Episode 5: Treating Hernias & Complex Systems Science | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

And we’re live. Okay. Well, I’m live here. We’re live there. Yes. No, we’re still,

Speaker 2 (00:00:07):

Yes, I’m here. Okay.

Speaker 1 (00:00:10):

All right. Let’s get us off broadcast mode. Okay. We’re totally live. All right. Let me bring the first shared screen here, which is an introduction for everyone. This is Hernia Talk Live. We are here every Sunday since the pandemic gathering questions on everything you’d like to know about hernia and hernia related diseases. So that, welcome everyone. My name is Shirin Towfigh. I’m a hernia surgeon. You can find me on Twitter and Instagram at Hernia doc. And this is streaming live on Facebook on my homepage, Dr. Towfigh. And just want to double check that that’s going on right now. Very good. And once this is done, I will archive this in our YouTube channel, but we have a very special guest today. His name is Dr. Bruce Ramshaw. Most of you that know anything about hernias or have had any hernia problems have probably heard about Dr. Ramshaw. He’s the past president of the American Hernia Society. And let’s see him here now. Do you all see him? Hi Bruce.

Speaker 2 (00:01:30):

Hey Shirin. How are you?

Speaker 1 (00:01:32):

Good. Nice to see you. So we’ve got some people coming on board. Thanks for your time.

Speaker 2 (00:01:37):

Oh, thank you. Thanks for having me. It’s great to see you and you do wonderful things with this website. Thank you. And especially for the advocacy for patients.

Speaker 1 (00:01:47):

Thank you. Thank so much with your help. So you are streaming to us from Texas, is that correct?

Speaker 2 (00:01:54):

No, Knoxville, Tennessee. Oh,

Speaker 1 (00:01:55):


Speaker 2 (00:01:56):

Knoxville, Tennessee.

Speaker 1 (00:01:58):

So Dr. Ramshaw is still an adjunct professor at University of Tennessee in Knoxville, but he spend also a lot of his time for patient care. So his baby is CQI, which is continuous quality improvement, but he’s also writing a book. He’s working on a lot of projects. I personally will never forget his TEDx talk. You gave a TEDx talk, I want to say maybe 10 years ago.

Speaker 2 (00:02:26):

It’s almost 2012,

Speaker 1 (00:02:29):

Eight years ago. And it was such a moving talk because it’s lovely to see surgeons give TEDx talks to begin with, but you talked about hernias and your practice and the future and so on. And I hope we can touch on some of that sentiment during this session. But if anyone wants to look up the TEDx talk, it’s on YouTube for Dr. Ramshaw and it will move you. I promise you. Thank you. You removed yourself in giving

Speaker 2 (00:03:01):

The time. Yeah, yeah. It’s been a very emotional roller coaster because 15 years ago I became chief of general surgery at University of Missouri and I had never been chief of anything in my life and I started to study things like leadership and business and healthcare. And I learned that our healthcare system was not sustainable and it really led to building patient-centered programs. And I became leader on the hernia program and we shut that hernia program down about a year ago. But for 15 years we learned together all about how to better care for each other as human beings and a lot of the science behind complex systems. And about the time I gave that talk, I had been learning a lot about medical errors and how our system results in so much waste and harm to each other, mostly unintentionally. And it was very emotional going through that process of learning.

Speaker 1 (00:04:05):

So I think you can agree or disagree with me. I feel that over time there’s so much mistrust of the medical system by patients and for sure in pelvic mesh world and the hernia world that’s very, that rings very true. You can see it online on social media. We’re actually publishing a paper on that. It’s got accepted, it’ll be published I think in October of this year. And I just want to assure our audience that there are people like you out there that are basically spending almost a hundred percent of your time dedicated to some type of patient-centered care. Changing how we treat patients the way we’re doing it now is not efficient. It’s not the best for the patients. And hernias are just a perfect model to be able to improve the health system with just working on hernias as your center spoke of the wheel.

Speaker 2 (00:05:06):

And it took years. It wasn’t like this was a simple aha moment, it was a process over many, many years of learning and many collaborations. First of all, I definitely would say it’s understandable that people get so frustrated and angry with our healthcare system because of bad outcomes because of some of the treatment that they receive. But in studying this over now 15 years, I’ve learned that the vast majority of people are trying their best. They just don’t understand. And as you know, many of the physicians who patients feel they get treated poorly by are inactive burnout. And it’s because the system, the way we’re trying to deliver care is the problem and it leads to unsustainable costs. And I’m way too much harm in waste. And until we change the structure for how we deliver care and use data appropriately and measure our outcomes appropriately and use analytics appropriately, and I started learning this by studying hernia mesh and I learned that the same exact hernia mesh plays the same way. And two different people can have very different outcomes and undergo very different interactions in the body because we’re all complex systems and that means that one size doesn’t fit all. You can’t do the same thing to everybody and expect the same outcomes. It’s not reality.

Speaker 1 (00:06:36):

Yes. And I think that’s a great point. So based on that, we’re going to spend our hour discussing as many questions regarding mesh and chronic pain as possible because that is really your forte and what you’re very well known for. I have some pre-prepared, and for those of you that are submitting questions live, if they’re not related to chronic pain or mesh they’re not going to take priority. So let’s just go to our first question, which I think you’ll appreciate. It’s a very simple one and that is, what is the best hernia repair surgery and what is the best non mesh hernia surgery?

