Speaker 1 (00:00:00):
Hey everyone, it’s Dr. Towfigh. Hope you’re well. Welcome to Hernia Talk Live, our weekly QA q and a. Every Tuesday we affectionate, call it hernia Talk Tuesdays. My name is Dr. Shirin Towfigh. I am a hernia surgery specialist. I’m also a laparoscopic surgery specialist, which will come to be important because our topic for this week is about laparoscopic surgery and whether it’s superior or better than open, what is laparoscopic surgery will review all that. Many of you are joining me as a Facebook live on Facebook at Dr. Towfigh. The rest of you’re here on Zoom. This will be then published as a podcast on YouTube. So watch out for all that. I’ll make sure I post it on both of my other platforms on Twitter and Instagram at hernia doc. So I’m a general surgeon. I’m trained in general surgery. I also am very I technology, which is why I enjoyed kind of focusing my surgery practice on minimally invasive surgery.
Speaker 1 (00:01:13):
I was very fortunate to be part of a very prominent two different prominent fellowships in minimally invasive surgery and ran the program for a good while and train and continued to train fellows in minimal in minimally invasive surgery. So what is M i s or minimally invasive surgery? We’ll get to that. How is that the same as laparoscopic surgery? What is robotic surgery? How is that open of different from open surgery? So I know that there’s a lot of interest in this topic because I got tons of questions sent to me. I think we have like 25 or 30 questions that I’ve as usual, we never get to go through every single question because we also have this as a live session. So many of you are submitting your questions live and I’d like to take a make sure that you have priority because you take the time to come and join me live.
Speaker 1 (00:02:13):
So let’s get started with the questions and send me your questions live as we go through. So we’ll start with some simple questions and that’s specifically something as simple as what is laparoscopic surgery And a lot of people are like, oh, I had arthroscopic surgery or endoscopic surgery. Those are not the same. So the scope or the scope part means we are using a camera to perform any time of visualization. In other words, we’re not looking and touching ourselves. We’re looking through a camera to see other things. Now the beauty of that scope or scopic surgery is that the camera can be multiple times stronger than your human eye. So you’ve heard of microscopic surgery. Some people do microscopic surgery for really crazy microscopic like dermatology and cancer surgery, reconstructive surgery. Those are all, eye surgery is definitely under the microscope and it’s microscopic surgery. So that can be 4x, 10x stronger visualization of the tissue and would be considered superior to doing let’s say eye surgery without the microscope.
Speaker 1 (00:03:38):
So that’s the scope part of scopic surgery. Then there’s like everything before, so microscopic means they’re using the microscope. Laparoscopic means through laparotomy or a lap. Lap kind of implied like the abdomen, arthroscopic ARTHRO like arthritis that’s related to the joints. So joint surgery, let’s say hip surgery or knee surgery, that’s arthroscopic surgery. Endoscopic means endo, endoluminal like inside the lumen. So endoscopic surgery, you’ve heard of endoscopic surgery in the sinuses, so endoluminal sinus or often endoscopy going into the esophagus and stomach or colonoscopy. So you’re scoping the colon. So all of those are different scopic surgeries. And for general surgeons, we do laparoscopic surgery in the UK they often term this keyhole surgery. It’s kind of cute, it’s pretty name. It’s often used more commonly than the term laparoscopic surgery. So keyhole surgery is another good term. And I’ve heard lasers.
Speaker 1 (00:04:50):
So we used to take out a laser so we used take out a lot of gallbladders when I was at the county hospital. That was way too much gallbladders I found. I feel like I overdosed on gallbladder surgery. Everyone had a gallbladder problem. It’s very genetic as well. So many people said, oh yes, laser surgery, you’re operating with laser, not really. Of course there are abilities to use laser for surgery. It’s not gallbladder surgery. There was a time when the gallstones were lasered or kind of broken up. We don’t do that. But in layman’s terms, some people incorrectly refer to laparoscopic surgery, especially for gallbladder surgery as laser surgery. So we don’t use laser, just fyi.
Speaker 1 (00:05:39):
So how is that different than open surgery? Well, open surgery is the classic type of operation. You make an incision and you go inside whatever organ it is you’re operating. So for the abdomen, if you’re having hernia surgery or abdominal surgery, intestinal surgery, there’s an incision involved and you go in there with your hands and you’re doing the whole surgery. That’s classic open surgery. It was invented centuries ago and we still do open surgery now. How was that different from laparoscopic surgery? Well, at some point someone decided, and I believe it was the French, that you can start to use smaller incisions but still gain access inside the abdomen. I believe the gynecologists were the first invent laparoscopic surgery. And so effectively at the organ level, like the hernia or the stomach or the gallbladder, you’re doing the same operation but getting to that organ is less invasive.
Speaker 1 (00:06:48):
So that’s why that minimally invasive surgery term comes from. So that’s the main difference between laparoscopic and open surgery. And then many of you nowadays are hearing about robotic surgery. So robotic surgery is just another way of getting to do minimally invasive surgery. So with laparoscopic surgery, the surgeon and the patient are all next to each other and we’re both there. Were we’re holding instruments. We would a fork, a knife, and there’s a third instrument which is a camera. There may be more than three, but minimum three. And then we’re moving stuff around and using instruments. Some people call this chopstick surgery because we tend to use straight instruments for laparoscopic surgery. Robotic surgery is the next level in terms of how much more technology is involved to do a similar operation. Instead of the human surgeon holding the instruments physically in their hand and performing the operation, those instruments are attached to a robotic machine or we call it a robotic arm instead of a human arm.
