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Speaker 1 (00:10):
Hello. Hello friends of Hernia Talk Live. How are you doing? Today is the first time I believe, I’m pretty sure first time in the past four years that Hernia Talk Live is falling on Halloween, so I thought I’d dress up for the occasion just a little bit. I’m dressed as a hernia surgeon with a little bit of a orange flare. We didn’t do the full dressing up at the office thing. We do a big Christmas but not Halloween. I don’t know. For whatever reason, we don’t do much for Halloween. Do we just have lots of candy in the office? Anyway, welcome to Hernia Talk Live. I am your host, Dr. Shirin Towfigh hernia and laparoscopic surgery specialist. Thanks everyone for spending your Halloween mid evening, maybe late evening with me. Those of you that are here as a Facebook Live, hello, thanks for being there at Dr.
Speaker 1 (01:11):
Towfigh and also for those of you that are here via Zoom, thanks for coming. As you know, this and all prior videos archived of Hernia Talk Live are completely on my YouTube channel at Hernia Doc. And don’t forget, we also have a podcast, so I think we’re up to episode 70 uploading our podcast. We’re kind of slowly uploading it so that you all can catch up if you’re on the podcast route. Again, Hernia Talk Live is the name of the podcast. So listen, I’m super excited about Halloween. We have an hour or two discuss all the scary hernias, scary spooky hernia problems that you may have many of you have already written to me. So I have some of those to talk about. I’ve had certain patients of my own that I want to scare, that I want to share that are scary, and so that’s the plan tonight and then afterwards I’m going to go trick or treating and hopefully you all can enjoy your evening as well. So yeah, I thought I’d expand on the whole scary Hernia thing given that it’s Halloween and try to be a little bit cute about it. So here’s the thing.
Speaker 1 (02:29):
I could have an entire show just dedicated to the stories that I hear in my office alone every day that I see patients, which is about three, sometimes four days a week. I hear a scary story after scary story and the reason for it is that in some respects I have retrospective vision. I see what was done, I hear what the decision making. Sometimes I cringe when I hear about it because I know what the next problem’s going to be and then they exactly have that problem. But I’ll be honest with you, my specialty is I see people after the problem often, and so they say hindsight is 2020 and it is true because if you talk to the surgeon they have before, so let’s classic scenario, I saw a patient that had a complication and was sent to another surgeon to deal with that complication that was addressed. They had a hernia recurrence and the next surgeon that dealt with their hernia recurrence did the exact same thing that was wrong with the first surgery. They just repeated it. Again, to me that makes no sense. Why would you repeat the same exact problem that you knew didn’t work with that patient the first time? You’ll do it again the second time. That makes no sense to me. So I spoke with the surgeon because it’s a friend of mine.
Speaker 1 (04:14):
When you hear their side of the story, the other surgeon’s side of the story, it kind of made sense. The way they were seeing it at the time and the way they were interpreting it at the time is different than the whole story that I was seeing. So I thought it would be nice to share some stories and hopefully use this hour to have you all ask me questions about maybe your scary hernia stories, but also for me to share what I see and maybe there’ll be a thread of, there’ll be some feeling that you relate to it maybe, and hopefully we can have a dialogue where we kind of understand things that may happen, things that shouldn’t happen, et cetera. So yes, happy Halloween to you all. Okay, so the thing that scares me the most and I think is the scariest thing are men who lose their testicles.
Speaker 1 (05:15):
Can we just be frank about that? I think that is the worst situation is losing your testicle. So can it happen from a groin hernia surgery? Yes. Should it happen? Usually not. Does it often happen? No. It’s very, very, very uncommon to actually lose a testicle as a result of any Hernia repair. This was actually a question that came up on hernia talk.com as well this week, which is the risk of losing a testicle. So the testicle gets blood flow from five different ways and it starts from way back in pelvis all the way down towards the scrotum where there’s all these different blood flows. So it is possible but not probable that all of those blood flows will get injured somehow as part of a hernia repair. It should pretty much never happen for an open, I’m sorry, for a primary inguinal hernia repair.
Speaker 1 (06:20):
It should also pretty much never happen with a laparoscopic or robotic repair because you’re addressing the hernia very far away from the testicle and there’s so much other blood flow mechanisms that can get to the testicle that there really should be little to no risk of losing a testicle with a first time hernia repair if done laparoscopically or robotically. The closer you get to the testicle as the area of your operation, the more blood vessels are at risk of getting injured and the less blood vessels there are to the testicle I should say, and therefore the risk of injuring that may potentially affect blood flow to the testicle, but the testicle is very hardy. Even then you should not be losing your testicle with the first hernia repair. What can happen, which is what some people call losing their testicle, but it’s not truly losing their testicle, is you can reduce blood flow to the testicle that is most common with if it happens, which it doesn’t happen too often, but if it does happen, it’s more likely done with open surgery and specifically open surgery with mesh because that’s a situation where you can actually block and erode into vessels and so on.
