Shirin Towfigh (00:21):
Okay. Hi everyone. It’s Dr. Towfigh How are you doing? Sorry about my voice. I hope to have this voice last the entire hour. Welcome to Hernia Talk Live. I am very excited to be back on Hernia Talk Live, thanks to those of you who are joining us on Zoom and also as a Facebook live on my webpage for the Beverly Hills Hernia Center. As you know, you can also follow me on Twitter or X at hernia doc or on Instagram at her doc. We’ve been posting some really cool stuff lately, but let me just say that I apologize. I’ve been struggling with this cold for the past. I’m going to say it’s going on three weeks, which is ridiculous, and the amount of voice issues I’ve been having, which as you know, the coughing or whatever has been ridiculous. But I decided, you know what? I sound nasal. That’s okay. It is what it is. And let me just see before I move on, it seems our Facebook dropped. Let’s get us all on Facebook Live, shall we?
(01:47):
On my page at Beverly Hills Hernia Center. Why can’t we do this? All right, so as I was saying, my voice has been preventing me from getting any of this done. And so you may hear the nasal in my voice. That’s not my normal voice, and if I last the entire hour, that’s great, but I’m not sure I will, which is why I’ve got some tea and I’ve got some tissues and we’re going to start. Okay, so the purpose of today’s session, besides the usual purpose, which is to educate you all and to get some of your questions answered live, the purpose is to also talk about what we do to educate surgeons and specifically is to have courses and teach hernia surgeons how to do, or sorry, surgeons, how to do hernia surgery. And in doing so, I’ve been spending a lot of time the past, let’s see, I graduated in 2002.
(03:05):
I’ve been spending a lot of time going to meetings as you know, because you can follow me on Twitter. I always live tweet from the meetings that I go to and I go do courses that help teach surgeons and I teach residents and I go to surgical education meetings and teach there. So I spend a lot of my time not only teaching you all here, but also teaching residents. In fact, surgical education is kind of my passion. So the reason why I did so well with my first job and was recruited to my second job was purely for surgical education. So I’m very excited to announce that as of this week, we will be launching our master course in hernia surgery, specifically focusing on the groin and the pelvic area as our first of hopefully a very successful series of courses talking about groin and pelvic hernias.
(04:17):
So the purpose of the course is to educate surgeons. It is definitely open to anyone who wants to take the course. It is a webinar, it’s seven hours and six of those hours are me lecturing all the different topics. Who should get surgery? Where’s the evidence for that? What kind of groin pains and symptoms are there and how is it different between men and women? What imaging will be helpful and what we’re looking for in images, and I’ll go through the different images to show you. And then we’re going to talk about mesh versus non mesh repairs and go through all the different ways of fixing hernias and give you videos on that. On how I do it looking, I’ll have a whole section on women’s hernias. I’ll have a whole section on the rare pelvic hernias that most surgeoners don’t even see ever. And then at the very end I will have kind of like what we do here where you can submit questions either live or otherwise, is to have a section where surgeons can submit their questions and their patients, and I’ll try to answer them within that hour.
(05:31):
So I’m super excited. It’s the master course in groin and pelvic hernias. We will launch it this week. If you are interested to be notified about it, just send me your email address, we’ll add you to the list or DM me. I’m very available on social media, and again, this course is intended for doctors, surgeons, medical doctors, gynecologists, urologists, anyone who would like to learn more about groin and pelvic hernias. However, if you’re a patient and you’re curious, you can also sign up for that. I’m totally okay with that. You can kind of see what we do in terms of learning about hernias on the medical side. Okay, so in summary, that’s kind of where I wanted to help promote. Here’s a question already. Let’s see. Thank you for providing this opportunity to us. Would you recommend, okay, sounds like we’re going for questions already, so I’m happy to answer your live questions.
(06:51):
Here’s the first question. Thank you for providing this opportunity to us. Would you recommend local IV sedation for open surgery for umbilical hernia repair? Would you do it with local IV sedation for this procedure? I heard it is how it’s done in Mexico. My friend experienced vocal cord paralysis after surgery, which is why I’m inquiring about open surgery with local anesthesia. Wow, okay. We actually had a whole session specifically dedicated to anesthesia with Dr. Edna Ma, who’s one of my anesthesiologists, I’m going to say two years ago. So if you want to go on YouTube or on the podcast and search for Dr. Edna Ma or anesthesia you, you’ll have a full hour dedicated to that and we’ll talk about the risks and benefits of general anesthesia, IV sedation, no anesthesia at all, et cetera. And that’s going to be something that will be probably helpful to you to go and watch that video.
