Episode 50: Pitfalls in Hernia Surgery | Hernia Talk Live Q&A

You can listen to this episode by clicking here.

Speaker 1 (00:00:01):

Hello everyone. Welcome to Hernia Talk Live, the weekly q and a that I host and I am going to announce today I’ve been hosting it officially for an entire year. Many of you are following me on Twitter and Instagram at Hernia doc and on Facebook as a Facebook Live currently at Dr. Towfigh. You guys, this has been the today’s the 50th episode. First of all, big five oh is also exactly one year since I started and I’m super excited. I didn’t think that it would be an entire year. That’ll go by so quickly and I think that I just love that all of you’re following me and enjoying this. I’m really impressed that so many of you find hernias to be so exciting to spend an entire hour every week. I know many of you come every week and some of you actually have been big fans of mine, so I really do appreciate that.

Speaker 1 (00:01:17):

So thank you. It’s been great. I’m going to continue doing this. I enjoyed every single week. I look forward to it. It’s how I end my day every Tuesday. Everyone knows in the office not to bother me at 4:30 PM and the guests have been so great, very, it’s been very fun for them. I learn a lot from them and they learn a lot too. And you guys all ask really fantastic questions. I see you interacting on hernia talk.com, which is my patient discussion forum, which is free to everyone in the world. I try and answer questions on that too as much as I can. But many of you have found friends on that forum. I do want to thank you all for being so respectful here. Too many of you are really suffering from a lot of problems with your hernias or your hernia surgery, and I hope that by introducing you to various specials all around the world that what I’m doing for the past hour has helped you.

Speaker 1 (00:02:20):

So thank you very much for congratulations. Ooh, that’s very cool what you’re doing. All the congratulations you’re sending me on Facebook. I really do appreciate it. Okay, so I am your guest today. I am just here for you to celebrate our one year 50th episode and I, I’ve had some requests from many of you to just sit down and discuss all of what I see amongst our patients, among the patients that I treat. We’ve been super busy since we are now officially open for elective surgery in the hospital that I work at, which is Cedar Sinai Medical Center, which is an amazing hospital, I must say is officially open to elective surgery. Now, we’ve been open for about a month and I’m finally going to operate again on a lot of patients that were out of town or out of the country that couldn’t travel because of the pandemic.

Speaker 1 (00:03:22):

So thanks for everyone for being so kind of gracious about the long wait. We’re not used to that United States usually to get such a long wait for care. And at the same time, I’ve been seeing a lot of patients lately with just super crazy stories. You should read my notes. The notes that I write is it just shows my angst and frustration, which is shared by the patient obviously about the stuff they’re told and the care that they’ve been given. And my last patient has been suffering with chronic pain since 2005. I mean, that just makes no sense to me. So anyway, I spent a lot of time and energy trying to figure out problems for you all and get you to a point of getting health health. And many of you are asking me like, okay, what are some problems that you see frequently?

Speaker 1 (00:04:18):

And I am going to spend some of this hour with you about that. I also have some questions that you’ve sent to me that I will try and answer as well and in advance. And then also there are questions that I’m sure you all have, but let me just start. I took some notes, which I usually don’t do because it’s always a q and a, but one question that was asked of me, and let me see if I have that in my list because I want to make sure that, okay, I do actually, here we go. So one question that was asked of me are, what are the most common misdiagnosis and surgical mistakes that you correct in your revisional hernia practice? This is a great question. As many of you know, I’m a hernia surgeon. All I do is hernia surgery, but that involves a lot of treatment of hernia related complications, nerve problems, testicular pain, pelvic pain, and also revisional hernia surgery.

Speaker 1 (00:05:23):

So 80%, at least 80% of the operations that I do and the patients that I treat are for revisional cases. They’ve had a complication and I have to figure out what the complication’s about. And in doing so, I learn a lot because I learn what not to do by seeing patients who have had complications. And let me share with you a couple of things that I’ve learned. Okay. One of the main problems that I see is that there’s no tailoring of care. So a thin young female gets the same operation as an obese older male. That’s not how I believe her new care should be performed. For example, I tend not to use Mesh in the groin for women, especially if they’re young, unless it’s done laparoscopically because laparoscopic surgery has been shown to have a lowest rate of chronic pain, even more than non Mesh tissue repairs.

Speaker 1 (00:06:33):

But if you’re super thin, I try and air on the side of no Mesh, and if you have an autoimmune disorder or a family history of an autoimmune disorder like rheumatoid arthritis or lupus, mast cell activation syndrome, pods, even Ehlers Danlos syndrome, I try, or sorry, not Ehlers, Danlos syndrome, I try not to use Mesh in those patients because I’m a concern of the ramifications of introducing an inflammatory object implant. The other thing that I notice is that there are plenty of patients that should have gotten a laparoscopic repair, young, healthy, athletic male as one great example, and they had an a more traditional considered standard of care, more traditional open inguinal hernia repair with Mesh. What I’ve noticed is that the young healthy males do best with a laparoscopic repair, especially the athletic ones and the more frail older patient does best with the open repair.

