Risks and benefits of hernia surgery

Episode 159: Hernia Surgery: Balancing Risks & Benefits | Hernia Talk Live Q&A

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Speaker 1 (00:00:10):

Hi everyone. It’s the day after Christmas Day. Welcome to Hernia Talk Live. My name is Dr. Shirin Towfigh. We’re ending 2023 with a bang, our last podcast episode of the year. Welcome to anyone who, oh, I see many of you already participating. Thank you for joining me on this Tuesday. We’d like to call it Hernia Talk Tuesday. My voice is still not a hundred percent, but it’s good enough to talk to you all. My name is Dr. Shirin Towfigh. I am your hernia and laparoscopic surgery specialist. You can find me on X formerly Twitter at Instagram at hernia Doc. Many of you are here already on my Facebook page at Dr. Towfigh via Facebook Live. Welcome, and also, as you know, this and all other prior episodes will be broadcast on my YouTube channel at Hernia Doc. And as you, I hope you know this can be seen not only on my YouTube channel, but you can listen to it as a podcast.

Speaker 1 (00:01:23):

So not all the episodes are yet uploaded as the podcast. We’re catching up with the three, almost four years of this Hernia Talk Live. But what I would like for you to do is at least subscribe and catch up on some earlier episodes. And then here we are. So I spoke to you all last week. It was my first week back from having a voice and mean a voice. Not only have a voice in hernias, but literally have a voice. So we talked about various topics. Many of you had questions, and I thought something very simple we can talk about, just kind of end the year, something very simple and straightforward, and that is to simply discuss the risks and benefits of hernia surgery. As you know, there are various different types of hernias. There are groin hernias. We call those inguinal. There’s femoral hernias, obturator hernias, Spigelian hernias.

Speaker 1 (00:02:29):

Then there’s your typical abdominal wall hernia, which includes umbilical hernia, epigastric hernia super umbilical hernias, flank hernias, incisional hernias. There’s diastasis recti, which we also talk about. Then there’s these weird lumbar ones that are very rare. That’s some weird ones down in the pelvis that are very rare, like the sciatic nerve Hernia, sciatic notch hernia. So great, what if you have a hernia, should you have it repaired? And what are the risks and benefits towards repair? So we’re going to kind of try and go through that question in as much of an algorithmic kind of simple way as possible. And for those of you who have simple questions regarding that, please just turn in your questions. You can use the chat function or just type it in your Facebook live and I’ll try to answer it. But here’s the story. Someone tells you you have a hernia, should you have it operate on?

Speaker 1 (00:03:33):

And if so, who’s? What should you be considering? So everything is a risk benefit ratio when it comes to surgery. The patients, the risk to the patient needs to be outweighed by the benefit and basically hernias or any surgery should be performed if the benefit to the patient is higher than the risk to the patient. Usually we do not offer surgery or recommend surgery. You should not really consider a surgery if it’s a high risk operation with a low benefit. That’s like buying high and selling low. That’s the worst combination, right? So what you want to do is be very clear with your surgeon and make sure that they are able to provide you with information to help differentiate the risks and benefits to you. Most hernia surgery, most hernia surgery are elective operations and therefore the benefit is usually to improve your quality of life.

Speaker 1 (00:04:35):

It’s not necessarily to save your life. So if you have surgery on an emergency basis, you end up in the emergency room, we got to take you to surgery immediately. That usually implies that the risk of not operating as high, you may die, let’s say. So in those situations, whatever benefit you get is like your life, right? And so there may be risk with the operation, but if you don’t operate, you may die. Now, unless you’re very sick to begin with or have a very short life expectancy or very old or feel that undergoing surgery is not worth it, you’d rather die. And there are patients like that. Unfortunately, there are patients that death is actually maybe an outcome that they would prefer rather than, let’s say undergoing a very high risk operation and me being stuck on a life support or having a very, very poor quality of life afterwards.

Speaker 1 (00:05:41):

I’ll give you an example. If you have a patient, let’s say with end stage cancer, they have three months to live. They have tumors everywhere. That’s a really, really sad situation. You don’t want to offer hernia surgery to them. That’s not going to benefit them. You prefer that they spend the last several months of their life at home maybe or with their loved ones and not in a hospital trying to recover. Another example would be someone who has, let’s say a ALS, right? Lou Gehrig’s disease, very debilitating, slowly progressing neurological disorder where you start to lose different functions. You eventually lose the function to breathe and then you may or may not want to be on a respirator and then you eventually some complications occur and you pass away. So in those patients, we usually do not recommend a hernia surgery. It’s usually intended to improve your quality of life, and most people that have much more serious illnesses to deal with don’t really get much of a benefit in quality of life by fixing their hernias.

Speaker 1 (00:06:53):

So those are extreme situations where regardless of the type of Hernia not undergoing surgery is probably a decision that would be made because their current standard of living is very, very poor and no amount of Hernia surgery is going to fix that. So that is where the risk benefit ratio is such that the risk of surgery, which be wasting time, recovery time pain, et cetera, is not really worth it because you’re not going to gain that much benefit if you’re, let’s say, have a low chance to live from another disease process. So that’s one extreme case. The other extreme case is a completely healthy person that has hernias and they don’t like the bulge. They keep pushing it back in and hurts them and prevents them from being active going to the gym. It prevents them from intercourse because it’s painful. It prevents them from something simple having their shirt off, let’s say, or wearing a midriff bearing outfit because they have a bulging hernia.

