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Speaker 1 (00:00:11):
Hey everyone, it’s Dr. Towfigh. Welcome to a Hernia Talk Live. I’m your host, Dr. Shirin Towfigh. Many of you’re joining me live on Facebook. I’m Dr. Towfigh. You may be on the Beverly Hills Hernia Center site. As you know this and all prior episodes are available to watch as a YouTube on my YouTube channel at Hernia Doc. And if you’re like me and you’d like to watch or listen to podcasts when you’re driving to work, I even do it on vacations. This is also available as a podcast. So if you like the podcast, please like and share, and that way more people can get to watch it. So I’m really excited because we have a great guest today. Her name is Dr. Karen Zaghiyan. I’ve known her for, well, I don’t know, she’s going to have to tell me how long I’ve known her. I’m going to say close to 16, 17, 18 years I
Speaker 2 (00:01:08):
Think. So
Speaker 1 (00:01:11):
She is a colorectal surgeon in Los Angeles, one of the premier ones because she is very, very caring and knowledgeable at the same time. You can follow her on Instagram at Dr. Karen Ziggy, under official or on Twitter at Karen Ziggy md and here she is. Hi Karen. Hi.
Speaker 2 (00:01:32):
Nice to meet everyone. Thanks for having me, Shirin.
Speaker 1 (00:01:36):
Of course. So Karen kind of has a practice like mine. In that addition to her training as colorectal surgeon, she inherits complicated patients. Patients no one else can figure out. If someone needs help, they usually call Karen. You’re just very approachable kind and knowledgeable and skilled. So it’s like a quadruple threat, I guess you can call it. So she answers my calls and my texts when I call her has always been helpful. And we’ve shared some really complicated patients together. So if any of you are on TikTok, what is your handle on TikTok? Do you know?
Speaker 2 (00:02:21):
I think that’s a good question. I think it’s the same, but my Instagram handle went to official because I got hacked.
Speaker 1 (00:02:30):
Yeah. So she’s so popular. She got hacked, and so she had to change her name to Dr. Karen Ziggy official. So is that the same thing for TikTok?
Speaker 2 (00:02:42):
The same thing,
Speaker 1 (00:02:43):
Yeah. Okay. So I follow you obviously, but if you follow her this past week, she went on a little bit of a rant because, well, maybe you can explain what your rant was.
Speaker 2 (00:03:02):
I had a company that came out to try and sell me a device, and they’re selling pitch for this device was, well, the OBGYNs are using this to treat people’s hemorrhoids all the time. And you guys, my draw was literally on the floor. When I heard that, I was like, wait, what? And she was like, yeah, the OBGYNs are using this and they’re seeing really great results for people’s hemorrhoids. And I, I didn’t know what to feel. I was appalled
Speaker 2 (00:03:39):
Because to clarify,
Speaker 2 (00:03:42):
To clarify, OBGYNs are not trained on hemorrhoids. They’re not trained on the anal canal. Yeah. That’s in the same area. We get referrals for hemorrhoids a lot from OBGYNs because of common complication of pregnancy, but they’re not experts in deciding what to do for somebody’s hemorrhoid if they can get the diagnosis correct. That’s amazing. But that’s not necessarily accurate most of the time either, because any growth in the anus is commonly just labeled a hemorrhoid. And so here I am thinking like, oh my God, there’s patients that have, who knows what they have being labeled as hemorrhoids and being treated in an OB GYN practice. Now, I don’t personally know of any ob GYNs that are using this. I’ve
Speaker 1 (00:04:38):
Never heard of that. That’s crazy. But the rep is telling you all the time,
Speaker 2 (00:04:43):
Yeah, yeah, exactly. And that their patients feel great with it. So I should use the device.
Speaker 1 (00:04:50):
Oh my God, that is so scary. But you know what? This is the issue that I hear as well. So anyway, you did this post on TikTok and I was like, I need to bring her on because the energy that she has right now is the energy I have every single day in clinic because there are people that are doing things that are, I can’t say necessarily that they shouldn’t be doing it. Some people that they shouldn’t be doing it, but they’re definitely not specialists. And something that I always say is find their specialists and then but you like, and then trust the recommendation. Instead of saying, I want X and I’m trying to find a doctor who’s willing to do exactly what you’re telling them to do. What is in my feeling? I want a non mesh repair, and yet they have this humongous hernia. And then they’ll find eventually someone who’s not an expert that’s willing to take their money and do a procedure they’re not an expert in. And it’s just when you said it, I was like, oh my God, this is exactly what’s happening in our specialty. It happens in your specialty.
Speaker 1 (00:06:05):
It’s
Speaker 1 (00:06:06):
Frustrating.
Speaker 2 (00:06:07):
It’s very frustrating. We see it on the other end. And when you get a referral, you don’t want to badmouth another specialist. You don’t want to say to the patient that somebody did something wrong. And it’s not even just doing the wrong thing, but it’s not having all the options. When I think of who’s an expert in this thing, I think of Dr. Towfigh as a hernia expert. So if I have a patient that has a complex hernia, she’s going to figure out what the best thing is for that patient. I don’t know, but she knows. So if she only did one particular type of repair, then that would maybe make her not an expert specialist. Not special. Not special.
Speaker 1 (00:07:01):
One thing you mentioned in your post was when you’re going to see a specialist, there are a lot of people that call themselves hernia specialist. As you know around me, ever since I opened up my hernia center, there’s like 15 other hernia centers, which is a lot of it is marketing ploy. But to be a true specialist, and I’ve mentioned this before, you should be able to, in my field, you should be able to offer open, laparoscopic, robotic with mesh without mesh, groin hernias, hernias, rare pelvic hernias, the whole spectrum. So when a patient comes in, I can say, okay, you have this entire menu, but in this menu of operations that can be performed. This one and maybe a second one is what I recommend for you because the rest are not appropriate, for example. But if you are only doing one procedure, then that’s not being a specialist. And what you were saying is to offer the whole spectrum. You do anal rectal, you do colon cancers, you do congenital problems. Right.
