Episode 24: Chronic Groin Pain | Hernia Talk Live Q&A

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Speaker 1 (00:01):

Good evening everyone. This is Dr. Towfigh. I’m joining you on yet another hernia talk Tuesday. Today’s guest is Dr. David Krpata. He is a general surgeon specialist in hernias I’ve known him for since he was in training. He currently heads the chronic groin pain clinic at the Cleveland Clinic in Ohio in the United States. We’ll be joined by him shortly. As you know, this is simulcast on Facebook, so please enter any of your questions to Dr. David Krpata. we will focus our entire hour on groin pain only, and this hour will then be broadcast on YouTube and you can share it with your friends. What I will say though is Dr. Krpata is in surgery and just finishing up taking care of patients. So he’s joining us by audio, but we can’t see him on video. But I do thank you David very much for joining us and taking the time.

Speaker 2 (01:08):

Well, thank you for having me. Just want to make sure you can hear me correct.

Speaker 1 (01:11):

I can hear you perfectly now. Okay. It’s seven 30 at night your time. So you’ve been operating really late looks like.

Speaker 2 (01:19):

That’s right. And good news everybody. I am not actually operating at the moment. I am finished, but I’m walking out, so Okay. But I’m happy to be a part of this.

Speaker 1 (01:30):

Excellent. So Dr. Krpata is you’re a general surgeon by training. You then did a fellowship and then continued on in the hernia world. Is that about right?

Speaker 2 (01:42):

That’s correct, yeah. I did my training in Cleveland, Ohio at university hospitals and then my fellowship training at the Cleveland Clinic in abdominal wall reconstruction.

Speaker 1 (01:52):

And then you stayed there

Speaker 2 (01:54):

And then Yep, I’ve been here for five years.

Speaker 1 (01:56):

They kept you, which is a good, always a good sign.

Speaker 2 (01:59):


Speaker 1 (02:00):

So tell me a little about your chronic growing pain clinic. It’s very unique. It’s built on experience with other what do you call it, other like breast cancer has these multidisciplinary clinics, a lot of oncology. We’ve never really seen one in hernias. I believe yours may be the first one. Can you just walk me through how you developed it, what the groin pain clinic is what patients may expect when they come to you?

Speaker 2 (02:35):

Yeah, so this is something we started couple years ago and one of the main reasons why is that especially associated with hernia repair.

Speaker 1 (02:56):

You’re going in,

Speaker 2 (02:59):

I’m sorry, go ahead. As you take care of people with chronic groin pain, you start to learn that there’s more factors involved than just the operation or the Mesh that they had. And it can be related to psychosocial issues. And really there’s also other causes of growing pain. And so the best approach is to really try and take the patient in a more complete overview. And so when patients come in, they’ll not only see a surgeon, but they’ll also get imaging and they’ll see a pain psychologist to start off with. And then what we do is we actually meet and talk about each patient individually and assess what is the best approach, whether it’s going to be medical or if it’s going to be surgical or if there’s additional interventions that we want to consider.

Speaker 1 (03:53):

So when they make the appointment what’s the average time they spend with you all?

Speaker 2 (04:00):

When somebody comes in, they’re typically here for a morning and they’ll be here for three hours to complete all their visits. And a lot of people come from out of town for these, so they can actually be very nice for them because they can get everything done in one visit rather than having to come multiple times.

Speaker 1 (04:23):

And how much of the data that you see is sent to you ahead of time? Or I should ask maybe a more open question. When they contact you, do you gather everything ahead of time or they just show up the day of and you figure it out when they come? What’s the process?

Speaker 2 (04:46):

So when people come in, sorry, there’s a little bit of background noise, so let me get it.

Speaker 1 (04:52):

It’s okay. For those of you that are listening,

Speaker 2 (04:55):

We typically go through a process of gathering as much of their past surgical history and some of the medical history as we can. So we’ll usually try and get their operative record.

Speaker 1 (05:08):


Speaker 3 (05:11):


Speaker 1 (05:12):

I’m losing you again,

Speaker 2 (05:12):

Some of the potential causes of their pain.

Speaker 1 (05:15):

Huh? I’m losing you. David.

Speaker 2 (05:26):

Have a full evaluation with our pain psychologist. So it’s a pretty complete and thorough evaluation from when they sign up to when they complete it.

Speaker 1 (05:36):

Okay. You got cut off a little bit. So when they contact you, does your office have an intake form or a system to gather all the data? And then when you do gather it, do you all meet before the patient or after you see the patient to come up with a plan of care or both?

Speaker 2 (05:56):

I’m sorry, could you repeat the question?

Speaker 1 (05:57):

Yeah, so the, I’m just trying to understand the process to help the patients understand what they should be up to. So when they contact a patient contacts your office, is there a system where they gather all the data and then do you sit down as a team to look at ahead of time or is it a team effort after the appointment visit and when do they get the plan of care? Is it the same day or later?

