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Speaker 1 (00:00):
Dr. Towfigh, welcome to Hernia Talk Live. We’re here every Tuesday with a special guest. Today’s special guest is Dr. Todd Ponsky. He’s a pediatric surgeon and I am willing to wager a lot of money that he is our top hernia specialist in the United States, possibly the world. He practices out of a Cincinnati, Ohio at Cincinnati’s Children’s Hospital, as well as Akron’s Child Akron’s Children’s Hospital in Ohio. And he’s coming to us live. Dr. Ponsky.
Speaker 2 (00:32):
Hello <laugh>. Good morning, good afternoon, good evening, whatever time it is.
Speaker 1 (00:36):
Thanks for coming and thanks for studying your time to this. Those of you who don’t know Dr. Ponsky, you may be the only pediatric surgeon that I know of that is in our hernia world. We have what we call hernia friends. We call each other hernia nerds and we have annual hernia meetings both in the United States and elsewhere in both the American Hernia Society, Sage, et cetera. And you’re really the only one I know of who specializes in children that actually talk to us.
Speaker 2 (01:16):
We have to get that right. Yeah, we have to get more up there. I
Speaker 1 (01:20):
Know, I know. Well, mostly I do enjoy it. We’ve actually debated on Debated Together. I was forced to debate against you. I think no one else wanted a debate against you. It was fine. It was fun. I enjoyed that. I think that was that. Yeah, last year
Speaker 2 (01:37):
It might have been last year or two years ago. It was last year. You definitely won.
Speaker 1 (01:41):
Oh, no, I don’t think I want, but I tried very hard. If it comes on YouTube, I may have to delete it.
Speaker 2 (01:49):
It was a good debate.
Speaker 1 (01:51):
So maybe you can tell our audience a little bit about how you got into hernias in the pediatric surgery realm.
Speaker 2 (02:01):
Sure. So hernias in children is one of the most common operations that we do in children that and appendicitis. And when I say hernias, there’s two types that kids get. Well, there’s three inguinal hernias in the groin, right? Umbilical hernias in the belly button, and then the epigastric hernias up in the top of the abdomen. And so every pediatric surgeon is a hernia specialist. I became interested because we started doing research on it and trying to understand what’s the best way to do this. And we started exploring how we can do it less invasively. And when I say less invasive the operation’s already small incision. But we wanted to figure out if there was a way, especially in the tiny neonates, the newborns who’s the most common baby that we operate on with a hernia. It’s the structures there are very, very fragile. And so we wanted to see if we could do it with a way without manipulating the structures. And so I learned flew out to California actually, and learned how to do a laparoscopic repair from a surgeon named Craig. And then since then we’ve modified the repair based on a Japanese approach, and they’ve been doing research on it for years. And the rest is history.
Speaker 1 (03:23):
I feel that hernias are so common that people who do research tend to focus on rare diseases. They’re really cool diseases. And so hernia advancement has not really been something that people aim to do. But those that do make such an enormous difference because in adults, we’re doing a million hernia repairs a year in the United States alone probably. I don’t think that includes pediatric. I think that’s only the adult data. So it fits a number one hernia repair for children as well. You can just probably one point something million a year.
Speaker 2 (04:01):
Right? That’s probably about right because it’s several hundred thousand.
Speaker 1 (04:04):
Yeah. Yeah. That’s pretty crazy. Now when you do the hernia pairs for the belly button is like, do you use absorbable or permanent suture?
Speaker 2 (04:13):
What’s the obturator? So right. So it depends. We use sometimes a permanent suture, an ethibond or a braided stitch. Some surgeons will use a Vicryl suture, which is a dissolvable stitch
Speaker 1 (04:29):
That dissolves in three weeks.
Speaker 2 (04:31):
Well, so we studied that and we found out the hard way that that’s the time. That’s as long as you could trust it. But when we studied it, it actually took several months for the Vicryl to go away because we kept going back in the research model and they were still there. But yes, it doesn’t last long.
Speaker 1 (04:51):
And is that adequate because
Speaker 2 (04:55):
Yeah, so why? So I use a permanent suture for that reason. And I think that in the tiny little babies, theoretically the skin is so close to the hernia that it could have a reaction, but we really don’t fix the belly buttons in the little babies. So that’s why most of us would end up using a permanent suture.
Speaker 1 (05:20):
So one of the reasons why you don’t fix the belly butter hernias is because they close,
Speaker 2 (05:24):
They go away 80% of the time. A belly button hernia will go away by the time the child is three to five years of age. So we usually wait till they’re three to five. Depends on the surgeon. We just did a study that found out the menage is four and we it did a study and another person repeated it that showed if you do it under the age of three, they have a higher chance of coming back again. So four is really that sweet spot. Four, five
Speaker 1 (05:54):
Years is it trying all the time.
Speaker 2 (05:57):
The integrity of the muscle.
Speaker 1 (05:58):
There’s a lot of pressure.
Speaker 2 (05:59):
There’s probably a lot of pressure. It’s true. And so it’s just usually end up using a smaller stitch. But for that reason most of us Wait. The other thing that’s huge is that there was a new body of research that’s been coming out. Yeah. That’s been showing that there may be some long-term deleterious effects of anesthesia in babies under the age of two. So we really have had a massive switch in pediatric surgery where unless it’s urgent, we try not to do any surgery under an age of two or three is actually at our hospital. So that’s another reason to wait on those.
Speaker 1 (06:45):
Our pediatric surgeons mentioned that too. Is that a, most of them close, but also you don’t want to do surgery and two or less unless it’s really urgent. Urgent. So you under get kids where the hernia incarcerates or causes an emergency during those watchful waiting
Speaker 2 (07:07):
Years? That’s a fantastic question. So the incidence of an incarceration where the intestines get stuck in the hernia is probably less than 2%. So we almost never see it in kids. And for that reason we feel very safe waiting. Now, groin hernias is a different story, but the umbilical hernias, the incarceration rate or the chances of a problem happening while you’re waiting to do the repair is incredibly low.
