Episode 21: Let’s Talk About Hernias | Hernia Talk Live Q&A

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Speaker 1 (00:00):

As most of my name is Dr. Shirin Towfigh and I am a board certified general surgeon. I love what I do with hernias and so when the pandemic started, let me share this screen. When the pandemic started I began this webinar. It’s a one hour webinar every Tuesday called Hernia Talk. I kind of call it Hernia Talk Tuesdays and I try and promote it as much as I can on all my different platforms. On Hernia Doc. At Hernia doc is my tag on Twitter and Instagram and also on Facebook. You can see me at Dr. Towfigh and then when we’re all done as this will all go on YouTube and basically I’m all yours today. Many of you know me from what I do online and the education that I provide and some of the articles that I write and everything that I say about hernias, I kind of have fun with it.

Speaker 1 (01:02):

I think it’s fun, fun and funny. But in addition, many years ago, around 2013, I started a free discussion group for patients that’s online. It’s open to anyone who wants to register. It’s free and it’s called hernia talk.com and that has right now thousands and thousands of people that are involved on it. They ask questions, I answer some of their questions. We have other surgeons who go on hernia talk.com and answer questions and it all started because I was getting bombarded with emails and questions from patients who may or not have been able to come and see me in person and I was answering all of these emails very diligently and it was the same question over and over again and I felt that if one person’s asking the question, there must be hundreds that have the same questions. So that’s how hernia talk.com was born in 2013.

Speaker 1 (02:07):

It’s now pretty active and currently the only website available for patients as a discussion group that also includes doctors involved in the question answers. And when the pandemic started back in April 5th, so it’s almost five months ago, I decided instead of sitting at home and just gaining weight, I should do something that is a little bit more fun and educational since everyone else is sitting at home and gaining weight. So we started, I started Hernia Talk live, so you’re here with me today. There’s a lot of questions that have been posed throughout these five months that we have not been able to get answered and many that you probably have that would like to be answered by me as opposed to some I guess. And so I’m here, I will answer whatever question you like I don’t care. And now if they’re mean, I will ignore the mean questions, but most, for the most part, no one’s been mean.

Speaker 1 (03:22):

Before we start, I just want to share this with you. Something that I thought would be interesting is kind of our top most interesting hernia talks in terms of engagement and that was as follows. If you look at the YouTube views and most importantly the Facebook Live engagement, the ones that had the most engagement and the most views were number one, the episode with the Complex Hernia Systems group. That’s Dr. Bruce Ramshaw who currently is in Tennessee. Second was our most recent one about chronic pelvic pain with our amazing gynecologist, Dr. Thais Aliabadi locally here in Los Angeles. Next was the one with the sports hernia surgeon. That was Dr. Mark Zoland who practices in New York. Our next most engaged and popular hernia attack episode was the one with the urologist where we talked about all the testicular pain. That’s Dr. Paul Turek and next was the ones with all the different abdominal wall hernia reconstruction surgeons.

Speaker 1 (04:39):

So Dr. Jacob, Dr. Brian Jacob from New York, Dr. Igor Belyansky from Maryland and Dr. Vedra Augenstein from North Carolina. They were the top three. Then it was the Shouldice clinic surgeon Dr. Spencer Netto who is in Canada, and finally one of our more recent ones, Dr. David Earle, who was also sorted that worked in the FDA and gave us some really amazing insights with regard to how the FDA works and the past, present and future of maybe Mesh. So thank you for those of you that are sending me some appreciative messages. I appreciate that. Let’s go to our first question and that is the question for the gentleman. I know he’s an asked it of many others in the forum and his question is this, many of us are frustrated and confused on how someone can tell the difference between an indirect and can you guys all hold on one second.

Speaker 1 (05:51):

Between an indirect and direct hernia, many of us want to pursue going to the Shouldice hospital only if we have direct hernias and want to avoid going there. If we have indirect hernias that said, what is a percentage probability someone has to find this out if at all before being cut open. We all understand ultrasounds are pointless because they’re too obturator dependent. Do we just assume the worst that these are direct hernias and go with the overly invasive Shouldice hospital to air on the side of caution? So I feel that it’s really slicing the bread too thin to try to over analyze the direct versus indirect. You can have a huge indirect or a small direct, you can have horrible tissue and all of those would be maybe appropriate or inappropriate for tissue repair and or specifically a Shouldice hernia repair. So I get this a lot.

