Episode 56: Hernia Repair for the Underserved | Hernia Talk Live Q&A

You can listen to this episode by clicking here.

Speaker 1 (00:00:01):

Good evening everyone. Welcome to Hernia Talk Live, our weekly Q&A with experts in the hernia field and related topics. My name is Dr. Shirin Towfigh. I am your host every week. You can follow me on Twitter and Instagram at Hernia doc on Facebook at Dr. Towfigh. And we have a channel for this hernia talk live sessions, which you can find on her that today’s episode is also posted tonight. Today’s guest is Dr. Charles Filipi. We call him Chuck. He is adjunct professor of surgery, but most importantly for today’s session, he is the founder of Hernia Help, which we’ll discuss, which is an international organization focused on helping disseminate hernia repair for the underserved. You can follow hernia help on Facebook and Instagram, and also they have a website, hernia help.org. So with offer their ado, welcome Dr. Filipi.

Speaker 2 (00:01:04):

Thank you, Shirin.

Speaker 1 (00:01:06):

Thanks so much for your time.

Speaker 2 (00:01:08):

Yeah, thank you for inviting me.

Speaker 1 (00:01:10):

So you’re coming in from Omaha, Nebraska, and you’ve been there. How long have you been there forever, as far as I know.

Speaker 2 (00:01:18):

Well, we have lived here longer than any one place since my wife and I were married. We’ve been here 26 years.

Speaker 1 (00:01:27):

Oh my. Yeah. And did you work at University of Nebraska this whole time, or Creighton this whole time?

Speaker 2 (00:01:34):

Yes, I

Speaker 1 (00:01:34):

How did you get involved?

Speaker 2 (00:01:36):

Full time at Creighton. It was really a esophageal surgeon. That’s my specialty. Although I was interested in hernias largely because of Dr. Fitzgibbons, and we’ve been partners all that time and came to Creighton because of Tom Demeester. Really?

Speaker 1 (00:02:00):

No, who was my chairman when I was at USC.

Speaker 2 (00:02:04):

Yeah. Yep. We got interested in Lap Coley real early and then lap Nissen and then lap hernia. So kind of evolved. Tom went to USC though shortly after I was ready to move. So we never really intersected, but

Speaker 1 (00:02:25):

We’ve, yes,

Speaker 2 (00:02:26):

Certainly learned a lot from him.

Speaker 1 (00:02:28):

So how did you go from esophageal surgery to hernia surgery? You, I feel like you downgrade it or maybe you upgraded.

Speaker 2 (00:02:39):

Well, I was interested in lab coley at first and then lap nissen and went into the esophageal arena, but then also thought, well, it makes sense that laparoscopic hernia repair be performed and did some laboratory work at Creighton. Tom Demeester asked me over a lot of times to come over and talk about lap coley, lap nissen, and that type of thing. And then did laboratory work doing pre peritoneal approach for lap hernia. We also did IPOMs and worked with ethibond lot. Then all of those courses happened and eventually became involved with the American Hernia Society and went from there. But I had mostly esophageal cases and hernias as well.

Speaker 1 (00:03:38):

That’s pretty amazing. So the, let’s talk about hernia health. You’ve been involved for a very long time now in kind of charitable organizations and charitable hernia surgery repairs for the underserved. You go to multiple countries. COVID’s kind of probably put that on hold for a short while, but maybe you can describe how you got involved, how you started hernia help. What was the precursor to that organization?

Speaker 2 (00:04:13):

Yeah, it really started in the 2002. We had a joint European American Hernia Society meeting in London, and Dr. Leon Herzog, a specialist from Argentina hernia specialist, described a mission that he had with residents up to a rural, very remote village in northern Argentina. And he was quite a believer in local anesthesia and open hernia repairs. So they literally operated on kitchen tables and did hernias under local. And he described that at the meeting and it was very exciting to me and Andrew Kings North also. In fact, that talk really was the impetus for us to start with Hernia Help and for Andrew to start with Operation Hernia.

Speaker 1 (00:05:07):


Speaker 2 (00:05:08):

So both, he went to Africa, we went to South America and Central America Caribbean, and our first trip, I actually at cr I’m at Creighton University still in on the faculty and working some and Creighton’s associated within the Institute of Latin American Concerns in Santiago, Dominican Republic. And they built a beautiful new surgical suite with three modern ORs. And so I thought, well, I was on the executive committee for the American Hernia Society, and I thought maybe we could do something down there. So I went down to see if they had hernias, and in one day they had 320 patients with hernias. Wow. Wow. Some of them had herniated disks and a few of them had hiatal hernia. But I was convinced. So then I came back to the executive board meeting and talked about maybe having what we called, I called it initially a volunteer corps, and Albert and Arthur Gilbert was really the father of the organization, as you know, and Yes, absolutely.

Speaker 2 (00:06:27):

And there was a long pregnant pause after I brought it up because I said, I think it’d be great if some of you on the board would go down there, volunteer. So there was a long pause and then Arthur said, I think that’s a good idea. And so our first trip, Smid and Arthur Gilbert and Wolfgang Ryan and Jean Piro Campanelli because I’d gotten to know them through the European Hernia Society went down and we did a lot of hernias and they thought in the Dominican Republic that we might be able to do about 12 in a week. And I said, no, we’ll do 120. And we did. And wow. Then it went from there because we really wasn’t hernia help then. We didn’t incorporate until 2011 and then broadened into total of nine different countries almost all in the Western hemisphere, although now we have trips to Ben in Africa.

