Episode 62: Hernia Surgery and Second Opinions | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

Hi everyone. Welcome to Hernia Talk Live. We’re entering the summer time right now and I’m super excited to host another session of Hernia Talk Live Q&A with you. My name is Dr. Shirin Towfigh. You know many of me as the hernia doc. I am a hernia and laparoscopic surgery specialist. Thank you for following me on Twitter and Instagram at Hernia doc. Many of you are joining me live on Facebook at Dr. Towfigh. And as always, this session will be hosted on my YouTube channel for you to review and subscribe and watch some more. So let’s do this. Today I decided the topic for this week should be on expert opinions or second opinions and surgery. The reason why I asked that, why I chose that is because I’ve seen a couple of patients lately and they’ve had two, three, sometimes four operations by the same surgeon or they were told something by one surgeon and basically for the past, since like today, patient today since 2014, he’s been suffering from pain and the doctors have told there’s nothing to do.

Speaker 1 (00:01:20):

So he kind of just went forward with no hope and then he reached out to me, but now it’s 2021. So that’s a lot of years to just follow with pain and it becomes chronic pain and some people can get really sick from it and it affects your quality of life. I see people who lose their jobs because of chronic pain, they’re depressed, suicidal people get divorced, their children leave them. I mean, it’s a pretty serious problem. And I don’t take chronic pain serious. I take chronic pain very, very seriously. I don’t think people should be suffering. And for example, this one patient, actually the second patient that I saw today made a comment or what a comment was made to that patient that, oh, don’t ever do this surgery. You’re going to be so sick. It’s a very lethal operation. I’ve had people being told that they shouldn’t have their Mesh removed because they can lose their leg.

Speaker 1 (00:02:25):

It can affect the erectile dysfunction, erectile function, they may get their testicle removed, like all these things, completely not true and yet it offers so much anxiety and stress to the patient so they end up losing hope and not moving forward with a potentially life altering surgery or life altering meaning that it will improve the quality of life. So hi to those that are logging in right now. Thank you very much for joining me. And I thought I’d try and dispel some myths that we hear among patients that are concerned about having a second opinion because listen, I’m often the second opinion surgeon. I highly encourage my patients to go to a surgeon local to them that I can work with. In fact, I’ve told ’em to go see other doctors if they want another opinion just to put them at ease to make before they make a big decision to undergo surgery.

Speaker 1 (00:03:33):

So based on that, I feel that we need to get something straight. First of all, let’s review. Why do you need a second opinion prior to hernia surgery? My personal shtick is unless you’re having emergency surgery and you need to make a life life-saving decision, if you’re having elective surgery, it can be anything from a bunion surgery and to a hernia surgery to a revisional operation or a cancer surgery or whatever the surgery is, I think you should get a second opinion. That’s just my 2 cents. I mean we’re all doctors, me and my friends and I, and even when we know this field that we’re talking about and we go to one surgeon, let’s say we need surgery and we go to a surgeon, we still go for a second opinion just to make sure that a second eye is looking at the problem in a different way.

Speaker 1 (00:04:36):

Sometimes some people will have a different take on things. They will provide you with less invasive option for the same problem. I’ve had patients that go to one doctor who wants to cut all the nerves and the other one comes and he comes to me and I say, you don’t even have a nerve problem. Let’s not touch the nerves. So it’s just a different take. In fact, maybe you don’t even do surgery, you need just injections. So every person will have a different opinion and I highly encourage for elective surgery to get a second opinion for anything. It could be breast surgery, it could be gynecologic surgery, your prostate removal. Do I need my prostate removed? One surgeon says yes, one surgeon says, no, get more than one opinion and then you can at least see if they both match, great. If they don’t match, then why is that and how can that improve you? So that’s kind of my shtick. I’m not a big fan of surgery in general. I think if you can get the same outcome without surgery, that’s a good option. And getting a second opinion is part of that kind of very conservative attitude prior to going to surgery. So that’s my thing.

Speaker 1 (00:05:54):

That’s another question I was asked. Does insurance pay for opinions? Insurance typically allows for consultations. That could be first, second or third consultations or fourth or fifth or whatever the term. Second opinion is actually an old term. There used to be a billing code where you code for a second opinion doctor but not really the treating doctor and it is just paid differently. As far as I know, that’s completely out the door and Medicare put a kabosh on that. So any doctor’s visit is treated the same whether it’s for a first opinion, second opinion, et cetera. So don’t worry about it not being covered by your insurance, assuming all other things are correct. So that was my stick on third opinions, yes, there is such thing as a third opinion. Now sometimes I see patients that I’m like the 10th doctor they’ve talking to and I don’t want to call it doctor shopping because often it’s because of a rare problem or a difficult problem or anxiety over a situation and they’re trying to understand their problem, not so much doctor shop.

