Henria specialist at Cedars

Episode 157: Being Thankful | Hernia Talk Live Q&A

You can listen to this episode by clicking here.

Speaker 1 (00:10):

Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live. We’re here on a Tuesday of Thanksgiving weekend. My name is Dr. Shirin Towfigh. I am your Hernia and laparoscopic surgery specialist. Thanks to everyone who follows me on Twitter and Instagram at Hernia Doc. Many of you’re joining me on a Facebook Live right now. I can see you at Dr. Towfigh. And also, as you know, we have a podcast, Hernia Talk Live, as well as our YouTube channel at Hernia Doc where you can listen to and watch respectively. All of these amazing episodes we’ve had we’re almost reaching 160. I’m super excited about that. I never thought in my wildest dreams that I would have a show, let alone about hernias, let alone a podcast, and so many of you are following through with it. I’m super excited about that. So as I mentioned earlier, we are in the Tuesday of Thanksgiving weekend and specifically I would like to dedicate this episode to just being thankful.

Speaker 1 (01:21):

I am so thankful to all of you because as you know, this podcast started as something for me to do while I was not able to provide elective care at the hospital or even in my city of Beverly Hills, we were shut down during the pandemic and I knew that there were tons of patients out there that had questions about their hernia and or required care that they weren’t able to get because there were too many, much sicker patients that needed to be addressed in the hospitals. And so I came up with the live version of hernia talk.com, which many of you are members of. And so I’m very thankful that those of you that were members of Hernia talk.com have remained loyal to the website and the forum since 2013, believe it or not, thousands and thousands of members and we just recently revamped that website and I’m very thankful to all of you who are still on the website and are giving us feedback on how to improve each of the little forum opportunities and so on to make your ability to discuss and communicate with this free discussion forum as efficiently and effectively as possible.

Speaker 1 (02:46):

And now we even have a podcast that is basically an offshoot of our live hernia talk. So I’m so grateful to everyone who like me finds hernias to be of interest. And of course the real question is, how thankful are you for your current situation? I in general am a very optimistic person. When I speak to my patients, I give them hope and it’s not fake hope. It’s real hope based on my experience and I don’t like to tell patients that there’s no hope for them or there’s nothing we can do. And a lot of the patients that I see are already told there’s nothing to do. I recently saw a patient who has been suffering for a couple years and saw tons of surgeons and physical therapists, urologists, pain management specialists, they’re all kind of circling around a topic and problem that they didn’t know anything about, which is pain after hernia repair.

Speaker 1 (03:56):

And they treated him like the typical patient that they thought would have pain after hernia repair. One surgeon just got imaging and it’s like, oh, your hernia repair looks fine. There’s nothing we can do. Send him to urologist. Urologists did what urologists do, which you look at the testicle and the spermatic cord and did a bunch of injections and said, maybe you have epididymitis, gave him antibiotics, didn’t get better, maybe it proselytized, gave him another antibiotics, didn’t get better and told him nothing you can do until he finally got to pain doctors. The pain doctors got to the point where they’re like, well, we blocked all your nerves. We can’t figure out why you have pain because of course you didn’t have nerve pain. And they said, well, we’re just going to give you a spinal nerve stimulator, which I am completely against. For almost every patient that has groin pain or pain after hernia repair, it is not the solution.

Speaker 1 (04:48):

So he was very grateful because he finally came to me and I was able to figure out what the problem is. It’s a rare problem, which is where your mesh and your spermatic cord interact in a very long segment. That’s usually because the Mesh is either placed too low laparoscopically or robotically. And anyway, long story short, there’s treatment for it and there’s tests for it. He needed an MRI. He had never gotten the right MRI. He needed an injection between the mesh and the spermatic cord, which I do under ultrasound guidance. He had never had that done before and for two years he’s just been suffering. So he was very grateful and really wanted a hug for me and I didn’t know if I should hug him. And towards the end, he kind of literally said, may I have a hug? So I gave him a hug Anyway, so I’m very grateful that I can help patients like that and I love that there are grateful patients out there as well.

Speaker 1 (05:51):

So I give thanks to those of you who refer patients to me understanding that maybe I can them hope and I thank you to you patients who come to me in search of answers and are grateful for the amount of help that I can provide to you either for free on these forums or actually asking for a specific personal consultation with me. So I’ll stop talking a little bit because there’s questions coming in, but I just want you to know that it’s been a great journey starting my own hernia center since 2013 has been a dream come true and I’m validated in my mission every single day, either by you all or by research that I do that gets published or newspaper articles that are written that talk about what I do or I already mentioned the research products, but any advancements that we do in care, it’s all because I’ve been able to focus on hernias and I’m in a situation where I have the freedom to do everything that I like to do with it without a lot of the restrictions that a lot of my friends and doctors have and surgeons have when they’re in practice.

Speaker 1 (07:17):

And I’m just very grateful to be in a position where I can determine exactly how much I want to do with hernias and my ceiling is wide open. It’s limitless, and I hope that you see that as well. So here’s some questions. We’ll go through them. There’s some others that have been provided ahead of time. I hope you have time for all that. Let’s see, let’s just jump right into it. Psoas muscle and SI joint. So sacred iliac joint issues replicate inguinal Hernia symptoms. Yes, I have a small inguinal hernia and so has problems and my doctor’s conflicted as to what is causing the lower abdominal pain and groin pain. He thinks it’s pain referral and my surgeon wants to operate. Okay, this is a great, great question because in December we will be launching hernia score. I want you all to go to hernia score.com, H-E-R-N-I-A SCORE.com.

