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Speaker 1 (00:00:01):
Good evening everyone. I’m very excited. Today is Hernia Talk Tuesday. You’re joining me today. I am your guest and your host, Dr. Shirin Towfigh. Many of you know me as Hernia doc. You’re following me on Twitter and Instagram at Hernia Doc. Thank you for joining me live on Facebook at Dr. Towfigh. As always, I will make sure that this session will be posted on YouTube and I’m super excited because I think I hit a nerve. Today’s discussion is on Mesh removal options and I know we’ve discussed Mesh removal often during hernia talk live and on hernia talk.com. It’s a common discussion and we dance around it, but we’ve never had an actual session where that’s all we talk about. So I thought it was about time. I’ve seen a lot of discussions that with a lot of misinformation being spread around. Of course I have my own bent about mass removals, but I do a lot of it.
Speaker 1 (00:01:11):
I did several this week alone, some very complicated ones unfortunately, and I think we need to kind of delve into it. So thank you to everyone who sent all your questions in. I have about 15 questions that were sent in before and I’m sure that tons of you are out there trying to submit your questions live. I will make you my priority, but just know that I’m with you for the whole hour. We’ll be talking about all different types of Mesh removal options, robotics, open, laparoscopic, and so let’s get it done. Okay, so we’re going to start with the first question. There’s no order the order these and let’s just go ahead. What’s the most common cause for Mesh removal? We actually published a paper. We called it Why we Remove Mesh, and I went through and discussed every single reason why in my practice I remove Mesh and it’s often for pain.
Speaker 1 (00:02:17):
It’s I do a lot of Inguinal hernia surgeries. So it’s often for pain patients that have abdominal wall or kind of ventral hernia repairs. Removal of Mesh is usually for infection and pain is not that much of an issue. It’s more infections, fistulas complications related to Mesh erosion into the intestine, whereas in the groin it’s almost always for pain. And what’s interesting then is we looked at the reasons why I’m removing Mesh over a span of years and we tracked it and there’s a small population of patients that’s slowly growing in my practice and that is patients that need Mesh removal because they’re reacting to the Mesh. So it’s an allergy to the Mesh or it’s invoked some type of Asia syndrome. We’ve had a whole discussion about Asia syndrome in the past. Asia stands for A S I A or Shoenfeld syndrome is another term.
Speaker 1 (00:03:18):
A S I A is autoimmune or autoinflammatory syndrome induced by adjuvants. It’s kind of complicated name, but basically many of you have heard of breast implant illness. This is kind of like a Mesh implant illness and we’re seeing more of it. And my practice percentage wise is percentage wide. They’re seeing more patients having a need for their Mesh to be removed because of their reaction to the Mesh. But most commonly for abdominal ventral it’s infection. For the groin, it’s pain. Every so often we’re removing Mesh because we’re actually going in there to fix a hernia recurrence and the Mesh is in the way and so we remove the old Mesh, clean everything up and then put a new Mesh. So those are the top reasons for Mesh removal. Next question has to do with the different options.
Speaker 1 (00:04:13):
The options are three laparoscopic, robotic or open. Actually I should say open, laparoscopic or robotic. And that is kind of how we think about it in terms of advances in technology over the years. So open Mesh surgery, sorry, open Mesh removal is almost always done for in patients that already had an open Mesh placement. So for the groin, if a Mesh was placed via open surgery, that’s a scar over the groin area, then removing it is the reverse of the same exact operation, so the same open scar for the ventral or abdominal wall hernias. If the Mesh is placed on top of the muscle or on top of the fascia, we usually do that in open fashion and that’s also usually removed by open fashion. The reverse is also true. So if you’ve had laparoscopic or robotic surgery and you had your Mesh put in laparoscopically or robotically in the groin, then that Mesh is behind the muscle and it makes no sense to go through the muscle to get behind the muscle.
Speaker 1 (00:05:29):
You might as well attack it again from behind. And so for inguinal hernias, which is a groin laparoscopic or robotic Mesh that was placed, it’s also removed laparoscopically or robotically. And I just want you guys to understand, I use the term laparoscopic and robotic interchangeably when I’m discussing the approach. There are two different types of ways of doing it, but fundamentally it’s the same thing. The skill set is different, the instruments are different, but it’s the same thing. It’s like saying SUV versus sports car. They’re both cars and you’re comparing it to a bicycle. So they’re both vehicles, they get to the same place, one’s more fun to drive and one’s maybe more practical and there’s different skill sets and driving SUV versus a sports car. So think of laparoscopic and robotic as two different instruments that do the same, ultimately do the same operation. So this is very important point because some of the other questions that were presented have to do with robotic surgery and the safety of it.
Speaker 1 (00:06:38):
And I just want to clarify that there are two instruments that basically do the same thing. There are reasons why we choose robotic or laparoscopic sometimes same way, sometimes we like to drive our sports car versus when you go to Costco you don’t take a sports car, you take your SUV. So there’s different reasons for choosing laparoscopic versus robotic surgery. Assuming your surgeon has skills in both, but they are fundamentally different than doing open surgery. So open surgery is a scar and you enter from the skin and then you go deeper, laparoscopic or robotic surgery, you start inside the belly and you work your way towards the skin. All right, we have some more questions. My Mesh was removed partially from bowels twice. I have chronic chest infections constantly still have it in me, so you should be having maybe Mesh infections if you have a Mesh infection, that Mesh needs to come out and if you have any erosion of Mesh that is co into bowel, usually we like to remove all of the Mesh because bacteria can kind of crawl down all the paths of the Mesh and cause kind of smaller low grade infections that will continue to make you sick and then we’ll become a bigger infection.
