Episode 2: The Value of Hernia Specialists | HerniaTalk LIVE Q&A

You can listen to this episode by clicking here.

Speaker 1 (00:00:00):

Good. So, let’s see. I hope, oh, people are, are coming on already. All right. This is Dr. Towfigh. Uh, let’s see. Oh, we have some familiar friends on this. I’m joined here today with Dr. Brian Jacob. He is a hernia specialist. Uh, like me, we share a lot, uh, in practice. We’re on each of the two coasts. I’m on the West Coast and he’s on the East coast, um, in Manhattan. And just a little bit about, um, let me share my screen here so you can all see, uh, you are now all watching, uh, hernia talk live our second, um, every Sunday episode. And basically what we are going to do is spend one hour talking about all of our hernia questions. Uh, I am Dr. Towfigh. I have a practice, uh, completely hernia related on, um, in Beverly Hills. And you can follow me. Uh, we are currently live on Zoom and also live streaming on Facebook, uh, on my homepage. And we are very gifted to have Dr. Brian Jacob. Um, you can follow him on Twitter at NYC Hernia. He is a esteemed top hernia specialist, good friend of mine who practices out of Mount Sinai. And, uh, you wanna say, hi, Dr. Jacob.

Speaker 2 (00:01:26):

What’s up everybody? Brian Jacob here from actually New Jersey right now in my house. And Dr. Towfigh, thank you very much for having me live today. It’s amazing to be here. It’s amazing what you’re doing for the patients, uh, that are out there. And I hope everyone’s staying safe. Uh, I do see some familiar names and so hello to those who logged on that. I know. Uh, it’s great to see you again.

Speaker 1 (00:01:49):

I didn’t know you live in New Jersey?

Speaker 2 (00:01:51):

I do live in New Jersey. New Jersey is a commuter town to New York. It takes about 25 minutes, uh, during these COVID times when there’s no traffic.

Speaker 1 (00:02:00):

Oh, okay. That’s good. Yeah, I don’t live in Beverly Hills either. I haven’t live in Los Angeles, but, you know.

Speaker 2 (00:02:05):

Yeah. With, uh, non Covid times, I’m looking at about a 45 minute drive.

Speaker 1 (00:02:11):

Are you seeing a lot of Covid? Uh, are you working at the hospital doing covid stuff? A little

Speaker 2 (00:02:16):

Bit. Uh, I’m, I’m drafted. I’ll start this week to help out on the front lines. Yep. Uh, so my routine practice is currently paused and I’ve been converted into, uh, an ER slash icu, uh, attending just to help out with the volume until this thing passes, which hopefully will be in the next two to four weeks.

Speaker 1 (00:02:36):

Yeah. I think it’s, uh, you know, as surgeons are used to saving lives, that’s like why we go into surgery because we wanna save lives. And yet during an infectious disease pandemic, uh, it’s really the medical

doctors and the intensivists in critical care and er docs that are most valuable right now in, in putting their lives at risk.

Speaker 2 (00:02:55):

Yeah. I’ll tell you, I’m late to the game, but there’s been a ton of our colleagues who’ve been out there working really hard already for the last three or four weeks. So my hat’s off to them, uh, and to everybody else who’s been really working hard, uh, trying to keep things going, uh, you know, while the world is on pause.

Speaker 1 (00:03:13):

Okay. Well thank you for donating your hour with us. Um, we have questions that come in live and I also have some pre-prepared questions from, uh, people who have sent me hernia related questions in the past, uh, uh, week or so. So let’s go into it. This is gonna be one hour, uh, for those of you, if you wanna take notes, know that this will be then posted. Um, you can follow it as a Facebook live on my Facebook homepage or on YouTube. The full hour will be uploaded. So let’s go with our first question. The q and a. Um, uh, this is from Daniel Hauser. He asks, I had a tap, laparoscopic double hernia repair with mesh. The second opinion surgeon says he prefers tap t p, so he had a tap. His second opinion surgeon prefers a tap. Is one easier to recover from? And what’s the difference, Dr. Jacob?

Speaker 2 (00:04:07):

Yeah. So I hope I wasn’t the second opinion surgeon cause I’m a tap surgeon.

Speaker 1 (00:04:11):

Me too. I’m a tap surgeon too.

Speaker 2 (00:04:13):

Yay. Tap. Uh, no, I don’t think one is easier to recover from than in the, the other. I think when the surgeries go well, uh, the recovery should be about the same. Uh, it’s hard to compare recovery between the two, uh, because most people will only fall into one group or the other. Uh, but I think in general, I wouldn’t tell a patient that one was easier than the other. Uh, it’s just my 2 cents. What do you think Dr. Towfigh?

Speaker 1 (00:04:39):

I mean, sometimes you have to convert, right? Um, I would say maybe 99 per 99.5% of the time I can do it tap. But every so often you have to convert to a tap. T A P P. Yeah. And the robotic era, it’s all tap. I don’t think, uh, I think people tried to do a robotic tap. It’s very difficult. So it’s all tap T A P P. And just to review the main difference, t e P stands for totally extra peritoneal. T A P P stands for transabdominal pre peritoneal. And it’s just how to access the hernia. Do you go, do you cut through the peritoneum or you don’t cut through the peritoneum? And everyone has their own style. It’s like saying, do you like, uh, you know, Nike or Adidas? Do you like high tops or regular tennis shoes, or they both launch.

Speaker 2 (00:05:27):

That’s right. The, uh, you know, surgeon preference. But from a patient’s perspective, you know, there was a time not long ago where we would just tell ’em we were doing a laparoscopic and there was not a

tremendous amount of discussion about whether we were doing a tap or a tap, because in the end it’s the same operation. Uh, you know, from the perspective of the hernia and the body, it’s pretty much the same operation. There’s some very subtle differences, but recovery, you know, and everybody owns their own recovery to each person. That word how, what’s recovery like means something slightly different. But in general, recovery’s about the same. And by the way, just because I can’t tell, am I coming through clear?

Speaker 1 (00:06:13):

You were coming through clear. I want to see. Okay. I just wanna double check that we’re going live. Go live.

Speaker 2 (00:06:22):

That’s great.

Speaker 1 (00:06:24):

Just wanna make sure that we’re going live on Facebook wants me to add things, but I don’t think it needs anything. We’re having problems with the go-live. I’m gonna try the go live one more time. So you guys, you wanna talk Dr. Jacob while I figure out the Go-Live part?

