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Speaker 1 (00:00:00):
Welcome to Hernia Talk Live. This is our weekly episode of Hernia Talk Live Q&A every Tuesday. We call it Hernia Talk Tuesdays. I’m your host, Dr. Shirin Towfigh, and today we will be talking about myth busting and discussing all the misinformation that’s out there. I hope that you all can join me and provide me with all the questions that you may have regarding what you thought you’ve read or conflicting information you’ve read, but I have a laundry list of things to share. Thanks to all of you who are joining me on Facebook as a Facebook Live at Dr. Towfigh. The rest of you are here on Zoom. Thank you very much. I will make sure that this is posted on YouTube so that you can watch and share. And I think this is one of our more important discussions that we’ve had so far because you should kind of review what we discussed today because I really do want to bust a lot of the myths that you were told or misinformation that’s either fed to you by others, by physicians, by non-surgeons, by the internet.
Speaker 1 (00:01:11):
It’s kind of like it really pisses me off. I have a lot of this fed to me and I hope that I can kind of share it all with you all too. Thanks for also following me on Twitter and Instagram at Hernia Doc. So let’s just get into this. I have tons of pre-prepared questions for you. What I’m planning on doing is going through all of them. Hopefully we’ll get to as many as possible. And then for you all, I assume that you have questions from you as well, which are myths or misinformation. The way I’m going to use these terms is myths are basically false information that we used to believe in or people would believe in, and it’s no longer true. Whereas misinformation means that there may be a smidgen of truth in what is being told, but it’s so distorted that it’s a completely wrong information, very kind of takes you wrong along the wrong pathway. So that’s kind of the way that I see how I can help you all with that. So let’s get started.
Speaker 1 (00:02:24):
Thanks for everyone tuning in. So number one, this is a discussion we had among the surgeons. And myth number one is all hernias must be repaired. I see it all the time on Instagram reels, Facebook, lots of ads were physicians saying, you have a hernia, you must get it fixed. I have patients that come to me in the office. I have a hernia. I went to my family doctor and they said, go to a surgeon. I went to a surgeon and the surgeon said, it must be fixed. And the question is, do all hernias need to be repaired? The answer is no. Very definitively, there’s no evidence to show that every single hernia must be repaired. Now, when I was a resident, we didn’t have enough data to do otherwise, and there was a thought that hernias will eventually cause a problem. And so hernia repair is a life-saving opportunity to prevent patients from strangulation, which means your bowel or whatever organ is in the hernia will get stuck.
Speaker 1 (00:03:28):
And so to prevent you from having emergency surgery because we didn’t really know what that means, who among the people that we see will have emergency surgery, let’s prevent that. And so we would say, oh, you have a hernia, let’s get you repaired. And so every single clinic that where you see patients hernia, okay, surgery, that was just routine. I’m sorry to say that that still seems to be the routine in most offices. I hear it all the time. I actually even hear it from my colleagues who are specialists and know the data. And I want to share with you exactly why that is. So in 2006, there were two clinical trials. One in the United States and one in the United Kingdom only on males. So what I’m saying is not related to females because we don’t know, but only in males, they looked at what happens if you don’t fix a hernia?
Speaker 1 (00:04:23):
It was a prospective randomized clinical trial. Very well done. And the main question was, is it safe to do what’s called watchful waiting, which means wait, if someone does not have symptoms or didn’t even know they had a hernia, is it okay not to repair it? So this does not include people who have symptoms. We pretty much agree if you have a hernia and it bothers you, you should get it repaired. Number one, by repairing it improves your quality of life. Number two, the theory is if you’re having symptoms, you’re probably pinching something. And that pinching can imply something worse in the future like incarceration, which means something gets stuck in the hole or strangulation, which means it’s so stuck that it blocks off the blood supply and whatever goes in there is dead like a dead intestine. So we knew that probably it’s not ethical to not operate on people that have pain, but if you don’t have pain, a lot of people there, they didn’t even know they had a hernia.
Speaker 1 (00:05:33):
They went to their doctor, had a physical exam, doctor age didn’t have a hernia. And anyway, 2006 it was studied only for groin hernias, inguinal hernias, so male and groin hernias. And what they found was it’s perfectly safe not to operate on asymptomatic hernias, which means no, no symptoms or minimally symptomatic hernias. And that was defined as a little bit of achy and pains here and there, but it does not affect your ability to perform normal daily activities. So they can work, they can exercise maybe a little twins here and there if they’re on their feet too much. So they found in the American trial that one patient out of I think almost 800, ended up in the needing surgery because they had incarceration and then a couple patients had also incarceration in the United Kingdom trial, but no one had a major emergency and the rate of that was really low. So
Speaker 1 (00:06:37):
The take home message was, it’s safe. Now, everyone can make their own decision about what they want to do, but at the very least, if you’re a patient that’s really old or sick and have now been given a diagnosis of hernia in the groin, just know that it’s a safe decision to not operate if you choose not to, especially if you have barely any symptoms. And secondly, if you’re younger, just know that you probably will need surgery, but it’s safer to delay the surgery. I want to share with you another screen, which is a great new paper that was recently published. Let me see if I can find it for you. Okay, hold on. I got to find it for you. Okay, so
Speaker 1 (00:07:35):
Let’s see if that goes. Okay, so this is a newly published paper this year. I’m going to be writing an editorial for it. So it takes all those studies I talked about and put it into one and looked at it long term. So there’s now three trials, one in the United States, one in the United Kingdom, and one from the Netherlands. And here’s the summary. So in the North American trial, which is the United States trial, 720 patients, they’re all adult males in the United Kingdom. They enrolled 160 patients, all males over age 55. And in the Netherlands, 496 patients, all males age 50 or greater. And they were followed. And this is the important information, hernia accents in the short term. So at about two to three years was somewhere between 0.6% and 2% risk of ending up having a hernia that needs a surgical attention. So this was considered a safe decision because as you know, hernia surgery has about a 12% risk of chronic pain in the groin.