Speaker 1 (00:08:05):

So in those patients, they don’t have necessarily any life altering hernia, but they’re otherwise young, healthy, they would undergo surgery without really much risk to them, and their benefit may be completely psychological, not even a medical benefit. They just will look better or feel better about themselves if they have their hernia repaired. That is the complete opposite situation where you’re fixing a hernia to improve a quality of life because it’s considered a relatively low risk operation in a young, healthy patient and they would like to have the hernia repaired for that purpose. So those are two extremes. When we talk to patients as surgeons, we do two things. One is we assess the patient’s lifestyle and what’s important to them. Why do you want this Hernia repaired? Because a doctor told you you have a hernia, you didn’t even know you have no pain. You can’t even see a bulge and no one told you until you got some random CAT scan because you were in a car accident and now they say you have a hernia or you’re coming to me because it’s hurting you, it’s bulging, it’s painful, it gets stuck.

Speaker 1 (00:09:26):

You don’t like how it looks. Or let’s say part of your job, you’re either a wrestler or gymnast or a model or actor and you like to have a flatter look. Is it a cosmetic thing? So first we determine the goals of the operation. If you’re an elderly patient that’s at home and plays billiards or plays bridge or what’s the new one? Mahjong, let’s say, and you have a hernia, and oh by the way, you had a heart transplant or you’ve had multiple strokes and heart attacks before. If you didn’t really have any symptoms from your hernia and your lifestyle is relatively sedentary and the hernia is not affecting that and you have a lot of other medical problems, that’s a situation where the goal, which is to have a normal lifestyle, it’s not really being hurt by this Hernia. So you can elect not to have surgery. So let’s first figure out what’s your goal? Why are you here? You’re here because someone told you you have a Hernia. You’re here because you see your Hernia. You’re here because your Hernia bothers you and hurts you. You’re here because you’re disabled from your Hernia, right? So those are all different.

Speaker 1 (00:10:50):

That’s two things. Then the second question is, what is the implication of repairing the hernia? Am I saving your life from hernia by repairing your hernia? In some situations, that’s exactly what happens. So let’s say you have a femoral hernia. We know that if a femoral hernia ends up in the emergency room, 5% of those patients will die 5%. In our world, that’s a very large number. That means one out of 20 patients that end up in the emergency room with a femoral hernia will die. What are they die of? Sepsis, infections, bowel obstructions and so on. So repairing a femoral hernia is a lifesaving operation right now, how many of those patients with femoral hernias end up in the emergency room? That number is not as clear but’s a fair number. So that’s the situation with femoral hernia. Femoral hernias, if left untreated, are at risk of causing complications and there is a significant death rate associated with that complication. And what is a femoral hernia? Those are hernias in the groin way down in the groin. The pain is not in the groin, pain is down to the groin crease or lower like upper thigh area. Those are uncommon.

Speaker 1 (00:12:17):

They’re commonly in females, less likely males, and they’re just uncommon in general. So when you see a femoral hernia or when a surgeon sees a femoral hernia, usually we recommend surgery. Now, if you’re very elderly and in a nursing home and have dementia, then where I’m not really saving a life by putting you under surgery because the surgery itself may kill you. So that’s not usually the situation. The situation is someone, let’s say my age or younger or slightly older, that’s otherwise active that has a femoral hernia. That femoral hernia should be fixed because you’re saving a future complication and the future risk for organ damage and death. So femoral hernia is one of very few. Maybe the only primary hernia where repairing it is actually saving your life. So therefore, in most situations, the risk benefit ratio favors repairing femoral hernias. That’s not true of almost every other Hernia.

Speaker 1 (00:13:36):

So if you have any other hernia that causes pain, et cetera, for which you’ve never had to go to the hospital for it, repairing the hernia, improve your quality of life, maybe, but it doesn’t necessarily mean we’re saving your life. The exception is when you already have shown a complication from the Hernia, like an intestinal obstruction, if you have any Hernia, wherever the hernia is, and there’s a loop of intestine that’s in the Hernia, and there has been at least one episode where the loop of intestine, small bowel, large bowel colon gets stuck in there and it had to be manually released or whatever, or it cannot be released, it needs to be surgically released. Then in those situations, surgery is recommended because if you allow that to keep happening, the risk is that one day that bowel will actively get stuck, and when it does get stuck, then you need emergency surgery and there’s a complications associated with that.

Speaker 1 (00:14:51):

So if we can prevent you from having an uncontrolled emergency surgery instead deal with it while you’re still doing well, then that benefit is that we’re preventing you from having a complication. And so that’s usually a situation. So we’ll go through a couple more scenarios of risks and benefits. I have specific situations where you may have a hernia and you should not get it repaired even though you’re otherwise young and healthy, and we’ll go through those specifically because when you undergo a consultation with your surgeon to talk about hernia surgery, I want you to kind of think you would want your surgeon to think, which is what is the risk, what is the benefit and what should I do to maximize the benefit and minimize the risk in my decision? Okay, we have a couple questions coming up, so let’s go through that real quick.

