Speaker 1 (00:00:00):
Today. Today is Hernia Talk Tuesday. Welcome to everyone joining us for our weekly Q question answer session. As you know, my name is Dr. Shirin Towfigh. I’m your host every week here. We are currently on Zoom as well as simulcast on Facebook Live. You can follow me on at Twitter and Instagram at Hernia doc on Facebook. Many of you are with me on my homepage at Dr. Towfigh. Once we’re done, I’ll make sure that this is posted on my YouTube channel. I’m very excited because today we have a guest panelist from Germany, professor Andreas Koch. We can’t call him doctor because in the US is doctor in Europe is Professor. Professor Andreas Koch is a hernia surgery specialist. He is most well known for his work with professional athletes, as you know, a lot of great German athletes, especially soccer players. So we’ll discuss some of that. And he is also very good at tissue based hernia repairs and like me treats a lot of women with hernias and hernia related complications. You can follow him at Twitter at k Koba, which I believe is that’s your practice. Right? Hi, professor Koch.
Speaker 2 (00:01:19):
Hello Shirin. Thanks for the invitation. It’s a great pleasure for me to be here online with you and with all your followers from hernia talk. And I’m looking forward to our discussion about hernia complications, pure tissue repairs and the problems of the athletes and the most or many athletes. Not even surgery is the only thing we have. There are a lot of conservative treatment we can do as well. So that’s a very special part. A bit out of hernia surgery.
Speaker 1 (00:02:01):
Yes, and you’re very good at it. So Dr. Koch is practiced in Germany. And where is your actual practice? In Cologne or outside of Cologne?
Speaker 2 (00:02:12):
No, no. I’m close to Berlin.
Speaker 1 (00:02:14):
I’m close to Berlin.
Speaker 2 (00:02:17):
It’s a 100,000 inhabitants city between Berlin, Andres in the middle and the former East Germany.
Speaker 1 (00:02:26):
Former East Germany. So last was it last? No, two years ago I was in Hamburg for the European Hernia Society. I got to go to Berlin. I’d never been to Germany before. It’s now officially my favorite country. It used to be France, but Germany is really, really amazing. Hamburg was fantastic and I got to visit Berlin as well and many don’t know, but Germany is one of the key countries historically in hernias and hernia related advancements. And that continues to be true. There’s a lot of great specialists and coming out of Germany and German hernia society is very strong and has its own kind of leaders within it. Dr. Koch for sure is one of them. So thank you for coming and joining me. I know that there’s been a discussion about you on hernia talk.com because you’re one of few surgeons in Europe that does regularly offer tissue-based angle hernia pairs. So we’ll talk about that a little bit. And we already have tons of people on Facebook as well logging in to ask you some questions. So maybe we can start on the sports hernia side and then we can go with a tissue or women’s hernia side. Is that okay with you?
Speaker 2 (00:03:51):
Speaker 1 (00:03:52):
Fine. How did you get involved with this? Because sports hernias are something that general surgeons aren’t really trained in doing in their residency.
Speaker 2 (00:04:00):
Yeah, I come or myself, I’m coming from sports, from winter sports. I made bobsleigh as a pilot for many years. Oh, professional level and from that side at a lot of interest in sports medicine. And we have a very famous soccer team here in my hometown. We are playing six years in the Bundes League now. We have strange times. We are going down to the fourth league. It’s so amazing for us. But when we were playing in the first league, I was the team doctor of this soccer team and one of our most famous players here was Greg Behar, who is now the head coach of the US National Team. Oh
Speaker 1 (00:04:58):
Speaker 2 (00:04:59):
US National soccer team. And he was fantastic. Our team and we are playing in the Buddhi League and from my work with a lot of professional football players, there was a growing interest from hernia surgery to groins of professional athletes. And we see that many times in soccer players and hockey players as well. And Greg Beholder, when he was a national player for the United States, he got an operation at Will Meyers in Philadelphia and he connected me with Bill Myers so that I got in 2005 the opportunity to visit him in Philadelphia. And I have learned a lot of things there when I visit Myers. And I’ve introduced his technique here in Europe and I do his technique in selected cases of soccer players and I can, for all the people which are online now, I can show a wonderful book by Will Meyers.
Speaker 1 (00:06:17):
Introducing the core,
Speaker 2 (00:06:19):
When you’re interested in this topic here, I think it’s a 400 pages book and everything is written, you have to know about the core of high performance athletes. It’s very interesting if somebody’s interested in, it’s very interesting to read this book.
