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Speaker 1 (00:11):
Okay, everyone, welcome. It’s Dr. Towfigh. I just need a little bit of a moment to connect to Facebook. For some reason, that’s always been an issue. Welcome. As many of you know, my name is Dr. Shen Towfigh. I am your hernia surgery specialist and I’m joining you once again Tuesday afternoon in Los Angeles, in Beverly Hills, California from the Beverly Hills Hernia Center. Many of you’re joining us live on Facebook as I’m on at Dr. Towfigh and also at Beverly Hills Hernia Center. If you’ve been following me on my academic journey on Twitter at Hernia Doc, you would know that I’ve been, two weeks ago I was in Nashville at the American Hernia Society meeting, so I plan on spending a little bit of time today discussing all the topics that were fascinating to me from that session. But specifically, my goal is to get you all engaged and help answer your questions. So for those of you who are interested, please submit your questions live. It helps current audience. It also helps future audiences that start looking through these sessions. As you know, I am available as a podcast as well as on my YouTube channel at Hernia Doc, and this and all prior episodes have been archived on YouTube. So let’s get started. Very quickly, has anyone been to Nashville? I’ve always wanted to be in Nashville.
(01:57):
There was an opportunity several years ago for me to go to a meeting in Nashville and I couldn’t make it, but I’m a big country music fan ever since medical school when one of my apartment mates was a big country fan and we would share a car because she had a car and drive together to medical school from our apartment and sometimes we’d work out together in the apartment building, and so she would put on country music and I really was not exposed that much to country music. I’m from Los Angeles and mostly it was West Coast rap and I loved it, especially the lyrics. So I got to learn to love country music. So I really wanted to go to Nashville. I used to wear cowboy boots throughout medical school and mostly residency. They’re very, very comfortable and they’re chic, and I was a big fan of country music, so I thought Nashville would be great. So I was super excited that I was able to go to Nashville and that’s where the American Hernia Society meeting was this past, just a little over a week ago.
(03:20):
For those of you, whenever I go to a meeting, a surgical meeting, I try to live tweet from there. The purpose of that is it engages the audience, it gets people involved in the societies to know what’s going on. Many people can’t attend surgical meetings, so this is kind of my way of sharing my time and effort and experience with them while they’re in another country or another city and they couldn’t go to the meeting. So that’s what I do on a regular basis. So if you’re interested to know what happens at surgical meetings that I attend a live tweet, for example, next week, sorry, next month, I’ll be at the American College of Surgeons. It’s the largest global surgical meeting in the world. I’m giving three talks there. I’m actually running one session, one course and then giving two talks. So while I’m there, I will also be live tweeting from the American College of Surgeons.
(04:20):
Most of what I live tweet about is related to hernias, but not all the time. So join me on Twitter at Hernia doc for that. Now at the American Hernia Society meeting, if you want to go back to my Twitter pages, and it’s only on Twitter, you can read and watch some of the videos that I posted. But I’d like to take a moment from this week’s hernia talk live session to go over things that I thought were very interesting and it’s going to be all over the place. There’s no hierarchy in importance or topics when we’re talking. So one thing that was quite interesting was there were two, so the way the meetings are part of the meeting are actual original research projects that were chosen to be discussed. The other portion is experts are asked to give talks on certain topics. So in the research part, there was some really, excuse me, there was some really interesting research projects.
(05:33):
There were two in particular that looked at patients anxiety and depression pre-op and correlated that with their outcomes. And it’s interesting, there was two separate teams that had report about this, but anxiety and depression is often a topic that most of us don’t really ask the patient. We ask if they’ve had surgery before we ask ’em about their symptoms of their hernia, but we don’t necessarily dwell on whether they have any anxiety and or depression. And so we don’t really have that much what’s going on here? And so we don’t really have that much data to share and know now we do because there are more emphasis on tracking that information. And so what’s interesting is patients that have baseline anxiety and depression, regardless of whether it’s well controlled or not, are more likely than the average patient to have higher levels of acute postoperative pain. And the other one looked at also chronic pain. So that’s kind of interesting because the what’s going on, why does it say it was live? Let’s see, am I not live on Facebook? Let’s double check.