Speaker 1 (07:00):

I have a lot of patients that come to me and they’ve done so much research and in their research they have figured out all these algorithms for themselves, but what they don’t appreciate necessarily is that surgeons like us have our own algorithm and let us do some of the work for you. In other words don’t try and narrow yourself down this one pathway to determine what’s the best type of treatment before you see a hernia specialist. There’s a reason why we’re specialists. We do tailor your findings and your needs with what we recommend. So we may recommend no surgery, we may recommend laparoscopic surgery with Mesh or without Mesh or open surgery with Mesh or without Mesh. So I would recommend that you do your research but don’t corn yourself into this. Oh my God, what am I going to do if it’s a direct and then I chose to do a stroll ice repair.

Speaker 1 (08:09):

There are tons of surgeons out there, sorry, tons of patients out there where the Shouldice clinic has performed direct hernia repairs and they’re doing just fine. It all depends on the patient and the patient’s needs. Now, if you pick a hernia specialist and that specialist says, I think this is the best technique for you, and then in surgery they decide that they’re totally wrong, they found something new in their, that’s really where it’s important, where they may have to change the technique or the kind of algorithm and that’s why it’s so important to find the right surgeon as opposed to kind of decide what you want and then go to the surgeon and say, this is what I want, and then kind of maybe not necessarily make the right choice. So I don’t believe that a Shouldice hernia is overly invasive. I think whatever is appropriate for the patient is what’s appropriate and to kind of call it an overly invasive repair is not appropriate. Also, men and women are different, so their biology or their hernias are different. That’s my take on it. Some people may not agree, but

Speaker 1 (09:28):

I don’t know. I think that’s my 2 cents on it. Next question is, is there a doctor close to the east coast that does what you do? I believe you called one of your guests your East coast New York twin, and you have shared patience, but does he handle complicated cases with Mesh reactions, allergies, and multiple recurrences asking for a friend? Okay, for your friend yes, there are and for sure most of this doctors that I bring onto hernia talk are those that are ones that I would basically can you give me one second? Hold on one second. So what I recommend is do seek out surgeons that I try and put on hernia talk. I think they’re great. You can see their personalities. Do they necessarily want to do everything that I do? I don’t think so. I also really recommend that you really carefully listen as to what we talk about.

Speaker 1 (10:43):

So for example, if you see a really great surgeon and we don’t talk about Mesh complications, nuerectomies, whatever the situation is, that probably means that that surgeon would prefer not to take care of those patients even though they’re totally capable of doing it. It’s just a priority. Everyone chooses to have their own type of practice. So the topics that we discuss are usually ones that the surgeon is also very interested to inherit but if they don’t talk about certain topics, then that’s kind of a hint that maybe you should not go to them for that specific type of problem. I hope that’s helpful. Okay, is pain aggravation? Next question is pain aggravation with prolonged sitting with relief with standing and walking help distinguish different causes of groin injury, hernia, hip athletic pubalgia and sports hernia? Absolutely.

Speaker 1 (11:51):

So if you think about it, it’s very phasix based. If you’re standing, coughing, bending, those are all activities that increase abdominal pressure. And if you have pain with coughing, standing bending, then you may have a her sorry groin pain. Then you may have a hernia because what you’re doing is you’re increasing abdominal pressure and pushing content into that hole, which is the hernia. Prolonged sitting is another one that slightly increases the abdominal pressure and you can actually pinch. What you’re actually doing is you’re closing off the groin space and pinching into the area, and so when you’re pinching it, that can cause pain as well if there’s content in your hernia. Now hip injuries

Speaker 1 (12:44):

Usually don’t cause pain withstanding, but certain types of sitting may hurt because of the angulation of the hip and then other things can make it worse, such as like going uphill. And we were supposed to have Dr. Snibbe today, but he decided that he had a lot of patients to take care of today and was saving lives. So we are rescheduling Dr. Snippy who is the orthopedic specialist who I admire, who treats a lot of my patients that have hip problems. And when we do have the hip session, we will go into real details as to what specifically is a hip related pain and should be worked up by an orthopedic doctor as opposed to a hernia related pain where it needs to be worked up by someone like me, for example. It’s very, very important because those two overlap a lot and it’s really important that the overlap is one where you go to the right people. Okay, next question. Oh, the other question two was about sports hernia sports are very different. Those are just only activity related usually and things like sitting and standing and so on and gravity does not affect. It’s mostly activity related.

Speaker 1 (14:07):

Okay, next is another question. Hi, I’m a physio, which I think that means physiotherapist or physical therapist. I have a patient with a banana shaped bulge near her Rives. She has pain with walking more than three to four blocks along with some numbness and tingling.

Speaker 1 (14:30):

She’s worked on improving her thoracic extension and that worked to decrease her pain and numbness and tingling, but the bulge is still present. The bulge does not hurt with any other activities. She can do all other activities and no issues. MRI showed bulging disc, the thoracic and upper lumbar spine that would correlate to the peripheral nerve distribution in the area of the banana bulge. The patient had MRI and CT scan, neither showed hernia. Also, she also had an in-person visit with a hernia doctor. I’ve only seen this client for a video visit. Is there any advice, could this be an abdominal hernia?

