Speaker 1 (00:01):
Hey everyone, welcome to Hernia Talk Live. So glad to see you guys. It’s been a busy week and I’d love to share with you what’s been going on. My name is Dr. Shirin Towfigh. I’m a hernia and laparoscopic surgery specialist. Many of you are following me on Twitter and her Instagram at Hernia doc and you’re here live on Facebook Live at Dr. Towfigh. Thanks for joining me via Zoom as well. And after all of this is done tonight, I will make sure that you can watch and share and all of my sessions, including tonight’s on YouTube. So I wanted to tell you about the week I had last week was SAGES. It’s the Society of American Gastrointestinal and Endoscopic Surgeons. Even though the focus of the conference is on min, minimally invasive surgery, hernia is a huge portion of it because we do laparoscopic and robotic surgeries.
Speaker 1 (01:01):
It’s very common operation as you know. Next end of this month is the American Hernia Society. It’s going to be held in Austin, Texas. Following that is a European Hernia Society, which this year is in Denmark, Copenhagen. We have the Western Surgical Association coming up. So these are all meetings that I go to that I participate in. I either chair sessions or give talks. I’m really excited because my residents and fellows got their research with me accepted so they get to present and give talks. And I thought it’d be kind of cool to spend today’s session talking about what’s new and what we’re talking about. Because most of what I do here with hernia talk is me talking to you as patients and I share with you what I know, what I learn and my expertise and experience with different scenarios. But I thought it’d be kind of cool to see what we as surgeons going to go through.
Speaker 1 (01:59):
So last week we were in Las Vegas. It was interesting to be outside of your comfort zone. During a pandemic, I was triple masked to make sure that I did not accidentally contract the delta variant of the coronavirus, which is highly contagious. We’re all surgeons, were all vaccinated, and we were all very good at wearing masks. So that was good. I can’t say the same for everyone else who was in Las Vegas that maybe wasn’t at that surgical conference. So it was a little bit tricky. However, it was a private event. So public was not intermingled with our conference. And like I said, the stages is the largest conference ever. It is for laparoscopic surgeons. We usually have thousands and thousands. It’s a very international conference. However, because of the fact that travel is restricted and they made it a virtual combination in person, a virtual conference because a lot of, our European colleagues, Asian colleagues, et cetera, could not travel.
Speaker 1 (03:11):
So just want to make sure that you guys can all see me here. Are we live on Facebook? Looks like we are great. So please ask me any questions. I’ll kind of give you a gist of what the trends are a lot of times. These conferences include talks and topics that are cool and unique for surgeons. So you guys may want to be able to know what we think is important to talk about. And then it also gives me kind of an idea of what industry is doing. So we also have industry meetings and industry comes out with new products and ideas and so on. For those of you that follow me on Twitter a lot of what I’m discussing today has been kind of discussed and hashtag on Twitter #SAGES2021. But I just think that it would be kind of cool to review that.
Speaker 1 (04:10):
So already many of you’re on Facebook. One of you just said, I just watched a SAGES presentation on YouTube. So SAGES is very cool, very because it’s a laparoscopic meeting, it’s all also relatively advanced in its technologies for the meetings. So it was livestream for people to watch and then that registered and then after, in about a year or two, they also put a lot of, the more important topics online for anyone to watch. If you just go, S A G E S and type in sage and can put hernia or something on YouTube, then they have their own YouTube page and you can watch it. And then some of those that I’m in, I’ll, I will also cross post on my page, but one of your wrote, I just watched a SAGES presentation on YouTube about the complications of tar versus open. So robotar what we call it, which is robotic TAR, robotic T A R, trans versus abdominals release.
Speaker 1 (05:05):
It’s like big hernias versus open TAR. Very interesting. I heard you would lose 50% of your abdominal muscle if you remove Mesh from the retro rectus space. So I was trying to do some research. That’s not true. You do not lose 50% of your muscle. We would never do an operation ever that would result in you losing half of your muscle. That’s just insane. I don’t know where you heard that. Never, ever, ever happens. The Mesh is stuck to a layer of tissue. That layer can be fat, it could be fascia, it could be muscle. And in removing the Mesh, if that’s what you need, a sliver of fat, fascia and or muscle will go with that mesh- a sliver! So if the Mesh is a hundred percent, maybe there’s an extra 101 or 102% tissue on it, you don’t leave a lot of tissue on the Mesh. So for sure you are not losing 50% of your muscle. That would be horrible complication.
Speaker 1 (06:08):
Even in the worst of hands, I would say people who don’t really do it for a living, I don’t think that they would be leaving 50% of the muscle that’s that’s like a chunk that’s like taking a piece of steak and just cutting in half. We would never do that because then what do you do with all that leftover missing tissue? You’re going to have to fix that. It just makes no sense. So I hope that helps you a little bit. So at the meeting we discuss a lot of interesting topics. We had some hernia video sessions, which were very cool, new techniques, something that was very interesting. There’s a lot of robotics, et cetera. So if you have any questions, let me know. I actually would love to get some feedback from you at this session because I feel that what your input is really important. So let me ask you some questions as we go through this hour and give me some feedback because I’d like to know your impression as a patient as to what is important to you because I have a feeling as surgeons, we enjoy all of these toys and yet that may not be really important to you as patients. For example, robotics. Okay, so let’s go back to what we were discussing earlier, which was, hold on, let’s see.