Speaker 2 (00:07:31):

But that’s just started. And we did a lot of surgery, but we chose expert surgeons because we wanted to live by the preferential option for the poor, which basically says that we’re going to, as I interpreted it from a hernia surgical standpoint, is that we would operate on people such that they would receive an operation that they would be comfortable with their family member having. And so we thought, well, let’s add the best hernia surgeons. And then with the organization, the hernia surgeons were the team leaders and they would choose the anesthesia people and the nurses. And naturally I think they brought wonderful people with them. And that’s been true throughout. So in 2011, we incorporated and became a 501(c)3 organization. And since we’ve started that part of it, and that trips to iILAC, the Santiago, Dominican Republic site continued, but we’ve had other teams go to other places. In the Dominican Republic, we’ve gone to 22 different sites and done over 6,000 hernias without a death and with a complication of 0.8%. Although the follow up long-term is very questionable because the people are all poor, it is free for them. And we’ve had some good success, we’ve had some problems. It’s not easy sometimes. And the environment where we go, depending on what country it is, can be very austere and difficult.

Speaker 2 (00:09:34):

It is even dangerous. Now in parts of Haiti, we have a team, well part of a team down there, and it is significantly dangerous, but every other place we’ve gone has been safe. I wonder about malaria, but we haven’t any problems with that. Dengue Fever, one volunteer from another organization that went to the same place we went in the Dominican Republic happened once, but really we’ve had no serious team injury or sicknesses.

Speaker 1 (00:10:11):

That’s pretty amazing. So for the audience, lot of the names that you mentioned are presidents of our European and American hernia societies, really premier surgeons in our community, both in Europe and in the United States. And yeah, you have a board and your board members also are all very prominent members in our society. So what you’re doing is you’re taking really experts to go down to different countries that are poor. The people are poor, they don’t have access to surgery. Now, hernia surgery is pretty common. Why don’t they have access to their, are there not enough surgeons that meet the needs of these poor areas of the countries,

Speaker 2 (00:10:59):

The surgeons that are there are so busy with emergencies that hernia surgery isn’t done very much and the hernias are bigger and more dangerous because there’s no pediatric surgery in these countries and locations that we go, pediatric anesthesia is a specialty and you can’t have an adult anesthetist or nurse anesthetist doing small children. And so many of the mothers in these places that we go will not allow their children to have surgery of any kind. And so some of the hernias we see are really huge because they’re pediatric hernias that have gotten bad basically in adults and very large and high risk.

Speaker 1 (00:11:56):

And the surgeons that you recruit to do this, are they paying their own way? I assume they’re not getting paid for what they’re doing.

Speaker 2 (00:12:04):

That’s right.

Speaker 1 (00:12:05):


Speaker 2 (00:12:06):

We don’t receive any remuneration except the goodwill of the people and the association with the other team members. It’s a wonderful experience to, yes,

Speaker 1 (00:12:19):

It really

Speaker 2 (00:12:19):

Is to work with these kind of people. And the anesthesia. Nursing personnel have been wonderful. Also. We are sometimes asked because the word gets out that there are these expert surgeons coming and some wealthy people want to have their surgery done, but we don’t do that. We do get them with a good in-country surgeon. The other reason that there isn’t access for many of them is that there are in some countries, very few surgeons that are fully trained and so they’re poor to the point that they can’t afford even the transportation to get to the hospital. In Haiti, for instance, the death rate for appendicitis is 43% and

Speaker 1 (00:13:19):


Speaker 2 (00:13:20):

43%. And for those die, die, wow. With appendicitis and the United States, for those that aren’t aware, it’s less 1% for appendicitis and there just aren’t qualified surgeons, but the public is not educated, they don’t know what they have. They might come in four or five days later, they have become so sick that they’re operable that maybe septic shocks. So they’re very seriously ill. So a lot of these patients that we do see have very big hernias that are difficult to do. They come late and they just haven’t been educated at with basic healthcare issues. And that goes. And

Speaker 1 (00:14:08):

Which countries do you serve?

Speaker 2 (00:14:12):

Well, we go to the Dominican Republic. Haiti was the second place went. We went to Ecuador. Ecuador actually is a fairly affluent country, so we didn’t need to keep going there. But we’ve gone to Guatemala and Paraguay and Brazil, been in Africa, we’ve been in the Dominican Republic a lot and in different places. And we work in the United States also. And it’s interesting because there are a lot of people in poverty here in Omaha. We have five Fortune 500 companies, but we also have the second poorest black population in the United States. So there’s a tremendous disparity and there are a lot of people that don’t have any Medicare, medicaid, any form of insurance. And so we take care of those people if they’re at the poverty level or lower with, that

Speaker 1 (00:15:10):

That was one of our questions. I feel like we can use these experts help in the United States because there’s such disparate levels of care. So I’m actually very interested. How is your US population mostly in Omaha or Well, how do you choose where to go for

Speaker 2 (00:15:32):

It? It depends.

