Episode 47: All Things Hernia | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

Hi everyone. Welcome to Hernia Talk Tuesdays. My name is Dr. Shaman Towfigh. Thank you for those that are joining me on Zoom and also those that are on the Facebook live at Dr. Towfigh. Today we will be discussing anything and everything you want to learn about hernias. Basically, I’m all yours today. Every so often I like to kind of take the opportunity to answer all your questions because I know that you have so many and I have a lot of guests that come on. I like to share with you the people that I feel are super intelligent and really good at what they do, whether it’s due to hernias, what they talk about, hernias, or if it’s kind of hernia related. So thank you for all of you who joined me for that part. But in addition, addition, I know you have a lot of questions on just like hernia complications and hernias in general and every so often I’ll just take the time to be the one that answers all of your questions and hopefully we can get those out and I know you’ve been itching for it because I really haven’t done my own since the beginning of the year, the new year, and we have tons of questions.

Speaker 1 (00:01:19):

So the plan is for me to just kind of do as many of your questions ASAP as possible. I will run through them because we typically run out of room, run out of time for your questions. If I’m going too fast, let me know, but I hate it when people come on and they have so many questions and they don’t all get answered. So let’s get started.

Speaker 1 (00:01:49):

Just as a reminder, this will be posted on YouTube and those of you that are online, Facebook Live or Zoom, please type in your questions. I will try and get to as many as possible, but there were tons that were submitted online and I have those pre-prepared to answer and some of you’re already logged in about that. So let’s get started. Okay, question number one. Can you get an umbilical hernia from a cesarean section? Many of you know a cesarean section by this other term, a c section. So C-section is basically a low transverse incision in the abdomen used for birth. The incision at the fascia level, which is what we hernia surgeons are interested in is usually left to right, but for really, really big hernia babies or maybe some of the older techniques, they go up and down. So technically when you’re having a cesarean section, the decision either left or right or up and down at the fascia level and those areas also theoretically are at risk, at risk for hernia, but for whatever reason it might be your hormones and the fact that you’re already so loose. We don’t see a lot of hernias from cesarean suctions and no, an umbilical hernia is almost never a side effect or a risk from a cesarean c-section. A pregnancy can be pregnancy can cause C-section, pregnancy can cause umbilical hernias to be more prominent, but a cesarean section, no. So the short answer for that one is no. Next question, can an umbilical hernia give you a sharp pain from the belly button down to the vagina? While let’s review some symptoms from umbilical hernias. Most people have no symptoms.

Speaker 1 (00:03:47):

If they do, it’s usually localized pain at the belly button. Some people have pain to the left or right of the belly button. So if you have pain just the left or just to the right of the belly button and you have an umbilical hernia or belly button hernia, then yes, that could be from the belly button hernia, it can give back pain and it usually wraps around to the back, but rarely it can, but rarely it can shoot down into your vagina. I’ve seen a handful of patients, maybe two or three in my lifetime so far about this. So it’s possible that your umbilical hernia is giving you sharp pain from the belly button down to the vagina. Not always, not typical. And then in terms of other causes, you can have rare causes that are causing pain from your belly button down to the bladder for example, or vagina. That can be, for example, due to urachal cyst, that’s a urologic problem. Or if you’ve had C-sections before, you can have scar tissue from your C-section and your uterus to the C-section. Sometimes that can be painful.

Speaker 1 (00:04:57):

Next question, when I push in my umbilical hernia, it hurts all the way to my back. Why is that? I don’t know why that is, but that does sometimes happen. As you may know, the belly button is in right in front of your spine, so pushing on the belly button if you’re thin or if you don’t have that much tissue, maybe that you’re actually pushing further back than you think because people have a curve to their spine and that curve is kind of maximal around the belly button, so it’s possible that you’re having symptoms from that. Why? I don’t know. Can a hernia be repaired at the same time as a panniculectomy? This is important question because we also need to make sure we get the terms right. One time I was asked, can a hernia be removed at the same time as a panniculectomy?

Speaker 1 (00:05:51):

Let’s just be clear, you cannot remove hernias hernia is a hole, so I can’t remove a hole. If I have a hole here, I can’t remove it, I can remove my finger. It’s a thing object, but the hole you cannot remove, you can patch it, you can close it, you can repair it, you can operate on it, but no. So no, you cannot remove any hernia. You can repair it. Now, can a panniculectomy repair a hernia at the same time? Okay, so panniculectomy is a removal of the panis and the panis is extra loose skin usually in the lower abdomen and that is pretty much part of a tummy tuck, but it’s not the entire tummy tuck. A tummy tuck is two operations in one. It is removal of the excess skin of a lower abdomen, plus at the muscle level, the fascia level, they start sewing in the loose muscles or the diastasis to close that up.

Speaker 1 (00:06:45):

So if you plan to undergo either a panniculectomy or a full tummy type, which is usually what surgeons do, and you have an umbilical hernia, yes, it can be done at the same time. In fact, it is routine to repair an umbilical hernia at the same time as a tummy tuck to not address. That is kind of kind of weird on Facebook live. We have some questions too. I have imagine it has been hurting since the operation femoral hernia big and I am thin. What’s next if you were my doc? Okay, so it sounds like you had a femoral hernia repair with Mesh, which is the standard. It is appropriate repair. Femoral hernias are very difficult to repair with tissue. It can be done, the recurrence rate is high in the chronic pain rate is high and therefore a Mesh based repair is considered standard for femoral femoral hernia repair.

