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Speaker 1 (00:00:10):
Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live, our weekly q and a. My name is Dr. Shirin Towfigh. I am your hernia and laparoscopic surgery specialist. Thanks to everyone who’s joining me now via either Zoom or Facebook Live at Dr. Towfigh. And as you know, many of you also follow everything I do on my other platforms on Instagram and specifically Twitter or X at hernia doc. So I wanted to tell you that I do listen to all of the feedback you give me and I read all your comments. I answer a lot of them. One thing that has come up a couple times is that you wanted me to specifically discuss surgical techniques, which I thought was very interesting because when we go to surgical meetings or when we have our own Facebook groups among surgeons, we talk about surgical techniques and we debate ’em.
Speaker 1 (00:01:07):
And every surgeon has their own idea of what’s better, what’s not and how they do things. And it’s a lot of anatomy and a lot of really surgical topics that are not lay person type. So I don’t usually talk about surgical techniques at a granular anatomical sense when I’m on platforms like this, which are really aimed at patients because I just feel like it’s too technical or maybe it’s too boring, I don’t know. But interestingly, I’m getting people requesting it. And if you go on herniatalk.com and you join some of the discussion, patients are actually discussing a lot about surgical technique. It’s pretty crazy. They’re asking questions about what layers or what sutures and Shouldice is four layers, but some people do two layers. And what about the stainless steel? And then laparoscopic surgery is in the type of mesh and where the mesh is placed and the quality of the mesh and all these things.
Speaker 1 (00:02:18):
So it’s super interesting to me because I never thought that would be something patients would be talking about. But I feel the more transparent we are, the more opportunities there are for people to discuss and read and go on social media and encyclopedias and so on. The more it seems likely that there may be certain questions. So when we don’t have guests and there’s no topic where I’m like desperate to talk to you guys about, I will start sprinkling in discussions about surgical techniques and feel free to send in questions, ask me questions, whatever you want to specifically address your questions about surgical technique. And I’ll try and answer them during these live sessions. So that’s kind of where I’m at today and I want to say that that’s what we’ll we’re going to be discussing. I thought we’ll start our very first episode with regard to surgical techniques.
Speaker 1 (00:03:22):
Review will be TEP versus TAPP. And I do this because even my own residents sometimes get TEP and TAPP wrong. I go to meetings and they misspell TEP or TAPP. So it is spelled T E P with one P and TAPP is spelled T A P P with two Ps. And the reason for this is TEP is T E P, totally extra peritoneal. That means the approach for the hernia never involves going inside the belly where the intestines are. It’s always extra peritoneal. So on the outside of the peritoneum and the peritoneum is that sac that holds all the bowels together. T A P P is the reverse. It’s transabdominal pre peritoneal, T A P P, transabdominal pre peritoneal. So it’s not extra peritoneal eTEP, it’s pre peritoneal PP, which means you’re in the abdomen looking at intestines first like any other operation. So it’s the same approach for gallbladder surgery, appendix surgery, what’s another common one? Gynecologic operations, colon cancer, all of those operations are done Intraperitoneal and then they go extra peritoneal or pre peritoneal. So that’s where the PP comes from. So it’s a little bit easier to start where most surgeons are very comfortable being, which is in the abdomen. And then find the plane towards the hernia outside the abdomen, then starting outside and knowing your way around the anatomy. Now TEP and TAPP used to be techniques specifically for inguinal hernias and I was trained in the TEP approach. With robotics, it’s almost always TAPP.
Speaker 1 (00:05:17):
And so that’s usually how it’s always been for inguinal hernias. However, most people who were trained in a laparoscopic approach found TAPP T A P P. The more traditional anatomy to be easier. And the anatomy is easier because it’s a more familiar way because it’s the same approach as any other surgical operation in the abdomen when you first get in there. So tap T A P P is more common now that we’re doing more robotic surgery. It’s almost always TAPP for inguinal hernias, but also for laparoscopic, it’s always been more common to do tap T A P P than TEP T E P P. So why does it matter? Why it matters is the well, okay, in the grand scheme of things, it doesn’t matter. That’s the short answer. In fact, one of my friends texted me like, why are we debating TEP versus TAPP already? Because that’s been one and done. So if you talk to the greater bulk of surgeons, they’re like, we don’t care. TEP AND TAPP- It’s the same operation at the endpoint. It’s just each has its own certain amount of risks.
Speaker 1 (00:06:34):
So for example, TAPP because you go in the abdomen to begin with has the risk of causing any injury in the abdomen like any other operation just by going in for hernia surgery using TAPP. Also, if you go for gallbladder surgery, colon surgery, gynecology, appendix surgery, because you’re working in the same community as other intestines, you may risk injuring those intestines accidentally. So that is the main risk with TAPP that a lot of people don’t like. The other risk with TAPP is once you’re in the abdomen, now you have to go outside that layer one layer more superficial, which is the extra peritoneal, extra peritoneal space. And so you have to cut the peritoneum to get there.
