Episode 3: Tissue Repair for Inguinal Hernias and Sports Hernias | Hernia Talk Live Q&A

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Speaker 1 (00:00):

Welcome every, everyone to, uh, hernia Talk. This is our live weekly, um, session on Sunday nights this week. Um, we are here with a lovely guest panelist, Dr. William Brown, who will be a answering, uh, questions for us on Inguinal hernias. Uh, so just so you know, uh, all of you, you can, um, uh, join with a question and answers on this webinar as well as on the, um, as well as on, uh, Facebook Live, which should be streaming. And then what we’ll do is, uh, post it on YouTube if you miss out on anything. And here we have Dr. William Brown. He is a general surgeon and hernia sports specialist. Um, he does a lot of inguinal hernias and works on sports hernias as well. And the, um, his practice is, uh, north Vietnamese. I’m in Southern California. He’s in Northern California. Welcome, Dr. Brown.

Speaker 2 (01:03):

Thank you for inviting me.

Speaker 1 (01:05):

And, uh, what we’ll do is, um, see who’s joined us already on this, on this session, and, uh, if they have any live questions, we’ll ask them, uh, of everyone if they have, uh, we already have two questions. Wow. Okay. Uh, and I have a series of questions for you as well. Let me, looks like we’re on live on Facebook as well. Okay. Are you ready for some questions? Dr. Brown?

Speaker 2 (01:32):


Speaker 1 (01:33):

I know you love hernias as much as I love hernias, so, um, I know this will be fun and exciting. Last couple ones were super great and everyone had lots of fun. And, um, I like Inguinal hernias. I think Inguinal hernias are much more challenging than abdominal wall hernias. Uh, a lot of my friends do the really huge giant ventral hernias, incisional hernias, and they love that it’s very taxing on the surgeon’s body in addition to the patient’s body. But I think, um, in terms of complexity of anatomy, anatomy for, uh, for sure the, uh, inguinal region is more complex. What are your thoughts on that?

Speaker 2 (02:14):

There are a lot. There are a lot of things that you need to just be careful of the local nerves, uh, the various tissue layers, the spermatic cord. So there’s a lot of little things that if you are careful of, you can get good results. Uh, but a little lack of caution can cause some long-term problems. Um,

Speaker 1 (02:32):

And what’s your thought of that? You know, inguinal hernias are the most common general surgical elective operations performed. Um, we do about 800,000 a year in the United States, and there are many more, uh, millions of people who have hernias that don’t get it fixed. Um, and yet, even though it’s such a common operation, I think of all the operations we see a lot more potential for complications. What is your thought, do you think that surgeons are, are not taking hernias as seriously? They just think it’s a hernia, just a hernia, you know, I’ll fix it, um, as quick and dirty operation move on. They don’t give it the respect that maybe, um, we give it. Or is it a training issue? What do you think is going on with Inguinal hernias? Why is that such a problem?

Speaker 2 (03:22):

Uh, I agree with you. It’s, it’s a complicated anatomy, so it’s something that, uh, experience makes a big difference on or with, in addition, um, a lot of surgeons just go and fix ’em. Um, but there’s a lot of things you can do to prepare the patient, get their weight, uh, down, make sure they’re off smoking, make sure all the diabetes well controlled, and then during the operation if all the tissues are handled very gently or very careful with all the nerves, and then it requires a lot of care post-operatively in terms of when to get back into activities. Um, so there’s just a lot of little steps that if we’re, if we’re taken, can get you a very, very good result. On the other hand, um, if the surgeon just fixes anybody and sends ’em on their way, then results aren’t gonna be as good.

Speaker 1 (04:17):

Yeah, I would have to agree with that. Um, so you do most of your operations in open fashion, I understand, but um, you also see a lot of people who, uh, come in to see you after, uh, laparoscopic surgery. Is that correct?

Speaker 2 (04:34):

Yeah, so I also take care of a lot of patients who have pain after either, uh, laparoscopic, uh, mesh repair or an open dine or plug type repair. Uh, and those patients are difficult to treat. It takes a lot of care and thought and a lot of hand holding both before and half to the op operation. And I wish I could say the results were perfect. Um, I don’t think I, it’s very, very hard to get rid of the pain, uh, once they’ve had it for a long period of time. And I feel if, if I can get rid of 80% of the pain that I consider that a good result.

Speaker 1 (05:12):

Yes, definitely. It’s complicated. Um, for all of you who are, uh, watching and listening right now, Dr. Brown, uh, practices in Northern California, he’s a hernia specialist, which, um, really has made his name in, uh, her sports hernias and also tissue repair of anal hernias. Um, so we do have some questions rolling in. We already have four questions live, uh, on Zoom alone, and if there are any on Facebook, I will answer them as well. So let’s start with our first question and that, um, is from, uh, one of our friends who comes every week to see what, uh, uh, each expert says about this question. So he has had a bilateral inguinal hernia repaired laparoscopically with polypropylene, and he did well, um, was sore from the surgery. Um, but he’s never completely recovered. So he’s, he has sought second opinion and has done lots of physical therapy. He’s now 10 months out and he’s still not perfect. He’s still sore in the groins. What is the longest time you’ve seen a patient recover, and is it too much time to wait over a year to have it addressed? Does waiting for more than a year make any revisional operation more difficult?

Speaker 2 (06:31):

Um, has a general rule. If the patient has severe pain, you know, within a week or two after the operation, then there’s something technically wrong. A nerve has been entrapped by a staple or a suture, or there’s been some trauma to the spermatic cord. If the pain comes on three or four months after surgery or longer, then it’s often related to some scarring around the mesh itself, and that’ll often resolve with time. I encourage everybody to wait at least a year if they can put up with the pain for that long. Uh, because the, the various studies out there show that if, if you wait a year, uh, the pain will often go away. If it goes on beyond a year, then uh, there’s various treatment options that can be, um, are available. Nerve blocks can often be beneficial. I often will inject the mesh with some steroids to see if that’ll soften it up. Uh, the last resort would be to, to take the mesh out.