Speaker 1 (00:07:58):
So as much as possible we like to remove as much Mesh as possible in the face of infection for pain. You don’t have to remove all the Mesh, it has to do with the purpose of removing the Mesh. And if you’re allergic then you absolutely have to have all the Mesh removed, every single bit of it. Next question for transplant then it’s not a candidate for liver transplantation but has a recurrent hernia with Mesh.
Speaker 1 (00:08:29):
Is there a risk for just doing watchful waiting? The patient has non-cirrhotic portal hypertension, ascites and portal and mesenteric vein thrombosis. I’m having a hard time finding a surgeon who will do repair robotic or open. Okay, this is very, very, he’s kind of a intense question. Okay, so here’s the thing. If you have liver failure and you’re not so sick that you can need a liver transplant but you’re sick enough that no one’s offering you surgery, the reason for that is you have fluid in the abdomen, you’re bleeding risk because your platelets don’t work and so on. So you’re bleeding risk or Mesh infection risk and you are a hernia risk because of the abdominal pressure from the ascites and fluid in the abdomen. So if you are doing okay and you’re not super sick, usually we wait for you to undergo transplantation. If you’re not sick enough to go undergo a transplantation, then we like to do your surgery before you get sick. So there’s something called child scores, a, B and C or MELD scores and usually a MELD score under 15. We like to fix you before you get sick. MELD score over 15, you’re too sick to have surgery and you should have your transplant first.
Speaker 1 (00:10:01):
So if the, you’re having a hard time finding a surgeon who you repair, robotic or open, yeah, so robotic surgery is, or laparoscopic surgery can be dangerous in patients that are cirrhotic and have portal hypertension. And that is because your veins are blocked going through the vein through the liver and so there’s backup of veins, you have humongous veins, so if you go into the abdomen and you nick one of those veins, you’re going to bleed and potentially bleed to death. So we don’t usually like to do a laparoscopic or robotic surgery in patients that have portal vein thrombosis or portal hypertension or severe cirrhosis with portal hypertension. Open surgery is usually safer even though it’s a bigger operation. But also you need to find hernia surgeons that work with transplant surgeons. So do the transplant surgeons have a limited skill when it comes to hernia surgery and in my practice I tend to do all the complicated hernias for our transplant teams because I have the hernia skills and I’m trained enough from my past residency experience to know what it’s like to treat a transplant patient.
Speaker 1 (00:11:15):
But the typical liver transplant surgery will not do a like complicated hernia repair and the typical hernia surgeon will not do an operation on a complicated liver surgeon. So you need to find a center like our center where the hernia surgeon and the transplant teams work together. Okay, nice question regarding the Mesh infection with the bowel erosion, they said they picked out what they could, okay, what they could is not enough. If you’re having recurrent Mesh infections, you can’t just cherry pick little pieces of Mesh and then hope for the best because that’s operation. You have to go in there and do it all. So what they could is not enough, at least not in my hands. You got to work extra hard and get out all those little extra pieces of infected Mesh, otherwise you’ll never get healthier. You’ll always be sick, you’ll have chronic pain and chronic fatigue, which is a big problem.
Speaker 1 (00:12:17):
Next question. I had open surgery for left inguinal hernia with a plug and Mesh so it’s, it’s usually called a plugin patch repair that’s open surgery for inguinal hernia. It was removed and replaced by another surgeon five months later because I was in so much pain that was open surgery also. So yes, that’s seems to be a good choice. So you had open surgery, you had problems with it. They went back in and did another open surgery. Remove the old Mesh. Now I have two hernias, a super pubic and an inguinal the same sort of now says he does robotic surgery. He says if he sees the Mesh from my previous left Inguinal hernia, he will remove it. So far I have refused. Okay, I’m confused where the suprapubic hernia came from. If you had an Inguinal hernia that is different than a suprapubic hernia.
Speaker 1 (00:13:10):
So did you have surgery cause that caused the super pubic hernia, where did that come from? People don’t normally get suprapubic hernias unless there was surgery done in the area. And then the next question is the same surgeon now says he does robotic surgery and he says if he sees a Mesh from my previous left ankle hernia, he’ll remove it. But I thought the previous Mesh was removed so I’m a little bit confused about that. Maybe if you could answer that, I’m happy to answer that question. Moving right along. Okay. I heard you can see and feel more with open surgery. Is that true? Okay, I hear this all the time. I have patients that underwent open Mesh removal that should have in my hands undergone a less invasive laparoscopic or robotic Mesh removal and their surgeon told them, oh you don’t want laparoscopy or robotics, I can use my hand and put it in there and I can feel everything.
