Episode 149: Most Important Questions to Ask Your Surgeon | Hernia Talk Live Q&A

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Speaker 1 (00:00:09):

Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live, our weekly session. My name is Dr. Shirin Towfigh. I am your hernia and laparoscopic surgery specialist and today we are joined by my dear friend from across another continent, Dr. Hakan Gök. He is a hernia surgery specialist and very involved with the European Hernia Society and the Turkish Hernia Society. He is based out of Istanbul, Turkey, but I get to see him often at all the different meetings. You can follow him on Twitter or X at h Gök, so please, please welcome Hakan. How are you?

Speaker 2 (00:00:52):

Thank you. I’m very delighted to be join this YouTube session and to have your talk. Thank you. I’m learning too much from your sessions. It’s a big endeavor. You already achieve it. More than 100 sessions.

Speaker 1 (00:01:12):

Yeah, one

Speaker 2 (00:01:14):


Speaker 1 (00:01:14):

This may be hundred 50th session, I think if I counted

Speaker 2 (00:01:18):

Right. Too much big endeavor. Congratulations for that.

Speaker 1 (00:01:23):

Thank you so much. You do a lot too. You’re very involved with all the different hernia societies and guidelines and their social media. So I mean you’re very busy and influential as well. So I learned from all my friends including you.

Speaker 2 (00:01:41):

Me too. Thank you.

Speaker 1 (00:01:43):

So when I approached you to say would you be my guest, your offering was, let’s talk about questions that patients should ask their surgeons and I thought that was great. Most people say, oh, we’re going to talk about this surgery or that surgery, but I love that your interest was patient-centric.

Speaker 2 (00:02:06):

Yeah, we talked, we discussed the polarities of the patients and the surgeons are very different. We should learn, look at the diseases from patient’s perspective, from their expectations we should consider in our decisions. We should include them to they decision making process such as wait, watchful waiting and we should discuss the technique or surgery or things together and we should make decision together with the patients. So recently we also do, there is an ongoing important thing that patient reported that we generally use generic ones that just ask the question the patient’s quality of life, but they are not enough. So maybe we discuss later. They should also include the disease specific patient reported outcome users should be considered for hernia specific or other diseases or the colorectal or

Speaker 1 (00:03:24):

Yeah, it’s a lot of work because the quality of life questionnaires that are out there have been validated for thousands of patients over years and we do have some hernia related questionnaires, but they haven’t been validated as strongly as just the standard quality of life questionnaires have been. But you’re absolutely right. So what’s interesting is usually when we talk about, oh, getting the patient involved and patient rights, it’s usually something that’s very strong in the United States. That’s something that so much of our policies and so on are geared toward it. But the European Hernia society seems to be leading a lot of the ways. You all have a whole section of your meeting dedicated towards patients. You have patient advocates coming to your meetings. You have I think a committee, right? For

Speaker 2 (00:04:28):

Yeah, recently we established patient advisory committee under the general secretary. So JT Bullock, she’s a good friend of us. She’s her new friends from UK. She’s in the group.

Speaker 1 (00:04:48):

She’s actually watching you right now. So she’s watching right now.

Speaker 2 (00:04:52):

Hi Jackie. Next week we’ll meet in Prague with him. Her,

Speaker 1 (00:04:59):


Speaker 2 (00:05:00):

I’ll be there. So she’s doing a very great job. She’s very busy with that. So she’s also managing the hernia patient support group. So this group is, last year we established, founded the group. So there are more than 3000 hernia patients there. We are hernia surgeons there in the group, but we are not involved with too much, but we learn too much from the patients. They are discussing their problems and it’s more education for the surgeons, but we are just observing.

Speaker 1 (00:05:43):

Yeah, I completely agree. It’s so important, the whole concept of including the patient. I’ll give you my experience. I do this every week almost. And there are certain surgeons that are very uncomfortable talking like we’re talking when there’s a patient audience and part of the reason seems to be that they, if I say something to a doctor, it may actually be rude or disrespectful If a patient’s listening, talking about obesity, talking about failures, hernia failures, these are words that we use that we don’t consider it to be weird, but if you talk to a patient about a failure, that’s a much different sentiment than what we talk about hernia failures all the time. It’s not like we’re not making a judgment call. So the language that we use, the words that we use often amongst ourselves is maybe not appropriately translatable to a patient population. So I’ve learned that, I’ve learned that it’s very important to make that balance. But some surgeons are very uncomfortable because they feel that they’re not as comfortable saying what they’d like to say when they’re being scrutinized. Maybe they feel they’re being scrutinized by a patient population. I mean we’re being scrutinized I think every week I’m being scrutinized, so that’s not bad. I need to be aware of the needs of my patients. What do you think about that?

