and University of Minnesota doesn’t really have a strong hernia presence either.
Speaker 1 (26:49):
Yeah, maybe I should come to Minnesota. I’ll be like a visiting scholar at the Mayo Clinic. How’s that? I don’t know if they do that. If they do that, it’d be kind of cool. You’ll be kind of cool. I’m talking out loud right now. There’s no plans for this would be if my job could just be running around to different places and just traveling all the time and then doing Nebraska, Oklahoma, Virginia, Maine, all these different areas that maybe don’t have expertise and just taking care of patients there for let’s say a month and then moving on. The problem with that is if I travel, then if a patient needs my help after I operate on them, then I’ve already left that town. So it’s kind of hard to get continuity of care. Continuity is very important and most of the patients that I treat are already complex. So how does that work where I have to figure out all your story before I even show up so that when I show up, if I need to operate on you, that I can operate? Of course, this is all fantasy because I would need to get privileging at a million different hospitals and that’s not going to happen.
Speaker 1 (28:12):
But let’s say I could is weird because I’d have to get used to the fact that I’m not physically there for every patient. I don’t know if I like that at all, actually. I don’t think I like that at all. So yeah, that’s never going to happen. Unfortunately, what really should happen is that I should be training. I am training. I am training surgeons every year, both our residents and our fellows. Some of them go do hernia surgery, most of them end up becoming bariatric surgeons or other things, but they still call me. They still call me and they say, yeah, I’m like a liver transplant surgeon, but I have this hernia I’m doing. Can I run the case by you? In fact, today one of my former residents called me about a patient and two days ago, also a former resident called me about a patient.
Speaker 1 (29:08):
And those are just people that I personally trained. Could you imagine about all the other phone calls I get? Let’s see. Yes, please come to Minnesota. I was going to come see you because we wintered Arizona, but a druggie burned our winter home to the ground. So I’m stuck in Minnesota and Minnesota is really cold. I don’t do cold, but I would love to visit Minnesota. I have friends there and I’ve never been to the Mayo Clinic. I’ve been to the Cleveland Clinic, but not the Mayo Clinic. I’ll be in Cleveland again this year. One of my many trips I had to go to. Alright, so many of you submitted questions and I’m just going to go through them because I thought they were fascinating. Since I did want to talk about cancer, some of the questions were related to cancer, actually, I guess not knowing how I was going to spin this whole cancer topic, but here’s a question I’m happy to answer, which is, have you ever unexpectedly encountered cancer when repairing your hernia?
Speaker 1 (30:10):
And what do you do in such cases? That’s actually a really good question. I have multiple times now, it’s not common, but the most dramatic one was in a patient who went to, he came to see me, he had a bulging mass in the groin. It kind of felt a little bit hard and it was weird that he would have a bulging mass in the groin that was so hard and not reducible, and it kind of didn’t just show up. He kind knew he’s had it for a while. Anyway, so I got imaging because sometimes you have a gut feeling that it’s just not feeling or right. Guess what? He had a retroperitoneal sarcoma. Sarcoma is a very rare tumor growth in the insides, and it was growing, growing, growing so large. It was basically half of his left abdomen was his tumor and he didn’t even know about it until it started poking out of his groin basically.
Speaker 1 (31:14):
And of course, I sent him to a specialist who actually I trained with who is one of the top specialists in sarcomas, and he took care of the patient and the hernia did not need to be addressed. It was really not a hernia, it was tumor poking out. What I have seen a couple of are what’s called schwannomas. So it’s a tumor of the nerve. So people have nerve pain and they think maybe it’s a hernia in the groin area or they have a growth of this nerve, but it’s in the area where the hernia is. So I had one ilioinguinal nerve schwannoma, which was a mass in the groin, and another one was a mass in the obturator canal. So they told the patient they have an obturator hernia, and I’m looking at it, I’m like, there’s no hernia. There’s just a mass in the obturator canal.