Speaker 2 (00:08:10):
And I mean, even if you take the single one diagnosis, let’s just make it simple and say hemorrhoids, right? Let’s just say I am only a hemorrhoid specialist. If I’m a hemorrhoid specialist, I should be able to offer all the, I should be able to do sclerotherapy, I should be able to band, I should be able to do surgery. I should know the different kinds of surgeries that are appropriate based on the patient and what they have. Somebody that has external hemorrhoids doesn’t need the same surgery as someone that has prolapsing, internal hemorrhoids. So to really that way when I see the patient, I could say, okay, out of this toolbox that I have that is for hemorrhoids, which 1:00 AM I going to select for this patient based on what they have, what they want, whatever. But if you only are trained to do in general surgery, we trained on doing excisional. We learned that in general surgery. So I mean,
Speaker 1 (00:09:13):
I’ve done hemorrhoidectomy, but I was in my late twenties. That was a long time ago. I’ll never do a hemorrhoidectomy ever. You pay me a billion dollars, I won’t do your hemorrhoidectomy.
Speaker 2 (00:09:31):
Yeah.
Speaker 1 (00:09:33):
So the question that sometimes the patients ask is, as a patient, how do I know if my doctor’s a specialist or not? They say they’re a specialist on their website or they seem nice, or my medical doctor referred them to them. I mean, there’s a lot of surgeons that are very nice surgeons and they get referrals because they’re easy, approachable, they’re kind, et cetera, but they’re not necessarily specialists. So what’s the answer when the patients ask, how do I know if my doctor is a true specialist or not?
Speaker 2 (00:10:09):
I think it’s hard to navigate that as a patient. I think one of the things you could do is look at board certification. I know in hernia there’s no board certification, but in colorectal there’s board certification. So looking to see, I don’t know if there’s other kinds of certification or something that you get based on whatever in hernia
Speaker 1 (00:10:35):
You can check to see if they’re, first of all, always make sure that they’re licensed. There are plenty of unlicensed doctors out there. And then you can look at their, maybe their education, see if they actually did a fellowship in colorectal surgery. Like you said, in my case, there are people that are not even finished general surgery that do stuff, but that’s usually uncommon. And then board certified in general surgery, board certified in colorectal surgery. You guys have a board, right?
Speaker 2 (00:11:06):
Yeah. So we’re dual certified, so we’re general surgery certified, but then we’re also colorectal surgery certified. And it’s not uncommon that somebody says board certified, but you want to dig deeper. See, that’s the part that it’s hard as a patient to navigate. How’s a patient supposed to know that colorectal has a separate board, and if I have a colorectal condition, I should be looking for a boarded colorectal surgeon. But hernia doesn’t have a board and you’re just looking for a But for a general surgeon, but then maybe ISI think MIS tends to be
Speaker 1 (00:11:46):
Like a laparoscopic fellowship that could help, right?
Speaker 2 (00:11:49):
Yeah.
Speaker 1 (00:11:50):
We have societies. Sometimes I say if a surgeon is private society, sometimes that implies they have an interest in that topic, right?
Speaker 2 (00:12:01):
Publications, not every surgeon is academic necessarily and publishing, but if they have publications in the topic that you are looking to get treated, I think that is definitely a bonus and implies that they have
Speaker 1 (00:12:18):
Expertise.
Speaker 2 (00:12:20):
So not every doctor who publishes is a good surgeon, so you kind have to put That’s true. Another, and
Speaker 1 (00:12:27):
Yeah, that’s a problem. And then I don’t know. I think even though Yelp and all those are not exactly indicative of a great surgeon, but if they have a three or lower score,
Speaker 2 (00:12:43):
Definitely. Well, I think you can also look at the reviews and say, see what they’re saying. If you look at, I have good reviews, I have really great reviews online, but I have some negative reviews, and most of the time if you read it, it’s meaningless. Right? It’s not a substantial thing. I don’t know. Yeah.
Speaker 2 (00:13:07):
I’m
Speaker 2 (00:13:08):
Diagnosed the wrong thing and I don’t know. Yeah.
Speaker 1 (00:13:10):
I have someone who wrote me a bad review and said, I was popping potato chips during the exam, and I’m like, how is that even possible? Is that not even credible? First of all, I don’t eat potato chips, but even if I did, I wouldn’t eat it during a physical exam of a patient. So patients usually read those things or that’s not credible.
Speaker 2 (00:13:35):
What about referrals? If it came from your trusted primary or is that
Speaker 1 (00:13:43):
Yes and no. I don’t know about those.
Speaker 1 (00:13:46):
A
Speaker 1 (00:13:46):
Lot of the referrals it has to do, not necessarily that you’re a specialist, but there’s a personal relationship with that doctor. And that could be because they shared patient care and they’re having a great experience, or they both go golfing at the same country club. I mean, it’s unclear. That part’s unclear.
Speaker 2 (00:14:06):
Yeah.
Speaker 1 (00:14:07):
I say always get too, if you’re contemplating surgery, get two opinions. I mean, I’ve had my own surgeries. I know exactly who to go to. I still went and got more than one opinion. I just want to make sure.
Speaker 2 (00:14:19):
Yeah, totally.
Speaker 1 (00:14:21):
Yeah. Here’s a question for you. You said research papers in the field is important to indicate a specialist. There’s a doctor who wrote a book regarding his field or her field, but no peer reviewed articles carry the same weight to indicate a specialist.
Speaker 2 (00:14:37):
That’s a good, I mean, I think if they’ve, what kind of a book?
Speaker 2 (00:14:44):
A mystery book. A novel.
Speaker 2 (00:14:48):
A novel.
Speaker 1 (00:14:49):
There’s a lot of time that needs to go into a book. I would add that.
Speaker 2 (00:14:53):
Yeah, totally. Yeah. If it’s a legitimate book, I think so.
Speaker 1 (00:15:02):
I mean, there are certainly people that write promotional books, but I would say in general, that’s usually an indication they have a special interest at least. Do you think that it’s always important to go to a specialist?
Speaker 2 (00:15:20):
I would want that. I mean, for myself, I would want a specialist, especially if one exists. If a specialist exists and you have access to a specialist, I think it’s important to do that.