Speaker 1 (00:15:54):

One says, I had keyhole surgery, which is considered laparoscopic surgery. We don’t use the term keyhole United States as much. It’s usually a British thing. I wonder if you’re from the Great Britain. I had keyhole surgery to fix a large inguinal Hernia. Now it feels tight, uncomfortable and is causing pain in the testicles and especially when I need to poop. Is it risky to remove this mesh and if so, how risky? Great question. So this, we’re not talking any longer in this situation about a primary anal Hernia. This is a revisional case. Revision operations are always riskier than the first operation. I’ll just put you that because we’re dealing with scar tissue, there may be Mesh involved, there may be organs stuck to the area, there may be nerves stuck to the area. So revisional surgery, which means you’re doing an operation after you’ve already had an operation, is always riskier than the first operation, number one.

Speaker 1 (00:16:58):

Number two, the question is how much problems is this giving you and what’s the risk of just doing the operation? And I’m going to caveat this, which is whenever I talk about revisional surgery, I’m talking from the point of view of a hernia specialist. So as a specialist, 80% of my work is revisional surgery, whereas the average general surgeon probably never does revision surgery or it’s less than 10, 15% of their volume. So Mesh removal, for example, is not considered something the typical general surgeon does. It’s usually something best performed by a hernia specialist. So therefore to me, I know there are risks with these operations. However, I do so many of them that to me, those risks are at least in my mind, reasonable. Whereas if you have the same operation with a surgeon who is not a specialist, then you could really mess up a patient.

Speaker 1 (00:18:11):

You can cause a lot of injuries today already. I’ll tell you today’s story. So today it’s day after Christmas full clinic. I mean, I don’t know if people just had the time off or what since I’m working, they maybe have time off. I had back to back to back to back back patients. Every single one was revisional. One patient was in a wheelchair. Can you believe it? From a hernia related complication, I had a patient from Germany, Canada, Mexico. People are traveling. Every single one of them had a prior operation. Every single one had operations prior by non-specialists. And these patients are suffering. They’re in the hands of non hernia specialists that are doing the wrong procedure, providing the wrong plan of care, and causing years and years in a couple of these situations of suffering by the patients. So when I talk about revisional surgery, I usually mean if you go to a hernia specialist that does this for a living.

Speaker 1 (00:19:22):

So in your situation you had laparoscopic surgery for a large inguinal hernia, now you have tightness and discomfort, testicular pain, and when you poop, it actually hurts more. So let’s figure this out. Number one, do you need mesh removal? Not necessarily. You may have too tight of a repair that may get better with certain injections or time or massage. You don’t need to remove the mesh for that. You may have testicular pain because of the mesh or because of the type of repair and it’s not an automatic, you may just need some injection again or some surgery to provide a little relief of your spermatic cord interaction with the mesh. My point is never jumped to straight to Mesh removal. One of the patients I saw today, they jumped straight to mesh removal, completely, did not need the Mesh removal by the way, but now that’s another operation that was done unnecessarily, which is causing even more problems.

Speaker 1 (00:20:32):

It was done by a non-specialist and now we got to deal with the consequences of that second operation. So never jump straight to mesh removal. Mesh is not always bad. It’s not always a problem. It could be an adhesion problem, it could be a recurrence problem, it could be too tight of a problem, it could be a fixation problem. So what you really need to do is to go to see a Hernia specialist and they can help figure out for these patients. I spent more than an hour on every single one of these patients. One patient canceled because she was sick, which allowed us some breathing room in the office to catch up because I was spending more than an hour per patient. That’s how complicated the patients were today. So yes, removing Mesh is risky, especially laparoscopic Mesh because you have major vessels in your groin.

Speaker 1 (00:21:23):

You have spermatic cord and nerves that go down to your testicle. There are nerves in the area and the bladder is nearby and intestines are nearby. So in the hands of a specialist that does this on a weekly basis, it’s not as risky to the patient, but it’s still a complicated operation. So I don’t want to downplay mesh removal ever, ever, ever. If anyone says, oh, it’s a Mesh, let’s go straight to the mesh, maybe double check and triple check. I always say to get second and third opinions because these are risky operations for revisions. But thank you for asking that question. Okay, here’s a question. I have a cystocele and they want to use polyurethane, maybe polypropylene mesh, and I’m sorry, I’m concerned about using this kind of mesh due to so many people having issues to this type of mesh. Well, you do have multiple mesh options and we don’t usually use polyurethane, but there’s polypropylene mesh, polyester mesh, there’s biological meshes, there’s hybrid meshes.

Speaker 1 (00:22:32):

I personally prefer for cystocele that hybrid meshes be used. There’s a least amount of synthetic product in the area. So I’m with you. I’m not a fan of placing meshes against potentially risky areas of organs because those, you’re right, there have been complications in those areas. So we talked about are you saving a life? Are you improving a life? Most of the time we are improving lives. We’re not necessarily saving a life because the risk of dying from a hernia is relatively low unless it’s like a femoral hernia where we discussed it, but there have been clinical trials to try and figure out how much are we improving people’s lives by hernia surgery? The two clinical trials that we know about are the long-term studies for inguinal hernias called watchful waiting, and then also a umbilical hernia watchful waiting trial. These are primary hernias where patients were told half of you get surgery, half of you.

