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Speaker 1 (00:00:00):
Everyone. My name is Dr. Shirin Towfigh. Welcome to Hernia Talk, another Tuesday evening with our favorite people. As many of you know, my name is Shirin Towfghi. I am a hernia and laparoscopic surgery specialist. Many of you are joining us live on Facebook at Dr. Towfigh. Thank you also for following me on Twitter and Instagram at hernia doc. At the end of this episode, I will make sure that you have a link to share and watch it again on my YouTube channel. Today’s guest is Dr. Michael Brunt. Dr. Brunt is a laparoscopic surgeon at Washington University in St. Louis, Missouri. He’s actually much more than that. He, he’s an amazing leader and has built an amazing program at Washington University for hernias as well as forge surgery. I’ve known him ever since I’ve been involved at sages, which is our huge laparoscopic society. Welcome, Dr. Brunt.
Speaker 2 (00:00:59):
Thank you, Dr. Towfigh. I really appreciate you having me for this and talk a little bit about the sports hernia problem. So yes, it’s an honor to be here. Thank you.
Speaker 1 (00:01:09):
Yeah, thanks very much. So thank you for your time. You’re clearly still at work. What is that central time? Are you in central time? Yes,
Speaker 2 (00:01:18):
Yes, yes.
Speaker 1 (00:01:20):
So thank you for that. The question I’d like to ask you, which I’d never asked you is you’re most well known for your laparoscopic surgery and your forgo surgery, and yet you do have this little bubble of patients that you specialize in, which is athletic injuries and sports related hernias. How did you get involved in that?
Speaker 2 (00:01:41):
Well, that, I get asked that question quite a bit because it’s unusual for a general surgeon by training to get involved in treating athletes. Yeah. When I first started in practice, and I almost don’t want to tell you how long ago that was, but it was around 30 years ago, and it was at the Jewish Hospital of St. Louis and now Barnes Hospital and Jewish Hospital emerged, but there was one full-time orthopedic surgeon at Jewish Jerry Gilden, and he was the head team physician for the St. Louis Blues, and I was one of the few full-time general surgeons there. So he started inviting me to a couple of games and I would help cover visiting team a little bit, so sew up some of the players that got cut, and then occasionally there would be a blues player with groin pain. And so he would ask me to see them.
Speaker 2 (00:02:37):
And initially I remember the initial player I saw and examined him. He didn’t have a hernia. I thought this is not anything related. And then it turned out I read later that summer, he went off and saw somebody else actually in Vancouver and they diagnosed him with a sports hernia operated on him. And I thought, I don’t know if I believe in this or not. And then a year later or so, one of the players had a similar problem and he’d been operated on in Minnesota on the opposite side. And he said, doc, this feels just like the one on the other side. So that was kind of my leap of faith and I operated on him and he did great. And so then once you have one experience, it starts to snowball a little bit. That player actually was featured in the movie, the Mighty Ducks, if you may remember, there’s a visit to the arena.
Speaker 1 (00:03:28):
Yeah, hockey player,
Speaker 2 (00:03:29):
Minnesota North Stars back when the stars were in Minnesota is featured in that film briefly. So that was kind of the beginning. And then it did a few in the nineties here and there, and then started getting asked to speak at some of the team physician meetings, particularly the National Hockey League because I’ve, since 1994, I’ve been the team surgeon for the St. Louis Blues, and it just kind of evolved from there.
Speaker 1 (00:03:53):
That’s pretty cool. But how did you know what to do? Because we’re not taught that anatomy watch during general, general surgery residency. Yeah. How did you know what to do?
Speaker 2 (00:04:01):
So initially I didn’t, and I treated this more or less like a regular hernia. And then I pretty quickly learned that you can’t just approach this, it’s another hernia. You really have to learn about the constellation of pelvic injuries and pathology that can occur in a high level athlete. And most of these are muscular strains and tendon injuries and things like that that aren’t require surgical interventions. So I really had to learn about this. The field also evolved in the 1990s and early two thousands, and so we understand the pathophysiology of this better and why people get these injuries and what anatomy we’re trying to restore. So it’s kind of like a hernia repair, but it’s modified somewhat. So it’s been a gradual evolutionary process.
Speaker 1 (00:04:58):
This is our first question that was submitted, which is what do you believe are the anatomic abnormalities and pathology that cause the syndrome of sport hernia?
Speaker 2 (00:05:08):
Yeah, so this is
Speaker 1 (00:05:10):
A be clear, it’s not a hernia, correct?
Speaker 2 (00:05:12):
It’s not a hernia in the sense that there is a bulge or a protrusion, but it does involve the same anatomic region to an extent. And so there’s been the concept that’s been promoted by Bill Meyers, who’s done more of these than anybody else in the world, is in Philadelphia as a hernia, sports hernia institute there, and he doesn’t call it that. And there’s this concept of the pelvis pubic joint. And if you think about the pelvis bone is where your trunk and your lower body connect. And so pelvis is kind of this fulcrum around which these powerful forces act. So a lot of the thinking is there’s an imbalance in the forces and you’re strong and powerful in your upper thigh muscles and don’t maintain the strength in your trunk. And that creates an imbalance across the pubis. There can actually be tears in where the rectus abdominus muscle attaches around the pubic and connects to the abductor, which is your one, your inner thigh muscle that’s involved in a lot of powerful sports movements. And that attachment can be torn and that can be the source of the injury, but it’s also a little bit like more of a wear and tear injury where things get frayed rather than an acute tear. And oftentimes the athletes present on a gradual basis. It’s not a sudden acute injury, but it’s more gradual onset. But it does affect some of the same anatomic areas that you see with groin hernia, but with some differences.