Speaker 1 (00:07:36):

And so that’s kind of how I, for ink hernias and for the abdominal wall, how you repair it, the incision you make laparoscopic, robotic or open makes a big difference. So in people that have Crohn’s disease or ulcerative colitis, which tend not to put Mesh inside the abdomen or use Mesh at all, patients that have small hernias like one centimeter even up to one and a half, sometimes two centimeters, and the umbilicus, I try, I try not to put Mesh in them. I think it’s unnecessary understanding that the studies don’t support that in terms of recurrence, there’s higher recurrence and then sometimes you just need a good open surgery. That’s my shtick. I think that just because you can do something laparoscopic or robotic doesn’t mean it’s superior both for inguinal and for ventral hernias. And doing something open where I can give a nice tummy tuck at the same time may give a better outcome, especially in someone who already has an incision, I can revise that incision and make it overall outcome look flatter and with less pain and better incision, better looking incision.

Speaker 1 (00:08:50):

Whereas maybe if someone has a high risk like you’re morbidly or have other risks for chronic for wound infections that a laparoscopic or robotic would be better. So there’s different ways of doing things. I notice that in people that have recurrences, it tends to be because the Mesh that was placed and was too small, there’s standards for how much Mesh you should put in patients. If you’re having recurrences over and over again, it may very well be that technically speaking, the Mesh was too small. I just had a patient last week. The CT scan shows a big wide hernia and the Mesh is just floating inside. I mean, if you want to use Mesh, use it correctly. I also feel that there’s tech, there’s a technique issues. So for an Anglo hernia laparoscopically, you want to make sure you develop a wide working space. I describe that space as like the envelope and the Mesh as the letter within the envelope.

Speaker 1 (00:09:55):

If the envelope is made just wide enough for that letter, your letter will fit just perfectly. So if you make your surgical incision wide enough, surgical space wide enough and the Mesh will fall into place, what is a problem is people don’t make a wide enough space and they try and fit this Mesh in there. That’s when you get meshoma Mesh folding and then sharp areas of the Mesh recurrences, chronic pain, difficulty with walking and so on. And in many cases, the Mesh is blamed as being the problem. It’s really the surgical technique of how you place the Mesh. I’d like to talk about chronic pain. Chronic pain is very difficult problem to handle. Sometimes it’s caused by a surgeon who’s just very heavy handed, doesn’t understand the anatomy, is not careful to identify nerves, is very rough with the tissues and causes a lot of extra additional tearing or additional inflammation in the area, and that can kind of translate into a bad outcome.

Speaker 1 (00:11:05):

What’s also important is that if you make a hernia too tight, that could give you chronic pain. That’s true for abdominal ventral hernias and the groin. So a tight hernia, it’s like me putting you in a tight shirt, you’re going to pop those buttons or the seam of that shirt or you’re going to be super uncomfortable in that tight shirt. So in patients that have chronic pain after hernia, sometimes it’s just too tight of a repair. And that’s an important thing to notice. I had a patient last week that was adamant that he wants a tissue repair. He already failed a Mesh repair and he had a really huge hernias to begin with. I can’t promise that I can do a tissue repair because based on the original opera report, he had huge hernias. So for me to do a tissue repair, no matter how much I move the tissues from his inguinal hernia, I have to really pull that tissue tight.

Speaker 1 (00:12:04):

And like I said, tightness causes chronic pain. I have patients that have really tight tissue repairs and I’m putting Botox in them because they’ve had multiple surgeries and I don’t want to do another hernia repair on them and they don’t want Mesh, but it’s a problem. And the fact is, if you make it too tight, those sutures will kind of try and pull apart. That’s very painful because you’re constantly tearing your own tissue and once you tear, you’re going to have a hernia and even less tissue to work with. So it’s best that your first surgery is done correctly without tension and without tissues. And sometimes that implies you have to use Mesh. The other thing that I notice that contributes to chronic pain is that is knowing your anatomy. A surgeon should be very careful in the growing to identify the nerves as part of the operation.

Speaker 1 (00:12:53):

And the abdominal wall is to be very careful in how you handle the tissues so you don’t cause extra tension and tissue injury. And then they say the perfect surgeon has the hands of a woman. I think it’s eyes of an eagle. Oh shoot, what is it anyway, eyes of an eagle, hands of a woman, and I really believe that. Now there are a lot of very heavy handed surgeons that are female, I’m sure, and very delicate surgeons that are males. But I do feel that how you handle the tissues has a big outcome results in patients. And I learned that from really great mentors and plastic surgeons that I work with. And believe it or not, there are plenty of plastic surgeons that are heavy handed and I don’t understand how that can be. But I hope this gives you a little bit of idea of what I see and every time I see a disaster, it’s because there was some failure of understanding what you’re actually doing and why you’re doing it. Not knowing the anatomy, where the nerves are, and therefore putting to or sutures right at the nerve, not knowing that this patient has, let’s say they’re a singer or they’re a rower or they’re an electrician, they’re always on their belly like crawling in our basements and stuff. You’ve got to change your procedures to meet the needs of the patient. So that’s kind of my how I’d like to start today.

Speaker 1 (00:14:34):

Thank you for kind of sending in your questions. I’ll try and do a little bit more of these stories. I don’t know if you guys enjoy hearing patient stories. I try and be respectful of patient privacy, but at the same time I get some great examples of stories and patient examples of what to do, what not to do, and the kind of process that I go through in figuring things out. So I get a note here. Cedars is amazing. I received top-notch care from you, my wonderful surgeon and bell, the hernia nurse all the way down to the food service, thanks to all who have taken such great care of me. Well, thank you very much for being so kind. I do really enjoy working. I’ve worked at a lot of different hospitals, mostly in Southern California, and I must say that working at Cedars is definitely, or Cedar Sinai is definitely a pleasure.

