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Speaker 1 (00:00):
Oh, hello everyone. I’m finally getting my bearings. Happy Mother’s Day to all of you who either are mothers or have mothers, as we all do at some point of our life. And I got to spend some time with my mother today and I’ve been very grateful about everything I do in life and therefore understands that for the next hour I will be with you all discussing everything about hernias. So let’s go ahead and ask me questions as you wish, but I know that we have some pre-prepared questions. This is so weird. I can’t even, okay, I can’t share my screen. Okay, so let’s start with some questions. And as you guys come on board, what I’ll do is answer any questions that are live. In the meantime, we will move ahead with our regular questions. Welcome to Hernia Talk. Live, as you know, can find me on Twitter and Instagram, and that is where most of my activity is on Facebook as well. Many of you follow me on Facebook live with my weekly hernia talk, but this will have to be prerecorded. And then also once everything is done, I will take this hour and show it on YouTube. So I will start with questions that we had tons of before and they’ve just been lingering over weeks and weeks and weeks, and we’ve had excellent guests that have joined their knowledge with me and answered your questions. But for sure, we’ve never had enough time to go through every single question.
Speaker 1 (01:51):
And so what we’ll do is go through those old questions and hopefully answer those for you. So one of the old questions, which was a really smart one, is why is there little consensus for waiting? And basically what watchful waiting, as many of you may know, is the concept that you have a disease in this case, a hernia, and you plan not to do anything about it surgically or definitively. And that’s called watchful waiting. It’s considered safe for both inguinal and ventral hernias in general with some exceptions. And it used to be that if you had a hernia, was it groin hernia or an umbilical hernia or a ventral incisional hernia, you went to see a surgeon, the surgeon that you have a hernia, let’s go fix it. And in some situations they would say, oh, it has to be fixed like immediately. And none of that was based on any signs.
Speaker 1 (02:49):
We had no idea who of the, let’s say there’s a thousand patients and they all showed up with the same hernia who will have a complication and who will not. And so instead of guessing, let’s just treat everyone, fix everyone’s hernia because we know that a fraction of those people will be saved from either a bowel obstruction or incarceration where something is stuck or even worse, a strangulation where it’s not only stuck, but whatever stuck is dying and that is a life-threatening problem. So basically in 2006, simultaneously, two different studies got published. One is an American study and one is a European study. And they both looked at men with inguinal hernias. The US city was all men with <inaudible> that were what we call asymptomatic. So no symptoms or minimally symptomatic, which means ah, they fell a little twin here and there, but it wasn’t something that really affected their daily living in the Europeans today.
Speaker 1 (03:58):
They only looked at men, I think over age 50 that had inguinal hernias. And the question was, if they really don’t have many symptoms, is it worth operating on someone who’s a little bit older? And both studies showed the same thing, which is nothing happens if you don’t operate the risk of incarceration, which means something gets stuck was considered to be 0.0 0.01% per year, which is a very small number. It’s not zero. So it can happen, but I think there’s only three cases and all the thousands of patients, patients that they studied over a span of five years and then in the European studies similar, no one died, no one had a bowel obstruction by waiting. And so based on that study, I can tell my patient now with some science that yes, you do have a hernia. You tell me stop bothering you.
Speaker 1 (04:57):
Oftentimes they, it’s either a work related or school related exam that demonstrate the hernia. Patient didn’t even know they had one or they went to their physical exam, annual physical exam with their doctor and their doctor said, oh, you have a hernia, go see your surgeon. And so it’s considered either asymptomatic or minimally symptomatic. So in all those patients, I can say with some evidence if you want your hearing heart of your parent, that’s fine, but from a medical standpoint, it’s okay to wait. And that’s called watchful waiting. What they didn’t take into account was the needs of the patient and the wants of the patient. So scientifically, yes, you’re not going to die from your hernia if you don’t repair it, if it’s a minimally symptomatic or asymptomatic groin hernia. What they noted was though, if they followed these patients through about a quarter, almost a, were tired of having a hernia and they just wanted their hernia repaired and they were allowed to do that as part of the study, but that was something that was tracked.
