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Dr. Towfigh (00:00:05):
Alrighty. Hey everyone. It’s Dr. Towfigh. Welcome. I don’t know if you can believe it. This is our 200th 2-0-0 200th episode of Hernia Talk Live. I’m your host, Dr. Shirin Towfigh hernia surgery specialist. Thanks to those of you that join me almost every week on Hernia Talk Live via Zoom. Many of you’re now currently on Facebook Live. I am just in love with the fact that this episode can be on your podcast, feed, your YouTube feed. You’re watching it live all these years, and I really hope that you enjoy this week’s episode because it’s going to be a nice little recap. Of course, as usual, I will be answering your questions as I always do live. So for those of you that have hernia related questions, I’m here to answer them for you live. But in addition, we have some questions that have been sent in, which is awesome.
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Thank you to all my followers. It’s all about you today. I’m here for you. You are my very, very dedicated followers. So thanks for being here on Facebook Live and on Zoom. And as you know, this and all future and all back prior episodes are available on Twitter, on my YouTube page, follow me on Twitter and Instagram at Hernia doc, just wherever I can share information, I’ll share. If you’d like to listen to this as a podcast, join me on a podcast, et cetera. So where should we start? Okay, so it didn’t really occur to me this would be number 200. I’ve been counting like 1 92, 1 93, 1 95. I was getting closer, but when it went from 1 99 to 200th episode, I don’t know, it just hit me in a weird way that I never thought would be so lovely. So lovely. And again, thank you to all of you for continuing to listen and inspire me and sending your questions.
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What we’ll do today is try and give you a little bit of a big picture of what’s been going on. I think it’s fair to say that since the pandemic, when this started in 2020, a lot has gone on in the hernia world. There’s a lot of advancements and a lot of interesting things that I’m really, really excited about and I think it’s good to kind of recap a little bit of that. Some of you had sent in questions, so I’ll answer some of that. And if you’re here live and of course have questions to be answered, I’m here for you. So let’s start with the history of Hernia Talk Live. As many of you know, I have had a free discussion form about hernias since 2013. It’s been free. We have tens of thousands of people who have gone through the process of either posting their questions, getting their questions answered, answering other people’s questions, or just lurking and just looking through questions to be answered.
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The impetus for hernia talk.com was I would get patients calling the office and asking the same question and I would try and answer them, but it was kind of inefficient. I was doing them one at a time and it occurred to me that if one person has a question, then probably a hundred other people have a similar question. And there was no resource online to share the knowledge. And the initial intent of for talk.com was for me and my friends to collaborate and help answer questions online that patients were presenting. Now it’s kind of grown into its own community where people talk amongst themselves, they make friends, they share experiences with other doctors or procedures they had done both positive and negative. And it’s been really the best resource online to help find out things such as I’m in Ottawa, Canada, where can I get a hernia specialist?
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My doctor’s telling me I need a triple, is that a good idea? And then people can chime in and of course I go on it intermittently as a moderator and help answer some questions as well. So then the pandemic hit, and as many of you know, my practice is in Beverly Hills at the Beverly Hills Hernia Center. The city of Beverly Hills shut down all medical care, all I should say, all elective medical care. And for those of you that know about Beverly Hills, most medical care here tends to be cosmetic. And so I think the goal was to prevent people from coming and getting Botox to their face and lip fillers while people are dying of covid. And by reducing that interaction, then they’re hopefully reducing the spread of the coronavirus. Well, I’m also in Beverly Hills and I had patients that I could not see and I could not treat because the hospital was closed because of the pandemic crisis needing so much more attention to the very sick patients.
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The clinics were closed in a city where they shut down all the clinics. So I was at home mostly answering emails and doing things like that, walking the dog, and I felt maybe I should start doing some things on the internet and Zoom became kind of a thing. So I started hernia talk live and now we are on episode 200. I haven’t stopped doing it. I haven’t run out of topics to talk about and there’s a lot more interest in hernias. So let me just recap. In the past five years, I think it’s been over five years, right? I think I started April of, I think we had our five year anniversary, April of 2020. I would say that a lot has changed very rapidly in the past five years. Not necessarily because of the pandemic, but because of patients like you and collaborations like mine where we are here to improve hernia care.
