Dr. Towfigh (00:00:11):
Hi everyone. Welcome. Happy New Year. Happy 2025. This is so exciting that we are celebrating a new year, new you, and we’re going to talk about new hernia symptoms. My name is Dr. Towfigh. I am your hernia and laparoscopic surgery specialist. Many of you follow me on Instagram or Twitter at hernia Doc. You’re here live via Facebook Live at Dr. Towfigh. Thank you for listening and watching. You can watch this episode and all prior episodes on my YouTube channel at Hernia doc and also you can listen as a podcast. As you know. Thanks for joining people. I know that many of you’re excited to start the new year. We had a little bit of a hiatus during the holidays and I’m glad to be back. We have lots of questions already submitted. We’re going to talk about hernia symptoms and what do they mean and what’s a real symptom, what’s not a real symptom?
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How is that going to determine your need for hernia repair? Does it matter if you’re male or female or what your age is and coming up with these plans of care based on your symptoms and also what is a symptom that maybe you go to your normal doctor and they’re not aware that that’s actually a hernia symptom. So the episode title is New Year, New Hernia Symptoms, What To Do All About It. Please do feel free to chime in and type in your questions for me. I’ve pre-prepared many of your questions already because I know.
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Can you hear me now guys? Okay, now you should be able to hear me, yes. Alright, did you hear any part of what I said earlier? Alright, so just to recap, welcome, what a way to start the new year. Did you guys literally not hear me? That’s so weird. Okay, did you hear any part? Oh, okay. Cut out. Got it, got it, got it. Okay, so just to recap, we’re going to be talking about symptoms today because I think it’s important to know what your hernia symptoms are, how it may determine the plan of care for you, and also whether the type of symptom indicates like a hernia or not a hernia and all that stuff. And then how those symptoms can relate to whether you need surgery or not. And we’ll talk about ventral hernias, angle hernias, et cetera. And many of you have already turned in your questions, so we’ll go over that.
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If you have questions as I’m talking, please also go through that. So as we were saying, and as many of you know when I do these hernia talk live sessions, I have told you that the history is the most important part of this puzzle of whether you have a hernia, what are your symptoms and whether you need surgery. So when patients come to see me, they fill out a form and that’s what we call the hernia health questionnaire. It’s on my website, you can share it with anyone you want. This hernia health questionnaire has very specific questions to help me determine with key questions whether you have a hernia that I can help treat. And if not, let’s figure out what you can have. Now, we have actually come up with a scoring system so that you can take this at home and fill out the hernia score and determine whether your symptoms are due to a hernia.
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A lot of people come to me mostly because they need to know what their symptoms mean and if it’s due to a hernia because a typical hernia as you know is a bulge and those are easy to diagnose. It’s the hard ones that I enjoy helping diagnose. So the history is very important. If you tell me that you have pain, no matter what you do, lay flat, cough, bend, stand, sit, sleep. That’s usually not a hernia. If you tell me your symptoms are activity related and that activity can be anything from walking, standing, bending, coughing, yelling, shouting, golf, stroke, picking up your child, vacuuming, opening up a heavy door, tying your shoe laces, crossing your legs, any type of physical activity that you do. It doesn’t have to be running a marathon and that’s what brings on the hernia pain, your pain. And when you don’t do those activities, you’re lying flat, you’re resting, you’re watching tv, slouching back, and if that pain goes away, usually that’s hernia related. There are few diagnoses that would follow that pattern where it’s purely brought on with activity. I see there’s already a question here.
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Okay, I’ll answer that question when I’m done with this session. Not a problem. So the question is what are these symptoms? Is it, let’s talk about groins and we’ll talk about the abdominal wall for the groin. Those symptoms can be pain directly over the hernia, which is above your groin crease or that crease where your leg starts. It’ll start above that and most people, when they have pain, it’s just there as a primary pain, but you can also have pain that shoots to your inner thigh around to your lower back, into your vagina or down into your testicle. You can shoot up towards your belly button. You can have other symptoms outside of the groin area. You can have bloating, nausea. Some people have urinary frequency, urgency of urination, some people have rectal pain, not commonly, but you can have rectal pain. Many patients have pain with orgasm or with sexual function or specifically with intercourse.
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So these are a wide range of symptoms that can occur, that can be consistent with a hernia if seen in the big picture, right, like the syndrome of symptoms. What about the belly button? A lot of people have pain at the belly button due to their hernia, but there’s good fraction of people that have pain to the side to the left of the belly button or to the right of the belly button, two or three finger breaths away, but not at the actual belly button. So that’s kind of interesting because then they get thrown into getting a colonoscopy, endoscopy being treated for their GI symptoms when it’s really an umbilical hernia. There are other hernias you can get in the abdominal wall. You can get hernias from your incisions. Those tend to be localized pain from them and may or may not cause GI problems.