Speaker 1 (00:06:41):
Yeah, that’s great. So usually the typical sports injuries in the groin occur in soccer or football, what you call football. We call soccer hockey, right? Yes. Maybe basketball a little bit,
Speaker 2 (00:06:57):
But let’s maybe
Speaker 1 (00:06:58):
A little bit of tennis, but mostly it’s the hockey and soccer players. So what I struggle with sometimes is people come to me that are 70 years old or just a regular housewife and they’ve been told they have a sports sports hernia. Is that even possible
Speaker 2 (00:07:21):
In my opinion? And when we are talking about that, we are on the bridge between hernia surgery and yes, treating pain because when we have a non-high performance athlete who comes to us with pain, there’s pain in the groin and there is no incarceration of a hernia, then we have to search for the reason of the pain. And we know from the literature that especially woman, woman with small hernias have a high level, high pre-operative level of pain and they got an operation and they have the same level of pain. So that means we found a hernia, we fixed the hernia, but we doesn’t solve the problem. And in my opinion, in these cases, which are coming with pain and they say, yeah, I have a kind of sports hernia, the first question should be, you are really, really doing sports on a high level
Speaker 2 (00:08:32):
And if not, we have to search what’s your problem? We have to find the right diagnosis for your pain. The hernia is not a diagnosis which causes your pain. Correct. And that’s a different in high performance athletes, when they got a weakness in the so-called Hesselbach triangle and get a compression of the ilio inguinal and especially the genital branch of the genital femoral nerve, then they got a compression when they do their spots on a high level. And this compression of the nerve could cause pain, which is going to the inside of the upper leg and to the outside of the vagina or outside of the scrotum, the lateral side of the scrotum. And these are the typical symptoms. And sometimes high performance athletes are coming and say, yeah, I’ve typically sports groin. And when you mine them, they have problems at the doctors. They have problems under zoom fuses, but not really groin pain.
Speaker 2 (00:09:54):
And these are the cases where we have to talk about core stability. And these patients or these athletes are getting in the first step a core stability program and sometimes combined with injections under ductus or on the sys or around I pubic bone. And this combination of injections sometimes combined with shock waves, intercourse, stability, you can treat more than 60% of these athletes because what we have learned is especially in hockey and in soccer players, they trained not really good in the whole core. Yes, they’ve very strong rectals muscles, they’ve very strong adductors. They have no back muscles and so you have to train them. And there’s interesting paper from Australia, from Australian football, they picked up one team and they gave one team in the professional league cost stability program and they did it twice a week. And that team, they have a decreased more than 90% decreased rate of injuries, which are called schizophrenia or groin pain or something like that.
Speaker 2 (00:11:47):
Yeah. And the etiology of the real groin pain is that you get a mild rupture in the Hesselbach triangle and then a weakness in the floor in the inguinal floor. It’s not a typical hernia, but with ultrasound or with an MRI. With Valsalva, you can see how the bulge comes up and these cases you are able to treat with an operation. And all the other cases you need three to six months of course stability. And then around 70% of the athletes are completely free of pain. And then you have another 30% where you are not able to treat them with these conservative treatment. But then you have to do a very complex surgery. This is the repair where you replace the lateral cert of the rectals muscle down to the Coopers ligament where you stabilize the floor and sometimes release of the insert of the adductors and sometimes a release of the sartorius muscle on the IC spine Ontario.
Speaker 1 (00:13:20):
Oh wow. Yeah, that’s pretty extensive.
Speaker 2 (00:13:23):
That’s extensive surgery and only for real selected cases. And to find out who is able to profit from this extensive surgery, you need a lot of experience
Speaker 1 (00:13:39):
To, so what’s important is to understand then what is the core. So the core is not just your abs or what we call abs, it’s your rectus muscles and all the abdominal muscles in the front. It’s also your back muscles in the back and your side muscles and the flank. It’s also your pelvic floor as the bottom, and it’s also your diaphragm up top. So all of that is part of your core. And you’re right, hockey players have enormous thighs, for example, an enormous rectus, but it’s all a pulley. It’s like a system where if one is weaker than the other, that’s where injuries occur. And so that’s very interesting that they are in fact doing a lot of core-based. That’s why athletes still do yoga and Pilates because those are very core-based activities. They don’t only have to do weightlifting at the gym or running, and then they need to do a lot of these other girly girly stuff.
Speaker 2 (00:14:40):
And the typical sign is the so-called C sign when you go to the hip and you made the C here. Yes. And when the patient in the sea, then yes, that’s the first step to see the road to the hip impingement. Yeah. Yes. And we have to know about these hip impingements and we have a lot of athletes, especially the goalies in hockey when they met the butterfly, most of the goalies have these cam or pincer impingement on the hip. And you need a very experienced orthopedic surgeon who who is able to deal with these hip impingement. And many, many athletes are coming and say, yeah, I have a spots growing. No, they have hip impingement.
Speaker 1 (00:15:41):
Yes. We had an orthopedic hip specialist on hernia talk live maybe two or three months ago. Dr. Jason Snibbe. And yeah, I always teach my residents the C sign when they do make a C and they push put around their hip. Every time a patient describes that, the first thing you have to look for is a hip problem. And there’s a lot of hip pain and issues that present with groin pain and that’s why it’s, it’s a complicated area. But what you’re telling me, which is very good, and I would like our audience to know is sports hernias are usually a strain or an injury or a entrapment of a nerve because of the strain of the muscle, but it’s often at least 70% not surgical. Whereas a hernia, if it has pain, is a hundred percent surgical. So when you say not surgical, you offer them core stability, physical therapy I assume. And then what else do you also do
Speaker 2 (00:16:48):
Speaker 1 (00:16:48):
Do you recommend?
