Choosing Hernia Repair Techniques

Episode 164: Choosing Hernia Repair Techniques | Hernia Talk Live Q&A

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Speaker 1 (00:10):

Hi everyone, it’s Dr. Towfigh. We are going to do this as a Facebook Live on my Beverly Hills Hernia Center webpage. So for any of you that are also logging in from that aspect, please, please try to go on my Facebook page, the Beverly Hills Hernia Center Facebook page. For some reason, the regular Dr. Towfigh Facebook page is not linking in. But for those of you that have joined me, welcome today’s a Tuesday Hernia Talk Live Tuesday. Thanks for joining me. My name is Dr. Shirin Towfigh. I am at the Beverly Hills Hernia Center. I am your hernia and laparoscopic surgery specialist. As you know, I am on Facebook at Dr. Tophi, but I also have another Facebook page called at Beverly Hills Hernia Center. So please try and go there if you want to join me live via Facebook. And then as with all prior episodes are, they’re going to be on my YouTube channel.

Speaker 1 (01:20):

So go and subscribe to So hernia doc is also my moniker on YouTube, Instagram X. I’d love to see you all there. So I kind of was deciding what to do for today’s episode, and it turns out it’s a perfect episode for today. So we’re going to talk about choosing the different surgical techniques for your hernia, whether it’s open, laparoscopic, or robotic. Those are the three options that you have as a patient. And you may have been approached, you may have been told, oh, you have to get this done open, or you have to get this done. Laparoscopic robotics, the only way to do it, et cetera, that may or may not be true. And so how do you know which technique to choose? And that’s what we’ll discuss today. And we have a lot of questions that was submitted and there’s already one question that’s live here.

Speaker 1 (02:11):

So we will talk about open, laparoscopic and robotic surgery today. We will talk about mesh and non Mesh repairs. We will talk about all types of abdominal hernias, whether it’s abdominal, ventral, incisional, flank, perineal, pelvic, inguinal. All of those will be addressed and I’ll kind of give you my bent. Doesn’t mean it’s the most correct bent, it’s kind of the way that I approach things. But I’m going to share with you some different patient case scenarios. Some of them were done or patients I saw already this week, and hopefully they’ll give you a little bit of insight. Prior to any minimally invasive surgery technology, which was first brought around in the, I want to say eighties. Prior to that, every surgery was done open, which means there’s a scar, you make an incision and you go in there and do the surgery. So when we say open surgery, that’s what we mean.

Speaker 1 (03:11):

Then the gynecologist initiated what’s called laparoscopic surgery and United Kingdom they call keyhole surgery. And that involves not a big incision, but smaller incisions usually ranging between five and 12 millimeters. And those incisions would take the place of the open surgery incision, but effectively the similar operations done on the inside, usually inside the abdomen. And that’s what a lot of general surgeons do is either open or laparoscopic surgery, and that could be for gallbladder, appendix, stomach surgery, colon surgery, et cetera. Somewhere around the early two thousands, the robotic surgery technology or late 1990s, the robotic surgery technique started usually mostly with the urologists. They couldn’t really get it with the general surgeons, but now a lot of general surgeons also offer robotic surgery. Conceptually it’s the same exact operation as open or laparoscopic surgery except, and it’s very similar to laparoscopic surgery from the outside because you have multiple scars from the inside.

Speaker 1 (04:22):

It should be very similar to open surgery. However, the technology is different. So with laparoscopic surgery, we call ’em like chopsticks. So the surgeon is doing the operation, they’re holding instruments like chopsticks, and those instruments are being manipulated with my own hands and I’m touching tissue inside the abdomen. Whereas with robotic surgery I am, I have a robotic approach to it. So I am not physically touching the instruments that go into your body. Those instruments are attached to a robotic machine. And then kind of like you would with the RC car or any type of radio control car or video game, I have a separate console or machine that I sit behind and I manipulate those robotic arms. So the robot’s not doing the surgery. I’m fully in control of the surgery. But the technology is different. Theoretically, all the operations give you the same type of surgery, right?

Speaker 1 (05:30):

So hernia, surgery, fix a hernia, you can do that open, laparoscopic or robotic. However, because of the different approaches, you can have different risks, different benefits, different recoveries, different complication rates, and not everyone is a good candidate for those different options. And I’ll give you an example for the groin, there’s open, laparoscopic and robotic surgery. The open surgery, you can do it without general anesthesia. The laparoscopic and robotic surgery, you typically cannot do it without general anesthesia. So if you’re perfectly healthy and you can undergo general anesthesia, it really doesn’t make that much more of a difference anesthesia wise, which one you choose. But if you’re 90 years old or need a heart transplant, then you should err on doing the operation with the least amount of anesthesia for the patient, which is almost always open surgery. So that’s kind of where we are. The same is true of the abdominal wall. You can do a small little belly, but Hernia through an open surgery. You don’t need multiple incisions to do that.