Speaker 1 (00:07:44):

So I guess the hernia was big and you were thin. So what’s next? If you have pain because you have a hernia recurrence, do you need another hernia repair? If you have pain because you have suture type or Mesh type pain, then that can be addressed. You can redo the repair, you can use a different type of Mesh. We use a term Mesh very broadly and many people, including people that follow me, have this feeling that all Mesh are bad. That’s not true. There’s a wide variety of Mesh. There’s synthetic Mesh, biologic Mesh, there’s absorbable Mesh and non-absorbable Mesh. There’s synthetic absorbables and biologic absorbables. There’s hybrid Mesh, which is a combination of synthetic and biologic. So every single Mesh has its own shape, size, weight, density, inflammatory, potential, absorbability thickness stiffness, and not everyone responds poorly to Mesh. In fact, most people do not fortunately.

Speaker 1 (00:08:50):

So if you have pain, first you have to figure out why the pain is. It’s usually because you have a hernia recurrence or the repair is done in a way that for some reason the Mesh is folded or interacting with surrounding structures. So number one is to figure out why you have the pain and what I do if you come to see me is I demand to have all your preoperative, sorry, prior medical records, so that includes your operative report because I want to know what do they see, what do they do? What suture do they use, what size Mesh, what was the technique? All of those are factored into why you may have pain. And then I also need imaging to look to see what does the Mesh look like? What does the hernia look like? Is there inflammation, is there infection? Is there a fluid collection?

Speaker 1 (00:09:37):

All of these are potential causes for pain or complications after a hernia repair. So there’s no one answer, there’s no one correct method to address these. It needs to be tailored to your needs and looking at reviewing your old opera report and imaging is very important. Prior doing any revisional surgery, those of you that follow me know that 80% of what I do is revisional. And so there’s a huge amount of work that is done in the back end to figure out what’s been done so far, learn from what what’s been done to you and then use that information to come up with a plan.

Speaker 1 (00:10:17):

Okay, next question is on Zoom. What are the best types of binders in the lower sign of flag? Great question. Okay, well I’m doing a lot of research on binders. I will do a video for you showing you the binders that I think are very good. I’ve done a lot of research on them. I bought tons and I’ve worn them myself. I’ve given it to my patients. So I think the binders that for the flank and for the lower abdomen are tricky. For the lower abdomen, you need to have the binder go over your hip. So if you have really wide hips in a narrow, relatively narrow waist, that’s a difficult one to find. And then if you have hernias in the upper abdomen and you have breasts, then that’s also a difficult area to bind and and not interact with your breasts. Plus you want to be able to sit and get up and so on.

Speaker 1 (00:11:17):

So I believe Caromed has a really good binder, C A R O M E D. I’ll do a post on this later so you can see what it is. Also there are some softer ones, depends on your weight, where the hernia is and what you’re trying to get out of it. If you want maximal compression but it’s still soft, you need to get the pyramid three panel or multi-panel, but it’s three panels, 12 inch binder. If you want something that’s just kind of limited, you can use the softer binders and there are multiple companies that make that You don’t want the thick ones. The ProCare brand tends to be thicker. We use ’em in the hospital often and you don’t want anything that can rub on your skin or be too tight. There’s another company mom bod Fit Mom, BOD Fitness that sells these fit. What’s it called fit?

Speaker 1 (00:12:15):

It’s through mom BOD Fitness. It basically is, it’s neoprene so it makes you really hot, but it has a good soft stretch to it. So for people with diastasis or a small hernia, that’s also a good one. I’ll do a video post for you guys on that one. Okay, another question. Will a CT catch a femoral hernia on the right with a previous right al hernia pair with Mesh done in 2014? I’m still in pain. Also is a vaginal canal hernia seen on CT scan or an internal pelvic ultrasound? Okay. Internal pelvic ultrasound does not help any hernias. That is a GYN ultrasound. It can show your bladder, your uterus, your ovaries did not show any hernias, so pelvic ultrasounds will not be helpful. You need an actual hernia ultrasound if you have had prior surgery. Most of the time hernia ultrasounds are also not helpful because the Mesh gets in the way from a lot of the visualization from the Doppler ultrasound and only really highly skilled technologists can identify hernias through Mesh.

Speaker 1 (00:13:23):

So I don’t like using ultrasound. CT scan is a very commonly used imaging. It is not good for hernias that are hard to detect. If you have a big honking hernia, it’ll show it, but if you have a small one or if there’s Mesh nearby, everything looks the same shade of gray and it doesn’t give you the details that you need. So if you had prior surgery, I do not get CT scan for the groin hernias. MRI is preferred. MRI will distinctly show small hernias, fat bowel but also Mesh and it’ll tell you where the Mesh is relative to the hernias and it’ll show you the and give you the most information. The problem with MRIs are it’s long, long procedure. You have to sit there for 45 minutes or lay there for 45 minutes. Also, most surgeons are not comfortable reading MRIs. We’re very comfortable with a CT scan.