(07:56):
But just specifically for your specific question, I like to make the suggestion, so I would like to make the suggestion and the suggestion is this, everyone has their own risks and benefits for surgery. As with regard to anesthesia, open umbilical hernia for sure can be done with IV sedation only. That’s my preference. If there’s any way to reduce the need for general anesthesia, I take it because as you notice said about this vocal cord paralysis, which by the way is very, very, very rare, like a fraction of a fraction of a percent, but it is a risk with general anesthesia. And in general, most people do well with general anesthesia. However, I would say that they do better without general anesthesia. And the main reason why I prefer not to use general anesthesia is from a hernia standpoint, people who wake up from general anesthesia number one, are higher risk for nausea and therefore maybe vomiting. And that is a lot of abdominal pressure and because there’s so much abdominal pressure that can put a fresh hernia repair at risk. So I personally do not like the risk of nausea and vomiting if I can prevent it. And therefore, if you have a hernia that can be repaired under IV sedation alone, which is most umbilical hernias and most open ular hernias, then I take it, I think that’s a good option.
(09:49):
Laparoscopic surgery, definitely need general anesthesia. There’s very few cases where you can do it under sedation with spinal anesthesia, we don’t recommend it. It’s usually not the best option. So you’ve mentioned this is how it’s done in Mexico, it’s also how it’s done in the United States. However, I would guess that the chance of getting IV sedation is higher in Mexico than in the United States. I know plenty of really good hernia surgeons that do general anesthesia for everything in groin hernias, open umbilical hernias. That’s not my practice. I am a big fan of using a lot of local anesthetic and sedation and foregoing general anesthesia, but know that most surgeons, from what I understand, do actually prefer general anesthesia. Why is that? Well, it’s easier as a surgeon and as an anesthesiologist, if you just take control completely, take over the patient’s anesthesia and not risk them moving around or so on, there’s actually more, you have to pay more attention during surgery, both from the surgeon and from the anesthesiologist standpoint.
(11:11):
If you’re doing it with sedation only because some patients can wake up, they can feel it, they may move a little bit, and that’s not ideal for certain surgeons. I don’t mind it because I have excellent anesthesiologist and so my patients don’t wake up during surgery or move around or feel anything, and I use a ton of local anesthetics, so you should not be in pain when I’m operating on you under IV sedation. And so from my standpoint, I love it, but I do understand why a lot of surgeons and anesthesiologists prefer IV sedation or what’s called regional anesthesia.
(11:57):
The next question is what substances do you use for IV sedation and what is better spinal anesthesia or IV sedation? So I would say spinal anesthesia is really good in centers where they do a lot of it. Most centers in the United States do not do a lot of spinal anesthesia unless they’re doing obstetrics, whereas outside the United States, they really use spinal anesthesia as a bridge between IV sedation and general anesthesia. And part of it is due to, cause part of it is due to lack of technology with anesthesia machines and so on. And so I don’t use a lot of spinal anesthesia. So if I had a choice between IV sedation, spinal anesthesia, IV sedation is a lesser degree of anesthesia and I like it better, but there are people that really like their spinal anesthesia. Your question is what substances do you use for IV sedation?
(13:09):
So usually it’s propofol based, which is an IV propofol, you need some type of pain medication. So either I give a local anesthesia or you get narcotics or non-narcotic anesthesia is also possible, so you get that with, you can get Toradol or Tylenol ketorolac or Tylenol, and that’s kind of what you use for IV sedation. You get versed, which kind of makes you forget that you are experiencing this because that can be stressful for some patients. So you should ask your anesthesiologist, most anesthesiologists will call you before surgery or see you the day of surgery and review all of this before submitting you to anesthesia. So that’s kind of how it is. Here’s the next question. How would you treat a patient with a history of reoccurring hernias? Times five? Oh my god, in the MRSA infection inside abdominal wall, oh MRSA infection inside abdominal wall, no diabetes, no high blood pressure, no smoking or drinking.
(14:26):
Patient weighs 150 pounds and five three. Last surgery was 2011 to remove mesh. Okay, so you have a 150 pound and five three patient, which means you’re definitely overweight or obese category. Otherwise healthy patient with five prior surgeries including a mesh removal, I presume due to infection, maybe hernia is rather large about the size of a mango. Okay, mango is not a big size hernia. If you only have a mango size hernia, that’s not that bad. Anything over 10 centimeters wide is considered large or I should say very large. And then the question is what type of mesh surgery in hospital? Okay, very good question. So this is a patient that has failed multiple surgeries and therefore is missing a bunch of tissue, most likely including muscle. They’ve had MRSA infections, so putting in synthetic mesh is at risk of getting infected again, because even though you’re not clinically infected, there may be MRSA hanging around somewhere.