Speaker 1 (15:07):

So basically here’s a situation. The banana shaped bulging in the upper abdomen may be due to a denervation or a weakening of the abdominal wall muscle and that could be from an impingement of the nerve or any problem related to the nerve being impinged. So muscles get their nutrition from the nerve. If there’s any end to the nerve and that’s why the nerve got cut or the nerve, the nerve got impinged or the nerve is in any way kind of diseased, then that muscle is not going to get any nutrition and then it will lose its strength and its kind of a function. So if you are seeing that there is an area where there’s a bulging and there’s no hernia associated with it, what you usually see is like a diagonal bulging. You must work up a back issue that may be a disc issue or some other nerve problem and it may be very uncommon to have a thoracic or upper lumbar disc, but in those patients that they present with these problems only, so that for sure seems to be right. In other words, the bulging is due to derivation. Now here’s a problem. You want to catch these and treat these before they have permanent muscle damage. Usually within the first three months that’s safe even up to six months that’s safe, but longer than that, it’s going to take a while for the muscle to regenerate. So you want to diagnose these nerve damages early. Usually a spine surgeon can help you do that and then if it is a disc, for example, decompression of that nerve, we’ll get rid of the muscle dysfunction,

Speaker 1 (17:22):

We’ll get rid of the muscle dysfunction and then you’ll take some time for the muscle to regenerate, but up to a year and it’ll come back. Hope that was helpful.

Speaker 1 (17:40):

All right, next question. For someone who currently has or previously had a pure tissue repair for a bilateral hernia, is it better to urinate frequently with smaller amounts or urinate less frequently With larger amounts I’ve read comfortably holding off to urinate will strengthen bladder function and allow someone’s body to need to urinate less frequently. But on the other hand, will holding urine put more pressure on the hernia, making it worse? So from a hernia surgeons standpoint, is it better to empty at every chance you get and take a proactive approach urinating in urinating to avoid any pressure on the hernia?

Speaker 1 (18:19):

Okay, for sure. Holding onto your urine is not a good idea whether you have pelvic floor dysfunction or hernia or any other problem. That said, holding onto your urine does not put any pressure on the hernia, so it’s not going to make your hernia worse, but you also don’t want to strain to urinate which you can see with some pelvic floor dysfunction. So if you want to strengthen your bladder function by strengthening your pelvic floor, that’s a different story, but to kind of urine less, that’s a disaster because that can cause a lot of other urinary problems, but it does not affect the hernia itself. Lots of interesting questions you guys. <laugh>. Okay, going back to the bulging the banana, banana bulge it is diagonal, so that’s correct. It’s always diagonal because the nerves are also diagonal and she can do exercises and otherwise the bulge with no pain or symptoms.

Speaker 1 (19:32):

So yes that’s correct. Whatever you do has to be related to the spine and you should not do anything that will affect the it’s not a hernia, it’s a nerve problem. So exercising and all that has no effect on it. You’re welcome. Thank you. Thank you for all your positive comments. All right, next question. These are coming in really great. I love it. Okay, except I’m trying to lose my voice. All right. I’ve been watching, I’ve been watchful waiting my bilateral angle hernia for about a year. I want to avoid surgery as long as possible. As I’ve read war stories about people having chronic pain and regretting even having the surgery, I notice it comes out very easily now and one side stays out. Now a hundred percent of the time I experience very little pain. Is this causing irreversible damage and compromising my ability for future hernia success?

Speaker 1 (20:36):

No. So there is no evidence that shows that watchful waiting will in any way compromise your success in another surgery. Now, it depends the type of surgery you want. Most United States surgeons offer Mesh based surgery and if you have a super small hernia or a medium hernia or a large hernia, it doesn’t really matter. They all do well with Mesh repair. If you have an extremely giant large hernia, and that means down to halfway down your thigh or to your knee, and there are hernias that are that big in the groin, believe it or not, then yes, if you wait until it’s that big, you are compromising your options for tissue for hernia repair specifically, you are not a good candidate for tissue repair. Now, most people won’t be getting tissue repair most likely anyway, so it doesn’t matter. But if you’re someone who’s young, thin female or has a lot of disorders that are related to autoimmune or you have a lot of allergies to things you may want to consider a tissue repair as opposed to a Mesh repair, and if you wait until your hernia is humongous, there’s not that much tissue to use to repair.

Speaker 1 (21:57):

That’s why Mesh was invented. So no watchful waiting is perfectly safe. The reality is the majority of patients over time will want the hernia repaired, but short of that, it’s totally safe to do. There’s no issues with that.