Speaker 1 (06:06):
So the crossover of people wanting to have surgery that were randomized to having the nose surgery as opposed to the surgery home was pretty significant. Almost a third of the patients. And so the reality is if you’re like 80, 90 years or you have other medical issues and you have a hernia, doesn’t bother you, the chance that hernia will ever cause you a problem is close to zero. You’re 20 years old and you have a hernia. The risk of having a complication is about 0.01% per, sorry, 0.08% per year. Presumably you have 70, 80 more years. So if you multiply that number, that’s a larger number. However, the option to watch is there and the reality is you’ll probably get tired of waiting and not getting your hernia repaired. So about a third of those patients will be like, thanks, I appreciate you following a very conservative treatment doctor.
Speaker 1 (07:18):
The watchful thing was good, but I’m kind of tired of having this bulge or my partner doesn’t like it or it’s weird underneath a swimsuit or something like that. And so they choose to have the hernia repair, but the key is you’re not going to die most likely if you wait on an AL hernia. The same is true for small belly button hernias. So why is there little consensus on watchful waiting? That’s because not everyone A reads the literature. B follows through with their five year and tenure results to see what happens to those patients. Also, again, in the literature, and everyone has their own bias as to how they interpret the data. To me, the data is that’s great. 70 to 80% of the patients never need their hernia repair. They went on with their life. It was an unnecessary additional procedure. Could prevent having others sort of be like, yeah, but look, I think a third of the pages are unhappy.
Speaker 1 (08:24):
Why should that be it? Let’s offer them surgery. So that’s why some surgeons are a bit more aggressive than others. They either don’t know the literature or they interpret the literature in a different way than others do. But if you want the real facts, those are the real facts. Okay, no questions yet. So let’s move on to the next old question. I hope that was helpful, which is how will treatment of hernias change in the next five to 10 years? Okay, this is where I love to talk because I think I’m always thinking future. In fact, I have patients that come to me and I said, listen, we don’t have, let’s say the best mesh yet or the best technique yet. So wait another several years, five years, 10 years sometimes and at that time we’ll have something good for you because I am constantly in touch with people from all over the world, not just the US but also the companies.
Speaker 1 (09:33):
I’m trying to be as on top of it as I can in terms of what each company is working on and developing. And those are all super exciting things for me. So there is a lot of amazing stuff that’s going to come up. My personal opinion is I believe that we are currently overusing mesh. Mesh is great for certain people, it’s not great for certain people and there’s a population in between that we don’t know about. So I think with time, with the help of many of you out there who are very vocal about the risk of mesh, I feel that we will be moving away from the overuse of mesh in the United States. Not a hundred percent of patients need to get mesh for their hernia repairs for example. That’s number one. Number two, the quality and the type of mesh that we have I think is also going to change.
Speaker 1 (10:40):
I know that we’re already moving towards more interesting mesh products. There are synthetic absorbable meshes, there are hybrids, there are newer resins that are being used that are less inflammatory to develop as products. So let’s see how we can move on in the future to develop hernia treatment that is more patient. That’s my belief is that everyone should be interested in what the patient wants. And I feel that up to now we’ve been working with industry as surgeons and the surgeons are appeasing the needs of the surgeon, sorry, the industry is appeasing to the needs of a certain and not as much the needs of the patient, assuming the surgeons want the best for their patients, but sometimes we kind of like our toys. So you work with industry and you make a nicer toy, doesn’t necessarily necessarily mean that it’s the perfect thing for the patient.
Speaker 1 (11:54):
So my personal opinion is the treatments are going to move towards better mesh products, less synthetic products, and hopefully also come up with newer techniques that can maximize how much natural tissue we can use. And that’s kind of my take on things. So looks like we have a question. All right. Okay. So I actually have your question up already. Let me see if I can bring that up. Howard’s been great. He’s been very, very, very, very how should I say persistent and patient at the same time. Let’s see, do I have your, okay, sports journey is that’s where he wants to go. So first of all, one question we had was is a sports hernia really a hernia? The short answer is no. In almost all cases, a sports hernia is not a hernia, it’s a horrible term. We don’t really like to use that term anymore.
Speaker 1 (13:09):
It’s mostly a terms like athletic pubalgia, which means pubic area pain after an athletic event or activity or some type of instability of that region. So a hernia implies a whole through which something is going to go through with a sports hernia or athletic pubalgia. It’s a tear without there necessarily being a hole. So it’s often not a full thickness tear. So you have a humongous kind of bulky muscle with the fascia. Part of those may tear and part of it may not, but that causes lots of pain. So that’s really what a sports hernia is. That’s something referred to now the question for Howard, so I’ll read you his question for today and I think it’s similar to what I wrote. So he says, how do you approach so-called sports hernia or athletic pubalgia, which is due to partial detachment of pre pubic aponeurotic plate from a pubic bone.
