Episode 35: All Things Hernia | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

Welcome everyone to Hernia Talk Live. This is our weekly question answer session live on Tuesdays. Thank you for joining us on both Facebook Live and on our Zoom registrants today. I am the person who will be answering all your questions. I’m very much looking forward to them. As you know, this is simulcast on Facebook Live and after we are done, I will post the rest of this session on my YouTube channel. I will make sure that you have all of those links on my other social media accounts including Twitter, at hernia doc and Instagram on hernia doc. So just want to first say welcome to everyone.

Speaker 1 (00:00:52):

I kind of enjoy doing these myself because it tends to be a kind of fast paced, more like a speed chess rather than regular chess session. So I’m okay with almost any question that you guys can want to ask. I will answer as many as I can. Last time we ran out of time, there were so many questions that were not only provided before this session but also provided live, and I’d like to do as many of them as possible. It’s almost the end of the year. We have one more hernia talk session. Next week will be our last one of the year. It’s going to be a fantastic surprise. It will be with another hernia specialist colleague of mine, but as a teaser, he is not only a hernia surgeon that I’ve relied on for many of my patients because I have patients in that state that reach out to me and he’s been able to help a lot of them, but he also operates on other mammals.

Speaker 1 (00:01:54):

That’s all I’m going to tell you and he’s going to share his experience with us about that. That’s next week, so I hope you look forward to that. All right, let’s get on with it. There are tons of questions that have already been proposed and I’d like to just go through them one by one. Some are simple, some are a little bit more complicated, and they’re all great and I’m always so impressed by the quality and level of questions that you all ask me. So the first question is what are the signs of a hernia? Well, we’ve been through this multiple times. Actually, my website has a lot of really good answers to the more simple questions like what is a hernia? How do you know I have a hernia? My website is beverlyhillsherniacenter.com. I also try to get some of those simpler questions answered on my Instagram because I like to post pictures.

Speaker 1 (00:02:51):

We had an interesting one early this week, which everyone got stumped on, but we can review that later. So what are the signs of a hernia? First of all, a hernia is any hole through any muscle layer. That’s a typical hernia. We call those abdominal wall hernias. You can get hernias that aren’t classically through the abdominal wall. Any hole, any hole through which something goes through that is abnormal. Some people call hernias. There are things called internal hernias where bowel gets stuck underneath other bowel or fat inside the abdomen. There’s a hiatal hernia, which I do not treat, which is more hernias by the esophagus, diaphragmatic hernias, which are through the muscle of the diaphragm. But in general, when we talk about hernias, we’re talking about a protrusion of something abnormal through a hole that shouldn’t be or as too large to accommodate normal stuff, and the signs of a hernia can be something as little as pain or as much as a big bulge and any combination thereof. Every so often you’re not going to have a bulge and you may not actually have pain, but you may have other symptoms such as bloating,

Speaker 1 (00:04:12):

Back pain, testicular pain. Those can all be due to a hernia and it’s not until you figure out other or rule out other causes that you say, okay, well maybe it’s a hernia or it gets sent to me. It’s more of these like Dr. House type consultations where they ask me, we don’t know what’s going on. Maybe you can figure it out and then it turns out to be something really rare. Perineal hernia was a recent one that I helped figure out. So back pain, bloating and testicular pain are symptoms that don’t, aren’t as classic, but can be due to a hernia.

Speaker 1 (00:04:54):

But most of the time there’s either pain at the site of the hernia or a bulging and or a bulging in the area as a major sign of signs of a hernia. All right, we already got tons of questions coming in live. Let’s go through them. Here’s one from our Facebook group. Lovely saying Hello. Okay. Is the potential damage from a robotic hernia Mesh removal inserted robotically a serious enough concern that one should consider living with mild to moderate pain and discomfort instead of risk of removal? No, you do not need to live in pain. Now, mild pain is different. Mild pain means life is fine. I can work. I have a normal family life. I’m not depressed. I can live with this pain, that kind of mild pain. You should not consider a major operation unless it’s seriously affecting, let’s say, some athletic ability or something else you like to do.

Speaker 1 (00:06:01):

But modern pain for sure should be a consideration for revisional surgery. Now, obviously you have to make sure that the cause of your pain is the Mesh or the hernia repair or whatever it is, but robotic surgery or robotic removal of Mesh is considered complex. It’s considered, has tons of risk to it, but in the hands of a specialist is actually really good and should cure the vast majority of people. We submitted our are, let’s see, we looked at laparoscopic and robotic surgery. Both were super safe. There are some risks of vessel injury in a handful of patients. Again, still super safe. Almost everyone is cured of their pain and what I mean by almost everyone is upwards of 80%, so that’s cure, not better, just cure and everyone else is either not better or needs other things to be addressed before they’re cured. So for mild pain, major surgery, probably not the best idea for moderate pain.

Speaker 1 (00:07:10):

If you have a specialist who does this for a living, not like, oh yeah, I can do it, sure. Then finding a good specialist that can do it and we’ve had many of them on this site on this webinar, then I would definitely consider it because your quality of life is very, very important. I hope that answers your question. The other question is do you work with Cigna International Insurance? Do hospitals where you perform robotic surgery of Mesh removal work with Cigna? What is the difference between open and robotic method in terms of efficiency? Okay, so good questions. All the hospitals and surgery centers that I work with are in network with the majority of insurances. You can always call my office to double check that I am out of network. So if you do have an insurance that has out of network benefits, then we can work with that. Otherwise, we offer like a discounted cash rate for people that don’t have the ability to pay at least partially with their insurance. I hope that clarifies it. It’s very complicated. This whole insurance thing, basically the hospitals, yes, they’re all pretty much in our including with Cigna, including with international insurances. So the next question is what’s the difference between an open and robotic method in terms of efficiency?

