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Speaker 1 (00:00):
Good evening everyone. It’s Dr. Towfigh. Welcome to another episode of Hernia Talk Live. This is our weekly q and a session. We hold it every Tuesday night. As you know, I am a hernia and laparoscopic surgery specialist. You can follow me on Twitter and Instagram at hernia dock on Facebook. Many of you are joining us live at Dr. Towfigh, and after this episode, I’ll make sure that you all have access to this episode on YouTube. This week’s guest is Dr. Megan Nelson. I’m super excited to have her. She’s a laparoscopic surgeon at the Mayo Clinic at in Rochester, Minnesota. We have so much to learn from her. I’m waiting for all of you to turn in your questions and thank you to everyone who submitted your questions ahead of time. So please welcome Dr. Nelson. Hi.
Speaker 2 (00:51):
Hi. Thank you so much for having me. I’m really
Speaker 1 (00:54):
Here. So it’s later in the evening on in your part of the world. Did you just run over from office or were you operating today?
Speaker 2 (01:02):
I was operating a little bit of office, and I did literally just run in. So this is hair that’s been into scrub cap all day.
Speaker 1 (01:11):
We all have scrub cap hair, and that’s why I don’t have bangs. I look so much better with bangs, but it gets
Speaker 2 (01:21):
So true.
Speaker 1 (01:22):
So no bang is better than
Speaker 2 (01:25):
Horrible, crazy bangs at the end of the day. Absolutely. And I have to warn you, I have two little children and usually they will stay out, but they might join us at some point.
Speaker 1 (01:34):
Oh yeah, no problem. No problem. In fact, we are with, you probably know Barbara from Czechoslovakia, the Czech Republic. She had a newborn when she did this. Oh my god. Brand new like months, maybe one month old, maybe two months old. So yeah, the baby came and when we got to see him, it was very good.
Speaker 2 (01:54):
Yeah, it’s the life of it of a female surgeon or of any surgeon.
Speaker 1 (01:58):
Surgeon. Yeah. That’s great. Well, you’re unique as one of our guests because you operate at the Mayo Clinic, which is a world famous institution. People come to you from all over the world. The Mayo Clinic traditionally has been known as a multidisciplinary, multidisciplinary hospital, multidisciplinary practice. They may have actually invented the whole idea of having more than one specialist see you for your complaint or symptoms or whatever and try and kind of one stop shop. Is that still true?
Speaker 2 (02:36):
It’s very much still true, and we may have invented it or the Mayo Brothers, not me, but yeah, I don’t know. They were really forward thinking. But I do think that’s one of the things that’s really special about here is there is a good setup for collaboration, and it’s something we kind of pride ourselves on of how to streamline when people come to see us, how do we streamline process so they’re getting their CAT scans and seeing the different specialists that they need to as much as possible. It’s not always possible, but we really do try to make it an itinerary and then work together from a lot of different angles to make sure we’re covering all aspects of it.
Speaker 1 (03:15):
Is there a patient coordinator that kind of oversees this because trying to, I feel that, so I’ve worked at a county facility, I’ve worked in a private hospital, community hospital. I’m in private practice. I feel like in private practice it’s the easiest to coordinate because our schedules are a bit more flexible and our ability to work outside of a system is easier. But how does it work out in an institution where you need imaging and a pain specialist and a hernia specialist and maybe see the gynecologist for pelvic floor? How does that all work?
Speaker 2 (03:49):
It’s amazing. I don’t know how it all gets done, honestly, but I do know how it gets done. But it really comes down to our schedulers. We have these amazing schedulers and they are just to the person. So our motto at Mayo Clinic is the needs of the patient come first. And I have to say I’ve worked at a lot of hospitals, but here we talk the talk, but also walk the walk for that. And I think that is so true when it comes down to our schedulers because they will find every possible way to go the extra mile to make sure that patients can get in and try to streamline that process. So the schedulers are, I think, the hardest working people at Mayo probably on trying to coordinate all this because we do have people that come. A lot of our patient populations just from down the street. We’re also a county hospital too for our local population, but then we also have people that come internationally, and so there’s an international office that helps coordinate those types of visits as well.
Speaker 1 (04:49):
So you try and predict which specialist they need to see, or sometimes they show up to your office and you say, oh, well, you need to see an orthopedic doctor. Maybe it’s a hip,
Speaker 2 (04:58):
A little bit of both. So sometimes when people are coming to us, they are at the end of a journey, and so we know that they kind of have this complex problem. So I guess one thing would be groin pain. We know that that can be sort of multifactorial, and so if we know that going into it, we try to schedule as many people as we think would be appropriate, whether it’s physical therapy or pain clinic and hernia, get all those people together. Orthopedic specialists are fantastic for their approach to grim pain too. So when we know it, we try to do that preemptively, but then if it comes up while they’re there, then our schedulers work really hard to just say, okay, we see you’re from out of town. Can we get you a CT scan today? Or can you stay till tomorrow and we’ll try and get these things done as it doesn’t always work. But whenever we can, we do.
Speaker 1 (05:47):
I think having that philosophy upfront is so helpful because then when the patients come, they understand that there may be a need to get an extra test. I mean, I’ve had patients that have lived there for a month, and I don’t know what they meant by live there, but do you have a hotel or a
Speaker 2 (06:06):
Lots of
Speaker 1 (06:07):
Hotel living area for patients to hang out for a while?