Speaker 1 (00:07:35):
There are risks in doing that because once you cut it, then you have to close it. Sometimes you don’t close it very well or that closure falls apart or some surgeons don’t have the skill to close it very well. You can get a hernia from that closure or the act of closure may cause adhesions or stickiness of intestines to it. So the two main drawbacks for TAPP is intestinal injury or some type of either obstruction or herniation through that cut you have to make for the peritoneum. Now that is a very low risk. Almost everyone who does TAPP has learned how to do it, understands this is a risk and they don’t have such complications. So that complication of bowel injury or obstruction after closing, that peritoneum layer that you have to cut to get to it is minuscule. It’s like a fraction of a fraction of 1%. So it’s not a reason to consider TEP over TAPP. Why do I like doing TAPP? Well, first of all, it has less steps I believe. So in approaching, you don’t have to go in the abdomen then go out the abdomen again. You just always stay extra peroneal. So outside the abdominal contents, and to me that’s great because once you’re done with the hernia repair, you don’t have that extra step of closing the peritoneal fold.
Speaker 1 (00:09:14):
And I think,
Speaker 1 (00:09:17):
But the anatomy is much more complicated and most people who don’t do tap don’t do it because it’s a very difficult anatomy and therefore it’s harder to learn. So most people learn TAPP and never go away from TEP. I learned TEP. So I’m actually very glad that I did by one of the private practice doctors that used to teach at U C L A great great surgeon. He then moved up north, but he was a great surgeon and I really took careful notes about how he did it because he did a very, very good inguinal hernia repair out in the community.
Speaker 1 (00:10:02):
So obviously there are drawbacks with TEP as well. So one of the drawbacks with TEP is you can’t do it. There’s scar tissue in that space because another surgeon has been there. How all C-sections destroy that space. Any open surgery like prostate surgery, open append, appendix surgery, open colon surgery, anything in the lower abdomen that has a scar can complicate a TEP approach because the plane you have to go into is already obliterated. Here’s a question, does a hernia location determine which to use? No. For inguinal, no. So for inguinal, whether it’s a indirect direct femoral or obturator hernia, you can do a TEP or a TAPP for any of those hernias. And I’m going to switch over to abdominal hernias shortly. But going back to the drawbacks of TEP one is it’s more difficult to learn and the anatomy is trickier once you’ve mastered that. The other one is you have to still know how to do a TAPP because if you can’t do a TEP, you have to convert to a TAPP. So why can’t you do a TEP? Mostly because of scar tissue. Sometimes really, really large hernias are harder to do TEP and you have to do those TAPP.
Speaker 1 (00:11:43):
And then the really big hernias, you have to go inside the abdomen and take down all that intestine because you can’t. So an incarcerated hernia or any hernia that’s stuck, you have to unstick it or unstuck it. I dunno what’s the right term for it. I think unstick it. So you got to take it out intraabdominally and then you can convert to TEP. But some people just stay intraabdominal and do a TAPP. So that’s kind of where it is with TEP versus TAPP. Now is it possible to injure bowel with a TEP? Remember I said the most dangerous reason for TAPP is bowel injury? The answer is yes, much less common. But recently we heard of a situation which is devastating situation, but this patient, it’s a very interesting situation. So the patient had diverticulitis, the patient had diverticulitis, and that is an inflammation of the colon, the large intestine down in the pelvis. And because of that inflammation, there’s a lot of scarring on the inside. Now if you go in and you do a TEP, you don’t see any scarring because it’s all away from the intestines.
Speaker 1 (00:13:09):
So you’re actually not aware that there’s any scarring on the inside. That’s usually not a problem. That’s actually one of the reasons to do TEP. You don’t want to deal with prior operations and dealing with intestinal adhesions and so on. But what happens is in this patient, very, very uncommon by the way, but good for you to know, because all operations have risks. This patient had a perfectly good standard TEP operation, so they stayed away from the abdomen, they reduced the hernia, the surgeon put the mesh in, finish the operation, not really knowing or appreciating that the patient had diverticulitis in the past, never needed surgery for it, but all that scarring and inflammation was there. So when the hernia was reduced, maybe there was some tearing, I’m not sure. But the bowel on the other side that the surgeon couldn’t see was injured as part of the hernia reduction because the hernia and the scar tissue from the diverticulitis from the large colon, the large intestine were linked. And what happened several days later, the patient started having stool coming out of his wound. Horrible, horrible, horrible complication. Requires open surgery, colostomy, potentially bowel reset, colon resection and all these things.
Speaker 1 (00:14:47):
So one of the problems with TEP that a lot of people don’t like is because it is somewhat blind from knowing what’s going on inside the abdomen. I like it because I think it’s a very delicate operation compared to TAPP. And the only reason why I don’t do, well, let me rephrase this. One of the reasons why I don’t like robotic inguinal hernia pairs for routine hernias is because it’s usually done TAPP and I just think TEP is a better repair, but there’s absolutely no evidence to show that either one is any better for inguinal hernia pairs. And we believe the surgeon should do whatever operation they do best and usually that’s a TAPP repair. Alright.