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And as I’m talking, I’m getting questions coming, so I’ll be answering questions back and forth. So here’s one, have you heard of a new anti adhesion barrier T 5 2 2 4 or TTX three application after lysis of adhesions? Would you be willing to use this as compassionate use? The TTX 3 3 3 is in phase two waiting for funding to start phase three. I’ve not heard of it because it sounds like it’s not yet FDA approved to be used. It’s under investigation. Phase two is a very small clinical trial that’s looking for not only safety but also efficacy. And then phase three hasn’t even started yet and I’m not a principal investigator in that clinical trial, so I won’t be able to enroll you in a clinical trial, let’s say, to use it. And I’m sure it’s a very controlled setting as to when they allow use of it. Also, there’s no way to use it under compassionate use because there are alternatives in the market such as seprafilm and intercede, just to name two that are available in the US market that we use for intestinal adhesions. So very nice of you to do the research. You may want to go to a local clinical trial, a hospital that has a clinical trial specifically looking at this product to see if you are eligible to be enrolled in it. But I cannot use it. That’s just not legal.
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Are there any Canadian hernia specialists you’d recommend, and if Canadians travel to you, are you able to do surgery on them? So yes, I actually have quite a few Canadians that I see on a regular basis. I think I’ve seen ’em from every single province. Actually. Unfortunately the Canadian insurance has not been able to allow for coverage of my services, but I’m happy to see you and take care of you. I’ve had patients drive all the way from Saskatchewan down to see me three or four days of driving. Others have flown in. We have quite a bit of out of town patients. So my office is very good at trying to give you some advice as to how to plan your trip and how long to stay, where to stay and that kind of thing. And again, you can have surgery recover and then go home.
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Canadian hernia specialist, so there are a handful I have interviewed. Let’s see, I interviewed a surgeon at the ROIs clinic. I interviewed a surgeon at McGill and I interviewed a surgeon in University of Toronto. So those are all people that I’ve already interviewed, haven’t really found someone interview from the British Columbia area. I do have an interview coming up from I think Ottawa. Don’t quote me on that. There are a handful and if you go on hernia talk.com, we have shared some names of hernia specialists in Canada. Next question, 54-year-old female had anal hernia mesh surgery October 24.
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Can I still feel the mesh? I can still continue to feel the mesh when moving laughing and in pelvic floor movement, dayday living is this normal, will it go away? Can it be fixed? So I don’t know if that’s the mesh that you’re feeling. It’s unclear where the mesh was placed. So if your mesh was placed in open fashion, you should not feel the mesh with pelvic floor movement. But you may feel the mesh if your ultra thin and the mesh is ultra thick for laparoscopic or robotic angle hernia surgery with mesh, you should not feel the mesh at all if it’s placed flat and you have flat mesh. If you have mesh that is wrinkled or balled up and placed laparoscopically or robotically, you may feel the mesh move in the pelvic floor. I guess a little bit if you’re having feeling of mesh moving with laughing and pelvic floor movement, if any of a mesh plug or some type of three-dimensional mesh, perhaps it’s an unstable repair in general, you should not feel your mesh. So people who are feeling their mesh are either feeling something else or the mesh is unstable or not positioned in the right way. Can it be fixed? A hundred percent, yes. Will it go away? If it hasn’t gone away already, then it likely would not go away and no, it’s not normal.
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Okay, so oh, we’re going to talk about a recap of the past five years. So here’s what’s happening. Number one in a very strange and lovely way. More surgeons are interested in hernia surgery and more hospital systems are interested in hiring surgeons that are interested in hernia surgery. Those two are very important. They have to come together. If there are surgeons that like to do hernia surgery like I did when I first started, but there’s no hospital that is interested, then that doesn’t promote those specialty at all because you don’t have a system that promotes the hernia repair and I have to build my own hernia center now. It’s changed. I would say in the past five years for sure, there’s been a boom in hernia specialty groups, hernia specialty centers, hospitals that have their own hernia group of surgeons or specifically are hiring hernia surgeons.
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That’s a big deal. There’s also an interest in making centers of excellence for hernias and getting certifications and hernia surgery that we don’t currently have outside of just general surgery. So this is all really, really exciting. There’s a talk about having hernia fellowships, which is an extra year of training after general surgery training to specifically a focus on hernias. There are a handful already, but there’s interest to make this nationwide and actually the same as getting cardiac surgery or colorectal surgery. So having a very truly certificate designated hernia specialty. So that’s all really, really exciting.
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I would also like to say that because of you all, and hopefully also because of what we are doing online and with social media, there is more interest by patients in getting to know more about their hernia in doing online research and getting involved with meetings, being vocal online, et cetera. So I would say that the European Hernia Society has had multiple years now where they have a patient advocate group running part of the meeting and or patients are part of the meeting. The American Hernia Society has done the same thing. And Sages a Society of American gastrointestinal and endoscopic surgeons is also including a patient on panel discussions to offer the patient view specifically for their hernia, hernia pannus. So that’s all really exciting. We did not have this before, we all started back in 2020. So super exciting.
