You can listen to this episode by clicking here.
Speaker 1 (00:00):
Hi everyone. Welcome to Hernia Talk Live. Welcome to another session of our q and a. Every Tuesday joining me, my name is Dr. Shirin Towfigh. I’m a hernia surgeon in Los Angeles. You can follow me on Twitter and Instagram at hernia doc. Thank you to all of you joining by Facebook Live at Dr. Towfigh and those of you here on Zoom and let’s see when we’re done here, I’ll make sure that this is posted on YouTube so you can watch and share with everyone because today’s going to be an amazing party talk session because it’s not going to be your usual one. We’re joined by a surgeon, Dr. Edward Felix. He is one of the pioneer laparoscopic surgeons in the United States, and he has some really great hernia stories and to share, we’re going to be focusing on the history and evolution of hernias. You can follow him on Facebook at EL Felix MD and let’s introduce Dr. Felix. Hi Ed.
Speaker 2 (01:04):
Hi there. Good evening.
Speaker 1 (01:06):
So you’re coming in from your lovely home,
Speaker 2 (01:10):
Correct? I’m in what used to be one of my son’s rooms and it’s now become the Zoom room.
Speaker 1 (01:16):
Oh, is that right?
Speaker 2 (01:18):
We do zoom’s in this room.
Speaker 1 (01:20):
Yeah. So behind you is are all the books in which you’ve written chapters in almost all the books you’ve written chapters in? Yeah. I see my book is there, the Sage’s Manual of Groin Pain. Right. It’s at the manual of hernia surgery behind
Speaker 2 (01:36):
You. The groin pain.
Speaker 1 (01:38):
Yes, there you go. The manual Groin pain. That’s my book. Very proud of it. You got like Dr. Nyhus, his hernia book. He was your attending surgeon and mentor in tons of laparoscopic books
Speaker 2 (01:53):
Right now. So
Speaker 1 (01:56):
Yes,
Speaker 2 (01:57):
Those are just what’s kept me busy for the last 40 or 50 years is trying to put things in those little books.
Speaker 1 (02:06):
Yeah. Well, I think, I don’t know, I, I’ve enjoyed writing chapters. I feel like writing a paper is great, but you have to bring in a lot of evidence and if your novel in what you’re talking about, it’s really hard to write a manuscript if you don’t have that much to kind of support yet. But writing a chapter or you can kind of infiltrate the textbooks with your ideas without necessarily having to make it a research project.
Speaker 2 (02:39):
Chap chap books are fun, but for me now, what’s even more fun is I’ve got, next month I’ve got a editorial coming out in our, what’s called general surgery news, which is fun because it gives me an opportunity to say what I think. Yes, it’s my opinion. I’m sure a lot of people will disagree with me, but it’s an opportunity to get down and dirty and say what I think is right or wrong about something.
Speaker 1 (03:07):
And as many of you know, medicine is no different than many other specialties and including politics. There’s a lot of people that disagree. Everyone has their own way of doing things and beliefs, and we do fight amongst each other quite a bit. Usually not fistfights, but verbal fights and articles and discussions at conferences. And you’ve been certainly witness to and maybe even party to a lot of it.
Speaker 2 (03:39):
Yeah, I, for the audience, let me throw in what I think’s really important is that yes, that medicine is an evolving science and I think that more people are seeing that right now with COVID and with this whole thing about mask wearing. Because in the beginning, for example, the data was there. You don’t need to wear a mask. Don’t wear a mask. And when a lot of us, including myself, changed our personal opinions based on data and science, people said, oh, we were not telling the truth, we were lying. No, that’s not the way it is at all. It’s that we change and that’s great about science and about positions in particular. You change with what you learn when the data is there. You are free to change. You don’t have to stay rigid, you don’t have to say the world is flat. You can now say it’s round. You may get attacked initially, but eventually everybody will agree with you and come to that conclusion. So I think it’s important, and that’s true for the whole COVID mask wearing and it’s surely true now with the evolution of hernia, which we’re going to talk about, is that it’s based on ever changing data and facts. And as we learn more, we have to learn to change. And I think that’s important.
Speaker 1 (04:57):
I think that’s very true. That’s, it’s what a lot of people are uncomfortable with, which is that things do change. I was told once that if you’re an engineer going into medical school, it’s very difficult because in engineering or in math, everything is structured and there’s an answer for everything. One plus one always equals two. Whereas in medicine, I mean sometimes it depends on the patient and the risk factors, and there’s multiple answers and multiple ways of doing things. Not everyone has the same presentation for the same illness, a blood test, a white vessel count, maybe normal for one person, but not normal for another person. There’s a lot of gray zones and people can get very uncomfortable with the fact that it’s, they’re unsure
Speaker 2 (05:47):
And how a person will react to something may be different than another person. So you have to take a lot of that into consideration. What’s be, as say, especially in the hernia world, the right operation, what’s the right operation that you can do as a surgeon and what’s the right operation for that patient? And I
Speaker 1 (06:06):
Think, yeah, and it’s hard for them to,
Speaker 2 (06:07):
There are a lot of variables and that has to be explained to the patient and they have to understand that it isn’t totally black and white there. There’s opinions and there’s gray areas.
Speaker 1 (06:20):
And having gray areas doesn’t mean that you’re incompetent or you don’t know. It’s, in fact, many of the people that don’t believe in gray areas are not the good doctors because everything is the same. Everyone with groin pain has a hernia. Everyone with Mesh has Mesh pain. I mean, it’s pretty interesting how some people can be very dogmatic about it and you can hurt patients by treating everyone the same.