Speaker 1 (07:53):
Also, the larger the hernia, like these huge scrotal hernias down to the knee, those often have compromises to blood flow to the testicle, but what can happen is not so much that you lose a testicle, but that the blood flow to the testicle is compromised and so you have less blood flow to the testicle and then the testicle shrinks as a result. So you have a smaller testicle on the side of the hernia. Those usually do not require removal. It’s really if the testicle is dead and dead like dead like that as opposed to dead over longer period of time. Only then would you need to remove the testicle because you basically have dead tissue. Again, very, very uncommon. Now if you have revisional surgery, so you had an open surgery and another open surgery and then mesh removal and then mesh put in and then laparoscopic surgery and et cetera.
Speaker 1 (08:50):
If you’ve had multiple operations each time you operate, a little bit of the blood flow to the testicle may be affected and then over a span of 2, 3, 4 hernias, you may get reduction in blood flow to the testicle or even no blood flow. We had a patient, let’s see how many operations, I think you had three. You had three hernia operations. One was an open, I think it was an open Lichtenstein repair or maybe it was a mesh plug repair. Then he had a second operation where the plug and patch was removed and he had a laparoscopic repairs, a third operation, and he may have had another operation as well. So by the time he got to me, he had zero blood flow to his testicle. He had no pain, maybe a little bit of pain, but it wasn’t his main problem. Very little pain and the discussion was you have basically a completely non-functional testicle.
Speaker 1 (09:50):
Do you want to leave it in or do you want to take it out? And there’s really no indication to take it out. If it’s not bothering you, you may want to take it out because you don’t want to feel this little walnut of a testicle or since we’re planning on operating anyway, then we offered him to remove it. Here’s a question. What about the problem of testicle and squirrel sac lying lower than preoperatively and how low is worrisome? Great question. So that can be a scary thing too. So you go in to have surgery come out, your testicles are no longer symmetric. Usually the situation is the testicle retracts up and is entrapped in scar tissue at the spermatic cord higher up in the groin region, and the testicle in its natural state is higher than it was before surgery. Those are very hard to deal with.
Speaker 1 (10:44):
I actually to ask the patient to just massage the testicle down, especially in the early phasix to break up some scar tissue, but sometimes you have to just release it from the mesh and then the testicle will fall down again. The reverse problem is actually scarier, which is when the testicle drops and drops very low. The reason why it doesn’t drop low naturally is because the cremasteric muscle is a muscle that’s like a tube that surrounds all the blood vessels and spermatic core that gets to the testicle and that tube is this muscle and when the muscle contracts, it pulls a testicle up and when it relaxes, it allows the testicle to fall down. But if you cut that muscle and injure it in a way that is completely dysfunction is completely gone, or if you cut the nerve to that muscle, which basically makes the nerve dysfunctional, sorry, the muscle dysfunctional, then what can happen is you have no muscle tone at all and the test will completely drops down and it can be pretty severe.
Speaker 1 (11:51):
There are situations where that testicle can fall down so low that it touches a toilet bowl, and that’s like the scrotum hits the toilet bowl water. So that’s kind disgusting and very difficult situation that you don’t want to have. Now there’s treatment for it. You artificially pull the testicle up, kind of like a breast lift, but it’s a testicle lift, similar in concept, but what is worrisome is if it’s fallen down so low that it affects you in some way. The worst scenario, the scariest scenario would be if it actually touches the toilet bowl water. The other scenario would be the way that fallen testicle now interacts with the other testicle in the same scrotal sac. There have been situations I’ve seen who’ve come to me where the testicles are so disparate, they’re not side by side anymore, but they end up stacking one on top of each other and they get stuck that way. That’s very discomforting. And then lastly, if it’s fallen in a way that it affects the way you sit can be a problem. So those are really good points and I would place testicle issues kind of top on the list because they’re very difficult situations. They’re hard to handle and to treat, and it is what it is.
Speaker 1 (13:19):
The other really, really spooky, scary, difficult problem is derivation injury. So injury of the nerve. So we talked about injury of the blood vessels specifically to the testicle, but what about injury to the nerves? And that specifically can be the most likely the abdominal wall. So we’ve had a couple episodes before where we talk about this, but what can happen is you can have injury to the nerves, to the muscle and the muscles get fed by those nerves. So if you don’t have nerves feeding the muscles, those muscles basically are no longer functional. It’s kind of like if you have a paraplegic, those are nerves that are cut or injured to the muscles, so you can’t walk anymore and you’re wheelchair bound and you’ve seen people that are wheelchair bound due to paraplegia where their legs are just super thin, the muscles have no tone. The same thing can happen to the abdominal wall.