Speaker 1 (00:08:08):
And the surgeon is feet away from the patient against this what we call console. It’s basically a video console, like video games and we are telling the robotic arms were to go what to do. So we’re a little bit distant from the patient. We’re not usually outside the room, we’re in the same room. Although interestingly, if you’re ever curious a really cool, theoretically you don’t have to be there with a patient. Of course we always are, but you may have heard of Trans-Atlantic surgery. So there an awesome, there should be a video on it on YouTube. I know 60 minutes did a episode on it too. So what you have is the surgeon was in, lemme get this right, the surgeon was a French surgeon. He was from Strausberg where this all started and the patient was in Strausberg and then he flew to I believe New York and was in the console in New York.
Speaker 1 (00:09:16):
The patient was having surgery in France. So that was a transatlantic operation. Obviously they needed really good internet connection or wired connection because whatever he was doing while he was in, let me stop sharing this. Whatever he was doing while he was in New York was then translated to the arms moving in the patient in France, which was really cool. It was a little bit scary because there was a delay. So if any of you ever talked on a phone or remember decades ago, there’s always a delay. There’s not as bad anymore. But so what he would do here would be delayed there. So if there was a complication, it could have been something terrible, but that was Trans-Atlantic surgery. And with the robot you can do that because what you’re doing is a surgeon is telling the machine what to do. And this machine technically does not need to be in the same room though functionally it is.
Speaker 1 (00:10:16):
And when we do robotic surgery or right there in the room at the operating room with the patient, I believe they still do what they call telesurgery. So distant surgery robotically in Canada because if any of you are familiar with Canada, humongous country, very few people and most of the people are on the southern border of Canada. But there are patients north out in a very, very sparse sparsely popular land. Some of them need surgery, not everyone can fly down or travel down to have surgery. So there was this kind of initiative, it may still be going on. There was an initiative where the surgeon was in Montreal and a surgeon over in some area way north in Canada would connect with the surgeon in Montreal, the surgeon would be in his office and he’ll probably be having some tear coffee at the console. And then the other surgeon that wasn’t able to do the minimally invasive operation but can do the open surgery was in northern Canada and was able to hook everything up and was there in case something bad happened.
Speaker 1 (00:11:29):
But the surgeon in Montreal, which is southern would Southeast would be able to do an operation, someone for the north. So that was an ability of surgeons to be able to provide advanced surgical care or minimally invasive surgery to people that couldn’t afford to or couldn’t be able to fly or travel to the larger cities because it’s such a huge, so these are cute little stories and if any of you are interested in surgical history, I love surgical history. I think we learned so much from it, but the ability to go from open to laparoscopic and now laparoscopic to robotic surgery is fascinating. And it’s not just fascinating because it’s about surgery, but it’s fascinating because all these stories and how surgeons who were trying to do laparoscopic surgery were literally thrown out of conferences and booed and prevented from operating in certain hospitals. We have surgeons in our own hospital, Cedar Sinai, which is one of the meccas of laparoscopic surgery. Some were denied privileges because people thought laparoscopic surgery was dangerous and should never be done. Why do you need to do it? And now it’s pretty much the norm. And if you don’t offer laparoscopic surgery, you’re kind of not really providing care in this century, even in poorer countries or countries with low facilities. Laparoscopic surgery is becoming kind of a good thing and I’ll explain to you why most of it is because it is minimally invasive and patients tend to heal much better.
Speaker 1 (00:13:17):
So let’s discuss the term minimally invasive surgery. It really is related to how much healing the patient needs to undergo. So if you had a gallbladder surgery, you would get a huge scar underneath your rib margin and you’d be in the hospital three to five days. Breathing would be painful, of course you have to breathe and wound infections were a problem. Hernias were definitely an issue and you can get what’s called denervation. So there’s a lot of reasons why it was kind of nice to start with gallbladder surgery as the first kind of general surgical operation that became popular laparoscopically. Now we do laparoscopic gallbladder surgery. As an outpatient you get four little scars, three of them you can barely see because they’re five millimeters and one where you take out the gallbladder is a little bit bigger. It’s one centimeter as opposed to like a five centimeter, six centimeter, 10 centimeter or larger scar. The rate of complications is much lower wound infection rate, lower scars, lower pain and lower incisional hernias because there’s less incision to hernia through it.
Speaker 1 (00:14:32):
So that’s why we call it minimally invasive. Right now both laparoscopic and robotic surgery are in the same realm as minimally invasive surgery. And so whenever we call i s or our fellowship is called i s fellowship, minimally invasive surgery fellowship. So we teach our fellows advanced training in both laparoscopic surgery and robotic surgery. We had a whole segment on robotic surgery before, so I don’t want to kind of talk too much about it, but I really want you to understand the pros and cons of choosing a minimally invasive surgery. So here’s a question that was posed, which is a good question, which is open. Let’s say you had an open abdominal incision, now you have a hernia from that open abdominal incision. Is that best repaired again open through the same scar or should you consider a laparoscopic or robotic surgery? This is a great, great question.
