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Speaker 1 (00:00):
All right, we’re live. Welcome everybody. Today is the last Tuesday of the year 2020. We are having our hernia talk Tuesday Live Q&A. Thanks for everyone who’s been joining me since we started this earlier in the year. I’m very excited to finish off our year. My name is Dr. Shirin Towfigh, as you know. You can follow me on Twitter and Instagram at hernia doc. This is a Facebook Live event on my homepage at Dr. Towfigh. It’s also a simulcast Zoom event. And as you know when we are done with this, we will make sure that you have access to the full hour on my YouTube channel. Today’s guest, and actually today’s show is very unique and should be very fun. I’m hoping that it’s my gift to you all for being such great audience. So my guest today is Dr. Andrew Wright. He is a board certified surgeon, hernia specialist at the University of Washington in Seattle. You can follow him on Twitter at Andrew S. Wright. So I’m, before we do anything more, welcome, Dr. Wright. You have the most amazing background we’ve had so far of all our guests. Thank you for being so Christmasy.
Speaker 2 (01:22):
Oh, absolutely. My daughter was helping me set design for a little bit to get just the perfect background.
Speaker 1 (01:28):
It looks fabulous. It really looks fabulous.
Speaker 2 (01:31):
And at some point we might have a cat join us that our cat likes to jump up on the fireplace mantles.
Speaker 1 (01:37):
Oh, okay. That’s good. You have one cat and anything else we should be aware
Speaker 2 (01:42):
Of? One cat, one dog and two daughters.
Speaker 1 (01:44):
Okay, two daughters. So welcome home to your daughters. So most of this hour we’re going to spend discussing your very unique hernia surgery experience outside the human world at your local zoo. So we already kind of advertise about it before today. A lot of really interesting questions about it. I can’t wait for you to tell me how we got involved. And then midway through, there’s a special Christmas gift that I will announce, very special message. And then we’ll go on to the hernia questions that many of you have because you are after all, a surgeon for humans. So we’ll talk about
Speaker 2 (02:28):
That most of the time.
Speaker 1 (02:29):
Most of the time. And then we’ll say our goodbye. So I wanted you to give us a little bit about yourself. We’ve known each other through the professional world at meetings, hernia meetings, laparoscopic surgery meetings. We’ve shared a lot of patients together. So I do appreciate the back and forth. I’ve sent you patients, you’ve sent me patients. I love the kind of camaraderie and collaboration that we have. I feel like you and I have similar wavelengths in the way that we think about our patients. That’s also really helpful. And I assume you live next to a zoo, is that right?
Speaker 2 (03:09):
So I live in Seattle, so I’m a hernia surgeon. I run the hernia center at UW Medicine here in Seattle, and so about 90 plus percent of my practice is hernias of one variety or the other or hernia related issues. And we live about five minutes down the road from the Woodland Park Zoo, which is our local zoo. And I was actually at home one night and a friend of mine who’s a ear nose and throat surgeon called me and asked me what I was doing the next day and would I be willing to go to the zoo with him and examine their gorilla Vip, which was a alpha male silverback gorilla, sort of the leader of their local troop of endangered gorillas at the zoo.
Speaker 1 (04:05):
Wow. This is a major gorilla like
Speaker 2 (04:09):
Oh yeah. Yeah.
Speaker 1 (04:10):
Four times larger than a human being.
Speaker 2 (04:12):
Oh yeah. Is Zvi weighs about 400 or so pounds. He’s a little bit less than five feet. So pretty stocky, but built more like a linebacker, sort of shortened and muscular. VIP could probably lift a car if he wanted to.
Speaker 1 (04:28):
Oh my God. And VIP stands for very important primate.
Speaker 2 (04:32):
Exactly. Yeah. So it’s an endangered species and he is one of the breeding colony at the Woodland Park Zoo.
Speaker 1 (04:41):
So very important. Yeah,
Speaker 2 (04:43):
Very important. In fact, VIP has a, now probably about two years old baby Yola, who was sort of a big deal here in Seattle when she was born. Everybody was excited about naming her and all that. But VIP actually had a problem a couple years ago. He was eating bamboo and a bamboo shoot actually got stuck in its sinus. And so they had called my friend Greg Davis, this ear, nose and throat surgeon, and he did endoscopic sinus surgery to extract the bamboo. So when VIP started to get sick and looked like he had a hernia, they called Greg and asked Greg, who do you know that is good at hernias? And he called me up. And so the next morning was a Saturday and he and I went to the zoo about 8:00 AM to go examine, examine Vip.
Speaker 1 (05:31):
Okay. So cool. I know that you have some pictures to share with us.
Speaker 2 (05:36):
Yeah, here I can share my screen.
Speaker 1 (05:39):
This is so fascinating. I wonder if the l la would ever call me. That’d be so cool.
Speaker 2 (05:45):
So here, let me see if I, can you see the screen
Speaker 1 (05:50):
There? Yeah. Beautiful.
Speaker 2 (05:51):
So yeah, it turns out Vip actually had a hernia for some time. Several. And the vets had known about the hernia. It was an umbilical hernia, hernia in the belly button, but it hadn’t really been bothering him and was pretty small. And so they decided just to do watch while waiting and leave it alone. And I think we can get into talking about that for humans, but certainly not unreasonable if a hernia is not bothering you that much to leave it be, especially given the difficulties of fixing a hernia in this giant gorilla that you know, can’t exactly tell the gorilla to take it easy after surgery. So they had just been watching it, but VIP actually had gotten to a point where for a couple of days VIP wasn’t eating and was really looking pretty sick. So that’s when they called us in to take a look at it.
Speaker 2 (06:40):
It’s very hard to examine an awake gorilla. So they actually darted the gorilla and sedated the gorilla so we could go in and do an exam and at that point we actually didn’t know for sure that it was a hernia that was a problem. So a radiologist was there with a portable ultrasound machine there. You can actually see on the screen that the ultrasound machine, we were using Greg Davis, that my, your nose and throat friend had brought a nasal endoscope and we basically gave him a complete physical while he was out along with the veterinarians, obviously I’m a hernias surgeon, plenty of vets do due some animal surgery, but this was something beyond what they were comfortable dealing with, which is why they called me in as a specialist.