Speaker 2 (06:21):

Yeah, so when patients contact, which is something that they can either do by calling the office or through the Cleveland Clinic website for it’s Clevelandclinic.org/chronicgroinpain, which will get you all the information for the brain pain center. Well once they initiate that process we set up everything as far as their appointments and get everything beforehand depending on what the circumstances, sometimes we’ll review more of the records beforehand in terms of some of the operative reports to see if maybe we want a different imaging modality because most commonly we’ll have people come in and get a dynamic ultrasound, but in certain circumstances we might want to get a CT scan instead. And so there is some evaluation beforehand, but majority of that is going to occur on the day that they come in for their visit. And what’s somewhat unique is that we’re really not trying to give, have each provider give their own individual plan to the patient. We meet afterwards to discuss the patients and then eye contact everybody either later on that same day that they visited or the beginning of the following week with their multidisciplinary approach.

Speaker 1 (07:42):

Okay. And do you also offer virtual consults? That’s one of the questions asked.

Speaker 2 (07:51):

Yeah, we do have have some capacity for doing virtual consultations and I think that’s always a good way to start some of these, but what I have found is that the physical exam on patients is for chronic groin pain is so incredibly important that it does offer an initial link to see maybe if it might be worth it to come in. But a lot of times that just leads to an in-person visit for more thorough evaluation.

Speaker 1 (08:24):

Yeah, that’s been my experience too. One of the questions posed is do you tend to see patients that have Mesh related chronic pain or do you see people who’ve had hernia repairs with chronic pain but they’ve never had Mesh like a Shouldice or a Bassini or McVay or Dasarda, whatever the tissue repair is.

Speaker 2 (08:48):

So chronic groin pain patients come in all versions and it can be after Mesh repairs. I’ve seen patients after primary tissue repairs. I also have seen patients for chronic groin pain who have not had any Anglo hernia surgery before or other not uncommon reasons would be patients who have had abdominalplasties, patients who have that they get neuropathic pain associated with their scar foundation. Yes.

Speaker 1 (09:26):

Yeah, exactly. That’s very true. We’ve had some questions submitted ahead of schedule through the different social media outlets. I’m going to review some of those. So you mentioned that you’ve seen people with Mesh with groin pain without Mesh with groin pain or just groin pain for other reasons. Can you just go through a list of what kind of groin pain or what kind of what’s in the differential diagnosis of someone who’s never had surgery, who has groin pain?

Speaker 2 (10:00):

So in terms of people who have never had any surgery, there’s probably three main buckets that we would consider non sort of musculoskeletal relating to the groin areas would be related to their back. And so I always consider if somebody’s had back trauma or past back his or surgery also from the hips yes, people don’t realize that they can get pain that feels like it’s in their groin, but it’s actually occurring within the joint of the hip. And so it’s just more of a deeper type groin pain that they can actually be sensing. And then more towards the musculoskeletal would be something like a core injury or what is probably more commonly known as a sports hernia and we consider that as well.

Speaker 1 (10:55):

And if they come to you, let’s say you determine their growing pain is from the hip when they come to your clinic, do you then refer them to one of your own doctors? Do they seem same day or what’s the process for your clinic?

Speaker 2 (11:12):

Yeah, I think in an ideal world I would always have an orthopedist available for me at my beck and call, but unfortunately they don’t necessarily see need to see everybody who comes in. So it’s not the best utilization of their time. So what we typically would do will refer to one of our orthopedist or if somebody’s coming from out of town, I have no problem with them seeing an orthopedist that’s closer to their home as well. But I usually want to have some evaluation of by an orthopedist to do a more thorough look at somebody’s hip or at least rule that out as a possible cause of the groin pain.

Speaker 1 (11:51):

I have a smart question for you look at this question. So smart, because this is the first part of the question, so I’d like to get your thoughts. So this patient wrote, I’ve heard their pre-op pain as a predictor of post-op pain. I’ve heard this also multiple times. Do you feel that that’s true? What are your thoughts about that statement? And then I have a follow up question to that.

Speaker 2 (12:17):

So I do think it is a predictor but and I think it’s probably for one of two reasons. The first is that you either are misdiagnosing the cause of the pain and it’s not from the hernia. And so I’m always asking people about what the pain experience they had before the operation and how it was immediately afterwards and if it changed at all because usually if somebody had the same, they say I got my hernia repair and nothing changed. Usually maybe they had a hernia but it we’re misdiagnosing what the actual pain is coming from. And so that’s going to focus more on some of the other primary diagnoses for groin pain, spend much more time trying to evaluate their hip or their back or find other potential causes. The other side of the coin is that people who maybe have a history of chronic groin or a history of chronic pain or have nervous systems that may be more sensitive are a set up to also have more sensation from their hernia repair. So they’re set up to have more discomfort with an operation.

Speaker 1 (13:32):

Yeah, I understand that. Yeah, that’s a small population though, I think.