(15:35):
MRSA is a methicillin resistant staphylococcus ous bacteria, which is very difficult to get rid of when there’s an implant. And so both of those situations make it so that because you’re missing muscle and you can’t use traditional mesh or I don’t suggest use traditional mesh, then you end up having the need to move a lot of tissues around to bring it along. It sounds like the patient’s 55 years old and the hernia is 11 centimeters wide. Okay, so what did I say? Over 10 centimeters is considered large at 11 centimeters. So anytime you hit that nine or 10 centimeter mark, you’re definitely going to need some type of extra surgery that’s reconstructive, that moves adjacent muscles towards the middle so that you can close the hole. That’s not enough. You still need mesh, but at least there’s something to support the mesh as opposed to just bridging the mesh between two gaps of muscles in between.
(16:40):
Now what kind of mesh? Well, there are different meshes that are available on the market nowadays that are a more resistant to infection than typical synthetic mesh. And B, still durable enough to use, similar to synthetic mesh. I like the hybrid meshes, so that’s like 95%, 96% biologic, absorbable, and then 4% or less synthetic. So that’s what I would do. So you need to open most likely an open surgery, what’s called component separation. Either anterior or most of us now do posterior component separation and then some type of hybrid mesh to bridge it. It will definitely be done in the hospital.
(17:30):
It will definitely need a mesh of some sort ideally and you should do well, but it is a lot of surgery. I definitely like to redo your scar. I’m sure you have a scar that may not look the best, so you add that to the surgery to make sure that the patient wakes up with a flat belly and a beautiful scar to make them feel better about themselves. And I usually use a lot of drains, make sure there’s no infection that gets hung up in the area. I give you a binder to help add to the area and kind of cinch it in while you’re recovering. So there’s a lot of little tricks that we have too to make everything go smoothly. A delicate surgeon helps so you don’t get too much bruising and swelling and that helps with your pain and recovery too.
(18:29):
If using narcotics, what do your anesthesiologists use to counter nausea? So nausea is multifactorial, some of it’s due to narcotics, some of it’s due to gas, which we use for general anesthesia. So in order to reduce the nausea, there’s about five things that an anesthesiologist does and all of these, by the way, were reviewed in the session I had a couple of years ago on her knee talk live with Dr. Edna Ma, who’s the anesthesiologist. I highly recommend that you go back and watch that. She’s great and she tells you a little bit about her life story, which is really amazing. So we often give a scopolamine patch, which is like an anti-nausea patch behind the ear. They usually get a lot of good hydration and Pepcid to help make sure that there’s the stomach, the stomach acids are addressed. We try to prevent, oh, there’s a medication called Zofran, which is a strong anti-nausea medication that’s given some people get steroids that also helps reduce the nausea associated with gas or narcotics.
(19:47):
What else do they do? They try and prevent using gas and you know what? You can do a non-narcotic anesthesia as well, so that will help as well. So work with your anesthesiologist if that’s important to you because there are some people that just get all sorts of nausea. I had a patient, she gets nausea with every single anesthesia. We did all of that and never gave her narcotics and didn’t give her gas and just use IV sedation and she’s still got nausea so you can’t win them all. Is moderate disc disease at L5 S1, can that influence hernia surgery in any way? No, not at all. Why is that? L5 S1 lumbar discs either give you local lower back or buttock pain or pain down the back of your leg. It doesn’t affect your pain related to the hernia, it does not contribute to pain to the hernia. There’s no hernia pain that could overlap with that area and it doesn’t affect your ability to have surgery or recover from hernia surgery.
(20:56):
All right guys, we’re almost halfway through and my voice is still hanging on. Woo-hoo. Okay, next question. Would you suggest performing surgery for a five to eight millimeter umbilical hernia within a one centimeter diastasis? Considering there is no pain? My short answer is no. Umbilical hernias and inal hernias have both been studied with regard to watchful waiting. What does that mean? That means if you have no pain, what will happen to you if you don’t have surgery? And what happens is nothing, you have a 0.2% per year chance of needing surgery because you either have pain or get incarceration and that risk is very, very low, 0.2%, so less than 1%, it’s one fifth of 1% per year. And if you just watch your lifestyle to make sure you don’t gain weight that you exercise that you are not constipated or strained to urinate that you don’t have a chronic cough, you should do fine.
