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Dr. Shirin Towfigh (00:00:11):
Hi everyone, it’s Dr. Towfigh. Welcome back to Hernia Talk Live. It’s been a minute. My name is Dr. Shirin Towfigh. I am your hernia and laparoscopic surgery specialist. Many of you’re joining me as a Facebook Live on Dr. Towfigh and via Zoom. But this and all prior episodes, as you know, is available on YouTube at Hernia doc, as well as on our Hernia Talk Live podcast, which I’m really excited about because I’ve seen that grow. And I’m really grateful that you all are tuning in as a podcast. And then I kind of reserve my Twitter space for most of my academic work and hernia doc. At Hernia Doc and also on Instagram. It’s at Hernia Doc. For those of you that follow me on Instagram, I’m very grateful for that. So as many of you know, it’s been, I’m going to say a little bit more than a month possibly.
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I don’t know, is that accurate? But what’s going on is a lot. So the last month, month and a half, it’s been busy. I’ve been to a couple of different meetings I think I talked to you about. I was in Colorado for the Western Surgical Association where we gave a great talk about hernia sac and these occult angle hernias that don’t need a hernia sac. And so try to teach surgeons, it’s kind of difficult to make people change, but try to teach surgeons and hopefully others that just because you don’t have peritoneum stuck in the hernia doesn’t mean it’s not a hernia. You can have fat in the hernia. That’s what we call pre peritoneal fat. That is one layer away from the peritoneum and that’s basically something that radiologists need to be aware of and also doctors and surgeons. Why is that important? Because many people have pain from occult inguinal hernias or from hernias that don’t have peritoneal extension.
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It’s just the fat is in there and doctors are not trained and it’s not taught in medical school that can be a hernia. And so on imaging, they look at it and the radiologist doesn’t call it a hernia. And then a well-intentioned surgeon, either a gynecologist, urologist or more commonly a general surgeon will stick a camera inside the abdomen as a laparoscopic exploration saying, you know what? I understand you have all this pain. Let me put a camera in there and let me take a look and see maybe you have a hernia. And what they’ll do is they’ll just look without doing anything else and they won’t see the hernia from the inside because it’s blocked by this fat in the hole. And they’ll tell the patient, you know what? We checked for everything. You don’t have endometriosis, you don’t have a hernia, it’s all in your head.
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Or you just need nerve blocks or a spinal stimulator or something crazy like that. And they actually miss the fact that there’s a hernia. And that is kind of what I would like to change. I hope to change it at the medical school level, which is why I teach at the medical school and I would like to change it at the clinical clinician standpoint, which is why we give talks and we do research and we show our experience. And interestingly, the session in which we were assigned, there were seven or eight different speakers and most of the speakers, there were interesting talks. They were asked maybe a question, maybe two questions. And then my fellow went and gave his talk about our research about this new definition we’re trying to push, which is that if you don’t have a hernia sac, it still can be a hernia.
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And let me tell you, there were so many questions. First of all, there are many questions because there are people out there that still are a little bit, they’re not really happy changing. So there’re pushing back. What do you mean? So every patient that has a little piece of fat in the groin has a hernia. Well, the answer is yes, but that doesn’t mean you have to operate on all of them. And then they were say, okay, well what does that mean? Every radiology needs to be reread or we’re saying is listen, people have groin pain or belly button pain or whatever, and it just needs to be appreciated that there are subsets of patients that have pain and symptoms. The quality of life is affected by these pains and symptoms and the fact that on imaging there’s no peritoneum involved in this hernia, which we call hernia sac, doesn’t mean that there’s no hernia.
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There could be fat, and if you’re going in there to explore, then you need to make sure you go beyond the hernia sac to explore. I just had recently a patient that years, years and years of chronic groin pain, and that’s exactly that happened to them. They said, I went to the doctor and they did exploratory laparoscopies showed nothing, and I said, yes, but when they went in there, did they just look or did they specifically go beyond looking, cut the peritoneum, look beyond the fat, look at the muscle itself and see if there was a hernia. They didn’t know we got the operative report for this patient and of course that wasn’t done because if you look at the imaging, they do have a hernia, and so it’s just sad to see when imaging shows a hernia and then a surgeon goes in there and says, Nope, no hernia.
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When they don’t understand that, that’s conflicting with what the imaging is showing. So maybe you should do more during surgery to look for the hernia because that is a curative plan for the patient. That’s where I’m at. Here’s a question. During any of these meetings, were there any sessions you attended on athletic pubal or sports hernia and did you learn anything new? So this meeting that I was at is called the Western Surgical Association. It’s the oldest regional meeting in the us. It’s very traditional I should say. I love it because it’s a lot of deans and chairman and just really kind of top-notch academic people. It takes a while to become a member, and I was a member many years ago and I never gave up my membership because it’s a real honor to be allowed to be a member of the Western Surgical Association, and it’s even more of an honor to get your research accepted to present.
