Episode 54: What Hernias Require Repair? | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

Good evening everyone. This is Dr. Towfigh. Welcome to Hernia Talk Live, our weekly q and a on Tuesdays, what we call hernia Talk Tuesdays. My name is Shirin Towfigh. I am a hernia and laparoscopic surgery specialist, as many of you know are also sharing your time with me on Facebook Live as well as logging in on Zoom. Thank you also for following me on Twitter and Instagram at hernia doc. We are going to have a great hour because you’re joined by me every four to six weeks. I like to do a webinar with you all where it’s just me and you and the reason why I do that is I feel like we get so many questions submitted and many of them are not related to the topic at hand with our guest and I really want to answer them for you, but I feel guilty because we have, let’s say a physical therapist or a gynecologist or someone who’s a specialist in let’s say autoimmune and they’re not necessarily there to answer questions about groin pain or Mesh complications. So a lot of questions remain unanswered. I feel guilty that they remain unanswered and therefore every four to six weeks I try and take some time away from a guest panelist for me to respond to your questions. And I feel that that’s something that you guys seem to enjoy every time I do it. It’s been like a lot of, I get a lot of, how should I say it? A lot of really, really great positive feedback. I feel like not everyone has joined me on Facebook. Is that right? Let’s double check this.

Speaker 1 (00:01:56):

It seems like it’s not going. Give me one second everyone. Cause I want to make sure we have a really good strength of presence on Facebook and so many of you join me on Facebook and I’d like to be able to stream this on Facebook as our webinar, so let’s just double check if that’s moving forward. So we have about 20 questions that have been pre-submitted. I put them all on slide so we can review them and then of course any live questions will take precedence, so feel free to submit that as you do as you go through. Looks like Facebook is not liking me today. All right, let’s do one more thing. Give me one second everyone. I’m going to do this one more time. There’s this whole thing where you can, there’s this whole thing where you can go on Facebook. I’m not sure why it’s not going live. Last time this happened, which was about a year ago, there was some glitch in the Zoom kind of program where we weren’t able to live stream. If that doesn’t work, then we’ll just move forward with Zoom and I will go ahead and post this separately on Facebook

Speaker 1 (00:03:35):

Working. Yep, it’s not working.

Speaker 2 (00:03:48):


Speaker 1 (00:03:49):

Be a glitch in the Zoom. So if somebody, let’s see. I’m thinking maybe we should, let’s join me on Zoom everyone and then what we’ll do if someone can post that on Facebook and let them know that I’ll repost this on Facebook separately.

Speaker 1 (00:04:23):

Okay. Sorry, everyone can help me out. That would be really great. Okay, so moving right along. What we’ll do is you guys ask me questions on Zoom and then I will share it on Facebook. For some reason there’s a glitch in the system and I can’t do anything with Facebook right now. Okay, so we have tons of questions. I hope that you all can join me. Let’s see, we already have some questions. Okay. What types of symptoms occur with nerve compressions opposed to direct surgical damage to the nerve? Does entrapment not direct damage cause somatic type pain or more neuropathic electrical burning? And are these different symptoms pretty specific for distinguishing nerve compression from other ideologies of pain and can there be a lot of blood? That’s a really great question. So in general, nerve pain is very different from Mesh pain or groin pain or hernia recurrence pain. Nerve pain is usually a shooting pain. It’s often in the direction of the nerve itself. It is often burning and can be like a hot poker as one description. The other one is like it could be stabbing but as hot burning electrical zapping, that’s another one.

Speaker 1 (00:05:51):

Whether that’s from an injury to the nerve or entrapment of the nerve or compression of the nerve is very hard to determine. If there’s permanent injury to the nerve or if there’s permanent entrapment of the nerve, then that’s usually a constant problem, whereas if something is impinging on it or pushing on it or it gets kinked in a certain way that you walk or stand or bend, what can happen is that can be more intermittent pain and that’s usually how we figure out at least before surgery, like what the problem is. But if it’s constant persistent pain and is severe and doesn’t get better with a lot of other modalities, that’s usually neuroma or some type of nerve injury. All right, let’s go to the next question.

Speaker 1 (00:06:43):

I have a large diastasis recti. It is not a true hernia. Do I still need a general surgeon or hernia doctor available in the case? No, you do not. Diastasis recti is almost exclusively an operation, well it’s not a hernia as you mentioned, it’s not a true hernia and it’s more of a spreading a part of the rectus muscles which are your abs. Like your six pack is not something that requires Mesh. Usually it’s, although some people do use Mesh on the really big ones and it’s not a hernia that requires a general surgeon. The people that are best to treat a diastasis recti if you wish to have it treated, you don’t have to have it treated is a board certified plastic surgeon. I highly recommend it be a board certified plastic surgeon and not a doctor that did a course in aesthetic or cosmetic surgery because the level of training and expertise is very different between those two sets of patients. Okay. Going back to the nerve question, great answer, but are the symptoms from nerve compression and direct surgical damage similar other than intermittent versus constant? Not necessarily. It can be.