Speaker 1 (07:25):
Now this gorilla is on all fours usually, or does he?
Speaker 2 (07:31):
Yeah, so mostly ambulates on its legs but then can use its arms as well. So sort of leans forward and actually, I don’t think I have a picture in this slide deck, but the way it stands, it’s belly almost drags because it squats, it’s belly sort of drags in the ground and the hernia is actually sort of dragging on the dirt or on the pen enclosure.
Speaker 1 (07:52):
Yeah, because I see there’s no hair where the ultrasound is.
Speaker 2 (07:55):
Yeah, so here the, because the gorilla was sedated gorilla’s on its back, and essentially I think I have a better picture in a moment. The hernia had actually gotten to the point where the hernia itself had strangulated or the hernia contents had started to die off and actually the skin had become necrotic or the skin had started to die on top of the hernia. So normally there is hair in this area, but that necrotic skin, the hair had basically fallen off at this as the skin had gotten necrotic and you couldn’t see this at all until the gorilla was asleep. I actually saw the gorilla when it was awake before it was darted and you couldn’t see it because it was guarding, it was protecting its belly and not letting anybody look at it.
Speaker 1 (08:41):
Wow.
Speaker 2 (08:42):
Yeah. So pretty much as soon as the gorilla was sedated and we could do an exam, we knew right away you could feel that this was a big hernia and you could see the skin necrosis. But we still use the ultrasound. We wanted to see if we could tell if there was bowel involved in the hernia just so we would know what we were getting into. But by this point, once we were able to examine the Vip, we knew it was going to need emergency surgery.
Speaker 1 (09:09):
Did you know how big the defect was?
Speaker 2 (09:12):
We had a rough idea from the ultrasound. It was a pretty small defect, actually. It was only about a three centimeter defect.
Speaker 1 (09:18):
Okay. Yeah.
Speaker 2 (09:19):
So pretty small on the ultrasound, but a nice big, probably 10 or 15 centimeter firm mass that had herniated through. Fortunately it turned out it was all actually omentum, which for the non physicians in the crowd, everyone has an apron of fat on the inside of their abdomen called the omentum. Some people call it the guard dog of the abdomen because if anything in the abdomen goes wrong, yes, this apron of fat sort of goes there and sticks to it and tries to protect the body. So often, for example, an appendicitis, we find the omentum stuck to the appendix or in a hernia we find the omentum in the hernia. In fact, that’s what we found in this case.
Speaker 1 (10:01):
Okay.
Speaker 2 (10:02):
Yeah. So at this point we are actually in the animal’s pen, not in the veterinary hospital so that the zoo has its own hospital, but it became clear that the VIP needed surgery. So we loaded VIP into the ambulance, they have their own animal ambulance and took it through the back roads of the zoo to the animal hospital there at the zoo. And they have a fully equipped operating room there. In the meantime, they had some limited surgical supplies at the zoo, but I knew that they wouldn’t have what we would need if we got ourselves into a situation where we needed Mesh. We needed staplers for example, if we had had to do a bowel resection, that sort of thing. So I called up my friend Rob Yates, who’s one of my partners at the hernia center, and said, Hey Rob, what are you doing this morning?
Speaker 2 (10:58):
This was about 10 o’clock in the morning on Saturday. And fortunately he wasn’t very busy. And I said, Hey, if you’re not busy, swing by the hospital and pick up some supplies and then come to the zoo. Oh my God. I also texted one of our Mesh company reps and asked if they would be willing to donate some Mesh if we need it, which he said, take it off the shelf at the hospital and they would restock it. And then I also texted my boss, my surgical chairman, Doug Wood, I didn’t want something bad to happen. And this end up in the newspapers and none of the superiors at the UW Hospital knowing about it. So sort of rallied the troops and as we were getting Vip to the animal hospital, and a lot of thanks to Cook Medical by the way, is the company that provided the Mesh for us. So
Speaker 1 (11:51):
Cool.
Speaker 2 (11:52):
Yeah. So here’s just another view. You can see here the white and actually the black skin there in the middle. Normally the skin isn’t that color. That’s actually necrotic skin there.
Speaker 1 (12:03):
The black is
Speaker 2 (12:04):
Necrotic, the black and the black is really necrotic and then the white is
Speaker 1 (12:08):
Pretty good. Where’s getting there? Oh, okay. Yeah, pale. Got it.
Speaker 2 (12:13):
I don’t think I have a picture of it after we shaved, but once you shaved the hair away you could really see it pretty warm. Yeah. Rob Yates and I acted as the surgeons and our veterinarian actually acted as our anesthesiologist. So it really did take a team team approach. So he intubated or put a breathing tube in the animal while we were for surgery. This is just a
Speaker 1 (12:38):
Picture, his
Speaker 2 (12:38):
Teeth. Yeah, exactly. So again, if you’re not a physician, we use our anesthesia colleagues will use this thing called a laryngiscope to lift the tongue out of the way and put a breathing tube in. This laryngiscope is about three times the size of one that we use on a person. It’s really pretty remarkable. And I like vet tech actually holding the tongue out of the way to put this in.
Speaker 1 (13:05):
So cute though.
Speaker 2 (13:07):
And then this is the, the VIP with a breathing tube in. And again, this breathing tube’s about three times the size of one of our normal breathing tubes. It was pretty massive. And you can also see the size of the teeth there. Now gorillas are herbivores, but still they have teeth for defense and you certainly, certainly wouldn’t want to mess with the gorilla when it’s angry.
Speaker 1 (13:31):
Oh my god, this is so cool.
Speaker 2 (13:38):
We had some of the vet techs who were acting as our scrub nurse and circulating nurse and as I mentioned, the veterinarian is our anesthesiologist. You can see this red that’s a warm air heating blanket. So we like to keep our patients warm. We do this for humans too. We put a warming blanket on them to keep them warm during surgery, our sterile drapes in our lights. And here’s Rob Yates and myself operating, and I just like this picture because you can see how big the teeth are here in the foreground. That’s
Speaker 1 (14:09):
A great picture. Yeah.