Speaker 1 (14:19):
So what can happen is the abdominal wall then loses its function. Now if you have a really highly functioning abdominal wall, then you have a nice flat belly, you’re very muscular, you’ve got the six pack and the less functional your abdominal wall, the bigger the belly. Well, we see that with people that are not fit right? If they’re not very fit, they’re not really using their muscles very well and they get a rounded belly. Well, that can also happen if the nerve is injured. So let’s say you have an injury to the nerve, to the abdominal wall muscle, that specific nerve only, that specific nerve will result in paralysis and therefore, what’s the right word? Protrusion of that specific muscle group. So if you have one nerve that’s injured, then that one muscle area that nerve is responsible for feeding will loosen up and bulge out, and it’s a very disfiguring difficult problem.
Speaker 1 (15:32):
We see it most commonly with operations that are done in the flank area where the nerves can get injured. Typically they are kidney operations, aortic aneurysm operations, or any other kind of weird or spine operations where those nerves aren’t injured and there’s no good treatment for that. There’s no way to, well, okay, I take this back. There are certain situations by highly gifted surgeons who can add nerve and innervate those muscles by bringing a nerve from another area and feeding that area. How they do it, I don’t really know. We have a surgeon at Cedar-Sinai and I hope to work with him for some of these patients because it’s a very difficult situation, but that is kind of the situation. So the question is how can you determine if your bulging is due to a denervation problem or the nerve has been injured or due to a diastasis?
Speaker 1 (16:44):
The diastasis is a completely normal abdominal wall functioning abdominal wall. The muscles have just pulled apart and there’s a thinning in between the muscles and that thinning is in the middle of the abdominal wall. So it gives you kind of a rounded belly and when you get up, you get a pooching out of this area. It is very different from denervation, which is limited to a single muscle group or series of muscle groups to which the nerve was feeding. It’s usually one sided, not both sides. So you get to see a very asymmetric abdominal wall where one side is bulging and the other isn’t. Here’s a question. I have a hernia that has returned for the third time close to my groin and testicular area if it hasn’t gone any worse in three years, but it is painful at times. A doctor said it would be complicated to do surgery and I might lose the testicles, so I’m afraid to get it repaired.
Speaker 1 (17:45):
Again, the question is can I leave it or should I get it fixed? So I hear this all the time when patients are told they’re going to lose their testicle, and as I mentioned earlier, it’s really, really, really rare and not expected to lose your testicle. I don’t know how many operations, I don’t care how many operations you’ve had, the risk is there, but it’s a fraction of a fraction of 1%. So there are so many other risks that I often don’t even tell my patients about it, or if I do, it’s really in the higher risk patients because it’s not an expected risk. People often tell you, you may lose a testicle because they don’t do a lot of these operations and they’re worried that they’re going to injure the testicle or the blood flow to it. So if you’ve had a third time repair, you definitely want the fourth one to be perfect, and if your hernia recurrence is causing you pain or in any way affecting your quality of life, I would recommend repairing it.
Speaker 1 (18:54):
Make sure however that you repair it in a manner in which it would bring you the best outcomes. And that means figure out with your surgeon, do a forensic analysis of why your last three operations failed. Was it because you were obese because you had COPD because you smoke, use nicotine because you have a chronic cough? Was it because you’re coating, constantly straining? Do you have a collagen disorder? Is there a diabetes that’s poorly controlled? Are you doing certain physical activities that make you more prone to hernia recurrence and the hernias were just not repaired. With that in mind, what kind of technique was used for the repair? Did you have Mesh repair if there wasn’t mesh repair? Did the surgeon use too small of a mesh or didn’t fixate the Mesh or not? I tell you, I was recently at a meeting and when I go to hernia meetings, it’s all surgeons or surgeons that are interested in hernias, and so we’re very like-minded and we speak the same language I should say, but sometimes I go to meetings where it’s a general meeting, it’s not a Hernia society meeting or a laparoscopic group meeting, but it’s a meeting of general surgeons from all over the world are general surgeons that take call for emergencies.
Speaker 1 (20:25):
So they’re a little bit jack of all trades and not specialty in hernias, but they understand that they should learn about hernias. So it’s a very different audience, and when I give talks to those audiences, I understand that the way I talk and the terms I use need to be downgraded to the level of my audience because we use a lot of acronyms and we assume a lot of things at these hernia society meetings that we really can’t assume the surgeon knows at a more general meeting.
