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Speaker 1 (00:00):
Hi everyone. Welcome to Hernia Talk. Today’s another Tuesday on our hernia Talk live question and question and answer session. My name is Dr. Shirin Towfigh. Thanks for joining me on both Zoom and Facebook at Dr. Towfigh. You can also follow me on Twitter and Instagram at hernia doc. Once we’re done with tonight’s hour session, I’ll make sure that it’s posted on my YouTube channel with all the rest of our hernia talk sessions today. You have me, I have been receiving a lot of questions from all of you, so I have tons pre-prepared from what you’ve sent me already. And I know many of you are excited to get some of your questions answered. Every so often I choose to be the one that’s posting hernia talk live alone because there are a lot of questions that we have to catch up on. They keep streaming in, which I love.
Speaker 1 (01:03):
And so you have me, you can follow me, Dr. Towfigh on Facebook. As you know, I’m a board certified general surgeon and hernia specialist. I live e Breathe, do everything that’s related. It’s kind of my thing, and I know it’s a little weird for some people, but for me, I really enjoy it and I think those of you who know me, you know enjoyed as well. So let’s get started with our question and answer sessions. Those of you that are on Facebook, please type in your questions for me. And those of you that are on Zoom, you can also type in your questions. Today is hodgepodge day. You can ask me anything you want that’s related to hernia surgery and hernia related complications, and we’ll go right at it. Okay? Here are the questions that you’ve submitted to me already. First question is the only treatment for hernia pain in operation?
Speaker 1 (02:07):
Very good question, yes and no. So traditionally, yes, if you have what we call a symptomatic inguinal hernia, which means a, or sorry, symptomatic hernia, any hernia that hurts, then the treatment for that is almost always surgical. And that’s because surgery can cure the hernia. And if the pain is from your hernia, then the pain should al also go away. There are a couple of ways of moving around it though. So for example, if you have a hernia that hurts, but you’ve also gained a lot of weight or been told to stop your exercises because your doctor felt that, oh, you have a hernia, don’t lift anything, don’t do anything, and pain actually got worse. That in those situations, going back to your exercises, focusing on core strengthening and losing the weight may actually either reduce or get rid of your hernia related symptoms and pain because it’ll decrease your abdominal pressure.
Speaker 1 (03:18):
And so that’s just one way that I encourage my patients with that kind of story that I encourage my patients to maybe forego surgery and instead get better symptom relief. Now, your hernia doesn’t go away. Your hernia is still there, but you have no symptoms. And for the most part there are exceptions and we can discuss those exceptions later. But for the most part, if you have a hernia and it doesn’t hurt, so what we call asymptomatic AL hernia, then the choice to repair it really is optional. In other words, what you can do is actually just do what’s called watchful waiting, and that tends to be safe for the majority of hernias. Not everything but the majority of hernias. All right, so that’s question number one. On that same note, let’s see, you did have a Inguinal hernia pair. This is for people that prefer not to have Mesh for their inguinal hernias if you have an open non Mesh inguinal hernia pair, and the same is true for ventral hernias or umbilical hernias, if that fails, do you have to use Mesh the next time?
Speaker 1 (04:33):
The correct answer to that is yes. So if you already showed that a tissue repair will not work for you, and we already know from almost every single study that’s been shown that tissue repair will have a higher recurrence rate than a Mesh repair. That’s just a known fact. You cannot argue other elsewhere. Otherwise, every single study shows that. So now that those numbers don’t necessarily have to be high, but it’s higher than using a Mesh Mesh for hernia repair. So if you then fail the tissue repair to do another tissue repair usually does not make any sense because now you’re going to double, triple, quadruple your hernia recurrence rate and therefore the next step should be to use the Mesh. And the Mesh is there to support your tissue repair. It’s not there to bridge or act as the repair. It’s there to support a tissue repair.
Speaker 1 (05:33):
So a better way to explain it maybe will be, let’s say you tear your shirt right at the seams. Well, for those of you that are tailors that you can’t just sew it back together again without it looking actually tighter or having an abnormal look to it because you’ve lost some tissue, you’ve lost some of that fabric. And so the next time you sew it together, it’s going to be tighter in the area unless you add some type of patch behind it. So the same is true with your own tissue. When you fail a tissue repair, you have less healthy tissue to work with and the defect, the hole is often even larger than what you originally started with. So the next option is a Mesh repair. Now Mesh, and I’ve said this a lot me, there’s not any one Mesh, there’s a wide variety of Mesh is different sizes, different weights, different materials, and the type of Mesh that that’s best for you may not be the same as it is for your neighbor or your spouse or your child.