Speaker 2 (00:07:20):

So to begin to answer those questions, I’ll say there’s no one right answer. So the best hernia repair surgery is the one that leads to the best value for each subpopulation. And what I mean by that is clearly a non mesh hernia repair works very well and has the best value. And I actually gave a debate where I chose, well, I was given a side on opening WIL repair, even though I’d almost always done laparoscopic, but I was learning the data science and I learned that for some subpopulation of patients, the best value for them would be an open non mesh repair. But in another subpopulation of patients, the best value would be a laparoscopic mesh repair of the

Speaker 1 (00:08:08):

What do you mean by value?

Speaker 2 (00:08:10):

So the lowest cost best patient outcomes. So best outcome for the patient at the lowest cost for the whole procedure for the care process. The problem is without using data appropriately and applying analytics appropriately, we can never really know those subpopulations. The best we do today is I know what you also do and what we’ve done in our hernia team for 15 years. And that is a shared decision process with the patient. So we talked to patients about options. We talked to patients about pros and cons. We talked to patients about what I as a surgeon felt comfortable offering them because no surgeon does everything well. You have different things on your training experience and the numbers that you’ve done that you do better than others. And most surgeons don’t want to do a procedure they’re not good at. So the best he repair is the one that you think is what’s right for you today.

Speaker 2 (00:09:11):

I hope in the near future it’ll be also partly data driven in terms of what the data shows that each patient falls into these subpopulations. There’s a really good TED talk by Malcolm Gladwell about spaghetti sauce, where a data scientist learned about this in the consumer food industry and how not everybody has the same taste. We have taste clusters. That’s why we have so many different varieties. It’s the same with hernia repair. So the best non mesh, her hernia surgery, again, same kind of answer except I’ll add a little more of complexity. And I think many patients who would choose a non mesh repair are finding this. That is for the past 30 years, we have been doing almost exclusively mesh repairs in adults. And so we have me many surgeon, probably most surgeons aren’t comfortable offering a non mesh repair. The ones that do offer it I think the best non mesh repair is the one that they do because they’ve learned it and adapted it. And they’re all fairly similar with some slight modifications. But even when you say a Bassini or a Shouldice repair, that the actual technique that’s done by each surgeon may vary to some degree.

Speaker 1 (00:10:35):

Yeah, that’s probably true for mass repairs too. And I think that’s very, very important. Do you feel that there’s enough momentum to be able to tailor, cause I use the word tailor a lot, which means I try and tailor the hernia repair options that I provide to the needs of the patient. So for example, a thin ballerina, I’m not going to put so heavyweight mesh in, but a morbidly obese like weightlifter, I’ll probably put heavyweight mesh

Speaker 2 (00:11:05):

In <laugh>, right?

Speaker 1 (00:11:06):

So those two are not equal in terms of the type of patient. Do you think we’re, but that’s based on my experience and and the knowledge that I have that is hard to transfer on to as an algorithm is are we getting to a point where there’s enough data someday that we can make a bit more objective decision about who should get what

Speaker 2 (00:11:29):

Only after we have a data infrastructure in place. Because right now we’re not collecting, collecting data primarily to document things and code and bill and get paid. And in our current system, that’s what we have to do. But we’re not collecting data for the benefit of the patient measuring outcomes and using analytics appropriately. And again, this is whole science that is foreign to healthcare, but if you collect data appropriately in each local environment over time with the appropriate analytical tools, you can begin to define algorithms with different factors. And then if each local environment combines their algorithms, you can get much more accurate algorithms. They’ll never be perfect though. So we’re always going to be a human centered healthcare system. The data is only to be used as an adjunct in terms of a shared decision process. But without it, the best we can do is what we’re doing. Now for experts like you and I and others that really dedicate their whole surgical career to hernias, we have just common sense over time, seen some basic patterns like you described, but with data science and infrastructure, we can get much, much better than that.

Speaker 1 (00:12:46):

Okay. Let’s go on to the next question. It’s all kind of in a similar vein. Can you repair a hernia with that mesh? I think that’s a yes or no question.

Speaker 2 (00:12:58):

And the answer again is yes, but it depends. The outcomes will depend on a straightforward inguinal hernia or very small ventral hernia you can see very good outcomes with relatively low recurrence rates, eight, 12% for inguinal 20% for small umbilical. So that means 80 to 90% of patients didn’t have a recurrence. So it can be done now when you have patients who have multiple recurrences or very large defects, or especially in ventral hernia patients, incisional hernias so far we’re definitely evolved techniques like component separation that potentially can be done without mesh. We also now have classes of mesh that are resorbable. So you can have resorbable synthetic or biologic mesh that’s there for a while and then resorbs after the healing process. So certainly the short answer is yes, but outcomes are going to depend a lot on all those variables.

Speaker 1 (00:14:04):

That’s very true. And how do you get a surgeon to do a non mesh hernia repair? This is a very important question because patients often feel that they should just be able to go to a surgeon and say, I want this type of hernia repair. So that’s not how we approach patient care. So how does a surgeon, if you’re the patient, how do you get a surgeon to do a non mesh hernia repair?

Speaker 2 (00:14:31):

Yeah, so first of all, you don’t want to put a surgeon under the pressure of, I’ve never, I’ve not done one since presidency, but I’ll give it a shot. Surgeons, we’re doctors, we’re human beings too. And we feel pressures. We want to do our best for patients, but if we’re being asked to do something we’re not comfortable with, unfortunately, sometimes you feel pressure and you do something that you probably shouldn’t do. That happens sometimes. I know I’ve done it early in my career. You learn by doing things that you shouldn’t do. And we’re, again, all human beings. I think the best thing is doing the best you can in terms of research who does a non mesh repair and who feels comfortable doing a non mesh repair and then search them out. And I know more and more surgeons are learning mesh repair because of some of the issues we’ve seen with hernia, mesh complications are related to mesh and also patient choice. Patients are requesting it. So hopefully we’ll see more and more surgeons comfortable with doing non mesh repairs, but it’s going to take a little bit of time.

