Dr. Towfigh (00:00:11):
Okay, everyone. Hi, it’s Dr. Towfigh. Welcome to Hernia Talk Live. I’m your host, Shirin Towfigh, a hernia surgery specialist. Thanks to everyone who’s joining us on yet another Tuesday-based hernia talk live. Many of you are joining me via Facebook at Beverly Hills hernia center. You can also follow me at Dr. Towfi on Facebook. Thanks for those that are physically logged in to our Zoom-based live webinar. Thank you very much for that. As you know, you can type in your questions or submit any of your questions ahead of time, which many of you have already, but also right here live, that’s how we have it live. That’s what’s so unique about our podcast. As some of you may have been following me over the weekend, I do live tweet from meetings that I go to. So thanks to everyone who followed me on Twitter or X, as we call it, and saw everything that I was posting.
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There was actually, this was in Santa Barbara this weekend. My research team with Ian, my research fellow had one of the top presentations, the first session of the Santa Barbara-based Southern California chapter of the American College of Surgeons Meeting. And we talked about medical illness and how that may or may not determine how well you do from your hernia repair. Specifically, we looked at what’s called ASA Class, which is the American Society of Anesthesiologists, excuse me, American Surgeon of Anesthesiologist classification for people and their risks during surgery. And what we found is even though your risk for surgery may be higher if you have heart disease or diabetes, et cetera, that has not really been shown to dramatically change your outcome from the hernia repair itself. So we found that you may be doing a disservice as a surgeon. You may be doing a disservice to your patient if you deny them hernia care purely based on their ASA class.
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It’s not a scoring system that should determine whether you should offer hernia repair because not only did it not change the type of hernia repair options they’re offered, but the outcomes, the clinical outcomes were similar to patients that were healthier. And very interestingly, the quality of life score of patients that are sicker was so much better and more improved after surgery than the average patient with a ventral hernia. So we kind of had a debate about that. There was actually two hernia talks in this, otherwise
Dr. Towfigh (00:03:19):
Pure general surgery. Excuse me, had a major sneeze right there. There were actually two hernia sessions at that talk during my time. Trying to sneeze and I don’t want to interfere.
Dr. Towfigh (00:03:42):
The second one looked at inguinal hernias and whether obesity made a difference in terms of inguinal hernia repairs. And similar to what we found is yes, there’s always a slight difference in outcome between obese and non-obese, sick and not sick. But what I was trying to portray and what they also were portraying was even though statistically there was a difference, the difference was like 2% or 3% difference. So is it really appropriate to deny someone, especially someone who’s symptomatic, a hernia repair because they’re obese, when the difference in outcome is like two or 3%? Sometimes we feel like we look at these clinical trials and they’re like, “Oh my God, significant difference in outcome, significantly poor outcome, significantly higher recurrence rate.” And you look at it and it’s like, yeah, it’s statistically significant, but is it clinically relevant? And what we see is it’s oftentimes not clinically relevant.
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So if you have a, let’s say, 11% risk of recurrence versus 13% risk of recurrence, do you offer surgery to the 11% one who’s not obese and you don’t offer surgery to the 13% one that is obese? To me, that seems not fair. And what you end up doing actually, which we show in our ventral hernia study, and then they showed in their inguinal hernia study is you’re picking and choosing patients not to operate on for a fear of complications when the difference in complication rate is actually not that bad. And then they don’t get surgery even though they need surgery because they’re symptomatic because they have symptoms and they end up in the emergency room with a more complicated problem, more advanced hernia, higher risk operation, higher complication rate, and worse outcome. Whereas if you had operated on them the first time, you could have prevented all of that.
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So that was kind of the discussions we had. And I’ll tell you just so that people understand how cool hernias are. So every year they have what’s called surgical jeopardy. Now, all of you have probably seen jeopardy. So surgical jeopardy is basically jeopardy, but all the questions are surgically related. And we have 18 surgical residencies in Southern California. And since this was the Southern California chapter of the American College of Surgeons, we had 15 of those 18 programs join in competing for surgical jeopardy. And Huntington Hospital, which is one of the hospitals that I go to down on the east side of LA and Pasadena, one for the third year in the row. And guess what? The final jeopardy question was a hernia question. So the fact that … And actually all of them got it right, so that’s kind of cool too. But yeah, there was a whole category on hernias, but there was also the final jeopardy question on hernias, so I thought that was pretty cool.
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Okay, let’s move on.