(22:12):
One ultrasound showed a circumscribed three by one centimeter per umbilical hernia containing fat only. The other indicated a four by five centimeter iso, correct mass, possibly a lipoma. A third ultrasound showed a tiny partially reducible fat containing umbilical hernia or possibly no hernia at all. Okay, that’s crazy. First of all, who needs three umbilical hernia ultrasounds? You need none because you can tell from your exam that you have a bulge or a little hernia. Let’s say you got one. All we need to know, we don’t care about how much fat is through it, that’s irrelevant. We want to know the width of the hole, which you just told me is five to eight millimeters and we need to know if there’s a diastasis, which is a thinning between the muscles of the belly button and how big that is. That’s all the information we need.
(23:20):
This repeat ultrasounds to measure the fat that’s out of the hernia is completely unnecessary. Okay. An MRI showed no hernia. Okay, I’m a hundred percent willing to bet the MRI did show a hernia, but the radiologist did not mention there’s a hernia. Okay, getting pissed off at this situation, it’s so unnecessary. Okay, what is your opinion on using stratus mesh for this repair? I a hundred percent do not support that. What do you think about general anesthesia with laryngeal mask anesthesia? Okay, so I do not recommend stratas mesh. Why? It’s a biologic mesh stratas is a pig derived biologic mesh. It’s a hundred percent absorbable. Why do you need absorbable mesh? You either need mesh or you don’t need mesh. So for a five millimeter hernia, you don’t need mesh for an eight millimeter hernia, you don’t need mesh, you just need stitches. So I don’t recommend any mesh.
(24:28):
If you want to use mesh, you should just use mesh. Okay, then what do you think about general anesthesia with LMA or laryngeal mask anesthesia? So for this small hernia, I don’t recommend general anesthesia, but if your doctor chooses to use general anesthesia, you can use LMA orotracheal intubation. So what’s the difference? One is a tube that goes through your vocal cords, one stops above your vocal cords. It’s purely a risk benefit ratio. So again, in our hour of talking about anesthesia with Dr. Edna Ma, several years ago we discussed the differences in general anesthesia using LMA is one option. LMA is this tube. That’s kind of why it goes down your mouth and kind of obstructs your airway to allow the anesthesiologist to take it over. It doesn’t go through your vocal cords. So technically it should be safer on the vocal cords. However, it doesn’t protect your airway.
(25:35):
So if you accidentally aspirate, there’s nothing to protect your airway. It’s much better to have an at tracheal tube. So if someone is at risk of aspiration, let’s say they’re full stomach or they have gastroparesis or they have known acid reflux disease, usually we do not choose LMA. Okay, for a standard inguinal laparoscopic hernia repair is your go-to mesh 3D max? Depends on how I do the repair for laparoscopic repair, yes, my standard is 3D max tried and true. We’ve been using it since late nineties early, yeah, late 1990s. There’s also the pro mesh, the anatomic, which I prefer for the robotic approaches and yeah, so that’s my answer to that. A lot of questions guys. I love it. Okay, next question. How often do you see testicular and spermatic cord edema after tap, TAPP, transabdominal, pre peritoneal, laparoscopic or robotic ular hernia repairs? How do you manage it and how long must the patient wait to see?
(26:57):
Totally edema. Greetings from Ecuador. Okay, hola, me, Ecuador. I hope to visit Ecuador one day. I heard it’s very, very cool place. Lots of good meats. Okay, to answer your question, yes, regardless of the type of hernia you have repaired, open or laparoscopic with or without mesh, you can get swelling in the scrotum. The testicle itself itself should not be swollen, but the tissues around it may be swollen. The larger the hernia, the more swelling you’ll get after surgery in that same space as where your hernia was, that’s really what this swelling is. The swelling is just downstream blood from where the surgery was done going downstream or swelling because your surgeon remove the hernia and that act of peeling the hernia off of the other structures and the scrotum causes swelling. So yes, it can occur if it’s just swelling and not bleeding, then within a week that should go away.
(28:07):
If it’s bleeding, then that may take months, three months, four months, even if it’s a lot of bleeding because your body needs to go in and the blood vessels soak up the old blood and return it back to your heart. But to do that, it happens piecemeal like blood vessel at a time. Sorry, red blood cell at a time. So that can take some time. So I’m very excited that we do have this option. I just want to complete my discussion about offering courses. So I was thinking at some point I should be taking what I do with you guys for hernia talk live and translate it over to what is helpful for doctors. I am told by many doctors that when I go to meetings that they actually watch hernia talk live. Now I try not to do too much medical talk and if I do, please let me know.
(29:10):
But I try to address my audience on these episodes, which are not usually doctors or surgeons. And so I try and make sure the words I use and the topics that I discuss are relevant to you as a patient. But what’s really cool is I have people, some are in training and some are early out of training, and so they’re like, oh, she’s going to talk about blah blah blah, lemme watch. And then they learn from it, which is great. So I thought, okay, well why don’t I do that separately as these webinars for doctors. So if you are interested also to enroll in a course that I’m offering starting this week, it’s up to seven hours. You don’t have to do all seven hours, but you’re basically paying for seven hours. Feel free to send me your email and I will add you to our email list, but it just knows it’s not meant for patients.