Speaker 1 (00:15:32):

Charitable hernia surgery in the United States,

Speaker 2 (00:15:35):

It depends upon the receptivity of the hospital administration. And at Creighton, we were able to start without trouble. And then the University of Nebraska’s here in Omaha also. And so they were very welcoming to the concept. And there’s an abundance of patients. I mean, we have a number of free clinics in Omaha and they’ve got a big list of hernia patients. And so we’re able to do them and the hospitals absorb the cost and the surgeons and anesthesiologists volunteer and don’t charge. One of the most difficult parts is to get the people in billing. We’re so used to sending out bills to everybody to stop sending out the bills for these people. So we have to remind the patients, if you get a bill, get it taken care of. The computer just can’t quite figure it out sometimes.

Speaker 1 (00:16:35):

That’s pretty amazing. And then tell me a little excuse, sorry, go

Speaker 2 (00:16:40):

Ahead. Well, I was just going to say, so what we do in the US is we do surgery on one day in three ORs with the three surgeons, and we don’t do ventral hernias because they may require hospitalization and we don’t do real super risky people that could have trouble with the anesthesia.

Speaker 1 (00:17:07):

Sure, yeah, sure. And then also the other question that was submitted was what types of hernia paras are most more commonly performed in these poorer countries? So are they all inguinal hernias? And what type of technique do you do? Do you do umbilical hernias? Incisional hernias?

Speaker 2 (00:17:29):

We don’t do incisional hernias because most of the places we go don’t have the ability to hospitalize the patient. And so often they need to be hospitalized, so we’ll refer ’em to a tertiary center for that. For incisional hernia, we do a lot of inguinal hernias and we do pediatric hernias. We have pediatric surgeons doing pediatric hernias. All of the children under the age of 16 are done by a pediatric surgeon. And most of the hernias are inguinal or groin hernias, but there are a lot of umbilical hernias that especially the pediatric surgeons do.

Speaker 1 (00:18:13):

And then what languages do you speak there? Or do you have interpreters?

Speaker 2 (00:18:18):

Well, you learn after a while, but Spanish is the primary language in Haiti and we’ve had a lot of trips there. And that’s by far the poorest country in the Western hemisphere. They speak Creole and but they can understand some French. And so we have some nurses that can speak Creole and or we have in-country translators certainly. Yeah.

Speaker 1 (00:18:49):

Yeah, they’re French. It’s like a French derivative. You can understand some French words with them when they speak. Right.

Speaker 2 (00:18:55):


Speaker 1 (00:18:56):

And is any healthcare worker able to volunteer their services for you?

Speaker 2 (00:19:03):

Well, yes. We do want to have, if we don’t know them personally, we want to receive letters of reference. We do an interview and if there’s a fit, then we’re willing to take volunteers. We have a roster of 330 or so volunteers that have worked with us in the past, and this includes surgeons and anesthesia providers and nurses. One of the things that we really have a need for are sterilization technicians because sterility and especially the sterilizers that are available in those countries are suspect, and we can’t be bringing those into the country. Customs. If you bring in a big piece of equipment, customs goes crazy, no matter pretty much whatever

Speaker 1 (00:20:01):

Country. No, absolutely, absolutely.

Speaker 2 (00:20:05):

But we’re glad to have people contact us if they’re interested in volunteering. Very much so.

Speaker 1 (00:20:14):

That’s really great. So you probably have a combination of surgeons who can offer the surgical care, probably technicians to help assist in the surgery, anesthesiologists nurses, and you probably have some lay people that check in patients and the do they fill out forms?

Speaker 2 (00:20:34):

Yeah, we keep statistics. We have people wash instruments that are laypeople that are willing to do that. We’re always able to keep people busy. It just seems like there’s no end to what needs to be done. But we normally, we will have a site with two operating rooms, we’ll do, one is pediatric, one adult, and our team will be between 15 and 18 people that that’s their typical size. Wow.

Speaker 1 (00:21:12):

Do you live on campus? What are the living quarters and yeah, what are the living quarters?

Speaker 2 (00:21:19):

It varies greatly. We have a site in Guatemala City where, and our team stays in a hotel, but a lot of the other places they stay in nearby facilities. Although we’ve been able to find a good secure places. One of the priorities, we have a very elaborate site evaluation protocol, and number one on the top is safety of the team members. And so we don’t go someplace where there’s going to be kidnapping or one thing though that you do have to watch out for in developing countries that are motorcycles and crazy driving. And so we don’t let anybody go on it. We have code of conduct, that type of thing that people have to sign. We don’t let anybody ride motorcycles or ride in the back of a truck, or we encourage people not to get on [inaudible] because they’re kind of crazy. Yeah.

Speaker 1 (00:22:26):

So question that’s being asked by one of our viewers is what kind of surgical technique do you use for the inguinal hernias?