Speaker 2 (13:39):

I agree. Yeah,

Speaker 1 (13:40):

But the reality is we really don’t know. We don’t know. It’s the pelvis and nerves are so complicated, they talk to each other everyone’s body acts differently. I feel that we don’t know enough. One problem I have with this statement is well pre-op pain predicts post-op pain. And so then a patient will have post-op pain, will go to a surgeon and they’re told this kind of idea, which is somewhat based on data, but it’s not very clean data and they kind of blame the patient. It’s the patient’s fault that they had post-op pain. Well, you had pre-op pain, so we’re surgeons, we can only do so much. And I feel that it doesn’t help the patient get the care they need necessarily sometimes because it’s just discounted that therefore there’s nothing to do. It’s just like the way you are and don’t, in my experience, most patients have a treatable problem when they have post-op pain.

Speaker 2 (14:43):

I agree with you completely and I think that that’s one of the key parts is that recognizing that just even if those are predictors of postoperative pain, it doesn’t mean that something can’t be done because you’re experiencing pain. You still deserve a thorough evaluation. You do still deserve that workup. You as a patient don’t know, you should not be ruled out as somebody who can be helped just because you were experiencing pain before the operation occurred. It’s just in my mind it’s something to consider because it lets me think about what the potential causes are and it may change my approach, but I still think that it’s patient patients should not be written off for that reason.

Speaker 1 (15:35):

I agree. So the question follow follow up question is, this is a two-part question. So is there a way patients can reduce their chance of post-op pain? That’s a smart question. I don’t know that we know that.

Speaker 2 (15:51):

Yeah, I would tell you that if you figure it out, <laugh> really going to help a lot of people. That’s true. I wish we had the answer to that right now. I don’t think that there is a great way to predict it or to try and reduce it, but I think it’s probably a great area for focusing future research on when it comes to pain and surgery.

Speaker 1 (16:17):

I agree. I think we know that there are certain risk factors for a hernia recurrence. So if you don’t want to have pain because your hernia recurred, then treat your chronic cough, don’t smoke, don’t use nicotine don’t get constipated, that kind of stuff we know, but in a more kind of global way, can someone reduce their chance of postoperative pain? That’s tricky. I would say make sure you’re seen by a talented surgeon who chooses the right or the best option for you in terms of what you need to have done.

Speaker 2 (16:57):


Speaker 1 (16:58):

Yeah. Okay. So here’s the smart part of the question I really like. So this patient falls up and says, okay, great, I’ve heard about watchful waiting, so what am I waiting for? Am I waiting for pain or increase in size? And if I’m waiting for pain, you just told me that pain is a risk factor for post-op pain, so why is squat waiting? Okay, what do you say to that and what are they waiting for?

Speaker 2 (17:24):

Yeah, so if we always consider exactly what a hernia is, I like to explain it as simple as possible and that a hernia is a whole that allows things to go through it that shouldn’t. Right? And that thing that you really don’t want to go through it that shouldn’t is your intestines. And if that occurs, that’s a surgical emergency. So when we talk about watchful waiting, we’re talking about people who have what we call minimally symptomatic or asymptomatic small inguinal hernia where their risk of an incarceration or their bowel getting stuck in there is very low percentage less than 1% over five years, over 10 years, probably about two and half percent. So the real question there with watchful waiting to me, is it safe for me not have surgery and not end up in an emergent situation? Now whether or not you’re going to develop symptoms along the way while you’re waiting, that does occur. That occurs in 60 to 70% of patients over a 10 year period. So people can kind of consider that as hernia surgeons. We also consider that in terms of defining whether or not somebody should have a surgery based on some of their comorbidities and whether they can tolerate an operation and is it actually just safer for them maybe not to have an operation because the risk of incarceration or bowel getting stuck in is actually pretty low.

Speaker 1 (18:52):

That’s correct. Yeah. Very good. All right. We have some more questions coming in with regard to the patients that you see for chronic groin pain that have had a Mesh based hernia repair. Have you noticed any one particular type or style or type of repair presents to you or not or material?

Speaker 2 (19:18):

So one of the things that I always try to avoid is plugs, hernia plugs or bilayer meshes. Essentially the more bulk of Mesh, I think the higher the risk of having somewhat pain associated with it and specifically for plugs where it can have that mass effect where it compresses or pushes on areas. I do feel like the Mesh may be more associated in those circumstances.

Speaker 1 (19:54):

In my practice too, I feel the plug and the prolene hernia system with the two layer meshes, those are more likely to cause Mesh related complications where it folds or gets stuck to organ systems like the sperm rheumatic cord that it shouldn’t be stuck to. But we actually looked at that. I wrote a paper called Why We Remove Mesh, and I looked at all the meshes that I removed both for groin and non groin and I thought anecdotally I thought that the plug would be so much more than everyone else, but actually the number one most common Mesh that I removed was just flat Mesh. Just to show you that it’s possible that also most repairs are with flat Mesh. So my interpretation was that if you look at it, if let’s say 30% of I’m going to make up this number, 20% of all hernias are made of with the plug and 80% with flat Mesh. I think something like 40% or disproportionate number from the plug had problems. But all comers, it was more common with just a flat Mesh. And the prolene hernia system is a specific two layer Mesh. There’s a top layer and a bottom layer. It’s a good idea, but the plug, there’s a lot of interaction with the Mesh and the spermatic cord. And then secondly, you have to be really good at making space for the Mesh, and if you don’t, the Mesh will fold. And that’s kind of the Achilles heel of that Mesh.