Speaker 2 (14:12):
Wow. So basically again, we found fortunately no intestine, no bowel was involved. It had some necrotic or some dead fat, which is part of this omentum, which we removed. While I was waiting, by the way for this to start, they had a textbook of Gorilla Anatomy. I quickly reviewed and it turns out essentially identical to human anatomy. One of the big differences, their colon is a little bit bigger than ours because they eat a lot more roots and leaves and things like that. But fortunately they have to get involved with the colon at all.
Speaker 1 (14:48):
But they have the two rectus muscles. And do they have a normal center or do they have a diastasis recti?
Speaker 2 (14:56):
No, they have a normal, just like humans, we have the two recti. So if you think about somebody with a six pack abs, those are the rectus muscles. You have your lateral muscles, the external oblique, the internal oblique, and the transverses abdominal muscles, all of those are essentially the same in a gorilla compared to a human. The one difference is that there’s a very, very thin layer of muscle which humans have lost everywhere except for the neck and the face, the called the platysma. Right. That muscle is in humans gone, but gorilla still have a very thin layer of platysma there. And it’s interesting, the best way you can see if platzsma is actually on a, if you ever watch a horse, if a fly lands on a horse, it can twitch its skin in that location to get to shake the fly loose. And that’s actually the platysma twitching there. So cool. So gorillas still do have a small platysma there.
Speaker 1 (15:52):
Okay.
Speaker 2 (15:54):
But yeah, so basically the hernia was small enough that we could have fixed it without Mesh. However, I was really worried about the amount of weight that the gorilla carries right in its belly and the way that it stands, and also the fact that it basically drags its belly on the ground. So we decided to reinforce the repair. On the other hand, I was also really worried about wound infection because trying to keep this wound clean was almost impossible. So this is an absorbable Mesh of biologic Mesh that we used. A biologic Mesh doesn’t necessarily prevent infection, but if it does get infect infected, it can melt away a little bit easier than if a permanent synthetic Mesh were to get infected.
Speaker 1 (16:44):
So three centimeters in humans usually implies a Mesh repair for the umbilicus. And this guy, he’s more weight in the belly, drags it and he tends to be on either all fours or midway upright. So maybe more tension
Speaker 2 (17:01):
The tree branch or Oh,
Speaker 1 (17:03):
Right, that’s right. I forgot about the tree branches. Yeah. Wow. And hard. You primarily closed it and Yes.
Speaker 2 (17:11):
We didn’t underlay, so the Mesh underneath the muscle, there are some fancy techniques we could talk about in abdominal wall reconstruction. I didn’t do anything fancy in this situation. I didn’t do a retro muscular technique. I just did an underlay. Got it. An intraabdominal underlay and then closed the hernia overtop of the Mesh.
Speaker 1 (17:34):
Wow. So
Speaker 2 (17:35):
Cool. Yeah, you can actually see here’s the finished product. You can’t see the Mesh because the Mesh is underneath the muscle. Yes. The reason, even though it’s only a three centimeter hole or defect, a lot of that skin was necrotic and dead. So we actually to remove some of the skin in the mi middle here and that’s why that’s such a big incision. True. Fortunately we were able to get that closed without any tension. We undermined a little bit of the skin flap and we’re able to get that closed. Wow. But it’s actually in this picture, you can sort of see some of the stitches that we used here in the center where the hernia repair has done and then we closed the skin. I thought this was interesting. I normally close skin in a hernia, in an open hernia using dissolvable sutures. And that was my inclination on the gorilla because I thought, well that way we don’t have to come and remove the stitches later. Correct. Our vet actually though, had us instead use steel wires, which is a very old school thing they used to use in humans a long time ago. In fact, the Shouldice clinic still sometimes uses steel wires. Correct. But what they wanted us to do is the steel wires, you take the ends and you twist them almost like barbed wire. Yes. And that way they don’t pick at the wound because if they pick at the wound, their fingers brush on the little bars,
Speaker 2 (19:00):
Which I thought was interesting. We
Speaker 1 (19:02):
Use wire in shouldice or the chest or on muscle. We never use wire on skin. This is a deterrent then
Speaker 2 (19:13):
That was supposed to be a deterrent to them picking it. The wound, yeah. I had obviously never heard of that before, but I was more than happy to defer to the expertise of our vet. You can barely see it. Cause the picture’s a little overexposed. I didn’t want fluid to build up or infection to build up because it had been an infected field. So I left a little drain. Normally in humans I use something called a closed suction drain, but in the gorilla I couldn’t do that because you can’t attach a bulb and clip it to their clothing or anything like we do in a human. So this is an old school drain called a penrose drain, basically to let any fluid drip out. It turned out that didn’t work very well because the first thing the gorilla did after it woke up is pull the penrose out, drain out and eat it.
Speaker 1 (20:02):
Eat it. Oh my god.
Speaker 2 (20:05):
Fortunately the penrose drain was, I cut it pretty short and so I wasn’t worried about it eating it, so it would’ve passed in the stool. And the vet techs that worked in the gorilla enclosure were really worried that they had to sift through all of the gorilla poop to try to retrieve the Penrose. No. And I told ’em not to worry about it. We didn’t need it back. So I think that’s actually the last picture I have in this slideshow.
Speaker 1 (20:37):
That’s pretty
Speaker 2 (20:38):
Cool. I did, I was able to go back, oh, we kept obviously in touch sort of on a daily for the first couple of weeks and then I went back in about two weeks when they sedated VIP again so he could remove those skin wires. And at that time I got to feed Vip. I got to feed him some yogurt, which apparently is his big treat and some fruit. And they kept VIP sort of away from the public side of the grill enclosure. They have a whole backstage at the zoo where the public can’t see and can’t go. So they kept him back there for about a month or two while he was healing. The big thing is VIP has his sort of harem and he was very upset because they were keeping away from his harem. So eventually
Speaker 1 (21:34):
Of course of his, wouldn’t you be? Yeah,
Speaker 2 (21:38):
They eventually had two of his female gorillas back in his part of the enclosure to hang out with them while he was recovering. But he did well and has done great with this. So yeah.