Speaker 2 (00:06:58):

Not a problem. So for those attendees, uh, that are logging on now or recently, my name is Brian Jacob. I am a general surgeon specializing in hernias. I am working in private practice in New York City. I am an associate professor at Mount Sinai. And currently, uh, the hospital is been diverted as an emergency hospital. We’re taking care of covid patients. So my practice is on hold, but I was invited tonight by Dr. Towfigh to talk about groin pain and hernia. And the main, uh, purpose is so that I’m able to help answer your questions, uh, as opposed to just talking continuously. Uh, what’s up Desi? I see Desmond Hunt is out there. Uh, yes he, uh, started his journey, uh, back as a medical student at Mount Sinai. It’s great to see him growing up, become a, a big surgeon, like he’s gonna be

Speaker 1 (00:07:56):


Speaker 2 (00:07:56):

Um, you know, my practice, I see about three or four new chronic groin pain patients every week now. Uh, I didn’t start off my practice like that. And I think Dr. Towfigh and I agree. You know, when patients come in with a chief complaint of groin pain, it’s a whole new ballgame. This is not something that I ever appreciated, uh, as I began my practice. But groin pain deserves a lot of attention and a lot of listening because the answer to helping people with brain pain is usually in the story. It’s in the description of the pain and when it started, where that pain spreads to how long it’s been there, what makes it worse, what makes it better.

Speaker 1 (00:08:45):

We’re good. All right. Let’s see if we have more questions. Um, let me share my, my screen with you. We lost Dr. Jacob. There you are.

Speaker 2 (00:09:00):


Speaker 1 (00:09:02):

All right, we got you back. Okay, so we’re gonna start with some easy peasy questions. Um, and then we’ll go to the harder ones. Question. Uh, next question. I have a minor hernia. Is this still okay to work out and body build and do ab work?

Speaker 2 (00:09:21):


Speaker 1 (00:09:22):

Yeah. Yes, I agree. Why is that?

Speaker 2 (00:09:25):

Uh, I have a minor hernia. Is this still okay to work, work out with a mi Well, look, just because you have a hernia doesn’t mean you can’t live. Um, I think there’s a interesting philosophy out there that once you have a hernia, um, you, you live in fear of, of needing an emergency surgery, uh, whether it’s mine or major. And that fear is probably the result of dogma from before you. And I wanted to practice. I do think a lot of people with hernias were, were told that if you don’t get it fixed soon, you may strangulate. And I just think that the risk of that happening is pretty low in general. Uh, and so I can say even not only as a doctor, but someone who’s living with a hernia, a minor one, that you can live a very long time with minor hernias. You can work out, you can run, you can lift, you can dance, uh, you can do Pilates, you can do yoga. And as long as it’s not getting in the way of your ability to do those things, it is safe to do those things.

Speaker 1 (00:10:34):

And do you, I know you can do it, but do you recommend that they do it?

Speaker 2 (00:10:39):

Sure. I mean, I don’t

Speaker 1 (00:10:41):

Have you ever anyone come to see you and say, I was at the gym and, and now I’m in the emergency room with an incarcerated hernia? I’ve never had that.

Speaker 2 (00:10:53):

Yeah. Can you, can you repeat that again? So they were in the gym

Speaker 1 (00:10:56):

Working out body building or doing abs and then they all of a sudden incarcerated or strangling and had to come to the emergency room. I’ve never had that story.

Speaker 2 (00:11:05):

Never had that. Never ever, ever had that. I’ve had. So here’s the other thing. You can have a minor hernia and still hurt yourself. You can still sprain the conjoined tendon or the aoc or the inguinal ligament or the elisos tendons in that area. And this, this is like the lethal combination because you get a groin sprain, which you and I, you know, you know, label as a specific tendon that’s injured. Uh, some other people label it as sports hernias. Some other people just label it as a groin sprain. But if you came in with a hernia and a groin sprain, everyone assumes that if you fix the hernia, you’re gonna fix the pain. And that’s when you get into trouble. Cuz now you’ve fixed the hernia, but the hernia wasn’t the thing that was causing the pain. So especially when someone comes out of a gym and tells me they, they have a new symptom, that is the time to at least do a really good physical exam and get an MRI before you operate. This is just my 2 cents, it’s my opinion because you wanna document it if there’s any fluid or edema, uh, around the groin to show that there’s any of my minor injuries.

Speaker 1 (00:12:16):

Very good point, very good point. Um, in that just because you have a hernia doesn’t mean the groin pain is being caused by that hernia. A good history and physical exam. And some imaging sometimes can help, um, rule out something different like a sports injury.

Speaker 2 (00:12:32):

Yeah, I’ll, I’ll give you an example. So again, I’ve been living with a hernia for a long time and this nev never bothered me and I was in the ocean. And you know how when you’re in the ocean you have to stabilize yourself against the waves. It’s almost like you’re surfing as the waves are coming in like near the shore. And all of a sudden I felt this horrible pain. It literally started near where the hernia was and went down my leg a little bit. And I, and it dawned on me, I’m like, wow, this is why people think hernias are so bad. Cause the pain was actually pretty bad, but I knew it wasn’t from the hernia. I knew I had pulled something mm-hmm. <affirmative>, uh, it took, it took some Advil, it took about two weeks and the pain went away. Still have the hernia.

Speaker 1 (00:13:07):


Speaker 2 (00:13:08):

Um, so it’s, it was a good lesson in the symptom for me.

Speaker 1 (00:13:12):

Plus what I tell my patients is we’ve actually looked, uh, this is an old study now was it was a new study back in the day. Um, and basically they looked at what happens to abdominal pressure when you do sit-ups, uh, uh, deadlifts and coughing and burpees, squats. And what they found was that, you know, doing a, a sit up for example, or deadlifts or overhead lifts, pullups, uh, those didn’t really cause a lot of abdominal pressure increase, uh, coughing and straining of a bowel movement. That’s so much more pressure. Uh, so if you think that hernias are caused because you have ab abdominal pressure increase, um, most exercises do not cause that increase.

Speaker 2 (00:13:58): Agree. So to the person out there who asked if they can work out, the answer is absolutely. Uh, the other thing just to point out, you don’t really need surgery until the hernia that you know you have is

preventing you from doing the workouts that you want to do. Yeah. And that’s, that’s sort of how I help patients decide when it’s the right time to do it. If it’s in the way of your daily life or your routine workout, then fix it. And don’t be afraid of mesh in that situation because you will feel better after you get a hernia fixed. It’s if it’s done correctly with mesh, but only if it’s getting in the way of your workouts.

Speaker 1 (00:14:35):

Okay. We have, um, a question about chronic pain, which I know you treat a lot of.