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Okay. All right, so I’m just reading your question here. We decided to talk about sutures today. That’s our topic. Of course, as always, I’m here to answer any questions you may have or want to propose for me to answer. However, the topic of choice today is specifically on sutures and what are sutures? Why do we use sutures? What sutures should be used and shouldn’t be used in the different topics related to that? So I see there’s a couple questions already up on the board and I’ll try and help answer those, et cetera. So the first question is, how do the sutures rank in thickness? So just to be clear, there’s two types of sutures. There’s the actual thread that just comes like a needle on thread, just the thread that you would be able to get. And then secondly, there’s the thread attached to a needle.
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And as a surgeon, you have a choice of the type of thread, which includes the size and color. And then you have the type of needle, which are different sizes of needles and different shapes of needles, and the combination of those. Now, that sounds like a million different combinations. We don’t have that many choices, but the choices are very deliberately made. So let’s say you’re doing a very defined surgery, you want a smaller needle. You’re doing a huge surgery, you need a bigger needle or a thick tissue, you need a bigger needle. Same with the actual thickness of the suture. So ideally, you want to match the needle in the suture to be similar in size and the suture or the thread, the suture to be similar in strength, at least of the tissue to which you are sewing the area.
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So believe it or not, there’s so many mistakes made in the choice of suture and needle that boggles my mind. And I feel like people need to take a tailoring class before they are a surgeon because as a tailor, you would never choose a really thick thread for your silk shirt, for example, or a really thin thread for your leather jacket. You have to match the strength and the size of the thread and the needle to the fabric that you’re using. The same is true for surgery. So if you’re operating on a really thin old lady’s tissue, you don’t want to use a thick thread or suture. And if you’re operating on a muscle builder, bodybuilder or someone who’s morbidly obese, you also don’t want to get a very weak threat or tissue or suture. So it boggles my mind how there are surgeons that really don’t think about it, and then they use the same thing for everyone because that’s what they do.
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And I’m just telling you, you would never do that as a tailor. So why would you do that for a human being? Anyway, so the question is how do the thicknesses of the sutures rank? So if you take, it’s a numbered system. So zero is like the standard number, and then you can go number one, number two, number three. So the higher that number, the thicker it gets. So zero is a certain thickness, and then number one is thicker, and number two is thicker than that, and number three is thicker than that. So that’s one level, but you can also get less than zero. So less than zero is zero zero, which we call 20. Less than that is 000, which we call 30. And you can go all the way down to 15, 150, which for the eye, if you want to just operate in the eye, you want microscopically visible suture.
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So that’s like a 15O. If you’re operating on the face, you may want very small, like a 50 or 60. So it’s not number five, that’s above zero. It’s 50, which means it’s actually 0000, which is less than zero. It’s just the way that the standard is. This is a international standard. Anywhere you go to operate, that’s the way the sutures are going to be categorized in terms of thickness. So that’s the ranking of the thickness of the sutures.
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Usually for most hernia surgeries, we use 20, so it’s OO. It’s really uncommon to use 3O for anything hernia related, but we can. And then it’s pretty common to use just straight O or even number one, which is one layer thicker than O, but studies have shown that going above 20, which is OO and using O or number one is actually detrimental and more likely it’s just too thick. So because it’s too thick, then it will more likely tear through the tissues because the suture almost never tears and cause hernias. So that’s why it’s so important to pick the right thickness of the suture from the very beginning. Now, what I’m teaching you this is not so much for you to go and tell your surgeon, “I want you to use 2.0.” And it’s unlikely you’ll ever be able to tell a surgeon what to do because that’s really up to the determination of the surgeon to pick and choose what they believe is best.
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But it’s really for you to understand that not all hernia repairs are the same, not all suturing is the same, the same way the way a Birken bag is sewn is not the same as the way a coach bag is sewn, which is not the way a Target or a Trader Joe’s bag is sewn. They all have different types of sutures and qualities of sutures and thickness of sutures, et cetera.
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Okay, let’s move on. The next question is, what is the difference between interrupted sutures and interrupted running suture? So you either are interrupting, which means you put a stitch and you tie it, you’re done, and you put another stitch, you tie it, you’re done. Or you have running suture, which is you run it. You just basically tie a knot and you go stitch, stitch, stitch, stitch, stitch, and you tie knot. So running means one single uninterrupted suture is used for the length of your wound or scar or whatever. Interrupted means multiple interrupted sutures. So you know like the Frankenstein stitches, the Frankenstein look, or if you’ve seen anything on the face, those are usually interrupted sutures and there’s pros and cons to interrupted versus running sutures. So if you think about it, if you do a running suture, so it’s one single thread from beginning to end.
