You can listen to this episode by clicking here.
Speaker 1 (00:00:01):
Hi everyone, my name is Dr. Shirin. Welcome to Hernia Talk Live. This is our weekly Q&A. As you know, I am a hernia laparoscopic surgeon at the Beverly Hills Hernia Center. You can follow me on Twitter at hernia doc, as well as on Instagram at Hernia doc. Many of you are following us currently on a Facebook Live at Dr. Towfigh as well as Zoom. And at the end of the show, we will make sure that you all have access to the YouTube version of this so you can share it with others and watch it again become more informed. Because today we have Dr. Sean Orenstein as our guest panelist. Dr. Orenstein is a hernia specialist. He is laparoscopically and robotically gifted surgeon. He works out of Portland, Oregon at the Oregon Health Sciences University, which we call O H S U. You can follow him at OrensteinSean and at Twitter. And thanks for joining us, Dr. Orenstein.
Speaker 2 (00:01:05):
Well, thanks for having me, Shirin. This is wonderful that you’re doing this program for everybody and appreciate the invite.
Speaker 1 (00:01:11):
Thanks. So many of you who are on herniatalk.com have seen Dr. Orenstein’s name come up multiple times. He has really been great gracious in helping many of you patients and seeing him. There’s very few of us hernia surgeons on the West coast. He’s one of them. And I do refer, we share patients and I refer him patients that are closer to him than to me. So I’m very grateful to have you on my side and the same time zone, which helps as well.
Speaker 2 (00:01:44):
Indeed.
Speaker 1 (00:01:47):
Why don’t you start first as people are all logging in, giving us just a quick brief as to what your practice is like in Oregon.
Speaker 2 (00:01:56):
So again, well thank you again for having me Shirin again, this is wonderful that you’re doing this for patience other physicians out there. There’s a lot of information out there when it comes to hernias, whether it be hernia repair, Mesh placement and everything associated with that. And so, it’s nice to have a forum to be able to communicate our thoughts as surgeons with regards to hernia repair and some of the subtleties as well as the complexities of it. With regards to my practice, I’m a general surgeon trained as said fellowship trained in minimally invasive surgery, but a big portion of my fellowship was in hernia repair and complex abdominal wall reconstruction. And my practice has really evolved to mostly hernia repair. I would say 80 to 95, 90% of what I do is some form of hernia repair, whether it be groin hernia repair or other ventral abdominal wall hernia repair. I still do other general surgery, non hernia related as well, but that is the bulk of my practice.
Speaker 1 (00:02:56):
And just curious you, was it because of the type of fellowship you went into that you were so exposed to hernia stuff or did you actually know you’d want to do this before you started your fellowship?
Speaker 2 (00:03:09):
Well, I certainly didn’t think I was going to be a hernia surgeon when the grand plan of being a doctor started years and years ago.
Speaker 1 (00:03:15):
True,
Speaker 2 (00:03:15):
True. But I actually started during my residency in the middle of my residency program, I wanted to go out and do some research. So I joined Dr. Yuri Novitsky and his lab out at University of Connecticut out there on the east coast. Oh wow. And through that lab I spent a couple years of dedicated time studying Mesh and anything hernia related. We built our own animal lab and other we did invitro and invivo testing trying to test out every Mesh that we get our hands on and other forms of hernia repair sciences.
Speaker 1 (00:03:48):
For those of you that are watching, no one enters medical school. Our residency wanting to be a hernia surgeon, it’s not considered the most glamorous of the specialties. It’s not like brain surgery, orthopedics, cancer surgery, big liver operations, transplant, heart surgery. Those are like the big ones, but those who see the light as I say, and the believers for sure, I think among those surgeons, the hernia surgeons are pretty happy people.
Speaker 2 (00:04:23):
No, I agree. I think we’re a nice, fun, tight group knit family. We are. It doesn’t matter whether conferences have been a year delayed from COVID or whatever the reason is, we all get together and have a lot of fun talking about what we have passion for and it’s getting back. We’re trying to make hernia sexy again. We’re getting there. Yeah,
Speaker 1 (00:04:44):
We totally are. But because of people like you, I mean when you get people that are so enthusiastic, they’re younger, it didn’t used to be the hernia. Surgeons used to be all really old. Yeah. I remember my first meeting that I went to was in Orlando, I think was in 2002 at the American Hernia Society. I literally opened the door to enter the auditorium or the conference room and all I saw was a back of everyone’s heads, all male, either white hair or no hair. And I had just finished residency. It was my first year into my academic job and as a female surgeon, you’re kind of used to having a mostly male dominate conference, but this was beyond, I was well below the age, the average age there, well below and it may have been the only or one of two sort females or something. So things have certainly changed for the better. Yeah, for sure. And it’s been very fun, I must say. Everyone is so fun and we enjoy being around each other. Some of my friends ask me, would you talk about all day you have yet another hernia meeting? What do you guys say every year? And there’s so much to talk about I think.
Speaker 2 (00:06:05):
Yeah, it is. It’s never any and hernias don’t get old. We’re continuing to learn. We’re continuing to evolve in our practice patterns and technique and what we use to fix these multitude of problems.
Speaker 1 (00:06:18):
Yes, very true. So you basically do all types of hernias, but because of your kind of laparoscopic and robotic skills and mostly the ventral hernias that you do, I thought we would focus as much of our talk today about incisional hernias. So if you could just briefly explain to our audience, what do you define as an incisional hernia and how do you approach that different than any other typical hernia?
Speaker 2 (00:06:47):
Well, that’s a great way to start an incisional hernia very simply is if a patient has had a previous incision, they’ve had a cut for whatever reason, whether it was ovary removal or a colon removal or a biopsy or something else inside, typically the abdomen and pelvis, that incision can lead to a weakness through all the layers of the abdominal wall. And specifically for hernias or hernia by definition is a hole in the fascia being the strong tough tissues that holds our insides in. Well, if that incision, the deeper parts of it don’t close right adequately, or if it stretches and weakens over time, that can lead to a hole there. And so that would be an incisional hernia as opposed to other hernias that may have been there from birth, say a small umbilical hernia. These are commonly start up birth and slowly and large over a patient’s lifetime, there has never been a cut there. So that’s not an incisional hernia, but yet that can lead to a hole or a defect in the abdominal wall and an incisional and a umbilical or other type of hernias can lead to similar overlapping symptoms and problems. Right.