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You may have diarrhea, bloating, or even constipation due to the body’s reaction to having a hernia. So these are all questions that I ask because then if it’s not clear that you have a hernia, I find it’s my duty to figure out what can it be? Could it be an intestinal problem? Is it a spine problem? Is it a gynecologic problem or urologic problem? Could this be completely unrelated and due to some type of rheumatologic disorder? There’s a lot that goes on in our minds when I see a patient trying to figure out their symptoms. Okay, let’s go through some of your questions and then I’ll come back to some of the questions we have about hernia symptoms. Here’s one of the first questions. I have a 28 centimeter incisional hernia. Okay, that seems like that’s the length of your incisional hernia if it’s truly 28 centimeters wide.
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That’s really, really, really big. My surgeon plans a tar TAR transverse abdominal release, so that is an abdominal surgery either done, open or robotically that is intended to move all the different abdominal wall components together to close the muscles from 28 centimeters down to zero. What questions do you recommend me to ask? Well, number one, the question is, is this done open or robotic? And then the question is how often do you do these? You want a surgeon that does more than one a month, ideally more than one a month. If you can’t find someone near you who does more than one a month, then they should be doing at least five or six a year. The tar operation is not to be taken lightly. People who don’t do these for a living can seriously injure you. They can cause permanent damage that is no longer treatable.
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If you’re wondering what that means, go to the New York Times, they actually published on this or there are surgeons that want to offer you the operation but they’ve never done it before and then they overuse this technique for people that don’t really need it and as with any surgery, there are complications and these patients are maimed. So just look up tar or trans versus abdominis release and in the New York Times and you can read about it. So you definitely want to go to surgeons that do these for a living. There are many surgeons that I’ve interviewed on hernia talk live where we talked about the tar and or talked about reconstructive abdominal wall surgery. I highly stand behind them and then ask them how many days do you think you should be in the hospital? It shouldn’t be more than one or two days for a robotic surgery and maybe five days for an open surgery. Ask them what mesh they plan to use. Usually these are synthetic permanent meshes. I don’t recommend dabbling with absorbable meshes because if that absorbs and you have a hernia recurrence, that would be a horrible situation to be in to have a need for a second tar surgery. You should also ask them if they are in town, make sure your surgeon doesn’t leave town. Don’t do it before a major holiday.
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You really want the surgeon to be around if you have any complications because that is an operation that has complications. Next question. I had mesh removed on the 25th of November. I have pain on ejaculation and persistent testicular ache. Okay, well that seems like you have mesh that’s removed from the groin and that’s why you have some pain with ejaculation and testicular achiness. What can happen with that is question is number one, why did you have the mesh removed? Was the mesh somehow encasing the spermatic cord and its contents? These are basically nerves that go to your testicle and the vast deference which carries a sperm from your testicle to your prostate, was the mesh encasing the spermatic ward and if so, upon removal of the mesh, was there any injury to the spermatic ward? I would ask your surgeon, did they remove all of the mesh?
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Some surgeons feel hesitant to remove all the mesh because the mesh is over your vessels or over your vast deference or basically areas where they’re very concerned about injuring the structure by removing the mesh, and yet that’s exactly where you need the mesh removed because it’s causing obstruction, impingement or some other damage to the structure. So the question is do you have the mesh fully removed from that area and then determine what you need? Sometimes a simple spermatic cord block, which can be done by a urologist will help determine what the next step is. It may help with your pain control. If all the mesh is not removed, all the mesh should be removed, and then some people, if they’re not better, may need what’s called a spermatic cord denervation procedure where under a microscope, all the little nerves that feed the testicle are cut and you may need a vasectomy at the same time.
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Okay, answer means it seems like your answer is that you have two titanium coils remaining after the mesh. That’s fine. The titanium coils are not causing your testicular problems, so you can leave those behind, but you do see that you, I see the mesh had wrapped around this spermatic cord. Plus you had general femoral nerve damage. Okay, if you had general femoral nerve damage, they probably cut the nerve. That would’ve been the right approach. So now you’re left with the damage on the spermatic cord from the mesh removal. If you’re not better in six months to a year, I would seriously consider a spermatic cord block and even spermatic cord denervation as a remedy to address the injury from the mesh that was undone but still left with you with some traumatic cord injury. And usually a vasectomy may also be necessary because you, if you have pain with ejaculation, that means the testicle, the sperm is going from the testicle toward the prostate, but somewhere along its journey there’s an obstruction or damage to the vast deference preventing it from getting there and that can be very painful. It’s like hitting a wall or hitting an obstruction like a traffic jam. So the only way to treat that is to complete that injury and turn it into an actual vasectomy.
