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Speaker 1 (00:00):
This is Dr. Shirin Towfigh. Let me share my screen real quick so you can see where we’re coming from. We are live, uh, with Dr. Gina Adrales. This is Hernia Talk Live. We are here every Sunday for one hour. We take your questions and answers on anything hernia related. Uh, my name is Shrin Towfigh. All I do is hernia surgery. You can follow me at Hernia doc on Twitter, um, and, uh, Instagram. And your, many of you are on Facebook Live, which should be streaming, uh, as we speak. Let me just double check. That looks like we are great and, um, we are very privileged to have a good friend of mine, um, an amazing laparoscopic surgeon and hernia specialist, Dr. Gina Adrales. Hi Gina.
Speaker 2 (00:50):
Hi Shirin. Thanks for having me.
Speaker 1 (00:52):
Dr. Adrales is, um, associate professor of surgery at Johns Hopkins. She’s super intelligent. She is a past president of the American Hernia Society and the first female to hold that position, and, um, has really paved the way towards, uh, making our hernia society much more inclusive in looking at different differences among the sexes, but also the difference among the communities or races and everything. So I’m really happy to have her, Gina. Um, anything else you wanna add to that? You’re one of my favorite people, as you know, and I’m so privileged to to know you.
Speaker 2 (01:31):
That’s fine. I mean, you helped me pave the way you were the only woman on the board when I joined. So,
Speaker 1 (01:39):
Lonely on the board for a while, but, um, we’re getting better. We’re doing better on that. So, um, something interesting over, uh, you know, as it is, my practice is in Beverly Hills, and so by default, sometimes people come to you for their hernia surgery and they may. And, um, over the last week, the, um, Denise Richards had a femoral hernia. She had bilateral femoral hernias that it was posted on real housewives of Beverly Hills, which was very lovely to watch. I had a very small, like, I had my 15 seconds of fame, but based on that, a lot of people had questions about what is a femoral hernia and, um, why did she require surgery and what are the symptoms and so on. So in fact, let’s see. Here’s our first question. If we can just get right into it. What is a femoral hernia and why should women in particular be aware of them? And what are the first sides of femoral hernia?
Speaker 2 (02:48):
Good questions. Uh, femoral hernias occur very similarly, like other hernias. So, uh, basically, um, there’s a femoral canal or an opening where the vessels, um, from the admin pass down into the leg and there’s sort of this potential space there. And so in that space, um, the contents from the stomach area can go down into that space. Um, and it’s a fairly, um, uncommon hernia, um, among women growing her, uh, for women who have groin hernias and anal hernia is still more common. Um, but among those with femoral hernia, certainly women, uh, constitute a good proportion of that. Um, and so should be aware. And, uh, sometimes femoral hernias, uh, present as a first symptom, um, as a, a blockage or an incarceration where a hernias getting stuck. Um, but I think part of that is really just, uh, also reflective that it can be hard to diagnose a femoral hernia. Some people, particularly women,
Speaker 1 (03:52):
And usually when we talk about inguinal hernias and, uh, different treatments for it, we do not consider femoral hernia in that category. Is that right? Because femoral hernia has a very specific, um, diagnosis and treatment algorithm that’s different from an inguinal hernia. Do you agree with that?
Speaker 2 (04:11):
I agree that it’s different, uh, but I have found, uh, often in women in particular that, um, they have both. And so I, I think often the femoral hernia is an occult hernia. And I also think that when somebody presents with a recurrence after a groin repair, um, I mean often if it was a direct hernia, I know we’ll probably go get into the different types of al hernia, but if it were a direct hernia, often the recurrence is also direct hernia, but sometimes it’s a femoral hernia that was just missed, um, the first time around.
Speaker 1 (04:47):
So all the studies show that, um, uh, of that, like you said, the femoral hernias are missed in women. And so they, they, they have, they may even have a fem inguinal hernia. They get that repaired, but their symptoms don’t go away. So the international hernia guidelines is that women should always be surveilled for a femoral hernia. So either by imaging or by, um, surgically. But when you’re in there, you should make sure you’re not missing a femoral hernia. And the reason why a certain percentage of women have chronic pain after or need another surgery after an inguinal hernia repair, whereas the men do not, is because it’s a missed femoral hernia.
Speaker 2 (05:30):
Yes, I, I think so. And, um, and I, I certainly agree with the, uh, international guidelines in that. Um, but I, I think also women, um, you know, if we look at the database studies and we’ve done some of that, uh, work looking at, uh, the you know, big large database population studies and found that women as a whole, whether it’s a functional hernia or groin hernia, tend to, um, uh, have a greater risk of complications. And we haven’t really sorted out exactly why that’s true. I think in terms of groin hernias, part of it is a femoral hernia, and then sometimes femoral hernias, um, aren’t diagnosed until they’re presenting as an emergency. So that’s very different from an inguinal hernia. And, um, and so it really is, uh, pulling on us more operating on women in particular for groin hernias to really rule out the femoral hernia and use an approach that allows us to do a good assessment of that.
Speaker 1 (06:27):
And what’s the standard of, um, the standard repair for ephemeral hernia?
Speaker 2 (06:33):
Uh, that’s a good question. <laugh>, I think probably if you ask different people, you might get a different answer. But I think, um, uh, really a posterior approach. So really looking at it from the inside, I would consider the standard. And, um, that type of approach is really what’s recommended as well in international guidelines because it allows a full view of, uh, the inguinal area. So not just where an inguinal hernia is and indirect, indirect hernia, but also the femoral hernia and sometimes an obturator hernia as well, which is even more rare, um, but can be seen with that approach.
Speaker 1 (07:07):
Actually, I think our next question may be about Obturator hernias. Um, oh no, this one, it’s actually a really good question. One of our, uh, friends on hernia attack asked about this. So when discussing a direct al hernia, how come most doctors talk about a whole rather than a weakness? Do you wanna explain the direct versus indirect kind of nomenclature and which one’s a whole and which one’s more of a weakness and why that matters?