Speaker 2 (00:14:41):

Uh, yes, Josh’s, Josh’s question,

Speaker 1 (00:14:43):

Josh’s question. Josh had five hernias fixed October of 2019. One left side direct Ingle hernia and one left side indirect. So on the left side he had a direct indirect, he also had ator hernia on the left side. So that’s the three is referring to. Then on the right side he had a direct and an in, uh, I think the right side also indirect hernia, all fixed laparoscopically with mesh sounds like the right thing to do. I’m still having horrible chronic life-changing left sided groin pain in the adductor and inner thigh medial to the sits bone is showed to porosity. Well, that’s way deep. No one can gimme answers. I don’t know if it’s a nerve issue, ental or ator or an adductor tear, but I’m in really bad pain and I need help and answers please. So this is basically a patient he had bilateral or hernias and therefore had a laparoscopic repair. I think we would both agree that’s the correct, that’s the best option for the average patient, correct?

Speaker 2 (00:15:47):

Yeah. But let’s go back to, so the, there’s a key word in there. I know you and I, you and I are gonna focus on it mm-hmm.

Speaker 1 (00:15:52):


Speaker 2 (00:15:52):

Right? The, his, the word of that I see he typed that I need to go back to and ask him more questions about, is the word still.

Speaker 1 (00:15:59):


Speaker 2 (00:16:01):

So, you know, Josh, I’m still having horrible chronic life-changing pain. So did you show up and tell this surgeon that you’re having horrible chronic life-changing left side groin pain? You know, what, what did you present with before you had the hernias? I mean, that’s ex that’s, that’s where I start that interview. Um, because there’s one of two things. This pain is brand new after the guy woke up or he came in with this kind of pain and had hernias coincidentally that weren’t the cause of the pain. And those are, those are the two algorithm. Would you agree?

Speaker 1 (00:16:34):

I agree. It’s a lot of, um, it’s a lot of detective work. So did you have the pain? You had surgery, you still have the pain, which means it wasn’t hernia related pain usually. Or did you have the pain, you fixed the hernia, that pain is gone, right? And now you have new pain. And so then we gotta figure out, you know, whether the surgery caused that. So Josh, if you don’t mind, give us, uh, some answer to that and then we’ll figure it out. I don’t like to bring in ental nerve into the picture. I feel like that just adds extra complications. People don’t just wake up with ental nerve and for sure we cannot injure the pal nerve during hernia surgery. So Correct. That diagnosis I think is thrown out a lot when people don’t know what’s going on with chronic pelvic pain and it’s, um, very rarely the problem.

Speaker 2 (00:17:25):

Yeah, for sure. And you know, that’s, you know, the other thing is when you know patients like Mr. Westin start talking about a doctor and, um, initial tube verocity and prude and operator nerves and AOC tears, you know, you’re obviously an educated patient. You’ve been reading up on the possible causes of groin pain. Um, so there’s a lot more to that story. Uh, see you, there you go. All my pain was there before my surgery. And so that’s, that is so key mm-hmm. <affirmative> to every single person. And to be honest with you, it’s for a surgeon to assume that that severe of pain was from a hernia. You know, that may have been one of the, the oversights. So yeah, Sherwin, they did the right operation. I mean, there’s no question if you had hernias, love the laparoscopic repair, but it didn’t fix the cause of Mr.

Speaker 2 (00:18:14):

Weston’s pain. So we’re not gonna blame the surgery, but we gotta go back and, and start over. Uh, and, you know, so the next question, I don’t know what you asked Sirer, but you know, I wanna know when that pain started, right? How many years did you have that pain? What were you doing when it started? Um, I, you know, I get this lecture at Sherwin scene. It’s, it’s all about you, Josh. It’s, you came in with a severe amount of pain. We gotta dive into that. Uh, so your story about that pain is gonna help us figure it out and then I’m getting an MRI on you at some point.

Speaker 1 (00:18:47):

Hmm, absolutely. Yeah, that’s definitely the next step.

Speaker 2 (00:18:49):

Sitting in a doctor since March plus

Speaker 1 (00:18:51):

The physical exam I think is very important to help figure that out. Um, Dr. Jacob, if someone wants to see you either during this Covid pandemic or afterwards, how could they contact you? Should they go on Twitter on your account and figure it out for you? Or,

Speaker 2 (00:19:05): Or, uh, why don’t they email me and, we’ll, we set up virtual consults, so I use the same platform. I use Zoom, uh, my office will help process, uh, the information about that consult, and then we do a Zoom consult. And then when life gets back to normal, uh, you know, I’ll be seeing patients in the office again. So the zoom, as you know, we can do a lot, but we can’t do a physical exam. So when it comes down to it, we still probably, someone’s gonna have to do a physical exam here. Um, but yeah, that’s how they

do it. So the, the telephone number from my office is 2 1 2 8 7 9 6 6 7 7 or they can email me, which is nychernia@gmail.com.

Speaker 1 (00:19:48):

Okay. So, uh, very important. I know you had mesh and you, the fact that you had the pain before surgery and if that’s been unaddressed with the surgery, likely like please don’t go in, just get your mesh taken out. Um, no, the problem. So see Dr. Jacob, um, or to help figure that out for you.

Speaker 2 (00:20:09):

Yeah, no, you don’t need mesh meth removal does not cure pain if mesh implant did not cause pain.

Speaker 1 (00:20:15):

Yeah. Okay, another question. Uh, I know we have some questions on Instagram, but I will go to the zoom question first and then we’ll move to Instagram. So the question is about two weeks post-op I sneezed, which we know caused a lot of abdominal pressure and had tremendous nerve pain. I, it went away after 10 days. CT scan showed nothing, but I strong, but I’ve struggled with recovery 10 months. Any correlation? What do you think?

Speaker 2 (00:20:46):

Well, I would ask, you know, the same sort of thing, you know, um, I don’t know if it’s a, uh, woman or a man, but, you know, post-op, what, what operation are we talking about? Need a little more detail there.

Speaker 1 (00:20:57):

Patient. Um, I think I know this patient, I don’t remember what type, but it’s male,

Speaker 2 (00:21:02):

You know, but opening one all robotic inguinal lapping, little ventral. Um, you know, long story short, should you still be struggling 10 months later? No. Um, but again, then we would’ve to go back and figure out what exactly the struggle means. Uh, you know, there’s, there’s a, it’s missing a lot of information to sort of address it. Uh, but all we can say is without knowing your operation by 10 months, you should be not knowing you had an operation.

Speaker 1 (00:21:31):

Yeah, that’s true.

Speaker 2 (00:21:32):

That, that would be fair about. And, uh, so you know more about that, you know, for the audience out there, the theme about a lot of these specific presentations is gonna be, you know, how well did the surgery done that was done, address the chief complaint when you showed up at your surgeon’s office. Um, and this for me, my plea is like, just because you have a hernia does not mean you need to fix the hernia. Um, you fix the hernia when the hernia hurts and then, you know, so these questions are easy when it’s post-op hernia pain. They’re much harder when it’s musculoskeletal injury, uh, treated with a hernia repair.

