Episode 31: Hernias, Hernias, Hernias | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

Talk live. Welcome to Hernia Talk Tuesdays. As you know, my name is Dr. Sharon Towfigh. I do this for you all every Tuesday night. The purpose of this is to answer any of your questions related to hernias. And every week we have a special guest. Tonight I’m your guest because I know that you have a lot of lingering questions that sometimes can’t be answered by our specialists. I hope you find this very entertaining and educational. You can follow me on my different social media platforms on Twitter and Instagram at Hernia Doc, many of you are currently on Facebook Live at Dr. Towfigh, and this video will actually be rebroadcast on YouTube.

Speaker 1 (00:00:59):

So as you know, I am a laparoscopic and hernia surgery specialist. All I do is hernias. Everything I do is hernias and we do a pretty good job, I think with a really amazing guests. We’ve had some really cool specialists from urologists and anesthesiologists. We have pain management doctors coming up, physical therapists, rehab doctors, gynecologists. We’ve had, in addition to colleagues of mine that do operations for hernias, we’ve had plastic surgeons, people who deal with chronic pain, the Shouldice Clinic was here. So a lot of great specialists and colleagues of mine that I know and trust are on Hernia Talk live with me. I invite them personally. I have worked with them, I know them, and so they kind of have my stamp of approval and we have really amazing surgeons coming up as well. But today I thought I would join you myself.

Speaker 1 (00:02:00):

We’ve been so focused on our US elections and I think now’s a good time just kind of decompress and discuss any of the lingering questions you have. Many of the questions you’ve had to date have been focused on whatever the topic of the week was, whether it was urology or sexual dysfunction or anesthesia issues. And so some of you had questions that maybe I would’ve been better fit to answer, but we couldn’t pick them out at the time of the original Hernia Talk live session because we were kind of really focusing on the specialist that I had as our guest. So I decide today’s hour will be focused on all your questions. Ask me anything you want. If I can answer it, I’m happy to answer it. Many of you have submitted questions through Instagram, some through hernia talk.com, which is the original impetus for this live session.

Speaker 1 (00:03:02):

And if any of you have not already become members of herniatalk.com, I highly recommend it’s free. It’s a discussion forum. Many surgeons are on it, including myself. I started back in 2013. We have thousand thousands of members and just a huge archive of questions that you can browse through and search through to help get some of your questions answered. And if you can’t find them, then you can submit the questions yourself and your peers as well as some different surgeon specialists will be answering them for you. So let’s get on with it. Many of you are already on here, as many of you are already on here as a Facebook Live, and so welcome to you all. I will start sharing my screen here because we have tons of questions that have been submitted. I don’t think we can get through all of them, but if we can, I will have done a great feed.

Speaker 1 (00:04:04):

Okay, so let’s start. Many questions were about pregnancy. This one was from a female. Any advice for women who have an inguinal hernia and plan to get pregnant within five years? We discussed this earlier, I think it was the session with Dr. Sharon Bachman. She’s a specialist over in Virginia in the Fairfax region. So Dr. Bachman has is really smart and she’s done a lot of research on hernias and women. Also Dr. Gina Adrales, another female hernia surgeon. With interest in women’s hernias, obviously I have a huge interest in it. So pregnancy is unique in that your abdominal wall changes during the nine months, and so any operation on the abdominal wall should be done judiciously. The belly button and the upper and mid abdominal wall in particular change a lot, whereas the groin area doesn’t really change much. So in general, as a rule, we feel that any hernias of the abdominal wall, so umbilical hernias, ventral hernias, diastasis repairs should not be done during your fertile years and should be delayed until you’re done with all pregnancies.

Speaker 1 (00:05:25):

Whereas groin hernias, it doesn’t matter as much and women get their anal hernias repaired before having pregnancies and have no issues during their pregnancy. There’s no higher risk of hernia recurrence, no chronic pain issue due to the pregnancy. And so we do recommend that if you have an inguinal hernia and it’s symptomatic, that means you have symptoms from it that you can consider a repair at any time. You do not have to wait until you’re done with all your pregnancies. So that’s what we think is true for pregnancy. That said, if you look at the data, there’s not a lot of good data, but the data that we do have, if you have patients that they looked at, patients that had inguinal hernias and did not undergo repair and saw what happened during their pregnancy, basically nothing happened. So the risk of you having an emergency problem or some inguinal hernia, growing hernia problem during pregnancy, if you don’t repair before pregnancy is concerned to be close to zero. Doesn’t mean it can’t happen, but it’s it’s, it’s considered close to zero. It’s not a reason to repair your hernia.

Speaker 1 (00:06:43):

However, for belly bio hernias, I think we had a belly bio hernia question here. Here it’s for should women with epigastric hernia wait until done having kids before repair? That is true. So the abdominal wall, a belly button, epigastric, diastasis, all of those hernias should be delayed in their repair until you’re done with pregnancy because the most amount of stress is actually against that abdominal wall. And so the thought is if you repair a hernia before pregnancy, then you get pregnant, the chance of that hernia falling apart I think has been quoted about one third. That’s a large number. Also, there’s a risk that you’ll have pain in the area from sutures pulling or if you have Mesh, the Mesh will not stretch and you can get chronic pain in the area where you’re not stretching or where you have stitches that are going to be pulled through as your belly expands. Whereas if you have a hernia that really doesn’t really bother you that much or bothers you a little bit, then you shouldn’t have any problems with it during pregnancy either. So Tracy shares on, she’ll be a future guest of ours. Great, very talented public rehab physical therapist, so thanks for delineation of the abdominal versus single. Yeah, they’re very different. And for pregnant women, they do act differently.