Speaker 2 (07:35):
Yeah, I guess for, uh, we’ll step back a little bit and look at the indirect hernia. So an indirect hernia really occurs where there is sort of a natural opening. So in men, um, there’s an opening there where the Vas deferens and the vessels that go, uh, continue down to the testicle pass. And sometimes that area can enlarge, um, or doesn’t close all the way and allows an inguinal develop there. A direct hernia is more of a weakness that develops in the muscle wall itself, um, where there is not already a natural opening or canal to allow other structures to pass through. And just by the way that our muscles are in that, um, abdominal area or trunk are connected to the, um, pelvis, there’s sort of a natural area there that’s a little bit, um, thinner, um, than just adjacent to it. So it does start as a weakening, but you can, um, it really does present very similarly to the indirect hernia in that there is a breach of that muscle wall.
Speaker 1 (08:35):
Yeah, sometimes it does look like a hole. Um, but, or even a, I mean even like, like a punch down hole, you know, but the reality is, it’s, it’s more of a weakness in that region than, uh, than an existing hole that increase in size, like an indirect al hernia. And a femoral hernia is always a hole. It’s just a space that gets, gets larger. And do you have, so we discussed this with Dr. Brown last week about, um, tissue repairs. Cause he does a lot of sports hernias and tissue repairs. And we made the comment, which I agreed with, which is, of course, all these hernias, whether it’s femoral, indirect, or direct, um, can be repaired in a variety of modalities. So for like a femoral hernia, I think, uh, like you mentioned, the posterior approach is considered superior. Um, you, and usually it’s a laparoscopic or robotic mesh, but you can also have a tissue repair called the McVay.
Speaker 1 (09:35):
Um, it’s just the recovering outcomes have been shown to be better with the laparoscopic approach. It’s, it’s kind of difficult to recover from the McVay, although, you know, we do it. Um, same for direct. So direct we kind of felt, uh, I’d like to know your opinion. A tissue repair works really well for the indirect inguinal hernias cause it’s a lot of muscle that you’re moving, but with the direct, you have like the weakness, then you have the, the pubic bone and the inguinal ligament, which is stiff and you’re trying to bring all that together. And, um, we felt that maybe a direct hernia, um, doesn’t have as good of an outcome that an indirect because of that, uh, for a tissue repair. What do you think about that?
Speaker 2 (10:20):
I, I agree. I think direct hernias can be challenging with an open approach because sometimes the floor just, you know, where the direct hernia is, just feels like it’s completely blown out. It’s just so weakened. And so, um, uh, from a posterior point of view, laparoscopic or robotic assisted, um, it can allow really a reinforcement of that area. And if there’s a wide gap, um, and certainly if it’s a larger type direct hernia, you can still bring that tissue together. Um, and, um, you know, en close that, that is, uh, one recommendation at least from the Europeans, um, to do that in the, in the guidelines. Um, and then to reinforce it, um, with the mesh, I think there are certainly, uh, you highlighted a few things in that Shirin about different ways to approach a hernia. And, and there’s no one true way, I think, for all individuals, and it’s good to know different techniques. I do think that one thing about a mesh repair, um, and certainly, you know, folks can have a non mesh repair as well, but one thing about that posterior approach, um, or a mesh repair open or a laparoscopic or robotic assisted is that it can be really quite reproducible, I think. And sometimes when you’re buying a tissue repair, um, especially for a direct hernia, you’re trying to find, you know, tissue that you can really bring together that’s robust and it’s variable from person to person.
Speaker 1 (11:42):
Yeah, I was explain a a direct hernia. It’s like, um, I don’t know if people do it anymore, but remember, like your old professor would have this, this sweater, and then the elbows would always be like, overuse and then it would stretch out in that area. That’s kind of like what a direct is. It’s, it just gives away eventually, but it’s just a stretched out. And then when you wanna put it together, back in the day, they would patch it, you know, it’s like, it’s not trending anymore to patch anything, but, um, in clothing from a clothing fashion standpoint. But they would have all these elbows, Sue, remember those suede elbow patches? Yeah. <laugh>. Yeah. I mean that’s <laugh> because logistically, and, and from a tailoring standpoint, you couldn’t knit that part. You didn’t have an, there wasn’t enough material for you to knit that part of the sweater back together.
Speaker 1 (12:35):
Mm-hmm. <affirmative>. Um, and that’s what we try to do with a tissue repair. But that’s something that, uh, um, I, I feel like that’s a nice analogy sometimes. So we actually, uh, we don’t have any question. We have a comment, but I’d like your take on this because, uh, we’re gonna jump around a little bit. We have a lot of patients that live in areas where they don’t have good access to hernia experts. Um, and yet they really need it. For example, on Facebook Live, we have someone who mentioned, I have what they call loss of domain, right? Loss of domains, big ventral hernias. Um, he’s had six different hernia operations gone wrong, finally got insurance. So it sounds like before that he, he was working in a uninsured um, status, but Missouri can’t fix me. I need help. Um, last time I was in the hospital, 45 days.
Speaker 1 (13:24):
So what is your, it’s kind of a difficult situation. Um, we don’t have that many hernia specialists around the nation, and I feel like the Midwest, um, has a handful, but it’s not like prevalent. I don’t think every state has one. Um, there are certain a lot of states I can name right now that have no hernia specialist that I know of. What do you recommend for someone who needs, obviously a hernia specialist? This is a redo, redo, redo, redo, redo, hernia, loss of domain, um, lives in Missouri. What are your recommendations? How do you, how do you handle that?
Speaker 2 (14:05):
Yeah, that’s a good, uh, tough situation. Uh, Sharon, I mean we, um, I certainly see patients from many other states. Um, right now during this pandemic we’re, I mean, we’re still seeing, uh, patients virtually, but it can be limited. Um, but there are, um, because there’s some relaxation, I guess, um, per state to allow patients to continue to get care that might be, um, an area where you can access care right now. Um, but it really varies state to state in terms of you can see. Um, but I, I think it’s a, a tough question and I think, um, part of that goes to, um, where surgeons come from when it comes to hernias. Hernias are actually, can be really quite complex as you know mm-hmm. <affirmative>, um, there’s a lot of, uh, literature, you know, and evidence and studies that are being done, but it’s not, um, a highly recognized field, uh, like something like cancer yet, um, hernias can really affect a wide part of our large part of our population and can cause a lot of, uh, disability. So, um, I think it is beholden on us, um, you know, to like you do, to continue to train those who are coming out of surgery to really, um, know more and understand more about the abdominal wall and, um, in different ways to, to fix it. So hopefully that will change over time.