Speaker 1 (07:36):
Here we go. So our first thing that I thought was really cool that we are expecting in the next, I don’t know, one to three years are newer robots. So as many of you know, the Da Vinci robot is the current robot that is available in the United States. It’s the only f D approved robotic technology for abdominal wall hernias. It’s made by Intuitive Surgical, which is a California company. It’s really cool. We get to go up north a little bit and go to the actual company and see all the stuff and you can get trained there. So currently everything is Da Vinci robots. It’s very expensive. They range from about a mil 1.1 million to 2.2 million per robot. Now you don’t have to buy, it’s kind of like a car, you can lease it, but it’s a hugely expensive machine and every hospital is now owns robots because most of something like 98 or 99, I think 98% of prostate surgery is done robotically.
Speaker 1 (08:43):
And I learned a new statistics, any hernia that’s done in the hospital setting, 40% of those are done now robotically, which is I think insane. But the fact that this robot is becoming such a huge part of general surgery is pretty interesting, especially hernia repairs. And we’ve had a whole session about robotics and hernia surgery and whether it’s safe or not. And we went through the data, I hope you go back and watch. That was really great because there’s so much negative press about robotic surgery based on 20 year old data. And yet at the same time there is so much advances and I think the beauty of the robot is two things. One is it’s such an easy and intuitive machine to operate that anyone who was having problems laparoscopically because laparoscopic surgery is very technologically advanced, not just for gallbladders, but hernia surgeries specifically is considered advanced surgery with the laparoscope.
Speaker 1 (09:52):
And so a lot of surgeons do not offer laparoscopic surgery to their patients because it’s just complicated. And so they only offer open surgery and every study out there proves that there’s definite advantages to offering laparoscopic surgery are what we call minimally invasive surgery. With the robot you can do that surgery so much easier. So more people are offering minimally invasive surgery robotically for hernias, whereas before they were not offering it. At my own hospital, we have surgeons that were not really doing laparoscopic surgery and now they’re doing offering it to their patients because they’re so that’s one benefit of the robot. The second benefit is that for those of us that already know how to do laparoscopic surgery, we love it because now we can do things we couldn’t do laparoscopically. It was too complicated beyond. And so we tend to do it open these big hernias and now with the robot you can replicate open surgery skills robotically. So the reason is the robotic arms are kind of like this. So what’s really cool is everyone has seen this kind of uptick of intuitive surgical and how, what an impact they’ve made in the general surgery world, especially hernias that now they’re trying to bring more robots to the United States.
Speaker 1 (11:34):
For example, there’s a company that makes something called the versius robot. Well, you can go to Europe and use it even in Europe as socialized medicine. So not that many people use it, but the versus versius robot is trying to come to the United States and actually in doing so start with hernias. So that’s kind of really cool. I got to sit in the versius robot. It’s, it’s a little bit different. It’s a little bit more streamlined than the intuitive robot, but you’re basically doing similar things. You can stand, you can sit, it’s very ergonomically pleasing. It’s good for your wrists. And as many of you know, Jo Johnson, Johnson, Medtronic, Google, they are all coming out with their own robot and I think the Medtronic robot is not out in the United States yet, but I think we’ll be making a debut next year in the United States and maybe in South America sometime also next year. So really, really interesting things coming out in the new robots. So that was part of what was really interesting was there was so much robotic surgery at SAGES at this minimally invasive surgery meeting and a lot of, the surgeries for hernias that were being talked about were not necessarily robotic because it seems like no one even talks about laparoscopic anymore. It was not necessarily laparoscopic but it was robotic. So that was kind of cool.
Speaker 1 (13:07):
Thank you Heather. It’s by God’s grace that I found you. Now I’ve got to California. Thank you. You’ve given me hope and blessings. Thank you so much. That’s very nice. So that’s really cool. A lot of new robotic technologies coming out and then even people that a surgeon friend of mine has invented a new instrument that replicates robotic surgery without having to pay $2 million for a robot. Very, very cool. It’s called human extensions. I posted on Twitter, but currently with the laparoscopic technique, which is pretty much available anywhere you go, but we call it chopstick surgery because they’re straight instruments.
Speaker 1 (13:52):
He kind of turned those instruments into robotic instruments so that you can kind of do this with it where the arms and wrists articulate without having it attached to a robot. So it’s attached to you. Your hands are the ones moving it just like a laparoscopic surgery but without the cost of a 2 million robot. So super cool. They actually got FDA approved. They presented it for the first time at SAGES. So this is the meeting where all the new technologies come out. That was I thought, really cool. So the other thing that was interesting that I thought you guys would all really enjoy is the fact that these new techniques, so eTEP, you’re going to hear TAR eTEP. There are all these acronyms, we love acronyms. But basically the point was to reinvent hernia repairs such that the bowel, the intestines never sees Mesh. We know that Mesh is necessary for many hernias, not all but many hernias.