Speaker 1 (00:14:18):

I’ve learned to read MRIs to uncomfortable with it and then you have to then work with a radiologist who is comfortable reading hernias. So you have a surgeon that can’t read MRIs and an MRI radiologist that can’t really read hernias. So the two together will help. So if you have a surgeon that will sit down with the radiologist and review it, I almost never believe the reports alone. I always look at it myself because we’ve actually published on this up to three out of four imaging reports will be falsely reporting no hernias. So that’s for these smaller hernias and that’s a lot of what I see. So I hope that helps answer that question. So no CT scan may or may not catch a femoral hernia after prior al hernia repair and definitely a internal pelvic ultrasound will not help with any hernia diagnosis. Okay, next question. With umbilical suture repair, does the tissue eventually grow back together or is only the sutures that hold it together long term?

Speaker 1 (00:15:34):

Well, superb question. We don’t know the exact answer to that. We do know in a normal tissue we use absorbable sutures. So with normal tissue when we suture together the muscles or the fascia, then that will kind of meld together and you don’t need permanent suture for that. For a hernia that is not normal tissue, it is all proven to be lowering collagen, less likely to heal like a normal patient. And so we tend to use permanent suture or very long lasting suture. We don’t know what’s superior among hernias. I tend to use permanent suture, but it depends on the patient. Maybe if the patient reacts to permanent suture or is at risk, I would not use permanent suture. But in general, the tendency and the standard is to use permanent suture for most hernia repairs because we feel that it is not adequate to allow the tissue to heal on its own. I hope that, where do I work? Beverly Hills Hernia Center. Come on guys. This is a Beverly Hills hernia center. I work in Beverly Hills. I have my own hernia center. I’m in California la, Los Angeles County. I also work at a Cedar Sinai Medical Center, which is a fantastic top-rated, very large hospital and that’s where I work.

Speaker 1 (00:17:12):

I thought you guys were doing that right now, but thank you for asking. Would you ever use a binder immediately following surgery, day of or after? Absolutely. Most of my patients who have any abdominal surgery for hernias that are not super small get binders, almost everyone gets a binder. The purpose of the binder is twofold. One is it helps cinch everything and hold everything in, prevents things from jiggling, takes pressure off the repair, helps with pain control, helps reduce swelling in the area and may even help with the healing to take some tension off of the sutures and repairs. And a lot of patients feel very comfortable with the binder. So yes, I’m a big advocate for binders. There’s no good scientific study saying you must use binders for hernia repairs. Most of us who do hernia repairs though use a binder.

Speaker 1 (00:18:07):

Okay. What is the longest duration absorbable suture on the market and when should it be used? Yeah, so far what we have that’s commercially available that absorbs, it absorbs out to about eight or nine months and so we don’t really have anything that absorbs let’s say a two years. Well, I take that back. Silk is technically absorbable, but it basically acts like a permanent and it’s highly inflammatory, so I never use it, so I don’t really consider that an option. But the monofilament sutures like PolyOne or PDs, they lose our strength around six months and they stick around in eight or nine months. So that’s really what we have that’s available. That’s long term absorbable or what we call slowly absorbable as opposed to the rapidly absorbable. They’re absorb in three days to three weeks.

Speaker 1 (00:19:07):

Okay. Question. I have a hernia specialist that said that it was unlikely my hernia occurred from lifting a huge amount of boxes in a small amount of time. What are your thoughts? I agree lifting anything does not cause hernias. You probably had a hernia or have a tendency towards a hernia. If you did any activity that was a rapid movement and increased your abdominal pressure very rapidly, that can be a risk factor for hernia. But a normal patient with normal genes and normal collagen should not get a hernia. So if you did get a hernia from doing a rapid movement that caused increased abdominal pressure, usually lifting boxes does not cause that, but if you do it incorrectly and you’re hurting your back, you’re maybe hurting your front as well. In that case, you could be causing a hernia that was already prone to becoming a hernia or getting a hernia. I agree. Can a binder cause pain? No. Binders should not be causing pain unless you’re wearing them incorrectly. They should not be, for example, digging into your skin. They shouldn’t be too tight. You should not be wearing a binder over a hernia that’s not reducible unless you’re just using it for underlying support, but you don’t want to like squish a hernia. Usually her binders are play used for people that have had surgery as a support. It’s often not helpful for people that have a hernia to begin with.

Speaker 1 (00:20:54):

Okay, the binder’s not S sterile. How do you protect the suture line from infection? Well, the suture line is no longer sterile either. The skin is not sterile, the skin has tons of bacteria on it. The binder also probably has bacteria on it. Right now I have tons of bacteria on my, no matter how much antibacterial soap I use, I will have bacteria on my skin. So the internal organs are sterile. The wound should be sterile or have minimal bacteria, but the suture line itself is your skin is not sterile and therefore putting anything on it including soap and water, your clothing or binder is perfectly safe.

Speaker 1 (00:21:39):

Hi, Jonathan Martinez says Hi. Okay, having after having a squirrel hernia surgery, my friend lost sensitivity around the angle area. Is this normal? Yes. After? Yeah, any incision anywhere in your body involves cutting through skin. There are nerves on your skin. So if I touch my face here, I feel myself, but if I have a scar, I will be cutting through those same nerves that are currently giving me sensation. That numbness usually goes away over time because you’re only cutting through like a sliver of skin and all the nerves that kind of go and you cut through it, those nerves will regrow or you won’t really feel numbness in the area over time. But yes, it’s absolutely normal to be numb wherever your surgical incision is.