Speaker 1 (15:26):
I think the good news is, uh, because of many of us that are really excited about hernias, I feel the, the re the residents like hernias more than I liked hernias when I was a, I didn’t like hernias when I was a resident, I dunno about you, but it was definitely not my career goal to be a hernia surgeon <laugh>. Um, it kind of just fell into my lap and I, I will, would never, um, choose anything else. I think a lifestyle and the patient satisfaction is amazing, uh, but I do see that more the residents and the fellows really like, I mean, they come to our fellowship to train with me because it’s a special opportunity to be able to learn more about hernias and complex hernias and so on. So maybe it’ll change and there will be more specialists accessible. Otherwise, unfortunately, even though we’re a first world country and should have access to specialists, um, nearby, like patients may have to travel for, for their care, it’s unfortunate. But
Speaker 2 (16:26):
Yeah, I think so. And, and I think the, um, you know, the mar um, society website also is a good place to, um, find you can find a, a hernia specialist on the website. Um, and you know, our society represents a lot of, uh, surgeons who have interest and may not be the only thing they do, but have interest in hernia and keeping up with the latest evidence and, um, in a patient centered approach. So I think that is a good place to start.
Speaker 1 (16:53):
I agree. Okay. We have another question. Um, this is a female. She says, hi, I’ve had three laparoscopic operations, one prior pregnancy. I now have a bulge that begins at my belly button and extends up one inch. I don’t know if it’s a hernia or it’s a diastasis recti. Um, I’m a fitness nut and it’s driving me crazy. I don’t have a six pack anymore, just a two pack. So what are your thoughts on that? Is this a hernia? Is the diastasis, could it be both? Um, how do you tell?
Speaker 2 (17:24):
I think it could easily be both. I mean, just from experience, I guess from many patients, many women can develop an umbilical hernia. I mean, that’s the thinness, you know, the belly button is the thinnest part of the abdominal wall. And so it’s not uncommon to get, um, one of those, um, with pregnancy. And, um, certainly, uh, um, with pregnancy and the toll it takes on the abdominal wall, um, there is often a diastasis that can, there, most often it is in that upper part of the abdomen. So I really think it could, could be both. And certainly, um, if there’s umbilical hernia, you need to consider the diastasis as you repair that because the risk for hernia recurrence after an umbilical hernia repair is gonna go up. Um, if the diastasis also isn’t, um, addressed or recognized in some way,
Speaker 1 (18:10):
Um, I think that’s where, that’s where the specialty comes in. Uh, many surgeons don’t appreciate the, the link between a diastasis and a hernia. And so two things happens. One is you do a laparoscopic repair, uh, I’m sorry, you do a laparoscopic operation. You go through the belly button, which is traditional for almost every laparoscopic operation, usually has a belly button incision. And someone who already has a diastasis that’s already thin and they either don’t close that because that’s not their routine or they close it and they get a hernia there. So that’s unfortunately a complication that can occur when you go through a, the thin area of a diastasis mm-hmm. <affirmative>. And then secondly is the diastasis. It could be unrelated to laparoscopic surgeries. You can just have a diastasis with the, the area of the belly button becoming very superficial. So imaging, right. Imaging would help differentiate the two scenarios because the treatment’s a little bit different.
Speaker 2 (19:05):
Yeah, I think imaging in an exam, yeah, definitely an exam.
Speaker 1 (19:10):
And the, um, what kind of imaging? I would say for abdominal wall, not groin, I use CT scan or ultrasound.
Speaker 2 (19:18):
I, I do the same. Mm-hmm.
Speaker 1 (19:19):
<affirmative>. Yeah. Yeah. I agree. Okay. Another question for you. Um, this lady had an open inguinal hernia repair. The doctor attached my mesh to my hip bone and now I have recurring hip pain that I never had before surgery. Is that a typical approach to repair? I’ve never heard of hip bone.
Speaker 2 (19:40):
Yeah. No. No, I haven’t. I haven’t either, although, um, maybe she’s referring to really, you know, a suture of that, um, to the match that’s very far to the side. But that would really be more in the muscle, I don’t think. Right at the, you know, that lateral hip bone.
Speaker 1 (19:59):
Yeah. I think anatomically we don’t even see the hip bone or the pelvic bone in that region that she’s talking about. Um, so maybe in the region there maybe a suture or the mesh extends to that region, but we never put any, we don’t get anywhere near the hip joint or the hip bone or even the A ssis s uh, the pelvic bone, we don’t actually get to the bone itself. So two things can, can occur. One could be that, um, that’s the area of your pain. The other could be that you actually have a separate hip problem, right?
Speaker 2 (20:32):
Mm-hmm. <affirmative>. Yeah. And that’s not uncommon. I mean, you know, when you evaluate, uh, folks with groin pain and you might not necessarily find a hernia and go to imaging symptom, it’s very common on those MRIs to see labral tears, um, and things like that around the hip joint.
Speaker 1 (20:48):
Yeah. A lot of things that cause groin pain and a hip disorder, like a labral tear can mimic groin pain and some people get a hernia repair and their pain doesn’t go away or it actually gets worse for whatever reason. And it turns out it was a missed hip problem from the beginning. So I would recommend getting your hip hip addressed, um, if it’s truly a hip problem or if you are just referring to hip as the region, know that there’s no actual tack or suture to the actual bone. Um, but whatever it is, all of these are treatable, hip treatable problems. A hernia specialist would know what to do exactly, um, in your situation. Okay. Another question, this one from Facebook. Five, is there a light mesh with dissolving portions to reduce the amount of synthetic mesh and therefore reduce the potential for foreign body response for patients with a hypersensitive immune system? Think she’s referring to the hybrid mesh. Do you use any hybrid meshes?