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However, it is not a hernia meeting and athletic pubalgia or sports hernia is way beyond them. This is mostly like adrenal glands and cancer oncology and trauma hernias is kind of okay. They don’t necessarily have a lot of hernia talks, but athletic people would be way beyond, way beyond the benefit of the audience. The audience is mostly oncologists and transplant surgeons and very highly academic surgeons and almost no private practice doctors, almost. No, just pure general surgeons. I’m like a unicorn among them. So no, sorry, nothing on athletic pubalgia. Now after that meeting, a week later, I had to leave again, which is why we’ve missed so many hernia talk sessions and we had the International Hernia collaboration in Mexico in Meida, Mexico, which if anyone wants to go to Mexico, I highly recommend the Yucatan. Merida is the safest city in Mexico, one the most beautiful cities. It was amazing, and the Kote were just so hospitable. I absolutely love the session. So that was a several day meeting. I helped arrange the scientific portion. Yes, absolutely. At that meeting we did have a full session on athletic pubalgia. In fact, my friend Dr.
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Andreas Koch, from Germany flew in for that meeting and he talked about his experience addressing athletic people in competitive sports, highly professional athletes usually in World Cup type soccer, soccer players. That was a really good session. We had a whole session called the Hernia Cup, hernia World Cup, and we invited surgeons that are really well known in what they did. So the Botox surgeon, professor Ibarra from Mexico, the Andreas Koch, who pretty much is world renowned for his athletic people. He was actually a guest on Hernia Talk. I forget which episode, but if you look up Andreas Koch, KOCH, we talked about athletic people with him.
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We had Professor Rodrigo Alvarez who invented the dermatome mapping for chronic pain. We had Professor Jan Cleta who represents Switzerland, where he talked about loss of domain, abdominal wall. It was kind cool. We had an international group of surgeons for the oh, and we had Professor Yuri Naski to talk about his invention of the trans versus abdominis release the tar. So that was the World Cup hernia. World Cup was really, really cool. So at the IHC meeting, the International Hernia Collaboration, we had about 50% local surgeons give talks and 50% international surgeons give talks. I give a talk on what did I give a talk on? I think I gave a talk on the algorithm for treating chronic pain after inguinal hernia surgery. We had all the world leaders that you can think of and some really great surgeons from Mexico. For those of you that may not know, Mexico is actually a really great hub for hernia surgery. Some of the older surgeons were there, like I said, professor Rodrigo Alvarez and Toma Barra who’s actually a plastic surgeon who invented the use of Botox for repair of the abdominal wall. And then we had some of the younger surgeons, Alex Rodriguez, Luis Hernandez, Luis Fernandez, Luis Martin, Del Campo, Alvarez Gonzalez. He had the longest name of all of ’em. Who else was there? Ricardo Renoso, just really great surgeons that are highly respected in their field. Hector Valenzuela, he’s fantastic.
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And then some female surgeons locally as well, Nubia Ramirez and so on. So it was a great, great meeting. I really enjoyed it and the surgeons that were there, it got a lot out of it. So I always learn at these meetings too. a lot of new robotic techniques, a lot of great talks about tissue repairs and so on. Here’s a question. Can you pose to your PowerPoint of your presentation on chronic pain for us to see? What I’ll do is, and I need to be better at that I guess I have a lot of talks that I’ve given, but what I can do is record my talk and post it on YouTube. So I will do that for you all. I have a couple recorded talks already, which I’ll post and then I’ll post the one on the hernia diagnostic algorithm. I think that was a good talk. I have a really good talk on male versus female groin pain too, which I gave at the European Hernia Society meeting last this past year in, where was it?
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Oh, it was in Czech Republic. So I got a lot of really good feedback on that one. Anyway, so that was the meetings. I was physically gone. Then when I came back, I got sick and you can hear me, I’m still stuffy and so on, but at least my cough is better and my voice is back. So that prevented me from talk episodes, but now that I’ve gotten my voice back, I just recorded two podcasts. I really liked doing the Boss Business of Surgery series podcast with Dr. Amy Tric, who is a fellow general surgeon who now practices in Florida. If you want to hear a little bit about my life, not only as a private practice surgeon, but also as an inventor and entrepreneur, and I’ve got multiple patents, and hopefully we will be able to change a lot of what’s going on in hernia care for the good.