Speaker 1 (32:10):
And I reviewed it with the radiologist that knew what they were looking at and they’re like, yeah, dude, that’s a schwannoma of the obturator nerve. So I sent that to neurosurgery and they took care of it. And then another one, I’ve had several testicular cancers. So people who come to me with growth in their groin area, and it turns out it’s a testicular cancer or it’s a sarcoma of the spermatic cord or lipo sarcoma of that fat. It’s not really a hernia. I’ve treat that a couple of times. Those are actually kind of fun to repair. If it’s a true sarcoma, they need their testicle taken out. If it’s not a sarcoma, it’s just a fatty tumor that’s smaller and encapsulate, you can just take out the tumor and leave the testicle behind.
Speaker 1 (33:11):
But I have a really great team of urologists that understand surgical oncology and urologic oncology. So they’re great. I get to work with them, which I love. So yeah, those are all different cancers. And of course people, okay, so it’s actually a question here and I’m getting ahead of myself. Let’s see. Next question. Can synthetic Mesh be contraindicated in cancer patients? Usually not. So in patients who have cancer and their cancer is not spread everywhere, then they can for sure get a hernia repair like anyone else. If they have tumor, you should not be putting Mesh onto tumor. So that’s contraindicated. You should not be putting anything on that tumor. It’ll just increase its growth. And then let’s see, the follow-up question, is there a grain of truth behind the concerns that synthetic non-resorbable mesh might directly or indirectly contribute to an increase in the risk of developing cancer?
Speaker 1 (34:22):
So directly, no. There’s been zero evidence that anyone with synthetic Mesh got cancer because of that Mesh. There are lawyers out there that would like to spin that and claim that there is a correlation, or sorry, not correlation, like a direct relationship, a causation, but not true. However, there is a risk of getting cancer in a place where you had a lot of infection. So let’s say you had a burn wound or an open wound and you have anywhere where there’s chronic inflammation, you can get cancer. So for example, people with gastric ulcers or esophagitis from acid reflux, they’re all at risk for gastric cancer and esophageal cancers, you’re burning the tissues and you’re causing chronic inflammation over and over again and you’re at risk for getting cancer. In fact, if you do have bad reflux, you should be getting endoscopy every years or so to make sure you don’t have cancer with biopsies and so on.
Speaker 1 (35:44):
And if there’s evidence of early stages of cancer, you need surgery to prevent that reflux from continuing. You’ll get cancer, and that’s a horrible cancer to have. The same is true, let’s say of the abdominal wall. Let’s say you had a hernia and you had the hernia repaired, and then either you got a Mesh infection or a tissue infection, which then caused the Mesh to also get infected, or you had a fistula from the Mesh as a complication and then that continued with an infection. So any of those three scenarios, there happens to be Mesh in the area which then contribute to the fistula or the infection. And if you have it prolonged, so years of infection, chronic inflammation not being addressed as it should be, then that tissue is at risk for cancer.
Speaker 1 (36:45):
The fact that the mesh is there is completely irrelevant. It’s the inflammation and the infection of it. You could have a chronic and dwelling infection there from just infection or like a burn victim that has really high risk of infections. Those burn areas can cause chronic inflammation and cause burns. So to claim that the ME caused it is completely correct. It’s the infection or the inflammation that caused it and any infection or inflammation caused it, whether there’s Mesh there or not. So no, there’s at least one paper I know of that falsely claims it’s the Mesh infection that caused the cancer. It’s a horribly written paper. I don’t even know how that paper got published because they are mixing correlation with causation or causation with correlation and causing a lot of confusion in patients. Because if you Google cancer Mesh, that paper will probably pop up and it’s just to the non-sophisticated reader, you’re going to think, oh, Mesh caused cancer. And they’re very bad in the paper about being very clear that it was not a Mesh problem, but it was an infection problem that probably instigated the cancer.
Speaker 1 (38:14):
Alright, have possible associations between inguinal hernia and cancer ever been investigated? So have they specifically been investigated? Not that I know of. There are plenty of hernias being repaired since beginning of time. No one said, oh, there seems to be a correlation of cancers. We don’t see surgical oncologists say, oh, it’s so interesting. Every patient I see with a cancer happens I’ve had a hernia repair or has a hernia. That’s never happened. And then there are cancer databases which include patients prior histories including surgery and medical diagnosis of hernias that have never shown a correlation between cancer and hernias. And there are national databases of cancers in the United States and even more robust national databases, like I mentioned for hernias in Denmark, Sweden and Germany. None of them have shown a correlation between a history of hernia anywhere or hernia repair and cancer. So no correlation there.