Speaker 1 (08:20):

The website’s not up yet, but it will be soon. We will be launching this algorithm where people like you who have psoas muscle problems, psoas impingement syndrome is one of the problems or SI joint problems with maybe a small hernia and no one can figure out what you need. So this will tell you the percentage chance that an inguinal hernia repair will solve your groin pain problem. It’s hernia score.com or the Hernia score. So to answer your question before that algorithm is available to the public specifically SI joints can cause inner thigh and testicular pain, but mostly groin pain and inner thigh pain and it can wrap around to your lower back. And if you have something called ankylosing spondylitis, which is a type of sacroiliitis, which is an SI joint disorder, which is often seen kind of Scandinavian country origin patients, if you’re genetically prone to the Scandinavian, there’s a blood test for it called the HLA B 27.

Speaker 1 (09:37):

If you have that, you can have sacroiliitis, which is an inflammation of SI joints and that can cause groin pain rating to your inner thigh. It is not a hernia problem. You have to get the pain addressed in your back. Usually with injections, imaging can show it. Sometimes the pain comes and goes often so you don’t have it all the time. However, specifically a small angle hernia, and I like that you wrote small because I think that’s where the conflict is. One of your doctors at least is like this is a small hernia that can cause your pain. It’s too small to cause the pain, not true. If I pinch you a little bit versus a big bit, it’s actually going to hurt more if I pinch a little piece of your skin than if I pinch a big piece of your skin. So the same is true for hernias.

Speaker 1 (10:28):

We often see that inguinal hernias are more painful when they’re small and more visible when they’re large, and most people are used to treating the larger visible hernias which are not that painful, and therefore they discount the pain that a smaller hernia may have not true. What does inguinal hernia have? First of all, if that’s the cause of your pain, then your pain is activity related. When you’re bending, coughing, lifting, standing up for a long time, sitting for a long time, it gets better when you lie flat, which is not true for the SI joint and so problems, it doesn’t affect your gait, whereas psoas impingement syndrome does.

Speaker 1 (11:13):

You may have pelvic floor spasm problems with urinary frequency and rectal pain and pain with intercourse. So there’s a lot of factors and your pain may be not only into your inner thigh but wrapping around your lower back and into your testicle or vagina and so on. So specifically, the history is very important, not just the fact that you have a hernia or not, but what are your actual symptoms and then that’s why the hernia score is so highly validated and effective. I hope that’s helpful for you. I’m a big fan of figuring out groin pain and whether it’s due to your hernia or your psoas impingement syndrome or labral tear or hip disorder, femoral acetabular impingement, there’s so many things that can cause groin pain and this hernia score that’s coming out is going to be a game changer because your doctors can put in the answers to your questions in there and it’ll spit it out.

Speaker 1 (12:18):

You can go online and put in all your symptoms and it’ll give you a score. So it’s really, really great. Thank you very much, Paula. I wish you could one day come to South Africa. Thank you. I do too. South Africa, I do have a friend there in South Africa. She’s great. But yeah, I would love to go to South Africa. It’s on my list. I have a friend who’s Tanzanian and I hope to go visit him and his family there. I have friends who go to Nigeria every year for hernia. Not really hernia, but a lot of it’s hernias, so they want me to go there to treat hernias and I would love to do that one day. I wish you would come to Minnesota one day. Minnesota’s not really on my list. South Africa’s, Minnesota, but maybe you can come see me from Minnesota. If I do come to Minnesota, I’ll let you know. How’s that? Let’s see. Would be great if you could cover Inguinal and femoral hernias in women. Yes, we have had a couple of Women’s Hernia episodes early on. I would say the first year we did a lot of women’s hernias and we did a femoral hernia episode.

Speaker 1 (13:34):

If any of you have watched Real Housewives of Beverly Hills, I was on it for like two seconds and that promoted a lot of discussion about femoral hernias because Denise Richards had bilateral femoral hernias that I repaired for her and they kind of showcased it on the show. But my point is we did specifically go over femoral hernias and also hernias in women in the earlier episodes. If you want to go either my YouTube channel or podcast, it’ll be there. Let’s see what can happen if I’m not, oh, on similar note, what’s really amazing about our hernia score, another plug for it is it is equally sensitive and accurate for men and women. So there’s virtually no good studies on women for inguinal hernias. All the major studies really have been on men, but this is the first real robust database that includes over 40% were women, so that’s going to really help the data analysis and reliability for women.

Speaker 1 (14:51):

There is a CR app, C-E-D-A-R called cql, C-E-Q-O-L. It’s an app you can download by the Carolinas Institute that predicts the risk of chronic pain after inguinal Hernia repair, but it’s only limited to men and it’s therefore not helpful for women. And as well women are considered higher risk for chronic pain. But it’s interesting and I do share it with my patients sometimes. Let’s see what can happen if I’m not treated and not monitored by a doctor. What can happen to me since I’m not seen by any doctor in my country? Currently I’m having sharp pain and my stomach is growing.

