Episode 61: Why Hernias Fail | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

Alright, good evening everyone. Welcome to Hernia Talk Live. I’m really enjoying these q and as with you all. As you know, my name is Dr. Shirin Towfigh. I’m a hernia and laparoscopic surgery specialist. Many of you are joining me on my Facebook page at Dr. Towfigh as a Facebook Live. Thank you for those of you that are logged in through Zoom. You can also follow me on Twitter and Instagram at Hernia Doc at the end of this webinar session where I will answer all of your questions. I will make sure that this is linked to my YouTube channel so you can rewatch it and share it with your friends. So today I’m all yours for two reasons. One is our original guest had to have surgery. So yes, surgeons have surgery on themselves as well, number one. And number two, there’s been a lot of questions that have been gathering and I feel like sometimes we just need to have me just answer all the questions and not focus on a specific topic and keep it kind of wide.

Speaker 1 (00:01:08):

So today’s session, I thought I would focus on hernia recurrences or what I call failures. Failures kind of a difficult word. It sounds like very negative, but just know that all hernias are at risk for recurrence. A hundred percent of them are at risk for recurrence. What your specific recurrence rate depends on a lot of factors, but just know there’s no way that any surgeon can ever claim that their surgical technique or their operation has a 0% recurrence rate. That just doesn’t exist if you’re, the thing we say amongst surgeons is if you’re operating, you will have complications. If you’re operating for hernias, you will have recurrences if someone’s claiming they have no recurrences or no complications that they’re not operating. So it’s kind of reality in that when you commit to an operation or any procedure, there are risks. There are risks to me walking out the door today after this session, every action you do has a risk.

Speaker 1 (00:02:17):

Of course, there is balances. So the risk of me walking outside is somewhat low risk because today’s sunny and I’m wearing the right shoes and I’m in a safe neighborhood. But different situation, different time of year, different outfit that may or a different, maybe walking will be more not as safe. The same is true about hernias. So if you commit to a hernia operation, there will be a risk to that operation. Those are the risks that your surgeon will explain to you. And hernia recurrence is one of those risks and the type of hernia that is performed. The surgical technique, the decisions by the surgeon is partly contributing to that hernia, recurrence or failure. And your risk factors are also things that will contribute to your personal risk for hernia recurrence. So there’s a lot of things that can be quoted and told like as a population what can occur for a certain type of operation.

Speaker 1 (00:03:32):

But understand that if you really want more clear data, it depends on your surgeon, this vial technique and then your specific risk factors. I don’t know how many of you guys follow me on Twitter, but I just want to show this to you. I’ll share with you what I have here. So the, let’s see on Twitter, if you follow me, which I hope you do, I post a lot of things and most of my followers on Twitter are surgeons or other doctors. And so it tends to be more medical when I go to conference meetings, whether it’s a European Hernia Society, American Hernia Society, sages, American College of Surgeons, Pacific Coast Surgical Association of Western Surgical Association. I belong to all these different Southern California chapter of the American College College of Surgeons. I belong to all of these societies and I’ve earned my way through those and often they accept my research and publications.

Speaker 1 (00:04:38):

And so when I attend these meetings, I tend to live tweet. So if you want to follow me at hernia doc on Twitter, whenever I am at a meeting, I tend to live tweet things that I learn. And most of my followers are, like I said, are doctors, but I do have a fair number of patients that also follow. So I just want to show you what I retweeted today. This was a publication by a friend of mine and I really like this visual and I’m going to share it with you. So this is a paper, it’s published this month in the Journal Journal of the American College of Surgeons. We call it Jacs, j a c s, June of 2021 by Dipp Ramos et all. And they talked about risk factors for complication from hernias. So specifically they’re looking at incidents and risk factors for long-term Mesh explanation due to infection in over a hundred thousand hernia surgery patients.

Speaker 1 (00:05:43):

So this is a type of article or it’s a population study and they look at over a hundred thousand patients. Of course, every patient’s different and all the surgeons are also different, but specifically looking at the need to remove Mesh due to infection. And what are those risks? And I just want to share this with you because there are similar articles that have been published for hernia recurrences and risk factors of patients. So the risk factors for needing a Mesh removed due to infection number one is any emergency surgery. So if you need emergency surgery for bowel obstruction or strangulated hernia and Mesh is implanted during that operation, the risk of Mesh infection and requiring the Mesh to be removed is about 87% higher than the average patient. If you had a really long and complicated operation, that increases your risk of Mesh infection by about 83% and obesity will increase regardless of what type of hernia repair you have.

Speaker 1 (00:06:54):

Obesity will increase your risk of Mesh infection by 72%. So I see there’s a lot of posts by people suffering from the consequences of Mesh infection and they’re blaming the manufacturer. But really there’s a lot of things that go into why Mesh causes infection or Mesh gets infected, including obesity, emergency surgery, and a long operative time, which I believe is over four hours. And then lastly, and most importantly is if the surgery was done as open surgery and not laparoscopic or robotic, we had a long discussion about this yesterday, I’m sorry, last week. That’s about 257% higher risk than the average patient in having a Mesh infection. So what that means is laparoscopic and robotic surgery almost protects you from Mesh infection, whereas open surgery puts you at higher risk. Now, consider open surgery that’s really long in a patient that under that is morbidly obese and required emergency surgery.