Speaker 1 (07:35):

So, uh, this gentleman seems to have soreness, which can be interpreted different ways if the soreness is not life altering and he’s able to do his job and exercise, um, but it’s distracting, you would allow him to wait a year before you do any, um, extreme measures, correct?

Speaker 2 (08:00):

That is correct. You can certainly try the injection of the mesh, uh, with some steroids, that’s fairly easy to do. You can certainly try nerve blocks that sometimes will help differentiate pain between pain that’s related to the scarring and pain that’s related to nerves. Uh, gabapentin will sometimes help with, if it’s related to the nerves. I had mixed results with that, so I’m not enthusiastic with him. Certainly be trying.

Speaker 1 (08:26):

And then what if it’s the, uh, it’s more severe. So he’s, let’s say now 10 months out, can’t sit. Um, bending is difficult. He has children. This is a scenario I’m just putting out there that I see a lot and children or the pet wants to jump into his lap and he’s, it’s too painful. Um, would you still wait over a year? You think some of those will get better or do they need some earlier interventions

Speaker 2 (08:54):

If it’s, if really affecting their lifestyle? Uh, they can’t function, can’t play with the kids, can’t work. Um, then I, I have been talked into going earlier.

Speaker 1 (09:06):

Okay, <laugh>. All right. Let’s go onto our next question. Uh, with a natural tissue repair for Anglo hernia, is a surgical technique different if it’s a direct versus an indirect hernia? That’s actually a good question. Um, also, is the likelihood of recurrence different between a direct, um, versus indirect? Uh, specifically I think they’re wondering if you have, if you choose a tissue repair, are you expecting worse outcomes if it’s a direct hernia than indirect? These are great questions. We’ll, <inaudible>,

Speaker 2 (09:41):

Uh, the indirect hernias I find are easier to repair, uh, because most of the inguinal floor is intact, unless the in indirect hernia is very, very large, and, uh, reducing the s sac and closing the, the, the defect in the internal ring, uh, gives you very, very good results. Um, if you’re a young male, uh, and skinny, the recurrence rate for a indirect inguinal hernia with or without mees is the same. So there’s really no reason to use mesh in an, uh, both male indirect hernia. The direct hernias, the floor is diffusely weakened, and so you’re dealing with tissues that are, have been damaged over time from consultation or work or difficult with urination, those hernias are more difficult to repair. The tissues are, uh, not nearly as strong. So the results from an cure tissue repair is not as good with the direct as it is with an indirect al hernia.

Speaker 1 (10:48):

Yeah, so in the way I explain to my patients is an indirect hernia. The whole is completely surrounded by muscle and tissue fascia. So that expands and contracts and, you know, it stretches. And so when you bring the tissues together in a tissue repair as opposed to patching the hole, which is what mesh does, um, that tissue is more ma more able to move. When you go more towards the middle, the, uh, the middle hernias that’s indirects or further out, but the directs, which are more in the middle, get closer to the bones and the ligaments, and those are those you can’t move. So the muscles attached to the bone and ligaments more, they’re not as able to move. So if you have a big hole and you’re trying to bring it together with sutures, you know, the part that’s attached to bone, for example or ligaments is much harder to move. So the big hernias, I think, um, that are direct are a little, I agree that the recurrence rate is higher and I think, um, uh, a little bit more difficult to do those with tissue repairs. You know, uh, not all hernias are the same. Not, and not all hernias should be performed by tissue like femoral hernias. Another one. What do you think about tissue repairs for femoral hernias?

Speaker 2 (12:09):

Uh, as you say around femoral hernia, you have to deal with, uh, cooper’s ligament, which doesn’t, um, stretch at all, but you can still get a very good, uh, repair for a femoral hernia with pure tissue. Uh, but it’s still important to get, you know, this, if the person’s skinny. It just makes the repair so much easier. So I, I think it’s very important to get those weight down before any pure tissue repairs. Uh, but I still do many femoral hernias with the pure tissue.

Speaker 1 (12:42):

All right, very good. Let’s move on to the next question. This patient, uh, has had bilateral hip FAI and labrum repairs. So FAI stands for femoral acetabular impingement. So it’s basically the lining of your hip joint is not completely intact, and that hurts and tears and hurts, and the bone has been, um, traumatized, and so it’s not perfectly spherical. So, um, the patient also has an occult her hernia on the left side, remember the hip was on both sides, the hernias on the left side for several years, but have not had surgery to address it yet. I also have slight chronic detachment of my rectus abdominus on both sides. That’s something Dr. Brown can definitely discuss. So this is a 31 year old female. She’s an endurance triathlete. She’s worried about having more surgery since she’s already had her two hip surgeries, and it was very difficult to recover from those.

Speaker 1 (13:43):

She also has swelling in her groin crease and large lymph nodes, and the physician thinks there could, this could be lymphedema after her hip surgery. Any thoughts on dealing with hernia and these connective tissue disorders? So in summary, 31 year old high-end athlete, two hip surgeries, one on each side, and now she has a hernia on one side, which is occult. And occult means the hernia hurts, but it’s not a big, obviously bulking bulging hernia. Uh, so small hernia that’s symptomatic. Should she consider surgery and should she be worried about having surgery under these circumstances?