Speaker 1 (22:18):

Righty. Okay, so those were all the live questions, but as you know, I always come prepared because many of you submit questions online because none of some of you cannot come. In fact, I have a couple from outside the country who have submitted their questions. So we’re going to take this time to go through some of those questions unless we have other questions that are coming on live and I see there’s two questions already live. Okay. All right, let’s go through this one. This patient says, I’m allergic to a lot of things. The list is long. What are the most important questions to ask my doctor for hernia repair? Really good question. So I will preface what I say by, there’s very little data to support what I’m saying. It’s mostly based on experience and anecdotal evidence. However, if you are allergic to a lot of things, and I don’t mean things like bananas and strawberries and peanuts, I mean polyester, you get a rash tons of medications you get really bad reactions to.

Speaker 1 (23:32):

There are certain even even something like your titanium, what do you call it? Nickel allergies or you have an autoimmune disorder where you’re intolerant of a lot of things, then chances are you may it’s not a hundred percent may have a bad reaction to an implant such as Mesh, which is a very common implant we use for hernia repairs. Now, I use a Mesh term broadly, Mesh can be synthetic biologic, a hybrid of the two, low inflammatory, high inflammatory, low weight, high weight, so heavy weight. So when I say Mesh, I don’t mean all Mesh. And when I say implant, I don’t mean all implant. And when I say react to, I don’t mean you will react a hundred percent. However, there is a risk and that’s something you may want to consider asking your doctor. If your doctor poo-poos this and says and says, Mesh is a nerd, no one reacts to Mesh, this is ridiculous, stop reading Google and you legitimately have all these other concerns, then I would seek consultation with a hernia specialist that actually sees Mesh reaction patients because it’s not a common problem statistically numbers wise, there are a lot of patients I understand that, but statistically it’s a low percentage and based on that, most surgeons are not aware of it or do not believe that it exists, that you can react to Mesh.

Speaker 1 (25:09):

So if you’re getting any push back, just it’s a free country, go and see another specialist. Most of us nowadays offer telehealth because that is now covered by insurance, whereas before it wasn’t. So people that are far away from you can actually visit you virtually on something like this, like Zoom and then also and some of my colleagues offer online consultation where you can email us all your suggestions or questions. And so based on that I would recommend that you do seek a consultation and really understand what your per perceived risk would be in terms of having a Mesh reaction, and that’s what I would specifically ask. You’re welcome. Okay, next question. Another live question. How far medial can pain relate to hip problems extend within the groin? Does medial pain suggest that hip hip is not the etiology? Yes and no. So if you look at an anatomy picture, the hip joint is actually not where you think your hips are when most people point at their hips, that’s outside where they put their hands.

Speaker 1 (26:29):

When they put your hands on your hip, that’s not where your hip joint is. The hip joint is actually many inches inwards towards the middle. It’s not all the way in the middle. So people can have groin pain, which is kind of in the up above the groin crease, but in the middle of the thigh area and that cause that can be caused by hip problems because the hip joint is actually deep to that space. Hip pain can also sometimes cause testicular pain. It’s not common, but it can, and we’ll discuss a lot of this with Dr. Snibbe when he comes back online with me for a future heart attack, we will have orthopedic surgeons and multiple hip surgeons. I’ll bring them all in to discuss to discuss these questions for you in depth. That’s very uncommon though to have testicular pain. I’ve seen a couple times and some inner thigh pain, but the actual groin pain is often never more than kind of halfway in the middle of the groin.

Speaker 1 (27:29):

It’s usually not too medial, so you’re correct, usually medial very medial pain is not consistent with a hip problem. Next question, for someone who had recovered from a pure tissue repair over a year ago while riding a bike long distance increase the chances of the angle hernia coming back. In other words, is bike riding a high-risk activity because if someone is positioned on a bike seat that creates higher abdominal pressure while legs are pedaling? No, we do not believe that bicycling is a risk factor for hernia recurrence or hernia occurrence. All activities that are exercise related including sports and bicycling, are considered protective and not a risk factor for developing hernia. And that also means it’s not a risk for hernia recurrence. We don’t believe that there’s an increase in abdominal pressure with cycling because you’re actually using a lot of core as part of it and anything involves the core, engages the core muscles and does not actually increase abdominal pressure. And then lastly, we discussed this with Dr. Spencer Netto from the Shouldice Clinic. The shoulders leg actually has used cycle days zero one and two after surgery in their clinic they have stationary bicycles and they encourage their patients to cycle and that keeps the joint mobile. It may decrease scar tissue, improves mobility in this space and may reduce pain after a tissue repair. So if it’s good for the Shouldice, I’m sure it’s good for you.

Speaker 1 (29:10):

Let’s see. Next question.

