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Dr. Towfigh (00:00:11):
Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live. I’m your host, Dr. Shirin Towfigh joining you every Tuesday on Hernia Talk Tuesdays. Thank you for logging in, whether you’re here as a Facebook Live, on Facebook with me at Dr. Towfigh or via Zoom. Thank you. And thanks to everyone who follows me on X and Instagram @Hernia doc. Remember this and all prior episodes will be hosted on my YouTube channel at Hernia Doc and also if you prefer the podcast option, then we have that Hernia Talk Live is now available as a podcast. Please do subscribe and like the more you do that, the more people are able to find it when they’re searching for somebody here on a podcast. Thank you very much for that. Today we’re going to talk about mesh fixation. It’s something that we’ve alluded to and prior episodes, but we’ve never really looked at it.
(00:01:18):
Talked about mesh fixation on its own and just a quick brief overview. When surgeons use mesh, they implant some type of barrier. It’s usually a sheet, although it can have a three dimensionality to it, and that sheet needs to stay wherever it is that the surgeon is placing it. If you’d have a non mesh repair, it’s usually a closure of your hernia. Hernia is a defect, it’s a hole, so you close the hole. However, there’s nothing in addition to your own tissues that’s involved in a tissue repair. It’s your own tissues, hence the name. However, if you undergo mesh repair, which is the dominant type of repair, over 90% in the United States, and it’s not necessarily it, it’s very regional as to how much mesh is used outside the United States. Most first world countries use mesh repairs. Most third world countries do not use mesh repairs because mesh is expensive and they both are suffering from consequences of that decision.
(00:02:30):
So the people that live in first world countries are subjected to mesh related complications, and the people that live in third world countries are subjected to these horribly large, complicated deforming hernias that prevent them from being active and making a living. So you tailor it is what I always say. So specifically talking about mesh fixation. So it used to be that we thought that once you put mesh in place, you had to sew it in place for it to stay. And then that way, let’s say you want to put mesh over a hole, right? So you want to make sure the mesh is perfectly centered over that hole and then you would put some type of fixation to prevent the mesh from moving away from that hole. And that was part of the whole idea of improving outcomes from mesh repair is to make sure the mesh stays exactly where you intended to place it.
(00:03:38):
Now over the years, I would say since the 1980s, we have gradually moved towards different types of fixation and also less fixation because the techniques have changed and the type of mesh we have has changed. So current day hernia repair, you should talk to your surgeon about how they plan to fixate or not fixate the mesh mostly for your own education. I don’t think it’s appropriate to ask your surgeon to fixate or not fixate a mesh because that’s how you want it. It may or may not be appropriate for your type of repair or your surgeon may not be doing the right technique where you can fixate or not fixate. But the most common way to fixate a mesh is with sutures. You sew it in place the same way if you put a patch on your outfit, let’s say like a ExxonMobil patch or a cute little picture, some type of sequin or something, you’ll sew that to your outfit.
(00:04:46):
The same is true of most types of mesh fixations, which is they take a little a needle and thread, what we call it a suture, and your surgeon will sew the mesh in place and that can be done with either what we call interrupted sutures, so basically little darns tacking the mesh in specific areas or what we call running sutures. So we basically sew it all along the edges of the mesh. And then the second question is, okay, now that you’ve fixated with suture, what type of suture? Most mesh fixation technique, if the mesh is permanent, it’s done also with permanent suture. If the mesh is absorbable, usually we also do it with absorbable suture. It doesn’t make sense to use permanent suture for absorbable mesh because once the mesh is absorbed, why do you need the suture to be there?
(00:05:47):
That’s typical. However, there are some surgeons that you prefer to use absorbable suture for permanent mesh, and there’s been varying results in that, in my opinion, that subjecting patients to slightly higher risk of hernia recurrence because once the fixation is gone, if it’s a type of repair that demands fixation, then you may have a hernia recurrence because of mesh starts shifting over time and by over time it means years not immediately, but other surgeons feel it’s just as good to use mesh, sorry, absorbable suture with permanent non-absorbable mesh. So I’ve seen both occur by perfectly trained, well gifted surgeons. So that just goes to show you there’s different ways of treating the same patient. Once we moved to laparoscopic surgery and laparoscopic hernia repairs, we started moving away from suturing techniques because frankly it’s difficult to suture. There are surgeons that do really good job of suturing and it doesn’t matter to them if they’re doing it open or laparoscopic, but most surgeons do not know how to do a good suture and repair.
(00:07:09):
And for inguinal hernias or laparoscopic ventral hernias, the angle at which you need to sow is a little bit difficult. So the attacks were invented. Attacks were invented by industry to meet the needs of surgeons who could not basically do their hernia repair because they couldn’t suture in the mesh. So water attacks tack or some type of nail or screw type fixation method. It’s not truly a nail or screw, but it’s kind of the same concept where you’re attacking a mesh in place. That nail or screw type design will then push and hold the mesh usually into muscle or fascia, sometimes into bone, and we start moving away from suturing when we’re doing laparoscopic surgery because now we have all these attacks. So that’s how we did it. Then we got robotic surgery and robotic surgery added a whole different realm of fixation methods. So some people still use the tacks that we use laparoscopically, they still use it robotically.