Speaker 1 (00:08:05):

That’s just a setup for having a Mesh infection. The other thing they looked at is what type of hernias are at higher risk? And the rate among these a hundred thousand plus patients that underwent hernia surgery, the rate of Mesh infection was very low for inguinal hernia, 0.1%. It’s not zero, somewhat higher for umbilical hernia per umbilical hernias, 0.6% and then as high as 1.5% for any ventral or abdominal wall hernia. So let’s say you do an open ventral hernia repair, an obese patient and it’s a long operation or it’s emergency, all those risk factors will increase. And then lastly, they looked at what happens if you have wound complication? How does that affect the need for Mesh infection? And what it shows is the surgical site infection was associated with a higher rate of five year explanation. So even if you have a small wound infection, you have a 6.4% chance of a wound infection requiring Mesh removal because the Mesh got infected. And then the deeper you go into the space, the closer you get to the Mesh and the higher the risk of Mesh explanation. So I just want to share this with you. I put these things out on Twitter. I don’t really do it so much on my other social media on Instagram and Facebook because those tend to be more patient oriented. But if you are more interested to look at data and kind of the science and the discussions that I have with other surgeons about hernias, I think Twitter is a good one to follow.

Speaker 1 (00:09:55):

Okay, let’s move forward with a lot of these. Let’s see. I just want to say thanks for answering my question last week. That’s a one to one to us. My hubby is the one with a non-cirrhotic portal hypertension. We had a consult yesterday with one of your prior guest, Dr. Vedra Augenstein. Great. And she referred us to the liver transplant hepatologist at our center to discuss risks of surgery and liver considerations and potential decompensation. I’m so happy. So this was a patient who presented some questions last week about the risks of surgery and why can’t you do laparoscopic surgery and a patient with known liver problems. And I talked about the different levels of having liver diseases and how depending on the level of liver disease, you may or may not be eligible for certain types of hernia operations. And sometimes if you’re really sick, you should just have your liver transplant first and then move forward with the hernia repair.

Speaker 1 (00:10:57):

So I’m glad that hernia talk live and access to the specialist that I interview who I support and I think are great surgeons or great doctors in their field will help. Okay, I have someone who says, you did my surgery and I’m still in pain. You ignore me for years. I’m happy to see you if you just call my office. I don’t want you to be in pain. Whatever issues that are resulting in your pain from any surgery I did, please let me know. Like I said, everyone has complications. I have my own, I’ve had patients who have had recurrences, Mesh infections, chronic pain. It’s very much related to what you’re dealing with, what were the issues going in, but also afterwards what will happen in terms of recovery and risk factors and so on. So we have a lot of questions related to that that we can do. All right, yes, I do have one patient who came forward on Instagram and had a question about their match. I will answer that I have that prepared for you very much. Next question, I would love to work on a paper on how environmental factors and diet may impact Mesh reaction. Oh, that’s interesting.

Speaker 1 (00:12:26):

I have published many papers in environmental contaminants, in air, soil and water, but nothing in the human body. I would reach out to the large group of patients that are on Facebook or on Twitter that have already demonstrated signs that may be related to Mesh reactions and see if you can pitch your surgical discussion and surgical like a environmental research with them because I wish I could study them. Unfortunately, I have a feeling that there’s so much loss of trust in the doctors that it’s really hard for a doctor to get into that group so that they can get some light shut onto us to what the data is. But just like the article I just showed you, it’s so important to get that message out. This article is going to help doctors and thinking, oh, right now I’m operating on someone that has a higher risk than average of getting a Mesh infection and Mesh infections and meaning the Mesh to be removed is so complicated and horrible that you know have to prevent as much as you can.

Speaker 1 (00:13:49):

So if you already know you’re going to go into a situation where you have a higher risk of Mesh infection, then there may be ways that you can kind of change your technique. And on that note, let’s take a look at some more questions that were submitted. Well, first of all, how can I as the patient or what can I as a patient do to prevent my hernia from recurring? Really great question. So you can do a lot yourself. In fact, much of the recurrences are somewhat related to patient risk factors. So the top are nicotine use, obesity, chronic constipation, and chronic cough. So if you have any of those or a combination of those, those are for sure things that can be treated and therefore you can prevent a bad outcome from your hernia repair.

Speaker 1 (00:14:50):

Smoking, or using any type of nicotine affects how your collagen works and hernias are developed because the collagen is not strong, it’s not mature, it’s not laid right. So if you already have a hernia and you need a hernia repair and you’re a nicotine user, whether you’re smoking, vaping, patching, whatever it is, what’s going to happen is not only will the smoking prevent good oxygen to heal, but the nicotine itself prevents the collagen from being laid down in a pat pattern that’s strong. So you can stop nicotine if you’re morbidly obese, you need to get your weight down. We had a great session with Dr. Bittner who’s a not only hernia specialist, but a bariatric weight loss surgeon. And we reviewed the data on how obesity can contribute to hernia recurrence. You saw the numbers for Mesh infection alone. The numbers are even higher risk for hernia recurrence and so lose the weight.