Speaker 2 (00:22:34):

Yeah, we use the Lichtenstein repair. We’ve decided to standardize that because we are training surgeons to perform the Lichtenstein repair. And for those that are not familiar with that operation, it’s using Mesh, which has been shown, this is through an open incision, not laparoscopic. We don’t have the equipment and technology in these sites for laparoscopic surgery. We’ve done it in one place a few times. Bruce Ramshaw was person that went down, but we use Lichtenstein repair as a well known inguinal hernia repair that has an excellent safety and effectiveness follow up rate. And so that’s what we teach to all of the surgeons. And we have a day long course, and we only train surgeons that are fully trained in their country, and they do five or six hernias in that day with an expert. We have seven trainers, and they use the operating performance rating scale, which you’re familiar with. But for those that dunno what that is, it’s a very systematized method of training surgery that’s approved by the American College of Surgery. And it specif specifically for the Lichtenstein repair. And that’s what we use to train with. But that’s the operation that we do. And you might wonder where they’re going to get the Mesh after we leave, and that’s a good question. But we’ve been able to provide Mesh, it’s, it’s been quite gratifying working with industry. I can truthfully say I have never been denied when requesting a Mesh from industry to donate Mesh

Speaker 2 (00:24:40):

And in abundance. And so that has happened, and we’ve been able to give the surgeons that we have trained Mesh Mesh here in the country, this country for an England earning costs a hundred hundred and $50, which is just inconsequential here, but in developing country, that’s two months or three months worth of wages. And so there’s no way anybody can afford that. So we are able to donate though very large amounts of Mesh and what’s happening now that’s exciting. And we thought this would happen is that now some of the developing countries have started making Mesh, have companies making Mesh, and we have to check it out. We have to be certain that it’s good Mesh, but we’ve been grateful have a company in Columbia,

Speaker 1 (00:25:35):

Just generic Mesh.

Speaker 2 (00:25:37):


Speaker 1 (00:25:40):

Yeah, just generic Mesh.

Speaker 2 (00:25:42):


Speaker 1 (00:25:43):

Have you ever done the mosquito net? Oh, okay.

Speaker 2 (00:25:48):

So that’s why, that’s the repair we use.

Speaker 1 (00:25:53):

For those of you watching, there’s been some interest, I think it started in Africa by just using mosquito net as opposed to surgically developed and manufactured Mesh. And I guess the patients did fine, and the results of that is fine. So, well, as

Speaker 2 (00:26:17):

Far as I might just say,

Speaker 2 (00:26:20):

Well, I would just say though that there’s been a lot of reports because with mosquito netting, that would cost just a dollar or two to cut a piece of mosquito netting out and sterilize it. But the big issue is sterilization and to do it correctly. And so there’s a growing reluctance, especially with European surgeons, to use mosquito netting now because the issues of sterilization, if you overheat it, it shrinks tremendously. And so that hasn’t quite worked out as well. You can do surgery on the groin hernias without using Mesh, and there’s some charitable organizations that are promoting that.

Speaker 1 (00:27:19):

Yeah. And why haven’t you all done tissue repairs as your motive hernia repair? Or do you also do that?

Speaker 2 (00:27:26):

No. Well, we do tissue repairs for umbilical hernias, although we’re using Mesh reinforcement for a lot of those now too. If we’re going to practice preferential option for the poor, we’re going to give an operation that we would have for a family member. And so that’s why we are sticking with the Mesh because the results are so much better. I mean, there’s no question about the recurrence rate being much better with the Mesh. So we are trying to inject into these countries a high standard. And interestingly, the surgeons and the ministries of health have been very, very receptive to that. And so we have no trouble getting people, surgeons to enroll in our training program.

Speaker 1 (00:28:19):

That’s pretty amazing. And so the Lichtenstein by definition is use of flat Mesh. There’s different brands and there’s different weights. Do you follow any particular weight of Mesh or brand of Mesh or whatever you’re offered? You’ll take?

Speaker 2 (00:28:35):

Well, we use lightweight, large pour Mesh. Now we think that’s a better Mesh to use in terms of comfort postoperatively, and the recurrence rate isn’t any higher. And so that’s what we prefer. But if we get a prolene piece of Prolene Mesh standard generic piece, we will accept it because we can’t always get the large core lightweight.

Speaker 1 (00:29:09):

And then how do you manage complications after hernia surgery if there’s an infection a week later, for example?

Speaker 2 (00:29:16):

Yeah, that’s a good question. Well, what you need to do is, because we don’t stay for long periods of time on Monday, Tuesday, we try to schedule our most complicated patients so that if there’s a difficulty with them early on, we’ll be able to handle it while we’re still there. But you need to locate a highly competent surgeon in the area that will do the follow-up. And we’ve been able to do that. We train them, we don’t charge them for anything, and they’re thrilled to learn. They’re just hungry for educational experiences, especially with an expert. And they know who their trainers are and appreciate having time with them. And so we’ve been able to build up quite a loyalty among a few chosen surgeons in each locale that will do the follow-up for us. And if they’re complications, they’ll take a picture and send it to me with their iPhone of the wound. And if there’s, there haven’t been really any terrible complications. We’ve had a couple from hydrocele. We do hydrocele also, but we have good follow up with the people in the Dominican Republic because it’s a large network of healthcare providers that bring all the patients in and they know all of what needs to be done. And then these local surgeons that we’ve trained and then provide our follow-up are fully trained surgeons so they know how to follow a hernia patient.

Speaker 1 (00:31:03):

Right. Umbilical hernias without Mesh, the risks of any complication with that are close to zero, very, very low risk of any infection. The biggest risk would be recurrence, but no fistulas, et cetera. Complications from an open angle hernia pair with Mesh may include infection, including Mesh infection, also very, very low. Well below 1%. But how would you handle a Mesh infection?