Speaker 2 (14:25):

It, in her situation, it’s gonna be important to determine what the source of the pain truly is. Uh, she has the rectus chair, uh, hernia. She’s a distance runner, so osteotis pubes can be thrown into the mix. Uh, the adductors are very nearby, so all those structures can be a source of the pain. The adductor injuries are often missed on imaging, uh, tests. So I, she needs a very thorough examination by someone who’s familiar with all these injuries. And then I often do what’s called diagnostic injections. So say we’re concerned about the osteotis pubis or an abductor or the rectus, I’ll often inject that with a local anesthetic and then have the athlete run around the building and see how she feels. And if she feels significantly better, then I’ll know the rectus is a component of her symptoms. If she doesn’t feel better, then we can inject the external bake around the occult hernia, have her run again and see if she feels better, and then that way localize what the source of pain is and then put together hip an appropriate, uh, uh, treatment regimen for her.

Speaker 1 (15:37):

So I think assuming that the hip surgery was done and addressed, the hip pain, if there’s an occult hernia with no symptoms, I would leave that alone and do watchful waiting. You agree?

Speaker 2 (15:54):

Yeah. So I, I don’t think you need to fix anything that’s not symptomatic.

Speaker 1 (16:00):

Um, and then what about if it were symptomatic? Um, well, you answered that the symptomatic, uh, we would repair it. So I think having had hip repair doesn’t make you a poor candidate to have poor outcomes for inguinal hernia surgery. I think they’re unrelated, um, understanding that hip problems can give groin pain. So what Dr. Brown said was exactly right, really, we have to figure out as hernia specialists, is that pain coming from your hernia or from your hip? If it’s coming from your hernia repair should be done. If it’s not coming from your hernia, the fact that you just have a hernia is not reason enough to get it repaired. Does that sound like a good summary?

Speaker 2 (16:45):

Yeah. So it is just very important to determine what the source of the pain is and then treat that not, so the hernia may not be given her any trouble. The hips certainly could still be given her trouble. So sometimes I encourage them to get hip injected with the local anesthetic and then run around the building again and see how the athlete feels.

Speaker 1 (17:03):

Yeah. And then the, there’s a concern that she has, um, maybe a connective tissue disorder or connected disorder. Um, I don’t think these are necessarily connected. The swelling in the growing crease may or may not be from the hernia enlarged lymph nodes. We don’t really consider them enlarged, but more than one centimeter. So if you’re thin, you can feel your own lymph nodes sometimes, um, even though they’re not abnormally enlarged, uh, and then lymphedema after hip surgery, that’s kind of stretching it, that’s a lot of lymphatic disruption. And most hip surgery doesn’t involve the lymphatics.

Speaker 2 (17:44):

I agree with you.

Speaker 1 (17:45):

Okay. Awesome. All right. These questions are rolling in. Let’s see. Next one. Um, this patient has had bilateral inguinal hernia repair with mesh only on one side, that side recurred, he had a should ice repair with mesh still in there. Okay, so you had a hernia repair with mesh, it recurred, then you had a shouldice repair after that, the mesh is behind the rectus muscle rather than on top. Can this still be safely removed? Uh, and if so, can I still have a pure tissue repair after? So this an indirect inguinal hernia had a mesh repair that occurred, had a shoulder ice on top of that, and now he’s wondering if he can or should safely have the mesh removed the retrorectus mesh. Why do you want it removed?

Speaker 2 (18:43):

Yeah, it don’t only have to be removed if it’s giving trouble,

Speaker 1 (18:48):


Speaker 2 (18:49):

Um, so if the mesh has become fibrotic or in one of the local nerves are involved, then the, you know, the mesh can be treated. Uh, but if it’s not given any trouble, I definitely leave it in in place.

Speaker 1 (19:05):

So I’ll just say it’s uncommon to fix a hernia recurrence from a mesh repair. It’s uncommon to fix that recurrence with a tissue repair. Does that sound right? That’s not considered. I know we do it sometimes, but it’s not considered standard.

Speaker 2 (19:25):

Oh, if it’s an indirect hernia, I certainly wouldn’t hesitate to, to do a pure tissue repair.

Speaker 1 (19:30):

So if someone had a laparoscopic hernia repair with mesh for an indirect hernia and it recurred, what options would you offer that patient?

Speaker 2 (19:39):

So, so if it’s an indirect hernia, and I actually did one of those last week where had a mesh repair and I, they must have missed the indirect hernia, um, I just go back and fix it, uh, this pure tissue repair, and then if there’s mesh in there and they came back with a direct hernia, then I agree with you, it, it’d be a, um, which type of repair would require careful consideration. Occasionally I’ll put mesh in occasionally. If it’s really small, I might just do pure tissue repair. Um, uh, but the having the mesh in there makes the decision making a little more difficult.

Speaker 1 (20:15):

Okay. I’m curious why this gentleman would, wants the mesh removed if the mesh is there and not hurting you in any way. Um, I would leave that alone. Um, so his response is, the reason I want the mesh removed is due to pain, scratching, stiffness, burning, and a lot of inflammation.

Speaker 2 (20:35):

Yeah. So again, I certainly try conservative measures first. Um, um, nerve blocks, if there’s a nerve component injection, the mesh with, uh, steroids. And then, uh, the last choice would be to remove the mesh either, uh, with an open incision or laparoscopic, uh, approach. Uh, if the symptoms can’t be controlled with conservative measures.

Speaker 1 (20:59):

I agree. So if you, if for sure those are symptoms related to the mesh, um, and some of them do sound like it, that kind of scratchiness we hear a lot like sandpaper inside, um, feeling of stiffness, which, uh, can happen with the heavier weight meshes, especially in a thin patient. Then mesh removal will be, um, something to consider. Uh, and since you already have a tissue repair anteriorly, and this was mesh put in posteriorly laparoscopically, I would offer a, a laparoscopic or robotic mesh removal and not touch the hernia itself.