(07:06):
Sorry guys. Looks like I’m not live on Facebook. I’m just going to quickly fix that. Okay, that should fix it. So what’s interesting is we know that people who have pain before surgery are more likely to have pain and chronic pain after surgery. What we didn’t know so much about was whether they’re controlled or poorly controlled anxiety and or depression would affect their outcomes and apparently it does. So patients with anxiety and depression are more likely based on two separate studies to have acute postoperative pain. Now what does that mean? Does that mean that therefore, does that mean that patients who are having anxiety and or depression need more attention after surgery or does it mean, I mean what it didn’t address was okay then what? Do we just make services better available to them? Do we tell ’em more about the risks and benefits of a surgical pain after her knee repair more than the average patient?
(08:32):
Or what is this just a data point that we can’t really do anything about because whether you’re on medications or not, that’s just the way your body will react to any surgery. That part was not clear. Okay. Let’s see. Okay, we are live. Perfect. The question was, were there any other sessions on the management of chronic postoperative pain? Yes, it’s pretty typical nowadays to always have at least one, if not more than one session on evaluation and treatment and prevention of chronic pain. That can be from inguinal hernias or ventral hernias, and there were multiple of those from the American Hernia Society. Most of those sessions that we have are very, very well attended. They tend to be in the larger rooms. They tend to be multiple surgeon experts on it. I’m almost always part of those type of sessions. Kind of what I’m known for is treatment evaluation and therefore prevention of chronic pain, especially in the groin.
(09:36):
And so yeah, there were multiple sessions on that. I had some scheduling conflicts. I wasn’t able to attend one of the specific ones, but I did post about some of them. Here’s a question. There are three small hole incisions for tap or robotic tap inal hernia pair. How big are those three holes in tap? Usually the camera is usually 10 to 12 millimeters and the other two are five millimeters. Will the central hole be bigger than the two other holes? Usually, yes. How big are those three holes in the robotic tap? Usually all three are eight millimeters. Will the central hole be bigger as well? Not necessarily. How big of a chance is it that those holes cause incisional hernias later on? Particularly for the center bigger hole, it’s a chance, which is why not all hernia repairs should get repaired laparoscopically or robotically as well as the fact that everyone’s different. So if you’re morbidly obese or you’re, you have risk factors where you’re at higher risk for incisional hernia, then your surgeon should be very careful to either close that middle hole or sometimes we take the middle hole, which is around the belly button to the side of the belly button. That tends to reduce the risk of incisional hernia because you have a rectus muscle that you’re going through instead of what’s called the linear elbow.
(11:13):
Just so you know, the beginning of the session included introduction of the president, the vice president and all that at the meeting they were giving away named lectures. We had some prominent surgeons, all of whom by the way were guests on my hernia talk live. We had some prominent surgeons that were given awards and also named lectures. Unfortunately, unfortunately two separate surgeons that were part of our hernia community had died in the past year. Both were young one, I think both were in their early either late forties or early fifties. One died I believe on his way to work and what sounded like a heart attack while he was behind the wheel. And the second one had a metastatic cancer that eventually took his life and he actually died on the last day, second to last day of the European Hernia Society meeting. So we had a lot of time and effort spent in tributes to both of them and there was a scholarship or award presented and funded in the name of one of them. So that was really, really sad and lots of crying there because they’re friends of ours and they died way way too soon.
(12:38):
Question, were there any sessions on sports hernia? I did not see a session on sports hernia. It’s possible that there was, there’s always some talk about sports hernias. It’s not always a prominent part, mostly because there’s very few of us that actually understand sport hernias, so it’s thrown in there a little bit. I did not see one, but I am sure there was one. How important is the clinical examination before primary surgery? Oh, I mean before any surgery you should have a clinical examination. So yes, it’s important. I’ll tell you why it’s important. I have friends that say, oh, they’re like, let’s say, let’s say they’re, I don’t know, sometimes surgeon, they don’t do physical exams like I already know everything based on imaging. Why do I need to do a physical exam? Well, in the case of hernias, not only is it important to know that you have a hernia or not, which an imaging can show you, but it’s important to correlate the areas of pain with the clinical finding of hernia. Just because you have a hernia doesn’t mean you need hernia repaired. And so if your pain is actually distinctly different than where you would have a hernia pain, that would prompt me to maybe not offer hernia surgery and consider another cause for your pain. I had multiple patients in the past week that had abdominal pain close to a hernia and so I had to figure that out even though they also did have a hernia.