Speaker 2 (21:35):

Yeah, I think by principle you always want to try to avoid folding, avoid bulk or mass in order to try and reduce pain.

Speaker 1 (21:48):

Correct. Going back to your statement about groin pain and hip disorders so I understand, sorry, patients understand where the hip is and it could kind of interact in the same plain as the groin. The groin that I explain is where if you can see where your leg and your attaches to your torso, there is a crease there, that area and above that, couple inches above that, we generally call that the groin. When you see patients with hip problems that are causing the groin pain, how far medial do you notice that they get pain? Do you ever see them with testicular pain? Can they be pain in the midline or pubic synthesis or not really? That’s a question to one of our viewers.

Speaker 2 (22:42):

Yeah, I don’t find that it tends to cross to the midline or that it causes testicular pain. I think testicular pain is usually one of those things that helps kind of rule out hip as one of the causes. And a lot of times people have seen their orthopedic surgeon as part of the, if they’ve had any hip issues in the past, and I would will say that when a somebody’s had a hernia repair and they start to have pain in the groin, even if they see an orthopedist, it’s not uncommon that the orthopedist is going to say, defer to the hernia repair and say that that is probably more the cause. Yes. And I’ve had patients where we’ve removed the Mesh and we really haven’t had any significant improvement in their pain and then they go on back to their orthopedist and get their hip replaced or another hip operation and then they get resolution of their pain. And unfortunately sometimes just because inguinal hernia repairs and Mesh get a bad name, they also get cause and the blame for a lot of it, even though people from their own specialty might not realize that they’re missing the diagnosis as well as something like hip as the cause.

Speaker 1 (24:02):

Yeah, I would say my experience as they’re really talented general surgeons or in hernia specialists and there are others that are, don’t really think outside the box, and the same is true for orthopedic surgeons. I have a lot of patients that have been through the orthopedic route and because they’re groin pain didn’t perfectly match what the textbook says about a hip labral tear or a hip disorder. They were told it’s not your hip, it’s your hernia, for example. And then you send them to a hip specialist, let’s say that does think outside the box is bit more talented. They’re in their diagnostic abilities and they said, no, this is hip is just maybe a little atypical and they get their hip repaired. And I have a handful of these specialists in my back pocket that I rely on because just because you went to one doctor and they said, it’s not that I feel that patients should do a little bit more research or be open to getting a second opinion, whatever the question is. In our case, hernias or groin pain do you see that too where the patients come with you to you with all these urologists said, no, gynecology said everything’s normal. Orthopedics said it’s normal, but then you actually find it’s not a hernia problem, it’s a gynecologic or orthopedic or urologic problem. It was just missed.

Speaker 2 (25:32):

That happens. And to your point about the specialist even if somebody has had an evaluation by an orthopedist and then they come to see me, if I really feel like it’s related to the hip or I think that’s really not related to their hernia repair, then I will recommend that they get a second opinion and just to hear around somebody else and make sure that they do get to a specialist. Again, like you said, not everybody’s as keen on some of these findings and maybe some of these patients may come with a history of pain and they get written off. So I think it’s important that sometimes second opinions are also key factors in figuring things out.

Speaker 1 (26:20):

Yeah, I totally agree. Now they should be open to that. Here’s a question. Can a hernia permanently damage the body or nerves? Let’s say you follow watchful waiting. Can you have permanent damage by not repairing that hernia?

Speaker 2 (26:37):

From a nerve perspective, I don’t believe so. Obviously you would not want to watch a hernia until it was so large that it became something overly complicated to repair. But we repair some pretty large little hernias, so I don’t even think you could watch it to the point that we wouldn’t be able to do that. Right. But I think with reasonable expectations, I don’t really think that by watchful waiting you’re going to do damage to yourself. And if you look at the studies that actually look at those and compare surgery versus watchful waiting, people who waited longer for their operation did not have more complications as a result of when they did cross over to have a hernia

Speaker 1 (27:21):

Repair. Right. Good to know. There’s a Dr. Robert Wright, he does a lot of hernia repairs open and he has an interesting group of patients. So he routinely cuts the ilio inguinal nerve, which as you know is a known technique. But then he’s been sending these to a pathologist to look at actual more than just look at the nerve and study the nerve. And he’s found almost like a pressure necrosis, a neuropathy in those nerves. And he feels that the hernia pressure on the nerve can cause a pressure impingement, kind of like how a disc will push on a nerve and therefore he feels that not only was that the cause of the pain, but it may contribute to postoperative pain if you leave that alone. And that may be a subset of why patients have postoperative pain is because they have a damaged nerve from the hernia. It’s hard for me to believe that, but he does have data. It’s pretty interesting data actually.