Speaker 1 (00:08:47):

We don’t talk about efficiency. It’s either appropriate for robotic or appropriate for open. If you have a surgeon that knows how to do both, then usually your surgeon will tell you in your specific situation what is a better operation. So in some people, so I do both. I do laparoscopic robotic or open surgery, I do Mesh repairs, I do non Mesh repairs. So depending on the needs of the patient and where the hernia is a robotic or an open procedure may be more appropriate or a laparoscopic procedure may be more appropriate. It’s not about efficiency. We don’t look at efficiency, we look at efficacy. So which one is the most efficacious hernia repair for you? All right, let’s go to our zoom population. I have minimal to no pain unless working out. I would like to get back to the gym, but I’m nervous about Mesh and I wonder if open repair can further weaken the muscle.

Speaker 1 (00:09:44):

Can you comment on your robotic tissue repair? Are they only a solution for a fraction of patients? So good question. This is a patient I assume with a groin hernia because we’re only talking about the robotic tissue repair for groin hernias. So I do offer that it is another option for a non Mesh tissue repair. I believe it should only be restricted to small, indirect or direct hernias, not to anything large and not to anything recurrent as an elective operation, and it should not be done in anyone that is obese. So thin or normal weight. People with small hernias are candidates for the robotic non meshed tissue repair for the groin hernias. That said, if you want to have the more traditional open Inguinal hernia where there’s very few restrictions as to which hernias are best for that, this notion that it weakens your muscle is not valid.

Speaker 1 (00:10:55):

That’s kind of a layperson’s way of discussing it. Weakening of muscles has to do with if you lose a nerve function to the muscle, but hernia repairs do not weaken your muscles, whether it’s Mesh based or tissue based, so that’s not something you should worry about. Next question. All right, I love these a lot coming in and I have tons that have already pre-prepared because you guys sent them to me by email, so I hope to get some of those in there too. Okay, next one. I had a left direct inguinal hernia repair with 3D max light prolene. All okay, Mesh laparoscopically in 2015. Okay, so left direct hernia repair, laparoscopic. For two years I’ve been having pinching pain an inch toward the center from my left hip bone. Massaging soothes pain, I feel gassy, but I don’t think it’s gas.

Speaker 1 (00:11:57):

I also get lower back pains for the past two years, so lower back pain can be due to a recurrent hernia. Just so you know, I’m 195 pounds six foot tall. So normal weight. What could be causing this pain, removing the Mesh, what repair would you do? What would you recommend? Can it be sewn up without any material such as Mesh? Again, laparoscopically. Okay, lot of questions there. So this is a patient 2015, had surgery did fine sounds like until 2018, so three years of okay and now has some pain. So anyone that had a hernia repair and was fine for years and now has problems is someone who most likely has a hernia recurrence. Most chronic pain patients that have problems with their Mesh or their repair or a nerve injury or whatever Mesh folding, those typically occur within the first year. So if you have someone who had no symptoms for multiple years, which it sounds like this one, then the first thing I would do is to do an evaluation to see if the hernia has recurred.

Speaker 1 (00:13:06):

Hernia. Recurrence is best evaluated, number one by examination and number two by imaging and if you’ve already had Mesh in you, the best imaging is an MRI ultrasound confounds it because the Mesh kind of doesn’t get visualized fully and is too deep relief for a lot of good ultrasounds. It can be done, but only in really, really high tech places like Cleveland Clinic where they have special high 3D ultrasound and more importantly a radiologist that likes to do those things very hard to find. CT scan is not helpful because it doesn’t have enough specificity and sensitivity to look at the groin and pelvis area. Plus Mesh looks just like muscle, so it’s hard to tell if there’s a Mesh problem versus a muscle problem. MRI is the best. It’ll show you where the Mesh is, it’ll show you if you have a small hernia recurrence and that’s the next step that I would take.

Speaker 1 (00:14:09):

Okay, next question. I’ve had phasix Mesh removal in March due to foreign body reaction. I’m still dealing with systemic issues including pain, some nausea and fatigue. Have you seen any patients take longer than a year to recover? For those of you that are listening, phasix is a synthetic absorbable Mesh. The intention of making that Mesh is to prevent having a foreign body in you forever. Whereas so after about 18 months, it’s supposed to start dissolving and after 18 months, the thought is that you don’t need the Mesh anymore. Now the studies are not ideal. It shows it’s pretty good, but it’s not perfect. So it’s definitely is not a replacement for any synthetic Mesh. So your typical Mesh is synthetic polypropylene polyester, ptfe and it’s nonabsorbable, it’s permanent. That is considered the gold standard. phasix is synthetic. It’s made by, it’s his fancy name, P four butal something and it’s absorbable. So after by 18 months it should be out of your system or start to resorb.

