Episode 63: Hernia Repair in USA vs the World | Hernia Talk Live Q&A

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Speaker 1 (00:00):

Good afternoon everyone. It’s Dr. Towfigh. We are back on hernia Talk live every Tuesday, talking about any topic you’d like to discuss that’s hernia related. As many of you know, my name is Dr. Shirin Towfigh. I am a hernia surgery specialist. I also do lots of laparoscopic surgery, almost always for hernia related problems. Many of you are on Facebook at Dr. Towfigh. Thank you for joining me on Zoom. Also, for those of you that follow me on Instagram and Twitter at hernia doc, I’ll be posting the link to our YouTube video of this session on all these social media assets. So today I’m back and I’m looking forward to talking about hernia surgery and hernia repairs and the world because I feel that many of us in the United States seem to get very caught up in what is happening in the us. And the reality is the majority of patients that need hernia surgery are not in the United States.

Speaker 1 (01:11):

We do about a million operations a year. There’s much more than that done on a daily basis throughout the world. And the question is, does it matter where you have your hernia repair? Does it matter if your surgeon is in the United States or elsewhere? How does surgery differ in other countries in Europe, in Asia, Africa, middle East, Australia? I know that I have a lot of followers all over the world. I also belong to an international hernia collaboration where we have I think 12,000 surgeons or more from around the world. And we all talk about hernias and how we do things. And the reality is we’re a bit privileged in the United States in that we have access to a lot more technology, much more kind of advancements in the hernia industry. We also provide much more expensive care, which those two kind of follow each other.

Speaker 1 (02:20):

And even in places like Europe and we’ve had multiple surgeons from Europe that have been on hernia attack live, what they can offer, what they have access to is different than the United States. That’s it. They also have access to things that we don’t have access to because our FDA has not yet approved it. And it’s very expensive to get certain things approved in the United States to some products never make it to the United States. So it’s very interesting to collaborate with friends. I have a lot of friends outside the United States that are hernia surgeons and I find it very fun and interesting to learn their healthcare system is and how they treat hernias. And also the patients are different. I would have to say that the patients have different demands in the United States than elsewhere. We also have a bigger obesity epidemic than elsewhere. So it makes treatment of hernias and the incidence of hernia is different.

Speaker 1 (03:19):

We don’t have as many smokers as they do elsewhere. And so that’s something that we don’t have to deal with as much in the United States, especially in certain coasts. So it’s interesting, many of you know that I offer all types of hernia repairs, laparoscopic open tissue based, Mesh based, hybrid based. I do Mesh removals. I kind of offer everything. And I must say certain countries don’t. For example, laparoscopic surgery is most commonly performed in the more developed countries. You don’t have as much access to laparoscopic operations and repairs in outside the developed world. A lot more Mesh repairs in the developed world is much more expensive to provide care with Mesh. And so most countries, even in China, which is a huge country, but it’s not a very rich country when it comes to medical resources, they don’t use Mesh as often as we do in the United States.

Speaker 1 (04:27):

I think certain countries in Europe also tend to be more tissue based In Africa and some of the poorly developed countries, not only do they not have Mesh, if they do, it’s often a very generic, generic Mesh. The quality and the knit is unclear. There’s some reports of using mosquito net for Mesh in situations where you need an implant course much cheaper than medical grade Mesh. So it’s kind of interesting how each country has developed its own practice for hernias. And then lastly, what’s really cool, which I thought was really cool, some of our society meetings that we go to, and I go to as many of them as possible that are hernia related. They have a section for how we do it in the third world. And there’s a society called sages. It’s S A G E S. It stands for the Society of American Gastrointestinal and Endoscopic Surgeons.

Speaker 1 (05:32):

They are the world’s largest laparoscopic society. And so it’s technically an American society, but it’s very international. And I remember a long time ago, I would say maybe 12, 15 years ago, maybe 15 to 20 years ago, I went to a session that said how we do laparoscopic surgery in third world countries. And this was in Africa, small towns in India where the anesthesiologist doesn’t even have access to an anesthesia machine. So you need general anesthesia to do laparoscopic surgery because you need muscle relaxation to then expand the abdominal wall with gases and so on. And they don’t have carbon dioxide to pump the gas in. They don’t have anesthesia machine to give general anesthesia. So that alone is a kind of difficult to do laparoscopic surgery with. And then in addition, they don’t really have a lot of the laparoscopic instruments. Many of them are donated from the United States and elsewhere, but they tried to provide minimally invasive surgery and it was fascinating stuff that we would pay $700 for in the United States, like a dissecting balloon.