Speaker 2 (00:16:50):
I do injections, glucose injections, and sometimes with corticosteroids and local anesthetics and some homeopathic things like traumeel. And that’s what I do. Vitamin D, vitamin D is very helpful in many cases. High dose vitamin D for three to four weeks.
Speaker 1 (00:17:18):
Yeah. Wow. That’s awesome. What about P R P? Do you do P R P injections? The plasma rich protein?
Speaker 2 (00:17:27):
In very rare cases, very rare cases when they have a real osteitis, and sometimes I do that, but only in these selected cases
Speaker 1 (00:17:39):
And the muscles we’re talking about, one is the rectus muscles, so rectus muscles like the six pack we call the six pack. So the two rectus muscles that come down, they insert on the pubic bone. And so what happens, they contract a very strong rectus muscle and it pulls away from the bone. Is that right?
Speaker 2 (00:17:59):
Yeah, it’s an interesting description, the papers of Will Myers, because he said the symphysis in a high performance athlete is like a joint with all the muscles around and the symphysis in young people is flexible and it works like a joint. And when the pelvis is not stabilized by the core muscles completely, then you will have a lot of movement in the symphysis. And that’s the reason why you get Osteitis. And when you have on top of the pubic bone director’s muscles, which are very strong, and then there are doctors which are very strong, and especially in the soccer players or in the hockey players, there’s a high load on the symphysis and that’s the reason why you get these sitis and all these problems there. Myers is talking about the pubic joint.
Speaker 1 (00:19:22):
Yes, very interesting. So besides erectus muscle, you mentioned the adductor muscles. The adductor muscle is a thigh muscle that also attaches now to the underside of the pubic bone and its use is when you contract that it swings your leg inwards and that swinging inwards is what I guess it gets torn or something. If you’re doing the splits like the soccer players or the hockey goalie,
Speaker 2 (00:19:56):
You got this torsion on the symphysis and this cutting sequences of your whole pelvis. And that’s the reason why I’m not tired to talk about core stability. Core stability. Core stability.
Speaker 1 (00:20:19):
Yeah. Yeah. Okay. So we have a question. Let me share this screen really quick, which is what is your surgical strategy if they fail conservative therapy of physical therapy and injections? I know there’s a wide range of surgical options. Dr. Myers is the leader in a lot of his kind of approach. What does he actually do? He sews the rectus muscle down to
Speaker 2 (00:20:55):
The, yeah, you take off a part of the rectus muscle from the pubic bone and you replace it down to the conjoined tendon, to the coopers ligament and you refix it and then you stabilize the pelvic floor with not the pelvic floor, the inguinal floor with sutures, and then you have to do a adductor release on the insertion of the obtuator. Yeah. And in my personal experience, after these complex repairs, you need a minimum of 12 weeks to get back to full training.
Speaker 1 (00:21:42):
So the rectus muscle is used to provide more stability to a weak inguinal floor. Is that right?
Speaker 2 (00:21:49):
Yeah. And you change Change the load on the symphysis. Yeah.
Speaker 1 (00:21:57):
Yes. But you add it to the inguinal ligament. Yeah, instead. Okay. So another reason for having a weakened pelvic floor or an inguinal floor is a direct Anglo hernia, which you see more in people of older age, but it can occur in anyone. So we have a question about that is how do you differentiate what’s the relationship between a torn muscle or tendon from its attachment to the pubic bone and the weakness or laxity that you see, let’s say from a direct angle hernia? Can they coexist?
Speaker 2 (00:22:33):
They can coexist, but mostly I’ve seen this weakness in athletes with a real groin pain with a typical pain symptoms which are following the genital branch to the appetite and to the scrotum. And when they have load and they feel the pain there, that’s typically then real groin pain. And I say the more the pain is going down to the doctors or to the symphysis, the more you should do a conservative treatment, the more the pain goes real into the groin area, then the sooner you have to do the surgery. And Gilmore has described this type of injury many years ago, and that’s a might rupture of the postero wall of the floor, and this might ruptures there. You get finally a weakness there. And this weakness made a compression to the nerve when you bring load on your abdominal wall.
Speaker 1 (00:23:58):
Okay. Yeah, it’s very, very complicated anatomy. You talked about how hip pain can cause some groin pain in a patient with a sports hernia and a hip labral tear. How do you distinguish their symptoms? And let’s say they have both, which I’ve seen. How do you prioritize their treatment? Do you do their hip first and then the labral tear or and then the sports hernia or vice versa?