Speaker 1 (00:15:32):

It’s an interesting idea. Why do you all need Mesh in you permanently, especially in someone who maybe needs multiple operations in the future for other reasons, then it’s best not to have to go through Mesh each time. So it’s a good idea for some patients, I don’t think it’s the go-to Mesh, it has not been shown to be superior or even equivalent to the standard Mesh, but in some patients for me it works. I personally do not use phasix Mesh for two reasons. One is a super expensive and two, it is quite inflammatory. So the patients that I treat that need hernia repair and for whatever reason are not good candidates in my view of the standard synthetic permanent Mesh. Let’s say they have an allergy or they react to it or they have an autoimmune disorder or they have sensitivities to certain implants and you don’t want to introduce that in those patients.

Speaker 1 (00:16:38):

I have chosen not to use pH because it is still quite inflammatory and a lot of these people who don’t do well with Mesh products, it’s not because they have an actual true allergy. It’s that the inflammatory component of the Mesh sparks or worsens their underlying inflammatory state. So if you have someone like who has fibromyalgia, chronic pain syndrome, chronic fatigue syndrome, pots, anything that has kind of a sensitivity towards a hyper inflammatory response, certain autoimmune disorders, then putting in something that’s absorbable but still has the inflammatory component doesn’t make sense to me. So the question is after a year, they’re still having problems recovering. Number one, I would confirm that all the Mesh was removed. I have so many patients that are told that their Mesh was removed and you either see it on imaging or you go in there and you’re like, they didn’t remove the Mesh. They removed the easy parts of the Mesh, but they didn’t remove the hard parts. So that’s why it’s very important to make sure you’re operate on by patients that by surgeons that do this for a living because they take the extra step and understand the importance of removing every little bit. So if you had a systemic reaction or inflammatory reaction to Mesh, we call it Asia syndrome. A S I A stands for autoimmune or autoinflammatory stands for syndrome. I stands for induced bi.

Speaker 1 (00:18:26):

A stands for adjuvants, so autoinflammatory or autoimmune syndrome induced by adjuvant Asia syndrome. If you have that and you have a Mesh implant in you and you need to get that Mesh removed, every single little bit of that Mesh needs to come out. All of it, sutures, Mesh, everything. Leaving a little bit behind will not help you. So number one, make sure that the Mesh is completely removed. Double, triple, check that by imaging or by reading the opera report or asking the surgeon. And then number two, usually most of your symptoms should be gone by the first three months and the almost all of it by the first year. There are some people that have other underlying disorders that were not diagnosed that need to be diagnosed that are contributing to ongoing symptoms after the Mesh removal. So I hope that’s helpful. All right, let’s go back to our, okay, going back to the patient who had the question about the further weakening of the muscles with a tissue repair. If you’re young and have no other health issues, 185 pounds, six feet tall, so that’s pretty slim, and this is the first hernia, what would your typical recommendation be? Depends if you’re male and you’re athletic, laparoscopic with Mesh, if you are female and super thin, open tissue repair and then everyone else, pretty much we can discuss the pros and cons of each operation, but for

Speaker 1 (00:20:13):

Everyone’s a little bit different. Depends on what your family history is, what your personal history is, what your activity level is, how much recovery is important to you. Do you have any autoimmune disorders or tendencies or reactions to implants? All of those are important questions, but the short answer is you have a lot of options. You can have open tissue repair, laparoscopic Mesh repair, robotic tissue repair, not the best, but it’s an option. I’m not a big fan of open tissue repair because that has the highest risk of chronic pain.

Speaker 1 (00:20:52):

Okay, since I did say I will ask, answer any question, I have one that says, how do we get our qualities of life back after polypropylene poisoning? On my end, I had double recalled hernia Mesh. So the hernia hernia Mesh was, I hope we’re talking about hernia Mesh hernia. Mesh was recalled for the abdominal wall, the composites kugel and the, what’s the one by not phasix, but I’ll remember it. So only two sets of hernia. Mesh recall if they’re removed and your symptoms should be resolved. If they’re not, there are other ways to kind of help tame down any problems, but if you have, don’t have lingering symptoms, if it’s neurologic, that can be treated if it’s from a hernia recurrence or some scar tissue that can be treated. There’s a lot of treatment options once the actual hernia Mesh has been removed, if that was your original problem. All righty. All right, let’s talk about a form by sensation. Going back to the person who asked the question about, let’s see, the

Speaker 1 (00:22:23):

Efficiency of Inguinal hernias, it’s the answer that’s being proposed is it’s mostly foreign bias, sensation and regular mild soreness on and off, but occasionally quite uncomfortable. Dr. Belyanky is my surgeon. Well, I told you that we have the best or the best only on hernia talk. Anyone who comes on this webs webinar I bring, because I know them personally, I’ve worked with them, I’ve shared patients with them, I would be completely comfortable having them operate on me or my family members or whatever. If they’re not surgeons treat me or my family members. Dr. Belyanky was among the first that did my webinar, hernia talk live. So you’re in excellent hands, whatever he recommends, I will say go for it. And it’s super important that what you do is with a surgeon that you trust. And in the United States, you do have the luxury of traveling if you need to to other places. And we have a lot of specialists, so I know a lot of patients of mine who travel to see me, and if you are happy with your surgeon, great. If they’re your specialists and you’re lucky to be in a city where everyone, your surgeon’s a top-notch surgeon,

Speaker 1 (00:24:03):