Speaker 2 (06:45):
Yeah, no, to me, I want a doctor, when I ask ’em a question or her question are going to say, if they know the answer, they’re going to say it. But if they don’t know it, they’re going to say, I don’t know it. Maybe no one does. Or maybe someone better than me or different than me knows it. That’s what I want from my own personal physician. I don’t want a dogma.
Speaker 1 (07:07):
One of my earliest guests on this show was Bruce Ramshaw, and of course he’s very evidence-based, but he also is in this kind of study of this where we just don’t know a lot. And I got some of the best feedback from that talk because patients saw that surgeons are constantly struggling to know what’s best for the patients and that we don’t know what we don’t know.
Speaker 2 (07:35):
And I think that what many patients don’t appreciate is that a good doctor remembers and knows not just the good results, but if something has not been easy or gone wrong, you never forget about that and you learn from that. This may sound strange to your audience, but someone always asks me, good friends, Omar says, well, what makes you an expert? And it’s because I’ve seen so much. I know what can go right and what can go wrong, and therefore I have the good defense. I know what to do to prevent those complications. Yes. Someone who hasn’t seen them and they don’t know what they is, we always say they don’t know what they don’t know. And that’s the most dangerous thing.
Speaker 1 (08:23):
Tom Byrne,
Speaker 2 (08:25):
I’m
Speaker 1 (08:26):
Not sure from USC,
Speaker 2 (08:28):
I think I know he
Speaker 1 (08:29):
Is. Yeah, he, he’s been at USC forever. We lost him about three years ago. He was my mentor when I worked at USC. And he said, to be a good surgeon, you have to be a compulsive pessimist. And at first I was like, compulsive pessimist. I’m an optimist. I don’t want to be a pessimist. But he was right. He’s like, every operation you do, you have to worry. You have to wonder the ones that the surgeons that are the most capable are the ones that are constantly thinking and worrying and making sure that every little thing is done. He is just a great, great mentor. And for those of you who know him would kind of agree with me. But what he would also say is, or the way I teach my residents is like, and as an intern, your first year as a resident, you really don’t know everything. And so you don’t worry as much. It’s when you become more senior and you’ve seen complications, you’ve seen what can go wrong, even for a simple hernia pair or a gallbladder or something like that. As the more senior you get, the more you have to worry, the less you can relax because you actually know everything that can go wrong, the more senior you get.
Speaker 2 (09:51):
Yeah, I know, as you know, I’ve this for multiple reasons this year because of COVID and so on, I’ve decided to retire from active surgery and for the first time and now it’s like 50 years, I could actually go to sleep at night and don’t wake up thinking about the case I did that day. Yes,
Speaker 2 (10:10):
I miss surgery a lot. It really is fun and I wish I could do it, but I don’t miss the worry. Yes. And that’s what you want in a physician. Yes. You don’t want someone that does your operation. I’ve always wondered how, and this is going to sound bad, but I’ve always wondered how someone could be an ER physician because all they do is see a patient and they never see ’em again, and they just go home. And surgeons, we live with our patients forever. They are ours forever. We think about them forever, good results, bad results, whatever we think about them. And even in retirement, I can go back and think, but at least I sleep now.
Speaker 1 (10:53):
Yeah, that’s very true. So let’s discuss a little bit about what we’re talking today, which is a history and evolution of hernia repair. I posted on Instagram earlier that the first, so the Egyptians actually knew there were hernias. This is 1500 before Christ, and there are evidence of mummies that I guess had inguinal hernia. And the only way they knew how to fix it was to castrate them and basically clean, chop their, take their testicle off, chop their balls off, and just sew that whole sack so that you don’t get the hernia go into scrotum anymore because there’s scrotum. Yeah, we don’t do that anymore.
Speaker 2 (11:36):
Well, for those go to hernia lectures, almost every hernia meeting has somebody putting the old slide, someone laying on a table with the person with the knife about to do exactly what you said to treat the hernia.
Speaker 1 (11:53):
Yeah. And
Speaker 2 (11:55):
It took many, took a lot of years before it got any farther along and they actually tried to sew up and do some kind of repair to the floor for
Speaker 1 (12:06):
The Yes. And in fact, I misspoke. I said, we don’t do that anymore, but we actually do perform orchiectomy on purpose in giant, enormous hernias as a means to help as a Stoppa type repair. Of course, those are huge, enormous. We usually don’t see it in the first world, but sometimes we see it. But those, that is still a technique, even though it was back during the Egyptian
Speaker 2 (12:36):
Time when I was a resident, we used to send, and I didn’t do it, but we used to send, Nyhus used to send a resident for six months to Africa, and each resident who went to Africa would try to compete with the previous resident to have the world’s biggest hernia.
Speaker 1 (12:55):
Oh,
Speaker 2 (12:55):
Really? So we had actually people presenting with a hernia and a wheelbarrow, I mean Oh, wow. Totally ridiculous. Oh, really? I wish I, yes, I wish I had some of those photos they presented, but the person would come up to the clinic and they’d be carrying their hernia in a wheelbarrow, so that, oh my God. In third world countries, people ignore ’em because if it’s not interfering with their life, they just go about it. They just handle it.
Speaker 1 (13:23):
I had a lady who had her hernia into a shopping a plastic bag, and she would wear a skirt so that can hang under, and she kind of carried under. So then she put the bag between her legs while she was at work and just hit hung in there. And then she would just walk out and then she finally got treatment. This was back at the county, but she didn’t get treatment for until it started to lose blood flow to it and then smell, and then she came in. It’s pretty
Speaker 2 (13:53):
Bad. Hopefully we don’t see many of those anymore.