Speaker 1 (00:15:49):
Okay, so then the question is didn’t you say TEP and TAPP is also for things other than inguinal nowadays? Yes, it didn’t used to be. So now that we’ve mastered inguinal hernias, we can try and think about doing other hernias like belly button hernias and some incisional hernias, TEP or TAPP. So what does that mean? That means the techniques that we’re promoting nowadays as advanced abdominal hernia repairs almost always include using mesh that’s not touching intestine and not touching bowel. Those of you that are on a lot of the Facebook forums and the forums where people are Mesh injured have seen patients who have had intestinal fistulas and erosions of mesh onto their intestine. Mesh was not intended to be placed right on the intestine back in the days in like the forties and fifties and sixties, they’re routinely placing mesh on the bowel and then they start learning.
Speaker 1 (00:17:00):
That’s not a good idea because there would be erosions, not in everyone, but in a lot of patients there were erosions in what’s called fistulas. So then in the seventies and eighties they started coming up with techniques to coat the meshes so that the mesh is not directly on the intestine. There’s a layer we call a barrier that prevents the small intestine or the colon from touching the Mesh directly and therefore eroding. And now we’re saying, well you know what? Let’s come up with better techniques that can be done laparoscopically or robotically that prevent the Mesh from being against bowel altogether.
Speaker 1 (00:17:46):
And that’s where the TEP and TAPP approaches have advanced to. So in the future we’ll talk about surgical techniques for ventral hernias, specifically the IPOM I P O M, that was the very first both inguinal and abdominal hernia repair done laparoscopically was I om repair because we didn’t have the skills to do it any other way. And so there was a lot of Mesh being placed inside the abdomen. Nowadays we still do IPOM, but it depends on the patient and the risk benefit ratio because TEP and TAPP repairs a little bit require a little bit more skill and more time and potentially more resources. And so laparoscopically or robotically, you can do a TEP or TAPP. So the TEP is again, you enter the abdomen all the way to but not including the peritoneum. So you’re always outside of the bowel area. And then the TAPP is you start inside the abdomen with the camera and then you open up the peritoneum and fall into that extra peritoneal space.
Speaker 1 (00:19:00):
And both of those are really good repairs, depends on the quality of the patient, their obesity and the quality of the patient’s tissues, obesity, the size of the hernia, the skill of the surgeon and what prior surgery they’ve had. So when we talk about doing a hernia repair, there’s so many techniques and for the abdominal wall there’s so many techniques for one centimeter versus two centimeter versus four centimeter wide hernias versus six centimeter wide hernias versus 10 centimeter wide hernias. So depending on where the location is, maybe if it’s the upper abdomen towards the chest, that’s a different technique. If it’s belly button area, different technique, flank hernias, we use a different technique and so on.
Speaker 1 (00:19:52):
But the consensus is if you can and if the patient is healthy enough to undergo a more complicated operation, then a TEP or TAPP repair where the mesh required for that hernia repair does not see bowel ever is a preferred technique than putting any mesh inside the abdomen where it sees the intestine. And that’s kind of where we at. There was someone on, I think it was on YouTube that messaged me and they had intestinal obstructions or adhesions from that exact problem, mesh inside the abdomen and then basically had multiple operations for that and were told just to have the mesh removed. Lemme tell you this, once the mesh is placed, that is the highest level of inflammation that is afforded by the mesh against the patient’s abdominal abdomen and that’s where things start sticking to it usually muscle and the repair. However, once that three to six weeks of inflammation is gone, you don’t get recurrent scar tissue from the mesh.
Speaker 1 (00:21:12):
You can get recurrent scar tissue from any other inflammatory process such as trauma or another operation. But specifically they were told they need their mesh removed because it keeps causing scar tissue completely wrong. That makes no sense to me because mesh doesn’t cause scar tissue after the initial implantation time. So people are giving her this person, it seems to me wrong information, I’d like to know more. So I invited her to approach my office for a consultation for us to figure it out because it doesn’t make sense what she’s being told. So either she’s being told something wrong or I’m hearing a wrong interpretation of what she’s being told. So okay. Some questions for you guys. Can you discuss some patient cases or situations where robotic surgery, which I believe requires tap approach with entry into the peritoneum would be advantageous and why? How would you use a robotic technology to achieve your surgical goals and outcomes and improve outcomes? Okay, really good question. So it’s a two part question. One is what’s the pros and cons of robotics as opposed to other approaches anyway. And then second is understanding the pros and cons of robotics.