Then perfect. But if you’re not and you’re in a town that doesn’t have tertiary care or surgeons with a lot of experience and you have a complicated situation or your health is a complicated,

Speaker 1 (00:24:18):

Please do use the resources available online. Hernia talk is one of them. And then travel. Save up if you have to and travel. Just prioritize your health. I can’t say it enough how important it is. I have friends that not friends I know patients that tell me they can’t afford to have, they’re very important reconstruction surgery because they’re saving to go on a cruise or a trip, and I just don’t understand that your health should be first. If you’re okay to spend and to save and then spend on a luxury, then your health should be one of your luxuries. You should really consider it as something that’s worth investing in. And I see so many people that don’t do that, and then they fall into this vicious cycle of complication after complication after complication. At the end of the day, they’ve lost their job, they’ve lost their quality of life, and it’s just not worth it. I just see it so, so often and just please invest in your health. I can’t say enough. My office helps so many people to get the care that they need, and I hope that you take advantage of that.

Speaker 1 (00:25:37):

All right. Good evening, Dr. Towfigh. Good evening. Thank you for joining us, everyone. Okay, next question. I would like to know your thoughts on double al laparoscopic hernia repair with six by six inch mush and a violent emergence from anesthesia. So actually that happens the younger you are. So young males tend to wake up from anesthesia in a much more violent manner, and by violent it means like they’re thrashing, they’re fighting and actually punching. You don’t remember. It is definitely nothing that’s done on purpose, but young males tend to wake up a little bit more violently then.

Speaker 1 (00:26:25):

Oh wow. So this patient had a torn rotator cuff and pulled rib muscles. Oh wow. I’m so sorry to hear that. That’s pretty extreme. I have not seen anyone actually get injured coming out of anesthesia. Okay, this happened in February of 2019, and I’m still suffering terrible groin pain. Lastly, I would like to thank you sincerely and also to all the guests you write. Oh, thank you very much. So in general, when you wake up from anesthesia for hernia repair, at least I insist on it. I insist what’s called a deep deep extubation or basically a very smooth, I don’t even want you coughing after surgery. You know when the tube comes out of your throat, I don’t want you to go, because even that’s extra pressure so early on a fresh hernia. Now that’s said in general, we do as much of our operation to be as safe and foolproof from different straining as possible, but if you actually tore your rib muscle and your rotator cuff, it’s very possible that you shifted your Mesh repair because it was so fresh and or you actually pulled a groin muscle. That’s also possible. So I would get evaluated for both of those. Imaging with an MRI will demonstrate a groin pull and will also show where the Mesh is, and it should be done with Valsalva, which the technique where you bear down. So that’s what I would recommend, man, I’m so sorry.

Speaker 1 (00:28:13):

You must be a young and very, very muscular male because that’s pretty harsh. Okay, next question. I have a 3D Bard Mesh implanted without fixation over 10 years ago. Now I deal with depression and anxiety. I believe it’s from the pelvic discomfort and sexual discomfort. Is Mesh removal worth a consideration? Okay, so if you had your 3D bard Mesh implanted with, so that’s a laparoscopically placed Mesh, it was implanted without fixation, which is how it’s typically placed. So that’s all correct and standard, and you had it 10 years ago. The question is when did your sexual discomfort and pelvic discomfort start?

Speaker 1 (00:29:07):

It’s possible that the Mesh folded or wrapped around your spermatic cord or both, maybe it folded and as a result of the folding wrapped around in all of those cases, Mesh removal is very, very effective. It’s like the way I explain it is because there’s no good treatment for like a Mesh or a bald of Mesh. The way I explain it is if you have a stone in your shoe, the best way to treat that pain is not narcotics or a cream. It’s to remove that stone in your shoe or that pebble. Remove the pebble in your shoe. So if the Mesh is pushing on strangulating, in invading, folding onto an area and it’s causing you sexual discomfort and pelvic discomfort, then removing the Mesh will have, I mean, you’ll wake up with a complete change. You’ll know the difference when you wake up after surgery. So find a surgeon who does that for a living and consider removing it. Yeah, definitely worth consideration. All right, let’s move on to our zoom members. Lots of questions. Okay, for recurrence on patients with Mesh, does this mean the same hernia protruded underneath the Mesh? MRI did show a small recurrence by the radiologist, but said he wasn’t a hernia specialist. Is there anything other than surgery that can help? If no, would removing the existing Mesh

Speaker 1 (00:30:39):

Help, and can it all be repaired without Mesh? What complications could happen afterwards? Yes, all options are available if you have a hernia recurrence from a laparoscopically placed Mesh. The standard care for that is an open repair. If you had a recurrence from an open repaired Mesh, this is hernia, Inguinal hernias, then the standard is to go in laparoscopically and repair it since you’ve already had a recurrence with Mesh. The thought is the logic is another hernia repair without Mesh will have an even higher recurrence rate because you’re already failed a Mesh repair. So you’re going backwards because we know that non Mesh repairs have a higher recurrence standard. So a primary repair, a primary repair done without Mesh has a higher recurrence than a primary repair with Mesh. Then if you have a recurrent hernia, typically that should be done with Mesh. Now you can have that discussion with your surgeon, and if you do not want Mesh anymore and you agree that you can, you’re at a higher risk for another recurrence and you need a third operation, that is something to consider and have a discussion with your surgeon. Also, note, there are meshes and there are meshes. There are synthetic Mesh. There’s heavyweight lightweight, ultra lightweight.