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I’m not saying you have to do it, I’m just saying that needs to be part of the discussion. Okay, so going back to some more questions. Can hernia severe pain be in the right flank in the evening? I had incisional hernias before, after ruptured appendix and sepsis 10 years ago, so good question. Depends on where your hernia was and what was done to it. So in people who had hernias after an appendix surgery and your appendix surgery was done in the classic what we call McBurney’s point. So in the right lower abdomen is where your hernia, where your incision was and then after that they fixed the hernia. That is a tricky place. So if you look at your abdominal wall below the belly button above the groin crease and out towards the sides towards your hips, that is a very risky area for nerve damage because there are multiple nerves that are coming around from your spine down towards your abdominal wall, and these are actually big nerves.
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They’re not small nerves, so the risk of injury to them is higher in fixing your hernia in that region. You could also risk injuring that nerve trapping the nerve. It could be involved in scar tissue or in the mesh or in the sutures holding the mesh together and when that happens, you can get pain that wraps around your above your hip bone, wraps around towards your back because the ileoinguinal and or the ileohypogastric nerve are at risk for injury and if they’re injured, you’ll get shooting pain around your lower back. So if you had a right lower abdominal surgery for appendicitis and you got a hernia from that and they fixed the hernia and now you have flank pain on the right side, that may be related to a nerve injury from the hernia repair. Now it’s totally treatable by the way. It depends on what’s happened to the nerve. Is it entrapped by suture? Is there scar tissue? Was it injured directly? All of those can be treated at the extreme. We can just cut that nerve if it’s injured beyond relief, but don’t do more than one nerve cutting in that region.
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Let’s see, another question. The genital femoral damage already was evident before mesh removal. Sounds like your workers’ compensation insurance is fighting tooth and nail against you. Yeah, obviously fight back, but the problem is the more you fight these insurances, the more you’re delaying your care. So do try and balance your ability to get care and your ability to afford it. Unfortunately, what I see a lot are patients that are given the runaround and their quality of life just goes down while they’re dealing with insurances and so on. Whereas if they had either done a GoFundMe or helped save some money to actually pay for their care and left the insurance BS to a later date, then their quality of life would be much better, at least that’s the way I think about it. Let’s see. You mentioned crossing legs. I have pain following a bilateral recurrent hernia repair done open or anterior.
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Why does crossing my legs relieve my pain to some extent? Interesting question. So usually if you have a hernia, then crossing your legs will pinch that hernia and therefore cause the pain. So if you don’t have a bulging in the area and the actually crossing the legs maybe will close the area and take it off tension. So you may have an area where it’s actually on tension and by closing or narrowing that area, you’re actually reducing tension on your repair. That’s one thought. I don’t know what else. Small no name nerves may be cut during opening or hernia pair. Can that be a source of pain and what can be done for it? Not really. Technically, anytime you have a cut, you’re cutting through a nerve. There’s nerves all over your body, but it’s really the larger named nerves that we’re worried about because those can give neuromas and cause actual pain. If you’re cutting the small nerves, which is what you do with all surgery at the most, you’ll get numb and then the area revives itself.
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Okay, let’s go to some of the other questions that were submitted. I had an open inguinal hernia surgery with mesh 15 years ago and I have no issues then. By the way, this was sent to me by a follower from hernia talk.com, so I do recommend you go there because there’s a lot of good things to read about and share with your friends and colleagues, but he wanted to share this because he felt that it’s a question that he has but also a lot of people have on the site, and I’m going to read it to you. I had an opening or hernia surgery with mesh 15 years ago and no issues since then. Great. Two years ago I got a small recurrence which I decide to fix or to have fixed via laparoscopic tap TAPP method.
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Okay, that sounds right. If you have an open hernia repair and it recurs, we usually go after it laparoscopically. It turned out to be a fat or tissue lipoma only and the surgeon placed new mesh, which is the correct thing to do, yet unfortunately left some of this fat or lipoma in the inguinal canal size one to three centimeters confirmed on CT and after and ultrasound after surgery. That’s that’s a tough problem. So this can happen. It happened to me as well where you believe you removed all of the fatty tissue or lipoma, but in fact there was some fat or lipoma left in the inguinal canal. It’s one of the drawbacks with laparoscopic surgery and because we know that, because we know that we also are diligent in doing our best in removing lipomas. So if you go to historical papers and stuff, so there’s some great papers that are written that said, Hey guys, we’re not removing enough laparoscopic, we are not removing enough lipomas and fat in the hernias laparoscopically because we’re not seeing it.