Speaker 1 (00:06:54):
Yeah, very painful. I’m a huge Los Angeles Lakers fan. We’re out of the playoffs this year, and part of it is we have a lot of injured patient injured players, a lot of them with groin injuries that are, they heal and they recur again because they come back to play and it’s been a problem. So is most, from my understanding is this is mostly in athletes that have enormous thighs, so disproportionate strength to of one set of muscles versus the others, or they do very rapid movements that involve the splits, so hockey player, soccer player and so on. Is that correct or how do you view
Speaker 2 (00:07:44):
Well, it tends to occur in elite and professional athletes, although I get referred a lot of recreational athletes, usually high level recreational athletes. I I’ll say, and it’s a lot of the symptoms occur, they don’t occur so much at rest. We’re just with kind of normal activities, but it’s with high level accelerating movements. Yes. And so ice hockey, soccer, and professional football, those are the three most common sports that we see this in. Much less common in baseball and basketball, for example, probably because of the differences in the physical movements and amongst those sports. And yes, oftentimes it involves some degree of tension or tightness in the lower body that puts more stress across the pubis.
Speaker 1 (00:08:36):
And I’d like to accentuate what you said earlier, which is these occur in elite or athletes, A 70 year old male that was grabbing some groceries and felt a pole should not be having a sports hernia and a stay-at-home mom that’s picking up her child should not be getting a sport turn, even though many people kind of refer to this kind of unclear growing pain as a Oh, that’s a sport hernia, right?
Speaker 2 (00:09:05):
Correct. We do see it sometimes are similar type injuries in some laborers and that they can have a similar energy with perhaps a sudden work movement or something, or they’re really lifting something heavy and they get out of balance and they can pull something. So it can occur in that population, but not generally in individuals who are sedentary and doing relatively low level non-impact activity.
Speaker 1 (00:09:33):
Now, there’s a lot of discussion about how these should be approached If you have a, let’s say a partial tear of either the rectus muscle off the bone or the abductor muscle off the bone. Some people say you should just complete that tear, so you have a partial tear completed, then you take attention off of the area and the pain goes away. Others say, no, you should do the reverse. You should tighten it up and restore the anatomy. Are both of those correct options?
Speaker 2 (00:10:04):
Well, I think what I would say is you have to separate a little bit the abdominal side problem from the groin, the upper thigh, groin, and abductor. The most common groin injury in sports is an abductor or muscle strains. And of the muscle strains, the most common are in the abductor muscle group, which are the inner thigh muscles involved primarily in pulling your leg in. So you extend your leg and then come in with a kicking motion or a skating motion. That muscle group is most commonly injured and you can see complete tears with even separation. And the majority of those will heal without requiring any surgical invention intervention. And generally we try to manage those conservatively initially. Yeah. The problem you get into is on the abdominal side, when you have an abdominal side tear, those are much less predictable in terms of responding to conservative treatment, although some of them will generally in the elite athlete, professional or collegiate athlete, those will come to early surgical repair.
Speaker 1 (00:11:12):
And there’s consequences to releasing some of these. You can have, let’s say if you’re a kicker or you going to have leg weakness or if you’re a runner. Yeah, leg weakness if you actually release the abductors. Correct,
Speaker 2 (00:11:24):
Yes. So on let’s, let’s go back to the abdominal side. We generally want to repair, strengthen, reinforce going to solidify the abdominal side of the pubis. If they have predominant abductor symptoms and a lot of tension and tightness, then sometimes the only way to get them over that is to do a release. And I typically will do a partial release of the sheath, not a complete release, put a little local steroid in. So you want to loosen that abductor side and then tighten up and reinforce the abdominal side of the injury. But it’s a subset of athletes that require any direct surgical intervention on the abductor.
Speaker 1 (00:12:06):
And there’s also been discussion about posterior approaches. So do you believe that a posterior approach, let’s say a laparoscopic approach like you do for a regular inguinal hernia, putting Mesh back there or any other type of buttress back there will in any way take tension off of these and help them there? Here?
Speaker 2 (00:12:26):
Yes, there are. I think to make this is confusing even to general surgeons and hernia surgeons because there are a variety of different approaches that are being used and there are some pretty strong opinions out there amongst various surgeons that this is the best way or this is the only way to do it. Right. I think the bottom line is that there are different ways to approach this from a surgical technical perspective that do work in most athletes. And I think the most important thing is that you are making the correct diagnosis and you’re doing the right operation for the right athlete. And I think that’s the most important thing. When you have, I preferentially do what’s called an open anterior repair. So that means we make an incision about two and a half inches long over the groin because we’ll see pathology in all layers and do a broad-based tension free repair of the floor that incorporates a little bit of the lateral rectus and medial support more than I would do for a typical standard inguinal hernia repair. But I’ve done laparoscopic and the laparoscopic is done just for the patient audience from the backside of the abdominal muscle or floor and provides broad based strength and support on the backside. And that works in many athletes as well. So in selected cases, I’ll use that also. And there are groups out there particularly in Europe that preferentially do laparoscopic approach to repairing these.
