Episode 7: Ventral & Incisional Hernia Repairs | Hernia Talk Live Q&A

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Speaker 1 (00:00:01):

All right, we’re going live everyone. I hope you we got some participants already logged on. This is great. Let me just start by saying hello to everyone. We are here with Dr. Igor Belyansky, one of my favorite, very talented surgeons. We are here with hernia talk live every Sunday during the quarantine. At least we’ve been doing this, going over your questions and you can follow me on all the different social media platforms once this is overall post-it all for you. But we are here with Dr. Igor Belyansky from Anne Arundel Medical Center, which is a beautiful hospital in Maryland. He is probably one of the most gifted, laparoscopic and robotic surgeons that I know, but also probably within our entire hernia kind of world. So it’s really a pleasure. And here you are, Igor <laugh>. Do I see you?

Speaker 2 (00:01:13):

Yeah. Can you see?

Speaker 1 (00:01:17):

No, I can’t see

Speaker 2 (00:01:19):

I here. Can you see

Speaker 1 (00:01:24):

Me now there? I don’t see your video. Do you see me?

Speaker 2 (00:01:28):

I do. Yeah. Let’s see. Let’s try this here. You do see

Speaker 1 (00:01:32):


Speaker 2 (00:01:33):

I do see you, yeah. Can you see me now?

Speaker 1 (00:01:37):

I don’t see you. Okay. Sounds like other people are saying. Okay, let it go. So I think I’m having problems on my side because I also, oh, there you go. I also am having problems logging on Facebook because it’s not allowing me to go on. There’s something wrong with our internet. I’m not trans.

Speaker 2 (00:02:01):

Sorry to hear that. So

Speaker 1 (00:02:02):

Igor, welcome.

Speaker 2 (00:02:04):

Thank you. Shirin listen, thank you for your kind words, really, really kind words. And you set the bar too high and hopefully I don’t disappoint answering questions. Really nice to, it’s the true. Yeah. Well now listen nice to see you remotely. And when was last time we saw each other? I think Which meeting was this? Was it did I see you in Utah? No, maybe not, but it feels like it’s been forever now that we’ve been locked away here at home in Maryland and they just, our governor.

Speaker 1 (00:02:37):

I know. It’s been way

Speaker 2 (00:02:40):

Too long. Yeah.

Speaker 1 (00:02:43):

Are you going to the American Hernia Society meeting in New York?

Speaker 2 (00:02:47):

Yeah, unfortunately because of everything that’s going on, all the commitments I’ve made to travel now I have to put on hold until February of next year. Just that I think I’ll have to focus on picking up and making up the missed time. I missed nine weeks of non-op operating and it’s going to be probably at least a couple more months until we get to normal elective volume that we had. So we’re planning to start doing initial elective cases in about a week, but it’s going to be slow trickle. But just because of all the commitments I have here and because of practice, I’m going to have to skip on some of the strips unfortunately.

Speaker 1 (00:03:31):

I mean you have very, even volume wise, you have very complicated patience, but also volume wise you’re very busy and you must be behind in terms of your normal pace by a lot of patients, it’s going to take a while to catch up. Is

Speaker 2 (00:03:49):

That right? As everyone is, I think and as what we’ve been doing in our hospital is we’ve been hearing the cases based on kind of priority and we came to the point where we only were doing emergent and urgent cases and urgent cases were defined in some cases that need to go within 24 to 36 hours. And most of my patients did not fall under this definition. And so been a huge dialogue of cases. Yeah. Yeah. So I mean I’m sure you, you’ve been faced with very something very similar. All of us have been going through the same, it’s not just me, it’s all the surgeons, nurses. It’s feeling it. Everyone’s feeling it.

Speaker 1 (00:04:30):

Yeah. No, I hear you. So Dr. Belyansky let me ask you, when you were in training, obviously laparoscopic was already an established technique because you’re much younger than I am, but robotic was not though, right? There was no robot when you were in training?

Speaker 2 (00:04:52):

No, I did. I assisted on very few robotic cases was a gentleman named his name is Dr. <inaudible> he was mostly bariatric specialist a great guy. He was just only going through his learning curve back then on a older platform platform that was a SI platform that was available at the time and I just assisted in the cases it was I didn’t get to basically do any cases during my fellowship on <inaudible>.

Speaker 1 (00:05:23):

Yeah, no, I understand

Speaker 2 (00:05:25):

Basic understanding of how things worked at the bedside, that’s all. Yeah. Yeah. But the fellowship I did when I did my fellowship was 2010, 2012. And the fellowship, as you said, I specialized like you did in laparoscopic or we called it minimal invasive surgery, so small central surgery. But the guy who trained me, his name is Todd Hannaford, so I trained at Charlotte, North Carolina and Dr. Hannaford is at the time still is very well known for his skills and ability as well as leadership in field. And so that’s where I learned a lot of my early foundation of understanding of abdominal water construction. And that’s kind of when I came to work in Annapolis, that’s what I brought and that’s why I worked to establish the last few years being able to address some of those patients as we probably will talk the procedures, the interventions that have changed dramatically in the last eight years and continue to change. So we’ll see what, maybe we can talk about it for better or worse. Yeah.

Speaker 1 (00:06:28):

Yeah, I think it’s fun. As part of the surgery, when I trained, there was no laparoscopic match there. Bruce Ramshaw had a apprenticeship or Ed Phillips had an apprenticeship. George Furley had apprenticeship, but there was no match. So I basically turned my residency into a mini fellowship and went straight into laparoscopic teaching as opposed to doing an actual fellowship. We just didn’t have ’em back then. It was right. Kind of hit and miss.

Speaker 2 (00:07:05):

Exactly. Exactly.

