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Speaker 1 (00:00:11):
Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live, our weekly episodes talking about hernias. My name is Dr. Shirin Towfigh. I am your hernia and laparoscopic surgery specialist. Thanks for everyone who’s joining me on Facebook as a Facebook Live at Dr. Towfigh. And please follow me on X and Instagram @hernia doc. As always, this episode and all prior episodes will be uploaded on YouTube, so make sure you subscribe and follow me on YouTube at Hernia doc. So today we have a great guest, Dr. Annie Ehlers. She is a very talented surgeon through the University of Michigan. We’ve had Dr. Telem prior to her from University of Michigan, and she is the great second surgeon from that group to talk about hernias. You can follow her on X at Annie gel, and please provide a very warm welcome to Dr. Ehlers. Hi.
Speaker 2 (00:01:12):
Hi. Thank you so much for having me. I’m really excited to be here today.
Speaker 1 (00:01:16):
Today. So I mentioned earlier that Dana Telem was one of the guests on Hernia Talk Live, and she was able to talk about just in general how to get funding for research for hernias, and you’ve joined her group and under her leadership and you’ve really taken things in a very wonderful direction, very needed, which is specifically looking at women’s or females with hernias and how that all works out.
Speaker 2 (00:01:47):
Yeah, so I joined the faculty there almost five years ago, and Dr. Telem was one of my first mentors there. And we kind of started with some small projects, but one of the projects we did that really got me interested in this was actually not specific to hernia, but it was looking at a statewide discharge database we had in Michigan to understand for people undergoing common surgeries like gallbladder surgery, hernia repair, how often are they needing to use something like physical therapy after discharge discharge to acute rehab facility, basically any sort of post-discharge care. And what we found was that while usage was overall low, when we looked specifically for inguinal and ventral hernia, women were significantly more likely to need those services than men, which was just sort of a really, like what’s going on and why would that be the case?
Speaker 1 (00:02:44):
Yeah. Well, I think the thing we talked with Dana, which I’m very curious to do a deep dive in, is number one, why don’t we actually look at females when researching hernias up until recently, right? And number two, does it even make a difference looking at female versus male issues for hernias?
Speaker 2 (00:03:09):
Yeah, great questions. I think for the first question, it’s sort of a two-parter. So as background going back, many, many decades there from National Institutes of Health and other research organizations were guidance on when women should be included in research studies. And there was a lot of concern, of course around the usual things like childbearing or hormones before and after menopause that led many of the seminal studies we used not just in Hernia, but across the board to be performed only in men. And what we’ve seen both for cardiovascular diseases, other operations, and of course Hernia, is that when we apply those studies that didn’t include women to women, it sometimes doesn’t work and we see worse outcomes.
Speaker 1 (00:03:59):
So the thought was because women that enroll in these studies may be pregnant during the study, it may prevent them from let’s say, getting a certain, let’s say it’s a drug study, is this antibiotic antibiotic better than that antibiotic? They used to not enroll women because what if they’re pregnant? Or at least not enroll people that can get pregnant because what if they’re not ready yet to say that this drug is safe during pregnancy, but why not for hernias?
Speaker 2 (00:04:28):
Yeah, I’m not sure specifically for hernias. And I think one of the main reasons is that we, particularly for inguinal groin hernias, it’s often thought of as disease that only men have. So I’m finishing up some interviews with patients that I’m happy to talk about later, but one of the most important themes that’s coming out is they didn’t even know that women could get them. And so it’s an education problem, I think not just with patients but with their doctors too, that many doctors think this is really only something that affects men. And so I don’t have to worry about it for my female patient that comes in with a groin bulge.
Speaker 1 (00:05:07):
Well, I’ve had doctors say they didn’t know. ER doctors have said, oh, women can’t get hernias. People have seen their gynecologist of all people that have said women don’t get hernias. It drives me crazy that that’s actually taught to them at some point they didn’t make this up. Someone taught it to them. Right?
Speaker 2 (00:05:24):
Yeah, definitely. And so I don’t know where that came from, but I think another reason we didn’t do as many studies in women is because a lot of the Seminole studies were done in a VA population. And when those studies were done 20, 30 years ago, it was such a small number of women in that organization that I guess it made more sense to only do it for men.
Speaker 1 (00:05:49):
Yeah. Something like only seven women were involved in multiple studies done on hernias, thousands of men and seven women, some ridiculously. Yeah, it’s very true. And then there’s also this thing called bikini medicine. So if women come in with any aches and pains, it’s either the boobs or it’s the uterus and ovaries, but they don’t think of, I’ve
Speaker 2 (00:06:11):
Heard that term before,
Speaker 1 (00:06:12):
Cancer, just like a male, they can have diverticulitis, they can have hernias. They just think, oh, let’s get a pelvic ultrasound and make sure it’s not your ovary or things like that.
Speaker 2 (00:06:24):
Absolutely.
Speaker 1 (00:06:26):
So you are one of the leaders in looking at specifically females or gender-based studies and hernias. Can you maybe explain how you even started with that research or I always get asked, how did you get into hernias? Because as a female, people see it as a male disease. So they’re like, how did you as a female become a male doctor? At the same time? Some people text me, not text, DM me, and they say, you also treat, do you treat men or do you only treat women? I’m like, of course they treat men. Ally actually treating more men than women, though in my practice it’s 51% women.
Speaker 2 (00:07:11):
Oh, interesting.
Speaker 1 (00:07:12):
Yeah. Isn’t that interesting?
Speaker 2 (00:07:13):
I think many women prefer to see a woman doctor, but I think how did I get into hernia? I really got into the field of minimally invasive surgery in general. I really like that we’re able to do these operations that are safe, very effective, fairly short, often outpatient, and you can really make a very fast improvement in someone’s quality of life. And that really spoke to me about helping people of healthier lives. Bless you.
Speaker 1 (00:07:43):
Thank you. And did you like hernias when you were a resident?