Speaker 1 (06:46):
So just because we say Mesh, it doesn’t mean that it’s just one heavy weight, a highly inflammatory Mesh. It doesn’t have to be that we have a wide range of Mesh type availability. We have absorbable Mesh, we have have partially absorbable Mesh, we have hybrid Mesh, synthetic Mesh, lightweight synthetic Mesh, heavyweight synthetic Mesh, medium weight synthetic Mesh, ultra lightweight synthetic Mesh, and then different types of synthetic meshes that can come with polypropylene polyester Vicryl PTFE. And in Europe there’s P V D F, which is a different type as well. So there’s a lot of range in what we’re talking about. And so that’s where kind of US specialists who know that there’s a wide variety and understand like the pros and cons of each type of AM Mesh can help tailor the repair. And then the next question, the same realm is, okay, so how do I prevent a hernia recurrence?
Speaker 1 (07:50):
And the top two ways of preventing it is, number one, do not be constipated. So abdominal pressure significantly increases with constipation. I’m going to show you some data on that later. So any pressure you have to strain for bowel will add pressure to your hernia repair and increase the risk of recurrence. And number two, if you have a chronic cough, you have asthma, you smoke marijuana or cigarettes, you have C O P D, you have acid reflux. If any of those are causing you to have a chronic cough or you just get a cold, do treat that because every time you cough or clear your throat, you’re increasing your abdominal pressure and that will potentially increase your risk of hernia recurrence. Other things are gaining weight that will in or being obese that will increase your hernia recurrence and U use of nicotine. So those are the top four and I hope those are helpful to you. You have a lot of questions already coming through, so let’s go through these.
Speaker 1 (09:00):
Okay, first question that’s being submitted live is I’m a male with possibly a diastasis recti. Other than physical exam, is there any imaging available that can diagnose a definitively? Absolutely. So a diastasis recti is a separation of your rectus muscle. So you have your two six packs right, left and right, six packs in the middle. The two are fused and there’s a natural separation maybe up to one or one and a half centimeters in between that may separate out. It’s a very kind of genetic reason for it often. And so it can happen in men or women. We see it more often in women, let’s say after their second pregnancy or if they’re very petite, they have a huge baby. And then in men it’s very, very genetic. So what you see is some men are 50, 60, 70 years old, they have a very flat abdomen, and the other men, it’s kind of like a rounded barrel shaped abdomen that’s usually due with diastasis. So ultrasound or CAT scan are the two top ways of really measuring the distance of that diastasis. That really helps in surgical planning if you choose to have surgery for it. And then ultrasound CT scan can also help evaluate the growth of that muscle to see if it’s a thin or is it normal in caliber. It also helps to rule out any hernias that may be living within the diastasis.
Speaker 1 (10:40):
All right. Question, are you urologist? I am not a urologist. I’m a hernia specialist and general surgeon, so thank you for that question. Is testicular atrophy curable? No, that’s not reversible usually. Sorry about that. Cause that’s usually a vascular problem. Okay, next live question. I’ve learned so much from you and I’m piecing together my condition from information you’ve shared. Thank you. How would you address eventration of the left lower quadrant? I’ve had a horizontal incision, hip to hip and vertical sternum to pubic bone in order to remove pH Mesh due to foreign body reaction. Ooh, that sounds like a very extensive incision. So eventration implies that you have a bulging of the muscle, but there’s no actual whole causing the bulging. There’s no hernia. And almost always the eventration is because the nerves to the muscle have been cut or damaged. And basically, if you can think about it, the way that I explain it is that the muscle needs to be fed nutrition and the nutrition to the muscle is given by the nerves.
Speaker 1 (12:02):
So if you don’t have the nerves feeding the muscles, the muscle kind of becomes weaker and thinner and less strong. So you’ve seen people that are paraplegics in wheelchairs and their legs are super atrophied, very thin, no bulky muscle because the nerves to those muscles are basically no longer functional. So in your situation where they did this kind of sounds like they did a cross. So when you have a cross like that, not only are you cutting off the blood supply, but you’re also putting cutting off the nerves or you’re putting the blood supply and the nerves at risk. That’s kind of a very odd incision to have. And so yes, the way that you would treat an eventration if you wish to treat it because it’s causing pain or you want a better cosmetic look is to do a placation or basically. So the way I like to describe it is, for example, if you have, I’m going to use my mask. Here is my COVID mask. So this is an eventration.
Speaker 1 (13:15):
This is placation. Okay, so you basically take take the muscles and you sew them, not this is like three or four layers, but you just need one layer. So you basically sew it so it’s tighter. You take that extra bulge and you kind of tailor it down. Same way you would if you had a jacket, you want to take the seams in a little bit. We do the same thing with muscles, so it’s called plication. I do it for patients that have eventration due to let’s say spine surgery or kidney removal surgery where again there’s this diagonal or kind of cross incision and it gets nerve damage to the muscles. It’s a very extensive operation. It’s like a, what do you call it?