Speaker 1 (20:59):
So I was recently at a meeting and I gave multiple talks and one of the talks was, oh, one of the sessions wasn’t even a talk. I was helping moderate a session on videos and these are all hernia videos and some of the videos were really great, just these fascinating, really rare hernias or very unique techniques and really nicely done. But let me tell you, there were a handful of videos that were put up there and I was just getting chest pain. I was like, are you serious? I can predict the recurrence rate right now. I can predict the complication. There’s big scrotal hernia, and they didn’t fixate the mesh with permanent fixation there. They didn’t deal with the scrotum, but the potential for a hematoma aroma, there was another one where it was just they chose the wrong Mesh, they chose the wrong technique.
Speaker 1 (21:54):
They didn’t use wide enough of an overlap. They use absorbable mesh in a very, very difficult area where recurrent hernia would be really hard to repair. They were operating and doing an operation not understanding that this patient needs to have an operation that will not recur because this is such a difficult area that to have already to fix the Hernia is very complicated in this area, and then now you’re going to potentially make the patient have a complication or recurrence and the patient now has to deal with that with another surgeon. So that was scary to me. I literally texted one of my friends and I said, I don’t ever want to moderate these sessions again because I’m getting chest pain watching these videos and these people are not specialists. They’re presenting these as if they did a really great job and it wasn’t a bad job.
Speaker 1 (22:55):
It was clearly not done by an expert and I was not happy. Let’s just say that I didn’t like it and I wasn’t in a situation where I could spend a half an hour on each of these videos explaining to the audience how much better thinking and better planning and better surgical technique could have been done. And it’s the reality out there that there’s a lot of surgeons that are really good surgeons, but maybe for hernias they’re not thinking in the right direction or they’re considering one aspect but not the other and they just want a pat in the back for doing a great job and you’re like, that wasn’t a good job. So I don’t how to explain it. I just feel that I felt really conflicted because I wanted to take over the session and take every single one of those videos and explain to them how it could have been done better.
Speaker 1 (24:00):
And yet at the same time, that was not my position. They were like 12 different videos to be presented and I gave my opinions, but my role was not to be the opinion I was moderating the audience anyway. I just felt bad about it. So that was kind of scary to me, and I literally told my friend, get me out of here getting chest pain. I know this kind of stuff happens out there where decision making may not be all optimal and there are consequences to patients about that. And of course you can’t expect every surgeon to be an expert, but to actually actively be an observer in this situation, really I couldn’t handle it. It was too much. Anyway, going back to our discussion, I think we discussed the testicle issue, right? We’re over to the derivation issue. So the issue with denervation is one is you had a, let’s say lifesaving operation or a very serious operation and the nerve was injured, so you had kidney cancer removed or an aortic aneurysm that needed to be repaired or in a more common situation you had spine surgery and the nerve was injured as prior of spine surgery.
Speaker 1 (25:28):
Oh, here’s a question. I had a recurrent Hernia repaired, but an open technique as was the primary repair. Okay? So the first hernia repair was open and the second hernia repair for the recurrence was also open. That is usually not the way to do it. Usually if you have a recurrence from an open inguinal hernia repair, the recommendation is to attack the recurrence with a laparoscopic or robotic technique. Okay, I have postoperative pain in the lower groin and left testicle not near the internal ring. I have small recurrence at the reconstructed internal ring seemingly far from the pain. How could I tell if my pain is from the repair of the inguinal floor with too much tension versus a recurrence? Well, recurrence and tension repair are two different things. So if you have a recurrence you would get, and if the recurrence is from an indirect anal hernia, you may get groin pain radiating to the inner thigh into the testicle around the lower back.
Speaker 1 (26:33):
And activities that increase abdominal pressure could exacerbate that, and that can include coughing, talking really loud bending, and so however, if you have a too tight of a repair in the groin, certain activities that increase pressure in the area can cause problems. But usually you feel a very tightness and a tearing sensation because tight things want to tear open. So it’s really a searing pain where it’s pulling in tight and tight, it’s very sensitive over the area. You usually do not have testicular symptoms. You usually do not have pain rating down the inner thigh around the lower back. You prefer to be sometimes kind of scrunched up. You don’t want anyone to touch the area, you can’t do any torso extension. Reaching up to get a cup or plate from an upper part of a cabinet will hurt. Sometimes even trying to wash your hair or comb your hair and that reaching up part can hurt, but usually it’s like reaching up high on that side can hurt and maybe going up or down hills can hurt.
Speaker 1 (27:54):
So that’s where you have to figure out if it’s a too loose of a repair or if it’s from a recurrence. Because like you mentioned, even though imaging may show you have a recurrence, you’re trying to figure out if there’s another reason besides what imaging is showing you that is causing the pain. Oh, let’s see. I had a CT scan at Cedars. It showed I have bilateral hernias of fat tissue. How do I know if I need surgery or treatment? Great question. So we had a whole episode with the leader of the major trial on watchful waiting, and the watchful waiting trial took males with inguinal hernias that were either asymptomatic, so no symptoms or minimally symptomatic. That means they had minimal symptoms. It didn’t affect their ability to do their daily job and randomized them to two groups. Half of ’em got hernia repair and the other half were watched and they were watched for five years and then 10 years, and the patients did just fine.
