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Speaker 1 (00:00):
Welcome to Hernia Talk Tuesdays. We are live. My name is Dr. Shirin Towfigh. As most of you know, I’m a hernia and laparoscopic surgery specialist and I love what I do. And today’s guest panelist who’ll be sharing the hour with me is Dr. Aali Sheen. He practices in Manchester, United Kingdom. I should be calling you Professor Alai Sheen. That’s the European way. You could follow him on Twitter, Alai Sheen. And without further ado, welcome Dr. Sheen. Or Professor Sheen, I should say.
Speaker 2 (00:36):
Yes, that’s very kind of you. Yes. Unfortunately I do have a chair and I’m called Professor where Alai’s absolutely fine. And thank you for the invitation.
Speaker 1 (00:44):
But I’m told actually in the UK it’s not appropriate to say, doctor, you should say professor because
Speaker 2 (00:51):
Is that true? Well, actually, actually, if it is doctor for everyone, but then once you become a fellow, the Royal College of Surgeons, you become mister we go back to our
Speaker 1 (01:01):
Mr.
Speaker 2 (01:03):
Yeah, we go back to being barbers because we were the company of barber surgeons. Yes. And we became the company of Barbers and Company of Surgeons. And then we got a royal charter and then we, that was it really. So
Speaker 1 (01:16):
I should have called you Mr. Sheen. That’s so weird.
Speaker 2 (01:19):
No, no, I know. Professor’s fine. Yeah, fine.
Speaker 1 (01:22):
Okay. So as you all already heard from my quick introduction Mr. Professor, Dr. Sheen works in the United Kingdom. He’s a friend of mine. We’ve met through the hernia society world. He’s been a lovely partner for patients who reach out to me and need help in the United Kingdom because he’s among very few surgeons that not only specializes in hernias, but also sees some of the more complicated hernias deals with groin pain. And very specifically, you have formed a very well-known niche in the sportsman’s hernias. And that is kind of a misnomer. They’re usually not hernias, but they are typically in sportsmen or sportswomen or sports related, athletic related, some people call it athletic pubalgia. It can be some type of disruption of the pelvic floor or the abdominal wall. So I really want to spend as much time as possible on that part of your practice. But before we do that I want you to do two things. One is you shared me before we started, you shared with me the two books that your two favorite books right now, you want to tell the audience what you have right now,
Speaker 2 (02:48):
<laugh>. Okay. Right. I’ll get one of them by Bill Bryson, who’s an American who lives in the UK. He’s called The Body. It’s called A Guide to Occupants. It’s a very good read. If you’re a clinician, I think you’ll enjoy it. And the other book, which is a fantastic read, it’s by Shirin, it’s on chronic pain. Yes. Stages manual guide, which is absolutely brilliant. Read. And for if there are any physicians or physios or healthcare professionals that are logging in, I thoroughly recommend you read this book especially if you are thinking about managing patients with chronic pain. It is a brilliant guide.
Speaker 1 (03:28):
Thank you very much for that. Okay. So can you describe a little bit of your practice in the us? We usually are either employed or we have our own private practice or some kind of hybrid of that sort. But in the United Kingdom you have the national healthcare system, the NHS and you are an employee of the NHS. So people can get care from you there. And you also have your own private practice. And what’s the name of the clinic that you work out of?
Speaker 2 (03:59):
Manchester General Surgery.
Speaker 1 (04:02):
And that’s where you do a lot of your athletes, I understand their Manchester may have a soccer team. I’ve heard of them maybe before. <laugh>, yes. You want to describe a little bit of what you do in that realm?
Speaker 2 (04:19):
Sure. Well, in the UK we have the National Health Service, which is free healthcare for absolutely everybody. You don’t pay a penny. And every single doctor is trained by the National Health Service and they practice in the National Health Service. Now, when you fully train or become a consultant, then you have the right to do private practice because you are a fully trained individual. You can work independently and until that time you remain in the National Health Service. Now, whether you wish to do private practice is up to you. Some consultants don’t wish to do any, so you don’t have to. The further south you’re going out in our country, i e London and the Southeast, which is slightly more affluent than the more private work there is available. So you have to just divide your time and work that way, and that’s what we do.
Speaker 1 (05:16):
And what’s your connection with the soccer world?
Speaker 2 (05:20):
I see a lot of patients and it usually comes through reputation. Someone with who’s been around a long time seeing a few footballers. So I look after anything between 20 and 50 clubs including rugby league, rugby union football, soccer. I see jujitsu, British TaeKwonDo, British Olympics come to me. And a lot of high profile athletes end up in my clinic. There’s a few of us that do this sort of surgery and we all try and work out whether they’ve got a groin which needs repairing or not. And I hopefully don’t need to repair most of their groins, which I can talk about if that question arises.
Speaker 1 (06:07):
Yeah, we’ll get to that shortly. And then lastly, just to get a grip of things as the healthcare system has been hit with this COVID pandemic worldwide in the United States, we were on lock down for providing any elective healthcare. So I was not operating for about just under two months. And then slowly our hospital opened back up. The purpose was to focus the resources on the very sick patients and also not to expose healthy patients to this subset of sick patients that are infected with the novel coronavirus in the us Most hospitals have opened back up to elective care. There are some that are limiting it and prioritizing it, but for the most part, if you need a hernia repair you should be able to find a hospital or clinic or surgery center that can provide you that elective repair. But I understand right now that’s not the case in the Great Britain or United Kingdom. Is that right?