Speaker 1 (00:32:14):

There’s polyester Mesh, polypropylene Mesh, A P T F E, Mesh. There’s what we call hybrid Mesh. So it has only 4% synthetic product, and there are two companies that make those. So there are a lot more options nowadays than Mesh, and so I would have a good discussion with your surgeon about that.

Speaker 1 (00:32:34):

All right, so going back to the phasix Mesh removal patient who still has symptoms, one year later, Dr. Yunis did my removal. As you know, Dr. Yunis was also a guest, so he’s a very, very good hernia surgeon and does Mesh removals. Yes, you did see him talk on hernia talk a while back. The operative notes say that the mesh was entirely removed and he confirmed that. However, I have PDS and Vicryl sutures, both of which by the way, are absorbable sutures. So you should not have a foreign body reaction to them in Vicryl three weeks later, three weeks later, and for PDS eight months later. I imagine they cause similar foreign body reactions, but to a lesser extent, to a much lesser extent actually. Are there any that are less likely to Cause reaction? wire? We think wire has a least reaction, but Vicryl and PDS would be the next options, and we don’t like to put wire in people, at least not in the United States because it can break. All right. Can a direct hernia cause tenderness to palpation in addition to a spontaneous? Oh, I have this question prefilled for you already, except that

Speaker 1 (00:33:55):

I’m so bombarded by you guys asking me live questions. I don’t get to answer the ones that are pre-prepared. Okay. Can a direct hernia cause tenderness to palpation in addition to spontaneous pain over the mid pubic body or bone i e a location somewhat removed from the actual hernia? No, it does not. So a direct hernia can cause tenderness over the hernia, but usually direct hernias are not painful. There may be some discomfort or feeling of fullness or heaviness in the groin, but a direct hernia, which is not the most common type of al hernia, is just a muscle weakness, and so it’s more likely to have a protrusion, less likely to have symptoms. In general, everyone’s different and no, it usually does not cause pain or symptoms immediately along the pubic bone or pubic body. All right. Next question. Oh, another pre-prepared question. Hold on. Let’s see if I can get that for you.

Speaker 1 (00:35:05):

Oh, here’s a good one. This was asked on Instagram recently. I had a cricket ball hit me in the testicles. Can I have a chance to get a hernia? Well, hopefully you do not have a chance to get a hernia. No. Getting hit in the testicles will not cause a hernia getting kicked or stabbed. Well, maybe stabbed can because that the knife will cause, but not the testicles. Any injury to the testicles will not cause a hernia. So be careful playing cricket. Be careful playing cricket and don’t be afraid of your hernia pain. All righty. Okay, next question. This was also sent ahead of time. This is, can nerves become permanently damaged from chronic groin injury or hernia with delayed treatment secondary COVID such that the nerve will continue to cause pain even after the structural abnormalities repaired? Usually not any nerve injury due to a hernia, not hernia surgery, but due to just a hernia. It’s usually like at the most, it’s stretching of the nerve. There is one surgeon in Washington state that has done research on nerve damage, seen on pathology from hernias pushing on the nerve, but there’s no evidence that cutting that nerve or destroying that nerve is any better than just allowing it to heal once the hernia has healed. So no delaying surgery because of COVID for a hernia repair is perfectly safe and should not cause continuous nerve damage.

Speaker 1 (00:37:04):

And then the next question is a long one, but let’s ask that anyway. And that is if athletic pubalgia or sports hernia is caused by injury to the anteriorly located rectus abductor app, neurotic complex, very complicated question, at least in some cases, as some surgeons believe. How does a laparoscopically place Mesh, even if the Mesh extends below the pubic bone, as in the Manchester repair, help heal or stabilize the anterior injured structures as was demonstrated in Dr. Sheen’s randomized clinical trial of open suture repair versus totally extra peritoneal repair for treatment of sportsman hernia. So the thought is that a posterior stabilization of the rectus will reduce tension of all of the rectus off of the bone by offloading the tension onto the Mesh itself, which does not stretch. It does not affect the abductor strain, but it can affect the rectus strain. And the short answer is we just don’t know enough. But that’s one. That’s basically the thought process. All right, more questions. Good evening.

Speaker 1 (00:38:21):

Good to see you, and please ask her questions. Yes. Okay, next question. Four layers of Mesh, right angle hernia left side has one layer. Okay, so four layers. That’s a lot of hernia mesh and still plenty of metal coils. Last surgery, 2019, done in Dallas with a robot, right testicle pain and left pain from old hernia area. Last doctor to look at this God CAT scan and said he doesn’t see a hernia 2020, doctor Eunice, even, I’m sorry, with every surgery, all doctors said same thing. What are the odds of a 58 year old mate being repaired from the Mesh sandwich? I feel if there’s a removal, there will be a massive injury, et cetera. This seems hopeless death sentence. It is not a death sentence. Listen guys, I hate to tell you this, but I mean I’m a hernia surgeon, but I help quality of life.