Speaker 1 (00:14:21):
That is completely not true. So the fact that you can physically feel with your hand doesn’t mean that that’s an indication of doing anything open. Otherwise we would never do laparoscopic or robotic surgery. You actually see more and have better visualization with laparoscopy and even better visualization and see the same with robotic surgery. So anyone that’s telling you that open better because I can go in there and touch it. When you know that the recommendation is laparoscopic or robotic, I’m sorry, it usually means the surgeon doesn’t do laparoscopic or robotic. So if you’re told that, ask the surgeon, do you offer a laparoscopic or robotic Mesh removal surgery? If they say no because I feel open is better, then that really means no and the best is to go to a surgeon that can offer all three options, open, laparoscopic, robotic, and then have that certain state.
Speaker 1 (00:15:26):
In my experience I can do all three, but in your situation you’re better having it open or laparoscopic or robotic. So that’s my take on it. So no, it is not true that you can see and feel more with open surgery. It’s just not true and I feel a lot of patients have been given misinformation or had the wrong operation and cause more like a bigger scar, more surgery, more nerve injury because they did an open surgery when they could have had something better. Okay, question, what is the best Mesh for an open umbilical hernia pair with diastasis? Two different docs recommended the Gore N form Mesh or the synthetic Mesh. So synthetic Mesh is always better than N form or any other biologic or absorbable Mesh. So I do recommend synthetic Mesh, especially if you have a diastasis because you need that permanent situation to address your hernia repair.
Speaker 1 (00:16:36):
There’s really no indication for biologic Mesh at all. Hello, great information. Thank you. Thank you. Okay, going back to another question. I had one foot of my colon removed many years ago. My angle hernia Mesh was removed but then replaced. I’ve been in horrible pain for six years now I have two hernias. Okay, so this is going back to the original question, which was a patient that had a plug-in patch as Anglo hernia, it was removed and replaced with another Mesh and now she has a hernia from that surgery and a hernia from a prior colon surgery. Okay, so those usually I would do a laparoscopic or robotic approach to that incisional hernia pair. I think most medium, sorry, medium size, just kind of somewhat large size hernias are done best with laparoscopic or robotic approach and super pubic is definitely better done laparoscopic or robotic.
Speaker 1 (00:17:47):
What are your thoughts on Mesh with dissolvable sutures? Depends on the Mesh and the type of hernia. I’m generally not a fan of using absorbable sutures in non-absorbable Mesh. It doesn’t make sense to me. There are studies that support that by showing that there’s a higher recurrence rate, so if you’re going to have absorbable, sorry, synthetic Mesh, that’s not absorbable, the suture should match the Mesh. That’s just my thought. There’s other surgeons that don’t do it that way and we just don’t know enough but that’s pretty good. My doctor said he would do a combination of both open and laparoscopic Mesh removal. Another doctor was shocked that an open option was offered. What is your opinion? So usually we don’t offer a combination of open and laparoscopic Mesh because usually you can do one or the other. Of course there are exceptions so it’d have to determine what the problem is. But if you can do it all with laparoscopic or robotic and forego the open, usually that’s a better option because it’s less invasive because it’s, it’s smaller scars and usually less hernias from your scars, less nerve damage and less surgical site infection rates.
Speaker 1 (00:19:20):
All right, one more question over the muscle or under for a ventral hernia or with diastasis, is it worth to try to go any way to know ahead of time if you will have a reaction? So those are three questions over or under. So under the muscle, sorry. Mesh placement under the muscle is almost always better than Mesh placement on top of the muscle for many reasons. The Mesh effectuates much less that ER erosion rate is about the same and the recurrence rate’s usually much lower is a word to try and go without Mesh depends on the size of your hernia. If it’s a less than one centimeter umbilical hernia with a diastasis or two centimeter hernia with a diocese and that’s going to be repaired, you can opt assuming you don’t have other risk factors like obesity and smoking and recurrent hernias. Otherwise no Mesh is the way to go for that.
Speaker 1 (00:20:26):
And then any way to know ahead of time if you’ll have a Mesh reaction, man, I wish I knew. No, we are dabbling and using allergy testing. Skin allergy testing to date our data is not good. About 40% of the patients that are going to go Mesh allergy testing don’t show an allergy and yet they still have the allergy or the reaction. So it’s not a perfect study and we don’t have any good way to know ahead of time if you’ll have a reaction. Now if you do a skin allergy testing, which is not cheap by the way, if you do skin allergy testing and it shows you have an allergy, well then that’s a way to know a hundred percent. But if it doesn’t show you have an allergy, oftentimes that’s also incorrect. So we don’t really know. Can groin pain, hip pain and buttock pain on the right side be related to a hernia? Groin pain can be related to an Inguinal hernia. Hip pain can be related to anal hernia. Buttock pain is not related to anal hernia.
Speaker 1 (00:21:32):
How’s that for answers? Okay, going back to our lovely lady with the Mesh erosion to her intestines and then chronic Mesh infections which I’ve sounds like are because her Mesh has not been completely removed. The first Mesh was stuck to my bowels. Second surgeon picked off my bowel keyhole, which is laparoscopic and then stuck more Mesh in. It was prior text Mesh and it failed straight away but all he could say was, oh insight inside I was over ambitious to do in this laparoscopically. Two years later they did laparotomy in which they found out was nearly dead because the bowels were so damaged. That’s when he told me he picked out what he could and didn’t put any more in. Also he then told me that I didn’t have a hernia, just saggy parable Nyhus from, it’s now 17 centimeters wide and full bowels are through into my abdominal wall.