Speaker 2 (00:31:33):

We have not had any chronic Mesh infections. Unbelievable. Especially with the questionable sterilizers and all. It is real interesting, some of the literature, I still review articles for the World Journal of Hernia and abdominal wall surgery, and there’s some evidence now that people in very dirty environments seem to do better, and Covid has not had a big impact in 80, which is, and it has a Dominican Republic, the Dominican Republic’s, the high middle income country. 80 is the low only low income country in the Western Hemi. Right. And they have not had nearly as much. Now, it may be way under reported. Sure. So it may be that with the living conditions that extremely poor people are in, that they may have a more robust immune system. But we just have not had any long-term Mesh infections. We’ve had a couple just recently actually in Haiti, which was concerning, but they haven’t have to have the Mesh removed. So

Speaker 1 (00:33:06):

Yeah, that’s really fantastic. And I must say what you’re dealing with are typically healthy patients that are not morbidly obese or diabetic, which is what we see more often in Western countries, especially the United States. And secondly, you’re having very efficient surgery done by experts, and it makes such a big difference. The same operation can have much more complications. A, you’re doing so many operations and it’s very efficient. So the time of surgery, which does impact infection rate is probably lower. But also the technique that you’re using by the experts implies a better hernia repair, lower risk of chronic pay, lower risk of nerve injury, lower risk of Mesh related complications. These are not heavy-handed surgeons. These are surgeons that understand the anatomy really well and don’t disrupt the anatomy as part of their hernia. Hernia repair. Some of these surgeons, you watch them operate and it’s so beautiful to watch them.

Speaker 1 (00:34:11):

It, I mean, I just really enjoy watching good surgeons operate. It makes such a big difference. And then sometimes I watch other surgeons operate and I get hard palpitations, and it’s, it’s so interesting. I’ll give you some, I’ll tell you something funny. So we recently published a paper that talks about YouTube. So YouTube, there are all these doctors that do hernia repairs laparoscopically, and they post their hernia repair on YouTube. And if I were to post my hernia repair on YouTube, I would make sure it’s a well done repair, not one that that’s complicated or too busy or you know, want to show your best on videos. And so we looked the top 50 most viewed laparoscopic Anglo hernia pairs on YouTube. Let me tell you, doing that research, I had to watch 50 videos for more than half of them. I was getting, I almost got P T S D because just watching what they were doing with the anatomy and how they were poking and prodding and causing potential injury, and the way the Mesh was placed and the way the dissection was done, I mean, was at the screen. I almost didn’t want to finish the research because I was having serious problems watching. And then every, so watch, you’ll see every so often you’ll see another video and it would be like a gorgeous, beautifully done hernia repair. So for patients out there, the surgical technique is such a predictor of how well you do Oh, yeah. From hernia repair, because that anatomy is not delicate, right? I mean, it is delicate. You can’t just wing it and think everything’s going to be okay. Don’t you agree?

Speaker 2 (00:36:13):

Oh, absolutely. And one of the things that we learned, because we were working with fully trained surgeons, that in developing countries, the one deficiency that they often have is respect for tissue. Using delicate maneuvers and precise handling of tissue. They’re just little rougher. And that can create all kinds of problems as so yeah, I call ’em intraoperative accidents, and they can be little tiny ones, but if mount up, if there’s a lot of them, or there can be just one that can be disruptive. So yeah, technique is very important. And one of thing, I’ll just mention this, maybe I shouldn’t, but I, I tried to always have surgeons that were well-known, but what I would always do is have them come to the ILAC Center, the Dominican Republic, because I wanted to watch ’em operate first. Yes. So it doesn’t make any difference who their name was it. I would always do that. And I didn’t tell them, but I was watching because just what you said, there’s some people that are excellent speakers and wonderful public relations people, and a great chairman and a leader, but they may not be a great surgeon. And I’ve worked with some wonderful surgeons who were down in the, they were in a small town and they really knew how to operate. And so they don’t get known so much. But they do buy a small community eventually because they have good results all the time. But technique is huge.

Speaker 1 (00:38:04):

It makes a big difference. I teach that to the residents because I feel like as a medical student, and sometimes as a resident, you’re assisting. And so you want, you’re really good job assisting. So you’re really yanking on the tissue and exposing great for the surgeon, not appreciating that there’s a human being, that you’re really distorting the tissue a lot, adding a lot of trauma to the tissues. And I just teach ’em like be gentle, only retract as much as you need. Be very careful. And then after surgery, the patient has no bruising. No swelling, barely needed any pain control, super happy. And I do a lot of revisional surgery as removing Mesh or redoing hernia repairs. One of the questions I always ask is, how was your recovery from the first surgery? And if they tell me, oh, I couldn’t walk for three weeks and I was so swollen and bruised, sometimes that’s a reflection of how heavy handed and aggressive the surgeon was, which to me implies that they don’t have as much respect for the anatomy. And maybe that’s why there’s a complication. And then I’ll do the surgery and my surgery’s completely undoing that surgery, redoing it, you know, would expect that to be more difficult recovery. And often the patients say, oh, that was the best recovery I’ve ever had. Because it’s, you’re just being a very gentle surgeon. And anatomy is so key for the groin. It’s so key for the groin, and it’s such a difficult anatomy at the same time.