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You can go listen to the Boss series of podcasts. I thought that was really fun to do. And then on Monday I recorded a podcast on endometriosis and how you can determine if your chronic pelvic pain and groin pain may actually be from a hernia, not ovarian or endometriosis related. We talked about Ehlers Danlos syndrome and hyper flexibility and how that complicates the treatment of hernias and so on. So Alana Zinsky is a great patient advocate for endometriosis. She has this podcast called Endo Battery Podcast, B-A-T-T-E-R-Y, and that was fun. So I hope you all go to these podcasts. I will post ’em on my social media so you can directly link to them, but it’s been a minute, right? So that’s why I thought that I would spend some time as we wind down 2024 to go over a little bit of how the year has been and how grateful I am to all of you, but also to help answer any questions you may have coming my way.
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I’m happy to answer questions. I had a lot of patients come in the past couple of weeks to see me a lot. I’m a little bit overwhelmed with the amount of work I have to do to meet everyone’s needs, but we’ve had patients one day, actually I had no patients from California all day. It was like Ohio, Pennsylvania, New York, Washington State, Nevada, Illinois, Florida. I think we had one from Texas, if I’m not mistaken. Yes, from MD Anderson. So it was great. I’ve had patients from Canada, Mexico, middle East, United Kingdom. It’s been great. It’s been great. I love my international patients and I also love the fact that many of you choose to travel to see me and whatever I can do to help you, it’s my pleasure. I was talking to one of my patients and I was saying they’re apologizing. The patient was apologizing for being so difficult and complicated and sorry for all the medical records they gave me and so on, and I was like, listen, I don’t know if it’s an illness or if it’s my strength.
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I actually enjoy these complicated patients. So I know many doctors just run away. If there’s a patient, that’s a little bit too, I know doctors that say only one problem, you can only talk about one problem at this meeting because they only have 15 minutes at the most that is dedicated to you. But I don’t have 15 minutes. I usually put away a good 60 minutes for the new consult patients and sometimes I go more than 60 minutes. That kind of ruins a day, but it is what it is. So when you come to see me, I spend a hundred percent of my time dedicated to you, and I like to solve problems and figure things out. So I get really excited when someone comes to me with a lot of other things because I like to try and figure it out, and it really bothers me if I can’t figure it out because I feel that I don’t want to call it a failure, but it’s like not being able to solve a puzzle, like getting to your New York Times puzzle and not being able to solve the crossword or get the word all within three or four attempts.
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These are all things that I enjoy doing. So I hope you do understand that that’s what motivates me, but also appreciate that there are those of us out there that like to solve problems. And if you’re one of those patients that is getting the runaround because you keep hitting a brick wall every time you have a problem that needs to be solved and your doctors are not giving you the time of day, then there are those of us that are here to give you our time of day. Here’s a question, can mesh be removed after eight years? Absolutely.
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There is no time limit for mesh removal. The amount of scar tissue due to prior surgery is actually less over time, so that’s usually good. Here’s another question. Does placement of laparoscopic mesh reinforce the attachment of the lateral and medial heads of the rectus muscle to the pubic bone without directly suturing it to the pubic bone? And if the answer is yes, how does the placement accomplish this? Thinking of Hernia Talk Live presentation on Manchester repair on hernia attack live. So first of all, the Manchester repair is actually an inguinal hernia repair without fixation of the mesh. So it’s nothing novel. It’s been given a name by Dr. Ali Sheen, but Dr. Namir Cuda actually is probably the pioneer of that before the Manchester repair was published. So that’s number one. And for an inguinal hernia period, it has nothing to do with sports hernias. Number two, no, the laparoscopic mesh doesn’t do anything about reinforcing the muscle from a muscle tear back to its original position. The laparoscopic mesh purely as a patch that is not intended to recreate your anatomy. So if you have a hole, it’ll patch the hole. If there’s muscle that’s torn, the torn muscle will stick to the mesh at that region, but the mesh will not encourage the muscle to go back to its normal position if that’s kind of the question that you’re wondering about.
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Okay, so looking forward to 2025, I would like to say that we’ve already expanded to two more hospitals this year, St. John’s Hospital in Santa Arnica and Huntington Hospital in Pasadena. So we’re trying to get better Western and Eastern Los Angeles County access for those of you who would prefer to have your surgery a little bit closer to your home. That said, I would, my dream for 2025 is to expand to Northern California and London. I’ll be in Paris hopefully next year for the European Hernia Society meeting, and I already have patients and great collaborators in London that I already work with. So how cool would it be? I already have patients in the uk. Why not treat them in their home country or for those of you that are in other countries in Europe or the Middle East Africa, tell me and DM me if you feel that coming to London would be easier for you than coming to Los Angeles.
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I know my Asian patients, it’s easier for them to come to Los Angeles than to the east coast, but I feel like that whole section of uk, Europe, Africa, middle East, it’s easier for them to come to London than to come to Los Angeles. So if any of you have any input on that or would like to give me some feedback about whether you think it would be good or not for me to expand to London, I kind of love London and Paris. I try and go there every year if I can. I have two beautiful goddaughters in Paris already who I visit, so why not make it also like a work trip that will be kind of, that’s actually typical Towfigh, right? Instead of just going on vacation, just turn it into a work trip. But I do enjoy it. Okay, next question. Sorry to persist on this.