Speaker 1 (06:46):

But for a big abdominal wall reconstruction, you may choose to do it robotically because there’s less risk of Mesh infection and complications. So we’re going to go through that piecemeal and then as you send me your questions, I’ll answer your questions as well. We already have a great question, which says, for bilateral hernia repairs, either inguinal or femoral, number one is laparoscopic, extra peritoneal Mesh repair a standard repair. And number two, what are the dangers of this repair? So there is no standard Hernia repair. There are excellent hernia repairs that are either open, laparoscopic or robotic, and there is no gold standard for inguinal hernia. There are preferred operations. So if you have, let’s say bilateral hernia repairs, hernias that need to be repaired in the groin, it’s recommended that a laparoscopic repair is superior to an open repair because with the same incision, you can do both hernias at the same time without changing the patient’s recovery.

Speaker 1 (07:58):

Whereas if you did the same thing for an open repair, doing two open surgeries left and right at the same time would involve a lot of scarring, a lot of incision to heal, longer recovery and higher recurrence rate. So we have good evidence to support for bilateral hernias in the groin. Inguinal and or femoral laparoscopic repair should be the best choice. Is it the best choice for everyone? No. I’ll give you an example. If you are a 90-year-old male with congestive heart failure and you have really painful hernias that keep getting stuck on both sides, I would not offer you robotic or laparoscopic surgery. Why? Because I need to put you under general anesthesia to do that, and that may be too detrimental to your heart and brain. We talked about general anesthesia and brain stuff with our pain management doctors last week. So in that situation, I would do open surgery.

Speaker 1 (09:13):

Let’s say another patient that I had recently. He has something called mastocytosis. So mastocytosis is kind of an overly active situation of your mast cells. People who have allergies know what mast cells are. Mast cells, MAST, mast cells are part of the allergic reaction that you get to grass and pollen and so on. So if you are overly in that stage where your allergies are overly reactive, then you can have more allergies and more reactions to what normal people would otherwise not have. So this patient because of his mastocytosis for example, is on a very restricted diet. If he eats a diet that is gluten-free, very low and inflammatory, call it an anti-inflammatory diet, he does great. If he eats, let’s say hot dogs and beef jerky, highly processed foods, say chips, then he’s going to break out into a full body rash. He’s going to feel ill, his joints may start hurting, et cetera.

Speaker 1 (10:30):

That is the life of someone with mastocytosis. Now let’s say that patient has bilateral, so left and right, inguinal hernias. In a normal situation I would say, oh, you look like a healthy patient, male hernias on both sides, you’re healthy, you want to be active. Yeah, absolutely laparoscopic repair of both sides. That would be my recommendation for the typical patient. It involves mesh though it involves Mesh. So this specific patient that has mastocytosis as an example, I would not permission. Why? Because that is an inflammatory implant. I would not recommend being placed in a patient with a known inflammatory disorder because they will be at risk of reacting to that mesh.

Speaker 1 (11:27):

And by reaction, I mean they may get into full body rash, their mastocytosis may be poorly able to be controlled, they may have body aches and pains and joint pains and swelling and so on, kind of like that mesh implant illness situation that we’ve talked about before. So I would not knowingly want to induce that or risk inducing that. We don’t know exactly how much that’s going to bother them, but that’s kind of situation. So that’s a situation where yes, it is true the community standard, actually I can’t even say that the best practices for the typical bilateral inguinal hernia to be repaired would be a laparoscopic with mesh. What if you are in a country with poor resources perfectly okay to do open surgery with them, perfectly low, not even to use Mesh in those patients. It’s not considered below standard to do that.

Speaker 1 (12:24):

So the question here is, is it a laparoscopic extra peritoneal mesh, a standard repair? It is considered standard. What are the dangers of this type of repair? So number one, you’re using general anesthesia, so you got to make sure the patient’s healthy for general anesthesia. Number two, at least in my practice, I always put a urinary catheter in patients in doing so that may induce potentially inflammation of the prostate or urinary retention after surgery possibly, but not necessarily. Number three, there are not that many nerves that can be injured. There are two specific nerves, the general femoral nerve and the lateral femoral cutaneous nerve. Both of them are at risk of injury, very low risk. Your surgeon pretty much needs to not know what they’re doing to risk those nerves because they’re very hard to injure. They’re typically deep to a fascia and most people who do laparoscopic surgery that do it for a living understand where those nerves are and do their best not to injure it. Number four, if you have a lot of fat in your hernia and you’re trying to reduce that fat laparoscopically, there is a chance, small chance, but there is a chance you may not be able to reduce all that fat.