Speaker 1 (00:23:40):

Let’s see what happens if we don’t operate on you. And their quality of life was not considerably lower in most situations. They did just fine. None of them died because their surgery was delayed. So that’s kind of the data that I go with. So for example, the watchful waiting trial for inguinal hernias showed that by year five, about a quarter to a third of patients, their quality of life is affected by the hernia and they undergo surgery. And then between years five and 10, about two thirds to 70% of patients end up having hernia surgery because their quality of life is reduced. They feel they’re tired of having that hernia and the bulging and they just wanted to have surgery. However, the people that ended up, there’s about almost a third of patients that ended up not having surgery even at 10 years out they were doing fine, and also the people who waited five or 10 years did not have any poor outcome.

Speaker 1 (00:24:47):

They didn’t die because of it. So my personal thought is I don’t offer surgery to every single patient. If you have virtually no symptoms and are perfectly happy having a hernia, whether it’s bulging or not, then let’s not repair it until it starts getting bigger. Or you have symptoms. Why? Because up to a third of patients that you 10 years don’t eat surgery. So why should I operate on let’s say a hundred percent of patients when only about 60 to 70% needed it? That means potentially other people did not need it. So that’s the way I think about it. a lot of surgeons don’t think about that. They actually think the reverse.

Speaker 1 (00:25:37):

They say most patients end up needing surgery, so I might as well do the surgery now while they’re healthy. Well, that was an interesting thought except that they weren’t unhealthy when they eventually needed their surgery and they weren’t dying from surgery or anything. In one of the trials in the uk, a patient had a stroke, I think maybe would’ve had a heart attack while waiting for surgery, but that doesn’t mean that fixing their hernia would’ve changed that situation or they didn’t even need hernia surgery afterwards. So I am not part of that bandwagon that says, oh, you can get a hernia anyway, let’s just do it now. I say kind of wait unless the patient wants it, but I would never be the one that pushes it. Thank you for your time. You’re welcome. I have nothing else to do on a day after Christmas day.

Speaker 1 (00:26:40):

Actually, I do. I have so many notes to write because the patients were so complicated today and I have to take, I took a lot of notes, but my dad was a very famous writer, so I was raised to be ultra sensitive to writing. And so my notes are a little bit OCD, and it’s very difficult to write really comprehensive notes in a short period of time. It takes some time. Okay, next question. In addition to recurrence of inguinal hernia, what are the other causes of postoperative pain, both with an open tissue repair and a laparoscopic metric repair? Can you discuss some of the mechanisms and pathology that could be causes of pain that someone like you would need to sort out? Yes. So for both laparoscopic, robotic and open ular hernias with or without mesh, you can get cause of pain or recurrence, nerve entrapment, neuroma nerve injury, spermatic spermatic cord injury causing testicular pain, infection, inflammation from the mesh. Those are the top five or a folding up like a mechanical problem folding up of the Mesh we call mesh. So those are the top causes.

Speaker 1 (00:28:01):

And the question is, if you present to me with an inguinal hernia repair, let’s say, and chronic pain, which of these five do you have? You could have more than one. One of the patients say she has probably neuroma and she has a recurrence. So those two, another patient, she has a recurrence only and no nerve problems and she doesn’t even have mesh. So those are kind of the situations that we need to figure out. Infections fortunately are uncommon, but you should always consider it in your differential mesh reaction and inflammation, unfortunately very uncommon, but it should be considered in your differential.

Speaker 1 (00:28:44):

Here’s another question. What test will show mesh and a Mesh plug used for left inguinal Hernia surgery eight years ago, I’ve had horrible pain since day one and the pain is moving into my pubic bone. Can the mesh and plug move? So a mesh plug and patch will be shown on all imaging, ultrasound, CT scan, and MRI. The best study is an MRI, but not everyone can tolerate an MRI, but an MRI very nicely delineates the mesh from all the other structures, including fat and muscle because it looks different. CAT scan, they all look the same, but you can still tell if there’s a mesh plug and what it’s close to and a really good ultrasound can also show it to you.

Speaker 1 (00:29:25):

Going back to the watchful waiting, there was one interesting study that looks specifically at really large hernias. So we don’t talk too much about really large hernias here. It’s not that common fortunately, but every so often someone has a huge hernia, so four inches or wider, like nine centimeters or greater, and those are very difficult to repair, should only be repaired by Hernia centers or of excellence or Hernia specialists because those require not just you need good surging your techniques, you need to have good perioperative care during surgery, during anesthesia, and also afterwards on the ward and so on. So there’s a great study, and by the way, we discuss all of these in my Hernia Talk Live show. When I had my guest on Dr. Robert Fitzgibbons, he was a primary author for all these studies that I’m talking about with regard to watchful waiting.