Speaker 1 (21:51):
So no infection healed fine.
Speaker 2 (21:54):
He did actually, to be perfectly transparent, he did get a wound infection and the skin opened up and then had to heal. By secondary intention, you can’t pack a gorilla wound. So it had to heal on until, but it did eventually heal up.
Speaker 1 (22:07):
That is so fascinating.
Speaker 2 (22:10):
They actually just interestingly have a giraffe also with an umbilical hernia. But again, just doing watchful waiting doesn’t seem to be bothering the gorilla or the giraffe. And I think operating on a giraffe would be even more challenging. I’m not quite sure how you would get a breathing tube down at a giraffe’s neck, but
Speaker 1 (22:31):
Yeah, I think you may have to start looking at your giraffe anatomy.
Speaker 2 (22:36):
Yeah, exactly.
Speaker 1 (22:37):
Before they call you. Yeah, that is so interesting.
Speaker 2 (22:40):
Now since then, I know of at least one other gorilla hernia pair that was done. I think I’d have to look back through my emails, I think in Kansas City, but that was done electively. So this was sort of an emergency repair with dead skin and all of that. So we did it as an open repair. They were able to do it on a sort of scheduled basis and they actually did it on the robot and did a robotic what? IPOM? Yeah. Or intra. So for those, again, Shirin and I tend to talk and hernia nerd talk and IPOM, Intraperitoneal Onlay Mesh. It’s not really onlay, but yeah, they did a robotic assisted IPOM.
Speaker 1 (23:23):
That is crazy.
Speaker 2 (23:25):
And Vip. Vip has a recurrence that gets symptomatic. When we were to do it as a scheduled case, I would try to do a robotic repair just to keep it clean, but I think that hopefully you won’t need another surgery.
Speaker 1 (23:40):
Wound healing and postoperative care is important in humans as well as in these animals and children, you know, would change what you do based on how much control you have over the patient’s activities and so on, and how much they would tolerate things like suture removal and all that. But wow, that was so fascinating. Yeah,
Speaker 2 (24:04):
Fun. I mentioned at the very beginning our animals, I came home and my dog completely freaked out because I came home smelling of a gorilla and our dog didn’t know what to make of that. It was kind of freaked out. It smelled very primal.
Speaker 1 (24:19):
Oh my God. Yeah, I can imagine. Yeah, I was going to say something, but I’m not going to say. Yeah, yeah. These are some pictures that I found online. Oh
Speaker 2 (24:31):
Yeah, that’s
Speaker 1 (24:31):
You doing your hernia exam or feeling around before the ultrasound
Speaker 2 (24:37):
In his enclosure. So before we made it to the animal hospital, so that’s a good, probably a better picture than the one I shared.
Speaker 1 (24:45):
And then And here. Oh, here it
Speaker 2 (24:49):
Is. Yeah, here that’s after you was shaved. So you can see the size of the hernia and you can see the normal skin color and then you can sort of see that where it’s pale is where the skin has started to get necrotic.
Speaker 1 (25:00):
So the bulging starts from way up here.
Speaker 2 (25:03):
It was quite a large amount of omentum that was herniated so relatively, and that of course is one of the dangers in a hernia is if you have a fairly small neck that’s fairly tight with a lot of stuff coming through it and that’s what allowed it to,
Speaker 1 (25:18):
Yeah, so the three to one ratio, so the one paper was published on if the neck of the hernia is one x and the contents that go through is three x, that significantly increases your risk of strangulation in those or incarceration strangulation. So emergency needs. And so those should be repaired more than let’s say a one to one or one to two ratio of a hernia neck to kind of the bulb of the hernia. The question we had, if you could just clarify. So how was he, did he get pain medication? Was he fine?
Speaker 2 (25:57):
Yeah, great question. Comfortable. I did sort of a tap block. So a tap block is a transverses abdominal plane block basically trying to block the nerves out to the sides that go, yeah, that’s actually my friend Greg doing his nasal endoscopic nasal surgery when he had the bamboo stuck in sinuses. Oh, interesting. You can see there he is, got a flexible endoscope in his hand scoping, scoping the nose. Sonia, I did a block and a nerve block, and then he was on basically the animal equivalent of ibuprofen, almost known narcotics. They gave him a few narcotics in the first couple days. And it’s interesting, actually it goes back to my days when I was doing research in the lab and I had to do a lot of the animal surgery and animals almost need no narcotics. And it’s really led me to believe that the humans probably a lot of times don’t need as many narcotics as we give them a lot of pain.
Speaker 2 (26:56):
You can manage with non-narcotic medications, with mindfulness, with I think expectation setting. So if you operate on a gorilla, they wake up and they start eating and they start moving around right away. And a human is sort of scared and doesn’t want to move and rigid and lays in bed. And I think that actually hurts worse than if you just start to slowly get up and move around. So, so I really try to encourage my patients to use minimal narcotics and we do as much as we can with ibuprofen and Tylenol and getting him up and early mobilization.
Speaker 1 (27:32):
That is so interesting. So the gorilla had symptoms because he wasn’t eating and was basically not performing normally, and they already knew. They already knew that he had a hernia. So as part of their exam, they kind of figured it out. Now are gorillas prone to hernias? Just like, I mean,
Speaker 2 (27:56):
Just like the anatomy is pretty similar. So I think not uncommon. I think that the VIP is in his forties, which is very old for a gorilla in the wild. So part of it may be that hernias may be more common in gorillas than we realize, but oftentimes just like in humans, we may not see them until they get a little bit older. And so in the wild they may not manifest, but in the zoos they get old enough, we show up. So
Speaker 1 (28:28):
Fascinating, so fast. Okay, so that was fascinating. Thank you for sharing. Would you want to do it again? I would want to do that again.
Speaker 2 (28:39):
Sorry, what was that?