Speaker 2 (00:07:31):

Yeah, we should change, the patient is in the center. We should focus on, we should listen to them. So we should understand their sufferings, their complaints. So hernia surgery is, we always say that tailored surgery, so it’s not to all, there are different variables such as the patient’s, comorbidities, physical features and the features of the hernia type of hernia size or anything else. The location. So also we have a surgeon factor. So surgeons expertise, so capabilities of to do that kind of surgery and then what type of annual repair he has or she has in her armamentarium. So it’s a complex disease, so many variables. So if you focus in the one subs such as hernia, surgery and abnormal surgery. So we see and we observe that the good outcomes with the patients.

Speaker 1 (00:08:51):

So I’m curious about your take on this because what I maybe would like patients in the United States to ask their surgeons, I don’t know if that’s the same as true in Turkey. So I’ll give you an example. I’m okay with patients and I encourage patients to see multiple doctors. I don’t take it personally that they’ve seen a second opinion. I think that’s a good thing. I encourage that. And then I have patients that come and they see some patients come with pages and pages of questions and I allow time for that. Most people in the United States that practice don’t have an hour, hour and a half to spend with a patient. It’s 10, 15, 20, 30 minutes. So they get put off by a person who shows up with a book of questions and I get a lot of questions on Instagram and YouTube and people go on Facebook and they direct message me with questions. The Europeans or the Americans, they’ll send me two pages of their history on just a direct message. But people from the Middle East, they’ll say, thank you for your time, I hope I’m not bothering you. May I ask you a question? And that’s it. And they expect me to respond back with yes or no before they send their question. Whereas the American will send me two pages of their history without even an introduction. So in Turkey, what is it like?

Speaker 2 (00:10:37):

Yeah, across the phone it’s different. They don’t ask too much, but before they come to you, so I’m running a private business before they come to you, they look at search on social media. So they look at your social media presence because it’s like not internal medicine or something that will, we will prescribe something and they will send to the home. We will do surgery, we will operate them, they will get anesthesia, they will sleep a serious process, but they don’t ask. But for my inguinal hernia patients, I talk around one hour, but institute hernias are very complex. So I probably more around two hour I explain everything. I separate them. It’s because they are very important patients. So processes they should know in every details. So I sometimes tell them, I think I said able to think your condition and the disease, but if you remember something later you could take notes and come again. We discuss on it. I will reply them, but they don’t ask too much in my country because, but that conversation, you get their trust. It’s very important. You should give time for them. It’s very important. Every patient deserves this.

Speaker 1 (00:12:22):

Yeah, I agree. I think they need to have your trust and the openness to be able to answer their questions is an important part of the trust. I also do the same at the end. I say if you have any more questions, feel free to call us or email. I work well with email almost no one does. It’s not like I’m bombarded with every single patient coming back with questions. But I think that helps and it helps gain patients trust and understand that you’re not there to just operate, not consider their situation.

Speaker 2 (00:12:56):

I don’t have such a big patient list, so I’m not working in the public. So every patient, they get my private phone number anytime they can. Oh wow. They are very kind. They don’t call,

Speaker 1 (00:13:16):

I should have put your number down instead of your Twitter page. Twitter

Speaker 2 (00:13:21):

Also Twitter. Twitter or X is changing to policy X. So changing the policy, it’ll be a new communication tool for the people email, video conference or something.

Speaker 1 (00:13:39):

So what are your thoughts about questions patients should ask? I feel that last week we talked about this a lot, which was patients do a lot of research and then they get really stressed out and they feel like they personally need to figure everything else out on their own. And I say, no, do your research, understand Mesh, laptop, et cetera, all these things. But then you should go and talk it over with your surgeon and have them feed you the information. Patients on hernia talk.com literally are stressing over the very detailed that you and I think of already, but I don’t expect a patient to think about it. So do you want patients to come to you? Somewhat well read and then you kind of ask questions. I have patients that come and they tell me what they want. Hi, I came here for a Shouldice hernia repair and now they have this huge scrotal hernia that’s recurrent and I’m like, I’m not going to offer you Shouldice. And they’re like, I drove two days just for you to do a shoulder ice. And I tell them maybe that wasn’t what I would offer them. So what do you expect of your patients? So

Speaker 2 (00:15:06):

In general perspective, most patients they don’t aware that Mesh use it to reinforce in the repair in the hernia area. So we should inform them, but we’ll place a Mesh area. So we should also mention about the complications including the Mesh and pain issues or something. But in steps, first they should ask the diagnosis, what’s the diagnosis? Treatment methods. They should also sometimes ask that there is any treatment without surgery. The heart surgery, the only cure is surgery, but they asked if they don’t get the surgery, what happens. We have virtual waiting in inguinal hernia surgery, so it’s trustable, but in my opinion, in issues in hernia, I don’t vote for the virtual waiting. For instance, in hernia they should be as soon as possible, they should be operated. They will not stop in same time they will get bigger in time, so I should be done early.