Speaker 2 (21:35):

I agree.

Speaker 1 (21:36):

All right. Here’s a question about imaging. Do you do a lot of imaging, Dr. Brown?

Speaker 2 (21:43):

Um, I order a lot of imaging. I, I don’t have an ultrasound machine or an MRI in, in the office.

Speaker 1 (21:49):

Okay. Um, I do ultrasound in the office too. Do you order CT scans or MRIs ever for inguinal patients?

Speaker 2 (21:58):

Uh, in most patients you can feel the hernia. A lot of people like to have imaging for documentation or they don’t trust my fingers <laugh>. Um, and then for sports hernias, I almost always order an MRI because there’s often a hip component, often an adaptor component. Uh, so I wanna get all the information I can before making a decision about sports hernia. The classic hernia, I don’t necessarily do any imaging.

Speaker 1 (22:25):

Yeah, sports hernias are an entity on their own. They’re very complicated. So many different dimensions to, um, look at in a non-contrast, m r i with a sports protocol, uh, which most institutions have, um, can really identify areas of the hip joint or the rectus sub dominance or adductor muscles, and where there may be associated inflammation or tears, um, in those regions. So the question for you is, would an MRI show mesh problems? Is there a certain type of MRI that you would recommend to give the best results? I know my answer.

Speaker 2 (23:02):

Okay. <laugh>? Um, the MRI often doesn’t even see the, the mesh. So, um, if there’s a big fluid coming collection around the mesh or an infection around the mesh, uh, the MRI can identify those. Um, but the MRI often is, is not particularly helpful in evaluating mesh. I i doesn’t mean I don’t order one occasionally, but I depend on the diagnostic injections for injecting the mesh. See, if the pain goes away, then I think the mesh is the source of pain. If I do nerve block in the office and the pain goes away, then I think the nerves are a major component. So I depend more on physical examination and diagnostic in, in the MRI.

Speaker 1 (23:48):

So, um, imaging for hernias is actually something that I’m very interested in. We published a couple papers on it. Uh, for MRIs, the issue with MRIs, you need someone to be able to read it correctly. Most radiologists are not trained to read MRIs for mesh related problems. So I read my own MRIs. Um, so a non-contrast MRI with a hernia protocol or a dynamic protocol, whether you push out, um, can give you a lot of information. If you have groin pain, you think it may be a hernia, it’s more likely to catch a small occult hernia than a CT scan or ultrasound, um, by a lot. I think in our study, the ultrasound was about 50 50 and, um, CT scan it was incorrect. Uh, it was about 20 20, 20 5%, um, of the time. Right. And then the next is if you have a mesh in place, if you do an ultrasound, often the mesh distorts your vision of what’s going on and there’s too much, um, uh, artifact CT scan, everything looks gray.

Speaker 1 (24:57):

So in the groin you can, it’s okay for the abdominal wall, but for the groin it’s such a complicated anatomy there you really want to know how the mesh interacts with the soft tissue and the muscles. And on CT it all looks the same color, so it’s hard to differentiate what’s mesh and what’s not. With MRI, you can actually, um, tweak it so that you see the mesh separate from the muscles. So usually the mesh comes out dark black, and then the fat is bright white, and then the soft tissue is more of a grayish color. So therefore you can tell if the mesh has folded, if it’s falling into the hernia, if there’s fluid collection around it, if it’s displaced, if it’s too low, too high, too medial, if it’s affecting the bladder. Um, those are all little things that an MRI can, um, demonstrate.

Speaker 1 (25:46):

So we actually have our hernia protocol for MRIs. You can go on hernia talk.com and um, look up hernia, hernia pro, our MRI protocol protocol or MRI hernia protocol. Um, you can search on that website and I’ve uploaded our, um, protocol. You can just download it and share it with any doctor or radiologist. Um, I also have it posted on all my social media platforms. You just have to search for it. And then the protocol, I believe is also on my website. Um, if not it should be <laugh>. Uh, but we published that. So it’s, uh, you have to do the MRI with Valsalva. So it’s a bare down view where you push out and um, uh, I think it gives a lot of information, but I, you know, I’m a kind of a minimalist, so I need to know exactly what’s wrong to and address that problem instead of like undo and redo everything. Um, and so I, I really rely a lot on imaging to figure out where exactly I could figure out the problem, um, and address it there. That’s my take on imaging

Speaker 2 (26:59):

<laugh>. Okay. No, I’ll take advantage of your protocol. I’ll download that.

Speaker 1 (27:03):

Yeah, it’s great. So the way we did is we wrote it as if you’re a radiologist or radiology tech. So if you just show it to the, uh, radiology tech, they can put those, um, codes in there and, uh, give you exactly what you need. Because the hospitals around me, like Cedar Sinai and a lot of the imaging center centers around me already have that protocol, which is great, but the minute you drive 10, 10 minutes out, um, they may look at you like, I don’t know what you’re talking about. Um, but if you offer that additional information about the MRI hernia protocol, which again is on hernia talk.com, that’s the easiest way to find it. Um, then you’re kind of communicating with the radiologist within their own language and it makes sense. Okay. Question about pregnant patients. Um, there’s a lot of concern about hernias and pregnancies.

Speaker 1 (27:52):

I think it’s a, it’s a bit more than what really, um, is reality in pregnancy. But here is a question. What are some tips for pregnant people who have pain after femoral and inguinal hernia repair with mesh? As a baby grows, the pressure is getting worse. Okay, so this sounds like a lovely lady who’s already pregnant and she’s already had a mesh based femoral and inguinal hernia repair, which I’m gonna presume was a retro muscular mesh, like a laparoscopic, correct me if I’m wrong. Um, so as the baby’s growing the pressure and the groin is getting worse for her, what do you recommend?