Speaker 1 (00:15:34):

It’s really great and I, they’re really excellent with patient privacy and also our patients who may be a little bit more famous than others. Okay, let’s move on to some other questions, and if you want to chime in too, please feel free to let me know your question. So this is a male who says I had perineal pain. The ultrasound shows bulging of fat upon Valsalva with no definitive hernia defect. Is this a hernia? Yes. Any bulging of fat upon Valsalva implies it’s bulging for a reason. Bulging has to be through something. I don’t understand why they wrote no definitive hernia defect because where is it bulging from or through? That doesn’t make any sense. There’s not that much fat in the perineum outside of the muscle, so it has bulged through something. Now in males that’s really rare to have a perineal hernia. In women, especially those who have had multiple pregnancies, it’s much more common.

Speaker 1 (00:16:41):

That’s that. It’s still perineal Hernias in general are very rare hernias and the operation super complicated because you operate next to the kidney, next to the rectum, the bladder, the nerves that go down around the rectum and bladder and around the intestines and behind the sacrum, the coccyx, it’s very complicated surgery. If you have any questions, feel free to just write them into Facebook live or zoom and I’ll answer that. So yes, it is a hernia. Sometimes I’ll tell you, I feel like radiologists don’t want to commit to a diagnosis, so they kind of explain what they see without committing to a diagnosis. So bulging a fat, no definitive hernia defect. I mean maybe there is a hernia defect, maybe there is an, I don’t want to commit to that. And so they leave it up to the surgeon to identify the patient, their examination and their symptoms with the ultrasound to see if that’s a problem that needs to be addressed surgically. In that case, after the ultrasound, I would get an MRI or a CT scan with Valsalva as a next step. And in terms of exercises, any pelvic floor physical therapist can provide you with good exercises. They’re usually core based and kugel type based exercises. Okay, that was pretty good. Let’s see.

Speaker 1 (00:18:17):

Okay, when measures involved, what are the signs that your surgeon is not seeing? Let’s see. Let’s move on to some questions. I know I’ve asked this before. Have you ever had a patient with brain fog and no pain? I currently lost my job due to my cognitive decline. Oh, sorry. I have to hear that. I’ve had good days and bad days. I would need removal of abdominal Mesh and placation of the abdominal wall. What is a success rate and is Mesh necessary for diastasis erectile? Okay, very good questions. So yes, brain fog. There’s some really cool recent studies that show that brain fog is due to inflammation and that inflammation can be anything. It can be from like autoimmune disorder or an actual true inflammation like an infection. Urinary tract infection can give brain fog or it’s inflammation from, let’s say a reaction to an implant such as Mesh.

Speaker 1 (00:19:15):

In that case, you don’t necessarily have to have pain. Pain is due to hernia recurrence, nerve damage to of a repair, anything local to your hernia. We can have a perfectly good repair with no pain from it and have a reaction to the Mesh that the systemic reaction head to toe is what we refer to as Asia syndrome. Brain fog is one of the elements. It’s not usually the only element. Patients often have other problems such as weird zigging nerve pains in their hands and feet, joint swelling, visual changes, hearing changes, hair loss, the brain fog. We discuss chronic fatigue syndrome and sometimes weight loss and loss of appetite and depression. So brain fog is usually not the only thing with Mesh reaction. So yes, Asia syndrome by definition has no pain associated with it at the hernia site. It’s a reaction of your body to the implant.

Speaker 1 (00:20:16):

With regard to that, if you need the Mesh removed, you do need a tissue repair. You must be low risk. You can’t be morbidly obese. That needs to be addressed first, for example, and diastasis recti, the one question you wrote is, I would need removal of the abdominal wall Mesh and diastasis recti. Placation is that is Mesh necessary. So if you only have a diastasis erectile with no hernia, typical postpartum female going for a tummy tuck, then you don’t need Mesh and most plastic surgeons don’t use Mesh as part of the tummy tuck. If you have diastasis recti and a hernia, then oftentimes you do need Mesh if the hernia is huge, so more than four centimeters or if you, it’s an incisional hernia.

Speaker 1 (00:21:19):

Not always though. Not always. So that’s helpful and the success rate is very good, very good success rate. Okay, next question. I have rather unique hernia issues and I wanted to go to a top-notch hernia specialist on the east coast. The problem is that it’s a teaching hospital and consent for treatment indicates that the surgeon might not even be in the room for the operating room. That is completely false, absolutely false. There is never a consent that says the surgeon will never be in the operating room. That’s illegal. You cannot bill for an operation if you’re not in the operating room. Medicare will not pay for it. What’s a federal law against that? So anyone that’s claiming that there was no surgeon in the room during an operations, completely false, especially nowadays, number one. Number two, what you are consenting to in teaching constable is to have residents involved in your care, and that could be low level residents, high level residents, whatever it is.

