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Speaker 1 (00:00:00):
Hi everyone. It’s Dr. Towfigh. You’re joining me on another Hernia Talk live. Thanks for coming. So let’s see here. Today is Tuesday and many of you, as you know me, have been following me for all my hernia talk sessions. I am a hernia and laparoscopic surgery specialist. You’re following me on Twitter and her and Instagram at hernia doc. Thanks to those of you who are live on Facebook and that’s at Dr. Towfigh. So we decided that today would be a revamp of another myth buster that I had last week, not last week, sorry, last month, maybe a month and a half ago, which I thought was one of our best. So I did a hernia myth busters session about six or eight weeks ago and you guys just went nuts in that you had tons of questions, but afterwards I saw I went to SAGES at a meeting and people that were in industry and people that were surgeons had watched it.
Speaker 1 (00:01:13):
There were patients that wrote back to me and said, that was absolutely your best of all the different sessions. And I think because I really went head on and answered as many kind of these questions that people really don’t know about that are wondering, is it true? Is it not true? That’s what I was told. And so I decided to do a part two because believe it or not, all the questions we went through the first session, I had about 40% more questions still left. So we’ll go through many of those plus many of you have already sent me questions as well in advance. So as usual, we have tons of questions to go through with each of you, and if you do have any that you want to kind of show me or ask me, you can do that online and just type it in on Facebook and on Zoom and wow, I already have a huge one. Okay, before I do that, a really big question that was submitted, let’s do a couple of these and see what you like about it. All right, let’s get to the right session here.
Speaker 1 (00:02:37):
Let’s see. All righty, so let’s move on to the first question which has to do with Mesh removal and your surgeon. So one myth is I don’t understand if my surgeon is putting in the Mesh, they should also be able to put it out, take it out. A surgeon should not put Mesh in if they don’t know how to take it out. Now that sounds logical. I would say that sounds reasonable. In fact, the reality is it’s not because putting in Mesh has a certain type of skills and removing Mesh has a totally different set of skills. It’s like saying the same guy that puts the engine in my motor at Ford should be able to know how to fix the motor or remove the motor. They just don’t. They’re two different people, two different sets of skills. So it’s the same with surgeon surgeons of any kind.
Speaker 1 (00:03:36):
So you have in general surgeons that do certain cadre of operations and then there’s a different set of surgeons that deal with complications of those operations, revisions of those operations. And that can be for cancer, for your hip or shoulder replacement, for any number of procedures, you usually do not go to the same surgeon to remove your Mesh than the one that put it in because the skills are different. Now you can choose to go to a surgeon that takes Mesh out or for a living. So I do that and 80% of my practice is treating complications from hernia repair, anything from hernia recurrences to Mesh erosions and Mesh removals. So about 20% of my patients come to me and say, you remove these and you deal with the complications. So I want you to do my repair for two reasons. One is you know that you kind of know all the little tips and tricks of what not to do so that I as a patient don’t get the complication.
Speaker 1 (00:04:41):
And number two, if something goes wrong, you can fix it or you can take care of it, which I think is true. So based on that, I hope you just don’t feel that just because your surgeon put in the Mesh that they should also be responsible to remove the Mesh and often that’s not the case and often I don’t recommend it either. The flip side is also true, which is that going to the same surgeon for advice is a good start. You should always start with the same surgeon, go back. Maybe they know, oh yeah, this is why you have certain pain or this is why you have a bulge or something. But you may want to get a second opinion if the answers you’re getting are not what you need. Because the same way that there’s different cert skills technically to remove Mesh for example, there’s also separate skills and just knowing what questions to ask, what imaging to get, what examination findings to look for, to then determine whether you need Mesh removed or injections or some other treatment of a complicated situation.
Speaker 1 (00:05:58):
So what I’m trying to say is there are in all operations, we’re talking about hernias, but for all operations there are surgeons that do them and there are surgeons that do specialize even further deeper into that niche in dealing with complications and removals. So to claim that the surgeon’s poorly skilled because, or that you shouldn’t put Mesh in if you don’t know how to take it out, is unfortunately good marketing but it’s it’s not really reality. The next question of our MythBusters is that neurectomy is without consequences and I really want to spend some time on this because neurectomy means cutting a nerve and sometimes we do that because a nerve is damaged. Sometimes we do that because we feel the nerve may be damaged and then sometimes we just do it prophylactic to prevent future pain. I do not believe neurectomy is without consequence.