Speaker 1 (07:37):
So babies up to age three to five, you kind of wait for their belly, bottom hernias to close. If they don’t close, you operate in the three to five range, usually with stitches, usually with some type of permanent stitch, right?
Speaker 2 (07:50):
Correct. Now, some people would say, what if you just leave it alone? Why do you need to fix it? It’s a small little hole. Well, I don’t have the answer to that. I’ll tell you my theory and I’m curious what your response is to this. My theory is twofold. Number one, for a child to have an umbilical hernia repair, it’s basically four stitches and you’re done. They go home, they’re out playing the next day if you don’t repair it, and a problem does happen when they’re older and the hernia defect grows, you may have to use a Mesh material, which could be a more complicated operation. So I believe the reason to do it is that it’s just so easy and it’s so safe that why not fix it?
Speaker 1 (08:40):
Yeah.
Speaker 2 (08:42):
So another thing that some people do is they do it by gender. So if it’s a female and there that a lot of, there’s a high incidence that it’s a tiny little defect, but it grows during pregnancy, that might be a reason to fix it when they’re younger as well. I don’t have a gender difference. I do it in any gender, but that’s what some people say.
Speaker 1 (09:04):
That’s interesting. And then we’ll get to the Mesh question later because we already have some questions on Facebook live about Mesh, which we’ll get to shortly. So groin hernia is different. Those don’t close, correct.
Speaker 2 (09:20):
However, or do they? So the thinking historically forever is no, that they don’t close now. Now you’re getting me started because this is my whole body of research, so I know, but I will say that the thinking, so there’s two things about a baby hernia most present right in as a a newborn, correct. The chance of it getting stuck as a newborn is 30%. If they’re premature, that means one out of three babies that have an inguinal hernia as a newborn, that’s a premature baby will have an incarceration. So for that reason, we fix those relatively quickly because we don’t want them to get stuck. Now there’s that balancing act of trying to get them a little older so they don’t have to go into surgery at such a premature age. So we oftentimes we’ll watch them very carefully and get them to that point to fix the hernia. Once they get over a certain age about one year of age, that incarceration rate starts to really drop the same to the level as adulthood, which is really low.
Speaker 1 (10:23):
Yeah, it’s very low.
Speaker 2 (10:25):
So it’s less than 1%. So in a newborn, we do fix them. Some people think that as I do that I’ve thought forever is that they don’t close and you need to fix them. But we do have one patient that we just presented. I forgot which meeting we presented it at that we had an image where we were doing an appendix operation and we saw a hole. We didn’t fix it because it wasn’t symptomatic and it was a dirty operation and the patient went back with groin pain years later, five years later, and it was gone. So maybe they do go away.
Speaker 1 (11:03):
So the thoughts of what the premature baby is, is it that the whole hasn’t had a chance to close yet because they were born or too early? Or is it that they have an intrinsic collagen deficit or defect because of their prematurity?
Speaker 2 (11:18):
We don’t know, but we do believe it that the process of, so what happens in a baby is that the testicles or the ovaries start off in the abdomen, high up in the abdomen, and during the third trimester is it towards the end of gestation, they drop down into the pelvis. So the girls, the ovaries drop down into the pelvis. The boys, the testicles drop down into the pelvis, but they keep going and they go outside of the abdomen and a little canal is made between the muscle. So no hole in the muscle, but the muscles sort of part like the red sea and the testicles find their way down into the groin. And that path, that little tunnel that was made, usually closes right behind them after they get down. And what happens when this goes awry often because they may have been born early that never had time to close behind them, so now there’s that canal that remains, and so other things in the abdomen can follow that canal like the intestines. So that’s the thinking of why it happens.
Speaker 1 (12:21):
And for groin hernias, you perform both open and also laparoscopic repairs without Mesh, which is something that we’re not taught as adults to do. But how was your research going on with the outcomes of the laparoscopic non Mesh repair?
Speaker 2 (12:40):
Great question. So when you say la, what what’s happening now is we used to call it, when you say laparoscopic hernia repair, there’s like 10 versions of that now. So it’s hard to study because everyone does a different technique. What is emerging as probably becoming the most popular technique is a way that we do it where we look inside with a camera, but we do the operation actually from the outside with a little needle poking in and coming out. And we studied that multiple ways. So the many studies have shown the recurrence rate that which is our big measure of did it work, is how often does it come back again is less than 1% and multiple studies. Now, the original laparoscopic hernia repair had a three or 4% recurrence rate, but we don’t do it that way anymore. We’ve learned a lot of tricks through research about really impressive techniques to add to make it stay together much better. Cool. And with much less pain, and it’s less than 1%. The second thing we did is, well, I’ll stop there because we did also study this in adolescents too, but for at least all comers, it’s the same as the open repair, which is less than 1%.
Speaker 1 (13:59):
So for either the belly button or the groin hernia repairs, if it comes back, I know it’s low, but 1% of a big number is still a fair number. So if it comes back then, and there’s still children, and we know we don’t like to put Mesh in children because Mesh doesn’t stretch and it’s a foreign body and kids are in the growth stages and you don’t really want to do something unnecessary in at that stage what do you do with a recurrent hernia?
Speaker 2 (14:33):
Big difference between the adults and the kids that the pediatric operation, so here’s the biggest point I can say tonight is that a baby hernia is very different than an adult hernia. Correct. So a baby hernia is That’s very
Speaker 2 (14:51):
Right. So it’s not a problem with the muscle. The muscle is totally normal. That little path that went between them stayed open. And so all you need to do is remove that thin layer of material that went between the muscles, that thin tissue called peritoneum. You need to just remove that and the muscles close again. So the reason I’m telling you that is that the operation, if it fails, something went wrong, it’s hard to know what it was. Maybe not all of it was removed or maybe the stitch fell out. But unlike the adults, it’s very easy to fix again. And so the chances of it failing twice I guess would be really, really low because the chances of it failing once is less than 1% Got it. Failing twice. So unless the baby has some sort of connective tissue disorder almost all the surgeons I know would just go back and do it again and probably laparoscopically because that’s your best way to approach something that’s already been operated on. Right.