Speaker 1 (13:47):

And so if the dominant hernia is cord lipoma or a lot of fat in the space, then with a laparoscopic repair, one of the risks compared to an open repair would be to miss being able to reduce all of that fat. It happens, it is a risk. Number five, there are major vessels in the area that you can injure. Again, it’s a risk, but it’s fraction of a fraction of a fraction of a percent. If you pick a surgeon who’s good at what they’re doing, that should never happen. There’s different approaches to getting to that extra peritoneal space. And older studies using non-specialists, they found either vascular injury, which means those major vessels that I talked about could be injured and they had patients that had their intestines injured. I shared a story maybe months ago where the large intestine was injured as part of an extra peritoneal repair in a patient that I think he had some type of prior severe diverticulitis with perforation that caused the colon to get stuck where the Hernia was.

Speaker 1 (15:12):

And so that area was dissected for the hernia and in doing so they injured the colon. So complications occur with every surgery, but these are the main complications that we talk about. Also, lastly, laparoscopic surgery has a higher risk of blood clots than open surgery just because of the gas that we have to insufflate into the abdomen. Again, this is a lot of complications that we can review with the patient. Most of ’em are not relevant. They’re fraction of fraction of refraction of a percent infection. For example, very, very low risk mesh infection. I’ve had it in one patient. So it happens, but it’s really, really, really, there’s some serious epidemiology you have to look into if a patient gets a mesh infection, like was the mesh itself already not sterile and things like that because very, very low risk to get a mesh infection from a laparoscopic surgery.

Speaker 1 (16:15):

Not that it hasn’t happened, but it’s not something that we typically talk about. So those are the quote risks of the procedure with a laparoscopic repair and you have to see how much of a risk is there. So for example, oh, lastly the fact that you have to have mesh in you. So the Mesh based laparoscopic repair, which is considered the standard type of laparoscopic repair, does involve mesh. So is a patient at risk of having their mesh folded? Were they going to feel the mesh? Will the mesh erode into any nearby structures? Will it impinge on the spermatic heart cord and cause testicular pain? Could it fold and touch the bladder and cause urinary frequency? Is it placed too low and it can cause pain with bending at the hip going upstairs and sitting? So these are all risks of the surgery not intrinsic to the surgery. More surgical technique complications. If you use some type of, what do you call it, tacks for example or fixation, you have a higher risk of fixation related injuries to the nerves and chronic pain and tearing of the muscles. And I had one patient that bled from the attack going like dislodging and hitting a vessel. So again, these are all low risk probabilities, but it is what it can happen. So that’s the risk of a laparoscopic approach for inguinal hernias.

Speaker 1 (17:55):

So why would someone you may be like, wow, that’s a lot of complications. Well, surgery has a lot of complications. Those of us that do surgery and the more senior we get, the more complications we know about and are aware of. So when we go in to do an operate, actually let’s back out When we recommend a surgery for a patient, we usually do it understanding that all these risks, so if we have a wider view of what we’re offering, and so when I tell a patient I recommend laparoscopic surgery, it’s understanding that I know the whole cadre of complications this patient may be at risk for compared to all the other techniques and the complications, they may be at risk of let’s say for open surgery. So that’s kind of where it is. Let’s see. We have another question. What symptoms would you expect if general femoral nerve is injured?

Speaker 1 (19:02):

So the general femoral nerve maybe injured during a laparoscopic repair or an open repair or robotic repair. So that area is exposed and it’s near the hernia often. So it is at risk people that have genital branch of the genital femoral nerve. So the genital femoral nerve branches out. There’s two branches as the name implies, the genital branch and the femoral branch of the genital femoral nerve. The genital branch symptoms, sorry, causes sensation to the scrotal skin on that side in men and to the mons skin for women. Okay, so if you have that nerve injured, you’ll either be numb or you’ll have burning sensation over your scrotal and hypersensitivity over your scrotal skin in males over the mons and female females. Now the femoral branch is less likely to be injured, but if it is injured, you would get numbness or painful numbness or burning and hypersensitivity in a small area in the upper thigh just below the groin crease.