Speaker 1 (00:39:18):

I don’t really save lives, and people don’t usually die or have death sentence from hernias almost every single, and by almost, I mean nine, 9.999% of hernia related problems is treatable, fixable. There are very few that I can think of. I’m trying to think of who I’ve not been able to fix even the most dire situation you can fix. You just need to very systematically go through the story, go through the symptoms, figure out what’s the best treatment option, and just do it. And you need a skilled surgeon who can actually physically do the operation. So four layers of Mesh plus coils and symptoms associated with it in my hands, I’d have to review all the details of why this all happened and forensically go through to see, try and figure out the decision making each time and when your symptoms started to figure out what you need.

Speaker 1 (00:40:23):

But I usually clean out, undo everything, clean it all up, and just start fresh so everything comes out. That’s usually my approach in these more complicated situations is not a death sentence. Listen, I work at Cedars Sinai Hospital. We are the number one heart transplant center in the world. Even patients with heart transplants don’t die. So to think that a hernia operation would cause death, I mean, I guess it can happen in emergency situation, elective situations, that’s usually not the case. So I’m happy to figure it out for you if you want to start an online consultation with me. But yeah, you should not have to suffer. Good to see you. Thank you. Okay, I have groin pain. Three years after Inguinal, Mesh was put through laparoscopy in Germany, no citizens or attacks. They said they don’t do it anymore. Is it possible that this groin pain is due to Mesh migration? I have no systemic symptoms. Only groin and leg pain, not necessarily Mesh. Migration is not common. Most Mesh sticks or is fixated if you didn’t have any tax or sutures or stitches, great. One less reason to have pain, and then you’d have to see if the Mesh folded or if the Mesh is in good position, sometimes inappropriate position or kind of shifting of the Mesh. But migration implies moving a lot. Imaging will help determine that in a good physical exam.

Speaker 1 (00:42:05):

So groin and leg pain, depending on where the leg pain is, has to be in the front of the leg or inner thigh, nothing below the knee. Those can be attributed to the two two al hernias. I’m happy to help figure it out for you. Okay, three ultrasounds, two CT scans all show different problematic results. I would review that. They should all be consistent if some may not show it, but they can’t have conflicting data. So I love imaging. I think imaging is super helpful, but you have to really be able to know what you’re looking at. Here’s a good question that was presented. I’d like to share that. Why does hernia pain persist after surgery and what can be done? Okay, hernia pain should not persist after surgery. It persists after surgery. If your pain was never due to the hernia, that’s the most likely reason, or actually that’s the only reason.

Speaker 1 (00:43:08):

If you had hernia surgery that actually fixed the hernia and your pain persists, then your pain was never due to the hernia. You had a hernia, but you didn’t need the hernia surgery to address that pain. So I would pursue other reasons like hip problems, pelvic disorders, autoimmune spine disorders, et cetera. So if you have pain after hernia surgery that’s different from the pain before the hernia surgery, then that can be worked up to see why that is. But if you have the same exact pain after hernia surgery and it actually was a hernia repair, then your pain was not due the hernia. Sorry, I’m remaining hopeful I can fix. Yes, I think about you all the time. I want to fix you, but you need a big operation and I’m not sure you’re ready for that. I’m happy to do it. Love you. What do you believe the cause of pain is an athletic pubalgia? Is it tendons rubbing against the bone? Is it due to fibrotic or granulation tissue? No, it’s the tension. It’s purely the tension and trying to tear muscle or tear the pubic off the pubic bone.

Speaker 1 (00:44:31):

All right. For inguinal hernia, Mesh removal for a man 37 years old implanted eight months ago, open Lichtenstein repairs. This is open groin. Typical Lichtenstein Onlay Mesh repair in the groin in terms of risk of neurectomy. So the risk of what happens to cutting the nerve and the risk of losing testicle and losing part of the soft tissue that became st the Mesh. What is the safest way? Oh, okay. So first of all, if you had an open tissue, sorry, open Mesh repair for your groin, the only way to remove that is by open. You cannot do laparoscopic or robotics. So take that out of the picture. You can’t even see a laparoscopic or robotic, not possible. So the question is what’s the risk of neurectomy? What’s the risk of losing a testicle? What’s the risk of losing soft tissue, losing testicle? Pretty much zero.

Speaker 1 (00:45:23):

You’d have to have a major damage from the Mesh to lose your testicle. It’s almost impossible. I’ve only had to remove two testicles from Mesh removal, and one of them was a tumor that was involving the testicle, so it wasn’t like a technical surgery issue. And the other one, why the one was his testicle. I think the Mesh had, I think, oh, he had had multiple prior operations and the Mesh had eroded through and just guillotine off the testicle. I think that’s what the situation was. So almost not zero, but almost never lose a testicle. That should be the lowest risk of all the different complications. Neurectomy is pretty high up there. So if you’re removing the Mesh for whatever reason, that Mesh may be stuck to nerves and by taking it off, you may be damaging that nerve. The way I describe it is the Mesh is like Velcro. If the tissue, the muscle and the nerves underneath it, it’s like cashmere sweater. So if you take Velcro and you put it on your cashmere sweater, it’s going to damage the sweater and cause it to kind of have these hairs on it and destroy it, the fibers a little bit. So if that happens to your nerve, you can have problems with the nerve and neurectomy is indicated.