Speaker 1 (14:20):
Is it safe to re-secure the plate into the periosteum of the pubic tubercle and pubic bone or is there a very high risk of pain from placing sutures into the periosteum? And what about the Myers repair? Okay, very advanced question. I’ll try and make it a bit funner and easier to understand. So athletic pubalgia is a tear of the muscle from the bone. So if you think about it, bone is super firm and hard and does not stretch. Attached onto the bone is muscle. Muscle is super stretchy and not firm. So if you are super athletic person and you have bone, here’s the muscle and you do something crazy, a very jerky movement or an extremely fast movement, you can think of the soccer players that kind of do this with their legs or the hockey players that do these splits and football players or sometimes basketball players that are doing these.
Speaker 1 (15:30):
Basically what they’re doing is they’re actively stretching or pulling on their bulky muscle, whether it’s their rectus muscle, which is the middle two muscles of your six pack or the adductor muscles, which are the muscles of your thigh, which allow your legs to go inward as opposed to outwards. So those muscles attach onto the bone and if you do a jerking movement, you can imagine the muscle is pulling bone doesn’t go anywhere, and so as a result you get a tear. Now the majority of those patients do not need surgery. In other words, rest anti-inflammatories, maybe some injections to promote healing. Reduced inflammation such as steroids, injection or P R P are the first and second line. Treatment surgery is not the treatment for athletic pubalgia in the vast majority of patients.
Speaker 1 (16:39):
It does help in the really big ones, the really big tears. And the reason for that is if it’s such a huge tear, the chance that it’ll heal will be low and it’s often in an athlete that’s worth millions and millions of dollars. And so there’s an incentive to hasten or kind of make the healing more rapid. So there’s two main approaches for the surgery. Again, it’s not first or second line treatment, but there’s two main options. One is completely detach that muscle from the bone. Now it won’t spring away, it’ll just move off because there’s so many other attachments and scar tissue which will keep the muscle nearby so that you don’t lose the function of the muscle as much as you think, but you’ve released it so it’s no longer attached to remember muscle stretches, bone doesn’t. So if you release those two, this can stretch and not pull on this and there’s no more tearing.
Speaker 1 (17:45):
That is a very common way of treating athletic pubalgia worked for most athletes as well as non-athletes. And it’s the simplest way of doing it. And the drawback is if you’re like a kicker or a sprinter or someone that will notice the slightest change in your muscle function, then cutting that off the boney attachment will hurt your athletic performance. You can still walk and run and swallow. You may not be as fast, you may not be able to kick as well. So in those situations they prefer usually not to cut it, but almost every surgeon that’s in this prefers to cut the muscle off. The other option is what Howard Willens is referring to, which is to take the muscle and sew it back on. But you can’t sew it here because most of it’s torn. So you kind of have to sew it like implicated and sew it, which by definition makes it even shorter and more intention.
Speaker 1 (18:55):
So there’s release, there’s ways to release the other tissues to release the tension on that and therefore what you’re doing is you’re sewing the muscle to the bone. The question is, one of his questions is, is it even safe to put suture in bone? So we know from inguinal hernia surgery that permanent suture, permanent suture in the bone is not a good idea because that can cause chronic pain and we kind of don’t do that anymore. It’s one of the things you teach the medical student and you teach the resident don’t put the suture into the bone because it’s always pulling at that area and it’s a permanent suture. In athletic surgery, they usually don’t use permanent suture they use absorbable suture. And so that problem of the chronic pain is not as frequent. But yes, there’s still that risk of chronic pain. A lot of the athletes already have pubic bone related spurs and reactions as a result of all of this injury from bones so on.
Speaker 1 (20:14):
So that can make it even worse. And then other options are laparoscopic. There’s there’s some evidence in certain patients that just have an instability in very small tear that if you put laparoscopic mesh to support that area, then it won’t tear as much. But often what you’re doing is you’re adding an inflammatory foreign body to an area that’s already inflamed and that doesn’t help. So most of us don’t do the laparoscopic mesh placement. It’s kind of not a very anatomic way of treating the problem. So I hope that helps. He’s referring to the Meyers repair. William Meyers is a very talented actually liver surgeon who also has become very famous for his operations on super super high value cleats that have athletic pubalgia. I wish he had a course where he would teach us all what he does. It’s a little bit of an enigma as to what he actually does. So most of us aren’t really privy to the Meyers repair but it is basically a multiple, it’s like the Shouldice of athletic pubalgia.