Speaker 1 (00:15:41):
Yeah, I would say that the same thing, but it costs money. I understand that, but nowadays, at least you can do telehealth, so you don’t have to necessarily travel all over to see a doctor. So that’s a positive. Since COVID, a lot more people, I
Speaker 2 (00:15:55):
Do that all the time. I’ll have patients call in and they’re having surgery somewhere else, and they just want to get my opinion as to whether the plan is what I would do. And they’re not necessarily willing to travel to do the surgery, but they just want to make sure that the plan that’s set forth is appropriate. I think you can always do that, even if it’s not feasible to leave where you’re at or go outside of your insurance.
Speaker 1 (00:16:32):
The other thing is skill.
Speaker 2 (00:16:36):
Oh, yeah. So
Speaker 1 (00:16:36):
That’s a hard one.
Speaker 2 (00:16:37):
That’s a hard one.
Speaker 1 (00:16:38):
Yeah. I think as I have a friend, she was proctoring another surgeon. So when you proctor, let’s say you have a new surgeon in your hospital, your new surgeon is mandated to perform a bunch of operations and have it be proctored by someone who already is privileged in the hospital. So the hospital can assure that that’s a skilled surgeon. So she called me and she’s like, dude, this was a hernia and it was the worst performed hernia as a proctor. You’re not there to teach them anything, it’s observational. But she was telling me about how this is a surgeon who’s not even a junior surgeon. The surgeon has been in practice elsewhere before, and they picked the hernia to be proctored. And she said it was one of the worst. And she’s like, I’ve never operated with these people, so I don’t know how other people do it. But she assumed people that get hernia stories. I said, Nope.
Speaker 2 (00:17:44):
I think the other thing I always say, the thing to ask and people ask this is, I used to get asked a lot until I got all my gray hair that how many years have you been out in practice? But I think the more important question is how many of these cases do you do monthly? How many of these cases do you do yearly? And then also knowing what that surgery is, you might have a very, very rare thing that it’s being done and maybe it’s not that common, or you may have a very common procedure that’s being done. I’ll tell you in our field, couch surgery has dropped so significantly to the point that our fellowships are now, we are actually only required to have our fellows do three J patch operations. Really?
Speaker 1 (00:18:35):
That’s for ulcerative colitis.
Speaker 2 (00:18:37):
Yeah. So J patch surgery for anyone who doesn’t know is it’s when patients have severe ulcerative colitis or for familial polyposis where the entire colon has to be removed, and then we have to reconstruct the small intestine into a new rectum and then attach that down to the anus. So it’s pretty much like that. And rectal cancer surgery, like the two probably most complex surgeries that we do in our field,
(00:19:04):
And because of improvements in medical therapy, the number of patients that are having this operation has dropped very significantly. And so our board had to make a very difficult decision because people were not completing their numbers and fellows were having to leave their institutions and go out to tertiary and quaternary centers to get their JPO numbers. Our board had to make the decision to say, okay, if you do three J pouches during your fellowship, you’re allowed to graduate. Now. Hopefully that person is not going to, now the person who trains at the low volume JPO center hopefully is not then going to go out into practice and be offering that surgery to patients. But how would you know as a patient, how do you know? And it’s the same with our rectal cancer numbers in rectal cancer with the really great improvements in chemotherapy radiation, and now we do watch and wait, what we do for anal cancer, we’re doing it for cancer, for rectal cancer.
(00:20:12):
So we give chemo radiation, and a lot of, probably about 40% of patients have a complete response and don’t need surgery at all. So our numbers have tanked. So now it’s become even more and more important that if you’re selecting a surgeon, you’re picking somebody who does that operation a lot and sees that volume a lot in cancer. It’s kind of like one way to know, was your case presented at a tumor board at a multidisciplinary case conference? That’s one way to know. If you’re a high volume center, that’s a lot. Or if your surgeon attends that conference, that’s one kind of way to find out. So always ask that. But in JPO surgery, no. I dunno. There isn’t as much, and it’s such a complex surgery that could literally impact the rest of your life if something goes wrong.
Speaker 1 (00:21:07):
This is so fascinating. What’s unique is in your specialty, it sounds like that’s pretty amazing. I am clearly not a colorectal surgeon. I did not know there was such thing as watchful waiting for colon cancer, and I did not know that J pouches are not as frequently done
Speaker 2 (00:21:28):
For You used to think that’s like a bread and butter. I have more than read my residency like bread and butter. Oh my god, surgery. But now, I mean the management has gotten so complex. There’s so many different pathways. It’s really gotten complex on not just the surgical level, but also the medical decision making that you really need to be at a center that has expertise and a surgeon who, I mean the number of patients you’re in, I still see who, who have been recommended an A PR who don’t need an A PR
Speaker 1 (00:22:03):
That’s completely removing their colon down to the rectum and closing the butthole,
Speaker 2 (00:22:08):
Closing it up, permanent colostomy. Patients are being recommended. This surgery still today in the US don’t need that surgery. They can be reconnected.
Speaker 1 (00:22:19):
Wow. But that’s specialized. What do you think about the person who lives outside of somewhere near a major city who doesn’t have access to that kind of specialty? Do you think they should? I think they should at least go speak with a specialist and understand what the options are out there. And if they therefore make an educated choice to go back to their hometown with their local doctor, that’s fine, but I think you need to know, know more. That’s the way I feel about it. Okay. Should we do some questions that were submitted?
Speaker 2 (00:23:04):
Yeah.
Speaker 1 (00:23:05):
Okay. Let’s see. Hold on one second.
(00:23:25):
Okay, there we go. How can you avoid an unending chain of referrals when trying to find the root cause of an obscure illness? Oh, I see. So you keep going. I think the problem is, well, I don’t know really what this question’s asking. I think when you have an obscure illness, you will be seeing multiple referrals because it’s obscure. So someone say, oh, this is a nerve problem. Go to this doctor. Oh, this is a hernia problem. Go to this doctor. Oh, this is a autoimmune disease. Go to this doctor. That’s usually what happens. We don’t have a privilege of one doctor knowing everything,
Speaker 2 (00:24:08):
Which is a good thing with specialization, but is a bad thing with specialization.