Speaker 1 (00:22:12):


Speaker 2 (00:22:13):

Of questions. So anonymous, let’s get some more detail from you.

Speaker 1 (00:22:16):

Lots of, uh, questions on Facebook live. First one is, uh, male patient. I had a left-sided inguinal hernia containing peristalsing bowel that caused me burning aching pain from October to late February. It’ll get, would be be since February. I have hepatitis, constipation and different types of stools. The old hernia pain doesn’t happen anymore. Could the tube be related? So can bowel function be related to your hernia? Especially if you know there’s intestine in your hernia?

Speaker 2 (00:22:52):

I dunno about bowel. I mean, how much intestine, right?

Speaker 1 (00:22:57):

Yeah, yeah,

Speaker 2 (00:22:58):

We’re talking about a big loop that’s partially being squeezed.

Speaker 1 (00:23:05):

Well, it’s inguinal so unless it’s, it’s enormous, right? Uh, usually we don’t have a lot of bowel function changes, um, with a bowel hernia with this is a typical one, right? So the same, uh, question, same person asking the question is, could my angular hernia possibly be pushing or constricting my bowel in some way? So usually, usually I would say not unless you have a lot of pain associated with it. Um, if you have bowel that is entrapped, if you have bowel in your hernia, then the chances that that’s causing any problem with no pain is very low. If you have bowel in your hernia, but you have pain, um, some type of, uh, um, like burning pain or anything that would, you would think is either incarceration or strangulation, then yes, I would be worried that any bowel changes would do that. But that’s an acute problem.

Speaker 1 (00:24:10):

That’s usually a problem that occurs within minutes to hours and doesn’t go away. Um, and you need some type of emergency medical care for that. If it’s a longstanding problem. I would say that there’s a little to no reason that the, in the hernia is in any way narrowing or constricting your bowel. Now the reverse is true, which means if you have constipation baseline and you’re pushing and straining because of your constipation, that can make a hernia worse and it can make your hernia symptoms worse. But the reverse is usually not true unless it’s an acute problem where you have to end up in the emergency room. So I hope that that helped. Um, in your questions, uh, I have scheduled a hernia repair for May colonoscopy in June, so may June. So colonoscopy after your hernia repair. Uh, could my hernia possibly related to a change of bowels?

Speaker 1 (00:25:09):

I think we answered that in general. Um, just so people know, colonoscopy is safe to perform if you have a hernia, unless there’s an enormous amount of, um, uh, bowel in your hernia and, sorry, large bowel colon in your hernia, in which case you maybe should not do a colonoscopy. Your gastroenterologist should be able to help figure that out. But in general, it’s safe to have a colonoscopy, even if you have a hernia, especially if there’s no colon in your hernia, which is almost always Okay. Another Facebook live question. I see other questions coming in as well on Zoom. We’ll make sure we get to that. And I think Dr. Dr. Um, Jacob is working on his internet issues, so hopefully we’ll get to him soon as well. So another male patient for men with a very enlarged prostate. Uh, does open surgery make more sense than laparoscopic if prostate surgeries needed down the road?

Speaker 1 (00:26:10):

Thank you. Doctors Towfigh and Jacob. Okay, very, very good question. Short answer is no, no issue because we, uh, the urologists now do robotic surgery for their prostate. And almost always, um, a prior hernia repair is a non-issue. So it used to be that we were doing laparoscopic hernia repairs and the mesh was going in the same plane where you have to dissect the bladder and the prostate for prostate surgery in open. So in open surgery they’d go in and they’d be like, we can’t even get to this. We can’t even find the prostate because there’s mesh and inflammation in this area. So, um, Dr. Jacob, this is a great question. So is it okay, sh if you have an enlarged prostate and you think you’re going to need prostate surgery, should, and you also have a hernia and you wanna get the hernia fixed first, should you choose open or laparoscopic or does it not matter?

Speaker 2 (00:27:14):

Uh, debatable, depending on the experience of the people getting involved. Um, we sh at, at Sinai, we will offer two things. One is we offer simultaneous, uh, which is, I don’t know if you offer that as an option, but a lot of times when they’re doing the robotic prostates, uh, a member of my group will come in Yeah. And fix the hernias with mesh. And we’ve not found in the last two years there to be an increased risk of infection. Uh, this risk, this fear, uh, has been a huge concern of ours and it just hasn’t panned out to be true. So simultaneous repair is an option as far as getting it done first.

Speaker 1 (00:27:55):

Robotic? Robotic? Correct. Let’s just clarify that, that’s robotic repair. Yes. So the, the process is done robotically and then you go in robotically and also do the repair at the same setting. Is that correct?

Speaker 2 (00:28:16):

Sorry, so just

Speaker 1 (00:28:17):

Clarify, that’s robotic surgery,

Speaker 2 (00:28:20):

Correct? Correct. Correct. Yes. Are are we talking about robotic surgery or No,

Speaker 1 (00:28:24):

He’s asking, he’s saying, you know, I need prostate, I may need prostate surgery and I’m going to have my hernia repaired scheduled. Should it be lapper, open, or does it matter?

Speaker 2 (00:28:35):

Yeah, I, I really think that it, it is based on the experience of the people involved. So you gotta talk to the, the first thing is do is talk to the prostate surgeon and the second thing is to say to them, you know, what technique are you using if they’re doing robotic? My next question is, is there a robotic hernia surgeon that can come in and fix ’em at the same time? If you’re gonna have your hernias done first and you’re planning a robotic prostate, then all you have to do is make sure that your robotic prostate surgeon is okay dissecting after there’s been mesh in there. The unanimous answer has been, they don’t mind, it doesn’t seem to bother them.

Speaker 1 (00:29:16):


Speaker 2 (00:29:17):

You know, it’s, it’s sort of academic to say that the mesh there is a problem. It just doesn’t seem to be an issue. Uh, so I think they’re both gonna be fine in that situation. The, the more, the old fashioned answer though, oh, you’re gonna be in that plane for your prostate, just get it done open. And I think that’s great too. Like, listen, if your hernia surgeon is really good at open Lichtenstein or, or open, should ice then get it done open.

Speaker 1 (00:29:43):

So it used to be, yeah, I’m sorry. The neurologist, when they were doing open prostate surgery, they had, some of them could not do the surgery because there was a laparoscopic in the area. But in the United States, 98 or 99% of prostate surgeries now done robotically. And we looked at our data at Cedar Sinai to see if people who had robotic prostate surgery were able to get laparoscopic angular hernia pairs. Yes. And if people who had laparoscopic angular hernia pairs could then get a safe robotic surgery. Yes. So in the robotic era of prostate surgery, we’ve noticed that obviously with the skilled surgeon, that they didn’t have any problems doing the prostate surgery if there was mesh there in the past, in the, if you’re having open prostate surgery, that’s different, different, uh, scenario. And like I said, 98 or something percent of prostates are done robotically.