Speaker 1 (00:08:18):

The next question has to do with imaging. As many of you know, I should have been a radiologist. If the surgery thing doesn’t work out for me, I would be a radiologist. I love the arts and I’m like an artist. I have pain to draw and that’s kind of why I like surgery because anatomy is very much like a three-dimensional sculpture and you have to really, I know it and know how to navigate around it to be a good surgeon. Radiologists are also really good anonymous and they need to understand the three-dimensional body and then they need to understand the three-dimensional body and then be able to interpret it through a two-dimensional image like a CT scanner, MRI, and I really like that. So I think that’s really cool. So I actually published two papers on imaging and whether the type of imaging you do changes your diagnosis.

Speaker 1 (00:09:18):

So ultrasound, CT or MRI for groin hernias. And we found that ultrasound is pretty good. It’s about 50 50 sometimes, which are not good oz, but it’s better than a CT scan for small groin hernias. CT scans, horrible. Something like forget our data. I think something like 20% or something or less were correctly identified and the MRI was the best or about over 90% of the patients that got MRI got the correct diagnosis from imaging. And what we also learned is that the radiologists in general do not look at hernias as kind of high ranking in their list of things to look at. So look at cancers and look at like tumors and the vessels, but they don’t look at the abdominal wall. So you can have a hernia anywhere and it can show on the imaging but not dictated in the report by the radiologist.

Speaker 1 (00:10:16):

So anyone who’s seen me as a specialty consultation knows I read my own imaging. I demand that your ultrasound CT or MRI CD is actually given to me so that I can download the images. I don’t trust the report itself because for hernias I think I do a better job. It took me years to learn it, but it’s something that I enjoy and I’ve had a lot of patients. This question is very, very apt, which is how many times does it take to before an imaging is finally diagnosis it and it’s, it can be once or it can be 10 times. I’ve had people that have had years or decades of pain undiagnosed and if you went to their very first image, it was there, it just was undiagnosed. And they went from doctor to doctor to doctor, and each doctor read the radiology report and the radiology report said nothing.

Speaker 1 (00:11:19):

Didn’t mention hernias or specifically said no hernia. Usually they just don’t say anything because they don’t even look for it. And because of that one radiology report, that patient got misdiagnosed into other things. They got endoscopies, colonoscopies, maybe it’s endometriosis, should we block this and cut that? And if they looked at the first image, they would’ve done better. So that is super important to know. It’s not that repeating the imaging necessarily gives you the higher chance of it getting caught. It’s that you just need the right person to actually look at the images or re-look at images. And so I do offer them, any of you have actually asked me to do a consultation just to read your images. I don’t like to do that. I like to know the whole story, but it is something that I offer as an online consultation. Okay, another live question.

Speaker 1 (00:12:20):

Hello. I recently had open Mesh surgery on Inguinal hernia on the right side, 11 days postoperatively. Oh, okay. This patient is currently 11 days postoperative after an inguinal hernia repair on the right side. The bulge at this point is bigger than it ever was. I understand that this may have to do with swelling. My concern is that there’s a very tight ligament or tendon from the hernia area to the base of my penis. Very painful to walk. Is this common? Okay, so open Mesh hernia repair, depending on the size of your hernia, how much kind of tissue injury there was at the time of surgery may cause fluid or blood to accumulate and you can get really swollen. And so hematomas when you get blood there, seromas, when you get fluid there, if you’re on a blood thinner or take aspirin, the chance of blood is a little bit higher.

Speaker 1 (00:13:16):

So basically it’s most likely that the swelling in the area is not from the hernia coming back. It’s mostly directly a result of swelling and or blood forming in the tissues. Now that usually goes away and so your surgeon should be notified about it to figure out if there’s anything that needs to be done, but usually there’s nothing to be done. Ice packs look really well massaging the area works really well and with time, all of that should subside. Now for open surgery in the groin there’s also a phenomenon called a healing ridge. Healing ridge is basically a finger, it’s about the size of my finger, the width of it, and it’s a swelling that you feel along your incision that takes up to three months to go away and become flat. That is just a consequence of cutting multiple layers and then sewing multiple layers back together again. So don’t get too worried. Almost everyone gets a healing ridge. So I hope that that helps answer your question.

Speaker 1 (00:14:29):

All right, keep these questions coming. I’m happy to answer all of them for you. This is a question one of my hernia. Number one, away after the surgery. Well, depends on what you mean by never went away. If your bulging never went away, then either you have a fluid collection in the area which is mimicking your hernia or you have a weakness in the area. So the hernia itself is fine, but the muscles are weak or the Mesh is bulging for whatever reason. Sometimes some people get like a bridged repair. Imaging helps identify a lot of that. So if you do have bulging in the area where your hurting was repaired, you need to be evaluated for a fluid collection, a muscle weakness in the area or a bulging on the Mesh in the area, which sometimes replicates your symptoms.