(00:08:31):
That’s not what I recommend for my own patients. For my patients, I go ahead and go back to the old fashioned suturing method. So the same way we were suturing with open surgery for hernias, suturing the mesh in place robotically, I also suture it’s much easier to suture robotically than laparoscopically. So I do go back to using robotic suturing. Again, you can suture continuously or what we call running or an interrupted fashion where you kind of put little darns in place and you can use absorbable or permanent suture depending on the type of mesh. And the type of repair glue was kind of cool for a hot minute. This was initially used for the groin and inguinal hernias where instead of suturing laparoscopically, we were using glue. I was doing that for a while. Then we found out you can actually probably just not use anything.
(00:09:37):
So why use glue? And then for open surgery, there’s a great trial that glue may work done by the group of Campanelli in Italy, the Temelli trial, we actually, when I was at USC, initiated an animal study to see if gluing works for the ventral or abdominal wall hernias. In terms of stickiness, it didn’t work as well. And so no one was really gluing the abdominal wall hernias. And then now we’ve graduated to meshes that stick on their own. So there are meshes that have these little Velcro grips. They’re called pro grip meshes. Oftentimes you don’t have to fixate those at all because once you put it in, it already sticks to where it needs to be and they don’t tend to migrate very much. We’ve learned to put meshes in certain areas of the body where it sticks better. So if you sandwich the mesh in between layers of tissues instead of just putting it on top of a layer of tissue, then that sandwiching alone can help hold the mesh in place and you either need very little suturing or no suturing at all because it’s like putting a letter in an envelope, right?
(00:10:51):
You don’t need to staple the letter to your envelope as long as it fits perfectly in the envelope, it’ll stay in your envelope until someone takes it out. So that’s of the other technology and there’s some newer technology. So I actually saw some really cool idea coming out, which is, so it’s a mesh that has glue on it, but that’s been used before. It doesn’t work very well, but now they came up with a mesh that has glue on it, but the glue is inactive until after you place it in place. And then once you place it in place, there’s this glue light that you can shine on the mesh and that activates the glue and then it glues in place. It’s kind of cool In general, we’ve learned over time that the less you fixate the less pain people have because they tend to hurt where their sutures or attacks for fixation.
(00:11:59):
Also, the less you fixate, the more natural the mesh will lay. You’re not forcing it to be fixed in certain areas. And lastly, we’ve learned it’s better to have the entire surface area of the mesh a adherent than the individual areas where you put the sutures. That’s why the pro grip mesh has been such a good product over the years. So I going back to similar to sutures, they’re both absorbable and non-absorbable. I tend to use the permanent non-absorbable ones the same way that I use the sutures, non-absorbable. And then if there’s any way that I can do any hernia without fixation, both inguinal and rub ventral, I do prefer the not fixating the mesh. And I always tell my residents, you got to be a really good phasix person. So it’s all about forces and vectors. I don’t know if any of you enjoy phasix, but I really liked phasix.
(00:13:09):
I understood it very much, not enough to be an engineer, but enough to be a good hernia surgeon. So in order to be a good hernia surgeon, you should understand how the different forces and vectors are applied when you do abdominal wall repair and then apply your fixation for example accordingly. So I’m going slow down here and answer some of your questions. Here’s a comment. I had a small ular hernia surgery and the doctor put a mesh plugin patch in me nine years ago. I’ve had a horrible pain for nine years and I was told my mesh is over my pubic bone. I have three more hernias, but I’m afraid to have surgery. So that’s a good point, which is if you have a mesh plug, which we don’t recommend anymore, but for sure there are tons of doctors that are still using mesh plugs, but it’s still a very commonly sold mesh.
(00:14:06):
But let’s say you do use a mesh plug, it is a very three-dimensional product. So if you put that into a hole, you want to make sure that it fits into the hole perfectly. I’ll give you an example. If you have a wine bottle, right, and you have the cork in the wine, I’m sure there’s a better name than cork. If there is a better name than cork for wine bottles, let me know. So if you take the cork out, you want to push it back in. You can’t push it in like at an angle. It has to go perfectly parallel to the mouth of the wine bottle for the cork if you want it to fit. The same is true about a mesh plug, so you want it to be perfectly perpendicular into the space and you want it to stay in that location.