Speaker 1 (39:26):
Can cancer therapies like chemotherapy and radiotherapy have an effect on the risk of developing an incisional hernia after surgery or having a recurrence of an existing hernia? Excellent question. The answer is basically yes. Short answer is yes. So there are patients who let’s say have a sarcoma or gastric cancer, colon cancer, whatever situation is, and they needed to have surgery for it. Those patients may get a hernia just from the fact that they had surgery. So that’s about 11% risk for an open operation to give you an incisional hernia. Let’s say that patient had gastric cancer, wasn’t able to eat for a year and is now like 85 pounds. So they’re very malnourished. They’re not going to be able to heal that operation. So their risk of hernia from that operation is going to be much, much higher than the average patient due to the malnutrition. Let’s say it was an emergency operation, no one knew that the cancer was obstructing and now you have an obstruction of either the colon or intestine or wherever the cancer is, and now you have backup of bacteria. So it’s considered a dirty or contaminated situation that increases your risk of wound infection, which increases your risk of incisional hernia. And then the most common scenario is with regard to cancers and hernias is you have a perfectly good operation done open usually because those have the highest risk of hernias. The laparoscopic robotic ones do not.
Speaker 1 (41:18):
Any incision less about a centimeter has very, very low risk of hernias. These are all like 10 centimeter above hernias, sorry, incisions. So the most typical scenario is you have a cancer, you need an operation for it. Let’s say you have good nutrition and everything is fine. However, based on the pathology, you now need chemotherapy. What does chemotherapy do? It kills rapidly dividing cells. Cancer cells are rapidly dividing. What also rapidly dividing your wound is trying to heal and the way it heals is by rapidly dividing cells and trying to make that scar tissue. So chemotherapy actually destroys the ability to make scar tissue. It’s kind of a fascinating scenario. So on the one hand, you need the chemotherapy to kill any cancer cells that are outside the surgical area to help reduce the risk of cancer recurrence or improve your survival, your cancer-free survival.
Speaker 1 (42:41):
On the other hand, you need to heal that wound. So usually, usually we say, listen, big wound, give us three weeks or so and then start the chemotherapy. They may say, Uhuh, this is a very, very aggressive cancer in let’s say young patient. We’re not going to risk that a hernia may happen. It’s just a hernia situation. So in those situations when they do an open surgery, they oftentimes, if they’re smart and think outside the box when they do a cancer operation, knowing that the patient’s at poor risk of healing because they’re either malnutrition or they need chemotherapy or maybe they’re even on chemotherapy and that’s when they’re actually having surgery too, that’s another situation. Then they should take extra steps in reducing the risk of hernias. So one is to change the type of incisional closure you have. Some people put extra sutures for example, or different types of sutures.
Speaker 1 (43:57):
They may add a binder to add extra external reduction in tension on the wound. They may improve your nutrition and give you certain supplements to take. And then they may also, we used to do retention sutures. We don’t really do those anymore. It’s very morbid, but they do what’s called internal retention sutures. So it’s the second level of sutures on the inside. So those are all extra things. But yes, absolutely, you’re right, chemotherapy will prevent healing. Now it won’t cause hernias. So if you’re already healed, you’re done with the healing and you had surgery, let’s say three years ago, and now you have a cancer for whatever reason you need chemotherapy, you’ll not get an incisional hernia three years later. Okay, so that’s not something we see, but if it’s happening during your healing stages of an operation, then yes, it could happen.
Speaker 1 (45:00):
I promise one of our really great patients that I would help answer this other question, it’s not related at all to cancer, but many of you may find it useful. So this question was submitted to me. I’m just going to read it because it’s really long. It says, why do doctors frown upon hiatal hernia repair? Now, I don’t repair hiatal hernias. It’s a more of a Foregut surgery. It’s not an abdominal wall hernia. It’s an internal hernia around the stomach and esophagus. So people who have hiatal hernias get lots of acid reflux. The larger the hernia, the more risk that your stomach, your actual stomach that’s in your abdomen will creep up that hole or the hiatus, which has the hernia, hence the name hiatal hernia, and then go up into your chest oftentimes behind the heart. Now, we don’t usually see that in young people. It’s seen in frail elderly patients more commonly than in young healthy patients.