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Females and hernias and females is like, I’ve been talking about it for over 20 years. I used to be called Towfigh. She’s talking about stuff no one really cares about, not anymore. We now have portions of meetings that are dedicated specifically toward female hernias. Those rooms are packed, packed, packed, packed as of several years ago. And now we have the Hernias Alliance, hernia Surgeons Alliance, which you can follow at herniasalliance.com I believe. And they are a group of younger female hernia surgeons that have gotten together. And for those of you that follow me on social media, I actually did a mini podcast with them introducing them to our surgical environment. And you can watch that on my social media pages, whether it’s Facebook or Instagram or Twitter, and you can kind of learn more and do your own research about this new group. It’s they’re younger surgeons.
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They’re all hernia surgery, fellowship trained. They are all practicing in a situation where almost a hundred percent of their surgical practice, it’s hernia related and they’re all females. So they would like to help focus on more research and education on hernias in women, which is fantastic. And like I said, we have much more infiltration of females surgeons in hernia surgery. Before it was just me. Literally I was the only female surgeon in the entire American Hernia Society meeting at my very first meeting. And I was think only the second person ever female to be on their board. That’s all changed. We have women on the board, we have women in leadership, and the sessions are led often by females and usually that implies that the topic of hernias in women will be more likely to be discussed than in the past.
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Yeah, and here’s a comment that is good news. I hope this trend has followed in Australia. I will be having one, maybe two different surges from Australia on my show pretty soon. So stay tuned. There used to not be that many, maybe one to two, and now there’s about four or five that are showing interest in Australia. And then another comment here, finding you opened my eyes, such valuable information. Thank you so much. It is really nice to every so often just kind of stop and look back and count all the major changes and improvements that have been made over the years, all of which are in some ways the fruit of your labor over the past several decades. Let’s talk about occult hernias. Occult hernias are small hernias that are hard to find, but they cause a lot of problems, whether it’s pain, pelvic floor spasm, testicular pain, pain with intercourse, urinary frequency, all of these atypical symptoms that most surgeons in most textbooks don’t talk about being related to hernias.
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Well, we had our sentinel paper, my favorite paper that I’ve ever written and I’ve written a couple hundred. It’s called A Hidden Hernias Hurt, hidden Hernias Hurt. It’s obviously an alliteration I’ve been wanting to use for ages. But we finally were able to gather our data to support a very strong paper where it very clearly delineates what is a hidden hernia, how do you diagnose it, what are the specific questions that a doctor can ask to help see if this kind of chronic pelvic pain or groin pain can be from a hidden hernia and the success rate of fixing these. When I first gave a talk on hidden hernias, it was in Milan in 2010 at the European Hernia Society meeting. Prior to that I would make comments and those comments were always poo-pooed of like there is no such thing as occult hernia if there’s no bul, there’s no hernia, and other kind of BS like that.
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And when I would give these talks, they would come up with ways to kind of poo poo it and say, well, how do you know this ET bt little piece of fat in the hernia is the cause of all these symptoms you’re claiming. So then I said, okay, well the only way to talk to surgeons and make them listen is by providing data. So my first paper that came out was a small group of patients that I talked about females in general and how females can present and then showed our data of how they tend to be different than men and was met with some skepticism. I’ll just say that my student was presenting it, he’s a doctor now, but at that time he was an undergraduate student and he got a trip to Milan to present all of this great research. He had three different papers and he was like, why was everyone so mean?
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I said, it’s not that they’re mean. First of all, their surgeons we’re not exactly like lovey-dovey as a group. And then secondly, yeah, they’re just skeptical because this is unknown to them and they’re uncomfortable with it and I’m introducing a topic that is new to them and give it some time. And guess what? Now we actually got the paper published 15 years later, much more patients, much more data to support much more talks that I’ve given. So this topic is now not as strange. I have doctors that call me and say, Hey, I have this guy. I think it’s an occult hernia. What do you think? I have urologists that regularly send me patients because they see people with testicular pain and they understand it’s actually not the testicle and it could be a hernia Up above, I have gynecologists that are treating chronic pelvic pain and really kind of unique diagnoses like PAD, which is genital arousal disorder and so on and pelvic floor spasms and they can’t figure out why the patient has it.
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And then wait a minute, I was talking to Towfigh and she was talking about these occult hernias. Maybe it’s an occult hernia. So this whole idea of occult hernias can span a lot of different specialties. It could present with back pain and physical therapists can see it and so on. I’m really proud of the fact that we’ve been not too shy about sharing our data and being persistent about it. And then over time, the people that run meetings would invite you to give talks and then someone would invite you to write a chapter about women’s hernias or occult hernias and then this topic becomes not as foreign anymore and they start seeing maybe a patient or two that they treated. What they kept telling me before was, this is wrong. You’re over diagnosing people and then you’re offering them hernia surgery that they don’t need.
