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Speaker 1 (00:11):
Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live. It’s Tuesday afternoon. Again, thanks for joining me every week so diligently on Hernia Talk Live. I am your host, Dr. Shirin Towfigh, hernia and laparoscopic and robotic surgery specialist. Many of you’re joining me as a Facebook Live welcome. And also thanks for those of you that just joined via Zoom. Please follow me on those on Facebook at Dr. Towfigh, also Instagram and X at herniadoc. As always, this episode and all prior episodes are available to be liked, subscribed to, et cetera on my YouTube channel. And for those of you that like podcasts, Hernia Talk Live is now also a podcast and we’re catching up on all the hundreds of episodes that we have each year. So today we’re going to talk about Opterator hernias. Of course, if you have any other questions, I’m happy to field them.
Speaker 1 (01:11):
But we have not talked about Obturator hernias. It’s been a couple years, several, I think three years and a half years I’ve been doing this podcast. We’ve mentioned Obturator hernias, but lately I’ve had three patients come in with Obturator hernias, and as you know, I like to choose my topics. I’m inspired by my topics based on patients that come to the office and so on. They tend to come in threes. You may have heard of this before. So this time I’ve had three patients that have come back to back with obturator hernias. One patient has an Obturator hernia. It’s kind of small. Two others. Another one actually has a pretty big obturator hernia and a third one had surgery for an Obturator Hernia. And so I’ll kind of go through their situations and maybe you can relate to it. So what is an obtuator hernia?
Speaker 1 (02:07):
As with most hernias, it’s a hole in the muscle of your abdominal wall. What does that mean? That means there’s supposed to be a muscle that is a barrier that holds your belly in. And if there’s a hole in it, you can have contents that are nearby, pushed through that hole. With an obturator hernia, it’s usually fat, but it can also sometimes be intestinal. When we teach our residents, they know that obturator hernias are rare. We tend not to see them into healthy individuals. It tends to be not always, but tends to be in frail elderly patients, usually female that already have lost a lot of their muscle mass. And so that muscle that usually covers the Obturator space, which is in your pelvis, is that space is usually covered with a curtain of muscle called the Obturator muscle. But if you become really frail and thinned out, and usually it’s seen in people with very thinned out muscles, then that muscle can have a hernia puncture through it.
Speaker 1 (03:23):
That’s the easiest way I can tell you. Now, similar to other common hernias such as the inguinal hernia, the Hernia also obturator space, similar to the inguinal space also has nerves and vessels that go through it. So there’s the obturator nerve and the obturator artery and vein. Why is that important? Well, it’s important because that means there’s already a little bit of hole for natural object to go through it. So that’s like an inguinal hernia, where in women, as you know, the round ligament goes through it and men, all the stuff that goes down the testicle, the artery vein, vas, deferens nerves, et cetera, go through the inguinal canal. Well, the obturator canal or the obturator space is similar in that an obturator nerve and the vessels go down to it and those vessels feed your muscles that cause abduction, which means pulls your thigh in. You’ve been on those exercise machines, right? You got those exercise machines that you sit in a chair and you, there’s padding at your knee level and then you push out, those are abductors with a B muscles and then they’re the same machine. You can switch around and have the padding on the inner side of your knee called the medial side, and then you squeeze that. I remember who was that actress?
Speaker 1 (04:53):
Oh, what’s her name? The one that was in Chrissy and three’s company, Suzanne Summers. Suzanne Summers had that machine. You may recall it was almost like a spring that you put between your legs and you squeeze. Those are squeezing and developing your adductor muscles. So the obturator vessels feed those muscles and the obturator nerve gives function and strength to those adductor muscles. So people who have a hernia through that obturator space are now, yes, ThighMaster. Good job, Suzanne. Summer to the ThighMaster. Thanks you guys. Yeah, the ThighMaster, I’m kind of aging myself I think with that analogy, but it’s technically an adductor master. It’s not everything of the thigh, but it does kind of work on the inner thigh. So my point is if you have an Obturator hernia, then the contents that fall into the obturator space are now competing with the blood flow to those muscles and the nerves that hit those muscles.
Speaker 1 (06:10):
So in extreme cases, you may actually have weakness of those muscles, so crossing your legs and so on. Sometimes certain walking or stairs, you may feel a relative weakness in your legs. That’s really extreme situation. Most people that have Obturator hernias do not have weakness in their muscles. What they do have possibly is irritation of the nerve, the Obturator nerve. And that nerve gives sensation to the inner thigh close to the knee. So if you can think of inner thigh, the upper part of the inner thigh is comes from nerves in your inguinal canal. In your groin canal. The lower part of your inner thigh towards your knee gives you sensation to the nerves.