Speaker 1 (14:55):
And what are the complications of Mesh which new patients may have endured or it’s reported about that we treat are adhesions and erosions. And that’s often because Mesh is placed against intestine. There’s a barrier, but that barrier is not a hundred percent. So more and more techniques are coming out to manipulate the anatomy so that when you replace the Mesh for the hernia repairs, it’s away from the bowel but it’s still a durable repair and that’s all being done laparoscopically or robotically. Very, very cool. eTEP is the new thing people have been talking about for a while and the more people are performing it, the more skilled they’re getting at doing the actual operations. So it’s kind of like you’ve heard me talk about Rives Stoppa or Rives Stoppa is like a French technique from the sixties and fifties and sixties. This is the robotic version of it.
Speaker 1 (15:57):
It’s really, really good. One question that’s being proposed is do robotic repairs have the same rate of success as an open surgery? Sometimes more, sometimes more. Sometimes there are patients that will have a much better outcome with robotic surgery for multiple reasons. Number one, less scarring, number two, less infection rate because it’s smaller scars. Number three, much easier recovery. So a TAR like those big open hernias, we usually keep the patients in the hospital three to five days, often seven days with robotic surgery you go home the next day like less than 24 hours. So in some cases, yes, in some cases, no. If you have to do a lot of tissue reconstruction, you have loose skin, your scar’s already ugly, you need that revised. That is not done robotically. But in skilled hands, robotic surgery can be just as good as open in most scenarios. So thank you for that question. That’s a very important question. Another question is, is being able to have better dexterity with robotics at an advantage in a straightforward TEP inguinal hernia repair, not needing much fixation to trump the risk of entire entering the peritoneal cavity.
Speaker 1 (17:20):
So the robot is not perfect and one of the reasons not perfect is that it is bulky. So the scars are larger than laparoscopic surgery and you need more space for the arms. So TEP inguinal hernia pairs are not easy to do and not recommended with laparoscopy. And tap basically is again, we talked about eTEP, this is regular tap. eTEP is extended tap. So for larger hernias, abdominal wall tap, we usually talk about inguinal hernias. So TEP stands for T E P, totally extra peritoneal. So everything is the mesh, the dissection, everything is done away from the intestines. You never see intestines. I love it. I think TEP is excellent. That’s how I do my inguinal hernia repairs. I never place Mesh against bowel for inguinal hernias for straightforward inguinal hernias. And then also I never have to see the bowel. So that’s one less thing to worry about.
Speaker 1 (18:19):
You cannot do a robotic tap. You can do an eTEP, which is a much bigger operation, extended tela but not a robotic tap. And so for Inguinal hernias, I personally don’t think that there’s that much of an advantage with a robot over laparoscopic Inguinal hernia pair for routine inguinal hernia pair. However, for some people it’s better because they feel that they’re more skilled robotically than they are laparoscopically. But for inguinal hernias robotically, it’s not TEP, it’s TAPP. T A P P stands for transabdominal pre peritoneal. So you do enter the peritoneal cavity and then once you do, you then go to the extra space. Next question is if the abdominal wall has fallen and doctors don’t risk surgery. Won’t risk surgery and someone on someone because of other medical issues, any advice on how or whom to contact on living with a bump or pregnancy?
Speaker 1 (19:23):
Look for the rest of one’s life. Any support groups or national organizations that I can contact? Well, let me tell you this. If your abdominal wall, if you have what’s called a loss of domain, which means you’ve kind of lost the opportunity to have a closed abdomen open and so now your intestines are kind of everywhere, those are tricky and should be done by hernia specialists and we do those in a very planned, coordinated way. However, most people don’t have that. Most people just have a complicated abdominal wall and you need to just get it repaired and I don’t understand why you can’t have it repaired. So I would recommend that you seek out 1, 2, 3, even four hernia specialists and get their idea of what is available to you for surgical options. If you don’t have loss of domain, you should be able to be closed and should not have pregnant looking abdomen. If you’ve lost nerve function to your muscle, that is a serious problem. I even repair those. It’s, it’s a very different technique than most hernia repairs. I do repair people who’ve had muscle damage, sorry, nerve damage to their muscles. But even that you have options. It’s all a risk benefit ratio. How sick are you? How many medical problems do you have? Are you obese? If so, all of that needs to get repaired, get addressed, and then we can go after the hernia repair.
Speaker 1 (21:05):
What you don’t want to do is fix a hernia when someone has much more significant illnesses as part of their problem, you want to address those problems first. Alrighty. Is there a cutoff for the size of hernia that can be repaired with a robot? Yes and no. So yes in that if you have a huge loss of domain where most of your belly is outside the body, most of your intestines are outside the body. That is not a scenario for robotic, but actually the TAR, the T A R, the transverse abdominal repair done robotically will be call it robotar, kind of like cute name for with a robotar actually it, it’s indicated for 10 centimeter to 20 centimeter or 25 centimeter defects, but depends on where your intestines are and where your muscles are. So for 99% of people, no, it doesn’t matter for that 1% that has these really amazingly enormous hernias. Yeah, we don’t like to do those.