Speaker 2 (07:13):
Yes, I think unfortunately there are problems. I mean, we were shut down from March, April, may through to June for all benign non-emergency. Sorry for all. Yeah, all benign and elective surgery. There was a complete shutdown. So cancer surgery continued, emergency surgery continued. Now we are slightly opening up, so the orthopedic surgeons are undertaking hip knee surgery and so on. But overall, the hernia surgery is slowly coming back. We are calling patients making sure that they’re still fit and able, but the specification specifically for surgery is you have to isolate for two weeks and you have a COVID test 48 hours before the operation. And that’s for every single patient right now.
Speaker 1 (08:08):
Got it. Got it. Yeah, and that’s unfortunate. And you told me you have a very, very long waiting list for your elective patients on the NHS side.
Speaker 2 (08:17):
I do. I have over a hundred patients.
Speaker 1 (08:19):
Wait, and that’s just you alone have over a hundred patients.
Speaker 2 (08:22):
It’s just me for hernia. Yeah, I know. Wow. I know.
Speaker 1 (08:27):
And that includes chronic pain. What if they’re in chronic pain?
Speaker 2 (08:31):
Yes, it does. And I’m slowly trying to do some patients now, but very slowly. I mean, I think we have to just persist with painkillers, injections if we can and those sorts of things.
Speaker 1 (08:46):
I know you’ve been sharing a patient that needed injections at the very least, and you’ve been helping me get that patient to get their injections because you couldn’t offer surgery in the system to them. And even getting the injections was difficult because that also was not offered as an outpatient in a lot of places because of the restrictions. So we’re hoping that all of our countries become safer so we can provide more elective care. Absolutely. Okay. I would love to talk about the sports rooms, but we already have a lot of questions live. So just briefly, you have one patient which asking if you can help her, she has incisional hernias. You do operate on incisional hernias, correct?
Speaker 2 (09:25):
I do, yes.
Speaker 1 (09:26):
Okay, perfect. Another one. Well, okay, so these are really big hernias. This lady, she had a bulk intestinal cancer, probably colon cancer back in 2014 and had an incisional hernia. She had a colostomy at one point. And then it seems that she was told to wear a binder for a while. She did have a hernia repair and then looks like she recurred. Are these operations that you would do like a recurrent hernia repair? And then what do you offer open laparoscopic. You have the versius robot now.
Speaker 2 (10:05):
Yeah, I mean I think you see now the most important thing about the hernia repair is obviously I think it’s good. She’s got through her cancer surgery and the colostomy I believe has been reversed. The abdominal wall has already been operated on a couple of times. The new tissue is always weaker. Now I would look at the patient, I want to undertake a scan to see how big the hernia is. I’d want to know exactly what operation was undertaken, where the Mesh was placed. Was it placed like an Onlay or was it placed between the rectus, which I think probably it was, or was it an inlay Mesh? So basically like a laparoscopic IPO repair where Mesh goes inside the abdomen. Yeah, I’d want to know. And then I’d decide on what I would do. Now if the hernia is under six centimeters for me and it was a previous open repair, I would try a laparoscopic repair.
Speaker 2 (11:01):
If the hernia is larger and it was a previous laparoscopic repair, I would try an open repair. Generally I’d go to whether it is open or lap, I’ll go to the other one for a recurrent hernia. But you probably will need more Mesh. And I know Mesh is a bit of a word which can cause patients to frown, but I’ll definitely put in another Mesh. And the type of Mesh will depend upon the size of the hernia, the location, and obviously the tissue integrity. Now as for yourself if your BMI, your body mass index is greater than 35, I would definitely over 40. I would encourage you to lose weight. I don’t,
Speaker 1 (11:49):
Any obesity should be treated. Absolutely,
Speaker 2 (11:52):
Absolutely. And also if you’re a smoker, you would need to stop smoking.
Speaker 1 (11:56):
Yeah. Because the nicotine and the smoking itself can prevent healing. And it’s been shown to increase your recurrence rate, I think by seven. Seven x. Yeah, that’s a huge number. Or you’re just not healing and so you’re not getting oxygen to your tissues. And there are other ways that the tissue changes and you have hernia recurrence. So smoking is a big deal in California. Most people don’t smoke. So it’s not as big of an option problem in my state unless I get people from out of state. But Europe, people like smoking all the time.
Speaker 2 (12:32):
Yeah, I mean we’ve got quite a high tax, I think what’s helped in the UK actually in Europe I suppose we’re technically still part of Europe. I think what’s helped is the smoking ban in public places that’s helped.
Speaker 1 (12:49):
Okay. Yeah,
Speaker 2 (12:50):
Restaurants, pubs we can’t really smoke in any of those places now. So yeah it’s helped a lot.
Speaker 1 (12:58):
And if this patient’s worried about strangulation, what do you say to people with really large hernias that have occurred about strangulation? Should they be more worried about? I would say I’d be more worried about the outcome of the operation and to optimize that. Whereas strangulation for big hernias is not as big of a problem as some of the smaller hernias or the more symptomatic hernias.
Speaker 2 (13:21):
Yeah, big hernias. I wouldn’t worry about strangulation. And what you do worry about sometimes if you see your overlying skin becomes red and angry, it means is bowel just directly below it and it’s very unhappy. Yeah. That’s the thing we worry about. But actually strangulation. Strangulation, it’s more common in the smaller hernias or the smaller defect if you just pop through a loop of bowel if you cough and then it won’t pop back.
Speaker 1 (13:48):
Correct. All right. Let’s move to what is your specialty which is the sportsman’s hernia. So what is your definition of a sportsman’s hernia?