Speaker 2 (28:34):

Um, I’d, I’d like her to get through the pregnancy if she can. And then there’s a good chance that pain will resolve once the intra-abdominal pressure resolves. Um, again, conservative measures, uh, maybe abdominal binder, uh, something that provides a little bit of external support, uh, Advil, uh, some analgesics, heat, um, um, injecting the mesh with local anesthetic would help, but it’s gonna be just very temporary. So I would, I wouldn’t, I wouldn’t put that high on my list, but I do everything I can to try to avoid removing the mesh until after the baby delivers.

Speaker 1 (29:14):

So I agree. Um, these are not, uh, things that would alter your pregnancy. Um, and so we usually don’t like to operate on women that are pregnant unless it’s going to either improve their, um, their lifespan, <laugh>, make the pregnancy go better, like an, you know, like if you had a gallbladder surgery, uh, or it would improve your quality of life. Some women have so much pain that you take narcotics and then that’s not good for the baby. So that would be one indication to operate. But sounds like in this situation, so in general, you, if you have any type of growing hernia repair mesh or no, mesh pregnancy should not negatively affect that in that you should have a normal pregnancy with no pain. I think that’s the expectation. Do you agree, Dr. Brown?

Speaker 2 (30:04):


Speaker 1 (30:05):

So if you are having pressure and it’s getting worse, you either have a hernia recurrence, your mesh is, it could be your mesh is too tight, but that area, the groin doesn’t really stretch that much. Belly button’s different, but down in the groin, the belly doesn’t stretch as much during pregnancy. So I would get it looked at. It’s possible you have other pregnancy related problems. Um, you can have, uh, basically venous congestion, which is a well known reason for groin pain and groin pressure during pregnancy, which is mistaken for hernias or hernia related problems. A standing ultrasound will help show any labial, uh, varice, which are basically varicose veins that you get the same way you get varicose veins in your leg. You can get it in the groin area during pregnancy because the pressure of the baby. Um, and that can mimic groin pain or groin pressure. It really shouldn’t be from your hernia repair if the hernia repair is fine. And then lastly, I’m a big fan, as Dr. Brown mentioned of pregnancy belts. So pregnancy belt is made to lift the gra abdomen off of your pelvis and that helps a little bit with groin pain, growing pressure, um, maybe even release some of the pressure on your lymph nodes. You don’t get the swollen legs. So that’s my 2 cents on p pregnancy and women.

Speaker 1 (31:34):

Okay. These questions are coming right in. Um, yeah, so just going back on the last patient, it was a laparoscopic tap repair. So, uh, my question, my answers are the same. Uh, so this patient has concerns about having surgery for pain, uh, producing indirect Anglo hernia as a woman in her low thirties, a woman who wants to have children in two to five years, should she, if she has, so there’s a young lady who’s in her fertile years, she has an indirect al hernia. Should she get repaired before the kids or after the kids? She wants to have kids in about two to five years, doesn’t matter. What are your recommendations for, for the timing of inguinal hernia pair in someone who’s considering pregnancy in two to five years?

Speaker 2 (32:25):

If the hernia asymptomatic now, then I definitely would get it repaired, uh, whenever convenient. And if it’s completely asymptomatic, I, if she’s planning to have children, I’d probably go ahead and still repair it just so she doesn’t have trouble during the pregnancy. Uh, once repaired the pregnancy should do both. There shouldn’t be any complication from the pregnancy and in terms of recurrence of the hernia or anything like that.

Speaker 1 (32:52):

Um, yeah, I agree with, uh, if it’s, if it’s symptomatic, you should get your hernia repaired, your, your al hernia repaired. Um, in general, patients who have any type of al hernia repair do not have any problems during their pregnancy from that hernia repair. That part of the body does not stretch as much as the abdomen does. And so mesh or non mesh repairs do find an, if you plan on having a c-section also that um, doesn’t get, uh, in any way affect the C-section, the ability to them for them to do a C-section. So go ahead and do what’s best for you in terms of the hernia if you don’t have any symptoms. Um, the reality is if you have no symptoms and you are pregnant, you probably will also not have symptoms during pregnancy either. Um, there’s one great published study in the past five years. I looked at big population study and the rate of al hernia need for inguinal hernia surgery during pregnancy, and I think the number was zero. Uh, if it’s not zero, it’s very close to zero. So, um, even though people are worried about it in general for Anglo hernias, um, it’s uh, I would just focus on being pregnant and having your baby. Do you have children? Dr. Brown?

Speaker 2 (34:15):

Three and three grandchildren

Speaker 1 (34:17):

And two grandchildren. Oh, and do you get to see them during this pandemic?

Speaker 2 (34:23):

Uh, two of them live in my guest house, so I see them every day.

Speaker 1 (34:27):

<laugh> <laugh>. Okay. Well that’s very nice. I know so many that are disconnected from their parents or their grandparents because of this pandemic and it’s kind of sad, which is why we have zoom and FaceTime and all those things. Okay. I hope that answered your question. Um, here’s a question from a lovely lady who I know very dearly. So if mesh is inserted robotically, does it also have to be removed robotically? Let’s talk about GUI hernias, Dr. Brown, what are your, what’s your take on that?

Speaker 2 (35:05):

Um, if it’s put in robotically or any sort of laparoscopic, then removing it laparoscopically is a very, very good way to go. Um, it, if there’s a, uh, hernia associated hernia recurrence, then the laparoscopic report removal and it can be repaired at the same time laparoscopically or a hybrid operation where, uh, an incision made on the outside and an open repairs before, um, it could also be removed openly. That’s a little more complicated cuz you have to go through all the abdominal wall to get to the mesh, but that also is very doable.