Speaker 1 (00:14:07):
Yeah, very interesting. And so you are a general surgeon, general surgery train. There are orthopedic surgeons that also do this. How does one know who to see? Is it purely based on experience or I think even orthopedic surgeons aren’t get much training on this in their residency either
Speaker 2 (00:14:28):
There, as far as I’m aware there, I don’t know of any orthopedic surgeons that are doing abdominal side inguinal floor rectus abdominus repairs for this. Yeah, there are orthopedic surgeons that are doing abductor procedures, but not on the abdominal side. What’s more common is for a general hernia surgeon to do this in conjunction with an orthopedic surgeon. And when I first started doing some of the abductor procedures, I had one of our sports orthopedists join me and it wasn’t anything particularly technical difficult and their logistics logistical challenges and pairing up surgeons unless you’re working together all the time. So I do them myself. And I think the most important thing if you’re an elite level athlete is to go to somebody who sees these on a regular basis because getting the right preoperative initial evaluation and diagnosis and making sure that if conservative treatment is an option, that you’ve had the appropriate type of conservative management early on to try to get you through this. I think that’s probably the most important part of this. And this is something that general surgeons and hernia surgeons are becoming much more aware of and familiar with. And so thanks for
Speaker 1 (00:15:53):
You.
Speaker 2 (00:15:54):
Well, I think there are a number of people who’ve tried to help educate us about this, but fortunate, unfortunately, some of the insurance carriers are not well educated about it yet and they still have a problem for the professional and high level collegiate athletes. It’s not a problem the schools will cover, but some of the carriers consider this quote experimental and don’t want to cover it unless you list it as just hernia surgery, which it’s not. Exactly.
Speaker 1 (00:16:24):
So there’s multiple different modalities who do conservative therapy. One is just rust and stop playing your sport. The other is different types of injections. What is your protocol for that? Or do you have a team that helps you with that?
Speaker 2 (00:16:38):
Well, I mean the initial approach is to rest and to get some local directed therapy, and that includes ice. It may include anti-inflammatories. There are some more sophisticated soft tissue therapies that can be used, some groups that’ll use a lot of dry needling. We try to avoid using P R P injections around this area. I will occasionally do a local plus steroid injection in part sometimes to temporize and perhaps to get an athlete through the late phase of regular season or through a playoff or something. And sometimes we’ll use it just for diagnostic purposes to inject a trigger point to see does that eliminate the pain and that may give you more confidence in going in and then doing a repair in that individual.
Speaker 1 (00:17:32):
Tell me more about PRP and why you don’t believe it should be done. Well in Los Angeles, it’s given out like water. Yeah.
Speaker 2 (00:17:39):
And I think that’s a little bit of the issue with it. I mean, it’s expensive. There’s not really a lot of good evidence or data around the benefit out of certain areas within orthopedics. And I will confess, I don’t know that literature extensively. One of the issues that has come up around its use in the abductor groin and Dr. Myers has talked about this, is that athletes can get what’s called heterotopic calcification so they can get significant calcium deposits along the tendon and that can be a problem. And so in the abductor groin, we tend to counsel against getting P R P there. I think Dr. Towfigh is frozen. Hello, shaman, I don’t hear any audio from you. Oh, you’re back.
Speaker 1 (00:19:16):
I’m back. My computer thing. All of a
Speaker 2 (00:19:24):
Sudden computers do that.
Speaker 1 (00:19:26):
I hear you. I did hear you. So yes, that’s exactly correct is that the hetero heterotopic classification can mean an issue interfere with, I think it can interfere with their rehabilitation in many ways. I’ve seen some pretty bad calcifications in some patients.
Speaker 2 (00:19:46):
Yeah.
Speaker 1 (00:19:50):
We have another question about nerve entrapment. Let me share a screen with you. So some of the issues is what if you have a tear and you’re entrapping the nerve where you have scar tissue and you’re entrapping the nerve. Do you believe nerve compression or entrapment or traction injury is contributing to some of these for hernia symptoms? And if so, how do you address it preoperatively?
Speaker 2 (00:20:17):
This is a really good question, and the answer is yes. I think it can be a factor in contributing in some cases, but it is not the predominant mechanism in most athletes. And so some of the symptoms that maybe are a little bit of a tip off, if there’s more of a burning type sensation that an athlete gets, this can also be a situation in which a local block or injection can you preoperatively. And we always look at the nerves when we go in and do this open, which is an advantage of doing it in an open fashion. And sometimes we’ll find a nerve branch of the ilio inguinal nerve, which is a superficial sensory nerve that runs through the groin canal, passes through a slit in the external bleak, which is the roof of the inguinal canal, and it can be pinched or trapped. And sometimes we’ll just release that so that it’s not going through a slit anymore and on occasion, but in a relatively small percentage, sometimes I’ll just go ahead and resect the nerve, which can leave you with some numbness, but doesn’t cause really any other long-term consequences. So I think this is a factor in some athletes, but it’s a relatively small percentage, probably 10% or less.
Speaker 1 (00:21:41):
We have some fans of yours on this webinar. So here’s a question, Dr. Brunt, in your excellent book on sports hernia and athletic pubalgia, you included several different surgical approaches. Can you comment on the all suture repair described by Dr. Litwin and Busconi in particular the safety of reattaching, the rectus abdominus to the periosteum with a broad capture of the highly interviewed periosteum? Well, now if you think that my patient population, my audience is not educated, that is a question that is pretty fancy.
Speaker 2 (00:22:15):
Well, first of all, I’ll say I’m impressed not only that you saw the book, but that you asked a specific question like that. So yes, kudos to that individual. It’s a really good question. This is one of the controversies. So just so you’re aware, Dr. Litwin is at University of Massachusetts in Worcester, and that’s where Dr. Myers was chair of surgery for several years. So Dr. Litwin learned a little bit of that technique. It’s essentially the same or similar primary sutured technique that Dr. Myers uses. And it’s a couple of layers of sutures where the healthier tissue is kind of sewn over to back over towards the pubic and to the inguinal ligament, the issue. And I think it works really well in those hands. The issue in my experience for the primary sutured repair is avoiding excessive tension on the floor. And 25 years ago, essentially inguinal hernia repairs migrated away from primary sutured repair for that very reason.