(00:14:58):
A lot of people involved in the mesh lawsuits have been told that about this concept of mesh migration. Well, for most meshes, there is no such thing as mesh migration. I’ve had patients come to my office and they’re afraid they have mesh in their eye. They have mesh in their brain, they have pain in the upper abdomen. Even though though I had mesh in the groin and they think the meshes migrate to their liver, that doesn’t happen. However, mesh plug, if it’s not fixated securely in place with at least three sutures that mesh can rotate or move around or migrate. So why three? Three prevent, remember, it’s a three dimensional product, so it’s kind of like this glass, right? It’s three dimensional. So if you’re going to put this glass into a hole or put the plug into a hole, if you only put two sutures, it’s going to rotate along that axis. So if you put three sutures like a triangle, it will prevent the mesh from twisting in itself again.
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So now that you have one of our viewers who always shows up, thank you very much. I’m very honored to always have you and hear your story. She’s saying that she has a mesh plug, but it’s on her pubic bone now. So it’s possible that hers actually rotated and now is in a very painful position over her pubic bone. Okay, here’s another question. I had a laparoscopic inal hernia repair with non-absorbable mesh. My mesh was attached to the Cooper’s ligament with two tacks. Could attachment to this ligament cause pain? No, typically not. So a couple of things about T. So they’re usually like screws. They’re these spiral screws or sometimes titanium, sometimes plastic, and those are placed in areas when you place some laparoscopically into cooper’s ligament, often they don’t put it in the ligament, they actually put it in the bone. And depending on certain people and how they respond and how deep in the bone it goes and whether it’s being tugged on, yes, that could cause pain.
(00:17:33):
Just tacking into Cooper’s ligament itself should not cause pain. And we do it all the time. It’s actually the correct technique to do to put two tucks in Cooper’s ligament. Sounds like usually the right thing to do, but if you have five tags into Cooper’s ligament or 20 tags in your abdominal wall, that’s a bit excessive. Next question, what determines which inguinal hernia laparoscopic repairs need fixation? In my case, you’ll use will you need to use tacks. So yes, depends on the type of hernia. So for your typical hernia, indirect inguinal hernia, not a very large one, laparoscopically placed or even robotic, you do not need to secure the mesh as long as you develop a good enough area like your envelope to allow for your letter, which is the mesh to fit in there perfectly and flatly without a wrinkle and in perfect size.
(00:18:39):
Then when you close that envelope, IE: the space you made for laparoscopic or robotic repair, that should hold the mesh in place. And these are flat meshes we’re talking about. However, there is. So that’s only for indirect inguinal hernias for a femoral hernia. The issue with femoral hernia is number one, you want to make sure when you fix a femoral hernia, it doesn’t recur because it is the one hernia that actually has some type of death rate associated with it. That’s significant. So you want to fix a femoral hernia because you’re saving someone’s life by doing that. And the difference between femoral hernias and other hernias is when you repair them laparoscopically, the amount of mesh overlap is less than for the other hernias. What does that mean?
(00:19:37):
Let’s say we do an indirect inal hernia, you usually have four to five centimeters of mesh overlap on either side. With a femoral hernia, you may have two centimeters about half of that. So if there’s any shift of the mesh to left right up or down for an indirect inal hernia, you’re still fine. You’re not going to shift four or five centimeters. There’s not that much space for the laparoscopic mesh. However you can imagine one or one and a half centimeter shift of e femoral hernia will then make it so the space, sorry, the mesh doesn’t adequately cover the femoral space and you’ll get a femoral hernia recurrence. So for a femoral hernia, again, I do fixate the mesh to Cooper’s ligament, which is the lower border of the femoral space to assure that the mesh does not flip up or shift upwards and expose the femoral hernia. That’s my routine. I think it makes sense from a phasix standpoint.
(00:20:45):
Direct hernias is a situation most people with direct hernias are older and or by definition have a weakness in their muscle. It’s called the transversesalis muscle. It’s your inner girdle. So when you stand with a direct hernia, you have a bulge. Even small hernias, you have a bulge. And what happens is the bulge is not necessarily a hole, although it can be, but more typical for a direct hernia as a weakness of the muscle, it is just pooching out. So if you have that situation and you put mesh, you don’t want the mesh to be dragged by that direct hernia and pooch it out, right? What’s a good analogy for that one?
(00:21:39):
We’ll have to figure out that one because I can make a clothing analogy, but it’s not a good clothing analogy. So what you want to do with a direct hernia is to take that weakness, tighten it up, make it flat, and then put a nice mesh on it, and also secure the mesh. Again, triangulate in three positions. And the whole point is for the mesh not to billow into the direct space. So you may have a weakening of that space, but you want the mesh to be flat. I just saw a patient this, what’s today? Tuesday? Yeah, I saw a patient this week that actually had that. So it’s very interesting. He had a direct hernia, which is a bulging, and then he had a mesh repair, but the mesh was very flat. Now what they didn’t do, which I wish they had done, is they didn’t taper down or plicate or tighten up the weakened direct hernia muscle.