Speaker 2 (21:49):
No. No, not really. Do
Speaker 1 (21:51):
You? I do. I’m like a huge fan now. Mm-hmm. <affirmative>, I think that, uh, I think that I personally think we’re overusing mesh, but there’s definitely a lot of patients that need mesh. Um, and this idea that the whole world can be, uh, can have their hernia repaired without mesh is, is not true. Um, but I have, in fact, we’re turning this into the A hs <laugh>. We have an abstract, um, that we’re really excited about where we looked at our experience with hybrid mesh. So a hybrid mesh, for those of you listening, it’s a hybrid. So it’s, it’s mesh. Um, the one that I use has about 4% mesh compared to synthetic mesh was like a hundred percent mesh. And then the rest is abor, some absorbable component like a biologic mesh. We know that pure biologic mesh doesn’t work as a standard for care. This is hybrid VASH is certainly not considered standard.
Speaker 1 (22:51):
But, um, we looked at our results where we had patients that had a mesh reaction, so like a massive inflammatory or autoimmune reaction to the mesh. And, um, we took out, out to that mesh and replaced it with the hybrid mesh and other symptoms went away. So I think there’s definitely, uh, there’s definitely this concern that foreign body can instigate either an heightened inflammatory response in some people or an autoimmune like response. Um, and if you put in a product that has a good enough outcome that has less inflammation associated with it, I think that works.
Speaker 2 (23:36):
Now the back to that patient, uh, from my curiosity, was, um, the base material different in that patient? Was it, um, the non-hybrid component, the permanent component, the hybrid mesh, was it the same base material as a permanent mesh that you removed?
Speaker 1 (23:52):
Well, in some people yes, it was. So we did allergy testing, so we’re reporting our results also for the EHS um, for allergy testing. So some people are not allergic to polypropylene, but the response is dose dependent. So for example, they’re fine with polypropylene suture, you know, a lot of the operations we do, we close the abdomen with polypropylene or anywhere else with polypropylene suture. People are fine with that. But if you put in like a lot of mesh, um, I had one patient who had one last, she was okay, that rec recurred, he put in a, they put in a second mesh, um, he was okay, that recurred again, then they put in a big mesh and then like all, you know, his whole system kind of fell apart. We took it all out and then he got cured. So, um, uh, yeah, if you, if you’re not technically allergic to the polypropylene and it’s more an inflammatory response from a, like a dose dependent, then I’ve seen that this, this hybrid does work. Yeah. Mm-hmm. <affirmative>, um, they’re asking for the name of the hybrid mesh. Third, there is a handful of different hybrid meshes. Um, telebio makes, uh, ovitex and, uh, gore makes, um, is it synecore,
Speaker 1 (25:11):
And those are the only two that I know of in the market, um, for that product. Okay. Okay. So going back to the lady with the hip, um, she says, my doctor’s words were exactly, I had to attach me to your hip bone because I followed up with her regarding my hip pain after surgery. I saw an orthopedic and I have no labral tear or hip. Okay. So that just sounds like then if there’s no true hip problem, then it’s, I think it’s a figure of speech. There’s no way that, that this, it was attached to her hip bone, unless it was attached to her ASIS her anterior superior iliac spine.
Speaker 2 (25:52):
It could be, in that case, there definitely is high risk for pain just because of the nerve in that area. I mean, but it’s so,
Speaker 1 (26:01):
But it’s treatable.
Speaker 2 (26:03):
Yes.
Speaker 1 (26:03):
Yeah. You just take out the suture or, or shave off the mesh mm-hmm. <affirmative> if that’s a situation.
Speaker 2 (26:10):
Yeah. Yeah. But it depends. I, I guess treatable Sharon, but also, you know, it, it also depends in terms of the degree of, um, resolution I think can be variable depending on how long it’s been from the original, uh, incident, how long versus has been living with chronic pain.
Speaker 1 (26:28):
Yeah. What is your thought on that? Is there a certain time period that people, um, should consider or what’s the time period do you think where chronic pain becomes, gets to a point where you’re uh, it may still linger after you treat the underlying problem locally?
Speaker 2 (26:49):
Well, I, I don’t think there’s an absolute number, but I certainly, I mean, if you have somebody that wakes up in the recovery area or immediately after surgery with pain, that’s unusual. Uh, you know, I strongly believe that person should just go right back to the operating room and you should check and make sure that you didn’t have a nerve injury. You know, because the best, um, treatment really is first and foremost prevention, you know, being careful about the nerves in the first place, but two, to be cognizant of that if there is an injury, to try to, um, address it right away. Um, but I, I’ve certainly have helped people who’ve had, you know, been, you know, several years out from their hernia care. But it, but it’s variable. And I think, um, some of that also probably has to do with patient factors. We know that certain people are, are more at risk for pain after groin repair. Like folks who have chronic back pain, for instance, um, women also be higher risk, so
Speaker 1 (27:42):
That’s true. Um, one of our pain doctors said that after nine months of uncontrolled pain, then the, the brain has starts, you know, getting reprogrammed. So that doesn’t mean in everyone at nine months, like there’s no hope for you. Uh, but once you let it go for long enough, then uh, the longer it goes, the the more likely that, um, you may have like a chronic pain syndrome. Uh, but I think that clock starts around nine months according to their literature.
Speaker 2 (28:19):
Yeah. I, I think the role of a cognitive therapist in these settings is very important. And I think, um, you know, the, the evidence is fairly limited and Bruce Ram has done a lot of work in that area, but, um, you know, it’s really about that pathway and it, and it’s not ever, um, I always, you know, counsel of patients, it’s not ever that I’m saying that it’s in your head. A lot of people have been dismissed for that, and that’s not true. It, it’s that your head is part of it, you know, that circuit and it’s really trying to, um, adapt your body again, back to a baseline where you weren’t living with pain.
Speaker 1 (28:55):
So do you have a pain psychologist that you can refer to for your patients? Or how does that work?