Speaker 2 (00:16:38):

And the other aspects they should, the patient has to complications outcomes. They are curious about how when they will discharge from the hospital, when they will go into the daily life and when they will drive even they ask the impact on sexual activity. It’s so obvious but they don’t ask our expertise. It is very important. We are general surgeons, we are treating the hernia patients, but we also do the other surgery. Not me, I am only doing the abdominal hernia surgery. But they should ask the expertise or related questions such as when the surgeon when to do any hernia congress recently they could ask that.

Speaker 1 (00:17:45):

That’s a good point.

Speaker 2 (00:17:46):

If you’re academic surgeon they could ask the publications. The surgeons are a member of any hernia society. There are many hernia societies, country societies clubs, European hernia society. So today they could also be European Hernia Society is publishing hernia guidelines. So I always mentioned the patient that I always mention from the guidelines in England hernia or the hernia. So it’s because top knowledge on the hernia surgery guidance, very important. I always mention and I make my decision on that guidance. So there is a thing that I do in hernia like this way, this way, there is no self surgery. It is already determining technique for hernia. There is a name Lichtenstein Bassini or T E P /T A P P. There’s no other technique actually.

Speaker 1 (00:19:00):

Yeah, I think what you started to say from the very beginning was very important. Just because they’re seeing a surgeon doesn’t mean they should have surgery. And so I always like it when patients say, well do I need to have surgery? And I’m like, oh, thank you for asking. That’s a great, great point because there is data in support of watchful waiting for primary inguinal hernias and small umbilical hernias. Not incisional hernias, not recurrent hernias. We don’t have that data. And then what’s good, people ask me, how old are you? I tell them my age. I don’t care that people know my age. But I think more importantly is how long have you been in practice? That’s good to know. You don’t want someone the first two to three years of practice probably if you want an expert that would not be the person and then yeah, I do tell them exactly what you said. Have they been to a meeting lately? If they publish, that usually implies there’s some critical thinking and interest in asking questions and getting to learn. If they talk or give presentations, usually that implies that they’re knowledgeable, not necessarily, but that they are knowledgeable about the topic doesn’t mean they’re a good surgeon still.

Speaker 1 (00:20:24):

And then what’s your definition of a hernia specialist? That’s one thing People are like how do I know if my doctor’s a hernia specialist?

Speaker 2 (00:20:32):

Well, tough question. Yeah, but hernia specialist is not just doing the hernia surgery. They could also do the other surgery, but following the current program to developments to publish literature. So also it is a community doctor or in a rural one even they can publish. They can publish, they can go to the congresses, they can present their experiences. Also in the previous session you made that talk with [inaudible] and I joined the session. If you promote yourself as the hernia surgeon, so you get more complicated cases, you don’t have primary cases because people also other surgeons refer to the complex cases to use. So you also deal with that kind of complex patients. So it it’s a route to become a hernia specialist, but it’s not easy to, even in the hernia surgery to progress in the world.

Speaker 1 (00:21:58):

I always say if at least 50% of your practice is hernia, then at least that shows you have some special interest in hernias.

Speaker 2 (00:22:10):

But it’s not enough.

Speaker 1 (00:22:11):

But it’s not enough to be a specialist for

Speaker 2 (00:22:13):

Example. It is a big issue is the of chronic pain you should deal with should treat chronic pain. If you don’t treat the chronic pain issue, it is a huge amount of patients out there. So if you don’t deal with them, so you should take the hernia surgeon,

Speaker 1 (00:22:35):

That’s 99.9% don’t do chronic pain.

Speaker 2 (00:22:42):

Last week in Istanbul, I’m currently in Madrid

Speaker 1 (00:22:48):

By the way to the audience, Dr. Gök who lives in Turkey, it’s currently in Madrid. Do you want to explain why you’re in Madrid?

Speaker 2 (00:22:58):

So it’s a long story but in short I brought a patient of me because he has a big complex incisional hernia. He has kidney transplant hernia, so he has C O P D and complex case. There’s a center here in Madrid. They are my friend Miguel and Javier. So we decided to, because the surgery, it’s also in hernia. The surgery start before the surgery, yes. Rehabilitation. Yeah, I did Botox, the patient in Istanbul. So he has uncontrolled diabetes. We tried to fix the diabetes with the ozempic and we had success. So he came here. So they did P P P, progressive pre peritoneum to make room for their organs outside of the optimal cavity. Yeah, they inject air in the belly to yeah, every day the belly day we inject. So yesterday we did the surgery, it all went well. So he’s in IC now.

Speaker 2 (00:24:22):

He’s stable so we going to see, so he will come later after me because I’m going to back Istanbul next Friday. The other flights I was coming to do Austin for the AHS American Hernia Society Congress. Yes. Last week in Istanbul in robotic surgery collaboration meeting I spoke to the audience and Bassini Italian surgeon as the father of hernias surgery. So I made a diagram in my [inaudible] and I said that how Eduardo Bassini and my name be mentioned in the same sentence. And then I said that I became a surgeon essentially after Eduardo Bassini. So I made the same sentence. So I always say my patient, my expert is almost 30 years. I mean the surgery in the beginning, I’m very interested with the hernia surgery. I can say another story. When I was younger surgeon, a patient came to me in 1997.