Speaker 1 (06:48):

They would kind of rig it, so it’ll cost ’em like a dollar or $2 by using, instead of using a fancy balloon, they’ll use a glove finger instead of gas, they would use fluid or they didn’t have the gas to fill. So they had these special things they made at some shop where it just elevates the abdominal wall. It’s just really fascinating. So I hope that some of what the information we get out from today’s session in addition to the questions you’ve submitted, because I see some of you are already on that have submitted me questions. So I will definitely get to yours maybe even earlier than expected because I don’t want to keep you waiting. But I hope some of the other stuff that we discussed today is going to enlighten you a little bit because those of us in the United States sometimes forget that hernias are practiced differently in different parts of the country. There are limitations in the United States and there are limitations in other countries, mostly in other countries. And they deal with different types of complications that we do. And I know that many people travel to the United States for their care, but many Americans also travel to Europe and elsewhere for their care. So I would love to discuss that in Canada. Let’s not forget Canada and Mexico and other countries in North and South America. So let’s go through all your questions. Let’s see.

Speaker 1 (08:24):

I know one of you is really interested in the answer to your question. So let’s go through that first and then I’ll come back to the topic at hand. So the question that was presented to me on Instagram was multiple fold. One is, I have a sublay Mesh, can you remove these meshes and just to kind of discuss what sublay is. So where you put the Mesh in relationship to the hernia has different terms. If you put it on top of the hernia, which means superficial to the hernia, we called it an Onlay repair. So a typical Lichtenstein hernia repair for the groin is considered an Onlay because the Mesh is on top of or superficial to the hernia. Many surgeons offer Onlay hernia repairs for abdominal wall hernias. It’s, it’s kind of grown out of favor, but there are situations where if done correctly, it can be done with good success. Then there are sublay and underlay options for Mesh placement. And that has to do with how deep you put the Mesh in relationship to the hernia. So sublay is when you put the Mesh deep to the muscle. We also call that retrorectus. I would say that a typical laparoscopic inguinal hernia or robotic inguinal hernia repair is a sublay.

Speaker 1 (09:54):

Also, there are situations where you have a retrorectus repair. We call it a Stoppa or a Rives Stoppa repair. Those are TAR. Those are usually sublay repairs. So it’s deep to the muscle, but it’s not inside the abdomen. And then there’s underlay, which is deeper to all the other components. So the underlay can be deeper to the fascia or deeper to the peritoneum, which implies it’s inside the abdomen and against the small intestine and the colon and all that. So a sublay Mesh is unique because it’s kind of sandwiched between nice juicy, healthy vascular muscle. And the fascia, which is the strength layer, I think it’s the best place to put the Mesh because it’s away from the intestines. Number one, it’s away from the skin. So if you have any skin problems, wounding complications, the Mesh is not exposed and it’s against healthy vascular muscle, which makes it stick better.

Speaker 1 (10:59):

And also it’s less likely to get infected. It’s also the most difficult place to remove Mesh because it’s sandwiched. So you can’t access it directly from any mode. You have to completely undo the repair and then redo the repair. So it is a much more invasive operation if you need to remove that Mesh. Fortunately, we almost never have to remove subway Mesh. I personally, I’d have to think hard about when I’ve had to remove subway Mesh. It may have been during a fistula or an infection. Very, very, very uncommon. So sublay Mesh when needed to be removed is a big deal. And I would say probably is almost always done in open fashion. Laparoscopic or robotic is not a way to do it. So can it be removed? Yes. Is it complicated? Yes. Does it imply a lot of morbidity, which means that it kind of affects the way the hernia can then be repaired? Yes, it does. So that’s kind of my 2 cents about the question about can you remove Sublay Mesh? The next question is for the same patient. So this patient is now three years after umbilical hernia repair with Mesh in sublay fashion. The Mesh was placed, she still has pain and she had a CAT scan, which shows a lot of inflammation. What can the inflammation be from? Let me tell you, if you have lots of inflammation three years after hernia repair, that’s an infection until proven otherwise, you should not have persistent infection. Sorry, you should not have persistent inflammation. So much so that you can see it on CT scan

Speaker 1 (12:55):

After maybe months to a year after surgery. That should be a well-healed area. It could. You can have scarring. That’s okay, but not inflammation. The CT scan’s showing inflammation. That’s inflammation due to an infection, which is an active process until proven otherwise. And that can cause pain and the infection can be low grade or high grade or whatever. So any CT scan finding of inflammation that far out from surgery isn’t is most likely an infection. Now can this be an allergic reaction to the Mesh? Usually not. So in my experience, patients who have Mesh allergies, Asia syndrome, any reaction to the Mesh, which is systemic, even a local reaction to the Mesh, the CT scan is often normal and the findings are not very suspicious on imaging is mostly a clinical diagnosis. So usually no, it is not an like a Mesh reaction, but it may be a hernia, what do you call it?