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If something happens to that suture, your knot gets untied, it accidentally gets torn or pops, the entire thing can unravel, right? The entire thing can unravel. So that’s the negative part of using a running suture. However, if you interrupt, okay, that’s not good, so I’m going to interrupt. I’m going to do one stitch, tie it, cut it, next stitch, tie and cut it and go on. Well, if that tears, then only one of it tears and it doesn’t affect all the other interrupted ones, that sounds like a good idea. Why doesn’t everyone interrupt? I’ll tell you why. Back in the day, I’m going to say 1996 era, a great surgeon looked at the difference in hernia rates between running and interrupted sutures. And lo and behold, running was better, even though it sounds like it should be worse. Why? It has to do with blood flow.
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So you need to heal and healing requires blood flow. If you have dead tissue, that’s never going to heal. So what type of stitching is most likely to give you the best blood flow? Well, the one that’s not the tightest. So if you’re doing interrupted sutures, at least this is the theory, if you’re doing interrupted sutures and each place where you put the single stitch and you tie it is cinching that area and maybe strangulating or causing less blood flow intermittently at these spots. So if you tear that, that’s going to be a hole, and then you tear another one that’s another hole. So that can be a hernia. So it’s a hole in the muscle because you’re tearing it or what you’re actually doing is you’re decreasing the blood flow in the area and not allowing it to heal. If you run the suture, yes, there is a risk that it can get unraveled, but if you theoretically put it perfectly, it should not unravel and the pressure or the tension on your tissue is not focused to these individual interrupted sutures.
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It’s the pressure is stretched out and throughout the whole suture. I’ll give you another example, tying your shoelaces. Most shoes, the shoelaces, it’s one shoelace, right? It’s one shoelace, you run it through and you tie it. So if you tie one part too tight, it’ll loosen up because the entire tongue of your tennis shoes, let’s say, will equalibrate. Whereas if you make individual, if you have five shoelaces and you tie each one separately, if one is tied too tight, you can’t loosen it by just nudging the other ones. Does this make sense? You have to redo that one. It’s a blood flow issue. So the hernia rate and therefore the tear through tissue rate, and therefore the blood flow issue rate is best with a running suture, so when you kind of run it. But if you think your tissue is so crappy that it’s not going to support a single suture, you may choose to do interrupteds because that will reduce your risk of the whole thing unraveling because the patient has shitty tissue.
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Sorry about my French.
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Okay. Question. Ola doctor pertaining to the first subject, does obesity affect the suture selection, number one? And secondly, does suturing technique affect post-surgical scarring complications? Yes and yes. So plastic surgeons are the best at this because they want a beautiful scar, a cosmetically pretty scar. Therefore, they choose the smallest amount of stitch necessary to do the job. They reduce the amount of inflammation from the stitches. They tend to use low inflammatory stitches like on the face, for example, like for a facelift, and they tend to use less knots because knotting can also cause extra inflammation. It can trap bacteria in the knots and so on. So yes, the type of stitch that you choose can reduce or augment the amount of sleeping based on the quality or material of the stitch, the size of the stitch, and the number of knots you put in it.
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So we’ll review all that. Secondly, yes, obesity also affects the suture selection. Now, many patients that are obese actually have very poor quality tissue, so you don’t want to make their repair or closure of any abdominal wall area tight, because tight is not good. It’s just going to tear. If I give you a tight shirt, you’re going to pop those buttons. Oh, that’s a good analogy. Okay. So buttons versus zipper. Buttons are like the interrupted sutures. So if you pop a button, you’re going to have a hole in that one area, that’s your hernia, but your whole shirt doesn’t unravel.
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Zipper is like the running suture. So the zipper will be able to provide tension, distribute along the entire length of the zipper, but if you break the zipper, the whole thing unrevels. Okay. So for patients that are obese, you can’t make anything tight because it’ll just tear through their tissues and you don’t want to use … But also they have such huge abdominal pressure that you don’t want to make it so that the stitch can’t be too thin because it needs to have some extra strength to fight against and not tear with an abdominal pressure like a cough or something like that. I hope that’s helpful. Okay. Next question. What is the difference between ethicon and proline? Okay, so ethicon is a brand name and it’s owned by Johnson & Johnson, and it’s known for a wide range of sutures. Ethibond, Ethibond is a brand name of suture made by ethicon.