Speaker 1 (20:24):

That’s where the femoral branch of the general femoral nerve is. Sometimes some people may have inner thigh symptoms from general femoral, it’s not as common, but there is some inner thigh sensation from the general femoral nerve. So that’s the answer for that. So you may say, okay, well why would you choose an open or a laparoscopic repair over an open repair? Again, let’s focus on inguinal and we’ll move on to the abdominal surgeries. Well, I’ll explain to you my thought about it because I do offer open laparoscopic and robotics. So when I talk to a patient, I’m able to offer them all opportunities and then figure out which one’s best for them. So I think the patient is best served. Okay, let’s go back again. However, there are some surgeons that do not offer laparoscopic surgery at all. Mostly because the laparoscopic inguinal hernia repair is considered a complex operation that not all people are really good at and most surgeons in the United States do not offer laparoscopic surgery. That said, your surgeon may say, oh, you should get open surgery. The question is, do you offer laparoscopic surgery, doctor, surgeon, and are you offering me open surgery knowing you can also perform laparoscopic surgery, but you’re choosing the open surgery as the preferred operation for me? Or are you offering me open surgery because that’s the only technique you know how to do?

Speaker 1 (22:15):

That’s a very important distinction. I’ll give you an example. I had a patient recently who is married to a doctor, so he has a bilateral inguinal hernias and they talk to all their doctor friends and one doctor friend said, oh, you must have it done open. Another one said, oh, you must have it done laparoscopically. Oh, you must have mesh. One said you shouldn’t never have mesh. As you know, I do not like the must have and should never. And those are very absolute terms because every patient’s a little bit different. So when would I choose or recommend an open surgery? Well for sure if the patient wants a non mesh repair or is a candidate for a non mesh repair or should get a non mesh repair, then the open repair would be the first choice.

Speaker 1 (23:11):

There is a robotic non mesh repair that I do offer for the groin. It’s only for really small occult hernias that are symptomatic and not for any femoral hernias. So it’s a limited number of patients that are eligible for that. So let’s say you’re not in that category and you know have a bulging Hernia. So an open repair would be best for number one, people that are not good candidates for general anesthesia. Number two, if you want to choose a non Mesh repair. And number three, if they cannot have a mesh like the patient I just mentioned with mastocytosis, so typically an open mesh repair, it’s called Lichtenstein repair. It’s considered gold standard by many people. I don’t like that term because a laparoscopic repair is not any less gold standard, but if you look at the world and the type of repair it’s done in the world, they’re almost always done open laparoscopic really hasn’t penetrated the world, mostly because it’s expensive and it involves a lot of technology. So you can do an open inguinal, her repair in most countries and where it mesh is available. And prior to Mesh we were doing open tissue repair. So the open repair has a longer recovery and a higher risk of chronic pain, especially if it’s not done by a specialist.

Speaker 1 (24:44):

But again, you can be a really amazing open surgery surgeon that never does any laparoscopic surgery and have excellent outcomes. Or you can be a horrible open surgery surgeon, let’s say mostly due to mostly because you do laparoscopic surgery, you’re not really good at open surgery, it’s possible or you’re uncomfortable and you can do great laparoscopic surgery and a horrible open surgery. So every surgeon is different in their skillset and what they offer. And so when you do go for a consultation, if they offer you a certain operation, you may want to ask why they’re offering that. Is it because they offer all operations like I do and based on their knowledge of all the risks with all the three different choices, that’s the one they recommend for you? Or is it because that’s the only operation they do or it’s the best operation they do?

Speaker 1 (25:43):

Let’s say they dabble in laparoscopic surgery, but they’ve been doing open surgery for 30 years in that population. Don’t force your surgeon to do a laparoscopic repair when the best outcome in their hands would be if they did open surgery. Does that make sense? I hope that makes sense. Raise your hand if that makes sense because I feel like I need to make sure that we’re kind of understanding this. Thank you’re raising your hand. Alright, great. Appreciate it. Okay, so going back, so we did inguinal. Now let’s go to the ventral Hernia pairs. So ventral hernia pairs or abdominal wall hernia pairs include belly button above the belly button. Ventral means front of the belly. It can be the flings, the side of the belly, the back, or some rare hernias you can get in the pelvis. So hernias that occur outside of the groin, we usually call abdominal wall hernias.

Speaker 1 (26:42):

Sometimes you’re born with it or you develop it, sometimes you get it after a surgery. So let’s say you had a trauma and then they have to cut your belly open to save your life. You have high risk of getting an incisional hernia from that. I think it’s the 20 to 25% risk for traumas. Let’s say you had colon cancer and they did open surgery for your colon cancer, that’s about 11% risk of having incisional hernia from that. So depending on the type of surgery you have, you may be at higher risk for hernias. The smaller the incision, the lower the risk of your incision having a hernia the further out from the midline, well, let me rephrase this. The midline and the very far right far left hernias are incisions are at higher risk for having a Hernia.