Speaker 1 (00:22:33):
In what situations would you Dr. Towfigh specifically prefer a robotic approach for the tap? So I’m going to just focus on inguinal hernias. So robotic technology is basically the same as laparoscopic from the way the abdominal, what the abdomen sees, the abdomen sees a bunch of holes, robotics about eight millimeter holes currently, maybe in the future they’ll get smaller with laparoscopic, usually they’re five or three millimeter holes and sometimes 10 millimeter holes or 12 millimeter holes, but robotics is usually eight. So that’s one main difference from laparoscopy. It still requires general anesthesia, it still requires insufflating your abdomen with gas, which is carbon dioxide to allow for space, working space in the area and it still requires a skilled surgeon on the other end to move the arms. So it’s not like the robot does anything maybe in the future. But right now, no. I may be out of a job in the future with robots doing surgery, but I’ll still repair all the complications.
Speaker 1 (00:23:55):
So there robot. Okay, so what’s different with robotic technology is though functionally the abdomen sees it as the same as laparoscopic for the reasons I just explained. Mechanically, it’s like doing open surgery so the instruments all move like the fingers, hands and wrists would move as opposed to laparoscopy, which we’re dealing with like chopsticks. And so you can do much more delicate operation and do more operations that you’re probably comfortable doing open surgery. And so surgeons who are not comfortable doing things laparoscopically because it’s got some advanced skills, find robotic surgery very easy compared to laparoscopy. I found robotic surgery much easier than the laparoscopic. I still like laparoscopic, so I haven’t given it up because I think it’s a daintier to your operation for certain situations. Therefore, or more surgeons are providing minimally invasive surgery, which includes laparoscopic or robotic surgery as opposed to open surgery because of the robotic technology that’s available to them. Whereas before they would’ve done everything open. So that’s the beauty of robotic technology is it’s advanced the ability to provide less invasive surgery and it’s only less invasive at the abdominal wall. Scar issue inside is very similar surgery to open surgery, but you get less scar tissue, less wound complications, less surgical scars and less surgical infections. So that’s always good.
Speaker 1 (00:25:51):
Why do I use robotic surgery? So I feel that robotic surgery allows me to do things that are very difficult to do laparoscopically and yet still do it minimally invasively. So for example, mesh removal, I used to do mesh removal laparoscopically, now I do it robotically. I think don’t think we actually published our results of doing laparoscopic mesh removal versus robotic mesh removal. The outcomes were the same, the patient still did very well. The blood loss was a little bit higher with the bull loss, a little bit higher with the, sorry laparoscopic approach and the ability to not injure vessels was better with the robot, but the patient still did just the same.
Speaker 1 (00:26:45):
If there’s any reason why I can’t use a robot, I can still do the Mesh removal laparoscopically, but my preference is robotic technology. The other reason why I would do anything robotic are these large inguinal scrotal hernias. So most hernias that I see that are in the groin are visible, but they’re not down to the knee. You know what I mean? They’re visible, they’re easily reducible and so on. Every so often you have someone who has what we call inguinal scrotal hernias. So the hernia falls into falls out of the hernia, marks his way down all the way to the scrotum and it’s a big mass. You can see it through their pants, it’s very discomforting. Some of those can be returned back inside the atoms, some of them not. There’s just so much content in there, those cannot be done TEP. Those have to be done TAPP at least initially because all that bowel needs to be reduced before you approach the hernia itself.
Speaker 1 (00:27:51):
And if you’re elderly and not healthy, I can do those open no problem. But if you’re young and healthy, laparoscopic repair is always better from a rehabilitation standpoint and therefore what I recommend is the robotic approach because it’s much easier to kind of close off that space and do whatever sewing we need to do with the mesh, not the cuffs today. Not sure why it’s a really hot, hot desert-like weather lately, which is weird because we just had a hurricane last week, but we have really dry weather and it’s hot. It’s like over a hundred degrees.
Speaker 1 (00:28:47):
I think that combination is making my throat really dry anyway, so that’s the second reason, which would be large inguinal scrotal hernias. And the third would be large direct hernias. You’ve probably heard me talk about direct hernias before. It’s different than your typical indirect hernia because with direct hernias you have a weakness or laxity of the muscles and you need to taper that down or plicate it, and that involves sewing. You can do it laparoscopically too, but it’s not as nice for a small one. I’m okay laparoscopically, but larger ones I prefer robotics. Again, that’s completely my preference. I can bring other surgeons here and we can debate all day about the intricacies of that. And some surgeons don’t even like laparoscopy, so they wouldn’t do any of this laparoscopic, they would do all of it robotically. And so for them the answer is I would do everything robotically. And that seems to be the case, especially as newer trainees are being educated on the robot, they’re not getting as much experience laparoscopically, although my residents are, but other residents may not be. And so they don’t even really have the skills to do or know how to do it laparoscopically to begin with.