Speaker 1 (00:07:07):

I think it makes a difference. Absolutely all. So for those of you that are here I’m kind of unhappy that I can’t get you on Facebook because of the internet connection, but that’s my fault. I don’t know why we had a fire, we had a brush fire just down the street, so there’s like I almost canceled today because we may have to evacuate. I live in a fire zone. Oh,

Speaker 2 (00:07:35):


Speaker 1 (00:07:35):

You’re lucky that I’m here, but I think screwed up our internet. I don’t know. I don’t

Speaker 2 (00:07:39):

Know. Yeah,

Speaker 1 (00:07:40):

Lots of helicopters and so on. So for those of you that are joining us, we will be restricting today’s talk to ventral hernias. The reason for that is Dr. Belyansky like does everything. So what he really is most kind of famous for is all of his surgical techniques for ventral and incisional hernias. So I really want to take use of his time here to focus on those questions and we have a lot of questions turned in and we’re going to have a lot of questions and answers. So okay, here’s a good starter questions already turned in. If a patient wants to see one of you specialists out of state, you or me out of state, I know you see a lot of patients from out of state as I do, yeah. How does that work? How long do you stay after surgery? How many follow-ups after surgery? What are your thoughts there? What’s your protocol for out-of-state or out county patients?

Speaker 2 (00:08:52):

Well, I can tell you thinks I got to change now even more because of COVID 19 of how we see patients moving forward and I think it’s going to be for the better actually, especially for patients that we’re seeing remotely. What has happened in the last two months and this is around the country, all of us have become experts at telemedicine visits, understanding how to set up platforms and being comfortable talking in front of the camera, asking patients questions, seeing patients in the camera, sometimes even asking the patients lift up a shirt to really get a bigger picture. So before in the past what I would do is ask the patients to send all the records so I can review them and typically then afterwards I would just get in the phone with them. We were just getting the camera telecommunication ready, but a lot of times they would have to come and visit me and as sometimes especially in ventral incision, a hernias before the decide to proceed to operate, sometimes you need to get those patients ready, whether it’s a lose weight controlled diabetes I make sure they quit smoking beforehand to all the big things beforehand.

Speaker 2 (00:10:01):

And so it’s not a one shift, it didn’t used to be a one shift visit. So whenever I did operate, we would usually have them stay there. If it’s kind of one day stay surgery, I would still ask them to stay here for seven to 14 days depending on how big the case is in case there are any complications immediately after surgery. So I can manage them myself. I always have trepidation because just like anyone else, I do have complications, things can happen in surgery. This is real. No matter how great hands your surgeon has, how come I experience? Those are real risks when we talk about them no matter who they are. And so I ask them to stay for seven to 14 days depending on what kind of the magnitude of the case and I see them before they leave or a member of my team will see them before they leave and then afterwards, those that are kind of patients who travel remotely, we can usually touch base on the phone, but now things are going to change. Now I think we’re going to stay in touch with each other better where we can again, one of the things we think about is also how to decrease exposure to our staff, how to keep our staff healthy as well. This is includes patient people, our staff and operating room and our staff and office as well. So one of the things mandates as we come back right now after this yeah, that’s

Speaker 1 (00:11:25):

A growing concern. We don’t even know enough about the virus to and we’re very cautious, but we still don’t know enough to be really doing exactly what we needs to be done. Yeah, so do you have them consult ahead of time then to get their imaging to determine the plan of care? Yeah, before they show

Speaker 2 (00:11:45):

Up? Yes. For vent and social hernias, a lot of times CT scans, priceless, really look in the images of CT can really helps to understand the problem, the magnitude of the problem. Previous operative notes are extremely important as well to see what was done, especially in the field hernia repairs. And so I’d like to review those records beforehand. So at the time I have was a patient that first meeting, I can really meet the patient and also get a focused history specifically about their disease process. A lot of times trying to figure out what is a patient presents to us with a failure. And one of the questions is how can we potentially make things better for you? What are you looking for us? Kind of realistic expectations and this is the first time to set up some realistic expectations and some questions and then proceed afterwards. Yeah,

Speaker 1 (00:12:38):

Yeah, that’s true. You, I offer what’s called an online consultation, so it’s kind of telehealth in that they don’t come to see me, they’re often far away or they have insurance issues and at least they need some kind of guidance as to what needs to be done. So they, it’s if they’re seeing me but they’re not physically seeing me, it’s all the chart, the whole chart gets sent to me with the imaging and the reports and then I type up a whole recommendation evaluation. Do you offer that for your patients?

Speaker 2 (00:13:18):

Usually I don’t type up the evaluation. What I end up doing. This is really nice what you described, but no, I usually just review and if I think I can help the patients, some of the things that I can, I just don’t want to waste some things I think I cannot help. And I’ll meet with them, I’ll tell ’em when the dance says you’re meeting me, I may probably will not be able to help you, but I like the face-to-face things and then afterwards I just kind of give them information how they need to go. One thing you mentioned is insurances and it’s kind of one of those things that we unfortunately I don’t make a lot of decisions who I’m able to see. There’s some patients who may have insurance that we don’t accept. I am a hospital employee, so some of those decisions are taken out of my hands. I actually can’t see pure cash patients. Sometimes we actually have to work some of that to see but can’t, if they have insurance, we can’t see people. So it’s weird. Maybe insurance, I’m not accepting but I can’t see them. It’s it’s very frustrating. But what we try to do is try to figure out which region they’re in and try to help them find a provider, which I think can be very trustworthy and can help them based on their problems.

Speaker 1 (00:14:30):

Yeah, okay. Yeah. Okay. Yeah, I agree. Okay, let’s move on to, I’m going to share my screen here. I come prepared for these meetings. Okay, next question. Can you see the screen? I hope you can see the screen.