Speaker 1 (15:36):

What you have sharp pain and your stomach is growing? Well, if it’s growing because there’s something intestinal in there that needs attention, then of course you need to go see a doctor. If it’s growing because your Hernia is growing and because no one is paying attention to your needs from a hernia standpoint, that hernia will continue to grow and the larger it grows, the more you are at risk of having what’s called loss of domain. What is loss of domain? So loss of domain by definition is when more than 50%, so more than half of your intestinal contents are outside your abdominal cavity because they’re pooching out due to a Hernia. That is a very difficult situation because in order to fix your hernia that 50% that’s out needs to join the other 50% that’s in and we have to close your abdominal wall over that, which means if your body’s not used to having all your intestines inside and now we’re trying to shove it back in, that may not be possible.

Speaker 1 (16:40):

Your belly may have contracted to a point where it’s used to having very little intestines in place and therefore Hernia surgery is complicated. So I agree with you that maybe you don’t have someone near you who can effectively treat your Hernia. However, I highly recommend you do get it treated because the longer you allow a large abdominal hernia grow, the more difficult the hernia will be and the worse the outcome. So higher recurrence rate, higher infection rate, higher length of stay for the hospital, higher chronic pain rate, and so on. So when you get to a point where your hernia is so big that it’s interfering with your quality of life. A great study which we reviewed with when Dr. Fitzgibbons was one of my guests when we talked about watchful waiting, he specifically wrote a paper that showed that if your hernia is nine centimeters wide or larger, so about four inches or wider or larger, then watchful waiting is not recommended as in your case because the quality of life is dramatically improved when you repair hernias that are that big.

Speaker 1 (18:06):

And so that’s very important to know though. We talk about watchful waiting for small belly bone hernias for small groin hernias. Once it gets that big, the quality of life is dramatically improved if you address and don’t let the hernias get larger over time. Let’s see, please come to Australia. There are limited Hernia surgeons and I have been to many and all have mixed opinions. I would agree with that. There’s a handful of hernias, sorry, a handful of lemme talk this again. There are a handful of surgeons in Australia that we know of and each of them has their own approach and their own specialty within hernias. So one of ’em doesn’t do laparoscopic, does open surgery, one of ’em does mostly laparoscopic robotic surgery but doesn’t really do revision surgery. My point is you’re absolutely right. You don’t have a very broad range of surgeons in Australia that do complex abdominal wall hernia surgeries.

Speaker 1 (19:07):

Now it’s growing and there’s a growing interest of hernias all around the world, including Australia. But you’re right, and as you know, many Australians tend to travel for healthcare as well as other things because you’re kind of isolated out there in your own beautiful island, which I would like to visit one day. Let’s see, I’m seeing a hernia consultant tomorrow regarding inguinal and femoral hernia. Anything I should ask? As I know they are all likely to want to repair it with Mesh, which as you know, I’m not keen on. Okay, so all inguinal hernias and femoral hernias as long as they’re small to medium can be repaired without Mesh. Specifically inguinal hernias can be repaired without Mesh the hernia.

Speaker 1 (20:05):

If you’re a good candidate and if your surgeon is very knowledgeable and skilled. So you don’t want to just go to any surgeon who doesn’t know how to do any repairs with tissue and say, I don’t want Mesh, I want a tissue repair. But if you look at a really good tissue repair and a really good mesh repair for inguinal hernias, not femoral for inguinal hernias, and you’re kind of a low risk patient then, and by low risk, I mean you’re not morbidly obese, you’re not smoking cigarettes all day and coughing, then really either of those repairs should be fine. Femoral is a different beast. So femoral hernias are not common hernias. Fortunately, when they do occur, they happen to occur more likely in women than in men. And what can happen is the femoral hernias are very complicated because they’re the only hernia that really truly has a severe mortality rate. You’re more likely to die from a femoral hernia than any other hernia in terms of risk of death. So you really want to get a good femoral hernia.

Speaker 1 (21:20):

You really want to get a good femoral hernia repair. Now how does that happen? The best femoral hernia repair is a femoral hernia repair with mesh that’s laparoscopic and a posterior repair, so laparoscopic or robotic with mesh. Now, there are lots of different types of meshes. It doesn’t have to be polypropylene mesh. There are polyester meshes there. In Europe, there’s PVDF meshes, which is very well liked. Also, there are biologic meshes that are hybrid meshes that have some polypropylene or other product in it, not a hundred percent synthetic. And so those patients who are reluctant to have mesh and have a good size femoral hernia are well treated with laparoscopic or robotically with these hybrid meshes. Now, it is possible to do a tissue repair for femoral hernia. Again, small to medium size, not good idea for a large size femoral hernia, but the McVay type repair, which is a tissue repair specifically addressing femoral hernias can be performed.

Speaker 1 (22:27):

And again, in order to get the best outcome from a tissue repair, you must go to an expert who does these often, and there are several in Europe that do a lot of good tissue repairs including the McVay repair, and that’s what you would want to do. However, if you choose a non mesh repair, understand that the risk of its recurrence in the best of hands is at least the same as mesh or more than a typical mesh repair, and therefore you must be open to a mesh based repair if the hernia recurs after a tissue-based repair. So I have this discussion with all my patients, yes, I can do your tissue repair. Yes, you’ll have a good outcome. You’ll have 97%, let’s say 95% chance you’ll do great, but in that smaller chance that you do recur, you must be open to having some type of mesh based repair.