Speaker 1 (00:30:14):
Okay, here’s another question. Does previous open standard hernia or sports hernia repair, which included suturing the rectus or the pubic tubercle or the mesh of the pubic tubercle sometimes complicate the retro rectus dissection preclude the use of TEP? No, it does not. So I’ve operated on N F L players who’ve had sports hernias repaired and rectus tears and so on, and I’ve done those TEP. Most sports hernia repairs and suturing of the rectus of the pubic tubercle are done from an anterior approach and do not in any way affect the posterior space, which is a space behind the muscle. And even if it does, it’s very little. So even patients who’ve had other operations in that space, which includes prostate surgery and bladder surgery, C-sections, the most common, all of those, I still carefully do a TEP repair and understanding that I may have to convert to a TAPP, but again, I told you I prefer TEP, so that’s my preference. But a lot of people would either not do it TEP and they would start TAPP or they would just not even offer it. But any operation done anteriorly in the front, the mesh, sorry, in the front of the muscle does not affect your ability to do posterior repair, which is the back of the muscle. Here’s another question. Hi Dr. Towfigh. As I listen, I truly don’t want mesh if at all possible regarding my hernia type.
Speaker 1 (00:32:03):
I mean that’s a discussion that all patients should have with their surgeon. If it’s possible to do a non-mesh repair and the risks of it are reasonable or the outcomes of it are reasonable, it’s never better. Remember that, from a hernia recurrence rate, it’s never better, but it’s reasonably the same or maybe outcomes related to mesh reaction or let’s say chronic pain may be lower in some patients, that’s reasonable. Those are all options for non Mesh repairs. But when we say TEP or TAPP, it’s always always a mesh based approach because the P part, the EP or the APP part, that part refers to where the mesh goes and it’s always extra peritoneal or what we call pre peritoneal, which is basically the same thing.
Speaker 1 (00:33:08):
Another question, are there problems healing from the retro rectus dissection in TEP such as weakening of the rectus muscle or worsening of a diastasis recti? No, it doesn’t have anything to do with healing of the muscles or definitely has nothing to do with diastasis recti. So there were some other questions that were really great that were also submitted prior to today. What are the factors that affect your choice of technique between TEP and TAPP? So I kind of already answered that. My preference is TEP. Some people may always do TAPP. I would say though in patients that have severe inflammatory bowel disease like Crohn’s disease, I would not do TAPP because you never want to be looking at that bowel. Just Crohn’s patients, their bowel has a mind of their own and any bit of irritation of that bowel may cause an outbreak. And so what I recommend is if you have Crohn’s disease, just everything needs to be extra peritoneal always. Don’t even try and go intraperitoneal for anything.
Speaker 1 (00:34:24):
So that means T E P. Here’s another question. What happens if you get your hernia repaired and lose 20 pounds? Does it affect the repair? It doesn’t. It’s actually great if you do lose weight, the hernia repair is not affected by weight loss. It probably will be less tension on the repair and therefore better long-term outcomes such as better lower risk of recurrence meshes do shrink themselves 10 to 25 in some cases 40% depending on the Mesh. So losing weight is always a good thing. Next question, do you routinely use a Foley catheter when using general anesthesia in older men with mild bladder outlet obstruction symptoms which may become temporarily worsened due to the general anesthesia? Is it important to totally empty the bladder to make a smaller target during TEP or TAPP? So another controversial question, if you ask any urologist who always operates in the pelvis and specifically the bladder, they will say anytime you do any pelvic surgery includes appendicitis surgery, colon surgery, and hernia surgery in the groin, you must protect the bladder by putting a Foley catheter in it. If a specialist says that, then that’s what I do. So I always almost always place a Foley catheter when doing a TEP or TAPP because you want that bladder to be out of the way of where you’re going to be putting the mesh.
Speaker 1 (00:36:03):
However, not everyone needs a Foley catheter, sorry, not every surgeon believes in that. Many surgeons feel it’s an extra step and therefore placing a Foley catheter has its risk such as increased risk of urinary tract infection. Some people believe that it increases the risk of postoperative urinary retention, which is what you’re referring to, and increases the risk of actually injury due to the catheter. Now none of that has been panned out. There are several very large population studies, including a recent one looking at the entire Kaiser Permanente population, which showed no significant difference. In fact, patients who had Foley catheters did better than those that did not. And there are a lot of ways to prevent postoperative urinary obstruction. One is to make sure that the prostate is already shrunken down before surgery with appropriate medications. Second is to have judicious use of the type of anesthesia you use and reduce how much opioids are used.
Speaker 1 (00:37:13):
So all of those are kind of different tips and tricks on how to address that problem specifically. But I always put Foley catheters in because you don’t want, oh, I’ll give you a good story. So I had a lady, she was a stewardess and that part of the story is actually important. She’s a stewardess and she had a incisional hernia I think from a C-section or something. So she had a hernia repaired in the lower abdomen, very low abdomen with Mesh by actually a really, really famous surgeon. If I give you the name, you’ll know who the name is. And ever since that surgery, she’s had bladder problems, like constantly having urinary infections, a lot of pain when she urinates, a lot of pain when she urinates and so on, and no one could figure it out. And she’s had multiple urologists. Look at her, they did cystoscopy, which is they look inside their bladder, everything looks normal, your bladder’s totally normal.