Speaker 1 (28:40):
Would you want to do that again? I think that would want to do it if they asked you, you would do another hernia surgery, huh?
Speaker 2 (28:47):
Oh, a hundred percent. Yeah. Yeah. So I would like to do it on a more elective basis scheduled and planned, and I think it’d be really interesting to try to figure out how to get the gorilla into the UW medical center and do it on the robot. I’m not quite sure the logistics of that, but it’d be fun to try. Oh,
Speaker 1 (29:10):
They’ll bring the robot. They’ll bring the robot to the
Speaker 2 (29:13):
Sure. I guess we could do that. We could take it to the zoo.
Speaker 1 (29:15):
Yeah, absolutely. That’s totally doable. That’s so cool. Okay, you let me know next time. Yeah,
Speaker 2 (29:22):
I’ll
Speaker 1 (29:23):
Fly
Speaker 2 (29:23):
Out. I do it on a scheduled basis. You can fly out from LA and help
Speaker 1 (29:26):
Definitely fly up during your normal business hours. You two, you work on humans. How much of your practice would you say is hernia based?
Speaker 2 (29:37):
So almost all of it, depending on how you hernia. So there’s a trend actually in the world of hernia surgery to rebrand instead of calling it hernia, calling it abdominal core health because it’s not as, and as you say, it’s not just a hernia, right? Yeah. So chronic groin pain, complications of hernia repair. I also, about half my practice is diaphragmatic hernia, so not hernias of the abdominal core muscles, but actually the diaphragm. So hiatal hernias, paraesophageal hernias and acid reflex surgery, which involves typically a hiatal hernia. So you’re about half my practice is dealing with diaphragm hernias and about half with abdominal wall hernias and other hernia related issues.
Speaker 1 (30:26):
And you offer open, laparoscopic, robotic, all those different options.
Speaker 2 (30:29):
Yep, yep.
Speaker 1 (30:30):
All right.
Speaker 2 (30:31):
So we have, I heard robot skeptic for many, many years and I started using it a little bit more in the last year.
Speaker 1 (30:37):
I was a skeptic too. And then I saw colleagues of ours doing these really amazing operations that I couldn’t do laparoscopically. Cause I thought I can do everything laparoscopically, so why should I use the robot that’s for sissies. And then I saw, oh no, you can actually do things with a robot that you can’t do laparoscopically that why should do open. And yet with the tech robotic technology, you can actually do certain open surgeries robotically. So using minimally invasive surgery
Speaker 2 (31:07):
Less I have administrative roles. I look at it both from my perspective and the patient’s perspective, but I was also looking at it from the sort of hospital system perspective and how much a robot costs and yes, cost effectiveness and all of these issues. And so I was always sort of the opinion that the robot just added cost without adding a lot of value. And it’s really only been in the last year that I’ve been persuaded that it has some value in certain operations. There’s some operations I can do on the robot. I couldn’t do laparoscopically, which I was skeptical about before. The other issue, just to be honest, is the ergonomics of laparoscopic surgery are so bad for the surgeon. I was starting to have some ergonomic issues with my elbow where I was having trouble operating. Wow. I had to take a whole month off from the OR because my elbow was hurting so bad and I found moving to the robot has protected me from an ergonomic standpoint.
Speaker 1 (32:05):
Yeah. I’ve always had, surgery is a very physical career. Everyone knows I’ve had spine issues. It’s a genetic kind of predisposition I guess to get discs and then plus you add on the weird ways we stand for hours and laparoscopy hasn’t helped actually, it’s maybe worsened the ergonomics. So yeah, for sure the robot has been better on the body, at least from a spine standpoint all should we go in,
Speaker 2 (32:37):
If OSHA know they do these health and safety inspections of factory workers and Amazon, whatever, if they came in and analyzed what we did in the operating room, they would shut us down because we’re so,
Speaker 1 (32:49):
Can you imagine? Yeah, yeah. I would be totally wrong. That’s a very good point. Never thought of that. They should come up with something because I’ve been to some lectures, Sherry Ren who from Stanford, she gave a great talk at the American College of Surgeons about ergonomics and she’s also had multiple operations that she shared about and she talked about the angles of your neck and the natural angulation and rotation and HyperFlex’s not good and the angles of your elbows and your hands and wrists and all that. And it was very enlightening, but no one to use that to you and I, it would be really cool actually if you know anyone at OSHA to, because the way that we were put our screens and the bed height, all those things are not appropriate often for the surgeon. All right. Shall we jump into some questions?
Speaker 2 (33:45):
Yeah, absolutely. Okay,
Speaker 1 (33:46):
Great. So these are going to fall in randomly as they’ve been provided. This is relating to open angle hernia repairs. Do you recommend performing a neurectomy during open angle hernia surgery? Why or why nodes?
Speaker 2 (34:01):
Yeah, there’s a lot to unpack here. So in an inguinal hernia repair, there are three nerves that run through the area, the ilio inguinal, ilia hypogastric and gen ephemeral.
Speaker 2 (34:15):
And there are lots of variations of the nerves, so they’re not always in the positions that you think they are. So personally, I think that you need to identify the nerves so that you can protect them. But then once I identify them, I try not to touch them. I don’t want to disturb them. I don’t really want to manipulate them because I think the more you manipulate the nerves, the more potential there is for trauma or what we call a neuroma. There are some people that advocate for routinely cutting the nerves to prevent chronic pain and you basically are rendering the area numb. But I think doing that on a routine basis doesn’t make a lot of sense to me. And there’s been some studies that have really not shown that it provides any benefit. So personally I would say leave him alone.