Speaker 1 (13:56):
Yeah, yeah. Let’s hope not. But
Speaker 2 (13:59):
Hernia has come a long way. The initial people who tried to repair hernias just kind of so what we call good stuff to good stuff. And it wasn’t until it’s now a little over, it’s about 120 years ago that Bassini, an Italian was the first one who really changed hernia repair. He knew he was an anatomist, he knew the anatomy, and he basically took everything apart and then put it back together in a very scientific way. It’s sort of like someone, it’s a difference between just when you remodel your house, throwing wallpaper over it and covering up, he demolished the house and then put it back together. The biggest problem though is that people didn’t believe him in the beginning. And then once they believed, the next problem in modern history that I see is that people thought they were replicating what he did and they’d say, oh, I’m doing a Bassini repair. But it is, it’s sort of like the game telephone game
Speaker 1 (15:06):
Where you
Speaker 2 (15:06):
Talk to someone and they talk to someone else and you talk to someone else. By the time it gets to the end, it did not resemble, it was still possibly a good message or a good hernia repair, but it didn’t truly resemble what Bassini originally described.
Speaker 1 (15:21):
That’s why we called the modified Bassini.
Speaker 2 (15:23):
Well, they didn’t, they? Yeah. Well, sometimes they didn’t use the word modified, they just said Bassini. And then in the United States, people did a lot of other things to try and make that operation either better or change it. And McVay was one that when I left the university, I used to be a assistant professor at the University of Illinois. And when I left, my chief, Dr. Nyhus was very upset with me because he was trying to have me carry on and take over there in general surgery and got very mad at me for leaving academics. And he actually said to me, and I remember this very well, he said there was this guy named McVay who was a hernia surgeon out in Kansas, and he was in private, it was anonymous, but he was really in private practice and he invented a hernia repair, which modified a lot of what is done after that.
Speaker 2 (16:21):
And Nyhus said to me, well, you can do that someday, even if you go into private practice. And I said, you’re under my breath. I said, oh, you’re crazy. I wouldn’t say it to him, but I said, oh, you’re crazy chief. I’m never going to do that. And then what happened was, I actually did go on when, as you talked about with laparoscopy, yes, to get back into hernia and did make a lot of the major changes from private practice. So people can do a lot in surgery. They don’t have to be at a university to make changes.
Speaker 1 (16:55):
Very true. We’re both living proof of that. So Bassini was the first to identify a tissue repair for inguinal hernias that was an 1880. And we still use Bassini repair or some iteration of it. So the Convey repairs also very popular. Shouldice repair is also very popular. These are all been tested, tried and true for a long time. We have some questions to help guide us as to your evolution. So when you were in residency, how were hernias taught during residency and what were you taught to do to repair a hernia?
Speaker 2 (17:33):
Okay. Well, when I was a resident, everything was done open and nobody there at first, there was no use of any Mesh. It was essentially doing either one of the pairs, we just talked about the Bassini or the McVay or some modification of that, and we would start the hernia back then. It’s interesting, was thought to be an easy case, which it’s not, but it was thought to be an easy case. And so we used to call it an interns case. So the first and second year residents would teach the more junior residents how to do the hernias, and then when you got a little farther along, you would teach the next. And that’s how it went. And it wasn’t until, I would say the era of LA almost of laparoscopy that we realize that the hernia is not a easy case, that someone has to be an expert in the area if they want to get good results. It doesn’t mean that’s all they do, but they have to really know what they’re doing to get good results. And so the teaching of it has changed dramatically. Now. Residents learn hernia repair all throughout their residency, all the way up to their chief here. In fact, a lot of the laparoscopic and robotic stuff isn’t taught until they’re more senior because they have to learn those techniques.
Speaker 1 (18:53):
And what specific techniques were you taught during residency?
Speaker 2 (18:57):
It was mostly we did McVay’s. We didn’t do a true Bassini. I don’t think I e ever did a true Bassini during the Rives residency. Later in my residency, in about the third or fourth year, we began to do what we call the news repair or the open posterior repair for recurrent hernias. They weren’t done for primary hernias. Yeah, they were done for recurrent hernias and for women that we thought had a femoral hernia, we might do a posterior repair. But that was a more difficult operation and difficult to see what you were doing because the first assistant doesn’t always get a good look to learn from the professor. Yes, it was held off until about the third or fourth year. But that operation, which is the posterior repair, and we used first no Mesh, and eventually we began, when we found the recurrence rate was too high, we used, began to use Mesh, which was Dr.
Speaker 2 (19:57):
NE’s idea. Basically that operation was what caused me to get into laparoscopic hernia repair, repair, because I had a great experience. I did. I’ve probably done 50 or a hundred of those operations as a resident who have been involved with that many. And I knew how to do it. And when laparoscopy started, people were coming up with all kinds of crazy ideas on how to repair a hernia laparoscopically. And I said, I could just do what I was taught to do open laparoscopically. And that’s how I got involved in it. And was lucky enough to be one of the first three or four people in the country that was crazy enough to think they could do it. But the difference was we took the approach that my chief had taught me to do open hernia repair and fashion it after that. There were some other really good surgeons, guy veer and others who took the wants repair or the Stoppa repair, but more wants and took that repair and made it into a laparoscopic repair.