Speaker 1 (00:07:55):
And so do you tend to do different operations or have different type of planning for incisional hernias than if someone’s never had surgery before?
Speaker 2 (00:08:05):
Well, it really depends. There’s a lot of factors that go in through that decision making on how I choose to fix it, whether it’s an open repair with a bigger incision or a minimally invasive approach with small little cuts like laparoscopy and robotic assisted laparoscopy, a lot of it is on the size and the location. So if it’s a small incisional hernia in the upper abdomen, I have multiple options. If it’s a very large incisional hernia, say underneath the sternum or the breast bone, for example, if somebody had a previous coronary bypass surgery that can lead to an incisional hernia actually in the abdomen, not just of the chest there, that would require perhaps a different method of repair. And there are different options for that. So there’s a lot that goes into the decision making as far as what type of repair I’m going to do, what type of Mesh I’m going to use, and even the location of that Mesh.
Speaker 1 (00:09:02):
We already have a question. Let’s just move on to that. So this is a patient who’s already had a Mesh based repair and now they have Mesh sticking out of their skin. So can you explain, a, that’s not normal and B, what could be done about it?
Speaker 2 (00:09:20):
Yeah, so a correct Mesh out of skin, probably not the preferred. Correct. So right off the bat, if a patient comes to see me and their Mesh is protruding out, first of all I want to confirm is that truly Mesh that’s sticking out or is it another foreign body? Perhaps it’s suture material or something else.
Speaker 1 (00:09:39):
Yeah, which is a much simpler situation usually if it’s a suture and not a Mesh. Yeah,
Speaker 2 (00:09:44):
Exactly. We also need to find out what were the need to review the operative note to see what type of Mesh in the location it was placed. Were there any wound complications that is perhaps did, was there a wound separation or infection that left some Mesh exposed? And that’s why we’re seeing Mesh closer to the surface of the skin as opposed to being underneath or between tissue planes as originally designed.
Speaker 1 (00:10:07):
That’s a good point because the Mesh can be placed. We’re talking abdominal hernias here, like front of the belly, so the Mesh can be placed anywhere from deep to the skin and fat, so on top of the muscle within the muscle or below the muscle. So depending on the type of repair you had and where the Mesh was placed, if you’re seeing Mesh exposed, which is totally not normal and a very difficult problem to address, and by the way, I highly recommend that that kind of problem be addressed by someone like you or me or others that deal with this on a regular basis. This is not something that your regular general surgeon can handle because they may be able to handle locally, oh, we’ll just take out the piece that’s exposed, but completely removing it, reconstructing knowing how to not burn bridges in doing so, making sure you’re not missing an underlying problem like a fistula or infection. Those are all things that go through our minds when we see exposed Mesh. But like you said, figure out where the Mesh was originally placed and then these things don’t just happen by chance. It’s usually like you mentioned because there was some wound complication to begin with, wound infection or separation, and then that started the top, that’s the tip of the iceberg, and then it worked its way backwards towards the Mesh. Right,
Speaker 2 (00:11:35):
Exactly. So a thorough evaluation, and this is where we’ve been doing a lot of telephone and virtual visits in our COVID times, which has been very helpful to get our patients into the system and seeing them and do some form of evaluation. But when you start to talk about complicated hernia repairs or complications following hernia repair or even other surgeries, not just hernia repair, those people need to come in to see as you suggested, somebody with more experience when it comes to Mesh and hernia related matters, we can really lay our hands and our eyes on the patient, see what’s going on and formulate a plan. And when it comes to things like exposed Mesh, it could be as simple as trimming the edges and trying to get to healthy tissue so the body goes over that. Sometimes it requires a little more complex staged approach where step one is just to reduce the infections or the foreign bodies suture and Mesh and otherwise temporize that hernia and come back to fight another day with a more definitive hernia repair.
Speaker 1 (00:12:37):
Back in the day before you were born, probably when I was on my first job, AlloDerm was a big deal. It had just come out, I think year 2000. Now we’re talking 2002, and I used to work at the LA County Hospital at USC and we had a lot of access to biologic mush because we were a huge burn unit, so they had basically synthetic skin to be used for burn patients. As a result, we had a good relationship with company lifestyle that made other products too that were biologic, which we could use for hernias. That was a new thing. And because of the county experience, we had a lot of people with exposed Mesh infected Mesh, and those were very difficult to do. And what I learned from that experience, we present our data, but then I left the institution and it was the opportunity that I missed in actually publishing that great data, which we presented at the Pacific Coast Surgical Association, which was removing, and the staged approach is so much better in dealing with these people than what we used to do, which was we removed the infected Mesh and you put the biologic Mesh in one operation, you clean everything up because you were kind of told, oh, biologic Mesh, it’s resistant to infection.
Speaker 1 (00:14:04):
I mean, it is more resistant to infection than aesthetic Mesh, but it’s not like, well, I mean magic
Speaker 2 (00:14:12):
Different meshes can be more susceptible or more tolerant, the study of infection. And so yeah, there’s certainly a lot that goes into that and meshes a passion of mine studying in the lab for a couple years. It really depends on what you find in that wound. And sometimes it’s hard to find those old op notes, but we try to dig ’em out storage or get ’em from somewhere else to really figure out exactly what was in there on. There are occasions though where we don’t have that option or the luxury of viewing the old operative reports. And so we have to wait till we get our hands and eyes in there operatively to debride, remove the Mesh.
Speaker 2 (00:14:48):
And I think you raised a great point though about not burning bridges. When we proceed with hernia repairs, especially the more complex abdominal wall reconstructions we want as pristine and as perfect as a tissue plane as possible before we embark on those repairs. And so that’s why along with you and many of our colleagues, we spend a great deal of time talking in counseling our patients about pre-operative optimization, getting their bodies and their tissues as healthy as we can, smoking cessation, diabetes management and weight loss, all these things for the sole goal of getting their health to as optimal of a stage as we can get them so we can do these big reconstruction repairs and give them the best possible outcomes.