Speaker 2 (00:07:49):
I did. Yeah. I think that, and even it’s funny, when I look back at when I was thinking about what my research arc would be even way back then, hernias was a big part of it. And I think there’s a lot of interesting things about hernia, not just the quality of life aspect, but the many different ways that you can approach hernias. There’s open, laparoscopic, robotic, there’s also considering patient preferences into it. And so I really love talking with my patients about what’s the best thing to do? Do we need to fix it? When are we going to fix it? How do we get you back to feeling your best in a way that aligns with your values? And so all of those components really piqued my interest in this.
Speaker 1 (00:08:36):
So true. And there are definitely a lot of options. I think those of you sort of like you who are gifted and open, laparoscopic, robotic, can really have a good discussion, say they have all these options for you, here’s the pros and cons of open, laparoscopic, robotic, Mesh, non mesh, all these different options. And you’re also looking at specifically maybe even non-operating, right? We had Gibbons on it as a guest and he talked about his watchful trials. Yeah, it was so good to have, if you’re ever interested, go listen to that episode. I always like to hear people’s stories. And so how did you even get involved in this study? But it was, it’s a great story where he talks about at the va, they were just overloaded with people with hernias, and then the question was, should we even repair it? That’s kind of how it all started. And he’s one of the few people that actually has federal funding for hernia research. But you’re now looking at it on the women’s side, is that right?
Speaker 2 (00:09:39):
Exactly. Yeah. So when you go back and look at those initial studies, and it’s fascinating to hear that before those studies, the teaching was you have to fix hernias right away. And this could be urban myth, but a lot of my older mentors would tell me, yeah, we would admit people to the hospital and repair them right away because there was this huge fear that people were going to have an emergency. And I think the same thing, perhaps not quite to that level, but the same concern is there for women right now that we’re worried that we don’t have the data. And so for fear of preventing an emergency, we have to do surgery on everyone, even though we don’t have data to say that. And many women that come as are probably diagnosed incidentally, they didn’t even know they had a Hernia until they get a CAT scan for something else.
Speaker 1 (00:10:31):
So when I was in residency, everyone who had a Hernia was scheduled for surgery and they were told, if you don’t have surgery, you may end up in the hospital with incarceration or strangulation, which is an emergency situation you’re going to have intestines will be cut out and so you very sick, you can die. That was a very common discussion during my residency was when the watchful waiting trial was being performed at the va and we were part of that. I was one of the residents that was enrolling people and then as a chief resident, I was the one who was checking them for their annual visits to look for yes, hernia, no hernia. It was a good trial, but it wasn’t the best. My attendings were nowhere near the appropriate for doing any of the laparoscopic arms.
Speaker 1 (00:11:27):
The reason why laparoscopy was not very good outcomes was because those surgeons at the VA were just not good laparoscopically. They didn’t know, what do we do with these? It was very interesting. So yeah, now we have a very good discussion with patients. Mr. Right patient, you can have surgery or you know what? It’s okay if you Foregut surgery, you want to wait five years, 10 years, you have a 0.18% chance per year of getting an incarceration. No one dies from waiting for surgery for elective surgery if you have no symptoms or you’re minimally symptomatic. Right? That’s a discussion for women. What do you say?
Speaker 2 (00:12:16):
I think for women right now, we kind of have the conversation of we should probably fix this. We don’t have data to say that it’s safe, but I’m really hoping to bring about that data and develop that data in the next few years to start. My goal is eventually to kind of repeat that trial that Fitzgibbons did in women so that someday we can say either yes, it’s just as safe for women as it is for men to do watchful waiting or no, the prior data showing that we should probably fix them was true and we really should be going down this path.
Speaker 1 (00:12:53):
And is this a trial that’s going to be at Michigan? Is it a multi-institutional trial? Yeah,
Speaker 2 (00:13:01):
I, great questions. a lot of those, I’m still ironing out. So right now I’m doing a lot of the preliminary work. And so what we’ve seen in previous trials and surgery is that if you don’t kind of get all the ducks in a row early, there’s a high risk of failure, right? Because especially we’re asking people, would you randomize to have surgery or no surgery? That’s a big ask of patients. And so before we do that, I’m interviewing patients, I’m going through transcripts right now from almost 40 women that have been diagnosed with an inguinal hernia to get their perspectives. We’re going to be doing similar things with surgery, and the goal would be, it would be a multi-institutional trial. Hopefully in the next few years to get going on that,
Speaker 1 (00:13:46):
I highly recommend you just become friends with Bob Fitzgibbons because he went through a lot. He had to go through every, he’ll share his story. He did it on our podcast. He had to go to every single VA, make sure people had to watch videos to make sure all the repairs were done. Similarly around for institution, the nurses to make sure that the followups are done. It’s very expensive, very expensive, very
Speaker 2 (00:14:19):
Expensive. And I think to that end, another question that I think has been asked a lot in men but not in women is what’s the best approach? And so we have that initial VA data plus dozens of other studies to tell us that the relative merits versus open versus laparoscopic, and we don’t really have that for women. And when we look, the majority of women, at least in some of our most recent studies, are getting an open approach, which is different than what men get.
Speaker 1 (00:14:48):
True, true. So Mike can tell you my take on it, and then we have a question I want to answer, but like I said, most of my patients are women, 51%. So they say, well, is it safe? What if I just don’t have surgery? And I say, the reality is A, we don’t know. It hasn’t been studied. I’ll now say Dr. Ehlers will be studying this, but I tell them, let’s say it’s 10 times higher risk than men. That’s a very large number, but you’re 10 times more likely to do poorly than men. That’s a 0.18% for your risk times 10, which is 1.8% per year
Speaker 2 (00:15:29):
Risk. So very
Speaker 1 (00:15:30):
Low, a low number. So I kind of put it in perspective like that with the caveat that we must make sure you do not have a femoral hernia. But these are all inal hernias. The femoral hernia complicates the women’s plan of care because it’s the only hernia that we know of that has a high risk of death. If you end up with an incarcerated or strangulated femoral hernia, you have a 5% chance of dying. That’s not true for any other hernia. So the European Hernia Society guidelines say, and therefore watchful waiting is not appropriate for women. They can die. And the best repair for femoral hernias is laparoscopic surgery. So you should do laparoscopic hernia repair with mesh. I have an issue with that. Number one, you can take gut imaging and see if their bulge is an inguinal or femoral if you can’t tell from exam. So it’s not like our hands are tied like, oh my God, what should I do? What if it’s a femoral image it instead?