Speaker 2 (14:00):
This is a good question. Now I’m going to say a sports hernia is a misnomer, really. And there was two key publications, one in 2014, which came out from Manchester and one in 2015, which came out from Doha. And what they’re basically describing is, first of all, the Manchester one said it is really a disruption of the inguinal canal. I e, the inguinal canal isn’t as strong as it should be. And that’s what it is. Why was it called a sports turners? Because repetitive strain injury was mainly athletes that were undertaken this activities, mainly athletes that were presenting to surgeons with pain in the groin. And that was the main problem. So it’s called a sports hernia but isn’t actually a true hernia. You could call it an incipient hernia or almost an hernia. Now if I’m allowed to share screen you. Yeah, please share then if you need to stop and then I’ll share.
Speaker 1 (15:07):
Oh, sorry.
Speaker 2 (15:08):
Yeah, that’s fine. Go ahead. I share and I’ll show you the picture. I hope you can all see that. That’s from the Doha statement. That was 2015. So 2014 they said it was inguinal or disruption, but Doha went a little bit further where they said a groin pain is really divided into four categories. It can be related to the abductor attendants. So abductor related chronic pain. It can be.
Speaker 1 (15:34):
And that’s the muscle that That’s the muscle that moves your leg inwards.
Speaker 2 (15:39):
That’s right. Yeah. Brings both your legs in. So sometimes you can actually test that on yourself if you put your fist between your knees and squeeze tight. If that hurts, means my abductor’s not happy.
Speaker 1 (15:49):
Okay.
Speaker 2 (15:50):
Okay. So then you’ve got the psoas muscle at the back and that’s the one that brings your leg up like
Speaker 1 (15:56):
Inflection.
Speaker 2 (15:57):
Absolutely. Absolutely. So brings your hip up, brings it up, and in order to know if you’ve got tenderness there, if you lie flat on a table and with your hips almost at the end of a bed or a table. And then if you try and lift your leg, your thigh upwards with resistance, that’s a psoas problem or psoas tendonopathy we call. Yeah, honestly, I’ve just described inguinal related pain and then this pubic, so you get pain around the pubic burn. So when patients come to me, athletes, absolutely. What I do is I rule out a the green, make sure there’s no ilia psoas pain. I rule out the blue, make sure there’s no pain from the abductor. Yeah, make sure there’s no pain from the six pack muscle, which we all proudly display every day. And also there’s no pain from the pubic bone. And then if there’s no pain from anywhere around these, and I feel that after an ultrasound examination there is a bulge or a weakness in the inguinal canal and I’ll offer them a repair.
Speaker 2 (17:00):
And basically that’s what I do. So the question then arises is that how do I repair it? And what I always say to surgeons is that repair it the same way you would repair any groin. So if you wish to do keyhole, then you can repair it by a keyhole technique. If you repair it, either technique or an open technique, you can repair it. Now some surgeons choose to use Mesh, others use a suture just on the back core. But what you’ve got to do, you’ve got to do slightly, I say a more widespread repair. Now if I do via keyhole technique, I make sure the pubic bone, I go way way below that without injuring the bladder. And I make sure I go as far across laterally to the side without obviously going into the abdomen and make sure the Mesh is higher. So the Mesh I use is bigger for these and they do very well.
Speaker 2 (18:02):
But what’s interesting is that in the canal you may find just the fatty lump, a lipoma and something as simple as that can be causing the pain in the groin. Why? Because you are overusing your groin so much. The lump is irritating your groin. It’s going in and out, in and out. And it can be something as simple as that. But 24 to 30% of my patients will have an abductor injury. That’s the muscle that brings your legs in. Yes. And about 5% will have a pubic bone injury or what we call inflammation around the pubic bone. Now by and large, most of that doesn’t need any treatment. So after I do any sort of repair I encourage a rehabilitation program. And what this involves is complete rest for four days and then I get the patients up and then I get them to get on a crosstraining, a crosstraining, just moving your arms back and forth and you’re using your legs up and down.
Speaker 2 (19:02):
And that really just allows you to start moving your core. Everyone talks about the core and you need to really improve your core. A few days later I’ll get them to start doing plank positions, arm raises on plank, improving their cord. And then after the first week I start the abductor rehabilitation. Now you can just have a towel on the floor and you can put one hand and then you can put both feet on the towel and just move your foot in, make sure the floor’s a bit slippery. Don’t try on carpeting Cause it won’t work. Yeah, yeah, yeah. Move your leg in, move your leg in and then do the other side and really get your adductors working. So core strengthening abductor strengthening I is very, very important. And that will go on for about two weeks. And then after two weeks you should really start upping it.
Speaker 2 (19:50):
So you start some physical exercises, you can start some light jogging. A lot of sports hernias or in green or disruption patients are keen runners, the keen soccer players, they can rugby. I very, very rarely see cyclists and swimmers and knowing this fact. The other rehab I do is I tell patients some people can’t swim, which is absolutely fine. You can go to the shallow end, go up to waist height, <affirmative>, just walk up and down the pool, walk up and down in width. And that really gets your groin going and really gets your core moving as well. And the other thing is cycling. Now if you can’t ride a bike, you can sit on a bike that doesn’t move an exercise bike. So you can cycling. Thanks. Carry bike. Yes. Now, I dunno about Shirin in your experience dealing with these kind kind of patients, but I very rarely see cyclists because cycling is fantastic rehab for the groin.
Speaker 2 (20:49):
It is absolutely brilliant. I saw one cyclist years ago and I think he just wanted to get out of an event. So I said, fine, you’ve got groin pain. So he could then tell he is sports doc, look, I’m not cycling today. And I’ve seen one boxer. And again, I think he just didn’t want to fight with the person that he was supposed to fight with. But boxing is all upper body, all strength. And they’ve got really big heavily built muscles and six packs and cause if anything they’re, they’re more likely to get lyse in epigastric pain. But boxers I don’t see, cyclists I don’t see, and swimmers I don’t see. So getting your fitness back, all of their sports are good sports to actually undertake to get your fitness back if you’ve got a sport right?