(00:22:44):
And because they didn’t do that, if we got an imaging on it, you could see that his natural state of his pelvic floor at the direct hernia, the natural muscle state of this weakened transversesalis fascia is for it to bulge. So he has a bulging area of muscle, but it’s not clinically relevant because deep to it, the mesh is flat and doesn’t bulge into it. And probably that’s because they did a good job of fixating that mesh, otherwise the mesh would fall into that bulge. And many people who have direct inguinal hernias that are repaired are unhappy because either A, they see a bulge still, B or B, they have pain, sorry, B, they have pain because the mesh wants to fall into that hole and it’s tugging or C, the mesh falls into the belowing with certain activities. So let’s say my favorite story is the one I had a lady, she was a grandmother and she would go to her kids, sorry, her grandkids soccer games, and she’s like, every time I’m out there yelling at the kids, I get this groin pain.
(00:24:08):
But it’s because you’re increasing your abdominal pressure. When you’re increasing your abdominal pressure, you’re pushing hernias out. If you had a good hernia repair, that hernia repair would be a blockade to the otherwise weakened muscle that’s trying to push out. It would be like a wall. What you’re doing is a curtain. That’s a good analogy. Okay, that’s a good analogy. I like that. So what you want against a weakened direct hernia is a wall and that’s your mesh. What you don’t want is a curtain that, so it just follows the weakness of the mesh. And when you flip that wall, you want it not to break away because it’s not a very thick wall. So you want to fixate in at least three places to prevent the mesh from falling into it. a lot of surgeons don’t understand that a lot of surgeons are not good at phasix and therefore they treat a direct indirect femoral all the same, and they pride themselves in doing mesh repair without fixation. Listen, I do mesh pain mesh placement in the groin without fixation, but not if you have a big weakened direct space that doesn’t make any sense. It’s just going to mean that your mesh will fall into that space.
(00:25:31):
You told me to go see a good doctor that was going to Rochester last December. I forgot her name and my son said to ask you again for a name. He lived in Rochester. I also have four more hernias I’m afraid to have fixed. Please tell me the doctor’s name again. Thank you so much. Wish you would come to Minnesota. Oh, well thank you very much actually since the last time I spoke with you, the doctor I told you has left and there’s a new doctor, but you’re lucky because I have also interviewed her. Her name is Dr. Charlotte Horn, H-O-R-N-E. She works out of Mayo Clinic now is now the dedicated hernia surgeon at the Mayo Clinic. And she’ll be a great person for you to see because she’s gifted and she would be able to definitely help you out at the Mayo Clinic. So best of luck there.
(00:26:24):
Okay, another question I see, will ProGrip address the direct hernia below you described? No. And is there a risk of adhering to spermatic cord of the program? So good question. So I just talked about ProGrip is that mesh I told you that has a little grips, it’s like Velcro. So it works great on a flat surface, right? So if you take anything that has a flat surface and you Velcro something to it, it’ll stick. So if you have a hernia and you clear the hernia and you close the hernia, let’s say for a ventral hernia or it’s a small indirect inguinal hernia, then you can use a ProGrip and it’ll stick exactly where it needs to go. However, for areas of weakness, you either tighten up the weakness or the program or you have to suture in place the program and you have to suture in place the program, excuse me, because it doesn’t do the program. The grips of the program mesh. The grips don’t work if it’s just what we call bridging. So if it’s not stuck to anything, it won’t work. So you don’t want it stuck to just bridging.
(00:27:56):
And the issue with a billowing is still there. So if you put the program grip onto a direct hernia and there’s a weakness there, it will stick to that weakness and just below out and that’s not good. So yes, in general, the program is a great mesh. It stays in place where you want it. If it’s on a flat surface and it’s not bridging, if it’s bridging a large gap, you need to A, prevent the bridging. But B, if you can’t fixate the measure so it doesn’t fall into the bridging, and B, if it’s over direct space, which is a weakness, you either have to tighten the direct space, but in addition you have to sew it in place so it doesn’t have that tendency to fall into a hole. Is there a risk of adherence to this spermatic cord of the program?
(00:28:57):
Not as much as typical meshes because those grips are actually absorbable. So they initially grip and then over three months or so those grips are gone. So the program grip is actually a really good design because of that. And I don’t see as many complications requiring measurable with the program mesh as I do with the non-program. Meshes. Let’s see a lot of talk here. I need a good surgeons in SC. That would be South Carolina. All the ones around me are not experienced enough. Actually South Carolina has excellent surgeons in Greenville. If you go to Greenville, that team has really good hernia surgeons, many of them. Let’s see. I would love to chat with you. I have a support group for women with complications from tram and DIEP flaps. We are very limited to surgeons who can repair us. This is true. Many surgeons have done just basic repair.