Speaker 1 (00:15:30):
First of all, number one, it really depends on your surgeon. If your surgeon is comfortable to provide all different options, that’s usually best because they can tell you, okay, there’s open, laparoscopic, robotic, I think it should be done open for this reason or laparoscopic for that reason. Often what I see is that people are not offered a choice mostly because a surgeon cannot or does not do laparoscopic or robotic surgery. They’re what we often term an open surgeon. Perfectly good surgeons, very gifted patients probably do really, really well, but in some situations they should really be referred for minimally invasive surgery and they’re not. So there’s no right answer to this question.
Speaker 1 (00:16:20):
In my case, if you had come to me with an incisional hernia from an open surgery, let’s say you had your uterus removed, your colon removed any type of intestinal surgery that was done open, even a laparoscopic surgery where they took something out like a spleen or a stomach or a gallbladder, you can get a hernia from where that was removed. So if you have a hernia that’s up to maybe six centimeters wide, which is, let’s see, it’s about two and a half, a little under two and a half, sorry, 2.54 centimeters per inch. So six inch, sorry, six centimeter incisional hernia y we’re talking width length, we don’t care about the width. Then that’s about maybe two and a half inch. So anything about two and a half inches or smaller I would for sure consider laparoscopic or robotic surgery for it. Even though the original surgery was done in open fashion, that’s usually what I go by is by the size.
Speaker 1 (00:17:32):
Now what if you also have a really ugly scar? Well, I personally would prefer to also fix that scar as part of the whole reconstruction of the abdominal wall and sometimes doing the whole procedure open allows you to reconstruct the scar and give you a nice hernia repair at the same time. And lastly, if you have a diastasis or a width and you need a tummy tuck to be associated with that, that’s usually done open and sometimes we can do it robotically. If you have loud excess skin, we prefer to those open. So there’s no good answer to this. Just know that open surgery and laparoscopic surgery are always, almost always options for hernia repairs and there’s pros and cons to both.
Speaker 1 (00:18:27):
So in my situation, if I see a patient who’s already had open surgery, if they don’t have a scar issue, they don’t have excess skin issue and they have a defect six centimeters or smaller for sure, I would do those laparoscopically. By the way, we discussed how laparoscopic surgery has smaller scars, five millimeters, maybe 10 millimeters, which is just a centimeter, like less than half an inch. What’s cool about that is you also have less skin to heal. It’s often less painful therefore because there’s less muscle that’s being cut through and you have less infection. So if you’re morbidly obese and you’re already at higher risk for incisional hernias and wound complications, I would tend to err on using a minimally invasive procedure like laparoscopic surgery to reduce your risk of hernia and wound infection from this second operation or whatever the first operation basically.
Speaker 1 (00:19:26):
That’s the way that I think of it. So morbidly obese patients really benefit even more than normal weight patients from laparoscopically or minimally invasive surgery, which is why if you know anyone who’s had weight loss surgery when I was a resident, we’re kind of right at the transition moving from open surgery to laparoscopic. Pretty much almost everyone nowadays gets laparoscopic weight loss surgery. They do not get it in open fashion and even many of them don’t even know how to do it. The ones that are trained, I’m not sure they even know how to do it. I think I told you this story, I was mean I was trained to do it open and laparoscopic. It’s not what I do, but I know how to do it and I needed a patient who needed a stomach removal, not for weight loss, but her stomach needed to be removed as part and she was my patient.
Speaker 1 (00:20:25):
So I asked one of our bariatric surgeons who’s a very gifted kind of stomach surgeon to join me in the operation, so I will take care of the hernia part and he would do the stomach part, but it was open and so he’s like, yeah, great, we’ll help you. No problem. We went in, did the joint operation and then we got to the stomach and he just paused and I looked at him, he didn’t say anything and I, I’m like, why is he pausing? And it occurred to me, I said, you’ve never had to go around the stomach in open fashion, have it was always laparoscopic. And he kind of looked at me like no. And I said, let me show you how it’s done. I mean he is a gifted surgeon. He does this every single day laparoscopically. So the techniques are a little bit different and honestly we don’t really do a good job of training our residents in open sometimes open surgery the same way that we don’t really train much in Shouldice or Bassini or McVay, these kind of tissue repairs. Everything is laparoscopic and laparoscopic implies Mesh for hernia repairs. So I was like, let me show you how it’s done. Of course it’s been like 25 years since I’ve done an open bariatric surgery or stomach surgery. But anyway, long story short, patient did very fine, but it’s just a little bit of a different animal. Open surgery and laparoscopic and robotics, a little bit different than laparoscopic.
Speaker 1 (00:22:03):
All right, enough stories I think. I hope you enjoy the stories, but sometimes I get carried away. I love stories. Okay, so let’s talk about really big hernias. So what if the hernia is bigger than six centimeters? Actually really big 20 centimeters, right? You’ve seen some pictures I posted on the internet like huge hernias. Can you still do laparoscopic hernia repair if the hernia is really big? All right, well, depends on what really big is. The goal of all hernia surgery in general is to close the gap. We want to close the gap. Now let me give you a good analogy. If you try and close the gap, let’s say you have a jacket and it won’t close like it’s too far apart. The only way to close that is to let go of the seams, right? Open up the seams. We call that component separation in hernia repairs.