Speaker 2 (00:23:30):
And so with a Mesh repair, you basically can create a tension free approach. And that’s what has worked well in my hands. It’s really there’s not often an actual R rift rift Orrin of the abdominal rectus insertion off the pubic that you can feel and reattach down to the pubic. And so basically what we’re doing is broadening out that whole area of support and attachment across the pubic and the posterior inguinal floor. When we do this in attention free Mesh type fashion, I know that the results are good in Dr. Littman’s hands and of course in Dr. Myers’ hands, Dr. Busconi actually was the blues used to have their American Hockey League team was in Worcester. And so got to know him through that. And he does the abductor portion. Dr. Littman does the abdominal side.
Speaker 1 (00:24:31):
Very good. Yeah, we had one surgeon from the Viera Institute, and we hope to get Dr. Myers in the future too for these sessions. So educational. When you do the Mesh repairs, do you use a particular Mesh or do you think synthetic Mesh is appropriate all the time or there’s some hybrid meshes out there, biologic Mesh, what do you think
Speaker 2 (00:24:54):
About? Yeah, I use a lightweight, and I think it’s this key lightweight, polypropylene based Mesh that has an absorbable component, but it is a permanent synthetic Mesh. It’s really well incorporated into the tissues. There’s some modifications I do covering the Mesh with part of the internal oblique that minimizes the contact of the Mesh with the spermatic cord in males. Yes. And also helps protect it from the nerves. And so that’s a modification I use particularly in the majority of athletes. But it’s a lightweight Mesh with a little bit of an absorbable component.
Speaker 1 (00:25:31):
Yeah, I’m a big fan of interceded intercenes, basically seprafilm a anti adherent barrier, but unlike seprafilm, it’s not really difficult to handle. It is very fabricy sold mostly for gynecologic operations, but so it’s marketed towards a gynecologist. But yeah, I wrap the spermatic cord with that, especially in the AL procedures where they already have testicular pain. I feel that it really helps reduce the risk of the interaction of the Mesh with the right with spermatic cord, which can can cause symptoms
Speaker 2 (00:26:09):
Or situations when you’re having to go in for chronic groin pain and excise Mesh. Yeah, makes sense to use something like that. Sure.
Speaker 1 (00:26:16):
I just did that today just, yeah, as I ran here right after finishing surgery was revisional and I used the nerve was involved too, so I put some of the adherent intricate over the nerve and also the spermatic cord for that patient. The other question has to do with direct hernias versus indirect hernias, and how much of that can be related to sports injuries. So do you believe that attenuation of the inguinal floor or like a laxity and a tear of the muscle or tendon at the pubic plate contribute are basically equal in terms of how they present? Or how do you differentiate if someone has a hernia recurrence or a direct hernia versus a true sports hernia? Is it based on history exam imaging?
Speaker 2 (00:27:13):
Well, I think let’s just, let’s start just focusing on the athletic groin pain situation. So not every athlete who has an abdominal inguinal fluoride problem has an imageable tear of the rectus abdominus aponeurosis attachment around the pubic. The most consistent finding in my operative experience, and we just looked at this and have around 400 cases now that we’ve looked at and looked specifically at the operative findings, but this attenuation in the posterior inguinal floor without a true direct hernia bulge is the most consistent finding that we see there. So in my view, there’s no question that is contributing to this. Certainly the rectus abdominus attachment and what that does when you lose that support is that puts more attention on the rectus attachment and maybe it’s contributing to the tear that you see in some athletes or not. So I think it’s hard to give that complete weight, but I think it’s definitely a factor, but there’s not typically a direct hernia bulge when you examine these athletes. You often can appreciate relative weakness in their floor compared to someone who’s age matched and doesn’t even have a true hernia. They usually have a little more substance there. And we think it’s probably in part just because of the long-term repetitive nature of the movements and
Speaker 1 (00:28:51):
Yeah, absolutely. Plus there’s so much scar tissue from the history of multiple episodes of strains and inflammation and micro tears and healing and fibrosis and scarring from it. How much of just the scar tissue do you think Condon can contribute to growing pain?
Speaker 2 (00:29:11):
Well, I think I don’t see as much of that on the inguinal side. I think it certainly can on the abductor side, as you heal and develop fibrosis and in some athletes have had a significant abductor injury, they may even have some calcification along the tendon. And I think definitely that probably is a contributory factor to some of the pain. I think you maybe intermittently froze there. Yeah. Okay. Yeah,
Speaker 1 (00:29:46):
I did what I feel that, so I recently did a lady, she was a former very professional theater and just chronic pain, no one could figure it out. I finally explored or she had so much scar tissue in the retroperitoneal space and also in the retro word, she felt it. But it’s just amazing when I operate on N N L flare, I just see so much scar I feel from years of injuries and overuse maybe in the area.
Speaker 2 (00:30:31):
I think one of the other variables maybe sometimes get asked, why are you seeing so many of these athletes today? And I think it’s partly increased recognition and awareness. It’s properly, it’s partly more sophisticated imaging that can sort some of these things out. But I think it’s also that we see so many athletes today at the high level, they’ve played one or mostly one sport for most of their lives. And whereas 30 years ago, kids were playing multiple sports and they would vary in the seasons. And now if you’re hockey player, you play hockey year round from when you’re seven or eight years old. And so repetitive movements and just the analogy is a little bit, you can see what’s happening, major league baseball with all of the ulnar collateral ligament injuries, the so-called Tommy John injuries that have occurred in pitchers. And of course they’re throwing harder, but they’ve also been throwing most of their lives. And so I think there’s probably a factor as well in some of this we’re seeing. Yeah.