Speaker 1 (00:30:39):

So do whatever you think your surgeon is best at for your hernia repair. Uh, it should not affect your prostate surgery, because almost everyone does it robotically now. Right. I hope that’s helpful. All right. We have a long question, um, from Zoom, uh, one of two. Okay, I’m gonna read this. I had a left ankle hernia pair laparoscopically in 2008. No pain before surgery, but I did have surgery and it took a year to get the surgery. So that was 2009. By this time, every time I stood up, my intestines would fall through the hernia unless I held it up with my hand. So large scrotal hernia sounds like, uh, the only way to remedy this was to lay down with my feet and pelvis elevated until I heard a gurgle and left insides left my, and felt my inside shift. So reducible hernia, the surgeon said, in all his years of doing the surgery, I was the second largest opening of the inguinal ring he had seen.

Speaker 1 (00:31:40):

And he almost couldn’t repair it. The surgery took more than twice as long as it should have. After the surgery in the recovery room, I couldn’t urinate for five hours. That happens. I kept drinking water and felt it could, uh, uh, I had to explode, but couldn’t. So that’s called urinary retention. It happened especially with, with many open operations, um, or laparoscopic. When I finally went, they let me go home and I had to pull over to pee again. Over the years, it took me longer and longer to empty my bladder. Sometimes up to 45 minutes. I also get shooting pain across my lower spine to my anus. Whew. All these years later, I’ve seen many doctors as specialists, MRIs, no answers or help. The only thing that helps me is to eat a mostly raw diet, which is high in water and easily digestible. When I eat more cooked foods, I feel it. My GI tract, it’s painful until I pass the food. Also, when something’s irritating in my bowel, my bladder pain, continuous feeling of needing to urinate, intensify until the food is passed, I still have to lay down with, okay,

Speaker 1 (00:32:39):

This doesn’t sound like it’s a hernia related problem. I feel things move up my pelvis and back into place. What te what tells me to do this is a pinching feeling in my anus that gets worse the longer I stand up. I mean, this was an open hernia repair.

Speaker 2 (00:32:57):

Yeah. Whatever’s going on isn’t related.

Speaker 1 (00:33:00):

Yeah. Sounds like you have an enlarged prostate and that was probably what made you higher risk to go under, uh, urinary retention to begin with. And now you have a slow urinary string. I would for sure get that treated optimally before delving into anything else. Uh, imaging maybe can help to see where the mesh was. I would have to, if it were me, I would look at your opera report to see what they saw and where they put the mesh. Sometimes they put the mesh, you know, retroperitoneal or there’s a plug that maybe can, can cause adhesions. But the,

Speaker 2 (00:33:34):

The only thing I can think of in this situation, yeah, sometimes a diagnostic laparoscopy mm-hmm. <affirmative> helps to kind of confirm that the open repair didn’t do anything. Uh, what

Speaker 1 (00:33:46):

A big sac. Maybe that sac when it was pushed back in is like,

Speaker 2 (00:33:50):

Yeah. Stuff gets stuck. It pulls on stuff. Uh, you know, you, you know, when we do laparoscopy robotics, there’s a ton of information our brain gathers just visually that you’d never get during open. And so one thing I’ve learned in this business of chronic pain is nothing’s textbook. Mm. Nothing’s textbook. And, and while, and this is where I think Sherwin, you and I, uh, agree, you know, where a lot of surgeons may maybe just don’t wanna do a diagnostic surgery looking for possible causes of pain. Well, I’m willing to go there. And so in this kinda situation, look, I I don’t know what’s causing a pinching anal pain. Right. I I would bet it’s not related. But if I put a laparoscope in and there’s nothing there, then it’s not related.

Speaker 1 (00:34:38):

What about, okay, so the clarification, it was originally a laparoscopic repair. Does that change your answer?

Speaker 2 (00:34:45):

Not really.

Speaker 1 (00:34:46):


Speaker 2 (00:34:47):

Not really. I mean, just go look, if there’s nothing visibly long wrong, then not, you know, so there’s one other slight cause of chronic pain that we didn’t discuss in this guy’s case, but that is when the mesh that we put in shrinks and it can pull on tissue and it’s, it will look visibly normal, but because it’s got this chronic pulling to it or clams shelling to it, it’s pulling on subtle on the tissue surrounding it, uh, that wouldn’t cause this patient’s symptoms in this case. But you could argue in certain other cases if they presented with, you know, chronic pinching pain every time they sat, um, you know, that’s a, that’s a hip flexor maneuver. That’s, that’s putting the iliopsoas and the flexor femoris on tension. And if those are already on tension from mesh at shrunk, it’ll exaggerate. So in those patients you can remove mesh and, and say that they would have about a 50% chance of a cure, but a 50% chance of, of having no symptoms and just getting the hernia back.

Speaker 1 (00:35:49):

So I would say that if you were to see me, I would first look at your operative report to see what technique was used, tepper tap we discussed, and also what size mesh was placed. Did they put like an enormous piece of mesh, uh, which went down way too low and now is affecting some of those pelvic floor muscles. And also look at your imaging, not just to see if there’s a hernia recurrence, but to see if I can on MRI. Often you can see the mesh and see if it’s low place, lower than usual or more medial than usual. Those are all like little details of the repair that, um, uh, we need to kind of figure out to see if any of those symptoms are related. And I agree with Dr. Jacob, which is, it’s not cool to live with these symptoms and just say, well, imaging doesn’t show anything. Oftentimes a a surgery is worth doing because if we find something that we can fix and repair, that can completely change your life, uh, quality and with low risk. So I have a low threshold to offer, um, a wide variety of interventions as long as the risk benefit ratio is there to help patients, uh, finally get a cure for their symptoms. Agree.

Speaker 2 (00:37:08):

Yeah. As long as, and I agree in short, but it takes a little bit of time to get the patients on the same page as us mm-hmm. <affirmative> and more, more specifically to make sure they understand that the surgery is not necessarily a cure, but a diagnostic tool in that situation.

Speaker 1 (00:37:27):

So, uh, going back to the gentleman who had, um, his laparoscopic repair and then 10 months later he’s still struggling. The question is, he still gets sore when he’s active. Uh, but it’s more of an annoyance than, um, than a huge life altering problem. So he’s been doing pt, et cetera. At what point would you consider revising his, his repair? I mean, that’s a high risk procedure. It that risk.

Speaker 2 (00:37:59):

What does revise it mean? Um, anytime someone’s complaining of the same thing for 12 weeks after surgery, I start considering revisional surgery. Mm-hmm. <affirmative>, um, three

Speaker 1 (00:38:13):

Months. Yeah.