Speaker 1 (15:51):
In my, yeah. Okay. So that’s a legitimate practice, and the outcome is expected to be good if you just redo it with a tissue repair, whatever that repair is. Yes. What even for belly button hernias.
Speaker 2 (16:05):
So it is, it’s even excessively more rare than much more rare than even an inguinal. An umbilical hernia repair must mean that a stitch popped out because it, it’s a stitch broke or a knot came untied or something, and all you have to do is go back in and put another stitch in a,
Speaker 1 (16:26):
And you don’t have to deal with smoking and alcoholism and correct obesity, diabetes. That’s not usually something you have to deal with, which are all risk factors for hernia complications.
Speaker 2 (16:39):
That’s why I went into pediatric surgery
Speaker 1 (16:41):
<laugh>. Right. You have to deal with the parents, which I’m sure is not
Speaker 2 (16:44):
Easy. That’s true.
Speaker 1 (16:46):
Okay. We have some pre-prepared questions from before. Let me go through this real quick. You’ve answered a lot of the questions already. This is great. Yeah. Okay. What ages do you treat Inguinal hernias? I guess all ages.
Speaker 2 (17:05):
My question obviously, but
Speaker 1 (17:07):
What do you treat? I should say maybe that’s the questions. What ages do you treat? How high up do you go?
Speaker 2 (17:12):
That’s the question, right? Because obviously we’ll do any young age, the question is what age do we stop doing them? So once I get to an adolescent, it becomes quite controversial because the adult surgeons and the pediatric surgeons do quite different operations for a hernia. As I told you, a pediatric surgeon just removes that tissue. An adult surgeon most of the time does either a repair of, they repair the muscle either with suture material or with Mesh material. And so is an adolescent more like a or more like an adult. And that’s what a lot of our research has been focusing on, and we’ve taken some roundabout ways of trying to figure that out. And here’s what I tell. I have a very long discussion with the family because there’s no one answer. Here’s what I say. My answer is that, as I explained before, a pediatric hernia repair has an incredibly high success rate. We studied this in the adolescent population, and it’s less than 2% for all comers of an open repair. And the laparoscopic repair is about the same exact thing. It’s about two,
Speaker 1 (18:26):
Which means 98% do not need another surgery.
Speaker 2 (18:29):
However, I’m going to tell you my own flaw of our research is that I don’t follow them their entire lifetime. So we do a five year follow up. Does it recur 20 years later? Maybe we won’t know that. That’s a much harder thing to find out, but at least five years out, which is covers, most recurrences happen early after surgery. We think that at least shows that it’s a pretty good operation. That operation is very simple. It’s just a stitch. It’s not putting Mesh in. And so what I tell parents is there’s two choices. I can send you to my very talented good adult colleagues and talk to them. And I oftentimes will give them a number, have them meet both of us, and they can decide, because there’s no one answer, I recommend doing the laparoscopic non Mesh repair because if it fails, which is incredibly rare, they can then go to have an adult surgeon put in a more permanent type of repair.
Speaker 1 (19:24):
That’s right. There’s been no burned bridges for
Speaker 2 (19:27):
Sure.
Speaker 1 (19:27):
Right? Yeah. Well, I’ll tell you, as an adult hernia surgeon almost all my practice is revisional. And I do get some patients that have had a hernia pair as a child. But I’ll tell you the typical scenario is they were born with a hernia, a groin hernia. And so they had their repair as an infant, maybe up to a year old and then they’ll see me at age like 40 or 50 and they’ll have a hernia. So I can’t really even say it’s a recurrence from the childhood repair. It’s just probably an adult hernia now of some sort. In other words, yeah, they’re not coming to me at age 19 <laugh> or 20 saying, sucker that operated on me two years ago because I was pediatric recurrent, that I don’t see that that doesn’t happen.
Speaker 2 (20:16):
It’s the main question. The Mayo Clinic did a 50 year follow-up study, and they said that most of the very small number at 50 year follow-up had an reoperation, but that did had a direct hernia, which is an adult type of hernia. So it’s possible that a new hernia.
Speaker 1 (20:32):
Do you see drugs in children?
Speaker 2 (20:34):
I have only seen one. I’ve been in it for 20 years. I’ve only seen one. And it was from a patient that had been operated on by another pediatric surgeon, and they did it. I think it was caused from the surgery, which can happen. One of the other main reasons we do it laparoscopic is that can’t happen because with the open repair, you have to REM get in there and lift things up, and sometimes that can cause an injury to the very thin floor. True. Which caused an hernia. If you make that injury in a baby, it’s just a couple cell layers, they can get a direct hernia. So with laparoscopic, we don’t mess with that at all. We just put a stitch in. And so we think that we will be long-term having a lower recurrence rate for that reason.
Speaker 1 (21:25):
And just to be clear, the tissue repair, you’re doing the laparoscopic, but in the open tissue repair for children, it’s not like a Shouldice or Bassini, it’s more of what we call a Marcy. You just close the hole. Correct.
Speaker 2 (21:36):
So if you’re saying for a direct hernia or an open indirect
Speaker 1 (21:41):
Child with an open indirect,
Speaker 2 (21:43):
Yeah, no, yeah, it’s a Marcy at most. So at most it’s usually a high ligation. So all you do is find just that inner, that little bit of tissue that went along, you find it, you tie it off at where it starts and you remove the excess tissue and that’s it. That’s what 90% of people do. Sometimes if you see that there’s also a little weakness in the muscle. You put one stitch that’s called the Marcy. Yeah. But that’s unusual. Most people just do a high ligation, which means they just stitch it.