Speaker 1 (35:02):
Yeah, I agree. We had a session with one of the pain doctors and we talked about the horrible complication of crps complex regional pain syndrome in patients that have neurectomies or any kind of nerve related injuries, surgeries, whatever. So the international guidelines for sure promote exactly what you said, which is identify but don’t disturb the nerves. There are still data that supports prophylactically cutting the nerves, but I think if you want to be a surgeon that kind of understands neurosurgery and pain, pain management and so on, you would understand that it’s not a benign procedure, not there are motor and sensory effects. There’s a risk of neuroma like you said, and there’s also a risk of complex regional pain syndrome and it’s cutting your leg off so you don’t get a foot fracture. I don’t understand that theory, but it is a common theory in our world. Yeah,
Speaker 2 (36:11):
I mean I guess I would say if you were doing an inguinal hernia repair and realize that you injured the nerve by accident, maybe it might make sense to cut it rather than leave a burned nerve or something. But certainly not as a routine thing. And I think if you can avoid the nerves from the very start for the better of course, just to show my bias, my bias is actually to do a laparoscopic or robotic inguinal hernia repair it, you’re underneath the muscle instead of on top of the muscle. And I think it’s not that it’s impossible to have chronic pain after a laparoscopic hernia repair, but I think you’re less likely to have nerve entrapment. So for sure, that’s why my personal bias is towards not an open approach, but a minimally invasive approach,
Speaker 1 (36:55):
Less nerves to injure. They’re much further away from where you’re at dissecting for sure. And I think all the studies support less chronic pain with laparoscopic Mesh based repair for the inguinal hernias than for open Mesh based repairs. On that note, what types of Mesh do you tend to use for abdominal hernias?
Speaker 2 (37:15):
So
Speaker 1 (37:17):
Question.
Speaker 2 (37:18):
Yeah, what’s that?
Speaker 1 (37:19):
Another loaded
Speaker 2 (37:20):
Question. Yeah, exactly. So in the US there are essentially two types of Mesh that are available in FDA approved. There’s polypropylene and polyester. They both have advantages and disadvantages. There are some surgeons that are super proponents of one, super proponents of the other. I do think they both have their role. I think that a polypropylene Mesh is a little bit, I don’t think there’s any difference in the rate of infection, but polypropylene Mesh, if it does get infected is a little easier to manage. Yes. So in bigger operations and operations with a higher risk of infection, I certainly would use polypropylene. On the other hand, I think polyester is a little bit more pliable and a little softer than polypropylene, so I tend to use it in operations with a low risk of infection. So I use a polyester Mesh for example in my groin hernias, very low rate of infection.
Speaker 2 (38:20):
I like the compliant Mesh. And coincidentally or not, I use a particular type of polyester Mesh in the groin called progrip, which is a self adhering Mesh. It sticks to the tissue instead of needing to use tacks or sutures. And at least in this country that’s only available as a polyester. So that also is why I use polyester more commonly in the groin. But I do use both polypropylene and polyester as far as differences between companies, just like I’m sure Toyota will tell you their cars are better than Ford, realistically speaking, if they’re both polypropylene, they’re both still pretty similar. There might be little differences in how they’re constructed or woven versus knitted or all of these different parameters, but I just use Medtronic because that’s what our hospital has a contract with. I don’t feel so strongly that there’s differences between manufacturers.
Speaker 1 (39:15):
So you’re a purely Medtronic hospital, you don’t use any of the Bard BD products?
Speaker 2 (39:20):
I have used them in the past, but we could spend a whole hour talking about hospital contracting and sole source and all of this stuff. Basically I don’t have a choice at this point because that’s what our hospital has a contract with.
Speaker 1 (39:33):
Yeah, okay,
Speaker 2 (39:33):
Cool. Which is fine. I think honestly, when you’re talking about a uncoded, polypropylene Mesh, it’s a commodity product. It doesn’t really matter who you buy it from.
Speaker 1 (39:42):
Yeah, I agree. Like your standard.
Speaker 2 (39:47):
Yep.
Speaker 1 (39:49):
Okay, next question also related to open surgery. Why is it not recommended to do bilateral? So left and right opening or hernia repairs at the same time,
Speaker 2 (40:00):
I would say it’s possible to do bilateral opening or hernia repairs, but it’s almost like you’re recovering from two surgeries at once. It’s two separate incisions and they both hurt. And so I think it’s a little bit harder to recover from in terms of pain and sort of mobility, getting up, walking around, getting to the bathroom, that sort of thing. But generally speaking, I don’t recommend it. But again, this is my bias towards minimally invasive surgery because if you do a minimally invasive approach, you can fix both sides at the same time. It it’s the same incisions. You don’t have to do extra incisions to do both sides. The recovery is pretty straightforward.
Speaker 1 (40:40):
The recovery for an opening while hernia repair is definitely typically not as easy as a laparoscopic repair. And so for that reason, many people do not offer left or right done at the same time because you’re really not allowing either side to heal. There’s at least one study that shows that if you do them at the same time, so bilateral versus staging them. So I stage them, I do ’em like minimum three weeks apart that if you do them together as bilateral that you’re more, your hernia recurrence rates slightly higher, so that’s another reason to do it. The insurance companies want you to do it all together at one time. Yeah. In fact, there was one insurance that was claiming I wanted to make more money by doing two surgeries separately than doing it at the same time. I’m like, that’s ridiculous. First money the same. It doesn’t make a difference.
Speaker 2 (41:36):
And not only that, we could spend a whole hour on how physicians get reimbursed, but if you wanted to make money as a physician, you wouldn’t do hernia repairs. One of the most poorly reimbursed things that we do in surgery, at least
Speaker 1 (41:49):
It just bogged my mind, but they kind of rejected that because of that. Going back to the crps, so complex regional pain syndrome is something we talked a couple weeks ago with our pain doctor, very complex, horrible complication. The question is, is it congenital because this patient has had Brother Anne’s sister. Do you know anything about that? I don’t know if it’s congenital or not.
Speaker 2 (42:17):
I don’t know the data. Yeah, I suspect that there’s probably, so there, I think in complex regional pain syndrome, there’s some sort of injury or inciting event, but a lot of it isn’t the injury, it’s the response of the body and the neurologic system to that injury. So a relatively minor injury that in many people would not lead to chronic pain and somebody is likely to get C P R S. It seems to be that their neurologic system is sort of primed to respond in that way. And so there probably is something, I mean, who knows why that happens, but it, there’s probably something familial in that. I have certainly heard of people who’ve said that their mother had chronic pain, that they had a sibling with chronic pain. I don’t know the literature there, but I certainly would believe it.