Speaker 1 (21:37):
Yeah. It’s usually soccer players, NHL like sorry, hockey players. Sometimes baseball, sometimes tennis, but yeah maybe some basketball. But it has to do with the thigh and going in the wrong direction. And also the mismatch of the muscles. Some muscles being too strong without balancing the counter muscle, which is why physical therapy is so important with is they’re the ones that are doing that. Yeah.
Speaker 2 (22:07):
Twisting. Twisting and turning motions.
Speaker 1 (22:11):
So I understand the whole thought of, okay, if you see a little piece of fat, I just call those hernias. I don’t call those sportsman’s hernias. If it’s groin related with a herniation of something, I just call that a hernia. But when you have a tear of the abductor muscle, a tear in the external oblique epi, neurosis, a tear in the adductor where do you fall? Do you offer, do you release it? Do you sew it back on? Do you ad Mesh? You don’t ad Mesh. What are your thoughts? And then by the way, just for everyone, when we say Mesh, there’s a million different types of Mesh. There’s synthetic Mesh, biologic Mesh, hybrid Mesh, there’s a wide variety. So we’re going to talk a little bit more about Mesh later cause I’m getting a lot of comments on the Facebook side. But just so you know that just because we’re saying Mesh, it doesn’t mean we’re causing some destruction of the body necessarily. Yeah. So we’ll discuss that later because that’s a very important topic for me as well. But just
Speaker 2 (23:20):
Doctor injuries. Yeah.
Speaker 1 (23:22):
So do you use Mesh if you have a rectus or a doctor injury? Yeah, not. And then do you release reattach? What is the thought process of that?
Speaker 2 (23:32):
Sure. So adductor injuries generally present with heavy bruising down the thigh you get a huge amount of bruising. It’s very painful. They usually feel a snap. They may be kicked a ball and ex’s excruciatingly painful. Sometimes they can’t even walk. Now the first things first you need a magnetic scanner, the magnetic scan, an MRI which you are an expert on Shirin and will show whether you’ve got an abductor injury or not. Now if it’s say three to five centimeters, you could ride it out. But if it’s like a five centimeters complete disruption, you could think about replanting it and that will just be a simple non-absorbable suture and you can re-implant it back on.
Speaker 2 (24:20):
Or you can just leave it to heal by secondary intention. Because if you think about it, that player or that person’s actually undertaken their own tenotomy actually yes, divided them to themselves. So maybe the abductor is too tight so they’ve undertaken their own tenotomy. And if it just heals with fibrous tissue in two, three months time, you’ll find they’re actually few better. Now how many abductor tenotomies have I done? If I see a hundred patients with groin pain, I may undertake one. I think, right? It’s an operation that is undertaken a little bit too much. I think I’ve seen a number of patients over the years that have undergone abductor tenotomy and they’re actually not better. So why aren’t they better? It’s because they probably didn’t need the abducted. Now when you feel the abductor, when we feel the abductor tendon, it feels really tight and it feels like you can pluck it.
Speaker 2 (25:11):
And if the other side’s nice and smooth, then you can work on that abductor. You can work on it with physio, massage therapy and also shockwave. I’m a big believer in shockwave. And then you can also do dry needling. Now dry needling is where you just put needles in it and you make it bleed. You make it bleed, it’ll get bruised, it’ll be very sore. But what has blood got in it? Blood has got all those healthy factors, healing cells and white cells, if I’m, it’s got fantastic healing. The next approach after massage shock qua dry needling will be P R P injections. And that’s taken your own blood, spin it in a centrifuge, you take the plasma, you mix it with some other constituents and then you inject it back into the abductor and three injections maybe over a year. See if that helps. And generally you’ll find it does help some patients. If they’re really stubborn and it’s tight, it’s not getting better, then I may consider a tenotomy. Got it. But I would compare it to the other side. If the other side is the same, I’d say, look, why don’t we just see how it goes? I don’t think your doctor’s ever going to get better. Yeah, they eventually do get better. If you can tie your shoe lyse without pain, I will discharge. That’s a very good sign for abductors.
Speaker 1 (26:33):
And when you get an MRI, does it always show the problem and what you see on MRI, does that correlate with the severity of the injury?
Speaker 2 (26:43):
Yeah. Now when you see some MRI reports, you can decide where the MSK radiologist is strained. Yeah, because in across the pond in your neck of the woods, you use the term athletic pubalgia quite a lot. Yeah. Okay. And that is a conglomeration sort of of all the findings. So if you have an abductor tenotomy or abductor tendinopathy, if you’ve got a rectus abductor aponeurotic plate tear, if you’ve got a tear in the [inaudible] muscle or if you’ve got a bruising of the osteitis pubis, then a radiologist may say, there are signs of athletic pubalgia and I’d accept that. That’s absolutely fine. But each one of those needs a different treatment. Yes. You see tendinopathy needs rehabilitation, it needs physio, it needs rehab, it needs shock wave possible dry needling lyse, P R P, rectus abductor tear is purely conservative management. You leave it alone.
Speaker 2 (27:46):
You do not do anything. It will get better. Yeah, you can try a local anesthetic injection just local into the area. You may get some pain and tingling with the injection, but if your pain resolves after that injection and it will resolve for about a day or two, then that’s the diagnostic. These are diagnostic injections. If that doesn’t resolve it, I’ll put some local into the abductor tendon and say, go away for a day, come back. And they come back and they say, right, I still have pain. I said, fine. Then I will inject into the inguinal canal with local anesthetic. I’ll get my radiologist to do all my injections and ultrasound guidance. And then if the pain goes, it’s fine, I’ll repair your inguinal or canal and I can do that whichever way I wish. And that’s a diagnostic way of determining the cause. But it’s an umbrella like term, an MRI scan can say, yes, this is a sportsman’s hernia because it has one of those four findings, which I’ve
Speaker 1 (28:49):
Got it. Got it. Got it. It you have coined the term Manchester groin repair. Can you explain what that means or what’s different or why is it so special?