Speaker 1 (07:02):
But the obturator nerve gets sensation to the nerve, the skin of the inner thigh. So if you have weird kind of burning tingling sensation in the inner thigh, but closer to the knee, not inner thigh, closer to the groin, then that could be Obturator Neuralgia or nerve irritation or nerve pain from the Obturator nerve. Then you have to look up at the Obturator space to see if there’s a hernia there. So most people have a little bit of fat already in their Obturator canal. We call that kind of god’s little fat plug and we don’t touch it. And when we go and operate for hernias for other reasons, inguinal hernias, et cetera, which are much, much more common, most of us see that fat and we leave it alone. It’s not considered a pathological finding to have a little bit of fat in the obturator canal.
Speaker 1 (07:58):
What we don’t know is how much is too much. So in general, if you have imaging for example, and there’s a big wad of fat in your Obturator canal, so much so that it goes through the canal, follows the nerves down into the pelvic floor muscles, then that is considered an Obturator Hernia. But a little bit of fat just plugging a little bit of space around the nerve and vessels that go through that muscle already as a natural space, it’s considered normal and we don’t touch it. So why are we talking about Obturator hernias? Well, it is the number one most commonly affected problem in elderly female patients that present really, really sick. So like I mentioned, it’s not a common hernia when it happens, it tends to be in frail patients. The classic situation we teach the is nursing home patient who’s lost a lot of weight, usually female, probably has had multiple children with weakened muscles in the pelvis already and presents very sick with a lot of belly obstruction.
Speaker 1 (09:16):
Obturator hernia should be among your different differential reasons for why the patient’s very sick. And the reason is you can get intestines stuck in there. Now the classic finding on examination, you can’t see the bulge through your thigh, it’s through your pelvic floor and your thigh. So unlike a belly button hernia where you can see a out belly button or a groin hernia where most patients you can see a bulging in the groin, you tend not to see any bulging bulging down the thigh as opposed to outside. So most patients don’t have that. However, there’s a classic sign called the Howship Romberg sign. It’s one of those questions we ask medical students and residents, which is what is a Howship Romberg sign?
Speaker 1 (10:11):
Classically, again, not everyone’s the same, but classically people who have opt obturator hernias that are large enough to cause a mass effect in the thigh, they usually prefer to have their thighs kind of laid out, kind of like what we call frog leg, where the knees are outward and your ab abducted abducted because a deduction abduction is painful. It’s also painful because that space, if you rotate your thigh inward, your hip inward, that closes the obturator space. And if you have a hernia there, let’s say you have intestine in there or inflamed fat inward rotation of the hip can pinch that fat cause a lot of pain. So people tend to be frog lagged. So classically you’ll have a sick patient in the hospital, emergency room bed lying flat on their back with their affected side kind of in a frog like position. Again, these are textbook situations. Most people with obturator hernias don’t present in a textbook fashion.
Speaker 1 (11:28):
So the other question that we ask is not only how the patients look, but also the how or bromberg sign, which is the surgeon actively forces the pain to see if you get pain. So we take the leg and we passively bend at the hip and then rotate the knee inwards. So a deduction abduction, and if the patient can’t tolerate, it’s very painful. Then that’s a howship, wrong bur sign, which is severe pain with flexion at the hip and internal rotation at the hip. What that does is it closes the gap, the space in the obturator space and causes a lot of pain.
Speaker 1 (12:26):
So one of you who may have an obturator hernia that’s symptomatic says, yes, it’s killing me to cross my left leg over my right. Yeah. So that would be consistent. It’s bizarre. It’s so informative. Thank you. Yeah, this is what I’m here today. Thank you for tuning in by the way. So I don’t want to get to surgery yet because it’s really, really tricky to repair these. There’s a question that was submitted. Lemme see if I can bring it up, which was, oh, okay, here’s some good questions. I love when you guys send me the questions ahead of time because you’re all really smart. I love these questions. Here’s a question. Is the obturator foramen and width, so the obturator space, foramen and width and shape, the only cause of the relatively greater incidences of obturator hernias in women. So it’s almost a 10 to one ratio. I think it’s technically nine to one females to males. So for every, so nine out of 10 patients who have obturator hernias are female. Have I seen it in males? Yes. Is it more common in females? Yes. And the reason for it being more common in females is because at least we think the pelvic floor is very flat and wide in women, whereas it’s very narrow and sharp in men and therefore by it being very flat, the obturator frame or obturator space is actually wider, more triangulated than in males.
Speaker 1 (14:11):
And that’s important because the space that’s exposed to herniation is wider. And then women often have had pregnancies, so they’ve already pushed against this pelvic floor weakening it over time. And then if you’re older and you thin out that space, you can get herniation through the area and sometimes people just get obturator hernias and we don’t even know why I applied plenty of relatively young people that are perfectly healthy that have obturator hernias. In fact, there was one lady that I saw, this is a long time ago, I’m going to say maybe 15 years ago. So she had an obturator hernia. Actually two patients, one had an obturator hernia and no one knew what it was. So they basically saw a mass within her pelvic floor and they thought it was a cancer. So they went in to do a cancer operation. They found out it was a hernia.