Speaker 2 (00:24:29):
My preferred approach is to do the hip treatment at first and followed by possibly the hernia treatment. But I have learned the most of the pain is coming from the hip. And when the hip is fixed, when they hit their hip arthroscopy, sometimes there’s no need for another surgery. Yeah.
Speaker 1 (00:24:59):
Yes, I agree. Because I think if the hip is clearly the more symptomatic, then that’s a better repair to get done and addressed. And then you reassess there may or may not have any more hernia related pain. The hernia may just be what we call a red herring, not necessarily the primary problem, but if they have, let’s say they need a hip replacement, so to not labral tear, clearly they have bad bones and they need a hip replacement and they have a hernia. I often fix the hernia first and then have them do their hip replacement later because all the physical therapy that’s associated with recovery can then be done without them being hindered by the hernia. What do you think about that?
Speaker 2 (00:25:55):
Yeah, in this case, when they have a real arthrosis in the hip and need a hip replacement, then I do the hernia first. Yeah.
Speaker 1 (00:26:04):
So another way of treating sports hernia that’s in the literature is laparoscopic and also the use of Mesh. What’s your thoughts on that?
Speaker 2 (00:26:16):
That’s good because I had a lot of discussions with my colleagues who are doing the laparoscopic approaches. So I’m personally not a friend of these laparoscopic approaches because I think there is, in the most of the young healthy athletes with wonderful muscles, with wonderful tissue, there is no need to place a Mesh in really young patients. And in these cases it works. You can stabilize the floor and when you’re on the hands of experienced surgeons, they will have good results with that as well. And I think we will talk later about that topic when we are coming to the tissue repairs because in the last years, in my opinion, there was too much better between Mesh and non Mesh repairs. And we doesn’t talk about tailored approach about listening to the patients. What is the need of the patient, what wants the patient for himself?
Speaker 2 (00:27:39):
And we have to find the consent with informed consent with our patients to find the best way for the patient and for the surgeon. And I think that’s the same with laparoscopic or approach for hernias, for sports hernias, whatever. I think the battle should not be laparoscopic open. The battle should be how careful we are, how skilled we are, how trained we are. And when you’re in the hands of a well-trained laparoscopic surgeon, you will get good results. When you’re in the hands of the well of a well skilled open surgeon, you will have good results. And finally, we have to talk about complication risks in especially not so experienced heads and yes, agreed, but that’s a topic we can talk later about. But I think for the sports hernia, in my personal opinion and my personal experience, an open repair was Mesh is less than a laparoscopic repair with a Mesh placement, especially in high performance athletes because we know sometimes the meshes are shrinking, the meshes are fixed to the muscles, and when in high performance outlets, the muscles are not really good sliding against the fascia and then you can get other trouble.
Speaker 2 (00:29:34):
But that’s my personal opinion. I know there are different opinions about this topic. Is
Speaker 1 (00:29:41):
Any truth to using Mesh? It says it can Mesh posteriorly actually offload any tension off of the bone.
Speaker 2 (00:29:53):
I’m not really convinced about it.
Speaker 1 (00:29:55):
Yeah. Okay. Yeah, it seemed a little weird discussion. Yeah. Okay. Okay, last question on the sports hernias and then we’ll move on to women’s hernias and tissue repairs. So this is a 70 year old male. He’s had two previous direct angle hernia repairs 20 and 40 years ago. Then he injured his groin three years ago and had another injury two years ago during physical therapy. So he says he has persistent severe pain over his pubic bone that radiates upward, maybe along the rectus, I don’t know. I’m contemplating undergoing pelvic floor repair and adductor release, but I am not a muscular athlete and I’m concerned about the risk of dehiscence, which means not healing and it falling apart. What are your thoughts?
Speaker 2 (00:30:48):
I think that’s not a surgery for a 70 years old patient. It doesn’t matter how active he is or not, but this is surgery for high selected cases in high performance athletes. Yes. I think when I see this, I would recommend ultrasound and MRI to see if there is not a recurrent hernia, which it could be that more recurrent hernia and not this problem we see in high performance. At least
Speaker 1 (00:31:40):
I hundred percent agree with you, I actually know this patient. That’s what my diagnosis, but I a hundred percent agree with you. I think he just needs a recurrent hernia repair. Yeah, yeah. The chance is that this, he needs some type of sports hernia type tissue release. Just doesn’t make any sense.
Speaker 1 (00:32:03):
Yeah. Okay. Well that’s fantastic. Thank you so much. So can you please tell us a little bit about your practice? As you know, I’m very interested in women’s hernias as part of what I enjoy. We do do a lot of research on it, and my belief is that the female pelvis is different than the male pelvis. And we all know anatomically it’s different. It’s been shown to have more nerve innervation in the pelvis in women than in men. The shape is different, the organs that are in the area are different and we have different hormones. So based on that, my personal issue is that every hernia repair we do is exactly the same for men and women. The technique, there’s no gender-based technique. And the Mesh that we use is exactly the same size and the same everything from men versus women. And I feel that it needs to be tailored. I feel that women should not get as much open Mesh repairs as maybe men can tolerate. Laparoscopy works very well for women, and I do more open tissue repairs on women than I would for the typical male. So what are your thoughts on that and how do you tailor your care? Because I know you treat a lot of females as well
Speaker 2 (00:33:28):
As you know, I had a lot of battles with the European Hernia Society when they presented their guidelines.