Speaker 2 (00:14:49):


Speaker 1 (00:14:49):

So the next question we’ll start with an easy one. How’s that? My boyfriend has a bulging navel that sticks out quite a bit when straining, if he sucks in the belly, the navel becomes smaller. Do you think this is an umbilical hernia? He’s afraid to have surgery, but his belly button is so big and really sticks out. Does he need an operation? What’s your criteria for operating on umbilical hernias? Because I mean, let’s just say this sounds like umbilical hernia, most

Speaker 2 (00:15:17):

Likely. This does sound an umbilical hernia and I just have a frank discussion was if this is a young gentleman at some point his life, he most likely will need surgical intervention. If it’s a easily reducible hernia, not causing pain, the first thing I want to do is just kind of give them, it’s very not likely that this will cause them problem in near future. But the thing about hernia, as you know they do grow in size over time. Things that are not symptomatic, they become symptomatic pain discomfort thinks that are not incarcerated yet. Meaning where the contents are stuck and you can’t push them back they can become incarcerated and sometimes become strangulate. But the kind of progress of to that point usually takes longer time. So a younger gentleman, I’ll tell him that he probably should have this fixed at some point at his convenience.

Speaker 2 (00:16:14):

If it’s not bothering him yet, it’s unlikely to cause him a need for emergency surgery in the near future. That’s kind of how I clear that. And usually those that are kind of surgery so to speak, and if they’re not symptomatic, I kind of make sure I teach them kind of what to do, how to lie down, how to reduce this. And what I find is a lot of people, after a while the certain attorneys do become more symptomatic. They are becoming more aware. They do do usually come back to have those fixed the incidence of strangulation where you need to go to emergency room. Again, that’s a rare incidence of overall. And so it’s kind of interesting. In three months I had hundred patients that I need to operate on in three months. How many of them did I have to take emergency surgery? I can tell you there’s one patient that I actually had to go to a different hospital because she lived far away that had to get surgery. That’s it. The rest of the people as there’s several people in pain and discomfort and that’s why we need to fix this and they are at risk of strangulation, but nobody has needed in my cohort patients that I have in my hands right now need an emergency surgery. So kind of some things to think about.

Speaker 1 (00:17:25):

Very good. I agree. I think nothing’s more satisfying than turning it out into an any. It’s such a simple little operation and they get a beautiful, I mean especially the small milks, you can and see the scar, they get a nice in their life is transformed. But from a quality of life standpoint, I think all the studies show the bigger of the big hernias should be repaired. That really has been shown to improve quality of life. But the smaller hernias, those watchful waiting is considered appropriate. All

Speaker 2 (00:18:01):

Right. Was that, I mention, I mentioned one more thing. That was a study back in 2012 of Carolinas Medical Center and the first author was Paul Colavita, an attending there right now. And he specifically looked at asymptomatic umbilical hernias and repairing them. And what he’s shown is those hernias that were not symptomatic, those patients actually end up having least amount of postoperative symptoms. There’s a degree of patients that may develop some kind of chronic discomfort or continue having chronic discomfort. And usually the predictor of discomfort before surgery was somebody who were having symptoms. They were at risk of having prolonged or actually persistent symptoms after surgery. And those that did not have symptoms actually end up varying better. So just also that in mind as well. Yeah.

Speaker 1 (00:18:52):

Okay. All right. You ready for the more difficult questions? Okay,

Speaker 2 (00:18:58):

Sure. Yeah, yeah, let’s

Speaker 1 (00:19:00):

Have it. Okay. So this is your bread and butter. I had a large incisional hernia repaired with mesh. I have chronic pain. The imaging shows a lot of adhesions. My surgeon says the mesh is not touching my intestines, so it cannot be the cause of ad adhesions. Could adhesions cause pain after incisional hernia repair with mesh?

Speaker 2 (00:19:21):

Yeah, so that’s a good question. And the first first of all based on this information, given this question, we would have to need to know more information, I think. And so let’s just kind of assume certain things. Let’s assume possibly that this patient suggesting that his mesh is intra-abdominal and size his abdominal cavity and so that by assumption then I’m going to assume that this patient probably had some kind of laparoscopic ventral hernia repair. A traditional repair which we refer to as laparoscopic IPOM, Intraperitoneal Onlay Mesh where the mesh is inside abdominal cavity underneath the abdominal wall and the surgeon uses some kind of penetrating device to secure the mesh in place. Like we use stack as little screws that can be either absorbable or metal screws and as well as fixation with stitches that goes through the abdominal wall into the mesh, back into the mesh and through the abdominal wall again.

Speaker 2 (00:20:21):

So those is, and this is one of the several repairs me of several repairs out there that’s available. So that’s just because you had a laparoscopic repair does not mean necessarily you had this type of repair refer to this type of repair as laparoscopic IPO repair. So when you place the mesh in predominantly what can end up happening, you can develop adhesions to it. Now by the way seeing adhesions on CT scan, you can assume their adhesions in CT scan, but knowing for sure that the actual adhesions, you can’t really appreciate that on CT scan whether they’re true adhesions or not because it’s just impossible to tell. But when you get in, that’s where you see things actually plastered against the mesh sometimes. And the companies that rights of companies out there, they all, as I’m sure as they make this protective barriers to protect the intra-abdominal contents from the mesh so they decrease adhesions, but those barriers don’t want great and multiple times and meshes that placed myself through this approach.

Speaker 2 (00:21:25):

I’ve gone back and I’ve seen adhesions to it. Now I hope you agree with me. Majority of the time the adhesions are not going to cause clinically significant symptoms, but up to 20% of the time you can have some kind of significant visceral adhesions, which means adhesions or intestine to the mesh. Can that by itself coast pain? In my opinion, probably not. You can can’t because of adhesions you can develop a bowel obstruction or a partial bowel obstruction and that can cause you to have symptoms during your digestive tract kind of. And that can have cause pain, discomfort. The other pain that you can have could be muscle-like pain, especially you have multiple nerve fibers that run throughout abdominal wall that can potentially have been interrupted as a penetrant fixation. So that in itself, I think a penetrating fixation now repair really sometimes has CO can cause people some crying discomfort in.