Speaker 2 (00:16:30):
Yeah, 2024.
Speaker 1 (00:16:32):
So yeah, so if you can image it, that’s what I do sometimes, because some women don’t want surgery or whatever. I said, let’s rule out femoral hernia. I can’t tell. It’s kind of low lying. It’s hard to tell sometimes. If it’s not a femoral hernia, then I feel much more comfortable saying, yeah, you can wait a couple years or whatever. If it gets bigger, I’ll fix it. If it becomes more symptomatic, I’ll fix it. But if it’s femoral, I don’t feel comfortable saying that because there’s a risk of death, so let’s fix the femoral. So that’s one discussion I have. And then the other is the fact that the guidelines say that women should get laparoscopic repair with Mesh implies every female must get general anesthesia and every female must get Mesh, and I don’t agree with that. So it needs to be a little bit more tailored than that guideline. And I
Speaker 2 (00:17:26):
Think a lot of that rest on this same issue about the femoral hernia, which as you mentioned, if we can rule that out, you’re not worried about that as much, then probably either approach is Okay.
Speaker 1 (00:17:38):
Well that’s the question. So if I, let’s say I do an open anything, right? Either an open tissue or open mesh repair, I will not be doing anything that would prevent a future femoral hernia, whereas laparoscopic repair will, does that matter? I don’t know. Many studies show that the reason why women have more recurrences or bad outcomes because they had a inal Hernia and they come back with a femoral, that’s kind of falls into that category. But was it really a femoral that they missed and did inguinal or did they have an inguinal? And then later on, as years went by, they developed a femoral, I have no idea.
Speaker 2 (00:18:19):
I think we always assume it’s the former that we missed the femoral hernia, but you’re absolutely correct. It could have just been years down the line that they developed another hernia.
Speaker 1 (00:18:28):
Add that to your list of things to study. I have so many questions I need you to answer all of them. Love
Speaker 2 (00:18:34):
It.
Speaker 1 (00:18:36):
Okay, let’s go to the live questions real quick. Okay. This is a great question because it’s related to females. It says, I want to know about abdominal wall repairs after TRAM or deep surgeries. So TRAM flap is, it’s basically a rectus flap for usually breast reconstruction when you remove the rectus muscle, DIEP is a similar flap, but you don’t use take the rectus muscle, but you can injure the neurovascular bundles and get hernias from it. So those are difficult hernias to repair regardless of whether it’s a TRAM or a deep flap. You want to talk about your experience with that or
Speaker 2 (00:19:24):
I would actually love to pick your brain on that because I fortunately or unfortunately have only had a couple patients come through and it’s always sort of a multidisciplinary conversation with the plastic surgeons and oftentimes we’re sort of like, there’s not a lot that we can do to fix it, this muscle laxity versus a true fascial defect as an a hernia. But what’s your approach that you take?
Speaker 1 (00:19:48):
So when the TRAM flap came about, it was when women were getting mastectomies and as an alternative to getting a breast implant, they can get their own tissue, so muscle and skin and fat to recreate the breast. And it was billed as, oh, you’re getting a tummy tuck at the same time. So how cool is that? You get new breasts mastectomy and you get a tummy tuck. So if they’re taking either one or two sides, since you’re losing the rectus, there was two ways of dealing with that. You either just used a piece of mesh to act as your erectus, so they would tighten it and you would use mesh. Or if it was one side, they would actually just close that rectus and then put mesh. And some of them didn’t use mesh. But what you end up having is a very distorted abdominal wall losing muscle mass and it’s asymmetric regardless of whether you use mesh or not, and those can fall apart.
Speaker 1 (00:20:50):
So those are very difficult and unfortunately what can happen is the side that’s tightened actually stays tighten, and then the other side that’s not tight actually gets looser. So patients are like, why am I bulging? But they’re not actually bulging. It’s actually the area that was snatched where they used the rectus muscle to recreate the breast is what’s abnormal. The deep flaps are difficult because they often, you’re not supposed to get any muscle or fascia as part of that surgery, but they do want the blood vessels to feed the flap a free flap that goes to the breast so they can sometimes injure the nerves that gets to the muscle and then you get a denervation. And with those, it’s very difficult. You have to treat it like, I call it like a tummy tuck of one side. You have to take that side that has no good nerves to it because it’s not a true Hernia, it’s just a bulging, and then you have to plicate it, which means you have to tighten it. And then you have put a very wide piece of mesh as an on lyse on top to treat it. Either way, you have to get these done by women who, by surgeons who’ve done it before, understand how these flaps are performed, see if a mesh was used originally or not, read the opera report of how the abdominal wall was handled, look at imaging, and then it’s never a perfect scenario.
Speaker 1 (00:22:28):
There’s a follow-up question to that. I have a group of over 500 ladies and many of us have complications. This is true, and we are limited to surgeons for repair. That is not true. I have personal, I personally have no rectus or obliques and transversus abdominis. I had a tar procedure. Oh, you can’t do a tar for these. That is a wrong approach. I had a TAR procedure and it failed. We have ladies allergic to mesh. Do you have options? So doing a tar is a wrong operation. This is not a hernia. And releasing the posterior aspect is not, you’re basically not understanding what the problem is. The problem is for a TRAM is a, it’s not a fascial defect, it’s a laxity because all you have is a posterior fascia. You just need to strengthen anteriorly, not posteriorly. And yeah, some women have allergies to meshes. Do you see mesh allergy patients or Mesh implant illness patients?