Speaker 1 (15:17):
And another one, actually it was a tumor. It was what’s called a schwannoma. So the nerve, the obturator nerve that’s naturally supposed to be there had a growth on it. And so they had to go in surgically to do that. But they said it to me, they thought it was a hernia. I’m like, that’s not a Hernia, that’s a schwannoma, which is a nerve growth, but it happened to be on the obturator nerve, which goes to the obturator foramen. And so this round mass in that area was due to the actual growth on the nerve and not technically an obturator hernia and it’s not treated that way.
Speaker 1 (15:55):
Okay, so let’s see what the next question poses. Yeah, so what are the symptoms of an Obturator hernia? I kind of reviewed it so it’s not always intestinal obstruction, but it can be the first presentation. Most people who have obturator hernias don’t even know they have it. It’s similar to femoral hernias where often it doesn’t show up until they’re in the emergency room in severe pain with stuck into it. So the symptoms typically are some type of vague kind of inner groin, like inside pain kind of inside the upper thigh and into the groin area. It’s hard to pinpoint by the patient crossing legs or abduction. Where you pull your legs together is painful. You prefer to have your legs splayed out. If intestine is stuck in it, you’re usually sick from it or you have an intestinal obstruction. It’s not common to have intestines, but that’s usually the ones where we see them come in extreme distress. And then we do the physical exam where we cannot find an inguinal or femoral hernia. Then we do the physical exam where we lay the patient flat on the examination table and then we flex them at the hip and interally rotate. And if that’s severely painful, that would be a positive how ship berg sign.
Speaker 1 (17:43):
So it’s kind of an interesting anatomical problem. So surgery. Now the reason why, so surgery is both easy and difficult. It’s easy because accessing it nowadays with robotic or laparoscopic surgery, it is almost exactly the same as any other inguinal hernia. Most surgeons, general surgeons have done laparoscopic or robotic angle or hernia and therefore understand the approach. It’s just everything is moved a little bit more down and kind of posterior. So access to it and doing the surgery itself should not be difficult. Diagnosis is important. However, what I say when we first started is there’s a major nerve called the obturator nerve that runs through this Hernia. And this is not a hernia that we can do a tissue repair on. I mean I guess technically you can really sick patient, but it won’t last.
Speaker 1 (18:56):
You have to use mesh. But what I just say, there’s a nerve nearby. The problem is putting Mesh on the nerve. Let’s see, there’s a question here. Which kinds of hernias more often cause obstruction is the main symptom. So obturator Hernia is one of them and the most common is femoral hernia. femoral hernia is the most common one to first present with intestinal obstruction. obturator Hernia would also be one. Spigalian hernia is also another one. So those are the top three that cause bowel obstruction. And the reason for that is they’re often misdiagnosed or undiagnosed until they eventually get diagnosed when there’s a bowel stuck in it. So people don’t look for these, they’re rare hernias and so they don’t present until late stage. That’s really the reason why there’s no other real reason why bowel should be in these.
Speaker 1 (19:55):
Whereas like a groin hernia, a lot of people notice the bulge first before it gets large enough for a bowel to get stuck in it. And it’s usually a wider area. So going back to surgery, the issue is you kind of have to use mesh and almost everyone except anyone who’s nearly dying or you don’t want to waste your time, you just want to save your life. And putting mesh A over nerve and B, in a space where you need that kind of flexibility of your hip to adduct to close in thigh master situation is tricky. In my experience, it’s kind of a disaster to put or it can be a disaster. I shouldn’t say that. It can be a disaster to put mesh over the obturator nerve. I’ve seen it done before. I’ve done it before, it is not pretty. So we’ve learned over time or I’ve learned over time that number one, don’t put a lot of mesh in.
Speaker 1 (21:10):
This is a non area that needs very wide coverage. And number two, make sure there’s some barrier between the mesh and the nerve and you often don’t need to tack it or suture it in place, just lay it over just to prevent bowel from getting stuck in there. So I have a patient that really needs a lot of help. I’m trying to get her help, but it’s become really, really difficult because she already had the femoral, sorry, she already had the obturator hernia repaired. It was repaired potentially by a surgeon who had never done it before but kind of knew about it. As a general surgeon, you’re supposed to know about these things and so it wasn’t performed in the best way. So she has multiple meshes on top of meshes in that space and now she’s a bit debilitative, so she can’t adduct or bring her hips in.
Speaker 1 (22:14):
She has weakness of her muscles and she has that kind of inner thigh pain. So she’s got the motor, the sensory and the functional problems all related to obturator or Hernia repair had gone wrong on vaginal exam, you can feel the mesh because it’s placed very low. You’re not supposed to place the Mesh very low over anything else. The bladder is there. You don’t want the Mesh to be against the bladder too much. The vessels in your legs are there. You don’t want mesh to be on those vessels in your legs. You just want it specifically. So over that space. So I do a tailored situation where I always joke to my residents when you, I don’t know if any of you’re into fashion, but there were certain fashion designers. I think Yves Saint-Laurent was one of them where he would, or Christian Dior, he would just lay the fabric on the client and then he would cut and design it on the body.