Speaker 1 (00:15:32):

Okay, this is a question about hydrocele. For those of you that don’t know what a hydrocele is, it’s a sac of fluid. Hydrocele means water cele means like a sac or a like spherical accumulation. Hydrocele is a sac of fluid, usually in the scrotum. In men it’s less commonly in women, although it can occur in women. We don’t call them hydrocele seals. We call ’em cysts or a canal of cyst. So the question is, do surgeons that fix hernias typically treat hydrocele as well? Possibly. So because hydrocele seals occur a lot in children, either pediatric surgeons or pediatric urologists would deal with addressing a hydrocele. Again, usually in males and those same surgeons know how to fix hernias. In adults, if you have a hydrocele, we have to figure out why is the fluid in there because you have an isolated hydrocele or is the fluid there because you have a hernia upstream from the fluid sac. So there’s your scum has the fluid and then the fluid leaked from around from the fluid around your intestines. Everyone has fluid around their intestines. It’s about a teaspoon full or tablespoon full. It’s just enough to moisturize the intestines and allow them to remain moist and kind of move against each other. It’s like your body’s oil.

Speaker 1 (00:17:15):

That fluid may leak into a hernia and cause bulging in the scrotum called a hydrocele. So if it does, and those two fluids communicate, we call those a communicating hydrocele. If it’s not the situation and you just have a fluid communication that’s just called a non communicating hydrocele. So in adults, if you have a hydrocele, you’re usually sent to a urologist. Like how we had, we’ve had two urologists on Hernia Talk so far and the urologist will usually treat the hydrocele sealants like a surgical procedure. What sometimes they miss is the fact that there’s a hernia upstream. So they’ll fix the hydrocele and either the hydrocele comes back because a hernia which communicates doesn’t, didn’t get fixed, or no, they have a hernia and they need a second operation. So do surgeons that fix hernias typically treat hydrocele? So I do, I treat hernias and if there’s a hydrocele associated with the hernia, I would fix it at the same time.

Speaker 1 (00:18:26):

If it’s a large hydrocele, usually urologists address those because it’s further down in the scrotum and the testicle and so on is nearby. So usually the urologists address that There are urologists that do hernia repairs. We often don’t overlap as much as we should, and so if you ever hernia repair that involves a hydrocele, often we deal with it at the same time as a general surgeon, if you have a hydrocele that has a hernia associated with it, the urologist can also address it. But not all general surgeons and not all urologists can do both. I hope that’s helpful to your question

Speaker 1 (00:19:13):

Along the same line, this was from the same patient who submitted their question, what does reinforcing the abdominal wall involve surgically if there’s no obvious hernia? So this patient has a hydrocele, they went to their surgeon and their surgeon says, okay, we’ll deal with the hydrocele and then will reinforce the abdominal wall if there’s no obvious hernia. So if there’s no obvious hernia, there’s no need to do anything. But there may be a small pinpoint hole. So think of this because water can go through a crack. Everyone’s probably dealt with a roof leak. Sometimes there’s a pinpoint hole or some crack in the roof and it eventually leaks inside through your ceiling to try and figure out that process is really hard. But water does creep through those really small areas. So same occurs with hydrocele. You could have a pinpoint hole communicating from the area around your intestines and that fluid can leak into make a hydrocele.

Speaker 1 (00:20:25):

So some people put it like a stitch or two called the Marcy repair to close that hole. That is probably what they’re talking about. You definitely should not get a full tissue repair or a full Mesh repair of your groin hernia if there’s no obvious hernia. Probably what they’re saying is that if there’s a suggestion that the hydrocele is that a couple stitches in the area may need to be done, and that’s separate from the hydrocele procedure. I hope that felt all right. Let’s answer some more live questions. This is on our zoom based attending. So is it possible to get a diastasis recti after a laparoscopic angle or hernia surgery? My doctor noticed a diastasis recti. I’m a male in good shape and it makes no sense to me. All I can attribute to is the surgery, anything to worry about. Thanks for all you do.

Speaker 1 (00:21:22):

Thank you. Okay, so the answer is no, laparoscopy does not cause of any sort, does not induce or cause or promote a diastasis erectile. Diastasis recti is a usually genetic problem. So it can happen in women or in men, women, it’s often associated with pregnancy, but doesn’t have to be men is definitely very genetic. It can be associated with obesity, but it doesn’t have to be. There are plenty of thin patients with diastasis recti. If you see men, some men as they age, they stay, they keep their flat belly. Other men as they age, they have round her belly regardless of their weight. And that’s a very genetic kind of situation. So if you got a diastasis rec eye and you happen to have had a laparoscopic surgery of any kind, including an Anglo hernia, the two are not related. So I hope that I, I’ve heard that question before a couple times and we do so much laparoscopy. We don’t have people running around with all these diastasis recti.

Speaker 1 (00:22:34):

So no, it’s not related, but it may have been a coincidence that you had the two. Another live question. Yeah, Jennifer Wall. Shoot. Any questions today? Well, it has to be hernia related, but anything that I can answer that’s hernia related, I’m happy to do so to my top fans. Okay, another live question. I had an umbilical hernia repaired 11 years ago. I got Mesh in my belly. Wow, four to five times last year I underwent surgery to remove a benign mesothelioma filled with fluid. Could the Mesh be causing that condition? The oncologist said, no, I’m actually afraid of removing mush. Okay, so the short answer is likely not related. Depends on where this mesothelioma was in relationship to your hernia repair. So sounds like you had one failure after another and that’s why you keep getting more Mesh put in. I don’t like to put Mesh on Mesh on Mesh.