Speaker 1 (00:33:35):
Yes, me too.
Speaker 2 (00:33:37):
Me too. About the women and the recommendation and the guidelines of the European Hernia Society or no, the international guidelines, the world guidelines or whatever, the world is not big enough for that. Yes, yes, yes,
Speaker 1 (00:33:56):
Speaker 2 (00:33:57):
They have written that every woman should be operated laparoscopically with Mesh implant. Yeah. Yes. And I’m completely disagree with that. When we are doing that, agreed. When we do that, then we don’t need any diagnostics. And they said, yeah, we can prevent a femoral hernia. But for that we have to know in all statistics, in women, we have more than 60%. Between 60 and 70% of the inguinal hernias in women are indirect hernias, not femoral,
Speaker 1 (00:34:43):
Speaker 2 (00:34:45):
The femoral hernia are 15%. Yes. And we have to search for this 15% and to find the right approach to the hernia when we have a true inguinal hernia. Indirect hernia. In my personal experience and opinion, Marcy repair, it’s enough. It’s a simple Marcy
Speaker 1 (00:35:17):
Speaker 2 (00:35:18):
Simple suture repair to tight the internal ring. Yes. Replace the hernia sac and that’s it. It’s a minimal approach. It’s easy surgery and the women have no risk of pain. You are not able to touch any nerves there. You should be a bit careful with the genital branch when you do the stitches on the internal rink, but that’s Yes. Yeah. And especially in young healthy woman with a complete stable floor there, there’s no direct hernia. Why should I open the transfer? Yes. The only thing we have to do is to search for the femoral hernia. And what I do very often, I open the hernia sec, I go with the finger inside to explore the femoral canal to see there is no femoral hernia at for the final decision for the treatment. And if there is a femoral hernia, then we can shift to a McVay repair or we can shift to a repair Tonia Mesh repair.
Speaker 2 (00:36:36):
That’s possible intraoperatively we can change. But when we do it laparoscopically, the way is Mesh repair. And the guidelines are based on the scandic papers where they had a lot of ephemeral recurrences within the first year after surgery. And these are not real recurrences. These are overlooked primary femoral hernias. And then we have to know that in Scandinavia, at that times when they made these studies, they did Lichtenstein repairs, Lichtenstein repair in women. And in my personal opinion, there’s no indication except very rare cases where we have to tailor to it. But in 99%, there’s no indication for open Mesh repair for Lichtenstein repair in women.
Speaker 1 (00:37:42):
I agree. Yeah.
Speaker 2 (00:37:43):
Women are completely different. Step one, exclude the femoral hernia in your pre-op diagnostics. If there is a femoral hernia, do a laparoscopic approach with a Mesh placement. If it is a really small femoral hernia, you can do a McVay repair. It’s easy to do. And for the indirect hernia, especially in young women, I prefer a Marcy repair.
Speaker 1 (00:38:12):
Yeah. This is why I love talking to you because I feel like I agree a hundred percent with everything you say a hundred percent, not even 99.9, you’re saying exactly what I do and what I experience. And at the same time what you’re saying and what I practice is not current practice.
Speaker 2 (00:38:36):
I know it’s
Speaker 1 (00:38:37):
Not even the guidelines.
Speaker 2 (00:38:39):
And that’s regarding to the guidelines. And on the other hand, and I think you have the same experience, I see a lot of patients with Mesh complications and my first question to the patient is, the first question is, was there a change in the pain pre and postop?
Speaker 1 (00:39:05):
Speaker 2 (00:39:07):
When they have the same pain post operatively, it was not the right indication, then we have to search for the reason of the pain and it’s
Speaker 1 (00:39:16):
Not the hernia. Correct.
Speaker 2 (00:39:18):
In my opinion, in these cases, the last step should be to explant the Mesh because explanting a Mesh is not a nice surgery. Sometimes it could be horrible. Yeah. Yes. And so we should be very careful with the indication for Mesh explants. And the second thing is when you ask the patients, so that’s my personal experience. How was your hernia preoperatively? Oh, there was a minimum bulge, close to nothing. And I never had a patient with Mesh related pain who said, yeah, pre-operatively I had such a hernia. Right. Never had such a patient.
Speaker 1 (00:40:09):
Speaker 2 (00:40:10):
Yes. And mostly women, small hernias and the female gender is a risk factor for developing chronic pain after hernia surgery. We know that more than 50% of the pain patients are females, but only 10%, five to 10% of all inguinal hernia patients are females.