Speaker 1 (21:05):
So the whole issue with, so let’s talk about Mesh a little bit. The first Mesh seems to have been used for her new parent, 1891. It’s not a concept that’s new and it’s been evolving, but we really didn’t have today’s kind of commercially made surgical Mesh until basically the 20th century.
Speaker 2 (21:34):
If I can interrupt you, the first Mesh. Yeah, the first meshes actually, they were faster from an animal. They would use the long tendon, the tensor from the leg, and they would cut that, make that into a material which you could implant. So that was before somebody came along with the idea of either polypropylene and eventually some other pro products.
Speaker 1 (22:04):
Yeah, polyethylene, I think. Polyethylene,
Speaker 2 (22:07):
Yeah. That was the first Mesh. It really wasn’t. It was Mesh, but it wasn’t Mesh. It was
Speaker 1 (22:13):
Right. It was some type of
Speaker 2 (22:15):
Animal product.
Speaker 1 (22:16):
Yeah.
Speaker 2 (22:17):
You were putting, instead of wearing your pants on the outside, you were wearing your pants on the inside.
Speaker 1 (22:23):
Right, right, right. Exactly. So first it was kind of these, well, they use these metal sutures to make their own Mesh, and then those would break. And then I think polyester became famous in Europe. And then in the us, polyethylene and polypropylene were the more common polypropylene being better than polyethylene in multiple ways. And then with laparoscopy, laparoscopy was always Mesh based, correct?
Speaker 2 (22:52):
Well, the very first laparoscopic hernia here wasn’t, Mesh was done by a guy named Ger, and he took a clip and he clipped it. I don’t know exactly how he did it, but he clipped a closed, he presented it, he presented that at the American College of Surgeons, and it didn’t go over too well as you can imagine. But he girl was the first one to do a laparoscopic. Next came a bunch of different things with putting different kinds of meshes in and plugs in to do it laparoscopically. I think an important point to make though, before we tried to do things laparoscopically with Mesh, the Mesh was put in anteriorly. And I think Lichtenstein, who comes from your neck of the woods, from LA should be mentioned. And he should be mentioned because just like laparoscopic, initially it was not accepted very well at all.
Speaker 2 (23:50):
He used to go to the American College of Surgeons every year and present in a booth his data on hernia repair, putting this Mesh in. And for I don’t know how many years, nobody accepted it. And it’s this editorial I was comment on later talks about it that’s coming on GSN is that at first people just think you’re out of your mind. And then the next thing thing is they fight you like crazy and say you this can’t be. And then third thing is they all accept it, but they take credit for it. They all think they did it, but that’s what happened. The Lichtenstein is, and then they actually played with a bunch of different meshes and eventually settled on polypropylene and put that in the groin anteriorly. And what’s interesting is when you go from back in the eighties when he was rejected, that’s the number one accepted hernia repair in terms of volume in the world. Yes. Now, yeah, in the world. And so as they say, we’ve come a long way and we’ve evolved with anterior. And then when we knew that Mesh was safe anteriorly and from Nyhus posteriorly, that’s why we were so readily willing to accept it laparoscopically. And you really, really want what we call attention free repair. And that was the idea. Lichtenstein came up from anteriorly, and that’s really the whole purpose of the repair posteriorly or
Speaker 1 (25:22):
Lap. Yeah. So I work at a Cedar Sinai hospital. The story that I am told is that Dr. Lichtenstein came up with this Mesh based repair because so many people had pain and tearing and disability from the tissue repair because everything was so tight. And so he felt that the Mesh can relieve the tension, hence the term tension of free repair. And he wanted to do these as outpatient. The patients had no pain after surgery and he was doing it as outpatient. And Cedars Sinai, the medical staff, felt that that was not considered standard of care to do outpatient hernia repairs. And he lost his privileges. They kicked him out of the hospital. He had to move down the street to another hospital to do his hernia repairs because he was considered too controversial because his technique he felt could be done as an outpatient. And back then everyone was admitted to the hospital after their annual hernia repair.
Speaker 2 (26:22):
So no, as I said earlier, with mass is it’s tough to make change. And sometimes you can be very, right. We have the same history, history with the gallbladder surgery. When we first started in an introduced laparoscopic gallbladder surgery, they wouldn’t let us do it as an outpatient. Now you can’t do it as an inpatient, correct. I mean, it’s like the world changes.
Speaker 1 (26:51):
So when did you start the laparoscopic hernia repair and why did you feel that hernias should be dabbled with laparoscopically it? Did you feel like you were improving open surgery or it was just another way to perform laparoscopic surgery?
Speaker 2 (27:10):
No, I thought there was two things. Well, number one, laparoscopy came about in late 89-90. And I was very lucky to be one of the people just by accident, who got to be the, to do it very, very early. And then actually, someone said to me that there was a guy in Minnesota who was doing, trying to do laparoscopic hernia repair. And my first response was, why the heck would he want to do that? And then I started thinking about it, and that was Leonard Schultz. And I said, yeah, there’s a 10% recurrence rate from open hernia repair. At that time, there was a lot of pain from open hernia repair, and people used to take off anywhere from two to six weeks from work after an open hernia repair. So I said that basically if we knew that laparoscopy got people out of the hospital from gallbladder the next day or the same day, we knew that they could go back to do whatever they wanted because incisions were so small, and I knew that they posterior repair that Nyhus had taught us with Mesh was not bulletproof, but it was pretty damn close to it.