Speaker 1 (00:23:04):
So we do that the same thing in hernia repairs. We separate as much tissue from other tissue as we can to kind of release the tension to get the middle of the abdomen closed. Again, that’s very easily done with open surgery. It’s not as easily done with laparoscopic or surgery. And that robotic surgery has made it so it’s easier than laparoscopic surgery. Now there are some really gifted surgeons out there are really gifted who can do these operations laparoscopically because you’re basically using chopsticks. One of them is a surgeon actually in Russia, Dr. Vlad Burakoff, he’s amazing and they don’t have a robot in Russia, at least he doesn’t have access to a robot. So he’s learned how to do this very complicated operation laparoscopically. You can go to Russia and he’ll operate on you.
Speaker 1 (00:24:10):
Dr. Igor Belyansky, we had him on as a guest, the show very gifted surgeon. He can do these really big hernias laparoscopically. I believe he chooses to do most of them now robotically because he has access to a robot. But if he were handcuffed or straight at another country, he can definitely do it laparoscopically. The majority of surgeons cannot. It’s very skilled operation. And so what we do is we do it robotically. So the robotic operation is laparoscopic surgery plus extra technology. And yes, the really big hernias in many patients can be done robotically. You need a highly skilled surgeon. The majority of surgeons do know how to know how to do it and will not offer it. A majority of surgeons won’t even offer open surgery for the really big ones. So it’s key to understand what’s in the best interest of the patient and what they have access to. You may have turned, you may have heard the term TAR, t a r, that stands for transverses abdominal release.
Speaker 1 (00:25:23):
And I said there’s this whole thing about releasing tissue. So if you release a, it’s a type, it’s a posterior component separation. There’s a more commonly educated or taught anterior component separation and the more modern way of doing things for even larger hernias is the posterior component separation, which we offer, but just know that it’s, it’s considered highly skilled procedure and most surgeons don’t offer it, but it is an option. All right. I mentioned earlier we had tons of questions offered to us and I must say there were amazing questions. Like I always come pre-prepared with questions. You guys always stomped me. I mean my audience is the smartest audience ever. The questions you guys presented, I was like, that’s really smart question. So I have tons of them to go through. One was just submitted right now. And component separation, is the Mesh always placed in the posterior rectus space? No.
Speaker 1 (00:26:31):
So there are different types of component separation, posterior and anterior. Typically we like to put the Mesh against the muscle. Usually what we call retrorectus or behind the rectus muscle. That’s typical. However, some people do as an Onlay on top of the fascia. Some people do it as a underlays, they put it not underneath the muscle, but they put it underneath the fascia and between the peritoneum in the fascia and some people put interim nominals like complete, complete underlay inside the abdomen. So just because you’re having a component separation doesn’t imply that your Mesh will always be in one place. So I hope that’s helpful. Another question, if a surgeon did both robotic and open to clear up old scar tissue, then how come the surgeon says he doesn’t know whether the ongoing pain in the rectus is nerve or what is causing the pain if we’re able to see everything and why then do some patients continue to have pain and problems after both approaches and what is the cause of scooped out areas in the abdominal muscles? Okay, that’s like four questions. I’ll try and answer them as much as possible. So pain has multiple causes. Could be from nerves, it could be from too tight of a repair, it could be from a hernia recurrence, could be from the Mesh balled up. The Mesh could be entrapping or folded in certain areas. You could be reacting to the Mesh. There’s so many different causes of pain after a hernia repair.
Speaker 1 (00:28:12):
Scar tissue is the least likely to cause chronic pain. It’s just not. I mean it happens, but it’s not the first thing that comes to our mind. Hernia recurrence is the most common and then there’s everything else in between. So yes, you can see everything. Now you don’t have microscopic eyes, you can’t see a nerve being injured necessarily, but usually in the middle of the abdomen it’s not a nerve problem. And then I feel a lot of times pain is because it’s too tight. So if I put a ring on your finger and the ring is perfectly sized, you won’t have pain. But if I put a really tight ring on your finger, that’s going to be really painful. Some people make really tight repairs. Either the Mesh is too tight, the sutures are too tight, the repair is too tight, there’s a lot of tension and that alone can cause a lot of pain.
Speaker 1 (00:29:06):
So to answer your question, why do some people still have pain after a revisional operation? Well, first of all, it depends on how early you are after your hernia repair revision because it takes time to heal. Then the question is what kind of pain is that? Is that pain exactly like before your surgery? Because not all pain is pain. So if it’s exactly the same as your first surgery, then whatever the first surgery, sorry, is the pain exactly the same before and after surgery? If so, then the surgery didn’t address pain and there must be another reason for it.
Speaker 1 (00:29:45):
If the Mesh was removed thinking the Mesh was the cause of the pain then and your pain is unchanged, then that wasn’t the cause of your pain. And then there’s scooped out areas of the abdominal muscles. I don’t know what that means. So most we don’t scoop out muscle areas. You can have indentations in your soft tissue, but your fat underneath your skin and that is related to prior operations and how you healed and if the fat stayed healthy or if you’ve had steroid injections, all those can cause scooped out areas. So complicated question, which is why I do what I do because revisional surgery and dealing with chronic pain is very complicated. I literally spent at least an hour on or more not only speaking with the patients and examining them, but also researching for them and trying to bring them some cla- figure out what’s wrong with them and back and forth and so on.