Speaker 2 (00:25:41):

I remember, well the internet was new, I had new laptop and the patient came recurrent inguinal hernia. So I made the search on internet. There was no Google that time, just Alta Vista, yahoo search engines. So I saw that in America site there is a new Mesh, really its name is p h s layer Mesh. So they say there is an advertisement on the site. So it’s saying that we could send you brochure flyer, we could send you the product also we could send you the surgeon. Wow surgeon. It’s writing surgeon, a surgeon is coming you we are doing the surgery together. It was amazing the time for me, but I couldn’t ask a surgeon because I was living in Turkey. So I just requested a flyer and the product, the day after the distributor of Edcon in Istanbul, they came to me, they visited me.

Speaker 2 (00:26:57):

You see that speed. So it’s very interesting. So hernia surgery also, it’s very interesting because abdominal wall, we do the abdominal wall surgery. The abdominal wall is the organ. Actually there is not such a skin fat or muscles, the layers, it’s a complex organ. So if you look at it has meat, it has land, but it’s the thick, not it’s like two dimensional organ. So in every hernia repair in even open, laparoscopic, robotic, we do it, we open it, we do it three dimension, then we make our repairs suture the hernia, we replace the Mesh and return it to the two dimension. It’s magical actually. It’s complex, different angles. So I like that kind of surgery. So I’m a fan of it.

Speaker 1 (00:27:58):

Yeah, that’s really fascinating. There’s some questions that are being asked from the audience. I’ll ask them to you. So should you ask your surgeon prior to surgery how they would manage a complication, let’s say with pain, chronic pain if it occurs, and whether they can manage it themself or refer to someone else? I think that’s a good question.

Speaker 2 (00:28:23):

Yeah, that’s a good question. We don’t expect if through performance, hernias, surgery, I’m talking about the inline hernia, but we don’t see much current pain in the arm abdominal wall. So if it’s properly performed, even open, even laparoscopic, we don’t see much pain. But I always warn surgeons that if emitted after the surgery, if you see the high level of the pain, then there is something wrong. So you should take back to the or the patient or you should check what did you, so it’s important. So to avoid chronic pain, yeah, laparoscopic surgery is recommended minimally as the techniques. So robotic surgery as well. So because in hernia repair is basically in the open surgery we see the three important nerves there, sensory nerve. So we protect them, preserve them, we observe them, we become very careful to kill them and to the groin between the muscles from the side. But in laparoscopic surgery we are behind the muscles. So we don’t see that. But we can risk that nerve by fixating the Mesh or suturing or wrong dissections in the area. But if you look at from publications and data, yeah, less chronic pain with the laparoscopic repairs.

Speaker 1 (00:30:11):

Yeah, you saw on hernia talk.com there was a post, what is the least painful hernia repair for inguinal. And I would very quickly say laparoscopic, but as you know the discussion online is that there are a lot of people on the site that underwent laparoscopic surgery and had complications. I do get those questions. You’re going to put Mesh in me, what if can you remove the Mesh afterwards? And so I do Mesh removals, but I guess that if you ask that of a surgeon and the question is the answer is, oh no, you can’t remove the Mesh afterwards or I can’t do it. Does that necessarily mean that they shouldn’t be that surgeon

Speaker 2 (00:31:00):

To remove the Mesh for the surgeon? Yeah. Yeah. That kind of issues should be referred to the referral centers, to the centers experts and surgeons because it’s changing a part of the car and replacing with the new one. When you place the Mesh, it’s very integrated with the body. It’s inflammation. So severe irritations in the area, it’s not easy to remove a Mesh. It’s very complicated situation. So also to Mesh decision is very important. If we are really sure that the measurable will have help to the patient, yeah, we try. But it’s better to send some complicated case to the referral centers, to the experience files.

Speaker 1 (00:31:59):

But do you think the patient should not go to a surgeon if they are not going to be able to handle the complication or what are your thoughts on that?

Speaker 2 (00:32:11):

No. Yeah, if we do the surgery, any kind of surgery including the hernia surgery, so we are able to deal with the complications. So that is not a question point that also it shouldn’t be asked to do a surgeon, I guess. Sure, the surgeon can handle those complications because

Speaker 1 (00:32:41):

Yeah, I would say true hernia specialist would be someone who can handle complications. That’s what makes a specialist. But they’re perfectly good hernia surgeons that are very good quality in terms of their surgical technique and what they do, and hopefully they understand what a complication is so they can refer it out. But I don’t think every single patient is going to be able to find a surgeon that is a special that also does complications. In other words, it shouldn’t be an automatic no. If your surgeon says, oh, I’ve never removed Mesh or I don’t know how to remove Mesh. But if they say, oh yes, I understand that it is a complication, I’ll refer them to so-and-so or then that’s okay. If the surgeon completely says, oh, I never have complications, I never need my MeSHs removed, I’ve never had a patient that needs another operation. That is not a good sign usually, right?