Speaker 1 (00:07:09):

So doctor shopping implies I want one specific type of procedure and I’m going to find the doctor that will agree to do that one procedure. So for example, it’ll be let’s say an incisional hernia in a patient on steroids with ulcerative colitis and they don’t want to have Mesh in them and they’re adamant that they don’t want to have Mesh in them. So they will go from doctor to doctor and every doctor will say, you need Mesh, you need Mesh, you need Mesh. And they won’t stop looking for a doctor until they find a doctor says, eh, we can do it without Mesh and then they will go forward with that. So that to me is doctor shopping where you’re not necessarily following the recommendation, but you’re trying to find someone to work outside the box but not in a good way. The alternative is trying to get an understanding of what’s going on with you in terms of your surgery and your diagnosis and you just haven’t found the one doctor that gives you the full shebang, like nice personality, skilled surgeon, knowledgeable physician, good bedside manner office that responds like to try and find.

Speaker 1 (00:08:28):

I mean I think I provide the full shebang to be honest. I think we have an amazing office and team and I’m a huge advocate of fighting for patients outcome and but at the same time, I will not do something that is outside of what is appropriate for a patient. So I would not compromise a patient’s care because a patient wants a certain thing to be done. I don’t agree with that. So there are patients that go from doctor to doctor and never really decide on what they want to do and sometimes that’s really because they don’t really want surgery and instead are just information gathering, which tends to add to more anxiety, but there’s never like a cure to the problem. So I prefer if a patient commits to a surgeon that they trust and then moves forward with a plan of care because spending five years trying to find a doctor when you’re suffering during this whole time, I don’t think is in the best interest of the patient.

Speaker 1 (00:09:45):

Okay. The other question that I get asked is I don’t want my doctor to know or will my doctor know that I saw you or got a second opinion or they’re very concerned that somehow our ego or our personality or something will be affected negatively. We would take it personally. If you see a second opinion surgeon, I do not. I encourage it and I think that you should not fear like retribution or that your surgeon will look at you differently if you went and got second opinion. I don’t agree with that, but as I’ve probably said before, we’re all human. We just went to medical school and did surgical residency and chose to do hernia surgery, but we’re still human and so we still have hiccups and there will be doctors that will take it personally. If you go get a second opinion, that’s just the way any human may react.

Speaker 1 (00:10:50):

That should not prevent you from doing what’s in your best interest. That’s the way I think about it. What’s the question I just saw on Facebook Live? It says depending on the specific situation, can some hernias be repaired without Mesh? Absolutely. Absolutely. There are a lot of situations where hernias can be repaired without Mesh. It’s a give and take. So for example, the patient that I presented ulcerative colitis on prednisone, multiple hernias have already occurred pushes to empty his J pouch. That patient is not a candidate for non Mesh repair. Now someone may offer it, but I think it’ll be the wrong decision. Can it be repaired without Mesh like physically? Can I do it? Yes. Will it pop open in a couple months and he will need an even bigger hernia pair? About 80% chance, yes, maybe higher. So that’s why we don’t do that. If you had an 80% chance of a car crash when you go out driving, most people would choose not to drive, but it’s always a risk benefit ratio.

Speaker 1 (00:12:02):

All right. Also, what’s your opinion on Shouldice? I’m a fan of the Shouldice. So the Shouldice hernia repair is a tissue based hernia repair for inguinal hernias. So hernias in the groin, it is for Inguinal hernias director. Indirect is not a repair for femoral hernias, even though there is a Shouldice version of the femoral hernia repair. It is the best studied tissue repair and though it’s not the oldest, but it’s a pretty old type of repair and there are other tissue repairs, Bassini, McVay, those are both types of repairs. There’s a Nyhus Condon repair. Anyway, I think it’s a great repair. It’s not for everyone. Most surgeons that are trained today are not trained to do the Shouldice repair, but as more and more of us are interested in hernia surgery and train in hernia surgery and the residents that I train, they all get exposed to getting Shouldice hernia repair done.

Speaker 1 (00:13:06):

All right. Is the general rule of thumb to leave a small rule hernia alone unless it becomes too painful? Will every hernia grow larger over time? Okay, so I told you we have a private group of surgeons that are international that talk about hernias all day. It’s like constant talking about hernias and asking questions and so on. So this question was posed actually recently saying, all right, what do you guys do if you have a patient that has no symptoms or what we would call minimally symptomatic and has a groin hernia or an angle hernia, what do you do? And I presented my evidence-based way of interpreting how to do things. I’m very conservative. I do not. I do offer watchful waiting for as many people that are good candidates for it. I always have that as a discussion. If you have no symptoms, I don’t feel like how am I going to make you better with surgery if you’re already having no pain?

Speaker 1 (00:14:13):

Now if the quality of life is better with not having a B of that would be one alternative, but I may also induce pain. So there’s that discussion that I have. Other surgeons say, no, every hernia will get bigger and a percentage of patients, those small will have their hernia emergency. I can’t tell you Mr patient or MS patient that you won’t be that one person. So why take the risk? Let’s just fix your hernia repair. So to me, that’s a different interpretation of the data. I don’t agree with it because that implies that everyone with a hernia regardless of symptoms should get repaired. To me, that’s a very old way of thinking about things and we have very good prospective randomized trials that show as perfectly safe not to operate on patients. So yes, hernias will get bigger over time, but that may be 20 years a small inguinal hernia and a female will probably never get bigger.