Speaker 1 (00:08:09):

That’s a good question. Usually the symptoms are either nerve or it’s not. Whereas the, how should I explain this? If you have nerve pain, that’s student direct injury as opposed to compression, the severity may be worse with any injury and the duration and frequency and extent of it may be worse, but the quality of the pain may be similar or it may not be. There’s like really no good science about that, but in my experience the quality is usually about the same. I hope that is good. Okay, next question. Looks like they didn’t just couldn’t, let’s try Facebook again. It just sent me a message that it wants me to do it again. Let’s try it. Okay, next question.

Speaker 1 (00:09:12):

Also, when do you allow your patients to drink? Oh, this was a patient, multiple questions, so I cut and paste. Okay. When do you allow your patients to drink hard liquor after surgery? If you’re off narcotics, which I don’t even prescribe usually, but if you’re on anything that can alter your mood which narcotics and opioids can do, then it’s usually safe to have some type of liquor. You do not want to mix that those pills with liquor at the same time. What type of MRI is best to ask for when you have a small hernia? Really good question. Okay, so a MRI is a type of imaging and it’s used best for pelvic or groin hernias. I do not use it for abdominal wall hernias. The type of pelvic MRI that I recommend, it’s on my website and it’s on, I think I’ve posted it on pretty much everywhere I I’ve have a presence.

Speaker 1 (00:10:14):

It’s an MRI pelvis, it’s a non-contrast MRI, so there’s no IV contrast, there’s no oral contrast, and the MRI is done of the pelvis alone. I like to have it done with Valsalva, which are bare down views and the bare down views will augment a small hernia. I’m lucky in that I have great radiologists around town at Cedar Sinai Medical Center at Mink radiology at Beverly Hills Imaging. They all kind of know my hernia protocol and they perform it. However, I have a lot of patients outside of my area, so what I’ve done is I’ve developed a chichi which I send to my patients, let’s say that patient’s in Oregon or Connecticut, so I send that paper, it describes the type of MRI want. It also has in kind of very specific radiology speak what they need to do to program the MRI to do the type of hernia MRI that I need. And then if they’re lucky they find a radiology group that will be okay to do that and then they send me the MRI. That usually works. Okay.

Speaker 1 (00:11:27):

The main problem is finding a radiology group that’s willing to add the extra steps and the extra images and do it correctly. It is what it is. I can’t, I try, but it’s not always possible to get everyone to do my my MRI. All right. Can I just live with a recurrent inguinal hernia? I don’t want another surgery. Male versus female. Really good question. For inguinal hernias, we have two prospective randomized clinical trials on men only. So I can’t say this is true for women on men only and for non-current inguinal hernias. So I can’t say it’s true for recurrent inguinal hernias where they submitted them to five years and then 10 years of what we call watchful waiting. And what happens is the patient then goes ahead and has a normal day, normal year, normal couple years without having their hernia repaired and then we observe to see what happened and in 0.18% per year patients will end up requiring surgery because their symptoms of incarceration, nothing more serious than that and about a little over a quarter of those patients in general got tired of having their hernia and wanted their hernia repaired, but it wasn’t like they were necessarily getting worse.

Speaker 1 (00:12:54):

So for non recurrent hernias in men, we have good data, we don’t have any data for women that needs to change and there’s very little data on recurrent hernias, but extrapolating from that, we do feel that patients that have minimal symptoms or are asymptomatic and they have a recurrent al hernia, male or female, that’s totally safe to watch watchfully wait on those. Now that’s only for al hernias and not femoral hernias. All right. I believe our Facebook friends have joined us. There was some weird glitch connecting zoom to Facebook and so many of you missed the first couple questions that we got answered about nerve symptoms and so on, so I’m sorry about that. However, what we’ll do is I’ll make sure that this is completely reposted on Facebook so that if you missed kind of like the beginnings of it, then it’s not a big deal.

Speaker 1 (00:13:59):

But I’m on Facebook, you guys should be on Facebook as well if you’re submitting your questions and I’m happy to answer your Facebook questions, but we shall move on. Thanks everyone for joining me. Sorry about the weird delay on Facebook. I’m going to blame Zoom for it. Okay, more hernia questions. I had a femoral hernia repair with Mesh. Will this affect me if I become pregnant? No groin hernias In terms of Mesh or no Mesh, femoral, inguinal, indirect, direct are usually not affected by pregnancy. Pregnancy and also do not affect pregnancy. Whether you need, you plan to have a regular, a normal spontaneous vaginal delivery or a C-section. How often do you use fixation for laparoscopic tap inguinal hernia repairs? That’s a great question. It’s actually quite controversial. TEP and TAPP in general are treated the same. Tep is the t e p. It stands for a totally extra peritoneal, which is what I prefer to perform TAPP T A P P is transabdominal pre peritoneal.

Speaker 1 (00:15:06):

In terms of hernia repair, they’re exactly the same. It’s just how you get to the space that’s different. So from a patient standpoint, it shouldn’t matter to you whether you get a tap or a tap robotically. It’s always a tap laparoscopically. It’s a TEP or TAPP. I do tap if that’s not confusing enough, but do I wouldn’t worry about whether it’s TEP or TAPP, I would just consider laparoscopic as one and robotic as one broad technique. So I sparingly use fixation if it’s necessary. So a small hernia, I don’t use a small indirect al hernia. I don’t use fixation, a medium indirect angular hernia. I don’t use fixation any femoral hernia or direct hernia. I do use fixation because the Mesh can either move or fall into the hernia if you don’t fixate and then robotically, I tend to feature those in if necessary, not typically necessary.