Speaker 1 (23:23):
I kind of do that. So while I’m in there, I map out exactly where I want the Mesh to cover and where I don’t watch. So mesh comes usually in Mesh, comes usually in a rectangle, some sort of rectangle, maybe a little ovoid, a mesh. They don’t come to your anatomy’s perfect kind of shape or size. So what I do is I often for these rare situations where there’s obturator or a big femoral hernia is I cut the Mesh to optimally cover spaces where I want coverage but not cover spaces where I don’t want coverage. So I don’t want too much overlap with the bladder and I don’t want too much overlap with the vessels and nerves that go down to your leg. But I want optimal coverage over the obturator space, let’s say. And then I put barriers such as anti-adhesive barriers over things. I don’t want it to stick to the nerve. So these are all my little tricks. Feel free to share with your surgeon. They may or may not follow what I do, but it works really well for me.
Speaker 1 (24:36):
My point is that the placement of Mesh in that area itself can cause more problems than potentially the obturator hernia did. So I tend not to use heavyweight synthetic meshes Anyway, this poor patient, she’s got two meshes on top of each other plus a third mesh on another side. So she’s got a combination of Mesh implant illness because she’s got all this mesh in her that’s triggering an autoimmune inflammatory response to her body, plus it’s placed in a situation where it’s very heavy weight, it’s stiff, it’s interacting with her obturator nerve, giving her nerve pain and it’s preventing her from having flexibility at the hip so that she can’t sit normally, which of course can be debilitating. So my point is that even though it’s an easy surgery because access to it is very similar to any other groin hernia repair done laparoscopically or robotically doing a good surgery where you’re not injuring the patient is not as easy because there’s a lot of little tricks that you learn over years of experience that they don’t teach you when you’re in residency because a hundred percent, the majority of surgeons that go through residency never even see an obturator hernia, let alone repair it.
Speaker 1 (26:08):
They just have to know about it and know theoretically what to do about it, but they’ve never experienced it. It’s like when you go, you do your driver’s exam and the written exam, right? And they tell you if you’re in a rain and you start skidding, are you supposed to turn your wheel into the curve or away from the curve? In other words, you don’t want to spin around yourself, you don’t want to spin into oncoming traffic when it’s raining. But if you’re skidding and your back is trying to turn on you, you’re supposed to turn into that curve. Now, I’ve personally never done that. I imagine most people who have not been in that situation. And so it’s very possible that if I’m skidding, I may do the wrong thing. I don’t even know because in that split moment you’re supposed to kind of know what to do.
Speaker 1 (27:12):
But race car driver who skids all the time understands how to maneuver his car so that he doesn’t twist around or like a stunt driver knows how to twist a car. They do that all the time and they’ve learned how to master it. But still you need to pass that in Question on your driver’s exam, at least in California, that’s one of the questions to be able to pass your driving test. This is the same with obturator hernia. You kind of have to, as a resident, you have to know about it. And then during your written or oral examination, you have to know the answer to the question. But the reality is you’ve probably never done this before and never seen one done before. And even if you have, you may or may not have learned the right way to do things. So I’m just sharing with you a lot of my tips and tricks because no one talks about obturator hernias and then all of a sudden I have three patients, one who really needs now complete removal of all of her mesh.
Speaker 1 (28:21):
So here’s a situation right now. You have a patient, she has two layers of mesh on one side, one layer on the other side, both for obturator hernias. I personally doubt she even had obturator hernias because I never saw it on any of her imaging. And yet the report of the surgery said something like huge hernia with bowel in it and stuff like that that you would see on imaging and it wasn’t seen on imaging. So I wonder if it’s being mistaken for another anatomy, I’m not sure. But the end result is she now has two measures on one side, one on the other, both overlapping the obturator space, which includes the nerve and the vessels. And now my recommendation to her, and I hope she’s able to have surgery with me, but I’m not so sure because she’s from out of state.
Speaker 1 (29:15):
Now the situation is I need to remove all of her mesh because she’s also reacting to the meshes because she has so many and I have to remove the Mesh off of the nerve. And for those of when we remove meshes, it’s usually off the muscle, muscle fascia. It’s usually done very carefully, but you may have a little bit of injury to the muscle or fascia, which is totally okay. It’ll heal. It’s like scratching your skin, right? It’ll heal. However, I don’t know how well the nerve A, I don’t know thick, how tightly the obturator nerve is stuck to the mesh, and I also don’t know how well I can take off the mesh off the nerve without compromising the nerve. So that’s going to be tricky. I’m going to do it robotically, but they’re also vessels. So what if the vessels are really stuck?