Speaker 1 (00:22:31):
So you have what’s called a loss of domain where you have very little abdominal wall and most of your bowels are outside of your abdomen. That is a very complex situation. Number one needs to be addressed in multiple stages. Number one, all number two, all of that Mesh that’s infected must come out first you must be cleaned out. Number three, there’s a stage procedure where we do Botox and abdominal kind of stretching in order to be able to get to close you and you definitely are not a candidate for anything laparoscopic or robotic. I hope that helps you.
Speaker 1 (00:23:07):
Okay. Does absence of Mesh reaction and Asia syndrome from a previous Mesh repair predict being non-responsive for a Mesh repair? For recurrence? No. That said it’s not a hundred percent. So it’s in some patients they do find with a little bit of Mesh but they get a systemic reaction with a lot of Mesh. So I had a patient, he had an umbilical hernia, not too big, they put a small Mesh in that was too small, it recurred. So he had a second operation, they put a little bit larger Mesh in, also not enough Mesh to address his has two mes in him that recurred and then the third surgeon would ended an actual real hot hernia repair, used an appropriate size Mesh which is much larger and then all help recluse and he started reacting with rashes and joint pain and brain fog and chronic fatigue and so on.
Speaker 1 (00:24:03):
So he has been sensitized through this process. So he was exposed to the product and first one, second one and then when more product got exposed to him and he had a higher volume of synthetic in him, then he reacted to it. So that’s kind of how it is. Next, three surgeries and three groin surgeries and a left groin testicle removed. I’m still miserable. I’ve been diagnosed with abdominal nerve entrapment. Have you ever run into this? I’m being scheduled for ultrasound guided nerve injection. Okay, so acnes A C N E S stands for abdominal cutaneous nerve entrapment syndrome. It is not in the groin currently on the abdominal wall, usually just below the belly button to the left or right of it, about one and a half hands breaths to the laughter right of it along the rectus muscles ultrasound guide and nerve injection is the treatment of it initially if you get good response just get keep getting those nerve blocks. Actually, I published on this, I’m probably one of the few surgeons that I’ve actually published on it. I have a lot of experience with it. With subsequent nerve locks, about 50% of patients will get a cure. The other 50% will need surgical neurectomy for that. I just did one this past week on a patient with a very similar story. You got to be patient but most patients do well when we don’t know why people get nerve entrapment. Totally weird. Okay, next question.
Speaker 1 (00:25:54):
I’m running through these fast guys because every time I come on you send me a lot of questions so I try to answer as much as possible. Is laparoscopic safer than robotic surgery? I don’t want to Robot operating on me. Excellent question. First of all, laparoscopic surgery and robotic surgery are pretty much the same operation in terms of safety as far as we know. Now there’s the skill of the surgeon. So one surgeon may be more skilled with laparoscopic surgery and one more skill than robotic. The main difference between laparoscopic and robotic surgeries are following with laparoscopic you have straight instruments, so we call ’em chopsticks. With robotic surgery it’s much more advanced and so instead of straight instruments, we have instruments that have a wrist so it’s straight and then there’s a wrist at the end. So it tends to mimic open surgery more than with the laparoscopic surgery, which is like chopsticks. That’s one main difference where robotic is superior to laparoscopic in my view. The other difference is, let’s go back, the other difference is robotic surgery has larger scars, so it’s eight millimeters and above, whereas laparoscopic you can do five millimeters and above and aesthetically you can put hide your laparoscopic scars better. So a lot of times I prefer laparoscopy because I like the scars aesthetically better, they’re smaller and I can hide them. Whereas robotics, you can’t cheat and hide it in certain places.
Speaker 1 (00:27:47):
And then the third thing difference is with robotic surgery you don’t have haptic feedback. So if I touch a bowel or do this, see how you don’t see my hand, if I also can’t feel where I’m touching, I may be touching bowel or causing an injury. Whereas usually with laparoscopy it’s like using a utensil so you have feedback. It’s like when you touch your food you can kind of feel that your food through your fork or your knife, whereas it’s kind of weird not feeling it if your fingers were numb. So that’s one of the drawbacks of robotic surgery. Now the skilled surgeon has learned that you can’t feel with the robot but you can see tissue distortion. But in the early stages there were issues with the robot because the surgeons were early in their career, the robot was just introduced and there were a lot of injuries recorded and that was because they treated robotic surgery exactly like laparoscopic surgery and it’s not exactly like it.
Speaker 1 (00:28:58):
And so they didn’t understand that they were pushing on the abdominal wall like that and they weren’t feeling how hard they were pushing for example because there’s no haptic feedback whereas, and they hadn’t learned yet the visual feedback that you’re really distorting the of don wall or even bowel. So based on, so those are the three main differences. What is not happening is the robot is not operating on you, the surgeon is operating, the surgeon is telling is moving the instruments, it’s just the surgeon is sitting at a console separate about several feet from the actual robotic the patient. And so don’t think that a robot is doing anything or that the robot has the mind of its own or that it’s programmed to do anything. In both cases the surgeon is doing the operation. All right, next question. I have chronic pain, nerve pain, chronic inflammation and autoimmune diseases diagnosed after open polypropylene Mesh for a large incisional hernia and bilateral anal hernias after breast reconstruction with a deep lap for abdominal for breast cancer instruction.
