Episode 52: Choosing TeleHealth Consultation with your Hernia Surgeon | Hernia Talk Live Q&A

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Speaker 1 (00:00:01):

Hello everyone. Welcome to Hernia Talk Live. My name is Dr. Shirin Towfigh. I’m your weekly host here. As many of you knew, I am a hernia and laparoscopic surgery specialist at the Beverly Hills Hernia Center. You can follow me on Twitter and Instagram at hernia talk. Many of you are joining me live on Facebook at Dr. Towfigh. And as always, at the end of our session, I will make sure that you all have a link to my YouTube channel where we will be reek broadcasting today’s episode. So I would like to introduce you to my good friend and hernia surgery colleague, Dr. Vahagn Nikolian. Dr. Nikolian is a new faculty surgeon. He is specialty is an abdominal wall reconstruction and he works at the Oregon Health Sciences University in Portland, Oregon. You can follow him on Instagram and Twitter at vNikolian. So please say hi to Dr. Nikolian. Hi, how are you? Yeah,

Speaker 2 (00:01:02):

Hey everyone. And hi Dr. Towfigh. Thank you so much for having me on the show today.

Speaker 1 (00:01:07):

Hi. Yeah, I introduce you as a abdominal wall reconstruction specialist because that’s really what seems to make you get all excited to come to work every day. So in addition to answering questions about abdominal wall reconstruction, I was hoping that we could also spend the beginning of the hour to talk about your academic interest, which is very relevant to our current COVID based pandemic healthcare, which is digital health or telehealth. Can you give us a quick, brief overview of what I’m talking about?

Speaker 2 (00:01:46):

Absolutely. So it all start for me, just so everyone has a little sense of where I’m coming from. I didn’t jump on the telehealth and digital health bandwagon because of the pandemic. Remarkably, I got into it way before it was cool back in 2016. Oh wow. And I was a trainee at Michigan and we were just trying to improve access to care, give patients the opportunity to see us in a convenient manner. And we had a lot of issues in our clinics or surgical clinics in particular of seeing patients in an efficient way. They would get a referral and there would be such a long delay before there could be time to see them. So one of our main focuses was how can we make this more efficient? And I felt like we’re already at that point in time connecting with friends and family, with FaceTime and other mechanisms.

Speaker 2 (00:02:43):

Why not extend this to our patients? It had sort of been dabbled with among surgeons but not necessarily formalized. And so we started it as a quality improvement initiative at the institution and we started it, we called it the Surgery E clinic. And it did great. I mean it really improved access. We started with what we defined as a relatively low risk patient population. We didn’t do any preoperative evaluations. We focused on post-op patient care in uncomplicated, minimally invasive surgery where there would be probably one or two incisions to assess. And we just saw how patients that rolled it out solely and it was very successful. We reviewed what patients thought and the vast majority of them really enjoyed the program. They thought it was saving them a lot of time. We were a big academic center and as you know, Dr. Towfigh patients will travel a long distance to get expert care.

Speaker 2 (00:03:45):

And so we were saving patients on average about a hundred miles in round trip. Remember, this is straightforward surgery. This isn’t subspecialized care where you’re seeking a specialist. That’s the only person that can do it in a remote region. And so for this patient population, it was advantageous and it’s expanded. It’s expanded quite a bit. And pre pandemic, it was slowly expanding. There was a lot of barriers, some of them made sense, some of them didn’t necessarily make sense. And then the pandemic hit, which has been an unfortunate tragedy for all of us, but it has shined, maybe given us a little silver lining in that it’s given us opportunities to explore new innovative ways to do things that we used to do so readily, which was see patients in clinic and every person’s been exposed to maybe an efficient encounter via telehealth. And many have been exposed to inefficient encounters via telehealth. But the bottom line is people have seen that there is potential and now we’re trying to build upon that potential.

Speaker 1 (00:04:59):

So telehealth means you and the patient are in separate areas, usually the patients either at home or at work or somewhere and you’re usually in your office, but you can be at your home during the pandemic. Many of us were at home, absolutely. And then is it always video based?

Speaker 2 (00:05:16):

So it depends and it depends on everyone involved. So we talk about the stakeholders and so the provider is a stakeholder and the patient is a stakeholder in this very critical relationship that we’re building. I mean to talk to someone about the potential of a surgery is one of the most important conversations that we’ll have with patients. And so we want to make sure that that conversation, that sacred interaction that we’re having, that we’re honored as providers to have. We want to ensure that that is as patient-centric possible. So I always ask myself one, if it’s a surgeon who wants to implement telehealth, are they comfortable with their, we used to call it bedside manner, but now their website manner and then

Speaker 1 (00:06:09):


Speaker 2 (00:06:09):

That’s a good one. I want to always remind our patients that this is an option. It’s not an absolute. So as a patient, if you’re comfortable with a digital health encounter, whether it’s telephone or video, then we’ll proceed. And then with regard to what’s better, video or telephone, it all depends on what you’re trying to accomplish. And everyone’s different. So every surgeon’s different, every patient’s different. I think it’s always nice to have it as a initial touch base, figure out what’s going on, ask some questions. You may not get the video feed, but you may get a lot of information. I think sometimes it’s more important that exchange of ideas than necessarily the visualization of someone. Now have I seen patients in the preoperative setting with a telephone or discussed it over a telephone call and then not seen them before an operation? I have, and that’s a very small proportion of patients, but for the most part I’d like to establish at least a video connection. And for most of my patients, I think they would all agree that they like to see me in person in advance of surgery. So that’s something that we try to do.

Speaker 1 (00:07:35):

So I’d like to ask this question about hip hop. From what I understand about HIPAA, if a patient agrees to be emailed, understand the risks of emails. Someone may hack into your computer and read all your emails, then there’s no HIPAA violation if the patient agrees for me to email them. The same, I believe is true for video. If the patient agrees to have a visit with me, a consultation via FaceTime or Google Duo or even Zoom like we’re doing now, then and the patient understands again, there’s a risk that someone can steal this feed right now and hear all about their groin pain. If the patient’s agreeable to that, then there’s no HIPAA violation. But I also see that there’s a lot of programs and new systems that are HIPAA compliant. Do I have to do it through a HIPAA compliant process or if the patient understands that we’re going that there are other easier options just so easy to do FaceTime or Zoom or dual with a patient, is that still okay? As long as the patient agrees to it?