Speaker 1 (00:40:38):
And that’s why I’m so passionate about it, because I’d like to change those numbers. And you try to educate other surgeons that women should be treated differently, they should be tailored, they should not have as many open Mesh repairs. Laparoscopic seems to be better with Mesh and then open tissue repairs. We have a lot of questions. Can I go through some of these questions for you? Yeah. Okay. So this say 58 year old female, she had a laparoscopic right. And then a lap that makes no sense. She had a left and a right angle. Her repair, she says it’s laparoscopic, but usually laparoscopic. We do both sides at the same time. So since you had two hernias within three weeks of each other, I’m going to assume these were done open. Now she has pain, it hurts when the seatbelt is over her. She is wondering if she should have her Mesh removed.
Speaker 1 (00:41:36):
She’s very skeptical, but feels like I’ll be back at work in two weeks and she’ll be riding and pushing a bike again in six weeks and none of those have happened. So she’s wondering why I’m going to assume these are open left and then open. Right. Laparoscopic repairs. Okay. She’s saying it’s definitely laparoscopic. So you had a belly button incision or are there incisions in the groin? Because some people mistake those, but let’s go through both. If it was a laparoscopic repair on the left side and then the right side three weeks later and she’s now unable to walk or bicycle ride, what’s the next step for you in that?
Speaker 2 (00:42:24):
The first question is when does the pain comes when she had doesn’t had pain before the surgery, then I think there should be something wrong with the Mesh placement or the meshes in that case, when the pain starts immediately, then I wouldn’t wait too long for the Mesh X plant.
Speaker 1 (00:42:57):
Yeah. Yes. Her surgery was in April. So laparoscopic repair in general has the easiest recovery. So if you’re not recovering well from a laparoscopic surgery and you had an April, it’s currently January of the following year, then I would do imaging to see where the Mesh is. If it’s folded. That’s usually the most biggest problem is that the space for the Mesh is not adequate and the Mesh is folded. And then also sometimes it’s that you’re a really thin patient and they put a very heavyweight Mesh and that can also sometimes give problems with mobility.
Speaker 2 (00:43:33):
Sometimes they’re using [inaudible]. Yeah.
Speaker 1 (00:43:38):
Yes, that’s true. Some tackers can also cause problems talking about a male. So males have a little bit more options that are viable, including the open Mesh based repair, tissue repair and laparoscopic repairs. The question is for a small indirect inguinal hernia in a male and they want an open tissue repair, do you have a preference? Bassini, Shouldice, McVay? Does it matter? Dasarda, do you think it’s based on the surgeon and not the technique? What are your thoughts about that?
Speaker 2 (00:44:17):
And I think in my personal experience, I’m not doing Bassini repairs only in very, very rare cases, but the difference between Bassini and Shouldice is not so big. And the Shouldice repair, you have to open up the whole floor including splitting the transfer fascia. And my preferred technique is to show those technique with some modifications and we have just accepted a paper in hernia about some possible modifications in shoulders repair compared to the original shoulders in Toronto. I’m not using stainless steel. I’m using normally two row. The first two rows I’m doing with permanent sutures, running sutures. And the third and the fourth suture row I do with with long-term absorbable.
Speaker 2 (00:45:34):
And that’s my preferred technique. But sometimes I’m tailoring interoperatively. So I do the Muschaweck repair, the minimal repair, which is modified shoulders repair. I do, especially in young men, young males with a stable inguinal floor. Then you split only a part of the trans fascia and then you are doing this minimal repair. Or in some cases I do the disorder repair as well, but for the disorder repair, and it could be that there is a bit difference between India and the European countries or the United States because you need a very good external upper neurosis. And what we see when we do the operations on our patients in the middle of Europe, or I think in the United States it’s the same. There are not so thin. Yeah, the Indians. And sometimes you have a really weak external upper neurosis, and with this weak external upper neurosis, it doesn’t make sense to repair.
Speaker 1 (00:46:59):
Yeah, we’re thinner, they’re in India, they’re thinner, we’re fatter, and we have more wrinkles. Maybe that’s what it is.
Speaker 2 (00:47:12):
Speaker 1 (00:47:13):
Okay. Here’s another interesting question. This lady had open inguinal hernia repair on both sides, Trabucco method, and that was back in 2006. Then she felt some pain in her groin in 2019, and she’s had nausea ever since. What do you think the nausea can be from? Could it be related to her groin?
Speaker 2 (00:47:42):
Whew. It could be related to the groin if there is incarceration of yes, of a small ball. But normally if there’s no incarceration, the nausea normally doesn’t come from the groin. I think so.
Speaker 1 (00:48:01):
But I have seen, and people with really small hernias, a cold inguinal hernias or any pelvic pain, they get nausea and sometimes bloating. And I’ve never been able to explain it. Why? Because there’s no intestine involved. But what I’ve read is that pelvic pain in general, especially in women, can manifest the pain manifests as nausea. So would for that patient, I would double check that you haven’t recurred your hernia.