Speaker 1 (27:42):

So based on that, the question is should you have your hernia done open or laparoscopic? And before I move on, looks like there’s a question. How do you decide in an inguinal hernia tap repair whether to fixate or not? And can you get pain from either suturing or attacking cooper’s ligament? So know there’s no pain from talking or suturing into Cooper’s ligament. The pain that we see from fixation is when it’s fixated to the abdominal wall to the muscle because they can go in too deep and penetrate the abdominal wall and get the nerve on the other side. They can go too deep and make it too tight to the tightness of the fixation can be a problem. But fixating to Cooper’s ligament has never been shown to have actual pain. You can use too many fixation devices. I just have a recent patient with 11 tacks on just one side.

Speaker 1 (28:40):

It’s not my record. I think 19 on one side was the record or was it 30 30 was the abdominal wall. So 19 in the groin. So too many attacks can cause muscle spasm and chronic pain. And in general, suturing tends to cause less pain than attacks because it’s a little bit more controlled. However, you can choose not to fixate. So for the typical anal hernia, you can do laparoscopic hernia repair and do no fixation. However, if you have an extremely large hole in your indirect space, any non-small direct Hernia or any recurrent Hernia, I recommend using fixation because, oh, sorry, and any femoral hernia, I recommend using fixation, understanding that most of those hernias are indirect anal hernias and do not need fixation.

Speaker 1 (29:51):

And then the lighter the Mesh, the more likely you’ll need fixation. So if the heavier weight mesh you use, the less fixation you need. Here’s another question. What type of repair do you recommend for someone that has a mesh reaction and has a growing hernia in her pubic area after a mesh removal surgery? Current surgeon recommending tissue repair Shouldice specifically, which he doesn’t offer, he recommends Shouldice surgeon in Stonybrook, New York. Dr. Samer Sbayi, which is yeah, he was a previous guest on Hernia Talk Live. So in people that have known mesh reaction or mesh implant illness, a non mesh repair is indicated and then the question is what suture to you use because you can make maybe also react to the suture. However, if you have a known collagen disorder such as Ehlers Danlos syndrome, a tissue repair is not adequate.

Speaker 1 (30:55):

That’s where the problem is in some patients is they really do need a mesh repair. Now can you do a tissue repair and then hope for the best you can? Is it going to recur? Not a hundred percent. And I don’t know what the number would be because most people with Ehlers Danlos do not get tissue repairs. The typical Shouldice technique should be about 2% to 7% recurrence rate depending on the surgeon, assuming surgeons that do a lot of it. But the understand that tissue repair involves disrupting the tissue before you sew it, so you’re actually cutting open and then reselling it. So in a typical hernia, that tissue is not open. You have to physically cause a hernia to then sew it. So in someone with Ehlers Danlos syndrome, you don’t want to do a typical Shouldice repair because if it falls apart, which is very likely, you now have a wide open hole that you didn’t have before surgery.

Speaker 1 (32:07):

So if you have Ehler Danlos and someone is offering you a tissue repair, they cannot do the traditional shouldice repair for example, or any traditional tissue repair. You have to do a modified repair because you just want to tighten the area. You don’t want to cut the area to then tighten it because that would fall apart and when it falls apart, now you have a big gaping hole that you did not have before surgery. So that’s my only recommendation for that part. Okay, going back to laparoscopic versus open versus robotic abdominal wall hernia. So my specific bent is if you have a really small hernia, so one centimeter, you should just get that fixed open and you can hide your scars so it looks scarless and most umbilical epigastric recurres are in that range. So could you do any hernia over two centimeters requires Mesh and any hernia between one and two centimeters is controversial. What is the best repair? Depends on the patient and their lifestyle. So a lot of people do laparoscopic or robotic surgery for the abdominal wall ventral hernia repair Y number one, those tend to have more pain, more risk of mesh infection and or surgical site infection when done open. So we’ve moved away from doing too much open surgery if possible, and so that’s where laparoscopic and robotic surgery has made the biggest impact for abdominal wall hernias. So umbilical epigastric, typical incisional hernias.