Speaker 1 (22:20):
All right. Next patient. I have a patient right now with rectal pain at 11 o’clock spot for 18 years he had bilateral inguinal hernia repairs, but on the left side he had to have it twice. The second time he had it with Mesh. I guess a question is rectal pain and its association with hernia repair. So typically there’s no association. Every so often people can have a very low lying Mesh, depends on how it was replaced. If it was done laparoscopic or robotically that a very low lying Mesh and some people can cause pelvic pain and that can present as a rectal pain. The follow up is I think his pain is coming from the postsurgical scars and his left groin. The doctor who did the last repair said there’s a lot of scar in the area and he had to cut it.
Speaker 1 (23:10):
Yeah, scar doesn’t usually cause pain, cause rectal pain, so it would not be from that. Next question, I had a hernia pair with cadaver Mesh and my body began spitting out the polypropylene sutures that were used. Okay, so you had the cadaver Mesh, which is absorbable, and then you had the permanent sutures, which by the way, there’s no reason to use permanent sutures if you had cadaver Mesh because the cadaver will melt away and then now you just have sutures hanging down to nothing. They were supposedly the least likely to cause reaction, but over the course of 10 months I had to have three additional surgeries to remove the surgeries as they would work their way to the surface. Is there a specific protocol that you would recommend for someone concerned with foreign body reaction? I’m very interested in that question because I don’t know the right answer and I’m trying to figure it out. I do perform allergy testing. Allergy testing works. If you actually react to it, then we can say, okay, you react to this, we shouldn’t use it.
Speaker 1 (24:15):
Or you have some type of reaction. However, if you don’t react to it at least 40% of the time that’s incorrect and you may in fact be reacting to it. So we don’t really have good tests about that. All we know is that foreign bodies, the more foreign body in you, the more likely you are to react to it and the heavier and more dense the foreign body, the more you likely you are to react to it. And in terms of polypropylene sutures, if they’re being spit out, they’re probably placed too close to the surface and often those sutures, they’re just too exposed to the surface and they’re very stiff. Polypropylene sutures are very stiff sutures. I don’t usually use them close to the surface because you can feel the knots. Sometimes those sutures can get infected. So I don’t know why they use cadaver Mesh in you.
Speaker 1 (25:06):
Did they think that you had an infection or were at risk for an infection and that’s why they put the cadaver Mesh in you because regular synthetic Mesh may get infected. If so, that permanent suture and the knots can also get infected. So spitting sutures doesn’t necessarily mean it’s an infected, it can be infected, but some people just spit sutures by spit. It’s like a terrible term, but by spitting means it gets exposed or wants to extrude your body wants to get rid of it purely because it’s kind of too bulky and it’s in the way.
Speaker 1 (25:52):
Next question, have you performed non Mesh repair for the scenario you mentioned with nerve damage? If so, does a repair hold? No, that’s exactly the issue. If you have nerve damage to your muscle and you would like that, and now you have a bulging because the muscles no longer healthy doesn’t contract, it’ll just expand, expand, expand over time. It’s like a stretchy fabric that doesn’t recoil. So over time it just gets bigger and bigger and bigger. The only way to repair that is to do what a, and I’m using this term lightly like a tummy tuck over that area and tighten it the muscle, but that muscle is not healthy, so it will not hold your sutures and therefore you have to put something to augment it. And that’s a big, very big synthetic Mesh that’s permanent and does not stretch. Even in that scenario, a lot of, these fail and recur. They’re very, very difficult scenarios to deal with. But even that scenario, they recur. Definitely a non Mesh surgery will fail a hundred percent of the time. So no, we don’t do that.
Speaker 1 (27:11):
Okay, so going back to the question about the cadaver and the polypropylene, it was during a pelvic Mesh removal and repair along with the hernia repair. Yeah, it sounds complicated, but if your polypropylene sutures are being spit out, they have to be taken out. At the very least, they’re at risk of hernia. Sorry, they’re at risk of suture, not infection. But usually we don’t like to put permanent suture on cadaver absorbable Mesh. Next question. I love your questions. I don’t even have to talk about my topic today. I just recently did a skin patch test immediately when they placed the Mesh on my back, my skin began to burn. When they took it off, there was welting and it was red, but they said it wasn’t significant enough to say I’m alerted to it.
Speaker 1 (28:04):
So they said the test was negative. After removing the Mesh, my skin stopped burning, but it was tender for a day before going completely away in 48 hours. That to me is a positive test. Any reaction to the Mesh? It could be redness, itching, welt, for sure, blistering redness. Those are all reactions. I would would consider that a positive test and I would not use that Mesh in you. Now some people react to the tape and so that gets tricky because you have to tape the Mesh onto the back. But specifically if you reacted to the Mesh itself, and that would be a response. The thing is a lata times the allergist do this and they’re very specific about allergy versus autoimmune versus a reaction. So a true allergy would be like, let’s say I eat a peanut and I just break out or stop breathing. That’s a true allergy. But I could drink, let’s say milk and have loose stools. That’s not a true allergy. That’s like an intolerance, but it doesn’t mean you should just continue drinking milk. You should still functionally speaking, you should still treat it as an allergy. But we use the term allergy much more loosely, whereas the allergist does it for a living, uses it much more like specifically allergy, autoimmune, et cetera. So from a surgical standpoint, I would not want to put a product in you if you react to it in any way.