Speaker 2 (28:30):
The recurrence rate was much lower than even for recurring than the anterior repair without Mesh. And so based on those ideas, I was kind of crazy enough because I was a surgical oncologist at the time, I was a cancer surgeon, and I was crazy enough to say, I think I could do this. And so we basically got patients who it explained to them what we were going to do, that we were going to replicate the same repair that I would do posteriorly open. And we did it. And we did actually, we did first a hundred consecutive patients as an outpatient and then presented that data in Belgium. The first time I presented it was actually in Belgium. Two weeks later, I presented it at the American Colleges Surgeons, and I got the usual response from the audience that the Lichtenstein got is basically they said, I was out of my mind.
Speaker 2 (29:35):
Despite that, I had very good data that in the first a hundred patients at one year, we had no recurrences, no failures, no complications. Everybody had gone home and everybody had done fine. Despite that. They didn’t believe me until I went on to present another 500 consecutive patients and Oh wow. Long term data and so on, which is fine. I mean, people shouldn’t jump on things right away. But once you have the data, people slowly, slowly came on board. The unfortunate thing for me, and is that because laparoscopic hernia repair is a very difficult operation, it takes a lot of skill, as you know. Yeah. It’s taken 30 years for the growth of it. Initially it was representing about 12 to 15% of hernia repair because many people found it much too difficult to do, and so they didn’t want to do it. Now as with robotics, that growth is taking off like crazy because it is so much easier to teach the same hernia repair to be done robotically. And there are multiple reasons for that, but that’s causing a tremendous growth now. And we’re seeing that probably it’s up to about 20 or 30% of hernia repair now.
Speaker 1 (30:55):
So one of the problems we have now is there’s so many different techniques, laparoscopic, robotic, open with Mesh without Mesh, that there’s a lot of holes in education for hernias as residents graduate, what are your thoughts about surgical education of hernias? Do you feel that it can be improved, should be mandated that they learn an open and a laparoscopic or robotic option? What about tissue repair? Do you think that we’re not teaching enough residents to learn how to do tissue repair even though it’s on the American Board of Surgery every single year for the examination?
Speaker 2 (31:37):
Yeah, it’s changed really dramatically. I think people are either doing, during residency, people are learning to do anterior repairs with Mesh and they’re learning to do laparoscopic repairs. And now if good centers are learning robotic repairs, the interesting thing is that my guesstimate is in another 10 years, there’ll be very, very few surgeons that know how to do a tissue repair. What I grew up on.
Speaker 1 (32:08):
Yeah,
Speaker 2 (32:09):
Because it’s just, it’s the reason, reason we got away from tissue repairs is be twofold. One, the recurrence rate was higher, was high, and two, the incidence of chronic pain following the hernia repair was high. Most studies have now shown that a posterior, especially laparoscopic or robotic repair, has a lower incidence of pain chronically. And the incident, the recurrence rate has the potential for being lower than an anterior repair because you see all the potential sites for hernia. That’s complicated. But that’s one of the reasons I think it’s a great repair is because patients will present with what for your audience, there are three sites in the groin that you can get a hernia, basically three what we call an indirect direct and femoral.
Speaker 2 (33:11):
And when you do an anterior repair, you miss out in most cases of seeing the femoral space. And a study that I did and that Ben David did out of the Shouldice clinic, which is open, her repairs found the 10% of recurrences actually have a femoral component, which means that a lot of surgeons when they repair or do an excellent super repair from the front, are missing unless they make a special maneuver. That one in 10 chance that patient additionally has a femoral hernia. And when you do a laparoscopic or a posterior repair or robotic repair, you don’t miss that because, and that’s one of, to me, when I used to give my lectures at the college meeting, that’s one of the major advantages for the laparoscopic repair. You automatically wipe out that 10% of missed femoral hernias.
Speaker 1 (34:05):
And the international consensus, actually, because more women have femoral hernias than men, and therefore more women have problems after hernia repair, anterior hernia repairs than men because of the femoral hernia being missed. They feel that all women should get laparoscopic corn repair, which implies they should all get Mesh.
Speaker 2 (34:26):
Which is interesting because this is one of the points I was attacked on 20 years ago. They would say to me, why are you doing a laparoscopic repair on a woman? And I would try to explain that. And so if you live long enough, you see people can finally, even the whole European consensus has come around to what I wrote about 25 years ago. But I can tell you people said, no, no. Why would you bother? It’s would you put Mesh in a woman? I mean, you shouldn’t have the Mesh, which is false cause there’s no problems with it. But now the consensus panel, as you said, has come around to say that is one of the reasons you should do it in women.
Speaker 1 (35:11):
Yeah. So here’s the question which I got to ask a lot and I have my own opinions about it. So tissue repair, which is what you were trained in and was a standard when you were a resident. When was that? The sixties?
Speaker 2 (35:28):
Yeah. No, 7 71. I finished medical school in 71, so it was
Speaker 1 (35:34):
Oh, okay.
Speaker 2 (35:34):
70, 71 till eight, eight, almost eight years. Seven, eight years. Okay,
Speaker 1 (35:40):
Great. So based on that, there’s pain – So it’s not a pain-free operation. No. That’s why risk-free operation, there are nerves that can get entrapped many times You, were you cutting nerves on purpose back then?