Speaker 1 (00:15:11):

A large hernia in a male may get bigger. So the data is out there to support watchful waiting as a safe manner. We just reviewed the data, so up to two thirds of patients over a span of five plus years will choose to have surgery even if their surgeon initially said, let’s just watch this, because they just get tired of the bulge, they get tired of dealing with it and may affect their quality of life, the bulge may have gotten bigger over time. So all those things are right. Okay. Am I trained in Shouldice? Yes. So I do perform the Shouldice hernia repair. I have been to the Shouldice clinic. It’s a hospital clinic. Really great people there. They have very dedicated to their craft. I do offer the Shouldice hernia technique for inguinal hernias to anyone that’s a good candidate for tissue repair. All right.

Speaker 1 (00:16:20):

Some patients who’ve had reaction to Mesh or implant or even sutures might seek multiple opinions because of the fear of another surgery, which can potentially cause a similar reaction. That’s true. The thought process is live with with the pain now or live completely disabled. How do you help these patients navigate their healing journey? Well, obviously the big deal is I’m not the one that has to live with the hernia, so I have to somehow do my best to give you somewhat of a picture of what the expectation is. So for example, some people think that they will get maimed and disabled for life. That’s almost never true, almost never. And by almost never, I say more than 99% not true.

Speaker 1 (00:17:14):

US surgeons, we surgeons will never offer you an operation where you’ll be disabled. Now, do complications occur? Yes, but most of the time complications are in the 1% to 5% range. We don’t usually like to do repairs that imply really high rates of complications. So the risk is there as with any surgery, but it needs to be put into perspective. So that’s one thing. The second is we just don’t know enough Mesh reactions, which is this question is an enigma. Some people get it, some people don’t. Some people at risk for it, some people aren’t. We have no idea how to accurately predict. Like if I tell you your blood sugar is 200, which is very high by the way, I can reliably predict you have diabetes, but I can’t do that with Mesh. I can’t say that you have a hundred percent or even a 50% chance of reacting to Mesh.

Speaker 1 (00:18:17):

I can say maybe you have a higher risk even that, what does that mean higher risk? We don’t really know. So that is an evolving, evolving study many of us are interested in. I’m very interested in it. We’re using our best judgment to guide people based on our experience and hopefully over time as our experience increases, we have more data to support what we offer patients. So yes, something rare like a terrible Mesh reaction and by rare I mean that almost no surgeon sees it on a regular basis and percentage wise we feel it’s very small even though it’s a large number of people.

Speaker 1 (00:19:02):

Those are difficult. Those are hard, and those are definitely patients that should see multiple specialists even though there aren’t that many of us to begin with. Okay, I’m interested in seeing someone that is trained in that technique or does a tissue repair. Yeah, so I mean the Shouldice clinic itself is the best place. They’re all trained there and do it for a living. Canada is still closed, I believe, to US travel, but once that opens, if you want a real Shouldice repair, you just go to the Shouldice clinic. Short of that, there are many of us around the nation that do offer the Shouldice repair. You just have to call and ask. There’s no database that shares that information. How much muscle is removed when abdominal Mesh is removed? What are the chances of absorbable sutures holding up with the plication? So virtually no muscle is removed.

Speaker 1 (00:19:58):

A very, very, very, very small amount of the muscle is stuck to the Mesh, but when we remove Mesh, we really shave it off. It’s like peeling a cucumber. You can do a really good job of peeling the cucumber, so all you do is take the skin off and leave all the cucumber behind. So that’s definitely a possible. What is the chance of absorbable sutures holding up with application? Depends on the suture. There’s slowly absorbing suture that do better than the rapidly absorbing suture, number one and number two, we don’t know as far as we do know, plications do best with permanent suture. So you’re kind of playing with the odds of recurrence if you’re relying on absorbable suture. Again, a hundred percent is not the answer or 0%. It’s somewhere between zero and a hundred percent. Patients will have a recurrence when using absorbable suture for hernias.

Speaker 1 (00:21:07):

Oh, fantastic answer, y’all welcome. I’ve had mine for 10 to possibly 15 years. Got it. Looked at eight years. Oh, your hernia, I assume I’ve had my hernia for about 10 to 15 years. I got it looked at eight years ago and the doctor told me to leave it alone for a while. Recently it started popping out more, feeling uncomfortable in certain positions. I lift weights regularly and I’m worried about tearing or popping out and it becoming an emergency. Okay, so here’s the data. There’s two prospective randomized trials. One in the us, one in the United Kingdom. They both looked at males and I believe you’re a male, both looked at males. One all males. The other one adult males. The other one males I think aged 50 or 50, I think 55 or older. And they took the men with hernias that were either asymptomatic, so no symptoms or minimally symptomatic.