Speaker 1 (00:16:08):

If I choose watchful weighting, do I risk that the hernia will get so big that it will need a more complex operation or perhaps I may not be a candidate for a non Mesh repair? Great question. So we just discussed the two clinical trials for watchful waiting of inguinal hernias. Again, they’re only in men and they’re only in minimally symptomatic or asymptomatic inguinal hernias. So if you fall into that category, we know that watchful waiting is safe. You have a 0.18% chance per year that you’ll end up needing emergency or urgent surgery because of an incarceration. But short of that, we feel that’s safe.

Speaker 1 (00:16:51):

The similar surgeons then went ahead did a watchful waiting trial in the United States to look at what happens with umbilical hernias. And a similar finding was if you’re minimally symptomatic or asymptomatic and the hernia is not large, then watch waiting is also considered to be safe until you become more symptomatic. Now for umbilical hernias, this is important to this important data for umbilical hernias. Data shows that anything over two centimeters wide is best repaired with Mesh as opposed to tissue repair. Otherwise you tend to tear with a tissue repair and you get a recurrence and when you recur, it’s actually bigger, which makes a hernia repair even more complicated to perform.

Speaker 1 (00:17:39):

More studies show even at any hernia gray than one centimeter is better with Mesh. There’s an argument whether that’s kind of slicing it too thin so to speak. But yes, if you have an umbilical hernia in the belly button where the hernia is small and with no symptoms and you want to ignore it, it’s considered safe. But do understand if it’s starting to get bigger and you’re hitting that one and a half centimeter to two centimeter width, which is almost an inch, just under an inch, you are falling into that category with where a tissue repair is not the best repair, you’re more likely to tear from it, you’re more likely to have chronic pain from it and you’re more likely to have a hernia recurrence if you do tissue repairs in the larger hernias. So if you are adamant about not having any Mesh or you shouldn’t have any Mesh because of any underlying diseases, you should get your umbilical hernia repair earlier.

Speaker 1 (00:18:35):

Inguinal hernia is different. Inguinal hernias are in the groin. They have a totally different anatomy. They don’t grow as big often, they’re often no symptoms and even the larger hernias, you are typically a candidate for tissue repair. Again, the larger the hernia, the worse you of a candidate you are to have a good tissue repair. So what I do recommend that is if your hernias become more symptomatic or you start getting bigger, then now’s a good time to get your hernia repaired. Otherwise, you are at risk of needing a more complicated and or Mesh based hernia repair when the hernia gets larger because you’ve been watching it. So do understand that though it’s considered safe to watch a lot of these hernias, especially if you don’t have symptoms, the implications of watching it can vary per patient and if they get larger, you will have a more complicated operation.

Speaker 1 (00:19:41):

In many cases, I have an umbilical hernia. Should I wait to lose weight completely? I am 245 pounds at a five foot two. The short answer is yes. Anyone who is 250 45 pounds and five foot two will have a B M I or a body mass index greater than 40. When it’s greater than 40. The risks of hernia failure, hernia recurrence, wound infection, Mesh infection and a lot of other complications from the hernia repair including pneumonias and blood clots and all that are way too high. And so in an elective situation, we do not like to operate on patients with a BMI over 40. It’s just a going to be a disaster because then you’re going to tear and have an even bigger hernia. Those patients should lose weight completely and by completely we mean at least a hundred, like eight to a hundred pounds before they commit to having an umbilical repair or any eventual hernia repair.

Speaker 1 (00:20:49):

So yes, you should wait to lose weight completely. Now if you have symptoms and it’s very painful for you or while you’re losing weight, the hernia gets caught and you need a little bit more urgent surgery, then it would be ideal if your B M I is under 40 at the time of the more urgent repair. But if you don’t need urgent repair, then you should wait until you’re at your ideal weight and then just get everything done at the same time. Hi, my Facebook friends, sorry that we had some problems linking earlier, but now you’re giving me questions so that’s great.

Speaker 1 (00:21:26):

How can I determine if I have a Mesh failure or a recurrence if the CAT scan is negative and the physical exam is negative? Okay, so first of all, I would need to know because I, I’m a big doubter. I get so many patients that tell me the CAT scan’s negative, all the imaging is negative. And I look at it and it’s like, yep, nope, not negative. Definitely showed a hernia or a Mesh complication. And also I see tons of people like, oh, I had a negative exam, I feel a hernia right here. So I always second guess. And so number one, I would recommend a second opinion if you’re told that you have no hernia and no imaging findings of a hernia on CT scan or MRI and no physical exam findings because a second set of eyes may notice something the first set did not see, that’s number one. Now let’s assume that your exam shows no hernia and your imaging shows no hernia and that’s for sure. Then you don’t have a hernia. You can’t have a hernia if there’s normal exam and normal imaging you can have muscle tears that don’t hernias but you can’t have a hernia. So I would get a second opinion and then based on that, determine what you need to do next. There are a lot of reasons for pain besides hernia recurrence and so I would kind of move on from hernia recurrence as a reason for pain.