Speaker 1 (00:30:30):

And it was kind of nice having the actual author of the main article because they have so much more insight. They know their data better than anyone else, and everything that’s published is not necessarily all the data that they have. So it was great because we talked about watchful waiting for the groin hernias, umbilical hernias, and he also did one study which looked at really big hernias. And interestingly in hernias, nine centimeter or wider, these are ventral abdominal wall hernias that are really wide, which cause a lot of deformity and usually gets in the way and it’s hard to walk and you got to wear a binder and then binder doesn’t fit and it can’t bend to tie your shoelaces, for example. So in patients with hernias, nine centimeters or wider surgery is actually recommended and watchful waiting is not recommended because there’s a dramatic improvement in the quality of life of people.

Speaker 1 (00:31:35):

Again, this is a revisional operations done by Hernia specialist. There’s a dramatic improvement in quality of life if you repair a nine centimeter or larger abdominal wall Hernia. So unlike groin hernias and umbilical hernias where watch weight weighting is considered safe number one and a valid choice for major hernias, nine centimeters or large, wider, it’s actually good to repair those. They’re very complicated. So don’t just willy-nilly do that, but that’s just kind of the best way to improve your quality of life for those really big ones is to get those repaired and must do it in a hernia center or a hernia specialist. And again, if you have any questions, I see many of you’re online, thank you very much, much. If you have any questions, just put ’em in the chat and I’ll try and answer them. Okay, so I wanted to talk to you about specific types of situations you may be in and how to consider the risk benefit of surgery. So number one is a pregnant lady. So in most women who are pregnant, a hernia will not cause a problem. I’m a hernia specialist. I have yet to need to operate on anyone who’s actively pregnant. It’s just not a thing.

Speaker 1 (00:33:12):

You can have pain from hernias, but you don’t need emergency surgery typically during pregnancy. So if you have a hernia and you’re pregnant, the benefit of fixing a Hernia is not usually there during pregnancy, right? Unless you have a life-threatening problem, like there’s bowel stuck, which never happens, but both for a belly button and hernias and in the groin during pregnancy, we tend not to operate. So the risk of surgery is just too much during especially elective surgery during pregnancy. Now what about after pregnancy? So for the belly button, the risk of operating is outweighed by the benefits. If you’re still planning on having more kids. So if you’re pregnant and you have belly button hernia, do not get that belly button hernia fixed if it’s not bothering you until you’re done with all your pregnancies because what could happen is you’re going to go to your doctor.

Speaker 1 (00:34:13):

Let’s say you’re 26 years old, you’ve had a kid, you go to your doctor, you like, I’ve got this Audi belly button, I don’t like the way it looks. They’re going to fix it. Then you’re going to get pregnant again, and it’s going to tear, I think more than 40% risk. I understand. And then now you have a bigger hernia, whereas if you just leave it left it alone, that hernia would’ve just kind of stayed the way it was. And then when you’re done with pregnancy and done with breastfeeding and three months to two years have gone by, then you can consider a repair. Now you have healthy tissue that you can close that’ll hold the sutures that won’t recur, that won’t bust open, and that’s what I recommend for pregnancy. So if you’re pregnant or plan to be pregnant or were recently pregnant and you have a belly bin hernia, do not get it fixed. If it doesn’t significantly bother you until you’re done with pregnancies, that’s where the risk benefit ratio is there, right? It’s a really low risk operation, but it’s high risk for recurrence if you have another pregnancy. So the benefit is not there as much.

Speaker 1 (00:35:26):

Now if you have a lot of pain and it bothers you, then that’s important detail. Now, what if you have cancer? So patients with cancer should focus on treatment of the cancer and not get hernias repaired, for sure, not during the treatment of your cancer. So most patients do not need hernia repairs while they’re undergoing whatever is radiation chemo, sorry, with one exception. And that is if you’re undergoing radiation therapy and for whatever reason the hernia is complicating the radiation, right? The hernia is like in the middle of the radiation, then in that situation, we do recommend the hernia to be repaired so you can get your radiation. But if you have cancer, we recommend focus on the cancer, deal with the Hernia later on. Do not complicate your cancer operation by also doing a hernia repair. Also, if you have widely metastatic cancer, the focus should be on treating or evaluating or handling your metastatic cancer, and that could be maybe radiation.

Speaker 1 (00:36:43):

Most likely it would involve chemotherapy. Or maybe you’re in hospice and you prefer not to have any further operations and that situation, there’s no major benefit in fixing a hernia. Yeah, you may have a hernia. So what? Right, we just discussed it’s okay to have hernias. People tend not to die from hernias. Okay? What if you want to have a tummy tuck or other plastic or liposuction? So people that need to go liposuction, we don’t like them to do liposuction around hernias because they can accidentally rupture the hernia and even cause more damage. So we like to have the hernias repaired. Oftentimes I go into it at the time of the Hernia repair, sorry, of the liposuction, or we can stage it, do the hernia repair, and then do liposuction later for tummy tuck. That’s a question of what you should get done. Usually if you have a known Hernia and you want to have a tummy tuck, if it’s a groin hernia, I like to repair those before the tummy tuck.