Speaker 1 (00:07:07):
In fact, I looked at all of my own data because as part of Mesh removals and revisional hernia repairs and people with chronic pain and neuropathic pain, I do deal with nerves. Many of them come with me with nerve pain or nerve entrapment from scar or Mesh or nerve damage from whatever, as well as just nerve pain, completely unrelated, like something called ACNES, which is anterior abdominal compartment ACNES anterior, yeah, abdominal enter component nerve entrapment syndrome of the abdomen. So the acnes is just happens randomly and sometimes neurectomy is part of the treatment. So the question is, is neurectomy without consequence? As you know, there are patients who’ve had neurectomy, they do just fine. In fact their pain is gone and yet there are other patients that are miserable and they have these kind of recurrent symptoms and so on. So I was curious to know what happens when you do.
Speaker 1 (00:08:15):
And so we looked at all of my data for the past decade or so and looked at every single patient that had a neurectomy and followed through with them to see how they did. And what we found was super interesting. We presented it at sages, the Society of American Gastrointestinal and Endoscopic Surgeons, the big laparoscopic meeting of the year, two weeks ago, and my team presented and they did an excellent job and the paper will be get published, but what it will tell you is if you have nerve pain or if you have nerve pain and you have a neurectomy for that, you have about
Speaker 2 (00:08:54):
A 7% risk of that nerve having pain again after the neurectomy and needing more injections and sorry, I’m needing another neurectomy and about a one third chance of not being cured of your pain from the neurectomy and requiring more injections and 7% of those will be under the neurectomy. However, interestingly, if you had what’s called prophylactic neurectomy, that means the nerve was cut to prevent pain. You didn’t have pain before surgery. Those people do just fine. 0% had any pain or consequence from the neurectomy. So I just want to share that with you. Neurectomy is with consequences, but in my data we just recently looked into, at least in my hands, when you do a neurectomy prophylactically, it’s really without consequence. If you do a neurectomy with in people with pain, you have a one third chance that they will have more pain, still some pain afterwards, they’re not cured, they need injections or something and 7% of those will require another neurectomy because of a neurectomy or so on.
Speaker 2 (00:10:14):
So that’s kind of interesting data that we teased out. No one really talks about, I thought was so interesting. We looked at the literature, people don’t really, they recommend neurectomy. You’ve heard of triple neurectomy, something that I don’t follow. I do more what’s called selective neurectomy, but both the triple neurectomy and selective neurectomy camp talk about neurectomy and and cutting nerves. But very few studies, relatively speaking, talk about what happens, what is the consequence of cutting a nerve. Now these nerves we’re talking about are what we call sensory nerves. They cause sensation to the skin and so the consequences are usually pain every so often Nerves can have what we call motor function, not sensory but motors. It actually goes down and innovates a muscle and in doing so, it gives function to that muscle and it feeds that muscle. If you cut a nerve that has muscle function, that has consequences of motor function regardless of whether it is done for prophylactic or therapeutic reasons. And that’s important because when I do those, I try not to do those neurectomies because of exactly those consequences. So those were really not part of my study. But yes, absolutely the consequences of neurectomy, especially higher up like laparoscopic neurectomy, which I think should not be considered standard is one where the motor nerves, the nerves get caught. All right, you guys, you already sent me tons of questions, so
Speaker 3 (00:11:53):
Let’s take a look at your question. So here’s one question says, during August and September, I have had only two episodes as listed below with no vomiting, although once I felt like I would, the pain was not as severe again, it is while sitting and driving. June/ July of this year, I began having pain from around the sides of my stomach and rib area until I got all from to the front. Spasms began and increased occurred when driving or sitting, nothing seemed to help laying down a cold heat, they could last for at least a few hours and I vomited twice. Once was projectile, I noticed a change in my bowel movements. They became narrow or squeezed and that’s improved with Metamucil. My CT scan shows a right paramedian ventral hernia containing bowel, which has markedly progressed from the prior study as well as another infr umbilical midline ventral hernia containing bowel.