Speaker 2 (00:22:22):

So I think you and I see a lot of patients that previously had laparoscopic eye pumps before and they usually have the pain directly at the center of their repair unless they have a recurrence but they usually have it at the periphery of the mesh and that’s how we know it is probably because of the tax adhesion he gets CT scan. If somebody had metallic tax please, you can usually see it. So anyways, I don’t want to take over here, but I can talk probably about this for five, 10 more minutes at least. But the question is yeah, go

Speaker 1 (00:22:57):

Ahead. I think your point is well taken because not all hernias that are done laparoscopically will cause adhesions, right? So that’s why we need to get the opera report to see where the mesh was placed and where the dissection was. Was it in the abdomen or was it multiple layers beyond, yeah, and also yeah, in general I would say 90 something percent of the time adhesions are not the cause of pain. You agree with that? Yeah,

Speaker 2 (00:23:27):

I think it’s very safe to say, yeah, I do.

Speaker 1 (00:23:32):

Yeah, it’s an over-hyped problem. A lot of people, especially non-general surgeons and medical doctors say, oh, it’s your adhesions, but that’s not an educated statement. That’s never adhesions causing. I agree. Okay, we have another question. This is a good one. What is the optimal B M I for operation? I have a large ventral recurrence. I have lost a lot, but I want to wait for the best outcome. So what can you explain what A B M I is and what criteria what range of BM I you do you recommend your patients be in before you offer surgery?

Speaker 2 (00:24:14):

Sure. So BMI is a, but stands for body mass index and essentially kilograms over meter squared. And it’s a number that’s gets generated. So I guess one, it depends what procedure I’m doing. It is be mind by itself is just a number. I just want to stop it right there. If you ever sit in a surgical meeting, you’ll see a spew out few things that we can already did that. By the way early when I was talking I was talking about diabetes, smoking and weight. Sometimes we have to address those and I think that’s very important. That’s really extremely important I think. And specifically an open reconstructive procedures and an open reconstructive procedures. The degree and the risk of wound infection and wound complications dramatically goes up if somebody is diabetic and obese and a smoker because what happens, diabetes is smoking affects the blood vessels that flow to heal the wound.

Speaker 2 (00:25:14):

And the overweight is the excess of the sometimes subcutaneous fat which sometimes doesn’t heal well, especially when you cut through this and it kind of predispose you to seroma formation. Sometimes wound infections, lot of times it’s just superficial, but it can extend deep into the muscle layer that then can pop open in exposing the mesh and really kind of complicates the postoperative recovery afterwards. So to answer your question for opener repairs, usually again it depends the opt, what is the optimal, it’d be great if all my patients were less than be minus 30, right? I mean that’d be great but that’s not our

Speaker 1 (00:25:56):

Practice. Let make 30, that’s ideal, right?

Speaker 2 (00:25:59):

Yeah. So that that’d be nice. So I’d be minus less than 30 if you have time, but I would really caution you while you’re reaching the mile of 30, but your hernia can be fixed. There’s like I fixed higher BMI patients sometimes like the 40 45, but again, selective cases you have to weigh the risk versus benefits enough. I think especially I can deliver it through small incisions and decrease because with small incision surgery, you don’t have the same risk of one complications as you do with open surgery. So you can cheat a little bit on the weight, but you have to make sure you deliver that. And again, because then while the patient’s losing weight, you are taking a little bit of risk of high risk patients with strangulation and operating in the middle of the night, which outcomes of those surgeries are usually not great no matter who’s operating. So I’m hop to answer be less than 30 would be great but otherwise I think I do it by case basis and operate in some high B my patients sometimes.

Speaker 1 (00:27:02):

All right. Let’s go to the next question. Okay, so this is another adhesion question. So if I consider having mesh removal surgery after incisional her repair, would that cause more adhesions? And how could adhesions be prevented after mesh removal surgery? I think there’s a lot of focus on adhesions as a problem. What’s your thought about that?

Speaker 2 (00:27:26):

Yeah, I just try to cool people down and just try to understand why they want their meshes out. Again, I keep an open mind to a lot of things that people kind of worry about having for material in their body, things I hear. But here’s the thing, if you do surgery, no matter what type of surgery you do, you can develop adhesions. There’s less chances with laparoscopic robotic surgery, but you can still get adhesions with those surgeries. Are you going to get more adhesions with sticking the mesh out? Not necessarily, but you can probably get the same amount of adhesions that were there before, except now the adhesions are going to be to the patient’s tissue versus a mesh. In my opinion as a surgeon, it’s much more challenging taking bowel off the mesh than taking bowel off the abdominal wall. So technically for me, I would rather all day take adhesions of a patient forming to their own tissue versus taking adhesions of the mesh. I hope I answered that correctly. And then the question, my most important question is why is the mesh coming out? Why do you want to mesh up? Yeah,

Speaker 1 (00:28:31):

Yeah. So the short answer is all surgery causes adhesions. Adhesions are part of the healing process. So you want to have the chances that adhesions will cause a complication, very slim. So we’re at the halfway mark Igor, and

Speaker 1 (00:28:49):

Some of the people that are on this are actually your patients because they love you so much and they knew you’d be on and they made time to come on this. One of them is actually a mutual patient of both of ours. Here is this question, I was very lucky enough to be treated by Dr. Belyansky and Dr. Towfigh over an umbilical hernia. Dr. Belyansky removed an umbilical mesh and I have not had any problems after I am, however, so he now has no mesh in there, just sutures. I am, however, a bit afraid of recurrence. Is there anything I can do to avoid recurrence? I have been avoiding regular exercise and surfing because of my fear. Any suggestions would be greatly appreciated.