Speaker 1 (00:24:15):
Yeah. I feel like besides the fact that I think it’s good to have specialists, I think it’s also very important that specialists talk to each other. So I learn from you when I refer patients, I don’t just send them out and don’t talk about it anymore. I either come in the or see what you see and do, or I ask you what are your plan with the patient so I can learn
Speaker 2 (00:24:42):
Because
Speaker 1 (00:24:43):
I’ll have another patient perhaps similar. And then that way when I see them, I can be a little bit more educated in the way that I discuss with them potential options and who they can see. So I think that we can definitely improve on, in the United States, we’re very siloed, but we don’t cross train. I would say though, you tell me how you feel about it. I think in private practice we’re a little bit more collaborative, I think than not. It’s easy to kind of be very siloed and not collaborate across specialties as much when you’re employed.
Speaker 2 (00:25:21):
It’s even harder when it’s across institutions.
Speaker 1 (00:25:25):
Oh, true.
Speaker 2 (00:25:25):
Right. Which is probably why people like the primary care doctor is going to refer you to his best friend because then it’s easy to get the information back from the best friend rather than trying to find out who’s the specialist or the expert in this. I’m just going to say my friend, because that at least the communication barrier is not broken, that’s packed because they can just text back and forth. Whereas if you have a person at, sometimes when I get cancer patients and they’re coming from another center where all their testing, their chemo, everything was done at another center,
Speaker 2 (00:26:07):
It
Speaker 2 (00:26:07):
Becomes harder to get all that information, talk to who saw them and treated them to begin with. That’s true. So that can be challenging.
Speaker 1 (00:26:16):
Yeah, that’s true. We do prefer to get as much work and specialists done within one institution system because of the medical records issue. Otherwise, there’s a lot of work by the patient to keep taking all of their medical records to other people and getting and finding doctors that care to go through those medical records.
(00:26:39):
That’s a lot of work and interest. I think that sometimes doctors are in a situation where their system doesn’t promote sitting down with the patient for an hour and going through everything and leafing through and figuring out things. They have other responsibilities given to them, including seeing so many patients or billing for so many hours. But when you don’t have that, I think that’s one of the things I love about my current situation is I don’t have that extra pressure on me outside of what I do. So I spend as much time as I want with the patient. It’s really nice. Very grateful. All right, next patient. Next question. What illnesses demand close cooperation between a colorectal and a hernia surgeon? Oh, you would ask this question and we just spoke about it before we went live.
Speaker 2 (00:27:49):
So I did an operation on a patient who that surgery where the rectum and the anus all have to come out. This woman had an anal cancer and had to have her entire rectum removed and a colostomy, and she got a hernia into her perineum. So basically she’s got a little lump hanging out every time she walks down where her rectum was. So I asked Dr. Towfigh if she can fix it, and she said she’s done plenty of them.
Speaker 1 (00:28:28):
So peroneal hers are interesting. There’s two types. There’s all three types. Now there’s the surgical one like yours, right? There’s all the prolapses, right? Rectal prolapse, vaginal prolapse, cysto seals, rectus seals, racal, all those are all in the midline often due to either some congenital genetic laxity or because the patient had multiple pregnancies and bad deliveries and so on. And then the third one are the ones at the side, which are what I call peroneal hernias that are primary peroneal hernias. Those we don’t know why people get it, like any other hernia, it’s rare, usually poorly diagnosed, they have problems sitting and so on. So those I actually enjoy doing. They’re very complicated. You have the rectum in the way, the bladder in the way, the uterus in the way, and then there’s some nerves and vessels. There’s a lot going on in the pelvis.
(00:29:30):
And hernia surgeons in general are not as comfortable in the pelvis as, let’s say colorectal surgeons because we’re general surgeons. And general surgery doesn’t teach you, I think that pelvis as well as the other parts. Right. Do you agree with that? Yeah. So gynecologists, urologists, they work in the pelvis. Colorectal surgeons learn to work in the pelvis, but if you don’t have those specialties, I think most people are uncomfortable. Over time, I’ve become comfortable because I do so much groin pain and pelvic pain stuff, but it’s still a tricky area. There’s so much going on. But yeah, so the A PR, that’s the problem with those is the once you get rid of the anus, those muscles are really weak to begin with, and then they don’t hold stitches very well. So they just loosen up. And the smaller they are, the easier they are to repair. It’s a really big ones that are more difficult to repair.
Speaker 2 (00:30:37):
I will tell you, this woman has scleroderma. Does that affect anything that you would do?
Speaker 1 (00:30:42):
Yes. Maybe. Depends on how severe it is. So scleroderma is an autoimmune disorder, and in general, I don’t like to put a lot of synthetic inflammatory mesh in patients with sclerodermas. So we would have to err on using less inflammatory mesh products, like the hybrid meshes still doable, but scleroderma is an interesting situation, both an autoimmune disease and a little bit of a, I think they also have a collagen disorder. I’ll have to look that up. There’s a combination of two things you don’t want to have at the same time. So it’s mostly the peroneal disorders,
Speaker 2 (00:31:27):
AAL hernias. We also have hernias,
Speaker 1 (00:31:30):
Atomal hernias. So colorectal surgeons fix those as well.
Speaker 2 (00:31:35):
Yeah.
Speaker 1 (00:31:36):
And what’s the thought in your specialty about a colorectal surgeon fixing it?
Speaker 2 (00:31:42):
I think it’s okay for us to fix it. I think, again, more and more as hernia surgery has become specialized and there’s so many different meshes and so many different things going on, I do have a tendency to refer those out too. I think there’s a certain population that we hold onto like our IBD patients, because we try to avoid putting mesh in those patients as much as possible. So we will frequently do local tissue repairs and stuff on those, understanding that they have a higher risk of recurrence, but not wanting to put mesh in a patient with Crohn’s disease if we can avoid it. I think when you have situations where the hernia gets really big and you have loss of domain, I think then it becomes really much more important that we have you guys on board. Because sometimes you might need tissue reconstruction, component separation, other things to reconstruct a large hernia than just slapping a mesh in there. And I think, again, we don’t do it a ton. So if you’re not doing something a lot, why not let somebody who does it a lot do it?