Speaker 1 (00:22:38):

Next question. I’m a 67 year old male with asymptomatic inguinal hernia. It was repaired six months ago with Mesh. I still have tenderness and soreness at the groin, base of my penis and my testicle, my interstitial cystitis has become worse. What do I do? Okay, some comments about this pressure. First of all, just know that if anyone is asymptomatic from their inguinal hernia, not femoral but inguinal hernia, that what we call watchful waiting, which is let’s just not operate and see what happens is perfectly safe. It is considered a safe option, but a quarter of people choose not to do it because they’re tired of having the bulging for example. But not operating on anal hernia is considered safe if you have no symptoms or you barely having symptoms because you almost never end up in the emergency room. One study showed a 0.18% per year risk of ending up in emergency room with an incarcerated hernia.

Speaker 1 (00:23:47):

That’s nothing. It’s a fraction of a fraction of a fraction 1%. So if you choose not to have surgery and you barely have any symptoms of your Inguinal hernia, that’s considered completely same. Second part is now that you’ve had the hernia, this is one reason why I don’t push hernia repair on most patients that don’t have symptoms is this gentleman now has symptom symptoms. He was doing perfectly fine before surgery and now he’s got tenderness soreness at the groin, pain base of the penis and his right testicle. So that is something that needs to worked up after about three months. If you have persistent symptoms, something needs to be done about it. We need imaging, we need nerve blocks, we need good examination. So the groin base of penis or vital all have certain nerves that cause sensation in the area and if you have any nerve injury or inflammation to the nerve, then those can be causing the pain.

Speaker 1 (00:24:52):

So the base of penis, the nerve there may be the ilio inguinal nerve. The testicular pain or the scrotal pain may be a genital nerve injury or inflammation or neuroma or whatever the situation is. And this patient also has interstitial cystitis, which is an inflammatory disorder and in my practice if you have interstitial cystitis, I tend not to use Mesh or if you absolutely need Mesh, it would be like a low inflammatory Mesh so that you basically have the lowest risk of causing more inflammation. So having interstitial cystitis, assuming it’s it’s been correctly diagnosed, may put you at higher risk for Mesh related pain. So the next question is could this be a nerve problem? Absolutely. The next step would be to get imaging to make sure the measure’s in good position and you don’t have complication from that. And then after the imaging, if you were to see me, I would do a nerve block in the office of the ileal nerve first and then the general femoral nerve and see how much of your symptoms go away with the nerve block. If a hundred percent of your symptoms go away, then you have a purely a nerve problem. It’s not a Mesh problem and that can be addressed with multiple nerve blocks for example. So that’s what I recommend.

Speaker 1 (00:26:23):

Okay, next question. Is it true they come back, let’s see what we’re referring to. Binder, I’m not sure what you mean about if they come back. Hernias do recur at a variable rate depends on all your risk factors. So if you’re obese, chronically coughing, constipated, all of those are used nicotine in any sort, then yes, you’re at higher risk for a hernia recurring. If you have a large hernia that’s we’re lucky to recur or come back than a smaller hernia. So yeah, hernias can recur. Usually we want the recurrence to be for inguinal less than 1% and for ventral hernias less than 10%. So that’s usually the range just so you know. Okay, next question. I’m still in crazy pain four years postoperative. So far I’ve been talking to Dr. Jacobs, but he says that when he removes the Mesh, the hernias will come back.

Speaker 1 (00:27:33):

Well, if you only remove the Mesh and that’s often what you need. If it’s a Mesh related problem, then yes, high risk, the Mesh will come back not a hundred percent but a high risk. Then you have to kind of plan for what will happen if the hernia does come back. So the goal is not to get you perfect with a perfect hernia repair, it’s to get your quality of life better. If that involves Mesh removal and Dr. Jacobs is has been a one of my first guests on hernia talk, I think he’s a very talented and astute hernia surgeon and specialist, then that’s what you need and you’ll deal with the repercussions of that decision secondarily, but first get rid of the pain and then you can deal with how to address the hernia that may recur from Mesh removal.

Speaker 1 (00:28:33):

Okay, I had a nerve block only one. Do they do more than one injection? Absolutely depends on how many nerves are involved and how you respond to the nerve block. Let’s say only one nerve is involved and you get a nerve block and your pain goes from 10 to zero. Perfect. Two weeks later your pain is now eight, you need another bro nerve block. Second nerve block is done, takes your pain from eight to zero. Two weeks later it’s back up to six. So we’re slowly going from 10 to eight to six and then you get three or four pain nerve blocks or ablations or whatever the need is and we’re going to work ourselves down to zero. So yes, absolutely you can have more than one nerve block and you can have more than one nerve blocked. All right, I have a femoral hernia and my surgeon wants to put synecore Mesh in, but I can’t read the rest. Okay, I’m just saying I’m probably, maybe you me, you’re a nurse. Okay, so synecore is a hybrid Mesh.