Speaker 2 (00:08:51):

Yeah. Yes and no. So how is it okay during this pandemic, there’s been a lot of emergency measures that have been taken to allow for increased access, recognizing that the system is not perfect. And so right now you absolutely can connect via any platform with a patient as long as there’s a exchange of understanding about the risks, benefits, just like everything else we do in life, it’s all about consent. And if a patient is having implied consent to the interaction, then it should be okay. That said, I operate and work through strictly my electronic medical record based interactions with patients. Why I just as an added LE level of security. But everyone’s different. I think especially when you’re talking about some of our patients that are being evaluated from afar who may not have that platform set up, it can work. And I think telephone is still a very safe option.

Speaker 1 (00:10:03):

Well, I would say that, well, thank you very much for that. And I would say that I feel that this option for telehealth has really helped so many patients. It’s cheaper than, so you hinted on this. I see a lot of patients outside of my area this week alone. I’ve seen patients from Canada, Ohio, Florida. I think Idaho was one, but it’s great. But I’ve also done telehealth with people that live 20 miles away from me, but LA has traffic. It’s so much lower not to have to ruin your day, to have to talk to a doctor for something simple. So for sure, I think it helps my patients. But the question that came up and we have some questions we’re submitted ahead of time was how can you make the most of a telehealth consultation?

Speaker 2 (00:11:05):

Great. And when I guess we’ll answer it from two perspectives, we’ll answer it. I want to focus on the patients since I know we have some listeners here and most of us are focused on the patient right now. I think information and data is critical. The more information that Dr. Towfigh has or I have before seeing a patient, the more I can cater my plans to what I already know. I always tell my team whenever I work with medical students, residents, and other individuals on my training team, if you have a lot of data, you can walk in with a better sense of where the missing elements are so that you can formulate a really structured patient-centric plan. And so the more information, the better. I think I saw in your recent post on social media about your typical consult and it was a folder full of operative reports, CDs with

Speaker 1 (00:12:13):

CDs. Yeah, it’s like a hundred page hundred page document and I loved it. Honestly, I love that

Speaker 2 (00:12:20):

That’s better than the alternative where you get patient name diagnosis or suspected diagnosis and a desire to be evaluated with that. You walk in blind and the conversation that you now have with the patient, there’s going to be a lot of elements of discovery, which sometimes ha will have to happen, but you’re not going to be able to focus in on knowing exactly where the missing elements are to guide you your recommendations during that consultation.

Speaker 1 (00:13:01):

Very time

Speaker 2 (00:13:02):

Data is king. We love data. If you have operative reports as patients, I always say operative reports tell us so much. Just the simple things of knowing what’s suture was used to secure a piece of Mesh, what Mesh was used, what approach was used. There’s a lot of things that the surgeon can interpret from that information that the patients may not have as much familiarity with, but we’re able to extract or AC take that out of there and sort of help that with our plan formulation.

Speaker 1 (00:13:37):

Yeah. Yeah, that’s pretty good. The next question is in the same line, which is can telehealth work if a diagnosis is ambiguous or controversial? So if you have an inguinal hernia or a bellybutton hernia and you want initiate a telehealth, that’s pretty straightforward and probably through even a low definition video base, I can look at your belly button and be like, yep, there’s a belly button, hernia, we can fix it. And I can also see if you’re morbidly obese or fit and probably see some scars in your belly or not. And then that’s pretty much most of the physical exam part of it. But I see patients with endometriosis and groin pain and pelvic pain a little bit, and then it shoots here and there and you can’t really see it, but if you touch it, it hurts. And there’s so many minutia, especially in the pelvis, not so much abdominal wall that I find that, well, first of all, my minimum is I have to examine you, so even if you choose a telehealth with me, if you choose to have surgery, you have to come in the day before surgery for me to lay my hands on you and confirm the plan of care.

Speaker 1 (00:14:52):

But do you find that all patients are equal? Like telehealth works for all types of patients or

Speaker 2 (00:15:01):

What? So I would say no. I mean pretty common that we’re not going to be able to assess everything over a virtual visit. I think especially in our realm as hernia surgeons, groin pain is one of the more challenging diagnoses. It has so many different ways that it can go. I need to do an exam to do a mapping of the groin to understand is there a specific nerve that’s disrupted or in involved, is it something that’s more consistent with athletic pubalgia? Is it something that seems musculoskeletal or orthopedic in nature or urologic? Yeah, so groin pain, I generally find it to be a very difficult one to set a final diagnosis by the end of the virtual visit. What I will say is that many patients can still benefit from that initial telehealth eval. Why you can refine your sort of this thoughts. We get a lot from the history.

Speaker 2 (00:16:11):

And so I’ve had patients who come in or are referred to me for groin pain and we do a pretty thorough history of pre illness and ask ’em a bunch of questions, review their history, look at their operative reports if they have any imaging. I review that and through that process, I’m able to then pick out the diagnoses that seem most likely and tell ’em, I can’t necessarily say I know exactly what the diagnosis is yet, but here’s what I’m thinking based on what you told me. I think we’re going to need an MRI. Why don’t we schedule you for an MRI? We’ll have you come in after that result so we can further understand what’s going on. Sometimes I’ll have a scenario where, yes, the presenting diagnosis or chief complaint is something that would make me believe is going to be difficult, but then the story fits something more straightforward and there’s a lot of misinterpretation of what’s going on by referring providers because hernia can be very complex. And so I never hesitate to at least start my initial interactions with patients in the virtual setting. Again, it doesn’t mean everyone has to do it, it just means that it’s possible.