Speaker 1 (00:30:22):
If Mesh is able to be explanted, what sutures would you use to do a tissue only repair? Can a patient with severe abdominal wall weakness after diep flap likely due to nerve injury be a good candidate for explanting a tissue only repair? Okay, that’s very tricky. So sorry, let’s share this. So a diep flap, it’s spelled D I E P and it stands for some type of reconstruction where they take your skin and fat and make breast tissue out of it. If you injure the nerves to that muscle you can get a hernia or kind of bulging. And some people, all some plastic surgeons who do this operation always put Mesh in patients. Yes, the Mesh can be removed. In fact, I have a patient right now that we’re discussing Mesh removal for and usually we would use permanent suture. I would allergy test you just to get more information about your reaction to the sutures potentially and the Mesh. And then there’s multiple different types of synthetic sutures.
Speaker 1 (00:31:31):
There’s nylon based, polyester based and polypropylene based as well as E P T F E based and most hospitals carry every single option. Usually the E P T F E and the nylon based sutures react less than the polypropylene, and polyester suture, but it depends on your surgeon. You could choose to do absorbable sutures. There’s something called PDS or maxon and those sutures absorb somewhere between three months and eight months. That’s usually not enough for most people that have incisional hernias, recurrent hernias or muscle denervation. And so I would not recommend it. Next question. I had bilateral inguinal hernias in 2008 with Mesh. In 2014 I had left abdominal pain trapping a pudendal nerve into the groin. 2018 I had left Mesh removed with the disolvable Mesh put in.
Speaker 1 (00:32:39):
I still had nerve pain, the left abdomen into the groin, left leg and back pain. Numerous nerve blocks did not resolve the pain that hovers. Okay, so pudendal nerve should not be involved in any more her inguinal hernia repair. So if someone’s labeling you as pudendal Neuralgia either don’t understand predental nerve anatomy or they don’t understand your inguinal hernia problem, you can get pelvic floor spasm from an inguinal hernia problem. The pelvic floor spasm can induce pudendal nerve pain, but it’s not true pudendal Neuralgia where the nerve is a problem and you should not touch that nerve. That’s an angry nerve. And we had a whole session on pudendal Neuralgia with Dr. Michael Hibner last year. So look that up. We had a lot of good discussion about it. You need to figure out what nerve we’re talking about. It’s not your pudendal nerve. Most likely it’s ilio or hypogastric nerve or maybe you have a hernia recurrent recurrence or you just have pelvic floor spasm for another reason that should be addressed first before you get sidetracked away from the groin into the pelvis, which is the pal nerve issue.
Speaker 1 (00:33:56):
Okay, one year ago I had a CT scan showed a suprapubic hernia and a right inguinal hernia. I just had a CT scan last week and now they said I have an infra umbilical hernia as well and a right inguinal hernia. Are they the same kind of hernia? So infra umbilical hernia is probably from a laparoscopic trocar site or so. It’s an incisional hernia from a laparoscopic or robotic incision that’s different from an AL hernia is different from a super pubic hernia which is closer to your pubic lung. Okay, next question. Is robotic surgery safe? I read that it is not FDA approved from meshable. Okay, can I please? I really need your attention here because I’ve read so much on Twitter, Facebook and other social medias and posts. Robotic surgery is a medical device it’s called right now the United States, the main one we use, it’s called the Da Vinci.
Speaker 1 (00:35:03):
It’s made by Intuitive Surgical. There are other robots that are not yet approved for the United States, but maybe in a couple years they may be. There are some that are being used in Europe that are not approved for use in the us. In order to get approval for a device, you need to get FDA approval. The FDA approves are for certain operations, for example urology. So now all the prostates like 90, I think 97% of prostate surgery is done robotically. In fact, surgeons don’t even know how to do it laparoscopically anymore. It’s really complicated and the robot has been so much safer and easier with much less blood loss than and much less nerve damage than laparoscopic or even open surgery. So the FD has approved the robot for general surgery. General surgery includes gallbladder surgery, it could include intestinal surgery. It’s approved for colorectal surgery and it includes hernia surgery.
Speaker 1 (00:36:04):
Hernia surgery by definition includes Mesh. So yes, the robot is approved to touch the Mesh to cut out the Mesh, to put in the Mesh, so in the Mesh to take out the Mesh. So yes, it is approved for all of that to claim that it’s not is completely not correct, number one. Number two, I’ve read a lot of misinformation about how the robot can melt the plastic of the Mesh. Completely not true. So first of all, you have to look up melting point of Mesh, understand that you’re working inside the abdomen. So if you have a thousand Fahrenheit torch going on inside the belly, then your intestines and your muscles will also burn at a much, much worse rate. So please do not buy into this concept that you’re melting plastic and not injuring nearby organs. That makes no sense. And also know when we do open surgery, laparoscopic surgery or robotic surgery, we use heat that prevents bleeding.