Speaker 1 (00:22:04):

So a little twins here and there but didn’t really affect their quality of life and they randomized them to two arms. One arm of the study, you got your surgery, the other arm, you didn’t get surgery and they watched you for up to 10 years and they looked to see what happens. The reality is nothing much happened. The risk of something bad happening in one study was quoted at 0.18% per year. Of course it’s not zero, but that is a low percentage. So if you don’t want to have hernia surgery, feel confident that that decision is safe. If you have no symptoms, do the hernias get bigger? Yes, we don’t know per patient how fast that will occur. Will the hernia become symptomatic so you move from having no symptoms of having symptoms possibly. And again, we don’t know the percentage of that in these studies. Up to two thirds of them had worsening pain up to around 10 years, so to the point where they wanted to have surgery, but every patient’s different. Just know that watchful waiting doesn’t mean that you’re committed to it for your whole life. You can reassess it at any time. In terms of emergency emergencies, it’s 0.18% risk per year low risk. So it’s one 0.18. It’s about one zero. Point two is one fifth, so one seventh of a percentage.

Speaker 1 (00:23:43):

I have an incisional hernia from a C-section. Is it possible to have it repaired without Mesh? Incisional hernias from any operation should be repaired with Mesh, and the reason for that is we have a great study out of the Netherlands that showed that if you choose to repair incisional hernias without Mesh, there’s a minimum 50% recurrence rate. Now, they were studying real hernias like big hernias. They were not studying C-section scars or small hernias. So if I have a patient with a small hernia recurrence, I don’t put Mesh in them, the chance of that, it’s going to be much less than 50%. Most likely C-sections. Also, if you have a small scar, or small hernia, you could consider non Mesh, but in general the answer is yes, you should use Mesh and Mesh is highly variable. There’s tons of different meshes out there.

Speaker 1 (00:24:43):

I’m all about being conservative and weighing the risks to benefits. So I’m on the same page as you. Thank you. Also, thank you for answering these questions. You’re welcome. Yeah, thanks. I don’t want to say we got into a fight, but we got into some heated debate on these surgeon interactions because some surgeons feel so strongly that a surgeon, like if a patient comes to your office by definition, that means they’re asking for help about their hernia and your help as a surgeon should be to operate and I disagree. I feel like they’re there to ask for advice and the impetus to operate should not be because a patient walks through your door. So I don’t know. I would love to hear what you guys think because I get plenty of patience that I say, oh no, you can totally wait on this and go do your exercise and be as active as you wish to be and like that was the best news ever.

Speaker 1 (00:25:51):

I was stressing and I thought, you told me I have to have surgery and I couldn’t sleep last night and I was hoping you would be able to say that I didn’t need surgery. And so that’s my experience, but I’d love to know what you guys think because at the end of the day, it doesn’t matter what I think or the surgeons think, it’s what you guys think. You guys with the hernias, I don’t have a hernia yet, but sometimes I feel a little twining, so I hope I don’t have a her. I hope I don’t have a hernia. What do you suggest for sutures? Have you heard of mono max? Mono max? I haven’t heard of. I’d have to look to see what it’s, what’s made of, but the typical sutures I use is prolene suture or ethibond. It’s a polypropylene or a polyester based sutures sometimes for people that have react reactions to that. I use nylon. Neuron is another type of braided nylon. So there are a lot of options. And then PDS or maxon are the sutures that are used for the long-term. Absorbable sometimes patients with five layers of inguinal hernia,

Speaker 1 (00:27:08):

Mesh and coils,

Speaker 1 (00:27:14):

I don’t know what they’re saying. Sometimes patient with five layers of inguinal hernia, Mesh and coils, weak, broke, tired, dying from this. I feel Mesh removal is super risky since after my many searches and all the hernia groups, I can’t find one male that has done well with this. I also realize I need to play Russian roulette with surgery then deal with the outcome. Yes, of course I have issues mentally from all this. How are long-term patients with recurrence issues over and over supposed to get help? I have never smoked drink, et cetera. Okay, so

Speaker 1 (00:27:49):

80% of what I do is revisional and much of that involves Mesh removal and my patients do not die. They do not have bad outcomes. I mean they’re a handful of patients that I’m still working on that we’re trying to get to be cured, but in general, they all do pretty well. I can’t say I have a hundred percent success rate. That would be not true. Every surgeon who operates for sure has their own complications, but I don’t want to discount the operations I do. It can be risky and it can be complex, but you have to get to a point where you want to have surgery and improve your quality of life and when you get there, you should look at finding a surgeon that does that for a living and then once you do get a second opinion too, to make sure that all your questions are answered and that you pick the right surgeon for yourself. Never had a positive test of any kind saying I have a hernia, but I always do feel like Groundhogs Day, if you’ve never had a study that shows you have a hernia, not sure why you have five layers of Mesh in you. So I’d have to review your…That doesn’t make any sense. Thank you for doing this. Don’t blackball me for being honest. I do not blackball anyone. In fact, I don’t even know if I block anyone. I don’t think I do. I don’t like to do that. I’m sure I’ve been blocked by many people though.

Speaker 1 (00:29:26):

True fact. I was told by one removal specialist in Florida that he could remove all my Mesh, but I would have the original hernias, which meant misdiagnosed for three, which went misdiagnosed for three years by three surgeons. So that is true. Most likely your hernias will recur if the Mesh is removing and you do nothing else. Sometimes there’s scar tissue, but scar tissue is weak and so you’ll get a hernia eventually, but that’s where the planning occurs. You try and plan, okay, I’m going to take out this and then ha, okay, fine, I’m going to take out the Mesh. That part I can do. Now let’s discuss what do I do once the Mesh is out? How do you want me to repair it? And the options are A, B and C or just a, who knows?