Speaker 1 (00:15:35):
That’s a really good point, and we’ll come back to that a little bit later in the hour. One of the questions asked is how long after hernia or abdominal wall surgery can an infection or wound infection occur? That’s one question. And the second is, can a Mesh infection occur because sometimes those two are not necessarily together.
Speaker 2 (00:15:58):
So well wound infections can happen anytime, but the most common scenarios, the first 30 days is the biggest window and then the 90 days after surgery is the next biggest window. And C D C even tracks these numbers when it comes to hernia repairs because we place a lot of prosthetics. C D C will evaluate for deep infections up to 90 days. Superficial that is skin infections up to 30 days. That’s for all surgical procedures. So that’s the most important window from a wound standpoint as far as infected Mesh that can actually happen, can happen much at a much later time point, even up to sometimes years later as the longer you go out, that chance and risk goes down and down and down. So that’s why that initial period of integrating that Mesh into whatever tissue playing we put it in is really such a crucial time point for Mesh placement in-growth into that Mesh and the overall strength and durability of the repair.
Speaker 1 (00:17:03):
And can you explain why the further out you are from surgery the lower likelihood that your Mesh can get infected?
Speaker 2 (00:17:11):
Sure. It all gets back to really what is the function of Mesh and what does it do once you implant it? So the Mesh itself acts not only as a barrier, it’s a screen that prevents things from pushing up or through the area of weakness. Now we typically close those holes down so it’s closed, but we make it stronger by putting that Mesh in there as a barrier to prevent the hernia from coming back. That’s part of the strength of the Mesh, but the other part of the strength of the Mesh in the repair itself is the body grows into that Mesh. The Mesh is usually these porous, like a screen right? In different sizes, the body grows into that forms new scar with it. Not only does that lock that Mesh in place, but it helps strengthen the overall repair of that region of their pair.
Speaker 2 (00:17:57):
And by the body growing into it, it’s not just scar, it also sends new blood vessel growth into it. Those blood vessel growth is crucial to fend off any bad actors. If bacteria got into the wound or some contaminant or infection, the body doesn’t just clear it off on its own. It takes our immune cells to get in there to clear any pathogen infection or anything like that. And so that’s why that in-growth is so crucial in and around the area of the repair. So if we can get good ingrowth in that shorter time period, that can help reduce the chance of something going on downstream. For example, there’s a fluid collection that say that would develop in the area that not that gets walled off. The body may not have the best ability to clear out that fluid and potential infection.
Speaker 1 (00:18:49):
Correct. The fluid can get infected and cause the Mesh infection. But we also have seen Mesh infections 5, 10, 15, 20 years out. Why do you think those occurred? I have some answers, but you go ahead.
Speaker 2 (00:19:05):
Yeah, I mean I think it’s multifactorial, but there’s a good chance that there was some form of contamination earlier on in the process or there was a breakdown in the wound in the vicinity of it. So for example though, if let’s say you had a wound that healed perfectly without any problems, let’s say the Mesh integrated perfectly without anything, the risk of something happening downstream is extremely low. But however, what if there was some form of contamination or early light infection? The body did a good job of clearing most of that infection, but some of it, that little infection maybe got walled off and isolated from it. Correct? There are, and some of those bacteria kind of get harbored and go to sleep, if you will. Those infections can sort of come out in a later in a stressful situation, a physiologic stress in that area or somebody’s immunosuppressed or whatever. And now that bacteria can perhaps flourish a little bit more, right? And if it has access to that prostatic, to that Mesh, to that foreign body, it can then start or sort of rejuvenate an infection.
Speaker 1 (00:20:16):
I mean there’s bacteria all over our skin in our mouth. Theoretically our insides are sterile. But you’re right, you can have, let’s say I’m going to make this up. One bacteria that entered the Mesh at the time of surgery, and if you are lucky, the majority of time your body will handle that one bacteria, but it can become two and then 200 and then 5,000 over a span of years, then you get an infection that would be unlucky. It would also maybe imply that you had some, maybe you’re a nicotine smoker may or user, maybe you are diabetic or obese or have any other or had a cancer, some other reason for immune suppression or poor healing that would affect it. What’s interesting though is I’ve seen multiple, and I would say by multiple, I mean maybe 10 in my 20 years of practice, that the patient did totally well.
Speaker 1 (00:21:18):
They had a mastery repair, totally fine, and then they got a tooth abscess or diverticulitis or perforated appendicitis or rectal abscess, basically a high volume of bacterial infection that then starts swimming in their bloodstream. And then that bacteria was unluckily swimming and then landed on the Mesh and shortly after that they got a Mesh infection and they were totally fine before and that is very, very rare. I don’t want to freak anyone out, but I’ve seen it can happen. So those would be rare instances why you would get a delayed Mesh infection that’s unrelated to a perfectly good operation earlier. All right, we got tons of questions. Okay. Can you have a low grade infection and not know it until after Mesh removal?
Speaker 2 (00:22:16):
It’s possible to have, I mean, yeah, it is possible to have varying degrees of infection and part of it depends on the immune system of a particular patient. Are they in the able to fend off and kill off any of the bacteria or other bad things that are near it? There are certain bacteria that form biofilms, and this is kind of getting back to what I was saying before there, that there are certain bacteria that sort of go to sleep and then may wake up at a stressed state. So you can have some low grade contaminants or low grade infection that doesn’t overtly turn into a big abscess or a wing infection at that time. But that said, the human body is pretty amazing and pretty resilient. It does everything it can to save the body and save different areas and if it sees something bad, it doesn’t like it’s going to go after it. And so in a healthy individual, it has a pretty good ability to kill off anything that it needs to.
Speaker 1 (00:23:20):
So there’s obviously a lot of different ways of fixing hernias. It’s great that there are surgeons like you that offer all options. A lot of times people go to a surgeon, they know how to do it one way. That may not be the best way, but you should always go to a surgeon that does their way well. So how does the size and the place of the incisional hernia affect how you repair it?