Speaker 1 (00:22:24):

I operate with residents and fellows as well. I was a resident at some point and I had to learn how to do things. That said the surgeon should never and almost never puts the patient at risk because a resident needs to learn. They’re always there and they are actually mandated to be present for the important parts of the operation. So whoever’s telling you that you kept a sign that there won’t be a surgeon in the room is that’s completely false. There’s no way that’s actually illegal, at least in the United States. Next question. I don’t wear clothes for 15 years and my nuts swell up big baseball. Is that a problem? Okay, I’m a little confused by that question. Are you saying that you have, okay, you’re going to have to give me more data on that. I don’t know what that means. Next question. Is this a common occurrence from hernia?

Speaker 1 (00:23:26):

Mesh reaction? So this or POTS syndrome, which is postural orthostatic, postural orthostatic something syndrome. That is when, so normally when you stand up from sitting position or standing from the laying position, your muscles and the leg kind of squeeze and brings fluid back up to your brain so that you don’t feel all woozy because your blood is all in your legs. Pot syndrome or dysautonomia, you kind of lose that reflex knowing when you’re flat versus up. So you can’t just stand up, you’ll pass out. Or there are people that are constantly need to hydrate and drink all the time so they have enough blood volume so that when they do get up, they don’t pass out. So based on that, we don’t think that that Mesh reaction causes pots. However, people with pots, I believe, and I’ve seen there’s not enough data to look at it I’ve seen can be at higher risk than usual for Mesh reactions because we feel the POTS is somewhat of an autoimmune disorder of its own and an inflammatory state of its own. So I think it’s one not the other.

Speaker 1 (00:24:52):

Okay. Let’s go on to another question. This is through zoom. One of my main symptoms I have after Mesh implantation is nausea, especially after eating. It helps keep my weight down, but does this have anything to do with where the Mesh is placed in the abdomen is associated with inflammation or adhesions? So I kind of know your situation, but yes, you can have adhesions causing nausea. Those usually show up on some type of imaging and you usually get very bloated. So the nausea comes with either vomiting or bloating. However, if that is not the case and you have nausea baseline, not even with eating, it may be more of like a Mesh reaction and the ones the Mesh is removed, then your reaction will go away. So it’s an inflammatory response of your gut to the Mesh. I hope that’s helpful.

Speaker 1 (00:25:59):

Let’s see. Yes, thank you, doctor. Okay. The T in POD stands for tachycardia. So POTS is postural orthostatic tachycardia syndrome. So usually when you stood up, you may have a slight increase in heart rate, but not enough to matter. Most people don’t feel fluttering of their chest, but in these patients, I mean they basically pass out because they don’t get enough blood flow to their heart. Their heart tries to pump to get more fluid to it and then they pass out. So that’s why they’re always drinking and keeping hydrated. And so POTS is considered to be in the autoimmune and inflammatory status. Thank you for Thank you for the notes. Oh my god. Sometimes you kind of forget things. Okay, next question. I had inguinal laparoscopic hernia repair in 2017 in August. Oh, in August I was, okay, so 2017 laparoscopic inguinal hernia repair. In August, I was training legs at the gym.

Speaker 1 (00:27:11):

I felt a tearing sensation two weeks after the doctor pressed on my lower abdomen strongly to check something and I was in terrible pain for a couple of months with many symptoms. Doctors cannot find the source of the pain, but there was no recurrence. Now the pain has subsided. Is it dangerous to keep working out? First of all, it’s not dangerous to keep working out no matter what your symptoms are. Secondly, if you felt a tear, probably the Mesh pulled away. It’s very likely it pulled away and caused like a sports injury, but not necessarily hernia recurrence. And that’s the reason why you had the pain, the inflammation similar to a sports injury like a pulled groin and then you got over it, which is great. In rare cases, the tear is an actual tear of the Mesh or a hernia recurrence, and that pain does usually does not go away. So if you need more information, I can always order you an MRI, kind of review your symptoms and the prior images with you and confirm that there’s no hernia recurrence. But if you have no pain anymore, then feel free to be as active as you wish to be. You’ve healed whatever it is.

Speaker 1 (00:28:27):

Aw, thank you. One of the things that makes Dr. Towfigh so extraordinary is that she has a great fund of knowledge and other disciplines of medicine besides her surgical expertise. Thank you for that. So if I could comment on that a little bit. I was a pretty good medical student. I wouldn’t say I was the number one student, but I was very inquisitive and I enjoyed all the topics that I learned. I think I got honors in psychiatry. I really wanted to be a psychiatrist at one point. Did very well in surgery. Obviously I’m a surgeon and I really paid attention to all of that. And then as my practice grew in surgery, like I said, I’m very inquisitive. I’m always on Google trying to search answers to questions. It really bugs me if I don’t know an answer. Even simple things, I don’t know what was the word I, I learned the word barage today, bladder barage.

Speaker 1 (00:29:28):

It means when they kind of try and do cytology during cystoscopy for bladder tumors, I don’t know what that word was until today, it’s my new favorite word, bladder cystoscopy with bladder barage. Anyway, so I always ask questions and I read the patient’s chart a lot and I work with a lot of specialists and I try and learn a little bit from that because then I can share it with my patients. And I also come from family and friends that are constantly calling me, asking me about, oh, I have a headache, I have knee pain and my chest hurts. What do you think? So I usually just refer ’em to good doctors, but I do want to know the answer myself too. So thank you for noticing that. I feel that more doctors we should be less kind of vertical in our education are more horizontal.