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I was told my muscle is attached, but the attachment is not broad enough. My question is more regarding reinforcement of a weak rectus rather than reattached rectus because it is attached, although the surgeon felt attached was not broad enough. So if you’re referring to rectus detachment and kind of the Myers type repair where it’s so down the rectus, down to the pubis, that’s one thing. But if you are the patient who has a weakness of their weakness of their direct hernia and you need wider mesh coverage, that’s a totally different animal. It has nothing to do with athletic people, algio or sports hernia as a consequence of a direct hernia that you do need plication of the thinned out loose direct hernia, and then you need wider coverage of that space to go beyond midline to the other side to give support to your direct angle hernia.
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Okay, there’s a couple of publications coming out pretty soon. We had recently our Hidden Hernias hurt paper, which I think is probably one of the most influential papers I’ve written to date. I’ve been wanting to write this paper for ages because I thought that was the best title. It’s an alliteration of hs. So Hidden Hernias Hurt, and that is kind of a conglomeration of a lot of the other papers that I’ve written talking about women’s hernias, occult inal hernias, radiology to identify occult inal hernias and the diagnosis of groin pain and people that don’t have an obvious bulge. For those of you who like to read books, the ultimate book on how to diagnose and manage growing pain of all sorts, whether it’s urologic orthopedic or general surgical, was written by me and my friends, Dr. David Chen, Brian Jacob and Bruce Ramshaw, and that’s called the Sage’s Manual of Groin Pain.
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I give it as a gift to every fellow that I graduate, and I’m very proud of that book after so many years of having finished it, it’s still one of the premier books talking about groin pain. But what I wanted to tell you about back then, I didn’t have the data to support what I was seeing in the clinic, and so we just wrote about it in the textbook, but now we have the data, it’s now published, it’s called Hidden Hernias Hurt, and it really is one of those topics that I think needs to be taught in medical school needs to be taught and surgical residency and hopefully medical doctors can also learn about it so that when a female, especially female, less often a male comes to you with chronic groin pain or pelvic pain, it’s fine to do ultrasounds of the ovaries and hormonal therapies and so on.
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But common things occur commonly. A hernia is very common even in women, and it can give you pelvic pain, pelvic floor spasm, Pudendal Neuralgia, pain with sexual intercourse, urinary frequency, rectal pain, pain with activities such as sitting, bending, standing for a prolonged time, coughing, laughing, talking loud. These are all things, by the way that I reviewed at the Battery podcast that I recorded on Monday, which will come out soon. I’ll let you know when that comes out. My point is this, it is so easy to diagnose a hernia when it’s a big bulging hernia almost slapping you in the face when you look at the patient, right? Those are easy, those are treatable, and we usually don’t have a problem with those in terms of diagnosis, treatment’s a different situation. However, if you don’t have the bulge, if you’re symptomatic from very small hernia, those are the patients that fall through the cracks.
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And what we showed was those tend to be female. They tend to be slightly, actually, the body weight’s about the same in our patients. They tend to be a little bit younger by about five years or more, and they tend to be diagnosed late. They tend to be given narcotics more often than others. They’re already coming to my office on narcotics, which is horrible by the way, because we all know that being on narcotics, even exposure to it can promote addiction and substance abuse. So the fact that there are all these young women that are being told it’s all in their head, they should just take some narcotics or maybe a glass of wine and their pelvic pain will go away. It’s complete bs. But the other thing that we really honed in on this paper, hidden hernias hurt, is the following. Surgeons for some reason, say you operate on pain, you get pain.
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It’s a total cop out. I operate on pain all the time. The goal is to get rid of your pain. I don’t tell the patient, oh, you’ve got pain. I can make you worse because I can’t make you worse. And our research now supports that. So our research not only showed that people with inal hernias that are occult present with a higher level of pain than people with traditional inguinal hernias, we also showed that their drop in pain after surgery is more than the expected drop that you see in patients with regular traditional inguinal hernias. So there you go, and that’s my armamentarium. When people tell me, ah, Towfigh, that doesn’t exist. We don’t see patients like that, et cetera. I publish the data so that the numbers do the talking so that people don’t discount what I say because I’m a female surgeon in Beverly Hills and therefore not seeing the kind of patients they’re seeing in Ohio.