Speaker 1 (22:15):
Oh, okay. Cool. Yeah. Another question that came in is you mentioned braided stitches. There’s this thought that braided stitches cause higher likelihood of stitch abscess or Mesh or stitch infection wound problems. Do you notice that? Is that an issue?
Speaker 2 (22:32):
Yeah, so it’s very, very unusual. What does happen is if you put in a braided suture in something that’s close to the skin, so if I were to do an open hernia repair and I in inguinal inguinal hernia repair, repair, and I used a permanent stitch, like a silk, cause sometimes a reaction and get an infection or an abscess. And so for that reason most people use a dissolvable stitch when they do it open. And so the laparoscopic, it shouldn’t happen because they’re all under the inside the abdomen. But it is certainly possible.
Speaker 1 (23:14):
Interesting. The other question that we have, which is I think a very good question insightful is does my child’s hernia need to be repaired by a pediatric surgeon?
Speaker 2 (23:25):
So I would say this is controversial. Okay, here, here’s how I would answer that. Of course, my answer would be yes, I think that this is all we do. This is what we’re trained to do. So my answer would be, however there are some incredibly talented adult surgeons that do a lot of pediatric hernias. So if it’s someone who has a great deal of experience in pediatric hernias and that’s all that’s in your community is an adult surgeon then I would say that’s probably okay. I think if it’s an adult surgeon who does mostly adults, they’re probably not that used to the pediatric anatomy. So I would recommend a pediatric surgeon and also then you get the benefit of a pediatric anesthesiologist. So for that reason, we do recommend that. Yep.
Speaker 1 (24:16):
Yeah, that’s a good point. We have an anesthesia question here too. Here it is. Anesthesia safe for children.
Speaker 2 (24:23):
So the answer is this. Here’s the general, the incidence of a problem from anesthesia from a child is less than your chance of getting struck by lightning. It is incredibly low. The actual number is that they say your chance of getting hit by a car walking down the street is greater than your chance of having a mortality from anesthesia.
Speaker 1 (24:47):
However, I mean in LA, we get hit by cars all the time.
Speaker 2 (24:49):
That’s true. Depends on
Speaker 1 (24:51):
<laugh>. That’s a bad one. Yeah,
Speaker 2 (24:52):
That’s true. However, here is what’s emerging, and this is unclear and it’s just starting to emerge, is this question that is not totally answered, but it was published in the New England Journal that there is a theory that if you have multiple operations, multiple anesthetics in a baby that is under two years of age, there may be some neuro developmental things that you may notice in adulthood. It is not really clear they’re actually going to refute that paper soon. So we just don’t know. It’s such a hard thing to study. But for that reason, because we don’t know, the new policy for most pediatric surgeons in the United States is to not do an elective operation until they’re two or three years of age unless it’s urgent.
Speaker 1 (25:40):
Got it. That makes sense. Tell me a little bit about your practice. Is it mostly hernias or is it like half hernias or it’s your interest? I would
Speaker 2 (25:57):
Say so. That’s a good question. I would say it’s not half, it’s so a pediatric surgeon is an interesting job because we do a little bit of everything. So a pediatric surgeon is your pediatric thoracic surgeon, a pediatric surgeon is your neck surgeon, your abdomen surgeon, even your pediatric gynecologist and your sometimes even doing urology and other things. So we kind of do a little bit of everything. Plus we do a lot of trauma. So oh, pediatric surgeons probably spend the majority of their time doing those types of things, appendectomies and urgent things. We do a lot of neonatal congenital surgery. Babies that are born with something wrong. Electively, without a doubt, the most common thing we do on an elective basis is a hernia umbilical and inguinal.
Speaker 1 (26:52):
This is a two part question. What is, do kids get incisional hernias?
Speaker 2 (26:59):
They do. They do. In fact we do different types of incisions on babies because the most common type of incisional hernia is in the abdomen when you do what’s called a midline incision. So straight up and down. And in children that, because the muscles aren’t that strong informed yet, they can have a higher rate of incisional hernia sometimes than even adults. So in the tiny babies, we usually make our incisions going the other direction, yes, across the abdomen because it has a lower rate of an incisional hernia. But absolutely babies can get them.
Speaker 1 (27:34):
Well in adults it’s still true. The midline up and down incision has a higher hernia rate than the left to right transverse incisions. That’s why C-sections fan steel incisions have a very low rate of incisional hernias. And in a lot of other countries outside the us Latin countries Malaysia countries, they go, so it’s not exactly midline. It’s just to the side of the midline up and down. And those have less hernia recurrences too. We kind of don’t do that in the us I think it’s more of a cosmetic issue. It’s a cultural issue. I don’t know. We definitely don’t go left to very often, but even in adults, it’s a better incision mostly because of, oh, based on an incisional hernia. So if you get an incisional hernia, what do you do? How do you repair those
Speaker 2 (28:32):
Again? So I’ll give you just anecdotal a lot. It depends on their age, but because they’re usually pretty small, we usually will fix those primarily first, unlike adults where you place Mesh. Now the reason that we don’t like putting Mesh, why do we keep trying to avoid Mesh?
Speaker 1 (28:50):
Yeah, let’s talk about that.
Speaker 2 (28:52):
So the reason is that children are still growing. So if you place a piece of Mesh over an area, depending on what age the child is and how fast and how much more growth they have, it will get distorted and moved off to the side. It won’t be in the same location and it won’t cover the area. So things grow with the child. So if you have an incision that’s this big, it becomes this big when they grow, because everything grows together, so would the defect. So for that reason, we try not to rely on a Mesh in children. Now, the reason this gets really controversial, but the reason we don’t like Mesh in the groin in children, the reason we don’t like that is several fold. Number one, we’re very lucky that the pediatric primary repair, doing a high ligation has a less than 1% recurrence rate. It works really, really well. There’s no reason to put ash. Right, right. And even up to adolescents, and we haven’t studied adults in this, but at least up to adolescents. So
Speaker 1 (29:58):
I have a population if you want to get into that.