Speaker 1 (00:23:00):

Let’s see. Next question. How is Mesh generally placed for umbilical hernias if greater than one centimeter is a placed between the muscle layers and how far of overlap is typical? Great question. The key to that is generally, so generally means different things in different people. Generally we like to put the Mesh, well I should say generally, I should say most of us who do hernias for a living put the Mesh behind the muscle. So retro rectus or retro muscular, other options are behind the fascia, so that’s like what we call a TAPP or IPOM type repair. Some actually many surgeons, mostly not experts do put the Mesh on top of the hernia on top of the fascia. That’s not considered ideal. Regardless, when you do use Mesh, you can’t use a postage stamp worth of mesh. I mean I’ve seen people that put this much, they’re wondering why the patient has chronic pain or a recurrence. You need to actually have wide overlap with normal tissue depending on the size of the defect, you want three to five centimeters of overlap on each side with the Mesh. So for example, a two centimeter, let’s say two or three, let’s say a three centimeter hernia defect will need a 13 centimeter wide Mesh. That’s for best outcomes. Having smaller Mesh sizes does not help the patient because you actually end up tearing or the Mesh kind of falls into the hole.

Speaker 1 (00:24:46):

Next question. I was born with hernia and it has reappeared recently. It’s very mild. It only hurts when I push heavy weights. Would you be able to do a natural tissue repair? What are the chances of it reappearing after surgery? Yes, so you are a candidate for a tissue repair assuming that you were otherwise a good kid to have surgery if you had a hernia as a child, and it’s not clear here if it’s a umbilical or inguinal, I’m going to assume it’s inguinal. If you had an inguinal hernia pair as a child, it is considered a recurrence but it does not prevent you from having an open tissue repair.

Speaker 1 (00:25:31):

And so yeah, you’re a good candidate. What are the chances of it reappearing after surgery? Depends on your surgeon. It’s usually under 10%, usually under 5% in most hands for tissue repairs. So the numbers are still pretty good. It’s not zero and it’s not 20%. Next question with regard to your answer about no hernia from the previous question. Can you elaborate on how muscle tears cause symptoms and how they should be treated or repaired? Okay, good question. So I’ll give you an example if you tear, how should I say this? I want to do a good analogy for you. So I see in athletes they have tears in their groins and it’s not a hernia but it’s a tear. Some people, I just did an operation, I’ll give you a good example. I saw a lady, she had four C-sections and had an hernia from her C-section.

Speaker 1 (00:26:30):

So that hernia, I repaired it, but when I went in there to look at everything, not only does she have her hernia, she also had these linear tears throughout her abdominal wall. I think those were just damaged from having four kids and each time they get bigger and you’re just tearing your abdominal wall. Those will not show up on imaging but can be painful. In athletes, you can get tears in the groin that may not show up on imaging as a hernia and your exam would not show up a hernia, but they would just cause pain. If you’re unlucky and the tear occurred right over a nerve, the nerve can hernia into the tear without, but you can’t see that on imaging and they can give it you nerve pain. So it depends on where it is, but it can happen.

Speaker 1 (00:27:26):

Okay, cool. Hi Dr., me again. Hello. I wanted to ask a similar question I asked last time about inflammation. If all Mesh implants have chronic inflammation present, doesn’t that say that every human body reacts? And if that is the case, why’d your surgeons still choose to use it? Also, when I presented to emergency so many times, why can’t anything be found in any test scans or MRI? And if the inflammation, the Mesh is enough to cause the pain, is there a diagnostic tool to test the Mesh? Besides explantation? So I believe I answered this last time, but I’ll recap. So every implant that’s put in you, whether it’s your cataract lens, whether it’s your pacemaker, your hip implant or your Mesh is considered a foreign body by your body and you’ll get chronic inflammation at the site. That’s just reality. I’ve published on this, you can read my paper on Mesh pathology and how what the pathology shows.

Speaker 1 (00:28:31):

It does not necessarily mean the patient has symptoms. So chronic inflammation does not mean you have pain, it does not mean you have a reaction to the implant that is unexpected. Now that said, every single person who gets a Mesh will have finding a chronic inflammation. So every time I take out a Mesh, every single report we say chronic inflammation, fibrosis and foreign body reaction, a hundred percent of them I publish on this, you can see it. But in the majority of those patients, I didn’t remove the Mesh because they had a Mesh problem. They may have had a recurrence or was it unrelated operation. And so the Mesh itself was fine. My point is that just because you have read that Mesh causes inflammation does not mean that therefore that inflammation is symptomatic and the majority of cases it is not. Okay, that’s number one.

Speaker 1 (00:29:31):

So why does surgeons still choose to use it? The same way we still put in pacemakers and we still do hip replacements and we still do cataract eyes and we still do dental implants and we still do plates in the head after brain injuries. These are surgical tools that we have and the inflammation of it is not an indication to not put in the implant. The next prior question is I keep going to the emergency room but they can’t find anything. First of all, emergency room is not a good place to get a chronic hernia or Mesh or pelvic pain evaluation. The emergency doctors are looking for something that’s going to save your life. It’s your gallbladder, it’s your appendix, it’s an obstruction. If it’s not any of those, they will no longer pursue your diagnosis and they want you out of the emergency room for sicker patients. So it is not a good place to get assessed for anything chronic.