Speaker 2 (00:23:47):
Well, again, it really varies. I would have to go through each specific area of the abdominal wall to describe it because as you suggested, there’s multiple ways here. So my first thing I think about is can this patient receive a minimally invasive approach? There are many benefits to a minimally invasive approach. When I say minimally invasive, I’m talking about laparoscopy and robotics. And so if you make little cuts, there’s reduced chance of infection. People tend to return to work quicker, they leave the hospital sooner. There are a lot of big time benefits to laparoscopic and robotic repairs. However, there are some reasons that we can’t do a minimal invasive repair. Sometimes it’s the size of the hernia, repair of the hernia or the location. Sometimes if the patient has some type of skin pathology, maybe they have a very large scar or non-healing wound. These are things that we may need to address and with a big incision to cut out that skin or that scar or other reasons or excise certain tissues or remove old Mesh. These are some reasons that I would go straight to an open repair and forego a minimal invasive approach.
Speaker 1 (00:25:01):
Here’s one patient with an umbilical hernia and a diastasis recti. How would you approach that?
Speaker 2 (00:25:09):
It’s funny. That’s a great question. There’s a lot of controversy in the hernia world about that. First of all, it depends on the size of the umbilical hernia. So for my practice, if they have a small umbilical hernia, say maybe one to three centimeter, a couple or a few finger breaths and they have a diastasis, I’ll probably just address the umbilical hernia alone and not address the diastasis. Diastasis by themselves are not dangerous. You can’t die from obstruction or strangulation related to diastasis. And let me even take a step back for audience. So they understand the difference between a hernia and a diastasis. A hernia is a hole in the fascia and fascia being a strong tough tissue where it’s just gone, whereas a diastasis, that fascia is there, it’s just thinned out and stretched out. So one can be potentially dangerous like a hernia where diastasis is not a dangerous finding. That said, some people can’t have symptoms related to the bolting from diastasis. So going back to the question, correct, umbilical hernia repair and diastasis, again, small umbilical hernia, even if it’s small and recurrent, I’ll probably just do the hernia repair alone. Now, let’s say there are a large umbilical hernia or perhaps multiple defects along not just the umbilical hernia, but maybe just other hernias along the whole length of the midline. That’s the kind of case we’ll tackle both the hernias as well as the diastasis.
Speaker 1 (00:26:40):
Yeah, this patient supposedly was offered a component separation and Mesh for treatment of umbilical hernia and diastasis recti repair. Does that sound like something you would offer or in what scenario would you offer that?
Speaker 2 (00:26:56):
I think if it’s a large enough hernia and symptomatic enough diastasis, I would consider a retrorectus repair for this. Because with a retrorectus, not only can I tackle all the hernias along the entire length of the midline, I can either excise or placate meaning kind of suture and fold up that diastasis at the same time to reconstruct their line album meaning basically get their rectus muscles, their six pack abs instead of being pushed to the side from a hernia diastasis. Yeah, you want to get those rectus muscles closer to the midline. That’s how the abdominal wall is a more functional and dynamic structure.
Speaker 1 (00:27:36):
So as you know, I practiced in Beverly Hills and we discussed this I think it was last week with Maurice Mo about plastic surgery and hernia surgery. I practice two blocks from Rodeo Drive and this is called the Golden Triangle, the most number of plastic surgeons in the nation like per capita. So I have some great plastic surgery friends, they’re really, really good. And patients who are candidates for tummy tucks and have hernias. So we collaborate and what we’re doing is for three or four centimeter hernias or smaller, even if it’s incisional. So these are patients that would’ve gotten Mesh otherwise if they’re good candidates for a tummy tuck that get the tummy tuck. And I do the hernia repair and we use the plication from the tummy tuck as a way to function as like a tension reliever in biologic, in quotes, biologic barrier over the repair. And we’ve have a series now we’re going to that up to four years now that we’ve been following and in the right patient. It’s an interesting kind of one approach of doing this.
Speaker 2 (00:28:54):
Do you place Mesh at that time of the plication hernia repair?
Speaker 1 (00:28:57):
No, that was the whole thing because we chose not to use Mesh and then the patients knew I gave them the options. They knew that it was not standard because all of those hernias would need Mesh and they were not necessarily pro or against the use of Mesh. As plastic surgeons tend to be against the use of Mesh, they’re much more into use of tissue. And it seems to me, assuming that as we enroll more patients, this will continue to be successful in the right patient. The taking tension off of the primary repair of the A hernias by adding the tummy tuck significantly improves the outcome of the hernia repair itself. I mean obviously tummy tuck is a big operation. Not everyone should have it, but the right patients, it seemed like it’s done really well so far. So I don’t know. That’s nice. Something to
Speaker 2 (00:29:51):
See results. And you raise a good point about skin and soft tissue is yeah, part of hernia repairs, not just closing the fascia’s, not just reinforcing with Mesh. For many of these complex hernias, getting good skin and soft tissue coverage over our repairs, a crucial aspect, especially if they have had history of wound infections or skin grafts and other things, other items that need to be addressed. If we can address it at that time, that gives not only a better cosmetic approach, but really more functionally gives ’em good healthy tissue on top of their repair.
Speaker 1 (00:30:25):
How do you repair incisional hernias from a C-section?