Speaker 1 (00:29:43):

I’ve talked about a hybrid Mesh multiple times on this program. It is a combination of synthetic and biologic Mesh, so part of it will stay behind not as much as a typical synthetic Mesh and most of it will go away. I think it’s a very unique technology. I predict that hybrid meshes will be kind of our standard over time. Why do you need a hundred percent synthetic when you can only have 4% synthetic? So I don’t know the exact percentage of synthetic in synecore, but it’s significantly less than if you were to get a standard synthetic Mesh. And so it’s a very good option if for some reason you should not be getting synthetic Mesh purely or that you have an inflammatory disorder where you don’t want to add too much inflammatory synthetic Mesh at one time.

Speaker 1 (00:30:44):

Oh, she’s nervous putting anything in your body. Okay. I mean that’s a discussion you should have with your surgeon. There are, regardless of what surgeon you have, you’re going to have something in your body because you need sutures, you can’t glue things. Even glue would be putting something in your body. So if you have a surgeon that feels that your femoral pretty can be done by tissue repair, that’s an option. But just know very high recurrence rate, very high chronic pain rate and that’s why the standard is to use Mesh. So also know that with hybrid Mesh, theoretically your risk of recurrence is higher than synthetic parasynthetic Mesh, but we don’t know enough about them. So far the data’s pretty good supporting the use of hybrid Mesh.

Speaker 1 (00:31:34):

Thank you Jonathan Martinez. Okay, next question. Can the dorsal vagus nerve be damaged during an umbilical muscle repair? No, that’s a quick one. Next question. I had tissue repair of direct hernia. What would cause my left testicle to ascend during ejaculation? Usually it would be, so usually any lifting up or ascending of the testicle into the groin is a hernia recurrence. So if you have a hernia recurrence from a tissue repair or the hole that they made is too wide, which is basically like a hernia, then the testicle will be highly mobile and move up and that would be the reason. The other possibility is that you have some type of scar tissue of your cremasteric muscle associated with the hernia repair. Depending on the type of repair performed, they may or may not have done a pull up or what’s called a suturing of the Shouldice clinic.

Speaker 1 (00:32:44):

For example, they cut the cream hysteric muscle and the nerve and then they sew it back up to the pubic bone and that can have a tendency to kind of lift up the test a little bit higher than usual. Are your nerve blocks doubled ultrasound or anatomic guidance Ultrasound? Yeah, ultrasound guidance is key to make sure you direct your needle for the injection exactly where anatomically the nerve would be. I do have an ultrasound in the office that I use pretty liberally for that. For the ileal hypogastric nerve, it helps. And then for the general femoral nerve, I usually go deep down the retroperitoneal for the nerve block. It’s very close to the vessels and nerve that goes down to your leg. So I absolutely use the ultrasound to make sure that I inject where the nerve is and not like two millimeters over where the major vessels are. All right. So many questions guys. Oh my god, we’re never going to finish today, which is fine. That’s okay. I had a five level cryoablation teeth faculty, nine to middle effect. Yeah, that sounds like a lot of unnecessary cryoablation. Next,

Speaker 1 (00:34:12):

Can women lift heavy weights including barbells if they have a couple of small hernias? Yes. So in general exercise including weightlifting, sit-ups, deadlifts, overhead lifts, all of these have been looked at to see how much increase in abdominal pressure. Cause it’s very little, in fact a cough or straining to have a bowel movement or straining to urinate against a large prostate has much more abdominal pressure generated than any amount of weightlifting or barbells or even sit-ups. So we do feel that these types of exercises are considered safe and that you should be doing your normal activities including exercise, including at the gym, including weightlifting and sit-ups if you have a with no problems.

Speaker 1 (00:35:08):

I have sensitivity and more softer and tenderness with touch sensations on the left side of my abdomen in my muscles. Could this have been injured by steroid injections or stretching the skin when attempting to remove lipoma? The sensation continues even after removal of Mesh. How can I address the sensitivity and ongoing sore muscles? Okay, I don’t know your exact situation. Sounds like you had Mesh removal at a different area of body, but you thought maybe the Mesh was causing this hypersensitivity and tenderness to touch over your left abdomen. Yeah, that’s not a known or kind of accepted complication of Mesh reaction. If you have any area of your body that’s sensitive to touch, you can have ac depending on where it is. You can have abdominal cutaneous nerve entrapment syndrome. It’s called acnes, A C N E S. We can look that up. There’s different treatments for that.

Speaker 1 (00:36:13):

Usually it’s nerve blocks or neurectomy of these little A T P T nerves. That’s one cause of it. You can have a spinal disorder which is causing a little bit of nerve impingement causing the hypersensitivity or what we call allodynia. So touching an area that shouldn’t cause pain is causing pain, that’s usually nerve problem. Or you can just have a hypersensitivity in the area. You can have fibromyalgia. That’s another reason why some people have pain sites. There are treatments for fibromyalgia. There are fibromyalgia societies. I recommend that you look into and find specialists to help you get treated for that. So that’s basically my recommendation. Usually nerve blocks or injections the first time we go through could have been injured by steroid injections? No. Or stretching the skin. No, those would be two causes that do not result in that pain. Let’s see, why would you stop if it was your patient?