Speaker 2 (00:23:31):
Not a ton of them. I do have a follow up question for you though. I’m curious when we’re talking about these really complex problems that maybe don’t have perfect solutions or do you build in expectation setting and management? For example, the bulging on one side, if you have Mesh on one side and not the other, how important or how have you built that in to help patients understand these complex problems that I think even a lot of surgeons don’t understand?
Speaker 1 (00:24:04):
So I try to be as honest as possible with the patient. So for example, the worst trimmed and deep flap patients are very complicated. Even more complicated is that the patients who have denervation from flank, flank, so I tell them there’s a treatment for it. It’s horrible. It’s the worst outcome of all the different hernias I treat is the flank denervation ones. But if you’re young, healthy, this is only going to get bigger. I can maybe make you a little bit better. You won’t look perfect or symmetric. You’ll be still a little bit more bulging on the one side and you may need more than one procedure if you’re otherwise young and active because these don’t last very long. But it’s better than having this grow and become an alien growing out of you. You’ve seen it’s very deforming. So I’m honest with ’em, but I think what you’re hinting at is what do you say versus what do the patients hear, right? Yeah. Some patients may come back and be like, I’m not the same, and I feel pulling and I have to remember our discussion, remember how you look before surgery, for example.
Speaker 1 (00:25:27):
Patients can’t predict how they will accept their new body, even though from a surgeon standpoint, I mean this is so much better than what you were, but they may have tugging and pulling and if I had known that it would be so painful, I wouldn’t have done it again. There’s a lot of that discussion that that’s difficult. I don’t know. Do you have a way to handle these?
Speaker 2 (00:25:56):
I try to really elicit what the patient’s goals are and to see if we can meet that goal with the surgery. Because a lot of people, as you know, come in and maybe their goal is they don’t want to feel bloated after they eat, and that’s probably not caused by their small inguinal hernia or whatever. And so I really try to figure out what it is that their goal is with the surgery. Is that a goal we can meet with the surgery and if yes, great, let’s do that. And if not, what are some other avenues we can go down? I think a lot of people get an operation not just for Hernia, but for many things thinking it’s going to be kind of a panacea when it’s fixing a specific problem and just setting expectations around that.
Speaker 1 (00:26:41):
Yeah, this is true. So I take very detailed notes and so I have, let’s say these patients with mesh implant illness, it’s very rare, but I see them and many people who are allergic to meshes actually do well with a lower inflammatory mesh, like I call ’em hybrid Mesh. It’s mostly biologic, but there’s some synthetic in it. But even that kind of mesh, you can still, I mean there are people that are allergic to biologics too, but when I see them, I take my note from pre-op, I’m like, all right. Okay. You said with walking, is that still a problem? Okay, twisting was a problem you still have and otherwise it’s very hard to just globally say, how are you doing when they’ve had, let’s say, Mesh removal and neurectomy or whatever the complicated situation is. But that’s what my notes are, like fricking, that’s
Speaker 2 (00:27:37):
Really smart.
Speaker 1 (00:27:38):
Wikipedia, I go back, I like, alright here you said you had burning and tingling in your scrotum, you still have that, so it helps quantify it, whereas
Speaker 2 (00:27:51):
Yeah, the one, it can be so nebulous for some of these issues.
Speaker 1 (00:27:54):
True. Here’s another comment. I was very interested in your discussion of TRAM complications. That’s TRAM. Can you explain how tiny laxity placing mesh complement each other in the way you address TRAM complications? Yeah, so the TRAM complication typically is the area where they remove the rectus muscle doesn’t have a bulky rectus, it just has a thin fascia and usually it’s the upper half. The lower half is preserved of the rectus, but regardless, so what you have is a bulging of that side that the rectus was removed. However, in some patients they actually during the TRAM have that space closed. So they take the midline and then where the rectus was removed laterally and they close that, it’s very tight, but in some people it’s possible and and then some of those people get meshed on top. For those that get mesh on top, they actually have that space extra tight and then as they age, the natural side starts bulging.
Speaker 1 (00:29:04):
And so there’s no good treatment for that one because comparing stiff abdominal wall with natural flimsy doll wall, but you can use mesh to kind of help a little bit, do a tummy tuck with mesh to kind give you a little bit more symmetry that can happen. Okay. Next question. Is there a clear explanation why younger slimmer females tend to experience more pain after an inguinal hernia repair? I had a repair five months ago with mesh and I’ve had chronic pain ever since. I’ve noticed that the younger they are and the slimmer they are, I think the more mesh problems they have. But what do you think?
Speaker 2 (00:29:49):
I think one of my collaborators that I work with is a pain researcher. And again, this is one of the things that not studied in women, so we don’t know. And women, I think he’s a pain researcher, researchers pain after surgery often have more pain after surgery in general. And we don’t know why that is, but I don’t know why it would be sort of the younger slimmer folks. I wonder if perhaps due to activity level or hormonal changes that are occurring or I’m not exactly sure of it.
Speaker 1 (00:30:23):
So I did read that women’s pelvis has more density of nerves than male pelvis. So that was one idea, which is why women tend to have more chronic pelvic pain with hernias and also with the hernia repair. And
Speaker 2 (00:30:41):
I also wonder if, because there’s so much less common, there’s probably not a lot of high volume surgeons for women with inguinal hernia. So I think that the question always comes up. Many people may only get one or two a year, and so they’re just not as familiar with the anatomy, perhaps not as slick in their repair, getting off track to where even the nerves we know that are there. So I always wonder if it’s something about just not feeling confident and understanding how best to surgically repair these.