Speaker 1 (00:38:02):

If it’s a belly bone hernia, it can be repaired at the same time as a tummy tuck. But what if you’ve had a tummy tuck already and then you get a hernia? Well, this is something you discussed with your surgeon. I saw a patient today, she had a tummy tuck. Her surgeon used a different scar than her tummy tuck. I tell my residents, listen, patients didn’t go get tummy tucks because they had to. This was an elective operation and obviously they wanted, part of the reason to do it was to look better. So if they spent thousands and thousands of dollars to look better and have a beautiful belly button and a well-heeled scar, respect that. And if you need to fix anything, laparoscopy, hernia, surgery, whatever, respect the fact that they’ve had a tummy tuck. What does that mean? Number one, put your scars in their scars. Don’t give ’em new scars. They paid thousands of dollars not to have any more scars that are visible. So why would you add another scar? Literally, this is what the surgeon did. So now she has an extra scar right next to her tummy tuck scar, which just boggles my mind. Why not just use the tummy tuck scar? It’s literally right there.

Speaker 1 (00:39:21):

So have that discussion with your surgery like where your scar’s going to be, and that’s something that if you’ve had plastic surgery, you need more surgery in the area, do review it because it may not be worth it to you to have an ugly scar nearby or ruin your tummy tuck by going to a surgeon who doesn’t understand what happened to you and then messes up the work of a perfectly good plastic surgery. So I’m going to spend a lot of time on this with a plastic surgeon in the coming months because it really irritates me when I see people that don’t respect plastic surgery and what was done to a patient and just do their thing like it’s the same. They treat a 300 pound male and a 90 pound female and a woman with a tummy tuck and a male without a tummy tuck the same exact way. You just should not. That’s a very different anatomy and different scar positioning. You got to change what you’re doing because you have to respect what was done to them before. It just doesn’t make sense to me.

Speaker 1 (00:40:34):

That’s what bothers me the most is these surgeons that end up not thinking about what was done to the patient and do their own thing the way we always do it this way. And now you have someone with a mess of tummy tuck anyway, so therefore, is it worth it to have some surgery? So let’s say you had a tummy tuck, and usually that implies that your belly button, you have a new belly button scar that is a very important part of the tummy tuck and the healing of the belly button is really, really important. If you have a hernia now in that belly button, make sure the surgeon is planning on fixing that hernia, understands the blood flow associated with the belly button after a tummy tuck because you could lose the blood flow to your belly button skin and lose your belly button because you underwent umbilical hernia surgery by someone who didn’t understand that.

Speaker 1 (00:41:38):

Same for the groin. If you’re having umbilical or inguinal hernia surgery, make sure you review where your scars will be in relationship to your tummy tuck because if you don’t, the type of surgery they do may mess up your tummy tuck. I just want to put that out there. Here’s another question. How does a specialist like you balance the increased risk of more pain being created by another surgery in a patient experiencing postoperative pain from a recurrent hernia repair? How can you approach going through nonvert tissue planes to ensure more pain is the result of the new surgery? Okay, so first of all, I have confidence in my skills and I very much do analysis, almost like a forensics of what was done prior to help identify what was done well, what wasn’t done well, what was the weakest link, and learn from that.

Speaker 1 (00:42:31):

I believe that as a surgeon, the daintier you are, the less tissue trauma you caused as part of the operation, the better the outcome. I also believe that a good surgeon has ultimate, ultimate knowledge of anatomy. So you’re not just going in there mucking around. I see so many surges, especially in the groin, have no idea what they’re doing. In fact, there was a New York Times article, I’m going to say last month, maybe two months ago, where they literally showed that surges are doing, causing damage, doing abdominal wall reconstruction because they watched it on YouTube or they maybe took a class or saw it in a conference, but they don’t understand anatomy. And so they go into these operations not knowing what they’re doing. Oh, it’s easy. It’s just a hernia repair, right? We’re just going to cut here and I’ll just fix it.

Speaker 1 (00:43:27):

And I’ve had doctors say that to me literally, and I’m like, please do not do this operation. You’ve never done it before and you can cause damage. But when you’re having major abdominal wall reconstruction and you don’t understand anatomy, you don’t understand blood flow and you can cause a lot of damage. So yes, as a specialist, I operate on revision stuff. Sometimes that means going through a lot of scar tissue and not knowing where the nerves are and potentially causing damage myself, but slow dainty skills. Sometimes I use these magnifying surgical glasses that we have for microscopic surgery. Sometimes we use the microscope or sometimes we just operate in a more virgin plane if possible. My point is just because the patient has pain doesn’t mean the operation I am doing is going to cause more pain. In fact, not to toot my own horn, but sometimes the patients are so traumatized by their multiple other operations because of swelling and bruising and chronic pain, et cetera. Then I come into the picture, I redo everything, and they don’t have that much swelling. They don’t have that much bruising. They’re in their mind, they’re thinking this is going to be the worst operation ever, and they come out and it’s not that bad. So I don’t know how to explain it, but just because the patient is experiencing pain doesn’t mean revising that repair is going to cause more pain. It all has to do with anatomy and surgical technique, and it’s super, super important that your surgeon is gifted in those kind of things.