Speaker 1 (00:37:25):

Not sure what I would be stopping. Oh, what do you use in nerve blocks? So it depends on the need for the nerve block. I start with just simple lidocaine, which is a short acting local anesthetic. They may need a longer acting local anesthetic like bupivocaine. They may need steroids, they may need Botox. I mean it depends on the need, but usually it’s local anesthetic and then sometimes steroids to give them a longer, longer length of results. Why would you stop if it was your patient? I need to know what you mean by stop. Why would I stop what? If you can answer that and I’ll try and answer for you. Can someone with a diastasis recti still be a candidate for robotic or low laparoscopic surgery? Yeah, absolutely. Completely not related. Having a diastasis recti is a benign finding and it does not interfere with any future surgery you want.

Speaker 1 (00:38:25):

Okay, so pain. Why would you stop pain if it was your patient? I don’t understand the question. Maybe you can type in your full question. I don’t understand the question. Okay, moving along. Let’s see. Could injections cause thinner muscles? No. Injections do not cause thinner muscles, but steroid injections can cause fat necrosis. Fat necrosis is when the fat dies from the steroid injection. It’s very important you do not get steroids injected into the fat. It should be injected into the muscle or the nerves and not leaked into the fat. So you can get a dimple or a kind of a cosmetic deformity in the area of steroid injection and supporting the people that are doing your injections. Understand that nerve blocks. Why would you stop? Why would I stop nerve blocks? So after about three to five injections, usually the effect of the nerve block is considered not to be any longer effective.

Speaker 1 (00:39:30):

Effective and you would want to continue on with something else like a nerve ablation or neurectomy to help with your nerve pain, assuming the nerve block help in the short term, but clearly they’re not helping the long-term. The goal is to get you long-term pain control. So the reason to stop nerve blocks is because it’s providing you perhaps with short-term pain control, let’s say two weeks, but not long-term pain like three months or one year. Okay. I think I, I’m understanding these questions better. I’m sorry. So injecting into the fat causes deformity? Yeah, absolutely. It’s called fat necrosis. The fat dies and it’s not replaceable. The only way to replace it is to put in filler or replace it with more fat. It’s kind of a very difficult to handle unfortunate cosmetic deformity. Do not get fat injected into your fat. Do not get steroids injected into your fat. How do you distinguish discreet retain cord lipoma from a fatty spermatic cord on MRI, if not retain lipoma. Does a fatty cord from the Intraperitoneal visceral fat or is it localized to the cord? Great question. Okay. If you follow me on Facebook, Instagram, Twitter, I think that’s where I posted those. You would know. I recently posted an amazing case I did in a patient that had a huge spermatic cord lipoma but no hernia.

Speaker 1 (00:41:04):

Most people that have spermatic cord lipoma, it’s a misnomer. It’s not really a spermatic cord lipoma, it’s a hernia and as part of the hernia contents going through, which can be bowel, can be intraabdominal fat, it’s extra abdominal fat, which is retroperitoneal fat and that retroperitoneal fat follows a spermatic cord and goes down towards statistically eventually and when you do surgery, you push it all back through the hernia. This patient that I posted on, you’ll love the surgery is like totally fine, had no inguinal hernia and this enormous spermatic cord lipoma, so that is a true lipoma, which is like a fatty tumors benign. We removed it through the scrotum, not through the groin because it won’t go, there’s no hernia higher, you have to go down lower the scrotum. So on imaging you could see that. You could see the lipoma but no hernia, so it’s like normal muscle and then the spermatic cord goes down with no fat and then down here in the scrotum you get the fat. So that’s a spermatic cord lipoma. Now there’s normal fat that goes with a spermatic cord that usually is minimal. There’s no communication with the Intraperitoneal fat and it’s distinct from any cord lipoma. So hopefully that will help figure that out for you.

Speaker 1 (00:42:35):

Okay. Let’s see. More questions? Yeah, I’ve I’ve developed major GI issues following ventral hernia repair with chronic nausea being one of the worst symptoms. Is this a frequent side effect that arises from abdominal hernia repairs? No. It is not a frequent side effect, but any type of abdominal hernia can cause nausea. Any type of pelvic hernia or inguinal hernia can cause nausea that is known and then when you repair it, that nausea should go away. If you still have nausea, it’s either not related to the hernia or the hernia repair or you may have adhesions for example, and the heaters are giving you nausea. Those are things to consider the, if you have developed major GI issues after a ventral hernia repair, then if you were to see me, the first thing I would do would be to image you and that imaging will look to see where the hernia repair is and where the bowel is and how the two are interacting. Do I see a loop of bowel that’s stuck in one area? Are there adhesions and sometimes you just need the adhesions taken down from the surgical repair and then that will release the bowel so you have less chronic nausea. The other thing too to consider, especially if you have associated kind of bloating is something called SIBO, S I B O. It stands for small intestine bacterial over small intestinal bacterial overgrowth. What happens with any surgery is we tend to give you at least one dose of antibiotics.