Speaker 1 (00:30:45):
So there’s a lot of like work that needs to be done to figure out why you have chronic pain and then when you get to surgery, I don’t really focus on that and not just like, oh, maybe it’s your Mesh, but maybe it’s not good enough. Maybe it’s something else. And why would you undergo Mesh removal if that’s not your problem? Okay, next question. Have you had any patients use frequency specific microcurrent F S M to treat Mesh problems? Do you refer patients for this treatment to help heal tissue after surgery? I’m told by lots of chiropractic doctors in California that they use us. I’m trying this now and after each of these treatments I’ve had increased severe pain around where I have the Mesh. I was informed today that since this has happened with several protocols that indicates, indicates I have an infection and microcurrent won’t work because of this.
Speaker 1 (00:31:43):
Okay, so are I believe they’re supposed to kind of attack your muscle, not necessarily your soft tissue or the Mesh and if it doesn’t work, it’s due to inflammation, not necessarily infection. So infection is one reason for inflammation, but inflammation alone, maybe another reason for it, I would like to learn more about it, about frequency specific microgram. I believe the attacking your muscles, but I’d have to learn more about it. So if you’ve learned more, please contact me. Or if there’s someone you specifically are working with, I’d like to kind of learn about too because there’s so much new technology out there and some of it works great and others don’t. At the very least it’s not causing permanent damage. So that’s at least good. Next question, does robotic repair require peritoneal access or can be done totally extra peritoneal? Okay, complicated question. I’m so impressed people are asking this question. So as many of you know, the peritoneum is the layer or sac that surrounds your intestines. So for example, how should I explain this? It’s like a sock, let’s call the peritoneum. Everything is inside it. Your liver, kidney, not your kidney, your liver, organ, stomach, intestines, large intestines, small intestine.
Speaker 1 (00:33:12):
Okay, before I go on, lovely lady, one of my top fans on Facebook, it’s trying to answer that question about the microcurrent. She’s had cold laser application on her abdomen and the pain always increases and she doesn’t know why. That’s very helpful. I’m not sure if it’s the same if F S M and cold laser is the same. All right, going back to the peritoneal access. So with robotic surgery to date all robotic surgery, or I should say almost all robotic surgery is done Intraperitoneal. So inside the abdomen and if they need to do extra peritoneal surgery, so between the peritoneum and the muscle, which is how we like to do it, you have to cut through the peritoneum, which is like the sheath, bring the peritoneum down and then you get to the muscle. So it’s called transabdominal pre peritoneal. So you go in the abdomen first, transabdonimal, and then you find the peritoneum, you slice it, bring it down, and now you’re extra peritoneal. So transabdominal pre peritoneal. So yes, pretty much everyone does it that way. There have been attempts to do extra peritoneal surgery, completely, totally extra peritoneal surgery with the robot. It’s failed. The reason why it’s failed is the robotic arms need a lot of room and space to work and totally extra peritoneal access limits that space. That’s the easiest way I can explain it to you.
Speaker 1 (00:34:48):
Which leads to the next question about TEP and TAPP. Many of you have heard about TEP and TAPP inguinal hernia repairs or laparoscopic TEP, laparoscopic TAPP, robotic TEP, robitic TAPP. These are all different types of hernia repairs. Ultimately this surgery is exactly the same. You find the whole, you scoop out the contents in the inguinal hole or you whatever hole and then you put the Mesh and the Mesh is always extra peritoneal. So between the peritoneum and the muscle and not between the peritoneum and the bowel. So the bowel does not see Mesh
Speaker 1 (00:35:27):
TAP stands for it’s T A P P, trans-abdominal pre peroneal. So you start in the abdomen and go from the skin all the way through into the abdomen and then you go pre peritoneal. It’s like a two-stage process. TEP is T E P stands for totally extra peroneal. So it’s a one-stage process. You just go through the abdominal wall and you stop at the peritoneum. You never go inside the abdomen, you never see intestine and you do all the surgery as a tap. That’s how the access is different. Ultimately operation is similar and most people do not believe there’s a major difference between tap and tap. Some of us, like me, I’m kind of like a, I’m purist, so I prefer to tap as much as possible. Laparoscopically, robotically, you can’t really do tap, you do tap, but if tap doesn’t work, you always transfer over to top.
Speaker 1 (00:36:27):
I don’t know if I confuse you guys anymore than that, but that’s kind of how it’s, okay. So next question. What is the best diagnostic that will help explain pain that it increases when applying pressure to the area and is applying ICE help relieve inflame muscles? So I’m a huge fan of ice. It’s a great anti-inflammatory and by that I mean that it reduces inflammation and if you have pain from inflammation, which is almost always post-surgical pain, then yes, ice works great. Now, if you have muscles spasm and the spasm is causing pain, then you want to relax those muscles in a hot bath or a heat pack does a good job of relaxing muscles. So if you need to relaxation and reduce inflammation, that’s where that kind of heat cold, heat cold pax works. But I’m a big fan of cold pax. What’s the best diagnostic to explain pain that increase increases when applying pressure to the area?
Speaker 1 (00:37:36):
Highly variable. So it could be a hernia, it could be a tear. In some patients with neuromas, if you press right over the neuroma, that can be very painful. I mean I have a patient who has an dissection of his artery in the groin region, history of aneurysms, and I put pressure right over that area that was very painful for him was an A hernia. Was a aortic, sorry, iliac artery dissection. So there’s a lot of reasons for it. It’s a very non-specific finding. Some people get all excited about it because they think it implies one diagnosis, it does not. And to kind of focus on that will would be a disservice. What’s the best way to heal at the flattened area on the muscles are caused due to steroid injections. Again, the scooped out areas that you see on the belly sometimes is not a muscle, it’s a soft tissue.