Speaker 1 (00:32:54):
Yeah, I would say that’s very good. You say that. So I am super cautious about patients with inflammatory bowel disease
(00:33:03):
Similar to the scleroderma patients, autoimmune disorders, you don’t want to bring in an inflammatory product when they’re already in an inflammatory state because higher risk of complications. And then specifically the Crohn’s patients, I’m like, I don’t even want to look at the bowel because I feel like just looking at it can cause a fist nerve. So why would I be that person that is causing so much potential injury? And once you get an injury from Crohn’s that patient’s life is really messed up. So I don’t want to be that surgeon. I’m very, very cautious. So we have different techniques. So the old school technique of peroneal hernia, it’s not really that old school, but the laparoscopic technique is to put mesh on the inside. And so you have mesh against all the bowel exposed and mesh around the intestine, but now we have better techniques.
(00:34:00):
Have you heard of the Pauli Preperitoneal repair? It’s a PPP repair. So Eric Pauli is a really smart hernia surgeon out of Penn State in Hershey. He was one of our guests, I think two years ago in one of our hernia attack lives. So he came up with this really cool technique, and I wonder what you think about it. So the stomas kept where it is the same way in a sugar baker where the stoma, if you go backwards from the stoma, the stoma goes down through the fascia, and then it kind of takes this whole little loop. Lazy S. That lazy S occurs not in predominantly, but one layer more superficial in the retro rectus space. And then the mesh is also placed in the retro rectus space.
Speaker 2 (00:35:04):
Oh, that’s interesting.
Speaker 1 (00:35:05):
It’s kind of cool.
Speaker 2 (00:35:07):
I’m forgetting that there’s a name for that, for creation of a stoma with that technique, but I’m blanking on what that’s called. Do you know what I’m talking about?
Speaker 1 (00:35:16):
Oh, yes, yes, yes, yes. You’re talking about the pre peritoneal pocket that,
Speaker 2 (00:35:24):
Yeah,
Speaker 1 (00:35:24):
Supposed to redo. That’s for primary stoma. So primary stoma surgery, what’s that called? I forget what it’s called. It’s supposed to reduce the risk of parasoma,
Speaker 2 (00:35:34):
Right?
Speaker 1 (00:35:35):
This is like a hybrid of those two. You already have your stoma, you got the hernia. So then you move into that space, but by default, your mesh goes extra perineal, but there’s still a length of mesh that touches the bowel. So for the Crohn’s patients, I just go anterior. So I do an onlay. The only part where the mesh touches the bowel is around the neck of it. I use a biologic, not a synthetic mesh. There’s no erosion risk. There’s so many things you got to do for to be careful with patients like this. That’s why you can’t be a one trick pony.
Speaker 2 (00:36:15):
Yeah,
Speaker 1 (00:36:16):
Yeah. Because then you’ll inju patients for sure. Okay. A related question to the previous one. What if you have seen multiple true specialists in multiple specialties and you get different recommendations from each one, what to do on what to do to resolve your issue? That’s a good question. I have patients that do that. What do you think?
Speaker 2 (00:36:41):
It’s hard. Sometimes there’s not one answer.
Speaker 1 (00:36:45):
Yeah. Yeah. And that’s true. There isn’t one answer that’s a good,
Speaker 2 (00:36:51):
I think in that situation, I would just, you got to go back and say sometimes you can reconsult not to become, I don’t want to say it, but the annoying patient. But you kind of want to become the annoying patient. You’re advocating for yourself, right? So, hey, Dr. Ziggy and I saw you. This is what I recommended. I did go see a second opinion. This is what they recommended. What do you think of that? Right.
Speaker 1 (00:37:15):
I think that’s good. I think you should pit doctors against each other in your consultation and get their opinion.
Speaker 2 (00:37:21):
Yeah, maybe somebody else had a great opinion that I didn’t think about. I mean, we’re not God, we’re not, but it’s possible for that to happen or that maybe there’s a really good reason I didn’t mention that other way. So you just, as long as you know it and you have asked, then you can make your decision how to move forward.
Speaker 1 (00:37:42):
I agree. I think sometimes patients don’t want to admit or show their hand that they saw other doctors besides you and they feel guilty or I don’t know. They think,
Speaker 2 (00:37:55):
Yeah,
Speaker 1 (00:37:56):
We don’t care. I don’t care. I would love to hear what I even ask. I said, who else have you seen about, oh, doc. Oh, I’ve seen two other surgeons. I always say, well, who are those surgeons? Because I want to gauge what the recommendation based on what I know about them, let’s say. And then I would say, oh, okay, well, they’re very smart, or something like that. And I would kind of try and guide the patient a little bit to understand why I agree or disagree with the other surgeon’s recommendation.
(00:38:32):
I don’t take it personally that they saw someone else. If I feel like patients think we take it personally, no. Okay. It’s an interesting question. I have testicular pain. My scrotum was hit and injured one year ago. Initially, the testicular pain whenever I moved, was severe nine out 10 for a month. I couldn’t sit for a single minute. One month later, the pain became less, seven out of 10, but I still could not sit for one minute after a colonoscopy in December, 2024, the pain was better. Five out of 10 when sitting and I could sit for about 10 minutes. Why did the colonoscopy reduce my pain, seemingly, is it because of lidocaine used during the deep IV sedation? What can I do to fully recover?
Speaker 2 (00:39:27):
I mean,
Speaker 1 (00:39:29):
I don’t what the answer.
Speaker 2 (00:39:29):
Interesting. It’s scenario. The pelvic floor shares a whole nervous system. So it’s not uncommon for somebody to have one pelvic problem have it affect. The other common scenario, Shirin, you know about is pelvic sepsis. If somebody has pelvic sepsis, if they have an infection in their rectum, they can’t pee. Can’t pee is a very common symptom of a severe infection in your rectum because of the shared nervous system. Or sometimes when we do hemorrhoid surgery on somebody and we’ve cut into their anus, they can’t pee afterwards. It’s because those nerves have been shock. They’re affected. So that might be one possible explanation. Another possible explanation maybe. I don’t know. If you were really constipated, for example, and didn’t know it, and then the prep that you did for the colonoscopy maybe cleaned you out and that was radiating to your testicle and causing the pain. My comeback question to that would be when I went down to five out of 10, is it a stay, a five out of 10, or was it short lived?