Speaker 1 (00:38:28):
And I think she had a TAPP repair or she had an IPOM, I’m not sure. Anyway, she had mesh put in and the mesh was kind of tacked to the hernia. So she’s here with her son to see me and she brought in her images and I’m looking at the image, I’m like, it looks like the bladder is stuck between the mesh and the hernia repair. So basically she had muscle bladder mesh and she had multiple tacks like securing the mesh to the abdominal wall through the bladder. So basically she had a segment of her bladder that was sandwiched as part of the hernia repair. No one, listen, she had so many CAT scans, not a single person figured this out. I don’t understand why. So I told her this and she’s like, wait a minute, wait, hold on. What year was that CAT scan you looked at?
Speaker 1 (00:39:40):
I’m like, oh, this is from six years ago. She lost it and she passed out in my office because it basically occurred to her from the very beginning when this happened, it was visible on imaging, let alone not only to a surgeon but to the urologist. The urologist and all, and the radiologists and the ER doctors. Everyone had missed it. So I showed it to one of our urologists. I said, Hey, can you help me out because I need to take out the Mesh and then I need your help to address any injury to her bladder by removing all these tacks and sutures from her mesh that are through the bladder. And he’s like, this is nuts. Are you kidding me? So of course we did all that. She was cured, very grateful obviously, but she could not stop crying in my office because she was misdiagnosed to the point where she was told it was all in her head. Can you believe that?
Speaker 1 (00:40:48):
What a story. So I went back and looked at her operative report to see if they used a foley catheter and they had not. This is where the stewardess story is important. So I said, you never had a foley catheter in during your surgery. She’s like, well, that totally makes sense because as a stewardess, she was like an old school stewardess, not modern day. We were discouraged from going to the bathroom while working. And so as a stewardess, they would hold in their urine for a long time and probably stretched out her bladder beyond where a typical patient would be.
Speaker 1 (00:41:34):
I would argue surgeons are the same because we don’t, if I’m operating, I’m not stepping out to go urinate, I’m just going to hold it. In fact, your brain kind of shuts down all those sensors about your bladder is descending until you’re done with surgery and you’re like, oh boy, I need to go to the bathroom. So she said we were trained to just kind of hold it. It was inappropriate to constantly go to the bathroom and sometimes these are like 4, 7, 12 hour flights and therefore her bladder was much more distended than the typical patient. And so she was probably told to urinate before going under anesthesia, being wheeled to the operating room. She probably did, but she probably never emptied her bladder because she had a large bladder and that’s the way she was used to it. So she probably, and talking to other urologists, it’s actually not uncommon for people to incompletely empty their bladder. So they go pee, but they don’t actually empty their bladder completely. So those surgeons, I feel, I feel those surgeons who feel like, oh, we’ll just have the patient urinate before surgery to prevent using a foley. I think they’re fooling themselves because there’s a fraction of the population that will not empty their bladder like this lady. And then now you’re working in the same space as a full bladder, not knowing there’s a full bladder and then there’s a risk of bladder injury. That’s my shtick.
Speaker 1 (00:43:15):
Now, is that malpractice? No, it’s considered standard. Are there risks with any operation? Yes. Can you argue? Well, that’s a small population, but there’s also the risk of all these other complications from foley catheter. Yes, but I choose not to have bladder injury. Instead I leave a foley catheter in place. It is an extra step though. Okay, more questions. Can both TEP and TAPP be used for bilateral? Yes. So you can have a left or a right or a bilateral TEP or a TAPP. That part doesn’t matter. Who generally places a Foley catheter? Oh, good question. Highly variable. It’s usually the nurse. It can be the surgeon and it can be someone that works under the surgeon, either a resident or even a medical student who who’s learning how to place it. The residents should know how to place it, but a medical student would be learning how to place it.
Speaker 1 (00:44:20):
They’re kind of taught on models and then they do it in a human being. So it’s actually a nice time for people to learn because the patient’s completely under, they don’t feel anything. It’s a safe enough procedure to be done. It’s low stress time for the medical student. And so medical students can learn to safely perform a foley catheter in teaching institutions, but usually it’s a nurse or the surgeon themself or the resident in training, which is similar in quality, fully catheter placement. No, the anesthesiologist does not do anything below the neck. They, they’re just airway. They don’t put in catheters.
Speaker 1 (00:45:11):
So I hope you like that story. Okay, let’s move on with more of your questions. Let’s see. What are the benefits of not entering the abdominal cavity? Well, I just went through the benefits and the risks, right? So there are risks in that. Let’s see. Is a TEP repair more difficult to perform than a TAPP? So most people think a TEP is more difficult because the anatomy is not native to them. How do TEP and TAPP compare in terms of intraoperative, postoperative complications? Overall, they’re similar. Chronic pain and recurrence, no difference. So the outcome of the hernia repair itself is no different with tap versus tap. Are there additional difficulties in performing TEP or TAPP robotically? No, it’s really easy actually to do a TEP robotically. Okay, so here’s the thing with TEP, it’s actually a smaller working space and it’s one reason why many people don’t like TEP is because you’re kind of constricted into a smaller space. It’s also why I mentioned earlier that the really large hernias, we don’t do TEP because we lose a lot of our working space.