Speaker 1 (00:15:42):

I think it has to do a little bit with changing how we train our trainees. Absolutely. And ourselves I’m going to ask you this question. So I came up with this analogy and I’m kind of proud of this analogy. It’s a little silly, but my personal opinion is, and I hope people like you can help prove it. I feel that we’re overusing mesh and that all of our data is supporting mesh because we’re interpreting it incorrectly. So for example, umbilical hernia, all studies, every single study has shown that a mesh repair for an umbilical hernia is superior to a non mesh repair in terms of recurrence that includes a two millimeter hernia and a four centimeter hernia.

Speaker 1 (00:16:32):

So the way I think of it is that’s always going to be true from a recurrent standpoint. So if I choose between walking and driving from point A to B, I’m always going to get there faster with a car. But we know if you’re going to go your neighbor’s house, you probably don’t need to take the car, right? Even though it’ll take you longer. It’s probably good for your health, but you may break a leg if you do it. But I mean there’s risks and benefits to walking versus driving a car. Exactly. Driving a car, it’s more expensive. You’re using gas and it’s not good for the environment, but it’ll get you there faster. So I feel that the mesh usage, the argument that it’s always better should not be the only reason to do it. In other words, are we potentially either burning bridges or causing harm by adding a foreign body in a situation where for the most part you’ll do fine only to improve our outcome from let’s say 10% to 1%. I mean, that’s a big number 9% difference. But is that a good enough? Using the same analogy, if I had to go down the store, the grocery store 10 miles away, five miles away, I will take a car. I wouldn’t drive I wouldn’t walk. Even though that option is there, the option is there, but I would usually choose not to walk and I would drive

Speaker 2 (00:17:59):

The problem. And that’s a good analogy because it’s two different methods. And this took me a long time in my thinking. You don’t want to think of any drug diagnostic tests mesh as good or bad. It’s not good or bad. It’s what happens in each patient that can have a good outcome or a bad outcome. And it’s going to be, there’s a term, the big problem, this is what my book is about, this is what articles I’m writing about. The problem we have in healthcare, the core foundational problem is we’re built on what we call science. And it’s actually what’s called reductionism. And then you just described it, you do a study and you try to get one right answer. And that’s not reality. That’s not right. It’s harmful and wasteful but the reductionism only looks at is it beneficial or not? Is it good or bad?

Speaker 2 (00:18:51):

And that’s just not reality. And that’s the biggest core foundational problem in healthcare is we’re trying to force this good or bad science into a system that’s complex and it’s not good or bad, it’s the term from system science is optimum variety. So there’s an optimum variety of options and you need to match the right treatment to the right subpopulation. So just like you described, yeah, I think we’re using mesh so much because we don’t have a data science infrastructure in place to tell us who is in that group of fairly large group that’s going to have a good outcome with a non mesh repair and not have a recurrence. But as surgeons in our entire medical training and in our careers as hernia surgeons, for a long time we were traditionally measured by our recurrence rates. And so you get locked into this reductionism thinking that it’s just got to be beneficial in this way that we’re measured by. And in the reality is when a recurrence happens, there’s so many different factors involved. It’s not just the surgeon technique. And that’s again the reality of the real world.

Speaker 1 (00:20:03):

So for those of the, you are joining us, we’re here with Dr. Bruce I think. Were you among the first to do laparoscopic ventral hernias? Is that real?

Speaker 2 (00:20:16):

It was early on. I think the first published, there’s always arguments. I think Karl LeBlanc published first Guy Veer taught the first course, and guy actually helped me teach one of the first courses when I was in Atlanta. So it was pretty early on. I wasn’t first, but I was one of the first surgeons teaching it.

Speaker 1 (00:20:36):

Yes. So we will be focusing on chronic pain and mesh related questions for this hour because that really is the forte for Dr. Ramshaw. I want to make maximum use of his time. So I apologize to anyone who’s asking questions that doesn’t fall into that category. If we get to them, we’ll get to them, but I’m not going to prioritize. So asking one question is about mesh mesh problems. So for a patient that cannot tolerate mesh due to severe systemic form body response, and that’s something that we’re seeing more often, I’d like to see here what you think about it. What type of repair, either with tissue or biologic do you recommend, and what type of follow-up therapy do you recommend to optimize the chance of successful non mesh repair? And where does this patient find this? This is a very tricky question. What do you know about systemic foreign body responses and mesh related reactions? Like actual what some people call Asia syndrome, which is autoimmune syndrome incited by adjuvants,

Speaker 2 (00:21:47):

Right. So you, I’ve seen it it’s real rare to have it be like severe, but even then we see it. And I think, again, our healthcare system is so limited because of the way we’re trying to do science. But out there in toxicology and other specialties, it’s pretty well known that things like this is just one factor are food sources wrapped in plastic. So we all have these microscopic plastic particles. And this is more of a recent, in the last few decades with the modern modernization of food processing. So that’s just one factor. There are many other factors that could be incidents where people have a higher level of inflammatory state in their body. But again, without collecting data and using analytics appropriately, we’re observing it. We have anecdotal and little pieces of the puzzle, but we really can’t predict for sure who’s going to have that. Now, what we did in our program, and you probably do it if somebody comes in and says, oh, every time I wear a piece of jewelry I break out. Every time I touch this, I break out. Well, let’s try to look at alternatives to permanent mesh because maybe you’re at higher risk. But that’s just, that’s common sense. And anecdotal

Speaker 1 (00:23:18):

What type of mesh reactions have you seen systemic mesh reactions?