(14:15):
It’s just important not to think just because there’s a hernia that all pain is due to the hernia and then deal with it of the consequences of surgery later. The other reason, which is why it’s important to do a physical examination prior to any surgery is to see what else is going on there. Do you have other scars? Have you had other operations? I had a lady with the hernia wanted her hernia fixed. She technically actually wanted her mesh removed, but she had a lot more going on. So if you have liver failure, those are physical exam signs that are important to find if you have a big tumor growing on your belly, if you’ve had multiple prior surgeries. One patient today had radiation, so he had tattooing from his radiations, so that would, the fact that he had radiation in an area that overlaps with the area of his hernias to me tells me that I need to change the type of hernia repair that I offer this patient to reduce the risk of inflammation, infection and non-healing due to the radiation and the same field as the surgery.
(15:24):
So that’s important. Also, cosmetically, you want to talk with a patient about where your scars will be and so on. So there’s a lot going on in the physical examination. You may find other hernias. A patient today had a lump that he didn’t really think much of. It was an incisional hernia separate from his other abdominal pain issue, which to date no one had even discussed with them. Have you heard of the one hole TEP for inal hernia repair instead of using three holes? What is your opinion on that? Yes, there is what’s called single port. So most single port incisions are three centimeters, whereas the other incisions for tap can range between five and eight centimeters, maybe up to 12 millimeters, sorry, five and eight millimeters maybe up to 12 millimeters. So incisional hernias are higher risk in patients. The larger the incision, they tend to hide the incision around the belly button area even though the fascial and the scar is three centimeters. So to date, I have not really dabbled in single port laparoscopy. It was a bit weird to do and cosmetically it’s better to have three little incisions and one bigger incision. There is now a sils or instead of sils, I guess it’s sirs. So single incision robotic surgery and sils is single incision laparoscopic surgery.
(17:08):
I think it’s good for me to know how to do it or know about it. I personally don’t like the robotic scar, so maybe a small three centimeter incision hidden somewhere in someone’s belly button is cosmetically nicer than three eight millimeter port sites across the belly where it is not very cosmetically pleasing, at least in my mind. So that is an option I would say for other types of surgeries in the where the port site is in the lower abdomen, sometimes a single incision may work very well. Next question. I had a left inguinal hernia repair with mesh this past June, experiencing ongoing pain in the groin, left hip and testicles, left groin, left inguinal hernia, mostly concerned with testicular pain and sexual function, little to no ejaculate. Initial ultrasound has shown hydros seals and cyst hydro seals. That may be a sign of maybe bleeding from the surgery going in for a second ultrasound because I believe the varicose seals are flared up too.
(18:26):
Yes, inguinal hernia repair with mesh, especially the retroperitoneal space, so laparoscopic or robotic inguinal hernia repair with mesh can increase your risk of worsening of underlying varicose seals. It doesn’t usually cause varicose seals, although in extreme situations it can, but if you know that you have varicose seals, this may make it worse. These symptoms did not exist prior to surgery. What do you think may be going on? So left anal hernia repair with mesh this past June. Ongoing pain in the groin, left hip and testicles. So a lot can be going on or this can just be result of a lot of tissue trauma which will then resolve. So at the very beginning I would get an MRI pelvis and not just rely on ultrasound. So the ultrasounds you’re getting are focusing on the area of your pain, which is a testicle, but the origin of the pain is higher up where the hernia repair was performed and so you have not had that imaged.
(19:34):
So you need an MRI pelvis, MRI Pelvis will show any fluid collection such as blood in the area that could cause some of the downstream pain. It will look at your mesh itself to see if the mesh has been placed in a flat position or if it’s balled up. It’ll also show if there’s any other findings such as some leftover fat in the hernia, which should have been taken care of, which is now trapped with the mesh and can cause some of your symptoms. If you have pain in the left hip, that can also be due to folding of the mesh or what else could it be from if the mesh is placed too low, sometimes hip flexion can be a problem. I just had a patient today who had mesh placed way too low and now all of his nerves are affected by it and he has problems sitting.
(20:30):
So these are all and his thigh is burning and scrotum is pulling. So all of these are consequence of how the mesh was placed, even if were we’re placed flat. So the next step would be MRI pelvis. Of course you need a radiologist and or a surgeon to correctly read and interpret the MRI. Sometimes if you wish you can contact my office to get a online consultation initiated, then that would include me reviewing all of your symptoms as well as your MRI. If you want to know what type of MRI if you go on my website under the patient instruction section, it will include a copy of the MRI hernia protocol that we use to specifically evaluate the pelvis after hernia repair in the groin and that you can share with your radiologist or your doctor who writes the order to make sure the order’s written exactly the right way.