Speaker 2 (29:02):
Yeah, I have a, uh, there’s in our, uh, physical medicine rehab, um, department, and we have a, there’s a wonderful, um, pain specialist who I, uh, collaborate with. Um, I’m, I’m lucky at, um, Hawkins, there’s several, uh, different, uh, physicians of other specialties who we work with, not just in radiology with imaging and, you know, and ablation, but in pain, uh, management and then in, uh, physical, um, therapy, physical medicine, rehab.
Speaker 1 (29:30):
Yeah. That’s really great. Yeah, it’s, I think cognitive brain therapy is, works really well. Bruce Ramshaw, um, has a lot of good research on that. And, uh, I had one patient, we couldn’t figure out why I had this testicular pain and we did everything that I was working with this Greg urologist I have, and we tried everything and then we didn’t hear from him for about eight or nine months, and he called, he said, I’m cured. And we said <laugh> we’re didn’t do any, like we, we were not the ones helping him out. Um, we ruled out a lot of things and he said he started cognitive brain, um, cognitive brain therapy, C B T, and um, it was like a mind over, sometimes you have to control how much, how much your brain senses pain. Um, and he’s like, fine, he’s cured. It was the best story ever.
Speaker 2 (30:25):
That’s wonderful.
Speaker 1 (30:26):
It works. I think those are things that, um, again, if you see a hernia specialist, it helps you. Oftentimes they’ll just throw some opioids at you and say, you know, you’re gonna have to live with this for your entire life. And that’s not necessarily true. Mm-hmm. <affirmative>. Yeah. Yeah. Um, by the way, one of the last questions, uh, she’s a retired or nurse, so she said woohoo to the, to us, so that was very nice of her. Okay. Okay.
Speaker 2 (30:52):
There’s also a question in the chat. I don’t know if you said Yeah.
Speaker 1 (30:57):
Oh, in the chat there’s a question mm-hmm. <affirmative>. Oh, I see that. Uh, thanks for the invitation. What’s the opinion on Rifampicin coded prosthetic meshes for inguinal or femoral hernias? Which one’s that
Speaker 2 (31:11):
I haven’t used it. I mean, I think, um, I’m not sure the brand name, but I, I, I think, you know, in general actually it’s controversial even about giving prophylactic antibiotics at surgery for groin surgery, just because the infection risk is so low. Mm-hmm. <affirmative>, um, you know, maybe you might consider that. Yeah. The companies.
Speaker 1 (31:31):
The companies, yeah. The, the big companies, many of them have dabbled in antibiotic coded mesh. Mm-hmm. <affirmative>, I know the same companies worked on antibiotic coded sutures and that failed, that basically never showed, it just is a more expensive, um, suture. Mm-hmm. <affirmative>, I think the same is true for mesh. The reason is, I think what I just remember being involved in, in some of these, um, with some of these in these companies where they asked you your opinion, uh, you know, the antibiotics, first of all, we don’t know which antibiotic is best and there’s only a handful that you’re allowed to put, uh, that doesn’t, you can’t like overdose on. And then it gives you like, maybe a couple millimeters of protection around the mesh. But if your wound is infected, having a millimeter or two or three millimeters of mesh protected doesn’t really change the situation clinically. And it’s never been, they were never able to show that it actually reduced surgical site infections or mesh infections. So, uh, I don’t know anyone that uses any antibiotic coated mesh and most of the companies that tried to make it fail and they’ve been removed from the market. Okay. Next. Ready for the next question.
Speaker 2 (32:54):
I’m ready.
Speaker 1 (32:55):
Okay. Um, all right. What are your thoughts on exploratory surgery? My doctor says imaging won’t show him much for chronic pain and he wants to do exploratory surgery. Is it dangerous?
Speaker 2 (33:09):
I was just explaining this term actually to a patient’s husband, <laugh>, how we use the term exploratory. Um, yeah, it sounds it. I, I imagine I was listening to him talking about it, and it sounds scary when you hear about it. You know, someone’s just going to get in there, cut me open and explore. For us as surgeons, it really is, you sort of have an idea already about what you’re going to see. And I think it’s also, um, our duty to explain that to folks, well, this is what potentially we’re gonna be looking for, and if we find a, we’re going to do this plan, if we find B, then this is what we would do so that the patients are really well informed. So I think, I guess my thoughts would be, well, what, just like any decision we would make, you sort of have to decide, well, what is the risk of this surgery in total versus what benefit could I potentially gain? And there are some patients we say, well, you know, we have a good suspicion that this is what’s causing them pain. And, and the only way we can really know for sure is if we look at it directly, then I think, um, you know, that that could be beneficial, you know, for a patient. But if you really have no idea, I’m not sure that operating sometimes is going to make things better. You can certainly make things worse. I don’t know. What are your thoughts about that? Tr
Speaker 1 (34:26):
I agree. Um, I do a lot of preoperative surveillance, whether it’s examination and imaging, like a really complete history to at least narrow down to a couple of diagnoses. Sometimes you’re surprised will go in, they’re like, oh, I know, you know, there’s like this thing that we never consider, but like endometriosis, sometimes it’s hard to diagnose without looking in there. Um, uh, in, in most situations that I see in a, in occult al hernia, I can tell from imaging and by their history and exam, um, but many, many resort to explore exploratory laparoscopy for that mm-hmm. <affirmative>. And the key is if they’re gonna go in there, make sure they do a complete exploration. So just to get a camera in and looking is not enough. If it’s looking for a growing pain, you have to really understand endometriosis and look for specific areas in women.
Speaker 1 (35:21):
And then also if it’s a hernia as a possible, um, cause for chronic pelvic pain, you have to take down the peritoneum and actually look at the muscle. Um, so it’s more than just a quick peak. I feel that some people get exploratory laparoscopy and they’re told e everything was fine. The reality was it wasn’t a complete exploration, they missed the hernia. But, um, you know, it’s, you know, you kind of have to go with, with your surgeon. I think if the surgeon has ruled everything else out and you’re otherwise, uh, healthy enough to undergo general anesthesia right. And some scars in your belly, then it’s something to consider, especially if your, your life is so affected by everything.