Speaker 1 (46:07):
It is often not treated because they tend to be older and unhealthy and frail. But okay, let’s go through this question. Why do doctors frown upon a hiatal hernia repair? I have one that hurts constantly. So how do hiatal hernias hurt? Usually it’s not the hernia that’s hurting, it’s the reflux associated with the hernia that’s hurting. So as long as the reflux is addressed, and oftentimes that’s by medication or lifestyle changes such as not eating late and sleeping at a tilt with your head up, then you can prevent needing hiatal hernia surgery. Okay, here goes the question. I have one that hurts constantly, and the only time I have a major issue with it is when I sometimes sit down, but not all the time.
Speaker 1 (46:56):
When it does, I can feel a pushup greatly and I start having heart racing. Okay, very important detail. What did I just say? If the hernia is really large, then the transition between the esophagus to stomach is distorted. So your stomach, which should be below your chest and in the abdomen, then can go up that hole up into your chest or your esophagus is where does sit right behind the heart. So that can sometimes trigger heart problems. You have a huge stomach trying to share space with your heart, so the heart’s constantly being poked upon by your stomach. Okay, so here goes the question. When it does, I can feel it push up greatly and I start having heart racing. So I stand up and then everything stops. I can feel it move up and down. Okay, that’s interesting. That’s not common. That’s a very mobile, what we call sliding hernia. But the reason why it hurts, it’s better when she stands because gravity pulls her stomach down. When she sits, you actually increase your abdominal pressure.
Speaker 1 (48:08):
Just try sitting with a really tight button down shirt versus standing can see there’s more tension on those buttons and then it pushes the stomach up. So I went to a heart specialist and my heart is healthy. Great. That’s not unexpected. You want to have a healthy heart. They had me do an echocardiogram. I wore the Zio patch and did my blood work. My heart is solid. Great. My primary care will not refer me out until I do a pH test. Okay, that’s ridiculous because if you have a sliding, have a sliding hiatal hernia, the pH test is irrelevant. Who cares if it’s positive or negative? That’s purely an acid reflux test. A true hiatal hernia where your stomach is in your chest and someone who’s healthy should be repaired because it could only cause problems.
Speaker 1 (49:06):
Now, tubes is a trigger for me. And granted, acid reflux do flare up. That’s a given, but that’s not the issue exactly. I’m really concerned that I will have a hernia induced heart attack. Unlikely. Just recently, an elderly guy that I know passed away due to heart failure because his hernia pushed so far up his diaphragm. Also unlikely, but because of his age and weak heart, they told him it was too late. Okay, so what did I say earlier? So the situation is often people are frail and in their frailty they also have loose muscles and then the stomach moves up behind their heart and they don’t even know that they have this until they have heart problems unrelated to the hiatal hernia, by the way. And then as part of the heart failure workup, like, oh, you also have this huge stomach behind your heart. That’s not the cause of the heart failure, so don’t mix the two. It can cause heart problems like chest pain and palpitations for sure, but it doesn’t necessarily cause heart failure. That’s a very different situation.
Speaker 1 (50:20):
So it won’t cause heart failure, but if you have these problems, okay, can I just make another comment here? This where it says my primary care will not refer me out until I do a pH test. First of all, this is why it’s so important to see a specialist doing a pH test is just a waste of resources and of the patient’s time to get to a specialist, send the patient to the specialist, and the specialist will say, I don’t care what your pH test will show. You need, let’s say a manometry study, you need endoscopy. Those are probably the two things you definitely need. pH test is not going to make or break any surgeon’s idea of whether you need surgery with this kind of hiatal hernia.