Speaker 1 (00:31:41):
You have two questions submitted for you about your hernia repair or sports hernia repair. So you alluded to how you kind of changed your technique just slightly for these sports hernias. Can you explain in more detail how your repair for these sports hernias in the open fashion differs from the standard Lichtenstein hernia repair?
Speaker 2 (00:32:03):
Yeah. Well, there are a lot of similarities. And I think one important aspect is it this should be a flat Mesh configuration. Yes.
Speaker 1 (00:32:13):
Number two, no plugs, no phs,
Speaker 2 (00:32:15):
No, no, I do not like Mesh plugs. Good for you. I certainly would not want to Mesh plug in my groin. Yes, I’ve taken quite a few of them out, but you want a flat configuration. Number two, the pathology is not at the internal ring. So you’re not trying to fix a problem where this spermatic cord comes out through inside the abdomen, out through the internal ring into the groin canal, so that that’s not an issue. We always examine it, but you just don’t find a hernia sac there. So you really don’t need much support up above that. And then I make sure that I extend my support immediately and I put a couple of two or three medial stitches down. I make sure that I’ve, in some cases I might do a placation stitch or two right at the pubis, but usually I accomplish that by making sure that I’ve got the Mesh support there on the medial side.
Speaker 2 (00:33:12):
And then the last thing I do is I, I’ll try to create a little pocket under the internal oblique because we’re anchoring the Mesh underneath that, and I’ll bring that over and sew it to the lateral edge. And I don’t know if this is too technical for the audience, but over by the inguinal ligament, so that native tissue is creating a true biologic barrier between the Mesh and the cord. And then the other finding that we didn’t really hit on very much that’s pretty consistent is these athletes have a very attenuated external oblique, which is the roof. And oftentimes their external ring is almost like not even there. And it’s like translucent, you can see through it. And normally it should be kind of white shiny tissue, even in individuals who have true hernias. So we make sure that we close that up appropriately. I use an absorbable stitch for that, but we bring that back together as well and make sure the nerves are protected, or if they’re entrapped in any way, either release them or remove the nerve. I don’t ever do anything about the genital nerve. It’s only been the ilial. Inguinal.
Speaker 1 (00:34:17):
Yeah. Okay. And the second one is about laparoscopic. So does opener, how does opener, endoscopic placement of Mesh address the mechanism? So you did agree earlier that it does take tension off anteriorly when you put a posterior barrier.
Speaker 2 (00:34:35):
Yeah. Well, I think it provides you with broad-based support across the posterior rectus and inguinal floor from the backside. And I think if you’ve got an demonstrable rectus aponeurosis injury, and then laparoscopic approach works for a lot of athletes. In my experience, it’s probably only about 10 or 11%. And the majority of those have been in athletes who had prior open inguinal surgeries. So I’m in part doing it to avoid having to go through the scar tissue in the anterior groin in the front of the groin.
Speaker 1 (00:35:10):
Yes, that’s very true. And nerves look like scar tissue, so it’s hard. You don’t want to injure those by accident. Yes. What sutures do you use for these repairs?
Speaker 2 (00:35:20):
Oh, now you’re getting really technical.
Speaker 1 (00:35:22):
I mean, it’s a question. I’m not making it up.
Speaker 2 (00:35:25):
Okay. I use a suture called O. Okay. Which is a braided nylon suture. It’s a permanent suture and it’s on a needle called a CT two needle, which is a great hernia needle. Yes, it’s really good. And I suture in immediately along the transversesalis, aponeurosis and rectus with that. And then I run a prolene stitch, which is a monofilament suture up the lateral side. And then when I do the further anchoring, immediately I use an absorbable suture for that.
Speaker 1 (00:35:54):
Right. And why do you choose a neurolon? Because I,
Speaker 2 (00:35:58):
We
Speaker 1 (00:35:58):
Must have neurolon, but I don’t really use it
Speaker 2 (00:36:00):
Much. I like the way it handles. I like the way it ties. Yeah, it is a permanent suture. I like that aspect of it, and I really like that particular needle that it comes on. I trained, when I trained, I think maybe I did one Mesh hernia repair as a resident. It was all primary suture repair, so you got used to using certain hernia needles. It’s a little shorter needle and it’s good at suturing in that kind of thicker aponeurosis tissue.
Speaker 1 (00:36:30):
Yeah, it’s still great. I actually use the CT two needle on the [inaudible]
Speaker 2 (00:36:34):
Right. See, great, great, great. Mine’s. Think alike.
Speaker 1 (00:36:38):
It’s a great needle. What suture do you use? I use two prolene for all of it.
Speaker 2 (00:36:44):
Okay. Yeah.
Speaker 1 (00:36:45):
And I think that I’ve never been exposed to lawn. I think maybe it just depends on the hospitals I’ve been trained at and I’m sure they haven’t. I’m going to try and
Speaker 2 (00:36:55):
I’ve not had any problems with that. I partly do it because, well, a little history of why I started doing it this way. The Lichtenstein group originally, I think they described open interrupted, I interrupted suture for the medial slide. And so I started doing it that way and you get used to it. And I think it just allows me to place those more precisely on that medial side. And I use the prolene laterally because it’s just easy to run it up to angle ligament.
Speaker 1 (00:37:25):
And I see a lot of patients with Mesh and or suture reactions like actual allergic reactions or inflammatory reactions to their Mesh and sometimes to their sutures. And we’ve been looking at allergy testing you to see if we can predict what suture they won’t react to. And nylon tends to be one that no one really reacts to. So I wonder if they’re braided nylon is a good option. Just,
Speaker 2 (00:37:56):
Yeah, I had any problems with it. So I have had issues on umbilical hernia repairs sometimes with ethibond suture, which is also braided non-absorbable suture, and occasionally having that suture spit or have a little suture abscess. But I’ve not had that issue with neurolon, I am sorry,
Speaker 1 (00:38:22):
Shirin, the about importance of picking the right needle.