Speaker 2 (00:29:36):

Yeah. So here’s how I go and this isn’t me, this is my opinion. Again, this is it’s kind of how do you live your life? I would want to live my life to the fullest. Now, the quality of life is not the same. If you’re living it in fear of doing something I can tell you I’m not exactly what the chance is. Not knowing and remembering exactly who the person is right now and we don’t need to. But if they don’t have a hernia right now, I would live your life to the fullest. And if you’re not having pain this confident, do everything that you can. If you develop a hernia, then one of the specialists can you talk to them and see, figure out which way to address this. Yeah, sure. In theory, if you stay away from any aggressive activity, then you can potentially have less chances mean, but here’s the thing, again, I keep that addressing, but I’ll answer the question. Todd Hanford had a great study with WIL Cup and two thousands where they fully catheter patients to medical

Speaker 1 (00:30:44):

Students, not patients medical

Speaker 2 (00:30:45):

Students. It’s medical students, medical, actually I think it was college students actually. And what they’ve done is they, me measured the pressure generated by each one of these participants while they were coughing, sneezing, lifting weights, working out, and they noticed that coughing is sneezing generated the highest amount. So you can stay away from all those activities, but then one day you get sick and you generate this horrible sneeze or horrible cough, you can really put your abdominal wall quite a bit of stress. So here you go. You can try to have fear and stay away from things, but I would go back and try to see if you and I have any symptom pains come from, just go back and do your things and live your life. That’s that’s my whole patience. I

Speaker 1 (00:31:27):

Agree. The word I agree. Stay away from coughing constipation, gaining weight, smoking, all those things that you reviewed earlier. Yeah. And then almost all exercise has not been shown to be very high risk for hernia recurrence. So if it’s going to recur, it’ll recur regardless of what you’ve done for whatever reason, whether it’s your genetics or your tissue. But I think for a small to medium size hernia, the scar tissue plus the tissue repair should be adequate. And please do surf. I mean, the weather’s beautiful today in Los Angeles. You should be out there. Once the quarantine allows, you should be out there surfing. Okay, another question for you. This is regarding umbilical hernias and diastasis recti. So diocese recti, for those of you that are listening just a, it’s a separation of the two rectus muscles. Your six pack should be together, but in a diastasis a little bit separated. So if someone has an umbilical hernia within a diastasis, what is the best approach to repair the umbilical hernia?

Speaker 2 (00:32:44):

That’s a little bit of a million dollar question. And again, I’m going to give you my opinion. Yeah, it’s my opinion. And so this is more of a technical answer why I fixed, I do fix the large diastasis at the same time with a ventral hernia through the diastasis. And the reason for that is there, what the already described to Dr. Towfigh described you have a tendon that usually is about 1.5 to two centimeters in the width. That’s a normal width of the tendon for whatever reason. Whether you had a severe weight gain and then you lost weight or whether you were pregnant and then delivered several children and your rectus muscles never went and your width of this tendon is now wide. And then you get almost this tent or cave like an alien sometimes popping out of your belly when you’re doing. And so diastasis can range from being very minor that doesn’t need to be fixed.

Speaker 2 (00:33:41):

But once it starts getting to four centimeters wide, that’s where I’m thinking about and associate with a hernia. That’s why I’m thinking about fixing. I get, so the reason I’ll do it a lot of times is not just for diastasis, but I just want to make sure to deliver repair, which long term will have the least chance of a recurrence. Because when may end up happening, if you don’t fix a diastasis and you fix one hernia, and I’ve had this many times happen to me with old eye pump repairs, old laparoscopic repairs, you end up getting a hernia just a little bit superior to where you measured position. A lot of times it resulted from the mesh actually tearing through to this very thin tendon itself, the attachment. So the hernia is, it’s not recurrence, but it’s a new hernia because of you mesh or even the spontaneous hernia through very thinly.

Speaker 2 (00:34:32):

So I try to get, if it’s a great four centimeters, I talk to the patients about it and I try to get it fixed up all the same time. And usually for those cases, I’ll either do a tap approach that’s a robotic approach where we go and take the inner layer of <inaudible> out or what we call EP access surgery, where we go behind the rectus abdominal muscle and we’re working between the muscle layers. So the mesh in both of those cases is not positioned intra-abdominal, not inside the belly, but in between the sandwiching between the muscle layers. And so that allowed us good.

Speaker 1 (00:35:09):

And then for the diastasis, how far do you go from xiphoid to pubis the entire length of abdominal wall to close the the diastasis or do you do something Just local work?

Speaker 2 (00:35:22):

If I decide to fix it, then I’ll do the whole thing from it. And usually most of the people that have diastasis will have it from their xiphoid process all the way down to their belly button. And that’s kind of the belly button is that some women do have lower midland diastasis, but that’s not frequent. That’s not a lot. Now another question is like how do you fix this people if you’re fixing, this is robotical laparoscopic approach, an answer to all diastasis out there. And my question answer is no. There’s some diastasis that should be still fixed. The old fashioned approach where you do the whole kind of what we refer to a layman terms money makeovers where you take the extra skin but you also expose the muscles outside and you bring them all back together and you kind of suture the muscles back together. The same thing that we do laparoscopically, but through an open approach. Because what ends up happening when if you try to fix diastasis that’s too wide when you bring the muscles together, the skin on top of hes up. And if it’s really wide, it doesn’t go away. And it’s just cosmetically the patients are very unhappy afterwards, cosmetically. And so it took nowadays I have there’s certain patients I still talk out of laparoscopy robotics because of that. There’s some patients that still to look cosmetically, well, they still need open surgery in my opinion.

Speaker 1 (00:36:47):

Yeah, I agree. In Beverly Hills, we have a lot of plastic surgeons. And so tummy tucks, sorry. Oh yeah, I’ll do a tummy tuck. So in my practice, if they have all the indications for a real tummy tuck, a lot of loose skin wide diastasis then that’s a good tummy tuck candidate. But if it’s a male or a female that doesn’t have any loose skin, but they have a hernia within a diastasis and all of those, I do, I think what you do as well, I do a right, I ply, I do robotic plicate. The diastasis as part of the hernia pair. It’s actually a better hernia pair. In fact, for open, I do like a tummy tuck. I do a diastasis closure for open two because I feel that just fixing a reto, just fixing a incisional hernia open sometimes doesn’t give them a good contour of the abdominal wall. Sure. So in addition to doing the incisional hernia, I also do a final layer of fascial plication. I think because I operate with plastic surgeons all the time, so I learn all the little tricks of the trade. So I throw in a <laugh> a tighter repair. Sure, sure. And I feel that that extra layer protects the underlying repair. You do that.