Speaker 1 (00:37:19):
It’s called cautery or electrocautery or bovie cautery and you burn things. We don’t always use it, but whether you use it with a open surgery, laparoscopic surgery or robotic surgery, it’s still electrocautery. It’s the same technology and it’s the same, even sticking in the same hole to the same machine to get the energy out of it. So to claim that somehow removing Mesh with a robot is unsafe and therefore should be done laparoscopically. There’s no data to support that. If anything, many of us, including myself, have presented and are publishing our data comparing laparoscopic versus open versus robotic Mesh removal, understanding that there’s different indications for each of those. In doing so, at least in my data, we have shown that the blood loss tends to be significantly lower and the vessel injury lower with robotic surgery than laparoscopically. Mostly because the visualization is more microscopic and the instruments are finer with the, but overall the outcomes in terms of how well the patients do and recurrences and pain after surgery are exactly the same. So I kind of went on a rant there, but it just really bothers me when people talk amongst themselves and they somebody puts out an idea and then five other people say, yeah, that’s right. And then that false information gets spread everywhere to the point where it’s completely loses its validity. So that’s my take on that and I hope that’s that’s helpful.
Speaker 1 (00:39:25):
Okay, if a patient is having constipate and a CAT scan detects there is medial buckling of the Mesh, is this enough to consider me removal? No, it is not. Most patients will have some buckling or some folding of the Mesh. It’s not always perfectly done. The reason for the pain needs to be identified. Is it a hernia recurrence? Is it what kind of pain? Is it a testicular pain or is it activity related? Is there Mesh fat entrapped or is it exactly where the Mesh has been buckled? But I’m glad you’re getting imaging because that does help in evaluating the need and the direction to move forward with Mesh removal. One size umbilical hernia is too large for diastasis recti repair to help effectively without Mesh. We don’t know. In my practice I’ve done up to three centimeters and the patients have done really well. So basically you have a three centimeter wide umbilical hernia within a diastasis and they get a tummy tuck or a diastasis closure and include the hernia repair as part of it. So you don’t use Mesh, you kind of use your own abdominal wall muscle as the Mesh or the buttress. And I’ve done it up to three. I haven’t pushed it to four. That’s kind of seems to be too wide.
Speaker 1 (00:40:47):
All right, next question. These are all from Facebook. What? I love it. Okay, next. I had an incisional hernia diastasis recti due to an exploratory laparotomy. Just to clarify, surgery does not cause diastasis. Diastasis is a naturally occurring problem. If you have a diastasis after surgery, that’s a hernia. I’ve been dealing with the stupid mental clarity immediately after surgery. It’s now going on 10 months and while it’s gotten better mentally, I still feel off. I had my Mesh planted laparoscopically and I’m looking at removing it with plication of the abdominal wall. What are the chances it’s going to hold? And also there’s will there be a lot of pain. Also can one test cytokines to see if you have a reaction. One last thing. I was taking antidepressants before surgery announcing that they make my mental clarity worse. Now, does Mesh affect serotonin? We don’t know much about the effects of Mesh on serotonin.
Speaker 1 (00:41:49):
The indications from Mesh removal are very clear. And also your risk factors for removing it and redoing the repair need to be very clear. Every time you do an extra operation, there’s risk with that operation as well as undoing the old operation. So even though we’re talking about Mesh removal all day, all hour, understand that I don’t take it lightly. I don’t offer it to everyone. There’s plenty of patients that come in and want their Mesh removed and I don’t offer it because I think it’s the wrong decision and there’s just way too much risk with the operation compared to the benefits. So in doing so, we have to know what are your risk factors? Are you morbidly obese? You are you a smoker of nicotine? Those are risk factors for bad outcome. And that said, if you do have a Mesh reaction and you need your Mesh removed, a good tissue repair usually done open can help you, but there’s some skilled surgeons that can do those robotically.
Speaker 1 (00:42:54):
Also, one set of my match is always slightly inflamed in one area with really no pain. Is that possible? Inflammation implies pain, so I don’t understand how you can have inflammation of a Mesh but no pain. Maybe you meet bulging. So bulging is not inflammation and maybe a mechanical bulging regard is perhaps one of the most conflicts cases in Australia with over 10. Okay, with bilateral angular hernias repaired over 10 times the left groin is problematic. Okay, first of all, I would love to see what your medical records look like because I need to, I do like forensic opera report analysis, trying to understand why it is that you’ve had 10 operations for the same problem. I had a Mesh plug migrate out of the femoral canal, so we should not be putting Mesh plugs in the femoral canal.
Speaker 1 (00:44:03):
I’ve had three new hernias in the left groin and the surgeons won’t touch me until it becomes life-threatening. I have C R P S, which is complex regional pain syndrome, which is a horrible diagnosis, a very painful, usually self-limited. After three years I have a dorsal root stimulation implant and I’m on pain medication. So that’s a very complicated situation. There is a possibility that the abdominal wall may have bulged any chance of looking at my case for advice I’ve had open laparoscopic, absolutely. I would love to see you just call my office. I want to figure this out. This is like, I don’t know if you guys figure it out, but I like to solve problems ever since I was a kid, I like to solve puzzles. So yeah, call my office. I’d love to figure this out for you. Is prolene hernia system considered a plugin patch?