Speaker 2 (35:56):
No, we didn’t though the Shouldice clinic did and said we were nerve sparing. But yeah, I mean the best study ever out is actually to me from Canada where they showed, they looked at because they really follow their patients because it’s a socialized system. And when they long-term follow up, 23% of patients who had open hernia repairs had some incidence of pain or chronic pain afterwards. Correct. And that was one of the driving forces to do it laparoscopically, because you’re avoiding, if you do it properly, you’re totally avoiding those anterior nerves. Yeah,
Speaker 1 (36:31):
The nerves for sure are avoided. So then you have, today, I believe we are overusing Mesh, but we have a large number of patients that have complications from Mesh. The Mesh can get infected, it can ball up, it can erode into structures and trap nerves cause testicular pain or erode into critical structures. It can be placed incorrectly and migrate. So there’s a lot of problems with Mesh.
Speaker 2 (37:04):
I have a big butt for you.
Speaker 1 (37:08):
I’d like to know your thoughts about how to reconcile those two issues.
Speaker 2 (37:13):
Yeah, I think there’s a misunderstanding. Yes, there are rare complications from Mesh, but if you take the incidence of causing or having a patient result with chronic pain in basically every study done, the incidence of chronic pain is higher from an anterior repair without Mesh than when you use Mesh.
Speaker 1 (37:42):
So it
Speaker 2 (37:42):
That’s correct. It, it’s like the person who’s afraid of flying, okay, they’re afraid they’re going to die in an airplane crash, but which is pretty dramatic.
Speaker 1 (37:55):
But
Speaker 2 (37:55):
The chances of them having that problem, it’s greater driving to the airport. So the driving to the airport. Airport, that’s true. The driving to the airport is really the open without Mesh repair.
Speaker 1 (38:07):
Yes.
Speaker 2 (38:08):
And so yes, you can have I ever seen Mesh erosion in an inguinal hernia repair Of all the cases, I’ve done something like 10,000 inguinal hernia now, and all of those repairs, one case of mine, some 10 or 15 years later developed Mesh eroding into the bladder. But it turns out that was from an attack of diverticulitis, which infected the groin and so on and so forth.
Speaker 2 (38:39):
So it’s a really rare, yes, if you bring in the lawyers, they love to find all these cases, but if you really look at the numbers, the incidents of any of those things happening, which you have to tell a patient they can happen, is much lower. Myself, as you know, because I presented it in slides at a meeting, have had both of my failed open hernia repairs, which were done 40 years ago and 30 years ago, repaired laparoscopically and have meshed in both of my groins. I know of every complication that can happen for Mesh, but there is no way in the world I would’ve had those hernia repairs done to myself without the Mesh. And I think that speaks, speaks for itself. Yes, there are risks of Mesh, but those risks are much when you take, all patients are much less than without the Mesh,
Speaker 1 (39:41):
Which were, what kind of repairs did you have? The tissue repairs? What
Speaker 2 (39:45):
I whatev whatev one was just a straightforward, I think Nyhus one probably did a McVay and my ex-partner also probably did something similar to the McVay. They were just anterior repairs and they lasted, I mean, the one was done, the funny story about my first hernia repair is Dr. Nyhus, who was the chief of surgery and whose book is, I can’t point to it on my computer here, but right behind me, it’s hernia book. He was scheduled to do my hernia repair and he had a habit of he wore glasses when he did hernia repairs. And so he kept dropping his glasses off his head for the few weeks before my hernia repair. So I went out and bought him a pair of those after, what do you call ’em? Strap around the back to hooked on his glasses so he wouldn’t drop his glasses into my hernia. So I had my hernia repaired and I was a resident the first year resident at the time I was on ped surgery and he did my hernia as an inpatient.
Speaker 2 (40:55):
I stayed overnight and in a gown. I made rounds on my patients because you know how residents are treated. Yes. We can’t not make rounds off. I wait. I made rounds on my patients and after my earn repair the next day, and then he discharged me. But that earn pair lasted and it lasted a long 30 plus years. So he passed away and my hernia repair outlived him. But my other hernia repaired by my partner and was done as a tissue repair. And it lasted about oh 15 or 20 15, 20 years, and then it wore out. So I had laparoscopic repairs.
Speaker 1 (41:35):
I think the issue we’re dealing with today is there aren’t that many tissue repairs being done. And so we really don’t have thousands of patients with complications because the number of hernias done by tissue is very low to begin with. But you have a million hernia repairs done mostly with Mesh in the United States and elsewhere. And a small percentage of that, even 1% of that is what, 10,000 patients.
Speaker 2 (42:05):
So
Speaker 1 (42:05):
It’s a very large number of people though. The instance is rare. Plus you have the lawsuit for the legal world, which kind of has been taking advantage of these patients that are having complications. So we’re not talking about complications of non Mesh repair. Everyone is there to blame the Mesh. It has blamed, but not to the extent that we are focusing on, people are out there saying that this should have been done by tissue or it’s a superior repair. It’s just not,
Speaker 2 (42:39):
No,
Speaker 1 (42:40):
There are complications though with any operation and you just can’t blame the Mesh when you do a tissue repair.
Speaker 2 (42:46):
Yeah, no. If I, there’s more than that. It, I mean if we went back to tissue repair and everybody, then we would be, the incidents of patients with problems would be higher. The incidents of failure would be higher, but also lawyers would go broke because the reason lawyers love Mesh is because there’s a company that makes the Mesh, they don’t get much money. In fact, they usually drop if they sue somebody. They don’t care about the surgeon, they care about the company, the deep, deep pocket. And so that’s what makes lawyers advertise so much about something.
Speaker 2 (43:35):
The incidence is very low of problems, less than probably 1%, 2% of any problem. But you’ve got a group of people who are going after those patients because they then want to turn around and sue the companies and make the Mesh because the rewards can be very high. And so you have a tremendous bias. If we were all doing tissue repairs, there would be more complications, but there wouldn’t be less lawsuits because there would be nobody for the lawyers to sue other than the doctors. And that’s not worth it for them. They want to sue the companies.