Speaker 1 (00:30:21):

So many patients come to me that saw the neurologist who said, it’s not my problem. Saw the urologist that said it’s not their problem. Saw the pain doctor said it’s not their problem. Like general surgeon said, it’s not their problem. As opposed to seeing one doctor, which it’s often me, and I say, okay, I’ll be your team of the, I’ll be the captain of the team and then let’s go to the urologist and see if they can figure out this problem. Okay, come back to me. Okay, now let’s go to the pain doctor. Okay, I don’t agree with what they’re saying. Let’s send you another pain doctor. So I’ve kind of become the captain of the team for a lot of my patients, even though I’m a surgeon, usually a primary care doctor does that. So I really appreciate the handful of primary care doctors that really follow up with their patients instead of just sending ’em to specialists without helping the patients kind of digest that information.

Speaker 1 (00:31:11):

Okay, enough about me. How would you treat a torn Mesh given the problems of placing Mesh on Mesh? Okay, we don’t do Mesh on Mesh because Mesh does not stick to Mesh. So if there is torn Mesh, then you need a redo of that repair. So if it’s an Onlay Mesh you put on top and then the redo of the hernia is behind. You do a posterior repair, so anterior repair, it gets a posterior repair. If the posterior Mesh is torn, you do an anterior repair. Mesh does not work on Mesh. Now a little bit of overlap is okay, but Mesh only works by having tissue grow into it and it sticks to tissue. It does not stick to other Mesh. Mesh does not stick to Mesh. So yeah, we don’t do Mesh on Mesh. Okay, next question. Hi Dr. Towfigh. I have a lot of penis pain after my inguinal hernia repair with Mesh.

Speaker 1 (00:32:06):

I’m now six months postoperative. My surgeon has sent me to a urologist. My general doctor has me taking Lyrica to help with the pain. I ask my surgeon for an MRI and he said it would not show anything. I want to know if it’s nerve pain or the Mesh is causing the pain. I’m waiting to see my urologist, what should I be insisting on? Okay, so penile pain of P, the actual penis is not due to the hernia repair itself. So whatever nerves are in the area and muscles, et cetera for the hernia repair do not overlap with anything related to the penis zero. You can however have something wrong with your hernia repair like a recurrence or a folding of the Mesh that gives pelvic floor spasm and the pelvic floor spasm then irritates nerves that run through the pelvic floor muscle. Oftentimes that can be sacral nerves or the pudendal nerve and that irritation of those nerves because like the nerves go through the pelvic floor muscle and then the muscles constantly in spasm because of whatever was done. And so now the nerves are being irritated and then that translates into penile pain. So it would be a good idea to get MRI pelvis to look at the Mesh repair. It won’t show you anything abnormal about the penis to indirectly identify if that problem is what’s generating the nerve pain that’s going, that’s giving you penile pain. I hope that’s helpful. So that’s related but not directly related. Alrighty, next question

Speaker 1 (00:34:06):

I had, let’s see. I had left Inguinal hernia surgery in May of 2015 in Minnesota. I had pain from day one. We went to Arizona for the winter. Okay, that’s good. I saw a surgeon and he decided to go in for exploratory surgery. Okay, hold on. Left angular hernia surgery, May, 2015 pain ever since. Okay, the surgeon removed the Mesh but he replaced it with more Mesh. I’ve been in constant pain now my Mesh has migrated over my new suprapubic hernia and I have another inguinal hernia in my right side. The Arizona surgeon now wants to do robotic surgery on my super pubic surgery and now and new inguinal surgery. And if he does, if he sees the Mesh, he’ll remove it. I think I need a new doctor.

Speaker 1 (00:34:59):

I’m almost 79 years old and live in horrible pain every day. Now I have a lump over my left inguinal hernia surgery. I’m scared. Well, let me tell you, please feel free to get other consultations. I’m happy to entertain a consultation if you want to call my office. You need more than one eye to look at this. It’s not normal to have so much pain. And if you had Mesh removed, I’d like to know why it was removed. I’d like to know what the new Mesh was put in, what kind of Mesh, what technique I started the beginning of today’s show to talk to you about all of what I see and if a Mesh is put in too tight, if the nerves are not identified, if the wrong size, Mesh is used, wrong type of Mesh, these can all add to patient symptoms. So let’s see what’s causing this problem.

Speaker 1 (00:35:57):

But you are your boss. You need to take over your care. If you don’t agree with one surgeon, look for another surgeon, you still don’t agree. Look for a third surgeon. Fortunately in the United States, you ha are at liberty to see whatever surgeon you want and we have a wide range. They may not all be within the same county as you. They may be in a complete different state, but like I said, 80% of my patients are revisional operations and I would say a good 70% are not from my city or county, all from outside the county or outside of the state. So people travel and you may have to travel but do prioritize your health. Absolutely. I see so many people that feel they have to stay within their means and they suffer. And I also have patients that say, oh, I can’t afford your surgery because we have planned vacation this summer and I understand it’s important to have family vacation, but you’re suffering your family life is destroyed, your work life is destroyed. I would prioritize your health more than anything else and if that means traveling or working outside your network or saving money in anticipation if you were to get married, you have to save money for that. So this is even more important I think to your health is more important than any party. So that may be controversial, I don’t know. But I strongly believe that patients that prioritize their health always get the best care.