Speaker 2 (00:30:30):
So assuming this is a lower fan and steel incision, so that would be in the suprapubic category of atypical hernias, meaning it’s a hernia that’s above the pubic bone? Yes. And again, size is part of it. If they have a say a small to medium size and let’s call it maybe five to seven centimeters or so in size, that’s a great one for a minimally invasive pre peroneal approach. So I’ve been converting my very good approaches to a robotic approach. I do straight laparoscopy as well, but using the robot, it gives nice dissection to develop pre peritoneal plane, reduce any contents, do my best to close the defect and a C-section. We should be able to, because there’s still some fascia below, but there are some hernias that do go right up to the pubic bone. They’re a little more challenging and that that’s a beautiful plane to put a piece of Mesh to reinforce widely in the same plane that we use to do inguinal hernias, we just center that Mesh more instead of to the side
Speaker 1 (00:31:34):
And it’s so good. It’s a great one. So often you get these little hernias from C-sections, so it’s not like an actual hole. Fortunately, it’s actually very uncommon to get incisional hernias from C-sections. It’s just that kind of transverse incision and they do a lot of muscle splitting and probably the fact that you’re so loose to begin with. So the repair is not under tension when you close it, the muscles are still loose from all the hormones that combination makes it. So hernias are not common. So if in situations where it’s really small, I do those through the C-section scar because they often just need maybe a strip of Mesh deep to the muscle, but you only like to filet the whole thing open. But yeah, I think that laparoscopic or now the robotic option is the best repair for those patients with Mesh. Yeah. How do you handle a recurrent hernia or bulge in the lower abdomen or in the flank if Mesh was removed due to a foreign body reaction to regular synthetic Mesh now, so they had Mesh repair of a, let’s say a flank hernia, then they had a Mesh reaction and that can be anything from chronic pain from the Mesh or rashes. And we’ve had a couple great hernia talk events on Mesh reaction. Now you have a hernia again because there’s the Mesh is taken. So how would you approach that?
Speaker 2 (00:33:06):
That’s a tough one. Flank flank hernias in general are very challenging entities for hernia surgeons and even ones that do this every single day. And part of the complexity of flank hernias is because of the location near a bony. So any hernia that’s next to a bony structure like the super pubic I just talked about, yes, flank hernias that are next to the pelvis or hernias that are underneath the Rives or the sternum, they make it harder because A, it’s harder to close the hernia defect if there’s no good strong tissue next to it if that hernia is right next to the bone. And a class example of this is a traumatic flank hernia where somebody had, they’re in a high speed motor vehicle collision and they had a rapid deceleration and their pelvis can kind of separate from the tissues there and it can lead to a big defect there that makes it very challenging to close that defect. The thing with that is that most if not all these repairs require some type of Mesh prostatic to reinforce that in general incisional or other complex hernias, while you can maybe temporize them with sutures only, they’re unlikely to stay that way without some type of reinforcing structure.
Speaker 1 (00:34:20):
For sure, especially on the side, those are very thin muscles with very little fascia. Yeah,
Speaker 2 (00:34:25):
Exactly. And not only that, it’s also that that’s a tough area not only to close the hole and reinforce it, but the nerves. We have lumbar nerves that come from the backside and wrap around. Yes, risk of pain and chronic pain is even higher for these particular types of hernias. That could have nothing to do with the type of Mesh that was used. It could be related directly to the tissue or the poor quality tissue from whatever procedures or trauma that was in that area be beforehand or previous dissection in that area. So to get back to the question, what type of Mesh or what would I do? Well, we could try another pre peritoneal approach, whether it be robotic or minimally invasive approach to develop a get into the lining of the abdomen to get a place to hide that Mesh. So it’s not necessarily exposed to the abdominal organs that’s hidden within the layers, but some of these require a component separation where we need to separate the layers out to give us enough advancement of these tissues as well as to provide a perfect plane for a new Mesh.
Speaker 1 (00:35:30):
Yeah, I would make sure I understand what the reasoning for the Mesh reaction is. Was it truly a reaction to the quality of the Mesh, the resin or the material of the Mesh where your body’s just allergic the same way you can be allergic to peanuts or is it something that was really a reaction to the technique or where the Mesh was placed or what Mesh was chosen, like thin patients, super heavyweight Mesh, something like that where you’re reacting to the effect of having a foreign body in you as opposed to truly your body reacting to it. Have you ever used either biologic Mesh or hybrid Mesh inpatients where you feel there may have a sensitivity to synthetic Mesh?
Speaker 2 (00:36:18):
The only time, I mean do use some biologics and some biosynthetic meshes. For me, I use those in patients that have been had infections. That’s the main reason. If they’ve had a previous infection, not an ongoing infection. If somebody has an active infection, I try to forego any Mesh, I’ll do my best to close them, clear the infection, come back to fight another day and stage this out. But yes, I have had some patients that have hypersensitivity to implants. They don’t pinpoint exactly what it is. Yes, but they’ve said that every time they’ve had suture or material being in them, they’ve had some
Speaker 1 (00:36:53):
Simple implants. Even dental history’s very important.
Speaker 2 (00:36:57):
That’s a good point. I haven’t thought about looking into that, but they’ve had some reaction to some foreign body in them. And so for these, depending on the location and the size of the hernia, I may use a bioresorbable Mesh in there that is give it some strength, let it in grow, let that scar in place and do that because of their history. That said, in my practice that’s been on the rare side, I have not seen a great deal of significant Mesh reactions or allergies. I don’t do testing of Mesh materials. I know you’re working on some great studies that look into that. Yeah, I’m really eager to look to see what those show because I just haven’t seen it as much in my practice. But I do think that there is some sensitivities to certain materials that we really haven’t been able to pinpoint. Well,
Speaker 1 (00:37:52):
Yeah, as you know, I see a lot of people with chronic pain, very odd medical problems, pots mast cell activation syndrome, sensitivities to a lot of things, Mesh allergies and I do want to learn more because these are not common problems. And so you want to take advantage of every situation to learn maximally to be able to help more patients in the future and share your knowledge. Allergy testing is something that we’ve started and if it’s positive it’s very helpful, but if it’s negative, it’s about 40% falsely negative. So a negative study is not very helpful and I have had good success in using hybrid Mesh. So biologic Mesh as we’ve discussed before and especially last week, it’s not ideal. It absorbs by definition and as far as we know, there’s no good product that we’ll absorb but still maintain the repair integrity. So some type of permanent needs to be there.
Speaker 1 (00:39:00):
The hybrid Mesh has a little bit of permanent and a lot of biologic absorbable and a lot of patients do well with that because you’re just not giving them as much synthetic and that seems to not spark an inflammatory autoimmune response like more synthetic wood. So there are people that will probably react to that as well, but other than that, it should be fine. So on that note, we have a patient who had an eight by 10 inch Mesh put in for an umbilical hernia, eight by 10, probably centimeters, eight by 10 centimeter synthetic Mesh put in for umbilical hernia repair that was removed and then a synthetic absorbable Mesh was put in. But she has these sharp pains all the time. Why do you think she would have sharp pains from an incisional hernia pair with absorbable Mesh?