Speaker 1 (00:15:54):

Honestly, if you need to enroll in a program, whether it’s Weight Watchers or some other program or get involved with a physician who will put you on a medically supervised diet, there are medications that can help you lose weight. There is surgery that will allow you to lose weight. There are a lot of options to allow you to lose weight, but losing the weight before surgery or even after surgery will have a big impact. And we do not like to operate electively on patients with a B M I or body mass index over 40 kilograms per meter squared. That is a huge red flag and so treat the obesity. Number three was the chronic constipation. Anything that increases abdominal pressure is considered a no-no for hernias. So you may be getting her your hernia worse by straining and adding the abdominal pressure. But let’s say you fix your hernia and now you’re straining because you got narcotics after surgery or anesthesia made you constipate or you just have chronic constipation and you’re constantly straining.

Speaker 1 (00:17:01):

That needs to be treated the same way you treat diabetes the same way you treat hypertension because the increase abdominal pressure from the straining will pop those sutures and just blow that all apart. And then fourth is chronic co cough. So coughing generates a lot of abdominal pressure. Many people got hernias after COVID because they were cough, cough, coughing from their COVID pandemic. I just spoke with one patient, actually two today that got hernias. One was in the hospital with a strangulated hernia after about of COVID. But the chronic cough, whether it’s a flu or a virus or acid reflux, whatever, asthma, whatever the reasons why you have a chronic cough that must be treated because you will have your hernia fail. And then for men, I’d like to add is please treat your enlarged prostate. An enlarged prostate prevents your bladder from easily emptying.

Speaker 1 (00:18:06):

And so what patients do do is they push, push, push to force that urine through the very narrow pathway through the prostate. And if you’re urinating five, six times a day, that’s the lot of pushing. You’re constantly putting your repair under tension and you’re going to pop those sutures or pop that Mesh. So again, the top five things you can do as a patient is stop nicotine use. Lose your weight, treat any constipation, treat a chronic cough or prevent a constipation or chronic cough. And for men is to get your enlarged prostate shrunken down with medication.

Speaker 1 (00:18:59):

Is it possible for T V T, which is basically transvaginal tape used for stress urinary incontinence to contribute to a lower abdominal incisional hernia? Yes and no. So the T V T does involve the Mesh from the transvaginal sling to go through the abdominal wall. Usually that hole does not cause a hernia removal of it can leave that hole behind and give you a hernia. Or if you had to have a revision of the T V T Mesh, then you can have the hernia. I just saw a doctor about my left Anglo hernia surgery with Mesh, but I still have horrible burning from it.

Speaker 1 (00:19:45):

Okay, well I hope you’re seeing the right doctor to help you. Are there any risk factors for umbilical cord hernias for people like me who are very skinny? So we do talk about umbilical hernias. That risk factor is the same as any other hernia risk factor, obesity, nicotine use, chronic cough, chronic chronic constipation, and enlarged prostate. If you’re super skinny, you are not at higher risk for hernia. In fact, you’re a lower risk for hernia. So that’s good. And exercise is a good thing because that will engage your abdominal muscles and support that hernia. Going back to this patient, she saw a doctor about her left Anglo hernia surgery with Mesh. Now he wants to do an injection in the nerve to see if it helps the pain. If it does, then he’ll send me elsewhere to get a nerve injection or surgery to help alleviate the pain. Great. That sounds like a good plan. All right, so we did have a question submitted, which was kind of interesting and it shares a lot of the anxiety that we get from hernia repairs with mush. So this patient sent this to me by Instagram. I thank you to those of you that send me crushes in advance.

Speaker 1 (00:21:15):

I had laparoscopic bilateral hernia repair with Mesh I believe earlier this month with Bard 3D Max Mesh. I’ve read terrifying accounts about this brand of Mesh MI ticking time bomb. So just so you understand, a laparoscopic Inguinal hernia repair with barred through the max Mesh is a perfectly good repair. It’s one of the more common types of repair. I wouldn’t call it gold standard because we don’t really have a gold standard for Inguinal hernias. Some consider open repair with Mesh the gold standard, but it isn’t the Bard 3d. Max Mesh is a very good Mesh and it’s commonly used. I use the 3D Max Mesh, it’s the right size and it’s the right shape and it fits nicely. And there are different types of it. What you’ve been reading is people that have claimed that the Bard 3D max in and of itself is causing their problem.

Speaker 1 (00:22:09):

And often what it is is it’s not the Mesh, but it was the surgical technique in placing the Mesh or the decision to use that specific Mesh versus another Mesh, which is given the problems and all meshes have a risk of complications, whether it’s folding recurrence, chronic pain, erosion, et cetera. And it’s not so much the, it’s not a hundred percent because of the Mesh. Oftentimes it’s from the surgical technique or the decision of which Mesh is used for which patient. So for example, I tend to err on the 3D max light for the thinner patients and women, but if you’re a big husky person or you have a recurrence, I would use a R 3D max. So the fact that you’re reading horror stories about a certain Mesh does not mean necessarily that it’s a bad Mesh. It just means it’s a very commonly used Mesh number one.