Speaker 1 (00:08:45):
And so the risk of chronic pain is actually the higher than the risk of what they called hernia accidents. What’s interesting though is what a lot of my colleagues are focusing on, which is okay, but look at this. If you follow them up to eight or 12 years, so on average 10 or seven and a half years, about two-thirds to three-fourths of patients end up having surgery anyway. That’s called the crossover rate. So long-term at about eight to 10 years on average, if you do watch full waiting, what you’re doing is just delaying when your surgery is. But that’s still safe. One over 10 years, there was a 1.2% hernia accident rate in the US trial and two and a 5% rate in the United Kingdom trial. And to me, those are good odds. So if a patient’s hesitant to have surgery, I just assure them that’s perfectly safe.
Speaker 1 (00:09:43):
Now you may come back and say, now I have pain, which happens often and will fix it. But the reason for this crossover rate where a 68 to 72% of patients ended up having surgery during this watchful waiting period is due to pain and not because their hernia is incarcerated and they need an emergency surgery. And that rate was only 1.2% in the US trial and 2.5% in the UK trial. So myth number one, busted. All hernias need to be repaired. No, most al hernias that are symptom symptomatic should get repaired if they have no symptoms or minimal symptoms, you can safely watch understanding that if you’re living, if you have a lifespan of at least another eight to 10 years, you’ll probably require some surgery. But you know what, a third to a quarter of patients will never need surgery in the 10 year span.
Speaker 1 (00:10:46):
So that’s kind of where I am at, which is I don’t tend to push hernia repairs. Now another thing is I just discussed males with inguinal hernias. We don’t have data on females and watchful waiting is not considered standard of care, especially if there’s a risk of having a femoral hernia in women. And secondly, we haven’t discussed watchful waiting data for umbilical hernias, but just know for umbilical hernias, not incisional, but umbilical hernias, which means you haven’t had surgery but you haven’t. Audi, the data is very similar and watchful waiting is considered safe. All right, so I hope that one is clearer. Okay, next myth is very much related where the, I mean, I see ads for it. I was scrolling through Instagram last night and just, I almost want to answer these ads, but it pisses me off. They’re saying, if you don’t fix your hernia, you’re going to strangulate.
Speaker 1 (00:11:44):
Actually, not a single patient in any of these prospective randomized clinical trials had a strangulation zero. The one or two or six patients in the trials that did have what they called hernia accidents were patients who had incarceration, which is one level below where they had a bowel obstruction or something got stuck in the hernia. None of them had a strangulation. Now, do hernias get strangulated? Yes. Is it possible that just by chance those people that were in the trial never strangling? Yes, but look at the numbers. It’s like one to 2%. So still the risk of strangulation is lower than the risk of complications from the surgery. And so that’s where I am at. I think less is more.
Speaker 1 (00:12:41):
Okay, this is a misinformation I see on the patient side, which is you never need Mesh, all hernias can be repaired naturally. What were we doing before Mesh was invented? Okay, well first of all, it’s like saying we don’t need cars. We can all cycle, but use a bicycle. What were we doing or walk? What were we doing before the car was invented? So it’s true that hernias were repaired before Mesh was invented. It’s also true that most hernias were not repaired and they were just left with deformities. So people, and we have pictures, which I can share one day of huge hernias, very deformed patients, and they were just told, sorry, there’s nothing for you to do for you. So many hernias can be repaired naturally, but no, all hernias cannot be repaired naturally. If you’re missing muscle or missing fascia, there’s no way I can bring in anything.
Speaker 1 (00:13:40):
Now, can I use take tissue from other parts of your body? Yes. Is it majorly deforming? Yes. Can that cause you disability and actual chronic pain from that process? Yes. We’ll give you a nice flat repair where you don’t look like you have an alien coming out of your belly. Usually not. So that’s something that I’d like to kind of clarify is not true that all hernias can be repaired naturally or with your own tissue. Okay, another myth, which many doctors mentioned, which I think I’m kind of putting a dent in that which is, oh, I don’t feel a hernia, or I don’t see a hernia, and therefore there is no hernia complete BS. The whole idea of occult hernias means you have something that is causing you symptoms and it is just too small to feel, or maybe you’re obese and that’s why I can’t feel it.
Speaker 1 (00:14:43):
Or you have scar tissue from a prior surgery and that’s why I can’t feel it. So it, that’s why imaging is so important for these occult hernias, which is if it’s small enough to cause pain, then we should address it to improve your quality of life. But if I can’t feel it doesn’t mean you don’t, it’s not there. It’s mostly by history. So patients who have hernias that have symptoms and see me are almost always diagnosed based on their story, their symptoms. When I bend, when I cough, when I sneeze, when I get out of my bed, those all cause me symptoms, whereas when I lie flat, the pain goes away. I have nausea or bloating. Those are all hernia related symptoms. And so based on that, then I kind of look at the physical examination and then maybe co order some imaging to help identify these occult hernias.
Speaker 1 (00:15:39):
But to say that if there’s no bulge, there’s no hernia, completely not correct. And what we’ve done is we’ve basically gone forward and presented our own data because I do see a lot of people with occult hernias that I treat and they get better, their pain goes away. And the only way I’ve said this multiple times on Twitter, especially if you follow me on Twitter, this is what I’m saying, the only way doctors will listen to you is if you’ve showed them the data, even though they sometimes don’t listen to you. But at least you can say, here’s the data. It’s not just anecdotal or in my experience. So I published it, I kind of said, I presented at the European Hernia Society. At the American Hernia Society, sages, all these different societies where hernia surgeons go to and it’s getting some traction. So more surgeons are open to repairing hernias that they don’t see or feel that are shown on imaging that are consistent with the patient’s symptoms. So if a surgeon tells you, you don’t have a hernia because I don’t feel it, if it shows on imaging and your story is consistent with a hernia, then that’s a hernia that should be addressed, and it’s a myth that you have to, hernia should must be palpated.