Speaker 2 (29:01):
It’s very special because I created, it said it’s slightly different from a T eTEP repair. And my colleagues would say that’s a very academic fudge. And I said probably, I wouldn’t disagree with you entirely, but we’re very polite experts. We never really point fingers at each other.
Speaker 1 (29:20):
So it’s a laparoscopic repair.
Speaker 2 (29:22):
That’s right. What this repair involves is the T eTEP, the taps are go extra peritoneal. And it’s basically what I’ve described is my dissection because I have a recurrence rate of less than 1% and a chronic pain rate of North 0.3. So I use a bigger Mesh most operations with the t p. And we did a review of all the repairs and everyone described a 15 by 10 Mesh. I use a 15 by 12 or sometimes a 15 by 13. So I use a bigger Mesh in a slightly small built person, I’ll use a 15 by 10 because that is a big Mesh for them. I use tissue glue fixation and I insist on fixating at least three centimeters below the obtuator fascia. And that’s quite, that’s different to what everyone else has described. And I always fixate laterally and inferiorly superiorly. I don’t think you need to fixate but if do you’ve got a little bit of glue left over, then that’s fine.
Speaker 2 (30:23):
Now, choice of glue is entirely up to you. There’s two brands that people use as the tisseel, which is a product by one company. The reason I use that glue is because it is absorbed in seven days, it completely disappears. And so there is no focus of infection. The other one is Cyanoacrylate glue. I think it’s a little bit more toxic. I think it sticks very well. But I don’t use it because I think it’s a focus of infection and it will remain. So I choose not to use that glue. But that’s all the Manchester groin repair is I, I’ve done, I mean, I don’t know, ballpark 2000 hernia repairs in 15 years. Probably a few more. I dunno. Plus minus two.
Speaker 1 (31:10):
Yes, exactly. Well, I think the key is surgical technique makes a big difference. I do hernia repairs, I do them with Mesh without Mesh and I see people that have chronic pain and complications, recurrences different types of pain injuries with Mesh and without Mesh. The problem I think that we see with so many Mesh related complications is, at least in the United States, almost all hernia repairs are done with Mesh. Now, there are people that react to Mesh, and that’s a totally different situation. Those are people that can just can’t have Mesh. But everyone else who has a Mesh related complication, I would venture to say at least half of them, if not more. It’s not the Mesh, it’s the surgical technique. So too small of a Mesh, inappropriate use of a Mesh, inappropriate placement, poor dissection, too aggressive of a dissection. All of those, the decision making technique of the surgeon, their experience, all that matters.
Speaker 1 (32:19):
So when you’re saying that you’re doing a much wider dissection and very careful placement of the repair, and you’re using a glue and you have a less than 1% recurrence and 0.3% chronic pain rate, that’s vastly different than the average hernia repair. But also the average hernia repair is done by surgeons that aren’t necessarily specialists. So it’s like having your haircut by someone who’s a specialist versus like me, you don’t want your haircut by me, done it myself once it was disaster. So I mean, I can learn, but that’s not the point. So I just want to alleviate a little bit of that discussion, which is there’s so much negative backlash on Mesh, rightfully so, because many people have been hurt by it. We don’t hear as much from the patients that have been helped by it, which are a lot of our patients. But I would like to talk about that because the UK is actually a country, I would say UK, Australia, United States, the three most vocal group of patient advocates trying to fight against patients being harmed by Mesh live in these three countries. And so do you even offer Mesh removal? Is that something that you see and have to do among your patients or what is that?
Speaker 2 (33:54):
Yes. Yeah. I mean, my secretary from my private practice was saying, oh, well you’ve got four new patients next week in London. I said, oh, what do they want? And they said, they’re all Mesh removals. They all want have chronic pain. And I think your summary of Mesh and its problems was very good. And in the UK and in Europe, and I was speaking in Bucharest from the same place here, my house yes, earlier this week. And basically the commonest hernia repair undertaken in the UK and in Romanian, I don’t know, you could correct me for the United States, was the Lichtenstein repair. That was the commonest, an open Mesh.
Speaker 1 (34:43):
We’re talking inguinal hernia. Yes.
Speaker 2 (34:44):
Yeah, inguinal. That is the commonest repair undertaken. So over 60% in the UK are undertaken. And by and large, the majority of these patients do not have a problem with Mesh. Now, my question is, I have never seen an allergic reaction for Mesh placement, a systemic inflammatory response from Mesh placement in any patient. I have never seen it and I’ve never heard of it. So I don’t know what your experience is.
Speaker 1 (35:12):
Yeah, I do see it. And we’ve done a whole segment on it with a specialist who has been able to help in the science behind it. But there is something called ASIA syndrome, Shoenfeld syndrome, Mesh implant illness, Mesh reaction, where a subset of patients actually the same way that they can react to dental implants or breast implants or other implants, they will have a systemic reaction that if you have a systemic reaction to Mesh, either never get Mesh. And what I, by Mesh, I mean synthetic. Mm-hmm. Mesh or if you have any that must be removed. That’s the only treatment for it. Sure,
Speaker 2 (35:54):
Sure.