Speaker 1 (35:47):

Uh, you know, one of the questions is, uh, we we, we use the word mesh so widely. Um, uh, what are your all mesh the same and can you discuss all the different types of mesh that are out there and how they may be different and how we as surgeons think about it?

Speaker 2 (36:06):

Uh, the, the one that I deal with the most is probably the plugs, which is a, uh, a bold up piece of mesh that’s kind of shoved through the hernia defect, either direct or indirect. And then it’s supposed to expand underneath, but that multiple layers of mess that are, that make up the plug, um, you just get scar tissue between all those leaves of the plug and then it turns into this big lump that is very, very painful or can be very painful. Um, uh, so I advise not using the plugs at all. People can avoid people bad. Um, there’s a, uh, hernia, I forgot what it’s called, but it’s a two layer mesh that, um, one component is put deep to the al ring and the other is left, uh, over the floor. And I found that that is also one is very difficult to remove and cause a lot of scar tissue.

Speaker 1 (37:04):

The proline hernia system.

Speaker 2 (37:05):

That’s correct. Uh, so those two, if not that, those people are going to be asked what type of mesh their surgeon’s gonna use. But those two, uh, the ones that I see very commonly is keeping trouble. Um, otherwise most of the low, uh, weight, uh, meshes, um, the results are pretty much equal, I think, as far as I can tell between the most of those.

Speaker 1 (37:30):

So what do you think about, uh, biologic mesh? Because most of the time when we say mesh, we, uh, we really are talking about synthetic mesh permit, synthetic mesh. What do you think of biologic mesh and what do you think of hybrid mesh? Do you have any, any, any, um, opinion about those two

Speaker 2 (37:48):

Options? Um, I’ve never had to take out, uh, um, a biologic mesh. Um, so I don’t know if that’s good or bad or it just means that not too many have been put in yet and they’re relatively recent, so I don’t know anything about the long-term re results of biologic meshes, but, um, I’m hoping someday that, uh, mesh will be developed. That doesn’t give any trouble. Um, I just don’t know enough about the biologic meshes yet. The hybrid meshes are usually, uh, prolene mesh with some sort of observable surface on those, and those are supposed to cause, uh, less trouble. Uh, but I have taken out several of those so I know that it’s, it’s not perfectly trouble free.

Speaker 1 (38:31):

Yeah, I think, um, in the early two thousands when, uh, the first biologic mesh came out, I think it came out in 2000, uh, AlloDerm, that was the first mesh approved for any type of hernia repair and they were marketing it as basically like stem cells for hernias. So you put this in and then your normal tissue sees this, gets all excited and transforms the biologic mesh into whatever tissue you sew it to. So if you sew it to muscle muscle, if you sew it to fascia, it’ll be fascia. If you sew it to your brain dura, it’ll be brain dura. Um, that was okay in the lab and that didn’t really turn out to be true in real life. It is absorbable. All biologics are, um, absorbable and so they’ll be gone now, they may be gone in in several weeks to months to years depending on the, the type of mesh.

Speaker 1 (39:29):

Um, but because they’re gone then, uh, what we see are recurrences once they’re gone. And now they even have synthetic absorbables like phasic mesh, which is cheaper to make, but they still sell it just as expensively, um, to compete with the other, uh, biologics. And that takes about two and a half years to absorb. And uh, then the hernia recurrences, um, show up then. So long-term studies on all of those are not productive. Um, I’m a big fan of the concept of hybrid mesh, which is it’s biologic plus synthetic. So we know the good thing about synthetic is it’s permanent. And so the recurrence rates are low. The bad thing is that it’s permanent and the material, it’s not common, but it could be too stiff, it could be it’s stiff, it could be causing inflammation, um, et cetera. And then the biologic mesh, we know that the good thing about it is that it’s very low in inflammatory potential.

Speaker 1 (40:44):

So it’s basically comes from human cadaver or some type of animal cadaver tissue. And it’s, it’s biologic. It’s like organic, organic mesh <laugh>. Um, so it goes away, which is not good, but it has low inflammation. So the pain, there’s no pain or feeling of foreign body sensation with those meshes. So if you put the two together, you have the low inflammatory potential of the biologic mesh and the permanence of the synthetic mesh. Um, there’s a product that I use called Tex, which is like 96% biologic, 4% synthetic. And um, we’ve looked at our data and which hopefully will be published, uh, soon, which shows that if you’re reacting to synthetic mesh, you should do well with a hybrid mesh. Um, but that’s, you know, kind of, that’s my take on it. The, the common thing is there’s no perfect mesh out there

Speaker 2 (41:45):

For sure. Yeah,

Speaker 1 (41:46):

Yeah. We’re still looking. We need something that acts just like the vascular, um, normal muscle or fascia and have that, uh, this is a question for me. Do you offer MRI reading as a service? I do. So I have what we call an online consultation. Before this whole telehealth, I was doing a lot of online consultations because I know not everyone can fly in to Beverly Hills to see me. So if you just contact my office or DM me on any platform, um, I’ll get you in touch with my office. We have a whole protocol, you sent us all your images, all your op reports and medical records and questionnaires, and I read all of your images again. And, um, that’s kind of how it all started. I was doing these online consultations and then I saw that people’s images were showing hernias, but it was reported by the radiologist, normal and no hernias.

Speaker 1 (42:43):

So they’ve like got moved on to, okay, not a hernia, let’s figure out why we have this pain. And the reality was it was just a misread imaging. So that’s why I got involved in imaging. So yes, please do contact my office and I’m happy to, I I really actually, I don’t know about you, Dr. Brown. I’m like a puzzle solver. I’ve always solved puzzles, even as a kid I would get those books, you know, with the puzzles. So I really enjoy these online consults. It’s kind of my talk, um, dot com. But I really enjoy them because I, I’m like trying to solve a puzzle for someone. I don’t know. That’s my thing.