Speaker 1 (00:17:04):
Thanks for all of you guys for coming on. I see a lot of people joining me. This is great. Okay, this for anyone that follows me, I hope this is a myth. Women can’t get hernias completely not true. However, we still don’t teach it in medical schools that women can get hernias just like men. In fact, I’ve had multiple physicians, whether they’re urologists, gynecologists, medical doctors, oh, I didn’t know women can get hernias or they out outright tell the patient, oh, women can’t get hernias because they’ve come to me and told me that story. So yes, definitely women can get hernias. It’s a much smaller lifetime risk. So for growing hernias, it’s about 3% risk lifetime for women where it’s like seven times higher for men, like 27% lifetime risk for men, belly butter hernias are a bit more common in women, mostly because of pregnancy issues and diastasis. But yeah, absolutely incorrect statement. Women absolutely can get hernias.
Speaker 1 (00:18:12):
All right, on the patients side, I hear a lot of misinformation being spread, which is Mesh is bad and all meshes are the same. And they use the term Mesh as if it’s like, it’s like me saying cards are bad because some pinto blew up and is been taken off the market doesn’t mean all cars are bad. So all meshes are not the same. There’s a wide variety of meshes. They’re they’re categorized by weight, ultra lightweight, lightweight, mid-weight heavyweight. They’re categorized by what they’re made of. So there’s either synthetics or biologics. They’re categorized by their absorption properties. There’s absorbable and you have synthetic, absorbable, synthetic, non non-absorbable. All the biologics are absorbable. Then there’s a whole group of hybrid meshes, which are they kind of partially absorbable, partially non-absorbable, partially biologic, partially synthetic. So to claim that all meshes are the same and lump them into one bull is completely incorrect.
Speaker 1 (00:19:16):
And so a lot of patients come to me and say, I don’t want Mesh. Okay, that’s fine. Why don’t you want Mesh or what? Because I read all these complications with Mesh, et cetera. Now, maybe it’s a patient where a non Mesh repair is completely the wrong thing. They’re a smoker, they’re obese, they’ve already had multiple recurrences, they’re missing tissue. It’s a large hernia. Those are all situations where you need an adjunct. You need something to help the patient to cure this kind of bad cycle they’re in. While tissue repair may not be a good option for them. And so you need a Mesh repair. And of course, I discussed all the different Mesh options, the pros and cons of each. We used to think, we used to think biologic was the thing, oh, take this biologic tissue and soak to fascia. And once your blood vessels go in, it’ll take all those stem cells and make it into fascia it, it just becomes scar.
Speaker 1 (00:20:15):
But in some situations, the higher quality biologics can be a little bit better in terms of providing better support, but they tend to absorb. And so we know that fully absorbable meshes don’t work. There’s a trial, long-term trial on, okay, if it absorbs at eight months, maybe that doesn’t work. But what if it absorbs at 18 months as an extra 10 months of support of your hernia repair when that doesn’t work either. So we don’t have the ideal Mesh, but we do have a wide variety of Mesh and not all Mesh are the same. So I think that’s some truth in it in that there are categories of where meshes are very similar, but that’s pretty much misinformation. Okay, this is something I’ve never discussed before, but I see the term come up a lot online, which is Mesh migration. I don’t know where this came about.
Speaker 1 (00:21:14):
Mesh migration is not a thing. It is not a major problem. It was a problem with one specific Mesh and that Mesh was the plug. So the plug was like an independent badminton, shuttle cock looking product used for groin hernias and sometimes belly hernias and it was sewn in place and for whatever reason, sometimes it wasn’t sewn correctly or it got released from wherever it was sewn and it would migrate. So we actually have, this is crazy, but colonoscopies with a Mesh plug that’s eroded into the colon meshes that have migrated and invaded into the bladder, the Mesh plug’s kind of hanging out in the abdomen where it wasn’t originally placed. So often the Mesh wasn’t secured with permanent suture, and so it kind of dislodged by the time it was the suture absorbed. So that’s the story with the plug. And there are different types of companies that make different types of plug meshes. We don’t promote plugs on hernia attack. We find that plugs are not, there’s so many different Mesh options that plugs should be your last option.
Speaker 1 (00:22:38):
However, what I do want to say is with all the other meshes, there is no such thing as migration. Mesh doesn’t move. It may move like millimeters, but it doesn’t move. It doesn’t migrate. If I put in the belly, it’s not going to end up in the groin and vice versa, if I put in the groin, it’s not going to end up in the belly. It’s not going to move to your heart or around your stomach. It can erode. It can cause complications where it was placed, but we don’t call that migration. It doesn’t actually move. So I hope that that kind of clarifies. I have a lot of patients that I do these kind of online consultations where they can’t come in to see me. So we do a lot of emails back and forth, and I feel like the one question that is kind of commonly asked, but it’s weird to me because is I’m worried about the Mesh migraine. I’m like, no, but then I keep seeing it over and over again. Oh, thanks for your question. The question is, is Goretex Mesh a plug Mesh? So first of all, Goretex Mesh, it’s Gore Mesh Gore is a company that makes Mesh. It is considered a heavyweight microporous Mesh. It is not absorbable by any means. It is a permanent synthetic Mesh. It’s not a plug. It’s a flat piece of Mesh. It doesn’t, they don’t make a plug. They did make a bio plug, which is the company Gore made, which was absorbable.