Speaker 1 (21:46):
Those of you that know the should eyes, it’s a four layer repair and it’s considered to be the best repair among all the different tissue repairs, although they’re all pretty good. But this is considered the best because it’s four layers and that’s kind of what he does. But for the athletic pub part, which is he does multiple layers of sutures over and over, my throat is getting dry cause I’m have a guest to take care of all my questions. So as many of usually we get not usually, but I have chosen to have my friends come on who are all hernia specialists and have them answer a lot of the questions for you and then that way I get to hear what they say and you get to hear by more than two one surgeon talk and it kind of makes it more interesting. Plus you get to know more people besides me and share the knowledge with you.
Speaker 1 (22:50):
But today’s Mother’s Day, and no one really wants to choose to work on Mother’s Day. This is kind of like my baby, so I, I’m happy to do so, but I decide I’d give the day off to all my friends and have them be with their spouses or family and not ask them to do me a favor and spend an hour talking to our audience. So it’s me alone today. All right. Next question from our attendee is if facing the onset of, oh, okay, let’s go back before we finish everything on athletic pubalgia. Dr. Towfigh, I believe you’re referring to cutting the adductor longest. Can you achieve the same result by releasing fascia or placing small incisions into the adductors without completely cutting it? Again, depends on the stage of the tear and the outcome for the patient. So for small ones you can do what’s like what’s called an elongating procedure, which is basically cut the fascia and release some of the tension.
Speaker 1 (24:01):
That is definitely doable for the larger ones or the chronically fibrotic ones. Mostly we just cut the entire tendon off. So I hope that helps you. Okay let’s see. We have another question and that is if facing the onset of pain and burning in the pubic region, or I’m facing the onset of pain burning in the pubic region over two years after lap hernia repair, what is your experience with this late onset repair? Sorry, with this late onset pain and how do you usually approach this type of case, including if a recurrence is not found? Do you see cases like this that resolve on their own? Okay, so it sounds like you had a laparoscopic hernia repair, everything was fine for two years and now you have pain and burning in the pubic region. Almost always that’s a recurrence and if they tell you it’s not a recurrence, my experience has been it on imaging and it’s there. So I would still get a second opinion.
Speaker 1 (25:20):
Many of you know that I really enjoy reading imaging so much that I actually offered online consultation to be able to read all of your images and I get a kick out of it. So if you want me to re-review the images for you and help you figure out if there truly is a hernia recurrence or not let me know because I’ve had a lot of people who have been told that for years and years and years and their pain is still not gone and then they show the image. I’m like, you’ve had a hernia recurrence for the past five MRIs and CT scans, you’ve been wasting your time with a misdiagnosis. So that’s number one. Number two, number three, recurrence, recurrence, recurrence. Other options depend on the type of repair you had, the type of hernia you had and your symptoms. So it’s possible that you have what’s called a shearing effect.
Speaker 1 (26:24):
So you were doing fine, your mesh is against the muscle and then you did some activity and the mesh just shifted and that shifting is enough to cause pain but not enough to cause a recurrence if that’s what happened. That pain will go away to the sports hernia scenario where the muscle tears off the bone, the bone stretch muscle stretches, muscle stretched bone doesn’t stretch, there’s a tear, same with a mesh. Mesh does not stretch. And so you had some type of activity, you tried to prevent someone from falling or you got this heavy suitcase you tried to lift and your muscle contracted, but the mesh over doesn’t contract. And so it shifted off of it. That may not cause a recurrence because it didn’t move enough. The mesh didn’t, the muscle didn’t move enough off the mesh to cause a recurrence, but there may be pain.