Speaker 2 (06:12):
Yeah, so that’s really something. Gosh. So I’ve been here, this will be my sixth year. Yeah, I guess starting up. But even in that amount of time, the amount of hotels that have just sort of exploded across the street even, there’s still a lot of growth still going on with that, but there’s also lots of rental houses where people will come and Airbnb type of situations, and they just stay for a month or so. They try to make them where they’re single floored so that it’s very accessible for people who are recovering from all types of things. So the whole city is essentially kind of builds around this
Speaker 1 (06:51):
Pretty amazing. So hernia talk live has been kind of a little passion of mine. I don’t know if you know, I started a website called hernia talk.com, which was intended to help patients get some of their questions answered. I felt like I was having the same questions being an asked of me all the time, and I assume other people would want to also know the answer. So it’s kind of a public discussion forum for patients. And then a little over a year ago when the pandemic started, I started this question answer live session. So thank you for donating your time to us, but we’re trying to do something like the Mayo does. So we’ve had orthopedic doctors, physical therapists, pain management specialists, gynecologist, urologists, men’s health, women’s health.
Speaker 1 (07:43):
What else have we had, palates instructors, rheumatologists. So it’s been really a really great way to address any aspect that may be important for hernias, groin pain, abdominal pain. We’ve had a gastroenterologist, so I’ve loved it. And it’s one of the things I love about my job. I think I would love to work at Mayo Clinic because that’s kind of a system that I love, right? Yeah. I wish more hospitals would do that. I know that stern hospitals have, their breast clinic is very multidisciplinary. So you go there and you get your mammogram, and then you get seen by the breast surgeon, the plastic surgeon, the medical oncologist, the radiation oncologist, all in one visit, but you just don’t see it elsewhere. It’s so inefficient to get care. Sometimes
Speaker 2 (08:36):
It is. And I think that’s the crux of it, is at a lot of places we kind of put that back on the patient. I think because we can’t, because it is really hard to coordinate. And I mean, that’s just the reality of it. To try and get all these surgeons together and find openings in the schedule. It takes a lot of logistics, I think. But that’s one thing that Mayo has really, they continue to prioritize that and hopefully every reason to believe they would continue to do that because it really is putting that patient first while they’re there. How can we not just bop you around and get you another test and then month come back? And sometimes that still happens despite our best intentions, but trying to just get an answer.
Speaker 1 (09:23):
So you are a general surgeon, you’re also laparoscopically gifted and treat a lot of hernias. One of our questions that was asked was kind of see how you can help patients out there. So what kind of hernias do you repair?
Speaker 2 (09:37):
Yes, so I love all different kinds. My practice is, so I have a real passion for robotic assisted hernia repairs. Cool. That’s kind of my favorite thing to do if I have an option. So I do a little bit of everything on mostly the anterior abdominal wall, so ventral hernias, incisional hernias, inguinal femoral in lots of flank hernias. Oh, lots of Mesh explanation and implantation.
Speaker 1 (10:03):
Yes.
Speaker 2 (10:04):
So a little bit of that. We are kind of specialized in that. Our colorectal surgeons, we have a fantastic one who’s specifically kind of focuses on parastomal hernia, so I don’t end up doing much within that realm. Who is that? Bob Cima.
Speaker 1 (10:19):
Oh, yes, yes, yes, of course. Yeah. Yeah, he’s great.
Speaker 2 (10:22):
He’s fantastic. Yeah, he takes on some really just amazing cases. Yes. So yeah, mostly kind of ventral abdominal wall.
Speaker 1 (10:31):
And so tell me a little bit more about your thoughts on robotic surgery, because it’s something that is being kind of talked a lot on social media, pros and cons. I’m obviously a pro on robotics surgery too, but what are your thoughts on how has it changed your kind of daily operations?
Speaker 2 (10:52):
Oh, gosh. So we could talk about this for days. Yeah,
Speaker 1 (10:55):
I
Speaker 2 (10:56):
Know. So I think the robot has really, really changed hernia surgery. So I feel like hernia surgery has been, it’s ancient. It’s one of our kind of earliest problems, and it seemed like there was not a lot of advancement. We were approaching things the same way and then laparoscopy came in. And so that was kind of a bump in some different techniques. But what I really think, and I’d love to hear your thoughts on this, but I feel like robotics really feels like open surgery. So it feels like my own hands, but in a miniature form. And the way that we’re able to see those tissue planes and then manipulate them because we’re not just in there with chopsticks, I think really just opens up the types of repairs
Speaker 1 (11:42):
That we
Speaker 2 (11:43):
Do. We’ve seen such an explosion in that.
Speaker 1 (11:45):
I think a lot of people don’t appreciate that the advancements that we saw going from traditional open surgery to laparoscopic was at the cost of reinventing how we operate. So hundreds of years have gone by and surgical technique has been perfected, and all of a sudden they’re like, all right, here are these chopsticks and start operating, which you can’t really sew. I mean, you can, but not really. Your angles are wrong. You’re often parallel to what you need to be instead of perpendicular. And therefore, we came up with more Mesh, we came up with tuckers instead of sewing and all these different kind of staplers, all these instruments that we weren’t using before to make up for the deficit. Yeah, I totally agree. I think robotics is basically a minimally invasive way to operate open, right?
Speaker 2 (12:40):
Yeah, absolutely. Yeah. I think there are two things that kind of really got me down that road too. The first was the silliest thing, but I dunno if they did this with your robotic training, but when I was first learning, one of the first things they had me do was put an instrument as close as I could to this little model in 2D vision without touching it. And then we switched to 3D vision and just to see how close I was. And it wasn’t like I was way off, but I wasn’t where I thought I was. And that was just such an eye-opener for me because I thought, if this is on this little model, what does that mean in the human body? If you’re just a couple cell layers difference, maybe you’ve done a lot in most places, but maybe it makes a big difference.