Speaker 1 (00:17:32):

Yeah, I think you’re right. Growing pain is difficult to do. I do it and the physical exam part of it is for sure inadequate and also very awkward, I must say. I don’t like it, but I do it and they almost always have to come in to see me. Yeah. Next question is, my surgeon doesn’t believe I have a hernia, but I cannot travel to see you for surgery. So what do you suggest?

Speaker 2 (00:18:01):

Well, there’s a lot of things to do. When you say my surgeon, I guess that the question is, is it the same person that you’re talking to visit or is it another surgeon locally, because I’ve had plenty of patients who have been told they don’t have a hernia and I evaluate them and we look at their imaging and I interpret it differently than say the radiologist just based on the morphology. That’s a completely different discussion in terms of what hernia urgency versus what a radiologist sees. Yes. But we oftentimes will have differences of a, not only opinion, but I think experience. And so yes, you can absolutely still get in touch with us via a virtual visit and learn more about what’s going on. I tell most of my patients that the interactions that we’re going to have, especially during the first evaluation, is centered around educating you the patient about what’s going on, and then you walk away from that interaction with a better sense of what may be the problem and we can come up with a plan together.

Speaker 1 (00:19:15):

I feel like sometimes the telehealth empowers the patient to get more informed, maybe ask more questions, go back to their original surgeon or seek, I’m happy to figure out surgeons or consultants that are near the patient to continue that. I have have actually a patient up north, she showed me her belly button and she was saying how she’s got super pubic pain, which doesn’t make sense for hernia because it’s either left or right in the groin, it’s not in the middle. And then shoots up to her belly button. And I’m like, all right, well show me. She pulled up her shirt and she had a purple belly button. I kid you not just purple, bright red purple. And I’m like, that’s, has anyone looked at your belly button? She’s like, yeah. And what did they think? Nothing. I’m like, how long has your belly button been so purple?

Speaker 1 (00:20:14):

And she’s like, oh, ever since this pain started three months ago, four months ago, something like that. And I was like, okay, she’s got urinary tract infection type symptoms, super pubic pain, and this purple belly button, this is a UCal. Yeah, abscess, right. But she lives way, way north from me, actually closer to you than to me. She should come see you. So she needs an incision and drainage and a urologist. And so I ask my friends who are urologists, who do you know up there? So I helped her up with the urologist, but then one didn’t work. So I found another urologist. But in some ways, at the very least, it gave her a direction to go. It would be horrible for her to drive all the way down to me for 12 hours and then I’ll be like, yeah, no hernia, but you do have this your right cyst abscess. So I feel like it helps give some direction

Speaker 2 (00:21:14):

By all means. And again, so what I love about it is that the geographic barriers that traditionally exist for evaluation are kind of taken out the door. Okay. There’s good and bad things about that, but in general, pretty

Speaker 1 (00:21:30):

Sorry. That leads to our next question, which is how does a consultation work if I live in Canada and you were in the United States?

Speaker 2 (00:21:38):

Wow. So I’ve personally not done any international telehealth or digital health. Dr. Towfigh. Have you?

Speaker 1 (00:21:46):

Yeah, just in one yesterday in Canada.

Speaker 2 (00:21:48):

So how does that, I mean I think this is a great question. Mean my goal is eventually to develop programs that will give us the opportunity to take care of patients internationally. But how have you navigated this? Because it can be Condon kind of challenging.

Speaker 1 (00:22:07):

So she’s in Saskatchewan, which is a very large but poorly populated province in Canada. And the medical care is equally kind of scattered. They have one MRI for 1.1 million people. Can you believe that?

Speaker 2 (00:22:20):


Speaker 1 (00:22:21):

I have one MRI per square foot in Beverly Hills. I’m exaggerating. It’s almost as common as Starbucks. So obviously those are patients that their insurance doesn’t cover anything in the United States. It’s often socialized medicine with no international benefits. But you know what? I have friends in Canada, I can refer, I actually called gynecologist friend of mine in Toronto to see if he can help her. Or I’ve had patients either drive or fly in, but now there’s a pandemic. So that complicates things about international travel. And Canada’s not in a good situation right now with the pandemic. So at the very least I’m giving her some ideas of what’s probably causing her pain, what she needs to do, how I can be involved, and how maybe she can get care in Canada.

Speaker 2 (00:23:16):

Well, yeah, definitely in an area where I think as someone that practices out of the academic setting, it’s PR or the purely academic setting I should say. It might be a little easier for me. I haven’t been able to navigate that particular scenario just yet.

Speaker 1 (00:23:34):

I think not being linked to an institution, I don’t have any barriers. So I can see anyone from anywhere at any time. That is definitely something that I love the freedom you’ll get there, you’ll get

Speaker 2 (00:23:48):

There. Yeah. I mean when I was in my fellowship in New York, we’d oftentimes at international sort of consultations, but they were happening in person. So I guess it’s kind of an extension of that.

Speaker 1 (00:24:02):

Yeah, it’s an extension. We have a comment about a patient of mine. Our teleconference was most helpful and informational. I didn’t have to fly from New York to California either, but I would have. That’s very nice.

Speaker 2 (00:24:13):

Very good.

Speaker 1 (00:24:15):

Okay, another question for you medical question. What is the thorough examination to detect causes for abdominal muscle discomfort, soreness, and irregularity of the muscles? How can someone strengthen the core if they’re still having constant lower back pain as a result of tender muscles of the abdomen?

Speaker 2 (00:24:34):

Alright, so we’re sort of switching the sort of focus here back to sort of abdominal core health from what I understand. I mean it’s a process. I think there’s a lot of ways to do it. It depends on what the issue was to start with, to then sort of develop a focus plan. So anytime someone’s coming in with abdominal core issues, yeah, we try to one figure out what the primary issue is. Is it a abductor strain, which is from your leg? Is it a rectus strain from your abdomen? Is it an actual defect, like a hernia that should be repaired so that you can have functional recovery? Is it something from your back or your hip? And so all of those, whenever we identify the problem, one, if it’s something that can be fixed with an operation, we’re happy to do so. And then afterwards, all of the accessory muscles that were sort of compensating will be engaged in the recovery as well as the area of interest.