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So both ethibond and proline are brand name sutures for permanent sutures. Ethibond tends to be braided polyester. Prolene is usually a non-braided polypropylene. So think of it as a rope versus a fish line. So the ethybond is more like a rope. It’s braided. It has a lot of filaments within it and it’s polyester-based. So it’s very soft and it can be tied very nicely and it stays, but it does have more risk of infection or counter-rejection. Rejection is not the right term. Prolene is a stiffer, more like a phishing line. Prolene is stiffer, does it not very easily, but because it’s a single, what we call monofilament, as opposed to a braided polyfilament like ethybond, because it’s like that lower risk of infection because it doesn’t have all these little filaments to trap bacteria, but it’s stiffer, so you can feel it. So if you’re putting a stitch very close to the skin, we often prefer ethybond if you need a permanent stitch and not prolene because you can’t really feel the tails and the knots of the ethibon, but you can of a proline.
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But if you’re going deeper in the body, we almost never use ethibon unless you want the pliability of the ethybond. So ethibon is softer and it’s easier to tie not with. Prolene is stiffer and more difficult to tie not with, but less likely to get bacteria on it.
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So it all depends on what’s important. They’re both permanent. They both have some type of inflammation associated with them. Some people like polyester, some people like polypropylene. That’s kind of how I think about it. So because the polypropylene is more like fishline, if you’ve ever had a fish line wrapped around your finger, you can see how easily it can tear your skin. So basically with that, some surgeons don’t want to use that. They want something that’s not as likely to tear through muscle or tear through tissue. I hope that makes sense. Okay. Next question. Which stitches are better dissolvable or permanent? What is the difference between hernia and muscle rupture? Okay. Hernia is a hole through the fascia, not necessarily the muscle.
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It’s a hole in the fascia and contents can go through. A muscle rupture usually refers to the actual muscle content, not the fascia that tears. So muscle ruptures, usually when people talk about muscle rupture, it’s usually like an athlete that tore a major muscle, or it’s a muscle that ruptures like in the hamstrings and it’s usually an extremity. Hernias tend to be very specific. They’re either related to a prior surgery or it’s in a specific anatomical region like the groin or the belly button, which are more prone to hernias. Regarding whether stitches are better if they’re dissolvable or permanent. In general, you want to use the least amount of stitches that gives the best amount of support, number one. And secondly, you want to match the purpose of the suture with the dissolvability. So for example, if you are fixing an aortic aneurysm and you want to suture close some type of vascular, an artery, you want to suture an artery, we don’t want that to rupture or open up.
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So you use permanent suture for that. If you’re having any vascular surgery, any surgery related to the vessels where there’s a risk of rupturing, you use permanent suture. So in that case, it’s better to be permanent.
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If you want to close your skin and let it heal nicely, we use dissolvable sutures. You don’t need permanent sutures because there’s no tension in that area. You close in multiple layers with different dissolvable sutures and your natural healing will heal that scar and you no longer need a permanent suture to hold that in place because your own body will heal it. Then it comes to hernia repairs. So we know from multiple studies that the more permanent the product, the better the results of the hernia recurrence. So for example, any type of tissue repair, should ice, Basini, McVay, all of those were performed with permanent sutures and there’s so much tension in these areas that you need the permanency of the sutures. And it has been shown that if you use absorbable sutures, the strength of the area reduces once the sutures are absorbed and therefore you’re going to get a hernia recurrence.
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The same is true of mesh. We know that there are absorbable meshes and permanent meshes, and the permanent meshes have always been shown to have a better outcome because it maintains its strength and allows the area to be supported during your lifetime. So recur Rinses are also lower with permanent mesh versus absorbable mesh.
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So that’s where the data is. Now, are there situations where it’s a low risk area, like a little itsy bitsy belly button hernia? Do you really need a permanent suture for that? Debatable. In general, we like to make sure that there’s some sort of logic as to why you use dissolvable versus permanent suture. Okay. Next question. I just saw it. Dr. Towfigh, I had an indirect inguinal hernia surgery on the left side using shouldice no mesh repair technique just last year. So great question so far. Let’s talk about it. Should ice repair is a tissue-based inguinal hernia repair named after Dr. Shouldice. That was first described using permanent sutures, specifically steel, stainless steel.
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And at the shouldice clinic and many other practitioners still use stainless steel as a permanent suture. Of course, steel does not absorb. Okay. Stainless steel suture was used. That’s the standard technique. I feel pain near the inginguinal canal. The area on top of the pubic bone. Will stainless steel suture cause pain? So yes, it can. The stitching alone can cause the pain if it’s too tight or if it’s trying to tear because of your tissue quality or how tightly it was placed. But also, although stainless steel does not tear, it can break. The same way … What’s a good example?