Speaker 1 (00:24:17):
That’s not meant to be the permanent solution for the hernias. Pure meant to plug the hole and you need to do a true hernia pair in addition to that. Yeah, gore Mesh is not a plug. The second question that’s been presented live here is I have an Ethibond Mesh and plug in me. I’ve had horrible burning pain for six years. So Ethibond does not make a plug, Mesh it. It may have dabbled in it early on as this kind of flat plug. It wasn’t like a true plug. It was kind of a flat plug. They sold it and they stopped selling it. They do have a two layered Mesh, which is like a sandwich Mesh called the phs, a prolene hernia system. And that can cause some folding and balling up if it’s not placed correctly. But ethibond matches with any other meshes can cause complications.
Speaker 1 (00:25:19):
Any device that you use can cause complications. And if you have burning pain for six years, you should be getting treated. Why are you suffering for six years? That makes no sense to me. We have all these people who can help you. I’ve interviewed many of them. I can help you get yourself fixed. Why are you in pain? What is the best Mesh for Inguinal repair on a thin woman? Thin woman is no Mesh. Okay, let me, so Inguinal hernia pair and thin women I believe are best performed with a tissue repair. I do not like to put Mesh in thin women. Now if you are very athletic and you’re agreeable to Mesh placement, then a laparoscopic Mesh with a very lightweight Mesh would be acceptable in my practice for you.
Speaker 1 (00:26:11):
There are different surgeons that have different practices, so I’m not speaking for others, but in my experience, and I believe I treat the most number of women percentage wise in my practice than any other surgeon because that’s kind of what I enjoy doing. A little over half of my patients are women. It’s kind of like my passion to make sure women are appropriately treated because we seem to kind of fall off the bandwagon when it comes to trials. I just discussed hernia trials. Not a single one of them had a female enrolled in those trials. So I have no idea what to tell my patients from a purely evidence-based standpoint.
Speaker 1 (00:26:52):
Okay, so that’s my thing I would not put mention of in a very thin female in general. The next question has to grow back to the horrible burning pain. My new doctor wants to give me injections and some nerves that he believes is giving you the horrible burning pain. Great, at least you’re doing something. But for six years, what have you been doing for six years? That’s terrible. And if nerve blocks are doing the job great, that should be exactly what you should be doing. You should not be suffering from pain for six years. Can a thin man? Okay, next question. That’s a good one is can a thin man have a no Mesh? Absolutely. I think thin, thin patients just should not get Mesh in them unless it’s a situation where it demands Mesh. But for most typical inguinal hernias, you don’t need Mesh if you’re thin.
Speaker 1 (00:27:50):
And I prefer not to use Mesh in thin patients is my thing. Now, have I used Mesh in thin patients? Yes, it’s a very kind of tailored situation, but in general, I think Mesh is worst in women and thin patients. And if you’re male within patients, sorry, if you’re a male that’s thin, then yes, I would say same thing. Okay, another myth. Now we actually discussed this on the robotic surgery talk that I had I think five months ago or so, and that was that you should not get robotic surgery because robotic surgery was not approved for hernia repairs or for meth removal. And so you should not get it. It’s like against the FDA or something to get robotic hernia repairs or to get her robotic groin mass removals or abdominal walnut mass removals. Completely incorrect and a complete, it’s actually completely incorrect. There’s nothing incorrect about that.
Speaker 1 (00:28:54):
There’s not even an ounce of truth to it. So the reason why this myth came about was because the different devices that come out and robotic surgery is a technology and therefore a device. They have to tell the FDA what this is going to be used for. Is it used for brain surgery or is it used for gynecologic surgery or what? And so every kind of subspecialty within surgery needs to be pre-approved. So there’s gynecologic surgery, colorectal surgery, et cetera. So general surgery has been approved. Guess what? Hernia surgery is part of general surgery and Mesh removal is part of general surgery. So the fact, and actually you know what? Hernia repairs are part of urology too. So based on that, it’s absolutely appropriate and safe to use robotic surgery for any general surgery procedure. And that includes doing the hernia repair and undoing the hernia repair.
Speaker 1 (00:29:58):
So please do not believe it when you read online that it’s some nefarious robotic kind of move to use a robot to remove Mesh. Now, early on when the robot first came out and it was mostly gynecologic and some little bit urologic use for pelvic surgery, there were complications with the robot. It was new technology people didn’t understand is different than laparoscopic surgery and there were problems. The company, which is called Intuitive Surgical, has since complete change the way they promote the product. They do not say, Hey, let’s do this surgery. They put you through classes. I personally had to go through hours and hours of online courses, reading and then in the lab, hours and hours of practicing. And then they had to take a test at every stage, a test from the online reading a test for the hands robotic, like these games you play where they rate you and then you have to go into a separate lab in person, take more exams, and then work on a pig lab.
Speaker 1 (00:31:11):
And then on top of that, you go and operate in the hospital with a proctor for every hospital has a different proctoring kind of situation. And then you can be a robotic surgeon. And even then often you want to have a specialist there until you become proficient and then you become the person that teaches. So I teach now I teach robotic surgery, but there was a point where I had to go through the learning curve and I think the company is doing a much better job now than it was doing, and it’s become a much safer technology. Is it a hundred percent safe? No. Are there complications with the robot? Yes. Is it the robot’s fault? No, it’s usually the surgeon’s kind of complication. Alright, next question. What are the risks of having a pregnancy after tissue Inguinal Hernia repair? I have pain now, so I don’t want to get pregnant before the repair.