Speaker 1 (00:37:42):

Okay? I had emergency Mesh removal due to migration into my bowel and intestine. I ended up having bowel resection and fistula. I have been left with a hernia the whole side of my stomach. It’s huge. I’ve not been told they cannot fix it. Is there anything that can be done? I do have a heart st and lupus. Would this be the reason not to fix it? Okay, so I’m really sorry that this is happening to you. Let me just say, first of all, lupus does complicate things for two reasons. One is your probably at risk for not healing well whether you’re on steroids or some other type of immune suppression drug. And secondly, patients, some patients with lupus don’t do well with Mesh. So synthetic Mesh, you’d have to use something more of like a hybrid Mesh or it’s inflammatory.

Speaker 1 (00:38:39):

And I want to make sure this term migration isn’t overused. Every single patient this past week has told me about, asked about Mesh migration. Mesh plugs have been known to migrate, not most of ’em, but some of them because the surgeon didn’t sew it in place but or correctly it sewed in place. Mesh flat Mesh does not migrate. It’s it can fold, it can bend, it can, it can tear. It doesn’t migrate. I can’t put Mesh in the left groin. It ends up in the right groin or put Mesh in the abdomen and it ends up in the chest. That just doesn’t happen. It may just be a term that’s used very loosely, but as a physician, I never use the word migration because that doesn’t actually physically occur. So erosion, it sounds like you have erosion of the Mesh with your bowel, which is worse than migration, but it’s not technically migration. So yes, there’s always options. You must be of normal weight to ever consider anything else depending on how much into muscle you have and the quality of the muscle that you have. There are options. Yes, the heart’s, well if you have a heart stent but your heart is fine,

Speaker 1 (00:40:01):

It just complicates things. But I operate on the heart failure. Patients at Cedar Sinai in the, we are the number one heart transplant hospital in the world, so it’s higher risk, but we still do it. We just have to be very cautious as to what technique we use. So there’s always options I would not give up. All right, next one. I’m having Mesh removal due to severe pain because of diastasis. I have three small hernias, less than three millimeters each. What complications would you mention to your patients after removal and lyse cage other than hernia recurrence? Okay, I’m going to assume that you had three hernias, less than three millimeters each within a diastasis and you had a Mesh based surgery. The Mesh removal is not due to pain from diastasis. Diastasis not, does not cause pain. You may have some type of

Speaker 1 (00:41:05):

Hernia related or Mesh related pain, but diastasis does not cause pain. What I do recommend though, and people who have a diastasis with small hernias within it is not to get a Mesh based repair. It’s just to get a tummy tuck, get a abdominalplasty and placation of that. You don’t need Mesh first three millimeter hernias. So the complications related to diastasis placation depends on the technique. If it’s done robotically, which is how I offer it, then there’s some risk of bowel injury and there’s a risk of the diastasis placation falling apart and you having a diastasis again or hernia recurrence again, that’s pretty much it with the plastic surgeons. There’s a lot of risk with wound complications and skin issues, but that’s about it. So many questions. Okay. How would you manage someone who wakes up in recovery from either, oh, I know you’re wanting me to ask the questions you submitted. Okay, we shall do that.

Speaker 1 (00:42:23):

How do you manage a patient that wakes up after hernia surgery and severe pain? I actually had this happen, so here’s my concoction. Almost everyone who has open or laparoscopic hernia surgery will benefit from local anesthetic widely used during the surgery. So what we call a tap block or just preemptive analgesia, Toradol, which is basically IV naproxen or IB IV ibuprofen, if you can think of it that way, because hernia surgery pain is inflammatory. Anti-inflammatories work great. So Toradol and ice packs, ice packs, ice packs. I had a patient recently who was young and writhing in pain and the reflex by the nurse in the PACU was to give him narcotics. No, no, no, you can flood him with narcotics. That won’t work. He got Toradol, Tylenol IV and ice packs. Pain went away. So that’s what I do when you wake up after hernia surgery and severe pain, you need toradol, Tylenol and ice packs. If it’s a large abdominal wall hernia, a binder also really helps.

Speaker 1 (00:43:44):

The other question is how do you recognize and manage surgical injury to the nerves? First of all, you have to know your anatomy very well. In the groin, it’s pretty much similar to in every patient, but there are some abnormalities that you should be aware of. If a patient gets nerve injury at the time of surgery and that nerve injury is not a clean cut of the nerve, they will have severe pain waking up after surgery as if the nerve was being triggered. So it’s not necessarily groin pain. They’ll say, oh, like burning into my scrotum, I’m burning into my inner thigh, wrapping around my back following the track of the nerve. It won’t be just incisional pain.

Speaker 1 (00:44:34):

In that case you have to go back to surgery and identify the injury and address it. Sometimes you put a suture through a nerve that you didn’t see. Sometimes it’s been injured and that needs to be manage. Now if it’s not immediate and is happens later, it gets entrapped in scar. For example, the nerve gets entrapped in scar or the Mesh folds over the nerve then, or you have a neuroma because it was injured initially and then there’s about a 5% chance of neuroma after that. Then those can be treated by local nerve blocks, possibly ablation and in rare cases hysterectomy. Hope that’s helpful. Okay, let’s go to some more questions.