Speaker 3 (00:12:52):
Okay, so what is the question here? Sounds like you have a hernia and need it needs to be fixed. I was seen by Dr. Kirby Schweitzer who is advised that I have abdominal, I need abdominal mal reconstruction and to see a hernia special that do to do that. I agree you have a hernia and the question for the hernia surgeon should be, does that require treatment? So they have to review your examination, look at the imaging to see what’s in exactly is inside those hernias and are those a cause of your symptoms? Because if they are, then hernia repair definitely should be performed.
Speaker 3 (00:13:32):
I’m happy to look at those imaging. I offer online consultations or you can just come to my office. But yeah, you definitely need to have all that reviewed very carefully. The next question is with regard to neurectomy, what causes the persisting pain? Is it because of the residual nerve dump remaining injured or is it because there’s another source of pain not identified? Very good question. So specifically in these patients that we looked at, a third of them had residual pain. So there’s some type of stunning of the nerve that happens when you cut it. One technique that I use is I numb up the nerve first before I cut it to kind of reduce that effect and I found that to be very helpful. But yes, the nerve endings should not be exposed to scar tissue and when they are or if they are, then that can cause scar tissue into the nerves and kind of irritate the nerves. And some people they’re just have very sensitive nerves. So a small proportion of patients, we had three continued on to have worse and worse nerve pain in what’s called C R P S or complex regional pain syndrome. It’s a devastating complication of nerve problems. It can happen in anyone, but mostly it’s in people who’ve had multiple operations on the nerve.
Speaker 2 (00:14:51):
And so in those people you don’t want to ever touch the nerve. You want to really calm down the whole nervous system. There’s a whole protocol that pain doctors go through with to help people with C R P S or Crips is what we call it. But yeah, it’s because the remaining nerve is injured and oftentimes you need more injections, ablation or neurectomy to kind of curb that problem. That’s a great follow up follow up question. Thank you for that. All right, next myth and misinformation. It’s really a misinformation which is you can see more with open surgery. I think I’ve discussed this before, I’m sorry, you cannot see more with open surgery. The only people that tell you that you can see more with open surgery are people that only do open surgery. I hate to say this, I don’t want to bash on surgeons that only perform open surgery because many of them are really good, but to claim that you can see more with open surgery is complete BS.
Speaker 2 (00:15:57):
In fact, in some instances you can see more with a laparoscope or the robotic camera because you’re actually going into nooks and crannies and crevices that you wouldn’t be able to see unless you completely, fully open the patient, which we never do. So some people are more comfortable with the open surgery approach as opposed to the laparoscopic or robotic approach, but to claim that you can see more is completely misinformed and often is not the reason why people are insisting on doing an operation in open fashion. It’s mostly because they do not offer you a laparoscopic or robotic option. This is something that I must admit, I used to say, I say Mesh is an earth, what are you talking about? And I don’t know where I heard that. I don’t know if I heard it at a meeting, if I was taught that when I was a resident, I really don’t know where that term Mesh is inert came from.
Speaker 2 (00:17:01):
It’s not true Mesh, like any implant, has a potential to cause inflammation, to spark up autoimmune disorders and at the very least, inflammation, that’s actually how it works. And so it is not inert. In fact, if it were inert then this is inert, this piece of paper that’s inert, that’s inert. If I put this on your skin, the chances are you’re not going to react to it. And probably also if you put it in the abdomen, you’ll probably react to it though. My point is that somehow that came into our lingo. Mesh is inert surgeons say it all the time and I feel less and less of us are saying that less and less and less of us believe in that. But yeah, Mesh is not inert and definitely a myth. Definitely a myth. One of those things where we kind of regret having said it in the past. Another myth, you can’t have a Mesh reaction if the contrast media MRI does not show angiogenesis around the Mesh.
Speaker 2 (00:18:21):
Someone sent this to me. It’s very interesting idea. So there is one paper that looked at MRI with IV contrast specifically looking for angiogenesis, which is new blood vessel formation around the Mesh and saying you can cannot have a Mesh reaction if that MRI doesn’t show that you’ve had any ingrowth into the Mesh. Not sure that’s true. The reason why I say that is we do allergy testing on the back and stick Mesh onto the back with tape and people react to it. So there’s definitely no angiogenesis going on at that level, and so it’s impossible to say that that is for sure what’s going on. They define Mesh reactions angiogenesis on MRI. Now it’s an interesting thought. They’re trying to objectively identify Mesh reactions. It’s unclear what they’re ca calling a Mesh reaction whether it’s like a systemic reaction like Asia syndrome or not. Now it’s true in order for Asia syndrome or any other kind of non-allergic reaction, more of a systemic reaction to occur.