Speaker 2 (00:40:04):
If I hear someone with sharp pain, I, I’d be less inclined to think it’s from the Mesh and probably related to either fixation of that Mesh correct or perhaps defect closure.
Speaker 1 (00:40:14):
Yes,
Speaker 2 (00:40:15):
And it could be focal nerve irritation of a certain location of that, but I’d be hard pressed to think it has something specifically to do with Mesh for that particular scenario.
Speaker 1 (00:40:27):
Yeah, I agree. It’s probably even though they used synthetic or absorb, sorry, absorbable Mesh, we don’t know if it’s biologic or synthetic. The sutures may actually be permanent or takes a long time for them to absorb. And so the points where all the sutures were placed can cause sharp pains and that would’ve been my answer to is it’s probably related to the fixation or the suturing of the Mesh or closure of the fascia with the sutures. So now you have suture related pain and that’s where expertise comes in. So when you have a patient that needs a hernia repair and you have to really pull it tight to close that, then maybe you have to do some more maneuvers to relax some of that tension because anything tight will tear. We know that from clothing and we know that therefore for hernia repairs. So that’s where components come in. You want to talk a little bit about component separation?
Speaker 2 (00:41:33):
So component separation is part of abdominal wall reconstruction where we have to separate the various layers of the abdominal wall apart. We basically take it apart layer by layer and put it back together layer by layer. And the whole idea of doing that, there’s a couple rationales for that. One, is to release part of the tissue, part of the layers of abdominal or release it enough to pull together to close that gap to close the hernia. And that’s one of the main reasons we want to offload tension. That is if it’s a big enough hole, if we just try to push it together with stitches only, as you said, it’s probably going to tear. So by cutting various layers of the abdominal wall and separating different layers of the abdominal wall, that allows these layers to slide against each other and so we can cover close our hole.
Speaker 2 (00:42:20):
It also depend on the type of component separation that’s done. It allows very large planes. So we can put very large Mesh prosthetics in there to reinforce not only the area right next to the hernia repair, but we want to reinforce very widely because when we cut some of these layers, we potentially weaken a little bit of it and we want to reinforce the strength in that. Now the interesting thing is that there’s some good studies that show looking at CAT scans after component separation, despite cutting various tissue layers, some of those layers may weaken by recreating the abdominal wall, as I already said before, by getting those rectus muscles closer to the midline, we set up this tension, this physiologic tension that our abdominal wall is originally made to do and that actually can strengthen the other muscles. So the other muscles actually get bigger and a little beefier and stronger after that repair. We’re talking months, sometimes years down the road after the healing has completed and the abdominal walls now set to its new state and then get stronger. So in some respects we have to sacrifice a little things here and there, yes, to close up the big problem and strengthen the rest of the abdominal wall.
Speaker 1 (00:43:34):
And I think some of many of the patients that are on tonight seem to have had 1, 2, 3, 4 hernia repairs and the key is prevention. So we can’t prevent you from having your genetics that maybe had caused the hernia, but please try and focus on taking the first hernia repair seriously. Don’t go to one surgeon even if you see me, please go see a second surgeon. Just get an opinion and try and figure out what is the right thing to do because these are all operations and so many of us, I’m sure you have your fair share of patients where they’ve had a little bellybutton hernia and you got fixed with a suture, but the patient was obese or a smoker or C O P D, coughing, nicotine use, whatever the situation was. And that popped open. So now you have a small hernia is not bigger because it’s torn.
Speaker 1 (00:44:27):
Then the surgeon again puts sutures in let’s say, or puts a small piece of Mesh, basically inadequate operation that tears patient remains nicotine use, patient remains with their obesity, the patient remains with their chronic cough, all things that can be treated, treated. So then progressively they keep tearing, tear and tear where they had Mesh infection and redo operations and now they have this enormous giant hernia that is very complicated. There’s very little tissue left to work with. So knowing the best operation the first time or if you have a recurrence the second time, let’s not get it to number two and number three and four. On that note, here’s a patient that says that she has a large incisional hernia. Her surgeon has tried twice to repair it once in August, 2018 and again in 2020. So two operations in two years. Both report repairs have failed. Although way I have not seen anyone from the hospital due to COVID, but I doubt they’ll make another attempt. I have a couple of questions. Number one, will this hernia continue to grow in size or do they reach a maximum and stay like that?
Speaker 2 (00:45:44):
The first question, hernias don’t shrink in size unless you’re a little kid like less than four or five years old or pregnant. That’s pretty much the only two categories that I’m aware of where hernias may shrink down to a little bit. Yes, short of those two categories, hernias will either stay the same size or they can enlarge over time, but it is variable from person to person. I’ve seen people, I’ve followed them for years and they had the same size hernia for years and years, they just never wanted it fixed. I’ve had people that have a hernia that drastically enlarges over a short period of time. So it definitely can get bigger, but it’s not guaranteed to.
Speaker 1 (00:46:16):
What if the surgeon says you should never have hernia surgery ever again? What’s your response to that?
Speaker 2 (00:46:22):
Well, as a hernia specialist, I’m pretty much willing to see anybody and try to fix any hernia, get my hands on. It’s very rare that I will tell a patient, no, this can’t be fixed. Now I think there is end-state hernias and I was just actually talking about in clinic today with my residents, but that’s on the rare side. I believe that most hernias can get some type of repair. Maybe they’re not a candidate for a big component separation, but there are other things we can use to help that hernia out. So yeah.