Speaker 1 (00:23:38):

Sometimes it’s necessary, but often just redoing the So undoing and redoing the repair is a better option than filling your belly with just more Mesh. Because Mesh doesn’t stick to Mesh. There’s no ability of Mesh to grow into Mesh or to stick to it. So those are very artificial areas where the Mesh overlap, and I don’t like that Mesh does stick to tissue. That’s what it’s made for to reinforce weak tissue. So when I see someone like you that has had multiple Mesh placed, I kind of like to do a forensic biopsy of your history and to see how big was the first one, how much Mesh was it put in, what was the technique, where was it sewn, et cetera. So I would, if you don’t have any problems and no hernia recurrence, leave it alone. But if you need another operation, seriously consider just getting a bonafide good redo of everything.

Speaker 1 (00:24:43):

And then with regard to the [inaudible], most likely not related to the Mesh. At least we haven’t seen that really reported. Okay. What are the risks in skilled hands with a Mesh removal with a robot for Mesh in the Anglo region? Percentage-wise, what is a risk of making matters worse? My main fear is neurectomy. Okay, that’s a good question. In fact, I can’t give you the data yet because it’s being in about four days we’ll have the data, but I do a lot of Mesh removal. As you all know, I do a laparoscopic robotic and open depending on the needs of the patient. If you are being told that you need or would benefit from a robotic Mesh removal it, my theory is that robotics if done by a skilled surgeon, is actually better than doing it laparoscopically. We’re looking at our data where we’re comparing my patients who had a laparoscopic versus the ones who had robotically.

Speaker 1 (00:25:50):

Our initial studies showed that the robotic patients did better with less bleeding and less nerve injuries. The problem is that we did follow that through for more years and they actually were about the same. So if you have a good laparoscopic surgeon or good robotic surgeon, the outcomes are pretty about the, pretty much about the same. The risk if it’s an abdominal wall, neurectomy is like a non-issue. We usually don’t involve any nerves in taking Mesh off the abdominal wall. If it’s robotically removing Mesh from the groin, there’s really only two nerves that are at risk and that’s the lateral femoral cutaneous nerve, which is almost never involved, and the genital femoral nerve, which can be involved. So if that nerve is giving you pain currently, then a neurectomy may be necessary because that nerve is involved in the Mesh and I don’t know why you’re having the Mesh removed, but if you currently don’t have genital femoral neuralgia and your surgeon would be able to help you identify that, so that would be kind of labial or scrotal skin sensitivity, sometimes inner thigh pain, then usually we don’t have to touch the nerve. In fact, most of the patients that undergo Mesh removal by me, laparoscopic or robotically or robotically do not need any neurectomy. So that’s usually a good thing. I hope that it helps answer your question. Okay. More live questions.

Speaker 1 (00:27:38):

Okay, so this patient says after 80% of my Mesh was removed, it was tested, a results came back, foreign body reaction associated with fibrosis. Sure, the remaining 20% be removed as well. It’s only logical, right? No, we actually published on this because this is a very important point. Every single implant, whether it’s suture or stapler or hip replacement, breast implant or Mesh, will be sent to pathology when removed or can be sent to a pathology when removed and every single one will say foreign body reaction associated with fibrosis, every single one. That’s just what happens to foreign bias. It’s not a negative thing. So we actually looked at all of our patients that where I removed Mesh or actually removed any foreign body suture tax, a hundred percent of them pretty much had the same diagnosis, foreign body reaction associated with fibrosis. However, the reason for Mesh removal was random.

Speaker 1 (00:28:53):

Some of them had a hernia recurrence, some of them had more Mesh put in. Some of them had an actual Mesh reaction. Some of them had chronic pain, some of them had neuralgia. There’s a lot of people that had direct Mesh problems and others who had no Mesh problems, but they needed their Mesh removed for another reason. All of those people had the same pathology. So the fact that your pathology shows you had a foreign body reaction, that’s a pathology diagnosis. It means your body has identified the Mesh as a foreign body, which it is. It’s not a nefarious diagnosis. It doesn’t imply that you’re reacting to the Mesh. It doesn’t imply that any portion of the Mesh, it doesn’t predict that any portion of your Mesh is causing any problem. We actually don’t have pathology currently to be able to identify that. I hope that’s helpful. A lot of people get this pathology diagnosis and it freaks them out because they’re like, oh my god, I was, see I was reacting to this Mesh all this whole time. You may have been, but it’s not because the pathology showed it. The pathology will show it whether you’re reacting to the Mesh or not. I don’t know why you only had 80% of your Mesh removed and not the other 20%, but the pathology report should not be a reason for you to go out for the other 20%. I hope that’s helpful.

Speaker 1 (00:30:18):

Okay. Another question, actually, hold on. This one was submitted earlier. Let’s go to that question. This one has to do with incipient hernias and so on. So the question is as follows, is there such a thing as an incipient hernia due to attenuation or weakening of the transverse cells, fascia or other component of the England canal? Okay, so very technical question. I apologize, but that’s how it was worded. So incipient hernia, I assume means a hernia that is occult or impending. So yes, a direct hernia, there’s direct indirect femoral. Those are three hernias in the groin that are most common. A direct hernia is a weakness. It’s usually not a punch dot hole like most hernias. It’s actually a weakness. And so it’s like a stretching out of the fascia and you can be at various stages of that. You can be at the early weakness stage or you can be late stage where it’s like there’s bowel in it. So it’s possible that a surgeon was in the groin and said, oh, there was a impending or very early stage direct hernia and weakness that that is possible. So yes, there is such a thing. And if the incipient hernia exists, can it cause symptoms and if symptomatic how it should be managed?