Speaker 1 (29:17):

I had a bilateral hernia pair 11 years ago with physio Mesh. I’ve been recently getting pockets of fluid collecting around the Mesh site ultrasound diagnosed as cyst after workouts or bike riding. Is this common or of concern? Okay, first of all, physio Mesh was not made for inguinal hernia repairs. It was made for intra-abdominal placement because it actually has a layer of covering that prevents it from sticking to things specifically the intestine. However, when you’re in the groin area, you want the Mesh to stick, otherwise you get fluid collections. So not only was physio Mesh not intent to use it in the groin, wherever it was used it did, it was associated with a higher level of seromas or fluid collections. So if you’re getting pockets of fluid collecting around the Mesh, it may be related to the Mesh itself because it’s actually quite low inflammatory in his profile and was made actually not to react too much. And the side effect was that it gets a lot of flu collections. I mean, I don’t know your situation, but if that’s a need, the situation you actually did have physio Mesh and you have recurrent, then you may want to consider having the Mesh removed. Once those fluid pockets develop, then they don’t go away. What’s not

Speaker 1 (30:52):

Consistent in your history is that your repair was 11 years ago. Do you seromas occur early on and persist so you think you had them and then you didn’t know until later and they’ve always been there for 11 years, they should not occur after 11 years. If you’re having fluid collections 11 years later, if it’s due to the Mesh, that’s a Mesh infection until proven otherwise. If it’s not due to the Mesh, you may just have a hydrocele not a cyst. There’s no such thing as a cyst after hernia repair. Okay,

Speaker 1 (31:37):

One patient. I need someone like that likes to solve complicated problems like yourself. I know I wish you lived on this side of the world. I think about you all the time, and that’s the honest truth. I feel like some of their doctors don’t want to get involved in my mess, which is true. Do you find that to be true that even some qualified doctors don’t like to take over a complicated patient that has had multiple surgeries, thankful that you don’t mind asking, don’t mind taking over someone’s mess? Well, unfortunately, yes I have. I know your situation very well. Unfortunately I have reached out to a lot of my surgeons in your part of town who are very, very gifted surgeons and I trust them a lot. They just don’t want to take care of situations that are so complicated. A lot of them are super busy surgeons and feel like they can’t give you their time and they understand that a lot of them are employed surgeons like I’m not employed.

Speaker 1 (32:37):

I can do whatever I want whenever I want. I can see one patient, I can see a hundred patients, no one is on my back telling me what to do and I choose to take care of complicated patients because you need more of my time and I have a luxury of giving you my time because I don’t have a boss handing on me saying, you see 10 more patients today. So unfortunately that’s a situation I wish I could be everywhere and help everyone, but I do think about you a lot. I do want to help you.

Speaker 1 (33:14):

I don’t think that we have good choices for you yet and I don’t like that you’re suffering. So I wish you lived closer or if I worked on the east coast, that would’ve been nice. I should have maybe opened up an office on the east coast, but I do love you very much. All right, you will get better, I promise you. I just hope I can get you better myself. Okay, next question. Could you please explain why a male with a bilateral inguinal hernia has one testicle much higher than the other? No pain but frightening. Seeing the right testicle sits an inch and a half higher than the left side. When I arch my back leaning backwards, the hernia bulge goes in however the testicle lifts even higher. Is this normal And when and what’s happening? Okay, so let’s discuss testicular motion and movement. So a normal testicle must move up and down is usually related to temperature and contraction of the muscles, the cremasteric muscle.

Speaker 1 (34:25):

If the hole through which it moves, which there is a hole, it has to be hole, it’s called the internal ring. If that hole is big, then you’re at risk for having a hernia. You also are at risk of having a reverse of a hernia, which is not things inside pushing up but things outside pushing in, which means a testicle can rise up and down much more freely, and some people actually have either a high writing testicle or high rising testicle or even a testicle stuck in their groin that they often manually reduce down. The point I’m trying to make is it’s all within normal. It’s nothing abnormal. If you know have a hernia and once you fix a hernia, that should get resolved. If you, because that hole is no longer wide open, gaping, open for the testicle to move up and down. If you have not been diagnosed with a hernia and your testicle moves up and down, then you should be looked into for possible hernia, especially for testicle moves up as high as the growing crease. That’s not normal.