Speaker 2 (30:01):
Well, I’m going to call up on you on that because we started a pilot in Norway, and when that they, they’ve done quite a few and we see in adults and seen very low recurrences. I don’t even think they’ve seen one yet but I think that’s the next step I’ll get to. First I have to work on the adolescents. So when you’re operating on a child, besides the fact that you don’t need Mesh putting Mesh in a person that hasn’t been through their fertile years yet, it theoretically could injure the spermatic cord. Yes. Which carries the sperm. So if someone’s past having kids, the, it’s not an issue, but if it’s someone who’s going to want to have kids, I get afraid to put a, because the way the Mesh works, and maybe I’m wrong, but my understanding is that it causes a scarring. And so as it creates a scaffolding, and so if that’s true, it probably could involve the cord in that. And so that’s our fear of why we don’t like to put Mesh in the bilateral, both groins of a child.
Speaker 1 (31:11):
Yes. So that’s true. There’s a controversy in adults whether having a hernia pair with Mesh affects your fertility. And the most modern studies say, no, it does not. There was some really cool study done in, I want to say Brazil, but somewhere in South America, and they wrapped the spermatic cord with the peritoneum from the hernia sac to prevent it from getting stuck to the Mesh. And then they did a pre and post sperm studies, not fertility necessarily, but sperm studies. And there’s a dramatic difference. The people with synthetic Mesh had a lower sperm count than those that protected the spermatic cord from the Mesh. I do treat a lot of people as with Mesh related complications, and one of the complications can be erosion of the Mesh into this spermatic cord, including the Vas. Usually it’s just testicular pain. But I have, there’s a handful of male fertility specialists around town who I work with, and they have to do a revision of the VAs because the Mesh eroded and the patient has having fertility issues.
Speaker 1 (32:24):
It’s like a vasectomy reversal almost, except the vasectomy was functional done by the Mesh as opposed to a vasectomy on purpose. Very, very uncommon, fortunately. But the risk is for sure, and I think you’re right I, I’ll give you my personal thought on this because I do take out a lot of Mesh, but I understand that Mesh is so useful in the adults specifically for big abdominal wall hernias. That’s virtually impossible to do a good job without it, without really naming the patient. But in the groin, we have a lot of options in the us the trigger point, the trigger, the knee jerk reaction is to put Mesh in there. But we do have a lot of options. So when you do your laparoscopic Don Mesh, I came up with a laparoscopic or robotic non Mesh for adults, but I only limited it to really small hernias.
Speaker 1 (33:30):
So it’s more like the pediatric hernia where it’s the inguinal canal is pretty much preserved. It’s just the, there’s content in it now as opposed to a gaping hole where it’s straight through, it’s you kind of maintain that anatomy still and they’re symptomatic. And so those people do very well with just closing the defect. And again, like you said, if they fail, then they can move on to something more advanced. But you haven’t burned any bridges in doing a tissue repair laparoscopically robotically with those. But the reason why I said I have the population is I have a lot relative to most surgeons, I have a lot of people with small hernias that are symptomatic and what we call a call hernias that people don’t think are hernias because it’s not some big old huge defect, but symptomatic. And those may be the perfect initial population to pilot your study in adults because they really don’t have a disruptive inguinal canal.
Speaker 1 (34:33):
It’s just a normal inguinal canal with a little bit of fat stuck in it. In which case if you remove that fat plug in, close off the peritoneal defect or whatever your technique would entail may work. I think we just need more. We need to do more. We can’t just say, oh, well what we have is enough. In fact, I posted on our group that, Hey, I came up with this great robotic option for non Mesh repair, and everyone was like, we already have all these repairs. I’m like, yeah, but we don’t have a laparoscopic non Mesh repair. It’s all open and then kind me, but it can’t be better than lap with Mesh. But you just adding more tools, why not have more tools? That’s like why? I don’t know.
Speaker 2 (35:20):
Absolutely. And we should never feel that we’ve found the answer. I think for something as common as hernias are, I think we’re going to look back 50 years from now and we’re going to be amazed because we’re going to have such better therapies. Just think that we’re doing the best we can right now and we’re much better than we used to be, but we still have a long way to go.
Speaker 1 (35:43):
Yeah, I totally agree. In fact I don’t know, were you with the AHS? We had something called the Great Mesh debate, and we had every single, this was not an educational thing. It was kind of a fun part where it was not a educational based, but we had these debates, they’re called the Great Mesh debate. Each surgeon had to promote their favorite Mesh and tell you, and then you debate, well, your shrinks more and yours encapsulates whatever. And I ran that one for the first year. It was really fun. And the comment I made, which I stayed and bite, I think it was like 2006 or something, five or six, the comment I made was, there’s going to be a time when our grandchildren will look back and be like, you’re putting plastic in people’s bellies. And you thought that was a good idea. Where’d that come from? And I we’re moving in that direction. And I think patients are pushing us in that direction too, especially patients who have been harmed by Mesh products. Again, I feel like we need something besides human tissue to help us with hernia repairs, but we certainly don’t have anything ideally yet.
Speaker 2 (37:04):
No, and I think you’re right. I think we’re, I’ve said the same joke. We’re going to look back and say, we can’t, we plastic in people, but we don’t have anything better. But I love that people are working on polymers, people are working on, I’ve seen such cool ideas and I listen to every one of them because I think that true innovation’s going to show us a new way of doing it.
Speaker 1 (37:24):
And I think bashing the companies is not adequate. We rely on these companies to come up with these polymers. There’s no one surgeon, surgeon or one human being that can come up with this alone. You need a whole village of scientists and engineers and people who do this for a living. Yeah, I totally agree. We have a question. It’s about a umbilical hernia after a lap appendectomy. You do a lot of lap append in children too, right? Yep,
Speaker 2 (37:53):
Yep.