Speaker 1 (00:30:34):

I do recommend that you get evaluated by a Mesh, sorry, by a hernia expert and that they can very carefully sit down and review all of your imaging to make sure that those imaging in fact are normal or maybe they’re not. They’re actually showing things. And based on your history and your examination, that doctor can help you figure out what’s wrong with you and diagnostic tools to test the Mesh, we don’t have any, there’s no blood tests that will show you inflammation or reaction to the Mesh. There are some blood tests from a laboratory standpoint under research purposes that are not available to the majority of people that may show some cytokine elevations. We don’t do those abnormal labs. There are. I’ve dabbled in looking at allergy testing to see if allergy testing is something that can help identify it. So far that has not been a good test either. Allergy testing can show you problems but it can’t. It’s not very accurate in what it shows.

Speaker 1 (00:31:47):

What are the best sutures to use if you have systemic symptoms from Mesh? Everyone’s different and everyone’s very different. In my experience, nylon seems to be less reactive than polypropylene and polyester P D S or Maxon, which is an absorbable long-term absorbable suture is another option and in some cases gore suture, which is PTFE suture, but they all have their drawbacks, but those are the top sutures. What are your options if you have a ventral hernia with Mesh and have pain along with systemic symptoms if removed were the other options to fix a problem? I mean you have options. It’s just going to be a very complicated operation and it depends on how sick you are and what kind of risks you’re willing to take with the Mesh options. Sorry, non Mesh options. Plus there are absorbable meshes and hybrid meshes. I’ve talked about ovitex Mesh, which I think is a great option for most patients because it does have some permanent C to it in addition to the mostly absorbable component. So it helps reduce recurrence and it’s low an inflammatory state, but you have options. It has to do with your risk factors, the size of the hernia, the location of the hernia and what your specific symptoms are. Allergy testing I try to do in these complicated situations.

Speaker 1 (00:33:18):

Understanding that a negative allergy test is not helpful at all. Oh, you thought it was helpful. You’re welcome. Okay, next question. Do I have to get my umbilical hernia repaired? How dangerous is it? Yeah, we just reviewed that. One thing that was calculated, which was very interesting is so if you have an umbilical hernia, then width of the actual hernia defect is different than how much fat falls into it. So if you do an analysis of how much fat is coming through it versus the width, if it’s more than a three to one ratio, the chances are that you’re at higher risk of having complications such as incarceration or the hernia can be dangerous. And so in those we like to repair them, but if you have no symptoms from an umbilical hernia, then you can watch it usually.

Speaker 1 (00:34:22):

Okay, more questions, more live questions. What are the symptoms of an Anglo hernia failure or recurrence? I have extreme bloating and nausea after growing straining for three months. Okay, so bloating and nausea can be symptoms of any inguinal hernia or hernia recurrence. In males you can have pain that radius into the testicle and women into the vagina. You can have pain that radius into the inner thigh or around the lower back intercourse may be painful. Anything that increases your abdominal pressure like coughing or sneezing or laughing can cause pain. Bending to tie your shoelaces or getting out of a bed can be painful. Sitting can be more painful than lying flat and standing for a long time can be painful. These are all variable and depends on the patient, but there are a lot of parts of the story that I ask patients very specific questions to see if these are painful in women also, they tend to have more pain during their menses or their period.

Speaker 1 (00:35:30):

What’s the recovery time for natural tissue repair, inguinal hernia? Would I have to take it easier for the rest of my life or can I return to normal activities after some time? So first of all, know that most of the world does tissue repairs, India, China, it’s almost all tissue repairs. So clearly those are people that are going back to work and don’t have the luxury of just taking it easy for the rest of our life. So no, all repairs that we perform are performed with the intention that you will go back to your normal activities including exercise and being active. Tissue repairs have a higher recurrence rate cause we’re totally relying on your own natural tissue strength and you’ve already proven to us that you don’t have good natural tissue strength because you have a hernia. If you had normal tissue with normal collagen, good strength, strength, strong collagen, very mature collagen, you would not have had a hernia.

Speaker 1 (00:36:22):

So the fact that you have one implies that your tissue is not as healthy as the average person and therefore tissue repairs are not considered ideal in comparison to a patch because of the recurrent part of it. Of course there’s other positive points about tissue repair, which some people prefer to have. So yes, you should be able to go back to your normal activities. The type of repair and the type of tissue you had and how much thinning there was and how much tension was in the repair are all factors in what I discuss with patients in terms of how their recovery will be like. I just did one this morning, I did a Shouldice. The patient had a huge hernia and a very thin direct space. So in that patient it was a good repair. It’s a four layer repair but I don’t, but he’s a golfer. I don’t want him golfing tomorrow. If he were getting a laparoscopic repair he would be golfing tomorrow, but I don’t want him golfing for about six weeks because the type of swing that you do in a very fast engagement of the abdominal wall is not good for a tissue repair.