Speaker 2 (13:26):
So that was a big thing that kind of grabbed me. And then I think just being able to, the magnification is incredible to be able to do that. And then also as I look around at a lot of surgeons that I think that one thing that we don’t think about is the physical toll that it takes on surgeons to operate laparoscopically. And so seeing surgeons that are having back surgeries, neck surgeries, because they actually feel tingling down their arms doing laparoscopy. I think being able to prolong their life as a surgeon where they’re the peak of their expertise, that’s invaluable.
Speaker 1 (14:04):
Yeah, there’s so much occupational injury as a surgeon. Yeah, I can attest to that for sure. Okay. We are having some questions being proposed by the live audience, and they’re usually hernia related questions. So what was about spermatic cord lipomas? If you can talk to me about how you assess the groin for spermatic cord lipomas laparoscopically. Is it able to completely remove them or can you accidentally miss them? And are they techniques to improve that?
Speaker 2 (14:33):
Sure. So these, I mostly would be doing robotically, so I do look for those. So as you know, well, there’s kind of a checklist, the critical view of the myopectineal orifice. Yes. So all the things that we look for
Speaker 1 (14:48):
Before the nine commandments,
Speaker 2 (14:50):
Exactly the nine, absolutely. And so one of those is looking for cord lipomas. And so certainly I think we have to do that. I think there’s definitely lots of patients that can feel those. Sometimes What I’ve encountered is as we’re kind of pulling those lipomas back in, I think a little can occasionally sort of detach and be left in the scrotum. Yes, I think so. Nice. People can even can feel that. But as long as it’s not passing through that canal anymore, that’s not something that I would generally worry about or go after. But I do try to clear that canal. Yeah. What do you
Speaker 1 (15:29):
Think? Yeah, no, I totally agree. So there’s a paper published by one of our colleagues over in Illinois, Indiana, and it was early on in the stages of laparoscopic surgery. A lot of cord lipomas were being missed cause they didn’t appreciate how much you have to carefully check through the inguinal canal. On the other side, you don’t see the other side of the hernia. You see the inside part of the hernia. And 99.9% of the time the inside communicates with the outside and vice versa. But there will be situations where you may miss it. So missed cord lipoma is a known complication of laparoscopic surgery. But since that publication over time, we’ve kind of learned not to be very quick and kind of really take a good look. And so that incidence has really, really decreased. I had one patient where I missed a cord lipoma and I always looked, but for some reason his anatomy was different in that the cord lipoma, which is the fat that you see bulging in the scrotum, didn’t communicate very well with the inside, which is not common.
Speaker 1 (16:44):
And so I never saw it. I missed it. And then after surgery it’s like, what’s this bulge I have? Yes. So I imaged them and of course there was this big huge piece of that, and he kind of was like, how could you not have seen this? I said, well, I’m looking inside the house, look, trying to find a bush outside the house. And if there’s no communication between, it’s hard to find. So unfortunately, he then went to another surgeon that completely, just taking out that cord lipoma was not a complicated operation, but in doing so, it was like nerves were injured and all that.
Speaker 2 (17:22):
Oh, so
Speaker 1 (17:22):
Cute.
Speaker 1 (17:25):
And he got injured and I told him, I said, I’m happy to figure do this for you, but he chose to go with a different surgeon. I said, if you go to a different surgeon, that’s fine. Let me make sure I speak with them. Because some people will see that lipoma, oh, that’s a hernia or a hernia recurrence, but it’s not the hernia’s repaired, it’s just that extra fat. And of course, that’s exactly what happened. He got injured. So yeah, it can happen. But I always think about him because I wished he had just stuck with me and I would’ve just taken care of that fat, but that was his decision and he made the wrong decision.
Speaker 2 (18:03):
So yeah, I think sometimes I understand that feeling of, well, this happened and I want to go somewhere else, but I think it’s kind of like a touch up sometimes. I think we do the very best that we can, but each human has their own anatomy. And I think the other thing there is to think about what is the harm of that? Is that something that he’s still really feeling he or she is still really feeling? And if so, then worth going back in there. If it’s just the presence of it, we know it’s not dangerous. So as long as that hernia repair is intact, I think then it comes down to symptoms.
Speaker 1 (18:41):
I think sometimes what happens is if you don’t completely remove the lipoma before it was open door would go in and out as it wish, but once you close that door with a Mesh and you repair the hernia, then now it’s trapped into a space that it wasn’t used in. Sometimes that can be symptomatic. Yeah, I
Speaker 2 (19:00):
Totally agree. Yeah.
Speaker 1 (19:01):
Another question submitted, obviously you do treat patients with hernias, but also complications from hernias as you mentioned. So what are the skills that patients should look for in a surgeon when seeking either just a regular hernia pair and also secondarily when for a Mesh removal or revisional repair?
Speaker 2 (19:23):
Yeah. Oh, that’s a tough one. Yeah, a lot of different directions at that.
Speaker 1 (19:28):
I know.
Speaker 2 (19:29):
I think so. Skills to look for in a surgeon when seeking a hernia repair, I think experience is important. So I think money, it’s okay to ask your surgeon, do you do a lot of these? It’s not offended if you ask that.
Speaker 1 (19:45):
Yeah, please ask. Absolutely.
Speaker 2 (19:47):
Yeah, absolutely ask. And that being said, also, they could do a lot. And if they’re not doing them well, I guess that’s not the only marker that they’re doing a good job, but I think you should look at how they’re treating you. So are they listening to you? That’s a good one. Yeah. Not just trying to talk over you and here’s the plan, this is what we’re going to do, but really listen to your symptoms. Do you feel like you have a connection and trust there? Because as you just mentioned, sometimes there are complications. And so I really think of this as it’s a journey that we’re on together. Our goals hopefully are the same, that we’re trying to get back to activities and things that you love to do. And so I think really finding someone that you can partner with. The other thing, and this one’s a little bit tough, but I see, and I’m sure you do, we see lots of patients that are on their third, fourth, 15th hernia repair.