Speaker 1 (14:07):

It may be a infection. So one comment you’re providing me here is removal of sublay. Mesh may increase risk of denervation. That’s a good point. So very good point. Usually removal of Mesh from the groin where there’s a lot of nerves, you have to be able to identify the nerves. And if there’s nerves that can be damaged from the Mesh removal, you have to address that and that may result in denervation. However, usually removal of Mesh from the abdominal wall, like a hernia in the belly area does not cause nerve damage. Usually does not co cause nerve damage. Cause usually those nerve meshes are either on top of or superficial to the hernia, which is an Onlay or deep to the hernia, which is an underlay. And those, there’s no nerves in those regions. However, if you need to have Mesh removed, that’s sandwich. That’s where the nerves live.

Speaker 1 (15:15):

So yes, you are correct where the nerves live are where the muscle is. And if you need to remove the Mesh and the Mesh is very widely placed all the way to your sides, that’s where the nerves live and it is a risk that nerves can be damaged as part of that. So thank you for mentioning that. That’s a good point. All right, so I hope that helped answer the questions. The other question that was submitted, I’ll also answer since we’re on a roll here, is a hernia more visible on CAT scan with or without contrast? So as many of you know, CAT scans can be ordered with contrast or without contrast. The contrast comes in two forms, either by IV through your vein or orally where you take it as a drink.

Speaker 1 (16:08):

Usually when we talk about iv, when we talk about CAT scan with contrast, we talk about IV contrast. And I almost never order CT scans with IV contrast because it’s an additional burden on the patient. You need a creatinine level check because it can affect your kidneys. You need an IV started and it’s just really unnecessary. So unless you’re looking for an abscess or infection, I almost never address or order a CT scan with IV contrast. It doesn’t help you. It also doesn’t help you find a hernia better. It also doesn’t make the Mesh look any different. So I don’t think it helps. However, oral contrast is different. Oral contrast is what you drink and it goes into your intestines. So it helps differentiate the bowel from everything else nearby because everything looks gray on CT scan. So if you’re drinking the contrast and it fills your intestines with the white contrast, it’ll sh help determine if there’s bowel in the hernia, how close the bowel is to the repair or the Mesh and gives you a little bit more information.

Speaker 1 (17:16):

So I do like to have the oral contrast part. It doesn’t taste very good, but some people don’t mind it and it can give you diarrhea afterwards. But IV contrast I don’t feel is necessary to give you a good CT scan. So CT scan I usually use for abdominal wall hernias, not for the groin. And in doing so I order it with oral contrast but not with IV contrast almost exclusively. All right, so thanks for those questions guys. Oh, we had another question. Let me review that one too. Another question was why would hernias hurt when eating? And also why would hernias hurt when applying menthol products to your skin? So hernias can hurt when eating because when you eat, your abdominal pressure goes up, you’re filling your stomach or intestines with food and you start to get a larger intestine, larger outpouching of the belly.

Speaker 1 (18:15):

And so if you have a painful hernia and now you’re increasing the abdominal pressure by adding a meal, then that can cause pain in your hernia. It doesn’t always, but it is a common complaint of like, yeah, I have this belly button hernia or a groin hernia, and then once I eat it makes it worse. Okay, yeah, that happens. You can also get more nausea with it, the menthol product, isn’t it? Okay, the question about menthol products, why would hernias hurt more when applying menthol products? This is an interesting question. So the way menthol works, it’s unlike bengay and a lot of those kind of topical creams, it cools kind of cools and heats you up and it kind of tricks your brain to thinking that you no longer have the pain. But I think what it does in some people, it can have a reverse hypersensitivity and that’s why you get it.

Speaker 1 (19:20):

So I don’t know that much more about mental products to be honest. I’m a big fan of topical anti-inflammatories like Voltarin, which is now over the counter in the United States. It’s been over the counter in Europe for many years. And in California and some other count states. We also have cbd, which is a derivative of the marijuana plant, which is a great anti-inflammatories. I recommend those sometimes for topical topically used for people with certain types of pains. Next comment. Hi Doctor, it’s great to see you continuing with these live q a. You’re welcome. I kind of missed these, so glad to be back. I have a friend going for surgery today. She already has Mesh, but the surgeons couldn’t see the Mesh on the ultrasound. Is Mesh visible on ultrasound? Yes, it is.