Speaker 1 (14:08):
Very big incision as often is open. I often use a plastic surgeon because you’re basically getting a tummy tuck, but you’re getting tummy tuck over the area and it’s kind of a little artsy because you have to make it tight enough to not be painful and not tear apart and tight enough to match the other side, but not too tight. So now the other side looks bulging, so there’s a little bit of art to it and you must have match. There’s no way you can do a non tissue, a tissue only problem plication because that muscle is not healthy. So you need some type of Mesh to be on top of it. All right, more urology questions. How do you treat erectile dysfunction? I recommend that you go to my previous hernia talk session with Dr. Paul Turk where we discussed erectile dysfunction for the entire hour, and that should help you completely, but unrelated to testicular atrophy, just so you know, not directly related, at least.
Speaker 1 (15:07):
Next question, where the odds of a hernia occurrence during pregnancy following Mesh removal with a natural repair? So this is a female, she had a hernia, then the Mesh was removed and had tissue repair, and she’s now seven months and is worried about a recurrence after pregnancy or during pregnancy. So for a groin hernia, very little, you actually don’t have that much groin pressure while during pregnancy. It’s possible that you’ll have a higher risk of recurrence if you undergo a really difficult laborer. So if you’re very worried about it or if your surgeon sends a tenuous repair, then I would see if you would talk with your obstetrician to do more like an elective C-section or elective induction and don’t do a prolonged laborer because that will increase a lot of pressure. But for the groin, inguinal hernia is probably okay. If you had an abdominal wall hernia that required Mesh, so that’s like belly button or somewhere around the belly button that required Mesh removal and then that was done as a tissue repair.
Speaker 1 (16:30):
We don’t have good data, but the thought is that that has a much higher chance of recurrence when you are pregnant because the amount of abdominal pressure and the stretching that’s required is much more. Now that doesn’t happen usually in the early phasix because up to about month five or six, you don’t actually increase your abdominal pressure. All the progesterone that’s released allows your muscles to stretch out, but once you get to your third trimester, that’s when all the pressure occurs and that’s when you start getting risk for hernia recurrence. So I hope that’s helpful, but it is if it’s an umbilical hernia. Yeah, tissue repair for an umbilical hernia has a higher than average risk of recurrence during pregnancy. Honestly, we don’t have good data for me to tell you exactly like quote you what that percentage is. Some say up to one third, but that’s not based on very strong data.
Speaker 1 (17:30):
The other thing that I would recommend to note, not in your situation but in general, is we who do these regularly do not recommend umbilical hernia repairs in women unless they’re done with their plans for pregnancy for this very, in other words, if you get a nice belly button, hernia repair and then you get pregnant, no matter if it’s five months later or five years later, the risk of that popping open is higher. So we’d rather not have to deal with the hernia recurrence and just have you wait till you’re done with your pregnancies and then we’ll do the belly button, her new pair, unless there’s a strong reason to get it done before. These are great questions guys. Thank you. Okay, next question. First of all, I absolutely love your talks. Thank you. I’m a scientist and I love the investigative approach of your sessions, so thanks a lot for these. Thank you. I feel like you’re, you understand me because I think, I believe that my thought process is very kind of systematic and logical, and I’ve been told I’m very process oriented. So in my mind, everything is algorithm based and the more knowledge I gain, the stronger that algorithm becomes. So thank you for, thank you for, appreciate that.
Speaker 1 (19:01):
Okay, let’s continue with that question. I was wondering what core exercises prevent Anglo hernia from getting worse? For example, are planks and lunges okay? Or is that too much pressure and our glued strength? Oh, this is a great question. Okay, so I was hoping that I would get some time to talk about exercises today because I get that question all the time and I actually have some data to share with you. Okay, so here’s data. Number one, what are your post-operative exercises? Well, first of all, we have some limited data, some limited data as to what is good and what is not good. There are a few centers that have looked into this and let me just kind of show you, okay, this is a good slide. So this is a study that looked in general like what do doctors do? And
Speaker 1 (20:10):
In my practice, I do recommend after surgery that there is a, here I’m going to show here. So this is by Dr. Lang who’s a colleague of mine in Texas. So he asked all these surgeons, okay, you operate for hernia, what do you tell your patients? So the blue are the non-specialists that do open surgery, and the orangeish color is the specialists that do laparoscopic surgery. So you can see the laparoscopic surgeons recommend return to activity earlier around two weeks and the open surgeries or surgery, the patients who undergo open surgeries recommended to undergo to return to work a little bit later six weeks. So that usually means that we feel that the recovery is shorter for laparoscopic than open surgery. I’m in this category, no restrictions. If you look at all the studies and the European Hernia Society guidelines and the international hernia guidelines, there is no evidence that restricting activities after surgery is something that necessarily benefits patients. So I do not restrict patients after surgery. Then the question is what kind of exercises do you recommend for patients? And that’s been studied back in 2005. This is a paper 2005 by Dr. Hek and his group back then Dr. Matthews and others were young newbies, but you can now see them in consultation. This is a study called Normal Intraabdominal Pressure in Healthy Adults. And check this out.