Speaker 2 (00:23:23):

Everything from skin pus to probably one of the most impressive was a patient had a laparoscopic bilateral hernia repair with mesh and his skin in his groin got red in the shape of a mesh <laugh> on both sides. It was obvious that that’s what stimulated that. And you see some people have some really bizarre neurologic changes and I don’t know how to piece that together because those are very small group, but those are the people that I haven’t seen much benefit in removing the mesh. The neurologic seems to continue but it’s devastating. It’s almost like ALS or something. Yeah.

Speaker 1 (00:24:09):

So I hope I we’ll see what happens with American Hernia Society meeting scheduled for New York in September but we turned in our abstract, which was looking at all of our patients that had mesh reactions, and it included things like headaches, blurry vision, ringing in the weird rashes that show up joint pain, joint swelling, burning sensations. Also the redness. I had a patient mean you just can’t make these stories up. He had a polyester allergy, so he couldn’t wear polyester socks. He is an engineer or something. So he would go to these shipyards and there’s polyester resin from the shipyards and his eyes would just like water and he would swell up. So he clearly had a polyester allergy. And then as you know, there’s different types of mesh, mostly in his polypropylene, but they also sell polyester based mesh. And guess what he had put in him?

Speaker 2 (00:25:12):

Oh, polyester.

Speaker 1 (00:25:13):

Polyester mesh. Yeah. Oh, the poor. He had a perfect circle, perfect circle where his of redness, where his mesh was, and he had to be on high dose steroids. And I mean he did well once everything was removed. So our study shows that if you do a really careful history and all of these syndromes start within weeks to months after the implant of the foreign body, then removal of the implant can reverse that. And so we kind of shared our data about that because it’s a rare problem. But when you have a practice like yours in mind, where we see the extremes of a population you see more of these rare problems. And it’s like a gives you a little insight into that world.

Speaker 2 (00:26:02):

And unfortunately, I think it’s going to happen more and more if we don’t change our system because all the different complexities in our world, more surgeries, more prosthetics placed, more plastic packaging all the stuff that we’re doing in our world is leading. 20 years ago we didn’t see nearly as many people with prior mesh repairs and prior surgeries. And on think of how many drugs people are taking now, how many medications are available by prescription now? It was much less 20 years ago.

Speaker 1 (00:26:40):

So talking with our European and Asian hernia friends, the Europeans don’t see the problem as much as we see it. And in India and China, we don’t see this problem at all. And their population’s like over a billion people. Yeah. So do you think it’s somewhat, we’re drinking plastic water bottles and microwaving with plastic over it, and do you think it’s somewhat an antigen issue maybe or an inflammatory issue from our environment?

Speaker 2 (00:27:13):

Well, I think it’s multiple factors. It’s very complex in a, you know, see the same thing with obesity. Well, obesity was a US problem then it was a Western problem. Now it’s a global problem. I think we’ll see this progress in many places as they follow what we’ve done in the US with an economy based on growth and volume rather than value to the customer. And we try to get the simplest, most high volume things and you have unintended consequences from that.

Speaker 1 (00:27:51):

And did you watch the 60 minutes episode about two or three years, three years ago on the pelvic mesh.

Speaker 2 (00:28:00):

Is that from Australia or

Speaker 1 (00:28:02):

No 60

Speaker 2 (00:28:04):

Minutes. I know there was one from Australia too on hernia mesh I think,

Speaker 1 (00:28:07):

Right? No, before that there was one through 60 minutes.

Speaker 2 (00:28:11):

I forget if I saw that one.

Speaker 1 (00:28:13):


Speaker 2 (00:28:14):

I forget if I saw that.

Speaker 1 (00:28:15):

I’m not sure. So that one it blew my mind because my question was why exactly what you said earlier, why is it we weren’t seeing these weird mesh reactions 15 years ago or lo or more or maybe 15, 20 years ago. And now we’re seeing a lot relatively speaking and we’re taking out much more mesh and we’re seeing much more chronic pain related to mesh. And why is that? And I was like, what if I kept asking everyone that I would see presidents of companies and people in the know like, have you changed your mesh manufacturer? Have you changed? Do you put specific oils now that you weren’t using something to kind of change the recipe for how they make? And everyone said no. And then 60 Minutes came up with this thing on Boston Scientific, which does not make hernia mesh. By the way.

Speaker 1 (00:29:09):

Boston Scientific was using Marx mesh, which is from Austin, Texas, Chevron, and for their vaginal meshes. And it turns out that all of a sudden women were getting ill and damage from it more than before. And Boston Scientific decided that Chevron’s Marx mesh production wasn’t able to keep up with their demand. So they looked for a different manufacturer. They went to China. The resin used in China only had two of the nine resins used in Marx polypropylene in Austin. So it wasn’t even the same product. And all these people and the people in China were not told that this resin was going to be used to make mesh to put inside human body and then I’ll help broke loose. Yeah. So I mean I’m not making any allegations, but if pelvic mesh was doing it, and that’s a small market, you could imagine that hernia mesh companies could potentially be doing the same thing. Maybe it is a resin difference or the recipe has changed.