Speaker 2 (20:45):
And some of it comes down to a little bit of what we call pre optimization. So I see patients that are very overweight or they’re smoking and that hasn’t ever been addressed with them before and they’ve just kind of undergone these hernia repairs and it hasn’t worked out and we know it’s not going to work out. And so I think that’s a little bit of it is sometimes if they are giving you a little bit of tough love, that might actually be the one that you want to go to because they are actually looking out for you in terms of trying to make sure that we can take care of all the variables that we can to make sure that you have the best possible outcome.
Speaker 1 (21:21):
I totally agree. I think hernias are so underappreciated in our specialty and maybe even among patients, but definitely within our specialty. It’s not like a glorious heart transplant or pancreatic surgery that those guys are considered higher in the hierarchy and yet when it goes wrong, it can be a very life altering. So I recommend that. Yes, like you said, someone with experience, someone that you’re comfortable with. And especially in the United States, you can see anyone you want. There’s no socialized medicine. There’s no long wait list that you need to, you’re free to go anywhere in the us, any state, and you can now, with so much telehealth going on, you can see so many kind of patients just by video to initiate. So you don’t have to invest in travel, at least not initially. So if you have any surgery, not just hernia surgery, I would get at least a second opinion. I think it’s worth it. And then not only just choose who you want to go with, but also make sure they’re seeing similar things. Sometimes you talk to a different surgeon and they give you a completely different outlook on what it is that they recommend. And so that starts opening up questions. Oh, I didn’t think about that. So I recommend second things for everything. I mean, surgery’s a big deal, even a small one.
Speaker 2 (22:52):
Exactly. And I think it’s something, of course we want to be cost conscious and things, but surgery on your body is not the place that you want to go to the cheapest, fastest thing and not, there can be some really good surgeons and setups like that, but I agree. I think you want to do your due diligence. We’re never offended if you get a second opinion and that’s sure you do this, I do this sometime. Sometimes that’s all I’m doing in a visit is just saying, yeah, what your local surgeon said is absolutely right. It’s a great plan. I would totally agree. But yeah, just getting that second opinion is pretty key.
Speaker 1 (23:27):
Also, a lot of us know each other, so we’ve shared patients before. We have other patients that we share with other surgeons and we talk, and that’s really good. If you have a doctor that kind of poo-poos questions and really talks down to you or in any way doesn’t address your needs or gets really offended by you seeking a second opinion, that’s probably not a good fit. And we really as a specialty should encourage that. Cause we would want that for our own family.
Speaker 2 (23:58):
Right. Absolutely. Yeah. I think the other thing where I see people sometimes get into a little bit of trouble is the internet is a wonderful thing, but they get, sometimes I’ll have people that will come in with a definite plan about what they want, and that is sometimes great. Sometimes they’re right on. But I would say pick your specialist and then go with what they recommend and certainly
Speaker 1 (24:24):
Say that all the time, trust and then follow lead. Absolutely.
Speaker 2 (24:30):
Yeah. Just so I think, because again, it goes back to that partnership. I think if you’re on the same page and you feel you have that communication, then we can explain to each other what the patient wants and what I can offer and why I think this is good. But when I call it a la carte surgery, when you’re sort of saying, I want this and not that, you’re kind of throwing the surgeon out of what they would recommend and what their routine is. And you want routine good surgery.
Speaker 1 (24:59):
Yes, I say that because many people come with their agenda of what they think based on their research or whatever. But if you’re choosing a surgeon based on their outcome or their reputation, then you have to understand that they got that reputation based on all the patients they already treated. So for them to change what they do, because they’ll say, I don’t want a resident. I don’t want any certain things. It’s like, yeah, but my reputation and my outcomes is based on that routine, based on having a resident based on whatever the protocol is that we follow certain Mesh types or certain tissue types, whatever it is. So some of us will be like, no, this is the way it goes. Others kind of want to please you. And then you end up with a surgeon that’s doing something they haven’t really done before or not comfortable doing before, and then that’s when you got into trouble.
Speaker 2 (25:58):
Exactly.
Speaker 1 (25:59):
Yeah, I totally agree with that. Let’s go back to some hernia questions. Sure. So laparoscopically or robotically, we do hernia repairs. Can you explain the technique you use with regard to fixation? So the question is, does the Mayo Clinic use a Manchester repair? The Manchester technique is basically laparoscopic tap Anglo hernia repair without fixation with fibrin glue. So no tax. What are your thoughts on that and what technique do you use?
Speaker 2 (26:31):
Yeah, so I guess I could only speak for myself. So the Mayo Clinic, we have a variety of surgeons that do hernia repairs, and so there’s a variety of options. And so we do try to kind of tailor it to the patient. So speaking for myself and not Mayo Clinic at large, but I do think less fixation if possible, is better. Yes,
Speaker 1 (26:54):
For sure.
Speaker 2 (26:55):
Kind of my guiding principle. Sometimes you have to have it if sometimes there’s situations where really trying to offset some tension or loading if there’s really destroyed abdominal walls, we don’t have a lot to work with. But I would say for inguinal hernia repairs specifically, I try to do as little fixation as possible. Yes. I usually use either a progrip Mesh, which has kind of a little Velcro back. Yeah,
Speaker 1 (27:21):
That’s great.