Speaker 1 (30:14):
Does that mean she’s going to have poor blood flow to those nerves? I just don’t want to cause permanent damage in her, but she needs a surgery anyway. I really hope she can come to see me. But the reality is there aren’t that many surgeons that are in her network. There are none in her state that I know of that can do this operation and they have done it before they had that experience. That’s kind of my issue with her. I really, really hope it can help her. Okay, here’s another live question. I’m getting pelvic MRI the end of April because of constant pelvic pain. They don’t believe it could be a hernia. Anything I need to ask them to look for? Okay, first of all, why don’t they think it can be a hernia, right? It’s very common to have a hernia and chronic pelvic pain in women. It is just like what we call a trash diagnosis, right? Everything is thrown into it. It can be a lot of things. But if you have activity related pain, which means when you’re lay flat and your rest, you’re good when you’re up and about bending, laughing, running, lifting, coughing, going upstairs, whatever.
Speaker 1 (31:33):
If that causes you pain, then it very well may be a hernia. Now the best pelvic MRI for hernias is using what I call the hernia protocol. We actually have an MRI with hernia protocol. It’s a very good MRI. They do just a regular MRI, which means you’re lying flat on the bed. Then they do a second MRI, which is a series of pictures with you pushing out. So if you have a small Hernia, which most radiologists will miss anyway, but if you have a small hernia and you push it out, it may look bigger and therefore possibly more likely to be seen on MRI than if you didn’t push out. So that’s called a hernia protocol, MRI or an MRI. With Valsalva, we have the protocol available for you. You can go either on hernia talk.com or on my website, beverly hills hernia center.com.
Speaker 1 (32:30):
Actually just go to that. Go to beverly hills hernia center.com. In the contact section where we have all the forms for you to, we have in the patient section where we have all the forms for you to download like questionnaires and stuff to see me. We also have a copy of the MRI with hernia protocol. Print that out and give that to your radiologist or to your doctor. You can do that as well with a CT scan where the CT scan is done with val Salva or with bare down. It’s actually much more commonly done with CAT scan if you just write CT with Val Salva or CT with bare down views.
Speaker 1 (33:09):
Most radiologists know how to do that. The techs know how to do that, but the MRI is tricky, so that’s why we have it printed in a form. They roll their eyes. If I mentioned hernia, I heard laughing, coughing, sneezing, even lying down or standing. So if you’re lying down in your pain, it may or may not be a hernia, but laughing, coughing, sneezing and standing causing pain can be due to a hernia. And if they’re rolling their eyes, just get some another who know the doctor. You can’t waste your time with doctors that don’t know about angle hernias as a major cause of chronic pain. And so don’t waste your time. Find another doctor that A will believe you and B will be your advocate because ultimately really you should be your biggest advocate and fire anyone who’s not your advocate. That’s the way I feel about it.
Speaker 1 (34:13):
Let’s see. Can you explain how you use the anti-adhesive mesh in the obturator or repair is the entire mesh? No, no, no. You want the mesh to stick, you just want the anti-adhesive in the region where the nerve is or is it only parts of the mesh? Okay, so the mesh itself is not anti-adhesive. You want the mesh to stick. What I do is I take a separate little piece of anti-adhesive. It comes in sheets. There are different names for it. Separate film is one. Intercede is the one that I like because it’s easier to handle and you carefully put that piece of fabric over the nerve and then you put your mesh. The mesh itself doesn’t come with the anti-adhesive. It would be great if they made meshes like that, but they don’t. If the anti-adhesive, how will it integrate into the tissues that need to have the mesh integrate with it?
Speaker 1 (35:21):
Do you do a similar thing with the spermatic cord? Yes, I do. So very good question. Yes. So I strongly believe that Mesh should be stuck. Mesh is made to stick to muscle and fascia, maybe bone in to give you a good Hernia repair, but mesh should not be stuck to your nerves, your bladder, your vessels, and your spermatic cord. So actually I have patented mesh designs, some patented, some patent pending that actually have your anatomy mapped out on the mesh. And strategically, there are places where anti-adhesive are replaced so the surgeon doesn’t have to think about it, they just put the Mesh in and by default the areas of your, let’s say spermatic cord, the nerves have anti-adhesive, whereas the areas where there’s muscle and bone and fascia, the mesh sticks. So I’ve learned that because guess who’s removing mesh and guess who has to shave the mesh off of the spermatic cord and the vessels and the nerves.
Speaker 1 (36:35):
And in obturator hernia in this patient, it has to be taking it off of the obturator nerve, which is a big deal. So I would love it if a company is actually interested to make such a thing. These companies, it’s all risk benefit ratio for them. And if enough patients and surgeons don’t understand this problem, then they’re worried about how are they going to teach it to everyone. But just listen to my podcast is what I say. Just listen to me. No, but seriously. Yes. But I do it also for inguinal hernias. So in patients, not all patients, but in certain patients that have testicular pain already, I do do the extra effort of taking an anti-adhesive and putting it between the mesh and the spermatic cord. Again, I don’t do it for all patients and not considered standard. I definitely do it in almost everyone that has revisional surgery.