Speaker 2 (00:33:50):

Yeah. There is no work like that. Yeah, there’s

Speaker 1 (00:33:55):

No such thing.

Speaker 2 (00:33:57):

There’s nothing there.

Speaker 1 (00:34:00):

But I would say just because the surgeon themself cannot handle a complication doesn’t mean they’re not a good surgeon. Does that make sense? They’re not

Speaker 2 (00:34:19):


Speaker 1 (00:34:21):

They just need to identify when you need a specialist that can handle let’s say Mesh removal or injections or whatever the chronic pain needs are, but just because themselves don’t do it is not necessarily an exclusion.

Speaker 2 (00:34:38):

The chronic pain is a complication. It needs multidisciplinary approach. So in such circumstances it’s better to, if you are not a hernias surgeon, it’s a general surgeon, I see that they can notable to follow the progress, the pathways to deal with the chronic pain. Yeah, that’s why we need referral centers of complex chronic pain cases.

Speaker 1 (00:35:10):

But I think the question that was being asked, I think the gist of it is it’s good to talk to your surgeon about how they would handle complications. Are they thinking what’s plan B? Right plan A, is this, what’s plan B? Because that determines they may have to change their plan during surgery even. So if they have the forethought and the experience to do that, that’s a good sign. If they deny that there’s ever any need to change or any complications, then that maybe is a sign that that’s not the right surgeon. They don’t understand hernias.

Speaker 2 (00:35:51):

Yeah, I agree. For example, we should, if you do minimal invasive surgery such as you do robotic hernia repairs, I don’t have any access yet. But mostly I will do soon and I do lateral surgery that there is a risk of conversion to open the complication. Even without complication we can convert to the open surgery. This should be also informative to patient because it shouldn’t be a surprise for the patient because they see a cut in the area. It’s surprising and they will not be happy when they see. So if you say before the surgery there is, it’s a less, but we should mention about it.

Speaker 1 (00:36:48):

Yeah, yeah. Agreed. How do you talk to your patients about Mesh? Do you give ’em any handouts? Do you tell them pros and cons? Do you offer them non Mesh? If it’s possible?

Speaker 2 (00:37:01):

Yeah, I talk about the Mesh. I also give, it’s very important to use of quality. Quality of the Mesh is important. Yes, I prefer so. And surgeon should know detailed about the Mesh technology in me. Science. It’s a science. So recently F D A released a paper for the Mesh on its website information. It’s a very good book that they’re informative. So I have foreign patients coming from abroad for annual repair. So when I chat them, I shared the link for their information. There’s very detailed. So American Hernia Society, the Publish Mesh paper in 2018 also Beauty Hernia Society did hopefully we’ll do in European and Society similar things. So it’s not the Mesh for the pain. So there’s a saying that Mesh injured patient, it’s a misnomer actually. So hernia surgery, injured patient is more proper for using because what’s

Speaker 1 (00:38:35):

What’s the more proper name?

Speaker 2 (00:38:38):

Hernia surgery, injured patient

Speaker 1 (00:38:41):

Hernia surgery. Injured. Yeah,

Speaker 2 (00:38:43):

Injured. Yeah, because it happens after the hernia surgery, there is it’s variable reasons for the complications such as nerve cut for the pain or inflammation in the tissue. So infection, recurrence. So we shouldn’t blame in every case the Mesh.

Speaker 1 (00:39:09):

Yeah, no, that’s true. a lot of people have recurrence, they blame the Mesh. I’m like, that’s not a Mesh problem. I have the survey. I highly recommend you send it to any patient groups you belong to. But it’s to learn more about Mesh Asia syndrome or kind of implant reactions, whether it’s breast implant or Mesh implants. And a lot of people you can have pain, but to actually react to a product is usually not painful in it is not painful in the area. It’s usually like hair loss and joint pains and chronic fatigue and rashes as opposed to I have groin pain after my hernia repair. That’s not technically a common reaction. It’s the way we think about autoimmune reactions to meshes. So people interpret Mesh problems differently. In the United States, we have so many, so lawyers and lawsuits and they are all basically putting everything under one umbrella. Recurrences, infections, fistulas, chronic pain, everything is a Mesh. Even nerve pain infection. Yeah. May not be related to the nerve. What’d you say? It’s the Indian, not the arrow.

Speaker 2 (00:40:40):


Speaker 1 (00:40:43):

Yeah. So it’s the surgeon. a lot of the complications are related to the surgeon, not necessarily to the Mesh or the product itself was a technique issue. Yeah,

Speaker 2 (00:40:54):

It’s one foot of the process. The surgeon’s very important.

Speaker 1 (00:41:00):


Speaker 2 (00:41:01):

So it’s difficult to do surgery in the United States. I saw some advertisement from the lab offices that if you had any complications in surgery or surgery, so come we help you like that.