Speaker 1 (00:38:35):
It’s the fat. If it’s due to steroid injections, that’s a bad complication should not have happened. Steroids should not be injected into the fat. When I do steroid injections, I always numb the area first so I don’t have to inject any numbing medication that involves steroids and I only focus the steroid on the area of the muscle or the nerve so that you don’t get that dimpling or what we call fat necrosis. The fat just dies and there’s nothing you can do about it unless you harvest fat from somewhere else in your body like liposuction and then inject the fat into that area, which is a bit of an extreme procedure. But if it’s bad enough it may be worth doing. But yes, steroids cause fat necrosis. Fat necrosis is permanent. You just lose the fat in that area and the only way to make it better is to take fat from elsewhere and inject it. Otherwise you lose the volume in that region. I’m sorry, it’s kind of a difficult problem. All right. For, yeah, I would love to learn more about F S M. I know red laser therapy is a great way to reduce inflammation. There’s also ultrasound therapy. Some physical therapists offer that, but I’d be happy to speak to your contact person for sure. More I learn the more I can help you guys and my own patients.
Speaker 1 (00:40:09):
Okay, going back to TEP versus TAPP, are there consequences of the retrorectus dissection during a TEP totally extra peritoneal approach? For example, does it reduce pain or scar or does the scarring provide more support? No, no consequences that we know of. Can all hernia surgeries be performed with a minimally invasive approach also? No. So most hernia surgeries can be performed minimally invasively, especially with robotics. So the limitation we have with laparoscopic surgery as our minimally invasive operation was there were just certain things we couldn’t do. I mean you’re dealing with chopsticks, right? And the robot more has what’s called wrist movements. And the wrist movements more mimics the typical human type procedure more than chop chopsticks. So once robotic came in, the way that I describe robotic surgery, it’s the ability to do open surgery with a minimally invasive approach.
Speaker 1 (00:41:21):
When minimally invasive surgery started and laparoscopic surgery started, we had to reinvent a lot of things because we just couldn’t do it. Sewing was an issue. We usually sew really well. Can’t do it as nicely laparoscopically. Many can, many cannot. That’s where tackers came into place. We weren’t tacking things in open surgery, we were sewing. But now that you have tackers because you couldn’t sew, you like tacking things and that could cause a lot of problems. So a lot of things were invented purely to allow surgeons to perform minimally invasive like clips and so on. Whereas with the robot, it more closely mimics open surgery. So to answer that question, it’s kind of a tricky question. Can all hernia surgery be performed minimally invasive? No. Some should not be like fistula take down, for example, or most Mesh infections. We usually do those open, but you know what? As technology improves and our experience improve, we are able to do more and more. Today I’m able to do more surgery minimally invasively than I was a decade ago. So all that’s really good.
Speaker 1 (00:42:39):
One is open better than minimally invasive surgery. Great question. Okay, so open surgery is better than minimally invasive surgery for the, if the following are true, for example, you’re super thin and therefore because you’re so thin, the scar that you need to do open surgery is going to be like this big anyway. And so why do minimum three scars of three five millimeter scars when you can do one small, small scar? Another good example is a belly button hernia. So belly button hernia, I like to do most of those through the open procedure because I can put a small scar, hide it inside the belly button so no one even knows you had surgery and fix the belly button hernia through the open procedure. If I were to do it laparoscopically, I would have to use three scars on the side of your belly. And I mean it’s a good operation, but it’s why and you need general anesthesia for it.
Speaker 1 (00:43:48):
For groin hernias, a good tissue repair is best performed in open fashion, not robotically. Now I do offer the robotic tissue repair for inguinal hernias. It’s a good, good option for thin patients with really small hernias. I do not offer it for anyone that’s overweight or that has more than a small hernia, but a good Shouldice Bassini, McVay tissue repair of the groin is only done via open surgery If you’re older and the choice is open surgery under IV sedation or a minimally invasive surgery with general anesthesia, maybe general anesthesia is not safe for you and your heart is at risk. Too much stress on your heart. And so that would be a better option would be the open surgery. So there’s a lot of reasons why. It could be anesthesia wise, scar wise, cosmetically or almost all robotic or laparoscopic surgery involves Mesh. There are exceptions but almost always involves Mesh.
Speaker 1 (00:44:49):
So if you want to prevent Mesh use, then you really do need to go the open repair, but we are coming up with newer techniques. So what I say today may not be true next year for those of you that are watching this a year from now. Okay, is the MRI at best diagnostic tool for all this? I spent an entire hour on imaging a couple weeks ago and we discussed why MRI is good in some situations and not good in others. So I recommend you listen to that one. It was a great imaging radiologic imaging for hernias one hour and you guys asked a lot of great questions for that.
Speaker 1 (00:45:33):
Next, how does extending the Mesh below Cooper’s ligament in the Manchester repair as described by Dr. Sheen, offer more support to the rectus muscle than the traditional TEP for relieving pain and problems related to athletic pubalgia? First of all, the Manchester repair is simply a TEP inguinal hernia repair without fixation using glue. So the placement of the Mesh is no different and it’s always below the Cooper’s ligament. So that question is not really that valid because the technique of doing the operation only varies in that the Manchester specifically uses glue for fixation and basically does not use mechanical fixation.