Speaker 1 (20:12):

Mesh is visible on ultrasound. Now, ultrasound may be more difficult in certain patients depending on what they’ve had done, the Mesh, if they have a lot of scar tissue in the area of the repair than it distorts anything deeper to it. Also, the Mesh distorts any problems deep to the Mesh on ultrasound. Also, if you’re obese, it’s hard to get a good visualization of the deeper meshes because you just have a lot of tissue to go through. So the way ultrasound works is this go, it’s like a scanner that goes on top of the skin and then it sends these ultrasonic sound waves, but how deep those sound waves need to go and then revert back to give you an image and how well it can penetrate deep has to do with how obese the patient is if there’s scar tissue and also or the meshes in correlation. So yes, you can see it on ultrasound. It really is dependent on the quality of the ultrasonographer.

Speaker 1 (21:21):

All right, let’s go back. Oh, let, with another question about Asia syndrome. Let’s ask that. So this was one from a few weeks back. What is the relationship between inflammation from the Mesh and the mind fog that many people report with Asia syndrome? So if you’ve looked@herniatalk.com or watched any of our hernia talk live sessions, you’ve heard me talk about Asia syndrome. Asia is an acronym. It stands for autoimmune and Autoinflammatory syndrome induced by adjuvants. It basically means you have an implant and that could be a breast implant hernia, Mesh implant spine implant, any implant pacemaker who knows any implant. And you are inducing a reaction of your body to that implant that is either inflammatory or autoimmune. And then that that reaction to the implant sparks a bunch of other symptoms. Mind fog or brain fog is one of them. There’s a great new paper within the past year and a half, almost two years that specifically discusses why people get brain fog. And the thought is that inflammation that could be due to anything, it could be inflammation from a pneumonia or it could be inflammation from hepatitis or it could be inflammation from the implant.

Speaker 1 (22:59):

Inflammation somehow sends out these different proteins and products in your system that then get to your brain, and when they get to your brain, you get brain fog. So the effect of inflammation in your body on the brain is what induces brain fog. So that’s kind of interesting to me because I always wonder too, why brain fog? It’s such a common story that I hear that, oh, I have difficulty concentrating, I have brain fog, and it gets better once you relieve the inflammation and it’s an inflammatory reaction of the brain, of the brain to the inflammation. Kind of an interesting finding. I thought it was really cool that someone was able to publish all that. I just wanted to spend some time to discuss the difference between the US and the world.

Speaker 1 (24:02):

Yes. One of you has is saying you have the brain fog. It is horrible. Yeah, it is horrible. But in just know, in the presentation we made earlier in the brain fog can be from inflammation due to infection. It doesn’t have to be the actual Mesh necessarily. Now, if your Mesh is infected, it has to be removed regardless of whether you’re reacting to it or not. But just know that inflammation can be due to infection as well as Asia syndrome. Okay. So you may know that I’m a member of the American Hernia Society. I’m also very active on our international hernia collaboration, which is over 12,000 surgeons all over the world that talk and discuss. I think I was one of the first two or three members of the society, this collaboration, which is really cool, and I remain active on that. And we have an annual international meeting of the international hernia Collaboration where we go to different countries.

Speaker 1 (25:04):

And as a group of handful of chosen surgeons, we go to countries usually less developed countries, and we provide expert training and teaching and talks and live surgeries, and anyone can attend the meetings, but it’s intended to reach out to provide expertise to countries where you know may not be able to travel to an international meeting because it’s expensive. So we come to you. I’m also very active with our European Hernia Society. This year’s American Hernia Society meeting is in Austin, Texas. Our stages meeting is in Las Vegas, which we’ll see what happens with this COVID. And then the European Hernia Society meeting is in Denmark, in Copenhagen. So I’ll be involved in all of those. And in each of these meetings, we get to work with not only people from our state, but people from other states, Canada, south America, central America, and then in Europe.

Speaker 1 (26:11):

A lot of the Europeans. And these are all really popular meetings. We know all our hernia friends and it’s really great. But what I really enjoy is seeing how other surgeons do what they do because you can get kind of landlocked in the United States where you think everyone does it the way we do. The reality is, for example, biologic meshes is not a thing outside the United States. It’s super expensive and the technology is just not, it’s, it’s somewhat overused in the United States and underused outside. What else? Robotic surgery, pretty much nonexistent in most countries. It’s just way too expensive. A robot costs 2 million, plus it costs about four to $600 just to use it each time in their reusable instruments.