Speaker 1 (00:23:08):

And there are lawsuits against that company because it’s also the largest company that makes the Mesh. So from a legal standpoint, that’s a big company to go after. And so the law firms are really focusing on the larger companies and not the smaller companies to father lawsuits. So if you’re a big company, rich company and you have the number one selling Mesh, well you’re going to have a lot more lawsuits fall against you. Plus it’s the most common Mesh for laparoscopic pretty much. So no, I don’t believe you’re ticking time bomb. Most of the top surgeons in the US use this Mesh and have been using, I’ve been using it since 2000 and I would say 2001, 2000 or 2001 when it first came out, maybe 2002.

Speaker 1 (00:24:03):

And I don’t have taking time bombs as patients. So also with time you are less likely to have actual Mesh related complications. So if you have a folding of the Mesh that occurs early within days to weeks to months, it does not occur years out. If you have erosion of the Mesh that occurs early, if the Mesh is going to entrap anything that occurs early, and by early I mean months to maybe a year or two. So I do want to say that to relieve your anxiety a little bit, find the right surgeon, get the unexperienced surgeon, trust them and what they want to do, ask some questions to alleviate your kind of concern about the plan of care. But no, I would not be too afraid about using that Mesh. Okay, next question. I’m wondering why surgeons are telling people with umbilical hernias and diastasis that placation is not necessary and a money tactic.

Speaker 1 (00:25:07):

I do not believe this is to be accurate, but there are people out there who trust these surgeons and are getting Mesh over umbilical hernias and diastasis because of this type of thought process. Can you explain why there is such a different thought process? Yeah, I don’t know why that’s true. Most of us who do hernia repairs understand that a hernia within a diastasis has a higher recurrence rate. And today our topic of discussion is hernias that failed or hernia recurrences. So if you have a widening or narrowing of your muscles already where the it’s thinner in the middle and then you get a hernia in that thinner space, just closing it or patching it is going to have a worse outcome than if you close off that space. And it is not a money tactic. In fact, insurance doesn’t even pay for that part.

Speaker 1 (00:25:57):

In fact, you’re getting more surgery for less cost because if you’re going through insurance and you’re doing the umbilical hernia repair with a diastasis, the you’re kind of going to get two for one. Now if you want your whole belly diastasis repaired, that’s a different question that’s considered cosmetic insurance does not pay for it. Most surgeons charge separately for that as a cash. But if you are just focusing on the umbilical hernia and using your abdominal wall to support that repair, I don’t see how that’s in any way the wrong thing to do. In fact, that’s what I recommend for my patients. Okay, next question. Thank you. Advanced. According to your recent MRI, I show two small Inguinal hernias. I have a longstanding 13 years of intense pain in my right groin and testicle. The surgeon who found the hernias on the MRI suggested getting them repaired. The surgeon I went to for a second opinion said to leave the hernias alone is too small to worry about and definitely not causing the pain. I don’t know what to do. What are your suggestions?

Speaker 1 (00:27:09):

All right, so size is not a determinant of whether we repair hernias or not. We’ve discussed this before and the symptoms and are what we go through. So if you have a small hernia with a lot of symptoms, I would repair that. But if you have a big hernia with no symptoms, no need to repair that. So that’s one answer. The second answer is you have to make sure that the hernias are causing the testicular pain. It’s not common to have testicular pain as the only symptom of inguinal hernia. You can have groin pain and testicular pain, which sounds like what you have, where the groin pain radiates to the testicle and it radiates around your lower back and radiate to your inner thigh. And all of that is consistent with the inguinal hernia being the cause of your pain. And I would repair that. But there are also patients that get hernias repaired that don’t have a symptomatic hernia and they only have testicular pain and usually those don’t turn out that good. All right. Why does erosion occur? Is it inevitable? Is it possible to erode or break in like 30 years? Okay, erosion occurs if a Mesh is it. First of all, when we talk about erosions Mesh erosion into a adjacent

Speaker 1 (00:28:32):

Structure, the erosion occurs if the Mesh is abutted against this, whatever it is, it’s either bowel or nerve or spermatic cord or bladder. And it’s unclear why some people get erosions and other people don’t get erosions, but basically know that they don’t occur commonly. It’s actually quite uncommon, number one, and if it occurs, it occurs early within the first year or two, but definitely not at 30 years.

Speaker 1 (00:29:09):

Do you think it would be possible to use plastic eating bacteria for a less serious way of removing Mesh in a hypothetical future? I know it sounds crazy, but I just wanted this thing out of me and no courage to risk removal surgery. So if the Mesh is causing you symptoms, that’s not a bad reason to have the Mesh removed, but I do not recommend Mesh being removed just because you don’t like it. This is not changing furniture. So that’s my 2 cents about it. What the future lies about what the future holds in terms of technology. I mean that’ll be interesting.

Speaker 1 (00:29:51):

Can you describe some of the common ways tissue repairs fail and which structures are torn? Okay, this was submitted to me earlier as well, so let me see if I can find that question for you. So one question was, that’s actually a really good question. I think I really like that question. What are the common ways that hernias fail? So here’s a question I had submitted it. What can you describe some of the common ways hernia repairs fail and which structures are torn? So this can be for either Mesh or tissue based repairs. This is a really great question. Why do these recur? What specifically mechanically is it that causes the recurrence? And what it is is oftentimes it’s the muscle that tears the Mesh almost never tears. There are reports of Mesh tearing. It’s not common and it happens when it does happen in really lightweight Mesh.