Speaker 1 (00:32:11):
Okay, so zero Inguinal hernias, no matter what type of repair you have, will not be affected by pregnancy. Pregnancy does increase your abdominal girth and does stretch out the abdominal muscles. It tends not to stretch out the pelvic muscles such as in the groin that’s really right by the bone. And we tend not to see any problems with Inguinal hernias. So if you have an Inguinal hernia, and sorry, if you’re a female that has an Inguinal hernia and the hernia is bothering you and you would like to get pregnant, I do recommend that you get the hernia repaired. Either tissue or Mesh, doesn’t matter. Depends on your risk factors or what’s good for you. Belly button’s different. So hernias and the belly button tend to get really pushed on and pulled on. So if you get it repaired before you’re done with pregnancy, the bulging from the pregnancy and the pushing can, how do I say it? Like causal recurrence. And so unless it’s bothering you, we don’t recommend you just fix a belly button hernia until you’re done with pregnancies.
Speaker 1 (00:33:26):
Labor is a different issue if you have to undergo labor and it’s intensive. There’s a lot of abdominal pressure there, but you’re also super loose. So in general, we don’t think that it’s a problem if you’ve had a inguinal groin, hernia repair and pregnancy or labor. All right, five failed surgeries for umbilical related Mesh. I posted one on TikTok, it was 18 failed surgeries and they’re going for number 19. It can happen if you were very unlucky and had let’s say trauma and bowel injury and then Mesh infection and then a fistula, and then those are like every time that happens, you have multiple, multiple, what do you call it, like revisional operations and you can call each one a hernia repair and I guess you could get up to 18 or 19, that’s really extreme, but five failed surgeries, something’s going on. Either they’re missing your risk factors that can be treated.
Speaker 1 (00:34:40):
You’re either obese or a smoker or maybe you have a tissue disorder like a collagen disorder that hasn’t been diagnosed yet or is purely a problem with decision making. The wrong decision was made the first time and then the second time and then the third time they used the Mesh, but they used the wrong Mesh or they placed in the wrong place or they’ve made it too small for your hernia repair or they use the wrong sutures and those decisions are important. You want to make sure that you go to a surgeon and dissects it. I love dissecting. I should been a forensics person because I love that stuff. Detective work. I listen to all his detective like podcasts right now. I’m on Detective Trop right now, which is kind of cool. My point is I enjoy that stuff. And so if you do come to see me, which I’m very happy to see you for, I will need every single one of those opera reports and I’m going to read it with a critical eye.
Speaker 1 (00:35:41):
Why? What did they do? What suture did they use? How big was a hernia at that time? And then review the decision making with each one for me to kind of understand why you had these recurrences. And then I will come up with a plan of care for you to prevent repeating the same problems. So I hope that’s something that helps you do. Surgeons do laparoscopic non Mesh repair. The answer is no. All laparoscopic repairs of both the groin and the abdominal wall are by definition with Mesh. Now, there was a paper many years ago in I think Belgium or maybe the Netherlands where one surgeon described a tissue repair using laparoscopy. Very unique. I have taken the robot, which is robotic surgery. It’s not technically laparoscopic, but effectively it’s the same. It’s much easier to sew with the robot. And I do offer tissue repairs for small Inguinal hernias in non-obese patients.
Speaker 1 (00:36:55):
And I do offer umbilical hernia repairs with diastasis closure, the tissue repair. So if your grand scheme is, can you have a minimally invasive surgery for hernias with no Mesh? Yes. Do most people offer it? No. Is it considered standard of care? Not really. Is it safe? I believe so. We’ve published our trial on it and I’ve written three chapters about it in three different books to describe it because there’s very much a lot of surgery surgeon interest in this technique, but it’s highly technical. You really need to know your anatomy, otherwise you can cause damage.
Speaker 1 (00:37:37):
And that’s kind of my teaching of that technique. But I do offer robotic tissue repairs for groin hernia repairs. I kind of enjoy it, but it only works for thin people. It doesn’t work for anyone who’s obese. Okay, next question, which is complete misinformation is Mesh removal as high risk procedure. Okay, so what’s a high risk procedure? I’ve had people come to me and tell me that they were told that if they have their Mesh removed, they will die. Not true that they will have to, their leg will, they will lose their leg if they have the Mesh removed. I’ve had people be told that they will lose their testicle if their Mesh is removed. All completely false. Now, can you die of a Mesh removal about as much as any other operation that is considered low to medium risk, but we do heart transplants.
Speaker 1 (00:38:42):
Cedar Sinai in my hospital is number one in the world in heart transplants and those patients don’t die. Don’t tell me that mass removal is going to kill you Again, I’m talking generalities. Have I ever had a patient die from Mesh removal? No. Do most surgeons have patients who die from Mesh removal? No. So why are they being told this? I think it’s a scare tactic. So if a surgeon doesn’t want to do the operation or wants to talk you out of it, they’ll give you everything bad that can happen. And I think that’s not fair because then you lose hope and you stop looking and you they say, oh, well I guess I have no other options. And then you suffer for the rest of your life. And I think that’s not fair. I tend to be aggressive when it comes to surgery. So that’s my shtick.
Speaker 1 (00:39:35):
Maybe I gave too much of a rosy picture about Mesh removal, but my patients do very well. About 80% do are cured from their Mesh removal surgery. And then the other 20% we either missed an problem or they had a nerve issue I had to deal with or, and by cured, I mean cured after surgery, they didn’t need anything else done. But some people they need some more procedures, injections, maybe it was a different diagnosis that needed to be made and so on. So you should not be losing your leg. That would mean that someone chopped off your leg, destroyed your blood vessels. A that means that the surgery injured those vessels. And can those vessels be injured? Yes. Could they be injured so badly they will lose your leg? No.