Speaker 1 (27:26):
So if there’s no hernia recurrence confirmed on imaging, then what I do is I inject the local area with steroids and local anesthetic to see if the pain goes away. If it does and you have a shearing effect that goes away, we treat it just like a sports hernia, rust, anti-inflammatories and local injections and it’ll go away with time. So those are the two top ones. Rare, rare cases, there’s an infection. So you are doing fine and I’ve seen that 10, 20 years out from surgery even, and you had two sis or diverticulitis abscess or some infection in your body that caused bacteria to run through your system and the bacteria landed on your mesh and then enough time passed for the bacteria to duplicate and continue logarithmic leak to increase to then get an infection. And so in that case it’s a mesh infection caused by some dental procedure or infection in your body. So that’s, those are my top three for you is recurrence sharing effect or mesh infection. Hope that was helpful. All right, you guys ready for more questions? All right, let’s do the next one. Okay, we kind of went forwards and backwards. So let’s go back because skip some. Okay, where were we here?
Speaker 1 (29:05):
Okay, question is why does my belly button, sorry, my belly look asymmetric after my belly button, hernia surgery, the left looks and feels different. Okay, so just know that surgery is an alteration of your body. We cut, there will be a scar, we sew, et cetera. So it is not unexpected for your belly to look a little bit different after surgery, if any of you had C-sections or appendicitis and or bladder surgery, you’ll know where your scar is, looks different after the scar than before the scar. That’s just normal. It also means the fat deep to your scar may be different. So some of the fat may have died, some of it may have bled into itself and all of those will cause differences in how it feels and also how it looks. So sometimes we do surgery and the belly is not fully symmetric. Obviously that’s not ideal, but it happens.
Speaker 1 (30:19):
So if that’s a situation, if you really want, you can go to a cosmetic surgeon, they can either redo the scar or they can inject fat into an area where you’re missing fat or they can inject filler or reduce fat, do lipo in an area where you’re got too much fat and it’s asymmetric. Those are purely cosmetic PR plans. However, every so often your belly’s asymmetric because your hernia came back. In other words, if one side feels or looks different than the other and maybe because you have a little hernia and to the side. And so now this side is a little bit poutier and a bit more firm or tender than they decide without the hernia and that’s always a possibility. So that’s top two reasons why the area may look different, depends on how far out from the surgery and what other symptoms you have.
Speaker 1 (31:14):
Okay. If mesh with micro hooks on the back of it is causing chronic pain, is it possible to remove the mesh? Yes, all mesh can be removed. I know a lot of people go to surgeons and are told your mesh can never be removed. I have yet to see any mesh that can’t be removed. All mesh can be removed. And so there are risks with are risks with every procedure, but from a purely technical standpoint in can be removed. The mesh we’re referring to is the program mesh made by Medtronic. The micro hooks are actually absorbable. So after a certain number of months those hooks are meant to go away. They’re there because they work like Velcro. And so the design’s actually interesting design in that instead of taking mesh and then sewing it or attacking it in different areas, it kind of sticks like with those micro hooks like Velcro.
Speaker 1 (32:14):
And that’s considered superior in some reasons. One is you don’t have to suture those mesh and so you don’t get pain from the actual suturing. The second is you have hooks along the entire area of the mesh, not just at certain areas where we would normally suture. And so if you think about it, it’s better to have a sheet where everything is glued down than if you just kind of put faster in certain areas. So the micro hooks are absorbable. The intention of the micro hooks is to reduce chronic pain that’s related to suture or tack placement. And yes, that mesh as with any other mesh can be removed.
Speaker 1 (33:07):
Okay, this was an interesting question. This patient had a tummy tuck after. Okay, so she had an umbilical hernia repair with mesh in 2006. Then she had a tummy tuck separate procedure and then she did some activity and felt a pull in pain and now she has pain in around the belly button area. So that’s her baseline. Now I tell her she needs a hysterectomy. It’s unclear why and she’s wondering if she needs to address the belly button paint at the same time. And she’s seen multiple doctors, multiple surgeons, they all told her something different. Most of them said don’t touch the mesh. One of them said, well, the mesh looks like it’s kind of hanging in one area. So yeah, we could take out the mesh. What should she do? Okay, first of all that’s a hard question. I would first look at the imaging to see what the mesh looks like.
Speaker 1 (34:10):
If she had a muscle like this and she had a mesh underneath and then did a tummy tuck, that mesh may look folded or hanging or something. Doesn’t mean that that’s the reason for your pain. So first it’s important to figure out what the reason for the pain is. If the reason for the pain is indeed that take out the mesh if it’s not the reason, and that’s just what you see on imaging, you have to really correlate what you see on imaging with why the patient has symptoms. Just because something looks abnormal on imaging from a hernia standpoint doesn’t mean that’s a reason for your pain. So is it now a tummy tuck related pain or is her hernia back? These are all questions to answer. Yes, the mesh can be removed. Is it due to the tummy tuck being done? Probably not. I mean the pain, it’s probably not. But those are all questions that are best done into consultation and let’s answer the next live question since it came up. I am curious, do you use self fixating mesh? Do you see drawbacks to that style of mesh versus other fixation? I do not. I wish all mesh were fix self fixating honestly.