Speaker 1 (00:46:55):
Yes, we talked about end stage hernia repairs about using flaps from other parts of the body to help bridge defects that you just don’t have any tissue to deal with. Usually that’s not the case 99.5% of the time. Okay. Question number two, same patient. Is there extra fluid in the cavities where the collapsed inside should be? My stomach is so swollen and it just feels as though it’s like a balloon. Even though when I lie in my back,
Speaker 2 (00:47:26):
If it’s talking about fluid, I mean if it’s a large sac, you can get some fluid in there, especially if somebody has ascites, which is fluid that builds up from usually from liver disease or some other back pressure in the body. But filling up with fluid is not a common finding unless there’s something else bad going on. Typically, if there’s a hernia sack that’s filled with either fatty tissue or organs from the inside that are pushing out there, and this also gets back to the sizing, if I can even take a step back, we asked about the hernia getting bigger. There’s a couple different sizes there that they can go hand in hand that can be different. There’s the hernia defect, that’s the hole in the fascia and the abdominal wall and there’s the hernia S sac. This is the space usually under the skin that can stretch out. Now in some people in a small hernia, small hernia, small little hernia S sac, I kind of liken it to a mushroom where there’s a small stem and then there’s sometimes there’s a big mushroom cap. While sometimes the hernia size, the defect can say the same size, but the hernia sac that is the area under the skin can stretch out to be very big. You can have a hernia sack that’s the size of a
Speaker 1 (00:48:33):
cantaloupe.
Speaker 2 (00:48:34):
Or shataki mushroom, big old mushroom, a huge hernia sack that has a lot of bowel and other stuff in it that can squeeze to a tiny little hole. So that doesn’t mean the hernia defect has gotten bigger. It means the hernia sack has gotten bigger. Also, you can have the same, you have a huge hernia with a huge hernia sac and it’s all one ginormous cavity. There
Speaker 1 (00:48:54):
Are biologic meshes good for this option. That’s what her surgeon recommended.
Speaker 2 (00:49:00):
It’s it possibly, but again, it really depends. I would have to know more of the history. Is there an infectious history, why? What happened with the previous two repairs, why they fail? What meshes were used for that I is the patient optimized medically this pre-op optimization it, it’s funny how it’s such a sort of a new thing. It’s not new because physicians have been trying to get patients healthier for years and years. But I think we’ve made a pretty good concerted effort in the hernia world to get our patients medically fit and optimize before we do hernia repairs. Especially the big complex ones, as you say, said we want to avoid this vicious cycle. We want to avoid hernia turning into bigger hernia, turning into bigger hernia, turning into infection and Mesh removal and another infection we want to avoid and stop that cycle. Preoperative optimization is one of the best ways to stop that cycle.
Speaker 1 (00:49:54):
So this is a perfect example where someone needs to stop repairing these hernias, figure out why they keep repairing. Is it purely a technical problem, Mesh was too small, sutures were too tight, something like that. Or is it because there’s obesity, diabetes, chronic cough, constipation, nicotine use, acid reflux with clearing of the throat, coughing, all these little things can add up and how many of these are right? And then you go for the repair. In fact, I’m sure you’ve had patients, cause I have patients, I had two today that they should have surgical weight loss, which is yet another operation which is at to the complexity before they should have any hernia repair because they’re never going to get to the weight that they need to be for the next hernia repair. And to just kind of wing it and say, well she’s never going to lose weight, for example, is a disservice because then that vicious cycle is really, really, really poor quality of life. Okay. Another one. Do you have tips on how to live with this type of hernia? I’m only 47 and I feel like it can no longer do so much.
Speaker 2 (00:51:14):
That’s a tough call. I see many patients that are in similar scenarios, they’ve had a long history of multiple hernia repairs, maybe had infection, maybe not many of them do have these medical problems, obesity or smoking smokers or diabetics. So my first evaluation is about getting that history and counseling the patients. That is my first step isn’t to say, okay, this is how we’re going to fix your hernias. It’s like, let’s take a step back. How can we get you and your body better and optimize for what sounds like is going to be a big operation down the road? And I think that a lot of it is patient education. Yes, patient. There’s a lot of misinformation out there in social media and on the web. Our job as hernia surgeons to educate our patients also give ’em some hope to say, yeah, listen, this is fixable but just not right now. We can fix it down the road after we get this, this and this taken care of. Yeah. Might be medical weight loss with diet exercise, it might be a referral to our bariatric center. Yes. Who can do a good multi-tiered approach to get you to have successful weight loss? I send many patients to my bariatric colleagues for surgical weight loss. It’s one of the best ways to lose weight. It’s not appropriate everybody, but it’s a very good thing for many patients.
Speaker 1 (00:52:31):
Not every bariatric surgeon’s comfortable doing bariatric surgery and so with a big hernia. So you have to find the right surgeon for that. But yeah, I have a couple that are really great. And so helpful question about Mesh removal. Is there an appropriate time to get Mesh removed? Does it matter, let’s say someone is having Mesh related pain. Does it matter if they take it out this year or next year?
Speaker 2 (00:52:55):
No, I don’t think the timing. Well, the only timing is that that patient may had continue to have symptoms, but if I have examined the patient, I look at their CAT scan and everything looks good, I don’t see a recurrent hernia, I don’t see fluid. If I don’t see anything abnormal on exam or on any imaging they have, I try to counsel the patient and see, well is there something else going on besides just it being the Mesh? Because yeah, the problem is that if the abdominal wall has good integrity with repair, if we go in to remove that Mesh, there’s a pretty significant chance of that hernia’s going to come back and then we’re back to square one with dealing, okay then how do we fix that hernia when they have a high chance of a hernia recurrence? So removal Mesh, removing Mesh is usually low down in the list for me.
Speaker 2 (00:53:44):
I tried to see if there are other things we can do to help with the pain or whatever is, or try to find the rationale for that before going straight into remove, removing Mesh because that’s there is a potential for harm by removing Mesh. Now that said, there are some select scenarios where it might be appropriate to remove Mesh and the patients have this conversation with them so they understand that if I remove the Mesh, I’m certainly not going to put any new Mesh at that time. Their risk of hernia occurrence is extremely high and then we’ll have to figure out what to do later down the road. So they need to be prepared for that conversation. And that kind of long-term.
Speaker 1 (00:54:28):
Talk about abdominal muscle. So sometimes the nerve to the muscle is injured, whether during surgery like a spine operation or a accident. Do those become hernias or how do you and treat those?