Speaker 1 (00:40:31):
Most people who have groin Mesh removed, the males should not lose their testicle. I’m very careful about that. And if you’re just aware, you should not just lose your testicle. I think that’s not right. Can you lose your testicle? If the Mesh is completely wrapped around the vessels and your testicles already completely shrunken down, which means you’re not getting good blood flow to it, then the active removal may actually make the blood flow even worse. But again, not the typical situation and then death is usually not something that we talk about with Mesh removal. Even abdominal wall Mesh, I have a lot of you that are here that have fistulas or a bowel that’s involved in your Mesh for the abdominal wall and you were told don’t touch it, you’ll die. I mean, I think you just need a more aggressive surgeon. That’s my personal take. I don’t think it’s cool to tell someone that to just live a horrible lifestyle just because that surgeon is not aggressive enough or doesn’t feel confident enough to remove certain meshes. I think pretty much every Mesh can be removed pretty much. Not every Mesh, but pretty much every Mesh can be removed. And if it needs to be removed, that should be offered to the patient.
Speaker 1 (00:41:59):
And if you’re being told that it can’t be removed, then you should maybe find another surgeon. I have plenty of colleagues that are talented in doing it and I’m happy to help. Okay, we’re really going through this pretty well. I have tons of more myths and misinformation, but okay, patients come to me all the time or call the office. I have recalled Mesh and me. Okay, first of all, we haven’t had recalled Mesh and I’m going to say it’s been a while, definitely over 10 years, maybe 15 years since the last truly recalled Mesh. So I find that a lot of the patients that come to me saying claiming they have recalled Mesh actually don’t have recalled Mesh in them. They were told by a lawyer or a law firm that they have recalled Mesh or that they should be contacted because they have recalled Mesh number one and number two, just because you have Mesh that has been recalled doesn’t mean the Mesh needs to be removed. So the reason for the recall may have been completely unrelated to its function in your body. And so all of the recalls to date that have been made on Mesh products, which it’s been a while since the last one have been unrelated to the Mesh that’s currently in you. In other words, it was recalled for future use, but there’s zero recalls where you had to go in to remove the Mesh. So just know about that. That’s complete misinformation.
Speaker 1 (00:43:51):
This one really pisses me off because there are, there’s at least one surgeon out there and I believe there’s more that tells patients all pain is Mesh pain. You have pain, let’s take your Mesh out. And they may have pain because their hip is messed up or their hernia has recurred or there’s a nerve that’s hyperactive or entrapped. That doesn’t mean it’s a Mesh pain. And we actually had this discussion, why don’t you work it up to see what the real problem for the pain is before you tell the patient all Mesh is all pain is Mesh pain that’s completely not evidence based. And he’s like, that’s what I believe. So I don’t believe in it. Most people do not believe in it. There’s a finesse to work up patients. It’s like saying all chest pain is a heart attack. It could be reflux, it could be muscle pain, it could be like arthritis, it could be a spine issue.
Speaker 1 (00:44:56):
There are a lot of reasons why people may get chest pain. It could be a pneumonia, but it’s completely incorrect. And to treat every patient with chest pain as if a heart attack and give everyone a heart surgery. I mean that’s basically what some of these doctors are doing. So I’m not a fan. Not a fan. All right. Going back to our friend here who has had six years of chronic burning pain from her Mesh. I’ve had nerve injections from my AL hernia pain before and they didn’t help before. I now have a right angle hernia and incisional hernias from my naval to my pubic bone from a colon resection surgery I had 25 years ago. My surgeon is more concerned about fixing the new hernias with Mesh rather than any concern about my six years of burning pain from my left hernia. All right, find a new surgeon.
Speaker 1 (00:45:45):
Sounds like you’re in the United States. We have plenty of surgeons in the United States. You really need to take this on in your hand. You’re free to go to any surgeon you want. This is a non socialist medicine we practice in the United States. You can go to whatever surgeon you want and if you’re not getting the answer from one surgeon, get a second opinion. We had a whole discussion about this. I’m going to say like six or seven months ago, about second opinions. You can watch it. It was a great, great session and that that second opinions are great. If you’re having surgery, get a second opinion even if you think it’s an easy hernia repair, if you need revisional surgery or you’re being told one thing that may be true, but it doesn’t hurt to get a second opinion, you can go back to that first surgeon.
Speaker 1 (00:46:34):
And we, I mean we do have egos. I think. I don’t have a ego, but I probably, I think we all have a little bit of ego, but I recommend patients to go see, get a second opinion. I think it’s important. When I had my own operations, I got second opinions, even though I knew the surgeon I was going to for the first opinion was the one person I would want to have surgery, but I still went to a second surgeon just to be careful. Surgery’s a big deal. And so if they’re not giving you the answer that you need or the care that you need change surgeons, at least that’s my opinion because I don’t think it’s cool to suffer and you have no idea what’s out there and what options are out there. Okay, another thing that I read online is tissue repair is less invasive than Mesh repair. Not true tissue repair is an option for many people. It is often not the least invasive because it involves a lot of suturing and cutting and sewing that’s very invasive. It’s often open surgery. Open surgery is not considered less invasive than the alternative which is robotic or laparoscopic surgery. Now, some open surgeries may be, and some tissue perish may be less invasive than a Mesh repair. But in general, we don’t consider tissue repair less invasive.
Speaker 1 (00:48:05):
I guess it depends on what you determines invasive. Okay, this is a big one. I’m calling this misinformation because there is some truth to it, but it’s not completely true and it’s meant to kind of dissuade you away from Mesh. Mesh has not been studied in humans, not true. Mesh absolutely has been studied in humans. I mean, that’s ridiculous to claim that Mesh outcomes have not been studied. The only reason we know about the data that we quote is because it was studied in humans. Now, are there meshes out there that got their FDA approval without human studies? Yes, absolutely. In fact, probably most of them have. What’s the consequence of it? Well, I believe as of this year, the European Union, the European Commission, which is the governing body of the European Union, has demanded that all meshes that are being marketed in the European Union must have human trials.