Speaker 2 (28:34):

Yeah, I think mean that’s certainly interesting and I applaud the effort to try and help figure out how we can help it to avoid chronic pain in patients with hernia repair. We do know from large series of studies that there’s in favor of it, not in favor of it, but if you look group the studies together that there hasn’t been a real benefit shown with routinely cutting somebody’s nerve at the time of their primary operation. So if that is true, then I guess to me maybe there’s not as many neuropathies occurring and that this appears to be more random effect.

Speaker 1 (29:21):

Yeah, yeah, I agree. I agree. Good point. Another question is a hernia harder to repair? The longer you Wait, let’s talk, we’re only talk just for the audience. We’re only talking about the groin this hour. So is a groin hernia more difficult to repair the longer you wait?

Speaker 2 (29:43):

I think if you wait a really long time it can be a much more challenging operation. But for the most part, if we’re talking about, let’s get specific and say, okay, I noticed a hernia and am going to, is my hernia repair going to be harder because I wait three months to have it repaired? No. Is it going to be harder because I wait a year to have it repaired? No. Correct. Is it going to be harder if I wait five years? Probably not. And the study’s about watchful waiting would show that it’s not more complicated to fix if you wait 15, 20 years, then maybe,

Speaker 1 (30:23):

I mean, yeah, if it’s down to your knees, then that’s definitely a different operation then when it’s just a visible bulge.

Speaker 2 (30:30):


Speaker 1 (30:32):

You have a lot of fans, by the way, logging in and saying hi and how much they love you and how you saved your life. So good job on that. I know that I, I’ve seen a lot of the patients that you’ve seen. I’m very impressed with the quality of the consultation you offer the patients. The amount of radiologic expertise that you offer with the 3D ultrasound is really amazing. I hope that somebody in your group can teach other radiologists to do the same because that’s just a fantastic ability to look at all the tissues and the groin and nerves and Mesh and the muscles and really understand the dynamic of the groin. We can’t get that information with most other studies.

Speaker 2 (31:22):

Yeah. I am very fortunate to work with a very talented group of musculoskeletal ultrasound radiologists who we’ve actually worked pretty closely together to make sure that we’re looking for everything that we want in a nice complete groin evaluation. And I think one of the things to point out to people who might, if they’re considering, well, how is this ultrasound going to be different than what I’ve got in the past is if you come in and get this ultrasound, it’s usually between 45 minutes and an hour long evaluation of the musculoskeletal system, how the muscles insert onto the pubic bone, looking for nerves, looking for hernia recurrences as opposed to the routine ultrasound, which is usually a five minute, do you have a hernia or not. So it is different. People will often say, well, I’ve already had an ultrasound, do I really need to get another one? But this is, you’re right, this is a different ultrasound. It’s very thorough and I’m very fortunate to work with some great radiologists.

Speaker 1 (32:29):

And does the tech do it or the radiologist does it,

Speaker 2 (32:32):

So the techs or they do it and then they sit down routinely the way they would normally do. They’d sit down with the radiologist. And because I’ve actually had I had a class or I sat down with all of the radiologists as well as the texts who do these, and I’ve explained to them what I’m looking for and I’ve shown them pictures of what we see in surgery correlating to some of the findings that they’ve demonstrated on their imaging. And I think an important part of that is, number one, it engages the technologist more, but it also makes them feel like they’re really a part of an individual patient’s care.

Speaker 1 (33:21):

Yeah. And I think what if the more they know about what we do it really helps them be able to help us in evaluating our patients. I agree. I have one radiologist who is older who really enjoys ultrasound ultrasound and he does it himself. And so if I can get all my patients to see him, that would be the best. He’s really, really great. And I hope he never retired, or at least not until I retired because he’s awesome. So let’s talk about Mesh allergies. Last week we had Dr. Tervaert. He’s a rheumatologist and specialist who’s written a lot about allergies and autoimmune problems related to implants, anything from a hip implant to breast to Mesh. He’s got some really interesting thoughts. He worked with the surgeons over the Netherlands and looked at hernia mesh. He’s looked at other Mesh as well, learned a lot from him. What’s your thought on well, do you see patients that are somehow reacting to the Mesh? I’m not talking about local pain or meshoma or nerve entrapment. I’m talking of systemic head to toe changes with brain fog and chronic fatigue and joint pain. Do you see that and do you have any special workup for them? What are your thoughts on this subset of patients?

Speaker 2 (34:58):

Yeah, so this is first off, I think that that’s all extremely interesting and I think I would like to first say I am not a rheumatologist or allergist or immunologist. And so I personally am very interested in that. But I think that it is an area that we have a lot of work to do as hernia community and hernia surgeons. And I’ve read some of that material and I have seen patients who have systemic complaints, rashes, generalized fatigue biologists and myositises type complaints. And I would say that I still sit in the boat of, I don’t know what it all means, but I really want to help try to figure it out. And so what we’ve started to do more frequently is when patients have a constellation of symptoms like that, we get a testing panel to really try and look at their immunology and see if there’s markers that the rheumatologist would normally look for in things like rheumatoid arthritis and some of those autoimmune diseases. Because there’s a concept of that autoimmune induced response from Mesh. Correct. So the shorthand for it is called Asia and we just call it our ASIA panel, which has about 10 studies of blood work studies that try and identify this or try and get these labs before their operation and then we remove the Mesh, then repeat them after the operation and see if we’re getting any change.