Speaker 2 (35:37):
And they’re not. The majority of mesh is not self fixating. The program is the only product to date the group line of mesh that is self fixating. I think it’s awesome. I’ll tell you why. So there have been a lot of lab studies done on the best way to fix mesh in order to get the best outcome. So the purpose, so think of this. If you take a sheet of paper, can I get a sheet of paper bill? If you take a sheet of paper and you want to put it against the wall, right? Can you guys see this? I can finally use my board. Want use this board since we started day one. Okay, I want to put this against the wall, right? Okay, if I put this sheet of paper against the wall, I can then kind of here, let’s do this. I have some fun today, I can then let’s see, these have magnets on it. I can paste it around.
Speaker 2 (36:48):
So not very secure. I can still move it around this area. Where is it? This area is kind of floppy, et cetera. So putting mesh and then putting collect sutures, it’s a good idea. And then the concept is that the mesh causes an inflammatory reaction and then the inflammatory reaction allows a hundred percent of the area of this to then stick to the muscle. Okay? That’s the theory behind normal mesh. That doesn’t stick to anything. Then someone came up with glue and they said, what if we spray this whole thing with glue? And that was actually a superior way. So if you do a laboratory test like an animal testing or in the lab where they can figure out shear forces, if you take a mesh and you put a handful of sutures in and try and pull it apart versus the glue, a hundred percent of the area in the glue is superior from a shearing standpoint. Then this company came up with these micro hooks, which is basically Velcro. And like I said, the micro hooks are absorbable. So the micro hooks then make it so that you don’t have to use glue. The problem with, it’s kind of hard to use the mesh because the minute you put it on and you haven’t really placed it perfectly, it starts to stick. So it’s kind of like the Saran wrap. Those of you that are old enough like me to remember the original saran wrap was so hard to use. It stuck to,
Speaker 1 (38:35):
But now they’ve made it just the right amount of sticky where it sticks but not so sticky that it doesn’t stick to itself. So that’s basically the concept of the micro hooks. They haven’t used it yet for so certain hernias, like ventral hernias, depending on where you put it, if you put it intra-abdominal, it doesn’t work as well because it’s sticking to peritoneum which moves not the fascia, which doesn’t move. So it’s still not the ideal mesh for every single type of hernia, but it’s pretty damn good. And I would like to use more of it if I can but don’t, first of all, it’s very expensive or it can be depending on your hospital and they only make a limited size and shape. So I don’t have access, the surgeon doesn’t have access to every single size and shape of mesh with that program.
Speaker 1 (39:44):
So it’s of limited availability. That’s my take on it. Hope that was helpful. Having fun with this guys <laugh> almost over. Okay, another question. Thank you Dr Towfigh. With regard to adductor longus resection, if one does not have pain rating into the thigh, but rather rating into the upward, into the abdominal wall rectus area, will simple resection of the Adductor longus still be effective? No, there does not seem to be consensus in various guidelines that adductor longus resection is the optimal treatment for <inaudible> like pathology. Okay, so is the tear, tear is at the rectus. Remember I said there’s two muscles, it’s either the rectus sub dominus or the a adductor longus. It’ll be very uncommon for it to be both. But if you are a super athletic person in the abs, so like a football, a weight lifter or a football player versus a hockey or soccer player where they’re bigger in the thighs you may well have a rectus muscle tear, in which case an adductor release will not do anything for you.
Speaker 1 (40:56):
So first we figure out where the pain is based on imaging examination and then injections to see what helps. And then for long-term results, you may need an actual suturing of the rectus. That’s where your question came from before, which is would a laparoscopic mesh help it? We don’t really know. It depends on where the area of the tear is. But if you have a rectus tear, some people think that you should sew it and then use mesh to support it because that’s easier to use than for rectus and for adductor tears. And then you have to choose which mesh. So mesh is highly inflammatory many use biologics. The biologic is there just long enough to need the support until your repair is done and then it absorbs. So the use of biologics is actually something of interest. Non-synthetic biologic mesh to help support that.