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Trying to come up with an example. The tines of a comb. You know those metal combs? Those tines can break. Times of a fort can break. So the stainless steel suture is … I forget what number suture they use. I think the stainless steel comes in different numbers, but it can break. And so we often choose to use that because it’s low inflammatory, it’s very difficult to handle, but in some patients it can break. Now, if it breaks, you now have two sharp ends, and those sharp ends can poke at you and they can poke into the area into which it was sewn.
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I also have posterior scrotal nerve pain and perineal pain. What kind of treatments are available for pain? Okay. Okay. That’s a full consultation to figure out why you have the pain. But you can most likely have a hernia recurrence. That would be probably the most likely cause of pain after a tissue-based repair, especially if it includes perineal pain and posterior scrotal nerve pain. And it can be related to just your tissue tearing, that can be very painful, or it can be related to the stitches tearing or breaking in this case. So I hope that’s helpful. You can either contact me my office directly or … Yeah, just contact my office directly or message us and we can help you either come in in person or do an online consultation to help figure out the exact reason for your pain and therefore the plan of care associated with that.
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So today, for example, I saw several patients. Every single one of them had a prior surgery and every single one had some type of pain, but also every single one had a different reason for the pain. One had a hernia recurrence. One had a balling up of the mesh. Another one had the wrong size mesh placed. So there’s all these different reasons like that.
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Okay. What should be the material of the stitch? So it depends on the purpose of the stitch. The different materials include cotton, believe it or not, but not … We don’t usually use it. Silk, which is running out of favor, but it’s available. Polypropylene, cat, gut. And I think it used to be actually cat gut before, but it’s not. It’s some type of synthetic cat gut. Something called PDS or Maxon. There’s Vicryl or Dexon. There are all these different brand names we use, but it’s polydiaxone and all these other different really technical terms. So really what we as surgeons think about is not so much the … Oh, and the polyester, we mentioned poly. So there’s cotton silk polyester, polypropylene, and then a bunch of nylon, it’s another one. So we have a wide range of types of sutures. They’re usually in a spectrum of absorbability.
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So they either absorb within three days, three weeks, eight months, several years, or never. Those are the permanent ones. And within that category, you then have sutures that are either monofilament means it’s like a single thread like a fish line or multifilament, kind of like a rope, but a thin one. Most threads, most things, if anyone does needle point, it’s like multiple threads within one.
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And then the choice is based on the type of surgery that you plan to have. Is it better to do repair with a mesh or without a mesh? Okay. There’s no answer to that. It’s like, is it better to be blonde or brunette? It depends on what you’re trying to get out of it. So if you are a typical male, mesh repair is usually better. If it’s a big hernia, for sure you need mesh. If it’s a tiny, tiny, tiny hernia, in most cases you can get away without mesh. Tiny meaning less than a centimeter usually.
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If you’re morbidly obese, usually you do better with mesh. If you’re super thin, usually you do better without mesh. If your hernia has already failed a prior non-mesh repair, then you need some type of mesh. And remember, there’s tons of different types of meshes. There’s permanent meshes. There’s absorb meshes. There’s rapidly absorbing meshes. There’s slowly absorbing meshes. There’s hybrid meshes, which has both permanent and absorbable mesh into it. There’s more inflammatory products and less inflammatory products. There’s heavyweight and lightweight meshes. And if you go to a very developing country, you may not have all these options, but in the United States, in the United States, pretty much most places have good access to a wide range of products. And if they don’t, the surgeon can ask for it and some company rep would be happy to sell it to the hospital. So we’re very lucky like that in the United States.
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Even in Europe, they don’t have access to too many different types of hernia meshes. They just don’t. It’s just not a thing. Even though it’s easier to get those meshes approved in Europe, actually not anymore. Not anymore. It used to be easier to get them approved in Europe. Now they mandate in Europe to have human long-term data before you are allowed to have the mesh and you can’t just say it’s equivalent to another mesh. Every new mesh that comes out has to be studied. You can’t just base it on … You can’t grandfather it in based on a similar mesh being already granted approval.