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And I think I mentioned this to you before. They have some surgeons use this thought of you operate on pain, you get pain, which completely is false. So in this paper that we published, hi hernias hurt, we were able to show that people who four out of five of the people that got the hernia surgery were cured within two weeks, right? Cured. So this whole dictum of you operating on pain, you get pain, completely false because 80% were cured and then the amount of pain, that reduction that they had was also greater if you had occult hernia than if you had a regular hernia and so on.
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It’s really exciting. Alright, questions are piling up. Let’s answer them. I have testicular pain. My scrotum was hit and injured about one year ago in May, 2024. Initially the testicular pain whenever I moved was severe for a month. I could not sit for one minute. One month later the pain was still less, but still could not sit for one minute. January, 2025, I could sit for 10 to 20 minutes maximum. The scrotum is very sensitive. Let’s see, feel pain if towel or jacket hits the scrotum lightly. Is this scrotum nerve pain and can the pain and scrotum sensitivity be treated? Well, the question is I don’t know, but if you have a situation where you think you have nerve pain, then it could be genital nerve or testicular nerve. You should undergo a genital nerve branch nerve block and or a spermatic cord nerve block and see if it takes the pain away. If it does, then maybe it is a nerve issue. If it doesn’t and actually have more pain, you may have a hernia.
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So that’s kind of the way if you came to see me, that’s kind of the process I would do. And then in my office I do spermatic cord blocks and nerve blocks under ultrasound guidance. So it’s very exact and you can know within minutes if your pain is gone or not. So that’s what I would recommend for you. Next question. What can an incarcerated ingal hernia present as prior to strangulation? Can they appear almost like an ingrown hair on the bikini line or a small ARI themic bump on the patient’s skin? No. What are the signs and symptoms to look for in patients with diagnosed small fat containing anular hernia to catch incarceration and strangulation before it becomes an acute emergency? So first of all, incarceration does not equal eventual strangulation. So there’s tons of people with incarceration of their hernia that may never get strangulation.
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Number one, strangulation is very uncommon usually. So incarceration similar to being incarcerated means it gets stuck, right? You’re either incarcerated, which means you’re in jail or your hernia is incarcerated, which means it’s stuck in a hole. So when the fat is stuck in a hole or the intestine is stuck in the hole, if the hole’s much, much smaller than the amount of content being pushed through it, then that’s going to hurt first. And then if more content is pushed in to the point where the blood flow is now compromised because it’s being pinched, similar to if I put a blood pressure cuff around your arm and cinch it down and don’t release it, then that can lead to strangulation. So you almost never have strangulation unless you first have pain. I hope that makes sense. If you don’t have pain, you will not get strangulation. And usually with strangulation we’re more concerned about strangulation of fat, I’m sorry, strangulation of intestine, but strangulation of fat can also occur. You’ll not see any ingrown hairs or little red bumps on your skin. That’s not in any way related to a hernia. It’s more of a diffuse bulge at the most.
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Next question. You have mentioned that recurrent hernia treated with another open repair causes pain because of tightness and tearing of a muscle. Is there a visible sign of this tearing such as bleeding or scar at this suture site when the open repair is visualized either on laparoscopic repair or another repeat open procedure? I’m not really sure what this question is. So I You’re saying that I mentioned that recurrent hernia treated with another open repair causes pain because of tightness and tearing of muscle. I’m not sure I’ve said that. So if you had an open repair for a hernia in the groin and that recurred and there’s no other problem besides the recurrence, then the next step is a laparoscopic repair. The reverse is also true. If you had a laparoscopic repair with mesh and you recurred and there’s no other issue, then an open repair is the right option.
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If you had an open repair that recurred and you had another open repair, that’s usually higher risk of recurrence and higher risk of chronic pain, the tightness and tearing the muscle. The only thing I can think of that I mentioned in that vein is that if you had a tissue repair with mesh put on top of that, that can be too tight because the tissue repair is already tight. You add mesh and mesh shrinks, so then once the mesh shrinks, it’ll make the tight repair even tighter. So the question is, is there a visible sign of such tearing? Not really. Usually you can feel it, you’ll feel it’s too tight, you can’t tolerate certain clothing over it, bending hurts.
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It’s painful before a bowel movement, that kind of stuff. All right. What imaging do you need for females with AL hernia? Any recommendations for hernia surgeons for women in the Seattle area? So I’ve already interviewed at least one, maybe two surgeons from the Seattle area that do great hernia surgery. So go back to my prior episodes somewhere between number one and number 200 and search for Seattle or Washington. You can do that on hernia talk.com or on my website where we have the podcast and yes, the great hernia surgeons in Seattle. What imaging do you recommend for females with inal hernia? If it’s an obvious hernia, you don’t need any imaging. If there’s a worry for a femoral hernia, either an ultrasound or MRI will work. If it’s an occult hernia, then I prefer an MRI over a ultrasound. And our special hernia protocol, MRI that I use is available on my website as well in the kind of for the patient consultation area. By the way, my website is beverly hills hernia center.com. Do you do genital nerve block? Yes, I do. I do spermatic cord blocks and various other genital nerve, ileal nerve ile, hypogastric nerve, and other superficial nerve blocks in the office with ultrasound guidance.