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Not true. I just rattled off all the states where I just saw patients in the past couple of weeks. My patients are not Beverly Hills Housewives. They are patients that are coming from your town to me because they’re not getting the care that they need near your town because there are doctors out there telling them they don’t have a hernia. It’s all in their head, and for years they’re suffering. That’s just not appropriate. So I’m hoping as I publish more, as I give more talks, as time goes by, more and more doctors, medical students, residents hear me read about me and my research and say, oh, you know what? Actually I’m now seeing these patients. I operate on this patient. Oh my God, they got so much better. And I said, there you go, you’re listening to me. And people wonder why it is that I see these patterns.
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It’s because I tend not to see the typical patient. Now, if you’re a typical patient, please come see me. I enjoy an easy case every so often. I enjoy seeing someone with just a belly button or Audi or someone with just a simple inal hernia that I can repair. I love that I don’t need every single patient to be complex. I do see regular non-complex patients. However, the proportion of people that come to see me that are complex, that have seen multiple doctors that either failed surgery or were never offered surgery is pretty high. And so out of the proportion of patients that I see, I’m seeing a narrow niche that most surgeons don’t see. And so the proportion of, I’m going to make up a number for a hundred patients that I see, I’m going to say five of them are just standard patients and 95 of them, and I’m not exaggerating, have something complicated.
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So either they’ve had a complication from a mesh or from a prior hernia, or they have basically a misdiagnosis, right? No one can figure out what’s causing their pain. And so they come to see me. I can help figure out what’s causing their pain. Now, the reverse is true for the typical general surgeon. Your typical community general surgeon sees of a hundred patients, sees 95 of them are just stuck. I have a bulge my family doctor sent me to see you. They see you, they say You have a bulge, we’ll fix it. And then they get five patients that are complicated. They have pain, there’s no obvious bulge. They failed multiple surgeries and they send these patients to pain management or they say there’s nothing wrong with them. So since my patient popul is very different, what happens is I end up seeing, I end up seeing patterns that other doctors don’t.
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So if I see a narrow number of people, but a large number of them, I will start seeing patterns. That’s why I was starting to see females with occult inguinal hernias complaining of the same exact symptoms better when they’re lying flat, they wake up, they’re fine. As they get more active, their pain went worse. When they’re more on their feet, they’re pain worse, et cetera. So if I keep seeing the same people over and over again, then I start learning the questions to ask. And that’s why we came up with their hernia questionnaire, which I’ve been using for decades because of their very directed questions. Before I move on with that, I want to help answer this question here. Hello. Thank you for being available for questions. Do you believe someone at age 68, which is not a lot by the way, with a two inch I believe, last imaging of Anglo hernia?
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She knows of it. Weight watch since 2009. Okay, I don’t know how this text is going. I’m just going to rephrase it. So it sounds like it’s a 68-year-old female with an inguinal hernia that she’s been watchfully waiting since 2009. History of multiple sclerosis would be best outcome with hybrid match versus ryp synthetic. So multiple sclerosis is not an indication to change your type of surgery. You should have the standard type of surgery. Same patient is a subarachnoid hemorrhage survivor with clipping almost three years out of the stroke. Recovery alone with mild aortic insufficiency in sleep apnea, healthy weight and diet, okay, healthy weight and diet, and you have an inal hernia you’ve been watching for a while. Assuming you don’t have a femoral hernia, you should have it repaired by whichever surgeon you choose, using whichever technique that surgeon recommends. Does this patient most benefit from open repair with local anesthesia to avoid general anesthesia?
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Not necessarily. If you have had a subarachnoid hemorrhage and it’s already been surgically dealt with, there’s no added risk for you to undergo general anesthesia or local anesthesia. The multiple sclerosis should not affect your need for general anesthesia versus local anesthesia. And the mild aortic insufficiency in sleep apnea should also not be a determinant of whether you do general anesthesia or local anesthesia. If you’re of healthy weight and diet and you’re 68, get your hernia repaired if it’s bothering you or if you have e femoral hernia, that’s very important in women especially to be ruled out. And the type of hernias repair options are laparoscopic or robotic with mesh, which includes general anesthesia, open repair with mesh, which can be done without general anesthesia with IV sedation or open repair without mesh, which also can be done without general anesthesia with IV sedation. And the surgical technique you choose is based on your physical exam, the size of the hernia, your risk factors for hernia development and your lifestyle that you’d like to lead and your surgeon and the type of operation that they’re willing to provide and that they are an expertise in.
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What I do not recommend is for you to force a surgeon to do an operation or use a surgical technique or even anesthesia that they don’t usually do. That is a recipe for disaster. So for example, I don’t like open mesh with, sorry, I don’t like open angle hernia repairs with mesh for most young, healthy, active patients, I like it for the really huge hernias and the elderly. They seem to do better. So does that mean that you should never get an open repair with mesh? No. I just feel like in my hands, a laparoscopic repair or tissue repair may do better because I could do all of those operations. You may go to a surgeon who does none of those operations and only does an open al hernia repair with mesh. Do not force that surgeon to do a tissue repair or a mesh repair.