(21:36):
I was asked to give a talk at the American Hernia Society about tips and tricks on how to have a successful private practice in hernia surgery. Many of you may know that I’m one of very few surgeons in private practice and specifically solo private practice that has been successful in the hernia world. It’s hard. It’s hard to be in private practice in general. It’s hard to be in private practice in the United States and hernia surgery in general is very difficult to be successful in private practice. So I reviewed all the pitfalls and recommendations on how to run a successful practice specifically in hernia surgery, but ultimately it was a good discussion about why anyone would want to do private practice. So if any of you watched Handmaid’s Tale, I’m right now starting season two. So season one seemed a bit scary, disturbing, very difficult to get through.
(22:49):
I really don’t even know why I’m watching it. It’s very high quality, but it’s also very, very psychologically I difficult for me to watch it. So the Handmaid’s Tale, I don’t remember if it was the end of season one or beginning of season two, aunt Lydia of Gilead, aunt Lydia gives a little talk about why the purpose of being where they are and why they chose to be in Gilead and why the Handmaids have a very special role in society and she reminded them, I’m getting to a point here, she reminded them that in the society, the Anarchy Society before Gilead, which is basically our current society, you were enjoying freedom to do things, freedom to X, y, Z. However, now in this wonderful Gilead world of hers that she’s describing, this is a better world she would say because you now have the freedom from, so you’re moving away from freedom too into freedom from, so you’re freedom from a lot of the vices and problems in the real world, freedom from all the burdens of the prior world, et cetera.
(24:19):
So I kind of hinged my talk at the American Hernia Society on that specific scene in the Handmaid’s Tale because the way I see it is when you have a private practice that offers you the freedom to do whatever you want, you can work four hours a day, you can work 12 hours a day, you can take no vacation, you can take three months of vacation, you can spend 10 minutes with patients, you can spend 10 hours with patients. You can have the freedom to do whatever you want. I have the freedom to run this podcast. I have the freedom to go to the American Hernia Society meeting without an administrator trying to question where I am and why I’m doing anything and why it costs this much money and limiting me and how much money I can spend on food and all that kind of stuff.
(25:22):
So those are all my reasons to go into private practice because it gave me the freedom to build a practice solely based on hernia care and very patient-centric without having to answer to the demands and the bureaucracy of a larger institution. However many people, in fact the majority over 80% of surgeons are not in any situation like me, especially not general surgeons that’s in the minority and they tend to be choosing, they tend to choose unemployed practice because of the freedom from the freedom from all the paperwork and administrative duties that they have to do to run a practice. Their freedom from billing, freedom from having to manage an office, freedom from all the HR issues, freedom from advertising, freedom from trying to find patients. And that is something that is very unique in the medical world, which is the freedom from is often chosen over the freedom too because dealing with insurance companies, dealing with the bureaucracy of running a practice and all the rules you have to follow can be very difficult in addition to just being an entrepreneur.
(26:55):
So that talk went really, really well. There was many people in the audience that specifically came to that because they aren’t happy in their type of work environment, but it’s very difficult to make that jump and take on the additional responsibilities of running a practice. Okay, question. I had an inguinal, her initial surgery on the left April, 2024 using the Shouldice technique. January, 2025, an ultrasound found a left indirect inguinal hernia, so that would imply that it’s a recurrence of the Shouldice and contains fat changes with Valsalva. September. So this month ultrasound found the same thing. Why is the hernia’s neck become smaller? Well, because we don’t measure hernia necks with ultrasound for inguinal hernias, there’s so much change to it based on what you ate, how much weight you’ve gained or lost, how much you press in and out because it’s muscle and muscle is very mobile. So for inguinal hernias, we don’t usually go by the dimensions of the hernia neck plus it also depends in what plane that they’re measuring in the hernia has become non reducible. Is that a problem? What shall I do? So non reducible hernias if they are not symptomatic. So no pain are usually okay. It’s the non reducible ones that are painful that require attention. Specifically in men, we do not have any data. Can you believe it on women?