(30:16):
But like I mentioned, we’re talking about everything groin and pelvic hernia. It’s called the master course series. It’s going to be focusing, the first series is going to be focusing on groin and pelvic hernias. So we have a whole section on tissue-based versus mesh based repairs and how to perform them. We have a whole section on all the symptoms and how to do a good intake. We have another section on radiology and imaging and how to interpret it. So I’ll go through all the different imaging. I have a section just on women and all the evidence we have on how to treat women’s hernias. I have an hour talking about the rare ones, right? I’ll opt rate a hernias, femoral hernias, rare pelvic hernias like peroneal hernias, sciatic notch hernias, et cetera. And then I have one hour dedicated to answering questions that were submitted to me in advance by doctors the same way you’re providing me with questions, I’m asking doctors to send me their patients and they can answer it. So here’s a question. How do you teach a doctor to ask for help when they’re in over their head with a surgery that didn’t go as planned and needs a repair operation?
(31:37):
Good, good question. We always, always recommend that doctors ask for help. And it’s true, it’s true that doctors have ego, especially surgeons, and sometimes they feel like they know it all. But in the hernia world, the hernia society, we highly encourage that you seek help. In fact, I just finished a podcast of one of my friends, it’s called the Hernia Gods podcast. It’s kind of cool. So kind of like what I do for patients, he does a hernia podcast that focuses on the stories of hernia surgeons, like how they got there and what they do, et cetera. And with the podcast I just record with him, we talked about this idea of asking for help and encouraging communication among the different doctors and so on. And we actually have a Facebook group that’s closed where doctors talk amongst themselves to ask for help. So how do you teach a doctor to ask for when they’re in over their head with a surgery that didn’t go as planned and needs a repair operation?
(32:46):
I mean, I can’t force them, if that’s your question, I can’t force a doctor to ask for help, but the best way is to have opportunities like we’re offering for them to just call us. I mean, I literally get weekly if not more than once a week. People that know me, whether they were trained by me or they just know me that send me questions and I help answer it. Last week I had a doctor from London who reached out to me for his patient. I had one of my former residents from 15 years ago ask me a question. I had two, I’m sorry, two of my most recent fellows ask me a question and one of my most recent residents ask me a question. So I’m totally okay. Oh, and I had one surgeon call me from during surgery, he was not a general surgeon, but he was doing another surgery unrelated to a hernia and he found a hernia and he’s like, what should I do with this?
(33:55):
So I was FaceTiming him with him in the operating room. So we encourage this, it’s good to ask for help. Okay, let me read the rest of your question. I had a minimally invasive robotic umbilical hernia repair with mesh that five days later ended up with an emergency room overnight stay due to over a pint of blood draining out in one day. Oh my god. Turns out there was an extra large burrito sized. Oh my god, that sounds so good right now you can tell I’m hungry. Extra large burrito sized hematoma, which is like a blood collection on both sides of my abdominal wall. I contacted the biologic mesh company from my hospital bed and they highly recommended I get the hematoma out immediately due to the risk of infection. Not true. I asked that they tell my surgeon this and they did. My surgeon said it would create more complications. I agree with your surgeon. Two weeks later I had an emergency laparotomy second operation due to infection and over half the mesh was removed. Okay, that happens, but doesn’t always happen. Now three months later I have a large new hernia emerging where the new laparotomy surgery was done.
(35:13):
I’m healthy. 55-year-old athlete. Oh athlete. I don’t want to see the same surgeon again, but I want him to know the results of his work. Okay, so here’s what I recommend. Most of the patients who see me have already been operating on by a different surgeon or have seen another surgeon. And so if you ask me to contact your surgeon, I absolutely will. And I can even share my notes with that surgeon to let them know I saw your patient, whatever. So that courtesy is always available for you to ask your surgeon to reach out to your prior surgeon. Totally. Okay, by the way, but we have to do with your permission.
(35:57):
Okay, lemme just say blood is a great auger for bacteria. However, hernias are performed in a sterile environment and unless you have bacteria hanging out for another reason, the risk of a hematoma, which is a blood collection getting infected is very low. It’s not zero, but it’s low. Now the larger the hematoma, the more uncomfortable the patient and or it disrupts the hernia repair. So it’s up to the surgeon to determine if it’s safe and appropriate to go in to address the old blood clot or not. Now if the blood clot is large, very painful for the patient, don’t wait six months for it to go away. Just go back in, take out the old blood clot.