Speaker 2 (00:30:21):

Well, anytime you make a change in something in a complex biologic organism, you can have unintended consequences, especially if you’re not measuring it and learning from it. I think there’s so many factors. It’s the thing that we learned and it’s really hard to learn because you want certainty in healthcare. You want, if you’re a patient, you want certainty. Yeah, unfortunately it’s not reality. You just don’t know. I don’t know what’s the right hernia mesh or the right procedure for each patient. All we have today is our experience and using the patient’s input and their goals and fears and you come to a shared decision process, we should do better. We should have data, we should have data science and analytics so that we have much better algorithms to see where patients fit into subpopulations. And when we do that we’ll, the amount of harm and waste will decrease significant.

Speaker 1 (00:31:19):

So more questions from our audience here. What’s longest time following inguinal mesh surgery that you’ve seen problems arise? No, we’re not talking about systemic reaction necessarily. We’re just saying problems.

Speaker 2 (00:31:31):


Speaker 1 (00:31:32):

Is the longer in the past the surgery the less likelihood of a potential problem?

Speaker 2 (00:31:39):

I think so. But it’s really interesting because when we studied our chronic pain patients, one of the data points we got was whether when their pain started, and you may have seen this, but almost half over half of the patients, their pain started almost immediately. They woke up, they could tell they were in a lot of pain. It seemed not right. That was, but it was barely over half, almost half. It was delayed, they seemed, and it could have been delayed days, months, but we had one patient where I think it was 18 or 20 years after their inguinal hernia repair and sometimes you could identify an inciting factor. I remember one patient, he was dating a new person and he used to do jogging and she liked to ride bikes. So the first date with her was a 20 mile bike ride and his chronic pain developed right after that. So that was kind of a little easier to pinpoint what the reason was. Here’s

Speaker 1 (00:32:39):

Another question which maybe will help clarify. What are the mesh complications and signs and signs? So very, there’s a wide range, both any implant, there’s a wide range of complications you can see. Can you just briefly tell us all the different,

Speaker 2 (00:32:58):

And they vary, depend on inguinal versus ventral and whether it’s open or laparoscopic, there’s some differences. The general complications that we see are wound and an infection, complications recurrence and chronic pain. Those are the three more common ones. Some of the rarer ones are the ones we just talked about with a variety of autoimmune type symptoms. Flu, a lot of people describe like flu type symptoms. I feel like they have a flu, chronically

Speaker 1 (00:33:29):

Chronic fatigue is a big one.

Speaker 2 (00:33:32):

And the differences between laparoscopic and open in general are laparoscopic. You have much fewer wound complications. And so that’s why for ventral hernia, we had some reason to go that way with patients that are at higher risk for wound complications. And in general we saw when we asked patients their fears and goals, some people have had history of bad wound complications and they want to try to avoid that. And so laparoscopic might be a better way to go. Others they have very disfigured scars and things. And so then an open where you can remove the scars, some of the other tissue reconstruct their abdominal wall or even their groin in some cases. So then an open approach might be more appropriate. But the general complications around wound complications, recurrent hernias, the hernia comes back and then chronic pain. And to me the most devastating is the chronic pain because they’re not mutually exclusive.

Speaker 2 (00:34:36):

You can have more than one of those together, but the kind of suffering that you see in somebody who’s in chronic pain is just devastating. I know you feel the same way when you see enough of those patients, you can’t not get emotional because it’s just you see people, healthy people that their lives are devastating and some end up deciding to end their life. And it definitely affects relationships. And I probably, you’ll see me if you watch a TEDx talk, you’ll see me break down and cry a little bit. But by far the most times I’ve cried in my clinical role where sitting in a room with a patient in chronic pain in their family,

Speaker 1 (00:35:24):

Yeah, I totally agree. In the chronic pain realm, it can be the mesh itself. The mesh can sometimes fold in those folded areas cause pain can feel it. Everyone’s very different as to how much they feel. You can have a perfectly ball up mesh that a patient is now disabled from and in the same problem with different patients like, oh yeah, I’m fine.

Speaker 2 (00:35:49):

Yeah, no problem. That’s the problem. That’s the problem. That’s the reality. That’s the reality is it? And there are, I think a small percentage. There are direct cause and effect where there’s a mesh and a neuro or something like that. But in the vast majority it’s not just the mesh. And that’s part of the problem. In fact, I had one patient, I think it was from Louisiana and he had a laparoscopic bilateral repair and his left side or his, no, his right side felt fine, no problem. Left side disabling chronic pain. So the plan was go in and take the left mesh out, free up the nerves, do whatever to try to minimize pain. So I go in there and I look at the left side mesh where the pain is and it’s perfect. It looks beautiful, flat, no inflammation. And I look at the right side mesh and it’s folded, sticking out. It looks horrible and it looks like it’s sticking in the about, but that’s fine. So I took out the perfect looking mesh and his pain got better.

Speaker 1 (00:36:48):

Those things it doesn’t make sense. And you can fold an entrap nerve it, there’s a lot of things that can

Speaker 2 (00:36:53):

Happen. There are other factors. That’s the whole thing. There are many different factors that combine for a good result or a bad result. And the mesh can be a factor, but it’s usually very rarely just direct cause and effect.

Speaker 1 (00:37:08):

So we have a lot of questions about mesh removal. Actually what I have a pre-prepared question, then we’re going to go to the other one as well that was answered because they’re all part of the same. But I want to post it so that people can read it as we’re going. Let’s see. I’m going to fast forward. Okay, so question about mesh removal. Can you enlighten us as to whether it’s true that more people are either the same, worse or trade old issues for new issues after mesh removal? Or in your experience, do more people range from getting better somewhat to almost completely better? So the fear is that you’re replacing one problem with another. And what’s the guarantee that you’ll be better once a mesh is removed? What’s your experience with that?