Speaker 1 (37:35):
So if I’m removing mesh now I have a space that’s raw and inflamed includes a spermatic cord that’s part of that raw inflamed surface, and then I put new mesh into fixer Hernia. I really don’t want the mesh to cause a lot of problems by sticking or eroding or impinging on or entrapping any content related to the spermatic cord of the nerves. So I do strategically place adhesives separately than the mesh over those structures. And I do the same for the obturator hernias or I do that for the obturator nerve. It’s really not pretty to have mesh on nerve. It’s just not the right thing to do. I’m noticing more lately with my left obturator hernia that even if I turn a bed and the leg crosses over, I get mega pinching. It’s becoming very uncomfortable. Is it? So obturator hernias are dangerous if you have intestines stuck in it with bowel.
Speaker 1 (38:42):
If you just have fat in it and it’s not, especially if it’s not a large piece of fat, it’s almost never dangerous. In fact, in people who have fat stuck in it, you’re actually kind of plugging the area and not allowing bowel to get stuck in it if you want to think of it that way. So that’s kind of the way that maybe I can ease your mind about it. How would you use the anti adhesives? In my case, as I saw you recently, and we discussed bilateral tap eTEP. So in primary hernias where no one’s been in that space before and you don’t really have testicular symptoms, I tend not to put anti adhesives because it’s usually not an issue. However, of course, if you wish for me to do it as an extra precaution, I’m happy to do that. It’s just not considered a standard thing and I don’t see the benefit of it. It just adds to a lot of cost. It’s like a thousand dollars just for the anti-adhesive or maybe more So it’s almost the cost of the mesh itself or sometimes more than the cost of the mesh itself.
Speaker 1 (39:50):
I don’t know why. Maybe it’s the technology, maybe it’s because not enough people use it and so they just need to make more money off of it than usual. I don’t know. It must be a marketing thing. Let’s see. I think I have two. The question, I think I have two posterior perineal hernias or a pouch of Douglas hernia that causes a constant feeling of something from my abdomen, spiraling in and out of my pelvis, buttocks, hips, and inner thighs. So what can go through a Hernia? Can it just be fascia? It feels like balloons made of me. That’s kind of cute. Okay, so obturator. Hernia is different than peroneal hernias. Peroneal hernias are hernia. The perineum or pelvic floor obturator hernias are hernias to the obturator foramen, which is in the pelvis, but it’s not as far down. It’s still kind of as the pelvis makes its curve down. So it’s further anterior or forward and further cephalad up from a peroneal Hernia. So technically an obturator Hernia is not a peroneal hernia, but it is a pelvic hernia. I don’t know how to explain that.
Speaker 1 (41:09):
So the two posterior peroneal hernias or pouch of Douglas hernias, those are in the midline in the middle. obturator hernias are similar to inguinal hernias in that there’s a left and there’s a right. And then depending on the type of hernia, it could be from a prolapse, right? Like let’s say you’ve had multiple pregnancies or it can be an actual hernia either due to trauma or other kind of pelvic floor damage, which also can be left or right sometimes, but they’re often also in the middle. So if you have, let’s see, something from my abdomen, spiraling in and out of my pelvis, buttocks, hips, and inner thighs. So buttocks is towards the back, hips is toward the side, and inner thighs is toward the front. So a CT scan or MRI of your pelvis should identify any hernia. And if you don’t have that Hernia noted, you may want to get a second opinion to make sure the radiology report was actually read correctly. In other words, you can’t have a very rare hernia, let’s say a sciatic notch hernia. Okay? The most rare of all hernias, and I’ve repaired three, but it’s absolutely the most, no one’s ever seen sciatic notch hernias. I would say 99.9% of surgeons have never seen or heard of a sciatic notch hernia.
Speaker 1 (42:47):
So those can cause buttock bulging and abdominal distension perineal. It’s a perineal hernia, but most people don’t know what that is. In fact, the one patient that I saw that I repaired recently, that patient actually had was seen by a spine surgeon because they found something by the sciatic nerve. They thought it was a tumor of the sciatic nerve. It turned out to be a hernia, but she almost had neurosurgery because of it. Anyway, let’s do some more questions. Our collagen and collagen related illnesses, major risk factors for developing an obturator hernia. So yes and no. I would not say there are major risk factors as far as we know. People with obturator hernias are not people that necessarily have a collagen disorder. You can’t argue that anyone with a hernia already has a collagen disorder.