Speaker 1 (29:00):
So no one died because of the delay in surgery. About a quarter of them the first five years ended up wanting surgery because the hernias got bigger and or became more symptomatic. And about two, between two thirds and three-fourths by year 10 wanted to have surgery. They started getting symptoms from their hernias. So usually we go by symptoms in terms of need for inguinal hernia repair and not femoral, but inguinal hernia repair. And obviously if you’re healthy to undergo surgery, that would be an option. Let’s see. Next question. I’ve had a laparoscopic inguinal hernia repair, but it doesn’t hurt only six years later, but it affects me when I walk. Every time my feet hit the ground, it sends pain in the inguinal area. Would it be safe to have this mesh removed? Okay, so if you had laparoscopic inguinal hernia repair six years ago and now you have pain every time your feet hit, you need to not have the mesh removed, but maybe have more mesh put in you. It sounds like you may have a hernia recurrence if you feel tension and you scrunch up a lot, that can be from a hernia recurrence as well. People who have done well from an inguinal hernia repair and then six years later have a problem. It’s almost always a hernia recurrence until proven otherwise.
Speaker 1 (30:43):
Let’s see. So I bring up denervation injury because there one issue, well, the pain was evident from day one. The pain was evident for day one, but you’ve lasted six years with it. That needs maybe a bit more identification maybe and make sure it’s not like your hip. That’s the problem. Okay, talking about denervation injury, the reason why I brought up was there’s a recent article by recent, I mean this week in the New York Times, and raise your hand if any of you read this article because I have immediately been bombarded with texts from patients and other surgeons about this article. So this is an article by the New York Times. They interviewed many of us surgeons, including myself because there was a research project I believe out of University of Michigan, which showed that in Michigan there seems to be an uptick in the number of component separation operations performed.
Speaker 1 (31:56):
And it seems that these operations are being performed not by experts, which is really how they should be done because it is a complex abdominal wall reconstruction. And I have published papers with my colleagues specifically looking at what operations should are best done in the hands of an expert for ventral hernias and doing a component separation, including abdominal wall reconstruction is absolutely an indication to have surgery by a specialist. But what this study seems to have shown is that not only is there an increased number of non-specialist, her surgeons doing these operations, but as a result, there are patients that are harmed because surgeons are dabbling in performing major abdominal wall reconstructions. They go to a meeting or they’re on YouTube or they read about it or they go to a dinner conference and there’s a surgeon or someone who’s promoting the operation and then they’re like, oh, okay, let’s do it.
Speaker 1 (33:06):
And then they do it. I personally have had many, many surgeons, many who have never done more than just maybe one or two centimeter hernia repair of the belly come to me and say, oh yeah, I’ve got this lady, so I’m just, just put the hernia back together again. I’m like, wait, this is not a routine Hernia. It’s eight centimeters, 10 centimeters. It’s complicated. There’s loss of domain, whatever. There needs to be a lot of thought into it like, oh, well, yeah, sure, I just put together and I am like, no, this needs a thoughtful plan of care. You got to go through all the risk factors and look at their, you need imaging to move forward to do your planning. And then they would say, oh, it’s not that hard. It’s just a hernia, right? It’s just a hernia. And then they start talking about how hard can it be to go in there and you release some tissues and blah, blah.
Speaker 1 (34:10):
So what happens is, first of all, I put a stop to that. I can’t believe you guys are just discounting this hernia repair is just a hernia and you can fix it because you really need to know your anatomy. But that said, this article seems to or has interviewed multiple patients where that’s exactly what happened is they went to a local surgeon who is not a hernia specialist, that surgeon offered them an operation they’d never done before or perhaps they had done it before, but it’s really not their thing, and therefore they ended up injuring the patient’s nerves as part of the operation and in injuring those nerves. Now the patient looks pregnant, the patient has one side of their belly is more distant than the other. The patient has what’s called Mickey mouse hernias, which means you no longer have hernias in the middle that was fixed.
Speaker 1 (35:08):
Now you have two hernias on the sides, kind of like the Mickey Mouse caps from Disneyland. And these hernias or derivation injuries are not very easily treatable. Many of them are not treatable at all. You end up just looking pregnant for the rest of your life. And if you’re young or if you’re frail, that can have a significant impact. Now carrying basically a sack of intestines around that has no trigger to it, no strength to it, it becomes very heavy and so on. And then it gives you back problems in addition, and it gives you digestive problems. You get chronically constipated and bloated. It’s very uncomfortable. Sleeping is uncomfortable because your belly kind of flops around. Going out is difficult because when you sit, it’s all lays on your legs and it causes leg pain. It’s a horrible, horrible complication. So this article, it’s interesting, the New York Times would have any interest in it, but hernias made it to the New York Times.