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So we have to go after it and be a bit more diligent about it. Otherwise there is a risk of now what’s going to happen is you’re now trapping fat in a space that was not trapped before and you’ll have more pain. It’s been three months since laparoscopy and it now causes more pain than before. See there I just predicted that. What shall I do now? Get it fixed via open approach. Again, knowing there’s old mesh and scar tissue, isn’t it too risky? I’d rather avoid another or third mesh. So you don’t need a third mesh, you just need that fat removed and depending on what the CT scan shows, if it’s a good amount, I would do this open. I assume it’s a good amount that everyone saw it one to three centimeters, I would do this open. There is a risk of nerve injury going back in, but you don’t need to undo the repair.
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You’ve already recurred from it. I would do an open surgery and remove that fat. That’s a really, really good question and very difficult clinical scenario. Okay, going back to the gentleman who had the somatic cord wrapped with mesh from his prior repair and now has testicular pain appendicitis, can this be related to scar tissue adhesions spreading from me? No, no, no. I think I know what you mean. Next question. Hi. Hello. I have had a tramp flap breast surgery. Okay, so we’ve discussed T tram flaps before. We had a couple episodes on breast reconstruction flaps and in fact I have a great surgeon coming up this year where we’re going to talk about reconstructive surgery and the nuances of it and where they cause abdominal wall problems. I’ve had a tramp flap breast surgery and I have three layers of mesh in my lower bikini line, 15 by 15 centimeter times, three times. Wow.
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The edges of the mesh are both sticking out into the hips when I walk. The doctors in Scotland will not do anything, any advice. Also, I have measured the hernia area in my belly button, but there is a bit moving in another hernia which has caused me to lose three stone. That’s a British thing, it’s some type of weight. Doctors here feel the operation will be outside their comfort zone contemplating to go to MPS. Okay, first of all, I did interview Dr. IC and he is currently in Scotland and is the go-to abdominal wall reconstructive surgeon in Scotland. So you do have help, you do have hope there. Go to one of my past episodes where I interviewed him. You can look it up. Dr. Mauch, M-A-C-I-E-K-I think I may be mistaken. He’s great. Really superb. The problem sounds like people who have tramp flaps, they don’t have a rectus muscle and if you had bilateral tramp flaps, so left and right surgery, you have no lower abdominal muscle.
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They used to sell this reconstructive surgery to patients saying, Hey, you get a tummy tuck at the same time, but they forget to tell them that A, it’s not a very pretty tummy tuck and B, you’re kind of missing muscle. That’s not cool. And so if you’re missing muscle, what can happen is you lose your lower abdominal core, you have no core and you’re now replacing it with sometimes you can just tighten it, but oftentimes you use mesh so you’re bridging with mesh. You’re not really doing a good job of reconstructing the abdominal wall and when people do this, they actually do it open as an onlay. So the measures on top of the muscles and in general we don’t like to do the lower abdominal muscles, lower abdominal wall as an onlay. So what I say earlier, the most important part issue with hernias below the belly button level and to the sides towards the ribs above the groin crease are the major nerves in that area.
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So if you’re going to do surgery in that region, we prefer to do it laparoscopically or robotically because you can see the nerves and you can stay away from the nerves much more easily than you can with open. And the area of space you have to work is much wider because you can wrap around the pelvis. Whereas when you do it open, the hip area is kind of bony and not accessible. So what can happen is patients get not as good of a repair and these mesh just flop. And then if it overlaps with your bony processes, it’s very uncomfortable and not a good look.
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And if you’re thin, you can sometimes even see the meds because it’s right underneath the skin. So plastic surgeons tend to do that procedure and we don’t like it. We hernia surgeons prefer to address these laparoscopically or robotically. The extended bladder was the other consequence of mesh. What is the relationship to mesh and deny urologists want to perform catheterization for further surgery on the prostate. So I didn’t say anything about distended bladder. If you have mesh that’s involving the bladder, you can have bladder pain and abnormal distension of the bladder because it’s being somehow interacting with the mesh. But if that’s not the problem, hernias alone, hernia symptoms alone can cause bladder symptoms. Y because hernias can cause pelvic floor spasm. It sounds too complicated, but your pelvis is like a solid bowl. It’s like this round solid bowl and within it are all your organs, your rectum, your vagina, your with your a uterus in your bladder.