Speaker 1 (29:50):
Yeah. Dr. Roz. So Dr. Roz is a specialist in urogynecology. He was at U C L A. I was actually a resident under Dr. Roz when he was there. He’s retired since. But yeah, he did use polypropylene suture just so in cadaver Mesh. I do know that for a fact. I don’t agree with that technique. Okay, next my thing is I place the tape on my back and another spot and it didn’t burn. The burning also only occurs at site three and they said that was where the Mesh was placed. So to me that is a reaction and I would not use that and that would be considered a positive test. Okay, talking about Mesh, one of the other things that came up very commonly is that’s concept of absorbable meshes.
Speaker 1 (30:47):
Very interesting. There’s a lot of interest in absorbable meshes, and this is where I want you guys to help me because there’s pros and cons. So currently there are a handful of absorbable meshes and some biologic, a lot of biologic meshes. So there’s biologic meshes which are cadaver meshes. They come from human cadaver or different animal cadavers. They are a hundred percent absorbable. Theoretically it’s just collagen and then the cells have been removed. So you’re not reacting to it as like a human animal reaction or human reaction. And then the thought is around eight months or so, your body will replace that collagen scaffold with your own type of tissue. Now, it doesn’t really happen that way, but in many cases it’s a nice non-synthetic nonabsorbable way to support a weak or tense hernia repair. So we know that tissue repairs have a higher recurrence rate than synthetic permanent Mesh repairs.
Speaker 1 (31:58):
So what if you take a tissue repair and you add temporarily a barrier, like a buffer that is absorbable. So after the advent of biologic Mesh, we found it doesn’t really work that well. So now people are coming up with synthetic absorbable meshes. That last a good time. We’ve always had a Vicryl Mesh that lasts three weeks or so. That’s not long enough. But there are a couple meshes. Phasix Mesh is one of them, which is supposed to dissolve around 18 months. So that’s a year and a half of meshing you. And after I think about three months, it starts to degrade and by 18 months it’s pretty much gone. So I may be incorrect on the three months part. So we now have this year at stages, they presented their three year data for the pH trial, and they found that at three years they had a 20 something percent risk of hernia recurrence.
Speaker 1 (32:59):
That’s kind of high. So it’s definitely higher than the eight to 9% risk that we see with synthetic Mesh. And so the question is, does it matter that it’s so high? And that’s the question I like to ask you guys. Do you care if you have a hernia repair performed with a Mesh that will be gone in a year and a half, let’s say two years, but the hernia will come back at a higher rate than you would with the synthetic Mesh. Understanding that with the synthetic Mesh, you’re stuck with the Mesh forever, whereas this absorbable Mesh, it’s gone now. They took that data and they broke it down into two types of techniques. If you put the Mesh on top of the fascia, the recurrence rate was 30%. If you put the Mesh, this absorbable Mesh below the fascia, below the muscle retro rectus, the recurrence rate was 12%. So now the question is, as a patient, would you be okay having a fully absorbable Mesh that absorbs after about one half to two years in you, but your recurrence rate is going to be somewhere between 12 and 30%. Are you okay with that?
Speaker 1 (34:26):
And what number would you be okay with? I really, really want to know because that is the major question that everyone is asking and wants to know. Should we have an absorbable Mesh that has gone a one year or two years or five years or 10 years? Where is that sweet spot where you’re comfortable having a Mesh repair but it’s absorbable? And then at what cost are you willing to undergo a hernia repair, a very good hernia repair, but knowing that the effects will last 88 to 70 to 88% of the time longer than three years, but at three years you may have a recurrence. It’s kind of like, yeah. So is the same material as phasix? GalaFLEX is the same exact material. Phasix is marketed for hernia repair. Gallex is marketed for the breast. So I personally would like to know what you guys think because I’m a little bit perplexed.
Speaker 1 (35:31):
I feel that we know that biologics clearly don’t work and we know that synthetics, oh, let’s rephrase that. We know that biologics clearly don’t work, but there’s very little downside to it that’s gone it. There are patients that I’ve had that reacted to it, but it’s very, very small that doesn’t erode, doesn’t cause foreign body sensation. But the recurrence rate’s really high and we know that synthetics really work like recurrence is low, but it has its downsides. It’s there forever. You can still get a hernia recurrence though not as high. You can erode. You can have foreign body sensation, you can have adherence to it and people can react to it. So how much biologic and how much synthetic are you willing to have? Like 96% biologic and 4% synthetic, sorry, and 4% synthetic where you still have some synthetic in you. That’s the ovitex Mesh product from Tela Bio or Phasix, which is a hundred percent absorbable, but it’s kind of synthetic, but it’s absorbable and it’s gone in about a year and a half and there are other products coming out.