Speaker 1 (22:04):
What they did was I think they took medical students and they put catheters in them and they measured their abdominal pressures doing different things, just regular activities, and then abdominal crunches and jumping branch press, arm curl. So look at the mean, this is the standard pressures. So standing 20 millimeters of mercury sitting, 17 millimeters, mercury, and then coughing, 81 with a maximum, 127 millimeters of mercury, much, much more than standing. And then let’s do sit-ups where sit-ups, abdominal crunches, 27 millimeters of mercury, compare that to coughing, which is 127 or average of 81. So doing a sit up averages, 27 millimeters of mercury of abdominal pressure doing a cough averages, something about, what is that? Three times more, 81 millimeters of mercury. And then if you’re standing and coughing, it’s even worse. So a lot more abdominal and pelvic pressure jumping up and down. Very high pressure 171, but look at bench press, basically weightlifting seven.
Speaker 1 (23:24):
Okay, so this is why we tell our patients no coughing. And Valsalva is another one. A lot of pressure, no straining for constipation, but go ahead and do your abdominal crunches at a rate of 27 millimeters of mercury and go ahead and do your weightlifting to 20 millimeters of mercury. So that’s basically where we are in terms of questions about exercises. Planks are considered safe for anyone that doesn’t have abdominal diastasis recti. If you want some more information, let me share this with you. This is basically, if you go to the abdominal, let me share this with you. If you go to the AHSQC, it’s basically the abdominal core surgery. We have, sorry, abdominal core health quality, Collaborative a AHSQC dot org. There’s a patient section for you. And in that patient section is this kind of protocol patient guide. It’s based on Dr. Ben Paulo’s research when he was at Vanderbilt. He’s now currently at Ohio State University. And we discussed this in length.
Speaker 1 (24:48):
We discussed this in length a couple months ago with Dr. Poulose himself where he basically talked about his abdominal core health center and all the studies that he did. So these are all exercises that are considered very safe to do for someone just before and after their hernia surgery. And it includes things such as different types of activities for your belly and your pelvic floor. And then look at this lunges. Completely safe to do this is for a post-surgical patient. So yes, lenders are great, sit-ups are great. They kind of looked at surgery early after surgery two to four weeks later, and it’s just a very, very good resource. And highly recommend that if you want hear straight leg raises, different bending these clam shells, cat to cow yoga type movements. So those of you that know me know that I’m a big fan of Pilates in general.
Speaker 1 (26:06):
People that do core strength exercises are less likely to have hernias. And focusing on your core is something that I highly recommend that you do for anything. So as a surgeon, I end up standing on my feet, bending over, doing these weird twists for hours on end. And I feel that Pilates has really been great in trying to prevent me from having occupational injuries as a surgeon. So I just want to share this with you because I did this with me on my Instagram as well. This is a move with mj dot com. MJ is my pilates instructor. She has a special for $20. You can do a week’s worth of classes, but she is fantastic. She’s basically super smart. She does Pilates, which you can do from home. Just go online and sign up for her classes. It’s like $10, $20 per class. And then gyrotonics, which is also really, really great.
Speaker 1 (27:16):
And she also has bar classes or the bar method. So here you go, you can you like all these on-demand videos, she’s intelligent. She will not have you do anything abnormal. She knows she also does personal training if you want, but these are all things you can do on a yoga mat at your home. And that’s what I do. And I’m already sore from my Sunday session, so I’m very sore right now, but in a good way. All right, next question. Dr. Orian has a question. What is, thanks for tuning in. What’s your preferred method in dealing with patients with umbilical hernias who want an abdominalplasty? Okay, so that’s a very common problem, which is you need a tummy tuck or abdominalplasty. That usually means you have not only loose skin but loose muscle and the muscle’s going to be tightened. And a lot of times people who have a loose muscle, they often they’re female, often they’ve had pregnancies, so it’s not uncommon for them to have a belly button hernia.
Speaker 1 (28:22):
Those hernias tend to be two centimeters or less and are not usually recurrent. And I believe that a simple closure of the muscle and then you do your tummy tuck on top of that is a perfectly good repair. I’m not a fan of using Mesh in patients unless you absolutely need it. So we’re actually going to be studying this because I have a handful of patients where if they just needed a hernia pair, they probably wouldn’t need mash. But since they got a diastasis placation or a tummy tuck closure, we kind of used the tummy tuck, which is again a tailoring or a suturing of the muscle over the hernia. We use that as a biologic closure. And so far we’ve had no hernia recurrences yet. So my recommendation is assuming the hernia is two centimeters or less in width, that a simple tummy tuck with no Mesh should, which is in two layers, should be able to address that without any problems. Next question, what can you tell me about D V T and Mesh? So a D V T stands for deep venous thrombosis. It’s a clot in your vein. Often it’s related to a risk factor, like you basically clot more. That’s one issue. The other problem, maybe you got the D V T because you had a risk factor for it, so you’re a smoker, nicotine increases your risk of D V T or you had a very long operation, usually four hours or more is considered a significant operation.