Speaker 2 (00:38:01):

So when we started to do this we had maybe 40%, 30, 40% of people got almost completely better. But we had still 10, 15, 20% had little or no improvement. We spent a lot of time on applying the continuous improvement model, trying things like multimodal pain, enhanced recovery concepts. And in the last five years we really put a lot of effort into pre-hab rehabilitation, including pre-operative cognitive behavioral therapy. And we’ve seen lots of ideas for improvement, lots of applying various things to try to improve outcomes. And we have seen improvement in outcomes up to close to 60% of people gotten almost completely or almost completely better. And after the pre-hab rehabilitation, almost everybody got at least some better. Now there’s still some trade-offs. We still had 10, 15% of patients would develop a new hernia and a lot of them developed a different pain. So it was rare that we saw anybody have, except the couple of cases where they had severe neurologic problems. It was rare that we saw people get worse. But I’ll tell you before we started the multimodal pain with long-acting locally aesthetic and the prehab rehabilitation, doing a mesh removal with our old way of doing pain control was pretty miserable for a lot of patients. What is

Speaker 1 (00:39:46):

Rehabilitation? Cause that’s something where you’ve really pioneered, and I dunno if it’s published but I’ve seen you talk about it where

Speaker 2 (00:39:53):

Just was published earlier last year

Speaker 1 (00:39:57):

Without pre rehabilitation.

Speaker 2 (00:39:59):

Our CQI model included working with data scientists and a analytics where we would measure outcomes you and look at what factors are most correlated with outcomes. And when we found that there were and haven’t figured out how to define it perfectly but in general, and this is in chronic pain literature a lot especially in the last decade or two, we’ve learned that people come in to a process in chronic pain. It affects them. It affects them not psychologically in their head, like psychologically. It induces neural brain rewiring, which is, it’s a chronic stress response. And you see this, a lot of the science or a lot of the research was done in the military and a lot of it was the neural rewiring that happens to a soldier that goes into a traumatic experience in a war zone. And we do that all the time in healthcare to our patients, not intentionally obviously, but they suffer traumatic experiences and it’s not a one size fits all, but in some people that induces a brain rewiring in a negative way that leads to worsening of the chronic pain.

Speaker 2 (00:41:21):

And if you don’t address that brain wiring, in some people we don’t identified those subpopulations and some people you can do anything you want, remove the mesh, cut the nerves and their pain will persist. And the analogy we used when we had our clinical hernia team was it’s like phantom pain. It’s not in your head psychological pain. It’s neural rewiring in the brain induces that pain even though the limb has been amputated. It’s real pain. And that’s something that at least I know for our patients, a lot of them ask us to help explain that to their significant others or their family because they, because you can’t see it. They think it’s psychological in your head and that is not it at all. It is real pain. It is neural pain. It’s just the wiring inducing that pain is from rewiring in the brain rather than something you can see in the local site.

Speaker 2 (00:42:21):

And it’s not just in your brain, it’s the interaction between the local site, the central nervous system, the rewiring in the brain and that chronic pain rewiring apparently happens in the lower brain in the amygdala area and the whole variety of therapies to induce neural rewiring in a positive way induces new synapses in the prefrontal cortex and in the higher brain. And it doesn’t work the same for everybody and that, but we did see some positive impact in our data over and over and over. Our data analytics showed that that’s an important factor for some subpopulations of people.

Speaker 1 (00:43:00):

There’s another question about the realities of the benefits of mesh removal for chronic pain. And what we’ve shown in our own data is if you have a hernia that’s recurred and that’s why you have the chronic pain, or if you have a mesh, what we call meshoma balled up mesh, those patients do very well. They wake up and they’re like a new person. But if you have nerve injuries and an inflammatory problem and less of a mechanical problem, then the mesh removal may not have as much of a success rate or the recovery takes a little bit longer.

Speaker 2 (00:43:40):

And there’s probably other factors too. That’s why it’s so important to collect data and analyze the data appropriately because I think the length of time might have a play a factor even. We’ve seen a pattern where work environment could play a role. We had a subpopulation of patients who were typically men because it’s inguinal hernia but they were in very high stress demanding jobs like we had one NFL football player police officer, FBI agent heavy manual labor. There’s this group where there was just not going to be a good result unless they kind of got out of that environment.

Speaker 1 (00:44:30):

Another question we have is if there was no pain and now there is constant burning and soreness moving after an incisional hernia pair at the belly button. So this incisional hernia pair did find post-op and then now there’s burning pain that’s constant in soreness at the incision. Can this be due to injury caused by the surgeon’s technique? Can it be reversed and somehow fixed with mesh removal? Is it possible to get pain rating to the lower back due to tension and pressure coming from the belly button area? And can all this go away with after removal?

Speaker 2 (00:45:07):

Yeah, may unfortunately. Best second answer is maybe certainly if you had no pain before and you have pain now some interaction of the surgery. An interesting thing and probably an important thing to bring out is chronic pain after a surgical procedure happens with any type of surgical procedure, including surgical procedures that don’t involve putting mesh in the body. So when a woman gets a mastectomy for breast cancer, there’s a pretty high chronic pain rate after that, after thoracotomy for a lung procedure, there’s a pretty high chronic pain rate. So it’s not just the mesh. Sometimes it can be a contributing factor and if you remove it, your pain can get better. So you see a whole host and we walk patients through a whole variety from less invasive to surgical invasive of options. And you can start with things like anti-inflammatory measures from anti-inflammatory drugs, anti-inflammatory diets to local ice, alternating heat, and I heat and ice stabilizing the abdominal wall with a binder and all these things can work in some people and actually make it worse than other people.