Speaker 1 (00:46:31):
That’s really the reason why. What was the question again? Additional difficulties. Oh, and therefore robotically you need space for the robotic arms that you don’t need for the very thin laparoscopic instruments. And so for inguinal hernias, TEP is usually not performed. Now, there are recent modifications, what they do, what’s called eTEP, which you can do robotically for ventral hernias in the abdominal wall, doesn’t matter. You can do TEP or TAPP robotically. Both are equally done well, and let’s see another, so all these questions you mentioned plicating a direct hernia during a TEP or TAPP, how do you avoid causing increase? How do you avoid in, how do you avoid causing increased tension in the repair when doing this laparoscopically, which may cause chronic pain? You don’t. So you don’t make it tight. This is just purely to plicate. It’s not intended to be a strength closure in any way.
Speaker 1 (00:47:41):
It’s not a tight fixture. How does it involve how the mesh is placed and fixated? So the purpose of placating a direct hernia, we’ve discussed this in prior sessions, is to prevent bridging of the hernia mesh of the hole. So you don’t want to bridge the hole, you want to fill that hole. And the way you fill that hole is either close that you basically reduce the very redundant tissue and allow for a space of tissue onto which the mesh should lay. Can you resect the general branch of the general femoral nerve for chronic pain by TEP or TAPP? Yes, you can actually and is approximal enough to avoid muscle innervation. So the gentle branch of the gentle femoral nerve, the only muscle that we know of that it innervates is a cremasteric muscle. And most people who have the genital nerve cut do not have cremasteric muscle effects. In other words, the cremasteric muscle holds a testicle up and down. They tend not to lose that. It’s uncommon. But anytime you do a posterior approach, actually any genital nerve branch cutting, but mostly the posterior approach, you can get muscle.
Speaker 1 (00:49:11):
So it’s just a risk of that operation. But yes, those nerves, any of those nerves can be cut laparoscopically or robotically TEP or TAPP. We just don’t recommend that it be done for the ilealinguinal or ilealhypogastric nerves, but perfectly okay for most genital nerve branches. Okay. Let’s see. Is there a difference in the layer where the mesh is placed between TEP or TAPP? No. No. Technically maybe there are two layers of peritoneum and I think many people who do T A P P tend to go too thin and not deep enough. Whereas with TEP, you are in the right space, but effectively it’s the same space. Is a mesh closer to the intestines in either one of those techniques? Usually not. It should be very similar. It’s possible that some people go very thin on their T A P P plane and therefore it’s actually thinner and closer to the intestines, but it shouldn’t be. Oh, here’s a question on MII Mesh implant illness, which is a subset of ASIA. So for a mesh implant illness or Asia patient, what technique would you choose to implant a biologic or hybrid Mesh to treat a recurrence occurring sometime after mesh removal? Honestly, it doesn’t matter. There’s no specific technique that makes putting in some type of biologic or hybrid Mesh in a preferred space for people with Mesh implant illness or Asia.
Speaker 1 (00:51:04):
Can you avoid denervating the femoral nerve? Femoral nerve, maybe the femoral nerve branch or the genital femoral nerve with the retroperitoneal genital femoral nerve neurectomy? You can, okay, here’s some anatomy. The nerve is called the genital femoral nerve because it then branches into the genital and the femoral branches of the genital femoral nerve. So if you can identify the branches of the genital femoral nerve and only cut the genital branch, yes, you can do that in the retroperitoneal space. Not everyone branches visibly. That’s the key. Not everyone branches visibly and therefore you can’t always only cut the genital branch when you’re in the retroperitoneal space. I hope that that’s helpful.
Speaker 1 (00:52:06):
Let’s see here. Last couple questions. Would TEP be contraindicated for a patient with dense Intraperitoneal adhesions from previous surgeries because the abdominal cavity is not entered and consequently adhesions are not lyse. What? Look at you. I literally just went through this one very unique situation. Wow, you’re smart. I tell you, my audience is so smart. Let’s see. Would you always choose TAPP for a patient with dense adhesions because you have to enter the abdominal cavity? No. So depends on the situation. If you have dense adhesions in the abdomen or prior operations, I personally prefer to stay away from those adhesions I. And if it’s a small enough hernia, that’s perfectly safe to be done. TEP. Now if you have a big piece of bowel inside the hernia, then you should still do those T A P P or just don’t do it, do it open, don’t do it laparoscopically or robotically.