Speaker 1 (00:46:52):

Don’t worry about losing the testicle in the hands of almost every skilled surgeon. That should be nil, but there is a risk of a neurectomy and that should be discussed with before surgery. So you’re aware of that and losing part of the soft tissue, it’s very little. It’s not even worth discussing how little soft tissue is removed with the Mesh. Very, very little. Do you prefer perform any inguinal Mesh removal surgery under local anesthesia with intraoperative, I don’t know what NR stands for. Yes, every single open surgery that I do that involves Mesh removal is done under sedation only with not general anesthesia. The laparoscopic and robotic Mesh removals have to be done with general anesthesia, but all other ones I do under local. My Mesh cause loss of sensation.

Speaker 1 (00:47:52):

So if you have numbness from a Mesh repair, that’s not because of the Mesh, that’s because of the nerve injury or nerve involvement from the surgery. The same risk is there whether you had Mesh or not. Any open hernia repair can cause that numbness if that nerve is cut or injured, whether or not there’s Mesh in place. Okay. Let’s do another one. Could pinching, could the pinching pain because from dissolvable tacks that may have left scar tissue behind, since it hopefully isn’t a Mesh movement because the hernia was far away from this hip pinching pain and recurred hernia, I feel pinching occurs more when leaning forward. Yeah, this is again the situation of having pain three years after your original surgery. The scar tissue should have been there at the time of the actual attack. So if the attack is gone that that should not be causing pain afterwards.

Speaker 1 (00:49:07):

If the attack didn’t cause pain when it was already there, I would still look over hernia recurrence as your number one feels like life and death for many of us. I understand that. It feels like it for sure. The depression, the anxiety, the poor quality of life. I understand that part, yes, but I just want to make sure people understand that it is not usually a death sentence to have any hernia problem. It’s a really bad quality of life can be, and all those are very treatable. I feel like people lose hope because they’re told it’s not their problem or there’s nothing to do, which is not true. Almost everyone that I see, I can treat almost everyone. 99% plus have a treatment option. They just have to choose to undergo that treatment and get the cure and be patient with me because not everything is a quick fix. Yes, I understand being ill for any reason can have serious consequences, but just know that in general people don’t die from the actual hernia surgery, which is fortunate. All right. Let’s see. Being told my continued growing pain is not related to my angular hernia repair. My left testicle is sore and swollen and I’m being told ultrasound showed mild varicocele seal more pronounced the left than the right testicle. There is significant scar tissue along this spermatic cord that is from the ablation surgery in January.

Speaker 1 (00:50:47):

I still cannot sit Ben without significant discomfort abdominal bloating. All right. Okay. Somebody is telling how they’re Mesh migrated and broken two pieces and now is repaired by sutures. So Mesh in general does not break in pieces unless it’s super thin. And there was one Mesh physio Mesh. That’s the one I wanted to talk about. Ethibond a physio Mesh is one of two Mesh types that were recalled in the past 20 years. Physio Mesh was so thin it actually tore. We thought thinner is better, lighter weight is better, but then this turned out to be too thin repaired with sutures. Great. I’m glad that that worked out for you. Death sentence from chronic pain and mental issues from the ride, not from the hernia Mesh. Correct. Yes. I just want to clarify. The hernia surgery itself should not be a death sentence. Autoimmune back pain, et cetera, saying quality of life is low, et cetera. Yes. Quality of life can definitely be affected by all sorts of problems, including big time and chronic pain. Yeah. I’m curious what kind of Mesh you had in that broke into pieces since, and then feel free to respond to me because I’m, I’m, I’m curious what actually tore in two pieces and was it groin or abdominal wall? That’s what I’d like to know because it usually happens with the much thinner meshes.

Speaker 1 (00:52:32):

Okay, here’s another good question. Can I have a hernia without a bulge? Absolutely. That’s part of what I’m famous for is these a cold hernias. We see it more in women, but a cold hernias can occur in anyone. This is what I was talking about where most people either have pain or bulge or both and the pain is due to the bulge, but the bulge may not be large enough to feel as a physical bulge even though there’s a hernia. So just because you don’t have a bulge doesn’t mean you don’t have a hernia. Many go to their surgeons with complaints of pain and there’s no bulge and they’re told they don’t have a hernia. That’s a false statement if, because you can’t have a hernia without bulge. I hope that clarifies. Okay, Ultrapro. Okay, going back to the Mesh spoke that broke into the Mesh was ultrapro.

Speaker 1 (00:53:36):

Okay, that totally makes sense because Ultrapro is a lightest weight Mesh we have on the market. Ultrapro is called ultrapro because it’s ultra lightweight. It’s not even lightweight. It’s ultra lightweight. So yes, lightweight meshes can be so lightweight that they break into and thereby they’re no longer functional as a Mesh. It’s the intention was to put in a lightweight Mesh in a female to reduce their risk of chronic pain. But if it’s so lightweight that it did not function, then you basically have another hernia recurrence. And so lightweight Mesh we think is good, but too lightweight maybe not so good. We don’t have the ideal Mesh yet. That’s a problem. Guys, I’m running out of time. There are all these questions left and okay. Can we do this one? Because she was so nice to submit. I’ve had a rather large hernia that needs abdominal wall reconstruction.