Speaker 1 (51:14):
So based on that, it would be best if your primary care doctor would just call the specialist and explain the situation and they say, just send the patient over instead of wasting your time in getting the care that you need. They’re taking you down the acid reflux pathway. You need to go down the hiatal hernia pathway, which is not necessarily the same. Some people don’t even have acid reflux. They can have the whole stomach in the chest, but the esophagus is where it should be. Those are called paraesophageal hernias as opposed to a sliding hernia. And those need surgery too, especially if you’re young and healthy. So I hope I helped answer that question because again, this is based on my knowledge as a surgeon that was trained during residency to do these things. I don’t do hiatal hernia repairs myself. I’ve never done a hiatal hernia repair since residency. I don’t wish to do hiatal hernia repairs as a toy different specialty. It should be done by people who have specialties in the stomach, stomach or esophagus or their chest, thoracic, not me the same way. I don’t want thoracic surgeons doing hernia repairs of the abdominal wall, which I know they do, but I don’t recommend it.
Speaker 1 (52:47):
All right, everyone, any more questions? Let’s see. You guys have been good. I hope this was helpful to you. So in summary, I’m hoping that what I’m doing here helps improve the outreach and promotes patients to take charge of their healthcare even though it’s just a hernia. I want to tell you it’s not just a hernia and you should get specialty care, and I want you to all know that the more you talk amongst yourselves, the better it is for everyone because you’re also kind of promoting knowledge amongst each other. Then lastly, remember, outcomes are always best when performed by a specialist in a high volume, large experience place. So don’t be shy to ask your local surgeon how many of these they’ve done, what their outcomes are, whether they follow their patients, what percentage of their practice is hernias, for example, if they offer a laparoscopic robotic open mesh and non mesh tissue repairs because those are all kind of great questions.
Speaker 1 (54:13):
If you go back, I think it’s on the podcast already. If you go back to some of the prior episodes that I’ve recorded, we had a great one, which was, what are the questions I should ask my surgeon before surgery? And we also did another one where we specifically address how if you have a hernia specialist taking care of you, everyone may differ, but my definition of a hernia specialist is different. I think a non-specialist is someone that definitely does less than 50% of their practices dedicated to hernias. That’s a kind of semi-interested person, is someone who does more than 50% hernias. A specialist, a true specialist can provide you a whole gamut of care, laparoscopic, open robotic Mesh and non Mesh repairs and revisional repairs. So not just outpatient hernia repairs where they do the same operation on everyone, but tailors the care of the patient, deals with chronic pain, nerve problems, meshes mesh infections, and can do mesh removals.
Speaker 1 (55:26):
That to me is a true hernia specialist. There are ranges of specialists, so there are some people that just don’t do tissue repairs or they don’t do Mesh removals and they’re perfectly good hernia surgeons for primary repair option. I personally think the more complicated the operations you do, the better you are at doing the simple ones. I really love doing the simple ones because it’s kind of a refresher, but I really enjoy doing the more complicated ones because I like the mental stimulation and the technical aspect of it. There’s a lot of surgeons that don’t. There’s a lot of surgeons that just want to do their operation, go home and not worry so much about their patients. And as you know, we’ve talked about this, it’s both my strength and my weakness, which is I worry about my patients all the time. I already have 10 different patients in my head right now that worried about, they’re all doing fine by the way.
Speaker 1 (56:27):
It’s just I worry all the time. And it’s kind of like a parent. We were talking about this. What were you saying? How did this discussion come about? It had to do with parents worrying. Oh, my friend was going through a downtime in his life and he was saying about how much he worries about caring for his kids and providing for his kids and making sure they have a good life. And I’m like, that’s just being a good parent. I don’t see anything wrong with that. And he’s like, you’re right. That’s exactly right. But when does it end? I’m like, listen, I’m in my fifties and my mom still worries about me. So I think never, I think I’ll be 70 and God willing, my mom will still be alive then and she’ll probably still worry about me. So I think that’s just reality. So on that note, everyone, I think I’ve maybe overstayed my welcome because we kind of had a very interesting discussion today, but I do want to urge you to subscribe to my podcast and start listening from the first couple episodes. I think you’ll enjoy them. You’ll also see how much we’ve grown since three years ago.
Speaker 1 (57:47):
Do subscribe to my YouTube channel because you can hear all these as they get posted every week. I will see you next week. We’ve got some really amazing guests coming up, some international ones, some not so traditional ones. Really great topics and I hope you all do well. Best of luck. Thank you for everyone who cared about me this weekend and I’m signing off. This is Dr. Towfigh on Hernia Talk Live. See you all next week.