Speaker 1 (00:49:10):
So if you’re a Mesh company that has been selling tons of Mesh and you don’t have clinical trials, but you’ve been selling it for the past 20 years, guess what? You can’t sell it anymore. Got to do your human trials. That has not happened in the United States yet. However, there are plenty of clinical trials on Mesh products, many of which happen around the time of FDA approval before the FDA approval or after the FDA approval. And secondly, the, I predict and I published a paper on this, I predict that the FDA will resort to something similar to what the EU has done in the United States, which is either ban certain meshes or demand that all meshes have human clinical trials, otherwise they cannot be sold in the market. So this whole COVID thing has really moved the FDA to get busier with vaccine related and virus treatment related projects. But once they have probably more time to devote to something like hernias or hernia meshes, I predict that that be what happens. Okay, another
Speaker 1 (00:50:34):
Question. I went in on July 9th for a small bowel surgery and to clean up adhesions and the doctor had to cut through the Mesh to do the small bowel surgery. The doctor said it was an absolute mess and the Mesh was entangled in everything. They had to go back in due to nicking a bowel and internal bleeding and had to stop and leave me open due to vitals dropping for 24 hours. They could not remove the Mesh. Right? So when you have emergency surgery and sounds like intestinal adhesion, surgery was at least urgently done, if not emergently done, then you should really focus, the surgeon should focus on doing exactly that. Now, if the Mesh is a problem, it can be removed. If it was not a problem, it didn’t need to removed. Is the Mesh at risk of infection now that you’ve had the surgery? Possibly. If it’s causing your problems, then it can be addressed electively. And actually we had a question about that submitted exactly, which is, let’s see,
Speaker 1 (00:51:46):
Okay, there’s a couple of, so just know that the Mesh can be removed. It’s just a matter of when and it may need to be kind of staged. So another one was question presented was about adhesions, that if you have adhesions and you have surgery for adhesions, they’re just going to come back again. And there these anti adhesives that are on the market don’t really work. So stop keeping going back to surgery for adhesions because then you’ll eventually end up to have a frozen abdomen. Now there are people that, there’s some truth to this. There is some truth to this. There are people that are just adhesion makers, they scar much more strongly and aggressively than others. And so you really don’t want to keep operating on those people. Now, laparoscopic or robotic surgery does cause less adhesions than open surgery. So if you can do it that route, that’s one option.
Speaker 1 (00:52:46):
Adhesion barriers do work within not a hundred percent. So that’s something to consider. The next question was, is it hard to remove Mesh the longer it’s been in you? No. So some people are like, oh, I got to get it out because if by next year it’ll be more difficult to get this Mesh out. No, not really. It has zero bearing how long the Mesh has been in you. It’s complete myth that the length of time the Mesh has been in you will affect the ability of the surgeon to remove the Mesh. And then the other question is, are larger meshes more difficult to remove on the belly than the smaller meshes? The groin? Not necessarily. It depends. The removal of the larger meshes are actually pretty easy. The anatomy is so easy compared to groin anatomy. So from a technical standpoint, it’s actually easier.
Speaker 1 (00:53:38):
The problem is what do you do once that Mesh is removed and that’s much more difficult to address for the abdominal wall than for the groin. Another question, what is the timeframe of the longest human trial for Mesh that you’re aware of? Similarly, what is the longest timeframe of follow-up studies with respect to Mesh that you’re aware of? It seems most trials or studies only took a few years and are not impacted for decades long of implantation. So you’re correct. You can’t have a clinical, first of all, clinical trials are very expensive. I’ve been involved in at least 30 super, super expensive. It’s why drug prices are so high and Mesh is so expensive and all that, well, maybe not. My Mesh is so expensive. But definitely for pharmaceuticals that contributes to that very, very expensive to do a clinical trial. There’s no standard as to how long a clinical trial should be.
Speaker 1 (00:54:42):
It’s usually a risk benefit of how much more information we have and how compared to how much money we’re spending. Most clinical trials are one to two years, some are up to three years. There have been some of up to five years, there have been no clinical trials that are 10 years out for Mesh, for hernias there haven’t, but not for Mesh. And then in terms of studies though, not clinical straws but studies, there are some database studies. The database studies I’ve looked at five year and 10 years out, what happens to Mesh and it’s remarkable, there are people get bowel obstructions and Mesh infections and hernias that recur. So I think it’s the Danish trial, the Danish database that has shown what happens over a span of decade because they have a great national database, which we don’t really have in the United States. We do have one, but it’s very dependent on patients telling you what’s happening to them at five and 10 years.
Speaker 1 (00:55:46):
And unfortunately the patients are not responding. So I feel strongly that patients should play a role in long-term database studies so that we can learn from what you’re telling us. But no clinical trials in general last one to three years, and it’s usually a financial decision, whereas we know that it’s very important from a hernia standpoint to know at least five years or 10 years what happens. Next question. And one of your videos you mentioned if someone has E D s, which is Ehlers Danlos syndrome, they need Mesh. I don’t have classic e d s as far as I know, but I am on the hypermobile scale. I’m very flexible with loose joints and I have fibromyalgia. Could that impact being a candidate for tissue repair? Yes. We don’t know by how much EDS or Ehlers Danlos syndrome is a well-defined named disease. Those patients have horrible tissue for hernia repair purposes and really need a tight repair with augmentation by Mesh because everything is so loose. However,
Speaker 1 (00:56:56):
There are patients that don’t really have the full E D S but are act like it. And genetically they may actually be like it. And so in those patients, it’s a difficult situation because you do want to treat them like an e d s patient. But in your situation, you also have fibromyalgia. So fibromyalgia is an autoimmune type disorder and many patients with fibromyalgia do very poorly with Mesh. Not all of them, but many do. So I would be hesitant putting Mesh in someone with fibromyalgia, but also very much would prefer putting Mesh in someone that has Ehlers Danlos syndrome or a collagen disorder hyper mobile. So in those cases, I use hybrid Mesh. My go-to is ovitex Mesh by Tela bio. It’s like 96% biologic and 4% synthetic. That’s what I consider appropriate for people with fibromyalgia that need Mesh. Can you react to it possibly? Is it common? No. Have I had really good luck with it in patients with fibromyalgia? Very much so. That’s kind of where I would go when someone will like you. We’re almost done here guys. Then I have an announcement.