Speaker 1 (43:54):
Most of us believe that, but it’s also possible that they’re just very frail and have a thinned out tissue. What’s the best way to get imaging of a sciatic notch Hernia pelvis? That’s usually a pelvic CT or MRI. It’s all in the pelvis. There’s a lot going on in the pelvis, but it’s all in the pelvis. Having had multiple patients with sciatic notch hernias, I now specifically always look for a sciatic notch Hernia, even though I know it’s so rare, but I hate to miss it. It’s one of those things. All right, next question. How does the body weight affect the risk of developing an obturator hernia? So that’s an interesting question. Most people who have obturator hernias are super thin and it’s not because they’re thin, naturally thin, they’re cachectic. So that would be the typical scenario. They’re cachectic, they’re wasting muscle and that waist of thinned out muscle involves wasting of the obturator muscle with things that therefore protrude through it.
Speaker 1 (45:10):
That’s just the way obturator hernias are. We don’t have people with muscle wasting that show up with typical hernias, but for some reason with the obturator hernia, that tends to be the situation. So no, we do not. Okay, lemme rephrase this. There isn’t enough obturator hernias out there for us to know enough about risk factors, but that said, they tend not to be in obese patients. They tend to be in those kind of thin cachectic unhealthy patients. Is permanent synthetic mesh the only way to repair an obturator hernia? It is not the only way. It is the best way that the muscle repair. There’s nothing just closing the muscle is not going to work. We do it if you’re dying and the last thing you need is a perfect hernia repair and so you can kind buy some time that way. But for a good repair, yes, because there’s no good tissue repair. A mesh repair is what’s preferred and only permanent mesh repairs, which are always synthetic work with elective hernia.
Speaker 1 (46:33):
As we’ve discussed in prior hernia talk biologic, purely absorbable meshes, synthetic absorbable meshes do not really work for elective cases where you’re trying to bridge or repair. Now, there is something called a hybrid mesh. You’ve heard me talk about hybrid meshes before. I’m a big fan of hybrid meshes. It’s basically an absorbable and a non-absorbable Mesh put together into one. And the one that I use, I really like because the non-absorbable part is not that much. It’s like 4% and it’s permanent and it’s synthetic. The absorbable part, which is about 96%, however, is a high quality product with very little inflammation and therefore it’s much more palatable to use in patients where you don’t want a large inflammatory reaction, they may have already shown a mesh implant illness situation. So in these patients, I recommend that they, in patients that don’t do well with synthetic meshes, the hybrid meshes is always an option.
Speaker 1 (47:49):
Not everyone does well with that one either, but of all the products out in the market, it’s the best. And in people with true big obturator hernias, it is my go-to. So it provides permanent coverage, but it doesn’t have that thick firm non expanding property of pure synthetic mesh and therefore you don’t get that stiffness where you can’t close your legs together. Next question, should CT and MRIs for pelvic hernias been done while lying flat or with knees Bent, always lying flat? Should there always be one with and without Val salva? No, not always. So most hernias do not need Val Salva. Of course, if you do it with val salve, that’d be great. It takes a lot more cooperation by the patient, a lot more time and dedication by the surgical tech to do it. It’s not as time efficient. But if you really want to identify hernias, bigger hernias and you want to be able to identify a smaller hernia, then definitely Valsalva or bare down is great because when I examine patients, for example, when I examine patients, they’re standing, I don’t have, I often never, I mean there’s a bed there, but I don’t usually have you lying on the bed because that makes all the hernias fall back in place, right?
Speaker 1 (49:30):
Gravity is not working for you. And so little hernias or how big a Hernia is, is not evident. Whereas if you stand up, that allows more bulging and more hernia out there. And so I prefer to examine you when you’re standing. However, when you’re getting the CAT scan or when you’re getting the MRI, guess what, you’re lying flat. There are standing MRIs and standing CAT scans very uncommon. So in order to reproduce that increased abdominal pressure that you get when you’re standing, we do have patients do this bare down or val Salva MRI or a CAT scan and that can kind of accentuate how much hernia or bulging there may be. I hope that’s helpful. Let’s see. Next question.
Speaker 1 (50:27):
Here’s a good question. So it says, let me share it with you. Can an obturator Hernia that presents at the same time as an AL hernia be missed when repairing the AL hernia? And in this case, does the surgical technique chosen to repair the AL hernia have an effect on the likelihood of missing the obturator hernia? Yes. Yes. So most obturator hernias that are not obvious are missed on most inguinal hernia repairs, regardless of the technique, open laparoscopic Mesh or non Mesh. And it’s one of those things, it’s a very rare, there’s no mandate to always check for an obturator hernia. In fact, with laparoscopy, which is the best way to identify an obturator hernia, we often choose not to look at the obturator space because there’s a major nerve, there are vessels there that you can injure. There’s always fat there. So reducing the fat is not anything to do.