(00:30:02):
That doesn’t work. Can we please chat? Yes, absolutely. I would love to be involved with that. So this is a comment from someone who runs a support group for women who’ve undergone tram and DIEP flaps. I know that I’ve talked about tram and deep flaps. I believe with someone recently. If you Google, lemme take that back. If you go on YouTube and you search for tram and deep DIEP flaps or hernia talk episode may come up. I know I put that in as a keyword. However, what can happen with tram and DIEP flaps is these are basically muscle flaps, sorry, skin and or muscle flaps that are taken from the abdominal wall to help fill deformities in the breast after a mastectomy usually for cancer, sometimes for prophylaxis from cancer. So in those patients that undergo TRAM flap and there’re not that many tram flaps anymore, they’ve switched, the plastic surgeons have switched to DIEP flaps regardless with the TRAM flap, the RA part of TRAM means rectusabdominus and the rectus muscle itself is gone in that section of the adult.
(00:31:31):
It’s quite deforming or it can be, and I remember when I was a resident, they would say, oh, you get a tummy tuck, it’s part of your TRAM flap, look what a great idea. But what you’re really doing is getting rid of one of the muscles. So you’re obliged to have a tightening of the muscles because you’re missing half your muscle on one side. So when those fall apart or if they’re not done correctly or whatever the situation is, you can have a very deformed problem even if they’re done perfectly. The site that’s tightened up often stays tight and then you have natural, if it’s only done on one side, you have a natural laxity of the abdominal wall as you age. So actually the other side that was not tram flap now starts bulging and the side that was tram flap is tight and it looks very odd. So half your belly is bulging, the other half is not. And there’s ways to fix it, but you have to be very cognizant of what was done originally. The DIEP flap, DIEP is an improvement over the TRAM flap primarily because you don’t use the muscle who needs muscle in their breast, right? You just need skin and fat. So in order to recreate another breast for people who lose their breast surgically, you can take skin and fat from the abdominal wall and then transfer it over to the breast and make a fake breast basically.
(00:33:07):
That is an interesting and much less problem with that procedure than the tla. However, what they try and do is to pick out good blood vessels that they can use to reattach to make sure that that flap is healthy and gets good blood flow in the breast. And in doing so, sometimes they’re in the wrong location or they end up causing damage to the nerves. You cause damage to the abdominal wall nerves. What can happen is you can actually get rid of the nerve in that region and what happens is you start bulging in the area.
(00:33:55):
So for example, you can have a perfectly good deep flap for your breast and then within a month to three months after surgery you’ll be like, why am I kind of bulging? And it’s usually on one side. I’ve seen a couple DIEP flap complications where it’s on both sides, but usually on one side that derivation injury is very difficult to treat. You can never bring the patient back to completely normal. But there are tips and tricks on how to reconfigure the abdominal wall with mesh. Can’t do it without mesh but with mesh to tighten it up to make it seem more or more flat. And then lastly, they can actually injure the most severe wrong plane and injure and cause hernia. That’s less common. Those are relatively easy to fix. The hernias from the deep flaps or relatively, let’s see. I’m Mickey from England, I’m Mickey. I’ve recently had a colonoscopy which showed mesh coming through my bowel from an old hernia.
(00:35:08):
The surgeon says he doesn’t want to operate. I’m worried I’m a ticking time bomb. As I can see the mesh on the imaging, the sacred tissues has covered the other side of mesh can at birth. Shall I leave it alone or go for surgery? Hello Mickey from England. I’ll be in your country in about a month. Looking forward to it. So had a colonoscopy was showed mesh coming through my bowel from an old hernia. Okay, hold on. So you are telling me your GI doctor who did a colonoscopy saw mesh inside your intestine. That definitely should get fixed definitely because the option of not fixing it, and by fixing I mean someone needs to go in there, take out the mesh and then close the hole in your intestine by not fixing it. You’re basically have best case scenario, a mesh infection. Worst case scenario, an intestinal fistula where you have stool coming out of wherever your mesh is from your skin.
(00:36:21):
Bad, bad, bad situation. I wonder if you had a mesh plug by the way. I’d like to know the answer to that. Light of hope. Thank you very much. What causes fighting and hardening? Sorry? What causes tightening and hardening? So all implants cause some type of foreign body reaction, inflammation and fibrosis we’ve published. That doesn’t matter why you have the mesh or what kind of mesh doesn’t add if matter what kind of implant, it could be a pacemaker for all intents and purposes, but that foreign body reaction, fibrosis and inflammation can make it so that the body encapsulates the mesh scars onto the mesh and therefore the mesh becomes much stiffer and more shrunken than when it was originally placed. a lot of these meshes, you take it out of the box, it’s beautiful, it’s like fabric, it’s soft, it’s got soft edges, it’s lightweight, and then you put in the patient, you come back let’s say five years later to take it out and now it’s firm, it’s stiff, it’s got rough edges and so on.
(00:37:50):
So that has to do with your body’s reaction. Now there are patients that don’t do that. They don’t react to implants like other patients do. Some patients react very, very strongly and it’s unpredictable who is going to be that person who will severely react to mesh. But in patients that severely react to mesh and it becomes very hard and stiff and tight, they actually kind of feel the mesh. It’s called a foreign body sensation. They feel stiffened by it. They feel restricted in activities by it because just think of it, you have a very firm, almost let’s say cardboard against an otherwise soft smooth abdominal wall muscle, which you can look at Cirque Du Soleil gymnasts, they’re very limber partly because their muscles are also very soft, but if you put something stiff in them, that’s going to be very difficult.