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And so if there’s a hernia there, either a peroneal hernia or a groin hernia angle hernia, that can cause some spasm of that muscle and that spasm can translate into rectal pain, not commonly pain with intercourse, pain with penetration act specifically of the vagina and then for the bladder, either pain with urination or more commonly frequent urination. Have you seen the TLC network show Botch bariatrics? A lot of hernia surgeries are shown. I will see it. I love all the botch series. I did notice, I think I saw maybe the first episode I was like this is a bariatrics, this is a hernia surgery.
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But yeah, I will take your recommendation. I’m going to search it and actually maybe binge watch some of the botched bariatrics. Thank you for letting me know. I’m addicted to all the reality shows, whether it’s 90 day fiance or married at first sight, which actually I don’t like anymore, but I’m addicted to the 90 day fiance series. If any of you guys like 90 day you’re in my camp. Thank you doctor for the answer regarding the lipoma left after top block, I’m sorry, after laparoscopic top hernia repair as you said, knowing the risk of nerve damage operating on the same place again, would you consider Neurectomy right away then looking like should be very experienced surgeon? No, I do not recommend neurectomy. Neurectomy has its risks. I don’t recommend it. What I do recommend is reviewing the imaging very carefully and understanding where the fat is.
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If the fat is quite distal, I would just focus on removing the fat and not messing around where the nerves are. Oftentimes the fat is on the other side of the mesh where there’s no nerves and you can just grab it with the open procedure. Do not do what I had one of my patients have done to them, which is this is a horrible story. The plan was just exactly your situation. He had an open surgery with mesh, he had a laparoscopic surgery with mesh and a big piece of fat was left behind. And I said, listen, don’t let anyone tell you you have a hernia recurrence. You don’t. You only have a piece of fat stuck in the area. Have your surgeon, he didn’t want to have surgery with me. Have your surgeon just go in there and take out the fat. Don’t muck around, don’t look for hernias.
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We have good imaging that shows your hernia is fine, the repair is fine, the mesh is fine. You just have this one last part of the procedure that needs to be done, which is removing that extra spermatic cord lipoma. Now I told him all that. I think I even wrote it for him. He went to a surgeon that did exactly that. The surgeon took out the fat and then looked inside. He is like, oh, it seems like the repair is a little bit loose. Let me tighten it. And he completely messed up the guy. He’s like, life is destroyed, nerves were damaged. I think his testicle blood flow to it was destroyed. It became narcotic dependent. Horrible story should never have happened. So yes, definitely go to someone who is very skilled but also conservative in what they like to do. Less is more because you don’t want to cause injury that is preventable.
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The fat can be clearly felt under the fingers. There’s a small bulge visible, great best scenario for open approach. Thanks so much. I shall try to contact Mr. Mo. This is the Scottish patient as the pain I’m in every time I eat food is excruciating. I’m on morphine. Oh my lord. Tapentadol amitriptyline daily and it’s debilitating. You are amazing. Thank you. I was told at the time it was just same as having a tummy tuck. Yes, that’s how it was sold and the women bought it. They’re like, oh wait, so I can get my breast cancer surgery and not look like a boy. They’re going to remove both breasts and then they’re going to use my own natural tissue from my abdominal wall to replace my breasts with tissue from my abdominal wall. In doing so, I get natural looking breasts and guess what? If I gain weight or lose weight, the breasts will increase or decrease in size with me because it’s my own natural fat. What they didn’t say is all the complications that can occur in the process. Oh, you can get a free tummy tuck as part of it. Yeah, no, not worth it.
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I was never told. I never got told about muscle removal and using muscle for the breast. So most people nowadays do not get tramp flaps. At least in my area of the world. They’ve moved on to deep flaps, DIEP, and we discussed all this in previous episodes. You may want to go look at it and listen or watch it, but the deep flap is specifically intended to do exactly what the T tram flap did minus the muscle. But of course there are risks with that procedure too. So I think I’ll do a great episode on wrist of all these procedures with a skilled, highly talented breast reconstructive surgeon.