Speaker 2 (00:19:41):
You do need your blood vessels to kind of communicate with the Mesh. That’s true, but Mesh reaction is not just an autoimmune problem, it can be an allergic reaction or an inflammatory reaction which is unrelated to unrelated to angiogenesis or blood vessel growth. Okay, next. Smith, hope you guys are enjoying this because I see a lot of you logging in Noah’s asking questions, so I think you’re all listening, so that’s good. It means you like these talks and you don’t have questions of your own. Okay, another misinformation. The only way to remove abdominal wall Mesh is to sacrifice the muscles. Okay, I think it was last week, somebody asked the questions. She was told that a third, I think a third of her muscle needed to be removed or half of our muscle need to be removed as part of the Mesh removal process. Yeah, sacrifice is a strong term.
Speaker 2 (00:20:42):
The only way to remove abdominal wall Mesh is to sacrifice the muscles. Not true sacrifice means you’re cutting it out or something like that. In fact, the whole Mesh removal process is performed in a way to minimize how much tissue, whether it’s fat muscle or fascia and hopefully not other things like bowel and bladder to minimize how much fat muscle or fascia is involved in the Mesh removal process. I explained this, take a Velcro off of a cashmere sweater, right? Cashmere is very delicate and you don’t want it to be too frizzy and then you put a big Velcro on it and then you shear the Velcro off of it. Well, you’re going to get lots of fuzziness and kind of, I won’t say you’re going to destroy your cash sweater, but it won’t look the same. Now you can still wear that cashmere sweater, same with your muscles, so the muscles will be intact and will be defined. You want to remove the Mesh with delicacy to minimize how much muscle it cells are left on the Mesh and everything varies per patient, but you don’t sacrifice the muscle, that’s for sure not true.
Speaker 2 (00:22:05):
Next question or misinformation is that an adhesions can severely impair intestinal motility. All right, so what are adhesions? Adhesions are areas where there’s stickiness. Usually inflammation or surgery or trauma or blood or something else that’s an irritant can cause inflammation in the area. And then two structures like bowel and muscle, for example, will stick to each other. Mesh can also cause inflammation and if placed directly against something like muscle, it will cause adhesions to the muscle. That’s how it sticks. If it’s placed along a nerve, it may have adhesions to the nerve and it’ll stick. If it’s placed along a against bowel, it can cause adhesions and stick to the bowel. That’s why we make Mesh with an anti-adhesive barrier so it doesn’t stick to bowel, it still kind of sticks, but it’s not bad. Can it impair intestinal motility? Okay. It may impair how much movement of the intestine there is locally in the area where it gets stuck, but intestinal motility, that’s the outside of the intestine.
Speaker 2 (00:23:20):
It has nothing to do with things moving on the inside of the intestine. So intestinal motility or GI motility usually refers to the movement of food from mouth to anus. And if you have impairment in that where things are not moving, it’s more like a pipe, that’s dismotility. Either pipe or it moves backwards, having adhesions does not affect the muscle of the intestine, the muscle of the intestine still moves things down in an orderly fashion. The outside of the intestine may be stuck, but the inside where the muscles are still moves things. So it does not affect GI motility, but it may kind of hold the bowel in a certain area for that. Next question. Going back to the nerve question, do you believe radiofrequency ablation or cryoablation has any role in treating chronic post inguinal hernia pain? In the absence of identifying an anatomically correctable cause of pain?
Speaker 2 (00:24:25):
Possibly, the question is, is your pain neuropathic? Is your pain due to nerves? If it’s not due to nerves, then any amount of radiofrequency ablation or cryoablation of the nerve will not help. So before you commit to any radiofrequency ablation or cryoablation, which is basically destroying the nerve without cutting it, you like either freeze it or you burn it through these needles, they stick through your skin. So before you do that, you do what’s called local anesthetic or nerve block, and if the nerve is blocked with local anesthetic and your pain goes away, then you know that that’s the problem and therefore you attack it with this cryoablation or radio ablation.