Speaker 1 (00:41:22):

Yeah, that was my talk at the

Speaker 2 (00:41:24):

E h. Yeah, that’s right. They’re advertising. It’s not good.

Speaker 1 (00:41:28):

Yeah, lots of advertising. So Turkey is becoming very famous for medical tourism, hair transplants, plastic surgery. Do they come to you also for hernias?

Speaker 2 (00:41:42):

Yeah, they come from, if you look at, we are mostly the patients coming for to the Europe, to the Middle East, to Gulf area from the east because there is a huge amount of wait list in the UK in the Europe because of healthcare provisions shortage. So for example, last year it was 6 million wait lists for the surgery in any kind of surgery in the UK. Last month I watched the British Prime Ministry, AK in the parliament. The opponents asked him when he came to the office to wait, this was 7 million in the uk. In the six months he replied them. It’s now 7.5 million patients waiting any kind of surgery. So it included tender surgery, ureter or breast. They’re helpless. So people try to find the solution. The Diego abroad, we mostly attract people for the plastic surgery, the anal surgery, hair transplants. So we have our Turk Airlines goes everywhere in the world.

Speaker 1 (00:43:13):

Yes, Turkish Airlines for

Speaker 2 (00:43:15):

Sure. Yeah, everywhere it goes to the directly. So it’s easy. It’s comparable prices. So there’s also recently a change in our current rates. Our economies big, so we have good prices for T tourism, but we have good infrastructure that there’s very high quality a plus hospitals in Istanbul. So we can do the surgery immediately. There is no way to, in my practice, I don’t like the patients see the first in the day of surgery. So I asked them before one day before I told them I examined consult them and I make the surgery before. So I also send some questions, surveys to assess his situation for the general health as well as the hernia. So I don’t want to have a surprise. For example, they could use blood thinner or something. So I should be aware before they come to

Speaker 1 (00:44:31):


Speaker 2 (00:44:32):

Here’s a good question, but the problem is on the quality of the treatment there is, it is economic, it’s a business. So they make packages too. So for example, they make four day package for the bariatric surgery. Yeah, after three days after the surgery, they’re going back to home country with plane. Yeah, it’s not bariatric surgery. It’s very complicated surgery. They should stay more, but there is market on it.

Speaker 1 (00:45:19):

Yeah, it’s not good. Yeah, the packages, I’ve heard about the packages. Okay, here’s a good question. So this patient sounds like they have chronic pain after their hernia pair. They went back to their surgeon, they did some nerve injections, they had MRIs, they had suture site injections. Nothing seemed to help. There’s no consensus as to why they have the pain. And so no surgical option was provided and then the patient was sent to pain management for spinal cord stimulator. What’s your reaction to that?

Speaker 2 (00:45:55):

Yeah, actually it’s important to distinguish the original pain. Is it neuropathic origin or non neuropathic? If it’s neuropathic origin, yeah, I bypass that kind of is complicated interventions performed by the ologist. So pain spaces. So I prefer to go to neuromectomy way. It’s proven already. So good outcomes with the neurectomies. So yeah, hopefully we have too much open cases. So we don’t see much chronic pain in the open cases. So in laparoscopic surgery, if chronic pain neuropathic, it’s very complicated to proximal neurectomy, triple neurectomy. It has side effects such as bulging. It’s an important issue. So

Speaker 1 (00:46:58):

I personally, I’m not a fan of a spinal cord stimulator until, yeah, me too. Everything is completely ruled out. And for most patients with hernias, unless you’ve had all the nerves caught and the Mesh removed, there’s no indication for a spinal cord stimulator. Spinal cord. There’s a lot of need for,

Speaker 2 (00:47:23):

It’s not selective as well. It’s not selective.

Speaker 1 (00:47:27):

So I would tell this patient to seek a second opinion from a real hernia specialist. They can call me for the office, go to Cleveland Clinic. a lot of the people that I’ve interviewed on Hernia, Talk, Live specifically about chronic pain, those would be a good option to see before you commit to spinal cord stimulator. Because spinal cord stimulator doesn’t cure you of anything. It just treats your pain and only treats really nerve pain. It doesn’t really treat hernia recurrence.

Speaker 2 (00:48:04):

Yeah, also, or

Speaker 1 (00:48:05):


Speaker 2 (00:48:07):

I see some patients coming with the ejaculation pain. This ejaculation. Yeah, it’s also, it’s hide under the chronic pain. Spinal, yeah, spinal

Speaker 1 (00:48:18):

Cord stimulator.

Speaker 2 (00:48:20):

Yeah, it’s another part of the chronic pain. There’s also the urologists are not aware of that origin of pain after the hernia repair. So I do sometimes and was degeneration, so scar xs or sometimes do hybrid operations do laparoscopic proximal cut off the gen internal as well. It’s a combination of surgery.