Speaker 1 (35:32):

All righty, we’re just running through these questions. I love it. Okay, here’s my friend from Bucharest. So this patient wrote in, I’m in Bucharest and I have a lot of pain from my hernia repair. My doctors do not consider Mesh removal. They say my hernia will just come back. Is that a fact? Okay. Yes, that’s very true. It’s a fact, but there are things you can do for it. That’s why we do what we do. So it is true that in Europe, especially in the poor parts of Europe, so eastern, mostly the eastern blocks or the areas where there’s much more socialized medicine,

Speaker 1 (36:15):

Having a Mesh alone is like a big deal and once they do have put Mesh in you, they’re very reluctant to remove it. One of the reasons is their experience with Mesh is very limited. In the United States, we have the largest experience with Mesh. Mesh is part of the training here, whereas and we have access to a wide variety of Mesh as a result, we also understand where to put Mesh and where not to put Mesh and all the risks associated with Mesh. I’ll give you an example. I was invited to go to China, mainland China, Beijing, and Shanghai. It was absolutely one of the best work related travel I had ever done. They were super nice to us. The food was great and we got to visit with all these different hospitals and we gave all these lectures

Speaker 1 (37:09):

At one of the hospitals. They gave lectures to us and it was a little difficult to understand because at one of the hospitals they had a translator with for the other one that they didn’t, but they were showing these awesome videos of surgeries they were doing and we were like cringing. We were in the audience front row and seeing, oh my God, this is stuff that we were doing 15, 20 years ago that we’ve learned never to do, such as put PTFE based Mesh in an infected or open wound. You just don’t do that. That’s a disaster. You’re going to get hernia Mesh infections and fistulas and so on. And they were showing us how awesome it is, what they’re doing. And the reality is they just didn’t know because they didn’t have the experience. They’re like about 20, 15, 20 years behind us. So everything we learned 20 years ago, they’re now going through that learning process.

Speaker 1 (38:15):

Now we do have publish, we do give talks, but not all that information is disseminated. And so going back to this question, the doctors in Bucharest possibly do not consider Mesh removal. Number one, because they’re afraid to do it, they then will tell you, you will die or you will be maimed or you will get bowel bowel injury if we remove the Mesh and they also may not have the technology available to fix the hernia either without Mesh using a certain type of abdominal wall reconstruction technology or technique or using a hybrid or biologic Mesh to replace the synthetic Mesh. Or they may not have access to it, they just don’t have access to it. We’re privileged in the United States in that we do have access to a wide, wide, wide variety of implants and surgical technology that’s not available in a lot of countries.

Speaker 1 (39:19):

It’s partially why our healthcare system is so expensive, but at the same time, you’re being given access to things that is not available in most countries. You may recall we had a hernia talk session, I want to say almost two months ago with one of our surgeons in Czech re Czech Republic, and she was very frank about availability, have one type of Mesh, that’s it. All these other measures we talk about at these meetings, the Europeans kind of laugh at us because they’re like biologic. What is biologic like $10,000 for a piece of Mesh this big? There’s no way that our system would ever support that. You Americans are all crazy.

Speaker 1 (40:03):

So they say your hernia, hernia will just come back. That’s probably a fact. If you remove Mesh and you in a abdominal wall hernia, not a groin hernia in abdominal wall hernia and you just try and close it with a tissue repair, it’s about a 60% recurrence rate. So it’s not a hundred percent. There’s a 40% chance you’ll do fine. That’s better if it’s a smaller hernia or you’re a thinner patient or you’re not don’t have a lot of a large hernia. But that’s said in general what they’re saying is correct. But if you go to the right specialist, which may not occur, may not be in cross, I do have one colleague who works there, but I don’t know that they do Mesh removals. They do kind of complex of Paloma constructions.

Speaker 1 (40:53):

It may be that what they’re telling you may be true in their hands is what I’m trying to say. Okay, more live questions. I love these. I should do this more often. Who cares about guests? It’s all about me answering all these questions. But I do love the love. I love that you share my love, so I appreciate it. Thank you. All right. Is there any way to tell beforehand whether a patient has defective tissue requiring Mesh versus tissue repair? How do you assess tissue strength intraoperatively if the patient is asleep and cannot cooperate with Valsalva? Okay, by definition, anyone who has a hernia already has defective tissue, and that’s been shown in a lot of pathology studies where they looked at collagen levels and mismatch of mature versus immature collagen. So the stronger versus the less strong collagen and other kind of genetic markers within the tissue itself.

Speaker 1 (41:55):

So what will happen is, but that’s why a lot of tissue repairs fail. We believe it’s because you’re sewing unhealthy tissue to unhealthy tissue and as a result the outcomes are not as good unless you have something to support that repair. And we don’t really know how long that support is, but we do know that you need it for longer than several years. Is there a way to tell whether the patient has a defective tissue where it won’t do well with the tissue repair? No. We can tell if it’s really thin versus thick tissue in the operating room. You can kind of feel if the needle goes through it with some trigger or if the needle goes through it like butter, you know, kind of get a sense of what what’s going to hold suture or not. It’s not a very scientific way of analyzing it, but scientifically it has been analyzed and we know that tissue that has, that’s involved in hernias are collagen deficient.