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I just had a patient last week who forced a senior surgeon, by the way, who’s only done one tissue repair in his life to do a tissue repair on him. It immediately recurred. I got the report, it wasn’t even a hernia repair, he just closed the hernia sack and left the hernia hole open and that’s all he did. How that’s going to be a hernia repair. I have no idea As a senior surgeon, he should have known better, but now the patient’s in my office with a huge hernia now a wanting a tissue repair, it doesn’t work that way. Okay, long question. Thank you for all your work on Asia syndrome or in the hernia mesh world mesh implant illness. Unfortunately, I have not had any resolution of all the debilitating chronic fatigue syndromes since mesh removal last April. I’m following here in Paris by a hospital professor who specialize in Asia syndrome, a medical doctor.
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I assume this service used to be dedicated exclusively to silicone implant illness for women, which we also call in the US breast implant illness, but is now turning to patients with mesh illness including following some of your public’s work. I’m very happy to hear that. I’m very happy to hear that the professor’s theory about mesh illness is that it is a neuromuscular pathology released by macrophages in the blood. Interesting. The macrophages attack the foreign body by inflammatory process and then turn to the body’s own cells staying locked in an autoimmune inflammatory reaction. They can see this on muscular biopsy that was done really. I would like to learn more about that. If you can send me what muscular biopsy was done, this would explain why I lost so much weight very quickly after the initial implant. Although most people are not like that. It was drastic muscle loss, a sort of macrophage myo fasciitis.
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I wanted to ask you, following your practice, what gross percentage of patients get better after mesh removal and why you think some improvement others do not? We actually published this and if I remember correctly, what was the title of our paper? If you DM me, I could send you my paper. So we actually looked at what happens in patients who have their mesh removed. And from what I recall, 65% of them had complete resolution or significant improvement in their symptoms. 80% had improvement and another 20% like nothing worked. And so the question is the following that percentage of patients that nothing worked, is it because whatever damage has been done to your autoimmune system where it’s now revved up by this response to the foreign body, is that something that will take time or even more time? In other words. So we saw at about two years you should be as close to normal as possible.
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So six months is still not a lot, or is it that you actually have another disease process? Because I had a patient who had actually ulcerative colitis, right? So all the bloating and the GI symptoms and the rashes and all that could have been explained by his ulcerative colitis. And then he had that. I made sure that he was optimized and treated for that before I did any mesh removal surgery on him. So it may be that your hypothyroid or a hypoadrenal or have an autoimmune disorder that’s not yet diagnosed, that is separate from your mesh implant illness. And the mesh implant either took your underlying disease, which wasn’t really that prominent and just fast forward it to present after the mesh was implanted and removing the implant doesn’t get rid of the underlying disease or the mesh had nothing to do with your underlying disease and it’s just unfortunate that you had the mesh implanted around the same time where this disease process came about.
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So those are things to keep an open mind in. I say all this because we don’t have enough information to very accurately diagnose mesh implant illness, silicone breast implant illness and so on. We just don’t, there’s no blood tests that can say this is what it is, and we can just surmise based on a syndrome of symptoms that you may have plus correlating it with a time in which you had the implant and hoping that removal of it will get better, but we’re not right a hundred percent of the time. I hope that’s helpful. Question do ketamine infusions help the body release the pattern of constantly feeling pain and illness?
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Well, from what I understand with ketamine infusions, it kind of resets your system. It works for people with chronic pain. Also PTSD, it’s a little bit of a reset button, but mostly for anxiety, post-traumatic stress disorder, which can be due to medical illness and chronic pain. So I don’t know that it will address pain and illness like the chronic fatigue that you may have. Thank you very much. You’re welcome in Paris when you want. Thank you. I’ll be there in June. Anyway, that’s enough of my French. Let’s see. What are the questions you have? Question and answer. Do patients with mesh implant syndrome have cytosis as a marker? Not typically. Some may have lymphocytosis or it starts with an E shoot. I’m blanking on the name of it. Lymphocytosis or starts with an E anyway, which is more of like an inflammatory or eosinophilia. Yes, eosinophilia. Thank you Eosinophilia. But I’ve not seen cytosis as a finding. In fact, most people have normal labs. So the fact that you have cytosis may not be related to anything from a hernia or mesh standpoint.
(00:45:51):
Alright, so since we are planning our 2025 Hernia Talk Live sessions, I would like to hear a little bit more from you all. Would you like more of the international surgeons who I interact with and hear from them? Would you like to learn more about robotic surgery and the new techniques that are out there for breakfast diastasis, for example? Or would you like to just hear about hernias from non-surgeons? Do you want to hear more from patients or physical therapists? Let me know the kind of talks you’d like to hear. Question. I had one side mesh removed, but the other side could not be removed because of adhesions will always not be able to removed. I’ve never had mesh that cannot be removed. So I don’t know why yours could not be removed, but the answer is no, it can be removed. Next question. What is the best diagnostic test to identify an abdominal slash vaginal fistula?