Speaker 2 (00:25:13):
I would not just willy-nilly go after those nerves. Like I said earlier, neurectomy or even ablation is not without consequences. So there’s no need to destroy a nerve that’s normal, and so I would not perform it. If you have pain and no one can figure out why there’s pain, there’s always a reason why there is. You just haven’t seen the right person yet potentially. However, if your pain does not go away with local anesthetic to that nerve, then it also will not get better with cryoablation or radio ablation. So no, I do not believe in using that as a treatment mode for chronic pain only for chronic nerve pain or neuropathic pain.
Speaker 2 (00:25:58):
Next myth. All hernias require Mesh repair. I have so many patients that go to their doctor and they say, do I need Mesh? Yes, absolutely you need Mesh. Is there a way to do it without Mesh? No, not possible. And actually I see a lot not just with ventral hernias like the abdominal wall, but also in the groin. I just saw a patient today that is having complications from their hernia repair to the point where they’re miserable, they can’t function, they are unable to have intercourse, they can’t exercise, just miserable because they had a really small hernia, a really small, no one can actually feel it. And they didn’t know why he had pains. They said maybe it’s a hernia, let’s fix it. He went in and had robotic hernia repair with Mesh and then he has pain since then. And actually the pain from before surgery hasn’t changed, so that didn’t help.
Speaker 2 (00:27:01):
Now he asked the patient, the surgeon, do I need Mesh? And the surgeon said, absolutely. And so he went and had went ahead and had the surgery. Now the surgeon, to be fair, the surgeon could not have predicted that he would’ve had a bad outcome from the Mesh repair the it’s a male, he’s not super thin, he doesn’t have any autoimmune or all or allergic problems. So as far as you can tell, there was no real predictor that he’s going to have a bad outcome with the implant he did. And so now I have to consider removing that Mesh and doing a tissue repair. The point is there’s always options for patients and sometimes those options are non Mesh based and those non Mesh based options, we’re hoping that surgeons learn to do it more often than they used to, and also offer to patients more often than they used to.
Speaker 2 (00:27:57):
And I feel that based on the meetings that I went to last week two weeks ago and the upcoming meetings, there’s a American Hernia Society meeting and the European Hernia Society meeting. Both of those also seem to be looking at a lot of identification of alternative methods, less invasive methods, less invasive methods, more patient friendly methods of hernia repair. So I feel like I really good, I feel like my people are following me a little bit and kind of hear what you guys are saying and what I’m trying to share with them from what you guys are saying, a follow up question that is however, is a diagnostic local anesthesia injection of a nerve specific for neuralgia or it also make no susceptive pain from an anatomic problem temporarily go away. No, it’s for Neuralgia. If you have nerve pain, Neuralgia pain and local injection takes it away, then that’s nerve pain and usually a last it’s it’s dermatomal.
Speaker 2 (00:29:10):
That means it follows a certain pattern. If they are not aiming for the nerve and they are randomly injecting you, that is not a nerve block. You know can treat local areas of swelling with steroids, for example, not with local anesthetic. That will give you whatever the time of numbing is. What you want to know is there a longer lasting pain relief? And that’s usually diagnostic of the effect of the injection. So situation one is you have a nerve that’s injured, you specifically aim the injection of local anesthetic to that nerve and the pain goes away and the pain lasts longer than the expected length of the nerve of the local anesthetic. Second situation is it’s not a nerve pain. It’s let’s say a muscle strain, right? Spoor hernia, adductor strain or tendonitis. You get local nerve, sorry, you get local anesthetic injection into that muscle, not the nerve muscle, and that makes your pain go away.
Speaker 2 (00:30:18):
If that makes the pain go away, great, it’s going last only as long as the local anesthetic effect is. It won’t be longer lasting. Now if that means that they then put steroids in it to reduce the inflammation from that strain, that muscle strain, not nerve muscle strain, then that will make the effect last longer. But specifically with regard to cryoablation or radiofrequency ablation, you have to have a nerve block and see if a nerve block gets rid of your pain. If it doesn’t, then no amount of cryoablation is going to get rid of your pain because that is also directed at the nerve. You can’t just cry oblate or radiofrequency of late muscle. So I hope that makes it go away. That’s why it’s so important when you see a specialist that they know what they’re doing. At one of the patients I saw this morning had like, I’m like, what’s that?