Speaker 1 (37:53):
It’s not necessarily open.
Speaker 2 (37:56):
No, we do them lap. Yeah. In fact, we do them different than the adults there too. We really do single port. So we just, because we reach in and grab the appendix out through the belly button and remove it with a single incision. And we also, I dunno if you do this, but we send them home from the recovery room so they don’t stay overnight. But incisional hernias can happen after. So when you’re performing a laparoscopic operation that you have to remove something like the gallbladder or the appendix, you have to make a big enough incision in the belly button to get it out. And usually that’s about 10 to 12 millimeters or about a centimeter. And although we put stitches in there, certainly the stitch can break the stitch. They’re usually a dissolvable stitch. They can dissolve too soon. And so you can get a defect or an incisional hernia at the umbilicus or at the belly button. And that again, is just as easy as I told you before that you just basically have to go put a couple stitches in there. Now the difference is there could be some scar tissue to things stuck there like intestines, but for the most part it’s putting in a few stitches. You shouldn’t need to put Mesh in a child.
Speaker 1 (39:11):
How much of an issue is obesity in the hernia repairs that you perform?
Speaker 2 (39:16):
It’s becoming more and more of a problem, and that is most of the babies are not very big. So that is unusual for us, but it’s becoming more common. And those are certain
Speaker 1 (39:31):
We’re teenagers are huge.
Speaker 2 (39:33):
They are. And now we’re getting into basically an adult sized patient and the dynamics change. And so that’s a great question. What do I do if a 17 year old morbidly obese teenager comes to me with a five centimeter umbilical defect? I probably would send that to an adult surgeon, to be honest with you. Right. Because when I trained under general surgery, I did a lot of those operations but haven’t done them in a while. And I firmly believe just same to the question that was asked earlier is should pediatric surgeons do pediatric hernia repairs? I don’t think pediatric surgeons should be doing adult hernia repairs. I think that we need to send those to our adult colleagues who in general in surgery, this is my philosophy, if there’s someone who does more of them than you, that’s who they should go to. And that’s good. I frequently will refer patients away that I think I could do the operation, but there’s someone in the same city that can do it better. I send them away.
Speaker 1 (40:36):
I suspect Ohio has its fair share of obese teenagers.
Speaker 2 (40:40):
Yep, we do.
Speaker 1 (40:43):
On that note, do you think that their inguinal hernia should be done like a 17 year old that’s 200 pounds. Do you think that should be done by a adult surgeon or is that 16, 17 kind of your cutoff where if they look like an adult, you treat them more like an adult?
Speaker 2 (41:03):
Great question. So again, this gets to the controversy of what is the chance of it coming back again? What is the risk tolerance of the patient and the family? So if we don’t know yet what predicts recurrence, so because the number is so small, we would need a huge population to figure that out. Is obesity a predictor? Because remember, if it’s still a teenager that has a hernia, they almost certainly had that from birth. And it’s probably a pediatric type of hernia where it’s not a muscle problem, but the inner lining is still persistent that we need to remove that little tissue. So even at that age, and even at that size, they still probably have the same problem. That can almost certainly be fixed by removing it. But I would have very little heartache telling the family, look, the way I do it is I would do a pediatric repair. I think the chances of it working are very high, but it may fail and you might have to go to an adult surgeon and most still choose to have it done. But I absolutely would give them the choice and the name of an adult surgeon.
Speaker 1 (42:10):
Right, right. Okay, that’s fair. Next question has to do with the Mesh again. So when do you ever use Mesh and when is it appropriate to use Mesh? Are there situations where there’s, I mean, would you rather use a biologic in children? I’m just right wondering when you would ever use it? And I’m thinking not only like a one or two year old, but like a 10 year old. What about a 16 year old?
Speaker 2 (42:42):
We do use Mesh and it’s not in the circumstances that you’re probably thinking of because they’re different diseases. But I will tell you this, that when we need it, sometimes we have to special order it because we don’t keep much Mesh in the hospital, but we do have Mesh and the most ex common example, sometimes babies are born, see, we see other types of hernias in kids. So babies are born with a hole in their diaphragm, the muscle between the abdomen and the chest. And we have to sometimes fix that because you can’t get the edges together. We put a piece of cortex in there to hold on. Now you do run into the problem that when they grow, it could fail because that little thing doesn’t hold it anymore as they get bigger. But by that time, a lot of the tissue has ingrown and we don’t see many older patient recurrences. We do have babies that are born with what are called abdominal wall defects. So babies are born, we just operated today on a patient that they’re born without their muscle being closed all the way in their abdomen. So their intestines are sometimes on the outside of the body and they have a big hole.
Speaker 1 (43:49):
This is like a omphalocele or a
Speaker 2 (43:51):
Gastro? omphalocele or a gastroschisis. I
Speaker 1 (43:54):
Did a month of pediatrics.
Speaker 2 (43:56):
Yeah, exactly. And again, forgive me, but I think the most of the audiences are families. So I’m going to use the non-medical terms, but so the thank you. But these holes sometimes can be closed by us with stitches, but sometimes they can’t be closed. And so we need to put in a Mesh to hold it together. Now your question about biologic. So biologic Mesh is a Mesh that dissolves away over time. It absorbs away over time and can leave a little bit of a matrix to help tissue grow, but we have found that they don’t work very well. And so we don’t typically use biologics. If we need to bridge something together, we usually would use either a polypropylene, we would use a or goretex type Mesh.
Speaker 1 (44:46):
So maybe this hybrid Mesh is of use.
Speaker 2 (44:49):
Absolutely.
Speaker 1 (44:50):
Bio. It’s like 94% biolo or 96% biologic, 4% synthetic.
Speaker 2 (44:56):
So that’s why I like to go to your meetings. That’s why I go to AHS. That’s why I go to sages because we have a lot to learn from the adult surgeons and the stuff that you guys are using and how we could use it in children.