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Okay. Next question. Which suture lasts for several days before dissolving? So Ket gut. Ket gut, several days, maybe a week before it’s basically useless. So yeah, Ketchut, we use it for not too many situations. I use it around nerves to help prevent bleeding when we cut the nerve and then allow it to dissolve into the muscle once it’s buried into the muscle. Next question. If a repair is done without mesh, it might not be as durable. So weightlifting is not advisable, correct? No, incorrect. That’s not correct. So all repairs are performed with the plan for you to return to a normal, healthy, active life, number one. Number two, exercise has never been shown to be a risk factor for hernias. In fact, the opposite is true. People who exercise, including weightlifters, are less likely to get hernias than those that do not. I exclusively perform hernia surgeries and see hernia patients.
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Do you know how many weightlifters I see in my office? I had one WWE person, but an actual professional weightlifter, they just don’t get hernias. If they did, they would’ve all come to see me. So if they have a strong family history, that’s completely unrelated to the fact that they chose weightlifting as a career. But in general, weightlifters don’t get hernias more than average Joe Schmo. If a repair is done with the mesh, it could cause autoimmune reaction, correct? Also incorrect. So all meshes do cause some type of inflammation, some more than others. The lowest inflammatory products are the ones that have the least amount of synthetic in them, and also the highest quality of absorbable biologic in them. So that’s inflammatory. That is very different from autoimmune. Most people do not get an autoimmune reaction. And by most, I mean, 99.999% of people do not get an autoimmune reaction to an implant.
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Can someone get an autoimmune reaction? Yes. Usually in our study, we saw 80% of people that showed concern for an autoimmune reaction themselves had an autoimmune disease or had a very strong family history of autoimmune disease. So both the comments that you’re making are incorrect and they tend to be misinformation that is fed by people that don’t really know this topic. And therefore, people are fearful of having surgery. They’re fearful of having mesh. I just had one patient today who chose specifically to travel to have surgery by a surgeon not to have mesh in him, and now he had an adverse reaction. In a patient who I personally would’ve put mesh in, totally healthy male would’ve been perfect situation for a mesh. He would’ve been perfectly fine and moved on. And because of his fear of mesh, mostly because of his research and the online forums, he now has an adverse reaction.
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So that’s not really healthy. Okay.
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Okay. If a repair is done with the mesh, it could cause autoimmune reaction, correct? No. However, if it would not cause autoimmune reaction, it is more durable. Yes, it’s always more durable. Even in patients with autoimmune disease, mesh is more durable than non-mesh. There’s no question about that. There’s never been any study to ever show even closely that a non-mesh repair is equivalent to a mesh repair. Not true. But there are risks with mesh. There are risks with mesh, and therefore as surgeons, we should pick and choose who does best and also which specific type of mesh, what size of mesh, which weight and density of mesh, which quality and type of product in mesh, and that’s the right approach. Again, going back to the tailoring, you want to pick and choose the right fabric, the right pattern to cut the fabric for the right size of the patient, use the right thread and the right size needle.
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So just like a tailor, you have to also be able to do that for patients as a surgeon. Next question. “You are a great surgeon.” Thank you. “Will SITS bath or bioptron light therapy?” I assume that’s red light therapy, “Help to reduce pain.” Well, I do know that light therapy can reduce inflammation. Will nerve block help to reduce posterior sclerotal nerve and peraneal pain? Where will the nerve block be injected to? So it should not affect the peraneal pain. Nerve blocks almost never affect peraneal pain unless you have true
Dr. Towfigh (00:44:55):
Pudendal neuralgia.
Dr. Towfigh (00:45:09):
Okay. The issue with peraneal pain is usually it’s muscle spasm and often the muscle spasm is related to pelvic floor spasm is related to your hernia being recurrent. So this is the patient that was talking about earlier with the shoulder ice repair and now with the pain, you most likely have a hernia recurrence and the hernia recurrence is causing the pain, causing what you’re proceeding to have, which is nerve pain, and then also the peraneal pain. So you fix a hernia recurrence and all the downstream effects of it are gone. That’s my usual situation that I see. Of course, yours may be different and imaging will help as well as a good physical exam.
(00:46:02):
Oh, here’s a great question. What are your thoughts about pig mesh for ventral hernias? Okay. So some of you may be like, “What’s pig mesh?” So we talked about permanent meshes, which are synthetic, almost always synthetic, but there’s also what we call biologic meshes. So biologic meshes come from a cadaver of some sort. The first ones were from humans, but then it was kind of expensive to get cadaver human meshes. So they figured out, oh, we can just take picked skin or other parts of cows and rabbits and so on and sheep and make them into meshes. So here’s my take on it. Biologic meshes, whether it’s from an animal or from a human, comes in good quality and bad quality. The same way you can have good quality meats and bad quality meats. You can have your USDA choice or your prime or you can have these kind of really poor quality meats.