Speaker 2 (00:38:14):

Yeah. I mean not exactly that, but the suture line that runs the, it is as is very important diastasis to make sure this stays intact. And the question is, let me ask you this, do you use nationals cases as well?

Speaker 1 (00:38:32):

So if it’s a robotic case and I’m doing a umbilical hernia or epigastric hernia, so small hernia within a diastasis, if a diastasis is about three to four centimeters maximum then and the patient’s low risk, I do not use mesh. But if it’s a big guy in my part of the world, it’s usually an older guy with, he was fit, but it’s like a rounder belly. And then he’s on girlfriend or wife number three. And so he wants, and she’s much younger and so it’s not just a belly but a hernia. He also wants a flatter belly. So for those, they’re tight, those men have a tight belly. So those I have to use mesh because otherwise Sure, sure. They’ll bust through the issues. Yeah. Yeah. That’s my wall.

Speaker 2 (00:39:28):

Do you ever do the scola repair where you do subcutaneous dissection?

Speaker 1 (00:39:36):

I don’t. What are your thoughts about scola? That’s the anterior application. Yeah.

Speaker 2 (00:39:42):

So that’s

Speaker 1 (00:39:42):


Speaker 2 (00:39:43):

So that’s essentially for those listening that don’t know, it’s essentially doing, placing the stitches the same way the plastic surgeons have been doing traditionally except doing this through small incisions. And our camera and the instruments are now in the space in between the skin and abdominal wall muscles. So we’re not all the way inside intra-abdominally, but we don’t take the excess skin inside. I think mean, first of all the procedure itself was described back in 1990s and described by plastic surgeons. I think the first paper was. But I think it’s a great combination for if you’re doing mini, again, this is more of a realm of plastic surgery. I do some of those procedures but I’ll do mini ectomy and diastasis plication with a hernia repair at the same time if I don’t want to burn the retro recta space. So I do some of those just but not often. Not often. And I think they give you better. I feel like cosmetic result though they do have a flatter look to them.

Speaker 1 (00:40:48):

Yes, I agree. The anterior plication, I tell my patients it’s always flatter and tighter than a posterior. Yeah. But I just feel like the scar is, I would like around the belly button. Cause I’ve tried the scola approach for, I had every so often get a male model or an actor that has an epigastric hernia, they don’t want a scar and it’s too high for an actual trans umbilical open. So I go in with laparoscopically and they get a sercoma. Sometimes you got to put drains in if it’s a big diastasis, I assume. Do you use drains?

Speaker 2 (00:41:35):

You do have to use joints, yeah.

Speaker 1 (00:41:39):

And the scars kind of, I dunno, you can see the scar scar, it goes beyond the belly button. You kind of like, right?

Speaker 2 (00:41:46):

Yeah. So you go beyond the belly button. And so the scars are kind of the waistline usually. So in that sense, if you’re talking about, again, your patients are very different from mine, but in my patients usually don’t care where their scars are. But yes, you can hide the scars in the bikini line, so to speak. The key with the scholar procedure you have to select patients very well. They’re truly patients who don’t need excess skin removed. But what does allow you to do that bulge, that subcutaneous bulge that you get likely posteriorly, at least that skin flattens out. But you have to be, you are right. What do you do by the belly button? You can actually move the belly button the same way. There’s tricks to that. If you do a mini ectomy, you can still replant the belly button. You can actually, the same way you use a lemon plate to cut around D umbilical you can do the same thing and put place that, and again, I’m getting two technical, but one of those Alexis retractors through the hole that’s created. And so essentially create a dome and the belly button is on the bottom so you don’t cut the belly button at the stop. So you can still replant it in some cases, but it’s just very rarely. I probably haven’t done more than 20 times at this swallow repair just because it’s very rarely in my own patient population that I need to use it. Yeah.

Speaker 1 (00:43:13):

All right. You ready for the next question?

Speaker 2 (00:43:16):

Yeah, sure, sure.

Speaker 1 (00:43:18):

All right. <laugh> having fun. We were almost done. We got 14 minutes. Okay. Okay. When, let’s see, oh, this was a technical question. When removing ventral hernia mesh laparoscopically or robotically, how can you remove the mesh through the ports without making a separate incision?

Speaker 2 (00:43:43):

Yes. So actually, so first of all, it’s a similar question. How do you introduce the mesh without making, so we’re usually kind of wet the mesh, lubricate the mesh, kind of roll it like a cigar and literally place it like literally a cigar and place it through one of the strokers with a laparoscopic instrument. When you remove the mesh, a lot of times the mesh is a little bit stiffer at that point, especially the ones we removed. And what you can do can actually zigzag and create a little snake, like a little strip inside. So you can have an oval mesh. So you Zack around it and when you pull it, it becomes a string and so you pull it through one of the straws without having to make a big incision. So that’s what I usually do.

Speaker 1 (00:44:27):

Yeah, I do the same. I make it more linear so you can pull it out. And what if you have to cut the mesh up in pieces, that’s okay too. There’s no need to, it’s not like it’s a cancer or tumor. You have to maintain the Absolutely. Okay. So this is a question about Botox. What are your thoughts on the use of Botox for ventral cardio repairs? Do you use Botox

Speaker 2 (00:44:52):

Right now? Very selectively. I do think there is some benefit to using Botox in selected patients, especially those that have very thick oblique muscles. So anatomy wise, again, for patients that are listening the middle, we have rectus abdominus muscles just to the side of the six step muscles. We have three layers of muscles, external, bi, internal, bi, and transverse muscle. And there’s some patients, and you can see them on CT scan that have very thick developed muscles. And what happens, you have to imagine if you’re trying to close the hole in the middle, think of those muscles as sprints. They kind of keep, and so thicker they are, the more difficult it’s going to be to pull the whole abdominal wall back together. So we refer to this as poor compliance of the abdominal wall. So thanks <inaudible>. So in those cases, I do think especially with more difficult cases like loss of the main, what have you, I would use Botox. The problem with using Botox, at least in my practice, is unfortunately my patients have to pay for it out of pocket. That’s about a thousand dollars expense for the 400 units of Botox. And so insurance companies don’t use,

Speaker 1 (00:46:05):

It’s a lot of Botox.