Speaker 1 (27:09):

And then in Europe, it’s starting to get popular. I’ll give you an example of my hospital, Cedar Sinai. We have seven or nine robots, that’s one hospital. We have three major hospitals within a matter of miles, and they all have their own kind of set of robots. I think in all of Europe it’s barely, I think 10 or 15 in the entire continent. And that’s just because I think Belgium may have one or two, and I think Austria may have one. It’s Germany may have a handful. It’s just not feasible. Most of those countries have socialized medicine and paying 2 million for a robot doesn’t provide added benefit because that takes away healthcare money that could provide, I don’t know, care for children or pregnant women or whatever their needs are. Cancer patients. So we have a capitalist system in the United States and do not have socialized medicine, and it’s much easier to introduce expensive technology in the United States, which is cool because I certainly have learned to integrate robotic surgery into my practice and I think it’s really awesome, but it’s super expensive.

Speaker 1 (28:38):

And if I had to run a socialized medicine, maybe robotics wouldn’t be part of it because it’s just, it’s very expensive. It’s like saying, I really love my Ferrari. It’s awesome. Do you really need a Ferrari? I mean, it may make you happier. It may maybe would be more fun to drive in the drive in the highway, but maybe a smart car would be more feasible if you’re running a national system. I’m talking a lot of nonsense. But the point is that every country is very different in what they provide, what they have access to. For example, we had a European surgeon, Dr. Barbara East from Czech Republic, great country, part of the European Union, they have one type of Mesh. That’s it. It’s not like when I go to my hospital, there’s a whole rock, actually, multiple rocks, and there’s about I would say four or five different types of Mesh and then within those multiple different shapes and sizes and so on. But they just get one, and that’s something that she talked about. All right, let’s go to some of your questions. Again, yes, I have brain fog, but for some reason, brain fog is not recognized as a medical condition.

Speaker 1 (30:11):

So the term brain fog is a layman’s term. There is no term, no medical code for brain fog, but there is kind of a sense of poor concentration. It’s poorly understood. Like I said, it wasn’t until a couple years ago that they finally published a paper that correlated inflammation with brain fog. This is an interesting question. If you had to pick a surgeon beside yourself to do complex multilayers of inguinal Mesh in a 58 year old male, four layers plus coils in the us, who would you pick?

Speaker 1 (30:56):

Why are you putting coils? So four layers, I assume you mean the Shouldice repair. So you’re asking who would be the best surgeon in the United States for a Shouldice repair? I don’t understand the question about the co coils. We don’t use coils for hernia repairs. So there are multiple surgeons that provides Shouldice type repairs. There are multiple surgeons in the United States that actually were trained in at the Shouldice clinic. I have seen many of them operate. They’re all very good. I have also interviewed many of them on hernia attack live. So in general, if I’m talking to a surgeon on hernia attack live, it means that I respect them as a colleague and as an expert in what they’re discussing. So they do have my endorsement in some kind of way professionally. Okay. Oh, four layers of Mesh.

Speaker 1 (32:06):

Why would you have four layers of Mesh? I don’t understand the question. Metal coils out in 1999 metal coils installed in 1999. Several have been removed. Yeah. Okay. So if you want to have a revisional operation in someone who’s had multiple meshes placed in, yeah, there’s a tons of, not tons. I mean I take that back. There are multiple surgeons in the United States that can provide care to you. Many of them are on hernia talk.com or I’ve interviewed them and we’ve discussed it. So hope that helps you. Gut health also contributes to brain fog. The gaps diet is helping me very good. Probably related to the inflammatory cascade that is provided by the intestines. The intestines are a huge harbor of hormones and intestinal cytokines. So when people have got problems, it can completely affect your lifestyle. All right. Next question. Or all surgeons train in hernia repair?

Speaker 1 (33:17):

Good question. So general surgeons are all trained in a hernia repair. Now what types of repairs and how good their training is? It varies depending on where their training is. But if you’re a general surgeon, you’re definitely trained in hernia repairs in some urology residencies in the United States, they are also trained in hernia repair, but it’s not a common finding. How is the US surgeon trained different than other countries? That’s a really good question. So in the United States, you have a multi-tier kind of training. It’s very difficult to get to to each tier. So first you have to get into college. That’s four years, usually four or more years. Then you have to get into medical school. That’s minimum four years as well. And then you have to get into residency, which is the clinical training that medical school prepares you for where you actually actively treat patients as a physician, as a doctor. And that training for surgery is five or more years. So five years, seven years. The program I went to was a seven year program because they required at UCLA two years of research. Most programs are minimum five years of clinical training. So that’s how it’s in the United States.