Speaker 2 (36:07):
Yeah. But I typically, I mean, that question was asking or stated that imaging went health and, and I typically don’t offer, uh, laparoscopy or robotic, you know, um, expiration like that without some baseline imaging. Typically, I mean, usually with a good dynamic, uh, through MRI, you can see a lot at the groin. I mean, if this, if this is referring to a groin hernia, I guess, and not something else,
Speaker 1 (36:31):
Mom is imaging, you have to be able to interpret it. And our, our studies have shown over and over again that most imaging for chronic pelvic pain is misinterpreted. If it’s looking for hernias, they often miss the hernias by like 75%. It was a very large number. Um, and even when you give it to the specialists, they often, um, miss it too. So, and then most surgeons are comfortable reading a CAT scan, but MRIs like MRI, to be honest. It’s, it’s difficult to read. So, um, you know, if you’re limited and your surgeon, um, has ordered imaging and it doesn’t show, that’s one thing. But I wouldn’t skip imaging because that does show a lot of, that can show a lot information. I agree with that. Yeah, totally. A lot of questions. Um, when does the patient, going back to your C B T, the cognitive brain therapy, when does a patient need to advocate for, uh, cognitive pain therapy before the pain gets centralized and memorized? Yeah. When do you, when do you start recommending C B T? Should they have already failed? Like an operation or
Speaker 2 (37:45):
No, i, I recommend it upfront. I mean, I, for me, you know, there’s always, there’s always risks and benefits of what we do. And there’s some patients who I can clearly, like, let’s say you get imaging on someone or, or they can vary much if you’re talking about groin pain after an inguinal repair and they can very much localize exactly the spot where it hurts, or you map them and you have an idea, well, it’s this certain nerve, and then you get imaging and you know that it’s nerve, then, then those people really, um, you may be able to go straight to surgery, one might argue. But I think there are a number of steps that I integrate first because really pain is a multifocal multi pathway, you know, multidisciplinary kind of problem. And I think it’s very helpful to involve a cognitive therapist even from the very beginning.
Speaker 1 (38:37):
Yeah. I wish we had more access to it and it was more available for sure around the nation. So helpful. So helpful. Yeah. Okay. Should we do the next question? This was a long one, let me read it. What is your view on the type of mesh to use, especially with the recent lawsuits against companies that produce synthetic meshes, resorbable or non non-absorbable preferences? There seem to be some interesting composite meshes coming into the market as well, uh, that are biologic with synthetic stitching. That’s the hybrid mesh I was referring to. Is this where you view field moving regarding meshes? Yeah. What’s the future of that? Are we, are, do you think two questions actually sounds like One is, do you think the lawsuits, um, against the companies are in any way affecting your practice and what you, what you’re, um, what you’re choosing, and are we moving in the direction of these hybrid meshes in any way?
Speaker 2 (39:39):
Um, yeah, that’s a complex question, but we’ll, we’ll just break it down. I, I think, um, you know, in general it’s very interesting how, regardless of the meshes that are out there now, apart from some of the biologic meshes or some of the component meshes that are part of these hybrid meshes that you mentioned, um, two which are prominent, um, most of these are really FDA approved based on, um, you know, it can be traced backed to only, you know, one major mesh <laugh>. Um, and so they, many of them are really interrelated. And so when you talk about, you know, focus on one company having national lawsuit versus another, a lot of them are interrelated in terms of the base component match. So, um, I, I think when surgeons choose mesh, there’s many factors that play a role. Um, one, it depends for me, first and foremost, it really depends on the situation with the patient.
Speaker 2 (40:35):
You know, some patients, um, present and they already have chronic infection or they are presenting, or they have to have another surgery that may risk, may increase their risk for, um, in, uh, contamination at surgery. Like they need a colon surgery and they have a hernia, um, for instance. And, and so there are situations like that where I most certainly, you know, and, and wary, although there’s also evidence to show you can’t put a permanent mesh in those settings. I personally am a little bit wary at that. Um, and what you’re sacrificing in those situations is a more durable repair. Um, but, but I’m choosing that to try to lessen the risk that, uh, my patient can end up with a chronic mass infection. So I think the question itself is very, you know, complex has, have these lawsuits, you know, affected my choices. Well, certainly recalls.
Speaker 2 (41:30):
Um, you know, I, I think that the choices that all surgeons, um, make and I think, um, the F D A, you know, um, does and should really play a big role in that in terms of monitoring of meshes, um, you know, some of the meshes historically that have been recalled, um, one in particular I never actually used ever because I just didn’t think the design, I personally didn’t think the design was very good and worried about that. Um, but you know, there are, um, there are a number of things that can happen without mesh and there are things that can happen with mesh, and there’s always going to be some lawsuits on either side, probably. Um, so personally I think you just have to know the most that you can about the mesh that you’re implanting into people and to be able to share that, um, with patients and involve them in the decision and try to find the best repair for them individually.
Speaker 1 (42:29):
So the, um, the European Union, uh, has, I think starting in, starting, uh, this month has basically clamped down on all mesh. So you cannot sell any mesh unless you’ve shown, um, pre-marketing data that’s, that’s animal and human based. Um, so like that kind of five 10 [inaudible] process is being squashed, FDA is looking into doing something similar. And as a result, it may mean that many mesh meshes that are out there today, um, are not gonna be able to be marketed, which is fine. Um, the question is though, like, how do you, plus, let me go back. The European Union has ex extended the, the, uh, approval to include requiring post-marketing data, which right now we don’t have, so mesh is not considered a, a high risk device, and so you don’t have to provide, you know, long-term data. And in the European Union, they want it for the lifetime of the implant.