Speaker 2 (00:38:13):

Three months. It doesn’t mean I’m gonna do it, it just means I start thinking about it as an option. Um, you and I shared a, a patient once, uh, my own case and if I had filed my own rule, I would’ve removed a mesh after three months. Cause I did a surgery and the patient had, you know, what he believed to be new, new chronic pain, uh, that kept going and going, going. I really had a search for a cause and the MRIs kept, uh, telling me things were normal, but the symptoms very much, uh, were about the sitting, sitting hurt. It was in one spot, mostly sitting, sometimes in a car, uh, when sitting in a car for a long time stepping on the gas. Uh, and I basically had to start doing sequential diagnostic injections into the different tendons that crossed that area just to see which one when injected will get relief.

Speaker 2 (00:39:05):

And that took a lot of buy-in from the patient. I gave ’em a lot of credit for working with me, but I simply didn’t wanna just take out mesh after three months, even though the pain started after surgery, uh, we were able to find out that the patient had an unread iliopsoas bursitis. Uh, and so we did two injections and, and thank God the pain went away. Uh, so I didn’t follow my own oral, but I, I labeled these people, these diagnoses as chronic pain after 12 weeks. Yes, you gotta go into overdrive and you,

Speaker 1 (00:39:36):

There was, there was, I don’t know if it was a paper or some discussion in the hernia world, uh, that got out to more of the community surgeons and you gotta wait one year. And I’m very much against that, I think for minor aches and pains. One year maybe, maybe fine. I’ve had my own operations before and I still have little twinges where the surgery site was. That’s okay. But to have severe life altering chronic pain and say you have to wait a year to see what happens, I think that’s not right.

Speaker 2 (00:40:06):

That’s correct.

Speaker 1 (00:40:10):

Okay. Uh, this is a good question again. Uh, in the chronic pain, uh, realm, I’ve read statistics ranging anywhere from a set of hernia operations can result in chronic groin pain. In your experience, what do you think the real, real world percentage is? And will a patient always have a weakness or discomfort from the operation? Or can one be completely cured and pain free?

Speaker 2 (00:40:36):

Um, I read the same thing. I I think I read the same stats.

Speaker 1 (00:40:41):


Speaker 2 (00:40:42):


Speaker 1 (00:40:43):

The numbers are everywhere.

Speaker 2 (00:40:45):

I think we, I think real, real world percent real world percentage is never the same as the statistics.

Speaker 1 (00:40:51):


Speaker 2 (00:40:52):

Um, I don’t know any surgeon out there who has a chronic pain rate themselves more than 1%.

Speaker 1 (00:41:00):


Speaker 2 (00:41:02):

You know what I mean by that statement? So if combined we all are quoting 1%, um, listen, I know surgeons who quote 0%, you know, my hat’s off to them. Uh, I think that the real statistic is about 6%. Uh, there’s a really, uh, very honest, uh, academic surgeon named Dr. Todd Hek. Um, and he put a lot of effort into trying to figure out what this real world experience looks like. And the number that he came up with on his app is about 6% normal non-pay patients develop pain after hernia repair. And he doesn’t actually believe that every surgeon has a 6% rate of chronic pain. But he says it’s a good conversation starter. It at least engages the patient and the concept that they may get pain that they don’t have before. Uh, but in general, if, if you go to somebody and they do the surgery that they do all the time repeatedly, and this is not, you know, a new surgeon who just started, but someone who’s been doing it for let’s just say at least three years straight, four years straight, um, you’re really gonna have a very low chance of chronic pain if you have the same surgery done to you.

Speaker 2 (00:42:16):

And it’s not a complicated case. And that I would feel confident saying that for everybody. I think that where, where some surgeons get into trouble is when they, uh, utilize a technique that they don’t need all the time, or the case is so straightforward that they don’t realize that the mesh folded. So, you know, things, things happen. But I would say that the real world experience is somewhere between three and 6%.

Speaker 1 (00:42:40):

So I think the goal is for the patient to in fact have a complete cure and be pain free. Um, I disagree that hernia repairs cause weakness. That’s not something that as surgeons we believe, I know that’s been talked about in public, but, um, that’s not true. Uh, you can get discomfort. There’s scar tissue, there’s inflammation, there’s sutures, the mesh, if, if you have mesh, the mesh doesn’t stretch very well. If you don’t have mesh now you’re tighter in the area. So there’s a lot of, uh, pros and cons to every procedure, which may cause discomfort. That discomfort should not be life altering. Um, and if it is, it’s, it’s in that kind of 6% sounds like. Right. I think, uh, in a lot of our talks we hear 12%. Um, and remember that’s at three months or longer. So after one year, that number needs to drop down.

Speaker 1 (00:43:35):

And, um, unfortunately there’s a wide variety of hernia surgeons out there. There are general surgeons that do hernia repairs, uh, as well as breast surgery and gallbladder surgery. And there are those of us, like me and Dr. Jacob, my practice a hundred percent hernias, and we both have a special interest in hernias. Then there’s urologists and gynecologists, um, who I know have done her hernia repairs and you know, that’s what they, and even plastic surgeons. So what they know and do is very different than our training. So, um, do your homework and, uh, you know, surgery, I don’t care what the surgery is, you should always get a second opinion if, if you are, um, uh, if you can because, uh, you know, you learn a lot from second opinions.

Speaker 2 (00:44:24):

Yeah, for sure.

Speaker 1 (00:44:26):

Okay, let’s go to Facebook Live. Uh, question is, what is a success rate for abdominal and Anglo hernia mesh removal?

Speaker 2 (00:44:37):

Um, we just looked at our numbers. They’re not as great as I want them to be. And, and we can talk about this. So this is an evolving field. Um, I think there’s about 20 surgeons in the country doing this primarily in their careers now. Um, and I would say that we’ve been quoting anecdotal numbers, but when you look at it, I would say that the cure rate is somewhere between 60 and 70%.

Speaker 1 (00:45:05):


Speaker 2 (00:45:07):

I don’t think it’s a hundred percent.

Speaker 1 (00:45:09):

No, I don’t think anyone’s shown a hundred percent.

Speaker 2 (00:45:11):


Speaker 1 (00:45:12):

Yeah. Numbers.

Speaker 2 (00:45:15):

Yeah. It depends what, it depends when you look at the numbers too.