Speaker 1 (34:53):

I believe it’s the same way in Canada, but in Europe it’s not like that. And it depends on the type of which country you’re talking about. In most European and also non-European, non-US countries, right around high school, you kind of figure out what you want to do and you fall into that track. So you fall into the medicine track, and if you add all the years, it’s probably similar, but it’s not as regimented and constructed as the United States is. And in many countries, the residency training is not like the us. So in the United States let’s you get into residency for surgery, and that’s a five year commitment. You’d get to rotate with different specialties. You do hernia surgery or laparoscopic surgery. With me, you got a team of cardiac surgeons you work with and a team of let’s say transplant surgeons, trauma surgeons, et cetera.

Speaker 1 (35:53):

In many countries outside the US it’s more of an apprenticeship. So you kind of pick a surgeon or a surgeon team and you’re it with them and you just follow their lead. You just train under them as an apprenticeship. And it’s kind of unclear when you finish your residency. It’s so weird to me because I know people that are in residency, residency, which is really an apprenticeship for nine years or more, and many countries, you really can’t start your own practice until another doctor dies. You can’t just have this overpopulation of it’s very kind of controlled who can get a medical license to practice on their own. So I really like the US system and I think most people find the US system to be the best, which is also why so many people come to the United States to get trained and so many people come to the United States for their medical care.

Speaker 1 (36:54):

It’s very excellent, well-rounded training. And it’s also a system where as a US trained physician, you pretty much can go to most countries and get a license to provide care there with some countries being more difficult than others. But the reverse is not true. No one can come in the United States and say, Hey, look, I’m this great surgeon in let’s say Czech Republic, hire me or I’m going to start seeing patients. No, you can’t even get your medical license like that. You have to pretty much redo us residency. We don’t accept anyone else’s residency with rare exceptions. There are some exceptional people that are highly recognized to be excellent that can get kind of a limited job, but pretty much you have to redo all your residency, which is crazy because some people comment like ages 40, 50, 60, and they want to Rives, they want to be a doctor in the United States and they have to read your residency with some 30, 25 and 30 year olds.

Speaker 1 (38:09):

So it’s kind of interesting that way, but I just wanted to share that with you because our practice is different. And then for hernias it’s also different, and I’ll go into that a little bit later. So do surgeons learn from and collaborate among different countries? Yes and no. So I certainly do and I love it. I love learning how other surgeons do it and how their care is different. Some countries, for example, have a big tuberculosis issue or hepatitis issue. So the patients they operate on are different. They have a lot of smokers. We have a lot of obese patients and diabetes in our population that affects how our patients heal. So my point is that it’s very good to understand the limitations and also what can be done in other countries. So we do collaborate. We have this international hernia collaboration of over 12,000 surgeons where we talk to each other and we learn. I would say most US surgeons don’t do that. It’s just not a thing. But we do have resources for them to do it, which I think is really cool. And then the big question is are hernias repaired the same in all countries? No, they’re not. It’s so interesting though. So if you look at hernia history, there’s a lot of it that originated from Germany and France, and there’s kind of the top two countries, usually Germany, really

Speaker 1 (39:58):

Dr. Stoppa from France and Dr. Rives from France, the Italian surgeons, Bassini Shouldice is Canadian. These are all a McVay as American. So these are all famous surgeons that have made an impact on hernias and hernia surgeries, and they’re from different countries. Some of these have been validated and now are pretty much done elsewhere. But as you know, Shouldice and Bassini and McVeigh operations are done in the United States, but not commonly. These are tissue type repairs. We tend to do the Lichtenstein hernia repair, which is a US based US invented technique, actually not just US Los Angeles, not just Los Angeles, Cedar Sinai Medical Center, which is the medical center where I work. So I think that’s a cute little detail, but the tissue repairs tend to be more common in the undeveloped countries and still also very common in the developed countries outside the United States. That includes Canada, Mexico, and most of Europe for the Inguinal hernias, especially

Speaker 1 (41:17):