Speaker 1 (23:29):

Again, there’s different types of meshes, but there will be patients that recur from a tissue repair and then at that time you have to have that discussion. So let see, they refuse to treat me. This is in South Africa. They say if they operate on me, I’ll die. The me attached. Now I’m left with a septic Mesh and a Hernia. That is completely not acceptable. If you have sepsis or infection, that Mesh needs to come out. If you are sick from an infection, that Mesh needs to come out. You can die if you have sepsis or infection from mesh. If the mesh is stuck to your bowel, then that’s a reality of yours that your surgeon needs to address. There is a great surgeon in South Africa that perhaps I can refer you to. Maybe she’ll be open to helping treat you and I’m blanking on her name, but once I remember her name, I will mention to you to see if maybe you should see that surgeon.

Speaker 1 (24:34):

Let’s see. I would love to come to the United States and see. Well, thank you very much. I would love to have you. I was told I have three. This is another viewer. I was told I have three more hernias, but I’m afraid to have surgery with mesh and a plug again, I went in, yeah, you shouldn’t have a plug. That’s not an option. I went in for an injection and for my painful in hernia and the doctor couldn’t find where to inject. He said, I only have one layer to my abdomen and there’s supposed to be three layers. Is that correct? I have a big stuck out abdomen. Okay, so what you’re referring to are is somebody trying to do a nerve block or some type of abdominal wall injection in your oblique? You should have three layers of oblique muscles. There’s the external oblique, the internal oblique, and the transverses abdominis. Those three layers, everyone has, you’re not missing three layers. You have all three layers. If you had a complex abdominal wall reconstruction where one of the layers has been released from the other two, then I can imagine that looking at it with the ultrasound would be weird. If you are elderly not in good shape, your belly is very distended. Those three layers may be very thinned out over time, but it’s not like you’re missing those three. You’re not born without those three meshes.

Speaker 1 (26:09):

Okay, it looks like you guys are talking to each other. That’s great. Oh, Australians are talking to each other. Fantastic. Thank you Shirin. We’ll definitely take your advice on board tomorrow and seeing them. Great. Okay, so, oh, sorry, there’s some live questions I missed. Are there ever any patients that you cannot help that need to get a neuromodulation device? Yes, very uncommon. Those are definitely what I call end stage patients. Those are patients that only those patients that have a nerve problem, that have exhausted all neuropathic options, including neurectomy, including nerve ablation, including nerve blocks, as well as a evaluation from neuromas. But Mesh problems, meshoma mesh infections, mesh adherence, Mesh related problems are not treated with any type of neuromodulation device and I don’t recommend it at all. It’s just a very kind, sloppy way of just saying, oh, we’ll just do a nerve nerve stimulator on you and not understanding the reason why the patient has the pain is it has nothing to do with their nerves here.

Speaker 1 (27:32):

Can the sacral plexus cause groin suprapubic pain? No. If limited to the SAP pubic area and no other pain locations, no sacral plexus has nothing to do with the suprapubic abdominal wall. That’s usually L one. So it’s high lumbar, not even lower lumbar. So the sacral plexus has everything to do with the rectum, the clitoris, the penis, but not the abdominal wall at all. Alright. I’m 81 years old and I did have some of my colon removed many years ago. Would that caused me to have only one layer of my abdomen? No, you may have a hernia, but you’ll still have the abdominal walls, layers, specifically the obliques. Now if you had a colostomy or something through or an incision through your obliques, and by the way, colostomies are usually not placed through the obliques, then that’s something to consider as a problem, but that’s really a hernia issue. It has nothing to do with you missing any abdominal wall.

Speaker 1 (28:46):

Okay. There are some questions also that I got that were related to. Let’s see, let’s go live here and I’ll share my screen so you can see some of the questions that were sent to me. What are the aspects of modern hernia surgery that have seen the greatest improvement? What is your contribution to these improvements? Well, thank you for that question and trying to follow our theme today, which is being thankful on the Tuesday right before Thanksgiving. So I’m very thankful that I am living in a part of my lifetime where not only am I seeing advances in hernia surgery, but I’m also able to contribute to those advancements. So how is that? As many of you know, I have a special interest in making sure that populations that are not getting adequate care get adequate care. One of ’em is women. Women have tended not to be in any large patient population studies. Their hernias are not considered real, and often women are told their pain’s all in their head and they have chronic pelvic pain. And so I actually fund an annual award every year to promote research that is done looking at specifically at gender-based factors and female factors in hernia surgery. That’s number one. That’s through the American Hernia Society.

Speaker 1 (30:18):

I also think that patients need to be better educated. We’re in a situation where we weren’t in decades ago where patients are highly educated, they ask good questions, they read, they have access to the internet, and I would like to fill the internet with as much positive and accurate information as possible because as you know with the internet, there can be people that just say incorrect things and leave patients astray. So this comment that you will die if you have your mesh removed is not true for 99.9% of patients out there. Also, I do believe that we are overusing mesh, and that’s just something that I’ve been part of in my training where I saw that happen and we need to bring that pendulum back towards more towards the middle where we judiciously use Mesh as needed and then we also have situations where mesh may not be needed.