Speaker 1 (35:55):
But it’s uncommon. Fortunately, it’s a rare problem. It’s like being allergic to certain type of food. Not everyone is allergic to a certain type of food, but if you are like peanuts, then you shouldn’t be eating peanuts. And sometimes you don’t know until you eat that peanut. So unfortunately, we don’t have any tests that measure Mesh reaction. And we don’t have any foolproof product implant. It’s an implant illness. So any implant, theoretically you can have a reaction to even biologic Mesh, even cow, human cadaver. I’ve seen people that react to that. So we don’t have a science behind it yet to determine who is that. But it’s a rare of all the people that have Mesh problems, that is the smallest group. Fortunately.
Speaker 2 (36:42):
Well, I think the audience need to know that Mesh the <inaudible> in the UK really came about from A T V T repair, which is a vaginal prolapse repair.
Speaker 1 (36:55):
And
Speaker 2 (36:55):
Obviously the Mesh is eroded, a very sensitive park of female anatomy. And I think they did suffer with pain, but we had a number of patients that were very vocal. But there are thousands of patients that actually did very well from the repair and they didn’t have a problem. Now just like you’re having a heart valve replaced, you’re having a knee replacement or a shoulder replacement, they use metal or synthetic material. So Mesh is our scaffold. That is our synthetic material, that is our prosthesis. So this is what I say to patients, can it get infected? Yes. Can it cause pain? Yes. Can it cause nerve damage? Yes. Sometimes. Does it need to be removed? Yes. What are the incidences? Very rare. That’s what I say
Speaker 1 (37:38):
To you may have a registry. Cause in the United States we kind of do, but we don’t. Don’t really,
Speaker 2 (37:45):
Well, our registry will hopefully be up and running later this year because in November, the president of the British Owner Society, Liam Hogan, has done a fantastic job. And no, November the third I take over. So it’s actually one day before your election. So I take over, I become president of the British Owners Society and I’ll have a only a two year term and there’s no debates at the end of it. So my job will be to get it going, to get it up and running, and then I think that will be key. But from the evidence from the Danish hernia registry, yeah, I think there’s evidence to say that yes, Mesh can cause pain and Mesh explanation is required, but it’s rare. It’s rare there. There’s over a hundred thousand hernia surgery reported on that registry. So I don’t think the Mesh problem is there, but we need to alleviate it and we need to tell people, look it, it’s, it can cause you problems, but we never know if it is the exact cause.
Speaker 2 (38:49):
Now, am I chronic pain patients? Now you see a lot more chronic pain patients than I do, Shirin. Yeah, I do. And what’s what I say to them the last line in my letter is there’s no guarantee of success. The Mesh may not be the cause of your pain. And I do a lot of tests before I operate on them and plant the Mesh. I do injection therapy, I try a TENS machine are trying nerve painkillers and see if these help. And if they don’t, then the last resort is an operation which involves Mesh removal and nerve division. But again, some actually do get better, but some just say I’m a bit better. And if they’re 50% better, I usually say That’s fine. I’ll take that.
Speaker 1 (39:34):
Yeah, I think, yeah. So there’s a lady who is on this who may have to come see you. Sounds like she has a meshoma. So the Mesh is balled up and that’s preventing her to do things like sit and bend and cross her legs and so on. So hopefully she can reach out to you. But during the pandemic, both on the NHS side and the private side, are you available to take out Mesh if it’s needed? Is that lyse available?
Speaker 2 (40:04):
Yeah, yeah, yeah. I do it. I and I take out abdominal Mesh as well when it’s needed. But I do it carefully. I do it with good consent and the patient’s knowledge as to why I’m doing this is to get them better. Mesh isn’t always the source of the problem. I do write to a lot of my colleagues and ask literally, politely demand the op note. Yeah, absolutely. I need to know what’s happened, what’s been put in where it’s happened. And all my colleagues have done a really good job and they’re all very experienced. But I think that’s where this book course comes in. It’s very handy. I read that a few years ago and it shows you how to manage. I think nerve mapping is very important. Cause for us to communicate a Mesh chronic pain patient to you and I do, and I use Shirin to all the audience. If there’s a difficult patient I do email her securely the
Speaker 1 (41:09):
Details,
Speaker 2 (41:10):
Try and find out we have, what else can I do here?
Speaker 1 (41:15):
We have our group of hernia surgeons all across the world that we do share and take care of that. One issue that I’d like to mention is that so the patients who are hurt by Mesh obviously want us to do more. I think we’re trying, we can do more. The registry is a good way to do it. The Danish registry, Swedish registry, they’re the strongest. And their numbers don’t really reflect the needs of the patients. And when I say it’s rare I think there’s one paper by the Danish registry that showed abdominal patients that needed abdominal surgery, again after abdominal wall hernia repairs over a span of I think 20 or 30 years was just under 10%. And those are not necessarily hernia Mesh problems, but that’s just any surgery related to the hernia repair. That’s the largest number we have to work on. And for groins, from what we understand, again, our data is flawed because we don’t have the registry Mesh reactions are a fraction of a percent.
Speaker 1 (42:39):
And Mesh complications are in the 10 to 12%. So Mesh complications are not rare, but Mesh reactions as far as we know, are rare. So until we have a better system and until we have patients groups that can work with surgeons to look at these numbers and publish it, I can say something and you can say something and a patient who’s suffering can say something. And we may not all agree, but that’s just the experience that we have. And almost everything I do is based on chronic pain and Mesh related complications. And I’ll tell you, I read the opera report and I can tell you exactly what the complication is based on the opera report. I’ll read it and be like, oh, they use the wrong size Mesh. They did the wrong technique. They forgot to do X, Y, and Z. I can’t believe they use this suture. And my nurse comes in after seeing the patient and I know exactly what’s wrong before I even heard from her because I read the OP report and I could predict what was wrong. So surgical technique is very important.