Speaker 2 (00:38:26):
Yeah.
Speaker 1 (00:38:27):
I also talked to the residents about picking the right needle to match the tissue. You’re dealing with the angle at which you’re trying to get to, it all works out really well. What do you do in patients that have already had a hernia repair and now they may have a sports injury? Does that happen?
Speaker 2 (00:38:51):
Well, yeah, it does happen. It, it’s not as common. I know Bill Myers has operated, a lot of people have had prior hernia repairs and particular laparoscopic hernia repairs. I have not seen as many failures after that. But if they’ve had a prior open anterior groin repair and I have something, an imaging finding rectus tear or whatever, then in that situation I would lean a bit more towards doing a laparoscopic repair because maybe all they need is just some of that additional broad base to posterior support, particularly if they’ve had a primary suture repair before and that avoids staying out of that scar tissue and potentially risking injury to the blood supply of the testicle, whatever. Yeah. Now I keep talking about the spermatic cord and blood supply of the testicle. I do want to say that these injuries do occur in women also. Yes. But they are much, much more common in men probably for a number of reasons, but they do occasionally occur in women as well.
Speaker 1 (00:40:01):
Yeah, that’s very true. And you know what I do, A lot of my practice is in women. So even though technically attributes seeing seven or 10 to one ratio of males to females, I’m a little bit above 50% women. About 51% of my practice is in women. And part of it is that you kind of alluded to, women don’t necessarily always get talked about when we have pretty discussions and there’s very little data and testing in women in clinical trials or anything like that. And then also it’s because I’ve noticed is women have groin pain and they’re symptom to gynecologist. Is it endometriosis? Maybe it’s an ovarian rupture, maybe it’s your fibroids. But they have occult inguinal hernia, small hernias with a little piece of fat in it that’s causing their symptoms. And some people label that as sports hernia because they feel any groin pain that is without a big palpable hernia. It’s a sports hernia. And it’s just such a misnomer. And we have surgeons around me too that label themselves or market themselves as like sports hernia surgeons. They’re really just fixing hernias that are small. No, I don’t know if you have any comment about that or do you see that often? Well,
Speaker 2 (00:41:25):
I don’t think, let, let’s separate the indirect and direct. So indirect hernias I don’t think are really a part of this problem in the athletes. I mean, occasionally there will be an athlete that also has a true standard inguinal hernia and you can fix those any way way you want, whatever you think is the best approach for them that’s different from the sport hernia. And I also should just say that the terminology around sports hernia is a little bit confusing. Yes. It, because it’s a little bit of a misnomer not being a true hernia with a protrusion. Yes. Even though it affects some of the similar anatomy. And so the term athletic pubalgia came into vogue, and that actually I think is a very appropriate description because it refers to athletic groin pain around the pubic, and it’s not just specific to the inguinal canal.
Speaker 2 (00:42:26):
It can be pubic related pathology where it’s a stress fracture, osteitis pubic, it can include adductor hip flexor muscle group. All those are in that athletic pubalgia umbrella. The problem with the athletic pubalgia terminology is it’s hard for lay people to say that, and it’s hard for the sports commentators to say, added surgery for athletic pubalgia injury. So that’s partly why sports injury, and that’s partly why Bill Meyers pushed this core muscle injury concept. And the challenge with the core muscle injury, yes, this is core muscle, but the core muscle can go from your ribcage all the way down to your mid thigh. And so it’s not anatomically very specific. So I think sports hernia is going to stay in the lexicon in all likelihood. But you’ll read now more on the sports pages about so-and-so had a core muscle surgery.
Speaker 1 (00:43:21):
From a marketing standpoint, it’s definitely the easiest term to use and most kind of intuitive way of thinking about it, even though technically it’s not a hernia. I have a question because I’ve been asked this question. I’ve never had a good answer for it. So the typical Lichtenstein hernia repair involves suturing a medial medial suture and the suture back when I was a resident, they said put it through the periosteum. Then there was discussion of, well, that’s going to cause chronic pain, maybe osteitis pubis, which is inflammation and pain from the bone. And so no, you should not do that. You should put your suture through the rectus muscle or the rectus insertion on the bone, so not through the bone. And that’s what I do. And yet part of these sports hernia procedures is actually suturing through bone and orthopedic surgeons, surgeons suture through bone and periosteum all the time. So is it an inaccurate statement to say that suturing Mesh to the pubic bone is can cause chronic pain or is Mesh the issue and not the suturing through the bone? What are your thoughts on that?
Speaker 2 (00:44:40):
Well, so I don’t try to suture to the periosteum of the bone. Okay. I don’t think want, that’s a good practice. I think I worry, I would be concerned that there is a risk of getting some degree of chronic pain from that and reaction around the periosteum of the bone, which is a very tight kind of dense layer right around the bone. But you do have very good quality ligamentous tissue where the LI ligaments come in and attach around the pubic. And that’s where I try to anchor my stitches in is that good ligamentous tissue, but with not putting the stitch down into grazing the bone, if you will, or the periosteum of the bone. So I think you can almost always find good quality tissue there to use without having to put a stitch in the periosteum.
Speaker 2 (00:45:39):
They’re actually, if I can just digress a bit, some of these abductor tears where the abductor’s completely torn off the pubic and even retracted, there have been some efforts to reattach those and that would require bone anchors and reattaching it into the bone. And there’s actually been a study of N F L players, and it was not a controlled case study, but they looked at athletes who had conferral degrees of separation and had suture repair with bone anchors versus conservative management. And the conservative group got back to full athletic activity a few weeks sooner than the ones that had surgical repair. So I think you want to be careful about suturing anything into the bone around the groin region.