Speaker 1 (34:02):

That said you need at least three, sometimes four incisions for laparoscopic or robotic surgery and if you have a little one centimeter belly button hernia or 1.5 centimeter belly, you need about a one to two centimeter incision to do that. It doesn’t make sense to make four separate incisions when you can get the job done in one incision. So that’s my take on it. However, definitely when thinking of abdominal wall, you should consider the risks and benefits of open versus the minimally invasive laparoscopic robotic. I would say follow your surgeon’s lead. So some surgeons are really good with open surgery, have ’em do it open. Some surgeons are really gifted with robotic or laparoscopic surgery. Have ’em do that. If they’re kind of wishy-washy about it, get a second opinion. If they say there’s no other way to do it, get a second opinion. That’s kind of my take on it.

Speaker 1 (35:05):

Now what do I recommend with regard to which one’s best? I’m very conscious of the cosmetic outcome for people and I also want to give the best surgery. So morbidly obese patient, don’t do it open, either do it laparoscopic or robotic surgery because the risk of wound infection and mesh infection is not worth any cosmetic benefit. If you have an ugly scar from your trauma surgery or an infected wound, I do those open because I like to give you a nicer scar and then maybe a little tummy tuck as part of it. So I like to do those open if it’s complicated or not less than four centimeter hernia, I like to do those laparoscopic or robotic. If they’re super complicated in the nine to 10 centimeter range, I like to do those robotically. If they’re complete loss of domain and they’ve had so many surgeries, it’s kind of too dangerous to do it any other way but open. So that kind depends on the patient. Now here’s another question about Ehlers Danlos. Is there an Ehlers Danlos like phenotype with poor collagen fascia quality without fullblown Ehlers Danlos and how can you recognize and manage it? So we’ve talked about Ehlers Danlos syndrome before. Ehlers Danlos syndrome or EDS is a collagen disorder. So if you watch Cirque du Soleil, actually I just recently posted a patient, I recently posted a dancer on my Instagram who I’m willing to bet has Ehlers Danlos syndrome.

Speaker 1 (36:53):

These are people where their joints can come out of their sockets and they’re hyper extensible. Their skin is or they’re hypermobile. They typically have joint dislocations of their knee or shoulder. They can pull their scapula in and out their some tests are their thumb can go all the way down and hit their forearm. If you check their elbows, they hyperextended the elbows and so on. Or they can sit in these kind of ways where their legs can go around their heads and so on. So Cirque Du Soleil is the classic situation. a lot of those dancers have some type of hyper flexibility or hypermobility, which is an Ehlors Danlos syndrome type. Now, can you have hypermobility or hyper flexibility syndrome without Ehlors Danlos? Yes, that’s what it’s called. It’s called hyper flexibility or hypermobility syndrome because Ehlers Danlos is a specific genetic disease. Does it matter which one you are? No, because you are prone to hernias, you may have direct angle hernias, chronic pelvic pain, pelvic floor disorder, umbilical hernias, acid reflux due to hiatal hernias. You may also have other problems like visual, like the muscles in your eye are weak and all that.

Speaker 1 (38:26):

How do you recognize that there are multiple tests? So one is the test of how flexible your joints are. Other is to look at, see the angle of you bring your angle of your thumb to be more 90 degrees. Some people when they open their hands up, they are hyper extensible at the joints of their fingers. If they’re standing and their knees kind of pull back further than a typical standing person, that’s a hyper flexibility. If their scapula can be pushed in and out, if they have some people they can bend down and put their hands on the floor completely and others can even put almost their elbows down on the floor bending down with keeping their legs straight. So these are all different tests. Some people actually have very hypermobile skin, so if you pinch their skin, you can really pull it up. The highly elastic skin, these are all collagen disorders.

Speaker 1 (39:39):

The skin has a lot of collagen and your joints have a lot of collagen. So if you are lacking adequate mature collagen in those situations, then you may have a hyper flexibility or hypermobility disorder. A genetic consult may be helpful, a rheumatology consult may be helpful. There are other implications besides the orthopedic implications with this. So why is that important? Because the type of surgery that you get, the outcome will be affected by it if you’re not aware that the Cerner is not aware. So let’s say you have colon cancer, you need colon surgery while the incision through which they’re going to remove your colon needs to be made a certain amount, you’ll a hundred percent get an incisional hernia. If you do have this hypermobility problem or alos syndrome and your surgeon is unaware of it and they close your hernia like a normal person would, doesn’t work.