Speaker 1 (41:58):
In fact if you read my book, I have a book that I’ve co-authored with Dr. Ramshaw, Chen, and Jacob, and you’ve already heard from Doctors Chen and sorry, Dr. Ramshaw and Jacob on this hernia talk. So we have a chapter on athletic pubalgia by orthopedic surgeon and then we also have a chapter by Dr. Edelman on his experience in biologic mesh for as a both, not a bolster, is that right term to help support buffer to help support sports tear. So rectus and adductors are two different muscles. Were two different symptoms and I hope that’s helpful for you. Okay, moving along.
Speaker 1 (42:55):
Let’s see what our next question is. Oh, we got these two. Let’s move on. Okay, there have been a couple questions. Oh, sorry, let’s go back. How about a brace or split brace or splint? So you’re talking about an abdominal binder that doesn’t help us Sports hernia rest does, but a binder often just pushes on the area and causes more pain. The reason for that is the binder goes this way and your rectus is this way. So by crunching this way, you’re not really taking any tension off of the rectus muscle. You are on the obliques but on the rectus muscle. So you want to prevent this kind of movement. So that’s why we recommend rest and not braces.
Speaker 1 (43:54):
Continue on. Sorry, I meant use term brace or splint. Oh, as opposed to word buffer. Okay. Is mesh a splint? Are you I think it’s, I guess a splint prevents movement. The mesh is meant to take the tension off. So for example, I think you’re a male Howard <laugh>, but for females we wear like a corset and then the tight dress over it. So the corset takes attention off of the dress theoretically. And so if you have a tight dress, if you wearing a coarse under it, you’re not going to tear the dress. Another example, the suits that you wear almost always lined. The lining is not just to make the suit fit better or look better, it also takes attention off of your seams and therefore makes you able to wear a suit multiple times a week for years and it doesn’t break down. So the thought of putting a mesh deep to our rectus injury is to take the tension off of the repair, I mean off of the tear to allow the tear to heal.
Speaker 1 (45:18):
I hope that’s helpful. So no, not brace or splints. More of a to take the tension off. Okay, I was going to answer a cool question. Let’s see. What sort of hernia would compress pelvic nerves and what would the symptoms be? So most hernias do not compress pelvic nerves. The only nerves that may be irritated – compression’s not a really good term for a typical angle. Her hernia, the most common nerves that may irritate are the ilio inguinal and the general femoral nerves because both of those either follow through or touch an indirect and sometimes a direct inguinal hernia, which is why many patients with indirect inguinal hernias have nerve type pain and are oftentimes misdiagnosed as having a nerve problem and go down that whole nerve block neurectomy route. It’s not, it’s your hernia and an ilio inguinal or genital femoral nerve pain, which is radiating pain around to your lower back into the inner thigh.
Speaker 1 (46:27):
The scrotum and labia is a common symptom with inguinal hernias. So that is an irritation, not really compression in a bad way, but more like it’s touching or irritating those nerves. A femoral hernia doesn’t impinge on any nerves. An obtuator hernia, which is very uncommon, often happens in elderly nursing home type constipated patients, but can occur in younger patients too. An obtuator hernia goes to the obtuator canal along with the obtuator nerve and vessels and can compress the obtuator nerve. And the symptoms are this kind of vague either painful burning or itching of the inner thigh closer to the knee and then the pudental nerve. This is very important because I think the person asked me this question is asking about pelvic nerves like the pudendal nerve. The pudendal nerve is not involved in anything related to her to groin hernias, inguinal femoral obtuator, no pelvic hernia that I do.
Speaker 1 (47:44):
Even the weird pelvic hernias compress the pudendal nerve, none of them. So if someone says, oh, you’re compressing your pudendal nerve or it’s pudendal neuralgia, it almost always isn’t. However, key point hernias of the pelvis can cause pelvic floor muscle spasm that can cause irritation or pain of anything else that goes through that pelvic muscle bladder. The bladder goes through the pelvic floor, rectum goes through the pelvic floor, vagina goes through the pelvic floor. So those can be irritated by the spasm. That’s secondary to the primary problem, which is the inguinal hernia. In which case you can have pain during sexual intercourse. That’s where the vagina is involved. You can have urinary frequency, your peeing 10 times a day. That’s where the bladder irritation occur from the pelvic floor spasm. From the inguinal hernia, you can have rectal spasm or this feeling of what’s called tenesmus where you have to feel like you have to poop but you don’t have anything to poop or rectal pain at the time of having a bowel movement that can be relayed to an undiagnosed inguinal hernia.