Speaker 2 (43:45):
Can I just say Shirin? The science we’ve just closed our randomized control trial, Taco Mesh, which is Intraperitoneal Mesh comparison of two T. And we’ve had to close it because of COVID, but we’ve also got a blood arm. So from 25 patients, we’ve taken blood preoperatively and blood on day one, day three, day seven, day 30, and one year. And we’re looking at 25 different inflammatory markers. My research fellow James is doing all of the analysis every evening. He’s working hard in the lab. And so hopefully in a year we’ll have some results to see if there is an inflammatory response from the use of Mesh. And it is a most invasive use of Mesh. It’s an Intraperitoneal Mesh, yes. Let’s see what that shows.
Speaker 1 (44:45):
We just need more data to be able to discuss this better. The other issue is I think the overuse of Mesh. You offer tissue repairs for groin hernias, especially probably the patients that have sports injuries. Many of them need tissue type repairs. Most surgeons, at least in the United States, do not offer tissue repairs. That’s an issue. And they also necessarily don’t see their patients once the complication occurs, see the patients don’t grow, whatever. So there are surgeons out there that are not aware of the problems and also surgeons that are not able to fix the problem. So it’s incumbent on the patient to kind of find their own specialist. Which adds to the frustration I think because your local surgeon may not be able to handle the complication, which is true for any operation. Any operation where you have a complication, the skillset for a complication after hernia repair or any operation is very different than the skill set to actually do the operation.
Speaker 1 (45:55):
So until we have a critical number of surgeons and I train every single year, I train surgeons and put ’em out there and they go to their different places. I have one in Georgia, I have one in Michigan where now they can offer those services because they’ve trained under me. But I’m like one person. We have only a handful of people in the United States that do what I do. I just want to kind of put that out there. I have a question that was asked of you about your tissue repair. So there are a variety of tissue repairs. There’s a Shouldice repair, there’s a [inaudible] repair, there’s your type of repair. They all involve cutting the genital nerve. That’s how it’s originally described. Is that something that is necessary? What’s your thought on that and what do you do?
Speaker 2 (46:45):
If you read the international groin hernia guidelines 2018, it categorically says you must identify the nerves and not cut them if you’ve got a nerve. No, exactly. Don’t cut it. Leave it alone. So at the Sports Institute in London, it was one V2 is me versus Eureka Muk and Ernest Shoulders and they happily divide the nerve and they claimed, and I think this is wrong, that the nerve was under pressure. It was subjectively sort of compromised. And I said, well, how do you know? What test have you done? What actual test have you done to show that this nerve is under pressure? There’s no test. Yeah, if you divide the nerve, you get incense area, medial aspect of thigh, maybe the upper third of the scrotum. And if that’s where they’re experiencing the pain, the pain goes. But when you divide a nerve, it can actually lead to more pain.
Speaker 2 (47:41):
Yes, because you’ve got more part can develop a neuroma, you can develop more pain. So why are you going to divide a nerve? So I would never divide a nerve. I do offer a minimal repair. It’s called a minimal repair. And I will offer it in patients age between 18 and 30, young, fit male or female that have a small direct or indirect defect and they will get a suture repair from me. Now if you look at chronic pain, what’s going to give you chronic pain? A suture repair, Mesh Lichtenstein or laparoscopic repair in Stina Oberg’s systematic review, which is published in 2019. He said there was no difference. That was a large study looking at lots of papers. She said no difference, but felt that the chronic pain was far less in the laparoscopic repair where you have to use Mesh. So that’s the first thing.
Speaker 2 (48:44):
Second thing, and this is really important, chronic pain preceded Mesh repairs. Now Mesh repairs was invented where you are Lichtenstein popularized it. Yeah, my hospital actually. Yeah, exactly. And so now that repair is still the commons repair undertaken worldwide. Why? Because it is a tried and tested. Good repair is tension free. And all we are doing is using a scaffold. That’s it. Do you need antibiotics? No, you don’t need antibiotics. All of the research and data shows only if the patient’s immunocompromised steroids or you’re worried or recurrent repair, then you can give one shot of antibiotics. But why we’re not giving antibiotics or the large majority of patients because they don’t need it. The risk of infection is very small. So it’s a straightforward operation. And when you see the nerves, you must identify them. The genital branch of the genital femoral nerve, you have to dig for it to find it.
Speaker 2 (49:47):
The ilio inguinal nerve is the commonest nerve, which you will see. You may not even see up to 30% of patients. You may not even see the ilio hypogastric nerve. So don’t go looking for them. And if you find them, preserve them, protect them. Don’t divide them. Do not skeletonize them. So dividing the nerve I personally think is a mistake. I disagree with it. Would you see, is it negligent? Is the question I don’t know. I don’t know it. It’s a difficult one to answer. However, when you are looking at causation and negligence, you have to decide would a responsible body of surgical opinion advocate the division of the nerve? So if the international groin hernia guidelines in 2018 are a body of responsible surgeons have said, do not divide the nerve. Yeah, you could say dividing the nerve when it is noncompromised is negligent. And I’m putting that out there. And
Speaker 1 (50:58):
Yeah, the shoulder, the Shouldice clinic routine, well the way that the original repair was kind of described includes cutting the cremasteric muscle because they feel that improves their outcomes. They looked at their data. If you cut the cremasteric muscle, they get less recurrence. And in some doing they feel they also have to cut the gentle nerve to reduce the risk of adversely injuring it. I don’t know why Michelle might cuts the general nerve.