Speaker 1 (43:01):

In general. Valsalva is not what’s important, how well the tissue handles sewing and manipulation and if it falls apart versus one that actually has good give to it. Those are two different things. It’s like hair. Some people have really thick hair, others really fine hair. You don’t have to tear the hair necessarily, but you can kind of see and the way that the hair gets some people have hair that’s constantly breaking off. Some have really thin hair, but a lot of it thick hair, but very little bit of it. The abdominal wall and tissues, you can think of it like that as well. It’s kind of a layman’s way of thinking about it.

Speaker 1 (43:52):

All right. Will you consider opening an East coast office or would you be able to use someone’s practice on the east coast, like a partnership or something that will allow you to have a place to perform surgery out here? I most certainly would have my surgery with you if that’s foreseeable. Well, thank you very much. That’s very nice. I have been offered to come to the East coast. I’ve also been offered to come to the United Kingdom and some European countries to, and actually some Arab countries to do stints there. I don’t know, I, I’m totally open to it.

Speaker 1 (44:36):

My only concern is the follow up because I have a lot of out of town patients currently, and for the more complicated ones, I force ’em to stay around here for a couple days, at least three or four days. But if they’re doing well and then all of a sudden they have, let’s say a complication of, and some of you are out there where you need more help, I can help you a little bit from far away, but then you have to come fly back to see me. So I’m totally open to it. If I feel that there are enough patients that would be willing to see me on the East coast where would that be though? Maybe not New York, that’s like too east coasty, maybe Boston. I know that there’s very few of us in the Boston area. Honestly, I’m open to anything. I think I really enjoy what I do and if traveling will make it so that more of you can be helped by me, I’m totally open to it.

Speaker 1 (45:41):

I love travel. I speak a lot of languages, so I traveled to Europe a lot and I tried learning Arabic. That was hard, but my French is pretty good and so is my Spanish. So Europe is always a good place. I don’t know. I’m willing. Let me know what you guys think. I’m happy to consider all of these. Well, thank you for mentioning that. Seriously, this is the best. Oh, thank you so much. You’re always on hernia attack. I appreciate your questions. You should offer more of these sessions amazingly helpful and thorough in your answers, Jack of all trades, but hopefully a master of my own. Thank you. Another thank you. Appreciate you acknowledging your my suffering, my quality of life is quite dismal and I’m just getting by, but I’m at wit’s end and my last appointment, her doctor said that the ball is in my court. It’s true, and I need to figure out what to do. I will be in touch. Please be in touch. I do think about you a lot trying to come up with some ingenious way of helping you out. I kind of may have an idea for you, give me a call. It’s a big deal operation, but you may be up to it.

Speaker 1 (46:58):

Yes. And if I do come, maybe DC is a good place because I like that area a lot and you would give me a proper Southern welcome to Virginia. I would absolutely love that. Thank you so much. Now that I have your attention, I know it’s the end of the session. Almost many of my friends have listened to hernia talk and they’ve mentioned that the content is quite good so I’m glad for that. And they have recommended that I snatch the audio from hernia talk and make it into a podcast. That way it’s readily available for all of you to listen to at your leisure while you’re driving or doing housework or gardening or whatever. And I’m curious if any of you would listen to a podcast of hernia talk. I have five months worth of weekly sessions now and we can continue to do that.

Speaker 1 (48:02):

So text me, email me, find me on social media. Let me know and be honest, if you think this is better as a visual thing because you get to see the doctors and it kind of humanizes us a little bit more and let’s not do a podcast because everyone and their mother is doing a podcast, let me know. But if you think that it’s something that you’d be worth listening an hour of I’m willing to do that for you. Why not? Okay, more questions. The only randomized trial looking at two of the many techniques advocated for sports hernia with Dr. Paul John being the lead author, found tap repair as well as minimal repair were highly successful. How can lap Mesh repair only for sports hernia and pubalgia if due to pubic played injury? We discussed this question with Dr. Zoland. He was not a proponent of doing a lap repair for a sports hernia.

Speaker 1 (49:09):

And I would like to say that he’s probably right because a posterior repair doesn’t necessarily offload tension from an anterior injury. And unfortunately, at least from what I’ve seen in my experience, there’s a lot of surgeons that call small hernias that they don’t feel a sports hernia, which is not. And then they of course do a hernia repair <laugh> for that small hernia and guess what? Patient gets better. And so they say that’s a appropriate repair. So I wonder how much of what you’ve read is really surgeons just doing a bonafide hernia repair for what I called a cold hernia. It’s a lot of what I do because it’s more common among women and then they think they’re patting themselves in the back because the pain goes away, but in fact, they just actually just repaired a hernia. There was a misdiagnosis the whole time. Last question I think.