Speaker 1 (00:44:26):

Those antibiotics are used to prevent you from having infection after surgery. What it also does sometimes is it treat, it kills off a bunch of bacteria in your gut system and the gut is very sensitive and has its own kind of ratio of bacteria that it likes. If you get a dose of antibiotics and that changes the ratio, but now you have let’s say more of one bacteria, not less of another, that can give you nausea, it can give you bloating, it can give you a combination of nausea and bloating. It may even cause changes in your bowel movements that you didn’t have before. There are tests on their breath tests. You breathe into bags and they test hydrogen in your system to see if you have overgrowth of bacteria and there’s treatments which ironically is more antibiotics and there’s a special diet as well sometimes, but it can be that what you have is related to the surgery but not necessarily related to the hernia repair.

Speaker 1 (00:45:31):

Okay. It’s quite questions coming in. Oh my god, I love it. It’s a normal to feel lumping and hardness from the area of a lipoma removal and on and off pain six weeks after lipoma removal in the upper abdomen. The same thing where the umbilical hernia incision was made Feels like a hard donut around the belly bind and hard lump under the incision. That’s a hard one. Everyone heals differently six months out you may still have some lumpy bumpiness. Yes, it shouldn’t be painful. If it’s painful, I would have to look into it to see why you have the pain if it’s a nerve issue or if it’s a fascial issue or if it’s a scarring issue.

Speaker 1 (00:46:21):

Yeah, the six months you should not be that tender at the incision anymore. I would go back to your surgeon, figure out the exact cause of that. All right. I had right hemi colectomy laparoscopically, so the right side of the colon was removed as part of the operation. I got punched a hole right above the naval. This developed into a hernia, so we called that an incisional hernia. I had no trouble with any of the other incisions. The surgeon said, oh, huh, we don’t even bother to close those, which is true. When I went back to him with the hernia, he was reluctant to fix the resulting hernia as he said it was likely to recur. He also said that if he repaired it, he would do an open operation. I voted for watch and wait, but how fixable is this? Very fixable. So most laparoscopic surgery involves an incision at or around the belly button. They’re usually between five millimeters and 12 millimeters. They may be larger if they have to take a specimen out of it like an appendix or a gallbladder. We do close those if they’re 10 millimeters or 12 mill millimeters unless they’re placed like off center, in which case we don’t U repair them.

Speaker 1 (00:47:42):

If you get a hernia from it, you should get it repaired. If you have symptoms from the hernia, you should get it repaired. Just know that if you don’t repair it, those will get larger. They will get larger over time and you can have it repaired either in open fashion or laparoscopic fashion. They’re both perfectly good ways of having them repaired. Depends on your risk factors. If you’re obese and have other risk factors for recurrence or not, is there a probiotic or a prebiotic protocol to use for SIBO? You know that’s a great question. We did have Dr. Leo Treyzon as one of our guests. I’m going to say before kind of fall winter of 2020. He’s a GI specialist. He also treats a lot of SIBO. We didn’t, I did discuss probiotics, but I don’t remember specifically probiotics for SIBO. Some people do feel that being on probiotics before surgery and after will help reduce the risk of cyber. The small intestinal bacterial overgrowth that you can get from surgery if you got antibiotics, I don’t know of any that is commercially like marketed for C.

Speaker 1 (00:49:07):

If you go back and watch that and you can go on my YouTube channel or just on the Facebook or look up the different hernia talk live episodes we have with Dr. Leo Treyzon for GI. So he did mention one company. I’ll look it up for you and I’ll post it if you can remind me. I’ll look it up. There’s one that he specifically thought was very good commercially available. I think it starts with a C, I’m not sure. Okay. Oh, going back to our patient with incisional pain, it’s six weeks, not six months. Okay, six weeks. It’s reasonable to be lumpy, bumpy, swollen, tender, not six months. Okay.

Speaker 1 (00:49:55):

One of our panelists who knows his stuff, I recommend lactate containing lactus as a good prebiotic or probiotic. All thanks for your questions. All right guys, we’re moving forward. I’m like this. Oh my god, the hour’s almost over. No way. That was so fast. Okay, we’ll keep on going. How much time after inguinal hernia surgery is a duplex ultrasound recommended for surgery follow up? Never. It’s not routine to follow up with your angle. Hernia surgery with any type of imaging. We only do imaging. If you have any symptoms or problems that need to be evaluated, please talk about Mesh brands, manufacturers and which ones do you use inguinal hernia pairs. So I’m someone who likes to use meshes that have good results known with it and also that I’m not just one that’s just going to willy-nilly use any Mesh that’s thrown at me. Fortunately, I work at a great hospital, Cedar Sinai Hospital and at our surgery center I pretty much have a lot of input as to what companies we market we kind of do business with and what meshes are brought in.

Speaker 1 (00:51:24):

But I use MeSHs from both Bard BD as well as Kavidian and Tela Bio. Those are like my top three brands. They all have great options for Mesh. Each one is has their own kind of variety of Mesh products and those tend to be the ones I use. Also, if I need a pure biologic, I tend to use a flex hd, which is an MTF brand, but everyone’s a little bit different. Not all hospitals carry every single type of Mesh. There’s literally like thousands out there and in the US there’s some Mesh that we don’t carry that is not carried outside the US and vice versa.