(36:57):
If the blood clot is pushing the mesh away from where you placed it and therefore at risk of causing hernia and you should redo that repair as well. But in general, going back in to address a clotted blood just to clean it up is not necessary. And I agree with your doctor, your surgeon, and that sounds like they determined one versus the other. Now why did it get infected? It’s unclear why yours got infected, but that’s not always a situation. It is definitely a risk, but it’s not always a situation. And remember the biologic mesh company that you called? I don’t know what’s going on with that. First of all, it cannot give medical advice and second of all is only caring about their device and not your best interest. Your surgeon should have been thinking of your best interest.
(38:01):
Okay? How much is the course if a patient will take it, which days and what time? Okay, so the course email will go out to you. There’s different tiers through which you can take it. The current course is $499 for the seven hour course. For those of you that are nurses or medical doctors, you get continuing medical education units. That’s why we’re that are charged for the course to provide the CME units and you can take it whenever you want. You just sign up for it. It’s just going to be on the web available. There’s no specific date. All that information on how to register will be in your email. Okay, let’s see.
(38:53):
Okay, this is going back to the patient with the multiple ultrasounds and MRI looking at an umbilical hernia within a diastasis, would you suggest doing a CAT scan to diagnose whether there is a lipoma or a ventral hernia on top of the umbilical hernia? No, I would ignore all this. If it bothers you to fix the umbilical hernia, if it doesn’t bother you ignore it. So you can’t get a lipoma on top of a ventral hernia. So you just have a ventral hernia and people are giving you bad advice. Okay. Next question. For laparoscopic repairs while in the recovery room and the patient has postoperative pain immediately in recovery, how do you decide what you need to go back immediately for to revise something? Does any degree of pain drive this or what factors do you consider based on your vast experience? Okay, so very good question.
(39:55):
There is a concern with any surgery that if the patient is in excruciating pain, that a nerve may be entrapped and therefore that you have to go back and entrapped the nerve. Now that’s usually an open hernia issue and nowadays we know well not to put stitches or cause injury to the nerve when we operate, but in the rare case of that happens, the suggestion is if you have clearly a neuropathic pain, so pain in the area of a specific nerve that is causing severe pain in the recovery room, you should just go back and just deal with it, not have the patient suffer. That is usually not the case with laparoscopically. It is very difficult to do a laparoscopic hernia repair and actively injure a nerve. So the main nerves that can get injured are the genital femoral nerve and the lateral femoral cutaneous nerve.
(41:09):
As long as you stay away from them, those nerves are fairly deep and do not get injured. So you just have to stay away from them. We also know not to put T in certain places where these nerves are. So those are attacks or sutures, any type of fixation that can entrap a nerve in many laparoscopic hernia or robotic hernia repairs, we don’t use any fixation. So there’s zero risk of causing nerve entrapment. So if you have a laparoscopic or robotic surgery done, especially if it’s done by a specialist and you have severe pain, it’s just a pain issue and it’s not a nerve entrapment issue, I should tell you that and everything else can get treated nonsurgically initially, what is your advice on finding the best possible skilled surgeon to repair a failed hernia surgery? Very good question. Number one, ask the office what percentage percentage of their patients have need for revisional surgery, chronic pain, does a surgeon do mesh removal surgery?
(42:29):
Do they treat, do they do ectomies, do they do injections? Those are all indications that the surgeon has at least a patient population where they do revisional surgery. You can also go online and look and see who’s written books or book chapters specifically addressing that. For example, I’m the editor of a book called the Manual of Groin Pain. So in it we talk about all types of groin pain including a whole section on just chronic pain in which we’ve written multiple chapters. So if they’ve written a book chapter, that’s usually a good sign. If they are giving talks, you can look all this all up, this is all, you can Google it, you can ask chat GPT or your favorite AI tool nowadays, like who is well known for dealing with chronic pain after hernia repair? And then also you can look at any literature that they’ve written, any articles that they’ve written that addresses chronic pain.
(43:40):
So that’s where I would stay. I would stay and you can dabble with your local doctor and they may say, oh, I do so many operations, I’m like the busiest surgeon. That’s not necessarily the surgeon you want to see for revision. So for example, in Los Angeles, we have some really great general surgeons, really great, but they don’t nothing of what to do with chronic pain or revision surgery. They just dunno. So sometimes they’re referred these patients because they’re considered like a top general surgeon, but they’re good for a regular hernia repair and not for a revision. It’s a totally different animal. So very good question that you understand there’s a difference. What are your thoughts on using P-D-P-D-S, long-acting dissolvable sutures or Monocryl sutures, which are also dissolvable, but rapidly dissolvable or VCAL sutures which are also dissolvable would figure of eight or running Monocryl sutures which dissolve within like three weeks in the skin be advisable for the skin closure in a five to eight millimeter umbilical hernia with a one centimeter diastasis?