Speaker 1 (36:52):
So that was a lot of discussion, and I’m really excited about that because I felt like for so many years I was the only one at these meetings that’s talking about, listen guys, patients are having complications, patients are not happy. We need to think of newer technologies, et cetera. And finally, I feel industry is paying attention. And the surgeons, let me tell you this, fascinating. So the surgeons are getting up to the microphone and actually saying, what about the patients? How about the patients? We need to think about the patients. And I’m loving it. I feel like five to 10 years, maybe more, I’ve been yap, yap talk about the patients and yet at the same time people are just now saying the same thing. Okay, lots of questions coming. Let me get these answers for you.
Speaker 1 (37:54):
Let’s see. Absolutely no synthetic Mesh for me, I would choose a high risk, but how high? Because with biologics it was up to a hundred percent. It was like 80% recurrence and of course very technique dependent. So as surgeons, we felt that that was inappropriate. And so we don’t really use biologics anymore. I would be concerned about my buyer’s reaction to anything synthetic. I’m very reactive now. So yes, the issue is these absorbables are also synthetic. So how much of a reaction are you going to see? It’s still synthetic, but it’s absorbable. Does that make sense? So up until recently, everything was either synthetic or biologic. Biologic was cadaver, synthetic was made in a lab. Then we’re coming, we’re say, okay, let’s not talk synthetic versus biologic. Let’s talk absorbable. So now you have absorbable synthetic and absorbable biologic, and the non-absorbable is always synthetic.
Speaker 1 (39:08):
So it’s kind of like interesting because again, we’re developing new products, we really don’t know enough long term, we really don’t know enough. They’re trying, industry is trying. I mean all of these products that are coming out are out with prospective randomized clinical trials as well in humans. So it’s not like they’re just putting it out there. But I’m concerned that because it’s synthetic, it’s definitely also something that the patients may react to. And I’m seeing more and more patients react, and so that’s why I want to know your ideas. Next, in case of hernia recurrence with absorbable Mesh, what kind of solution the patient anticipate? Yeah, that’s the problem. So if you agree to either a tissue repair or a repair with a fully absorbable product of Mesh, either biologic or synthetic absorbable, you also have to agree that if you do recur, so 12 to 30% recurrence if you do recur, would you be okay with a synthetic then a pure synthetic?
Speaker 1 (40:16):
Why? I think the hybrid is where it is because the hybrid Mesh recurrence is really low. I’ve been using it for years. It’s really, really low. We just need better hybrids out there to do that. Okay, that’s a hard question to ask, but I guess I’m biased because I have some systemic issues, so I don’t want anything that will cause that. Correct. Hard questions to answer. Correct. My incisional hernia tissue, my incisional hernia tissue repair returned, so recurred. I knew it was risky, but I’m terrified of the Mesh, but it looks like polypropylene is my only option because I don’t want to keep doing surgeries. Dr. Iraniha in Newport Beach did my surgeries. It’s very hard to know what to do as a layperson. Yeah, so the tissue repair for incisional hernias has a 60% recurrence rate. We know that very well. So incisional hernias, depending on the size, should not be repaired purely by tissue.
Speaker 1 (41:21):
Just doesn’t work because there’s too much, you already failed once by having that incisional hernia, which is a hernia after a prior incision. So it makes no sense to just do tissue repairs in mind and something else needs to happen unless it’s really small, like one centimeter. Anything more than that, you really should use Mesh. Now again, I’m a big fan of the hybrid, so it’s just a little bit of Mesh, but we don’t really know enough to be able to say anything definitively. It’s you guys are experiencing it as we are learning it. I hate to say that, but that’s just the way that that medicine is for almost everything. Is there a new absorbable Mesh that is good for patients like me that have a collagen disorder and reactive foreign body implants? Oh, there are new absorbable meshes. Are they good for patients with a collagen disorder that react to foreign body implants? Unclear because the absorbable meshes are synthetic now. They tell me that in their lab they don’t see a lot of inflammation from these meshes. I see patients with those meshes that are reacting to those meshes because it is inflammatory in nature.
Speaker 1 (42:50):
So at this time, I personally am very hesitant to put in synthetic absorbable meshes when I see patients come to me that have had it and have this kind of reaction to it. So that’s my sense. But yes, there are new absorbable synthetic meshes that are better than biologic because biologic is gone in eight months. These things are gone in about 18 months. So theoretically it can push you out to a longer situation. But usually people with collagen disorders like Ehlers Danlos or something similar to that do not do well with any absorbable Mesh period.
Speaker 1 (43:38):
Are there also long lasting absorbable sutures as well being discussed? No, I have not seen it. There are some companies that have come up with newer sutures, but in the labs there’s too much inflammation associated with it, so those stopped. So currently the longest lasting absorbable suture is silk, which is, it lasts for a really long time. It’s basically permanent, but it’s highly inflammatory or P D s, which stands for PolyOne something, P d s suture, which lasts about eight months. So those are the kind of the most common ones that we use. Did they also discuss the inflammatory response of pH? Yes. So the discussion about pH in the lab has been that it is not as inflammatory as typical synthetic non-absorbable. Mesh pH is a synthetic absorbable Mesh that is gone at about 18 months and they presented their three, three-year data at this meeting, and the recurrence rate is between 12 and 30% depending on the technique.