Speaker 2 (00:31:19):
Did you someone inject you? And he’s like, yeah, yesterday I had a injection, it was in the most random place. I have no idea why you had an injection there. And I’m like, okay, well were they trying to get, I don’t know a nerve because that’s not where a nerve is. I don’t know. The patient said that’s where his pain was, they injected it. There was no purpose of that injection. That injection needs to have a purpose. Either you the ilio inguinal nerve, the ilio hypogastric nerve, the general femoral nerve, whatever it is. Or like this guy, I injected his Mesh actually with steroids because I believe that’s the problem and they injected like far away from his repair. It made no sense to me. So you can’t just randomly get injections and you need someone to give you injections with a purpose. I don’t know how much better to explain that.
Speaker 2 (00:32:11):
All right, let’s go back with another, oh, you got our Facebook people asking questions now. Thank you. Okay, in my removal, a peripheral nerve was cut but has fully healed with proper sensation. Is this unusual with neurectomy? Can the nerve repair itself in a better state? So that’s really good that you had no consequences from a neurectomy. There are a lot of patients that I do neurectomy on and they should be numb because there’s no nerve to that area of skin anymore. Nope, not numb at all. And the reason why is the further out you get from the spine the more the nerves kind of interconnect and so they overlap and cutting one nerve means you’re not getting sensation from that nerve, but they’re the nerve above it, the nerve below it may be overlapping, so that’s good. The other possibility is the nerve was never really cut.
Speaker 2 (00:33:07):
They thought they cut a nerve or it was a branch of a branch of a nerve, but it wasn’t the full nerve and that’s why you had it. But no nerves did not repair themselves. They do not. I mean quickly, I think it’s one millimeter a year is how fast they can grow if it’s cut. So it does repair itself, but it’s a very, very slow process. Just to follow up with the last comment, the question is, so are you saying that only if the pain relief is longer lasting than the brief pain due to the local anesthetic injection, is it Neuralgia that would respond to radiofrequency ablation? No, I’m saying if the nerve block was specifically to a nerve, not nociceptive pain, you have to actually attack the nerve and the pain goes away, then yes, a radiofrequency ablation will help. But if you’re getting random injections and that helps, but in the short term, radiofrequency ablation is not going to help you.
Speaker 2 (00:34:09):
It has to be a follow-up to an actual nerve block. Also. Can nerve conductions study be used to evaluate paralysis in the abdominal wall? Is there no way to repair nerves themselves? Correct. So in general, it’s hard to do nerve conduction studies for the abdominal wall for multiple reasons. One is the place where they put the EMGs are tricky and the nerves travel through different levels also, there’s bowel deep to it. So a lot of, the people do not want to put the needles into the abdominal wall because they’re afraid of getting too deep in thinning bowel, which I say use an ultrasound, but I don’t know why they don’t use ultrasound. So is there no way to repair nerves themselves? No. Yes and no. So there are a handful of plastic surgeons and neurosurgeons that specialize in what’s the right term, I guess nerve repair.
Speaker 2 (00:35:11):
I’ll call it nerve repair. It’s not really repairing. It’s hooking up a disease nerve to a healthy nerve and hoping that the two kind of heal each other. It’s kind of roots of a tree where you kind of split one and put the other one on and you graph them. Yeah, it’s like a nerve grafting, highly suspicious whether it works especially for small nerves. So the smaller nerves in the groin, no one does any nerve grafting for that. The larger nerves towards the spine, you can consider doing that. And usually you do not do nerve grafting or any type of healing technique for sensory nerves. It’s only for motor nerves.
Speaker 2 (00:35:55):
All righty. Let’s see. Next myth. It is impossible to safely remove Mesh. I don’t know how often I hear that. Oh, so many patients are told, oh no, no, that Mesh cannot be removed. Nope, nope. You’ll die. You’ll lose a limb. No joke. You’ll lose a testicle. Yeah, you’ll the one where they say you’ll die. I just don’t understand that. So every single Mesh that is placed with almost no exceptions can be removed. Very few exceptions, very few. Now there are risks to it. I’m not going to say there’s no risk to it, but there are risk to it and you’re going to have to accept the risk, but the risk of death is not among them. I’ll just tell you that. And then specifically the question that was proposed to me was, okay, now I have abdominal wall hernia, Mesh, if that needs to be removed, of all the different techniques in which Mesh place like retro, muscular, pre peritoneal Intraperitoneal, so either on top of the muscle, behind the muscle or in the abdomen near the bowel, which one is the most difficult?