(00:46:59):
I have a consistent white discharge from my vagina since my ankle surgery symptoms are right. Abdominal pain, chills, fatigue and heartburn. Highly unlikely you’ll get any vaginal, anything from a hernia repair. So it’s unrelated. The anatomy is just different. I appreciate your time Dr. Towfigh. Apologies for the typos. You did amazing. I tried. I’ll be sending my mom’s medical records for your consultation. Sure, absolutely. Happy to help. Like I said, I enjoy this. For those of you who cannot come to physically see me or don’t live in California where we can do a video-based telehealth visit, I do offer what’s called online consultation. What does that do? I’m not your doctor with these online consultations. I’m just here to try and guide you through the process with your own physicians, which means send me your report, send me your imaging, send me your opera report, your medical studies, write me an essay about what symptoms you have and how it’s changed.
(00:48:07):
Draw me a picture of where you may have pains. For example, my nurse will guide you through that process. I have a hernia health questionnaire as well. I need you to fill out that kind of organizes your symptoms for me. Then you send that to me and you give me about several weeks to a month to gather my thoughts, review everything and write you a report. That report is very detailed. Usually it’ll review everything that you give me and based on what you give me, I kind of come up with a sense of what I think is going on with you and you can take that to any of the doctors that you would like to go to nearby and see if they agree or we can come with that information back to see me in person because you feel like now there’s someone who’s helping you understand and you’re getting answers.
(00:48:58):
So I’ve been doing these online consults for about close to 12 years now, and let me tell you, the number of pages I’ve helped has been enormous. If I could just do online consults for a living as a retired surgeon, I would do that. I think it’s again, feeds my love of trying to solve puzzles and figure things out. And plus it’s kind of a little bit selfless because I’m giving you all my information you can do with it whatever you want. Sometimes there are doctors near you. I can say, take this to doctor and they’ll help you.
(00:49:42):
Here it is. Good day. Dr. Towfigh. I haven’t been able to tune in at all this year. Why not? And I thank you so much for always starting sharing with us live. I would love to know more about diastasis rectocele repair during hernia repair. I’m so glad that it is an option for so many hospitals now. Yes. So I would say 20 23, 20 24, and perhaps 2025 is the year of rectus diastasis. So what has been the hottest change in surgery is the Scola, Milo, Mila Repa, lira, all these different terms of usage for usually laparoscopic or robotic surgery where a rectus diastasis repair is incorporated within the same surgery as let’s say your umbilical hernia. So we know that hernias are best repaired in the face of a rectus diastasis if both are repaired at the same time. And the purpose of the rectus diastasis repair is it kind of supports the hernia repair.
(00:50:58):
So even if the rectus diastasis repair doesn’t last, the hernia repair is a better repair. Of course we want it to last. And so there are all these new techniques and there’s less and less scars in doing so and you sometimes don’t even need mesh. So I think it’s kind of phenomenal. I just saw, but I will like to say it’s not without risk and sometimes there’s too much surgery and if it fails, it can fail miserably. So I just saw a patient with a very abnormal abdominal wall after having had a scala, which is A-C-O-L-A subcutaneous onlay laparoscopic approach without mesh, which is typically not how a SC is done. And sounds like with just one layer of suture, which is also not how a tummy tuck is done or back to DTAs closure is done. We usually want two layers of sutures. Anyway, my point is this.
(00:52:07):
If it’s not done by someone skilled like this one, I think it was the first time the surgeon had ever done the surgery and it was done under the guidance of another surgeon. It’s not clear where that surgeon was or how much guidance was provided. Anyway, it failed. And now this poor patient has a very, very abnormal abdominal wall. Half of her abdominal wall fell apart, the other half did not fall apart. It just doesn’t make any sense. So I have a lot of work to do to try and figure out what was done, what was undone at what tore, and then kind of redo it without too much scarring and so on. So yes, we will therefore do more talks about laparoscopic and robotic surgery specifically to address rectus diastasis usually in patients that don’t have thin skin, don’t have a lot of stretch marks that would benefit from surgical repair and or have a hernia in addition to all of that.
(00:53:13):
So exciting times the hernia world is expanding. People are more interested in hernia surgery than during my generation. Younger surgeons are loving hernia surgery. Those in practice are appreciating more about hernia surgery. It still is not a well financed part of surgery. There’s not enough money spent on research, there’s not enough money spent helping patients pay for their hernia surgeries. But that said, I think that we’re kind of living in the golden age of hernia surgery right now. I’m super excited to be part of it, but I’m considered one of the more senior surgeons, which hopefully means they listen to me. But sometimes I feel that these younguns, they get a little cocky and they think that they know what they’re talking about and they disagree with me because I disagree with ’em. And they like doing things nowadays like abandoning the sac, which I’m totally against for most patients.