Speaker 1 (44:56):
So the lowest you can expect is 12%, the highest around 30%, and it’s very technique dependent. As any hernia repair, I have seen multiple patients that had pH Mesh implanted and they get an inflammatory response from it. So until there’s more information, I am not recommending that everyone jumped to pH. It’s definitely out there. I think the beauty of pH and other synthetic absorbable meshes is the following. If you have a certain disease and you need Mesh and it’s very possible you’re going to need surgery again. So most people may will need another operation in their lifetime, either from adhesions, gallbladder, appendix, colon cancer, hysterectomy, all of these. It would be best if you did not have Mesh in the abdominal wall when the next surgeon goes in there to operate because it’s going to complicate your operation. So that’s the beauty of absorbable meshes, I think, is you fix the hernia and then years later, the next surgeon who may have to go in there, let’s say you have a Crohn’s disease or you have one of these recurrent sarcomas or a carcinoid tumors, which you keep going back in and operating, operating, operating like every two, three years.
Speaker 1 (46:19):
You have an operation in those situations. You really want to be in a situation where the next surgeon doesn’t have to go through Mesh to do your abdominal wall surgery, whether laparoscopic or open. So I think that’s where the beauty of these type of absorbable meshes is. I don’t believe we’re there yet to have the perfect Mesh. 18 months may not be long enough or the product may not be, excuse me, or the product may not be such that it is.
Speaker 1 (46:56):
You don’t want the proctor react very, very synthetically. You want the beauty of synthetic Mesh, which is low recurrence, permanently low recurrence, and you want the beauty of biologic, which is no reaction, and I think the current way to do it is the hybrid Mesh. You get a little bit of biological bit of synthetic, making it into one Mesh. I’m not sure the synthetic absorbables is the best way to go, but I may be wrong. I’m willing to be open. What do you think about FS microcurrent to help heal after absorbable Mesh implantation? I’m sure you could collaborate with practitioners to help heal after surgery. Yeah, you brought up Microcurrent before and I read about it.
Speaker 1 (47:41):
I don’t know enough about it. I will have to learn more, so thank you for that. I will learn more. I don’t understand how they can improve PHS for general use at the three year study has just been presented. I reacted horribly to it from day one, full-blown autonomic dysfunction. Yes, you’re absolutely right. Technically at the American Hernia Society meeting, which is going to be at the end of this, this month, they’re presenting their five year data. So technically their five year data is out. It just hasn’t been shared publicly and won’t be until the end of this month at the American Hernia Society meeting. However, yeah, full blood autonomic dysfunction. Now I’ve seen people react to biologic Mesh, cadaver Mesh, so I can’t say that pH is any worse than that. But what I do know is what I do know is that it’s not perfect, and I don’t think it should be like the go-to for every product.
Speaker 1 (48:48):
It’s really the only synthetic absorbable out there that is being marketed. But as with any, just like the robots where there’s one robot and then everyone else wants to make a robot back during the day during biologic, there was life AlloDerm by lifestyle, and then all of a sudden everyone else wanted to be biologic Mesh. Now with Phasix, everyone else wants to make these Mesh because they make a lot of money. These meshes are not cheap at all, which is also why it’s a very American thing. You don’t go to Europe and see phasix, it’s just not a thing.
Speaker 1 (49:28):
Yeah. So yeah, you’re one of the few that I know that has reacted horribly to phasix. So do you have a more favorable view of pH after status or still need more information? So the company is going to be sending me information about how they find it’s less inflammatory, but as one of our viewers just mentioned, she had a full autonomic dysfunction blowout after pH, so it’s out there. I think just like other meshes, there’s a risk of reacting to it and I don’t think it’s, it’s it yet. I don’t think it’s the answer. And some patients like you, you can’t keep getting like Mesh put, Mesh put out Mesh Mesh put out. That’s a lot of damage every time.
Speaker 1 (50:23):
All right, Facebook lovers. Sorry, I haven’t been going on to your, so 50% is your number, huh? 50% recurrence rate. You’ll be okay with a non-synthetic, non-absorbable going in you. That’s a really high number, but that’s really good to know. Next answer, as long as it’s not touching my colon, I will be fine with synthetic. Yeah, I think that’s the general concept, which is not everyone has anti Mesh, they just don’t want the Mesh complications. So if we could please change technique and improve it like the eTAP, like the TEP, the peritoneal meshes, like the lightweight meshes, maybe the hybrid meshes, if we can just make it so that people are not reacting negatively with adhesions and erosions and so on, most people are probably okay with synthetic Mesh as long as it is not touching my colon. She said that’s, I agree. Great to hear that surgeons think about the patients side more now.
Speaker 1 (51:23):
I agree. I was literally sitting there and surgeons who, some of whom I don’t even know were up there and they were saying we really have to think about the downsides and Mesh people were talking about Mesh overuse, which is something I’ve been talking about for years. There was a whole panel actually to talk about how to talk to patients about Mesh whole panel about it. It was my panel, but still the society was very interested to have a session on how to talk to patients about Mesh. What are they worried about and what’s their kind of interest. So it was very nice to see that.