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How do you do a genital nerve block? Oh, with the ultrasound? So depends on where the area of concern is. If it’s behind the muscle, I use the ultrasound to identify where the nerve will be just lateral to the vessels. If it’s in the front, then I kind of follow either the round ligament or the spermatic cord and injective superficial to the angle floor. Next question. Oh, more of a comment. Looks like you’re a great surgeon. I’m afraid of nerve blocks as are there any less invasive diagnostic methods available? Not sure why you’re afraid of nerve blocks. It’s pretty straightforward. It’s done in the office. There’s no bleeding from it, there’s no severe from it. You could try lathering either lidocaine jelly or gel, which is lidocaine or using a lidocaine patch to see if that helps. But oftentimes it’s not helpful and you need a true nerve block.
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Okay, this is a good one. I’ll throw this out is what she’s saying. A year and a half ago I had my incisional hernia with diastasis recile repaired. I spoke to you about this previously as I was afraid of the mesh. Now I get excruciating pains under my sternum and red upper quadrant. It’s positional. Could the scarring and or adhesions go up that high? I’ve had CT and ultrasound. They think I have a nerve pinch or muscle. Yes. So I’d have a look at your operative report to see what are the dimensions of your incisional hernia and then what are the dimensions of the mesh that were placed.
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If you, okay, if you had mesh, that is maybe where the mesh was sewed, for example. But if you have not had mesh and you have pain under your sternum and right upper quadrant, that should not be related to any diastasis closure. So there may be other reasons for it. Next question. Do you have any hernia surgeon recommendations in Florida that specializes in hernias in females and non mesh repairs for small fat containing angle hernias? Dr. Jana Sako of the hernia lines is on leave. I’m a 30 5-year-old first time hernia patient with a small fat containing anular hernia found on CT scan, not on exam. That is giving me a lot of symptoms including worsened, menstrual cramps, dull abdominal pain, nausea, and of course groin pain. So yes, I’ve interviewed many people including Dr. Sko, but I’ve also interviewed, I would say at least four surgeons in Florida that I can’t say any of them specialize in female hernias.
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There’s very few of us. I’m literally the only one that knows that much about female hernias exclusively. But all the people that I interview, I stand behind. I feel that they’re good surgeons, otherwise I would not invite them to or good doctors, otherwise I would not invite them to my show. So just search for Florida and see who I’ve interviewed within Florida, and you can search that either on my website, under the Hernia Talk live podcast. That’s my website. Beverly hills hernia center.com or just go to hernia talk.com and search for Florida or where else can you do do it? I guess on YouTube on my channel, you can probably search for Florida as well.
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Okay, going back to the diastasis. Okay, so if you did have mesh and you had mesh up high, yes. Then I would like to read your operative report to see if the mesh was sutured in place and if it was, it may be pulling on the suture. Sometimes if you gain weight or if the mesh repair was placed too tight, that can pull on the sutures and cause tearing. The first thing you should do is just have local anesthetic injected to the area to help with your pain. The second thing you can do is to have the suture removed with that completely undoing the repair.
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Okay, going back to the patient who’s afraid of nerve blocks, I’m afraid of nerve block complications. I just told you there’s no complication. It’s less than a blood draw. The needle is small, there’s little to no risk of bleeding. I don’t know what other complications there could be. I’m also afraid my pain conditions will get worse after the nerve block. Well, that’s not the purpose of the nerve block. It’s to get it better. So most people, either nothing happens or it gets better if your pain gets worse, it’ll be temporary during the six to eight hours that the nerve block lasts, in which case that’s diagnostic and usually have a hernia or other non nerve problem or the nerve block complications. Low chance of happening. Yes. Are my fears valid? I don’t want to say your fears are invalid, but of all the things you can be afraid of in someone who’s got so much pain already, nerve blocks should be very low on your list.
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Okay. I had a laparoscopic exam through my belly button area to look for a hernia. The surgeon did not see a hernia, so he left everything as is. We go through this every couple of sessions. Well, the surgeon have been able to see within my ular canal through my deep ring during that surgery. No, no. My concern is that I have a hernia or something wrong inside my ankle canal, but he wasn’t able to see it during the surgery because nothing was protruding through the top of my deep ring. You are smart and you are right. So I say this at meetings because most surgeons don’t know this. I say this on this show to educate you guys to talk to your doctors before you have this done. If any surgeon is offering you exploratory surgery for an inguinalhernia, go see another surgeon. That’s almost never necessary.