Speaker 1 (00:30:12):

Mono max is P4HB. Okay, so max is basically phasix Mesh, but the suture, in fact, let me rephrase this. The suture was originally used the mono max in Europe and then a company took that suture and made Mesh out of it. So the suture I believe has an 18 month lifespan, the which is a very slowly absorbing suture. The next one down is about eight months, but as with all absorbable sutures, there’s a limit as to their efficacy for hernia surgery and every patient is different. Let me just tell you, in my experience, phasix has a significant inflammatory component to it and patients have reacted to it more than a biologic. For example, number one, and we know from the phasix Mesh studies after three years, there’s about almost a 50% recurrence rate with that Mesh. So it is definitely something to look at.

Speaker 1 (00:31:31):

So if the Mesh lasts for 18 months and you look at it at three years, all those people that recurred occurred after the Mesh got absorbed or many of them did. So that’s kind of what happens. All right. Next question. I respect surgeons who suggest you consider waiting. We had one surgeon insist he could do my husband’s ventral hernia repair robotically. Two other surgeons said no to robotic and only one was willing to consider open repair. I mean the question is who was right? Who was right? I mean a robotic repair, if I had a choice between robotic and open, I would definitely go for robotic if all things were equal because less scars, less scarring, less incisional hernia pain, less surgical site infection rate, better long-term results often, but there are situations where open is better. If you have a lot of loose skin or you have some kind of weakness in the area, you can tighten it up or something. So I don’t want to discount the idea of robotic surgery for hernias. They’re actually really great options robotically. That’s kind of my 2 cents about that. All right, next question.

Speaker 1 (00:33:06):

I asked for a second, second opinion and now I’m even more confused. Help. This is exactly what I think you mentioned. So you went to a surgeon once said robotic once said, no robotic, and the one said open. And so now what do you do? So often it comes down to number one, really having your questions written down to query why a surgeon offers one option versus the other. For example, is the open hernia surgery surgeon recommending open because they don’t even do robotic or vice versa? Does a robotic surgeon recommend open because I recommend robotic because they don’t know how to do it. Open is a Mesh repair offered because they don’t know how to do tissue repair and vice versa? Those are questions that you need to ask. Why are they specifically recommending what they’re recommending? If they say, well, that’s how I do it, I would run away. Because you don’t want a surgeon that does the same operation on every patient. You want it tailored

Speaker 1 (00:34:15):

And sometimes you need more than one opinion, but in general, if you pick and choose the right surgeons, then go for it all. My other point also is don’t pit a surgeon against the other surgeon. We are all individual people and have our own ideas of how to do things and what works best in our hands. There may be a surgeon that has a great open surgery in a horrible laparoscopic surgery, do not force that surgeon to do laparoscopic surgery because you’ll have a complication and vice versa. They may be like, yeah, I mean I can do it if you want, but I usually do laparoscopic. Yeah, don’t force that surgeon to do your tissue repair, for example. So that’s one comment. The second comment that I want to make is that if you’re going to two surgeons for a second opinion,

Speaker 1 (00:35:11):

Go to two experts. Don’t go, or let’s do this. Let’s say you go to the community doctor that’s near you and you’re like, you know what I should do? I should invest in a surgical consult with a expert. Then you go see a surgeon who’s an expert and they say the same thing, great, then maybe you can stay local and have your surgeon do it, or you can choose to travel and to the person further away who has more expertise, but at least the operation. The two kind of have the same recommendation. The flip side is you go to one surgeon who does everything and hernias are one of ’em, and they don’t really care about hernias and they say they’ll do it one way and then you go to another surgeon that only does hernia surgery and they say, do another way. Those are not equal recommendations.

Speaker 1 (00:36:03):

You can say, well, why the other surgeon say, I mean, you can say why the other surgeon say that, but just understand that you’re, you’re kind of comparing two different surgical experts. And so if you don’t, may need a tiebreaker with another surgical expert. I don’t want to confuse this too much for you all, but my point is do your research not on what you think you should do online, but also with your surgeon. I’ll give you a good example. I had a patient it today? No, today. Wow. These are all today’s examples. I had a patient today who said, I want the Dasarda. Okay, so he’s got bilateral inguinal hernias and they’re not small. And it’s like, I’ve done my research, I want to do the Dasarda. All right, well why? Because I’m not a fan of the Dasarda technique and I have my reasons.

Speaker 1 (00:37:03):

And he’s like, well, I just read it. Everyone says Dasarda Dasarda is great. Well, that’s not true. Not everyone says Dasarda is great and there’s very little data to support Dasarda compared to other tissue repairs in terms of their long term outcomes. And I gave him my two sets about the Dasarda. Oh, he said, okay, well that’s great information. I didn’t know that. I didn’t read that. You know, can kind of fall into a rabbit hole when you do online research. And I was able to kind of open his eyes as to why we do one technique versus another, why he would be better with one technique versus another and so on. And so I also kind of gave him the data for chronic pain with open tissue repair, with open Mesh repair with laparoscopic Mesh repair and so on. And yes, the Shouldice is one of several open angle hernia techniques without Mesh. Yeah, so I hope this is clarifying. I don’t want to confuse you guys anymore, but it’s one of those things where it really bugs me when people are misled and because of them being misled and trusting one doctor or being told it’s all in their head. They just believe it and then years go by. I’ll give you another example. I had a lady, I think I told you this story before.