Speaker 1 (40:46):

So those are little things to think about if you’re hyperflexible or hypermobile and then you can get genetic testing to see if you actually have Ehlors Danlos syndrome. The reason why the naming of the genetic disorder is important is because Ehlers Danlos syndrome is also associated with other diseases like pots like SIBO, IBO, like endometriosis and maybe a reason for your acid reflux and so on. So it’s from a health standpoint it’s good to know all those. Also it is genetics, so it can be passed on to your children or you may have gotten it from your parents and of course that’s important with regard to open versus laparoscopic robotic. Unlike inguinal hernias, all of those operations can be done with or without Mesh. Now it’s not considered standard to do a laparoscopic or robotic surgery without Mesh, but it’s definitely doable whereas it’s not that doable for an inguinal hernia.

Speaker 1 (41:51):

Here’s another question. Does the balloon use to dissect the retro rectus space during tap cause widening of the diastasis recite and how can it not? It does not because it does not. The balloon dissects behind the rectus muscle, not in the midline. So it does not cause widening of the diastasis recti. So for example, the balloon that I use is not the I use only on one side and then the rest I do manually. So the midline never gets dissected out. But let’s say you do have the commercially used balloon where it dissects both sides at the same time or it can, but it’s introduced on the left side or the right side. So no, it doesn’t cause any widening of the diastasis.

Speaker 1 (42:45):

Okay, let’s see, what were we talking about? Here’s another question. Okay, multiple questions. This hernia recurred way sooner after measurable than we were hoping. I’ve never been diagnosed with full blown Ehlers Danlos and don’t have any of the extreme symptoms, so maybe Shouldice could be an option. Also, can stainless steel sutures cause inflammatory reactions like mesh? Okay, good question. So number one, yes, Shouldice can be an option, but if you’ve already failed prior tissue repairs, you may fail it again. Shouldice being another tissue repair. Again, if you do have Ehlers Danlos or some type of collagen disorder or hyper flexibility or hypermobility and you undergo a tissue repair, the key is not to treat you like the typical patient where you cut open the entire inguinal floor to then suture it. That is all tissue repairs do that. Bassini, McVay, Shouldice, your surgeon should revise the technique and maybe do a Bassini repair so that your tissue repair is not open, does not result you are not damaging tissue in order to repair the repair because damaging tissue in someone with a known collagen disorder is going to potentially cause your hernia recurrence to be even larger and more difficult to handle.

Speaker 1 (44:22):

Also, can stainless steel sutures cause inflammatory reaction like mesh? No stainless steel sutures in general are not as likely to cause an inflammatory reaction, so that’s a positive thing.

Speaker 1 (44:41):

That said, there are people that have reactions to tacks and clips which are titanium based and some of them have nickel in it, so you have to make sure that the stainless steel suture they’re using is pure stainless steel and does not include any nickel within it, but it is a good option. The other option would be a use of nylon suture, which is the least inflammatory of all the sutures that are permitted. Could extra peritoneal mesh affect the ileal femoral arterial velocities or would femoral canal Hernia repairs most likely affect blood flow in the sitting position? My common femoral artery velocities increase and the left external iliac artery doppler waveform supine are normal and biphasic throughout and the velocities were not elevated should this abnormality be rectified.

Speaker 1 (45:52):

So femoral hernias are best repaired. Okay, let’s go back. Femoral hernias are best repaired laparoscopically. That said, whether it’s inguinal or femoral hernia, the Mesh that’s placed will be having mesh on top of the external iliac artery and vein. Does that cause obstruction of blood flow? It should not because it lays on it like a blanket would. It doesn’t lay on it like a guillotine would, so it should not. However, it’s possible that the waveform from the mesh is affected because the Mesh that’s currently there can be impinging on the vessels uncommon and really uncommon for the artery to be affected. The vein can be. Now if you already have an arterial blood flow issue, I assume you’re going to be worked up for a blood clot or something. But if your arterial artery has a higher velocity, that means that somehow kinked or blood flow to it is compromised when you’re sitting, then it’s from the surgery.

Speaker 1 (47:31):

Then you have to see if your Mesh is kinked or there’s a meshoma pushing on the vessel. If you’ve not had mesh, I’m not clear if this patient has had Mesh before or not. If you’ve not had Mesh and you have a difference on one side versus the other of arterial velocity, then that’s a vascular issue that needs to be addressed to see why you have an obstructive problem when you’re sitting on one side and not the other. Do you have, let’s say, pelvic congestion syndrome, although most of those issues are venous and you are talking about arterial, so I hope that clears it up.