Speaker 2 (00:46:19):

And so it’s not one size fits all. Next level of therapies are things like acupuncture, injections, pain blocks cognitive therapy, like I mentioned a whole host of other things nerve stimulators that are not quite as invasive as surgery. And then there’s surgical procedures removing the mesh. The trade off there is if you remove the mesh now, you may get a hernia back and your pain may or may not go away. But certainly walking through all of those options, and again, if we just had whole data science infrastructure, we’d be able to identify the right subpopulations and the optimal treatments. But right now the best we can do is a shared process. And for a patient, I know you’ve probably had this, different patients have different feelings about what’s best for them and some people don’t even want to think about trying acupuncture. That’s fine, that’s okay then if somebody thinks trying acupuncture is a horrible idea for them, I wouldn’t recommend it. But if somebody thinks acupuncture sounds like a great option, then I’d recommend it. But I would go through that process for somebody like you just described.

Speaker 1 (00:47:32):

And I must say I think the timing is important. If you had surgery, it looked perfectly fine, no pain for years or months, and then you start getting pain. Often that just means you have a recurrence, especially your symptoms are similar. And this reading pain that he’s describing about rating to the back, I see that a lot with hernia recurrences. So sometimes the answer is very simple. Not everything is mesh related on everything is a nerve entrapment. Those are things we think about. But the beauty of seeing someone who’s done this before is they don’t treat every single patient as a nerve problem and send you to pain management. That’s the one that’s my biggest pet peeve, right, is they see a surgeon and they say, you got pain, go to pain management. And it’s not my problem. Almost never a nerve problem. Actually, they don’t need nerve blocks. And most pain doctors are specialists in nerves, not specialists and mesh and hernias and so on. So they treat you with all these nerve things to the point where they get a nerve stimulator in their spine and all they had was like, let’s say a hernia recurrence or a bald duct

Speaker 2 (00:48:41):

Mesh. Well, and brings up the concept, I’m sure you’ve seen this of interstitial hernia, especially if a mesh is placed on top, you can actually get a hernia recurrence that’s through the fascia but behind the mesh and it can get pinched and trapped and an examiner will examine and say, Hey, cough bear down. And nothing will poke out to their hand and they’ll say, oh, you don’t have a hernia. Well, you may have an interstitial hernia that’s trapped behind the mesh. So that’s seen several patients with pain from that.

Speaker 1 (00:49:13):

So true. Haven’t talked about nuerectomies. What are your thoughts on nuerectomies, especially triple versus selective? What are your thoughts on it?

Speaker 2 (00:49:24):

Yeah, again, I don’t think there’s a right and a wrong but I have studied a lot about neuroplasticity, meaning the way it’s laid out in the textbook and the way we talk about triple not reality nerves rewire they branch it’s not always just three of them like we described. I have done some focused nuerectomies, seen great results. When I go in to do everything I can think of doing to try to improve someone in chronic pain, I will laparoscopically most of the time during neurolysis free up the nerve because you have a magnified view and fine detailed instruments in open. I almost always am removing nerves, but I only remove the nerves. They’re embedded in the mesh and the scar tissue. I don’t go searching for nerves that are not embedded in the mesh or scar tissue.

Speaker 1 (00:50:20):

I think the original triple neurectomy recommendation was based on a meets where he showed that people that got triple neurectomy had a better outcome than those that had selective nuerectomy. But if you dissect that paper it’s very possible what was happening was if you bring all the comers and you don’t really pinpoint exactly where the pain is, what quality of the pain is and which nerve is responsible, then of course cutting all three, you’re more likely to get the right nerve than if you only select a handful. So that’s my theory, which is I do selective. I don’t like to nuerectomies at all. Yeah, because it starts a whole series of problems that you really would like not to. So nerve blocks are good. Even burning the nerve sometimes is less traumatic to the whole body system than cutting. And if you cut it, there’s like a techniques on how to cut it. That’s why I’m against routine nuerectomies with inguinal hernias, for example. I agree. I think that’s opening up a can of worms that we dunno how to handle.

Speaker 2 (00:51:34):

The other important thing about nerves, inguinal hernia is the difference between the nerves involved in a open Lichtenstein mesh placement versus a pre peritoneal mesh placement. They’re different nerves. And doing an open triple neurectomy for chronic pain after a laparoscopic repair is not likely to be helpful at all. Makes no

Speaker 1 (00:51:57):


Speaker 2 (00:51:57):

Because it’s a different set of nerves that are involved with a laparoscopic mesh. So just know if nerves are a contributing factor. The mesh and the nerves be aware that it’s a different set of nerves if the mesh is placed open versus in a pre peritoneal space, like a laparoscopic approach.

Speaker 1 (00:52:17):

So here’s a question from Iowa. The patient had a meshoma, which is a bald up mesh that was removed and a triple interacting was there the same time, so sounds like was an inguinal meshoma. The patient felt good for about a year and then moved some heavy totes of water and now the patient has severe nerve pain again. Is there any reasoning behind that? That’s a pretty question.

Speaker 2 (00:52:44):

Yeah, again, it’s the concept that even without mesh, we have scar tissue after surgery and the scar tissue can do the same thing the mesh can do, which is irritate nerves. And if you tear it through heavy lifting or heavy coughing or sneezing that can induce pain. It could be from a variety of things, either irritation of the nerve directly or you could bleed, you can have a small muscle bleed and that hematoma could negatively impact that interaction. And

Speaker 1 (00:53:16):

You can have a hernia recurrence and

Speaker 2 (00:53:18):

You can have a hernia recurrence. It could be a combination. No,

Speaker 1 (00:53:21):

No, it’s nerve pain. It may not anatomically be a nerve causing the pain.