Speaker 1 (45:10):
That’s why I enjoy these sessions with you. And we have urologists and gynecologists, we have orthopedic surgeons all coming to these sessions. I learned from them and I’ve learned from them in the past. And so I feel it’s very useful and I always like learning stuff. Got to keep on learning. Okay. Let’s see. Oh, let’s talk about athletes. It’s a good question about athletes. This is a good one. Do young athletes ever get sports hernias and how do you treat them
Speaker 2 (45:41):
All the time?
Speaker 1 (45:42):
Or do you treat them?
Speaker 2 (45:43):
No. Well, I treat them, but not with surgery usually. Yeah, so great question. Controversial topic. A sports hernia is controversial in my opinion. It’s not a true hernia. It’s a misnomer because it’s basically ligamentous tears that are from sports aggressive sports. Usually I will do six to eight weeks of physical therapy and rest. Here’s the worst part, who gets a sports hernia? The good athletes. So the worst thing you could ever tell them is you have to take a season out from sports. But if they want it to get better, that’s what they have to do. It’s probably not dangerous, but it will continue to hurt until they take a good six to eight weeks of rest and physical therapy. There are some surgeons who believe in doing a Mesh repair on those lay Mesh to cause scarring. I don’t but I’m sure some do. I
Speaker 1 (46:34):
Agree. No, there’s that. And also about do you have doctors, either general surgeons or sports surgeons, orthopedic surgeons that do releases, muscle releases? Probably not. It’s in a child, in a teenager.
Speaker 2 (46:52):
No, I’m not seen that. No,
Speaker 1 (46:53):
No, probably not. They just have to heal.
Speaker 2 (46:56):
Yeah.
Speaker 1 (46:59):
What are the topics have we missed? So
Speaker 2 (47:01):
Let me rapid fire through here. So common things. Another one is epigastric hernia. That’s a small defect in the top of the abdomen. That’s controversial. I used to fix them all. A lot of surgeons are now trending towards not fixing those because they’re more cosmetic. They can cause problem when they get older and they get bigger. So some would fix it now for the same reason that we fix belly button hernias because they could be harder to repair an adulthood. But a lot of surgeons, including myself, say, if it’s not bothering you might you have the option of just leaving them alone. So that’s epigastric hernias. That’s a little tiny hernia in the upper abdomen. That’s only a partial hernia, not the full thickness of the abdominal wall. Just the fat pokes through. Yes.
Speaker 2 (47:42):
The other things to talk about is what do we do if we find a hole? You sort of alluded to this earlier when we’re doing another operation. So I don’t usually fix those because I think a lot of us have those holes and they never cause a problem our whole life. So if we find a hole when I’m doing another operation, we let the parents know about it that it could become a problem and the other stuff might go down that hole and they should get a repair at that time. But I don’t usually fix it at that time. Some do fix it. So it’s depends on your surgeon. Another common question is that when we find to go to fix one hernia, 20% of the time in children, they have a hernia on the other side as well. And I give that choice to the parents, but because I do it laparoscopic in there, and most parents have asked to fix both sides. So that’s another controversial point.
Speaker 1 (48:40):
I remember videos where they would stick a camera through one hernia to look for another hernia. They
Speaker 2 (48:49):
Still do that, right? Those who do open hernias still do that, but I don’t do it because I do it lap. So I just go in, I see both and fix. Yeah a hydrocele hydrocele is a type of hernia where the hole closed almost all the way after the testicle went down, but it didn’t close all the way. So there’s a microscopic little hole. So just enough that fluid can get inside but not intestines. And so those are not dangerous. They actually are only really a cosmetic problem. Some wonder if the bathing fluid could cause a fertility issue that we do fix those, but we wait till they’re older to fix those because there’s not an urgency and most go away on their own. So
Speaker 1 (49:35):
Like those are roof leaks, you know, can’t really see that hole. But then the water kind of eventually makes its way through just little drip drip. Yeah,
Speaker 2 (49:45):
Just an annoying leak. Yes.
Speaker 1 (49:46):
Tell me about talking about undescended testicle In adults, it’s not normal for the testicle to rise up into the groin, but when it does, we should always look for an occult hernia as part of the reason for it. In children, you always look for undescended testes. Is that an association with hernia or no?
Speaker 2 (50:05):
It is. It is. And it’s a challenge because, so normally, as I said, the testicles go down and down into the scrotum. And when that doesn’t go just right, sometimes they get stuck. They didn’t go all the way down. And that’s a problem because the reason the testicles go down into the scrotum is because they need to be cooled down there. And so if the testicles stays up high by the abdomen, it can cause infertility and it can even have a slight increased risk of cancer. So for that reason, we like to bring the testicles down into the scrotum so that we can evaluate them and examine them throughout their life to make sure that they don’t get a lesion there. And also to maintain fertility we do those by about six months to a year of age. We fix those. But a lot of those, when they’re born with a high testicle, you wait and they come down.
Speaker 1 (51:00):
Oh, they do come down.
Speaker 2 (51:01):
Yeah, most come down. So we see them when they’re babies, we wait and they just retract down over time. By the time you
Speaker 1 (51:10):
Have the parents counseling like pulling on it or confirming,
Speaker 2 (51:13):
I don’t do that. No, we just examine them. You know what period I actually have them do is have them come back and see me at six months in a year because when we’ll fix it, there’s no reason to come back sooner. Right. Cause I won’t do anything. And a lot of places the urologists do that. Pediatric surgeons or urologists do it. There’s a common another situation that’s called a retractile testicle, which doesn’t need surgery. And that’s just that the testicles are so small in a baby that the muscles too strong and it pulls it up. But if you actually pull the testicle, you can easily pull it down. So you don’t need to do anything. When they get a little bigger, the testicles will fall normally.
Speaker 1 (51:51):
That’s too cute.