Speaker 1 (49:08):
With regard to the pal nerve, the pudendal nerve comes out from the sacrum and follows the pelvic muscles and wraps around until it gets the clitoris or the penis and so on. That nerve runs through the pelvic muscle. So if you have an undiagnosed inguinal hernia causing pelvic floor spasm, that will cause spasm and the nerves are running through those muscles. So the nerves are being irritated, not really compressed in a bad way, but more irritated. And you can have pudendal nerve type symptoms like clitoral pain, penile pain pain at the anal pain secondary to the spasm. And so fixing the hernia will relax a pelvic floor and then get rid of your pudendal nerve type pain. But don’t fall into the trap that you have a pudendal nerve problem because that’s very difficult to treat. There are very few surgeons in the US that really know how to do it correctly.
Speaker 1 (50:22):
And so you’ll get caught in this nerve blocks and nerve stimulators and even surgery on the pudendal nerve potentially by someone who’s not a specialist. And that is no joke. Do not mess with the pudendal nerve, let me tell you that. That can really mess you up. So a hernia does not compress a pudendal nerve, but it can cause pelvic floor spasm which will mimic pudental neuralgia, which is pudendal nerve pain. All right, I think that was pretty good. So I’m really sorry that for some reason I couldn’t livestream on Facebook this time and it just not even an option for me. So weird. And I tried my best to figure that out. So what I will do is wish you all a Happy Mother’s Day. I hope that many of you are going back to work soon. I know that I will be soon. I’m trying to slowly get into the patients in the office because they’re getting a little antsy and they want their hernias repaired.
Speaker 1 (51:34):
And as you know, most of my patients are chronic pain patients and it’s not fun to sit around and get no treatment for your chronic pain or hernia related patients. So May 18th is when I’m officially opening up my office. For those of you that are coming in to see me, looking forward to seeing you all. We’re going to have masks and we have gloves and sandy wipes and lots of space between patients and whatever we can do to have you be safe and also feel safe. And then, and our surgeries really won’t be our surgeries really won’t be to start until a little bit after that because the hospitals are still not fully open to elective surgery. So Happy Mother’s Day to you all. I will save this and let you know when it will be posted on YouTube. And thank you for participating and thank you Howard.
Speaker 1 (52:43):
I am in awe of your vast comprehensive knowledge in this field and your ability to present in a folksy fashion. Thank you. I think folksy is good. I could give a good medical lecture and sound really super scientific, but I think for this arena and for the benefit of my patients, I try and speak in terms that make sense. And as many of you know, I love analogies. So if any way I can give you a sense of explaining things in a way that makes sense to your everyday lives I do. In fact, I have a friend who’s also talks in analogies when the two of us talk. It’s crazy cause I love analogies, he loves analogies. And then all we do is do one analogy after another and it’s like it’s genius. Honestly. It’s the best thing ever. So thank you for appreciating that.
Speaker 1 (53:40):
Folksy is good for patients. I appreciate that. And our other person asking questions. Thank you for the time. I hope to continue this when we are not being quarantined but I do feel that all of you all with your positive feedback are really giving me the energy to do this every Sunday night. So thank you all and wishing you the best. And I will just say chow. And for those of you that are familiar, you already know my spiel, which is please do follow me on Twitter and Instagram. Most of my medical stuff is on Twitter. And then because I have a lot of doctor friends on that less so on Instagram and Facebook, which is mostly patient oriented. And I hope to kind of continue to add more content on my YouTube page. Oh, let me tell you one of our papers got accepted for publication coming in October that’s looking at the trends of how social media influences what we do as doctors and especially for hernia repairs. And we have two papers that I got accepted that will be presented in Cleveland at the Sages laparoscopic meeting this August. And Des, who sometimes is on here as my research fellow watching answer all these questions he’ll be presenting them and we’re looking at the value of YouTube as a teaching tool for a surgical technique and also another paper on, I think it’s on laparoscopic, like a robotic angle, hernia repairs without mesh. So thank you very much and I appreciate it. And goodbye. Thank you very much.