Speaker 2 (27:23):
It’s beautiful. Yeah. Yeah, it’s a wonderful Mesh for that. Or sometimes a bard 3D max. But even that, I would do just a very minimal fixation and really just relying on wide overlap and then kind of the pocket that I’m putting that Mesh in to hold it in place. So I don’t
Speaker 1 (27:41):
Yeah,
Speaker 2 (27:43):
Absolutely.
Speaker 1 (27:44):
For sure. Yeah, absolutely. Totally agree with that. Do you see patients with Mesh reactions?
Speaker 2 (27:50):
So I think in my, from med school till now, which I guess when I started to now, so that’s a total of 21 years, I think I’ve seen one patient that had a questionable Mesh reaction. I would say more Mesh infection, certainly. Yeah. Say that. How about yourself? Yeah,
Speaker 1 (28:11):
I see a lot. Yeah. So by law, I’m not going to say it’s the majority of my practice by any means, but it’s a growing fraction of my population. We actually had a great, one of our most popular sessions was with a rheumatologist who’s a specialist in Asia syndrome, where it’s basically Shoenfeld syndrome was reaction to implants. And for some reason in the western countries, we’re seeing more of that, I think because we’re exposed to so much more than people that are maybe out in the woods and don’t really get exposed to a lot of synthetic material. But we’re seeing more and more, it’s becoming more of a problem, and it’s a very unique population. They tend to be female, though I’ve had a lot of males, they tend to be thinner, they tend to have autoimmune disorders or a tendency towards it with a family history. They tend to have a lot of other allergies as well. So be because of that experience, I’ve become much more reluctant to put Mesh in that population, or I rely on kind of hybrid meshes, which are less inflammatory, although I’ve had maybe one patient that’s had a reaction even to a hybrid Mesh. So yeah,
Speaker 2 (29:31):
I agree. I think we’re going to see more and more of it for sure.
Speaker 1 (29:34):
Are there situations where you’re removing Mesh and then maybe don’t want to put Mesh back in or,
Speaker 2 (29:39):
Oh, yes. Yeah, remove. I feel like my practice is putting Mesh in and taking Mesh out. So we do see a decent number of Mesh infections. There’s usually a lot of other things going on in those situations. But yeah, I frequently remove Mesh. And then after we do that, we do a primary closure, so just close our own tissue back up and then readdress if we need to a hernia down the road. And in that case, I would be more apt to use a biologic in that
Speaker 1 (30:13):
Sense. Yeah. Yeah. You kind of limits what you have available to you, but yeah, we have one viewer who mentioned for bilateral inguinal hernia, she had 23 tacks put in. Yeah, that’s a bit much, right?
Speaker 2 (30:29):
Yeah. I just always think of how flexible we ask our abdominal wall to do so many things, flex and bend and twist, and then each time you have one of these fixed points, yes, just in my eyes, a source, potential source of pain.
Speaker 1 (30:43):
Yeah, so true. So I used three, maybe four if I ever need to use any fixation per side. I did have one lady, she had 19 on one side alone, and she was like, yeah, so how was your recovery? And she said, I couldn’t use my leg for three weeks. Three weeks. She was dragging her leg. She needed to walk, her daughter had to carry her. It was ridiculous. And she went to her surgeons, yeah, it’ll get better. And if you look, she had a tack put in right next to the femoral nerve, how hard it’s to do that. And when you have so many tacks put in, it’s they’re like pins or they’re spiral in nature, and you get muscle spasm, muscle spasm, that whole area gets so spasmed. And often it’s not your Mesh, it’s the attack that are causing the pain and removing it depending on the patient’s symptoms, removing it can get rid of those symptoms. Yeah, definitely. I freeze a lot. I’m sorry for this patient.
Speaker 2 (31:49):
Oh, that’s a lot. I think that’s one thing too, where the robot, even on ventral hernia repairs, if you’re able to stitch really precisely where you want those little points of fixation and make sure that you’re just getting it to fascia, that’s got to be better than just so much
Speaker 1 (32:05):
Better
Speaker 2 (32:05):
How we put tacks in. Yeah,
Speaker 1 (32:07):
Yeah. And tax were invented because we weren’t able to really sew or was very time inefficient or you needed a lot of advanced skills to do it laparoscopically. And so here’s that by the way. Just, I don’t know what tacks you guys use, but I’ve moved to the fast touch. Have you heard the fast touch? Yeah. Yeah. Yeah. I love it. I think it’s so much, it’s like a suture. It’s like a little mini suture. So much better than that. I’m not getting paid to say that. I just good products when I see it.
Speaker 2 (32:40):
Yeah, absolutely. Yeah, the engineering that goes into a lot of these things is just amazing.
Speaker 1 (32:45):
Yeah. Okay. Next question has to do with hernia repair failure. So what are the factors that may lead to less than optimal results after hernia repair?
Speaker 2 (32:56):
Yeah, so probably a lot that goes into that. Cool. I think so I think one thing that we see is when people get active too quickly. So I think you want to be up and moving and staying limber after a hernia repair. But what can be a little hard, I think with some of these minimally invasive repairs is you start to feel pretty good pretty quickly, and internally you’re still healing. So I know there’s a wide range in this. I do still recommend that people limit their heavy lifting for that full kind of about eight weeks after even a minimally invasive hernia repair.
Speaker 1 (33:33):
Oh, wow. And then do you operate on, well, the obese patients, smokers, those are all risk factors for hernia failure, actually, not just hernias, but hernia failure. Definitely. What is your protocol with those?