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Okay, going back to the patient who had the mesh removal and the testicular complications, mine was laparoscopic Anglo hernia mesh male, but I now have to send a bladder and the urologist denied any relationship to the mesh implant. Okay, so that’s not true. It depends. You need to have someone sit down and I’m happy to be that person if you want to initiate a consultation. But do you need someone to sit down and go back very carefully through your prior operative report and also your prior imaging? So what can happen is the mesh can encase the bladder When mesh is placed laparoscopically for groin hernias, it’s very close to the bladder. Usually that’s not a problem, but there are situations where the mesh kind of folds and almost covers or hugs the bladder and prevents it from expanding and then over time it can damage the bladder and or the actual act of removing the mesh off of the bladder if that was your situation.
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Removing the mesh off the bladder can injure the bladder and it’s just going to take time for the bladder to recover. Now usually bladder injury from mesh is not permanent. If you do have a distended bladder and you’re not emptying because you have let’s say an obstruction from an enlarged prostate over many years, that’s a totally different story. That’s a nerve problem where the bladder is given up and is actually very thickened walled usually because it needs the extra muscle to empty and contract against a big prostate and it becomes distended because it just doesn’t have the strength anymore because of prolonged exposure to a thickened prostate.
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Here’s another question I consulted Dr. Eunice about a year ago and I’ll be going back to him again soon. He was one of my guests by the way. I also would like another opinion and see if he would like to talk more in person. Excuse me, I’m happy to. I don’t talk to you in person if you’re not in California because I can’t provide personalized medical advice as your doctor if you’re not in California. But if you want to come in to see me, I’m happy to see you. I had inguinal hernia repair with mesh in 2007. In 2010. I had terrible lower back pain when doing scans like CT and MRI. They immediately saw it looked like I had concern for lymphoma. PET CT showed a lot of activity concerning still forward lymphoma. I had a surgical biopsy and there was no cancer again last year over 15 years later I had a CT scan and they thought lymphoma again, I went through the same steps, PET CT indicated the same and they did another biopsy which was negative for cancer.
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I’ve had a handful of autoimmune symptoms and no tests that will confirm any autoimmune conditions. A few months back I couldn’t stop throwing up and had to go to the emergency room with a blood pressure of two 30. I don’t think you can have blood pressure of two 30. Lymph nodes have grown since the PET scan over a dozen years ago. Do you think it’s possible this is mesh related? No, we don’t have any evidence that mesh can cause lymphoma. There is a finding of a type of B-cell lymphoma caused by breast implants specifically I believe textured breast implants from a certain generation can cause B-cell lymphoma. From what I know, there has been no report ever of any cancer including lymphoma caused by or correlate with placement of mesh in the abdominal wall or elsewhere. So the answer is no. Sounds like you don’t have lymphoma because all your biopsies are negative and you just have lymph nodes that are enlarged. Question is how are you being biopsied? Are these excisional biopsies or are you getting needle biopsies? That could also be part of the problem.
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Okay, going back to the patient with the lipoma that had the open and laparoscopic surgery and now has a retained lipoma, all the lipoma, should the surgeon also close the hole through which it ends up in the Ingle canal so it won’t appear again? No, that’s my whole point. Do not, do not. You don’t have a hole. What you’re telling me is you have a perfectly good laparoscopic repair that covered the hole and they just left behind the fat distal to it deep to it. Your problem is a trap, fat sounds like and removing the trap fat, it’s all they should do. Do not put the stitch, do not dissect, not try and remove that mesh. Do not. You’re asking for problems and there is no hole for them to close. The fat is trapped in this space. The hole is already bridged patched by your laparoscopic mesh.
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Let’s see. What are the typical symptoms due to retain lipoma that you were discussing? Great question. So let’s go back. Most hernias involve fat. We call those fats sometimes lipomas. It’s not technically a lipoma but’s a fatty tissue usually from the retroperitoneal space, which means space deep to the muscle but outside the intestines. So what happens is that fat near the hole wiggles its way through the hole and protrudes out and people say aha hernia. So as part of the hernia repair, we not only recommend closing the hole but also removing the fat. Whether you push it back in place or cut it out, it doesn’t matter, but removing the fat. Now why is it that people that have lipomas and often don’t have any pain and then you fix their hernia and you leave the lipoma behind, now they have pain. Here’s the theory.
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In a patient who’s never had surgery before and has a hernia, that hole is an open hole. Things go through and things go back in, go through and go back in. So a free movement of content, once you patch that hole, there’s no more coming back in. So if there’s fat that’s gone through and now you’ve closed that hole, that fat cannot go back in. So now you’ve trapped the fat between the patched with the mesh or clothes with whatever and the skin level. And that’s a space that is now filled with this extra content that it was not filled with before. It’s trapped content. You’re basically now are competing for space in this region. And that’s what happens with pain from a retained lipoma. It’s just localized pain. It’s like localized hernia pain almost. It’s often more severe than the original hernia pain because it’s trapped. And so it’s either pinching or it’s causing space type pain because it’s competing and pushing on nearby structures. I hope that makes sense. Okay, couple more questions. I love it. I love it when it’s a full episode. I love it. Question, can a hernia cause abdominal adhesions due to inflammation even before surgery?