Speaker 1 (00:45:18):

Yeah. And what you define as success,

Speaker 2 (00:45:21):


Speaker 1 (00:45:22):

Yeah. I think, uh, I think so we looked at our numbers and, you know, we remove mesh for different reasons. If it’s removed for as part of a hernia recurrence or a meshoma, like a mechanical problem where the mesh is balled up that success rate’s are very high. It’s, and ours is, it was the 90th 90 percentiles. Mm-hmm. And if you’re removing it because there’s chronic pain and there’s, um, um, weird reactions, nerve pain, something that’s not mechanical, but you know, affects your body a little bit more. Uh, that was in the high seventies, so we averaged like in the kind of mid eighties with our, um, percentile improvements. Yes. And, uh, the good news is that’s a, that’s a pretty high number. It’s better than 50 50.

Speaker 2 (00:46:10):

Uh, are we talking inguinal or ventral?

Speaker 1 (00:46:12):

I’m talking inguinal. Okay. But for ventral, I think the numbers are much better. Don’t you think

Speaker 2 (00:46:16):

Much better? No, that’s what I’m saying. My ventral explants, the numbers are much higher. Yeah. I, I looked at my numbers at a year out and, you know, you’re talking about a cure. You asked if they were cured. So improvement is, is also a different category. So I do think that a almost 90 to a hundred percent are improved Yeah. When the problems from their mesh and the groin.

Speaker 1 (00:46:39):


Speaker 2 (00:46:39):

But, but curate, you know, 80 percent’s pretty good. If you’re getting 80%, then, you know, we have to break down the cohort and see how

Speaker 1 (00:46:48):


Speaker 2 (00:46:48):

You know, you know, when do the pains, like you said, mesh plugs different ballgame than, than lap mesh. You know, mesh plugs to me or are slammed on. I love when a mesh plug pain comes in.

Speaker 1 (00:46:59):

I know. It’s so gratifying.

Speaker 2 (00:47:01):

Right. Not, you know, the patients out there with mesh plugs, most of them are, are non causing pain. But the ones that do, when they come out, you’re gonna get better.

Speaker 1 (00:47:08):

It’s like having a little pebble in your shoe. Just take out that pebble and like, it’s like night and day. Yeah,

Speaker 2 (00:47:14):

That’s right. That’s right. The, um, most common operation, by the way in our country is the plug.

Speaker 1 (00:47:21):


Speaker 2 (00:47:22):

Although that, that may, that may be different now with robotic taps. Yeah. Taps may be more now, but I would say up until about two years ago, most common operation, 30% were, were plug and patch.

Speaker 1 (00:47:33):

Yeah. I think the plug was the most common, most most sold mesh appliance, right?

Speaker 2 (00:47:38):


Speaker 1 (00:47:38):

Yeah. So last week, uh, there was a question asked of me, which I answered, but, uh, let’s see what the answer is for you. So what are some bizarre or uncommon adverse reactions you’ve seen with patients who’ve had inguinal hernia repairs with mesh?

Speaker 2 (00:47:57):

So mesh is easy because this falls into the category of, of foreign body reaction and foreign body reaction. It’s, there’s no limit to the symptoms. Uh, I will tell you that the most unique symptom that legitimately got better after mesh explanation, uh, this one patient had two symptoms that both got better. One was, uh, hot cold sensitivity, and the second was light sensitivity. Um, okay, interesting. Now I don’t, I don’t have a way to prove it, but this patient and his wife, um, would, would testify that after the surgery, the patient had to start wearing sunglasses. The, you know, he was always cold when he shouldn’t be thyroid normal, hormones normal, uh, no known cause the patient himself was just utterly convinced, had to be the mesh implant. Uh, CRP normal. Shirin, I don’t know if you send these kind of markers, but I look for like subtle changes. Everything was normal. I said, okay, look, I’ll take it out. I don’t know, we’re gonna, it’s, we took it out, the symptoms disappeared. Within a week now. I don’t have a way to prove it except for the patient himself and the wife. I don’t know why they would make it up, but that’s the weirdest symptom I’ve had. Get better. How about you?

Speaker 1 (00:49:21):

Yeah, I’ve, I’ve sent, uh, ESR and CRP and I’ve never had one positive. They’ve always been negative. So I’ve stopped testing, honestly. Um, sometimes they come with me with those tests already. Right. But I haven’t found any usage and not any of the inflammatory markers, even though systemically they’re showing me inflammatory, um, results.

Speaker 2 (00:49:44):

Yeah, for sure.

Speaker 1 (00:49:45):

I’ve had, you know, the rashes, um, visual changes, ringing in the ear. I’ve had those and they, they all go away.

Speaker 2 (00:49:53):

Yeah. You know, the most

Speaker 1 (00:49:54):

Common like brain fog and joint pain and, um,

Speaker 2 (00:49:57):

Chronic fatigue

Speaker 1 (00:49:58):


Speaker 2 (00:49:59):

<affirmative>, listen, if there’s a symptom out there, it’s possible. Um, but this, this is a word of caution to the, to the public. You know, mesh is not bad. Mesh doesn’t cause these symptoms in the overwhelming, huge majority of patients globally. Uh, the problem isn’t mesh. The problem is when there’s a patient who’s having a problem from the implant, them not getting listened to appropriately. Um, and so we need to raise awareness that the symptoms are possible and not to dismiss them. Uh, we’ve all saw, you know, acute redness of the abdominal wall after ventral hernia repairs in very rare numbers of cases. But they’re, they’re not infections. There’s some sort of reaction to the implant. You take the implant out and they get better. I think I posted one case in 2015 on the international hernia collaboration. Um, you know, they’re rare, they’re really rare, but they do happen for lots of different reasons.

Speaker 2 (00:51:03):

So, I don’t think that we need to be slamming mesh, but we do need to be slamming, uh, our ability to listen and, and keep an open mind to the possibility that the symptom is related to the implant. Not that it will be cured when it’s removed, because all patients need to understand if they’re gonna have mesh removed. That symptom may not go away and you need to be okay with that. But surgeons like Dr. Towfigh are willing to take out mesh because you believe it. Because we believe it, but it may not help the symptom. I think that’s important to throw out there.

Speaker 1 (00:51:41):

Yeah. I think we don’t, we have to be humble and understand. We don’t know as much as we think we know. And, uh, most important is to believe the patient. They come with very similar stories and just believe them and help them in any way you can too. And if, if that involves mesh removal, obviously we don’t do it willy-nilly on everyone, but, um, uh, it is a risky procedure and, uh, it should be done by only those of us that do it on a regular basis. But it does, uh, potentially could have life altering improvements in, in someone’s health.

Speaker 2 (00:52:17):

Sure. You see the, you see the question about, uh, a recommendation. I, I don’t know that I give recommendations online. Um, like that. There’s a question about a, a mesh removal surgeon in South Florida. Um, there are, uh, surgeons in South Florida and Florida that remove mesh and I’m sure Dr. Towfigh can talk to you offline about them.