Speaker 1 (30:22):
So laparoscopy puts you at higher risk for D V T in a long operation, four hours or less makes you higher risk for A D V T. Mesh is not considered a risk factor for D V T. Any inflammatory reaction from any implant is not considered a higher risk for D V T. So as far as we know, there is no link between the actual Mesh product and the D V T, but the surgery could be a risk factor. So a long operation or a laparoscopic operation can put you at higher risk for D V T, which is why in my practice, pretty much everyone who has a more than just a simple operation gets a blood thinner during surgery to reduce that risk.
Speaker 1 (31:13):
These are great questions guys. Thanks for asking them. Okay, next question. What would be a typical course of action for someone said to have Mesh entrapment of the spermatic cord? Okay, so the spermatic cord, it is everything that goes to your testicle. So only men have it. It includes blood vessels, so arteries and artery and nerves, sorry, artery and veins. It includes nerves, it includes muscle, and it includes the VAs, which carries the sperm from the testicle to the prostate. So that entire complex is called the spermatic cord. When you do a Mesh repair in the groin, either laparoscopic or open, there is a risk that the Mesh can erode into, adhere to impinge on, adhere to any component of the spermatic cord. It’s not a hundred percent, but anyway, so it can happen. The treatment is to remove the Mesh, so that can be either laparoscopic or open depending on whether the initial Mesh was performed laparoscopic or open.
Speaker 1 (32:33):
In some cases you can put an, I put an anti-adhesive, so I’ll remove the Mesh and then if they need more Mesh or they need another repair, I do an anti-adhesive around the spermatic cord to prevent scar tissue or any other reason for the cord to get more injury after the second operation. But the only way to release the entrapment is with surgery. I hope that’s kind of like where you were going with that. Okay, you’re welcome Dr. William. Next question, follow up to the same question. What would be a typical course of action for someone said to have Mesh entrapment of the COR spermatic cord? How does a doctor determine if there is Mesh erosion into the VA and para vasal nerves? Good question. Complicating this is I did not get relief from traumatic cord blocks. Okay, what’s next? Very, very good question. Okay, so if you have Mesh involvement of the cord, again adherence, entrapment, erosion, any combination, then you may have certain symptoms.
Speaker 1 (33:45):
So you can have testicular pain, you can have pain with ejaculation or you can have engorgement of the downstream veins or you can have engorgement of the VAs or the epididymus, which causes pain. So depending on which ones of those you have, you can kind of predict how extensive the problem is upstream or the Mesh is. So that’s kind of how it depends on your symptoms. Is it just testicular pain, which means the Mesh may be just entrapping or adhering to the cord structures or the VAs, or do you have pain with ejaculation, which means the Mesh is impinging on or eroding into the VAs? Or do you have engorgement of the vein or a epidermal like epididymitis or engorgement of the VAs or epididymitis, which means there’s an obstruction from the Mesh higher up. Just because you not get relief from the cord block does not mean you don’t have Mesh related problem. All that means is that the nerves on the bass are not being directly impinged. You have more going on than that.
Speaker 1 (35:11):
I hope that’s the answer. So imaging will help identify where the Mesh is and how it is in relationship to the spermatic cord. Usually I recommend MRI of the pelvis because that best shows the Mesh in comparison to its surrounding structures like the spermatic cord, a really good ultrasonographer, which most centers don’t have. I know the Cleveland Clinic groin pain does have a really good 3D high def ultrasonographer. Most places do not, but that is another option. But usually MRI pelvis and someone who can read it well will help determine that. And then also a good testicular ultrasound to identify any abnormalities in the girth and the flow of the spermatic or gonadal veins as well as the epididymitis and the VAs. The goal is to return on the spermatic cord to a normal, normal system. All right. Let’s see. Next question. Oh, question about the anti-adhesive. So there are two anti-adhesive products on the market. Actually three, I’ve only used two of them. One’s called Seprafilm and one’s called intercede. I’m a big fan of intercede because it’s easier to handle. It’s basically like a plant-based anti adherent, which absorbs at about seven days. So it prevents your whatever structure you want to prevent adhesion to another structure during the healing period when you develop scar tissue.