(00:47:15):
So the pig skin products, stratus is one of them, tend to be good unless they are made in a way that is highly synthetic. So the whole purpose of using a biologic mesh is to put in something instead of regular synthetic mesh, they all absorb or they’re supposed to absorb, and they all have a situation where the product … Well, the product is supposed to absorb, whether it’s human or … And then the human or animal. And then that area then turns into scar usually. We used to think that it just repopulates stem cells into whatever you’re sewing to. So if you sew biologic mesh to, what do you call it, to your muscle or fascia that you’re going to get that’s grow into that. No, that doesn’t happen, but it doesn’t matter if it’s pig or sheep or rabbit or it’s how it’s processed.
(00:48:37):
Even for humans, it’s how it’s processed. So if you have a well-processed, minimally processed, kind of like food, minimally processed food, then that’s a less inflammatory biologic and the body accepts it more, doesn’t treat it like a synthetic product as much and has less inflammation and therefore does its job. Whether the job is to be resistant to bacteria or to reduce chronic pain, whatever the situation is, regardless of whether it’s human or animal, as long as the processing is high quality and it’s not overly processed and therefore too syntheticly, then it’s a good product.That’s the easiest way I can explain it without getting too technical of that. Okay. Which suture lasts for several years. So silk suture, silk is technically an absorbable suture, but it just loses its efficacy after several years. It’s not technically truly permanent. The body does absorb or break down silk over time, but that takes years and years and years.
(00:50:03):
So if you go in someone’s belly who’s had silk, you often will still see the silk, but everyone’s a little bit different. In some patients, you’ll go in two years later, you see the silk. Others, 10 years later, you’ll see the silk. So silk suture is a absorbable suture, but it’s very slowly absorbable and many use it as a permanent.
(00:50:27):
Okay. Let’s see. Can you describe what a tack is and is made of and of what a suture anchor is? So tacks and suture anchors are all different terms for fixations. So they’re more like a screw or a nail. So it fixes things to the wall, but usually to the abdominal wall, the same way a nail or a screw will fix something to a wall. So these are just products that were mostly developed because laparoscopically we couldn’t put in stitches. It’s kind of complicated and very highly technical to do so. It was very difficult. And so what the interest rate made were these, what do you call it? TACs. So it’s like, what do you call it?
(00:51:33):
Those nail guns? It’s like a nail gun, but for the body. So tacks are usually like a curly cue suture anchor. It was literally like a needle that goes in and turns into an anchor. So they’re just different ways of fixating the same way a nail gun fixates things and it’s fast. It can be harmful if you put it in the wrong area or if you go too deep into the tissue and you injure whatever’s on the other side of the tissue, but it’s much more technically easier, less complicated to put in than a stitch if you’re doing laparoscopic surgery.
(00:52:14):
Okay. Well, this is the same patient who talked about the … Oh, you’re considered the very best doctor for hernia. Thank you. Appreciate that. Who told you that? ChatGPT? Just kidding. Okay. This is the patient with the shouldice question. “Dr. Towfai, you are right. Ultrasound found angulo hernia recurrence with fat. I told you. It’s all the story. I never saw you. I haven’t seen any imaging. It’s all your story. The story tells you everything. “Okay. However, two surgeons said no hernia recurrence. Are you serious? Will spermatic cord nerve block help to reduce posterior scrotal nerve pain and peraneal pain? No. No. Okay. Now I’m getting pissed off. You’re being fed way too much problems. If you have a hernia recurrence, just fix your hernia recurrence. Don’t go cutting nerves. Don’t go having spermatic cord denervation procedures or nerve blocks. This is not a nerve issue.
(00:53:22):
This is a hernia recurrence issue. Fix the hernia recurrence and then reassess. It’s the best, most likely way to be able to address your pain and most efficient with the least amount of risk. So yeah, if ultrasound found a hernia recurrence with that, why?
(00:53:43):
I feel like you’re going to the wrong surgeons. Now I’m pissed off because why would a surgeon in someone like you who has a perfect story and is fed this weird spermatic cord nerve block, posterior spermatic cord … Posterior spermatic nerve pain, which is by the way, I don’t believe that can be injured in any way by any hernia surgeon. Why are they giving you the gas line you to go left when you really need to go right? Okay. I really would like to help you, by the way, because now you got me all riled up. Goddammit, I need to fix you. Okay.