Speaker 1 (36:16):
So they talked about how there’s an epidemic of surgeons offering component separation operations in settings that are maybe not indicated. So small hernias or by surgeons that don’t have necessarily the gift to know how to do it because they don’t understand an anatomy, they’re not really clued in on things, they’re in the wrong plane and they end up injuring nerves. So my point is this denervation injury is very, very scary. There’s very little you can do about it. It’s a horrendous complication. The patients are often debilitated by this. It can affect your quality of life as well, and there’s virtually nothing that can be done with it for it. And and the point of the New York Times article was to kind of shed some light on this, and if we as surgeons are not policing our own peers, then maybe the New York Times can start shedding light on it.
Speaker 1 (37:28):
I started having patients call. I saw a patient within hours of me reading the article. I had a patient in the office who definitely needed an abdominal wall reconstruction, but not the full component separation because her hernia was only five centimeters. So you don’t need a full abdominal wall reconstruction or component separation to treat that. And she said, well, what kind of technique are you talking about? I just read about the New York Times. I just read the New York Times article where they talked about component separation and the Mickey Mouse hernia. I don’t want to get the Mickey Mouse Hernia. So it’s so interesting how powerful the New York Times can be, and I’m just really impressed that they would want to talk about this topic. But I didn’t consider it a big problem until this article, and I’m thinking, oh my God, nationally, there’s a good subset of patients that are being harmed with injuries of denervation to their abdominal wall because surgeons are dabbling in doing a major reconstructive operation.
Speaker 1 (38:43):
Hernia not understanding the abdominal anatomy. And I’ve said this before, which is that for hernia surgery, we’re dealing with skin fat, muscle, fascia, nerves, blood vessels, and people don’t consider it like a very complicated operation compared to let’s say heart surgery or liver surgery, pancreas surgery, a cancer operations or lung surgery and so on. And it’s so interesting. I have friends that do, let’s say bariatric surgery, weight loss surgery, and they also take call and they end up doing hernias and they tell me, they say, it’s really hard to screw up the stomach. You can cut to the stomach, you can sew it. It heals really quickly, really fast. It’s very hard to screw it up, man. So they were telling me, man, I get so nervous if I do hernia repair because there are nerves there and there’s blood vessels and I don’t want to injure ’em and am I doing the right thing?
Speaker 1 (39:52):
And what if it’s too tight? What if it tears going to cause quality of life problems with the patient? And they’re right. Those are the surgeons that are good surgeons. They appreciate that it’s not just a hernia. And it’s really scary to me when surgeons discount hernias and they just plow through these operations if it’s not a big deal. And they do these operations where the technique is horrible, the decision-making is horrible. It’s just the wrong thing that they’re doing. And then you get these horrible complications in these perfectly well-meaning patients that get this denervation injury. So I would like you all to read this New York Times article, and maybe I’ll put the link of it into the notes, but it’s kind of fascinating to me. I’m really curious to know how you all interpret the article, because among the surgeons, there’s a group of surgeons that are very much pissed off at the article.
Speaker 1 (41:11):
They feel like it’s invading their privacy and their ability to operate, and it’s affecting how patients now see hernias and they’re going to be under much more scrutiny. I say bring it on. Patients should know. Patients should ask questions. They should understand that there are these risks. And if this article in any way helps reduce the chances that a patient will have a bad outcome, I’m all for it. I’m all for it. What are we hiding behind? That’s my take, but I’m really curious how you read it. Please read this New York Times article and let me know if you feel that the article is biased, unbalanced, or very negative, or if you think, oh, this is a good educational piece and it’ll help me navigate and ask better questions and make sure I seek better hernia care. I’m really curious. I think it’s a latter, but there’s a lot of surgeons that are very unhappy with this because they don’t agree with a lot of the comments and conclusions in the article.
Speaker 1 (42:30):
All right, we had a question that was submitted. Oh, let’s see. There was a question that was submitted through Instagram. I’d like to take the opportunity to go through that. So the question was, I had had a laparoscopic tip to eTEP inguinal hernia repair with mesh, and now I anal hernia recurrence. I was told I am the unlucky one in 1000 patient. Well, obviously every surgeon has their own hernia risk, hernia recurrence risk number. If you look at studies done by experts, it’s not one in 1000. It’s more either like five in 1000 to a one-on-one hundred where you may get a recurrence from a laparoscopic type inguinal hernia repair. It’s not one oh 1000. No one has a 0.1% recurrence risk. That’s just ridiculous. But unless they’re just operating on very low risk patients all the time, that said, there are treatments to that.