Speaker 1 (44:16):
I think that’s why it’s so important to have you on, because you’ve seen how things have changed. You’ve experienced patients and their outcomes with tissue repair, with laparoscopy, with Mesh, with open, with Mesh, with robotic surgery, and now with the robotic surgery without Mesh. There’s like a lot of different right options. And I’d love for you to read my paper, which got published last year called hashtag Mesh. We looked at the social media where ramifications of discussions on Mesh, and we found, interestingly, it wasn’t even what we were looking for, but we noticed that at the top five accounts on both Twitter, sorry, top five accounts on Twitter, we looked at Twitter and Facebook. Four of those five were class action lawsuit law firms that were promoting so much negative sentiment actively within the PA population. You would like to think it’s an organic problem where it’s a patient-based uprising. It’s really not. If you look at the data, it’s so much more than that. It’s being promoted and fed by these law firms. And you can see it with our paper that we published on their Twitter activity. It’s very, very subtle, but it’s there. But let me, we have a couple questions with regard to all this. One is what are your thoughts about surgeons following up on their patients to see how they’re doing?
Speaker 2 (46:00):
Yeah, I have a big problem with what’s happening now. I am someone who thinks it’s very important to follow up on patients even for all diseases, but even especially hernia. And I think that you need to come back for an office visit. I know there’s a trend to do telemedicine now, and one of my friends, Greenberg from Wisconsin wrote a nice paper on how they were very accurate and not having the patients and just come back would just do phone call interviews. I’m old school. I want the patient. When I was running my practice, I wanted the patients to come back in a week, six weeks, six months year and try to get them back. Well, ’em want to come back but come back yearly because I think it’s important to actually examine the patient and see what’s going on. Don’t though the data is there now that these teleconference calls and telemedicine calls are a good way to do it. I’m kind of old school as they say, I like to put my hands on the patient in one way or the other, either on their shoulder or in their groin.
Speaker 1 (47:17):
Well,
Speaker 2 (47:19):
I think visits are important.
Speaker 1 (47:21):
Dr. Ben Poulose was a guest a few months ago in the ACH. AHSQC is the national database focusing on hernia, on hernias. If any patient is having hernia surgery, I highly recommend that you double check to see if your surgeon puts your data into this national database so that you will be followed for your lifetime with regard to your hernia repair. And if they don’t, please tell your surgeon to do so. And that’s super important because the surgeon and the patient are both responsible to kind of follow up to make sure that their patients are doing well. And the ACH AHSQC is a great, great,
Speaker 2 (48:00):
And I think I would say to this, the patient is, if you’re having a problem after your hernia repair, go back to your original surgeon. If you don’t like their answer, then see someone else afterwards. But that original surgeon should be aware that there is a problem. Yes, they should also be aware if you’re doing well, but it’s important for them as well as for you for that surgeon. The surgeon should know what’s going on and know what their results are. There’s
Speaker 1 (48:28):
Also some misinformation that surgeons are profiting by putting Mesh in. Can you help clarify that? We are not getting paid anymore or any less?
Speaker 2 (48:37):
Yeah, my
Speaker 1 (48:39):
Technique,
Speaker 2 (48:39):
You’re on Facebook with me and I posted the, about a year or two ago that my electric was, it was a plumber, wasn’t like just a plumber came out to fix a pipe eye cut and he got twice as much money for an hour’s worth of work on my pipe that I get for a inguinal hernia repair. Yeah, inguinal hernia repairs. No, no. Surgeons making a killing on inguinal hernia repairs. They’re not profiting from what approach. In fact, right now, surgeons actually get paid less if they do it laparoscopically. Yes. Than if they do it open. Yes. And the the justification, the crazy justification for that by the insurance companies was, oh, they do so well, you don’t have to keep ’em around so much when you do it laparoscopically. They don’t have to stay in the hospital. They basically don’t need as many appointments and so on.
Speaker 2 (49:31):
So you should get paid less. So you actually, a lot of surgeons who I tried to teach laparoscopic repair would say, well, why do I do that? I get a hundred dollars less if I do it laparoscopically. I only get $300 instead of $400 for everything. So I wish, if someone wants to pay me money to do something some way, be great. But nobody, no Mesh company’s giving me money. The only person who, person who got rich, well, not the only, but major person who got rich off of hernia repair was somebody named Rudcow with a plug and patch repair because he had a patent on the plug. And every time some surgeon in the United States put in a plug, he would get $3. Wow. Yeah. That added up. There’s another surgeon I won’t mention because he is much more, I respect him highly, who I never to this day, he actually had, has the patent on Mesh placed anteriorly, and that’s why he has a done very well. But it’s not just him, it’s worldwide. So no surgeon individually gets paid for putting in a Mesh. If they invent something, they may have a patent and may in fact anything else, get money for it. But we sure don’t.
Speaker 1 (50:51):
Yeah. In fact, in the United States, all that’s highly regulated, not so much in Europe and certainly less so in kind of third world, second and third world countries. But we are highly regulated as to how we get paid. Our relationship with industry, where the money goes. It’s a nice story to say, oh, you’re just doing it to profit. But it’s like you said, we are, the AMA determines what we call RVUs, which are relative value units for work. And they determine lower RVUs for laparoscopic surgery than for open and using Mesh or no, Mesh doesn’t pay you any differently for inguinal hernias.