Speaker 1 (31:22):

There’s a lot of new technologies such as laparoscopy and robotics that have come by and I’ve developed a non mesh repair for robotic surgery as a means to add minimally invasive technology because up until now all the tissue-based repairs for the groin have been open, like shoulder and McVay, Bassini, Dasarda, all of those are open repairs and now we have an option for minimally invasive repairs without meshing the groin. And then I’m very grateful and thankful that over time, although it’s been a slow process over time, we now have meetings where women are part of the panel. We no longer have panels filled with men only for hernias. We used to call them mans.

Speaker 1 (32:15):

We are moving away from that very happy that we have dedicated sessions only to female hernias. Last year’s European Hernia Society meeting in Manchester, the most popular session which I headed was standing room only in a medium to large size conference room that fits about a people. We probably had close to 200 people in there just jam packed sitting on the floor and everything. It was amazing and one of the most productive sessions talking about women’s hernias and also this whole push towards patient advocacy and really listening to patients. We now have the European Hernia Society has patient advocates on their board. We have the American Hernia Society adding patients on their boards. We have meetings and sessions where we include patients in our panels to talk about these things. So I do see that some of my advocacy and what I talk about and so on is a little bit different than the average hernia surgeon.

Speaker 1 (33:29):

I don’t go off there giving big talks about hernias that I’ve repaired. It’s mostly these other things and I’m glad that my society finds that useful and that they’ve integrated that into their toxin. I’m very grateful that I have had an influence in it and believe it or not, I’m kind of now one of the more senior people. I used to be one of the youngest people in the hernia society now I’m one of the older ones, which is kind of nice to see that there’s this hierarchy and I like that I have residents and people that I train who are now interested in hernias and there are jobs available for people with hernias, so that’s great. Here’s a question. Good evening, Dr. Towfigh. At what point or circumstances a Hernia mesh plug should be used? Never. Never. I recently had a right angle Hernia with a plug which has been causing pain in the region, inguinal pain and discovered, yeah, if you go through the European Hernia Society guidelines, there’s absolutely no reason to do any repair with a plug.

Speaker 1 (34:39):

The plug is available, it is on the market. It is being sold by multiple different companies. Specifically, the perfect plug is the most common one being sold by Bard or now Becton Dickinson or bd. There is absolutely no reason to put a very, very thick, large mass of mesh in anyone. A perfectly flat piece Mesh, a flat piece of mesh is perfectly fine for all hernias. We don’t need to plug the hole. That’s not the way Phasix works. So one of the reasons why we say we should not do not recommend the plug is because exactly what you’re saying, the plug is a very big ball of mesh. It’s unnecessary. It’s like putting a pebble in your shoe so you can have a pebble in your shoe and walk and not even know there’s a pebble there. But if the pebble lands exactly where your feet are in the shoe, that’s going to be very painful.

Speaker 1 (35:34):

The same is true for hernia repairs. If you do an inguinal Hernia repair with a plug mesh, it can cause pain in the region and guess what? The plug is placed adjacent to your spermatic cord because that’s where the hernia is. And guess what? Now you have the plug against your spermatic cord, which is nerves and vessels going down to your testicle and taking sperm back to your prostate. That’s going to cause testicular pain if that’s the cause of your pain. This plug, the only way to remove it similar to a pebble in a shoe, is to remove the plug. You got to remove the pebble. And so yes, if it’s causing you discomfort and pain, please see a specialist who does this for a living who takes out these mesh plugs. I just took out two last week if you can believe it, and I’m just tired of it.

Speaker 1 (36:27):

We need to stop selling these products and I don’t know how we can do that. I think you guys are doing it by suing the companies and forcing ’em to stop selling it, but they won’t stop selling it because if they stop selling it now they’re admitting that it was a bad product. But even the European Hernia Society guidelines have said, no mesh plug. Can you please do a letter for my country to help me get help? Please? I don’t see how that works. You just need to see a surgeon within your country or travel outside your country. I have a recurrent hernia after Mesh removal due to a car accident. After my experience with Mesh and learning that surgeons in not Australia don’t have limited skill sets and knowledge of mesh complications, I’m afraid to have the new hernia repaired and if I choose to have it repaired and after having complications with mesh previously, I don’t want mesh.

Speaker 1 (37:22):

And I’m curious as to how you would say to and which treatment options you would offer the patient in this position. So I do have patients like you that have complicated hernias, car accidents, these are traumatic hernias. You cannot do a traumatic Hernia without mesh. It’s just not possible. You just don’t have the tissues available for it because you’ve torn those tissues. So in patients like that, you must use mesh. The way I approach it is what is your reason for not wanting Mesh? Is it because you had a bad Mesh experience? Let’s review that. Why did you have a bad Mesh experience? Was it because the surgeon put a plug in you which they shouldn’t have? That’s the surgeon’s decision and the mesh manufacturer’s decision, we’re not going to be putting a Mesh plug in you. Is it because you had a mesh before and then the mesh got infected?

Speaker 1 (38:15):

Well, there are meshes that are less likely to be infected that can be used. Is it because you had mesh in you before or someone that you know of had chronic pain or you’ve been on all these forums or people are talking about chronic pain? Let’s assess that. Why do they have chronic pain? Was it because the wrong mesh was used? Was it the wrong surgical technique was used? Was it they had a hernia recurrence? Was it actually too little Mesh was used and therefore it was tearing in them? There’s a lot of reasons why people can have problems with mesh, but do you understand that there are certain situations that traumatic hernia being one of them, an incisional hernia being another one where a non Mesh repair is just not the right decision and you’re causing even more problems and more complications by not choosing mesh.