Speaker 1 (36:51):

And how far after surgery do you do the second study?

Speaker 2 (36:57):

The goal is to do it around three months once they’ve healed up more from the actual operation.

Speaker 1 (37:04):

Yeah. And do you know what, what’s in this panel, this Asia panel?

Speaker 2 (37:12):

I’d have to get my immunology hat on to give all the proper names. But there’s immunoglobulin that look for immunoglobin G, A, M it’s a whole panel anticardiolipin antibody. Yeah, there’s a whole host of antibody response immunology that we’re essentially looking for. And the idea is trying to look and see is your body reacting to the Mesh as an autoimmune type disease?

Speaker 1 (37:46):

Right. Yeah. It’s all I do similar tests and the typical autoimmune markers are, in my experience, have all been normal. I have not been doing any immunoglobulin studies, but my allergist does and sometimes they’re very immunoglobulin immunoglobulinnemic. And there are some in interleukin studies that Dr. Traver does. So all very interesting, all kind of up and coming work. Yeah, that’s pretty complicated. I hope that we figure it out.

Speaker 2 (38:30):

Yeah, I think it’s interesting but really complicated and I am not sure direction it’s going to go.

Speaker 1 (38:39):

Okay. So obviously you treat patients that may have a Mesh reaction.

Speaker 2 (38:46):


Speaker 1 (38:47):

Yeah. Okay. More questions. Let’s talk about some sports hernia or recta strain, adductor strain injuries, core muscle injuries. What’s the process when they come to you for that?

Speaker 2 (39:05):

So if you’re coming more for a sports hernia or core injury we tend not to need necessarily the complete chronic groin pain experience per se. Mm-hmm. Still get the ultrasound and that for me for chronic growing pain evaluation for a sports related hernia or sport of core injury I do lean on the ultrasound again, but I don’t feel it’s necessarily as important for them to see our pain psychologist. You certainly may end up still seeing an orthopedist or a back specialist because still the concept of corn muscle injury I think it’s a lot of people hear it and so any sort of growing pains sort of get referred as sports hernias, but may still again be one of those other primary diagnoses.

Speaker 1 (40:05):

Got it. And then when you do these ultrasounds, do you notice it’s any different in women than men? Are they are women more difficult to assess or view their anatomy for hernia on ultrasound?

Speaker 2 (40:22):

That is a good question. I’m not. I’d to ask our radiologist and the technologist if there’s any difference. They haven’t mentioned it to me, so I don’t know the answer to that. I don’t think so, but I’d have to ask them to fully know.

Speaker 1 (40:37):

Okay, good to know. There’s one patient that says that she does decompression for her lower back pain with electro stimulation afterwards. They like manipulations and then when they apply the electrodes to her lower back and turn it on, she feels a sensation from her back to her groin and gets chronic pain. Is that something that you’ve heard about?

Speaker 2 (41:07):

That to me would be a unique sort of clinical situation. Yeah. I’m not hundred percent aware of what that would be related to.

Speaker 1 (41:17):

I know that SI joint pain or sacroiliitis can cause groin pain and inner thigh pain. So sometimes one of the reasons for groin pain is actually from the back, like you mentioned earlier, but not necessarily the spine. It’s actually from the sacroiliac joint. Maybe that’s part being stimulated and that’s why it’s causing the pain. I dunno. That’s a good thought. Thank you. Okay, next question. We got so many questions today. My Mesh has been removed, I’m worried about recurrence. What can I do to protect myself? What do you teach your patients?

Speaker 2 (41:53):

Yeah, so this is also another good question. So first off, when I remove Mesh, most commonly will not put new Mesh back in. And part of the reason for that is I’m trying, I’m doing the pain, the operation more for pain than for the hernia itself. And I always talk to patients about the risk of hernia occurrence after that because it is certainly higher than if I put new Mesh in there. And I would fully admit that patients aren’t going to be at higher risk if in that setting. Yeah. That’s the whole reason why we use Mesh in the first place. Correct. So there, there’s a real risk of getting a hernia occurrence if you have your Mesh removed.

Speaker 2 (42:37):

And I always tell people when after the operation, the most important thing is to take it easy for the first six to eight weeks. And I really try and have them avoid heavy lifting, nothing greater than 15 pounds because the concept is that you’re really putting two tissue planes together that need to heal. And if you strain that too quickly or overexert and cause the suture that’s holding it together to rip or tear apart, as soon as that separates, your body’s not going to decide to heal it itself. So you’re going to get another hernia, as in with any sort of mitigation technique for trying to avoid a hernia, trying to avoid strenuous activity is key. Managing things like cough, constipation difficulty urinating and difficulty with some things like BPH. Those things should be managed in an attempt to try and prevent yourself from getting hernia in the future. I also advise people though that hernias shouldn’t run their life and that they need to live the life that they want to live and do whatever it is they want once they’ve healed. And if they get a hernia back, then I’ll deal with it. And you leave that part up to me, I don’t want people to necessarily stop living because they’re afraid they’re going to get a hernia back.