Speaker 1 (00:37:37):

All right, next, can platelet ridge plasma or P R P be used for chronic core injury or only for acute injuries? Do you give P R P in your office? I do not give P R P. That involves an actual centrifuge and bunch of machines I don’t have in my office, but most of the pain doctors that I work with do offer P R P. It is not considered appropriate for chronic injuries. It’s mostly for acute injuries. That said, chronic implies more than three months old, but some people consider chronic like more than one year old, so depends on where the injury is and the data about P R P is very much out there. We don’t really know if it works for muscle strains or not. We know the athletes use it, they seem to like it. Many patients have had good results with it and some patients have not. So it’s definitely an option, part of the armamentarium for any type of core injury. When can you start massaging a scar tissue after measurable from the umbilicus? Can this cause any damage to the incision? Does surgery swelling and inflammation settle over time? And how long do you tell your patients to wait for these symptoms to subside? These are great questions.

Speaker 1 (00:39:00):

I would answer with a caveat that what I’m telling you is based on experience and not based on any prospective randomized trial or anything scientific. So yes, massaging a scar tissue is great no matter what type of operation you had. Massaging the area will reduce swelling and scarring and make everything flatter and highly encouraged. It can start within days to weeks of the operation depending on the type of operation you had done. It does not cause damage to the incision. And by massaging I mean like gentle hand massaging with all some type of vitamin E lotion or something that’s smooth, not like a thera gun. I don’t want you taking a thera gun to your recently operated abdominal wall. Yeah, surgery, swelling and inflammation does settle over time. Usually within the first several weeks for sure. Within three months you should not have significant swelling and inflammation, although technically in their tissues there is inflammation and I do expect my patients to not be swollen within weeks to months after surgery.

Speaker 1 (00:40:13):

It all really depends on why they’re swollen, what kind of surgery they had. There’s a lot of ifs, ands or buts. What evaluating a hernia patient, is there any indicator that would suggest surgery rather than physical therapy? Let’s see. Good question. I think this was asked by a physical therapist because they do see patients with hernias. So I’ll tell you this, there’s no way to fix a hernia without surgery. There’s no cure to a hernia without surgery. However, I had a patient last week, so what’s last week? Yeah, I think it was last week. He was absolutely a hypochondriac, did not want any surgery, said he would pass out when he saw his wife having a C-section like definitely did not want to have anything to do with surgery. He had gained weight and was out of shape. So I’m like great, let’s get you back in shape.

Speaker 1 (00:41:15):

You can get back in shape either at the gym or because my impression of getting in shape is core health and core strengthening. You can go to a physical therapist and have the physical therapist focus on your core Pilates instructor who’s really intelligent and also to focus on your core and do physical therapy type exercises. So if you do that and you strengthen your core, what can happen is that hernia will be not as protuberant because the muscles around the hole are now stronger and they support the hole better. Also, you may be losing weight and so the abdominal pressure from the intraabdominal fat will be less and you’re going to have less pressure in a smaller hernia. It won’t get rid of the hernia but it may get rid of your symptoms and it may get reduced the bulging from the hernia. So when evaluating a hernia patient and I see that they are out of shape or overweight, I do recommend that they go back to the gym and exercise and focus on the core and lose weight and that is a good alternative to surgery in a handful of patients.

Speaker 1 (00:42:26):

I’m not going to say the majority of the patients, but in a handful of patients that is a good option and some people just want to get themselves in better shape and if they get they’re no longer symptomatic after that, great, they don’t need surgery. Okay, next question is a live question. I got Mesh to strengthen my diastasis repair. The Mesh is ethibond prolene four by six inches. I’ve had it since 2018 with chronic pain. Well removing the Spanish cause more painter issues. I know everyone is different, but I’m asking how likely will nerves be injured in that area? It should also be noted that I can’t feel most of my stomach from the original operation.

Speaker 1 (00:43:09):

Okay, first of all, a four by six inch. It’s like the size of my hand. That’s not a big piece of mesh. So a diastasis from like xiphoid chest down to pelvis. So that’s a big diastasis. It makes no sense that you had only a diastasis repair and they used Mesh for the diastasis repair. That doesn’t make any sense because a diastasis repair is a tummy tuck. Did you not have a tummy tuck? And when they place those meshes, they often place it deep to the me deep to the muscle, so we put it on top of the muscle. So number one is important to know how big the diastasis was. Number two, where did they put the Mesh on top or in the bottom? If they put it on top, that’s easy to remove and you’re done. There’s not much else to do. It is a redo operation, which can be a big scar and long recovery, but it’s not complicated and there are no nerves that can be injured if the Mesh is put deep to the muscle. That’s a whole different scenario. They have to completely undo everything, completely redo it without the Mesh it’s doable. It’s just a much larger operation. Again, no nerves are injured with abdominal wall mastery removal, so I would not worry about that part.