Speaker 2 (00:39:41):

Yeah, haste makes waste. I mean, people that are trying to get done rapidly, that does not work. The nurses like it because they can go home earlier to their family, but haste is not the right way. I had a really good teaching moment with the same point, actually, it was at the Virginia Mason Clinic. I practiced in Washington State for a number of years, and I was there watching an expert do surgery, and the resident was doing the operation and the surgeon stopped the case and said, and I don’t remember the resident’s name, but he says, I’ve watched you with patience and I see you sitting there with them and sometimes holding their hand and really being patient and listening to them. And I’m impressed with how respectful you are of them. But I wish that you would be respectful of their tissue

Speaker 1 (00:40:37):

Today. Oh, that’s a good

Speaker 2 (00:40:38):

One also. Yeah. And because he was kind doing the resident learning thing, but he wasn’t very respectful of the tissue. So yeah, it needs to be at the bedside, but it also for sure has to be on the operating

Speaker 1 (00:40:52):

Room. Yeah, for sure.

Speaker 2 (00:40:54):

One thing I think the people, people might be wondering was, well, how do I, because I’m not a surgeon, know who those people are that are respectful.

Speaker 1 (00:41:06):

That’s a good question.

Speaker 2 (00:41:07):

And what I say is find out who the doctors in your community send their family members to surgeons. And almost always, they know they may go to another system, even with their family member when they know that George over at the other place is really the best way.

Speaker 1 (00:41:28):

If you know any OR nurses or more importantly scrub techs, they know who’s the delicate surgeon and who’s not, who’s the one where, or even recovery nurses, who’s the one where the patients wake up in pain or who’s the one where the patients leave their recovery room. Really? Yeah. Fast. Yeah. I get that a lot. So how do you get funding for your missions?

Speaker 2 (00:41:59):

We get private donations. We get grant money from industry and different foundations. And sometimes we have grateful patients that donate how we get our funding. And

Speaker 1 (00:42:17):

You have a very good website, hernia help dot org. And I’ve donated on that before. It’s just a really nice resource to know exactly what you’re doing. And so all different types of funding from private donors. Do you apply for grant money grants as well, or It’s mostly just donations from industry and doctors and patients.

Speaker 2 (00:42:43):

We definitely have applied for grants. Mostly from industry but also from private foundations. But the truth is, I’m not, even though most of my time is spent or had been spent as a fundraiser, I’m not a professional fundraiser. So it was mostly donations from friends and colleagues and patients. And that’s

Speaker 1 (00:43:10):


Speaker 2 (00:43:11):

So, but if you’re dependent on grants, you’re, you’re really not going to have sustainable funding. Cause they can go away. And then if you get a nice big grant for two or three years and get dependent upon it, then that’s unstable.

Speaker 1 (00:43:28):

So because everyone else, everyone who’s donating their time is also self-funding their travel. Correct?

Speaker 2 (00:43:35):

That’s right. Yeah. We do have a couple of employees that one who’s equipment manager and we give her the cost of trips that she goes on. And then we do have a half-time employee. We have now an executive director that we pay has helped immensely with the funding. And so that’s made a big difference.

Speaker 1 (00:44:02):

Yeah, they’re very worthwhile. Another question that’s come in from the audience is, this is very fascinating. Thank you. What do you use for post-op pain control for these patients?

Speaker 2 (00:44:14):

Yeah, that is very interesting. People in developing countries are analgesic naive.

Speaker 1 (00:44:22):


Speaker 2 (00:44:23):

May never have had a aspirin or a Tylenol in their life or any pills. See, and so one of the things we find out rapidly with and teach and work with the anesthesia people, it’s given them half as much of the anesthetic agent as you would give it here in the US because they’re going to stay asleep for a long time in the recovery room if you use a general. So we use very little, and for a standard inguinal hernia in an adult male or female, we give them 200 to the 400 milligrams of ibuprofen three times a day. That’s it. That’s great. And all they need, it takes care of the pain. Now there are some very big hernias and they’re big bilateral hernias and they need more than that, obviously, but they need very little,

Speaker 1 (00:45:22):

I mean, that’s what I give my patients ice packs, Tylenol and Naproxen or ibuprofen.

Speaker 2 (00:45:29):


Speaker 1 (00:45:31):

That’s all you really need for a inguinal hernia or small belly button hernia. And lots of local anesthetic. I assume

Speaker 2 (00:45:40):

We are working on that, especially with the people we’re training. We are trying to encourage local anesthetic and we work on it with the anesthesiology people. Our preference is a little sedation while the local is going in. And that’s it for the anesthesiologist. They just wait. And then our goal is to walk the patient out of the recovery room and that way we can have an hour, two hour recovery and they’re ready to go. And they’re really ready. Perfect. But there are a lot of anesthesiologists that aren’t used to that. And they’re in developing countries. They’re used to having spinals on all their patients. Yes. General anesthesia is not used very much. Spinals are used for pretty much everything that they can operate on from the true. And so there’s a lot of education that needs to be done to get the local, an anesthetic as a predominant method.