Speaker 1 (00:44:56):
No. The plugin patch, there’s multiple companies that make it. The main one is by bard dayal or bd. The prolene hernia system is a two layer sandwich type Mesh with a connector in between that’s made by Ethicon. How do you diagnose a Mesh infection? What if there’s no fever or laboratory markers of Mesh, then you don’t have a Mesh infection. In some patients you can get an MRI, which will show the inflammation because ultrasound C2 will not. And in some patients there may be what’s called a chronic low grade infection, but you should still have pain associated with it.
Speaker 1 (00:45:40):
Yeah, please do send me your detailed medical summary report and contact my office to initiate a consultation. All the information is on all my social media, so you should have no problems finding that information. What are the factors that make Mesh removals such a difficult surgery that only highly specialized surgeries can perform? Excellent question. Okay, this is very important. Number one, revisional surgery, regardless of what it is, bra surgery, cancer surgery, orthopedic surgery, revisional surgery is always more complicated than the main operation. So don’t get unhappy when your surgeon says, oh, I can’t remove that Mesh. It’s because that’s now a revisional operation. Doesn’t mean the Mesh can’t be removed or your hernia can’t be redone. It’s just more complicated. And so your surgeon may not have the skill set. First of all, the anatomy is distorted. The anatomy is completely distorted, and so you really need to know your anatomy really well.
Speaker 1 (00:46:50):
I know my angle anatomy like the back of my hand and I actually don’t know the back of my hand as well. I know my ankle now be even better because it’s like second. It’s become second area where it’s all distorted because the Mesh is folded in the things that like the cord has been moved around from adhesions, I know where I am and therefore I’m less likely to injure your bladder, injure your nerves, injure your spermatic cord, injure your extra iliac artery and vein, injure your epigastric vessels or injure your bowels. Those all risks with meshoma in the groin. I haven’t even talked about meshoma in other areas like in the abdominal wall or the flank where you could injure nerves, spleen, colon, intestines. There’s a lot of risks with doing revisional surgery for whatever reason. And when you remove Mesh, you’re potentially removing Mesh off some of these critical structures like intestine and bladder and vessels and nerves. So yes, you need a surgeon that A does it for a living or predominantly does it for a living. B enjoys doing it and C knows our anatomy really well, really, really well. And you want a very delicate surgeon. You don’t want a heavy handed surgeon because you’re already causing so much tissue trauma. You don’t want the surgeon to also be heavy handed in adding extra inflammation injury to that area.
Speaker 1 (00:48:32):
We live in Minnesota in the summer and Arizona in the winter. That sounds lovely. I would love to be able to come to you for my exam of my hernias because every CT scan I’ve ever had has never showed my Mesh. Yeah, CT scans don’t show Mesh. Unless you have a really heavyweight Mesh. It’s really a hard to see Mesh on CT scan. That’s why I don’t order it. I get MRI what test shows the Mesh? MRI. I’ve been in horrible pain for six years and now I have new hernias plus a big lump where my left hernia surgery was. Happy to see you. Just call my office. You can go to my website. We have a contact us form or just call them directly or email us info beverly hills hernia center.com. If you can spell that, you can get, send us an email.
Speaker 1 (00:49:25):
I’m curious, do you believe that human trials should be done with Mesh implants before being flooded into the global market instead of manufacturers taking advantage of the 510(k) approval loophole? In my research, I’ve learned that when the FDA orders manufacturers to undergo clinical trials and manufacturers are withdrawing their products and introducing another in place through the 510(k) process, in my opinion, that is why there is so many people having problems and wanting removal. Do you believe this to be contributing to increase in injuries? That’s a great question. Currently, inguinal hernia, sorry, hernia Mesh in general currently in the United States is FDA approved at the level of a low-risk medical device is not considered a high-risk medical device. If it were a high-risk medical device in clinical trials and or post-operative surveillance, post-marketing surveillance must be done. All of that adds a tremendous amount of cost.
Speaker 1 (00:50:31):
Mesh is already super expensive. You may know that the pelvic Mesh, which is different than the hernia Mesh, but the pelvic Mesh has been recategorized by the FDA as a high risk medical device. And therefore any company that sells it must undergo, must have its Mesh to undergo either clinical trials or a post-marketing surveillance. Also very, very expensive. And you may have also noticed they don’t really sell a pelvic Mesh anymore. Most companies have withdrawn that from their platform in Europe, in the eu, the European Commission has ordered all hernia meshes to be recategorized as high risk medical device and in doing so, or higher class in class to cost three, something like that. In doing so, any me, any company that can show human trials can sell their Mesh. But if you’ve been selling your Mesh forever but there’s no human trials showing its safety and efficacy in a prospective randomized observed way, then you can no longer sell your Mesh.
Speaker 1 (00:51:43):
So it’s become an issue in the European Union. I completely agree that products should not fall through the five 10 [inaudible] loophole and they should be studied. Absolutely should be studied and I don’t feel right just testing it on patients, see how they do. And I’m hoping that that does change. I actually publish an article somewhat addressing, this is called, it really initially looks at like the social media, a discussion around use of Mesh and how it has affected the FDA’s approval process. And I think that, well, I predicted that by 20 22, 20 20 23, actually by next year I approve that they predicted that the FDA will start actively looking at changing the classification to a higher risk medical device and changing the way we handle it. That said, hernia Mesh will be much, much more expensive than it currently is and I don’t know how that’s going to work, but human safety comes first.