Speaker 1 (00:31:15):
I agree. And all of our techniques are based on male anatomy, the keyhole,
Speaker 1 (00:31:20):
All the different types of meshes, always the cord, this rheumatic cord, this rheumatic cord, that and the shape of the meshes and where they’re wider and so on is based on male anatomy is not based on the female anatomy. I’m sure the technique issue is part of it. With regard to the slim part, again, I have no data to base this on, but because I’ve also noticed that the younger thin, if you’re a young thin female, that’s like the triple problem for mesh related problems. So I tend not to do only lichtensteins in those people and if they do get meshed, they would get it laparoscopically, but I wonder if it’s because there’s not enough fat to buffer that inflammatory reaction from the mesh.
Speaker 2 (00:32:15):
Certainly could be
Speaker 1 (00:32:16):
Theory.
Speaker 2 (00:32:18):
No, I mean it as good a theory as anyone has, I think.
Speaker 1 (00:32:22):
Yeah, I think we don’t treat women well. We treat women the same as men, even though the pelvis is different, the Mesh size mesh weight mesh, everything is the same. And I think that should be changed. Hopefully we’ll have more over years, but maybe not in my lifetime. I think
Speaker 2 (00:32:41):
Hopefully.
Speaker 1 (00:32:43):
Hopefully we’ll see. I get my hernia and then yeah, it’s true. Chronic pain is higher in women at least after groin hernia. I don’t know about the data for abdominal wall hernias, but for groins it’s definitely higher than in females and males.
Speaker 2 (00:33:01):
The data is not quite there for abdominal wall hernia. But one thing that we’re doing right now in Michigan is we have a population-based registry where we collect data on clinical outcomes like infections, re-operation. But we’re finding now collecting patient reported outcomes at a year after surgery, and it’s the first time we’ve really been able to do this at a population level and some of the early data is showing us that yes, even after abdominal hernia repair, women are having more symptoms of a bulge, more symptoms of pain. And so I think another really exciting topic of research that we’re going to be digging into over the next few years.
Speaker 1 (00:33:43):
Sounds amazing. Yeah. Wow. Lots of more questions all of a sudden. Oops. Where I go, here we go here. How long is it to wait for surgery? How long is too long to wait for surgery? Males or females?
Speaker 2 (00:34:05):
Well, I think for males, the only time when it’s too late is I think for both people. The only time if it’s too late is if you’re one of the unfortunate few that has had an emergency. But I think for men, we can safely say that as long as the Hernia is not bothering you or impacting your quality of life, you can wait as long as you want. You never have to get it fixed. I think for women, the crucial question comes up as you discussed previously about the anatomy of their hernia, is it femoral or inguinal guidelines would say you have to fix all of them, but perhaps for some of these non femoral hernias, we may be able to explain some of the nuance and also allow for that shared decision making.
Speaker 1 (00:34:51):
Yeah, agreed. What types of hernia symptoms are considered reasons for going ahead with surgery versus watchful waiting?
Speaker 2 (00:34:59):
I don’t think there is a threshold. I think that that is totally up to patients. I think some people, I see a lot of patients that had an imaging study for something else, they didn’t know they had an inguinal hernia, but as soon as they know about it, it’s like this ticking time bomb and they can’t stop thinking about it. And so I think whereas I have other people that they’ve got a moderate size bulge and it causes them pain every day, but they really don’t want to have surgery. And so I really let the patient drive the decision making, and even if it is to help calm anxiety, think that’s a good reason to have surgery.
Speaker 1 (00:35:39):
It depends on your personality. Some people, I give them the whole watchful waiting spiel and they’re like, I don’t care. I don’t want to think about it. Just let’s repair it, which is fine, but watchful waiting is only for patients that are either asymptomatic low symptoms or minimally symptomatic. That’s the US trial. So have some symptoms, but it doesn’t really affect your quality of life. But if, oh, let me give you a good story. Okay, so we were at a meeting and the president of the meeting gives his presidential speech and I’m sitting in the front row, so he gives his presidential speech, great guy, he’s a vascular surgeon, and then he talks about life lessons and things like that, family a career. And then he says, so I got a hernia and I knew I had a hernia and he’s like a soccer player too, so it didn’t bother me at first. I would just kind of push it back in. I read so much stuff about how there’s a 30% chronic pain rate, which is not true, 30% chronic pain rate, and I was worried about mesh. And so I decided just to do watchful waiting.
Speaker 1 (00:36:52):
And he describes how he would push this hernia back and it would get stuck. So over the span of several years, it would get stuck and then he would try and push it back in. And I told, there’s a surgeon next to me, a female surgeon. I’m like, that’s not a watchful waiting criterion. If it’s incarcerated, that’s not eligible for watchful waiting. In fact, what he’s doing is he’s increasing his rate of chronic pain risk because he’s now causing inflammation upon inflammation, which it’s is going to make him worse for chronic pain anyway.
Speaker 2 (00:37:31):
Yeah, and I think it’s also this idea, a lot of my partners, I kind of offer watchful waiting if they meet criteria and they’re interested in it. Whereas many of my partners are like, well, the data also shows that if you look out to three or five years, many of those patients become more symptomatic and end up getting surgery, so why not do it now if you can while the hernia is smaller and they’re less symptomatic? But I’m not sure I necessarily agree with that for all patients.
Speaker 1 (00:38:03):
So there are certain certainly surgeons around us that still don’t follow watchful waiting and tell all the patients, oh, you must have surgery. So obviously that’s not evidence-based, but I think I interpret the data like you do, which is it is safe not to operate because at five years, about three fourths of the patients are doing fine. At 10 years, about a third of the patients are doing fine, so why are you focusing on the other two thirds of 10 years when a third are doing just fine? You’re basically possibly offering a third more surgery than you need to be offering possibly.
Speaker 2 (00:38:43):
And I think particularly for the people who have no symptoms, while it is a very safe operation, there’s still a non-zero risk of surgical complication chronic pain. So why take that risk if you don’t need to?