Speaker 1 (00:40:47):
Yeah, because maybe just anesthesia helped with pain around the time. But I do hear this though, that people get colonoscopies and one question is they always wonder, is it safe to have a colonoscopy while you have a hernia? What do you tell them?
Speaker 3 (00:41:03):
Yeah, it’s safe to have a colonoscopy
Speaker 1 (00:41:06):
Unless there’s all the colons in the groin. But short of that, I’d say. And then how does colonoscopy improve pelvic floor problems?
Speaker 2 (00:41:22):
How does it improve pelvic floor struggles?
Speaker 1 (00:41:25):
Yeah,
Speaker 2 (00:41:28):
I don’t know. I don’t know how it would affect it. Again, it could be local pain thing. There could be some nervous system thing where maybe you were impacted with stool or you were constipated or something like that. And by doing the prep, now that’s gone and that’s not affecting the nerves, and therefore it took the pain away from the testicle. I’m not sure.
Speaker 1 (00:41:55):
I dunno, maybe it’s just by chance because the pain as a follow up, the pain increases from five to seven if I sit longer. But maybe over time you’re just getting better. You may have had pelvic floor injury when you got hit in the scrotum. Is that possible? And that’s just getting better. That’s why sitting hurts. Sitting shouldn’t hurt. Sitting usually hurts if there’s a, I mean, you get patients that have pain when they sit,
Speaker 2 (00:42:26):
But the testicle hurts when he sits.
Speaker 1 (00:42:28):
No, his or
Speaker 2 (00:42:29):
His anus hurt.
Speaker 1 (00:42:33):
Oh, maybe the test. It’s unclear. Maybe he can clear it up. Initially the testicle pain was severe. I could not sit for one minute. So the question is, is the testicle pain severe when you’re sitting or you can’t sit because of pelvic floor pain, then that could be an injury. Yeah. Let’s do some more questions. What are the hernia and colorectal related illnesses in which a surgeon specialization is essential to maximize the chances of a positive long-term outcome? I think it’s these random ones, right? I mean, if you have colon cancer, obviously it’s better to go to a specialist, but that’s not as important than maybe someone with Crohn’s disease or is it all important?
Speaker 2 (00:43:29):
I mean, I think mean colon cancer, if it’s straightforward, colon cancer probably is okay, not done by a specialist. Again, specialist expertise. It does, I think impact outcomes. But is it critical? Critical? Probably not as much as it would be for Crohn’s, as for rectal cancer, as for a J patch operation, something like that. Again, just like most things, like doing a really high ligation of the nodes, maybe that’s not something your general surgeon is going to do. It depends on how much cancer your general surgeon surgeon does. Is your surgeon doing the surgery robotically? How are they doing it? There’s a lot. I think, again, things that we learned in our general surgery residency have become so complex. Like look at breast cancer. We used to do that all the time. I would not know what to do with a breast cancer today. It’s totally changed so much. So that’s kind of what happens, is something that you learned evolves. And if you’re not a specialist in that thing, you don’t evolve your technique. You keep doing it the same way that you learned how to do it 10 years ago and you haven’t really kept up. That’s the issue with non-special, even for some of the more simple things
Speaker 1 (00:44:49):
We’re so right. I would say that if I did a colorectal cancer, let’s say I was a general surgeon that did more than just hernias, then the likelihood is if I was just someone in the community that I would just do it the way I was trained to do it. Whereas a specialist that goes to meetings and keeps up with the times and has to recertify their boards and all that, you would know that you have to take X number of lymph nodes and go this far away from the colon. And if there’s much more nuance to it, maybe you have a lower risk of complications. Is that true?
Speaker 2 (00:45:27):
I mean, I don’t know if there’s a study that’s looked at general versus colorectal surgeons in colon cancer, but there has been studies that have looked at it in rectal cancer, like the number of cases done annually actually affects outcomes.
Speaker 1 (00:45:45):
So there’s a trend, I’ll tell you this, A trend towards trauma, patient trauma, surgeons trying to become hernia surgeons because they’re tired of taking, huh?
Speaker 2 (00:45:58):
Because they’re causing so many hernias. They
Speaker 1 (00:46:00):
Cause so many. It’s true. That’s true. So trauma surgeons are the number one specialty that they have the highest rate of hernia, incisional hernias, I guess what you call it. That is true. But you know who’s number two? Hilarious. Colon cancer. Yeah, colon surgeons. No. So anyway, so they’re getting older and they don’t want to take call as much anymore, and it’s just draining. So what else can they do? Maybe I’ll be a hernia surgeon. So a lot of them are moving into the hernia surgery world, but guess what? They were trained to do hernias like 30 years ago when they were a resident. So I literally get phone calls about things that are huge, no-nos in our world, like using a match plug. No one puts a match plug anymore. You really shouldn’t. I know they still do, but you shouldn’t. Or we are trying to reduce how much mesh we put in apparently exposed to the bowel. We’re trying to not do that. And yet both of those were commonplace when I was a resident. And therefore these doctors, I don’t understand why can’t we do this? And I would try and explain to them and they’re like, I don’t get it. I think it’s just fine. Like, oh, how are you going to be a hernia surgeon? I need you to go to some classes. Go take some courses.
Speaker 2 (00:47:31):
Yeah. Crazy. Are you seeing less hernias as we’re doing? If I’m doing an operation, right, if I need to make an extraction incision, I’m always trying not to place it midline. Choose a pH and steel because that has a lower rate of hernia off midline, lower rate of hernia, obviously smaller incisions, laparoscopic robotic surgery. Are you seeing less hernias?