Speaker 1 (00:38:37):

I think I told her the story because it really affected me a lot. She’s a lady, I think she was in her seventies for 21 years and that’s my record so far, for 21 years she’s had chronic pelvic pain. Her son brought her in. Lovely lady. She walks with a limp. She’s uncomfortable. She would like to be more active at home. She can’t be…she used to belong to a social club. Sitting hurts, bending hurts, all these things. I’m like, you have a hernia?

Speaker 1 (00:39:11):

What? I have a hernia? Yeah, I’ve had this for 21 years. You’re telling me I have a hernia? Yes, you have a hernia. Here’s the imaging. Here’s a study. Here’s where it is. I’m going to show you where the hernia is for 21 years. She was just told, it’s all in your head. It’s chronic pelvic pain. Let’s take out your uterus. She took out a uterus. Let’s take out your ovaries – cut out ovaries. Maybe it’s your gallbladder. She had her gallbladder taken out. Maybe it’s your appendix. Everyone was dancing around the diagnosis. Anyway, I fixed her hernias and I saw her after surgery cured like brand new person and the son started crying and it was because he had forgotten what it was to see his mom walk without a limp.

Speaker 1 (00:40:01):

I just get emotional every single time I tell this story. He does not remember what it was like with his mom to walk without a limp because now that the hurry is fixed, she’s walking normally without a limp for 21 years. She was told it was in her head and there’s nothing to do and everything that can be done has been done. So it really pisses me off when doctors or people tell each other, I see it on the forms a lot. Don’t do it. You’re going to die. I mean my patients don’t die. Most of us who are hernia experts don’t have patients that die. It’s not considered a life threatening problem and we’re there to improve quality of life.

Speaker 1 (00:40:50):

Which procedure do you think has the absolute least chance of injury or complication to occur open or laparoscopic? I was watching a lecture from a doctor about the numbers and he said Open is about one in a thousand and laparoscopic is about six and 1000. Of course, it’s highly dependent on the skill. Yes, it’s completely dependent on the skill. Just like driving, what’s the safest car to drive in? What car has the least car accidents? It’s really the driver. So a professional driver or terrible driver, someone who just learned driving, they’ll have different traffic accident or where are you driving in the freeway or in the streets? So in general, if done by someone who does this well, so if you’re an expert open, you’re doing open surgery or if you’re an expert in laparoscopic, you’re doing laparoscopic surgery, they’re pretty much equal.

Speaker 1 (00:41:55):

Laparoscopic is slightly better. So the chronic pain rate is slightly better and lower with laparoscopy than with open. That’s if done by experts. So expert laparoscopic surgeon versus an expert open surgeon. If you take all laparoscopic surgeons and all open surgeons, not experts, laparoscopic is definitely better and has much better numbers in terms of reduced chronic pain and reduced risk of recurrence. However, there have been serious injury reports with laparoscopy bowel injury, vessel injury. Knock on wood, I’ve never seen it, but I have read about it. It’s not common, but it does get highlighted in many of the literature. So that’s kind of the study what I think. I’m glad you guys think this is good information. It’s kind of one of those topics that I thought we should definitely review because no one ever discusses it. How do I know which surgeon choose once I get a second opinion? Yeah, we kind of discussed this.

Speaker 1 (00:43:11):

I think you should go for the surgeon that you feel closest to because if you have a question or if you have a complication, you need to be able to reach the doctor, not get ghosted by the doctor. I see this new term being ghosted. I see that being used now by patients. My doctor ghosted me and that’s horrible. But some doctors may be overwhelmed with their job or just personally feel like they don’t like interacting with patients who have complications and others are totally okay with addressing things head on. So my personal bent is I always choose a doctor who has good bedside manner and is approachable and reachable and will address a complication and be there for the patient. I think that’s a very important trait. That said, they also have to be skilled, but if they were equally skilled or one person’s like more famous, I would still choose the one with the better kind of bedside manner. I think that goes a long way. It really does.

Speaker 1 (00:44:35):

Thanks for watching you guys. A surgeon who seemed very confident gave the option to do robotic with synthetic Mesh or open with biologic Mesh. Why would Mesh type determine if open or robotic? Yeah, that’s ridiculous. No reason. All surgeons are confident by the way. There’s a joke where we say sometimes surgeons are sometimes wrong, but never in doubt. You’re kind of trained. It’s like very military surgical training is very military type and yeah, confidence can exude, but the skill has to be there to back it up. For people who have Mesh reaction, what is the suture you choose to use most? That’s a good question. I tend to use nylon or short acting, sorry, absorbable PDS or maxon suture. I’ve noticed that that tends to give the least amount of reaction, but is not the, it is not the suture of choice for the typical patient. Solid answer. Thank you. Okay. You guys are doing great. Time is flying by too. I like my first opinion surgeon, but my second opinion surgeon is more skilled. Which one do I choose? I kind of answered that already, but the take home message is you need to be comfortable with your surgeon and a skilled surgeon that I won’t address your needs I don’t think is as good as a caring surgeon. That’s kind of my stepdad.