Speaker 1 (00:46:52):

Yeah, that’s true. Two weeks ago I had a patient who says, I want zero anesthesia, not percent to make me forget, no propofol, no fentanyl, nothing. So he was wide awake for the entire operation. I’m totally okay doing that. By the way, I treat a lot of the heart transplant patients. Oh. At Cedar Sinai. So I prefer they get nothing. I’ll just, yeah, I’ll just do everything locally. And he did great. He, no, he got a shouldice repair. He got no bruising or swelling. He is, I just talked to him today. He looked great. Was like, he lives in Hawaii and he was like shirtless doing a Zoom meeting with me. But he was so happy. Remembered everything. It was a good experience. But you really just need good local anesthetic. And I assume you don’t have access to, and we don’t really do sometimes, but not commonly exparel, which is like the long-acting seven two hour.

Speaker 2 (00:47:56):


Speaker 1 (00:47:56):

Would be really helpful. You can get donations from Exparel. That would be a,

Speaker 2 (00:48:01):

Oh, I’ll, I’ll want to talk to you about that.

Speaker 1 (00:48:03):

Yeah, yeah. I’m sure they’ll do it if they have excess or something. Or they can help with a donation that’ll give ’em 72 hours of relief. You don’t even have to give them pain medication by the time it wears off. Sometimes it takes four days to wear off. By the time it wears off, they should be pain free.

Speaker 2 (00:48:25):

That’s great.

Speaker 1 (00:48:25):

Yeah, it is. Great. So are most of your patients males?

Speaker 2 (00:48:30):

Yes. Yes. Yeah. In the pediatric population, we probably have 30%, 40% females because there are a lot of umbilical hernias. But in the adults, 85 to 90% at least, maybe 95% are males. Yeah.

Speaker 1 (00:48:57):

Wow. And then are there any medical legal issues maybe for the patients in the United States or even outside the United States? Have you ever run into any legal problems?

Speaker 2 (00:49:07):

Well, no, we have not. And in the Dominican Republic, we’ve been there since 2004, and we’ve seen that country grow economically. And with that, there are now some malpractice lawyers. But the population that we serve is are rural people and they’re very poor. And they are just so grateful to have an operation. And because we’ve been there a long time, the reputation is good and they trust us. So we don’t carry any international malpractice practice insurance with the organization at all. Interesting. And we’ve talked with a lot of other nonprofits working in developing countries, and that’s the same for them too. They just have not had problems. So as I’ve mentioned, we don’t operate on wealthy people, but I don’t want people to think that we’re taking advantage of. I think we’re providing a good care, good care for them. And it certainly isn’t because we’re less worried about malpractice, but just hasn’t been an issue. I’m a director of Global Surgery Fellowship at Creighton. We have DR going to Africa, and we have a very hyperactive hyperacute legal section at Creighton University. And we don’t need malpractice insurance for somebody going over to a small hospital but doing all kinds of crazy things. They have to, they’re one surgeon. They’re in Rwanda, there’s 9 million people and there’s nine fully trained general surgeons. Wow. In one of our global surgery fellows in Tanzania was the only trained general surgeon for 1.2 million people.

Speaker 1 (00:51:14):


Speaker 2 (00:51:14):

It, it’s crazy the way it is in some of these other countries, it’s just being on a different planet in terms of healthcare. It’s more like being in 1950, their healthcare system and their equipment. And I mean, it’s not that way in every country. Of course. I mean their pockets of wealth and some good hospitals. But it is, it’s amazing. And that statistic of 43% mortality rate for appendicitis in Haiti tells you a lot.

Speaker 1 (00:51:52):

Yeah, of course. That’s crazy. Yeah. Do residents also join you all in these

Speaker 2 (00:51:57):

Missions? No, we don’t do that. We don’t want to have residents learning on poor people and they don’t speak English. It’s hard for them to even do. We get consents on all patients, but to consent them and explain to them that they’re just going to be a resident who’s still in training, way too complicated. A lot of our patients just sign with an X. They don’t read or write. Oh, the average fourth grade level or average education level in the Dominican Republic is fourth grade. And that’s a higher income country there. So of the developing country. So we don’t have residents there to be trained. They can go to assist, but they don’t want to do that.

Speaker 1 (00:52:52):

Right, of course. Of course. Yeah. And then, so your hernia help organization is primarily focused on Central and South America and

Speaker 2 (00:53:02):

Yes, but we think after the pandemic that we will be working in Africa, although that’s not finalized by any means.

Speaker 1 (00:53:17):

And there’s also Operation Hernia right through,

Speaker 2 (00:53:21):

There’s Operation Hernia, which you go

Speaker 1 (00:53:25):

To Africa,

Speaker 2 (00:53:26):

It’s the United Kingdom, and they work in Africa. And then there’s Hernia International, which is another nonprofit that works from the United Kingdom and goes to Africa.

Speaker 1 (00:53:39):

And is there still the global hernia relief from Germany? Or is that integrate with you all?

Speaker 2 (00:53:48):

I don’t know about that actually.

Speaker 1 (00:53:50):

Okay. Yeah. I think maybe Ryan Pulled was involved in that for a while. Yeah. I would highly recommend that you also enroll your organization. Facebook has a whole Facebook and I think also Instagram, which you have, you can enroll your organization for anyone who wants to donate to donate, you can enroll it as a nonprofit and gain donations just by being on the social media. So that’ll be kind of cool.