(00:38:58):
Okay, next one. I wanted to thank you so much for your medical advice here. Well, thank you. I was having ejaculation and systemic symptoms from a tap inal hernia mesh implant. I had my mesh removed by Dr. Brian Jacob, who you received here and all went well. Congratulations. This is fantastic. Dr. Brian Jacob was one of my first five guests on Hernia Talk Live back when I first started. I feel much better and got my sexuality back. Great. New York was easier for me because I live in Paris. Your advice here has led me to take this leap of faith and regain my health and morale. Okay, first of all, congratulations. Secondly, thank you for sharing that because sometimes I feel people get better than they just leave. And so we’re left with only people that are suffering without giving them any hope that they will get better.
(00:39:51):
So thank you for sharing that. And I just want to reread this. So it’s very obvious this patient had mesh in them and it seems the mesh was affecting their sexual performance causing ejaculation as well as other total body problems. And those are certainly complications that we see with mesh and mesh removal done by a careful surgeon who knows their anatomy and is very good technically can help treat that. Don’t let anyone tell you you’re going to lose a testicle. Clearly this patient did not lose a testicle or have any other kind of horrible complications like that. Here’s another question. Hi, I’m Catherine from Georgia. New here. Invited from a friend. Great. So we’ve got Georgia, Minnesota, South Carolina and Paris, France. This is fantastic. I’ve had an umbilical hernia for several years but have been terrified of surgery. What are my risks of not having surgery?
(00:40:52):
Oh, we’ve discussed this. Go back and listen to my, I think we’ve had more than one prior episode. One to specifically talking about umbilical hernias, another talking about watchful waiting. So most patients with very little symptoms from hernias that haven’t been operated on before do really well and you should obviously see a doctor to make sure that you fall into that category. But watchful waiting is considered safe in most patients. Thank you. I’m trying to find out what type of mesh I had. The scar tissue is holding in place the outside of the bowel. I saw the image of this. Meh. I can send you a photo of this and the report said I had a foreign body coming through the bowel, which is a big worry I have. Shall I speak to a new surgeon? Is there anyone in the UK who you may recommend?
(00:41:51):
Not that many in the UK, not that many. What I would like, you should may want to consider Dr. Neil Smart. He’s a colorectal surgeon and did I talk to Neil Smart? I think I had Neil Smart on as a guest. Go go see the episode with Dr. Neil Smart. But that may be an option. If not, I recommend just do an online consultation with me and I’ll help figure out what doctor can help you in the UK and hopefully one day I’ll be in the UK treating you guys. I’m looking forward to that. Okay, next question. I have weakness in bulging involving my entire inguinal floor, a direct hernia as you described. Would I need non-absorbable tacks or could I be successfully repaired by absorbable tacks? If you were being treated by me, I would use non-absorbable permanent tacks. How long would it take for a mesh or not tacks even sutures.
(00:42:50):
How long would it take for a mesh to reach its full strength and tissue adherence when done through laparoscopy and without fixation for inguinal hernia repair? Good, good question. So most of these synthetic meshes, which are the standard meshes used for hernia repairs, they say it’s become sticky and it falls into place within the first three days. So that’s why none of us really recommend that you restrict your physical activities because the mesh is pretty much stuck within the first three days and then it starts to increase in its strength for those that shrink. It shrinks usually within week six and that’s when sometimes if it’s put in too tightly for example, you’ll feel symptoms but it’s full strength and tissue adherence depends on the patient and the type of repair and so on. But definitely after about I would say three months you’re out of the woods.
(00:43:54):
When placing tacks in Cooper’s ligament in an elderly male with poor tissue quality, how can you gauge how deep to go into Cooper’s ligament to avoid going into the bone and periosteum, which may be more likely cause chronic postoperative pain? Well, you go through a ligament alone so that there’s a ligament and then there’s the bone deep to it. So it’s purely like a tissue plane issue. Is there something that can be done? So can be done to soften a stiff mesh, for example, massaging the area or physical therapy and how can if it needs to be replaced? Great questions. Okay, so the short answer is yes. The long answer is we don’t know.
(00:44:42):
So I do have patients that get a lot of scar tissue and their pain is clearly from the scarring of the mesh and I do recommend massaging of the area and most of them come back and say they’re getting better. And what you’re doing is you’re breaking up the scar tissue that holds or tugs or pulls on the mesh in a certain direction and allowing the mesh to kind of be more in a more natural state. Also, there are patients that actually have a stiffened mesh. Not so much scarring to the mesh, but the mesh itself is stiff that I’ve had to actually remove those meshes. There’s not much you can do. I’ve tried steroid injections in some of these patients. I have not seen good results with it. Massaging is usually too painful. The mesh is very, very stiff and it’s a permanent product. So I’ve had to take out those meshes in patients. But those are good questions.