Speaker 1 (00:53:00):
What does Mesh look like on MRI and can you describe or show a picture? Sure. Actually if you go on my Instagram or FA or Facebook, I have shown pictures of what Mesh looks like on MRI versus CAT scan. So it’s usually a black line, whereas everything else is gray or white. Whereas on a CT scan everything is gray so you can’t tell what it looks like. How do you avoid revitalization or devascularizing structures if extensive dissection is required during groin surgery, including Mesh removal? Haha. Well that’s the surgical technique. It’s like saying how do you do surgery? It’s purely a surgical technique. Very careful. You don’t grab certain critical structures. You get really good visualization, use the right instruments and it’s purely a surgical technique.
Speaker 1 (00:53:58):
Let’s see. Do you think Mesh eventually be a thing in the past due to systemic problems, migration, etc. What do you think would replace Mesh 50 years from now? We for sure need something tissue based patient’s. Tissue based repair alone does not work. And using your own tissue is very deformity and doesn’t work either because you got a hernia because your own tissue isn’t normal anyway. So why would you use your own tissue that’s abnormal and weak to repair it? So yes, Mesh is here to stay, but I use the word Mesh very broadly right now We have hybrid Mesh, which I think is the next best solution in general. I think in the future there’ll be more advances in stem cell technology and 3D printing and using tissue tissues to kind of grow your own Mesh. It’s so expensive right now. There’s no way that any company would allow like a $10,000 piece of Mesh for your groin hernia. But as advances occur and we get better at developing less inflammatory, Mesh is with less total synthetic in the patient. I think that’s where you can kind of benefit in the future. Definitely in the next 10 years, maybe 50 years. Which MRI sequences are best for cmh? Actually all the sequences show it. Usually T1 is better.
Speaker 1 (00:55:37):
Okay. Can you see MRI if done without contrast? Absolutely. MRI is done without contrast. The only reason to do MRIs for cancers in the brain. So for pelvis and hernia Mesh, it is a non-contrast MRI In Australia hernia Mesh is classed as a high risk implantable device. Very interesting. I wonder if that’s a new thing or it’s always been like that. And I will read more about Australian. Isn’t Mesh FDA cleared via five 10 [inaudible] loophole process not FDA approved. Johnson Johnson told me their ethibond prolene Mesh for pelvic implant hernia implant is the same. Polypropylene Mesh just sign location of implant is the same j j admitted in their Australian lawsuit that their ethibond pro Mesh does cause chronic inflammation response and which patients are impacted significantly from chronic inflammation isn’t able to be determined before Mesh implanted. Do you agree with this? So the way the five 10 [inaudible] has worked is that they are showing the substance to be the same or similar, but we know that where it’s implanted and how it’s implanted are definitely different. So putting Mesh against bowel, we don’t do that anymore. We used to do that in fact, before I was in training that was standard and then they cut all these bowel injuries, not a hundred percent, but quite a bit and erosions. So then they decide let’s put a, let’s not put Mesh against bowel. Then someone decide let’s put Mesh against the vagina or the urethra. Again, they just didn’t know or maybe weren’t aware that there would be these complications. So there’s a long history there.
Speaker 1 (00:57:27):
Okay, time flies people, oh you know, let’s do this. Can I take the last three minutes to just explain how lovely you guys are? So today I got a FedEx I’m going to show you,
Speaker 1 (00:57:43):
I got a FedEx today addressed to Dr. Shirin Towfigh by somebody in New York that I didn’t know. And we get a lot of FedEx as often patients that are looking for a consultation. So they just send us all their information and we don’t really actually know them yet cause they haven’t called to make an appointment. So I opened the FedEx and in it I got an envelope, Dr. Shirin, thank you. I said, okay, what are we getting thanked for? I don’t know who this person is. So I got a thank you note. I just want to share this with you. It’s not a patient. I got a beautiful thank you note, very fancy. And all it says is, thank you so very much letter and gift card. Enclosed, here’s the letter. So it came with this lovely letter. It’s a fancy, fancy stationary, long letter and it starts, hi Dr. Towfigh. We haven’t officially met, but we are a couple of New Yorkers with deep ties to Los Angeles that wanted to take a moment to extend a different type, to extend a different type of thank you. It’s just this lovely, lovely letter by people who I’ve never met before and I don’t even think,
Speaker 1 (00:59:12):
Don’t, they’ve been on hernia talk, like asking questions or maybe they have, but I don’t recognize the name. And they wrote this lovely letter about how hernia talk has helped ’em and how they’ve been watching these sessions and it’s really been fantastic to help them get through their own medical situation with this very complex. I actually don’t know what the situation is and there’s a fancy new restaurant in downtown Los Angeles and they sent me a gift card to go to dinner and this is a restaurant that I actually have on my list to go to dinner to. One of my friends recommended it and it’s just, I just can’t thank you guys enough. This is so lovely. Told random thank you by complete stranger who I must have helped with these hernia talk sessions or whatever else I do to try and educate everyone. I just want to personally thank you. I will call you because you left your number to thank you in person. And I hope whatever medical situation you’re in that you get that fixed and I will end hernia talk with that very positive note and what a wonderful day that was for me. So thank you very much and hope you all have a great day. I will see you next week on Hernia Talk Tuesday. Thanks everyone and have a great rest of your night. Bye-bye.