Speaker 1 (44:00):

Yeah, I agree. I agree. We have a patient with sweet disease, some people consider that autoimmune. Others it’s like a skin problem. It can be triggered by different illnesses or infection, maybe Mesh, we don’t know. Would you, cons in patient with sweet disease and I’ve had one patient, would you be okay putting Mesh in or do you have any hesitancy putting Mesh in any specific type of patient?

Speaker 2 (44:35):

I probably wouldn’t hesitate too much. I may alter my Mesh choice slightly by using maybe something that’s lighter weight so that there’s more or less material density. I don’t know if that would make a, I don’t know if that would make a difference or not but we do put mention patients who have autoimmune diseases. A common population that has a big issue with this would be patients with inflammatory bowel disease. And there’s a lot of research I think needs to go into this because these patients have a lot of abdominal operations and they get a lot of hernias and oftentimes they’re getting Mesh. And I think there is some concern by some people that whether or not that’s going to cause them worsening of their inflammatory bowel disease. I think one of the most important things is placing it, placing the Mesh outside of the abdominal cavity. So that’s not in direct contact per se with the bowel, but my current practice is that I do put Mesh in those individuals.

Speaker 1 (45:48):

We just need to learn more. Dr Tervaert considered IBS or irritable bowel syndrome as part of the ASIA syndrome. He just has really interesting data. I really enjoyed speaking with him last week. Okay. More questions. How often do you offer surgery for patients with core muscle injury or sports hernia? Is that something that almost always does need surgery? And do you offer that surgery a patient is asking?

Speaker 2 (46:23):

Yeah, so for cord muscle injury, I am in the boat that believes the first line therapy for a core muscle injury is rest, followed, rest followed by physical therapy and leading to core strengthening that hopefully stabilizes the core itself. And I think that surgery should be more of a last resort for somebody with a core injury if they’ve failed physical therapy and rest.

Speaker 1 (46:53):

Yeah, I agree. Yeah, the surgeries are not always successful and to be fair, unless you’re a super athlete, most people get better and do not need the extreme surgery for that next question. So this is a complicated patient. He sent me multiple pages of information, but basically he’s a gentleman. He had Mesh, Putin laparoscopically had a complication with that. It was taken out. He’s had a third surgery, he’s had multiple nuerectomies, he’s his original pain, never went away. He’s still in chronic pain and now has additional pain. He was told the next step is for an orchiectomy travel is difficult for him. So he’s a little bit of a loss. He doesn’t know what to do next. He thinks he has nerve entrapment, maybe isn’t clear why he’s got so much pain. So if a patient like this emails you and says, what do you recommend? What do you recommend as their next?

Speaker 2 (48:01):

Yeah, I get a lot of emails and letters like this. Yeah, unfortunately, unfortunately. And as you can tell by the letters, these are not straightforward situations. So I always recommend that’s the case. And I know you have limited resources, but if it’s something that’s really bothering you, if you’re able to come to our chronic growing pain center, get a through evaluation, do that. If it’s a regional issue where they’re not in, if they’re close to somebody else who I know who might manage chronic groin pain, I will refer to that person if it’s maybe easier for them to get there, won’t cost ’em as much money. But I still think that you know, need in these situations when it’s this complicated even more so you need to have a more thorough evaluation by somebody who has a lot of experience in this field.

Speaker 1 (49:02):

I absolutely agree. First of all, if anyone tells you to get an orchiectomy for testicular pain, get a second, third, and fourth opinion. It’s almost never a treatment for testicular pain. There are other treatments for it, but just taking out the testicle is not the answer usually. Yeah, I totally agree. So I understand for people they have children, family financial limitations, travel may be difficult because they’re in pain but it is so important to get good care. And when you get down to a situation where you’ve kind of lost, you exhausted the limitations in your own neighborhood or state, whatever the situation is, I can’t tell you how important it is to invest the time and energy and financial whatever to seek care that is highly specialized by doctors that do this all the time. So it’s very possible this patient never even needed hernia repair.

Speaker 1 (50:10):

Can you imagine all the money they spent getting the hernia surgery, then the Mesh remove and the nuerectomy and all the time lost from work. Just think of the money that was lost there. I just hope that people understand, it’s like chronic pain destroys your life, destroys your work, destroys your family. It is so important to invest in the time and expenses to get rid of that chronic pain. And that’s best done by people who do that for a living. And your chronic pain, chronic growing clinic as one of those out of curiosity how is your insurance acceptance? Do you accept all insurances? Are you out of network? In network? What’s the status for that?