Speaker 1 (00:46:24):
Yeah. Fantastic. Thank you so much. You’re aware of Dr. Muschaweck and Germany and others who everyone has their own way of doing things. They’re often quite similar. They’re just being touted as being more particular to one surgeon versus another. But part of the groin tissue repairs theories is instead of putting an all Mesh and you should actually plicate the defect more of a tissue repair or do both. What are your thoughts on those?
Speaker 2 (00:47:02):
Well, so I actually visited Dr. Wick in Munich, Germany. She’s an excellent surgeon and she does this minimal repair. And I think what she’s really contributed is getting athletes back to sport quicker. And so what she does is it’s analogous somewhat to a Shouldice hernia repair and basically opens up just the area of the bulging of the posterior floor and then does one suture running up and back down and then another one from the down and back up. And so the placation, I think is a good way to describe it or are implicating and there’s muscle layers over. So it is a primary sutured repair. I don’t want to comment about results and that sort of thing because I haven’t seen any of her results published lately. But that’s the basic technique. And getting back to what I said earlier in my hands, it’s difficult to get that kind of repair and to have a durable repair without tension. And so that’s why I use the approach I use
Speaker 1 (00:48:24):
Because it also does not, it’s a true cation. There’s no opening of the floor to release that tension like a Shouldice. Right.
Speaker 2 (00:48:32):
Well, it opens. It is just the part that’s kind of really attenuated in bulging. It’s not opened all the way down like you would for a standard Shouldice or any repair.
Speaker 1 (00:48:40):
Yeah, correct. Yeah. This is all fascinating. So do you teach your residents tissue repairs? I am, but I just feel that
Speaker 2 (00:48:51):
I’m
Speaker 1 (00:48:52):
Very little of that done.
Speaker 2 (00:48:53):
I’m probably about the only person here that may occasionally do pulmonary tissue repair, but I don’t do it very often. And the population that I will do it in typically would be a woman with an indirect hernia, not so much with a direct hernia, but a woman with an indirect hernia. If there’s not a lot of tension, I’ll do a primary suture repair. And the other situation in which I will use it is sometimes I’ll have a really young athlete who may be late teens and still growing. And in that situation I would try to do a primary suture repair. But our trainees get very little experience with primary suture repair for groin hernias.
Speaker 1 (00:49:37):
Yeah. I’m predicting that’s going to, the pendulum is going to start swinging the other way. I certainly do a fair amount of tissue repairs. One is of course I see a lot of women and I also have a lot of people that have problems with their Mesh. And then if it needs to be removed, they don’t want the Mesh anymore. So the tissue repair is always an option. But yeah, they enjoy it. It’s a great operation. The Shouldice, Bassini, McVay, all of those
Speaker 2 (00:50:06):
You do. We’ll need to talk more offline about this, but do you more Bassini repairs generally when you do primary suture repair or?
Speaker 1 (00:50:15):
I prefer the Shouldice and Shouldice for any femoral hernias. And we’ve had a couple of patients that surprisingly had femoral hernias and we changed our tissue plans to do a McVay and it’s part of their boards. They have to be able to understand the anatomy and know how to do a tissue repair in cases where Mesh is not indicated. So they get all excited when they’re learning that. And I think it’s really good anatomy too.
Speaker 2 (00:50:50):
I maybe done one McVay repair in the last 10 years.
Speaker 1 (00:50:53):
No kidding.
Speaker 2 (00:50:54):
Yeah, probably very.
Speaker 1 (00:50:56):
I didn’t chew this year already.
Speaker 2 (00:50:58):
Oh, wow. Well,
Speaker 1 (00:51:00):
When we Different patient population.
Speaker 2 (00:51:02):
Yeah. Well, I did in a number of males when I first started in practice and for more for direct hernia. And yes, I just over the long haul, a higher fair rate.
Speaker 1 (00:51:12):
Yeah, absolutely. Yeah, that’s absolutely right. And tell me a little bit about your practice. Patients come and see you if, do they call a central office? How do patients reach you if they They’re out of town, out of country?
Speaker 2 (00:51:30):
Well, are you referring to the athletic population?
Speaker 1 (00:51:33):
Both. Yeah.
Speaker 2 (00:51:34):
I, well athlete’s, a little bit of a different situation. I get referrals from a variety of sources in the athletic population. I get a lot of athletes regionally just because most of the sports people and therapists know that I do this and a lot of the general surgeons as well. So anytime they see somebody who has groin pain and doesn’t have a hernia, maybe it’s a sports hernia, go see brunt and those come through the office. We like to screen records in advance. And if they’ve had outside imaging, it’s become important for us to get the images and get them looked at first before they actually see me. Otherwise, we may find out it’s a poor quality MRI and we’re going to have to repeat it. And I have people driving here sometimes from 5, 6, 7 hours away and others flying in. So we like to know if we’re going to need to repeat imaging in advance.
Speaker 2 (00:52:28):
And we haven’t talked about it, but my go-to imaging test for athletes with going pain is a pelvic MRI. And they’re very specific sequences that we do. It gives you the most detail. CT scan is pretty non inform. We rarely do that. There’s some groups that do ultrasound, dynamic ultrasound imaging. We haven’t done that so much. I still think you need the MRI to look at the pubic and the abductor muscle groups and that sort of thing. And so in terms of, I’m on the NHL team, physicians and second opinion list for the NHL and NFL as well. So we’ll get calls directly from trainers and team physicians and from some of the colleges around as well. So it, it’s varied how you get your referral network. So some of ’em are direct to me from people who know me and others are through the office.