(00:54:26):
Could local anesthesia be used for a small umbilical hernia? What agents are used? Yeah, so most small umbilical hernias can easily be repaired under local anesthesia and a little bit of sedation just to make you comfortable. Yeah, that’s totally true. Can be done. How to determine hernia recurring, ultrasound, MRI, or CAT scan? So we had a whole series of podcasts on imaging. Go back and look at the imaging. We reviewed ultrasound, MRI, CAT scan, x-rays, different types of doing it, using contrast, not using contrast. Valsalva, we have our own hernia protocol, which you can download from my website and share with your radiologist if you want to do an MRI, hernia protocol for the pelvis and so on. But it all depends on your resources where the world you’re talking about, which part of your body you’re talking about, and whether you had prior surgery or not.
(00:55:31):
So we reviewed all of that in a whole hour of podcasts in the past. How do you distinguish between hernia and muscle rupture in a ventral or umbilical hernia from weightlifting for a woman? How does muscle rupture on the stomach treat it? So there’s no surgery for muscle rupture of the stomach, let’s say the rectus muscle.
Dr. Towfigh (00:55:57):
Imaging like an MRI should show … The
Dr. Towfigh (00:56:06):
Muscle rupture is not where the hernias are. On the abdominal wall, it’s usually to the left or right of a belly button area. It’s not in the middle. The middle is all fascia. You can’t get a fascial rupture, you can get a tendonous rupture or muscle rupture. So it’s more based on location and what you were doing. So muscle ruptures we usually do not operate on at all. Well, to be fair to the lovely viewer who gave us questions prior to today, I need to review these as well. Okay. Have mesh sutures enabled pure tissue repairs that were not possible with conventional sutures? Interesting. So mesh sutures, he’s referring to this new product called mesh suture or suture mesh. I think it’s called suture mesh or dura mesh. It is a suture or thread made out of mesh. So it was initially made out of just cutting up mesh into thin strips and using that to suture closed.
(00:57:23):
The thought is that instead of moving from stitch to mesh, you can use an intermediary, so you’re not really committing to putting in a big sheet of mesh, but you’re using the properties of mesh, which are the inflammation, to cause scar tissue and closure of the hernia repair better than you can with a flimsy piece of suture, basically. So the thought is if you have a patient with a, let’s say a belly button hernia and they’re morbidly obese, so if they weren’t morbidly obese, you would just put some stitches in. But because they’re morbidly obese, that same size of hernia, you would put mesh in. If you want to forego putting mesh, you can put in this dura mesh or this suture mesh with good results. I haven’t used it yet. I am interested in using it in this specific patient population where you want to forego placing mesh and for whatever reason.
(00:58:32):
I have my own reservations. It is a new product. The data seems to be promising. They do have clinical trials data that has been prospective and randomized, but I think I’m willing to use it in a limited number of patients.
(00:58:50):
Next question. “You mentioned weightlifters do not get hernias. Clearly weightlifting can increase muscle strength.” Absolutely. “Does it also increase strength of the transversal fascia?” I think it’s less the issue of increasing the strength of their fascia as it is. They don’t generate a lot of abdominal pressure by weightlifting. So if they get a hernia, it’s not because they were weightlifting, because they have very strong core and their transverse abdominis also is very secure. So it’s like having an internal girdle already. Is it possible that I have muscle rupture on the right of my belly button? I mean, yes. What could be done to help it heal? Well, first you have to see, do you have a belly button hernia? If you
Dr. Towfigh (00:59:44):
Don’t … Excuse me. If you don’t have a bellybutton hernia, then we can pursue the muscle rupture.
Dr. Towfigh (00:59:59):
How can I find the pod … Cast on imaging that you mentioned. Just go to YouTube and put it in Hernia Talk Live and imaging or something like that. It should pop up. What technology is more correct? MRI, ultrasound, CT. They’re all correct. It just depends on the purpose of what you’re trying to get out of it. So just like sutures, there’s no one correct suture or correct mesh. There’s also no correct imaging. There’s all different shapes and sizes. Okay. Some of these questions we answered already that were proposed. So let’s see. Last question. Oh, it’s time. Look at that. Look at that. Time has gone by so fast. So for those of you that are interested, do go back to the prior Hernia Talk Live episodes and you can just search on YouTube. I think it’s the easiest one. You can also go to my website to search for keywords and those should come up.
(01:01:19):
Excuse me. And until then, I will miss you. I originally was not planning on doing Hernia Talk Live next week because I was going to be in Northern California operating on a patient, but that got rescheduled. So I believe we’re going to have another episode next week. So I’ll see you all next week. Bye.