Speaker 1 (00:58:13):
If you have a one centimeter gap above my belly button, sorry. If I have a one centimeter gap above my belly button and a two to five millimeter umbilical hernia, do I need to have that gap placated as well as suturing the small hernia? Oh, so you’re saying a diastasis with a hernia? Not necessarily. It’s a risk benefit ratio. I usually do it. Most surgeons, it does affect kind of the timing of the surgery and what’s done during surgery. And we want to make sure it doesn’t affect the symmetry of your abdominal wall. But I do believe that people have diastasis with a belly by hernia, should have their diastasis addressed, otherwise they have a higher risk of hernia recurrence. Maybe that’s okay with you, but that would is usually not my recommendation. Going back to that, the hybrid Mesh, it’s called ovitex, ovitex ovitex, and it’s made by Tela Bio. All couple more questions that were submitted. If I can just share that with you. Here’s a myth. Negative blood tests can rule out Mesh infection, inflammation reaction, false. Almost every patient of mine that has had Mesh reaction has had normal blood tests. Inflammation is not well tested with blood tests. If it’s a Mesh related inflammation, because it’s so minor, Mesh infection often
Speaker 1 (00:59:53):
Will show a positive test. But if it’s a very low grade chronic infection and not an active acute infection, then no, it also will not show up on blood tests. Okay, let’s do some more questions. Okay, here’s a good one. Do all large abdominal wall hernias need to be repaired with Mesh?
Speaker 1 (01:00:24):
Pretty much that’s the standard. By large, we mean anything over four centimeters should be repaired. With Mesh, probably over two centimeters should be repaired with Mesh. Can you get away with non Mesh repair and doing a big tissue reconstruction that’s burning a lot of bridges? I’m not sure I would recommend it. But in a patient who absolutely could not have Mesh, which I do have one patient and has a large abdominal hernia repair hernia that needs to be repaired, yes, I would do a reconstruction, like a plastic surgery type reconstruction without Mesh. But no, in general, that’s not the right answer. Can you have pregnancy after a non Mesh Anglo hernia repair? If so, with what wait time? Yeah, we answered that earlier. So yes, you can have pregnancy. The wait time is usually two weeks before you, or sorry, three to six weeks before you get pregnant. Then you have about six months of healing before that belly really gets larger.
Speaker 1 (01:01:35):
Almost done. Mesh is a nerve false. I used to believe that. Honestly, back in the day, what are we all talking about? Medicine inert. But that was kind of what you were taught and I wasn’t seeing the Mesh population that we know now. So just goes to show you that we don’t know everything. What I’m telling you today may be wrong in a couple years. So science is always something that is an evolution, and I hope that people appreciate that. Don’t think that if we set something before and change our mind or if I change our tune or whatever, that we’re being nefarious in any way. We’re learning more and we learn more because of you all. And that’s why it’s so important that patients be involved in our ability to learn from you and share your data and be involved in our databases. The ACHQC, which has been discussed multiple times on hernia talk, is a great way to get patients involved and just know that we’re all humans. We don’t have the answers to everything. We try. Our best doctors are not evil people and definitely hernia surgeons are not evil people. We’re doing our best. And if some surgeons don’t know as much as others, we’re here to teach and we’re all here to learn. And I’m going to do one last question because I love you guys so much.
Speaker 1 (01:03:08):
Do you believe the medical community will eventually accept Mesh implant illness in the way that the medical community has finally started to believe women’s stories with respect to breast implant? Yes, I completely believe it. I’ll tell you, I’m very active on our hernia collaboration, which is I think like 15,000 surgeons, some enormous number of surgeons around the world. And I used to talk about it and there were a lot of people, what are you talking about? There’s no such thing as a Mesh reaction that’s all in their head and so on. I’m not getting that pushback as much anymore. There’s still people that don’t believe in Mesh reaction, never. They say, I’ve never seen it before. And then when I tell ’em that I’ve seen it, then they’re like, and I’ll kind of, they question it. But I must say in the discussion of the surgeons, there’s much more acceptance of Mesh implant illness, Mesh reaction.
Speaker 1 (01:04:09):
I talk about it, I publish about it. There are other surgeons that have seen it. They’ve taken out the Mesh and the patient gets better. I mean, there’s some correlation there. So even though we don’t completely understand why and in whom these things happen, I do feel that we are slowly moving in that direction. So that’s a good thing. And I feel that unfortunately it’s not a fast process and understand that it’s all in evolution. So on that note, this ends hernia talk. We’ll be here again repetitively. I try and do as many Tuesdays as possible, but just know that we’re starting to ramp up a little bit on surgical conferences. I’m very active that way. And sometimes I will be at a surgical conference or actually giving a talk or operating because we’re getting really busy. And so at those times we will not have hernia talk. Just follow me on my social media. I will tell you every time that we have another hernia talk live, it will be on Facebook at Dr. Towfigh on Instagram and Twitter at hernia doc. And then when it does happen, I will post it on YouTube. And on that note, enjoy evening as I will do mine. Take care guys. Bye-bye.