(28:50):
Next question. Would you trust a surgeon who advocates not doing pre-op exams and or downgrading a pre-op appointment to a phone call? My ular hernia was repaired without a pre-op exam. The size and location was not recorded. It was a right hand hernia on the side of an earlier handlebar impact from a cycling accident. It was repaired using a right hand specific mesh. A recent MRI has shown that the mesh has been used bilaterally reaching left hand inferior epigastrics. There is no obvious problem on the left hand side. The original hospital has been refusing to answer any questions since the repair was done two and a half years ago. So I don’t know how you would even get approval to do any surgery on a patient if you’ve never seen them or examined them. That seems to me not how I would run my practice and I would probably not want to be operated on by a surgeon who has not touched me and examined me. I’ve been in situations where surgeons have not examined me and have offered me surgery and did not choose them as my surgeon. The fact that the original hospital is refusing to answer any questions doesn’t make any sense. A hospital doesn’t answer questions, you’d have to talk with an actual doctor, physician, surgeon so you can make an appointment to see your older surgeon and ask them the questions. That’s your right to do question.
(30:31):
Will the recurrent rate about the same for open versus laparoscopic mesh inguinal hernia repair for small hernias? We don’t know the answer to that. We do know that overall laparoscopic surgery if done by an expert, has a lower recurrence rate than open surgery done by an expert, but it depends on your own type of hernia and risk factors as to which is the appropriate choice. Recurrence rate is only one of many different ways to determine whether you should have an open or laparoscopic inguinal hernia repair with mesh. Next question, I think you have a special laparoscopic procedure with no mesh. Can I have this lap procedure for my left inguinal hernia? So yes, it’s called a robotic IOP pubic tract repair. The acronym is RIPT ripped, which is kind of cute. It is limited to patients of normal to low body weight and size with tiny, tiny inguinal hernias.
(31:35):
I do not recommend that repair for the average inguinal hernia because it does put a lot of tension on the repair. There are much better repairs available. So I don’t know your situation, but if you have an irreducible hernia probably already it is too big to be an eligible for a robotic non mesh repair or the ripped repair. Next question. Hi Dr. Towfigh, thank you for providing this valuable resource. Is it common for the male genitalia to be bruised black and blue following hernia surgery? Yes, that is common. It usually lasts about a week, maybe up to two weeks in some patients and should go away. That bruising is not really bruising necessarily. It’s all the blood at the level of the surgical repair has now seeped through the fat towards the skin and gravity has pulled it downwards. So upper thigh, sometimes outer hip, but upper thigh, scrotum, pannus, all of that can turn purple. It should be not that painful and in most situations it’s gone within about a week, sometimes two weeks.
(32:53):
I saw a lot of the specialty talks. So we had two different research projects where they talked about outcomes after transplant hernias due to transplant. So one was from a liver transplant study and one was from a kidney transplant study. I’ll tell you, I didn’t agree with all of the techniques they were using. I was trained at UCLA one of the biggest transplant centers in the world and there’s a specific reverence to patients and their organ that got transplanted. In other words, as a surgeon, you should never, ever, ever choose any technique that could ever give any risk to the patient’s organ. That’s a big, big no-no. There have been situations where people choose a hernia repair for their patient based on what they do for any patient and don’t understand that maybe there’s a higher risk of infection or a higher risk of bleeding or a higher risk of organ injury or a higher risk of complications in this transplanted population.
(34:13):
And I highly recommend, and I made this comment at the meeting that the choice of technique should be the one with the least risk of organ injury, not the least risk of complication from a hernia standpoint, not the best hernia repair, not the lowest risk of recurrence hernia repair. Your number one goal in treating a hernia in a patient with liver transplant or a kidney transplant is to reduce the risk of organ injury. That organ can be injured directly by you. Let’s say you’re in the belly or you’re suing or cutting or indirectly by too much blood loss or infection and so on. So that’s my personal bent. I definitely tailor care to the need of the patient because it’s really not cool to have a great hernia repair and the patient’s back in liver failure and lost the organ that was donated to them. That’s just not cool at all.
(35:20):
Next question. Should my surgeon conduct a CT exam before my angle hernia tap repair if I already have an ultrasound before? Usually not. In fact, most patients don’t need any imaging based on physical examination. The other discussion that was highly specialized was complications after breast reconstruction using either TREM flap or deep flap DIEP flap. That’s something I’m very interested in. I have a lot of experience in treating patients after a deep flap or trem flap complication. I’m in Beverly Hills, so automatically more patients are getting those type of operations with our plastic surgeons than other cities and therefore I tend to inherit their complications. So what I didn’t like was so I love that there was this discussion and I loved that there was a situation where we could have an actual session on this because it’s very, very poorly understood by most people. What I didn’t like was there were some doctors that were treating complications from a tram or deep flop the same way you treat any other hernia robotically.