Speaker 1 (00:38:57):
I agree. I agree. And that doesn’t mean that waiting and the hernia gets bigger necessarily increases that risk. We don’t know that, right?
Speaker 2 (00:39:06):
No.
Speaker 1 (00:39:07):
Yeah. Okay. What are your thoughts about high BMI for abdominal wall repairs?
Speaker 2 (00:39:15):
Yeah, it’s a great question. We talk about this all the time. I think more so for ventral and incisional hernias, so not the groin hernias. I think for groin hernias it tends to make less of a difference, but for ventral hernias, a lot of the evidence suggests that having a high BMI at the time of surgery increases risk for complications in the short term as well as risk of hernia recurrence. And so we or I really try to get my patients to A BMI less than 40 if I can to really optimize them. And the conversation that I have is the data that we have shows that this is for all comers, not for high volume surgeons, but for all comers, at least 10% of patients will have a hernia recurrence. And after you’ve fixed it twice, three times, four times, that risk only gets higher. And so my job is to try to make that first operation the safest, most durable operation so that we’re not having this conversation again in three years. And I think I also do bariatric surgery, so I feel very comfortable having that conversation with people. The new medications are great, it can help us sort of bridge people. So I do think trying to get to A BMI less than 40 is ideal for people considering abdominal hernia repair
Speaker 1 (00:40:43):
For sure. And you can go online and there’s BMI calculators where you just put in your height and weight and it’ll tell you what your BMI is, and you want it to be less than 40, ideally less than that, but definitely less than 40. Going back to the young slim woman situation are suture knots and mesh less buffered by subcutaneous fat and young slim women with contact between suture knot and mesh causing the pain. Oh, suture. They’re asking about the interaction between the sutures and the mesh as opposed to, yeah, I don’t think we know,
Speaker 2 (00:41:20):
And some people just have a bad reaction, not just, I bet it’s much more common to have a bad reaction to suture because people do come in with these granulomas like draining sinus tracts as you know, here years after having surgery and you can pull out little bits of suture. So that’s another really interesting hypothesis about that.
Speaker 1 (00:41:41):
Is it possible that the mesh size affects how slimmer females feel pain? My understanding is that all meshes are made as one size fits all. To me, that doesn’t make sense that they would use the same mesh size for slimmer females as they would normally use for males who also have a completely different anatomy in the pelvic area. Isn’t that what I just said?
Speaker 2 (00:42:02):
Yeah, I think you did say that. And the good thing about many of the meshes is that we can trim them. So even though they all come as sort of standard sizes, that’s certainly something you can talk with your surgeon about, sort of modifying the shape if you’re a smaller person and make sure you’re not getting something that’s not right for you.
Speaker 1 (00:42:21):
Yeah, agreed. Any suggestion on the fatty tissue hernias despite already having an anal hernia that needs revision? I don’t know what that question means.
Speaker 2 (00:42:31):
Do you think you made cord lipoma?
Speaker 1 (00:42:35):
Yeah, I guess maybe a retained cord lipoma after already having had redo hernias. What do you know about or what can you say about cord lipomas?
Speaker 2 (00:42:44):
So cord lipomas is something we see in many men who have surgery, and it’s basically a fatty growth around the cord structures, which are the structures to simplify. They go from inside to outside, and that’s where we often find the hernias. It’s super important, I think, to look for these at the initial operation because I think that is the source of people’s discomfort or the bulge that they notice in a lot of cases. And so I definitely have seen that where you go back for a reoperation, and I don’t know if there’s data on this, but I would imagine it’s more missed in the laparoscopic or robotic
Speaker 1 (00:43:25):
That has been shown. Well, early you have
Speaker 2 (00:43:28):
It. Yeah, you have to really look for it. So I’ve definitely gone back where people have large and it’s obvious would be causing them a lot of pain.
Speaker 1 (00:43:38):
And then what you do is it’s actually more pain because before that lipoma was going in and out of this hole, now you close that door and now you’ve trapped that into a, that’s painful. Yeah. Ask, do you do hiatal hernias? I
Speaker 2 (00:43:55):
Do.
Speaker 1 (00:43:56):
Oh, great. I don’t. So let me ask you Hiatal hernia question. Can a hiatal hernia cause high blood pressure? I got mine during exercise and blood pressure reach 177 over 115 thought I was having a heart attack. Can a hiatal hernia give high blood pressure?
Speaker 2 (00:44:14):
Not that I know of. Generally symptoms of a hiatal hernia. So this is a hernia in your chest where the tissue that connects or that connects your esophagus to your diaphragm gets loose over time. And so stomach bounces in and out of your chest. Usually people experience that as symptoms of heartburn regurgitation. In some cases where people have their whole stomach in their chest and or other organs like colons, small bowel, they can experience things like shortness of breath just because it’s space occupying, but I’m not aware of it causing isolated high blood pressure.
Speaker 1 (00:45:01):
Interesting. This is an interesting question, Dr. Myers. Bill Myers is a really prominent sports surgeon sport, her surgeon. The question is, this is Dr. Myers, correct? When he writes an article, is that one of the reasons why there are fewer sports hernias in women is because they have a broader pelvic girdle associated with broader attachment of the practice muscle and other components of the pubic plate? Or is it because women have less muscle development, although many female athletes are quite muscular, more research for you to do more
Speaker 2 (00:45:41):
Research? I know it actually brings up a really great, great question, which I, or kind of topic, which I am not into myself, but I know a lot of people are getting into this, which is this morphs this field of morph foams where you look at CAT scans, MRIs, and look at the shape of someone’s body. And so I know people are doing it with ventral hernias, but that could be an interesting field looking sort of at differences because you can follow people over time. Do they have a hernia, do they not? How does it correlate with the shape of their pelvis, the amount of adipose tissue they have? So that could be a really interesting way to ask that question.