Speaker 2 (00:25:45):

So it’s a well-rounded approach to recovery. We don’t want to focus just on one, but recognize that it is a functional system, so to say. So we like to have a very robust and well-rounded recovery program. One particular program that has probably been highlighted on this show before when Dr. Poulose was on and as well as Dr. Rosen is the ACHQC application. And so as patients you can download the ACHQC app, I recommend it to all my patients at minimum. It gives you sort of the lowest bar to clear in terms of expectations and gives you some at home exercises that you can do. Yeah, some guidance on what’s too much, what’s too little, what’s like an appropriate amount of recovery at various time points after surgery. And then of course we’re always happy to be engaged with your physical therapist say and tell them, Hey, this is the operation we did, here’s how it’s going to impact their core. Here are some good exercises. If you have questions, ask us. We’re happy to provide some thoughts as to whether or not it’s a good idea or bad.

Speaker 1 (00:27:04):

Yeah, I agree. In fact, the last patient I saw today, I went through the ACHQC dot org website, showed ’em that the patient dropped down and how to download the app, but also kind of exercises that are considered safe and recommended for after abdominal wall surgery. It’s great. It’s great that Dr. Poulose has done that and as a result he’s really building a great center at Ohio State. And we had both Dr. Poulose and Dr. Yanis. So here’s the thing. I think this with regard to this question. Hernia can cause abdominal wall pain and soreness and feelings of irregularities and also lower back pain. But some people also get muscle strains. Do you often see just virgin abdomen never had surgery, but they get muscle tears of the abdomen? I know we get it in the groin, but do you see any in the abdomen?

Speaker 2 (00:28:02):

Not as common. I mean rarely we’ll see it. Yeah, usually there’s some sort of traumatic incident or some really abrupt movement or sports related injury. So we can see those. But it really is a complex diagnosis, very difficult to do in the telehealth environment and it requires a thoughtful history to be taken from the patient. So a lot of questions, some careful physical examination, and then occasionally some very detailed imaging studies, whether it’s an, especially for musculoskeletal injuries, I think MRI is wonderful, gives us a lot of information and then we’re able to develop a catered plan

Speaker 1 (00:28:47):

And you have to order it special. It has to be a soft tissue MRI. Otherwise they tell you your organs are great, great, great intestine. We’re like, where’s the adaptable? Yeah.

Speaker 2 (00:28:57):

My indications for the procedure whenever I’m trying to protocolize it with my radiology colleagues is almost as long as my history of present.

Speaker 1 (00:29:06):

Yes, yes. That’s so true. I wish more doctors did that. Yeah, doctors should write like MRI abdominal pain and then our

Speaker 2 (00:29:15):

Radiologists are great, but if they’re going in blindly, just like we talk about with us, the more data the better. Yeah, absolutely. And we try to inform them so that they can give us the answers we’re looking forward to.

Speaker 1 (00:29:26):

I think I should bring a radiologist on as a guest. What do you think? No, I

Speaker 2 (00:29:30):

Mean if there’s plenty of good options. I know at OHSU, we have a really good one. Yeah, a really great team. But yeah, I think a radiologist would be wonderful. Yeah. It would also be I think an opportunity for quality improvement down the road to have us work with them to better define things like diastasis recti versus hernia versus loss of domain. It would be pretty cool.

Speaker 1 (00:29:55):

Yeah. The one thing I have noticed is that people who have abdominal walls spasm for whatever reason, usually they’re athletic, their muscle spasm so hard, it feels like a ball and it’s usually not an area where you would get a hernia. So left upper abdomen, right upper abdomen. And they’re like, I have a hernia. See I have this ball. And sometimes you can even feel it. And what I’ve noticed is that that’s just muscle spasm and then you inject it or it can do what’s called dry needling and other physical therapy type things and the pain goes away. I’ve almost always had situations where those are strains or spasms. You can’t get hernias everywhere. But I’ll give you a great story. This week I saw my very first patient who actually had a traumatic abdominal wall injury in the upper abdomen, never seen it before. It’s almost always a muscle spasm. And I said, she’s like, I have this pain. I get this bulge every so often right below my rib. I’m like, that doesn’t make any sense. It’s always like a spasm. And I said, okay, how long you had it? 15 years. 15 years. You’ve had this bulging pain, push it back in. It goes fine. So I said, okay, how did this start? Okay. She was rock ice climbing. Do you know what that is? Oh

Speaker 2 (00:31:19):

Yeah. Wow. That’s pretty

Speaker 1 (00:31:20):

Impressive. And she fell like free, fell

Speaker 2 (00:31:23):

A spike,

Speaker 1 (00:31:24):

And then she grabbed an ice pick and pushed it in. And that stopped her fall. So much so that she dislocated her shoulder, had to get shoulder surgery, and then she got pain under her Rives. And if you look at her imaging, she tore her transverses abdominus offer rip.

Speaker 2 (00:31:43):

Yeah, that makes

Speaker 1 (00:31:44):

Sense. But the rest of the muscles on top are normal.

Speaker 2 (00:31:48):

So it’s almost like an intraparietal hernia. Yes. I’ve had a few of those. I’ve actually had upper abdominal intraparietal hernias because the now we’re getting into deets that our patients don’t necessarily,

Speaker 1 (00:32:00):

Oh, they know my patients

Speaker 2 (00:32:01):

Know. But there’s multiple layers to the abdominal wall, and sometimes you can have a hernia that sits between the layers and so never, even though you can’t necessarily see a definitive bulge, like the hernia that you see on Dr. Google, you can still have a hernia that’s in the layers of your abdominal wall. And I’ve definitely seen those. They can be symptomatic and when they’re present, if you’ve ruled out all the other causes of hernia or pain, it may be worthwhile to go after fixing those things.