Speaker 1 (00:31:56):

Good question. We don’t know enough to say if incipient hernias are symptomatic, they can be. So there are patients where we go in surgery if we see an impending hernia, we do address it. If the whole purpose was to address groin pain or an angle hernia, whereas we don’t really know if there’s an recipient hernia prior to surgery, most images would not show you that. So it’s more of a kind of finding intraoperatively. We think they can cause symptoms in some patients, but not in most patients.

Speaker 1 (00:32:39):

How do you define osteitis pubica and what is its cause? So osteitis means inflammation of osteum, which is the bone. Pubica is a pubic bone, so it’s inflammation or pain at the pubic bone. There are multiple different reasons for it. It could be due to trauma or any type of inflammation in the area, which can be from rheumatologic problems or instability of the pubic bone. Any kind of weird tensions on the area can cause it. Some specialists believe persistent or recurrent osteitis pubica as associated with the structural abnormality that might benefit from the intervention. Could be depends on the patient and what their activity level is. You have to kind of correlate what they do with what their symptoms are. If you have an unstable pelvis, whether it’s like due to, we have a patient today actually with unstable sacral iliac joints and she very well may have some element of osteitis pubis because of the instability of her multiple pubic bones against each other and she may need a stabilization, like an actual surgical stabilization of the area.

Speaker 1 (00:34:00):

And then in addition to steroid injections on platelet-rich plasma, what other treatments are there for pubic? Those are the most common. You can actually shave it down and release any tensions on it or you can treat the primary problem whether it’s rheumatologic or pelvic instability and actually surgically stabilize the bug. Okay. Getting tons of online questions. I love this. Okay, I’ve been sick immediately after August 11th when my surgery was done. I currently have Bard and Dave all Mesh six by 10 inch. Can you have a four body reaction immediately? I’ve had brain fogs and surgery. I’m sick all the time. The short answer is yes. We had a great hour, which I highly recommend you watch with Dr. Traver. He’s a rheumatologist who is actually one of the more experienced people in foreign body illness, whether it’s Mesh illness or and Mesh reactions or breast implant illness. And what you’re referring to is called the Asia syndrome or Shoenfeld syndrome and it’s a kind of an abnormally high inflammatory or autoimmune reaction to an implant such as Mesh. I think people have heard me say this before. So Mesh comes. There’s tons of different types of Mesh. There’s thousands of different types of Mesh that have been made.

Speaker 1 (00:35:32):

Usually when we talk about Mesh input unless we talk about synthetic Mesh, but you can the same reaction to biologic Mesh, everyone’s and even into hybrid Mesh. So not as common but more common with synthetic Mesh. The reason for that is the synthetic Mesh is intended to cause inflammation and the inflammation then dies down after a while. In some patients that inflammation is hyper inflammation and goes on and on and on and on. And brain fog is usually a symptom of inflammation and so surgery can give you brain fog. Anesthesia can give your brain fog. Usually that all goes away. But if you have an implant that’s causing inflammation, that could cause brain fog. So yes, in my experience, most patients who have a true Mesh reaction, that’s a systemic reaction. Were head to toe. You’re having symptoms, rashes, headaches, brain fog, chronic fatigue syndrome, blurry vision, ringing in the ear, joint pain and swelling, burning pain, weird nerve pains.

Speaker 1 (00:36:35):

In those patients that have such a Mesh reaction, it tends to occur anywhere from day zero to day six months after about six months, the chances that your symptoms are due to that Mesh implant are lower, not zero but lower. So yes, it can often be immediate. You kind of have to let it ride for a while because it may be a temporary problem. So if you had surgery August 11th, it can’t be for the Mesh unless it’s really severe. I wouldn’t recommend having another surgery until you can make sure that it doesn’t just go away on its own over the next month or two. But yes, in order to answer your question, you can get sick immediately and then have the Mesh reaction kind of mess with your brain.

Speaker 1 (00:37:37):

All right. Let’s go back to the Mesh removal question. So this is the patient that had 80% of his Mesh removal and then the pathology showed a fibrosis and foreign body reaction, which is expected. The question was should he remove the other 20% because it sounds logical. So he follow up by saying, I asked because I have no more pain where the Mesh was removed, but a lot of pain where the Mesh and 11 attacks remained. I had a core muscle injury, no hernia. The reasoning for leaving 20% inside of me was a doc doctor’s assistant said because the remaining Mesh was intact. No further explanation was given. I don’t understand it because Mesh shouldn’t have been used in the first place. They said for a core muscle injury, but that’s a different issue. I appreciate the reply. So yeah, the Mesh should be removed if that’s causing your symptoms or maybe the tax are causing your symptoms, but it doesn’t need to removed because the pathology showed that. So it’s more of a diagnostic dilemma where you’re starting to figure out and see what’s in your best in your needs.

Speaker 1 (00:38:55):

Okay, let’s go back to the other question. This is from the patient that was sick immediately after surgery and is concerned about a Mesh implant illness. The Mesh I had placed is Ventralex ST. Ventralex ST is a lightweight, polypropylene based Mesh, which is currently under lawsuit. I think all Mesh are under lawsuit, it’s not a Mesh that has been recalled. That’s very different. My surgery healed up nicely. I watched the video with Dr. Barrett. It was awesome. Thank you. Well thank you for watching. Another question. Thanks for all these questions. I love it. I have had groin nerve pain ever since I had inguinal hernia repair four years ago. It’s painful to sit. You just mentioned neurectomy of the ilio inguinal nerve. What does that entail? I did not mention ilio inguinal nerve, but I’m happy to discuss it. So the ilio inguinal nerve is a nerve that runs from your back to the front of your groin area.