Speaker 1 (00:46:16):
I always wanted to develop a research project where we map out my opec, new orifice over a series of scans of different heights, weights and genders, and then optimally design a mesh based on that data. Data is not very evidence-based. Someone just made up some mesh
Speaker 2 (00:46:38):
Than that would be so interesting and I think totally doable. And then you can imagine you’d get your scan on some in pre-op and you’d be able to use that information to tailor your operation. I love that idea.
Speaker 1 (00:46:50):
Yeah. In which directions is research related to herniated diagnosis and treatment in women heading? Maybe you can tell me a little bit about your different research projects that are related.
Speaker 2 (00:47:05):
Yeah, I think it’s heading in a really exciting direction. I think the fact that people are excited about this. We’re having this podcast I think at sages this year. We’re having another great session about this. But I think what’s really exciting is that not only are people like myself and Dr. Towfigh interested in this, but funding organizations are starting to be interested in this. And so myself and my partners have gotten funding from National Institutes of Health, which is sort of where biomedical research, how it gets paid for in this country in large part. And they’re funding these projects. They care about this. We’re showing them that this is a serious problem for hundreds of thousands of women that have surgery every year. No one’s paid attention to it. All the research have been in men. And so I think people are starting to catch on that this is an important topic and I think we’re only going to get more information and have more answers in the coming years.
Speaker 1 (00:48:07):
Yeah, it’s absolutely true. When I first presented the American Hernia Society meeting, I was the only female that presented. That’s how bad it was. And then we started talking about this and to the point where now we’re at the point where not only have we had a female president of the society and board members, but every year in that meeting for the American hernia side, there is some special section just on women’s issues with hernias, and same with sages. Our big laparoscopic meeting every year. We do have something that’s related to the women and hernia. I think this year is called hernia. So I believe you’re part of the panel and it’s going to be a really great, and I’ve got a patient that’s coming in to share her story too, which is a great story.
Speaker 2 (00:49:04):
Oh, that’s fantastic.
Speaker 1 (00:49:06):
Decades of pain. These women are labeled as chronic pelvic pain, and what they had was exactly what a male had, except they weren’t told it’s a hernia. They were just told it’s chronic pelvic pain.
Speaker 2 (00:49:15):
Yeah, that’s awful.
Speaker 1 (00:49:17):
I had a patient today that flew in all the way from another state, and her imaging showed hernias every single time, and the radiologist on two occasions actually mentioned it in the body fat containing lipoma and in canal. And then the bottom under impression, no Hernia.
Speaker 2 (00:49:37):
I’ve had a patient like that recently too, where all the classic signs, they weren’t big hernias, so not an exam, but kind of clearly there. And they didn’t call it a Hernia. They called it something like bulging or eventration, but didn’t use that word. It’s crazy.
Speaker 1 (00:49:54):
Yeah, they’re so afraid to use a word hernia, especially around women. It just doesn’t make any sense. Can women be included in other disadvantaged demographics regarding access to and outcomes of hernia treatment?
Speaker 2 (00:50:09):
Yeah, I think they certainly are. Anytime. I think many of the surgical societies consider women to be sort of a disparities group when we think about this, so absolutely.
Speaker 1 (00:50:20):
Yeah. Do men and women share the same development and recurrence risks of incisional hernias? Oh, incisional hernias.
Speaker 2 (00:50:29):
I think that’s another good question that the short answer is I don’t know of any differences. I’m not sure if you do an incident, I think across the board we say it’s about one in four, one in five people develop an incisional hernia
Speaker 1 (00:50:46):
Increases that risk. But
Speaker 2 (00:50:48):
That’s the thing. Yeah, if they had their laparotomy or their surgery before they got pregnant, this is another important topic is how do we treat hernias in women who may choose to become pregnant in the future? So I think those things not considered, there’s probably not some underlying reason that they should have a different rate of incisional hernia.
Speaker 1 (00:51:10):
Going back to inguinal hernias, we noticed, or I noticed that the round ligament is highly controversial. I don’t care about the round ligament. And for years, every time I see a urologist or a urogynecologist or a gynecologist, I ask them, do you think the round ligament is important? No. What if I cut it? No big deal. What if I cut both sides? No big deal. But then I go to these meetings with general surgery, oh, don’t touch the round ligament. They can get chronic pelvic pain and a uterus and it can affect their pregnancy and all that stuff. Prolapse. I’m asking the people that actually deal with that. They say, no,
Speaker 2 (00:51:50):
Not a problem. So
Speaker 1 (00:51:52):
I’ve always wondered what the evidence is on how we should handle the round ligament. It’s not published anywhere. I routinely cut it.
Speaker 2 (00:52:01):
Yeah, I think you see it both ways. And I think another important thing to build in once we start doing more of these trials is not maybe randomizing people, but to that, but understanding subgroups of people who did or did not have it cut happened to them down the road.
Speaker 1 (00:52:17):
So Ben Poulose has looked at the ACHQC data on round ligament salvage versus not salvage, and he found a higher, it was either a higher chronic pain or higher recurrence rate. If they didn’t touch the round ligament, if they cut it, I think it’s a better repair personally. But his data also showed through the ACHQC, which is of course not the best database, but that at least it’s some evidence that maybe it’s a better repair if you do cut the round ligament so much to learn
Speaker 2 (00:52:54):
So much,
Speaker 1 (00:52:56):
So much. It’s really great
Speaker 2 (00:52:58):
Work that out for me.
Speaker 1 (00:52:59):
You’re part of such an academic institution that values dedicated research time to get to answer these questions, and
Speaker 2 (00:53:07):
Yeah, I’ve been so fortunate and really lucky to, I’m about almost five years out of training, but have been very, very fortunate to be in a place that really supports me that way.
Speaker 1 (00:53:19):
Is that what you were looking for when you were looking for a job?
Speaker 2 (00:53:22):
Yeah, I did research during residency, not so much in hernia because at the time my mentor specifically told me it was impossible to study hernia. He’d written one paper on it and was never going to do it again. So I’m sort of told you so, but no, but I loved doing research early on, and so I was definitely looking for a job that would give me that opportunity.