Speaker 2 (33:48):
Yeah, so absolutely. I think those are the biggest modifiable risk factors. So obesity and smoking. We have a lot of patients that are also on chronic steroids, which can be kind of difficult as well. And so really I would try to partner with my patients and work really hard to get to weight loss. And so we have a goal B M I of 35 or less, and it’s not hard and fast, but that’s certainly where the data kind of shows a bit of a change in long term outcomes after her knee repair. So if we can go down lower, there’s my little guy. Oh,
Speaker 1 (34:24):
Cute. You’re so cute.
Speaker 2 (34:29):
So we do really work hard and we work with our bariatric medicine team to get that to help get weight loss going, smoking cessation. We partner with our smoking cessation group.
Speaker 3 (34:39):
Hi. Sorry, just watching. Good job, buddy.
Speaker 1 (34:44):
Oh, you can just watch.
Speaker 3 (34:47):
Just watching. Thanks buddy.
Speaker 2 (34:50):
He’s three.
Speaker 1 (34:52):
Aww,
Speaker 2 (34:55):
Cute. Yeah, so if it’s beyond that, so in patients that come in BMI is 45 50, and if they say they show up in the ER because they have a incarceration episode, then we do sometimes offer what we call a palliative hernia repair, which is saying,
Speaker 1 (35:13):
Sure, not an ideal one, but just to get you over the hump.
Speaker 2 (35:17):
Exactly. Hopefully to a bridge to get you better, more active and kind of help lose that weight. But that’s great. Yeah. So we always offer, if you come into the er, we will help you, but if we have the time, then we try to optimize.
Speaker 1 (35:33):
That’s really great. Next question, this patient says she has had open left hernia pair six years ago with a plugin patch, and then she’s had horrible pain ever since. Now the Mesh plug probably has migrated over to a new super pubic hernia, plus she has a separate right hernia. So her surgeon wants to do robotic surgery and then she wants to fix the suprapubic. Her surgeon wants to fix the suprapubic and the right anal hernia, and then if they see the plug kind of in the way, then they’ll remove it. But she refused for. Now, what are your recommendations about Mesh removal for the plug and combining with other operations?
Speaker 2 (36:19):
Sure. So it’d be great to see the CT and all that kind of stuff and a physical exam, but I think that actually sounds like a really reasonable plan. So I think a robotic or a posterior approach to look at both sides, often we’ll see those plugs have migrated. And so I love getting those out. If the key with that type of Mesh removal is to not go too crazy. So if it looks like that plug has really migrated, then take it out. If it’s parts of it that are plastered onto important structures, I think I would generally debunk, unless I knew for sure that that was a part that was causing pain. But I think that’d be a great approach to be able to see everything and really clean out that Mesh and also repair both sides if necessary.
Speaker 1 (37:10):
What do you think? No, I totally agree. Well, I’m a big advocate of complete Mesh removal, even though it’s quite risky in some patients, if it’s over major vascular structures, for example. But the problem is when they come to see you, and you do understand that let’s say a certain Mesh plug is the cause of the pain, you certainly want to debulk because that’s going to help them most. But complete Mesh removal kind of cleans up the area. I’m a big fan of just undo clean everything, start scratch, and may be excessive in some people’s views. But I feel that that most definitively addresses the problem. And then you can kind of focus on, so if they have pain afterwards, I can’t say, oh, was it that little piece of Mesh that I left little? Exactly. But I do know that there’s a little bit of risk and benefit to that. Obviously I don’t jeopardize anyone’s life in doing so. But so far it’s been the best option for me, I think.
Speaker 2 (38:14):
I think we’re on the same page. I would definitely advocate for that as much as possible. I think sometimes when you get in there, especially I’m sure you’ve been in there where there’s been, especially on ventral hernias where there’s five different pieces of Mesh and all these things. And I think I always have to remind myself to sometimes the enemy of good is better. And so I try to think about, okay, what are we
Speaker 1 (38:34):
Here? Yeah, ventral different. Yeah, ventral I think of for pain, it’s not as much of an issue. And so addressing the hernia recurrence and any kind of folded pain is fine, but you don’t really have to take everything out unless it’s infected.
Speaker 2 (38:48):
Yeah, I agree. And then groin, I think as much as you can get out as lyse. Yeah.
Speaker 1 (38:53):
Yeah, absolutely. Do you treat sports or is there a clinic that deals with athletic pubalgia? Are you involved in those? Yeah. Tell me more about that.
Speaker 2 (39:03):
Yeah, so I do that and I get to work really closely with our orthopedic colleagues. Correct. And then we work with physical therapy and physical medicine and rehab and pain clinic, of course.
Speaker 1 (39:16):
Is there a certain approach, do you do these open and releasing the aponeurotic kind of tightness or tears? Or do you do anything laparoscopically for these patients?
Speaker 2 (39:27):
I think it really depends. I mean, I feel like sports hernia come in so many different shapes and sizes. Yes. So very, I would say to what the problem is, I do some of it robotically, but then often we’ll work, like I said, with our orthopedic group, because often there’s a lot that’s more related to that, the adductors that are involved. And so we get to work together. So I would say each of that seems to be one of the most variable parts of my practice. That plan, I think has to be extremely individual.
Speaker 1 (40:01):
Yes, for sure. That’s something that’s not cookie cutter at all. Absolutely
Speaker 2 (40:05):
Not at all. Some days it would be easier if it was.
Speaker 1 (40:09):
So do you do any combination or operation with the plastic surgeons for a tummy talk and ventral hernia repairs or something like that?
Speaker 2 (40:19):
Yes. Yeah,
Speaker 1 (40:21):
Those are fun.
Speaker 2 (40:22):
It’s so fun. Yeah, so gratifying. The results are so wonderful kind of right away. And patients are excited and it’s just fun. It’s fun to collaborate with other surgeons and get to work together and learn from each.