Speaker 1 (00:32:34):

So I’m planning on robotically reattaching. It’s small. It’s not big to the Rives. Okay. Yeah, that’s a cool one. I thought that was really great. After 15 years, she finally got it diagnosed by me. Okay, next question. If I schedule a telehealth Condon consultation and I come with imaging, let’s say an MRI that has already been done, but not the imaging that was performed the way that you would necessarily do to detect at a called hernia, can the telehealth doctor order new imaging remotely at a facility that is local for me?

Speaker 2 (00:33:06):

Absolutely. Yeah. I always recommend if you have imaging, give us an opportunity to review it. We can often review the imaging ourselves, but also send it to our colleagues, radiology experts and colleagues who can review it. Sometimes it may be enough, it may not, yes, be the perfect protocolized study, but rather than having you definitively undergo a appropriately protocol exam, if we have the information we need, you don’t need to undergo further imaging if it doesn’t have the answers we’re looking for. I still like to do a history and sort of a history of present illness, get a as much information as you as possible so that we can cater the exam and the diagnostic tests to what’s problematic with the patient. So if you have a study like an that doesn’t exactly show what the other protocolized MRI would, I wouldn’t jump to just get another MRI, but rather chat with you as the patient, make sure that the story still fits what we’re searching for. Because if the story doesn’t fit and there’s a MRI that doesn’t show it, we may not necessarily ask for an MRI. We may Yeah, that’s right. Go for another option.

Speaker 1 (00:34:24):

That’s right. But as a telehealth doctor, you have developed that patient doctor relationship and therefore you can order studies, and at least in the United States, you can cross state lines with prescriptions. So I can write a prescription for an MRI and you can go to another state and provide that and they will honor that. So that should be okay. It’s just across country lines. Yeah. Often I just write the prescription, they hand it to their own doctor and their own doctor will then prescribe it because the healthcare systems are a little bit different.

Speaker 2 (00:34:58):

Yeah, no, for sure. And these are rules and regulations that we had been working on for years trying to establish that were not present as a doctor to practice across state lines. You had to have licensing across multiple state lines. There are organizations that help us do that, but it’s not necessarily straightforward during the pandemic because of all of the issues related to access to care, these rules and regulations have had emergency changes. So now we’re able to practice across state lines with no limitations, which is great, which is also something that we’re very careful about because it’s a slippery slope. But I think for now it’s a absolute necessity.

Speaker 1 (00:35:53):

What is the approach to thin abdominal muscle layers? Is there any rehab that could be done or surgery with Mesh or a flap needed?

Speaker 2 (00:36:02):

Very interesting question. Again, a lot to sort of unpack from this particular question. It all depends on what the cause of the thinning is. For instance, is it thinning at the middle portion of your abdomen because you have a diastasis, which is your six pack muscles or your rectus abdominus have splayed apart? Yeah, your connective tissue is still there, but it functionally feels like a hernia even though it’s not necessarily a hernia and it’s not necessarily something that absolutely has to be fixed. But is that the thing someone’s talking about? Is it a nerve issue from their spine that’s caused almost decreased sense muscular tone to the area served by the nerve? Those are going to be managed very differently. A diastasis can be managed surgically where we reestablish the position of the muscle. If you have complete loss of muscle nerve endings, we may not be able to give you the same result. So it all depends. In general, I think of the abdominal wall with two components, muscular components which give us function and connective tissue, which gives us structure. The muscular components are more difficult to fix than the connective tissue components. So if your connective tissue is the problem, generally that’s a hernia or a diastasis, I can fix that pretty readily. If it’s the functional muscle and the muscle is denervated or injured from trauma, be it an actual trauma, accidental trauma or the trauma of prior surgery, that’s more difficult to fix.

Speaker 1 (00:37:53):

Have you ever seen a patient who had a tummy tuck for a very wide diastasis and they used Mesh and then the Mesh was removed and the tummy tuck failed and now they have a really thinned out abdominal wall on one side? Have you ever seen that?

Speaker 2 (00:38:07):

Definitely. I mean, we’ve seen a variety of scenarios where patients abdominal wall has been manipulated and then we’ll find thinning. When we look at the CT scan, we can oftentimes figure out why that’s happened. Was it the blood supply that was go feeding the various muscles that were injured? Was it the nerves that were injured? We can, based on reading the operative reports, knowing what was previously done, and then looking at the CT, we can make a lot of pretty educated hypotheses around what happened to the abdominal wall. And then we can use that to guide our decisions for what are options for reconstruction.

Speaker 1 (00:38:51):

I like this next question. It’s something that I’m very passionate about. It says, can we discuss an issue? A lot of patients in the support groups have in common who have had failed or bad surgery outcome. There seems to be a repetitive concern by patients who have said that their surgeons didn’t listen to the patient thoroughly. And you can get this feeling that they already know what they’re going to do without actually listening to your problems. And this is a major problem. And then when you ask questions, they label you as having psychological issues. What is your take on

Speaker 2 (00:39:36):

Unfortunate? That’s really unfortunate. A technical issue. A technical issue. So I think my connection says it’s unstable, so hopefully my voice is coming through. But yes, what I will say is that, and Dr. Towfigh will 100% agree with this. When we operate, if there’s a problem, we are comfortable accepting that it may be a technical issue. I think if you’re going to be a thoughtful surgeon, you have to accept that. You also have to listen to the patient and try to understand what the issues are and keep a very broad differential in terms of potential complications. Plenty of patients come to our clinics where they had a surgery 4, 5, 6 years ago. They followed up with the surgeon multiple times and had maybe some concerns, but you read the notes from the clinic encounters and they’re like, patient doing well, there’s some subtle pain, it should go away.

Speaker 2 (00:40:44):

And then you’re two years removed from the surgery and still having those questions. And then they come to us and we spend time, and maybe it’s because we think about the abdominal wall a lot and we know that it’s not just a hernia. We think about it and we’re like, huh, yes, you don’t have a hernia recurrence, but when I’m palpating or touching your abdominal wall, it’s in the distribution of this nerve or that nerve or looking at your CT scan. I see a fluid collection around there that’s atypical. And so there we have to be open-minded and we have to be thoughtful in the way that we approach post-operative complications. They’re not necessarily common, but when they happen, it’s an opportunity to help.