Speaker 1 (39:05):

Your problem is you’re thinking of mesh as one single product. There are a million times of different meshes, different weights, different pores, different materials, different amount of absorbability and so on. So go to a surgeon who understands what’s out there. I’ll give you an example. There’s a recent, if you’re a female, you’ll understand this example if you’re not, I’m sorry. So have you heard of what’s called red bottom shoes? It’s by Christian Louboutin. It’s a French designer. He makes these shoes for men and women actually, but it’s most popularly for women, and the bottom is red. It’s a very specific red to his design. These are the most uncomfortable shoes you’ll ever buy, and they’re also very expensive. They’re around a thousand dollars, oftentimes more than a thousand dollars just for a pair of shoes. So people buy these shoes. I’ve tried these shoes on in the store. I’ve never bought one it’s very uncomfortable to the point where I’d rather have a brick shoe than that shoe. It’s literally that uncomfortable. I don’t understand why anyone buys it, but it’s become a designer thing and maybe people that are thinner or have narrower feet or slimmer feet or way less, I don’t know, can wear it. It is notorious for being very uncomfortable.

Speaker 1 (40:34):

People still buy it and people still sell it, and it’s just a thing. Now, you could be someone who was wearing a Louboutin shoes and you can say, that was a most uncomfortable pair of heels I’ve ever had, and therefore I will never wear heels ever in my life. Okay, that’s based on your experience with these red bottom Christian Louboutin shoes that are very uncomfortable. There are other brands and other sizes of heels and even flats or et cetera that maybe leather may not be leather, whatever the situation is that are perfectly comfortable. But for you, based on your one experience, and then talking with everyone else who’s had Louboutin shoes saying, oh yeah, so difficult, so the most uncomfortable, they tore my feet, I got blisters, et cetera. You’re like, okay, everyone else I talked to who wore low Bhutan shoes also had these problems, and therefore all shoes are horrible. Not true. So that’s how I want to kind of change people’s minds. As a surgeon, we have a limited amount of things we can do with your body, and sometimes we need to bring help with an implant, and there are different types of implants.

Speaker 1 (41:56):

If you have a knee that has zero cartilage left, your surgeon’s going to say You need a knee replacement. I cannot make you more cartilage. If you have a little bit of cartilage, you can start injecting the knee to encourage more cartilage or at least a walk without pain. But if you’re bone on bone with no cartilage, that knee needs to be replaced. No amount of injection or pain medication is going to help you. I hope those two analogies kind of give you a little bit of a sense of what I’m talking about. Here’s another one. Inguinal hernia, tons of nerve damage and pain. Doctors are giving blockers to stop pain not working because you may not have nerve damage. Not all inguinal hernia repairs cause nerve damage. In fact, most do not. Most people who have hernia pain, it’s because of the Hernia recurrence or a mesh problem.

Speaker 1 (42:56):

It’s not a nerve problem. So no amount of nerve blockers is going to help Go to a doctor, not a pain doctor. Go to a surgeon who is a hernia specialist who understands the hernia repair that was done, who understands how to look at imaging, how to examine you, and therefore help figure out the puzzle of why you have pain after your inguinal hernia. This is very interesting. Shirin, my GP referred me to hernia consultant because they said inguinal and femoral are more serious in women. Well, femorals are more serious in women. Inguinals, it’s about the same. The question is, do you also have femoral, which is something that all women should be surveyed for at the time of their hernia surgery?

Speaker 1 (43:41):

If you have imaging, that’s a good way to rule it out. If you don’t have imaging, it must be figured out during surgery. Thank you for your answer. Is removal of this hernia plug lead to greater effect or damages to the spermatic cord and nerve damage? Well, it depends. Typically, that’s a risk. Removing the meh plug can injure nerves and can injure your spermatic cord. Part of how much injury depends on how big is the plug, how intensely it’s irritating or impinging or eroding into your spermatic cord, your vessels and your bladder and the skill of your surgeon. Those three factors will determine how complicated the surgery is. But most that undergo mesh plug removal are super happy, like taking that pebble out of your shoe, taking out the Mesh plug, and then we’ll recreating your groin hernia. Here’s the one who’s very thankful. Thankful for the knowledge, care, and expertise of you and your staff.

Speaker 1 (44:48):

Oh, I appreciate you. In fact, I have your CD on my desk right now. Once I will get to it and I will report back to you after Thanksgiving. Here’s another question. How can you diagnose a special kind of recurrence of an open hernia, sorry, of an open repair, which you described as caused by mesh pulling away from the inal floor. If it is not seen on MRI, does this require diagnostic laparoscopy, Mesh pulling away from the AL floor? So mostly history. Also with imaging, you can see the mesh pulling away from, there’ll be a space between the mesh and the inal floor, or if you do bare down views, so like Valsalva or bare down views where you push out and you see a disproportionate bulging of that Mesh. That’s another way to tell. What type of mesh do you recommend for a patient with a recurrent symptomatic, but small indirect inguinal hernia via laparoscopy? What type of mesh? Oh, it depends on the patient and depends on the girth of the patient. So if it’s a small indirect inguinal Hernia, a lightweight mesh is usually what I would recommend. But if it’s recurrent and you’re an obese patient, then I would do a heavyweight mesh.