Speaker 2 (00:54:46):
So denervation typically does not lead to a hernia. I think in the worst case scenario it can if it weakens so much at the tissue, but it’s unlikely. But typically happens with denervation and as you suggest it could be from a traumatic injury, it could be from surgery. Surgery is controlled trauma or cutting through tissues to fix a problem or remove a tumor or whatever it is. Yeah. It also depends on where that incision, A lot of incisions on the side, these flank incisions from say kidney or adrenal or other operations like that or liver, gallbladder, those are tough areas to heal. There’s a lot of nerves and a lot of things go in into that and by cutting through those tissues or whatever the trauma or whatever happened to that area, that leads to loss of these tiny little nerve fibers that go to the muscle.
Speaker 2 (00:55:33):
And when that happens, the muscles then weaken over time. We call that atrophy where the muscles thin out and weaken. And so all you’re left with in some focal areas is a thinned out and stretched out abdominal wall. It’s called abdominal wall laxity. It’s just a very stretchy part of the abdominal wall and it can bulge out and it can look like a hernia when you just look at the bulge from the outside. But when you look for imaging at imaging, there is no hole, there’s no defect in there. So there’s no true hernia on most of those cases. So then you ask the question, so what do you do about that? Well unfortunately there’s very few options to that. There’s discussions about plication where you basically sew up and sort of bunch up some of that tissue to tighten it up, plus or minus Mesh reinforcement.
Speaker 2 (00:56:22):
I’m not aware of any good data to say that that is a very effective method for tightening that up. So it it’s an unfortunate problem with very few options for definitive repair. Most of the time I counsel patients that it’s about compression. You wear an abdominal binder or spank some type of elastic undergarment just to give ’em some compression. Yeah, the good news is that those are rarely dangerous. A loop of bowel can’t sneak up into that and get caught in obstructed or strangulated, but it can lead to bulging, it can lead to some pain. Another, there is some unknown causes of denervation too. Perhaps previous viral infection from years ago or childhood or some other non-traumatic event can also lead to denervation and muscle atrophy that we just don’t know the exact cause of.
Speaker 1 (00:57:11):
So my trick for these flying hernias, because I get a fair number them they’re usually from spine surgery, but they can be from, like you said, kidney, other operations. You’re right, they tend to have worse outcomes than the average surgery because you’re dealing with unhealthy tissue, you’re not dealing with normal muscle. But here’s the trick. So you ply Kate the hell out of the Deni area super tight like you’re doing a tummy tuck, but you’re doing a tummy tuck of the denervated area. Very tight. In fact, I used to do almost all of these with the plastic surgeons because I would make it tight and then they would make it even tighter. Cause they’re used to tummy tucks. They’re not used to like hernia repairs where we try not to make it too tight. And then you add an online Mesh and the Mesh needs to be secured very widely to the pelvis and to superior cross the inguinal ligament, the pubic bone and needs to go beyond midline to the contralateral linearal and then needs to go behind to get to the back muscle kind of perispinal fascia. And that’s the only way that’ll work. And even those aren’t a hundred percent, but anything less than that doesn’t work because
Speaker 2 (00:58:33):
Yeah,
Speaker 1 (00:58:33):
It’s not okay. I got,
Speaker 2 (00:58:36):
Yeah, two seconds though. Just to backtrack a little bit with what, a lot of times when people do have an incision over there, many of ’em can develop hernias there, so that’s not the same thing. Yes, correct. As just a thinned out strips abdominal wall. I just want to clarify that. So some of those are appropriate for a formal hernia repair and abdominal wall reconstruction?
Speaker 1 (00:58:53):
Totally true. And those you do robotically,
Speaker 2 (00:58:57):
It depends. Some are open, some are robotic. It depends on the size and location. I do a mix of open and minimally invasive.
Speaker 1 (00:59:05):
Yeah, agree. Okay, we’re going to do a lightning round. Two quick ones before we let you go and enjoy the rest of your evening. Okay. Number one, small umbilical hernia. No symptoms, barely visible repair or don’t repair.
Speaker 2 (00:59:16):
Watchful waiting. Don’t repair. And if it comes symptomatic, come back and see me. Will fix it.
Speaker 1 (00:59:20):
Perfect. Dissection of scarpa’s fascia. Can that diminish the strength of the rectus muscle or affect its role in the abdominal wall?
Speaker 2 (00:59:34):
Nope. Scarpa’s fascia is just an enveloping fascia. The subcutaneous tissues? Yeah, I do try to close it. I do a multi skin layer closure when I do my reconstruction, so I try to get all the layers closed, but that would’ve nothing to do with the durability and strength of the rectus. Either be the anterior rectus or pot rectus fascia or the muscle itself.
Speaker 1 (00:59:52):
Yeah. Scrappers fascia has no strength compared to muscle or regular fascia, and there’s no correlation. There’s actually fat between scrappers usually and the rectus fashion. All right. That wasn’t too bad.
Speaker 2 (01:00:08):
Oh, more lightning. I thought we were getting more lightnings. No,
Speaker 1 (01:00:11):
Just two quick ones. All right. Shall we finish this? It’s time and I don’t want to take up too much of your time, but I want to thank you very much, Dr. Orenstein. You’ve been a great friend and colleague. This ends our session of Hernia Talk Live on Tuesday night. Thank you everyone for joining me on Facebook Live and on Zoom. I will post a link of this to my social media channels for you to watch and share from my YouTube channel. Thank you to everyone. You guys had some really amazing questions, and I hope all of you that are having problems with your incisional hernias do get help and please get expert help because once you have a hernia from an incision or a prior hernia repair, it’s time to have it done by expert witness, expert surgeon, expert surgeon because you really wanted to be your last operation. Thanks to everyone and thank you, Dr. Orson. Again, enjoy your evening. I hope you stay warm and see you all next week.
Speaker 2 (01:01:12):
Thanks for having me, Shirin. It’s been a wonderful discussion. Take
Speaker 1 (01:01:14):
Care. Thank you. Bye.