Speaker 1 (00:30:56):

In fact, one Mesh called ethibond proceed was removed from the market. It was never recalled, but it was removed because it was so thin and lightweight that it actually tore. So if it wasn’t put up against muscle, it would tear. But in general, when hernias recur, the Mesh looks fine. It’s the muscle that tears. So either the muscle tears through the sutures or the muscle tears from the Mesh and that’s what happens. That’s true for both a tissue repair and a Mesh repair. The reason for the tear is usually there’s, if you’re a phasix, it’s all phasix. Hernia surgery is basically phasix and I love phasix, so I really enjoy it. If you don’t understand phasix, you’re not going to be a good hernia surgeon. So for example, if you put a small Mesh over a small defect, the amount of force that’s distributed to that Mesh per area is really, really high and therefore it’s not going to hold.

Speaker 1 (00:32:01):

So you want a larger Mesh to dissipate the forces from the smaller hernia. So that’s one reason. The second is also phasix based based on the sutures that are used. So if you do a really tight repair, that’s going to tear and get a hernia recurrence. So the way I explain it to my patients is if I gave you a shirt right now, a button down shirt that’s two sizes too small and you barely are able to fit into it to tie to close the buttons, those buttons will pop and you can see it trying to tear at the seams. That’s what happens when you do too tight of a repair. And sometimes surgeons either knowingly or unknowingly make it tight cause they think they’re doing a good job, make a nice and tight repair. You do not want a tight repair. You want your tissues just to heal so tight repair will actually tear and then that will cause a recurrence. This is also why we don’t recommend tissue repairs in people at high risk for recurrence.

Speaker 1 (00:33:06):

So if you’re morbidly obese and you have even a small hernia like one centimeter, which is half an inch, a little bit less than half an inch, do not get a tissue repair because what’s going to happen is you have a one centimeter hernia, they’ll put some sutures in it, you’re going to pop those sutures. And what I mean by that is the sutures won’t tear. The sutures are actually quite strong. Your muscle will tear. So now you have a two centimeter hernia or three centimeter hernia because you’ve now torn through the sutures and your muscle has torn. The sutures have not torn. That’s the important part. People think sutures, like sutures actually tear or pop. They don’t. The sutures look great. If you go back in the muscle has all these tears in it, so now you have a fray hernia and then you go back and if you get another tissue repair, oh, it’s small hernia, it’s only two centimeters, we’ll close it.

Speaker 1 (00:34:01):

No, because now the two centimeter will become a five centimeter. And if those of you have kind of watched me post some pictures of these ginormous hernias, they all start with a little umbilical hernia. They not start big to begin with is just failure after failure after failure. And so what I do, because I see a lot of patients that have had prior surgeries is I’m a forensic analyst. I go in there and I look at every single opera report. What would I have done differently? What was the decision making that prevented this patient from healing? Was this an open procedure? Was this done too tied to the user? Right? They use absorbable sutures that are more likely to dissolve before your healing. Did the patient have a chronic cough or constipation after surgery? Was the patient morbidly abuse at the time or smoker? How can I not repeat the prior mistakes? And you don’t want to repeat the same problem again and then have another bad outcome. So that’s kind of the way I look at things.

Speaker 1 (00:35:06):

Okay, next question is, is it safe to stitch a groin hernia after a recurrence laparoscopically and then use resorbable Mesh? I mean these are all options. I can’t say one is safer than another. Every patient’s different. You may not be eligible for a laparoscopic repair. This last patient that gave a little note in the beginning of our hour had liver disease. Definitely not an option, not a safe option. So, oh, okay. The last patient was stressing out over the 3D max Mesh where they had surgery in June 8th. Thank you. I’ve been a wreck over this. Thank you. From the bottom of my heart. You’re welcome. I feel like sometimes, I mean the information out there is good to open your eyes, but man, some of it is spoken like it’s like truth, like fact, like a hundred percent of all 3D max is going to kill you or all Mesh will kill you.

Speaker 1 (00:36:18):

All Mesh will get infected or it’s just not true. If it were, then we would have about a million people a year that are sick. And now we do have a large number of people that are hurt from different repairs. But just understand that whenever people are worried or talk about problems, it’s a percentage and that percentage may be high for a obese patient who’s a smoker may be low for an athlete that’s thin or maybe in between. So do analyze data if you want. Follow me on Twitter. That’s where I talk about data data, so that should help it. Okay, let’s do some more questions. You guys have been doing really well with these questions. Thank you so much. What are the recurrence rates of women who have tissue repairs for inguinal hernias? Good question. So again, it’s a risk factor. It’s a population based, but in general, women and men, we don’t have that data.