Speaker 1 (00:52:06):

I have a recurrence, hernia recurrence after a non Mesh tissue based repair. What do I do? Okay, first, don’t panic. You have a lot of options usually if you have a recurrence after a non Mesh tissue-based repair. The next option is a Mesh based repair. Again, there’s a wide variety of meshes. There’s lightweight heavyweight, synthetic biologic, absorbable, non-absorbable hybrid. So depending on where the hernia is, how big it is and what kind of risk factors you have for recurrence, you may or may not need one type of those meshes, but after a hernia recurrence, you do need a Mesh based repair.

Speaker 1 (00:52:48):

I have a hernia recurrence after, oh, what if I had a prior Mesh complication in the same patient? So hernia recurrence after a non Mesh tissue-based repair. Now what do I do if I had a prior Mesh complication such as chronic painters for complication? Okay, very good question. If you come to see me with a problem like this, here’s how I handle it. First of all, not all chronic pain is the same and not all spermatic cord complications are the same. If this was purely a technical issue, then you’re eligible for a lot of repair options. Even if you had a bad experience doesn’t mean that you were at fault or you had a bad reaction. It could be just technically done. The way it was technically done was one that put you at higher risk.

Speaker 1 (00:53:40):

So it all depends on why, what your previous history was, what it was that actually gave you the chronic pain or the complication to begin with and therefore based on that history, how does it go? How will the next hernia go? Is an MRI recommended to see a hes and loops in the bowel? Yes, it can be used very effectively as an MR in hysteroscopy m r e to look at bowel adhesions. Now you need a very good MRI radiologist to be able to read that. How long does it take for the body reaction to Mesh to be completed is inflammation around Mesh last forever depends on the patient. In most patients there is an inflammatory cascade and then it goes away and usually it goes away within weeks to months and that’s it.

Speaker 1 (00:54:44):

In patients that have known autoimmune or inflammatory disorders, pods disease, mast cell activation syndrome, interstitial cystitis, which we just learned about a patient earlier, different autoimmune disorders, it’s very possible that that inflammatory cascade will last longer than average and that can be interpreted as chronic pain, which is why I have hesitancy in putting typical inflammatory synthetic Mesh in that subject of patients. But just know that it’s not normal for the inflammatory cascade to be prolonged. Most people, it starts around several, it kind of peaks in a couple weeks and then by a couple months it’s gone. When will you be back? Every Tuesday I’m here with you guys. Just follow me on all my social media at Hernia doc on Twitter and Instagram right here on my Facebook at Dr. Towfigh. I’ll post. Every week you can see what we talked about. It’s always about hernias or hernia related stuff and I really thank you from the bottom of my heart.

Speaker 1 (00:55:59):

I really thank you for wanting to listen to me for an hour on hernias. I mean who does that? I really thank you very much for that. Can adhesions be caused as a result of inflammation from Mesh and can adhesions cause sensitivity and sore tosis that can be better after adhesiolysis. I’m going to say no to that. Yeah, so scar tissue results from inflammation usually and the adhesions can be a result of scar tissue, but the Mesh has to be against bowel for any intestinal adhesions. Thank you very much. Thank you for hosting these hernia sessions and for hernia talk website. There is precious little information available and it is immensely helpful to hear your explanation endpoint. Well, thank you. I do love what I do and unfortunately there aren’t enough people like me who do what I do. So I started this hernia talk live because I knew that there was a need and during the pandemic it could to your doctor and people were unhappy. So I do understand it. I love that you guys all follow me and find this to be entertaining for your Tuesday evening. I have many people from out of the country that follow me as well and I love that. So thank you very much.

Speaker 1 (00:57:21):

Please explain more about the possibility of pressure on the spermatic court according to body reaction to Mesh, which may be causing several complications. Should I be worried after surgery? Okay, so it’s not normal to have pressure on your spermatic cord. It’s also not usually part of the typical Mesh reaction. It can be part of the hernia surgery if the Mesh is placed too tight around the spermatic cord or if you are reacting to the Mesh in a way that the Mesh becomes so thick and inflamed that it’s then more like cardboard and it’s pressing on the spermatic cord. So not knowing your situation fully. If you find a surgeon that you trust and you follow them, you see that they love what they do and they’re very passionate about hernias and they can talk intelligently about wide variety of pre type operations, then that’s something to kind of follow those surgeons and allow them to lead the way. But do not be worried about your surgery. Just I always say trust your surgeon and there’s a lot of us out there that love what we do and I’m sorry if some of you have bad complications. I have had my own set of patients like that, but just know that we’re well-intentioned people. Okay, so everybody, the time has come. It is the end of our party talk.

Speaker 1 (00:58:59):

It was fun. I can’t believe when full hour went by. I thought we were only at half an hour. I wasn’t even looking at the clock. So thanks for everyone for joining me for this hour. I love that you love what I do and keeping going every week is a big deal with my schedule to have the time dedicated. But I do love this interaction. We have so many questions answered I had more to go through. We’ll try and do that at another time. Please do follow me on Twitter at Hernia doc and on Instagram also at Hernia Doc. Those of you on Facebook, I’m at Dr. Towfigh. I have my own YouTube channel where all of our hernia talk live sessions are posted. You can look them up and by topic and I hope that you enjoy them. Please share them and I will be back next week with another guest. And thank you everyone for being so lovely and sending me thank yous. I appreciate it. Have a great day. Bye-bye.