Speaker 2 (00:46:06):


Speaker 1 (00:46:07):

It’s a lot of Botox.

Speaker 2 (00:46:09):

And so now insurance companies, some insurance companies are starting to be more lenient. You have to send them a letter. We still don’t have great success. Some of my colleagues have had much more success getting insurance companies approving Botox. I can tell you I think that there’s some kind of interesting benefits to it potentially. Question is, do you get less pain after surgery because you kind of take that tightness off at least initially, and the patient for the next two months, they walk around with a little bit lax abdominal wall. It all comes back after a while but at least it allows the down wall, the muscle layers to heal. Well, there’s some potential benefit to that. Being able to close difficult defects that you would not be able to close without what we call component separation. That does help. Some surgeons will argue for use of Botox to prevent doing advanced procedures like what’s called external oblique releases or transversus, abdominal muscle releases.

Speaker 2 (00:47:13):

Again, those are procedures that will device want the muscles to get things back together. But where I personally stand on it is I think in the right hands, people who know what they’re doing, actually releasing those muscles does not give up your function of wall. So to me, Botox is a great adjuvant. I would use it all the time or a lot of my patients if I could but I just don’t have access to it. And yet even with my practice, I can get away with it. Most of valid, most of the time in a selected case is really big cases. I still use it.

Speaker 1 (00:47:52):

Yeah, I agree. I have my plastic surgeon connection where they get it really cheap from the reps, so I buy off them. Otherwise, if I were to order it, I’d have to charge my patients even more. So I kind of get it on the black market. Ok. The next

Speaker 2 (00:48:13):

Question, do whatever we can

Speaker 1 (00:48:14):

Is it’s a little bit complicated what

Speaker 2 (00:48:18):

I said, you do whatever you can. You do whatever you can

Speaker 1 (00:48:22):

Whenever you can, right. It’s so expensive and we’ve tried so hard to get it approved by insurance and try to be as creative as possible and we couldn’t do it. Sure. We tried multiple times. So the next patient story is a difficult one. He basically was a bad car accident, nearly died, big abdominal incision a lot of bleeding, et cetera. So trauma incision. And then he ended up with a skin graft over his abdominal wall and he was like that for 18 months and then he had a second surgery to actually fix his hernia. They just closed it. They didn’t, didn’t place any mesh. Which, what do you think of that?

Speaker 2 (00:49:16):

Yeah, I think white majority of the time the hernia will come back within a year or two years, at least to some degree. Majority of the time it will come back. Yes. Based on what you’re describing, the type of patient, it’ll come back, I think. Is that what that happened? Ok. I’m surprised they to close primarily

Speaker 1 (00:49:35):

Exactly what happened.

Speaker 2 (00:49:37):

Yeah, yeah. I’m surprised a

Speaker 1 (00:49:39):

Healthy, they lose a lot of weight with these things too. So yeah, I think their studies show at least a 50, closer to 60% recurrence rate of if you repair an incisional hernia without mesh. So 12 months later he has another hernia and he’s due for to have a tar. So they told him you need a tar and now he’s worried about the implications of atar. Can you explain what a tar is, why you would use it? And yeah, sure. His main question, should you be worried, is this a good thing to get a tar? What are the critical factors to consider before moving forward this procedure?

Speaker 2 (00:50:25):

Yeah, I mean, so or stands for transversus abdominal muscle release. It’s a procedure that was described originally 2012. It’s been first done back in 2006. The gentleman who the couple many people pioneered the procedure help pioneer procedure. One of the main guys being the name is Linsky. And another one that comes up is Michael Rosen. And of course I think it’s important to mention Todd Henne for collate foundation for those guys. Now that I gave the credit, I just want kind of talk about the procedure itself is complex in the sense of technically it’s difficult to do be because the surgeon who is doing it has to have a very good understanding of abdominal wall anatomy. And so absolutely. When someone who does those procedures a lot, I’m talking about hundreds procedures a year and has done hundreds before, the outcomes I think in those hands are going to be good in the sense of not like zero risk to anything, but as far as what you worry about is damaged to abdominal wall as a result of mistakes during the dissect.

Speaker 2 (00:51:36):

So it’s not a procedure that’s a low risk procedure in that sense, but when done well, yeah, in my opinion, it’ll give you a very low chance of recurrence in your lifelong. And as far as quality of life and functionality, again, when done well, people are very functional and have a very good quality of life afterwards. I mean, that’s my opinion about this procedure. It’s a long procedure. You certainly should not be shy asking a surgeon how many of those procedures they’ve done and don’t be shy asking how the procedures are patients are doing. And it’s a great procedure when done. Well, I’ll tell you that. So why is it great? Because it kind of kills two birds with one stone one of those two birds. And one thing is allows you to release the tenderness portion of the muscle and some of the muscular portion in order to take some of the decrease the compliance of abdominal wall in order to bring it all back together.