Speaker 1 (36:59):
And then the next question again about the spermatic cord. I know this, I feel like I’ve learned this part really well, but it’s kind of the most difficult part of handling hernia related problems, which is all the genital kind of complications
Speaker 1 (37:19):
It, which is cord denervation and can it help to respond if they respond to a block? So yes and no cord spermatic. Cord denervation should be done judiciously and not for every single type of testicular pain, number one. Number two, it should be done by someone who does it for a living, not for by someone’s like, oh yeah, I’ll figure it out because I’ve seen some opera reports and they never really did a cord denervation and in fact caused more damage. So make sure you go to a specialist and I highly recommend you tune into our urology segment from several months ago with Dr. Paul Turk where we specifically discussed spermatic cord denervation. He’s one of the national specialists in that and someone who I work with closely. So if you have a Mesh related
Speaker 1 (38:22):
Cord pain problem cord, denervation will not treat that because you, you’re treating the byproduct you need to treat the actual problem, which is the Mesh, and it’s a mechanical effect on the cord. If you ignore that upstream and just do the denervation downstream, that will not cure your problem because often not only is the Mesh impinging on the cord, it’s impinging it upstream. So it’s basically closer to your brain then where the denervation is, which so doesn’t really, you need to catch the denervation between the injury and your brain, not beyond the injury and further from the brain. And secondly, any other symptoms you may have may be directly related to the Mesh, like a folding or folding or erosion. And those cause other symptoms that a pure denervation does not cause. So I see sometimes people who’ve had 1, 2, 3 denervation procedures by urologists who just look at their box, which is the testicle, and there’s testicular pain, and the patient got a cord block and the results were 60, 70, 80% good results of pain relief. So they focus on the testicle. Meanwhile upstream you have the smash that’s folded, eroded, adhered, whatever the cause is, that is the main problem. And so it’s not dealing with a primary problem and that’s why I highly recommend you have a coordinated care with a hernia specialist and a urologist. And that’s kind of what I do. It’s why I have a hernia center because I work with different specialists and treat the patient as a whole, not just my own little box. Okay, thank you for that.
Speaker 1 (40:27):
All righty. Next question. I had an Inguinal hernia bilateral fixed with Mesh with a top transabdominal preperoneal. I feel sore when active. It’s been about two years. When I sit back or lay down, I feel pulling and when sneezing, I feel a little pain. It’s pretty good when resting, am I a candidate for Mesh removal? How long on average would a double Mesh removal done revive take? What are the risks? And thanks for all you do. Okay, thank you. All right, so sounds like you had a routine hernia repair with Mesh laparoscopic and you feel sore when you’re active. So that could be, oh, and some of the pain is sitting back or laying down. You feel a pulling or when you sneezing a little pain. I actually just had a similar patient today. So the reason for that is often not your heart repair was fine, but sometimes it’s placed too tightly. So it’s like you always have an inner girdle and way I explain it is, let’s use the mask again. This COVID mask is becoming very helpful. Okay,
Speaker 1 (41:45):
So here’s your Mesh. It does not stretch. Okay, meanwhile, here’s your muscle which stretches. So let’s put a Mesh in. Let’s get a little bit of a contour like the 3D max, the little contour to it. So that’s good. And then you want to place the Mesh to kind of follow the contour of your abdominal wall. That way when you cough and sneeze, stretch out, there’s a little bit of give to it, right? You want to do it, this is like how you want it. But if I put the Mesh in like this and I have muscle that kind of wants to on the other side that wants to stretch, well this does not stretch. This is totally stiff and you’re going to feel like there’s armor inside you or that it’s tight or that you can’t bend or hyperextend or cough or talk really loud. Even so talking out loud also increases abdominal pressure. So for those, it’s not that the Mesh is a problem, it’s the placement of the Mesh was too tight and so you need to loosen it and often the best way to loosen it just to remove it and then put a more kind of softer, looser Mesh in place.
Speaker 1 (43:06):
Usually I would do that laparoscopically or robotically. The robotic operation takes about for both sides, takes about two to three hours, sometimes longer depending on how much the Mesh is stuck to everything. But you have to remove all of the Mesh and then put in a newer Mesh. And then I also put anti adherence over the spermatic cord again to prevent that whole thing where the Mesh can get scarred down by the spermatic cord can get scarred down by the Mesh. So the wrists are the actual Mesh removal process. So there are vessels that feed your leg that can be injured or stuck to the Mesh. Your bladder may be nearby. There’s really one nerve only, maybe two that can be injured.
Speaker 1 (44:00):
That’s usually doesn’t happen. And then there’s the spermatic cord and males, the spermatic cord, which I explained has vessels and the vas, which carries the sperm and nerves and muscles. So that can be injured. Again, all of these are a relative risk. It depends on the skill of your surgeon. I do it for a living, so I actually enjoy these operations because it’s like a puzzle and you have very careful about it, but it’s very satisfying because you can remove everything and redo it. It’s like undoing a puzzle, like Legos, undo it, redo it. It’s kind of fun. And the risks to it can be exciting because it’s challenging. And most importantly, the patient feels really good afterwards. So in your specific situation, most likely these symptoms are from a tight Mesh. The Mesh will never loosen up because if anything it shrinks. So even if it’s put not totally tight, but a little bit tight, once it shrinks, it becomes tighter. So that’s why we recommend the Mesh not be placed too tight because it shrinks.