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I’ve been doing this since 2002, maybe once I’ve had to go in searching for a hernia that I couldn’t find elsewhere. Your physical exam, your story and imaging should be all you need to make the diagnosis. I’ve had patients, doctors, doctors who saw local doctors who were told, let me just put a camera in there and see what you have and if you have a hernia, I’ll fix it. If not, we’ll finish the surgery. Completely not necessary. Imaging will show what you have and don’t have and if the imaging doesn’t show it, it’s either misread or you don’t have it. So that’s why you go to a hernia specialist or specialist who likes to read imaging. I personally love reading imaging to get that diagnosis. So I had to put a stop to this poor woman who was seen by a doctor and told, oh, they’re just going to take a look inside for a diagnosis he would never have seen anyway because she didn’t have anular hernia, she had a canal of no cyst, but even if she had a hernia, he would not have seen it because that’s not the way to approach these things.
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Now, on the off chance that you’re seeing you’re having surgery, let’s say, let’s say this is a scenario.
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Let’s say this is very reasonable. Let’s say you’re having, you’re a female and you’re having gynecologic problems and your gynecologist wants to go in there. Let’s say for endometriosis, if that surgeon says, Hey, you may also have a hernia, maybe that’s what’s caused your pain, and they call me in, let’s say, to take a look just looking is also not going to take care of it. Like you mentioned, and you’re very smart for saying this in patients with big hernias, yes, you’ll see it because you’ll see all this stuff going through a hole, but in smaller hernias from the inside, you’re not going to see the hole because that hole is being plugged by a little piece of fat and that fat is not allowing you to see a hole from the inside. What do I mean by inside? When they put a camera in, when they put a camera in the belly button and you look, you’re seeing the intestines and you’re seeing what’s called the peritoneum, which is a sack that holds all the intestines in place.
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What you don’t see is a fat on the other side of the peritoneum and the muscle on the other side of the peritoneum that has the hole. Now, if you do have exploration and the surgeon cuts open that peritoneum brings it down, takes that extra fat, pulls it out, looks at the muscle and confirms there’s no hole that is definitive for surgically looking for a hernia, still not necessary because imaging is great. So yeah, please don’t ever have diagnostic surgery for hernias. It’s not necessary unnecessary. I just recently sent you all my medical files and stuff for an online consultation. Thank you for answering that. Yes, absolutely. And as soon as I see it, I will send it out. I’ll respond to you. I actually enjoy my online consultations. Can I tell you, so I’ve been doing online consultations for decades now. It’s something I really enjoy and the more I kind of do it, the more I enjoy it because as you know, I am licensed in the state of California. Medical licenses are provided per state. So because of what I do, many patients fly in to see me, but I understand you may not be able to fly in for whatever reason or you may be able to get perfectly good care next near you. You just need to know what care you need. You need some guidance. So I’m okay having you sign up for what’s called call an online consultation. So you say, I can’t get in to see you.
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I live outside of California and therefore what I really need is your help and guidance. And I say, I can’t be your doctor, but if you want to send me your stuff, I’ll take a look at it and give you some guidance based purely on the information you provide me. I can’t see you. I can’t examine you. We can’t have his doctor patient relationship because that would not be in the best interest of what my medical license allows. I’m not allowed to give care outside of California. I can initiate care outside of California so you can fly. Let’s be flying from Nebraska to see me in California. Once you return to Nebraska, I can still treat you as your doctor, but you can’t initiate care outside of California. It’s a little screwy, but it is what it is. I follow the law. So these online consultations are really just more of like a second opinion I guidance. I don’t know how better to say it. It’s less than a full physical evaluation and I can’t take over your care, for example.
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In your opinion, how does Ali Sheen get good results for inal hernias disruption in sports hernias using the no fixation technique? The Manchester groin repair isn’t fixation necessary for these large direct hernias or weaknesses. So Dr. Ali Sheen was one of our guests. He’s a surgeon in Manchester, United Kingdom, a former president of the European Hernia Society. He has coined the Manchester Groin repair. It’s basically a laparoscopic repair with glue instead of piercing mechanical fixation. It’s used primarily for your typical inal hernia. Perfectly fine. I don’t use any fixation. You don’t even need to use a glue. But the Manchester Corn Repair specifically is showing it without mechanical fixation and he has very good results the same way we get good results without any fixation.