Speaker 1 (00:45:29):

I had a hernia surgery and I had so much trouble where I haven’t been wearing clothes in 15 years and my nuts swell big as a baseball and my body will swell. Okay, so if you’re not wearing clothing including underwear after hernia surgery, then you have some serious entrapment of nerves or the spermatic cord. I had this very patient he was suicidal from this would not wear underwear. He made like a hammock, like a sling for his testicle because any swing of the testicle also hurt. But he also hurt so much that he couldn’t wear any underwear or anything, touched the groin area. So I cured him. But the problem for him was the Mesh had kind of rolled around all the contents of the spermatic cord, which include nerves and other nerve type damages. So you have to address all of those. It’s often a surgical problem, but there is a cure. I hope that helps. If you’re not swell big like a baseball, it can be because all the Mesh that’s entrapping the nerve is also entrapping the blood vessels to and from the testicle.

Speaker 1 (00:46:43):

So you basically have an obstruction of the venous blood flow from your testicle back to your heart and that bulges and can be very painful. So surgically you have to remove the Mesh, release the adhesions and allow for better flow and it it’s, there’s a cure for that. Done it multiple times. Can you have more than one umbilical hernia at the same time? I had one repaired with Mesh in 2016. That 2017 I was told I had another umbilical hernia. Is it possible to have a new one or just the original one that was repaired? So naturally you could have a hernia at the belly button in the stock or within an inch above it, and many people call those both umbilical hernias. It’s unclear. Or you could have one at the stock of the belly button and then that could recur because let’s say you had another surgery, laparoscopic surgery let’s say, and that caused another hernia and then you have a recurrence of that umbilical hernia.

Speaker 1 (00:47:37):

So either of those is possible. Next question. I have had numerous hernias, lyse of adhesion and Mesh. Now with polypropylene covering my entire abdominal wall, I had an abdominal wall reconstruction expert. Say he removed it along with a pathology report. No other surgeons were to touch me. He told me it could take 12 hours. Seems he’s part of the a r complex hernia community. Only later to find out months later with sonogram, he never removed anything. It seems I’m being blacklisted. Okay, you are in charge of your destiny. No one can blacklist you. There are tons of surgeons available who can help you. So I don’t understand how you can be blacklisted. Just go to another doctor if you have lost confidence in that first doctor. If you feel that you need more evaluation and identification of your needs, including removal of Mesh, I’m sure another surgeon would be able to help you.

Speaker 1 (00:48:36):

Alrighty, we’re getting close to time. Okay, let’s see. How do you recognize a managed superficial wounds and then also deep wound infections after hernia surgery? So there’s three categories of wound infections, superficial deep and organ space. That’s, as the CDC describes it, it’s not common to have any of those in elective inguinal hernia. Sorry, elective hernia surgery because they are always clean. If you ever have a break in sterility or it’s not elective surgery or you have any bowel surgery involved, those are clean, contaminated, contaminated or dirty wounds, which are different wound class than the clean wounds and you’re at high risk for superficial deep or organ space infection, superficial incision, superficial infections. You just open up the wound, clean the area, do wound care and give antibiotics. However, it, it’s very important hernia surgery because we often use Mesh or use sutures or use both and all of those are potentially implants that can be, can cause, can be infected as well as a deeper infection. So every time that you have a hernia operation and you have a wound complication, it’s super important that all steps are made to reduce the risk of the Mesh or the suture getting infected.

Speaker 1 (00:50:19):

Thank you Dr. Tofi for your hearing talks. Well, thank you. I have a question here about Mesh and sutures migrating into the inside of your esophagus. That’s from hiatal hernia surgery. I don’t do thoracic surgery, so I would defer to a thoracic surgeon for those. Thanks for your advice. Well, you’re welcome. Thank you. Love all these. What are the pros and cons of a femoral hernia being femoral hernia being repaired with Mesh and without Mesh? So the gold standard for a femoral hernia repairs is A, to repair it, not do watchful waiting and B, to do it laparoscopically with Mesh. The reason is there’s a higher incidence of not just hernia recurrence, but serious chronic pain with tissue repairs or anterior Mesh repairs for femoral hernias. So to reduce chronic pain and to reduce hernia recurrence, we recommend that these be done laparoscopically with Mesh. The pros and cons, recurrence and chronic pain. If a patient was vomiting immediately after surgery and was ill with flu-like symptoms not getting better, what would you do? Yeah, vomiting and coughing are two things you don’t want to do early after hernia surgery. Those cause the most amount of abdominal pressure and

Speaker 1 (00:51:51):

I mean one vomit is okay, one couple cough are okay, but if you’re constantly vomiting, that needs to be treated early and a cough needs to be treated early. Even with coating, if you have to surgery with Mesh, yeah, it doesn’t matter if it’s Mesh or no Mesh either way. All right. Next question. Deepen this one. Sorry, let’s go back.