China for sure. And then the Mesh based repairs tend to be more dominant in the United States, and then also some of the more developed countries such as UK and Australia. And what’s interesting to me as well, I’ll just make a side note, is this issue with Mesh related complications and Mesh related problems tend to be not exclusively, but mostly in the English speaking countries. So UK, Australia, United States, a little bit of Canada, which is so weird because Mesh is used in China. I don’t see patients in China. I see some patients from India who have Mesh complications but not really in China. So it’s kind of interesting to me and I don’t know why there seems to be a predominance of Mesh related complications [inaudible] in the English speaking countries. We’ll have to figure that out. I believe people with hernias have traveled to Europe for adhesion removal. I find it interesting that other countries are successful at doing certain procedures and the US has not implemented them. So adhesion removal can be done anywhere. There are certain surgeons and groups in Europe, in Germany in particular that are very active in educating patients about different hernia repair types and they’re getting much more international patients coming to them, and they’re actually expanding to the United Kingdom to kind of capture that patient population adhesion removal. As far as I know, the technology for adhesion removal or anti adhesives is the same in the United States as it is in Europe. I don’t know of any products that are available there. There’s not available in the United States, so that’s interesting. I’ll look into that to see what else I can learn from that.

Speaker 1 (43:34):

Okay, another question. I’ve had two meshes removed at the same time, but I continue to have pain from a nearby area of the abdomen.

Speaker 1 (43:43):

It is always sore and the area feels a bit caved in and disparity. You can feel the muscles are softer than the other areas of overall sensitive. I have to press on it to alleviate the discomfort. I’m so sick of this pain, what could be causing this? And who do I need to see for this? I also have mid-back pressure and pain laying down flat is painful and causing a lot of strain. I wonder, I mean I don’t know your situation obviously, but I wonder if you have a small hole or hernia at the edge of your Mesh removal. So when we put Mesh in, we often sew the edges and especially if it’s a ventral hernia like abdominal wall hernia, there may be what we call trans fascial sutures or sutures go through the full length of the muscle and the Mesh. And then in removing the Mesh, you tug on or remove the sutures.

Speaker 1 (44:39):

But I wonder if you had a tear there that never really healed. And so an ultrasound or MRI maybe able to provide a little bit more information so that once the Mesh was removed and the suture was removed, there was you left. What left behind was a small tear. By the way, this started after the first surgery of Mesh implant, not after the removal. So it could be from a trans fascial suture. The pain continues even after removal of the Mesh. The pain is not directly with the Mesh was, but a bit more to left. So when Mesh is placed, it’s often sewn or quilted on the edges. And then what can happen is if it’s placed too tight, then the Mesh pulls in and it kind of pulls at the edge of where the sutures is put. So if the suture was placed here and the Mesh pulls on it, you’ll have a hole here, even though the Mesh is moved inwards.

Speaker 1 (45:37):

So sometimes that could be the reason why you have pain is because you have a hernia or a tear in that region. I would start with some local anesthetic in the area to see if it gets rid of the pain. And sometimes more local aesthetics and steroids and or some P R P can help you heal that without surgery. But if you have a gash there or like a fascial hole, like a fascial tear that never healed from the suturing, the original suturing of the Mesh, then sometimes you need a local area explored either the suture removed or the fascial, the fascia repair. That’s kind of where the detective work comes into play. That’s what I like to do. Does sublay Mesh cause more adhesions to develop than other Mesh placement? Do different types of Mesh tend to create more adhesion? So no, the placement of the Mesh does not change how much scar tissue occurs. But yes, different types of Mesh can cause different types of adhesions. So usually the heavier weight meshes cause more adhesions than the lightweight meshes. And usually the ones that are coded cause less adhesions than the ones that are not coded. The whole purpose of the coating is not to have it cause adhesions.

Speaker 1 (47:05):

Okay, going back to that other one. So do I seek a general surgeon or plastic surgeon to fix the hole? I would seek a hernias surgeon. So most plastic surgeons do not do revisional abdominal wall operations. There are a handful and we did talk to at least one of no two of them on hernia talk live that do revisional hernia pairs that are plastic surgeons, but usually not a general surgeon or sorry, usually not a plastic surgeon. And as a general surgeon, I would only go to a hernia specialist because they’re the ones that have more insight. Kind of like what I was explaining to you, more insight as to what was done, what could potentially be the cause of this pain, and then how to approach it. So I would seek a hernia surgeon and no surgery isn’t easy and quick fix. It depends on your problem, but if it’s a simple fascial tear in the tear fascia, then once that’s diagnosed, then an exploration, just sewing that clothes should be all you need if that’s the problem. It’s all trying to figure these things out. Puzzle solving, it’s what I like the best about what I do. How are hernia meshes different in different countries?