Speaker 1 (00:39:56):

If your hernia repair was done in open fashion, whether with Mesh or without Mesh, that nerve is at risk for injury. And if you have pain that’s nerve pain, very different than Mesh pain or hernia pain or muscle strain or muscle tear pain, then the nerve should be blocked with local anesthetic to see if the pain goes away. If it does, then you need more blocks or have the actual Mesh, the nerve cut and you actually physically cut the nerve. Some people ablate it so they either burn it or burn it or freeze it. You can burn it, freeze it or cut it. The cutting is surgical, the burning and freezing is through the skin, so it doesn’t involve an actual scar usually. So I would be very cautious about willy-nilly cutting nerves. Got to be make sure that it’s definitely a reason for it.

Speaker 1 (00:40:58):

Okay. Another live question. I know all about the on and on of inflammation related to Mesh and how it can make you feel. What, if any, are the long-term effects of this constant state of inflammation? Thank you for your question. We don’t know. We basically don’t feel there are any long-term effects in that. Once you remove that inflammatory Mesh, the body should go back to normal. It may take some time to kind of wash out the toxins so to speak. As far as we know, there are no long term effects. Now, chronic pain is a different issue. If you had chronic pain, not just the inflammatory response but actual pain that the longer you deal with chronic pain, the longer it takes to heal back from it, it’s possible to heal back, which just takes longer.

Speaker 1 (00:41:54):

But as far as we know, a constant state of inflammation that you’re talking about, which is like a four body implant once addressed, does not have long-term side effects. Okay, these are awesome. Okay, more Facebook like Facebook is on fire. All right. Four Mesh implants and a partial removal. Oh, is this my patient from the earlier discussion about the four to five? No different patient. Okay, let’s see. Four Mesh plants and a partial removal. Now the scar tissue is growing around my rectum and bowels. They couldn’t cut the forearm out of my four muscle points. That sounds like a pelvic Mesh issue. I don’t do pelvic Mesh. That’s a seriously complicated situation because there are much more nerves and critical structures in the area.

Speaker 1 (00:43:01):

I would highly recommend you see people that do urogyn and do a lot of pelvic Mesh removal because that’s super, super tricky. So I can’t answer your questions about Mesh removal for stress urinary incontinence or a type of bowel or bladder issue. Sorry. All right. Going back to the Mesh implant illness. Thank you. Chronic pain and brain fog were my biggest symptoms. This is the patient that had the Mesh implanted and in August and has brain fog. When the pain increases, the brain fog increases. I’m in the neuropsych field, so I was curious if the two were related. I appreciate the time stay. Well, yes, this actually, so if you’re in the neuropsych field, there’s a great paper that was just published I think a year ago, which correlated brain fog as a symptom of inflammation and that brain fog is secondary inflammation. It’s kind of a cool study if you’re nerdy like me and to read scientific journals.

Speaker 1 (00:44:10):

Okay. All right. Let’s go back to our zoom people. How effective is neurectomy if resected, should it be an anterior approach or retropubic cutting the nerve approximately an injury motor nerve. Okay, you kind of answered that question yourself. Neurectomy should be done as close to the injury as possible. The further up and towards your spine you go with the nerve and cutting that, the higher the chance you would get some adverse effects from the cutting the nerve. Most of these nerves ileo inguinal for example, by the time they hit the groin area, they’re what we call sensory nerves. They cause they help with sensation. So if you cut it you will lose sensation. But they don’t usually have motor function, which means it doesn’t like your leg will still work for example. But the higher up you go, the more motor nerves they have. So they cause function of muscles. So for example, we used to do laparoscopic nuerectomies, which I’m not a big fan of anymore. The reason for that is we cut those nerves really close to the spine and what happens is that nerve, it addresses everything but it’s kind of a radical. So what happens is you also lose motor function of your abdominal wall and so one side of your abdominal wall will be weaker than the other. It’s like a terrible complication. So yeah, it should be cut as close to and proximal to the injury as possible.

Speaker 1 (00:45:47):

Okay. I recently met a hernia specialist and explained low grade deep soreness bilaterally after my inguinal hernia surgery. Apparently my surgeon used permanent tacks, which is fine. He suggests removing the tack and keeping the Mesh if it’s in place, what is the likelihood that the removal of the tack can alleviate this and giving back to normal? Have you ever just tack? I have just removed tack, but tack do not cause a low-grade deep sot cause a very specific area of pain at the tack. So if you have one tack and it’s right next to a nerve for example and that causes you pain, I could take out that one tack and leave the rest of your Mesh intact. If you have 30 tacks, which I’m implying is too much, you should have three to five tacks maybe if you have 30 tacks. So overuse or misuse of tacks in the groin, that can cause severe muscle spasm and removing of all the tacks can help. But if you’re in the middle where you just have a normal amount of tacks and you have a vague groin pain or something, then removing the tacks should not be the cure all. I need more. No more information. I don’t want you to take my word for it without more information from you, but in general for the groin, removing the tacks for non-specific pain is not going to treat your pain because usually the tacks are very specific in the area of the pain.