Speaker 1 (00:52:38):

Actually, if you go on herniatalk.com, you can search for that. So wherever you’re living in the US or outside the US we have, um, uh, many people all over that collaborate on herniatalk.com. It’s a free patient discussion forum, uh, from which we were making this live session every week. Um, and just search, there’s a search function search for Florida. There’s, uh, several surgeons on that and patients who have been to those surgeons who you can connect with to help figure, figure out, um, uh, you know, which surgeon is best for you. Okay. Have you ever had mesh that rolls into the vagina or the bladder wall? I think that’s pelvic mesh. Although I have had one patient with more than one patient that had inguinal mesh erode into the bladder wall, but not the vagina. Agree.

Speaker 2 (00:53:31):

Yeah. That’s, you know, and again, in those situations, I’m gonna throw a little curve ball. It’s not the mesh that did that. It’s a Yeah, I mean, I’m not, well it’s not the, listen, there was an over dissection. Either that or there was a thermal injury with, uh, energy that caused a delayed, uh, burn. And then the mesh eroded. You know, that implant, if it’s placed in the right position, is not eroding into your vagina or into your bladder. It’s only gonna happen if you over dissect. Um, it is easy to blame it, don’t get me wrong. It is easy to blame it. I’m with you blame the mesh. I get it. Uh, but you gotta, you really gotta be honest and look at that operation. Um, so have I seen bladder injuries? Yes. Uh, have I seen mesh erode into the bladder? No, I actually have not, uh, not, not inguinal mesh and I have not seen it erode into the vagina, but I know it’s possible, but I don’t think it’s just the mesh itself.

Speaker 1 (00:54:32):

Yeah. In fact, I had a patient who, uh, who did have mesh erode into her bladder. And if you read the operative report, it says basically I didn’t know where I was. I kind of got into this plane. It was very confusing to me. I put the mesh in there, I think I was in the right plane and then I inherited the patient. So in retrospect, what happened was, for some reason the plane between the bladder and the abdominal wall was, I think she had a cesarean section. Maybe that was why that plane was scarred in and they ended up putting in mesh in the bladder wall, not outside the bladder. So, uh, yeah, that was a technique, um, problem. Not the mesh itself, but you know, a lot of sequela from that. Okay. We have four more minutes. Um, let’s do a one more question from the zoom. It says, when I sit with my legs crossed my left leg barely can go down very tight right side. No problem. I’ve had a bilateral angle hernia pair. Any idea what could cause the tightness?

Speaker 2 (00:55:42):

What kind of repair?

Speaker 1 (00:55:43):

Repair, laparoscopic bilateral ankle hernia repair. Does that prevent you from being nimble?

Speaker 2 (00:55:51):


Speaker 1 (00:55:52):

Yeah. Unless you’re a ballerina,

Speaker 2 (00:55:56):

Even then, you know, I did, I did. Um, it’s interesting. And next time you’re in the operating room, uh, showing in your laparoscopic in the abdomen, take the leg and

Speaker 2 (00:56:12):

And flex it, extend it external, rotate it, internal, rotate it, uh, at the hip. The, the inside doesn’t move. The inside doesn’t move. It is super interesting. Um, so you know, when you do that a few times, you start to realize that laparoscopic mesh is very, very rarely, if at all gonna be blamed or related to external pain from movements, including when not limited to crossing the leg over. So if there’s tightness crossing the left leg over the right hip, you really gotta dissect the, the muscles that are being used there and get an number MRI to look at ’em specifically. That’s going to be an a doctor as, as you’re a ducting, the leg, it’s gonna be slight flexion. And that’s also gonna be a, an internal rotation of the hip. And so you wanna look at the hip and the groin MRIs for things that are causing that

Speaker 1 (00:57:07):

Because it could be a hip joint problem too. Right. That gives groin pain

Speaker 2 (00:57:10):

A absolutely hips lab terrace specifically. And sometimes impingement are the number one non-G groin related cause of groin pain.

Speaker 1 (00:57:20):

Okay. I’m gonna fit in one more quick question. Sure. And from Facebook Live, is umbilical hernia surgery under general anesthesia safe in an ambulatory day surgery center? Or should they always be done in a hospital

Speaker 2 (00:57:35):

Trick question. It, it’s actually more safe in an ambulatory surgery center under general, uh, as long as it’s a, a certified center with a board certified anesthesiologist, uh, and an outstanding center. Um, I think that the check-in process, the checkout process, the attention to detail, uh, are always gonna be slightly, you know, a better enhanced patient experience at a smaller center than a giant hospital. Uh, that’s not true for all hospitals, but I think in general that’s a true statement. Uh, as far as safe, absolutely safe, no matter where you have it done.

Speaker 1 (00:58:10):

Do you use general anesthesia for your umbilical hernia repairs?

Speaker 2 (00:58:14):

I mean, it depends if I’m doing them open or, or lap open. So open with just suture and I don’t, cause I don’t use mesh for my open tiny little ones. Right. Um, it’s up to the patient. So if they’re willing to be put to sleep, yes. Otherwise it’s not general. It’s something called IV sedation and local.

Speaker 1 (00:58:35):

Yeah. I try and use as much, uh, deep sedation as possible and a good anesthesiologist is very comfortable allowing you to take the anesthesia deep without general anesthesia so you can, I think the recovery is easier if you don’t use general anesthesia. And I do that for most of my open inguinal, open vest removals and the small belly button hernias that are open, not laparoscopic. You have to use general for that.

Speaker 2 (00:59:00):

Right? Sure. No, I appreciate that. It’s, it’s true. And, and just so patients realize when we say belly button hernias that are small, you know, everybody’s different. Um, but I think we’re talking about the, the little ones that are, you know, common in Beverly Hills in New York City. Yeah. <laugh>, they’re one centimeter ones. Right. Um, there’s a lot of patients who come in with bellybutton hernias that may be small, but they’re now, you know, once you get to the size of a quarter, uh, it’s a different ballgame. Yes. So we’re talking about the ones that are the size of a dime, not a quarter.

Speaker 1 (00:59:28):

Alright, that’s it for us. Please follow Dr. Brian Jacob. His practice is in New York City at Mount Sinai. He’s a laparoscopic and hernia specialist. He’s at NYC Hernia on Twitter. You can also follow me all over the different social media platforms at Hernia Doc. And lastly, if you missed or want to review this, this is a video of this one Hour is available on Facebook Live. Uh, my Facebook page, Dr. Towfigh. And also I will post it on YouTube and let you know the link to that on my channel. Thank you everyone. We’ll see you again next Sunday at 5:00 PM Pacific, 8:00 PM Eastern GMT plus seven hours. Love you all. Bye-bye.

Speaker 2 (01:00:10):

Thanks. Thanks, Shirin.

Speaker 1 (01:00:12):