Speaker 1 (00:54:41):

I basically look like I’m nine months pregnant. I’m an otherwise healthy 50 year old, but overweight. I’m nervous about getting the coronavirus. I’m also wondering if it would, it would affect me in a worse way because of my abdominal situation. Coughing is very uncomfortable. Haven’t slept on my belly side in over four years. I walk four miles a day. I’m not in any pain. Do you think I could ride a bike? Yes. Riding a bike is safe no matter what kind of hernia you have. I’m trying to lose weight in order to have abdominal wall reconstructive surgery and walking is just line up. Any exercise is safe, please do it. And what is the ideal B M I body mass index for abdominal wall reconstruction surgery? 40. So if you do your calculation, anything under 40 is considered appropriate. Depending on how big your hernia repair is. The lower you are in weight, the safer and the better the operation. So 30 weight is better than 40, 25 is better than 30, and you can do the calculations online. Next, is it possible to see Mesh problems with an MRI? Absolutely. Are you guys not listening to all my dogs?

Speaker 1 (00:55:51):

Okay. The best is to look at it for MRI, for groin, for abdominal wall, we use CT scans. I’ve had the results negative for recurrence. If the ME folder something, could it be seen? Yes. The only result was a three centimeter assist in my iliopsoas is they said there is nothing to do with the operation. I’m having terrible life with chronic pain, not knowing whether the match is cutting inside me. Groin pain, leg pain, fine. The front right above the knee. Okay. So there are multiple reasons for your pain. Potentially the Mesh can be one of them and the MRI will show the Mesh. It’ll also show if you ever heard any recurrence, the majority of MRIs are misread. If you want, you can contact me. I can review your situation and read all your images again to make sure they’re correctly interpreted. Three out of four are misread.

Speaker 1 (00:56:47):

That’s a huge number because most radiologists are not tuned into what it looks like to have a normal hernia repair. So even though the imaging may show it, the radiologist may misinterpret it and that’s all people kind of follow. What are your thoughts on removal of bovine Mesh by surgimend was placed for a failed umbilical Mesh plug. It’s been two years of extreme pain and fatigue along with other issues. Original surgery was 4 20 17. It had pain from the start. So depends on the reason for your pain. If it’s Mesh related or hernia recurrence, those are different reasons to undergo another procedure. Thank you for your time expertise. You’re welcome. Marx, at age 37. Let’s see. We’re winding down guys. Two more minutes. Okay, let’s see. Do you ever recommend watchful waiting all the time? If you have minimal symptoms or no symptoms and you have anal hernia, why not?

Speaker 1 (00:57:54):

How am I going to make you better if you have no symptoms? I could just make you worse potentially. So yes, watchful waiting is to totally fine. About a quarter to a third of patients get tired of having their hernia and end up wanting surgery, but it’s considered safe. Do hernias retain their size or always grow with time? They always grow with time. That time may be tomorrow. That time may be 20 years from now. We don’t have a idea as to how fast hernias grow, but they do grow with time. Do ultrasounds get misread? Yes, all the time. All ultrasounds are notoriously misread because usually it’s not even done by the radiologist. Read all my papers on MRIs and imaging for hernias. You’ll be surprised about how bad the imaging can be. How many surgeons have you had to do with athletic pubalgia for breakfast, doctor?

Speaker 1 (00:58:50):

Pubic injury? Fortunately, not that many. It’s not a common problem. I would love to see a database specific, specific specifying removal rates. Is this something that you’re tracking? Absolutely. And you can actually read it. I published on it. It’s called Why We Remove Mesh. Read my article. It was published last year. Why We Remove Mesh Tells you exactly all the indications that my practice has as to for removal purposes. Surgeons in Canada, there are multiple surgeons in Canada, Ontario, Toronto, Vancouver, not Vancouver, maybe V, not really Quebec. Go to the Americas hernia society.org for a list of them.

Speaker 1 (00:59:41):

Do not trust anyone to read your hernia imaging except Dr. Towfigh. Thank you very much for that. Is it okay to work out? Are there exercise that will help? At what point should I consider repairing it? Again, is it safe to wait it out? Can I send you my MRI call my office? I’m happy to do an online consultation. I don’t just read images. I happen to know the full story. So sign up as a full consultation. All the information is on any of my websites or contact information on the different social medias. Put your health first and don’t lose hope. I totally agree. I understand how hard it is to keep up the faith, but keep up the faith. There are solutions. So keep looking. Find health from mental health problems as well as physical. Absolutely. To hernia’s. Cause referred back in hip pain. Absolutely. And in fact, we did a whole session on this with Dr. Jason Snibbe two months ago, I think. So go to the other hernia talk lab. All we did was talk about referred pain from hernias to the hip.

Speaker 1 (01:00:42):

Yep. Another one. Her confirming no, well-read imaging. Her images were not well-read for three years. Okay. And lastly, thank you Dr. Towfigh, for your time. Well, thank you for tuning in. Sometimes I wonder why people want to listen to me because all I do is talk about her, talk about hernias. In fact, I think I’m the only one that talks about hernias. I don’t know, am I the only one I feel like who really cares about hernias? And yet all of you tune in and for this whole hour and spend your time. And I’m really, really, really grateful to all of you. So on that note, thank you very much. Glad you were able to learn something new. I will end this by saying stay tuned next week. We’ll be super fun and super exciting. We will talk with a hernia surgery specialist who also operates on non-human mammals for their hernias. It’ll be super exciting and fun. So again, next week on Zoom and Facebook Live, today’s session I will post on my YouTube channel and you can find a link of that on her at Hernia doc, on Twitter, Instagram as well. Thanks everyone, and I hope to hope you all have a very fantastic evening and see you next week. Bye.