Speaker 1 (43:43):
So if you’re a 10 year old getting mesh in, I dunno why you, okay, let’s take that. If you’re a 20 year old getting mesh in and you live till 90, the company or somebody has to study that for 70 years. So no one has figured out who’s gonna do the study, et cetera. In the United States, we have the AHSQC, which is the only, I think it’s the only database we currently have that follows patients and their mesh prospectively. Um, the problem with that is not enough surgeons input their data. It’s not mandatory I do it. A lot of us, um, input our data and follow up with our patients through that quality collaborative. Um, and, uh, patients who are on it should also be answering questions long-term so that we know what’s going on with these meshes, but we just don’t know.
Speaker 1 (44:36):
We know that there’s a lot of patients that have pain. Some of that can be just a hernia recurrence or it can be a mesh reaction. Those are the two extremes. And we just don’t know enough to make, like serious, um, protocol changes in policy changes. It’s a very difficult situation. I’m kind of stuck because, um, I don’t wanna hurt my patients. Uh, I’m limited by what’s out there in terms of me, uh, what I can use either tissue repairs or um, uh, mesh repairs. And then there’s a wide variety of meshes I can use, but I’m still limited by that, those meshes. So it’s, I think over the next 10 or 20 years, maybe 10 years, um, we’re going to try and move towards less inflammatory products, less foreign body in the patients. Whether that’s the current hybrid meshes, I don’t know, because they, they, there used to be three hybrid meshes.
Speaker 1 (45:40):
The third company, um, just took it off the market and gave no explanation as to why they took it off the market. And we don’t know if, if there was a problem with the, um, product itself or if it was just a business decision. Um, you know, these are problems that, you know, as doctors we’d like to be involved in mm-hmm. <affirmative>, but we’re not as closely involved in as we, like, I don’t know. It’s a difficult decision and I don’t like to judge, you know, my position. I don’t, um, I believe my patients when they come in, so they come in with these symptoms that every other doctor has said, oh, that never happens. I mean, I never say that because I don’t know enough. I don’t think we know, we don’t know what we don’t know basically. So I’m very open minded that way. But, um, I also don’t want patients to be kind of go into a rapid hole where they feel like every problem in their life is related to a mesh where, um, it may not be. We have to be realistic about it. I don’t know. That’s my 2 cents <laugh>. That’s a tough one.
Speaker 2 (46:48):
I, I think it’s important to consider how the mesh is used. I mean, these lawsuits or these advertisements that you would see about lawsuits, um, regarding mesh really started with, um, in GYN, with vaginal mesh and, you know, are suspending, you know, treating, uh, things like urinary incontinence and prolapse. And, and that’s a very, very different use of mesh than for hernias. Mm-hmm. <affirmative>. And so, um, but uh, you know, I, I, I think, I think we have a long way to go. If you look at the base meshes, I mean polypropylene, what it’s been out since 1950s and I mean, that’s when it was introduced, right? 1953. And you think all of the changes that we’ve had in medicine since 1953, and this is really the most, um, prominent base mesh, you know, base material that we’re using.
Speaker 1 (47:40):
Yeah. Yeah. Um, okay. What is Dr. Adrales’ thoughts on, or what are her thoughts on triple Neurectomy for treatment of post hernia repair pain, and what are the negative effects besides numbness of a triple neurectomy? That’s a good question.
Speaker 2 (47:59):
That’s a good question. Um, I think, uh, for sensation, do
Speaker 1 (48:04):
You do triple neurectomy or selective neurectomy?
Speaker 2 (48:07):
I do both. Mm-hmm. <affirmative>, I do both. Yeah. Um, but it’s sort of a last step when you talk about, you know, a pathway and algorithm. Um, it really starts with getting a thorough history and looking at, you know, the old operative reports and seeing what was done before and, and what, um, could be addressed now. So, um, a very thorough exam, you know, including nerve exam, my osteo cell exam, imaging, um, <inaudible> therapy. If we can get you in there, um, sometimes, and then it depends. So sometimes, um, you know, I will turn to, uh, one of our newer radiologists, um, to try to target, um, the nerves. And sometimes that can be diagnostic first. So before I would get to a surgical treatment for that, we would see, well, does a block of these nerves help? You know, even though we know it’s gonna be a temporary relief, does it help?
Speaker 2 (49:02):
Cause if it doesn’t help, then doing ectomy also may not help. And so, uh, and sometimes it can, and, and the neurologist may wanna do that or will do that first before they would consider ablation. As, you know, sometimes it takes, you know, a couple of those treatments really to, to get it fully ablated. So those would be sort of step, uh, stepwise management. But, um, for some patients, uh, triple neurectomy can be very helpful. Some downsides certainly is the numbness. Um, but many people would take that over pain. Um, but there is some motor component of some of those inguinal nerves. And so, uh, one other downside that might be under that some patients can get in the groin, again, if they’re dealing with daily pain, um, it might not be, um, uh, you know, that, uh, disturbing to a patient then have that laxity or bulge afterward. But, um, for some people, um, it can be when in fact they probably, um, went to have their hernia fixed in the first place because of a bulge.
Speaker 1 (50:04):
Yeah, agree. Totally agree. Great. These are great. Um, what is the best method to repair a large inguinal hernia without mesh? This patient is having a negative reaction to a mesh plugin patch? Well, I’m curious what the negative reaction is because the plugin patch is well known to cause, um, pain issues from like mesh or et cetera. But let’s assume the patient does not want any more mesh and has a large anal hernia. Is a tissue repair feasible.
Speaker 2 (50:41):
Is, uh, so do you the hernias on the same side as a plug and patch? Yeah, well, I would be, I, I would think, um, mesh is going to be involved somehow in that operation, even if you’re gonna do <laugh> a repair, because very often the hernia recurrence is really at the edge of that plug. Um, I, I am not, I, I’ve never liked the plug, I haven’t put any plugs in and I, they, I certainly have taken a lot of ’em out and oftentimes they migrate and then you also get, um, a hernia adjacent to it. And so I think a recurrent hernia often does involve handling of that mesh somehow. So, um, you know, it can be, uh, removed I guess. And, and certainly if there’s pain involved, I agree with you Sharon, and then probably, you know, that mesh has to be removed as well for that reason.