Speaker 1 (40:36):
Yeah, I really enjoy it. Yeah.
Speaker 2 (40:37):
Yes. It was fantastic. Plastic surgeons here.
Speaker 1 (40:41):
Yes. In fact, one of our residents trained there for plastic surgery, and I refer a lot of patients to him. He’s really, really great because he came back to Beverly Hills, obviously for plastic surgery, but his training was at Mayo Clinic, and he had a really great, great training there. Tell me, do you me about, what do you want to say?
Speaker 2 (41:03):
What are your thoughts? I’m interested on kind of large panniculectomy with hernia repairs. Do you stage those or do you do some together?
Speaker 1 (41:11):
Yeah, so the studies are not in favor. The studies show that the surgical site infection and complications related to adding a panniculectomy where you have all this extra loose skin dealing with that at the same time as the hernia repair complicates the hernia repair at the same time, I feel that all the extra heavy skin is kind of pulling on your repair in some ways. Yes. So it’s very individualized. Usually I do not do it. Usually I address the hernia and then anything that requires just a panniculectomy I would address at a later date. And the skin changes over time a little bit. So some people choose not to do the second, second operation.
Speaker 2 (41:57):
Definitely I same.
Speaker 1 (41:58):
I dunno. Same. Yeah. Yeah. Great. I feel like we’re sisters. Tell me about tissue repairs. Are there any situations where you remove, we’re talking groin here, remove Mesh. Because here’s a question about it. Any situation where you’re removing Mesh in the groin, let’s say, and then you have to do a tissue repair. And if so, what kind of tissue repair do you do?
Speaker 2 (42:24):
Yes. So sometimes that occurs for sure. So usually either a Shouldice or even a Bassini.
Speaker 1 (42:36):
What about ventral? I have a lady that is very dear, gone through a lot to try and get her to a better place because she is severely allergic to every implant that’s been put in her. And she’s had multiple operations with multiple surgeries, including myself. She just can’t get any Mesh in her. It’s horrible. And I can’t even rely, I may just have to put in biologic Mesh in her understanding that there’s a high recurrence rate. But what’s your experience in just a tissue repair for ventral hernia?
Speaker 2 (43:12):
Yeah, so I think it really depends on the size of the hernia, the quality of the tissue, what is there tension there. I think that’s the big thing when it comes down to primary tissue repairs with ventral hernia, I think making sure there’s absolutely no tension. So no
Speaker 1 (43:31):
Tension. Yeah.
Speaker 2 (43:32):
Yeah, I think that’s key. And then I like biologic Mesh. I think I’ve been lucky to have good experience with that. And so I think that’s,
Speaker 1 (43:42):
Which one do you use?
Speaker 2 (43:45):
So we use kind of a variety. Yeah. So we use some of that. I mean, really, I guess I think I’ve used all of them, it feels like. And I’m not one really that sticks out more than the others to me. Yeah. So it’s kind of the thickness.
Speaker 1 (44:05):
Yeah. Have you treated patient with Ehlors Danlos? That’s a collagen disorder that Yes. Really they’re very prone to hernias and then fixing them is challenging because you can’t really rely on their own tissue. So they do need some type of Mesh. But do you have any certain tricks on patients with Ehlors Danlos?
Speaker 2 (44:24):
Yeah, I think just wide coverage, wide Mesh coverage I think is the key. Yeah, you prefer to use,
Speaker 1 (44:33):
Yeah. So one thing that I learned is that in patients with, you may like this actually because you like the robotics and they get groin pain or pelvic pain because they have pelvic floor dysfunction because they have a very lax pelvic floor and they have very lax groin area with direct hernias. So I do those robotically and we report on this is really great. So I do those robotically and then I give ’em, like I’m using the word very loosely, tummy tuck of the groin. So I will do a tissue repair of the groin and then put synthetic Mesh, which will make it even tighter, which for a regular patients, patients way too tight. But I feel like for Ehlors Danlos, you need to plicate as well as add the Mesh because they just need that extra, you need to get laxity. You can’t just patch something lax because they’ll still have the pain.
Speaker 2 (45:31):
Right. Yep. I totally agree. That’s really interesting.
Speaker 1 (45:34):
Yeah, it’s really cool. I like the tissue repair, the robotic tissue repair of the brain. It’s really cool. Okay, next question. How would you address a failed hernia or muscle repair surgery that use a hybrid Mesh originally? Do you use hybrid meshes? There’s two types. There’s the ovitex, which is biologic with polypropylene base and synecore, which is biologic really bio with PTFE core.
Speaker 2 (46:06):
Yeah, not much. And I’m sorry, is that ultrapro earlier meant surgiment, but I haven’t really used much of the hybrid Mesh. I guess I’m just waiting to see longer term data on that. Sure, sure. And I think so far in my algorithm, I love the idea of it, and I think there could be a great future there. But I guess in my algorithm so far, it’s still more of do we need something permanent or yes, is there something more transitional that we’re working on? So yeah. Have you had much experience with it?
Speaker 1 (46:44):
Well, so I told my patients with either Mesh reaction or at risk for Mesh reaction. So I try and reduce the amount of permanent synthetic that’s in them. And whatever I choose, it’s a biologic. I try and choose the higher quality ones that they’re less synthetic mesh and so have less of an inflammatory response to them. And so I’ve used synecore, but I’ve also used ovitex, a big fan of it. I think that it’s like 4% synthetic and 96% biologics. So around nine months or so, you should pretty much be just a little bit of synthetic enough to prevent the hernia recurrence that we see with biologics, but not enough to cause this massive inflammatory reaction, which is how synthetic meshes work. So I’ve had really good results with that. I don’t know that it’s standard of care by any means, but in patients that also do not want Mesh, what they really mean is they don’t want the hard, thick yes. Foreign body sensation of a pure synthetic, non-absorbable Mesh. So in patients that do need Mesh because they have a large hernia or whatever their situations where they’re not amenable to a tissue repair, sometimes using the hybrid Mesh is a good compromise, especially if there’s a lot of adversity against Mesh, which I totally understand. Yeah.