Speaker 1 (00:53:24):
And then secondarily, if you feel you have some bowel or something stuck and you have Intraperitoneal adhesions, you have to be super, super careful if you want to do TEP. Otherwise, go back to the earlier part of this hour where I specifically discussed what happened, which was the patient had a perfectly good safe, what seemed to be a safe tip to TEP hernia repair laparoscopically. And then they had stool coming out of their wound three days later because the bowel inside the abdomen where you’re not seeing the bowel was injured while they were operating outside the intestinal cavity, which is in the TEP repair because they specifically had multiple bouts of diverticulitis with dense inflammatory inflammation and stickiness and adhesions. And that’s kind of what happened. Let’s see. I’ve been told my mesh is adhering to part of my bowel. So if you’ve had any Mesh inside your abdomen, which is usually what we call the IPOM technique, then you probably do have mesh stuck to your bowel.
Speaker 1 (00:54:37):
That doesn’t mean the Mesh will erode into the bowel and if it hasn’t eroded yet, the likelihood is it will not erode in the future. And your surgeon, and thank you, your surgeon will have to be aware of that fact. Now, anytime we operate, we try to get prior records and imaging to try and figure out what’s been done before and specifically identify where the Mesh is and where the bowels are. In fact, I’m giving a talk in Boston, the Boston, no, Austin, Texas at the American Hernia Society where I’m showing images where the surgeon really should look at the images themselves to help predict what complications may be out there to prevent it. And one of them is to look at the intestines on the images and look at the meshes and see where there are areas where it’s very close. So if you have fat between the bowel and the Mesh, then the Mesh, it’s a safe operation. If you have bowel stuck to the Mesh on imaging, you may have to be wary that there’s actually a physical communication between those two. And therefore when you go in there for surgery, be aware that you have to address that adhesion so you don’t accidentally injure the bowel. A surgeon that’s skilled should always be aware of that. Anyway, the more skill and experience you have, the more you’re aware of all these things you have to be careful of.
Speaker 1 (00:56:19):
On that note, since we’re talking about surgical technique, I want to make a comment, if any of you’re on hernia talk.com, you’ve noticed that there’s been a shift in discussion towards the minutiae of surgical techniques. I mean, these are minutia that a good surgical like hernia surgeon specialist knows about. We know about the layers and the nerves and the suture choices and the incision and when to use what. We don’t really expect patients to know all that. In fact, the more you try to learn all that, I think as a patient, it’s going to drive you nuts because you’ll start to learn how intricate surgery is, why it takes minimum five years up to eight years of training after medical school to even get licensed and boarded in surgery plus years after that to gain the experience. So when I do an operation, there’s a million things in my mind that I’m already aware of and that I kind of subconsciously go through.
Speaker 1 (00:57:42):
I don’t expect patients to know all that. And I feel that there are certain patients that are trying to learn all that and it’s driving them nuts because it’s overwhelming how many details there are. I’ll give you an example. I don’t know computers very well anymore than here’s my Apple computer and I know how to run other programs, but if you asked me to build an Apple computer right now, I absolutely cannot do it. I’m not skilled to do it. I wasn’t trained to do it. I didn’t do any education about it, but could I potentially go online and start learning about all the C P U units and the way that the board works and all that? I mean, probably I can try if I had an interest in it, but it would drive me nuts because I don’t have that background at all.
Speaker 1 (00:58:40):
So I really hope that instead of patients trying to learn surgery and become a surgeon, that they should do their research enough to understand, do I need surgery? Do I not need surgery? What are their options out there? Laparoscopic, robotic, open, Mesh, whatever. And then go see more than one surgeon so they can get multiple with a list of questions and then trust that surgeon based on your interview and your interaction with ’em and their experience or whatever to do the right thing because you can’t fake being a surgeon. And I’m very concerned about the direction that a lot of the discussion is going on in hernia talk.com because it adds to the anxiety of surgery. And then these patients, they go to a surgeon and they start asking questions about different techniques and sutures and Bassini versus McVay versus Dasarda versus Shouldice, and then why do you do it this way?
Speaker 1 (00:59:53):
What if it’s a direct turn? What if? And you’re driving yourself nuts, you’re driving the surgeon nuts and most surgeons don’t have my patients and won’t sit there and try and answer every single question. And at the end of the day, you’re not going to be doing the operation anyway and you have zero control over what happens during surgery because you’re going to be under anesthesia. So find a surgeon that you trust and then just move forward because that’s the only way to do it. And that’s kind of my departing message because I kind of don’t like the very negative direction some of the discussions going on these forums because is freaking everyone out and I think it’s not right. On that note, I have a very lovely guest. Next week it’s going to be international hernia surgeon, so it’ll be midday, not evenings to accommodate for their awake hours and have a whole slew of great guests now that the summer’s over that are available to all of you and will be answering their questions, will be answering your questions together and I look forward to it. Please subscribe to my YouTube channel at Hernia Doc. All of these episodes are archived on it, and I think I told you we’re a podcast now, so you can also listen to this in your car, for example, as a podcast. So subscribe to that as well and I’ll see you all next week. See you everyone.