Speaker 1 (00:41:33):

But you do see the problem though is that I feel part of it is lack of curiosity. So there are certain surgeons, I’m being one of ’em that I’m just turned on by puzzles and solving stuff. And when someone comes in with that a hundred page notebook, I get excited. I’m like, oh, this is so cool. I get to try and solve something. That lady who had 15 years of abdominal pain that I’m now going to fix, that stuff really excites me. Other surgeons, they’re human beings, anyone else, simple things that they understand and want to do and prefer not to have that kind of practice. In fact, when I posted that on social media, I got a lot of direct messages saying I would die.

Speaker 2 (00:42:24):

I like electronic medical records. So I will say the paper sheets coming out of the sheet protector scared me as well. But yes, I think a lot more information is better than a lot less information.

Speaker 1 (00:42:36):

So it’s a personality thing. And I feel that I was private institution for between 2008 and 2013, and I had to abide by the rules. And those rules are you see this many patients per day, and if you don’t, then you get a nasty letter from your chairman saying you need to see more patients or operate more or whatever it is. And it puts you into this working mill of volume. And when you become really good at what you do, then you start getting the more complicated patients and now it’s more quality, not quantity of time that you spend with the patients. And I feel that our medical system doesn’t support a scenario where, how much does Medicare pay for a visit? Like $30, somewhere between $3 and a hundred dollars, depending on how much time you spend. If you’re going to spend an hour and you’re going to get $30, there’s no way that that’s going to be able to be a viable system.

Speaker 1 (00:43:43):

So you don’t want those patients, and we have colleagues that you know about who are excellent surgeons, but they just don’t want to be bogged down by that subset of patients because it distracts them from the other volume of patients that they have to have to fix. I personally love it, but I’m in the minority and I understand that I was always the minority. I was like the math nerd when I was in grade school, so I’m okay with that. But I really feel bad for patients that are in towns where they don’t have access to. A lot of expert physicians financially cannot travel or afford to pay the consultations for people that are specialists. And I feel like they’re stuck in this chronic pain rut. And then they start complaining like they said in this question, and now they’re called crazy because they’re perseverating on their pain.

Speaker 2 (00:44:44):

Pain is one of the most difficult things to manage and understand, and it’s very different for every individual. But in general, I look at pain as there’s something wrong. We don’t necessarily know what’s wrong, but we have to figure it out. And it’s a process and it takes a lot of time to understand the pain and then determine if there’s anything that we can do to help. So yes, not a necessarily easy thing to do. I will say that pain, when we’re talking about pain associated with hernia repairs is often misunderstood. It’s often poorly worked up. And so you do benefit from seeing specialists that deal with this at a more common Yeah, sort of clip.

Speaker 1 (00:45:36):

Yeah. Have you heard of this term gaslighting by physicians?

Speaker 2 (00:45:41):

I’ve been seeing the term more, yeah, online. Honestly, I, I don’t fully understand what the term means, but I have been seeing it more. So do you know what it means? Because

Speaker 1 (00:45:53):

It’s when you go to your doctor after your hernia repair and you say, I just, I’ve got this burn in my groin. And they’re like, oh, it’s nothing. It’ll go away. And it’s like, no, I kind of still feel it. And they keep telling you everything’s fine and it’s like in your head or there’s nothing wrong with you and you go back to your doctor with legitimate symptoms, but you’re treated as if nothing’s wrong, everything’s fine. Whatever you’re feeling or seeing is not real. And isn’t that an interesting term, gaslighting by

Speaker 2 (00:46:28):

Physician? Yeah, it’s interesting. I will say that there’s certain times after a surgery that just with experience, you’re going to be able to advise a patient that it is expected or common or you will have some soreness at some point. And I usually define it as three months to my patients. I say, listen for the first two months in general, if you have some soreness, it’s not uncommon. Now I’m doing massive abdominal wall for my straightforward inguinal hernias. I’m pretty happy to report that the patients are doing really well pretty quickly. But for complex abdominal wall reconstruction, I tell them that for the first two months you’re going to have little pains, aches, source, and the general trajectory should be that it continues to get better by three months. If we’re still sitting in the clinic and we’re talking about severe pain, that’s an opportunity to then start asking questions about why. And so I think being proactive about it and informing our patients what to expect. Sometimes then the unknown can drive our patients to feel worried and concerned and just being not understanding the scenario. But I think being proactive, telling our patients about what to expect and being honest about it. I talk about what kinds of pains to expect and what kind of soreness to expect and sort of prep them for the marathon that is surgical recovery.

Speaker 1 (00:48:11):

And I think the comment was clarified is the gaslighting part of it is when you keep going from doctor to doctor and they keep telling you it’s on your head, it’s not real, it’s go away. There’s nothing wrong with you, then you start believing that maybe that’s true. Maybe my feelings or what I have is all in my head or it’s not true. And that’s part of that gas line part, which then you fall into this whole depression and chronic fatigue

Speaker 2 (00:48:45):

That’s for real and can’t seen many a patient, many a patient been told by multiple people that there’s nothing wrong. And then we finally see them and we’re able to come up with a strategy. I can’t say that that’s always the case sometimes, but what I always tell my patients that are struggling with pain is, I may not have all the answers, but I don’t want to disregard your pain and I’m not going to use the words it’s normal or that you’re fine because you’re not. And it’s not normal to live in pain. So what I will say is we’ll work it up and if there’s something I can do to help, I’m happy to. If I can’t do something to help, at least we’ll try to find someone that can’t. So

Speaker 1 (00:49:24):

Yes, that’s very important.