(00:45:51):
Okay, next question. I was wondering about your UK links. Yes. Are you speaking with the Scottish government about this? I’ve been trying to get them to reach out to you. As you’re aware, I run the petition against the use of measure in Scotland, also trying to create patient pathways for hernia mesh removal. I’m awaiting umbilical hernia mesh removal. Myself, my weight is an issue for removal, but due to all the health issues I’m struggling to have surgery. My BMI is 40, which is too much for what she’s asking. Do you feel this is classed as too high risk for removal? Sorry for the questions. Okay, so yes, thank you very much. I’m happy to speak with the Scottish government and happy to help. I personally am working on getting access to the UK to help provide expert surgery mostly in the complicated areas. I’m sure there’s tons of patients that can get good repairs. In the typical system, I would be someone who would offer expertise for let’s say mesh plant illness or mesh removals and so on. From what I understand, from what I understand, your Scottish government has provided support for mesh removals for pelvic meshes. I’m not aware that they have yet provided care and support for hernia meshes.
(00:47:35):
We did have a guest here, Dr. Masi Vic. He has moved to Scotland and is a great resource for mesh based repairs and complications. However, and he was a guest on our show I think about a year ago. So he would be someone good to work with locally. I would love to be able to be involved and help. It’s like one of my passions. So if the Scottish government would like to is open to working with me, even send the patients over to me, that would be really great because that’s part of the problem. Why I’m trying to get to the UK is that a lot of those patients can’t get to me. If the Scottish government can help hernia mesh removal candidates at least initiate a online consultation with me so I could figure out what’s going on and then determining what your needs are, then come sponsor your care to be with me. I would love that. That would be so cool. Alternatively, I would come to the Scotland. You have a very, very beautiful, I guess technically it’s a, is it a province?
(00:49:00):
I would love that and that would be something I would be willing to do first I have to get my credentialing and takes a couple years. I’m told to get that through the GMC General Medical Council. But yes, if your BMI is 40 and you need your hernia mesh removed and you have a hernia still you then you should can get weight loss surgery. That would be good for you because then you can expedite your care for your umbilical mesh removal. Let’s see. After inal mesh removal, I was warned I could get a recurrence. I had a form body syndrome. So what would be the good next step? A shoulder repair. Also any recommended sports to avoid recurrence. Okay, good question. So if you had a mesh removal for mesh implant illness, then first make sure you’re better. And then the question is how can we repair your hernia?
(00:50:03):
Either you have a hernia now or you’re going to have hernia recurrence. So definitely do not use mesh again because you’ve already shown a propensity to react to mesh. The question is do you react to suture because you at least get suture and I use permanent suture and aboral suture is not first line of treatment. So if you have permanent suture, I tend to use nylon suture because most of the patients that are tested have not reacted to nylon, but they have reacted to polyester and polypropylene sutures. But I’m very curious. So I would first test you against various sutures, usually E-P-T-F-E, nylon polyester and polypropylene suture to see what your propensity is to react to them and then probably pick the nylon suture for the tissue-based repair. And if it’s an inguinal hernia, I usually do a shouldice. If you have a femoral hernia, I do a McVay.
(00:51:10):
Sometimes I do a bassini but not as often as a shouldice. Oh, and then the second part of the question was do you recommend any sports to avoid recurrence? All sports are healthy and should be performed. They’re all good. Is it possible to email you to discuss my case? What is the best email? Thank you. Yes, just email my office. It’s info@beverly hillsherniacenter.com. All that’s on my website. It’s on which is Beverlyhillsherniacenter.com. It’s on my Facebook page, it’s on my Instagram page at hernia doc, wherever you want to find me. You should be able to see a contact us section or an email where you can contact my office. I do offer what’s called online consultation. So if you do not live in California and therefore I do not have a license to practice where you are, then you can request an online consultation. Send me all of your records. Basically my nurse will spearhead that. Make sure I have all of your imaging and a past operative reports or whatever it is that you have, review it and I’ll figure out what your problem is and help guide you as to the next steps.
(00:52:32):
Next question. Excuse my poor understanding of phasix, but can you explain how fixating the mesh three points prevents the mesh from billowing? Is it that the mesh is held tightly enough by the fixation points that non-structural mesh cannot bill below? Yes. How do I explain this? So if you have three points of fixation, then the mesh in between the three points is prevented from below of the mesh is not stretch. Okay? So if you have two points of fixation, you are only fixating in that one horizontal space and you’re not having any support in the me, sorry, vertical space and you’re not having any support in the horizontal. When you fixate with three, then you’re holding both horizontal and vertically any movement of the mesh into a defect.