Speaker 2 (51:05):

I would say it’s all of the above. Okay. We’re not in network necessarily for everybody, but there’s circumstances where people can get approval to go out of network to be seen. But it usually requires a letter from a surgeon that’s within your network who says this is something specialized where they actually need to go on a network. We don’t have somebody in our network who can deal with this. So there are ways around that to get coverage, but we do accept a lot of insurances. But we do have to work sometimes with insurance companies to try and get patients through the process. And there are sometimes where there’s insurance companies who too just won’t, won’t approve it unfortunately. And that’s sometimes our hands are tied in that situation.

Speaker 1 (52:02):

Yeah, I agree. I think what we do is so specialize. A lot of the protocols that insurance companies follow don’t really pertain to a lot of our patients. On that note this is our last question. How come there aren’t more clinics like yours?

Speaker 2 (52:25):

Well I, I think the most honest answer to that is managing chronic groin pain is not easy. I think most people would not necessarily view it as glamorous.

Speaker 1 (52:39):

Yeah. There’s no glamorous,

Speaker 2 (52:41):


Speaker 1 (52:41):

Not a sexy, it’s definitely not a sexy topic.

Speaker 2 (52:45):

Yeah. So I could just say personally that I work at a center where we have a lot of specialized hernia surgeons and so we have the opportunity to look at a broad spectrum of hernia disease and we also have the opportunity to specialize within some of that disease process. And I was, yeah, I’ve been impacted by some of the positive experiences that patients have had when they’ve gotten treated for chronic groin pain. And even though sometimes it doesn’t help people, when it does help people I think it’s one of the most satisfying things to, because as you mentioned earlier, I mean chronic groin pain, it’s debilitating and it can really, really impact your life. And so if you can fix that for somebody, you can really turn around and give them sort of new life. And I’ve seen that and I’ve had more patients shed tears of joy in my office than I have had necessarily tears of pain. So I just find it rewarding. And I think that that’s probably why. I think also being at a larger institution like the Cleveland Clinic, we have the ability to have specialized ultrasound. We have the ability to have a pain psychologist maybe more easily than some other hospitals that just don’t have that broad of a workforce.

Speaker 1 (54:18):

Yeah. We had Bruce Ramshaw as one of our guests on Hernia Talk live several months ago, and the importance of the pain psychologist in improving outcomes after surgery for chronic pain or even before the surgery really has been key. And he’s done such a good job with that kind of research. I think the financial question is also important. Your facility is very astute and very specialized, but at the end of the day, they would not agree to a chronic growing clinic if it was a money losing endeavor. And so since I’ve been in private practice, I’ve become more in tune with that and growing pain or growing disease in general hernia stuff is not considered a highly valuable disorder and it’s kind of undervalued by the insurance companies by valuable. I’m purely talking about how insurance looks at it. So maybe with your system where you’re able to bring in all the specialists at one time that may work. I, I’m really, really very glad that you do this because we need more groin pain specialists and then more clinics that are multidisciplinary that can treat the patient’s whole because it is so complicated. It’s such a complicated part of the body.

Speaker 2 (55:54):

Yeah. It’s very, very complicated.

Speaker 1 (55:57):

So I hope that the clinic, the Cleveland Clinic views your clinic as one of the, well, I would say it’s currently the leader in promoting this kind of system, but also I hope that you have a really good success rate and positive for sure. You’ve had so many of your patients that already came on, you’ve made such a great change, but in a very short period of time, David, I’m really proud of what you’ve done in such a short time, just like what three or four years you’ve been able to make this a solid functional clinic. That’s just a lot of work and kudos to you for doing that or for wanting to do it and then to go ahead and do it.

Speaker 2 (56:45):

Yeah. Thank you. I still find it rewarding and so anybody who needs it, I’m open. I’m willing to see you.

Speaker 1 (56:55):

So how do they contact you for consultation?

Speaker 2 (57:01):

Yeah, so all the information is on the Cleveland Clinic website. It’s Clevelandclinic.org/chronicgroinpain. Mm-hmm. Get you to the center’s page or if people are looking to schedule an appointment, they can just call the number for scheduling there, which is 2 16 4 4 5 9 9 8 9.

Speaker 1 (57:29):

Thank you so much. And for those of you that have been with us the whole hour, almost hour, Dr. Krpata just finished surgery before we started Hernia Talk Live. He is not on video because he’s walking around the hospital and trying to finish up a very, very long or day. So thank you, Dave. I really appreciate the time. I’m glad it worked out that you can join us and answer all of our questions. And on that note, I’m going to say goodbye to you and two of our guests and everyone that was involved. I do appreciate you all coming every week to hernia talk. As you know, I live, eat, and breathe hernias and everyone that I bring is a fantastic doctor and really caring and great at what they do. Like Dr. Krpata, you can follow me on Twitter and Instagram at hernia doc. This video will be posted on my YouTube channel. You can also watch it on my Facebook homepage at Dr. Towfigh. And on that note, goodbye everyone. Have a good night. Thank you, David. I hope.