Speaker 1 (52:10):
I was very excited and happy to see that the society and the surgeons and the audience and the participants and the panelists were all very interested to talk about how you talk to patients about Mesh, what are their concerns about et cetera. And actually for next year’s SAGES, I’m also heading a session that talks about all that and the lawsuits, what the surgeons, you know, because you guys actually know more about the lawsuits than we do believe it or not. And so I’m hoping to educate next year’s SAGES panel. Is there any Mesh made with the same material as P D S? There are hybrid meshes which have some PDS in them and some P D S and some polypropylene together. But pure PDS Mesh, I believe in Europe, there may be one, but not in the United States. Were there any sports hernia presentations at SAGES 2021?
Speaker 1 (53:12):
Not that I saw, but I may be incredible. I did not see any sports hernia presentations at SAGES 2021. You know, can go online sages.org and just look at the program and search for it. But as far as I know, no. Is there any match that is made of the same? Okay, we read that. Bless you. Thank you very much. When using robotics, is there specific types of stitching that is used or do all robots use the same stitching? So the robotic technique is an approach where the surgeon sits behind a console. So whatever is done at the level of the session, sorry, the level of the surgeon is whatever the surgeon does. So if the surgeon wants to do suturing the robot, the robotic technique, robotic technique will be suturing if they want a staple, if they attack whatever. So yes, whatever technique the surgeon chooses you can do with the robotic suturing. Same with open surgery. Any chance patients can be included on any of these panels? Maybe if they’re in the ACHQC? Yes. So good question. Back when Dr. Ramshaw was present of the American Hernia Society, he actually had a panel of patients, I think his own patients that took their time traveled, came to the meeting and actually presented their situation and what a difficult situation there it is.
Speaker 1 (54:46):
I think that’s a really interesting idea. I think patients like you and others that are so complicated, it may be interesting to have two or three situations where we bring the patient and the whole audience can now hear your story and then figure out what they recommend. I mean this comment called crowdsourcing, you’re basically crowdsourcing care all in a hernia society. That would be kind of interesting. You don’t even have to physically be there now that everything is virtual and teleconferencing. It would have to be for next year. But you’re making me think, I think I will, after we’re done with this, I will email the next year’s president and program chair. The president is Dr. Jeffrey Janice, who’s plastic surgeon. So I’m sure next year’s situation will be a very plastic surgery oriented, but I think your situation in particular would be a nice combination of plastics and not.
Speaker 1 (55:50):
So I will email them and suggest that as a potential for next year. And if you’d like to be involved, we would love to have you. Sounds like that’s a show diagnosis I would love to present in my case too. Yes. So diagnosis is that Netflix show, right? With the New York Times writer and Yale physician who basically crowdsources really complicated situations that medical mysteries that no one else has been able to figure out. Yeah, I really like it. I watched every single episode of diagnosis. I thought that was awesome for a few years. Now we have Endo Summits where we bring the doctors and the patients together. It is so great and highly educational. Yeah, I I’ve been to those. I agree. I agree. I think more and more, I’ll give you my 2 cents on this and I hope you guys agree with me. I have a feeling over the years as people like myself and others have been really trying to promote the patient side, that surgeons are coming more towards the middle about, well maybe we shouldn’t use Mesh every time.
Speaker 1 (57:10):
Maybe we are overusing Mesh. Maybe we should consider the patient’s viewpoint and offer them other techniques besides the traditional Mesh repair. I also feel, and I hope you agree with me, but I also feel that my interactions with many of you on hernia talk.com on this hernia talk live q and a on Twitter, other social media that patients are not as angry. I feel that more patients understand that there is a need for Mesh. We only have so many tools to work with and yet understand that their voice has been pretty loud in a good way in moving the surgeons towards the middle. But I feel also our discussions and other specialists that I bring on also demonstrates to the kind of situation that we’re in when we’re trying to do our best and there’s only so many tools available to us and we’re trying to, I feel like patients are not as angry as they used to be.
Speaker 1 (58:13):
I don’t know. Are you maybe seeing the surgeon standpoint and the surgeons are seeing the patient standpoint and there’s a better interaction? I hope that I have somewhat of a rule in kind of making that happen because in my mind I just feel that the more the two of us can work together, the better the care is overall for hernias. And I can only just talk about hernia care. I’m sure the breast world and the pelvic world has similar problems to deal with, but it’s time for us to kind of collaborate. So on that note, thank you very much. Thank you for advocating for me and I will always advocate for you the patience. I do appreciate you. Thank you for, appreciate me, you’re all fantastic. And as soon as I get go offline, I will make sure that I email my friends for next year’s American Attorney Society meeting and get of you in there and let’s do like a patient medical mystery hernia mystery session. So on that note, thanks everyone. This is another fantastic quickly finishing our Hernia Talk Live Q&A. Please do follow me on Twitter and Instagram at Hernia doc on Facebook at Dr. Towfigh. Follow me on my YouTube channel. I hope to make this a podcast pretty soon. So working on that and on that note, thank you very much. Appreciate you all. Bye-bye.