Speaker 1 (00:47:30):

Okay, continue if that is the case, why do many Mesh removal surgeons? Oh okay. Here’s a question going back to the triple nuerectomy. If that is the case, why do many Mesh removal surgeons continue to perform laparoscopic triple neurectomy close to the spine If a patient had bulging from a lab, triple neurectomy on one side isn’t the same procedure on the opposite side a bad idea. Yes, it’s a bad idea. Don’t do it. All right. I’m going to give you a little bit of surgical history. Somewhere about 10 or 15 years ago, I think in Belgium, somewhere in Europe, a surgeon talked about this kind of laparoscopic neuro, this kind of surgical neurectomy in the back and then around 2008 or 9 I said, well maybe instead of cutting these nerves where it’s difficult, we’ve already had hernia surgery, lots of scar tissue, et cetera, we can go away from that surgical area and go to the back.

Speaker 1 (00:48:40):

So I did like about 200 patients, 200 cadaver study where we examined the anatomies like 400 different nerve anatomies, about 1200 different nerves were identified and logged in. And I took that information and presented it at a surgical conference so that people could understand the surgical anatomy back there cause it’s not exactly like the books. And then with that surgical anatomy we said okay look, we can now address those nerves back there. And it wasn’t really clear back then back in 2008 or nine. It wasn’t clear back then how much motor function those nerves have. In fact, to this date, if you look at any anatomy book, it says those nerves, the ilio inguinal, hypogastric, general femoral, not general ilio inguinal, it’s still to date says those are purely sensory nerves. Well they’re not because I started doing these and I gave a talk where I had done three and I was giving so proud of myself because I said, look at this great new technique, it’s laparoscopic, you don’t need to go in there and deal with the hernia. And the patients did it very well. Then patient number four or maybe five got this bulging, how’s it possible?

Speaker 1 (00:50:01):

So then I stopped. I stopped, but I had already put out this information, this is a great idea. And other surgeons took it upon themselves to do it. And one surgeon who’s like does a lot of mesh removal published, I don’t know, I’m going to make up this number but it’s a lot of maybe a hundred patients and showed how great it is and how the pain goes away. And I talked to that surgeon and I said, wait a minute, I’ve stopped doing this because and I talked about it and when I give lectures I always say don’t do this. I talked about it and I said, I’ve had a patient that had this bulging and I’ve seen patients since then who had the bulging?

Speaker 1 (00:50:48):

You did like a hundred patients. Did you see that? Oh yeah, I saw it, but it’s not in your paper should that be listed as a complication because now you’re putting out this paper published in a very legit journal that says it’s a great new technique and it kind of pissed me off because you have to present your data as objectively as possible and if you’re having legitimately having 2, 3, 4, whatever number the patients is patients with this abdominal wall that’s bulging, you’re basically denervated the abdominal wall in exchange for the pain, which maybe for some patients that’s okay because they’re in so much pain, but man you need to change your technique or reduce the risk of it or put that out there. So that’s kind of the history of how it goes. I don’t do laparoscopic triple neurectomy the way I used to anymore if a patient absolutely needs it, it’s done as close to the injury as possible to reduce the risk of having motor injury. So yes, pisses you off too. I understand it could be a model to prove that it causes bulging. Absolutely. I wish more surgeons listen to me. I know and I give it. Every time I give a talk I talk about it. No one else is talking about it. Really.

Speaker 1 (00:52:12):

I think as lay people you see this, you think we must be horrible people. It’s kind of hard to change to put out information then try to retract it and when you have papers published which show no complications and then you see complications, people don’t necessarily read everything. So yeah, I am, the worst problem is there’s actually no good treatment for that. Once the Mesh abdominal wall is denervated, the only treatment is a tummy tuck basically suturing that all which you’re a candidate for but it’s a problem. Okay, sorry, I kind of get very emotional, but laparoscopic triple directory really bothers me because I’ve seen my own patients and other patients. You just have to change what we do with that. Okay, let’s see. More questions about neurectomy. What is the risk of exacerbating pain due to neuroma or phantom pain? About 5%. So we’re actually in four days have more data on that too because we’re, we’re going to publish our experience with neurectomy. About 5% will have worse pain or recurrence of the pain and they get a neuro and they need more surgery. Phantom pain, not as much but it’s more of a neuroma, so that’s about a 5% risk and of course the treatment is another neurectomy. Okay, shoot. Darn, I have such hernia Mesh implant illness in the midst of a medicine epidemic and we need to be able to be on a compassionate palliative care kind of thing until we can hopefully gain our quality of lives back for ourselves and our family.

Speaker 1 (00:54:01):

That’s so true because chronic pain destroys not just the patient but their family and loved ones at their work that many of us are losing because we can’t even take care of ourselves and no one but another Mesh rec patient can even begin to grasp exactly with the symptoms and paint our like when Mesh goes incredibly, incredibly wrong. I like it did in my case. Almost immediate by way. I’m very sorry to hear that. Our lives as they were before poly, poly Mesh, maybe polypropylene are just gone thanks to the residual Mesh coating. Not sure there’s any proof of that. I can understand problems with Mesh, but the residual Mesh coating has not been shown, at least in our studies. This whole thing is definitely comparable to cancer, the severe symptoms and severe pain. I have four friends that have had cancer, ended up with pelvic or hernia Mesh and all three said, holy she please give me back the cancer straight across. Mind you, at least we’d have a support system. I understand that not only do I, well I’m hoping that hernia attack is a little bit of a support system. I know it’s not, but it’s what I can do.