Speaker 2 (00:49:26):

So a patient comes to me and they had a groin hernia repair with Mesh. We get an MRI, we get a CT or whatever, imaging is already been done, we review it, we do an exam, we do a history, we do everything. We can’t figure it out. And it just does not seem consistent with Mesh related nerve entrapment or other issues like a recurrence. But we get the MRI and we see that the spinal columns have some issues and there may be nerve impingement or the hip has severe osteoarthritis, which may mimic the same pain that one would experience. Guess what? Opportunity for either intervention referral or continued sort of diagnostics. And we work, and I’ve had many a patient who’s come in with these scenarios and we’ve worked it out. I haven’t been the person that did the intervention that helped, but we helped find it. And I know Dr. Towfigh does this regularly. I’ve personally actually seen it happen. And it does such a good job of being thorough, especially with the patients who may have been told by others that there’s nothing wrong.

Speaker 1 (00:50:41):

So the comment back to you is, wow, you really understand what patients are going through. That’s exactly what is happening. Gaslighting and patients end up feeling alone and stigmatized. Thank you for your insight on this. It’s a real issue. So thank you for your question. Cause that was a very important question. We kind of glanced over what you actually do for a living, which is you fixed some pretty giant complicated abdominal wall hernias. Yes. I’m sure you’ve posted pictures of it. I posted some of mine, but I do mostly chronic pain and groin. I do have a fair number of abdominal wall, but certainly not as many as your practices and your training has prepared you to do. We only have nine minutes left, but can you use that time to explain a little bit about your practice and the type of patients you see and their complexity and kind of how you evaluate your patients?

Speaker 2 (00:51:42):


Speaker 1 (00:51:42):

Thank you. A little bit more

Speaker 2 (00:51:43):

About you and I will say that our practice is quite robust and diverse. And so what’s the process in evaluating patients for abdominal water? Great question. So we’ll, we’ll focus on this question, but I will say that we are a diverse practice and I, I’ll see everything from the patient who’s first noticing a inguinal hernia at the age of 30 or 40 to the patient who’s had six operations and has a very large abdominal wall defect with multiple pieces of Mesh. But with regard to planning and operation for abdominal wall reconstruction and who are we doing reconstructions for patients with? I always use this as my analogy on my virtual business, six pack muscles and they’ve spread apart and the connective tissue is gone. And now you just have a bulge of tissue, which can be anything that sits inside you. It’s usually intestine, but it could be fatty tissue, it can be even solid organs like portions of your liver, stomach, anything that’s inside you can bulge through.

Speaker 2 (00:52:50):

Yes. When you have this hernia, our goal is not to just patch up the hole. Our goal is to bring things back together, A intentionally performed surgical wound, but it’s a wound nonetheless. And so the same things that inhibit a simple scar from healing on your arm. We have to try to minimize those things that will inhibit the wound healing process. So the first step is learn as much about the patient as possible. Ask a ton of questions, figure out what surgeries have been done, if Mesh was used, what Mesh was used if previous abdominal wall reconstruction techniques were used, what muscles were severed, injured or compromised. And then understand how it’s impacting the patient because I want to make sure that I’m treating the patient not just a hole on a CT scan. It’s about the patient. So figure all of that stuff out. Then

Speaker 1 (00:54:00):

Like a tailor, you’re like a tailor only have so much fabric to work with

Speaker 2 (00:54:06):

Patient-centric. And it’s all about making sure that we do what’s right for the patient. So once we have all that info, then we start asking ourselves, okay, what is going to be the app? What do we need to do to reestablish the abdominal core health? And that’s a term that Dr. Poulose has sort of put out there. And our ACHQC colleagues definitely know what’s up when we talk about the core health. But to reestablish it, we want to put the muscles back where they need to be so that the function of the muscle can work again. And how do we do that? By reestablishing the structure of the abdominal wall with the connective tissue. Oftentimes with advanced techniques like cutting various muscle layers or abdominal wall layers. So to do that and put such a large wound on a patient, a controlled wound, but a wound nonetheless, we want to optimize.

Speaker 2 (00:55:00):

And so there’s a variety of ways to optimize. We talk about nutritional optimization, we talk about smoking cessation. Yeah, we talk about weight reduction, we talk about diabetes control among other things. Those are the things that I feel like our patients and us can engage with and are considered modifiable factors. Many other things are not modifiable. The number of times you previously had an operation, I can’t modify genetics and change the way that your collagen works and deposits, but those three or four things are modifiable. And we have criteria. They’re not absolute criteria, they’re general criteria. But I always inform my patients what it means to be as optimal as possible for the surgery and how it can change the results of the operation should we proceed. And through this process, we set up a plan. If a patient is already optimized great, and we have a surgical plan that can work wonderful, move forward with an operation that’s going to help them. If the patient’s not optimized, we ask, how can we help you get there? And so whether it’s a referral to an endocrinologist to get your diabetes under control, yes, whether it’s working with your primary care physician help you in this process of smoking cessation, whether it’s weight loss. And we have a very close relationship with not only our nutrition team and our physical therapy team, but also our bariatric team for scenarios where we need more significant weight loss. But we optimize.

Speaker 1 (00:56:44):

And we had Dr. Bittner last week about morbid obesity, bariatric surgery and weight loss and hernia surgery, which is a great discussion about that.

Speaker 2 (00:56:54):

And so weight loss. And then once they’re optimized, then we move forward with surgery. And then the surgery again is there isn’t a one size fits all operation for even this. I could look at the same ct, not the same CT scan, but essentially the same elements on a CT scan for two different patients and perform different operations. Why exactly? Right? Because every patient has a different goal

Speaker 1 (00:57:20):


Speaker 2 (00:57:21):

Maybe someone has a very large hernia and a scar, and let’s say they both have large hernias with scars. I have patients who come to me and are like, doctor, the hernia bothers me. But what bothers me more is the scar. Well, we have to remove the scar. I have other patients who say, doctor, the hernia bothers me. The bulge bothers me. I just want to get back to work as soon as possible. I’m not going to be taking my shirt off to go to the beach. I don’t care about the scar. I actually, I have patients who have even told me, I kind of like the scar in that scenario. Well, if we’re not going to have to remove a large amount of soft tissue and skin, then the reconstruction can be done with minimally invasive approaches. Robotic surgery, for instance, and we’ll accomplish the same goal.