Speaker 2 (00:54:28):

Okay. That’s good. Thank you.

Speaker 1 (00:54:30):

Yeah. So I look forward to being one of those surgeons.

Speaker 2 (00:54:34):

Absolutely. We But watch you very much.

Speaker 1 (00:54:38):

I know. I love my inguinal hernias.

Speaker 2 (00:54:40):

Yeah. They’re good to take care of. And it’s very rewarding for everybody involved.

Speaker 1 (00:54:49):

And everyone deserves to have an inny umbilicus, like, although, you know what? Let me tell you this. Did you know, there’s a fetish about belly button, about outty belly buttons.

Speaker 2 (00:55:01):

Oh yeah.

Speaker 1 (00:55:02):

There’s a fetish. Some people want their inny to become an outty and they text me about it, or they

Speaker 2 (00:55:08):


Speaker 1 (00:55:08):

Impresses me about it. Yeah.

Speaker 2 (00:55:10):


Speaker 1 (00:55:11):

Well. Yeah. That’s the world we live in. Yeah.

Speaker 2 (00:55:16):

That’s not been our experience.

Speaker 1 (00:55:21):

I know, right. Do you have any more parting words or anything else you’d like the audience to know about your website? Is hernia help.org and opportunities to donate? Are there? Or if you have any people that want to donate their services, even non-surgical services to help with the administrative part of running these clinics, maybe they can contact well,

Speaker 2 (00:55:44):

And we would be glad for you on the website. You have contact information. We have you. Yes. Glad for you to contact us if you’re interested in going on a trip. I would just mention a few other things. One is after the pandemic and the pandemic definitely affected our operations. We cut down our number of trips to almost zero. We did some in the us but otherwise nothing for about 12 months. But it’s given us time to regroup. And I think the future is very bright for our organization and training especially, and maybe we haven’t formalized this at all, but maybe training family doctors to do hernia repairs in Africa. Cause they just aren’t the surgeons, they’re just not around,

Speaker 1 (00:56:49):

Aren’t enough surgeons.

Speaker 2 (00:56:51):

And maybe there’s all kinds of possibilities. I mean, Zoom’s helped. And if we can real-time monitor our trainees with my technology, that’s a very exciting possibility. And we’ve worked on that a little bit, but I think we’ll be able to focus on that more.

Speaker 1 (00:57:12):

Sure. Yeah. There’s so many possibilities that are opening up as a side effect of this Coronavirus Pandemic.

Speaker 2 (00:57:18):


Speaker 1 (00:57:19):

Yeah. Well, you may not remember, but so my first year at a residency, I worked at USC and I got my abstract accepted to the American Hernia Society. I really was not familiar with the hernia world until then. And I went up on stage and I gave my talk. And the minute I came down, you approached me. You were the first person from the American Hernia Society that I met.

Speaker 2 (00:57:49):

Oh really? And

Speaker 1 (00:57:49):

You approached me and you invited me to serve on the editorial board for the hernia journal, which I gladly accepted. And it was the most positive experience. I was so impressed that you would want little me to be involved. And I’ve been part of the leadership and kind of direction of the American Hernia Society ever since. But I just want to thank you. That was one. You were the first person I met and it was the most positive experience. And ever since that, I’ve just had a fantastic career dedicated to hernias. And I’m sure if I had a negative experience, I would not have been so involved in hernias and maybe my career even would be different. So thank you for that.

Speaker 2 (00:58:36):

Oh, well that’s wonderful. I didn’t remember that, but I don’t

Speaker 1 (00:58:40):

Think I remember. Yeah, it was in Florida.

Speaker 2 (00:58:42):

For those that are washing, Sheridan is as a true expert and has added greatly to the science of Bernie repairs for sure. So

Speaker 1 (00:58:53):

Thank you so much.

Speaker 2 (00:58:55):

That’s the truth.

Speaker 1 (00:58:57):

Thank you so much. It’s a pleasure to know you, and thank you so much for your time, and I promise you I’ll be there the next time we can schedule a hernia help. I really do look forward to doing it.

Speaker 2 (00:59:11):

Okay, great. Everybody heard that?

Speaker 1 (00:59:15):

Everybody heard that? No. No. I’m giving you my word. I do look forward to it. It’s something that I do want to do. Absolutely. Great. And it’ll be fun. So on that note, everyone, thank you for joining us. Thanks for all your attentive questions and for your positive feedback. I really enjoyed this hour. Dr. Filipi is one of our very celebrated members of the hernia community, and what he does is truly unique. It’s one of the highlights of our meeting every year where he shares what’s been done. And I look forward to be more involved in it. I do support it as a donor and hope to be more involved hands on. So thank you, Dr. Filipi, for your time. This is the end of Hernia Talk Tuesday. I will make sure that you have access to this episode to watch and share with all your friends. Thank you to everyone who was writing all these great comments about how wonderful the insights and discussion work. Please also follow me on Facebook at Dr. Towfigh and on Twitter and Instagram at Hernia Doc. And on that note, see you all next week for another episode of Hernia Talk. Thank you, Dr. Filipi. Okay, thank you. Thank you. Bye-bye. Take care. Bye.