Speaker 1 (00:53:47):
Yeah. Well, it’s so necessary, and it’s the number one most common general surgery operation, and yet only one sexist study about it. It’s so crazy. More questions. These are all about mesh implant illness. Oh, here’s another one. In addition to the anatomical differences that make occult inguinal and femoral hernias relatively more common in women compared to men, are there any other factors that demand a more comprehensive approach to hernia treatment in women? There is a study that shows that from a genetic standpoint, having a female having a hernia is more predictive of a genetic kind of lineage than males.
Speaker 2 (00:54:40):
I would totally believe that. I got to check that study out, and actually a patient of mine recently when I was trying to assess out her symptoms, she’s like, yeah, my mom had an inguinal hernia. My sister had one and listed off all these people, which it’s kind of unusual because only one and 15 or 20 women will get her inguinal hernia in their life.
Speaker 1 (00:55:03):
We know it’s genetic, right? It’s like the whole collagen disorder. I started noticing that in my patients, that the ones that came in with symptoms, if they told me they had a lot of females in their lineage, then they’re more likely. And then this paper came out on children saying that if their mother had a Hernia, those children were more likely to have hernias as children than if their father had had a hernia. That’s what I’m seeing. But in adults, not in children,
Speaker 2 (00:55:37):
Well, it’s probably all ends of the spectrum and at what point in development that hernia is occurring. Very cool.
Speaker 1 (00:55:51):
So now we’re going to the mesh implant illness. Does female sex or preexisting history of immunologic disorders prevail in affecting the risk of developing mesh implant illness after hernia repair with Mesh? I mean, that’s the problem with not the problem with one of the main difference between men and women is women tend to have, females tend to have more autoimmune disorders than males. So there is that, and whether that’s a reason why or does that make them more prone to mesh implant illness? We think so because in our study, I think 80% of patients had either personal autoimmune disorder or severe allergic.
Speaker 2 (00:56:34):
Oh, interesting.
Speaker 1 (00:56:38):
Or very strong family history of it. So there seems to be that correlation. But
Speaker 2 (00:56:43):
Again, so when you have a patient that maybe has another autoimmune disorder, how do you counsel them about that?
Speaker 1 (00:56:51):
I share with them our data, and I say that we don’t know. We’re in the learning stage of things. What we do know is A: mesh and S is rare, and B: the people that are more likely to get it tend to be females, tend to be much on the thinner side, like ballerina level bodies and tend to have an autoimmune disorder themselves or family history. That’s very strong. Or some patients come in, they’re allergic to everything, every antibiotic, several me,
Speaker 2 (00:57:25):
Everything.
Speaker 1 (00:57:27):
So in those patients, I say there’s a greater than 0% chance that you will develop a reaction to the mesh, but you need mesh, let’s say, or I can do this without Mesh and here are the risks of doing it without Mesh. So we have that discussion. Some people are like, they don’t care. Others are like, oh yeah, let’s do it without mesh, or Yeah, everything I touch, I react to. So let’s definitely not use mesh. Yeah, interesting. Yeah, the patient I saw yesterday, I think, yeah, she definitely had autoimmune disorder herself, very thin, petite female, and then she reacted to the IUD that was put in her. Oh, wow. Also a suggestive, and I think she got some, the patient had covid vaccine and got rashes and headaches and joint swelling. So those are all similar reactions that we would see as with a mesh implant reaction.
Speaker 2 (00:58:26):
And you just try to take the mesh out in that case or treat through it.
Speaker 1 (00:58:31):
So the only treatment that I know of besides putting people on transplant level, immune suppression, is to remove the mesh if they get them. And we also looked at the outcomes for that. We’re presenting that data actually at stages this year, which is what happens, what are the outcomes of removing mesh? And when people that are considered to be Mesh implant illness and 60% got cured, but a good 40% either got slightly better or got not better. So it just shows that we’re not very good necessarily of diagnosing even mesh implant illness.
Speaker 2 (00:59:11):
Such an exciting time to be in hernias every time you work with residents and medical students a lot too. And it’s, I think getting back to this question of how’d you get into it, one of the exciting about this field, I think, is that there’s still so much to learn because it’s been so hard to research this in the past and there has been interest, but we’re really, I think, growing this field and it’s a really fascinating time to be a part of it.
Speaker 1 (00:59:36):
I a hundred percent believe that. And I think our audience that comes to this every single week and participates and asks questions, believes that, but my friends are like, you have another hernia meeting. What can you guys be talking about?
Speaker 2 (00:59:50):
What else? And you’re like, call me back when you get a Hernia pretty soon.
Speaker 1 (00:59:54):
Yeah, that’s very, very true. Very, very true. All right, well, can you believe it? Time is up already. It’s been a quick
Speaker 2 (01:00:02):
Yeah, it has.
Speaker 1 (01:00:03):
I enjoyed it so much.
Speaker 2 (01:00:05):
Me too. Thank you so much for having me, and I look forward to being part of this community.
Speaker 1 (01:00:10):
Thank you so much. I appreciate you and for everyone who joined us, thank you. A couple more questions, but we’ll try and answer them after the show. Thank you, Annie, for joining us. And don’t forget to go on my YouTube channel, subscribe and follow. And also remember, we also have a podcast, so if you prefer podcasts, we’re transferring all of these over to the podcast and we have over 2000 downloads already. I’m super excited about that. Is that cool?
Speaker 2 (01:00:35):
Very cool.
Speaker 1 (01:00:36):
Yeah, it’s beautiful. So thank you all and have a great rest of your night, and thank you, Annie for sharing your time with us and keep on doing your excellent research. It is so important.
Speaker 2 (01:00:48):
I will. Thank you so much. Take care.
Speaker 1 (01:00:50):
Thank you. Bye.