Speaker 1 (00:46:15):

All righty. Let’s see. I had two C-sections and umbilical hernia surgery with Mesh. I also have a diastasis recti. Can my diastasis ever go away? No, that does not go away without surgery. This far out from your operations, you said most of your operations are revisional. What are the most common complications you fixed that were misdiagnosed by previous surgeons? Great question. Yes. Most of my obtuator are to be visual. The ones that have had recurrences, it’s almost always because the of a technical problem. So the surgeon chose too small of a Mesh or placed it in two small of a space.

Speaker 1 (00:47:18):

What are instead the complications that were correctly diagnosed, but others, other surgeons were unwilling or unable to fix? Another great question. I feel that there are, if a patient has a groin pain after hernia surgery, there’s a reluctance to go in there and undo that repair because there’s a thought that you could injure the testicle or the groin or the whatever it is or the effective blood flow to the testicle or injure the nerves. So there’s a reluctance. They’re like, yeah, your Mesh is balled up. Yes, your nerve in the trap, yes, it’s affecting your sexual function, but I wouldn’t touch it. It’s very risky operation. You can die. I hear that a lot. I hear that a lot. Yeah. Let’s see. Next one. You’re one of the few surgeons who have extensive experience in treating Asia patients. That’s Asia stands for autoimmune or autoinflammatory syndrome induced by adjuvants. What are the anomalies you typically see in their immunologic studies? Well, not much. So if you look at their rheumatoid or autoimmune labs, always normal. If you look at their inflammatory labs, C R P and E S r, normal, there are some interleukins you can study. Those are not able to be done under normal circumstances or the normal lab. And yeah, it’s an enigma. That’s why I say it’s enig enigma.

Speaker 1 (00:49:10):

This topic, your comments, the women who had 21 years of pain. You’ve answered many of my questions. Thank you. You’re awesome and greatly appreciated. Thank you. Okay, next question. Will a spinal cord stimulator for lower back issues mask the groin pain from small bilateral inguinal hernias? Depends on the level. So most groin pain is L one, L two, and most people with spinal cord stimulators are L5, S1 or L4, L5. So usually not. Yeah. Wow. That was me. Few markers of inflammation. That’s right. It’s, it’s not common to see the inflammation. Do you think tensor fascia lata flap surgery could be a good solution for recurrence after meshable for people who have systemic Mesh reactions? Okay, let me tell you, tensor fascia lata flap or TFL is a major and very deforming operation. You’re basically using your own

Speaker 1 (00:50:18):

Body’s tissue as a biologic Mesh. It’s still a Mesh, but it’s your own body’s Mesh, but you’re moving it from one part of the body to the other. So you’re going to have a huge scar on your thigh. You’re also, which will give you chronic pain many people have and sometimes a nerve is injured in doing so. And the recurrence rate with that is about the same as any other biologic Mesh, which is in the 30 to 40% risk. So you’re now undergoing a huge operation with more than one out of three chance of it falling apart. I’m not a fan of TFL. I only use it in patients that are really end stage.

Speaker 1 (00:51:02):

There are a lot of other options you can do besides that. Okay. Does nylon sutures dissolve over time like silk, even though it is permit? No, it does not. If you sew the midsection, would you have to worry about tearing the muscles because of nylon? Anytime you sew, you’re at risk of tearing. That’s why we prefer not to sew things tightly because the sutures almost never tear. It’s almost always the muscle tissue that tears. I have chronic cough. Oh, because of a long microbacterial infection for more than three years, I have two inguinal hernias. The doctors say the hernia will come back because of the cough. I have a quite miserable quality of life with both hernias popping up every time I cough. New doctor wants to operate placing Mesh. I would like to know your suggestion. Yes. So there are patients that have risk factors for hernias recurring just baseline and it’s untreatable.

Speaker 1 (00:52:06):

Let’s say you have bad asthma and you’re coughing, or you have this chronic cough that no one’s been able to address, or you have straining, you have no colons, you have to strain to empty your bladder. There are a handful of patients that have problems that will exacerbate the hernia and you just have to work around opera singer. If you’re going to operate on a professional opera singer or a trumpet player or a tuba player, those patients are constantly, you can’t say, yeah, I’ll fix your hernia, but you can’t play the tube anymore. You have to drop out of the metropolitan Opera. No, can’t do that. So in those patients, you change your technique to accommodate for this increased risk in recurrence. So for example, I’ll give you an example. So for yours, if you have hernias, I would use an extra large Mesh, not the typical Mesh, so that there’s even wider overlap, giving you extra support.