Speaker 1 (43:47):
The typical treatment of a recurrence after a laparoscopic ankle or Hernia repair with mesh is, do you guys know if you watched me long enough? It’s an open repair. So open repair with mesh would be the next best step, and that’s the clear. Here’s another question that was proposed, which is based on your experience, could you rate the following factors regarding their probability and impact in determining negative and life altering outcomes and share some representative patient stories? Okay, you know what? I love my stories. Let’s see, okay, factors that can at least to some degree be controlled before surgery. So yes, the factors that can be controlled before surgery include your weight, the use of nicotine, the muscle, your fitness, constipation, any urinary symptoms, especially due to enlarged prostate state and any asthma or chronic coughing. So those are all things that can be controlled. So if you have a pneumonia or you have a chronic cough from let’s say covid or something, yes, you can control those before surgery. If you’re a smoker or you’ve even used any other form of nicotine, you can stop that. Those are all, if you’re morbidly obese, you can reduce your weight. If you’re diabetic, that’s another good one. You can control your glucose. All of those will help you have an improved outcome. Here’s another question before I move on. Can you get denervation injury from an open inguinal hernia repair?
Speaker 1 (45:34):
Usually not denervation, you can have of your cremasteric muscle in some cases, even that’s very, very uncommon, but usually not most of the muscles that we’re dealing with, or sorry, most of the nerves that we’re dealing with in the inguinal region have pretty much lost their motor function by the time they’re anterior and in full view with the only exception being maybe the genital nerve. And even that sometimes it’s only sensory by the time it gets through the internal ring. So no, what does discomfort elicit downward? I dunno what that means. Is that a question? What does discomfort elicited downward? I don’t know what that means.
Speaker 1 (46:25):
Okay, next question. What are factors that cannot controlled that cannot be controlled? Okay, so factors, obviously it’s your gender, your sex, I should say your age. If you have a true collagen disorder like your Ehlor Danlos syndrome, it is what it is. If you have an autoimmune disorder, you can control your symptoms, but the actual inflammatory tendency in your body or the autoimmune tendency you cannot change. You also unfortunately cannot change how well you scar or how much you scar. Some patients just scar way, way too much, and it’s unclear why, but you’ll be operating on some people and it’s like beautiful tissues, everything looks good, and others it’s like rock, heart, scar, tissue, knee. It’s unclear why. Based on your experience,
Speaker 1 (47:29):
You rate the following factors regarding their probability and impact in determining negative and life altering outcomes, surgeons skill and experience. Yeah, so going back to this New York Times article, surgeons skill and experience was in many situations not there. They were saying how people would watch videos or go to a course and then start practicing on patients and doing a total abdominal wall reconstruction is a big deal operation. It should not be operated on by people with that experience. And dabbling with it can cause a lot of injury, a lot of injury. There are a lot of patients that have chronic pain or complications from their hernia repairs, and we’re not infallible as surgeons. We all have our complications. However, it really does seem that the majority of these complications as a bulk is due to surgical mishap and poor decision-making or being a rough surgeon or choosing the wrong type of hernia repair or using the wrong technique, not understanding the nuances or not knowing your anatomy.
Speaker 1 (48:46):
So that really tends to be a lot of it. I know that patients are suing the mesh manufacturers and there’s a lot of mesh design that can be improved for sure. And for sure, mesh companies are cutting corners in their manufacturing and by cutting corners, their Mesh is now harming patients and they should be liable. But many of the situations, it’s a surgeon decision making or surgeon skill problem and has nothing to do with the mesh manufacturer, and yet people go after it. I don’t know. Okay, next question. What does discomfort elicited by downward traction or gentle pulling on the testicle downward indicate? I’m going to say one of two things. If you’re pulling on a testicle that hurts, that’s probably normal. But it could also imply that the cremasteric muscle is entrapped or eroded into or somehow involved in your inguinal hernia repair up top, whether by me or by a suture. As you know, like the Shouldice technique, the way that the Shouldice clinic has modified it, they have made it so that you should be cutting your cremasteric muscle, which makes your testicle drop, and they sew the tissue repair to the cremasteric stump that can cause pain, and then they also sew up the testicle. So all of those can cause pain problems.
Speaker 1 (50:36):
Let’s see. How does a type of hernia affect the patient? Okay, so let’s talk about femoral hernias. Femoral hernias are very uncommon when they happen. They happen about 10 times more frequently in women and missing that as the reason for a hernia causes women to die, literally 5% risk of dying and women with missed femoral hernias, we don’t see that number in any other hernia repair. So not understanding that women should be surveyed for femoral hernia is kind of scary. It means you don’t understand hernia disease, and I’ll tell you, I just certified on the boards and even these herniated questions come up on the boards, and you need to know what you’re dealing with when it comes to inguinal versus femorals and women and all that. Let’s see, another question. I have to wear a Hernia belt to ease the pain when I sit for long periods of time because the pressure from the binder eases this. Is this something I should worry about for quality of life in the future?