Speaker 2 (51:29):
I don’t know the cremasteric muscle dividing that I don’t particularly object to unless you’re a Canadian moose, which has got such a hyper developed cremasteric muscle to keep its testicles warm in the freezing <laugh> cold Canadian mountains, you don’t really manage without the cream hysteric muscle. So that’s fine. But no, no, you shouldn’t really be dividing. No, I don’t agree with it. I wouldn’t advocate it and I wouldn’t do it. So
Speaker 1 (51:59):
If a patient needs to follow up with you or see you, or if they’re on a wait list how do they kind of contact you? What’s the best way to contact you?
Speaker 2 (52:10):
Oh, you could just Google me with emails and you can just email my secretary and you get a reply very quickly. A bit like yourself, sheen. We’re very proactive. And then for overseas, I mean do see overseas, I look after a number of clubs in some European countries that I won name because then my competitors will find out and then we the blower. Yes, yes. And why are you sending this surgeon from this country this player, from this country to the surgeon? So I also have seen patients from the United States and they usually have seen some of you. And I don’t know, I think they just wanted to fly over and see me in London or maybe have a, but I think I’m available for Zoom consultations as well. Judging a time difference. I’m happy to speak to patients and discuss what problem they have. Cause I think zoom’s very good, what problems they have, how they’re managing and who also seen. But in Europe there are a few chronic pain specialists, but in the United States you’ve got lots of very good specialists like yourself. So I usually just send them to you, to yourselves.
Speaker 1 (53:25):
I would say of all the countries, US probably has most of the chronic pain specialists. That’s why I get a lot of requests from Europe because there aren’t that many. There’s you and maybe a handful of others in the entire continent. So it’s helpful to have someone to rely on, be able to get some feedback on. So that is it. Is there anything else you want to Well, you will be the president of the European Hernia Society.
Speaker 2 (53:52):
British. British
Speaker 1 (53:53):
Of Year.
Speaker 2 (53:54):
British, her
Speaker 1 (53:55):
British Society. But the EHS two, oh,
Speaker 2 (53:57):
No, no, no. I’m way down the pecking order.
Speaker 1 (54:01):
Okay fair enough, fair enough. And so I hope to be able to see you in that capacity when you have your meeting. Assuming that our pandemic will be over. I’m hoping.
Speaker 2 (54:18):
Yes. Thank you very much. There’s a question here to me,
Speaker 1 (54:23):
Who is that?
Speaker 2 (54:24):
He says Dr. Sheen answered this, he has a hundred to 200 on the wait list on the NHS, but the non HS side is easier to enter. Well, unfortunately it is. And that’s just the way the world works at the moment. Yes. I suppose the richest man in the world will get his hernia repaired the day he wishes to have it or she wishes to have it repaired. But I would never neglect one patient over another. They all get exactly the same care. But there is a bit of a wait, there is a bit more of a waiting list in a social medicine. And that’s that. That’s an issue with social medicine. But they still get me and they still get the best care when it comes
Speaker 1 (55:06):
Around there. Less, probably less of a problem in the United States because we don’t really have socialized medical care. But those that do belong to a government associated healthcare system, it’s hard to find surgeons that can meet their needs and be specialists and give timely care. So that is a problem. Yeah.
Speaker 2 (55:27):
So if you have an inguinal hernia and you say you work in your local mail room and you don’t have insurance how do you get that repaired? Do you just have to save up?
Speaker 1 (55:40):
So we have something called the Affordable Care Act. All employee, all employers that have a certain number of employees or more must offer health insurance to their employees. Okay, so you must have health insurance. Now how broadly that health insurance covers everything is debatable per state. But all my employees have health insurance that I pay for. Anyone that work has a job pretty much has health insurance unless they have a part-time job or it’s a very small family business where but in general, they’re supposed to have some type of stipend. Interesting. That was not true up until eight or 10 years ago. That was not true before. So we’re slowly moving in your direction. I think people in the United States feel like they should be getting early efficient healthcare more often than in Canada and UK where they’re more used to a socialized medicine. Understand there’s a wait list but our care is also more expensive than in those countries.
Speaker 1 (56:58):
So you do need to provide some customer service at the same time. And just to be clear there’s a lot of talk that surgeons are after the money in doing hernia surgery. First of all, hernia surgery doesn’t make money compared to cancer surgery, orthopedic surgery, it’s that and breast surgery are the two least money making <laugh> jobs in surgery. And secondly, we don’t get paid any lesser anymore for using Mesh. The fact that we’re using Mesh because it somehow pays extra or it’s a financial decision, has never been true. So let’s take that out of the picture. And that’s misinformation. That’s true in socialized medicine. It’s true in the United States. And if anything, it costs more to the facility to use Mesh because Mesh is expensive. Which is why most second and third world countries do not use Mesh because they can’t afford it. And more of the developed countries use Mesh because it’s more available.
Speaker 1 (58:01):
So doesn’t mean we’re always using it correctly. I do believe we were overusing Mesh, but to claim that it’s a financial decision from the surgeon is completely incorrect. And I stand by that because I live it every day. So on that note, thank you for your time, Dr. Sheen. Professor Sheen. Thank you Mr. Sheen. I look forward to seeing you in Manchester. Yes as soon as possible. Thank you for everything you do. Appreciate all the patient help you’ve given my patients. And I do very much thank the partnership that we have in our little hernia world. So it’s eight o’clock or actually it’s 9:00 PM your time. So time for bed and thanks for allowing me an hour of your time away from your family and children. This concludes our hernia talk. As you all know, you can follow me on Twitter and Instagram at hernia doc. Many of you’re follow me on my own Facebook page. This is being a simulcast at Dr. Towfigh and sometime later today, I will post access to this hour on YouTube so you can share it with everyone else. Hope to see you next week on another Hernia Talk Live. Thank you very much and enjoy your evening.