Speaker 1 (43:10):
Yeah, no, I agree. This patient’s brother had a fall and the sister had hip surgery and as you know, most people don’t get chronic regional pain syndrome from a fall or hip surgery, but if you have a propensity to it, yeah, that’s difficult. Okay. Next question is about a laparoscopic bilateral inguinal hernia repair. This patient had bilateral inguinal hernia repair laparoscopically last May. Their left side keeps flaring up. They had an MRI and it showed fat in the inguinal canal. The surgeon says it’s easy to remove with another surgeries, but why was it not seen during the original hernia repair? What’s your thoughts on
Speaker 2 (43:48):
That? Yeah, that’s a tricky question. So there are a lot of people that actually have a little plug of fat in the inguinal canal. As surgeons, we also often call that a lipoma of cord. Yeah, we could get super technical. It’s not truly a lipoma, which is actually a fatty tumor, but it’s basically fat that gets trapped in the canal. Correct. Part of the laparoscopic or open hernia pair is to look for that fat and try to remove it because there are some people that get pain from an entrapped piece of fat. That said, sometimes it’s actually quite tricky to see, and I have seen this before and teach, when I teach my residents, I teach them look very carefully for this because it’s easy to miss if you don’t look for it. The flip side is you don’t want to dig too hard because if there is some normal fat that lives in the inguinal canal attached to the spermatic cord, so if you go digging, trying to strip every little piece of fat that you see out, it may increase the risk of injury to the spermatic cord.
Speaker 2 (44:50):
So it’s a sort of fine judgment about exactly how hard you’re going to look for this. The other thing I want to throw out there though is just because an MRI says you have something doesn’t always mean that that’s the cause of the pain. Correct. It may be, and maybe removing that plug of fat will help the pain that this patient is experiencing, but not necessarily. And so I think any time you talk about chronic pain in the groin, whether it’s after surgery or not, whether it’s they’ve never had surgery, it’s often complicated and sometimes you’re not quite sure what the cause is. So you have to have some realistic expectations going into any surgery.
Speaker 1 (45:29):
Yeah, very, very good point. With laparoscopic surgery, the incidence of missing lipomas is slightly higher than with open surgery because you’re looking at something through the back door instead of the front door. But that said, where most of us are trained to look for it, but it definitely can be missed on laparoscopy. And once you close that back door with a Mesh, then sometimes you trap that fat and it can be symptomatic, but it’s not always the case. On that note, talking about
Speaker 2 (46:00):
The two of us just published a paper together actually looking at videos of hernia surgery that are surgeons put up on YouTube and looked at what we call the commandments of inguinal hernia surgery. And one of the frequently missed things is actually looking for that retained lipoma. And when we were rating videos, that was one of the things we would have to check off about whether the surgeon had done it or not done it. And it turns out a lot of surgeons actually missed that step for whatever reason. I do think it’s one of the more tricky steps of the operation.
Speaker 1 (46:32):
So Dr. Wright and I and Dr. Hak from Turkey, so we love what we do and we decided do this research paper. We looked at 50 YouTube videos, the top most watched YouTube videos on laparoscopic or robotical hernias, and we scored them. We scored them based on a standardized score sheet. And some of these operations were very well done, some were very well done. It was beautiful, we enjoyed it. Some were not. Were so bad. Oh my God.
Speaker 2 (47:08):
Horrifying. Yeah,
Speaker 1 (47:10):
I was freaking out through some of them I would watch and I had to look away sometimes because it’s like watching someone commit a murder. It was so horrible. The technique. And some of these people put these videos out there, look at me, this great surgeon. Oh my god. Yeah,
Speaker 2 (47:28):
I, this gets to a point about surgery in general is that surgery is very technical and laparoscopic or minimally invasive surgery is harder than open surgery. And I think that ideally you want to go to a surgeon that does a lot of something right. Because if you’ve done a lot of something, you’ve learned the mistakes and you learn how to avoid ’em hopefully.
Speaker 1 (47:57):
Right, right. Exactly. Okay, so question about growing pain. Do you also treat patients with sports hernias or what we call athletic pubalgia that doesn’t improve after conservative? So non-surgical therapy, do you treat those patients?
Speaker 2 (48:12):
I do, yeah. We’ve gotten away from calling it sports hernia because is most of these cases there’s not actually a true hernia, not a true hole in the abdominal wall. But yeah, I see these folks. It’s typically a sort of a multidisciplinary approach. So I work with our sports medicine team at UW Medicine and we approach them together.
Speaker 1 (48:35):
Pretty cool. Question about weakened abdominal wall. Have you ever had a patient develop a form of muscle paralysis of the abdomen after surgery resulting in a bulge but no actual hernia?
Speaker 2 (48:49):
Yeah, certainly. Most common reason I see that is after flank surgery, for example, an open kidney surgery or a spine exposure, a back surgery. So the muscles that come out of the spine wrap around to the front. And if those nerves are disrupted by surgery or I’ve seen it actually after a car accident, I’ve actually seen it after somebody got shingles, they had a segmental stripe of muscle that just wouldn’t activate. What happens is if the muscle really requires activation to twitch, if it loses that activation, the muscle starts to atrophy or melt away and the muscle gets thinner and thinner and so the muscle’s not holding in. So people will develop a bulge. But if you get a CAT scan or an MRI or ultrasound, you don’t see a hole, you don’t see a hernia. Right. Often we call that eventration. Unfortunately those are some of the most difficult things. You can’t really fix it. I mean, you can talk about different approaches, implication and physical therapy, but frankly most of the time it’s better off leaving that alone doing physical therapy to strengthen the other muscles around it to see if you can regain some function in that area potentially where binders or compression garments, those sorts of things. But it’s challenging.