Speaker 1 (00:48:59):

Some people they have, they’ve had a hernia repair and then they have urologic symptoms like testicular pain or ejaculatory pain, pain with intercourse and they’re sent to the urologist. I’ve had patients have their testicles removed. I’ve seen them have spermatic cord denervation procedures, nuerectomy, all these things. And what they had was let’s say a hernia that could have been fixed or they had some Mesh related complication. So I work with urologists that understand Mesh and hernias and what happens upstream can cause problems downstream, but there aren’t that many urologists that work with general surgeons that way.

Speaker 2 (00:49:44):

Basically the nerves are sensory that goes to the region that does not innervate the testes. The testicle is different innervation. It’s somewhat sensory nerve is very different. So it has some roots from the pudendal nerve. It’s also innervated, the autonomous nerve plexus inner the testicles. So

Speaker 1 (00:50:17):

That’s it’s nerve. But there are nerves around the vas that can be injured from Mesh or manipulation by surgery that can cause testicular pain. And then so do you think it’s appropriate for a patient to come up with a plan first and show up or should they have an idea of what they think they need before they go in to the surgeon?

Speaker 2 (00:50:47):

So if you mean that the patient indicate his or her repair to me and I apply to the patient. If it’s not, I don’t do that actually. So if it’s not a good decision for the patient, I reject, I sometimes reject the patient.

Speaker 1 (00:51:14):

I feel the patient stress. They have to know everything before they come to the office. Otherwise they’ll get wrong information or something.

Speaker 2 (00:51:23):

For example, if they prefer they don’t need any Mesh. So I do tissue repair, but I inform about a slightly increased risk of recurrence rate and the chronic pain. So the Mesh does itself not the reason of the chronic pain in most instances. So some patients don’t want general anesthesia because the minimal invasive of surgery requires general anesthesia and I don’t like applied the spinal anesthesia. I don’t like, actually it’s because of the complications. So I do local anesthesia and repairs, late time Mesh repairs and tissue repairs, most in cases. So in elderly patients. I also prefer the open surgery in some instances because there is this thing that in some people with mentally problems, dementia started to do, yeah, yeah. Alzheimer’s. So anesthesia may speed that. So I do the local anesthesia, but in step-by-step, first I block the nerve with the ultrasound guided local anesthesia. I do ultrasound myself and go, it’s always successful.

Speaker 1 (00:52:55):

Yeah, I completely,

Speaker 2 (00:52:56):

It’s a day case surgery.

Speaker 1 (00:52:58):

Yeah, I completely agree. So how do patients find you or contact you for a consult? Can someone from the United States come see you or even talk to you before seeing you? Or how do you,

Speaker 2 (00:53:12):

The complex ones is coming from other surgeons. They, they’re referring or they find me through the internet in some cases comes from the other. My patients they refer. So from some people coming from Google, I have websites. Oh really? Really? Yeah, they come. But if facilitate the connection easily, such as we have a WhatsApp line, so they can easily text me, they can share the pictures and emails. So it’s easy to go wow conversation.

Speaker 1 (00:54:03):

That’s really great. And what’s the way, oh, here’s a question. Let me ask, oh, this is a very specific question. Can the genital nerve and puedendal nerves be blocked under ultrasound guidance? I have been told you need CT fluoroscopy with radiation exposure. Yeah, of course you could do ultrasound guidance. I do genital nerve blocks with ultrasound guidance all the time.

Speaker 2 (00:54:32):

But the potential nerve is very low. I don’t know, it’s not in our region actually. It’s probably, it’s going out from the L four S one pudendal

Speaker 1 (00:54:44):

Nerve. It’s sacral. Yeah. So for pudendal nerve, there’s a posterior approach? Yeah, there’s a posterior approach and anterior approach. I don’t do pudendal nerve blocks, but urologists tend to do it from anteriorly and I don’t think they use, maybe they use ultrasound and then posteriorly pain doctors can do it. They don’t use CT fluoroscopy at all. They may use fluoroscopy, but they also use ultrasound or they do it anatomically based on,

Speaker 2 (00:55:16):

I do diagnostic block to genital nerve from both from proximal in the region, but just for the diagnosis temporarily. So I don’t do any permanent block with injections

Speaker 1 (00:55:33):

Like ablation.

Speaker 2 (00:55:34):

I prefer surgery. I prefer surgery.

Speaker 1 (00:55:37):

Yeah. There’s no good study to show that

Speaker 2 (00:55:41):


Speaker 1 (00:55:41):

Population or any of those have any better or worse outcome than surgical neurectomy. I try to look for it because we’ve published our study on Neurectomy to see the neuroma rate we found found if you prophylactically cut a nerve, the neuroma rate in our study was 0%. But if you have a pain issue like a nueroma, yeah, then your risk of neuroma, again, it’s not 4%. So I don’t know if it’s lower with ablation. I don’t know. There’s no study that shows what that rate is. Someone needs to do that study. So you’re coming to Austin, will I see you in Austin for the American Hernia Society meeting?