Speaker 1 (45:18):
All righty. Are there tests that can help determine whether or not a patient will have a reaction to Mesh, especially if they reacted to Mesh previously? Okay, short answer is nothing. No, nothing reliable. We currently do not understand or have any good testing to determine if anyone can react to an implant, nothing reliable. At least there are a Mesh allergy testing that I do in some patients, depending on the scenario in that Mesh allergy testing, if it shows an allergy to great, if it says no allergy, then that’s unreliable. It’s about 40% correct. So I’ve had patients that showed no allergy and then you put in that Mesh and they have the allergy. And by allergy, I’m using that term very loosely. Any inflammatory or autoimmune reaction I would consider reaction. I shouldn’t use the word allergy. It’s re reaction. So there are some patient, some studies that are mostly research based that look at blood tests to see if anyone reacts from a blood test that’s research based.
Speaker 1 (46:37):
There’s not a blood test you can order right now in your local labs that look at that. We’re we’re looking into all of that to see how if we can come up with a protocol or a testing that’s more reliable that we currently have. I’m working with Dr. Traver up in Ontario. We actually had a full hour with Dr. Traver early on in our hernia talk live sessions in 2020. So I highly recommend you go on YouTube or Facebook and search for my hour with Dr. Trat. Well, we talked about risk factors for Mesh reactions, how to help predict it, what tests are available and what the future of it lies. So if you reacted to Mesh previously, the question is what was your reaction? Was it allergic? Stay away? Was it inflammatory? Then sometimes less Mesh will help or autoimmune again, you would want to stay away.
Speaker 1 (47:43):
All right, lots of great questions guys. I’m really impressed by all of this. Let’s do this one. So this is related to diastasis recti. The question is, I have a diastasis recti since my two pregnancies 11 years ago. I look three months pregnant. Why do I hurt so dang much? Sorry that you’re hurting. Okay, so again, diastasis recti is when your muscles are separated and it can happen often after your second pregnancy or with really large babies, or if you’ve had twins or triplets or quadruplets. Just if you’re a small lady or big baby, the more pressure and the more times you’ve had pregnancy, the higher the risk of getting a diastasis. Now, usually diastasis, rect eye does not hurt. If it hurts, you have to make sure you’re not getting a hernia within the diastasis. That would be my number one recommendation is to rule out a hernia.
Speaker 1 (48:45):
If it’s a very wide diastasis, very that gives, makes you look three months pregnant or bigger, then that can disrupt your core. And what can happen is that core disruption can give you back pain and difficulties doing certain activities at home, but should not give you pain in general. So if you have pain, there are other reasons for the pain, often not your diastasis. Now if you have a very wide diastasis, you may just be thin in between the two muscles that layer in between maybe super thin and sensitive. So that’s a different story. And a tummy tuck will, will is a cure for that. Next question.
Speaker 1 (49:38):
Okay, this is more of a technical question. We had Dr. Ali Sheen from Manchester United Kingdom as one of our guests a couple months ago, and he has what’s called the Manchester laparoscopic hernia repair. What differentiates the Manchester laparoscopic hernia repair described by Dr. Sheen from the other conventional laparoscopic tap or tap al hernia repair techniques. So Dr. Sheen, his Manchester laparoscopic hernia repair is an al hernia repair. The way that he is unique in his technique, which many of us also follow, is that number one is tap t e p, which stands for trans, sorry, totally extra peritoneal. He uses a larger than usual Mesh. So instead of a 10 by 15, he uses a 12 by 15 centimeter Mesh. He does not use any fixation that’s mechanical. So no tax or sutures. That’s the main reason why he’s different. He uses fibrin sealant and he has specific areas where he puts fibrin sealant, which is basically tissue glue. And then I believe he uses mostly the progrip Mesh, which is like a, what do you call it, a like Velcro type Mesh. It’s polyester based. So that in a nutshell is the Manchester laparoscopic inguinal hernia pair with Mesh works very well. You often do not need to use the glue even I think I don’t even use the glue and then you know, can use sutures instead of tax. But there’s different ways of doing the same operation and that’s kind of the one way of doing it.
Speaker 1 (51:23):
Okay, this is an unfortunate story. Let me share it with you. So this is a 78 year old female. She had an open inguinal hernia surgery with Mesh five years ago. Okay? First of all, I don’t recommend open inguinal hernia pair with Mesh for women. Now, older women, you can argue, or if you’re morbidly obese, that that’s a good option because there’s no need for general anesthesia. But in general, I don’t like to do the open angle hernia surgery with Mesh in women. And if you were with us last week with Dr. Andreas Koch from Germany, he also treats a lot of women in Germany and we both agreed. So that’s where we are with that. So she had horrible pain after surgery. She had exploratory surgery, which showed the Mesh to be attached to a nerve. Okay, another comment. Do not do exploratory surgery. You need to have your surgeon go in there with a plan of care, not just, oh, we’ll just kind of take a look and see what happens. You need to have some type of imaging to figure out what’s wrong. And then a discussion with your surgeon as to exactly what will be done.