Speaker 2 (51:35):
The only place in me, what’s interesting is in Mexico, a lot of the private practice surgeons have to buy all their own stuff. And so they are actually getting money because they are selling, they sell you the Mesh or they sell you some, it’s the staple. They, they’re they’re involved. The United States, as you just said. Yeah. Not United States. It doesn’t work that way.
Speaker 1 (51:58):
So it comes down to experience hands of the surgeon. You agree with that? The technique and the surgeon that can give you the best outcome. Not necessarily Mesh, no Mesh LOP open.
Speaker 2 (52:10):
And that’s what I said in the beginning. The three factors are the repair that’s improving is good. The surgeon who knows how to do that, and finally doing the appropriate operation in the appropriate patient. And as we always say, we measure weigh risk, risk versus benefit. So if I have someone where the risk is greater than the benefit, even though I think it has a lot of benefit, I’m not going to do it. You know, very importantly, judge that risk benefit ratio for each patient and then a patient has to understand that.
Speaker 1 (52:49):
What are your thoughts on fixation? Well, how were you fixating when you first started your laparoscopic inguinal hernias and what are your thoughts on glue, tack, sutures? Nothing.
Speaker 2 (53:01):
Well, we’ve come full circle. When I first started doing laparoscopic repair, there was no fixation. So I actually, believe it or not, would suture the Mesh in place. And we didn’t have needle holders or anything else. We didn’t, wow. It was very difficult. It was time consuming. Then we went to fixation with tacks. And then from tack fixation, I became a big proponent in 95% of my inguinal hernia repairs. I don’t fix the Mesh at all because the body fixes it in place. So I don’t need think you need any fixation at all. Yes, if you’re going to use fixation, you just have to do it properly. There’s nothing wrong with using tacks. There’s nothing wrong with suturing in place. And there’s nothing wrong with using glue if you can get it, that’s, that’s FDA approved and each one has its place. And I’m one who believe is a bit proponent of, for most hernias, no fixation because you eliminate one of the causes of potential injury to nerves. But that’s a individual thing if I would not argue with someone who wants to fix it, as long as they know what they’re doing and where to put the fixation.
Speaker 1 (54:19):
This is fantastic. So tell me a fun story about something dramatic that happened on stage. Controversial.
Speaker 2 (54:34):
The famous hear
Speaker 1 (54:34):
The, I want to hear.
Speaker 2 (54:36):
Well, there is a famous story that Jorge Diaz, who’s a famous hernia surgeon now, loves to tell about me because this was about the third year of doing hernias at the American College of Surgeons. And I was up there as what we call the sacrificial lamb. And I was presenting laparoscopic hernia repair. And people from the audience were basically, if they had tomatoes, they would’ve thrown them at me. And so I’m from Chicago and brought up in an area where the mafia was very prevalent. So I’m just one of those kind of guys. So I happened to have a baseball hat, and this is with a suit and tie all dressed up looking really great for the college. I got so upset that I went down in my suit, my briefcase, and I had a baseball hat in there that I had bought for some reason, I don’t know, I put it on backwards and I stood up and I basically said, okay, you guys, this is how and why we do laparoscopic hernia repair. And it went over, some people were laughing, some of the old time professors weren’t laughing that I would do such a thing at a big prestigious meeting, very
Speaker 1 (55:51):
Formal meeting.
Speaker 2 (55:52):
But it, it’s, what I love about that story is that Jorge Diaz, who you should have on sometime Yes. From Columbia, was in the audience and he was thinking about doing laparoscopic hernia repair. And because of that episode of me taking on the world, putting a baseball hat on backwards at a prestigious meeting, he went back to Columbia and set up a hernia clinic. And the rest for him is history. How he started doing laparoscopic hernia repairs. So that was a fun story. There were other things that went on in the world. Laparoscopy, laparoscopy’s been, I used to say, if I’m a big proponent or fan of FA Saturday Night Live, as you know. Yes. And there used to be a guy who talked about baseball. Yes. And he used to say, baseball been very, very good to me. And that’s what I used to say about hernia repair because it’s been very, very good to me. Not so much financially because we don’t get rich, but it, it’s given me the opportunity to travel the world, to teach others what I believe in, to have fun with others and to benefit a lot of patients. So to this day, I’m, I’m going to turn 76 this year, but hernia repair has been very, very good to me.
Speaker 1 (57:10):
And it was not as popular back then. You and many others who have been the pioneers have been really instrumental in making hernias fun and innovative. And every year I have residents that are interested in hernias. And that certainly was not the case when I was a resident. No. So I love that fact about it.
Speaker 2 (57:31):
Yeah. When Dr. Nyhus said that I would be doing something like hernias someday. Yeah. I felt like saying, you’re, you’re local, sir. And then it turned out he was right. He made predictions. He’s up there looking down and going, see. Yes, I told you so.
Speaker 1 (57:48):
Yes. Love it. All right. On that note, we will end our hernia talk live. Our Q&A with Dr. Felix was very fun. I’m sure he is got more stories to share with us. I’ll have to eek it out of him. Thank you for everyone for joining us. This is Dr. Towfigh. Thank you for coming every week. We have another lovely guest panelist next week. I will make sure that the YouTube link to this episode is posted on all my social media outlets. And until then, thank you Dr. Felix. I hope you have a great evening and say hi to your lovely wife for me, and hope to see you soon.
Speaker 2 (58:26):
Thank you. My pleasure. Fun.
Speaker 1 (58:28):
Thank you, ed. Bye-bye. Bye-bye.