Speaker 1 (50:13):

No, we got some more time. You’ve made a great point for someone looking for a tissue repair to focus on a hernia specialist who is versatile in adjusting to what your needs are versus being set on a specific surgery beforehand. So which east coast surgeons you suggest are standout at being versatile with tissue repairs? Well, we’ve already had several. Dr. Yunis was one who does a lot of tissue repairs and a wider variety of them. He would be a good choice because he actually likes doing tissue repairs. The other surgeons that we spoke to on hernia talk like Dr. Jacob do tissue repairs as well as laparoscopic repairs. So he’s another good one. Dr. Zoland as well. The people I bring on are all people that I recommend and if you hear us talking on hernia, talk about tissue repair, then know that they do tissue repairs. I would not bring up that topic if I didn’t know that that was something of interest to them.

Speaker 1 (51:15):

I appreciate your answer, but this was sophisticated study with MRI control, right? So MRIs are notoriously misread. If you look at my papers about MRIs almost all of them, I would say three out four were misread for occult inguinal hernias, and many of them, many patients have tendonopathy, but that’s not the reason for their pain. It’s actually an undiagnosed inguinal hernias. So in a sophisticated study with actual hernia surgeons that read their own MRIs or are working with radiologists that will be able to understand that the MRI, whether it shows a hernia or not in those patients I think a lot of ’em are confounded by the fact that they’re just fixing hernias. Alrighty, all righty. Thank you so much. Another one I’ve learned so much through your talks, posts, et cetera, without suggesting an a cold hernia, none of the specialists I’ve seen would’ve considered it currently speaking with a general surgeon who is along the lines of, well, I guess I can pop in a scope and look.

Speaker 1 (52:26):

Okay, let me talk about that. The rest of your question refers to years of deep pelvic pain, hypermobility and just PO had a positive ultrasound for an Anglo hernia, but that’s more superficial than my pain. Your info is so encouraging and made me realize I’m not crazy or making this up. Yeah, for sure. You’re not crazy. I’d say this all the time. Patients do not want to have pain and they don’t really, I’m sorry. You can’t have a patient that comes up with a perfect anatomic lie about their pain. If it makes sense anatomically, then you got to believe them. You can’t just say it’s in their head or they’re or they’re making it up because that just shows your weakness I think as a surgeon. So be very careful about surgeons who want to go in and pop a scope and look, I’ve never had to do that and by never, I mean maybe once or twice in my 20 year career where the patient was just in so much pain and every other study was negative, an imaging, good imaging study and a good history and a good physical, those three combined will be able to diagnose almost everything that you need diagnosed and therefore determine your plan of care.

Speaker 1 (53:44):

Now let’s say you’re in a situation where your surgeon doesn’t know what else to do is offering to take a look very specific to an occult hernia is they are occult, which means they’re a hidden, which means putting in a scope or camera laparoscope will not show you that hernia. Most likely what they have to do is go beyond just putting a scope in actually physically take down the peritoneum level and the fat that’s plugging your hole. Look at the actual muscle and see if there’s a hernia there. If there isn’t, then you have your answer. But if there is, that’s the only time when you can tell. What I see often happens is the surgeon goes in there, pops a camera, no hernia, where whereas they did have a hernia just beyond the tissue that they’re looking at and what they then have years and years and years of not being treated for a very treatable inguinal hernia and it was dismissed and because they felt so confident about the surgical approach they know that they were basically misdiagnosed from the very beginning or misled.

Speaker 1 (55:06):

So if you do go under surgery, make sure make that the peritoneum is taken down and the fat in the inguinal canal is removed and they look at the actual hernia at the muscle level, not the Intraperitoneal level before they say you do not have a hernia. And honestly, I’m available to your surgeons please if you feel like your surgeon would like to call me or talk to me or ask me a question or get some advice, I am always available. They know how to reach me. Please just have them do that. If you feel like that’s going to help you out, and I know that most of you can’t physically come to see me, even though I would love to treat all of you and thank you for thinking that I’m an amazing combination of expertise, science, compassion, and kindness. I do really appreciate that.

Speaker 1 (56:03):

Looks like there’s some interest in the podcast. I will do my best to look into it and see how I don’t want to put bad quality content out there. So if it’s something that’s good quality, then for sure I will do that for you. And that is the end of hernia talk. Thank you everyone for joining me on another Tuesday. We have another excellent guest next week on Tuesday, 4:30. I will post our session here on YouTube and share the link with that on hernia talk.com. Twitter, Instagram and Facebook. And for those of you that couldn’t get to see me on Facebook Live is I’m very apologetic. Sometimes Zoom is not the best in getting its collaboration with Facebook, but I do thank you so much and hope you have a great night. Take care. Bye-bye.