Speaker 2 (00:48:29):
Speaker 1 (00:48:31):
Okay. Another 1 78 years old, she’s a female open left inguinal hernia pair with Mesh six years ago, terrible pain. And then she had the Mesh removed and he put new Mesh in saying that the original Mesh was attached to a nerve. So she continues to have pain and she has a CT scan, which shows that the Mesh has migrated over a new suprapubic hernia. So I’ll just explain for people that are looking to have their Mesh removed, please make sure it’s done for the right indication and by surgeons that do it for a living. Because there’s a lot of thought process and imaging and injections and physical exam fines are very subtle. That guides you as to what the right decision is. And just willy-nilly taking out Mesh and Oh, well just cut some nerves. No problem. That is not right. I don’t think you’re helping the patient necessarily. Often there’s a lot of discussion about removing Mesh will make you worse. That’s actually not true. If it’s indicated, it will cure you of your symptoms potentially. But if you’re just going to a surgeon that’s doing it because you’re asking for it, then you may actually be harmed. What are your thoughts on that?
Speaker 2 (00:49:52):
Yeah, that’s completely my personal approach because we as surgeons who are experienced in these Mesh plans, we have learned our lessons over years and we all have our worst cases. And where we were thinking that we are helpful with a Mesh X plant and some patients are getting worse after Mesh plant. Yeah. And we have learned our lessons about indication, about physical examination, about listening to the patient, what’s the characteristics of the pain. And sometimes you have to create a feeling in the discussion with the patient to to move on the right way. And sometimes you couldn’t explain why you say, okay, I do it now and I don’t do it. And when I started with the Mesh plans, I was one of the first year in Europe who has really done numbers of Mesh plans, and I was falling on my nose in these cases where I let me push to the explant. Yeah. Yes. When you as a surgeon are not really convinced about it and the patient pushed you and said, yeah, I want to get it removed. And in these cases, I’m always saying to the patients, we are able to remove every Mesh, but I can’t promise that it would be really helpful in your case. And what I have learned is the most success I had removing open place meshes, stein meshes. Yeah.
Speaker 2 (00:52:21):
Very successful are Mesh implants after laparoscopic repairs when they are using really heavyweight meshes, which are folded or tackled. You can be very helpful in planting plugs,
Speaker 1 (00:52:45):
Plugs. Yes. So match plug, those are very good. Yeah. When you remove it. Yeah.
Speaker 2 (00:52:50):
Most of the patients with Mesh related pain after pluck implant are completely cured. Yes. After implant the pluck. And I try to reconstruct the floor whenever it’s possible without a new permanent Mesh. And in some cases I’m using the phasix Mesh to get a better reinforcement than I place the Mesh
Speaker 1 (00:53:19):
Absorbable. Absorbable Mesh. Yeah. The
Speaker 2 (00:53:21):
[inaudible] to space. I do a modified Shouldice repair on top, and this pH Mesh induces better, stronger scar tissue, a bit inflammation there. And yeah, these my,
Speaker 1 (00:53:39):
So we have a patient from Sweden, and in Sweden, this patient’s doctors have told them that Shouldice hernia repair is not for women and that women should be repaired with Mesh. Have you heard that?
Speaker 2 (00:53:53):
Yeah. Yeah. That’s a discussion. That’s a discussion out of these guidelines. Yeah.
Speaker 1 (00:53:59):
Yeah. Laparoscopic with Mesh only for women. Yeah.
Speaker 2 (00:54:02):
Mesh only for women.
Speaker 1 (00:54:06):
We both disagree. Yeah. We both disagree with that.
Speaker 2 (00:54:10):
If she has femoral hernia, then the surgeon is right. If she don’t have a femoral hernia, then you can do a shouldice repair, McVay repair, marcy repair or a laparoscopic repair. But I would recommend never do a Lichtenstein repair in the primary inguinal hernia and woman.
Speaker 1 (00:54:33):
Yeah, I totally agree with that. And I tell them, I have a lot of patients that say they only want tissue repair. I said, that’s fine. Let me make sure you don’t have a femoral hernia. And then that would be a good option. Do you know of any surgeons in Australia that would be open to or have any experience with Mesh removal
Speaker 2 (00:54:53):
In Australia? I think John Garry. John Garry in Sydney.
Speaker 1 (00:54:58):
Yeah, John Garry. But yeah, I think in general, the Australian surgeons don’t do as much and they’re not as comfortable doing them. But if it would be anyone, it would be John Garrett. Yeah. Okay. We have a 45 year old male who’s a runner, and he’s asking, do you still recommend Mesh? As lots of people are complaining about it, I’m down for, I’m scheduled for a laparoscopic Mesh hernia repair next week. I assume this is inguinal. What do you think about that?