Speaker 1 (00:47:55):
Yeah, we are. So yeah, less open surgery for sure. And then the colorectal stool surgeons showed that if you want to remove the colon through an incision, let’s not take it out of the belly bind. Let’s take a suprapubic incision like a C-section scar that’s dramatically reduced hernias. The same is true of the urologists that take out the prostate. So they do everything robotically, minimally invasively, but they still need to make an incision to take out the prostate now that their consensus reports confirm that asbe to take it out similar to the colorectal surgeons in a supr pubic manner. So yeah, all of those are true. Yeah, we have less, even the spine surgeons, when they do these lateral approaches, they were taught to do it a certain way, but they were taught by a fellow neurosurgeon, which was incorrect. And so we published our paper and I gave grand rounds at our own spine surgery conference. I’m like, stop doing this. You got to use this type of suture and put ’em through these type of muscles. And I was seeing, I think we have the largest series of hernias after spine surgery published, and now I see very few because they all changed their technique. So it all makes sense. And I was seeing a slew of urologists having hernias, aro prostate surgery, and now you just change your technique.
(00:49:27):
Another question, specific hernia related question. I know each case must be individualized, but if you had primary hernia repairs and then another groin surgery for recurrence complicated by pain given fibrosis and the activated nervous system with sensitization and centralization, how do you decide when to attempt a surgical revision to reduce pain versus giving up and going for a spinal cord? Neuro modular? Do you have patients that require spinal nerve stimulators for colorectal problems?
Speaker 2 (00:50:04):
I have patients that have them but not require them. We put sacral nerve stimulators for fecal incontinence.
Speaker 1 (00:50:11):
Oh, how does that work?
Speaker 2 (00:50:13):
We don’t know. We don’t know. I mean, it modulates the third sacral nerve, which we know controls the rectum, it controls the bladder. But fun fact, we’re actually doing a clinical trial right now studying to use, we’re using it in our IBD in our ulcerative colitis patients, because it’s thought that when you stimulate the sacral nerve, that there’s a reflex arc to the vagal nerve that then is immune modulating and that it actually helps minimize the inflammation in the gut. So we’re implanting this in patients with urgency. They’re seeing not only a decline in their urgency symptoms, but we’re actually also seeing that when we scope them, we do colonoscopies on them. They have less inflammation. So it’s a huge area of we don’t understand, but it’s so cool and fascinating.
Speaker 1 (00:51:08):
Wow. Wow. So if you stimulate the vagal nerve, that could be immune modulating.
Speaker 2 (00:51:15):
Yeah.
Speaker 1 (00:51:17):
Isn’t that what they do for the gastroparesis patients?
Speaker 2 (00:51:19):
I think so, yeah.
Speaker 1 (00:51:23):
You live in a fun world, I tell you. Okay. I think we have some more questions. Let’s see. Are there any kinds of hernias better treated by a colorectal surgeon than a specialized hernia surgeon? I would say all the prolapses.
Speaker 2 (00:51:43):
Yeah. I mean, we do all the prolapses. I’m doing one Friday. It’s a combined repair with our urogynecologist. We usually tag team it. Those are all,
Speaker 1 (00:51:53):
How do you tag team it? What do you do and what do they do?
Speaker 2 (00:51:58):
The gold standard for a rectal prolapse has now become a ventral mesh rect opexy. So we use a lightweight polypropylene mesh. We open up the rectal vaginal septum, separate the vagina from the rectum all the way down to the pelvic floor, put the mesh on the rectum, use that up and secure that to the sacral promontory. And then if the patient still has their uterus in, they’ll remove the uterus and then attach a mesh to the cervix, and then they’ll put their mesh onto our mesh so that the whole thing gets pulled up. And then we close the peritoneum and repair the enteral over all that. So the mesh all gets covered into that space. So it’s not,
Speaker 1 (00:52:47):
And you’re sewing bare mesh onto the colon?
Speaker 2 (00:52:50):
Yeah, light. It’s a lightweight polypropylene mesh. We’ve used the various kinds of biologic mesh. It just doesn’t work. Even the half biologics, they don’t work.
Speaker 1 (00:53:03):
Oh, even the hybrids don’t work.
Speaker 2 (00:53:05):
The hybrids don’t work. So it’s kind of become accepted. And the gold standard that if you use a lightweight mesh that’s porous, obviously you’re not going full thickness into the rectum. You have to take serum muscular bites. But yeah, that’s what we use. And then they put the same mesh on top of ours. The whole thing gets covered up and it has the most durable long-term results. The problem with prolapse repair in general before, so mesh has made a full circle in Prolab to put meshes rapid around the rectum that was causing a stenosis that was causing all the mesh pelvic mesh complications. That was all over the news. We went away from mesh for a long time. We were doing resections of the colon like resection recopies, where we were dissecting the colon that was prolapsing and then tacking the rectum up. But people were still getting a recurrence. And so we’ve gone back to that cul-de-sac is the lead point where all the bowel falls in there and push everything out. And so you want to repair, you want to repair the prolapse, you have to go at it in that plane, and you have to support that plane completely and pull it up. And it’s best to do it together if the patient has both a middle compartment and posterior compartment.
Speaker 1 (00:54:38):
And then isn’t the small bowel exposed to the mesh too?
Speaker 2 (00:54:41):
No, because you cover the peritoneum, you close the peritoneum. Oh,
Speaker 1 (00:54:44):
Okay. It’s extra perennial. Got it, got it, got it. Okay. Still makes me nervous putting mesh on bowel, even the colon,
Speaker 2 (00:54:52):
Knock on wood. I know.
Speaker 1 (00:54:53):
Although we do it for parastomal hernias.
Speaker 2 (00:54:55):
Yeah.
Speaker 1 (00:54:56):
But yeah. Okay. Oh, I do not believe you addressed my previous question because you got distracted by the vagal immune interaction. What was the last question? Oh yes, sorry. He is right. It was about whether you should go in and re-operate on someone who already has a lot of chronic pain and maybe centralization of pain, or do you move on and just do a spinal cord?