Speaker 2 (51:34):
Um, and then, um, you know, a closure, sometimes it’s a staged approach, but it really, I, you know, for me, I, I, I know I’m dancing around because I, <laugh>, I think it really depends on what I find there. Sometimes, most often it’s a recurrence right at the, uh, plug and if I remove that and then I can do another repair depending on how it gets done. But you know, that’s somebody who’s already had an open approach and if you look at, um, the approaches, it’s better if they’ve had an anterior approach to repair it, then from the other side, which would be a laparoscopic robotic assisted. And so that’s generally my approach. But of course that’s not a primary repair, that’s a mesh repair.
Speaker 1 (52:11):
But in general, uh, I mean before we had mesh, they were doing tissue repairs on these big hernias, just the outcome’s not as good. You know, the recurrence rate’s higher and what you don’t want happen is to have tear out for tear out for tear. So if, if someone has a large hernia and it does choose a non mesh repair for whatever reason, um, understand the chronic pain rate and the recurrence rate’s much higher. And if it does recur, you basically really just, you have to go out and, uh, get some type of mesh repair. It’s, if you’ve lost all that tissue, there’s not much else to do unfortunately. So you have to have an open mind to, uh, some type of mesh repair. And we use a term mesh broadly. It can be, there’s a lot of mesh out there, lightweight, heavyweight, large pore, micropores, hybrid, et cetera. Um, okay, another question. Bilateral angle repair with mesh, I have little discomfort with when active, I have more irritation when inactive and standing doing dishes, et cetera. How is this possible? Hmm, more pain when standing or inactive? I wonder if you have pain when you’re lying flat, right? Yeah,
Speaker 2 (53:33):
I think, um, you know, some of, some of that may when you’re stand, I mean, depending on what type of activity you’re doing, um, some of that might be the effect of standing the weight and the gravity on the, on the groin, you know, in that particular situation. But also when you’re active, you’re also doing under the things and your mind is occupied in other ways. And so you might not be as reflective or, uh, cognizant of, of, you know, that aching or discomfort as in a moment where you’re standing doing dishes. I don’t know if, uh, that person’s like me when I’m standing doing dishes. I, my mind is thinking about all kinds of different things and some of that is like a reflective moment. And so you might just be more aware of it. I, I don’t know, Shirin.
Speaker 1 (54:17):
Be so no people lying flat, um, more people standing. I mean that’s a, that’s, that’s one where you really need to sit down with, um, a specialist and go through all, everything that bothers you and doesn’t. And then exactly where is the pain. Uh, because sometimes you can ha what I’ve seen in some people is they have, they have a tricky recurrence. It’s, it’s not like an obvious recurrence, but whatever anatomy, three dimensional anatomy they have, the recurrence is like right to the side of it. But that recurrence doesn’t manifest unless they’re, let’s say standing or doing something that, like for, for example, I had a lady with a mesh plug. So the mesh plug was in perfect position and when lying flat, it covered it. The minute she would stand, it kind of like shifted just a tad and that little shift was enough to, for something to go in and cause pain. Um, she just basically had a hernia recurrence. But it was a very positional situation. Um, I think you need someone to like really think outside the box and figure out a, if it’s related to your hernia repair. And if it is, is it a, is it like a unstable, like mesh positioning or, or what? That’s a, that’s one that’s, um, you can just go,
Speaker 2 (55:43):
Yeah, that could be, I mean if they’re, if the activity that they’re doing or exercise is more like swimming or cycling, then you might not notice it, I guess as you would if you’re running or standing perhaps. Yeah. Yeah, you might be right about that.
Speaker 1 (55:58):
Lot of questions. Okay. Let’s see. Okay. This lady pod, my 11 centimeter round polypropylene mesh removed laparoscopically from the belly button three months ago because of chronic pain and reaction, the sutures were also removed. The umbilical hernia was not there because it was covered with scar plate. We see that sometimes that’s all that’s holding me closed. My surgeon wants me to strengthen my core to help keep my abdominals strong from me. Herniating, I’m worried the scar, uh, that the scar plate, um, I’m worried about the scar plate holding. Will strengthening core and PT help reduce the chance of a recurrence? I mean, no. Right
Speaker 2 (56:51):
<laugh> no. Other than, um, just the overall health benefit of exercise. I think because one of the number one, you know, leading factors for recurrence right? Is obesity. And so if exercising and, and you know, doing yoga and things like that is what keeps you healthy, then I think it is beneficial to do that. But can you fix a hernia by exercise? You can’t. And can you reduce the risk of the recurrence from happening through exercise? I don’t think you can either, other than just reducing your overall risk factors for getting a hernia back again.
Speaker 1 (57:28):
Yeah. So the scar plate is there, but the scar plate is not strong at, at the same time on to fix a hernia or touch something and then that caused pain. So I agree with leaving alone if there’s no hernia at the time, but if you do what’s called kind of watchful weight to see, um, what will happen and having a stronger core and not being overweight and coughing and straining and those kind of things is a good thing, right? Um mm-hmm. <affirmative> for any hernia, but I don’t think that it would, it would, could it reduce your chance of that scar plate becoming a hernia? I don’t think we know the answer to that. On that note, I have another question. I have. Uh, oh, it’s six o’clock. Oh, that was so fast. I can’t believe it. Okay. Very good. Well thank you Gina. I appreciate all your time and your knowledge. It was fun.
Speaker 2 (58:26):
It was fun to see you. I’ll see you on a zoom. Uh, get together hopefully.
Speaker 1 (58:31):
Yes, yes. Looking forward to that again. And this is the end of hernia attack live with Dr. Gina Aras. We will be here next week with Dr. Bruce Ramshaw, another good friend of ours and hernia specialist. Super excited to spa speak with him. Um, I will post the, uh, the entire hour on my YouTube channel. Um, and you can also watch it on Facebook Live. It’ll be archived there as well. Thanks everyone.
Speaker 2 (58:58):
Thanks. I’m gonna tune in next week and post some tough questions for Bruce <laugh>.
Speaker 1 (59:05):
Take care of yourself. Bye-bye. Thank you.
Speaker 2 (59:07):
Bye. Thanks.