Speaker 1 (46:07):

I had left inguinal hernia surgery with Mesh and plug in Minnesota and had horrible pain when we went to Arizona. Five months later I had surgery to see why I had so much pain and he took out my Mesh and plug. Oh, good. And replaced it with a new mesh plug. Oh geez. I’m in horrible pain every day. Oh, no, this can still be fixed. My surgeries were eight years ago and now I have three more hernias and I’m afraid to have surgery. I was going to come to see you when we went to Arizona, but some druggies burned down our house down. Okay, good news for you. Good news. For those of you who are in Minnesota, Rochester, Minnesota, you have the Mayo Clinic, we now have a new surgeon in Mayo Clinic who is a very gifted surgeon. I have interviewed her on hernia talk. Her name is Charlotte Horn, H-O-R-N-E in Mayo Clinic. I highly recommend you go see her and see if she can help you.

Speaker 1 (47:03):

She’s a very gifted surgeon. I’m very glad Mayo Clinic has her because otherwise they don’t really have anyone there for hernias. That’s an expert. How can you diagnose a special kind of recurrence of an open repair? Oh, you already answered this. My mesh broke to my pubic bone later found out I was double meshed. It was removed and sutured, but I have nerve pain. Nothing works. Any advice other than pain doctor? Yes. So if you have valid nerve pain, you may have had a nerve injury, but now you have what’s called a neuroma, which is a bawling up of the nerve. It’s like a very hyperactive nerve. No amount of nerve blocks can help with that. So if that’s a diagnosis, then surgically, your surgeon can go in and do a neurectomy, but first they have to find that neuroma and diagnose it. Let’s see.

Speaker 1 (48:00):

Hello Dr. Towfigh. If doing a tar, which is a transversus Abdominis release, is the transverse abdominis only released in the area of the hernia closure, sort of like a partial tar. In other words, if I have an incisional hernia that is closer to the bottom portion, but why at the top does a transverse abdominal get released for the whole length of the Hernia? Even if a lower portion could be connected without Yes, yes. You don’t have to release the entire transverse Abdominis because that may make your abdomen too loose or make your contour abnormal. Now, there are surgeons that would do that. They’ll just do the whole length of it, regardless of how wide your hernia is. I don’t do that. I tailor it based on how wide your Hernia is.

Speaker 1 (48:47):

Here’s someone else. Hi Dr. Towfigh. I’m heading your way very soon for surgery. Yay. We’re going to be repairing bilateral femoral hernias. Yes, we are. I’m very active and do a lot of physical work, but now I’m worried as I didn’t realize femoral hernias were quite so serious in women. Is there anything I should limit or be aware of until I am repaired? I’m so glad I finally got to catch you live. Thank you very much. So yeah, just be careful that if you have any bulging that you always are able to push it back in and we get a repaired. It’s the people that don’t ever know they have hernias and sometimes older patients that end up in the emergency room and those that end up in the emergency room and have a serious problem, 5% die. So it’s very important. I’m glad we’re fixing you because it’s a lifesaving operation in your specific situation.

Speaker 1 (49:40):

But yeah, if you have any severe pain or problems, you should definitely not ignore those symptoms. Yes, I understand your analogies, but I believe it was a mixture of both. A reaction to the Mesh and surgical technique. As you stated previously when I questioned whether the mesh being buckled was a surgical error or design flaw, if the mesh removed was 10 by 15, does that mean I’d need a bigger mesh? Yes, and if I had a reaction to the mesh initially, wouldn’t I’d be more susceptible to triggering more autoimmune responses? Yes, that is true, but then we would not choose to use a mesh that would trigger you. There are sub meshes specifically that I have found are very well tolerated in people that have mesh implant illness. First, we have to confirm you indeed have mesh implant, and if you did, there are some mesh products that I have used that have been very well tolerated in most patients.

Speaker 1 (50:34):

Happy Thanksgiving. Yes, happy Thanksgiving. I’m so thankful I found you and you offer such great services to those of us not living in the United States. Thank you very much and I very much look forward to seeing you and operating on you. I wish and pray I get the help I need for my kids’ sake. Yes, I’ve done everything to get help in South Africa. I’m not getting help. I’m in hiding because I’m wanted dead because I blew the whistle on us being implanted without our consent with mesh. Oh my Lord, are you for real? I’m now not treated by doctors because I’m speaking up for my patient’s rights. I’m living with me plus or hernia. It’s hard. I can’t even raise funds to leave my country. I’m even getting help from Shane and other friends to get by with food stuff. Oh my Lord. So you need a sponsor of some sort. By the way, there are some charitable organizations for hernias that come to Africa. I don’t know if they come to South Africa, but you may want to reach out to them to see if they would be able to help you.

Speaker 1 (51:37):

Thank you so much for your expertise in answering my questions regarding mesh plug removal. May I be your patient in the future? That’ll be great. I’m happy to help you start us. May I recommend to start an online consultation? Don’t bother flying in to see me necessarily. Especially if your funds are limited. You want to focus on getting the best care you can and I can maybe sometimes help you get care near you, but my point is many pages I just recommend. Get an online consultation. Send me your stuff. I’ll review it for you, send it back to you, and then if you want an in-person consultation, we can move forward that way. I went through neuroma and neurectomy. I’m still in pain. Then that was not your problem. Then you need someone to help figure out the puzzle. If you went through a neuroma and that did not help you, then you have something else that is causing your pain.