Speaker 1 (00:37:21):

We can’t tell you that specifically. You’ll have a worse outcome if you’re male or female from a hernia standpoint. However, the studies that have been done, which are mostly for men, are very specific. The studies that are men and women tend to be very male heavy in terms like male dominant. But as far as we know, hernia recurrence, all things being equal should like the same. Risk factors should be the same between men and women. That said, for example, I’ll give you equal hernias. Women tend to have worse outcome from Inguinal hernia repairs than men. The reason is a lot of hernias are missed. The femoral hernias are missed, which are more common in women requiring more surgery for them. And they tend to have, I think more nerves in the pelvis. And so they have more chronic pain as a complication of their hernia repair. So women have worse outcomes in the groin. That said, someone looked at a recent study that got published I think this past month also, which I retweeted showed that, okay, the standard as proposed by the experts, national international experts say women should get laparoscopic surgery for their al hernia repair. Is that really what’s happening? Actually, not actually. Women are less likely to get laparoscopic surgery for their Anglo hernia pair. So is that contributing to worse outcome for women than men? Maybe hard to know. These population studies really need to be analyzed very carefully.

Speaker 1 (00:39:10):

All righty, thank you for those questions. I had a laparoscopic top

Speaker 1 (00:39:22):

Inguinal hernia pair with 10 by 15 centimeter ultrapro Mesh without fixation for a two centimeter inguinal hernia. That’s a big hernia. If it’s two centimeters, that’s a big hernia. Is it a safe procedure to do without fixation? One doctor told me afterwards it could not have been done without fixation. And is this ultrapro Mesh the one lightweight that you mute for ethibond? So ultrapro Mesh is the ultra lightweight Mesh. We don’t have a Mesh in the market that is lighter weight than ultrapro. A similar ultrapro was used for ventral hernias called Proceed. They basically took, and it was actually I think even lighter than Ultrapro. That is the one I’m talking about, not the ultrapro Mesh. Can you have anal hernia repairs without fixation? Absolutely. I do it all the time. Can you have that with Ultrapro? Probably was. Is it a good idea to do it without fixation in a large hernia?

Speaker 1 (00:40:21):

No, I don’t agree with that because what happens is you have a hole and then you have a lightweight Mesh and the Mesh will kind of fall into that hole if it’s not fixated early. That’s kind of my stick. Everyone’s a little bit different. It’s like saying how do you bake your cake? Everyone’s a little different. So there’s no gold standard as to whether you should use fixation or not. We know that people that do not have fixation, which means no sutures, no tax, actually consider glue as a fixation too. But those people that don’t get sutures or tax tend to have less pain than those that do get fixation. So I don’t necessarily disagree with what was done.

Speaker 1 (00:41:09):

Okay. Today I was told I also have a hernia from my naval to my pubic bone from surgery I had over 25 years ago removing one foot of my colon because of diverticulitis. So that sounds like an open surgery, which we already showed has a higher risk of problems. He said he would have to use Mesh and I’m scared because of the horrible pain I’ve had for six years after left Inguinal hernia surgery with Mesh. Would you suggest I do it? Okay, well, I totally understand your reticence to Mesh. You really don’t have much options for an incisional hernia, especially if you’re already someone that has a tendency towards making hernias. And I feel that that’s kind of something that we need to talk about, which is why are we talking about Mesh? Why, and can we just do without Mesh or what’s this whole thing about Mesh?

Speaker 1 (00:42:01):

So this was a nice question in the same realm, I’m going to share it with you where it says, you’ve said that when you have a hernia and it’s it’s caused by inherent weakness of the abdominal wall and then therefore some kind of reinforcement such as measures recommended. Is that true even for incisional hernias in an otherwise healthy person? So here’s my thing, if you have a hernia, whether it’s surgically caused or otherwise, by definition you have weakness of your tissues, you would not have had a hernia if you didn’t have a tendency towards getting a hernia. And that’s usually a collagen based problem. The collagen that you have most likely is a weaker, more immature collagen and you would’ve benefited if genetically you had more of the stronger, more mature collagen that said an incisional hernia. Oh, sorry, therefore an incisional hernia, which implies a hernia after having had an incision.

Speaker 1 (00:43:11):

Let’s say you had this colon surgery, almost always that is something inherent to the needs of the patient. So they have an incisional hernia because they had, they’re morbidly obese, they’re a smoker, sorry, they use nicotine. I can’t say smoker because in California that couldn’t imply marijuana. As far as we know, marijuana’s smoking doesn’t. Marijuana itself does not cause hernias. The coughing though from smoking can maybe you’re constipated. So there are factors that may have maybe had a wound infection. A wound infection is a huge risk factor. I think seven x of getting an incisional hernia. So is it possible that you can just close that hernia back together again and it’ll stay Okay? The right answer is likely not, which means that if you have an incisional hernia from this colon, let’s say surgery, and you want to just suture it back together again just like it was done when you originally had the surgery, your risk of recurrence is about 60% with no other risk factors.

Speaker 1 (00:44:27):

And if you add on smoking and obesity and all that, then you’re 70 80% risk. So it’s not a hundred percent, but that’s a horrible numbers. We don’t ever do any operation in for any reason. If your outcomes rate is your good outcomes rate’s like 20, 30%. So we therefore do not recommend any incisional hernia to be repaired without Mesh because you need that Mesh to take the tension off the sutures and to hold it in place. So some people said, fine, let’s not use Mesh, that’s permanent. Let’s use absorbable Mesh, biologic Mesh that’s been used. It doesn’t work still the recurrence rates around 40% lower than 60%, but still pretty high. Then they said, okay, let’s make a fancy Mesh that absorbs, it doesn’t absorb immediately. It doesn’t absorb its three months or eight months, it absorbs it 18 months. Let’s see how those do and the long-term studies for that at three, and I think we, I think we don’t have the five year data available yet, but at three years also pretty high recurrence rates in the 30 to 40% range.