(36:40):
They were sewing, they were putting mesh in, et cetera. And I will give you example, if you have a muscle injury, nerve injury from your deep flap and you get a bulging that’s not a hernia and no amount of hernia pair with fascial release and stuff is going to change that fact. In fact, cutting through muscle that has no hole in it in order to put mesh in deep to the muscle because that’s what we do with hernia repairs, I believe is not the right thing to do. Now I know that there’s other options for patients and they’re pretty good surgeons that do well with these, but cosmetically and for the patient’s benefit, I don’t think it’s appropriate to cut through muscle that has no hole in it to do a hernia pair on someone who doesn’t have a hernia but just has a bulge and the bulge is from a nerve problem, not a hernia muscle problem.
(37:48):
So those are kind of discussions that we were having back and forth. Surgeons could say their patient did well, but you have to understand when you’re giving talks at these sessions, you’re not talking to yourself, you’re talking to an audience, and the audience usually are not experts. They’re there to learn. They’re in smaller towns, they don’t have specialty access. Some of them are in training or want to do more. So my point is this, the patients that have deep flap and tramp flap complications should be treated differently than your typical ventral or incisional hernia. And definitely component separation is almost never the answer for many of these patients.
(38:45):
Let’s see. Oh, one of my former residents gave a talk, he’s now in practice. It was part of the pain control session. So as you may know, we have had two publications based on an anti-inflammatory bundle to help reduce risk of needing narcotics for pain control in a traditional Chinese medicine to help reduce the risk of opioid related pain control. Both of ’em were been published, you could read about it. We talk about use of arnica and ginger turmeric, alpha lipoic acid, brolin super B complex, and all these different Chinese herbs that can help reduce pain, nerve pain, inflammatory pain and bruising and swelling and that kind of bundle can help really reduce or improve outcomes after surgery. So he gave that talk that was kind of nice to give and it’s kind of nice to see that a former trainee is now out there representing the research that he did when he was a resident. Okay, next question. Do you think laparoscopic mesh ular hernia repair, especially the TAP T-A-P-P-P or even the TTEP has a higher chance of injuring intra organs than the open hernia repair? I mean, yes, but depends on the hernia. If you already have an organ going through the hernia, then you’re at risk of injuring that organ with an open repair as well.
(40:29):
But going in the abdomen with a T-A-P-P has a higher risk of injury to the organ, especially intestines than TEP. And that said, I don’t want to jinx myself, but I’ve never had such an organ injury and most, I would say most hernia specialists should never choose a technique where there’s a risk of organ injury. So your questions look very theoretical or appropriate if you are seeing a non-specialist. But if you’re seeing a specialist, it’s kind of irrelevant because it doesn’t happen. It’s like saying is it higher risk of running a car into a telephone pole than running a bicycle to a telephone pole? I would say yes, probably because of cars larger and I haven’t really heard of that many people running into a telephone pole with a bicycle. It’s kind of hard to do, but it’s kind of a theoretical question like how many people run their cars into telephone poles. If you’re driving normally and not intoxicated or you have good experience, you should not be driving your car into a telephone pole. So that’s kind of the way I think about it. I know it’s kind of a weird analogy, but I think it worked. I think that worked.
(42:01):
We gave a talk on our own research. My student Ian Kim, he’s great. He is a premedical student. For those of you out there there wondering what we do in the research lab, I have a full-time research student, his name is Ian Kim. He gave a great talk where we looked at surgical specialists and specialties and whether it affects the outcome. So if you go to a general surgeon, is that any different to get a hernia repair from a general surgeon? Then if you go to someone who is trained in laparoscopic surgery, what we call MIS surgeon, and is that different than the on-call surgeon or trauma surgeon that’s doing your hernia repair? So overall all populations together, the outcomes were similar, so you should expect a similar type of surgery, similar caseload, similar open, laparoscopic and robotic types of hernias offered and repaired. Whether your surgeon is a general surgeon is an MIS laparoscopically trained surgeon or is the on-call surgeon what wasn’t the same was your recovery afterwards. So surgeons who were MIS or laparoscopically trained, usually their patients had less pain after surgery even if they did open surgery than everyone else’s. And if you needed emergency surgery, your chance of feeling much better after surgery was higher than having surgery by a non on-call surgeon. Interesting data.