Speaker 1 (00:53:17):

I would use tacking and fixation and not just lay the Mesh in so that it’s kind of sucked in place and doesn’t move and doesn’t get pushed into your hernia. So there are options, definitely are options. Are some people just so prone to hernias that their tissues cannot be repaired without Mesh? Yes, I was told Mesh is needed for my hernia, even though no imaging was ordered to measure my hernia and it’s guest to be large, to need large enough to need Mesh. Okay. Depends on where the hernia is and how your hernia is and what type of hernia you have and what your risk factors are. So for example, if you have a connective tissue disorder, like Ehlors Danlos syndrome, you have to have Mesh. They’re just, you cannot have tissue repair period. So that’s kind of where the kind of evidence goes in.

Speaker 1 (00:54:04):

But you should get imaging, why not more imaging and more studies the better. So beside yourself, who else would you recommend that specialize in hernias that you believe has a high skill level, high success rate in California or Southern California? So go to hernia talk.com, which is where this hernia talk live q and a arose from. And there are plenty of surgeons that I think are great and that we’ve talked about on hernia talk.com. And also just look at the people that I endorse, so to speak, on these Q and as. This is I think our 61st or 62nd episode. So there’s plenty of surgeons that I’ve talked to that are great surgeons and those are some good resources. Have patients successfully tolerate biologic Mesh after having biosynthetic Mesh reactions?

Speaker 1 (00:55:03):

But I have had patients that have had allergic reactions to strattice and to phasix and to ovitex. So it’s not a hundred percent very, very low risk though biologics in general have very, very low risk. Is the systemic blood test you’re talking about called IL6? Yes. One of them is called i L six. There’s many ILs- interleukins. Okay, A couple more and then I’ll let you guys go. Do you encounter, do you encounter macroscopic evidence of Mesh illness during your surgery? No, I usually do not every so often I will see a lot of edema where the Mesh is, which is not normal many years after surgery. But in general, when we take out Mesh for a Mesh reaction, we don’t see anything. It’s more of a, it’s not even microscopic. We have looked at the pathology and no one that I’ve studied who’s had their Mesh removed had any difference in their pathology than someone that had their Mesh removed for not a reaction. This is my first hernia talk live. I’m watching, so I have to catch up and watch those. Yes, you do. And then you’ll be a fan forever.

Speaker 1 (00:56:29):

What is it in ASIA patients where the relationship between inflammation and Mesh and the mind fog comes into play? Many of them report mind fog. Yes. So we don’t know, but there’s one study that has been published that correlated brain fog as actually due to total body inflammation. So it’s not just from Mesh, but any type of inflammation in the body can induce brain fog. And that’s kind of where that correlation is, I think that’s what it is. Dr. Towfigh do a fantastic job getting everyone’s questions and hitting the subject matter head on. Thank you. You know what? I like that you say head on because many times I feel doctors are kind of told, don’t make a decision for the patient and just give them all the data and have them make the decision. That’s great. However,

Speaker 1 (00:57:38):

Some of us, and I fall prey to that too. I feel like I give you my 2 cents. I would recommend this more than that, choice A, more than choice B, but you can make your decision. I’m okay doing choice B, but here’s why I recommend choice A. Some surgeons actually, many surgeons say choice A or B, you figure it out and they kind of refuse to get involved in the patient’s decision process, which is totally okay. In fact, it’s why we kind of teach in medical school. But I feel that often patients do need some guidance. And so I do provide guidance, but it also means that I’m inserting my own biases into your decision making. So I don’t want to be a pushy doctor for any specific procedure, for example. But yeah, thank you for telling me. I do try and hit subjects head on and not kind of dance around.

Speaker 1 (00:58:34):

I have so many patients that come in and say, went to see Dr. So-and-So and I came out and I have no idea what the plan is. We talked about the hernia. I have no idea what I’m supposed to do. Am I supposed to go for surgery, not surgery? Which surgery? How do I treat the pain? Have no idea. And I, I’ve been in that situation myself for my family. So thank you to all of you who appreciate that and are not haters. Thank you. Thank you for that. Thank you for taking the time out of your life to bless us with your insight and wisdom. Thank you so much. And I’m glad to see that your training services, yes, in fact, I can’t show it to you, but over there in my office is a whole set of goodies for our new incoming surgical interns at Cedar Sinai.

Speaker 1 (00:59:26):

They’re amazing. Every year is even more amazing, and I’m super excited that I get to work with them. I often don’t get to operate with them until they’re in the third year because the service that I work at, which is the minimally invasive surgery service, tends to have more complicated patients, but I like to stimulate them with a little bit of hernia stuff in their first year. So they are encouraged to do some of that. So I’m super excited that we have a whole new class of interns that just started, I think last week, and they’re doing a great job of taking care of my patients and being educated. And if you were able to look over there, you would see some goodies and packages that I made for them, which I will deliver to them on Thursday. On that note, thanks everyone for joining me, another hernia talk q and a. I hope you all have a nice summer break. I will see you later, and we’ll have more great guests for the rest of the year. And thanks for everyone for following me on Hernia Doc, on Twitter, at Hernia Doc, on Twitter and Instagram at Dr. Towfigh on Facebook, and watch for all the episodes on my YouTube channel. So those of you that have missed it go watched on YouTube and I, nice job of making sure that everything’s done well for you. Bye everyone.