Speaker 1 (51:30):
And if they don’t have symptoms suggestive of an obturator hernia, you just don’t want to go down there. It’s not the safest area because of the nerves and the vessels. So yes, if you do an open hernia repair, you’ll not see an obturator space opt, hernia, obturator, anything. If you do an open repair where you actually explore the retroperitoneal, like the inner space, which is almost never, you may be able to find it, but we usually don’t look for it. And even in laparoscopy or robotic surgery where you go in specifically in a space where it’s easily visible to check the obturator hernia, there are some surgeons who routinely check for obturator hernias. I don’t. It’s so rare. And I get so much imaging on patients that if there was an obvious one and their symptoms were suggestive, I would be looking for it, otherwise I wouldn’t. And yes, so therefore it can be missed. And that’s kind of where we are with the physical exam. So it’s kind of also why I chose this topic of obturator hernia because it’s not common, but I’ve seen a couple and identifying is hard, diagnosing is hard. Even thinking about it as potential is not easy. And then doing a good hernia repair on obturator hernia is also not easy.
Speaker 1 (53:04):
So that’s kind of the situation we have, but I thought it was important enough to do it. Can men get it? Yes. Can young and healthy people get it? Very uncommon. It’s 10 tends to be elderly female, almost a 10 to one ratio then males. But it can still happen. It’s much more rare than even femoral hernias, which we’ve talked about. And so if one side is definitely symptomatic, but the other is also acting similar, it can be bilateral. Yes. So it can be on one side or it can be on both sides. And I don’t think we know enough as to what percentage of patients have it bilaterally. It’s always good to check. So like Spigelian hernia, which is uncommon as well, tends to be bilateral femoral hernias tend to be bilateral. I assume obturator hernias also can be bilateral. It is just the question is how big is it?
Speaker 1 (54:12):
What’s in it? And are your symptoms suggestive of obturator hernia? So for example, if you have clearly have symptoms suggested of an inguinal hernia and you have anal hernia on exam and on imaging, and oh by the way there’s some fat in your obturator space, would I go after it? No, because it’s normal to have fat in the obturator space. You really want to have the symptoms, the physical examination and the imaging all three to support a diagnosis of obturator Hernia before you commit yourself. Because like I said, it’s not an easy operation in terms of outcomes. The nerve is there, the vessels are there, the risk of damage to those is real. It’s much more consequential than operating on inguinal hernia where there aren’t that. I mean there’s still a lot of things to be concerned about for inguinal hernia, like nerves and so on, but it’s not as consequential as a big fat obturator nerve.
Speaker 1 (55:14):
Can ultrasound see the obturator? That’s a good question. I would say yes, but only if the right technologist knows what they’re doing and B, if it’s large. So the only way to identify an obturator hernia is by sticking the ultrasound like deep in your upper inner thigh and aiming it toward the obturator foramen. That’s a very uncomfortable place for a radiologist to be. And you have to get the beam of the ultrasound exactly to that area to identify it. The beauty of ultrasound is you can then tell the patient, okay, push out move and then you can move the thigh in and out. You evaluate that obturator space, but you really need a very skilled to do that. And there aren’t that many in the United States that would do that. What are the biggest risks of post-op on the obturator repair? Yeah, exactly what I mentioned earlier.
Speaker 1 (56:22):
So the use of mesh over the nerve and in the pelvis where you need flexibility of your hip is the major problem with obturator or hernia repair. So I tend to use the softer, more pliable hybrid meshes where there isn’t that much synthetic product and therefore it can’t be as stiff and allows more flexibility of the hip. I also don’t like a lot of mesh on the nerve, so I put an anti-adhesive over the nerve to reduce the risk of injury to that nerve. But those two things, like I said, this one patient, she hadn’t missed the first time they put mesh in, but they missed the fact that she had obturator Hernia, which again, I don’t even know if she had it, but that’s what they said. So they went back in, they put in more mesh, now she has two meshes, and then now she’s got Mesh on the nerve, which is causing obturator Neuralgia, right?
Speaker 1 (57:16):
Kind of this inner thigh burning pain by the knee. She has problems with anything that involves closing the gap between her thighs, and that includes crossing your legs, for example, even going up and down stairs. And then sleeping is difficult. You can’t put your legs together, you have to sleep with your legs far fall apart, and now she needs a mesh removed. It’s kind of a big deal. So this has kind of been a great little discussion about obturator hernias every so often. I’ll stick in like a topic on just a specific hernia type or specific anatomy. You had asked me all to give talks about specific surgical techniques. I’ll try and sprinkle some of those in there as well. But if you have any more questions or think you may have an obturator hernia or you’re wondering if it’s on your imaging, feel free to call the office and we can try and provide you with some type of consultation to help figure that out for you. It’s not uncommon, but if you relate to these symptoms, then let’s do that. In the meantime, you guys have been lovely. Thank you very much. I have really enjoyed this hour. Please do follow me on social media and also go to my YouTube channels to subscribe, to watch all of these videos. I have a lot of patients who tell me these videos have been very helpful to them. And if you prefer a podcast like and subscribe, my podcast, Hernia Talk Live, and I’ll see you again next week. Take care.