(00:55:34):
I would say that depends if there’s a clear obvious reason then with the involvement of a pain management doctor with the use of maybe ketamine, other things that can kind of reduce your chronic pain situation. I would operate, I’m not a big fan of spinal cord neuromodulator unless it’s for end stage process. So if it’s a treatable problem, so I’ll give you an example. I had a guy who was so debilitated, he was on his knees on the examining in the exam room, crying in pain. That’s how much pain he was in. He had made a sling like a hammock for his scrotum because the testicular pain was so severe. What he had was a hernia repair that completely was guillotining through his spermatic cord. And they told him he had too much chronic pain. He had a nerve modulator, and what he really needed was a TRO root. It was totally a mechanical issue. So that’s my kind of bent, which is if there’s clearly a reason that can be removed, it’s like giving you pain medication when you have a rock, a pebble in your shoe,
(00:56:55):
Just take out the damn pebble, even if you have a lot of chronic pain. I think in those situations they still do well, but if you’re dealing with nerves and you have chronic pain, the risk of crips, right? The complex regional pain syndrome is slightly higher. So I get nervous about those. All right. Shall we do one more question? Sure. Let’s see. In patients requiring, hold on. In patients requiring surgery for both a colorectal disease, excluding cancer and a hernia, does addressing the colorectal disease always take precedent if treating them in a I? What’s the rest of the question? I’ll look up the original question. Well, let’s just say does always take precedent if treating them in a sterile manner or I don’t like doing hernias surgery at the same time with colorectal surgery, some people do. It kind of violates my
Speaker 2 (00:58:01):
Recurrent bouts. Let’s say it diverticulitis. Someone has diverticulitis and they’ve had a few attacks. They’re considering maybe surgery and they have a hernia. What do you do in that situation?
Speaker 1 (00:58:14):
I mean, deal with the colorectal procedure, which is removing the disease
Speaker 2 (00:58:19):
Portion. If it wasn’t for the hernia, they don’t necessarily need to have surgery. It’s an option, but they don’t have to have a collective.
Speaker 1 (00:58:28):
Okay, that’s a good question. So I do discuss with patients that predictably we’ll need another surgery about the importance of understanding that if I do a, let’s say abdominal wall reconstruction, I don’t want anyone else to go through that if possible. So if they have someone who has recurrent gallbladder attacks or recurrent diverticulitis attacks and so on, the worst thing is for me to do this beautiful hernia repair with mesh and then have them have another bout of diverticulitis and need colorectal surgery at that time. And now you’re not only going to disrupt my repair, you may even infect my mesh, and that’s a disaster. So I do have that discussion. I feel that discussion, that discussion not made enough.
(00:59:19):
And there are tons of surgeons that are hernia surgeons that believe bigger is better and they’ll put mesh all over. And I’ve literally told them, I don’t think that’s fair to the patient because they’re going to need gallbladder surgery, colon surgery, appendix surgery, something, and now you’re putting them at higher risk for the other surgeon and they’re like, sucks to be them. So inappropriate. I don’t know. Do you agree with that? Would you be pushed, would you be pushed to operate on someone? If I said I need to fix their hernia, but I don’t want to.
Speaker 2 (01:00:01):
I think if it was reasonable, if they had a single attack of diverticulitis, I wouldn’t go doing a colectomy because they had a hernia. But if they had had a few attacks and otherwise I would say it’s your choice, I think I would kind of push them to just moving forward with it so that it’s not an ongoing issue. I mean, we think less that somebody who presents with uncomplicated diverticulitis could have a complication of diverticulitis that we used to worry that you’ll perforate, your bowel will rupture. We don’t think so as much anymore. It’s just like the nuisance of another flare, another flare. But if it’s happening frequently enough that it would be reasonable to do the surgery, I think I would kind of push them into doing it. Not push, but
Speaker 1 (01:00:50):
Before we leave, I really want you to be able to see if you can help this patient. This is a patient with the scrotal injury or pain sitting. He says, I cannot sit because of ongoing scrotal and peroneal pain.
Speaker 2 (01:01:05):
Oh, interesting.
Speaker 1 (01:01:06):
After injury to my scrotum and testicle, the posterior scrotal nerves and peroneal nerve may be irritate or compressed. While doing this formatic cord nerve block help. Is ural nerve or peroneal nerve block available? What kind of treatments are available? What’s your take on that?
Speaker 2 (01:01:22):
I think so I would, first I would get imaging like an MRI or something. I forget if he said he’d had that. Just to make sure there’s no actual a real injury like a fistula, like a sinus or something that’s not coming to the skin that’s causing an infection or something down there that’s causing those symptoms. I do that first and then I really like pudendal nerve blocks for our anal and pelvic fluorine patients. I think pelvic floor PT is really useful. A lot of patients will have a levator spasm or a spasm of their pelvic floor that can be ed out with a massage or other kinds of treatments.
Speaker 1 (01:02:06):
Repositories
Speaker 2 (01:02:07):
What
Speaker 1 (01:02:08):
Muscle relaxants suppositories.
Speaker 2 (01:02:09):
Muscle relaxants can be great. Yeah, I think those are the next steps. I would have them make sure they do a thorough anorectal exam to make sure there isn’t some other, they don’t have a fissure, there isn’t some other thing that’s causing pain that’s gone missed.
Speaker 1 (01:02:27):
Yeah, no, I totally agree. Yeah, it sounds like focusing only on the testicle and scrotum is not necessarily the best. So schematic cord block can be done to see if there’s any injury to spermatic cord causing the testicular pain. But the pudendal nerve block, what’s a peroneal nerve block? Is there a peroneal nerve? It’s a peroneal nerve, but I don’t think there’s a peroneal nerve. I think it’s a pudendal nerve. Okay, my friend. Well, I’m so glad that you accepted my invitation. If you can do any more rants on TikTok, you can join me again. This was so much fun, Karen. Thank you so much.
Speaker 2 (01:03:09):
Really fun. Thank you so much for having me.
Speaker 1 (01:03:12):
Yes. Well, that’s the end of Hernia Talk Live. Thanks everyone for joining, for asking questions. Don’t forget, watch and share on my YouTube channel or as a podcast. And next week I’ll be out of town because we have the American College of Surgeons meetings. So I’ll see you the following week and hopefully with a great guest. Looking forward to it. See you guys. Bye.