Speaker 1 (00:45:42):

So what that teaches us is at any point during the lifespan of the hernia, it’s at risk for recurring. If it doesn’t have extra support, external support, and we’re trying to come up with other meshes that will help. I’m a big fan of hybrid Mesh, so it has a little bit of synthetic in it to prevent that extra recurrence that you get from absorbable Mesh. But I don’t know, I hope this is getting too complicated. I don’t want to get into the nitty gritty. Sometimes I forget that I got to get in the mood, but I just don’t want to make sure that I’m not too making this too complicated. But just know that when you come and see me or other hernia specialist going in our mind, we have all this data that we’re chiming through and we’re understanding that we’re reading about that we ourselves are contributing to this data to learn more and more and more.

Speaker 1 (00:46:42):

And the goal is to improve your quality of life. We’re not out there to hurt anyone and we’re still learning. We’re always learning. Okay, let’s see. Is there a length of time postoperatively when the risk goes down for recurrence, say one year after removal and the scans still shows, still no hernia. Is it safe to say scar tissue will prevent recurrence? Okay, good question. So let me make a comment about scar tissue. Scar tissue is not strong and it weakens over time. So because you’re constantly look at your scar, if you have a, let’s say you cut yourself, that’s the nasty scar initially, but 10 years later you can barely see the scar. So scar tissue weakens over time and is not strong enough to prevent hernia recurrences. Now it may delay a hernia recurrence, but it won’t prevent it, number one. Number two, and by that I mean it’s again, not a hundred percent, but like 80%.

Speaker 1 (00:47:48):

So if you want to take a chance that 20% risk that your scar tissue will hold, I mean in some people that may be worth it. The other point is, forgot the question. Let’s see. Oh, you’re talking about Mesh removal. Let’s not talk about Mesh removal yet. Let’s just talk about recurrence. So recurrence, the risk of recurrence increases over time. So what I mean by that is if you follow a patient for a year, you may find some of the patients that recurred, but many will recur after one year, but the rate of recurrence peaks and then drops. So if you don’t recur in the first, let’s say year or two or three years, the chance of you recurring at 30 years or 20 is really low, you know, kind of pass the test. So there is that. The question you’re asking has to do with Mesh removal.

Speaker 1 (00:48:59):

So after removing a Mesh, how can you tell if a scar tissue left behind is enough to prevent a recurrence? You can’t tell. But in some patients it’s worth it. So let’s say you have a severe Mesh reaction, then that Mesh reaction requires a Mesh to be removed and suture, suture repair. So you kind of are playing this statistical game. If I remove this Mesh and make you feel better, let’s deal with the hernia. If you have 80% of a hernia recurrence risk, I’m just making up that number, that still means you have a 20% chance you’ll do just fine. So you may want to take that risk because the Mesh was making you sick and let’s say it was done at a time and place where the Mesh technology is not advanced enough to provide you with the Mesh where you won’t react to it.

Speaker 1 (00:50:03):

And so maybe in two to five years, if you’re a hernia recurs, we’ll have a better Mesh by then. I mean these are all things that discussions you can have with your surgeon. The other thing I wanted to talk about is kind of suture like Mesh infections. So Mesh infections are a different animal, the amount of inflammation and scar tissue that is generated by inflammation from an infection is huge. And in many patients, if you don’t have a hernia at the time of a Mesh infection, when the Mesh is removed, it’s very possible you won’t get a hernia recurrence. I’ve seen it. And if you do recur, you recur five or more years later. So in those patients, that’s a mesh removal with Mesh infection and you don’t have to do any tissue repair. Then sometimes the amount of infection and inflammation alone has to do with maybe enough. Okay, next question. Does robotic repair have to enter the peritoneal cavity? Yes. That was easy.

Speaker 1 (00:51:21):

Okay, let’s see. We had some really great questions and okay, this is good. So the surgical technique impact the risk of recurrence. Absolutely. The way I explain it is this, the amount of tissue injury that the surgeon causes I feel is directly related to the outcome. So if you have a fine tuned hands of a woman surgeon that is very delicate with the surgical technique, you have very little bleeding, very little inflammation and swelling after surgery, very little tissue damage that’s going to give you a better outcome in terms of pain in recovery and therefore also healthier tissue, less ischemia, improved blood flow, less lack of blood flow, and therefore better healing. And it’s that lack of blood flow and inflammation than you get from people who are very aggressive with the tissues that causes areas of dead tissue, fat necrosis and poor blood flow and those contribute to a hernia not healing well.