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The question is if it’s a really large hernia or a large defect, is the Manchester repair adequate? I prefer to have mechanical fixation because the rules of physics would demand that if you can close the hole and then use the glue, that will help. I don’t know that necessarily that he uses the Manchester groin repair for large direct hernias. I don’t know that that’s a true statement. Is it necessary to have surgery for inal hernias with omentum? No. Is it less risky than inal hernia with intestine? Yes. Okay. Next question. I, a female patient have a small fat containing inal hernia. It was found on CT but not on exam. Okay. Would the CT scan have also captured if there was an additional femoral hernia or is there another form of imaging I would need to rule out for femoral hernia? So the answer is sometimes yes. Is the femoral hernia only ever fully ruled out during surgery when going in for the inguinal? No imaging can very accurately rule out femoral hernia. Usually CAT scan is not as good as ultrasound or MR. I would say M MRI is best that ultrasound then CAT scan, but it’s still our kind of code of ethics to when you go in there for anular hernia and females to always double check for femoral hernia. Anyway, let’s see.
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I’ve got pain occasionally reading down the front of my thigh on the same side as my ankle hernia. So I’m concern, well, because you are smart as well, just for everyone that listening angle hernias should get repaired in men if there’s pain. And most women, and the reason why it’s different recommendation for men and women is because in women, there’s also a risk of femoral hernia much higher than men. Femoral hernias can be small and they can be deadly. So 5% risk of death if a femoral hernia is missed and there’s intestines stuck in it or something like that, that’s a big number 5% death rate. That means one in 20 patients with a femoral hernia with bowel stuck in it will die. That’s an unreasonably high number.
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So how do we overcome that? We overcome that by either operating on all females with hernias, which is a current recommendation, and during that surgery looking for femoral hernia or my current practice, which is in patients that either don’t want or have a surgeon anytime soon, I at least rule out a femoral hernia with imaging before I say no or offer them watchful waiting so that at I know they’re not going to, I’m not. At least I know that there’s no problem with missing a femoral hernia. I hope that makes sense. Okay. Let’s see. Oh, some more things about what’s happening that’s been positive in the past five years. There’s much more acceptance of mesh allergies and mesh reactions. This, by the way, happened very quickly. So I’ve been talking about mesh reactions for a while. I’ve been treating it for I would say close to 15 years or so, maybe just less than that.
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But most people don’t believe in it. Poo-pooed it. They said it’s not true. Mesh is inert. I was taught mesh is inert, completely is not. It’s very inflammatory. In fact, that’s how it works. How could you say it’s inert when it causes inflammation? And that’s how it works. Anyway, we’ve started talking about mesh implant illness about 10 years ago by presenting it at conferences and again, it was considered fringe. Then I started being asked to give talks at meetings specifically about this topic, which I was like, oh, okay, if they’re putting it in the meeting agenda, then it’s being thought about. Great. Then I started being asked to write chapters about it in books and in my own book was the very first book where we talked about mesh reaction and that was published over 10 years ago. That’s the sage’s Manual of Groin Pain.
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Great book by the way. And then now we have the sentinel paper published. It was very hard to get it published. We finally got it published because a lot of people are still naysayers and we coined the term MI or mesh implant illness to discuss this. And now I have legit doctors who would not have called me before calling me saying, Hey, I think I have a patient with a mesh reaction or mesh implant illness. How do you do your studies again? Or what studies do you test or what blood tests do you do? Or what do you think about these symptoms, et cetera. And I have a lot of patients, so I tend to do testing and not just jump in and remove meshes because I think it’s not appropriate to just remove mesh in everyone. Mesh removal should not be taken lightly. But there are surgeons out there that are like, I’m just going to take out the mesh. I don’t know if it’s the right thing or not, but the patient wants it, et cetera. I’m not a fan of the patient wants it and therefore I will do it. I’m not a mechanic, I’m not a plumber.
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I don’t just do what I’m told. It has to be medically sound. And often patients don’t understand the implications of mesh removal and the risks associated with it. So that said, more surgeons are open to hearing patients talk about this and a handful of more surgeons are actually offering mesh removal. So that’s very new. And in some ways I don’t want to promote it too much because I feel like all these doctors are going to just not do the right testing and just because they’re surgeons, they’ll just take out the mesh. But at least they’re listening now and not telling the patient they’re nuts. Let’s see the lawsuits, lots of lawsuits. What’s changed in the past five years is we’re finally getting to some resolution. The companies are understanding more and more how important it is to be patient-centric and not physician-centric and make products that benefit the patient, not benefit the surgeon.