Speaker 1 (00:44:27):

Okay, next, let’s see, today is 90 days from my surgery. I’m still experiencing the same pain though because of surgery, the pain is no longer waiting into the testicles but I feel the growing pressure and I’m unable to sit or bend over. Doing so causes left abdominal pain and bloating. Worse is with activity. Could this still be hernia pain? Yeah, if you had surgery and your testicular pain is gone, that’s good, but I need to know exactly what they did for you for your groin and see why those symptoms are not better. My concern is that your hernia Mesh or whatever the, let’s see, next question. My husband has a hernia. This was repaired with Mesh. This seems to have failed and entangled in the bowel. He has blockage of his bowel doctor say they don’t know how to put this right. Do you have any advice?

Speaker 1 (00:45:30):

Yeah, you should see a doctor who does these for a living and can do it, right? So those of you in the United States, we have an excellent medical system. We have tons of experts all throughout the us there’s no restrictions to you seeing a second surgeon. We don’t have socialized medicine. You can see whoever you want and you can pay for it or they can be covered by your insurance. So if you’re getting some answer that doesn’t sound right from one doctor, go see another doctor if it’s totally in your right and you should do that. So that’s my answer for that one.

Speaker 1 (00:46:12):

Let’s see. Are you aware of and share concerns about bone ossification that have been raised as a complication of P R P and can you comment on this? So I have seen bone ossification from B M P, not from P R P. So B M P causes boney formations. P R P maybe causes bone ossification, but there you can get that from any type of injury or inflammation. So I have not seen bone ossification from P R P. It does rapidly increase your healing, but some people just get bone ossification and what I’m talking about is you grow these bone like calcified, calcified structures in the areas of your injury and I’ve seen it from even trauma and scar tissue can turn into like that. So I’m not sure if it was directly caused from the P R P, but I’m not aware of that being a major issue with P R P.

Speaker 1 (00:47:25):

Next live question. I got med for a small femoral hernia, eight months ago. I’ve had pain and tightness in the area of the repair that wraps around to my back. I also have had chronic, continuous fatigue and loss of appetite. I’ve completed three months of pt, chiropractic and pain injections. At what point should I pursue removal? Well, that’s a difficult question. Removal should not be the first choice and regardless of the femoral hernia size, if you had a femoral hernia that needed repair or you needed Mesh, that’s the standard. There is a tissue repair option as well, but whether it’s a small or large femoral hernia doesn’t imply like any difference in the recommended repair. So I would have to really review your symptoms. Chronic fatigue and LOA is one of many systemic symptoms that can occur with Asia syndrome or Mesh reaction. Loss of appetite usually is not one of them and so I wouldn’t jump into Mesh removal. You’re definitely candidate for it, but I’m jump into it and certainly I would not do it with a surgeon who doesn’t do them for a living because that is definitely a high risk operation that we do and we enjoy doing. But even we know it’s like a high risk operation, you can have a lot of complications from it. Okay, we are really moving along guys. I’m so excited. Okay, what are potential complications of hernias that I should look out for? Whoa, that’s like, that’s like five years of residency.

Speaker 1 (00:49:07):

So hernia complications generally are incarceration where the gets cut or strangulation where it gets caught and the blood flow to whatever’s cut, whether it’s fat or intestine gets blocked, that is an emergency. Other complications can occur. Bloating and nausea and pain. Some hernias can burst but it’s not necessarily, there aren’t that many complication types, but there are complications from hernias, which is why we repair them. Now, femoral hernia like this lady had earlier that was repaired by Mesh is definitely a hernia that has a high risk of complications up to 5%, death rate, 25, 30% risk of bowel resection, a third of them end up in the emergency room deathly ill. So those patients are best femoral hernia. Patients with femoral hernias are best treated with surgery, whatever your symptoms. So we don’t want you to fall into the trap of getting femoral hernia complications. Whereas inguinal hernias, they have very low rate of death, very low rate of complications if you watchfully weight them, especially if you have no symptoms. And so the type of hernia is also important. When we talk about potential or potential complications, are there different types of hernias and what cause them? So what causes hernias? Number one, surgeons do you have a hernia from a prior incision? We call those incisional hernias and that can be anywhere. The incision is on the abdominal flank wall.

Speaker 1 (00:51:04):

Most commonly hernias are in the groin. So inguinal hernias are about three fourths of hernias that are being operated on inguinal femoral, indirect, direct, obtuator, those are all different pelvic hernias. There are some really rare pelvic hernias like sciatic notch hernias and perineal hernias. Those are really fun to repair. Then there’s all these different abdominal wall hernias, umbilical, Spigelian, epigastric, super umbilical. Plus you can get flank hernias. Those are almost always from trauma or surgery. Oftentimes kidney surgery, aortic surgery, spine surgery from a lateral approach. And then there are all these other hernias that had cute names like, you can get petit’s hernia, Grynfeltt hernia which are hernia is in the lower lumbar back. So almost all hernias are related to some type of collagen deficit. So people have less strong collagen, more weak collagen, more of the immature collagen, less of the mature collagen.

Speaker 1 (00:52:16):

And those patients, it’s very genetic and what we know is it gets handed down from your mother or father and if you have a female in your family with a hernia, then that is a much stronger genetic predisposition to pass on hernias than a male that has hernias. Even though males tend to have more hernias, it’s not, it just doesn’t penetrate as much genetically as that. Going back to our patient with the Mesh complication, I also have joint pain that has been worsening and did not have prior and I didn’t have prior to the repair. What would be some of the risks related to removing Mesh in the area related to the femoral hernia? So the main risk of Mesh removal from a femoral hernia repair is injury to the external iliac vein, which is a very thin but large vein. And if it’s done by a surgeon that is not aware of their anatomy or is heavy handed, you can bleed to death.