Speaker 1 (50:15):
Yeah, very challenging. Most of these eventration, so where the muscle loses its nutrition basically and starts getting lax and doesn’t contract as much, it’s not from the hernia repair. It’s from an injury to the nerves from the side in the front in the middle, there are no nerves. By the time the nerves start branching out from the spine out to the front, they’re almost invisible. So it’s the larger nerves that you cut through that actually have more function left over that get injured. So if you have spine surgery from the side or kidney surgery or sometimes large aorta surgery, those nerves can get cut then. So I have a fair number of those patients actually because there’s so much spine surgery done in la. And also I have a great relationship with the plastic surgeons. So we’ve had some good results in doing these really massive reconstructions to and address and they do very well, but you have to be pretty healthy. It’s a lot of surgery to recover from
Speaker 2 (51:27):
And have to be careful. You can sometimes placate or pull it tighter. It doesn’t necessarily restore the muscle function. Correct. And so again, it comes down to realistic expectations and you may be able to reduce some of the bulge, but the functional issues of the muscle loss are harder to deal with
Speaker 1 (51:48):
In 10 years down the road you’re going to have a on one side and then the other side will naturally get bigger and it may not look as good. Yeah, that’s a problem. The next question has to do with Mesh reaction. So if your patient has a Mesh reaction to polypropylene Mesh after incisional hernia repair, can that Mesh be removed? And how would you handle the hernia?
Speaker 2 (52:13):
Yeah, great question. And I see a lot of patients who come to me with this sort of question. I think there’s a lot to unpack here because it depends on what we’re talking about in terms of a Mesh reaction, yes, Mesh can be removed, not easy to do, and you have to have a lot of experience in hernia repairs and in Mesh removal, a lot depends on how the Mesh was placed and what layers of the abdominal wall. So it’s a pretty complicated question and you certainly want to find someone that has a lot of experience in this, right? So yes, you can remove it as far as what you would do afterwards, a lot depends on what the problem is. Is it a true allergy? In which case I might consider doing allergy testing, for example, to polyester Mesh. And I have had a patient that had terrible hives after a hernia Mesh, and I took the polypropylene out and we placed polyester, they hives resolved immediately. And on the other hand, if somebody is truly sensitive and we just have to do a primary repair without Mesh, sometimes we do that knowing that there’s a big risk, the hernia is going to come back again. Sometimes we might use a biologic or absorbable bioabsorbable Mesh, although again, I think your chance of the hernia coming back again is quite a bit higher if you have to go that route. So this is sort of one of those questions where a lot depends on the details.
Speaker 1 (53:45):
Yeah, totally agree. A hundred percent agree. But it’s doable if your patient did have a Mesh reaction to polypropylene Mesh. We already answered this question. Okay, we’re almost running out of time, but I’d like to take this moment to do a quick Christmas announcement. I don’t know how to explain this. I got this email and it completely just warmed my heart. So there’s a local patient who would like me to give a message. Their name is Ratica. The message is for their friend Mark Estevez in Sherman Oaks. So it sounds like Mark Estevez has abdominal pain that no one can figure out. They’re local. I’m happy to see them and I’m getting emotional. So Rodica will be calling the office, my office this week to make an appointment for you. Mark Estevez for the consultation. I will be personally handling the case to help figure out what’s wrong with you. I hope I can figure out what it is and pinpoint it for you. But do know that this is a Christmas present from Ratica to Mark and hopefully I’ll be seeing you maybe in January to get that done. So that’s my special Christmas announcement and I don’t know what this patient has, but I’m happy to help this help out with that. Isn’t that lovely?
Speaker 2 (55:24):
That’s a cute Christmas present. What a
Speaker 1 (55:26):
Great Christmas present. I’ve never
Speaker 2 (55:29):
Personally, I might want to massage or a spa appointment instead of a doctor’s appointment, but if that’s what you need, if the sounds like he needs to be seen, so that’s great.
Speaker 1 (55:39):
Sounds like those patients had a lot of medical issues. The email includes a lot of details, but they wanted me to specifically make those that announcement on Hernia Talk. So I’m glad to do that. I’m glad to be the one that helps figure these things out. On that note, in 2021, we’re hoping to have what we call the Beverly Hills Hernia Foundation, where it’ll be a nonprofit organization that will help patients like the one we just mentioned, as well as to promote more research in the field of hernias and get the word out and support a lot of what I do like hernia talk every week. So I hope 2021 one’s going to be a great one. What about you, Andrew?
Speaker 2 (56:27):
Well, I’m getting my COVID vaccine on Thursday on Christmas Eve. So if anyone is watching who is hesitant about vaccines or questioning about the severity of COVID, I know it’s getting a little astray from hernia, but it’s still medically related. Totally. If you have any hesitancy about vaccines, just watch how quickly physicians and nurses and healthcare workers are running to get their vaccine as soon as humanly possible. So
Speaker 1 (56:57):
Yeah, we can’t wait. I’m
Speaker 2 (56:58):
Looking forward to that.
Speaker 1 (56:59):
We can’t wait. I’m on the list. They haven’t told me yet, but in LA we’re struggling a little bit. So I will wait when it’s my turn and very gladly roll up my sleeve and get my shot. Just give it to me.
Speaker 2 (57:13):
Exactly.
Speaker 1 (57:14):
Alright, on that note, I want to say thank you, Dr. Wright. You’ve been a great friend and colleague and thank you for sharing your time with us and that great gorilla story. One of our patients who I told you is a vet says, thank you for the information. She loved the gorilla information and hoping all the best and good luck to Mark who I hope to meet one day. And on that note, everyone thank you for your time. This ends Hernia talk for 2020. We hope to start the first week of January. Until then, have a great Christmas, happy New Year. I hope everyone had a good holiday season. Hanukkah’s over. Follow me on Hernia doc at Hernia Doc on Twitter and Instagram will, I’ll keep posting some fun, her related stuff for you. For those of you that came on board with Facebook Live, thank you for following me and being so active with your questions. Have a great season and I’ll make sure this is posted on YouTube and I’ll see you all the beginning of the new year. Have a fantastic New Year and thank you again, Dr. Wright, for
Speaker 2 (58:24):
My pleasure. Happy New Year.
Speaker 1 (58:25):
Be with us. Happy New Year. Take care. Bye-bye.