Speaker 1 (48:15):

Let’s see, what other questions can we talk about open versus lap versus robotic? Okay, the one thing I would say is though I’m a big fan of laparoscopic surgery and my training was in laparoscopic surgery, the current wave in the United States, at least not in most of the other countries, is to start using robotic surgery. So I also do robotic surgery. There are some people that were never comfortable with the laparoscopic approach. It’s very complicated and difficult to do, and those people are now really enjoying robotic surgery because they’re able to provide a highly, very good quality operation with minimally invasive technique using the robotic technology that they couldn’t offer to patients before. So I think that’s a good thing, right? It’s always better to at least offer some type of minimally invasive operation if you can.

Speaker 1 (49:18):

Do I think the robotic platform should be used for everything? No, there are some people that do. I’m not one of those. I like to tailor to the needs of the patient. Are there certain operations that are better done robotically than laparoscopically open? Absolutely. For example, mesh removals from prior laparoscopic mesh, I prefer to do robotically. But can it be done with open or laparoscopic? Yes, it probably should never be done open unless in certain circumstances, but definitely can be performed laparoscopically, which is what we did before the robotic technology. Some people believe that the robotics repair is superior in many ways. Now, one of the better reasons for robotic surgery technology is it kind of mimics the open surgical technique more than the laparoscopic.

Speaker 1 (50:19):

Similar to how eating with a knife and fork mimics eating with your hands more than using chopsticks does. So when you use chopsticks, you have to kind of modify the type of foods you eat, right? You can’t eat soup, for example with chopsticks. So however, whatever you can eat with your hands, you can also eat with knife and fork and spoon. So that’s kind of the difference between laparoscopic and robotic. Laparoscopic, there are some limitations and we’ve had to change the type of technique we use for certain operations from open to laparoscopic, whereas we can go back to more of that authentic traditional surgery moving from open to robotic surgery. That’s kind of why I like robotics for many of the operations that we do. What I don’t like about robotic is the scars are a little bit bigger than laparoscopic and I have less control of how much tension the robotic arms put on the abdominal wall, and I don’t have as much leeway to hide my scars in patients when it’s robotic.

Speaker 1 (51:34):

That tends to be very visible and I think cosmetics is a good adjunct to your hernia surgery. So that’s kind of what I don’t like about robotics, but in some people that’s irrelevant and doesn’t matter. So in those situations, I do like robotics, you can do good suturing and stuff. And for example, here’s another question about do I use sutures or tacks? Well, robotically, I always use sutures because suturing is really easy robotically and there’s no need to use tacks. Were only invented when laparoscopic surgery came around to aid in fixation. When you can’t really sew or it’s very difficult to sow or the angle is different, that’s irrelevant with robotics. So for robotic surgery, I don’t use tacks, although some surgeons still use tacks for robotics, but for laparoscopic surgery, I don’t suture though many surgeons do suture, I use tacks. There are people that had tacks put in open, but the original purpose of tacks and reason why tacks are like these little curly queue fixation devices, the reason why tacks were invented was for laparoscopic purposes, not for open, although some people have had it placed open.

Speaker 1 (52:59):

So that’s kind of my shtick about laparoscopic versus open surgery. I don’t know if that was helpful. I would like to say that if you can at least get a consultation from a surgeon who knows how to do open, laparoscopic and robotic surgery to help determine the pros and cons of each approach for your specific type of hernia. And then let’s say that surgeon says, yeah, you’re best for a laparoscopic repair or you’re best for a robotic repair, or you’re best for an open tissue repair, let’s say, then if you don’t want to go with that surgeon, at least from a somewhat unbiased surgeon, what’s the best option for you? And then take that and then you can go to a surgeon who does that specific technique the best. So let’s say you come to me as a consultation and I say, I wouldn’t put mesh in you.

Speaker 1 (54:00):

I would just do open repair without mesh or something like that. And for some reason you can’t come to see me to do the surgery, then you can go to your local surgeon and find the surgeon who does the best open surgery. Or I say, I would definitely do this laparoscopically. Don’t let anyone do this open for example, or robotic, let’s say. And for some reason you can’t or don’t want to do the surgery with me. At least take that information and now find the best laparoscopic or robotic surgeon near you who can do that operation. So that’s my shtick, that’s how I think. I don’t know. I would love your feedback. Please give me some feedback. I’d like to hear from you guys. Go on my social media on X or Instagram at hernia doc on Facebook. As many of you are at Dr. Towfigh and on YouTube. As you know, all of these episodes are on my YouTube channel at Hernia Doc. Do subscribe. It really helps. And actually, if you’d like to listen to podcasts, do this as a podcast. And if you do, please like me on my podcast channel. That way more people can see and interact with it. So I really appreciate that. On that note, I’ve got a great guest next week. I’m really looking forward to it. See you next week for another Hernia Talk Tuesday. Thanks everyone.