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Hernias can cause scarring due to inflammation. Yes. We don’t really call those adhesions. Can abdominal adhesions have a beneficial effect in preventing an incisional hernia recurrence due to the fact that they limit the movement of the intestine and in doing so, reduce the pressure on the abdominal wall? Okay, great question. Very insightful question. You may be an engineer, I don’t know. So the short answer is yes, and we know this based on experience with the morbidly obese patients. So we have patients that are morbidly obese and as you know, morbid obesity is a known risk factor for hernias. Let’s say they have a belly button hernia, so this is going to be a fairly large sized belly button hernia over time and the fat that’s inside will start sticking into that hernia. What can happen is the inflammation from the hernia pinching this fat will cause scar tissue.
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And this fat in many patients is no longer freely going in and out. It actually gets stuck in what we call the hernia sac or the kind of compartment of the hernia. So you have the hole and beyond. The hole is like a little igloo, like a compartment with a shape of a light bulb, a typical light bulb and the fat goes through the hole and sits in this compartment called the hernia sac. And if you do sit-ups, you cough or whatever you do, the increases your abdominal pressure you will cause or a contraction of your abdominal muscle, you will cause inflammation and pain at the hernia that will cause adhesions. And over time that fat will just stick in there. And the situation’s very interesting because let’s say this patient that undergoes bariatric surgery, weight loss surgery involves going in usually laparoscopically or robotically and changing the anatomy, cutting the stomach, whatever so that you lose weight by either reducing the quantity of food you can eat or not being able to absorb as much nutrition through what you eat or a combination there of those two.
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So the question is if you go in there to do the bariatric surgery, the weight loss surgery, and then you see this hernia, what do you do about the hernia? The answer is nothing. If there’s fat stuck in the hernia, let it be stuck. You want the fat to be in the hernia basically plugging the hernia so that as the patient is losing weight, they don’t get intestine or whatever stuck into that hole. It’s already plugged with the fat. If you try and be a good citizen and fix the hernia at the same time or at least just reduce the content and by releasing all those adhesions, you are setting yourself up for a patient losing a dramatic amount of weight very rapidly and then having now thinned structures able to go into this hole. And the risk of an incarcerated hernia after such a problem is almost a third of patients.
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This is old data. We don’t really do this anymore, but the recommendation is not to touch it. And I’ve had a couple episodes, I think Dr. Bitner was one of ’em where we talked about weight loss and hernia surgery and which one comes first. If you have a hernia and you’re morbidly obese, should you have the weight loss first or the hernia repair first because you’re pinching and having pain or do them both at the same time? We kind of went through all that. It’s a lot of decisions that surgeons have to make to see what’s best for the patient and there’s good data to support delaying the hernia surgery until after you’ve lost weight.
(00:51:22):
Oh wow. This is the patient that had the problem, his blood pressure was 2 35 systolic. Wow, that’s a lot. They were scrambling. Okay, first this is a lymphoma question. First was excisional biopsy in 2010. Okay, that’s good. Second was a CT guided needle biopsy in 2024, often not adequate. I’ve also had numerous episodes where the area around my legs, buttock abdomen blow up like a giant mosquito bite. That’s only happened to me the last few years. Are there any tests that can help me determine if there is an inflammatory reaction to the mesh that’s been happening since it’s been in? No, unfortunately not. There’s no definitive test that you can do that will show or prove that you have a mesh implant illness. The best is to do what you’re doing, which is to rule out cancer rheumatologic problems, any type of autoimmune disorder or inflammatory disorder that can explain what’s going on with you and if it’s debilitating enough, you may need to find a surgeon to remove your mesh when all else fails. In my patients with mesh and plan illness commonly, commonly all their blood tests are normal, everything is normal. Even their why blood cell counts normal, their CRP and ESR, which are kind of signs of inflammation are normal. All of their autoimmune blood tests are normal. That’s very common and very frustrating. So don’t let that be. That should not rule out a mesh implant illness, but it definitely also cannot rule it in as well.