Speaker 1 (00:45:16):

Okay, let’s see. We talked about patients with cancer. Oh, let’s talk about patients. We talked about pregnant patients, plastic surgery patients. Let’s talk about patients with autoimmune diseases. So there are patients that have rheumatoid arthritis, lupus and other autoimmune disorders, and some of them are actually on immune suppression. So it’s very important that that disease process is taken into consideration when planning for hernia surgery. First of all, should your, can you use mesh? Second of all, should you stop their medication or can you stop their medication for the immunity? And third, how am I going to improve this person’s quality of life? Now, let’s say they need to use a walker and they can’t use a walker because a hernia hurts. Well, I’m going to improve their quality of life if I can fix that hernia. But what technique do I use? I should use a technique where they need to have the least amount of inflammation and the least amount of healing necessary.

Speaker 1 (00:46:23):

And so patients with autoimmune disorders, I treat very, very daintily because they have a lot of potential for A infection. B, not healing very well. C, having recurrences and D, chronic pain, especially mesh related problems. So when you’re talking to your doctor, make sure if you have an autoimmune disorder, they understand not only that you have an autoimmune disorder, but ask the surgeon, how do you think that autoimmune disorder will affect your decision making about what type of operation your recommend for me, and also what risks that I may have different than the average patient? And that discussion hopefully will help massage the surgeon into thinking more about you, your risk factors, and therefore better analyzing the risk benefit ratio for your hernia surgery. Here’s another question. If a patient has pain after surgery, you perform, are you so confident in your skill and the success of your surgery that the next step in managing the pain following surgery you perform is automatic referral to a pain management special?

Speaker 1 (00:47:38):

No, no, no, no. First of all, not every complication after surgery requires pain management specialist. In fact, most do not. So the question is why is the patient in pain? Is there nerve entrapment? Just go through the same thing, nerve entrapment, Hernia recurrence, meshoma, mesh related complication, nerve problem, and so on, right? Those five. So you get imaging, you do nerve blocks, and so I do all those myself because I want to learn from the nerve block. When I do immediately within minutes, I will know if the pain helped or not massaging. There’s a lot that can be done and I, I’m not claiming that I’m free from complications. Do not take that wrong. I have complications because anyone who operates will have a complication, but I feel confident that even if I have a complication, I am skilled enough to know how to work it up and help figure out what that complication is and address it.

Speaker 1 (00:48:47):

Whereas surgeons who are not hernia specialists do not have that knowledge base and automatically referred to a pain management specialist. I hate that I say referred to hernia specialists and have the hernia specialist figure it out because most pain management specialists have no idea how a hernia is repaired or how to treat pain from a Hernia. They think everything is a nerve and they’re going to do nerve blocks and they’re going to do nerve ablation and they’re going to give you spinal stimulator. That is not the treatment for the majority of patients who have pain after hernia repair. Alright, don’t get me started. I’m getting tired of this automatic pain management bss. I don’t like it. How do you personally feel about using Botox for muscle paralysis approximately six weeks before a large abdominal wall incision hernia repair? Oh, very good. Very, very good.

Speaker 1 (00:49:47):

First of all, it shouldn’t be six weeks, it should be three to four weeks. So if you have a very large abdominal wall number one and a large amount of your intestinal content is pooching out and your muscles are pulled back, shrunken, shortened, then Botox can loosen those muscles and over the span of three peaking at four weeks after that, those muscles will stretch out. So when your surgeon goes in there, your surgeon has more muscle and more length available, you may actually notice that your hernia gets smaller because your muscles start to grow around it more. But it should be done three to four weeks, not six weeks, six weeks. You’ve already gone beyond the peak of improvement with the Botox. So again, if it’s your first surgeon, always get a second opinion to make sure everything is done correctly before you choose a surgeon.

Speaker 1 (00:50:55):

Next question. How are you able to find the general nerve for injection? What landmarks do you utilize to find the general branch of the general femoral nerve? So depends on the operation that was performed and where I think the general nerve has been injured, but I prefer to always block the nerve upstream. That means closer to the brain than where it’s been injured. So usually I do my general nerve blocks in the retroperitoneal space. So I use ultrasound to identify the general femoral nerve, which would be where it would be deep to the ligament, iliopubic tract and lateral to the vessels. So I find the vessels and I go lateral to it and go retroperitoneal. So that’s how I do my general femoral nerve blocks. Most pain doctors do not do that and they do it anteriorly. It’s already beyond the area of where it’s been injured and I don’t think it’s as helpful both diagnostically and therapeutically.

Speaker 1 (00:51:58):

Should we talk about inflammatory bowel disease? So if you have an inflammatory bowel disease that usually Crohn’s disease or ulcerative colitis, then fixing your hernia, especially in the abdominal wall or the groin, needs to be balanced with the wrist of the operation because the risk of surgery in patients with ulcerative colitis and Crohn’s disease is much higher than the average patient. Why? Number one, it’s an autoimmune disorder. Number two, it’s an inflammatory disorder and those bowels can be inflamed. What is mesh meshes a highly inflammatory product. So number one, are they going to use mesh Number two, where is that Mesh going to be better not be next to the bowel. That’s where the risk benefits ratio of surgery is. The decision-making by the surgeon may or may not increase your risk for the operation. So if you have Crohn’s or ulcerative colitis, which are both autoimmune inflammatory disorders, then number one you should see what’s the surgical technique?