Speaker 1 (51:54):
So in adults, we believe that inguinal hernias actually all hernias, but mostly inguinal hernias are genetic. So if you have a family history of parents, siblings aunts and uncles have hernias than you’re more likely to have hernias. We fail. It’s a collagen deficit. And what I learned in my practice, because I see a lot of women, it’s about 50% women where if I saw everyone equally, I should probably see about a 10 to one ratio of males to females. But I’m about 50 50. What I’ve learned is because I ask about family history and everyone is that if they have a mother or sister or a female in the family with a hernia, that genetic link seems to be much stronger. And then I saw a pediatric pat study as a pediatric study done maybe like three years ago, that looked at family genetics and said, in children, the female genetic line lineage is much stronger in passing on the, so little kids are more likely to have hernias if their mom had a hernia than if their dad did.
Speaker 2 (53:09):
That’s interesting. That’s pretty cool. That’s very cool. I will tell you there’s absolutely a congenital nature to it, but it doesn’t follow the exact lines of genetic distribution that you would think with a true autosomal dominant or autosomal recessive trait. But it, there’s absolutely a familial component to hernias.
Speaker 1 (53:28):
Yeah. And you see a lot of children with hiatal hernias. Is that linked? Do you see that them also having other abdominal wall hernias or No.
Speaker 2 (53:36):
Great question. I don’t know the answer to that. I don’t know if there’s an association also, although there may be. I think the physiology, the pathophysiology is a little different. Different. But the yes, hiatal hernia is absolutely something we see in kids. And it’s very common, just like the England olds, it’s much, much, much more common in the newborns. That’s who as we all know, newborn babies vomit all the time. And so you can imagine that’s because they have really big hiatal hernias that get better with time. So we try not to operate on those, but eventually, sometimes we have to if they can’t feed.
Speaker 1 (54:15):
Man, I remember in my pediatric surgery rotations, we were lucky because we had at UCLA, we didn’t have a pediatric surgery fellowship so as residents, you were it. And we did these amazing operations. Eric Funks RU was practicing and he’s just an amazing guy. And we learned a lot. But yeah, there was so many hiatal hernias that we were repairing. Not as many inguinals and stuff, it was all hiatal. I swear to God. I would walk down the malls and I would see kids and I’m like, I’ll bet you every single one of you has a G-tube and you just, you’re cute. But I’m sure behind that cute little outfit, there’s a G-tube because it just seemed like every kid had a hiatal hernia.
Speaker 2 (55:00):
That pun pendulum has swung and it goes back and forth. Right now it’s in the era of we shouldn’t do as many. I was trained when one of the highest centers that did hiatal hernia, but we have really backed away from that recently.
Speaker 1 (55:14):
Got it, got it. There’s a question about a rouge hernia Mesh. Have you heard of some that I don’t. I’ve never heard of that.
Speaker 2 (55:23):
I’m sorry. Yeah, but we don’t use much Mesh, so I’m not in a Mesh expert. Yeah,
Speaker 1 (55:26):
Yeah, exactly. Yeah. So do you see patients outside of your area? And if you do, how do they, what’s the process for out-of-town patients to come see you?
Speaker 2 (55:36):
Yeah, so I get interestingly, a lot of the calls I get from out of town, I’ll just be totally honest with you. I would love for every patient to come see me, but you probably don’t need to. I think that the beauty about inguinal hernias is that it’s a relatively straightforward operation. And there I am sure that there are fantastic surgeons in your location that do the operation. And if you ever need, have a question, go ahead and email me and I can connect you with someone in your area. It’s a tponsky@gmail that’s just email me and I can find someone in your area. Now who does come to me are, what I get calls about are adult or older patients are adolescents that want to have the non laparoscopic, non Mesh hernia repair. If there’s no one in your area that does the laparoscopic repair here’s my answer. Definitely get a hold of me and we can do the operation. But you know what, an open repair is pretty good too, right? So I would say that if your surgeon only does it open, that’s fine. I don’t think,
Speaker 1 (56:41):
Yeah, don’t force that surgeon to do a laparoscopic
Speaker 2 (56:43):
For sure. No, and you probably don’t need to travel either. I would go with what your surgeon has. There’s pros and cons. I think if your surgeon does it open, that’s fine. Yeah,
Speaker 1 (56:53):
Yeah, I totally agree with that. I must say you have been very helpful. I do what’s called online consultations for patients and every so often I get a mother that emails me and says, I read about these stories about your patients and it sounds like my child, but my, it’s a child. <laugh> an adult surgeon. So if it sounds like something I can help, which is abdominal wall related or some, if I can help in any way, I try and help. And I’ve reached out to you a couple times and you’ve been super, super helpful. And the patients, they just need some direction and they need to trust someone and for you to be so open and available and your team was so available, your assistant was so nice to be able to reach out. You guys directly reached out to these people you don’t even know based on just my questioning and they got the treatment that they needed.
Speaker 1 (57:52):
And for a mother and seeing their child suffer like severe pain or not eating for because of different abdominal issues, it really means a lot. And I think that’s why I go into pediatric surgery because you can help so much. But, so thank you for your time for devoting for this and all the questions have been answered and I learned a lot. I’m glad I can see you during this COVID time. Yeah. But please do know that besides what you do in your hospital with your own patients, you have helped a lot of people outside as well. And
Speaker 2 (58:35):
Very nice of you.
Speaker 1 (58:36):
I myself have had multiple times when I’ve reached out to you, you’ve always been helpful. So thank you very much.
Speaker 2 (58:41):
Thank you so much. This has been wonderful. Thank you.
Speaker 1 (58:44):
Thank you. So for everyone that’s the end of hernia talk today. I will post the entire session on YouTube and share that on all our different social media platforms. You can follow Dr. Ponsky on Twitter at tponsky, and he also shared his email address with you all. I will see you all next week. Thank you very much and have a great rest of your day. Thank you very much. Thank you. Thank you.