Speaker 1 (51:55):
I mean, I don’t understand what the question is. If you’re wearing your Hernia belt because you have a Hernia and reducing, keeping the hernia reduced or applying external compression to keep the Hernia reduced helps you. Usually a hernia repair should also help you, but if you don’t want to get a Hernia repaired, you can continue wearing the truss. I don’t understand about how it affects your quality of life in the future. All hernias will get bigger over time no matter how much truss or hernia belts you wear. That’s just a natural tendency of hernias. Okay, next question.
Speaker 1 (52:43):
How do you having multiple abdominal surgeries, including recurrent hernias, negatively affect or cause life altering outcomes? I’ll tell you, having multiple abdominal operations, especially if they’re mostly causing tissue damage or tissue loss each time can make it so that each time you have a hernia is going to be even more difficult to repair. We’ll have more tissue loss and you need more component separations, more dependent on meshes and so on, and you add scar tissue. And if a bowel is involved, that makes even more difficult. So now you have bowel involvement and potential for bowel injury. And then bowel infections, mesh infections, fistulas, I mean, talk about scary. We didn’t even talk about fistulas. Fistulas are. So the testicle loss issue for groin hernias and the derivation issue, the other one, the other major scary thing for hernias is fistulas. When you have a bowel injury and now you’re pooping through your abdominal wall, and that’s often in a situation where the mesh is eroded into the bowels or the mesh is involved in infection and now it’s involved in fistula. Very, very difficult situations definitely should be addressed with a specialist. Do not try and go to your local community doctor who does breast surgery and lipoma surgery and also does these operations. Usually that’s not the right choice.
Speaker 1 (54:26):
Can weight loss cause a Hernia to become smaller? No. Sometimes weight loss makes the hernia look bigger, but improving muscle strength can make the hernia smaller because it helps support the hole and prevent it from splaying open and being bigger. Let’s see, mostly nerve pain. I don’t understand that question. Mostly nerve pain has to do with the hernia belt question. Okay, I don’t know what that means. Sorry. Yeah, if you’re having nerve pain, then a hernia belt usually doesn’t address the nerve pain at all. If your nerve pain is worse when your hernia is protruding and holding it in helps with your nerve pain, that’s fine, but really you should just get the nerve pain addressed. And if you need to call my office and seek a consultation with me, I’m happy to help you figure that out. But wearing a hernia belt doesn’t fix anything. Let’s see.
Speaker 1 (55:39):
The use of mesh, okay, how does the use of mesh become scary? Okay, so the scary part of Mesh is when surgeons misuse Mesh. So there’s a whole bunch of stool and contamination, and then they put mesh synthetic Mesh, not a good idea. Or in a really thin ballerina patient, they put a really heavy weight or bulky mesh, not a good idea. So the same way there are tailors, there’s Chanel and Yves Saint Laurent that are really great tailors, and then you’ve got H&M and some of the lesser tailors like manufacturers in certain countries like China that are just putting out high volume and low quality outfits. The same is true for hernias. You really want that tailor that understands intricacies of fabrics and hand sew techniques and are really dainty with your tissues as opposed to a tailor that’s not really a tailor, it’s just like a high volume manufacturer.
Speaker 1 (56:52):
There’s a need for both of those types of surgeons. But my preference would be every time I choose a specialist is to go choose a need for surgery. Let’s say I choose a specialist, I choose the one that’s more the Chanel, Christian, Dior Taylor, and not so much the high volume person. So that’s about it. If you have any more questions, let me know. I’m going to thank you all for joining me on tonight’s Hernia Talk. It’s spooky Halloween, and I’m going to get dressed. So for those of you who don’t know, west Hollywood in Los Angeles has a really fantastic Halloween parade. I’m going to try and get some dinner and join that parade tonight. It is awesome. Maybe you can go on TikTok or Instagram or something and find it because it’s really, really cool. So on that note, everyone, thank you for joining me.
Speaker 1 (57:57):
Thanks for all your questions. That was really fun. I hope I didn’t scare you too much because hernias should not be scary. Don’t forget, please do follow me on Twitter and Instagram at hernia. Do on Facebook at Dr. Tophi. Subscribe to my YouTube channel so you don’t miss any of these episodes at Hernia Dog. And don’t forget, I have my podcast, Hernia Talk Live. Do subscribe to that and just listen to all things hernias when it comes to all things hernias when it comes to the podcast, like driving or something on your commute or family vacation or whatever. Alright, everyone, love you all. Take care. bye-bye.