Speaker 1 (00:46:24):
What are the most common reasons of conversion to open? Another great question. This is great. Okay, great, great question. So all minimally invasive surgery operations may not be able to be done completely or safely and therefore they are convert open. We never convert open to laparoscopic or robotic surgery. I mean, don’t ever say never, but that’s not considered typical. However, if something is going wrong or you’re unable to perform surgery, minimally invasive surgery, your default is open surgery. That’s just like a given. So what’s the most common reason? Scar tissue, too much scar tissue and just unsafe. You just, there’s no working. You need room for those instruments to move. If there’s no room because there’s bowel and scar tissue and so on, then you want to convert to open. If you cause injury at the time of the procedure, there was a loop of bowel and you stuck your instrument in it by accident and you cause injury that that would be a safe way to convert to open. Again, you don’t have to, but most people do. If you find that the hernia is just too big and you can’t bring it together and be under too much tension, then conversion to open is another good one for hernias, those are the kind of the top three, which is it’s unsafe to proceed. You’re either cause injury or bleeding, there’s not enough space to work in, or you just physically can’t fix the hernia.
Speaker 1 (00:48:09):
After Mesh removal, can you exercise and do crunches without worrying about getting another hernia? Or is hernia inevitable and unavoidable after Mesh removal? And what would you do for your patients who develop hernias after removal? At what point does the night nightmare end? I feel like once you get any type of surgery, you’re doomed for more hernias and problems. I don’t agree with that. I do feel that risk factor adjustment is the number one best way to prevent hernias from occurring. That means staying fit, which includes exercise core based, not gaining weight, quitting any nicotine use, fixing any chronic cough and preventing constipation. Those are the top five. So that is the best way to prevent another hernia from coming since you don’t have Mesh to support the hernia completely dependent on your own abdominal wall. So the technique in which that repair was done is also very important and it must be done without tension because the minute you get out of bed, you’re adding tension to your abdominal wall.
Speaker 1 (00:49:17):
The minute you are sitting in your car or getting out of the car, you’re adding pressure to your abdominal wall. So we need to fix hernias to understand that people have a life and we can’t prevent you from doing your life, so it doesn’t have to be a nightmare. Lastly, if you have a tissue disorder or a collagen disorder or you’re very hernia prone, unfortunately you’re kind of doomed without Mesh and so you may have another hernia recurrence, but exercise should be safe. I would leave it up to your surgeon to determine when and what kind of exercise are best because that surgeon knows exactly what kind of hernia they repaired and how secure their repair was after the Mesh was removed, how much muscle damage there was or not, et cetera. I hope that’s helpful because I understand there’s so much anxiety like, oh, I’m going to get another hernia again because now I don’t have the backing of the Mesh and that is a real fear.
Speaker 1 (00:50:24):
Woo. Look at this question. But you know what? It’s actually quite insightful. Okay, minimal invasive surgery is regard to be superior to open in regard to visceral parietal adhesion formation, that is true. So if you compare a laparoscopic or robotic surgery versus the same operation open, the minimally invasive surgery has less scar tissue and less adhesions as a result of it. We don’t know why, but the theories are that gloves touching things with the gloves, the talk that used to be on gloves and exposure to air and increased bleeding are all contributors to adhesions. Also, when we touch instruments with little instruments versus our hands, there tends to be less trauma to the tissue and therefore less scarring and less adhesions. Alright? However, minimally invasive approach involves carbon dioxide insufflation true, and that can predispose patients to hypothermia not true and peritoneal injury not proven.
Speaker 1 (00:51:32):
So there are theories about carbon dioxide insufflation and whether that promotes injury, never proven a lot of theories, some animal experiments which have shown potentially that CO2 can cause injury. However, the millions of hernia, the millions of laparoscopic surgery that’s done, we have not seen a trend towards injury. We have experimented with heating up the CO2 that has not been shown to improve patient’s outcome, adhesions, bleeding or pain control. And so we don’t believe that’s to be true. Can this result in more visceral adhesion compared to open? No. Are precautions such as heating and humidifying CO2 effective in mitigating these issues? Not really. So we have tried humidifying the CO2 and warming it up before putting in the abdomen that has never been shown to be cost effective in reducing pain, reducing scar tissue, reducing bleeding or anything like that. So these are all good ideas. It’s been looked at, it’s been studied, has been shown.
Speaker 1 (00:52:47):
What’s the Russian doctor’s name in Russia that you mentioned earlier? Oh, Dr. Vlad Burdakov. He’s a friend of mine. Very talented Burdakov, B U R D A K O V in Russia. Very talented young surgeon, very cool guy. Is the precision of movements through the trocars of the instruments used in laparoscopic surgery? The same if the surgeon were holding the same instruments with their hands. Okay, that’s kind of a convoluted question, but what it’s asking is are you as precise as a laparoscopic surgeon, as open surgeon? And the answer is depends on the operation. So in general, no. In general, the average general surgeon is more precise with open surgery than laparoscopic surgeon. Now there are very gifted laparoscopic surgeons that understand how precise you need to be and are. I mean, sometimes I walk, we have some of them at Cedar Sinai. It’s you walk into the operating room and I tell you guys, it’s just beautiful.