Speaker 2 (00:58:11):

Remember it. The goal is always the same core health. So I’m not particular about the technique. I’ll do open surgery, laparoscopic surgery. Robotic surgery. That’s correct. Bottom line, we want to reestablish your core health and we want to make sure that when we establish that core health that it’s done with you and mind the patient. So we’re definitely targeting what you desire if you want the scar removed or not and whatnot. So very complex decision making, but we engage our patients and we have long conversations to make sure that we are all on the same page.

Speaker 1 (00:58:44):

I totally agree, and I think the tailoring is so important. I tell my patients, I think the best option is to see surgeon who can offer all the options and then try and tailor it through zoo. I see so many people that go to a surgeon that, let’s see, only does open surgery, and then they poo poo laparoscopic. It’s saying, oh, I can see so much more doing it open. I’m like, no, that’s actually not true. And vice versa. A question perhaps you can ask, what do you recommend for nutritional optimization?

Speaker 2 (00:59:15):

Wow. One, if you’re going to talk about nutritional optimization. Yeah, give me

Speaker 1 (00:59:19):

All your, just

Speaker 2 (00:59:20):

Refer back to Dr. Towfigh, one of her recent webinars with Dr. Robert Martindale. Yes. Who’s a partner of mine. Yes. Who is literally the godfather in nutritional optimization. Yes. He wrote the book on it and writes many, many chapters and books about it. I work with them. He’s one of the biggest reasons why I am at Portland because he absolutely has so much information to share with patients about nutritional optimization. When I talk about nutritional optimization, the big things are looking at some of the protein levels in your body and then looking at your overall health of, we, even on the CT scan, can tell about patients nutritional optimization and or overall health by looking at some of the mass of the muscle. So plenty of ways, but a relatively complex question. We want to make sure that our patients have a well-balanced diet going into the operation. So even with patients who need extreme weight loss, we’ll still say that you may be overweight or obese, but you may still be nutritionally malnourished. You may be malnourished because

Speaker 1 (01:00:35):

Do you use any of those commercial dietary supplements

Speaker 2 (01:00:40):

Or I think Ensure, and I think most of these protein shakes are good. I like them because especially when people are trying to lose weight, it gives them an appropriate proportion of fats, carbohydrates, proteins along with minerals and vitamins that can help them in the process of getting that foundation strong so that you can undergo the big operation for reconstruction. But again, I think nutrition in and of itself is a lecture webinar of conference. So if you want to get some good insider tips, check into Dr. Towfigh’s most recent cast with Dr. Martindale. I’m sure you guys talked about that,

Speaker 1 (01:01:22):

Right? Yes, we did. He’s one of my favorite people. He’s such a great guy. Such

Speaker 2 (01:01:26):

A good guy.

Speaker 1 (01:01:26):

You’re very lucky to work directly with him.

Speaker 2 (01:01:30):

I know. And he always beats me to the office. He’s been doing this a lot longer than me.

Speaker 1 (01:01:34):

He’s been different generation. We all work harder than you guys.

Speaker 2 (01:01:38):

Well, no. Listen, my goal every day is to make the coffee for the office. Okay. I walk in, I still make the coffee for the office. Good for you. But he beats me about three days a week. He beats me by about five minutes. So we’re working on it, trying to optimize my own set up. So today he beat me to the office cause I’m working from home, but in general, I beat him to the office.

Speaker 1 (01:02:03):

Please tell him I said hi. And Sean Orson as well. You guys have a really great program at O H S U. Can you just briefly tell our audience how they can reach you if they want a telehealth consultation or just a regular in-person consultation?

Speaker 2 (01:02:18):

Oh wow, that would great. So we do see patients from all around the West Coast and beyond. Actually, we’re a primary referral center for hospitals from Alaska, Hawaii, Idaho, Washington, Northern California, and course our state of Oregon for evaluation. We can actually put it on the web link if you want, with regard to my office phone number as well as our website. We’ll include that. And then it’s a simple telephone call. If you’re interested in being evaluated and you’re in the region, we’re happy to see you If you’re not in the region. Of course digital health is something that we pride ourselves on and we connect with patients all around the country, and so we’re happy to help out in any way.

Speaker 1 (01:03:05):

Great. Send me the link and I’ll post it or you can post it yourself on Facebook. One last comment. Someone saying the Portland Trailblazers have a good chance of winning the championship this year. Clearly they’re not Lakers fans. I’m a Laker fan, so I will disagree with that. On that note,

Speaker 2 (01:03:22):

I’ll say I’m originally an Angelino. So we grew up born and raised in LA actually, that’s where I got to know Dr. Towfigh back in. Yes. Like my medical school years when I was at USC and worked around Cedar Sinai as well. So learned a lot from her. And I will say many of my family members, my immediate family members are Lakers. Lakers, season ticket holders, so Oh yeah, we’re we’re Laker fans. But I represent the Trailblazers now. I like what they’re doing.

Speaker 1 (01:03:54):

My family’s been watching Lakers since Kareem Abdul Jabar, so you can’t exactly knock them in any way. Not on my time. All right, everyone, thank you so much for joining us on a hernia talk. Thank you to Dr. Nikolian. That was very fun. I always enjoyed talking to you fresh. Look on new things. Hope you all learned something. Thanks everyone for being on the Facebook Live with me at Dr. Towfigh and I will see you again next week. I will post the YouTube link to today’s show. I hope you all enjoyed it. Thank you for giving us your time away from family and work to educate our patients and answer their questions. I really do appreciate it. Hope to see you in person soon.

Speaker 2 (01:04:39):

Soon enough. Soon

Speaker 1 (01:04:41):

Enough. Yes. Thank you. You take care. Bye-bye.

Speaker 2 (01:04:43):