(45:02):
Yes. Could long-acting dissolvable stitches like PDS cause an allergic reaction? No. Would you recommend allergy testing beforehand? No. So first of all, there is no good allergy testing to begin with, so that’s not something that’s going to usually help anyone in any meaningful way. Even allergists agree with that. So the questions on the skin, so usually for skin closure we use rapidly absorbable sutures, usually Monocryl or in the deeper areas, Vicryl, and what you’re saying is common practice the allergic reaction. So I haven’t seen any allergic reaction to PDS, but I have seen it in Monocryl. It’s just a local reaction. You just take out the suture. It’s not anything that needs for you to stress out over and unless you know that you’re allergic to it from prior surgeries, we usually commonly use these sutures and most patients do just, well.
(46:12):
Okay, 55-year-old patient with a vast deference transection during hernia repair. How would it affect the patient? Okay, for men you have their testicle, which makes a sperm and the vast deference carries a sperm to your prostate and it comes out the pannus. So in order to naturally have children to be fertile naturally, you need to have at least one of those vast deferences open to carry the sperm from the testicle. So if your surgeon accidentally cut one of your vast deferences laparoscopically, there’s no good way to put that together again. And hopefully you have the other side so that if you want to have children naturally you can still have it. Now if you’re unlucky and both vast deferences were cut and therefore you have no sperm in your ejaculate, then you are not going to be able to have children. Naturally you can still have children because you’re still making sperm in the testicle, but you’re going to have to do some type of in vitro fertilization situation.
(47:33):
But usually cutting the vast deference laparoscopically usually does not cause testicular pain usually unless they damage the nerves in doing so. Okay, another lecture I listened to, hernia UA laparoscopic surgeon said regarding fixation of mesh that although it theoretically it is Cooper’s ligament as a fixation point and anatomically correct it is a bone, I think he said ischial or ischial. Pubic at this location that is a landing site for the attacker. Okay, I don’t know if that’s a question, but yes, as part of any posterior hernia repair and if you use fixation, the fixation is to Cooper’s ligament. Now some people fixated to the bone, the bony part of Cooper’s ligament, I don’t. You can actually fixate to Cooper’s ligament just above the bone and if you’re robotically suturing it, you don’t have to fixate it to the bone either, you just fixate to Cooper’s ligament. So what you heard is not a hundred percent accurate.
(48:55):
Is chronic pain possible after her neighbor? Absolutely. In fact, most concern is related to, oops, what happened to my, alright, so you guys should be able to hear me now, sorry. Okay, so the question about chronic pain, there’s about a 12% risk of chronic pain and a 3% risk of debilitating pain. That is the number that we use out there. So yeah, there’s a significant risk for risk of that. Let’s see, our stitches figure of eight running Monocryl in the skin, reasonable hernia repair. Okay, let’s figure this out. We’re talking about skin that is different than the hernia. The hernia is muscle or fascia. It’s fascia not skin. So using running Monocryl in the skin is normal using figure of eight and the skin is usually not done, but using a running or figure of eight but not Monocryl for the hernia can be done. Let’s see. Can you guys hear me now? I think you can hear me now. Yes. Can someone tell me if you can hear me? Yes. Oh no. Okay. Yes. Great, great, great. Sorry. What advice would you offer a patient for them to,
(50:44):
For the best possible outcome
(50:48):
And experience pre and post-surgery, what advice would you offer a patient for them to prepare? Okay, great question. We have multiple, multiple one hour episodes just talking about how to prepare for your hernia in order to get your best possible outcome. Literally your question. So we have one for before surgery. We have a great one for after surgery. I highly recommend you go backwards and just go to YouTube. That’s the easiest way to search for that topic. Just so I something like preoperative and do something like preoperative, I dunno, optimization or something like that. So what is your favorite? Her surgery? Oh, I like all of them, but my favorite is the one where you have a cute little belly button and we just saw it closed and give you a nice in. That’s my favorite. It’s just so simple and delicate. What’s the most difficult surgery? I would say the most difficult are the really loss of domain humongous hernias that you don’t have much tissue to work with. Those are very challenging, especially if they’ve had infection before. Describe the type of patient. Oh, you know what I also like are these really rare pelvic hernias? Call me weird, but that’s what I like.