Speaker 2 (00:55:33):
When it’s an experienced laparoscopic surgeon, I think he will get good results as well.
Speaker 1 (00:55:41):
I agree. Yeah, absolutely. It’s very much a experience based, and I think for a runner or an athlete, in fact, laparoscopy is a very good option because it’s a very quick recovery. You can tailor the type of repair to the weight of Mesh. You don’t have to use any attackers. There’s no cutting and sewing in the area. So the recovery and the long-term results are pretty good with laparoscopic repair. And actually for men, tell me if you agree with this, the chronic pain rate of open versus laparoscopic Mesh, it’s a better, less chronic pain with laparoscopic repair. Do you agree
Speaker 2 (00:56:20):
In Mesh repair CS and in the Yes. The tissue repairs. I have pain rates in my own series below 2%. Yeah.
Speaker 1 (00:56:31):
And someone saying, professor Lloyd in Australia may be another option. So thank you for that in Australia. Okay. One last thing I want to comment. I don’t know if you saw my paper. So you mentioned that in really small hernias in women, especially in women, you do what’s a Marcy repair, which is not a full opening of all this layers and suturing like you do with a Shouldice, but it’s a minimal repair usually done in children where you just close the hole and that’s it. And that seems to do okay for women. So I see a lot of women with very small hernias, and I also felt really bad taking a really small hernia hole and then opening up all that muscle to address a small hole on basically causing a bigger hernia to close a smaller hernia. So based on that, I learned about, I had already known about the Nyhus-Condon posterior ilio pubic tract repair, which I used for emergencies and incarcerated bowel, et cetera.
Speaker 1 (00:57:43):
And so with the robotic technology, since you can sew posteriorly, I then start offering the ilio pubic tract repair robotically. So it’s basically you’re closing the hole, but you’re not fileting anything open. And in thin patients, so they can’t be obese or even basically BMI less than 30. They do great. And long-term results were great and very little chronic pain issues. They all had basically no pain. The nerve is in the way that general femoral nerve yet be careful, but it’s a great way to treat bilateral hernias. And if you need a non tissue repair that you want to do it laparoscopically or robotically, it’s a good option. And for sure, not for everyone, but I think the, we call it ripped, R I P T, robotic Iio pubic tract repair.
Speaker 2 (00:58:38):
But no, I was the reviewer of your paper for her. I
Speaker 1 (00:58:43):
Know. I know. So you’re a fan.
Speaker 2 (00:58:48):
No, it’s a amazing technique. And that’s what we are talking about the whole hour. Now we have to tailor our approach there. There’s no one fits all, and it was amazing when the first randomized trial was published in 1998, Lichtenstein versus Shouldice repair for inguinal hernia from Mcil. And there was a comment by Nyhus. Yes. And he has written the biggest mistake in your paper is your one suit fits all approach. Yeah. The recommendation, we have to use a Mesh now in every patient. And was that kind of approach, we are training a new generation of Haber resurgence, and yes, sometimes we have to read the papers until the end. And he was talking about that in 1998 when everybody follows this discussion. We never had the discussion we have now with the guidelines and not the guidelines. I think tailoring our approach to the patient, there are some different options with Mesh without Mesh, robotically laparoscopically, open Classic, and there’s a place for everything. And we have to find the informed consent for our patients. And in my practice, I do more than 80% of all hernia surgery, inguinal hernia surgery, yes. Without meshes. But it was a process. Wow. And I’m not against meshes. I’m for meshes on the right place.
Speaker 1 (01:00:45):
Speaker 2 (01:00:45):
Agree with the right indication. And we have more to talk about training about skills and not about Mesh or not Mesh or laparoscopically. And finally, and I think you have the same experience. The most of the Mesh plants we do, the reason for the pain is not the Mesh itself. It’s folded. It’s not take out on the right place. And in many cases, the placement of the Mesh, the technique was the problem.
Speaker 1 (01:01:30):
Technique. Yes. It’s the technique and the decision making
Speaker 2 (01:01:32):
Speaker 1 (01:01:34):
I totally agree. That hour went by really quickly, but I enjoyed every minute of it. Thank you, Andreas.
Speaker 2 (01:01:41):
Thank you, Sharon. I know
Speaker 1 (01:01:43):
Speaker 1 (01:01:45):
It’s late for you, so I appreciate the time. I think it’s 10:00 PM right now at your home now. Yep. So thank you very much for lending your time, your free time. I hope that Germany opens up during this pandemic. We’re pretty much shut down in Los Angeles too. So thank you to everyone also for participating. We got a lot of great feedback from our audience, and I will make sure that I share the link to this on my YouTube channel so you can watch it again and share it with those of you who think you would be able to enjoy and learn from it. Thank you for your time. I hope to see you soon. Yeah, please take care. Please take care. Thank you very much. And for all of you, thank you for joining us. Come back next week where we’ll be joined by another great guest, and I look forward to another hernia talk Tuesday. Take care, everyone.