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That’s kind of exciting. The lawsuits, I’ve also promoted a shift away from a lot of synthetic meshes, which is good and bad. It’s good unless there’s a complete pendulum swing away from synthetic mesh because we do need some synthetic meshes. Otherwise everyone’s hernias are going to fall apart again. So we need a good balance. I would hope that instead of just moving away from purely synthetic products is to have pure, cleaner, less toxic synthetic products. So that’s kind of what my hope is for the next five years. And yeah, there’s a handful of new products that are out there, a handful. We haven’t had that much innovation. I would love to see my patented and some patent pending gender specific meshes out there because a lot of the design and the meshes to this day still are, they can cause complications. It’s not cool to feel the mesh.
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It’s not cool to have testicular pain after your hurting repair. It’s not cool to not be able to sit. These are all things that I hope well well be adopted soon so that the mesh is much better suited to male and female anatomy than it is currently. Okay, next question. What is the best or correct type of MRI and ultrasound imaging that should be done for hernias? Preoperatively, especially in females with inal hernias? So I have at least one episode. All I talk about is imaging and how to order it, what to ask for, what the results are. So go back and look at prior episodes that talks specifically about imaging. To specifically answer your question for MRI in the groin, I do recommend my hernia protocol. It’s posted on my website under patient. I think the patient visit or consultation visit where we have a copy of my MRI protocol for ultrasound, you have to order a hernia ultrasound with which is a dynamic hernia ultrasound.
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No contrast is needed for any of these. How would device companies be physician-centric rather than patient-centric? Aren’t the incentives the same and in line with each other? So with all the lawsuits, I would say that those interests are no longer in line. In other words, now the patients have the power with all these lawsuits to change the direction in which the mesh companies go. So if you’re legit changing your product to be safer and meet the needs of the patient instead of being easier to use for the surgeon, then I think that will help differentiate you as a company and make you a better company and therefore more profitable in the end in the long run. So that will be my answer to that. Aren’t the incentives the same and in line with each other? I don’t know what you mean by that. Obviously surgeons need to make money and surgeons and companies need to make money, but I can’t say that the two are symbiotic necessarily.
(00:55:36):
Okay. Next question. After hernia surgery, some people have central sensitization of their pain. The central nervous system undergoes structural, functional and chemical changes that make it more sensitive to pain and other sensory stimuli. Will central sensitization heal over time and are there any treatments available? So you’re qualifying this as after hernia surgery. I would say people who get severe pain, not necessarily due to hernia surgery, especially if they have nerve pain, can be at risk of central centralizing their chronic pain. And that if left untreated for let’s say nine months or more, then you can change the synopsis or whatever of your brain to the point where you have a chronic pain in what we call chronic pain syndrome. There is treatment for a ketamine is one of them. We’ve discussed this with some prior pain doctors. I think the Samimi Leilani group specifically on one of my podcasts talked about it. There’s some fascinating things coming up with it.
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The key is to reduce the amount of trauma during any type of surgery and specifically reduce any nerve injury to therefore reduce centralization of pain. How do you diagnose an occult hernia if it doesn’t show up on imaging? It does show up on imaging. That’s the key. And most people who are told that there’s normal imaging, their imaging is just misread, which is why I do so much. I offer so much imaging. Lemme rephrase this. It’s why I have online consultation where I review your imaging and it’s very common for me to find hernias that people have missed. Does centralization not improve even after nine months? If pain NIUs is removed and some people know that’s a whole issue of centralization. Once it’s centralized, the pain trigger is no longer in the groin or wherever the surgery was. The pain trigger is rooted in the brain. So it’s like people can get their arm chopped off and they can still feel the pain of their arm or their leg. They call it phantom pain, but it’s really centralization of pain.
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Let’s see. Okay, that was great. Did everyone enjoy it? I am so excited. 200, 200 episodes. What the hell? Who thought that this would be episode 200? I certainly did not, and I’m so grateful to you all. I always joke, seriously, people want to talk about hernias for an hour and they listen to this, but I think I’m hoping that I’ve made it maybe not so entertaining, but at least informational for you all that you keep on tuning in and maybe now that there’s so many episodes, you can pick and choose which topics you are interested in. Like let’s say imaging or I had a patient who called in and said, what did she have? She has some specific question. And I said, oh, we had a full episode on just this question. Go to episode number one or whatever. So again, go on my website.
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It’s beverly hills hernia center.com. All the podcasts are transcribed there. So if you just search for keywords like Florida, you could find those where we talked about Florida. You can also go on my YouTube channel at Hernia Doc or this and all prior episodes are there. And you can search on my channel for topics for the hernia talk live episodes. And obviously if you follow me then you can, I’ll learn these things. Oh, also on hernia talk.com, that’s also another good resource. Lots of people talking about that. Anyway, love you guys. Thank you so much for following me. Don’t forget, I am at Hernie Doc on Twitter and Instagram. I’m at Dr. Towfigh on Facebook and again at hernia dot on YouTube and I’m available as a podcast. Thanks everyone. This has been great. I really appreciate it. Bye.