Speaker 2 (00:53:26):

Right. Yeah, it it’s musculoskeletal pain and nerve pain. It’s not just either or the, there’s interactions and overlaps and

Speaker 1 (00:53:36):

Can a folded mesh cause swelling and pain?

Speaker 2 (00:53:40):

So the mesh, any mesh is a foreign body. And even without mesh, any surgical induced scar tissue can swell and it can be related to lots of factors. The most common is heavy lifting, but as a foreign body and with scar tissue, you definitely see patients that will have swelling and waxing and waning of inflammation for different reasons. Some people talk about the weather inducing it now other it’s not just the folding of the mesh necessarily, but you can also have real fluid, you can have acute seroma and you have chronic seroma that you see around more likely foreign body like a mesh but you can even have that with scar tissue. So the variety of types of swelling are fluid pockets, what we call seromas or edema. And that’s part of the inflammation. And you definitely can get that periodically for ever after any surgical procedure.

Speaker 1 (00:54:46):

All right. We have five more minutes. I’m hoping to get at least one more question in. Let’s see. Okay, this is an important one because it’s asked a lot. Can you explain why it’s better to have your inguinal mesh removed the same way it went in? So lap in, lap out, open cut in, open cut out. And what are the dangers of having laparoscopic replaced, mesh removed open and vice versa? Is it true for all mesh replacements or is it true just for inguinal mesh? That’s a really good question.

Speaker 2 (00:55:17):

Yeah. And it’s really complex answer <laugh> ventral mesh removal’s a lot easier in general because in the groin we have a much more complex anatomy with structures that are at risk of being injured. So when the mesh is placed open in the layers between the muscles, like a typical Lichtenstein, I haven’t had any I’ve never tried to cut through the deeper layers and remove that laparoscopically. I don’t see a reason for that. And so a mesh placed in between the muscles removed open, that was placed open. Now laparoscopically placed mesh, again, is in what we call the pre peritoneal space, which is the closest to the abdominal cavity. And I’ve always removed those laparoscopically because it’s just easier to do. It’s harder to do through an open approach because you’re having to go all the way to the deepest layer and you can’t see as well with laparoscopy, you have a magnified view from an inch away.

Speaker 2 (00:56:24):

It’s it you’re seeing much more fine detail. The dangers of the lap removal are that you lay the mesh in the standard technique directly over the iliac vessels and the bladder is right there. So it’s definitely at risk for injury. And in fact, I sometimes have to leave or make a judgment to leave some mesh that seems to be ingrown into the iliac vein rather than trying to remove it. So it’s definitely a technically challenging operation to remove a mesh that’s been laid in the pre-one space an open place mesh is a little bit easier. You still have the potential. I actually had somehow one Lichtenstein mesh eroded into the iliac vein and that was a surprise for me. And the, or fortunately, patient did well, but it, yeah, definitely it happened. So things happen and the groin is a very complex anatomic area with several structures that you really don’t want to injure abdominal wall much more straightforward and you can injure things like intragastric vessels and some muscle, but it’s not near, doesn’t nearly have the potential for harm to the patient.

Speaker 1 (00:57:48):

I think the lap and lap out and the open in, open out is like you said, much more valid for inguinal. We get this question a lot because there aren’t that many surgeons comfortable ticking out laparoscopic mesh laparoscopically or robotically. And so many patients go to their local surgeon who may actually do laparoscopic surgery. That doesn’t make a difference, but they still do an open approach to remove a laparoscopically placed mesh. They’ve been told that it’s safer, that it’s a better option, that they can see better and they can feel better. What are your thoughts on that? Because those are all things

Speaker 2 (00:58:34):

I can Yeah, it’s counterintuitive, right? Because again, it’s even placing mesh in the pre parallel space is a challenge. And even some of the people who teach that kind of repair, either the kugel repair or the prolene hernia system, it’s almost have to, unless you put in a lighted retractor and put a scope through the open incision, you really are doing it with your finger trying to feel the structures laparoscopically. It’s much, much easier to see everything.

Speaker 1 (00:59:11):

Yeah, I totally agree. And I think my concern is that patients may sometimes be given options because those are the options that the surgeon can provide them, but sometimes you just need to find a different surgeon in order to be able to get to those needs. I mean,

Speaker 2 (00:59:33):

Yeah, especially for this kind of problem, it’s just not something that the general surgery residency five years is, mine

Speaker 1 (00:59:42):

Does, but in general,

Speaker 2 (00:59:43):

Yeah, it’s really rare. It’s really rare. Yeah. And David Chen, some of the others, we have produced some more hernia specialists, fellows and residents, but that’s rare. That’s still pretty rare, unfortunately. Yes.

Speaker 1 (00:59:58):

Well, thank you Bruce. It’s been a pleasure. I love catching up with you. I hope to see you at the meetings.

Speaker 2 (01:00:04):

Yeah, I hope we can see each other in person sometimes soon. I hope everybody out there stays safe and healthy. And thank you very much, Sharon, for the time. I really enjoyed it and hopefully we can do it again sometime.

Speaker 1 (01:00:17):

Thank you so much. So that’s the for us, for those of you who want to follow Dr. Ramshaw, he’s on Facebook as mi. You can also follow me on Twitter and Instagram at Hernia Dog and this will be archived on YouTube if you want to go back and see what the answers to our questions were. As always, please join us on Sundays. We have another guest next week. Love to hear from all you with your questions and please have a great night. Thank you very much. Thank you. Bye-bye.