Speaker 2 (00:56:32):

Yeah, I’m coming on Wednesday. Yeah.

Speaker 1 (00:56:37):

Yeah, me too. I’ll be there Wednesday to Sunday. So

Speaker 2 (00:56:41):

There is something to see there. It’s not like Barcelona but

Speaker 1 (00:56:47):

Should investigate. Maybe our audience can tell us what to do in Austin.

Speaker 2 (00:56:53):

Yeah, you’re going to see that

Speaker 1 (00:56:55):

It’s in September, so it’s going to be hot still.

Speaker 2 (00:56:59):

It’s Texas. Yeah,

Speaker 1 (00:57:01):

Texas hot is no joke. And they have mosquitoes

Speaker 2 (00:57:09):

On Sunday. I came to Madrid in Istanbul. It was hot. It’s also in Madrid. It was raining when I landed here and when I opened my phone I got the message alert message from the information that says it’s the fluid alert in Madrid because of the heavy rain. Oh wow. Yeah. Oh interesting. Now it’s good. Yeah.

Speaker 1 (00:57:36):

Okay, good. There’s been floods all over the world it seems. Yeah. Okay, well I look forward to seeing you in person again. Yeah, me too. We hung out at the European Hernia Society meeting in Barcelona, so that was very cool.

Speaker 2 (00:57:52):


Speaker 1 (00:57:53):

Enjoyed that. Although I’m told that the other cities in Spain are much nicer than Barcelona. Is that true?

Speaker 2 (00:58:00):

No, Barcelona is better. Oh, Barcelona. Yeah. Madrid is good. But I visited two museums here. Reina Sofia, I’m very interested with the Picasso mural. Picasso, yeah. Yeah. In Madrid in I visited Reina Sofia and the museum there were huge amount of Picasso and middle, it’s too much. If you compare to the Picasso museum in Barcelona, it’s much, much from here. Here is better in Madrid.

Speaker 1 (00:58:43):


Speaker 2 (00:58:44):

So last one I didn’t visit yet is in Malaga where Picasso was born.

Speaker 1 (00:58:51):

Oh yes.

Speaker 2 (00:58:53):

Probably it’ll be next year.

Speaker 1 (00:58:55):

Malaga. Next time that will be a vacation. Vacation, not work.

Speaker 2 (00:58:59):

Good place.

Speaker 1 (00:59:02):

Okay. Any final comments about what patients should ask in their initial consultation when they show up? They should show up with questions, right, and concerns. I think

Speaker 2 (00:59:18):

In short, if they ask the surgeons expertise on the topics, so it probably covers all about other things. So the patients should ask their surgeons to have time to discuss everything, the most important things before. So to turn off everything before the surgery is very important.

Speaker 1 (00:59:44):

That’s true. So in some physical they should let the office know they have questions, they should come with questions like write written down.

Speaker 2 (00:59:53):

They should prepare before it come.

Speaker 1 (00:59:56):

They should ask if there’s non-surgical options. They should ask about surgical technique and outcomes and expected recovery. I also tell them what to do between now and surgery in terms of pain control or activities, that kind of stuff. And I think it’s important to know how much of the surgeon’s practice is dedicated to hernias and even hernia complications because that gives you a little bit of, a little bit of an idea as to how much they enjoy hernias as opposed to it being part of their general. Yeah,

Speaker 2 (01:00:31):

Totally agree with that.

Speaker 1 (01:00:33):

Okay. Well that was very fun. This was a great session with my friend Hakan, Dr. Gök from Istanbul. I hope to come to your country. I know I’m giving a talk in November because I can’t make it to Istanbul this year, but yeah,

Speaker 2 (01:00:49):

You miss this time.

Speaker 1 (01:00:51):

I know.

Speaker 2 (01:00:52):


Speaker 1 (01:00:53):

I need to plan

Speaker 2 (01:00:54):

Ahead time. You know that Yuri Rad and

Speaker 1 (01:01:02):


Speaker 2 (01:01:03):

David, yeah. They are coming together. They will stay one day in Istanbul. We are together. We will hang out there. Yes, yes. Tour and the grand, but two topics there.

Speaker 1 (01:01:18):

I need to plan it ahead of time so I can make time to untraveled. Yes. So that’s it for us on Hernia Talk Live. Thank you to everyone for joining us. It was wonderful. As you know, you can watch this again on my Facebook page, but also on my YouTube channel at Hernia Doc where this and all prior sessions are listed. So please do subscribe to my channel. And as you may have heard, I have a podcast now. So Hernia Talk Live is also a podcast. So if you prefer the podcast kind of way of listening, do subscribe there. And that’s available on Apple Podcast, Spotify and all the other ones. See you all next week. It’s going to be a great one. Again, thanks for everyone for showing up and participating and I’ll see you next week. And thanks Dr. Gök. Appreciate it.

Speaker 2 (01:02:12):

Thank you very much for having me there. Bye.

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