Speaker 1 (43:24):

Okay, here’s a question about ventral hernias, which I’m going to skip, um, because we have a lot of other questions and if you wish to come back next week when we have Dr who is um, does a lot of ventral hernias and a lot of women on hernias on women, um, we can answer that one. So I’m going to save this question for next week. Okay. So thank you for that question. On the, um, robotic mesh, what are the increased risks with a second mesh removal required if, uh, for systemic form body reaction? So this patient very um, complicated situation. It reacts to every product that’s ever been put on her, put in her. Um, so she has mesh put in, mesh put out, mesh put in, mesh put out. Uh, what are the risks of just having this constant cycle of mesh being removed, um, like as the second mesh and a little more complicated than the first?

Speaker 2 (44:25):

Well, the yes. So more times you have to take on mesh out. The more difficult becomes that tissue planes are, uh, destroyed. It’s almost impossible to find the nerves again unless you get really retroperitoneal. Um, it’s a little bit easier in women, uh, cause you don’t have to worry about this paramedic cord. Uh, so the fact is she’s female is a little bit of a plus, uh, but still more times as she has the operation done, um, the more difficult it’s gonna become. Uh, if she can get a pure tissue repair the next time around once the mesh is removed. That would be a, um, what I would suggest if as soon she’s getting it removed again. Is that the

Speaker 1 (45:10):

Yeah, I think so. I think so. All right. I’m gonna share my screen because we have some more questions that were turned into us through Instagram. Um, and I think these are questions you’ll enjoy answering Dr. Brown. So I’m curious to know the symptoms and diagnostic process of an occult hernia as well as repairs for a cold hernias in patient and someone with a known connective tissue disorder. Okay, let me ask you this, Dr. Brown, if you have someone who has a known connective tissue disorder, let’s go extreme. Someone with Alors Danlos, would you offer them a tissue repair?

Speaker 2 (45:49):

Um, I, you know, it, it really depend on the physical examination. If the aero down the tissues are usually, you know, stretchy and tear very easily. But, um, but there’s various degrees. If the tissues look pretty good, I still could offer a pure tissue repair. If everything is has, you know, torn and every other operation they’ve had done has had trouble, uh, then I’d probably put the mesh in.

Speaker 1 (46:16):

And what are the symptoms that you see in someone, um, that may have a hernia but it’s not palpable?

Speaker 2 (46:23):

Um, well they usually have pain with any sort of activities that increase the abdominal pressure. Uh, they may have some, uh, swelling. Sometimes the pain will radiate down towards the, uh, spermatic cord or testicle if there’s been some pressure on the spermatic cord. Um, and again, um, uh, ultrasound with Valsalva or your CAT scan with Valsalva, pardon the MRI with Valsalva might be able to evaluate the, uh, identify the, a cold hernia if physical examination, uh, hasn’t been successful.

Speaker 1 (47:03):

Okay. Um, you know, we’re actually looking at all that ourselves. I’m very interested in a cold hernias. I’m hoping to have a very defined like scoring system of different symptoms that people have that will kind of lead you to thinking Inguinal hernia as a cause of chronic pelvic pain. So stay tuned on that one. Uh, des if you’re on and you’re listening, uh, you’re being held to a very high standard on this one. Okay. We already discussed, um, imaging, uh, Dr. Brown. Do you see femoral hernias in men and is it more likely to be seen during laparoscopic or robotic surgery?

Speaker 2 (47:41):

Uh, femoral hernias do occur in males. It’s been several years since I’ve identified one in a, uh, ma. Uh, definitely more common in women, but England hernias are more common than fal hernias in women. Um, in terms of, uh, identifying it, it should be easily identified during a laparoscopic or robotic operation. Um, uh, I think that answers the question.

Speaker 1 (48:10):

Yeah, I think, um, so in women, the international hernia guidelines are that you should always look for a femoral hernia at the time of anal hernia repair because of the higher incidence of femoral hernias among women. And what’s been shown is the reason why many of these women don’t do well after hernia pair is they actually had a femoral hernia that was missed. And so then they have chronic pain and no one can figure out why. So, um, and femoral hernias are risky hernias. So for women, because it’s higher risk of having femoral hernias in women than men, that hernia should always be ruled out, not so in men, when we do laparoscopic or robotic surgery, the femoral space is very easily identified and we have these like nine commandments of how to have a critical view of the inguinal space. And one of ’em is to make sure we identify the femoral space and rule out of femoral hernia.

Speaker 1 (49:09):

So, um, it’s much more commonly and easily identified during laparoscopic and robotic surgery and therefore also the gold standard for femoral hernia pair is currently laparoscopic or now robotic surgery with mesh because of the easiness. This one I would love for you to answer Drs um, Dr. Brown because we get this asked every single week and um, uh, it’s a very important question. Everyone wants to know, is it okay to work out six weeks after hernia surgery and that workout can be squats, planks, three kilogram weights, et cetera. Okay. Do you allow your patients to work out after hernia surgery?

Speaker 2 (49:53):

Yeah, I do allow due to, uh, very easy aerobic exercise pretty much right away. Uh, if you measure tissue strength, you get about 70% of the final strength. That’s six three weeks in about 95% of the final tissue strength. That’s six weeks. So, uh, three weeks is a good start time to start, uh, exercises and usually right around six weeks you can start pushing yourself pretty hard. I encourage everybody to listen to their body. Everybody heals at different rates. So if, um, you know, six weeks after surgery you’re still going upstairs, slowly have a little trouble rolling out of bed and stuff, then it just makes sense to wait longer. But if it’s six weeks you’re, you know, bouncing out of bed and picking up all the grandkids and moving around fine, then just, um, go ahead and start pushing yourself.