Speaker 1 (52:43):
Is the plan to take out the Mesh, is it a nerve problem? Do we cut the nerve? Do you want a tissue repair afterwards where the risks and benefits of all the different options? At least that’s what I do with my patients. So the exploratory surgery showed the Mesh was attached to a nerve. My surgeon removed the Mesh and replaced another nerve. She didn’t tell me what she was done with the nerve. Now I have horrible burning in the left groin, horribly burning, left groin pain, numbness on my pubic bone and I walk with a walker. I have a new hernia on the other side as well. What are my options? So, okay, let’s dissect this out. It sounds like the surgeon went in there to see what they can do. They saw Mesh attached to the nerve. What you need to do is to remove the Mesh or address the nerve.
Speaker 1 (53:38):
It’s unclear what her original pain problem was. If it’s purely a nerve issue, you don’t need to remove the Mesh, you just deal with the nerve. So that’s kind of an issue already for me. But let’s say she had a Mesh and a nerve problem she removed, he had the nerve detached from the Mesh, but you also therefore have a damaged nerve. So just leaving it in place is not the right thing to do. You have to cut that nerve, especially if you you’re plant putting another Mesh, which will then stick to that nerve. So now she has horrible left growing burning pain and numbness of the pubic bone. So sounds like now she has nerve related pain. Again, not sure if that’s the same pain or different, worse pain than she had before. That’s a problem with revisional surgery is you can make the patient worse. Now that risk is much lower if you go in with the plan, if you’re kind of winging it when you go on in. That’s another issue.
Speaker 2 (54:35):
So
Speaker 1 (54:36):
This patient, of course, I don’t know the details of this patient, but sounds like she has now what we call nerve pain or neuropathic pain. And that pain is manifest with burning and numbness. Sometimes we call it, what do we, it’s called painful numbness. So it’s a, it’s when you have nerve pain or the nerve is damaged to your numb, but it’s nerve is damaged so you have nerve pain. So painful numbness is a true issue. So if it’s only the painful numbness that is a nerve problem, then we should direct the pain control and everything to the nerve. Don’t keep taking out meshes. Not all pain is due to Mesh. In fact, most pain is not due to Mesh. There are other reasons. And this lady, it sounds like it was a nerve issue. Now she’s got more issues because now this whole confounding of Mesh remove Mesh put in whatever. So what I recommend is that you get some nerve blocks and if the nerve blocks help you, then you get a nerve ablation or a neurectomy. And if you want to learn more about that, I recommend that you look at my hernia talk session. I think two or three months ago with Dr. Vahedifar, who’s the pain management surgeon? Pain management specialist who I use a lot for my patients.
Speaker 1 (56:06):
We talked about nerve pain and nerve cutting and nerve ablation and all the risks that are associated with it. So I hope that’s helpful. Yeah, painful numbness is real. Thank you. All righty, let’s do some more questions. These are really great. Okay, this is from one of my patients in Europe. If polypropylene meshes are in direct contact with the bowel or the intestines, are there concerns of complications including adhesions with consequent intestinal obstruction? Yes, we do not put bowel indirect contact with Mesh unless there’s some adherent adherence to that and that can cause fistula, sinus formation, infection and or obstruction. Have you seen these complications, especially in Tesla adhesions with pre peritoneal Mesh placement where there’s only peritoneum separating the bowel from the Mesh? No, usually not. The Mesh is separated from the peritoneum. Now sometimes that peritoneum has a hole in it or there’s erosion of Mesh through the peritoneum and that can cause problems.
Speaker 1 (57:22):
And that’s where you have to be open-minded because not every patient with a pre peritoneal Mesh will have no problems. Are adhesions or Mesh problems more common in patients who experience a long-term inflammatory reaction to the Mesh no matter how the Mesh is placed? Not really. It’s really unrelated to adhesions and Mesh problems are unrelated to whether you have inflammatory Mesh. It’s more related to how the Mesh is placed. So I hope that’s helpful. And then lastly, have you ever seen a Mesh cause adhesions as severe as to be impossible to cut? If you manage to release the adhesions, will they inevitably reform if the Mesh is not removed unrelated to the Mesh, adhesions can be cut, but the act of cutting will cause more adhesions. It’s kind of a vicious cycle. So in general, the Mesh is not, whether the Mesh is left there or not is not the issue.
Speaker 1 (58:20):
It has to do with the actual surgical effect. So we are done with our hour. Can you believe it? Okay guys, I’ll try and save the other questions from the next time. I’m all alone. We have some really amazing people that are already set up for the following two months, and if you have any recommendations of specific doctors or others who you’d like to have on this show, let me know and I’ll reach out to them and invite them as my guest. In the meantime, have a great Tuesday night for those of you in the United States. Tomorrow is our inauguration. So there’s a lot going on this week in the United States. I hope you all stay safe. This is Dr. Sharon Towfigh signing off. Please join me on my social media pages on Facebook at Dr. Towfigh and at Hernia Doc on Twitter and Instagram. And shortly I will post this entire hour on my YouTube channel. Until next week, take care guys. Thanks very much. Time flies when you’re having fun. That’s right. Thank you.