(52:14):
Describe the type of patient a surgeon enjoys having. Oh, fun, positive. If you’re a positive person, even if you’re in pain or whatever, it’s so much easier on the surgeon to kind of work with you. But if you’re just a negative patient, those are difficult. And by the way, good research shows that if you are positive in nature and your attitude is positive that you are more likely to do well, live longer, beat cancer, recover well from surgery. So stay positive. Okay. Chronic pain after hernia surgery is okay. So chronic pain after hernia surgery that’s debilitating is considered 3%. And typical chronic pains, you just know that there’s something there after surgery is 12%. Would you suggest obtaining cardiology and hematology clearance prior to procedure? No, most people don’t need cardiology or hematology. If you have a cardiac problem, you should get cardiology or if you know that you’re easily bruised, for example, you should hematology. Other than that, there’s no need. What is the hardest part about being a revisional surgeon?
(53:35):
I would say the best part is trying to solve whatever the problem is, like come up with the right solution to a problem. That’s my favorite part of all of this. The hardest part is when a patient’s not happy, you go through all of your hard work and you stress over the patient, you lose sleep over them. You see them at the hospital every day and they’re just not happy because of whatever reason. Their scar is not pretty or their belly button isn’t exactly in the middle or they still have a nagging ache somewhere that you can’t figure out. I think that’s the hardest part. What makes a hernia surgery fail? That’s not the patient’s fault.
(54:25):
A lot of hernia surgery failure is due to surgeon technique. Surgeon experience small mesh for a large hernia, small mesh for a large patient, large mesh for a small hernia or a large mesh for a small patient, thick mesh for a thin patient. These kind of stupid mistakes, overuse of technology, underuse of technology. I’m guessing that more experience is vital for a revision surgeon. Yes. Yes. So find someone that’s at least five years out from their training. I think the first five years you definitely go through a lot of learning. Can the surgeon see both direct and indirect hernias during a laparoscopic surgery? Oh yeah. Sorry, I forgot to answer that question. So yes and no. If your hernia is large enough, just putting a camera inside laparoscopically, you should be able to see the hernia. However, if it’s a moderate to small hernia, there may not be any indication from the inside and you have to do more surgery to actually get down to the muscle level.
(55:33):
When you go in laparoscopically, you don’t see the muscle yet. You just see intestines and the lining around the intestines. You have to take down that lining and then take down the fat and then look at the muscles. So that’s why a lot of people get laparoscopic surgery and are told they have no hernia. But that’s not necessarily true because what they actually have is a smaller hernia or a hernia that’s filled with fat and not intestine. Okay, I was practicing Pilates every day, but after my injury and the hernia diagnosis, I tried a pilates introductory class five months post-injury and felt uncomfortable. Does this mean I should avoid pilates and yoga if I want to prevent my hernia from worsening? No. What exercise and weights are safe to lift to avoid aggravating my hernia? Would you suggest wearing a hernia belt? So there’s no clear science?
(56:28):
Lemme just start with that. However, what we do know is core-based exercises, including Pilates and yoga, do not make hernias worse. They do not increase your abdominal pressure if performed correctly. The same is true for weightlifting. So weightlifting does not make your hernia worse and does not increase your abdominal pressure if performed correctly. Now, are there people that get pain with their hernia with these procedures? Yes, in which case you can choose not to do it, but I don’t believe that Pilates or yogurt bin in and of itself makes your hernia worse. And the last question of the day before we say goodbye, my understanding is that a stitch repair is not as strong as the body’s natural tissue without a hernia.
(57:21):
Well, yeah, if you have a hernia, your tissue by definition is not as strong. Furthermore, if we exert ourselves after the repair, there is a higher likelihood of recurrence. That’s also not true. That’s not been shown to be true. Even with meh surgery, if we strain ourselves is possible to develop a hernia in another location. Yes, straining is a big risk factor for any type of hernia on top of your underlying risk factor, which is genetic and base. Does it make more sense to use our bodies more gently instead? Not necessarily. So weightlifters, anyone with good core strengthening has a lower risk of having hernias, people who exercise or have lower risk of hernias. So don’t let that detract you from not being active and potentially gaining weight. So on that note, I would like to very kindly thank you for tolerating my voice, which actually wasn’t that bad.
(58:23):
And also for all your tens of questions, that was really, really good. I really appreciate that. Do I suggest wearing a hernia belt? Only if the hernia hurts you. Otherwise it doesn’t help you. So thank you for everyone. Send me your email if you want to be on the mailing list for the course. I will post it on social media if you forget. And I will be at a meeting this week. So if you want to be on Twitter, you can watch me on x at hernia doc live tweeting from the meeting. And then I’m actually going to be on vacation. Can you believe it? I’m going to take vacation so you won’t be seeing me for the next two weeks and I will come back after that with some new guests. See you all. Bye.