(00:54:23):
And they think it’s great, but we already lived through the abandoned the SAC age and didn’t work. So why they’re repeating it now means that they don’t understand history. But let’s hear from more international guests. Okay, cool. It’s always good to diversify our paradigms. Also, how much of the patient satisfaction is predicated on expectations. Thank you for making that comment. I would say you’re absolutely right. Your expectations before surgery need to be managed realistically so that it’s tamed after surgery. There are surgeons out there that will tell you everything’s going to be great. This one surgeon said, you can go, what did he say to the patient? You can be hit by a car and your hernia will still be fine. And of course now they’re here to see me because they’re hernia recurred.
(00:55:23):
That’s a weird thing to say to a patient, but it made them feel like they were invincible. And now that they’re hernia recurred, they don’t think it’s because of their abdominal wall or their genetic predisposition to getting hernias. They’re blaming the surgeon because the surgeon said, there’s no way you can mess up this hernia repair. It’s so tight. So the reverse is also true. There are surgeons that everything is horrible. Are you going to lose your testicle and you going to lose your leg and it’s so complicated, et cetera, et cetera. And then when the patient does well, they, they look good, right? They look like that great surgeon. These are all the complications that could have occurred. He could have died, and yet you didn’t. And so look at this great surgeon I am.
(00:56:10):
I tend not to be either one of those. I think if I were to go between the two extremes, I’m kind of a little bit more on the optimist side unless I really, really fear for the patient having a lot of complications because they’re morbidly obese or they have heart disease or all these other complications that can destroy a really good hernia. In which case I’ll be very honest with them and in many cases, not even offer surgery. But I do believe that the hernias that we repair, for the most part in most healthy patients are repaired with the intention that you return to a normal lifestyle. You don’t have to change your job, you don’t have to worry about the hernia and so on. And that’s really the goal. And many patients are told that they can no longer go to the gym or they can no longer travel or something like that.
(00:57:10):
And that’s just ridiculous. That’s not a good lifestyle. And it’s my hope that the operations that I offer allow you to be as close to normal and as close to a regular lifestyle for you as possible. And if that means going to the gym or traveling or bungee jumping, then so be it. Not that I’m condoning bungee jumping because I’m totally against it, but that’s the situation that I feel. But you’re absolutely right. The patient satisfaction is quite predicated on their preoperative expectations. Sometimes these expectations are based on their experience with their friends and so on. I saw a patient who did not want gallbladder surgery even though I fully believe that their abdominal pain is due to gallbladder. Why? Because everywhere they’ve read, people with gallbladder surgery have had bad outcomes, they can’t eat anymore, they’re always in the bathroom, et cetera. And I’m like, literally, gallbladder surgery is done as one of the most common surgical operations, second to hernias, millions and millions a year, and 99.99% of them do just fine and aren’t pooping all day and can eat.
(00:58:36):
So I don’t understand why. So okay, going back. So the expectation of this patient is even though she’s been suffering for pain for years, and it could be the gallbladder, she’s hesitant to get the gallbladder removed, which to me is like, take it out. You don’t need the gallbladder. If it’s a cause of your pain, you’ll be fine. You’ll be cured. But for her, because of her experience reading about gallbladder surgery and everyone telling her how horrible it is, then now she’s reluctant to take that step, which may potentially completely improve her quality of life. So you’re right, the expectations can be self-imposed. It could be imposed by the surgeons, it can be imposed by their family members. It can be imposed by Reddit and Facebook and any of the online scenarios. And we actually did publish a paper on how social media changes people’s expectations and really paints of very bleak and negative outlook on anything related to hernias, especially mesh related. And it really should not be like that. And I’m hoping that what I am doing with hernia attack helps to appease that a little bit. So my friends, that’s Hernia Talk Live December, 2024 edition.
(01:00:07):
Thank you for everything. Thank you for your time, your hour with me. I’ll be back next week. The only time I won’t be able to do Hernia Talk Live this month is if I’m operating because I’m not leaving town this month. But if I have patient care, it always comes first, as you know. So thank you to all of you. Do follow me on Facebook at Dr. Towfigh on Instagram and Twitter at Hernia doc. Go to YouTube and follow me. And you’ll be told every time there’s a new episode up, which will be weekly at herniadoc. And if you like podcasts, I do go on my social media so follow me so you can see and hear each time I have a new podcast up. And of course, all the Hernia Talk Live episodes are also up as a podcast. Thanks everyone. Have a good night.