Speaker 1 (00:52:20):

When should I be seen by a hernia specialist? Great question. Okay. I mean, if you were my family member and you had any disease, I including hernias, I would always make sure you’re seen by a specialist because that’s all they do is that one disease. So if you have a hernia, I would recommend you always be seen by a hernia specialist, but I understand that that’s not reality. So if we actually published a paper on this, if you have a complex hernia, then for sure you should be seen by hernia specials and complex hernia includes recurrent hernia, morbidly obese, patient with hernia and a very large hernia. So that’s what I recommend, don’t what I see, and I really hate to say this because we just don’t have enough hernia specialists in town to handle the volume, but

Speaker 1 (00:53:21):

If you have a complication from one surgery and this doctor was not a specialist, then maybe you should at least get a second opinion with a specialist before you pursue another operation with that same surgeon. Okay. When Mesh is involved, what are the signs that your surgeon is not seeing or that are hiding potential complications? That’s a great question. So one thing is that recurrences or Mesh related complications like folding and so on, or a tight repair, those are all things that are sometimes missed if they’re subtle. So I would say it’s the subtle findings that are difficult to handle. Oftentimes imaging is done and the radiologist doesn’t understand the details of what it means to read an image. And so they’ll say like, I like one patient I had today normal satisfied hernia repair, normal findings, and it’s not normal. He had a hernia recurrence but it was small and it wasn’t an obvious one.

Speaker 1 (00:54:32):

So one of the pitfalls, the ED surgery, which is what this whole hour is supposed to be about when of the pitfalls and hernia surgery is that people don’t read their own images. And I understand that not everyone should be expected to read their own images, but I do. And I think the majority of my patients benefit from the fact that I was another eye looking at that image and not so much relying on the radiology report itself and then believe your patients. I think that if you believe in your patients and if they tell you anatomically they have this pain, it’s not in their head. Patients don’t go read a book and then tell you exactly how their ilio nerve pain is. That’s just not how it is. So I always trust my patients very much.

Speaker 1 (00:55:27):

We talked about that and we talked about that. Great. So we’re covering all of the questions, that’s really great. Let’s see. What would the main cause of soreness be several months after Mesh based hernia surgery, both over the scar and in the inner groin area? Would it be more likely to be nerve related or Mesh related? Hard to tell. Nerve related pain is often radiating pain, whereas Mesh related pain is very focal to the area. Several months after meshing surgery, you’re going to still be sore. Sometimes everyone’s a little bit different. Massaging the area and being active does help. If you have a specific area of point tenderness, I would refer that to the doctor. I’m very liberal in using imaging early on after surgery. The main cause of soreness is just having had surgery, inflammation and scar tissue. So anti-inflammatories work such as an naproxen, ibuprofen and ice packs, massaging works to help make that scar heal. And I hope that’s helpful. If you still have pain, I would go back to your surgeon and help figure that out. Or is she, I’ve got another opinion.

Speaker 1 (00:56:44):

Let’s see. How are we doing on time? Almost done guys. Okay. I had an open gallbladder removal in 2009. Gallbladder was too bad to do it laparoscopically, which happens, it’s usually in males, not sure. I think this is a female. While I was in the hospital, I developed a hernia that said it herniate up into the incision. Okay, that’s called an incisional hernia. They went in the right. They went in right above, right above the belly button. Not sure if Mesh was used. I’m sure it was for a incisional hernia. And from a gall bladder surgery, I agree a Mesh was likely used. Old C-section scar, I have an old C-section scar with two kids and a long eight inch gallbladder scar lots. I have lots of numbness throughout the area because of summer surgery. Now after some heavy lifting and after a fall tripping, I am having a pulling sensation. The groin and hip, I have no pain really just pulling feels like something might have torn around the old C-section scar, probably not old C-section scars do not cause hernias. New ones may and even that it’s super, super low risk.

Speaker 1 (00:57:59):

There’s no bulge that I can feel. I imagine I have a ton scar tissue, not necessarily a scar. Tissue goes away over time. Well, it doesn’t go away a hundred percent, but it does remodel over time. So the longer you have your scar, the less scar tissue. Now some people make a lot of scar tissue, but in general is what I’m saying. The old gallbladder scar bothers me a lot. I guess my question is could the pulling be a hernia or can the scar tissue cause the same symptoms if much is going to cause issues, is there a timeframe year-wise? So most Mesh related complications occur within the first year after surgery. Also what you should know is that your symptoms may be a new hernia and the groin since you’ve already had at least one of the hernia. And it can be like a hip related problem.

Speaker 1 (00:58:46):

So we’ve had some prior hernia attack, live sessions that have been with orthopedic surgeons will have more to come. And last thing is, I totally agree with Dr. Towfigh, you may need to travel to find the best doctor for your problem. It is possible. I’ve traveled across the country several times, your health and well being is worth it. A hundred percent agree. Okay, that was an hour, hour number 50 of hernia talk live. Thanks everyone, I really do appreciate it. Thanks for celebrating my one year anniversary with me and wishing me congratulations. I love it. And if you have any interesting topics or specialists you want me to call in for our next year of hernia attack live, please DM me or host it on any of my social media platforms. I have plenty of them on Twitter, at hernia doc, Instagram at hernia doc, Facebook. Many of you’re on currently at Dr. Towfigh. And I will post all of these on YouTube and goes watch all 50 of my sessions on YouTube and it’s all categorized by topic. You can also search for it. So what a great way to finish number 50. Thanks guys. It was a truly a pleasure. See you again on Tuesday. Bye.