Speaker 1 (00:53:05):

How are you going to prevent a flare of my IBD, Dr. surgeon? Are you going to prevent the mesh from causing any adhesions or erosions or fistulas with my intestines? Number three, how are you going to reduce the risk of infection and so on. So these are all questions that if your surgeon and you sit down and you review like how are you changing my care because I have inflammatory bowel disease. If you have a surgeon that’s thinking about it, they understand that the medications you’re on is going to increase your risk of infection, therefore they’re going to use a mesh with a lower infection potential. They understand that Mesh can erode, so they’re going to bowel, they’re going to place the mesh away from, use the technique to place the mesh away from the bowel. They may choose a lower inflammatory mesh, for example. Those are all little details that can manage that risk benefit ratio to lower your risk of complications and improve the benefit of the surgery given let’s say you have inflammatory bowel disease.

Speaker 1 (00:54:23):

Let’s see, does the ultrasound penetrate far enough to find the general femoral trunk posteriorly? You don’t need the trunk, you just need the branches before it pierces the Iliopubic tract. I’ve had pain ever since having left inguinal hernia repair with large 3D max Mesh using robotic surgery six months ago. I can pinpoint where the sutures have been placed. Okay, nerve pills have not helped. First you have to see if even sutures were placed. It doesn’t matter if I’m at rest or actively, it can be stabbing or spastic and it radiates into the groin. A good night’s sleep is hard to come by because it hurts to sleep on. During this, I’ve developed diverticulitis of the same way colon that I’ve never had before, usually not related. Do you have any recommendations of hernia specialist surgeon teams near my area of Fort Wayne, Indiana? I recommend you go to either hernia talk.com and pose your question or search for Indiana as a keyword on hernia talk.com. And anyone can do that if they’re looking for doctors, because we talk about a lot of different surgeons on Hernia talk.com. Or you can also go on to the American Hernia Society webpage and there’s a find a surgeon section, which just basically shows you if there’s a surgeon around you who is a member of the American Hernia Society. And then based on that you can interview them to see if they will do something like treat revisional hernia patients.

Speaker 1 (00:56:04):

Here’s a question. What do you recommend for recuperation after surgeries? I don’t know. Walking on the tropical beach in Mexico. I don’t know. Walking on a tropical beach in Mexico with your sweetie. Oh, okay. Well, I do recommend walking on the beach with your sweetie, especially if the sweetie that I know about. But yeah, so recuperation after surgery do not gain weight. Number one, increase the activity level, especially of your core. Strengthen your core. That includes weightlifting, walking is good, cycling, yoga, Pilates, and so on. So those are all activities that improve your core strength. Do not use nicotine, prevent any coughing and treat any constipation. But walking on the beach is actually really good because it’s hard to walk on the beach, you know what I mean? So I would say that it takes a lot of core and muscles to literally walk on the sand. Living in Southern California, I do that a lot and I love walking on the beach, but it is a workout to walk on the beach.

Speaker 1 (00:57:25):

Let’s see. Alright, so just to summarize, I know that you’re going to have a situation where you’re going to see your surgeon and they’re going to talk about laparoscopic robotic open surgeries, Mesh surgery, non Mesh surgery, general anesthesia, IV sedation, or any combination of those three factors. Do a good job of reviewing what are the risks of each of those and what’s the benefit to you? Why would you choose one versus the other? Does it make a difference? Is it because one will make you look better? One will give you shorter recovery time, one has less pain. What is the situation? Where are the scars? Those are risks and benefits that should be reviewed. And I’m hopeful that some of the questions here get you thinking and also gets you more engaged with your surgeon. Here’s a question. Do you recommend abdominal binder for laparoscopic hernia repair? I do not for the groin. I do For the abdominal wall, yes. Can this be purchased near your center in Beverly Hills? I actually recommend the car med, C-A-R-O-M-E-D two panel and three panel binders for the abdominal wall. I’ll do a post about it on my Instagram, but that’s what I recommend. You can buy it from my office, but you could buy it online too. I don’t like make them one day I will make my own binder, but that hopefully will be the near future, but not this year.

Speaker 1 (00:59:02):

So again, talk about those three factors, type of anesthesia, type of mesh and type of approach and technique for the surgery, number one. Number two, if you have a surgeon who doesn’t want to talk about that, that’s the wrong surgeon, you need to have an educated discussion with your surgeon about those options. And then be very clear with your surgeon, what is your final outcome? You want a flat abdomen? Do you want good luck? Are scars important to you? Is it all about the recovery time? Do you have a lifestyle that involves a lot of lifting or heavy stuff? And then based on that, make your decisions so that you get the lowest risk operation that’ll give you highest benefit. And on that note, that’s all I have to say. I hope that was helpful to you. Thanks to everyone who participated, that’s a lot of people for the day after Christmas, I hope, oh, I’m going to go home because I’m working all week, but I hope many of you are on vacation and taking the time off to be with your loved ones. And if you’re not, you can listen to my podcast or talk live or follow me on YouTube and make sure you subscribe. And that way you can be alert each time a video is uploaded. By the way, next year, I’ve got some really cool stuff coming up. We’ll go over them next week, but I’m super excited because we’re going to have a lot of fun in 2024. Thanks everyone. See you next week.