Speaker 1 (50:42):

Um, is that true for both tissue repairs and mesh repairs for you?

Speaker 2 (50:49):


Speaker 1 (50:50):

Okay. And, and just to clarify, it’s a question on Facebook. I’ve been ignoring my Facebook group, I’m so sorry, I’ll answer those questions. Um, do you do more natural repairs or tissue repairs than mesh repairs or what’s your kind of, uh, practice look like?

Speaker 2 (51:08):

Yeah, I do mostly pure tissue repairs. Um, uh, just because I take mesh out so often that, you know, it just scares me to put it in. I’d hate to put it in and then have to take it out six months later or a year later. So I do mostly pure tissue repairs. Uh, I know you like the mesh repairs for the femoral hernias, but I, I usually do cure tissue repair version for those also. Is

Speaker 1 (51:32):

That the McVeigh repair you do for those? Yes. And what are your thoughts on the desta? We’ve had questions about that.

Speaker 2 (51:40):

Uh, the Desta uses a flap of the external bleed to reinforce, uh, or use. Is that the, as the only method to fix the hernia? In other words, uh, it takes a piece of the external o bleak aosis and comes down and covers the hole. I don’t think that’s strong enough. Uh, so what I usually do is often do, will be a, for direct hernia, often will do a ceia or should ice for the floor and then use it as starter on top of that to, to reinforce it. So I combine the two.

Speaker 1 (52:12):

So I had a professor, he was my mentor when I was on my first job as faculty at U usc. His name is Dr. Um, Dr. Uh, I can’t believe I can count it. Uh, so he, he actually trained in the fifties mm-hmm. <affirmative>, um, back when NI Houston in Conan then were, were doing surgeries as well. And there was a technique very similar to the disorder technique that they were employing. Then when we use the external oblique, a neurosis as your patch, um, and the failure rate, Dr. Byrne, I can’t believe I dr by who has since passed away. I’m sorry to say. Um, so I asked him about about the desa and he said, oh, we did that when we were like, when he was a resident. Um, and we abandoned it because the recurrence rates were so high. So from what I understand are the desar, historically that technique was named something else before and was abandoned because of high recurrence rate. What are your thoughts about the DESA in terms of recurrence rates?

Speaker 2 (53:21):

Yeah, I wouldn’t do it just to desar. So I usually combine it with some other tissue repair.

Speaker 1 (53:26):

Got it. Okay. Um, some patients, okay, so one question on, on Facebook is what’s the consensus on using a thin strip of goretex mesh? So it’s a goretex pro light ultra mesh, um, to help patch it as if it’s a da, but you don’t have enough tissue for a disorder. So you use a patch of goretex. Have you heard of that?

Speaker 2 (53:52):

Yeah, there’s various goretex as meshes. Um, I haven’t been fond of the goretex meshes because they just don’t get incorporated very well. Um, so they just kind of float around in there, even if you sew in there. So if you’re gonna get put mesh in, you know, put propane mesh in or something like that, I, I’m, I’m sure Cortex works occasionally, but I, it’s not, I’m not a fan.

Speaker 1 (54:15):

So Goretex mesh has been shown to shrink by 40%. So it was used for ventral hernia repairs because we have better mesh for, um, to put a round bowel and then we stopped using it because there’s better products out there, but it shrinks by 40%. So it doesn’t incorporate well like Dr. Brown mentioned. So it doesn’t stick very well to the tissues. Um,

Speaker 2 (54:44):


Speaker 1 (54:45):

Partially because it doesn’t really cause much of an inflammatory reaction either. So maybe there’s a benefit there with pain. Um, but it does shrink 40%. So if you think, if I give you a shirt today and say it’ll be shrunk by 40% in six weeks, you may wanna buy an exercise larger in two sizes higher because, so the same is with the mesh. So some of the shrinking complications with mesh can cause chronic pain. That’s, that’s like my take on that. Everyone’s so excited about these questions. Thank you so much. So we have two more minutes. I would just like to thank Dr. Um, brown very much. You know, these, these questions are very difficult to answer if you’re not a specialist and it kind of stumps a lot of, uh, surgeons because hernias are, are done by most general surgeons. But in terms of specialty, uh, there’s maybe two dozen of us that do this as a specialty and, um, Dr.

Speaker 1 (55:49):

Brown is one of them. So we’re really, really happy to have you, Dr. Brown. Thank you for accepting, um, uh, my invitation. And, uh, just as a parting, I’m, I’m going to share the screen again. Uh, this pod this webinar will be posted on YouTube later this evening and I will share the, um, share that with you on all the different social media. So you could follow me on Twitter and Instagram and Hernia doc. Um, many of you’re watching me on Facebook Live, so just follow me on Facebook. I will post the YouTube extension of this if you wanna watch it again, re-review it, share with wherever you wish, um, on my YouTube channel. And, uh, just so you know, this started not only because of the pandemic and we’re all sitting at home and don’t have access to, um, doctors readily, but uh, I have a free patient discussion forum call, uh, www.herniatalk.com. Dr. Brown is one of the lovely surgeons that does respond to your questions and give his expertise on that forum. So please, um, go on hernia talk and, uh, talk to other patients that are suffering or have questions just like you and many of us surgeons that are also on it that help answer your questions. Thank you Dr. Brown.

Speaker 2 (57:13):

Thank you Dr. Towfigh. I appreciate the invitation.

Speaker 1 (57:16):

Thank you and we will see you again next week. Dr. Gina Adrales, if Johns Hopkins will be our specialist. Um, there. And thank you very much and goodbye.