(43:51):
Next question. I’m wondering if you could help me make sense of something. In my hernia surgical report initially it says 10 by 16 barred mesh was placed later it says 10 by 15 proline mesh was put in. I confronted the surgeon because I interpreted it as him putting in two hernia meshes for a pantaloon inal hernia and wondered why. He then told me only one mesh was used, it was barred and that the proline was just a type of used. Does this sound weird to you? No, it doesn’t sound weird at all. So the barred mesh is a 10 by 16. Sorry. Now I’m making mistakes. The bard mesh is the brand of the mesh. It comes in 10 by 15 and 12 by 16. So you had the 10 by 15 mesh. It’s made of polypropylene. The brand name for polypropylene is prolene. Sometimes we use a brand name, but the correct term is polypropylene. So no, it sounds like you had a single mesh placed over a pantaloon inal hernia. It’s a size large barred mesh, also known as the 10 by 15 centimeter barred polypropylene mesh. If you really want to know for sure what was implanted in you, there is a log of the implant with a sticker in your chart somewhere that says exactly the lot number and everything of the mesh used and the size and the brand. Not weird at all.
(45:21):
Let’s see. So at Ohio State University, Dr. Ben Poulose, again prior guest of Hernia Talk Live gave a talk on collaborative research and he talked about how there’s so many questions that patients have that we don’t study. And so he has chosen to study it. He has a research team. It includes physical therapists but also includes engineers and chemists and all that because he’s part of a greater university system. He was talking about these research projects that they’re working on. I mean, some of the topics were so fun because these are questions that patients ask microplastics. How do we know that microplastics from the plastic, the polypropylene mesh that we implant into patients doesn’t then enter the bloodstream? So now they’re doing a study where they’re looking at testing for microplastics before and after hernia mesh placement and interesting questions like that. So fascinating. Here’s another question.
(46:50):
Do you think broad mesh is a good mesh? Yes. How does it compare to Medtronic’s Dile or pro grip or 3D max inguinal hernia repair? All good. All good. The Medtronic Dile mesh is a polypropylene mesh considered to be a in par with the 3D Max product. Just a different company makes it. The Medtronic program mesh mostly is a polyester base, although they do have a polypropylene option, also very good mesh. They’re all good. They’re not great. They’re all good. We don’t have any great meshes question. I had testicular pain. My scrotum was hit and injured one year ago. Initially the testicular pain whenever I moved was severe for a month. I couldn’t sit for one minute. One month later the pain was less severe, but I could still could not sit for more than one minute about January, 2025, I could sit for about 10 minutes.
(47:52):
The pain level increases from four out of 10 to seven out of 10. When sitting more than 10 minutes, is it possible that the posterior scrotal nerve and peroneal nerve got injured? And what treatments are available for these? These are urologic questions. I would seek evaluation by a urologist who deals with male infertility and specifically chronic post vasectomy pain. Those tend to be the urologists that also understand the nerves that go to the scrotum and so on. This sounds like this is not a hernia question. The abdominal pressure does not feel right when I’m lying on my bed face up. Can this be because of anular hernia? I don’t know what you mean by your abdominal pressure. Doesn’t feel right.
(48:49):
I have no idea what that means. How do you not? I don’t know what that means. I’m sorry. Abdominal pressure does not feel right when I’m lying on my bed face up. I don’t know what that means. MD Anderson. Oh, here’s another question. Will I be able to do different kinds of the same level of exercise after a few months after I finished the inal hernias repair open versus laparoscopic? Yes. Any limitations on exercise after six months of hernia repair via open or laparoscopic? No. MD Anderson, one of the biggest cancer centers in the world, has some really great surgeons that are also interested in hernia repairs. They’re not cancer surgeons. They are general surgeons and laparoscopically trained general surgeons. However, they’re a hundred percent of the population at the hospital has a diagnosis of cancer. So these hernia surgeons in the cancer center have to deal with patients with cancer who also need hernia surgery.