Speaker 1 (48:32):

Great question. I kind of discussed that earlier. So the US has the largest and most varied area of hernia meshes. However, we don’t have P V D F, Mesh. PVDF is this really long term. It’s like poly vinyl dia fluro something. PVDF is a derivative of polypropylene in some ways and it comes in braided form and sheet form. They tried to sell some as sheet form in the US and didn’t really work. There’s a company called DynaMesh in Germany that makes the P V D F in braided form and the Germans love it and they think it’s like the best type of Mesh. They tend to prefer that Mesh over polypropylene and over polyester, which are the more common types of meshes that are used throughout the world, including the United States.

Speaker 1 (49:27):

What I heard was they tried to get FDA approval in the United States and the hernia market is so tough to get into that the amount of money they had to spend for FDA approval and then to compete with the big boys, which is way too much and sounds like they’re just not there yet. They may come to the United States, but we currently don’t have PPDF meshes. So that’s kind of the state of meshes in the United States. And then with regard to sutures, most sutures are similar because Ethicon, which is the Johnson Johnson company and sorry, Medtronic are very international companies and they’re the two top makers of sutures. That said, I believe some of the much poorer countries tend not to use the branded sutures and they kind of make their own sutures and the quality control is questionable. It would never pass United States quality control, but it passes going back to back pain.

Speaker 1 (50:40):

So if you have a hernia or a fascial tear or a diastasis or any core instability, a hernia that can cause back pain. So not all the time because back pain’s pretty common, but there are patients that get their fascial repaired or their hernia repaired, the whole repaired and their back pain goes away. So I’ve had a half a handful of patients that were scheduled for surgery for their spine and I fixed their hernia and their back pain went away, saved them from spine surgery, which if any of you have undergone spine surgery, you understand it’s a big deal and it doesn’t mean that necessarily you’re going to have a cure. So interesting detail for you there. Okay, let’s see. Can I get the same surgical options in all countries? Yes and no. So common operations like the Lichtenstein for the groin and probably open mass repairs pretty much you can get in any country. The more complex operations like the tar, the transverse sub dominance repair tends to be dominant in the United States and they do some in Europe.

Speaker 1 (52:05):

That’s for really big reconstructions. The tissue repairs tend to be better done outside the United States. Those of us who do it here in the United States are far and few and we do offer it, but the volume is just not there as much as it is outside the United States. Certainly Canada and the Shouldice clinic has become the most popular place for tissue repairs for the groin in limited patients. If you look back, we did have a hernia talk live with one of the surgeons from the Shouldice hernia clinic and also a surgeon who used to work in the Shouldice clinic. So really interesting things, but no. And then there are certain countries that offer their own types of repairs that are very surgeon specific. So it is interesting that you can get different hernia repair options provide to you. Now, let’s go back to that question. Laparoscopic surgery, like I discussed earlier, is not commonly offered in third world countries or even many second world countries. It would be in the bigger cities and Canada, Europe, maybe a little bit Mexico and some of the larger cities in South America. But laparoscopic surgery is more expensive than open surgery and Mesh use is more expensive than non Mesh use. And so the more developed the country, the more technology and the more expensive the hernia repair options that are provided.

Speaker 1 (53:46):

Let’s see. Another question. I had a small lipoma removed, but I have a hard lump in the area that feels like the lipoma was never removed six months later. Is that normal? That’s probably scar tissue and that should go away. Just massage the area. Okay, next, how is hernia surgery different? I think we kind of discussed that already in the sublay Mesh.

Speaker 1 (54:15):

All right, well, I’m super excited that we’re back on hernia talk live, our q and as every week we have a really, really cool and different guests for next week. So I’m excited about that. I would like to answer some more of your questions. Here’s another question. How long does it take for a scar to go away? I mean, a year is the kind of the peak of when a scar tissue maximally remodels and then it continues throughout the life. The scar doesn’t go away, but it just remodels itself becomes softer. And so thank you for all of you that follow me. I will continue to post. Please follow me on Instagram and YouTube and Twitter. Twitter tests me more for the doctors. I tend not to do too much for that. So thanks for all your questions. You guys. Glad to be back and answer your questions. Please let me know if you have any specific topics you’d like me to discuss because personally I kind of like to talk about certain topics, but maybe you have certain things you’d like to focus on that I haven’t been doing for you. So on that note, I want to thank you all for your attention. You are awesome. Thank you. And I will see you next week on another episode of Hernia Talk Live every Tuesday. Thanks everyone.