Speaker 1 (52:31):

Again, if you want to reach out to me, I can help figure that out through an official online consultation. I like to add that I’m grateful for my journey for coming across your channel and learning so much from you and others and advocates. I love this. Thank you for sharing your thankfulness. I’m grateful that you do speak up and are creating awareness about complications both with mesh and surgical techniques. I’m also grateful for all you do to help other guide others. Let me tell you, I’m very, very, very happy with the fact that I go to meetings now and patients are involved in our sessions. People are talking about patient advocacy, including myself, and this whole issue of thinking about the patient’s benefit is actually integrated into the meeting is not kind of taboo or like, oh, that’s so silly. We don’t have that attitude anymore.

Speaker 1 (53:24):

When I first started talking about patients and I’m like, oh, I got this website hernia talk.com, and I’m seeing all these patients talk and I’m on these Facebook forums and you guys need to hear what they’re saying, and I was kind of brushed off as not being serious surgeon or something like that, and it was not considered something that a whole society would take on, and now it’s a complete 180 and I love that and I love that. Part of it is I think because we have a younger generation of surgeons involved, more open-minded and not so hierarchical. And also part of it is we have more women in our society which are more open to listening to the emotions and feelings of patients as opposed to how to fix a hernia. And I’m just really grateful that I was able to stick through it and not leave the society because I’m like, you guys are not listening to me.

Speaker 1 (54:23):

Eventually I was able to bring surgeons into discussing patient related stuff. Wow, great session. So many people chiming in. Yes, this is true. a lot of people chiming in. I love it. Really, really love it. Both live on Facebook and also on the Zoom, but mostly on Facebook. This time you help so many people with their questions giving us all confidence and seeking help and repairs. Happy Thanksgiving and thank you and thank you and have very happy Thanksgiving to you all. Let’s see, pain blockers didn’t help enough to get a shock stimulator doctor wanted me to have one implanted. Yeah, I’m not a fan. Most people, they need, maybe it’s a mesh. Have you even had your mesh removed? I, and if so, how did they fix your hernia? These are all questions I need to know.

Speaker 1 (55:24):

Thank you for your advice about Rochester. Doctor. My son lives in Rochester, so I’m going to check it out. Happy Thanksgiving. You made my day. You’re welcome. This is new news, new fresh news. I think she’s not starting until December. I think she doesn’t see patients until December. But Charlotte Horn, Mayo Clinic, Minnesota and go on my YouTube channel at hernia doc or listen to the podcast, Hernia Talk Live and look at the episode with Charlotte Horn. She’s great and she’s the surgeon that just moved. I’m very thankful for you and your staff on my journey to healing. Thank you. We’re not done with you yet.

Speaker 1 (56:11):

I’m also thankful you found and took care of my neuroma. Yes, I did. Yes I did. I was very happy about that. I feel a lot better and more sleeping at night. Let’s see. I love that my prior patients or current patients all come on this site. That’s great. Having had the pleasure of meeting you in person, you’re certainly a one-off for patient engagement and thorough information. Thank you. Thank you. It’s been my pleasure. My trip to the UK was life-changing. I plan to come back. Do you fix possible ileal injury from C-section or hypermobility of pubic bones since birth left pubic bone shifting upwards, causing left agro tendinitis. So I do treat ileal or ilio hypogastric nerve injuries, which we see after C-sections. Usually it’s a crash or a very large baby with a very wide C-section where the nerve may be adversely injured at the time of the incision. I do not do the orthopedic part, which is the stabilization of the pubis. However, those two operations can be combined in one if you would like.

Speaker 1 (57:21):

Okay. Yes, the Mesh was removed and sutured. Okay, so the problem may be you’re suturing. So I have seen people who have Mesh removed and then they’re sutured, but they don’t get an official hernia repair like a Shouldice or Bassini. They just get a sutured. So really what they have now is a hernia recurrence, but no one’s discussed it with them. So they feel like nerve type pain or groin pain or activity related pain and shooting pain. And what they really actually have is a hernia recurrence because the nerve was cut and the mesh was removed and the hernia that’s left behind was not repaired adequately.

Speaker 1 (58:00):

That was a lot. We did so many questions this time. The full hour went by that. I’m so grateful to all of you that came in. We had a huge number of people chime in on a Tuesday before Thanksgiving of all places too. I’m so impressed with you guys. I thought you’d all be on vacation or something, but I know that you’re not. And like I said, I’m very grateful to you all for being here and joining me every week. Some of you I see over and over again. I will be enjoying my Thanksgiving with my family. I hope you all do the same too. And don’t forget to follow me on social media, on Twitter X and Instagram at Hernia doc on Facebook at Dr. Towfigh. If you’d like to just chime in with others on hernia talk.com. We have a new website and form that we are improving to meet your needs. Hernia Talk Live is on YouTube at Hernia Doc all of our prior episodes or you can listen to it while you’re driving or wherever you like to listen to podcasts on the Hernia Talk Live podcast. I would love for you to subscribe, keep up with all of our sessions. Have a wonderful, wonderful Thanksgiving. I love you all so much. Don’t remember, do travel to get the best care you want and I’m available if you want to travel to see me. Have a great weekend and I will see you all next week. Take care everyone.