Speaker 1 (00:53:38):
Yeah, that’s fantastic.
Speaker 2 (00:53:40):
I think Dr. Towfigh, the other thing that we haven’t really talked about is that this taking care of athletes, it’s not just about the individual surgeon it, it’s really about having a program to manage these. That’s true. And a systematic approach. And it includes your orthopedic colleagues oftentimes because there can be other lap with over other injuries like hip problems. And I’ve had athletes referred to me with, and particularly middle-aged to with for a sports journey, and it turns out they’ve got bad arthritis in their hip. It’s a hip problem. So you have to know how to do those exams and you have to work with your orthopedic colleagues. But also the musculoskeletal radiologists are invaluable for me. And we’ve both educated each other about this problem and it’s all of our MRIs get sent to them. They do an official read and a consult, and sometimes we’ll talk about the cases.
Speaker 2 (00:54:43):
And then the rehab is critically important after the surgery. It’s important to have a structured rehab program. The one that I use was put together with the help of Ray, the head athletic trainer with the athletic St. Louis Blues that we’ve worked together for 27 years now. And so it’s important to have that structured rehab program for managing an athlete after surgery in order to get them back to full speed because it’s not just all about the surgery and correcting a problem, it’s also making sure that they restore their functional balance across their whole core and their lower body as well.
Speaker 1 (00:55:25):
Yeah, it’s so important. I feel that the core balance and the kind of balances of building the different muscle groups are so important to prevent these, number one. And also as part of the rehabilitation. Do you have any of that published where others can look at either the MRI protocol that you use or the sports kind of
Speaker 2 (00:55:48):
I don’t. Neither one of those. Well, actually, the rehab protocol or a version of it is published primarily in one or more book chapters that we’ve written.
Speaker 1 (00:56:00):
Right. Yeah.
Speaker 2 (00:56:00):
So I could probably send you that link at some point if you want, with a reference if need be. Yeah, I’d love to. That’s, yeah, that would be published there. Yeah,
Speaker 1 (00:56:11):
That would be great. Yeah. For MRIs, we use a, it’s a non-contrast pelvic MRI. We call it a hernia protocol. I’m sure there’s a lot of places they call a sports protocol, but it involves not only complete MRI, but also dynamic images where they push in and out. Some subtle findings of hernia recurrences are found on those that you can’t necessarily find if you’re just laying flat on an MRI. So it’s, I love MRIs. I think it’s great, but most surgeons are not comfortable with MRIs and CT scans where our comfort zone tends to be, and it’s hard to find a good ultrasonographer that can reliably give you information. So it’s one of those things where, yeah, CT scan is often the first study in the United States. At least that’s ordered and not helpful at all. Yeah,
Speaker 2 (00:57:06):
No, I just recently had one athlete CT scan completely normal to get the MRI. And there’s all kinds of pathologies, a rectus aponeurosis tear. Yes, Parasymphyseal edema, none of which showed up on the CT scan. So yes, you really need the MRI I, the ultrasound, I think in and experienced ends can be very good, but it’s very obtuator dependent. And the part of the problem with it is if somebody else does it all, you can, you have to rely on the report. You can’t actually interpret the images very well unless you’re doing it yourself. Not like looking at an ultrasound of the gallbladder where you can see there’s stones, there’s a thick wall or there’s not. But you really
Speaker 1 (00:57:48):
Very complicated
Speaker 2 (00:57:49):
Depend on that dynamic imaging and onsite interpretation.
Speaker 1 (00:57:53):
Yeah, very complicated. That’s so true. Which is why this kind of team approach really helps. I have radiologists that are very happy to read imaging that they didn’t do, and they understand my patient population. And it’s hard when you are seeing a doctor and you don’t know what to ask. And there the resources may not be there. So a lot of what we share during this webinar is there are people like you around with telehealth. It’s much easier since the pandemic to reach out to specialists that are not physically near you to at least get some guidance as to which direction you go. Do you even have a sports hernia? And if so, what images or interventions need to be done to help figure it out instead of having to travel all over the nation to try and figure that out.
Speaker 2 (00:58:47):
Well, I think a part, the good news is I think hernia surgeons are becoming more knowledgeable about this area and more comfortable in seen in managing some of these athletes. And so I think you’re find surgeons in all regions of the country that have learned about this and are willing to see some of these patients and athletes.
Speaker 1 (00:59:08):
Yeah, absolutely. Well, thank you so much for your time. I learned a lot, and everyone’s very thankful for you, and I appreciate the time to well do this with you, and I’m so glad to see you. It’s been so long,
Speaker 2 (00:59:23):
I’ve actually, yeah, it’s great to see you. Great to see you too. And thank you so much for the invitation. This has been a great conversation. Lot of really good questions from your audience, so
Speaker 1 (00:59:32):
Yeah. Yeah. I love my audience. Yeah, they’re great. They do a lot of their own research. It’s pretty impressive.
Speaker 1 (00:59:40):
All right, everyone on that note, thanks for joining us on Hernia Talk Live. We’ll see you again next week with another amazing guest. Thanks for everyone who follows me on hernia talk.com on our website, which is a free discussion forum for all of you. I will make sure that you get the link to watch and share from YouTube and it’ll be shared on all my social media avenues. And again, thanks so much to Dr. Brunt for his time and sharing all of his knowledge, and I hope to see you soon. I’ll see you at Sages. Hopefully maybe we can catch up there. And thanks everyone else for watching. Bye everyone. Thanks.
Speaker 2 (01:00:21):
All right. Take care. Good night. Thanks.