Speaker 1 (00:52:42):

And if you don’t heal well, you’re at higher risk for infection and you’re at higher risk for hernia recurrence. So absolute surgical technique, just from the pain plain, how you handle the tissue is very important. And we sometimes forget to teach the residents, I teach the residents that, but I have a plastic surgery bent to how I approach things and plastic surgeons are very keen on reducing tissue trauma because they like if you want to get a facelift, you don’t want to be all bleeding underneath the facelift and swelling and all that. That’s not good for a facelift and it’ll make you look ugly. So plastic surgeons are very key about that. The other thing is we already reviewed that laparoscopic and robotic options are superior to open in terms of risk of tissue damage and adhesions and Mesh infections and pain. And then lastly about surgical technique, the decision you make, whether it’s open or lap or robotic for that specific patient and the size of the Mesh and the quality of the Mesh, the weight heaviness of the Mesh, whether you use sutures or not and how tight you make those sutures, those are all part of surgical technique and will kind of really predict the risk of recurrence.

Speaker 1 (00:54:11):

This is true of every specialty. If you go to, what’s a good example, if you go to a masseuse and you have someone who’s really delicate, really understands the anatomy and gives you a good massage for someone that’s just mashing on you and you end up all sore and bruised and not relaxed, those are two different people that are doing the same procedure but different outcomes. Or if you’re going to a tailor and you have a tailor that’s like, I don’t know if any of you watch these, I love watching. They’re these fashion designers that show all this really intricate designs and hand beating and year, months and months of doing it over and over again and couture designs and how much work goes into it versus some cheap $3 that you buy that still has uneven collar and the string is still hanging off it. You have to cut your own string. I mean yes, they’re both outfits, but the amount of workmanship and care that goes into one outfit will make it last much longer. Many of you probably have invested in nice coat or jacket or shoes and last forever versus your $3 t-shirt will not last you forever. They’ll have holes in it order to fall apart or fade or whatever. So those are kind of things that I just want to let you know about surgical technique.

Speaker 1 (00:55:44):

All right, so this patient is 79 years old and maybe will not have their incisional hernia repaired, which is fine. They also have a right angle hernia and the doctor said, I have three main hernia issues. Maybe I’ll just wait longer for surgery. As long as your surgeon feels like that’s a safe decision, watchful waiting is usually adoption for most hernias. Okay, next question. I was diagnosed with a large ventral incisional hernia last week. I had a bowel resection in ileostomy in 2006. I also have an umbilical hernia, so there is a 60% chance of for me since I have an incisional hernia. Did I hear you correctly? Yes. So if you have an incisional hernia for prior operation and you choose to have that repair with sutures alone, the studies show now you may not be representative of who was in that study. It’s a European study Studies show a 60% recurrence rate of that hernia repair. That is correct. That’s why we recommend Mesh repair, which has more of like a, I think 10 or 11% recurrence rate. And of course there are different ways of putting in that Mesh. I’m going into hernia surgery number nine. No,

Speaker 1 (00:57:09):

That’s not good. Nine with recurring hernias, at what point do you decide that fixing hernia is going to cause more problems than a repair? I’ve had Mesh removed and then biological Mesh implanted. I seem to pop out hernias on the sides of what our repair has been done. Okay, first of all, I hope you’re seeing colleagues of mine that are really good at what they do and understand that nine repairs is not appropriate. Second of all, the fact that you’re getting biologic Mesh

Speaker 1 (00:57:42):

Already tells me that you are in a situation where probably synthetic Mesh was not an indication that you had a Mesh infection in the past. And what I just explained earlier is biologic Mesh has about a 40 plus percent recurrence rate. So it’s not unexpected that some of that surgical techniques to you underwent caused a recurrence. Now remember, not every hernia repair is done to prevent recurrence. Some hernia repairs are done to treat a bowel obstruction, some hernia repairs are done to treat chronic pain. And if that part is addressed, then the fact that you had a hernia recurrence is a side effect of the decision made for you. But please double, triple check and make sure you’re getting multiple consultations about what you should be doing so that you can understand the risks that you’re undergoing. You should not be undergoing multiple hernia repairs where they’re all failing. Your surgeon will say, you know what? We had to put biologic Mesh because you had a Mesh infection or a bowel involved or an official or something knowing that you will then for therefore have a hernia recurrence. And when that happens, then at that time in a more elective way, we’ll put, we will do a more definitive surgery. That’s usually the discussion that I have.

Speaker 1 (00:59:07):

Oh, so many questions my friends. Okay, so we’re done with today’s session. There’s about five more questions that have been submitted that I haven’t yet answered, plus about 10 that were submitted before. Beforehand. So this is why I do the ones I’ll just meet with you guys because I feel guilty that all your questions aren’t being answered. That said, I need a break, guys. I’ve been working nonstop since before COVID with no vacation. So I will be doing one more session next week and then I’m going to take some time off from hernia talk and we’ll do it again a couple weeks later so that I can catch up with the rest of my life. So don’t lose me, keep him coming. I’ll do some live talks to answer some of your questions. That’ll help relieve some of the pressure. And up until then, what I’ll do is, you know, can keep contacting me on social media. I’ll try and do all, I’ve been having fun with TikTok a little bit, so I’ve been doing some Wednesday hernia hump day Wednesday questions on TikTok. So follow me at Hernia doc on TikTok. And on that note, it was lovely to be with you all. Thanks everyone. Enjoy evening. I’m going to go home now and be with my family. Take care. Bye-bye.