Speaker 1 (00:54:00):
You just, it’s like you’re watching the most high end opera or something like that. These people are such gifted surgeons and the way that they handle their tissues is just beautiful. And so those surgeons have excellent precision and they’re the same in open surgery. They’re also very gifted and very kind of precise with their hands and the instruments with open surgery too. So that’s just kind of the way they are. But they have learned to be really skilled laparoscopic surgeons. I feel with robotic surgery, again, you have to be intrinsically a surgeon that is very kind of light touch and really respects the tissue planes and your anatomy, which I love dearly. I think that’s a great part of the surgery that we do. But precision and robotic surgery for sure is better than most open surgery. I would say that laparoscopic is kind of in between an open, open is also very precise, so it’s kind of a different, it’s hard for me to answer these questions.
Speaker 1 (00:55:17):
I don’t know. It’s so surgeon dependent. I hate to keep saying this over and over again, but I feel like there are certain surgeons I would want to go to if I thought, I mean open surgery and there are certain surgeons I would go to if I thought I needed laparoscopic or robotic surgery and sometimes they’re not the same surgeon. It’s very kind of difficult to admit to, but it’s reality. How should I explain it? Some people are really good at stick ship, others in with automatic, I don’t know. Is that a good one? I’m not sure. I’m not, if that’s a good analogy. I need to work on my analogies. Who is a top surgeon? Top general surgeon, the northeast that you would trust your life with for both. Oh my lord. Well, I would like to say that in the surgeons that I interview on hernia talk, I completely think that they’re just amazing and I would go to any of them.
Speaker 1 (00:56:22):
So go through my list of surgeons and I feel that they’re all really gifted. Dr. Brian Jacob I think was my first guest and I find him to be highly skilled in Manhattan for all types of open and laparoscopic surgery. And he’s very gifted laparoscopically and robotically. Dr. Belyansky, we also, I think he was one of my top ten first handful of surgeons that we interviewed, but it’s hard to tell, but look at my list of people that I’ve interviewed so far, and those are people that I think are just really great surgeons. I would not interview someone if I thought that I wouldn’t want to be associated with that surgeon. So that’s a clue.
Speaker 1 (00:57:13):
Okay. Do all large abdominal incisional hernias have to be repaired with mush? Have to. I mean, yes, they should be. Does everything have to be, I mean, it’s just all a risk benefit ratio. Back when the initial component separation was described where really big hernias were manipulated, the muscle movement brought together, again, we do those with Mesh, but we know that without Mesh it’s about a third will recur. So is it appropriate to do this amazing operation to have a third of the patients have a bad outcome? We think not as surgeons, but maybe you as a patient are okay with having a two-third success rate. If you have some issue with mush. I mean, it’s really a personal decision and it’s a risk benefit ratio kind of decision. You have to understand how much risk are you willing to take for how much benefit.
Speaker 1 (00:58:21):
And I’m just going to leave you with this last question, which I really like. Again, you guys are the best. I just have you guys run this show and I just ask me questions and I’ll just answer it because the questions that you all propose are so amazing. Oh, it looks like we have another question before I move forward. Is it possible to develop a hernia under your sternum? So if you mean below your sternum, like sub xiphoid, if you’ve had heart surgery or have an incision in that region, yes. If it’s under your sternum, underneath the bone, the answer is no. Okay. Just to clarify, last question. What are the most promising technologies under development for minimally invasive surgery? That’s a good question.
Speaker 1 (00:59:13):
The A S G B I, the Association of Surgeons of Great Britain, Ireland asked me to write up paper on future technologies in minimally invasive surgery, which I thought was kind of cool. They have a journal, you can go online, A S G B I journal, and I went through kind of all the different cool technologies that are out there. I mean, there’s like magnetic surgery, there’s surgery you can do to not even have scars. So I told you, you need to have at least three scars for laparoscopic surgery or robotic surgery. Sometimes you don’t need as many. Some of them can be using magnets across the abdominal wall. There’s definitely more robots coming out. Currently, the only company in the US that sells robotic surgery for general surgery is intuitive surgical. It’s called the Da Vinci robot. But Johnson Johnson, Medtronic, they’re all coming out with their new robots.
Speaker 1 (01:00:17):
Many of you may know. Next week is SAGES. It’s the Society of American Gastrointestinal and Endoscopic Surgeons meeting. It’s an annual meeting. It’s the largest meeting of the year for laparoscopic surgeons like me. And what we do is we get together, it’s the funnest meeting, it’s all laparoscopic surgeons. We’re all into technology and innovation. The entire meeting is focused on how to do things better with minimally invasive options. And then there’s a huge portion of it, which is based on upcoming technologies and so on. It’s a really fun meeting. And so in honor of next week’s meeting, which I’ll be very involved in, that’s why I chose the topic this week to be on laparoscopic and robotic surgery. Kind of tie it all in as sage’s month. So hope you guys kind of follow me on Twitter because I will be tweeting everything that I learned from the SAGES meeting next week. And that’s the platform that I use for all my kind of surgical education that’s focused mostly for medical professionals. So follow me on Twitter at Hernia doc. I probably won’t be able to do hernia talk next week because I’ll be at the meeting. But stay tuned for the week after that. We got some guests coming up. And thanks everyone for joining me and for your questions and hope everything is fine. I hope you like my honest answers. I appreciate it. See you in a couple weeks.