Speaker 2 (00:52:38):

In the same step as you are doing that procedure, you are developing a very large space for the mesh placement between the muscle layers. So when you get everything close together and when you heal up, if you ever need to have surgery down the road I’ve done those surgeries afterwards. You go back in there that you do not see the mesh, you still have adhesions, to be honest, you still can develop adhesions to yourself because that’s very good point. Yeah, that’s a very good point. But you don’t get adhesions to the mesh. And so it’s easier to get back intra abdominally inside the abdomen after this. And because the mesh can be sandwiched between the muscle layers, and again, not everyone’s doing this, but from my practice, and many my friends are doing this, we are not using any penetrating, which is placing the mesh in there, in this contain space. It’s kind of placing a bookmark inside a book. It’s not going to go anywhere. And then over the next several weeks after the placement of the mesh, the mesh integrates. Yeah, what’s that?

Speaker 1 (00:53:41):

That analogy Bookmark in a book. I may use that with your

Speaker 2 (00:53:45):

Permission. No, please do. Yeah, I use it all time.

Speaker 1 (00:53:48):

I use the analogy of a letter, A envelope.

Speaker 2 (00:53:54):

That’s a great one too actually. That’s a great one. Yeah.

Speaker 1 (00:53:57):

I use that for tap, I think for al hernias. I think that makes good sense. Yeah.

Speaker 2 (00:54:02):


Speaker 1 (00:54:06):

Okay. Sorry, you were saying no.

Speaker 2 (00:54:08):

So I think to answer this gentleman’s question, yeah, it’s a big procedure and so I’m not sure if we’re going to talk about complications from those procedures, but some of the complications that we worry about, people who do this a lot worry about is improperly done transverse abdominal release that results in essentially iatrogenic injury injury as a result of improper layers being dissected. And again, it’s very easy to make that mistake during the surgery. And so then some of those patients who do develop the problems, develop bulging, not in the middle now, but develop bulging on the sides because the new herniation happens in between the muscle layers now. And those procedures are very difficult.

Speaker 1 (00:55:01):

Difficult which difficult to repair,

Speaker 2 (00:55:05):

Very difficult to repair, very difficult to repair afterwards. And the function now down, which

Speaker 1 (00:55:11):

I think your first comment is the most important, which is these revisional operations, if have a recurrence or if you have to need some complicated procedure, absolutely. That needs to be done by someone who does that on a regular basis. Yeah, because it is a disaster if they injure nerves because you can’t go back with that. No. If it recurs. Well one of the questions was about recurrences. Yeah. That’s why I use the TAR as my kind of end stage need. If there’s any other procedure that can be done to address the patient’s need, I don’t use a tar because I feel like if that fails or if you have a complication infection, well things can happen then you, you’ve burnt a lot of bridges but it sounds like this patient legitimately may need a TAR question on that after TAR. Here’s a question for you. What do you do if you can’t close the anterior layer? These are very, very technically advanced questions, I must say. Yeah. What do you do? You do if you can’t close the anterior there after TAR?

Speaker 2 (00:56:26):

It’s those instances happen very rare. And this is somebody who does this. I’m saying this is someone who does a lot of those procedures a year, probably do over 200 of those procedures a year. And so we’re talking about we can’t close up abdominal wall on someone after having done a TAR or external <inaudible> releases. Those are the people who truly had very kind of loss of the main cases we say. And so in those cases, and you usually prepare those specific patients for possibility of what’s called bridging, at least a portion. So I end up closing whatever I can and then say the hole was this big and all of a sudden I can get a hole to this big. Essentially it’s okay to go ahead and leave that portion, not close, but have the mesh and inside and between the muscles restore the continuity of a down wall. So again it’s okay to lead a little bit of the gap in the muscle, but the mesh is going to be there still kind of reinforcing. But the choice of the mesh might be different. In those cases, you want to potentially use a stiffer mesh so the mesh does not bulge out in the middle. So that’s kind of some consideration that happens rarely. Rarely. And so again, just leave it open. That’s a question.

Speaker 1 (00:57:46):

Yes, totally agree with that. Absolutely. These are very difficult situations. It’s not common. It’s not a calm problem, thankfully. Yeah. Once you get to the tar state, you better be able to close that defect. And if you can’t, then it’s, and I’ve had a few patients where they have those giant, giant hernias. Yeah, those are very difficult to do. Right, right. Well, this is our last that’s it, Igor. That’s it. We’re all

Speaker 2 (00:58:18):

Done. All right. Awesome. I want

Speaker 1 (00:58:19):

To thank you for giving me your time. I know you have family and are you opening up your office yet? Tomorrow’s my first day at work. What about you?

Speaker 2 (00:58:30):

No, I mean I’ve been working as far as mostly administrative, but I’ve been seeing some telemedicine visits. The clinic volume has dramatically decreased. I’m definitely seeing less patients. For example, tomorrow I have 11 patients and usually Mondays I would have at least 30 patients in the office. Now the 11 patients I see, only one of them I’m actually going to see physically the rest are going to be telemedicine visit patients. We’re slowly going to restart right now. I mean, I have a backlog. I have 60 patients posted right now over the next we’re actually don’t have the posting time yet, but anyways but we’re starting up. Over the next two weeks we’re going to be operating and hopefully by July we’ll be going at least by at 75% of our regional volume. Here’s the thing, this pandemic is not going the initial, it’s only the initial phase. We’re only going back to normal for the next year, year and a half. We’re going to be living in a very different world, unfortunately, and we have to accept it and just roll with it at this point. Keep social distancing most important. Yes. Yeah. Alright, great. Thank you so much, Shirin. I hope you say good luck tomorrow. What’s that?

Speaker 1 (00:59:50):

I will be posting this on YouTube as well as Facebook and we’ll be doing this again next week with the doctor that you just mentioned. Yuri Navitzky will be with us next week so we’ll have much more tar related questions for him and I’m looking forward to seeing you all next week. In the meantime, I will post this video for all of you to rewatch and rewatch and share with your friends. Thank you all for joining us. Thank you, Dr. Belyansky, for your time. It was really lovely. Hope you’re all well and take care.

Speaker 2 (01:00:28):

Thank you. Bye-bye, Shirin. Good night.

Speaker 1 (01:00:31):

Thank you. Thank you. Bye-bye.