Speaker 1 (00:53:19):

So that’s a very big vein. Or you may need vein reconstruction and there’s complication with that. So that is the biggest risk. Of course, there are other things nearby. There’s a bladder which can be injured. There’s bowel that can be injured, there are nerves, the genital femoral nerve lal, femoral cutaneous nerve, which can be injured in women. That’s pretty much it. In men, you can injure their spermatic cord and their vast deference which carries a sperm. So those are all risks with the operation. And then the question is fine then what do you do with the femoral hernia? We just discussed how people can die from femoral hernias or get sepsis and bowel, bowel sections due to bowel obstruction. So it is definitely a hernia that should be repaired to prevent those al also life-threatening complications. So you do have options. You can have a tissue repair or a hybrid or biologic Mesh repair. But again, make sure number one, the diagnosis is very clear and not due to some other problems that you may be having health-wise. And number two, that if you do contemplate Mesh removal, that it’s done by a surgeon that does it for a living and knows how to do other types of femoral repairs including tissue-based repairs, which unfortunately very few of us do that I do it, but yeah.

Speaker 1 (00:54:52):

Okay, apologies. But I did not hear your answer about treatment options for the muscle tears you discussed earlier. This is in reference to the woman with the four C-sections. So she had a full hernia repair and the fascial tears were included as part of the hernia repair. What is a PCA two direct hernia that probably relates to the size of the direct hernia? One two is probably a two centimeter direct hernia. When seeking a second or third or fourth opinion, sometimes you find doctors that don’t want to get involved in treating someone else’s Mesh mask. This is true. I understand that some doctors don’t feel equipped to handle complications. I’m thankful for their honesty, but some of some that are experts don’t want to get involved.

Speaker 1 (00:55:38):

Obviously you are one of those doctors. Why are some experts reluctant to help? Okay, so I’ll tell you couple things. Our health system is not built to, even though we have a great health system, it’s so much better than most countries. It’s not built to treat a lot of complicated patients. I do that and my health kind of plan of care is built around my practice, which is almost exclusively 80 plus percent complicated, chronic pain, meth removal, revisional surgery, fixing someone else’s complications. However, if you have a surgeon, and this is reality, I’m just going to be very honest with you. If you have a surgeon who is paid per case, so he is an employee or she is an employee of a hospital system is paid per operation, they do, and that’s sometimes how surgeons are paid. They’re paid based on their surgical activity.

Speaker 1 (00:56:49):

Would they rather do three hernias and have them go home and relax or do one or let’s say five hernias or do one repair and with complications or wrists and it’s five hours or eight hours and so on. And so from a pure survival mode, surgeons that are paid and have bills to pay that are paid on a per case basis, not a per complications or complexity, they’re not paid based on complexity. They’re paid, paid based on volume. Then even though they’re very skilled surgeons and have the ability to take care of you, they just don’t have the resources to do that. So that’s one. Secondly, some surgeons are just uniquely inquisitive and to learn more and don’t shy away from complex questions or things they don’t understand. That’s kind of like me. I mean that’s why I’m doing hernia talk. I love these questions.

Speaker 1 (00:57:49):

However, there are also many doctors as there are any other human beings that don’t enjoy the process of figuring things out and not knowing the answer and struggling to figure out problems for patients. And those patients, those are surgeons that choose not to treat complicated patients and prefer that subset of patients be treated by others like me. So even though they’re expert at what they do, and they may be really good at what they do, they will choose not to have that added stress in their job or that added kind of income loss. And so unfortunately that’s it. That’s a short answer to that.

Speaker 1 (00:58:36):

And on that note, I will have to say goodbye. That was fast guys. I can’t believe we finished. We still had had several more questions, but I must say we got through a lot. Thanks everyone for joining me. Those of you on Facebook post the zoom of this in case you missed the first couple questions, but most of you were able to take care of everything. Thank you for everything. Thank you for joining me. We’ll be joined with a guest panelist again, again next week. So stay tuned for that. I have someone very special for you, a little bit out of the ordinary, but I hope you’ll enjoy it. So thank you for watching. Please join me on YouTube where all of my past 55 I think episodes are posted on my YouTube channel. The link to it is also on my other social media or you can just look up like just Google or search hernia talk as one word on YouTube.

Speaker 1 (00:59:47):

They should all come up. I’ll make sure this is on YouTube and I’ll post a link to it on my social media group. So thank you for following me on Twitter and Instagram at hernia talk, on Facebook at Dr. Towfigh and on YouTube and for joining me right now on Facebook Live and Zoom. I enjoyed it. Thank you so much. I’m going to go home now. I have a talk to give on Thursday at the A S G B I, which is the Association of Surgeons for great, great bi, great Britain and Ireland. So I’m super excited for that talk and I’ll update you on that later on. Thanks everyone. Take care. Bye.