(50:03):
So they give these great great talks. Actually, Dr. David Santos was one of my guests on Hernia Talk Live specifically talking about cancers and hernias. They talked about metastatic cancers and hernias and they talked about all the different cancer medications and how it affects healing from hernias and how to coordinate all that. So that was really great. And then we had this whole other session where surgeons were presented really difficult cases and I was so saddened by some of the situations because for example, there was a woman, she had breast cancer, then she had an abdominal wall flap, I think a T tram flap. Yeah, pretty sure it was a T tram flap to recreate her breast after mastectomy.
(51:09):
So, so far everything’s okay. Then she gets pregnant. I don’t know how someone is allowed to get pregnant with a breast cancer history. I believe that increased your risk of breast cancer. But let’s say that was a non-issue. She gets a C-section. C-section in someone who already had a T transplant. I would think that’s a big no-no. And if you do plan to do it that your gynecologist will work with your plastic surgeon to coordinate an elective C-section because that sounds like a horrible plan to do a C-section after tramp flap. Okay, so she gets a C-section. As you can imagine, her entire abdominal wall is now destroyed because you’re missing your rectus muscles and you’re cutting through the tissue that was put together to recreate the abdomen with a missing rectus. So then she had this humongous abdominal defect, then she had bariatric surgery.
(52:25):
So during the bariatric surgery they didn’t understand what was going on with the abdominal wall. And so they did the bariatric surgery of like, yeah, you got your hers if you want, we can go fix it. At the same time another no-no, you don’t mix a very complicated elective surgery with another complicated elective surgery. So they just put some mesh in there, which was the wrong thing to do, and then the mesh was wrapped around her intestines and horrible situation. So now she’s at the door of the hernia specialist saying, how can you help me? Whereas that hernia specialist should have been called before the C-section and there should have been coordination of care at that time. And then when the bariatric surgeon went in there, they should have called the hernia doctor during the bariatric surgery and coordinated care there instead of now her needing a complete revision undoing of everything you’re redoing. It’s just not a good situation. So sometimes I go to these meetings and I’m saddened because the stories that I hear are very similar to the stories that I hear when I have patients come visit me and it’s just not right. We need a better coordination. We don’t live in isolation. Doctors should be talking to each other. They should be coordinating care together.
(53:47):
Question thank you for answering my earlier questions. The surgeon in question posted an article in 2016 claiming that 517 patients were operated on between 2012 and 2015. It can be found on Google under single visit laparoscopic hernia repair. Yeah. So sills a single incision laparoscopic hernia repair sills. Yeah, it’s done. I don’t do it for laparoscopic because to me it seems like a very technically awkward way to fix the hernias and the incisions are larger. The newer technique is the robotic single incision port or single port surgery. SP they call it robotic sp, which maybe something I’ll look into, but at this time it’s not part of my practice. Well thank you for sharing that. Next question, will it be easier to kill the mild bacterial infection in a polypropylene medicine, a polyester mesh? Yes, that theoretically is correct. Although today’s polyester mesh seems to be a bit different and not braided like the polyester mesh from the meline days. And therefore the thought is that it’s more resistant to bacterial infection than the older generation polyester. But still we consider polyester more difficult to rid of bacterial infection than polypropylene.
(55:30):
In response to my comment about the abdominal pressure not feeling right, the explanation is there is squeezing pressure inside the abdomen belly. I feel like someone is squeezing my small intestine or large intestine. Can this be because of an inal hernia? I mean if you have inal hernia squeezing your small intestine or large intestine, yes, but that’s usually in the groin and not in the belly. So know it shouldn’t affect your abdominal pressure. Alright, that was a lot. You got a lot of questions. I loved it. I really enjoy these. I’ll try and do another one of these after the American College of Surgeons meeting. It’s going to be a really fun one. It’s in Chicago this year and I love Chicago. For those of you out there, I love, love, love Chicago. October is a great time for Chicago because it’s not too cold, not too hot. And overall, just a really great time to have the meeting. I have three talks to give so I’ll be busy.
(56:35):
For those of you who don’t know, Chicago is becoming much better for hernia care. Both Mike Rosen and Todd Heniford have been prior guests of my hernia talk live. They both left their prior jobs at Cleveland Clinic and the Carolinas respectively and are now heading up hernia programs or general surgery programs in Chicago at Northwestern and University of Chicago North Shore now called Endeavor. Exciting times and I hope to share some of what I do there. And this is good news for those of you that are in Chicago area looking for hernia specialists. That’s it my friends, thank you for joining me. I really enjoyed, there are tons of questions that you guys had for me. I will see you again next week with a guest to see you then.