Speaker 2 (48:20):
So what I think is you said it’s a conversation with your patient to say, yeah, look, these are the options. What are your goals? What can we offer? Yeah. And yeah, it’s an ongoing conversation I think.
Speaker 1 (48:34):
Yeah, totally agree. There’s a question on relaxing incisions because this is how I advance my patient populations talk about advance a relaxing incisions. And does a relax incision then cause a weakness in the area where you did a relaxing incision? Maybe you can explain what a relaxing incision is first.
Speaker 2 (48:55):
Yeah. So are we thinking more kind of for groin repairs,
Speaker 1 (48:58):
Groin or abdominal wall, like a component separation, like anterior components?
Speaker 2 (49:02):
Yeah, so I think, I guess there would be different types of those relaxing incisions. I think relaxing incision, like a component separation, I do that frequently. And so yeah, I usually do a transverses. Abdominus release is kind of my preferred. And in that case, I think it makes a lot of good sense because as we talked about before, you’re really trying to decrease that tension for your closure. But also I do think that primary fascial closure in patients is really important. And so anything that we can do to use their own tissue to be able to cover, I think is key. Yeah. So I think a component separation, relaxing incision is great. I think if you’re just doing a lot of previous inguinal hernia repairs had relaxing incisions kind of here or there, and I think those do create more of a weakness there. So I think it has to be a really targeted component separation that you’re doing.
Speaker 1 (50:01):
I think. So for those of you that are watching, a relaxing incision implies you’re trying to close the hole, but it’s too tight. So you release something outside of that hole to release attention to allow the hole to close. But then as a side effect, you’re now creating a weakness if you’re doing that as an anterior on top of the muscle of the fascia, that gives more weakness. What you’re explaining, which was the tar, which is a transverse abdominal release, is a posterior component separation, which tends to not cause as much of a problem for hernias. We don’t do anything posterior, it’s all anterior release because posteriorly, there’s no fascia. So yes, it does cause technically some weakness, it’s not an issue really for inguinal. But what I do see for anterior component separation for abdominal wall is, especially the thin people, if you do an anterior component separation, you release the sides, they’ll get bulging on the sides.
Speaker 1 (51:02):
So the key to those is to then do a big Onlay Mesh and cinch in the side so that the area that’s been released is then covered. So they don’t, they’ll come back in a year and be like, why am I bulging on my side now? It looks even worse than my hernia in the middle. So that’s a technique to prevent doing that. Yeah. All right. Well we have one more question that was brought, which is really to try and see how patients can come to see you. So how do patients see consultation? Is there like a central place and then do they send you stuff ahead of time? What’s the system?
Speaker 2 (51:44):
Yeah, so there’s I think a variety of different ways to do it. But you can, I think just call the main Mayo Clinic number and request to be seen. And depending on what your issue is, they will link you to the right department and then they’ll ask you lots of different questions. So if you have a hernia, you can just call the main number and request a consultation for hernia, and they’ll get you to our surgery schedulers and they’ll find out more information. Is this the first time you’ve had a hernia? Is it a simple groin hernia? Is this a complex abdominal wall reconstruction that you’ve already had multiple surgeries for? And then based on that, they will sometimes you then go to a nurse and they’ll find out more information if there’s kind of some details there. But then they will work really hard with you to try and get as much of your hospital records as possible over your CT scans, anything that you have so that we have that for before your consultation.
Speaker 2 (52:42):
And we’re doing a lot with telemedicine now. So definitely doing video visits. So if it’s just as we mentioned before, just a second opinion kind of situation, then we can do that here. And you don’t have to leave your home. And sometimes, I should say also, sometimes people will come here and get a primary care physician if they have really kind of complex medical care that’s going to need a lot of different coordination. Sometimes we people up with their primary, but usually it’s open for consultations. So if there’s just call that main number and they’ll get you in.
Speaker 1 (53:15):
Yeah. That’s really fantastic. Well, thanks so much for all your time and thanks for your time away from your little babies. You’re so cute. Oh, how old’s? One’s three old. How old’s the other one?
Speaker 2 (53:26):
Three and five and a half.
Speaker 1 (53:28):
Oh my Lord. They’re so fun. That’s really amazing. Well, you’ve been great. I hope to see you soon. We have a couple of meetings coming up in kind of end of summer, really beginning of fall. So I hope maybe to see you a couple of those. I know that we’ve invited you for some.
Speaker 2 (53:46):
Oh, yes. I would love to see you. It’d be nice to see you in person.
Speaker 1 (53:51):
I know, I know. I’m looking forward to it. We got Austin, we got Vegas, we’ve got Copenhagen. I’m looking forward to that. So yeah, I hope to see you in at least one of those.
Speaker 2 (54:03):
Absolutely. Well, thank you so much. This has been so fun. Thank
Speaker 1 (54:07):
You so much. And for all of you who joined us, thank you so much for joining me on Hernia Talk. It’s been a great, great session. Thank you to Dr. Nelson for affording her time with us. Valuable time everyone. Thanks for joining me on Facebook Live and on the Zoom meeting. I will post all this on YouTube and see you next week on another really fun hernia talk session. Thank you again. Bye.
Speaker 2 (54:37):
Thank you.