(00:53:47):
It makes sense to me. I don’t know. Going back to the Scottish thing, they haven’t provided any here yet. Haven’t provided in here yet. Hernia mesh patients, I heard about that. I believe your skills are moving in here. I’m very keen term process college government, reach out for expert opinion. Absolutely. Hopefully start conversations about you helping here. Absolutely. Thank you for getting involved with that. Next slide. I have a was rather fault with few breathing bowels. They want, should I save it, do the surgery and it doesn’t heal on anyway I don’t have but for most patients you must know therapy because surgery is not also get endoscopies, not burning your because you could cancer until fifth for surgical therapy.
(00:55:15):
Lot question work. This is that always shrink, not that shrink in tissue possibly. Yes, yes. Talk about pain associated with fixation. The last five minutes of a lot of that. So the issue with metrics sutures, what happens is that just only help those. Now if you imagine tooth, then those areas where it is so in place will get pulled on, which means you probably be tear liver tissue is going through would causes a lot of pain. So one of the reasons why people have chronic pain, their inguinal hernias or ventral hernias, the wall area is they’re actually trying to tear through a tissue and the mesh placed tight. So know that me shrink somewhere between seven 25% for most of the meshes up to 40% for one study that showed for the EPTFE meshes. So always the surgeon should understand that the mesh therefore needs to be labeled a little bit of give, a little bit of a, but it shrink
(00:57:08):
Perfect
(00:57:22):
Mesh. One of the issues is higher chronic pain with either sutures or tacks, but you don’t get pain as much or at all really when you use glue or no fixation. So we are therefore tending towards velcro or glued in meshes and or techniques such as sandwiching I talked about where the mesh can place without any fixation.
(00:57:56):
Is fibrosis around the mesh and or in-growth of the tissue into the necessary for the strength of the repair are weak and floppy right inguinal space or does the match itself do the job? No. People who think the mesh itself does the job are incorrect. What the mesh does is it supports the natural tissue. So what you’re trying to do for a direct her net is to tighten that area, that weakness and make it a flat surface onto which the mesh will then grow and make it more secure and stronger. What a lot of surgeons do is they just put the mesh on top of the weakness. So the mesh is just going to grow into a weakened wall and below out or they bridge the weakness and then the mesh doesn’t stick to anything. So it has a very poor function. It’s like a wall without any support on the other side. So no, the ingrowth into the tissue is part of the purpose of using the mesh and it’s repair. Let’s see. Next one.
(00:59:09):
Would chronic pain not be exacerbated by any kind of mesh fixation? Because the fixation points vocalize tension on specific areas instead of the entire mesh surface. And because sutures on the fixation points tear through tissues as the measurings? Yes, I mean you basically just repeated what I just said. So yes, you’re completely right. Thank you very much. We all know smoking is bad for your health. Could you explain if you feel there’s a link between smoking and hernias? Yes, thank you Mr. Frenchman for asking about nicotine use. Okay, so what we know about nicotine specifically is that the nicotine use itself can disrupt collagen formation. That’s why people have wrinkles. So people who use nicotine in all forms, whether it’s smoked patches, gums that nicotine disrupts collagen formation. So you want your collagen to be placed in this perfect patchy matrices lines. But when you have nicotine exposure, it actually makes your collagen in a very disorganized manner and therefore not as strong.
(01:00:26):
That’s why you have people with bad skin and lots of wrinkles who smoke. The same is true for hernias. So hernias already have collagen problems, so the collagen is weaker collagen, you add on top of that a disrupted pattern of collagen formation, which makes your hernia recurrence higher. So people who smoke have a higher recurrence rate, I believe seven x higher than the average patient. Now we don’t know that nicotine actually causes hernias. However, if you’re a smoker, any of your smokers, cough coughing definitely is a known contributor to developing hernias. You kind of have to have a propensity for hernias already. Nicotine doesn’t cause a hernia, but the coughing can cause a hernia. And then lastly, so we got the nicotine collagen issue. You got the coughing if you’re smoking the nicotine. And then thirdly, if you’re smoking and you’re not getting good blood flow, sorry, good oxygenation to your wound, if you have a hernia repair and you’re still smoking, then the lack of oxygen to the area that is trying to heal surgically will make it so that you have a higher risk of surgical site complications including infection and also a higher risk of hernia recurrence because you’re not getting good blood flow to the area to heal.
(01:02:07):
So yes, smoking and hernia is not a good combination. Don’t do it. Maybe that’s going to be a good incentive to quit smoking all. Well, my friends, that was lovely. We had a great, great episode. Talked a lot about how to answer your questions. I’m really appreciative of you. We’ll be here again next week and make sure you follow me on the different platforms. I’ve been having fun on Instagram lately. If you haven’t noticed, I’ve been putting some funny stuff up on the story section. So if you like to laugh about hernia jokes, go to Instagram and follow me to follow my stories. I don’t really post them so much on the other places, but if you want to learn, go to X at hernia doc. If you want to be funny, go to Instagram at Hernia doc. You want to make sure you don’t miss a Hernia Doc episode. Go to Facebook at Dr. Tophi, sign up for YouTube at Hernia doc and like subscribe to my podcast. See you all later. Bye.