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There are a couple tests which are usually research based like HLA tests and all that, which may be positive. I personally have not done those. Those are not readily available blood tests for most patients. I do offer allergy testing to date allergy testing, not been shown to be predictive in any great way. If your allergy test is positive, that’s I think a good sign that maybe you should have your mesh removed. But allergy testing against mesh has about a 40% false negative rate. So if that testing is also negative, then I would move forward with, I mean who knows what that means. Next question. When it comes to the symptoms as the title goes today, four months after small hernia, anal laparoscopic surgery, I have kind of puffy swallowed abdomen from the belly button down to the groin on that side. Not painful to touch, just enlarged down from the incisions placed, especially visible when laying is that normal. So that’s not normal.
(00:54:24):
Couple things you could at four months after laparoscopic any surgery you should look normal. So if you do look puffy on that side, I highly recommend imaging and I’ll tell you why. And that will be just a simple CAT scan. There is a problem called lymphocele. It’s basically lymphatic drainage and the lymphocele can occur where you gradually develop fluid, where your hernia surgery wise, it’s related to the surgery near the vessels where we take out tissue around the e femoral space looking for femoral hernias. But at the very least you should start there and see what’s going on. If it’s as visibly a swollen belly just on the side of your hernia that I highly recommend imaging because you may have a lymphocele and I don’t know if you ever did any episodes on lymphocele, but I believe we may have talked about it on hernia talk.com. But let me know if you want an episode on lymphocele.
(00:55:36):
Is CRP elevated in mesh allergy disease? Nope, it’s usually not. Are any of the interleukins or tumor necrosis factors elevated in mesh and plant illness? I know very little about these cytokines also. Usually not. There are patients that have had interleukins and cytokines, blood tested. Some are positive, some are negative. It’s unclear. There’s no real pattern. Yes, CRP was normal in this patient and the autoimmune was normal and so on. So great. We’re getting towards the end of our episode. I hope this was very helpful for you. I’m excited for what this year has to come. We’re to be in Santa Barbara this weekend. We have our annual meeting of the American College of Surgeons, Southern California chapter, which I was their first female president of. I’m very dedicated to this chapter having been the former president of IT and very involved since I was a resident. So I think 19 97, 19 98 was my first time going to the meeting and I’ve missed only one meeting ever since, believe it or not.
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So we’re going to be there. We’re going to be talking about femoral hernias and our research got accepted as one of the top rated papers talking about treatment, treatment algorithm for emergency surgery, femoral hernias. There’s nothing out there. Can you believe it? There’s algorithms on all different types of hernia repairs, but specifically acute incarcerated or strangulated femoral hernias, there’s no data to support any decision algorithm. So what happens is people just do all do whatever they think they need to do. And if you’re not a hernia surgeon where the algorithm is pretty clear in your mind, a typical emergency surgeon, trauma surgeon, general surgeon does not have the experience to know what’s the safest procedures to do for femoral hernias. And we’re going to discuss that. I believe Friday morning is when my research student is going to be talking about it. Thank you very much.
(00:58:07):
Regarding the swelling, did you mean lymphocytosis? No, I meant lymphocele. This is usually not a mesh rejecting the, it’s not a mesh rejection. Mesh rejection is, or what we call mesh implant illness for better clarity has nothing to do with a local area. It’s usually your body reacts as opposed to locally swelling. So usually what you want to rule out is lymphocele. It’s of fluid collection of lymphatic drainage due to dissection by the surgeon in the femoral space for a femoral hernia, which we do much more often in women than men. Let’s see, the mesh was destroyed apparently in the therapeutic goods administration, had no interest whatsoever in making any report or recording any adverse event about my need to have hernia mesh removed. Yeah, unfortunately that’s very common. I’ll reach out to see if we can do a zoom. I’m in Florida close to Dr.
(00:59:08):
Eunice and I would appreciate additional expert opinion is definitely not a small surgery. I agree. I cannot do zooms with you because you live in Florida and I don’t have a medical license in Florida and therefore can’t be your doctor. But if you’d like to come to California, I’m happy to see you. Or if you contact my office, we do offer what’s called online consultation. And online consultation means you’ll send me your information. I will send you my best interpretation of that without having seen or examined you. So at least that way I can help you a little bit, but not that much. And for you in Australia, I hope to visit Australia. That’s definitely on my list of places to go because I think Australia’s awesome and thank you very much. Let’s go. We had some more questions I didn’t get to, but that’s okay. We can save them for another date. So thanks everyone. I wish you the best. I hope to see you next week. I’ll do another hernia talk session. We have great episodes with amazing people that are really interested. Actually the ER now want to come on Hernia Talk and be my guest. So I’m looking forward to sharing that with you all as well. Bye.