Speaker 1 (00:55:12):

I think it’s all I can do. I don’t know. You let me know if there’s anything else else I can do. Not only do I or we have severe symptoms on one side, then there’s a severe horrific pain on the side and I truly have zero quality of life to all things to the six inch femoral and seven inch inguinal hernia that was recalled. Most inguinal hernia Mesh was not recalled. So I’m curious to know what you had in you but doesn’t mean you can’t get injured. And to be fair, most I’m by most, I mean like 98% or so of patients that have problems with their Mesh, it’s very treatable. You just may make sure you’re treated by the right surgeon. It’s kind of why I do this. Okay, going back to the, so there’s hope. Going back to the brain fog question, we have four more minutes guys.

Speaker 1 (00:56:09):

You can have brain fog for three months. Oh yeah, yeah, absolutely, totally can. I’m currently seeking your expertise for removal. My life has been turned upside down since, I’m sad to say this, but I tried to end my life because of it. Yeah, you’re not the first. I just thought that it’s horrible, horrible, horrible. Could anesthesia cause you to feel like this? I have no pain. Just the anxiety and stress. So anesthesia can mess with your brain a little bit. Usually general anesthesia. We actually had Dr. Ma as our anesthesiologist to help answer those questions a couple weeks ago and feel free to reach out to me. I know that you have, and I’ll try my best to answer all your questions with an online consult or other type of telehealth consult, but anesthesia, once that is out of your system, that should be no longer a problem.

Speaker 1 (00:57:04):

Okay. Oh, I’m going to search for that paper I told you, but yeah, it’s a great paper. If I find it, I’ll post it. Thank you for giving us your time, your rock. Thank you so much. I appreciate it. My whole point to my comment here is if I could get rid of the horrific symptoms, I would think the horrific pain would be a bit more toil and I would like to have the ultimate neurectomy to have a better quality of life. Obviously make sure the neurectomy is going to cure you of your pain. If a nerve block cures you, then a neurectomy would as well. Of course, I’m always available if you want to initiate a consultation with me to make sure you’re in the right track. Hi, I have an upper epigastric hernia repair. June, 2018. I had intense pain, swelling and burning. That Mesh was removed six months later and a seroma was found containing mycobacteria, ooh, infected seroma with mycobacteria. I then had a and repair and no Mesh. Then my gallbladder was removed than I had even more symptoms of deep pain, swelling and burning and tumor hernias appeared. Sounds like you’re genetically prone to hernias.

Speaker 1 (00:58:18):

My last repair was for that in the abdominal walls pulled back together. Okay, again, there’s multiple different types of Mesh, so make sure you can discuss that with your surgeon about what’s the best Mesh for you. More of these. Okay, I try, I like to bring guests for you guys. I’m not the one talking can see my throat starts getting dry. I have to keep drinking water, but I try and bring specialists. You can get different views and bring my colleagues in so you can kind of know other people around the nation and the world who can help you all and give them some kind of exposure so that patients near them can, I’m happy to take care of everyone, but I can’t, many people do travel to see me, but if I can help you find someone near you or at least guide you through this the case through online consultation, I’m happy to do that.

Speaker 1 (00:59:22):

26 tax. Oh wow. Yeah. 26 tax. That’s a lot. If that’s for a groin hernia, that’s way too much Abdominal wall hernia, it’s possible you couldn’t get 26 tax. Why aren’t more suture repairs performed? We’re not teaching it and therefore generations have not taught it to each other. It’s kind of outmoded. Why don’t we wear bell bottoms anymore? It’s perfectly good to wear bell bottoms, but we just don’t, it kind of got outmoded by newer technology. Same reason why people don’t run around with unicycles. Although there’s, I’m sure there’s a lot of stuff collar, I’m sure there’s lots of unicycles that are superior to bicycles. We just don’t do it. I think we are overusing Mesh in the United States. There’s definitely a role for Mesh. I use Mesh in patients, however, it needs to be done judiciously and the some hernias do not need Mesh and some hernias absolutely need Mesh and then there’s like synthetic Mesh and biologic Mesh. So there’s a lot of options out there and this is what I do. It’s like my specialties, so I know a lot about it. Some surgeons do like 10 million different other operations too. And so the intention given to a hernia pair, like I say, it’s not just a hernia.

Speaker 1 (01:00:53):

So guys, lots of questions. Oh my god, does Mesh cause depression, anxiety, not in and of itself, but your symptoms from it can. A specialist in Wisconsin, Chicago area. I highly recommend you all go to the American, either herniatalk.com to search for that and for guidance in other states or to the America hernia society.com, a website. There’s a Find A Surgeon, so anyone who’s Americans Hernia Society member as a surgeon, we will be listed on that so you can find surgeons near you and hopefully that’ll help. Thank you. We are over time. It’s actually my birthday, so I have to go home and celebrate with my family. They’re waiting for me. So do follow me on all my social media platforms and I hope that all of you get the care that you need. If I can be of any assistance or if you feel that Hart Talk live is where you can get a lot of your questions answered, I’m happy to be that person that does that for you. In the meantime, everyone thank you and best of luck. I will post the link to my YouTube channel for this hour on Twitter, Instagram, and Facebook. And thank you for the birthday wishes and see you all next week. Another cool guest, take care.