Speaker 2 (00:37:20):
So there’s three ways, well actually four ways where Mesh can be placed. If you have a hernia that’s repair, they can put Mesh in between, which we don’t really do, but some people still do, but you shouldn’t be doing. You can put Mesh on top, which is called the Onlay Mesh on top of the hernia. You can put Mesh deep to the hernia, which is called a retro muscular usually, or you can put Mesh inside the abdomen even deeper to the hernia against the bowel, which is Intraperitoneal or IPOM Mesh, the most difficult to remove is the retro muscular, but the least likely to need to be removed is also the retro muscular. So that’s hopefully a little bit of important difference, and that’s because the retro muscular is stuck to fascia and to muscle. So it’s stuck on both sides to important structures. The Intraperitoneal Mesh, you take it off the bowel, which can be tricky but it’s doable and against the fascia, which is always, and the peritoneum, which is always doable.
Speaker 2 (00:38:23):
And then the Onlay Mesh, which is on top is just against fat. No one cares about fat. So that kind of comes off. No problem. All right, next question. When an inguinal hernia is higher up than usual and there is involvement of the spermatic cord and cremasteric muscle, does one need a microsurgical approach? So inguinal hernias are always in the same anatomical position. I don’t know what higher up than usual means, but no, we do not use microsurgical approach for any general surgery operation, especially not inguinal hernias. Now I do use it for Mesh removal. I put on my loops, which are these like four X magnifying glasses for Mesh removal and open fashion and laparoscopically and robotically. There are situations where you can actually make it even more focused in get more magnification. But no, we don’t usually do microsurgical approach for any hernias.
Speaker 2 (00:39:33):
Let’s see. Yeah, so somebody’s saying yes, that’s what I was originally told. I was told I could never walk again if my Mesh was removed. I chose removal anyway because after five years I couldn’t walk anyway. Oh, I’m so sorry to hear that, but that’s kind of funny actually. But you’re correct. Yeah, I don’t know why people say that. I sometimes feel that weird random complications are thrown out there just to scare you and or make you leave and find another surgeon and come to me, I think. Okay. With regards to better visualization of the anatomy with laparoscopy for hernias, does this also apply to sports hernias or athletic pubalgia where the pathology may be related to anterior structure, attachment to the pubic bone? Some of your prior quads seem to suggest it is best seen and repaired with an anterior approach. So anterior approaches for the groin or any abdominal wall is not done laparoscopically or robotically. It’s done open. And that’s because that’s usually anatomically where we can do the suture repairs or the releases. It has nothing to do with visualization of the anatomy or the need of laparoscopic approach.
Speaker 2 (00:40:57):
All right, next misinformation. A well-positioned flat and uninfected Mesh never causes pain. So there are patients that have chronic pain from their hernia repair, especially in the groin or it can be in the abdomen and you get imaging and it looks beautiful, it’s flat, it’s well positioned, there’s no sign of infection, there’s no sign of inflammation, and yet they have so much pain. So those people are a little bit more difficult to understand because why are they having pain? Oftentimes it’s because they are thin or athletic and now they have a structure there that reduces the compliance of their abdominal wall or their groin. So it’s different. It’s like putting cardboard in your underwear. That’s going to be very uncomfortable. I’m exaggerating, but that’s kind of trying to give you an analogy. So that’s where the pain comes from. It’s from stiffness of the foreign implant.
Speaker 2 (00:41:59):
Another reason for the pain may be it’s too tight of a repair. So the Mesh is perfectly placed, it’s flat. Everything looks good on imaging, but the reality is that imaging is done with you lying flat and not pushing or doing anything. The minute you get up or bend or cough or talk really loud or do anything engages the abdominal wall, your muscles want to pull and expand. Naturally that Mesh is placed too tight, it won’t move. So the one area of your abdomen where that Mesh repair is placed will not move and therefore will have a sensation of chronic pain. So it’s either from stiffness or too tight of a repair and it’s a misnomer to say, oh, that can’t be it. Mesh looks great. You can’t have Mesh related pain. You can if it’s too tight or if because it’s too perfectly placed, too flat or if it’s like you can feel it as a form by some people describe it like armor, like they feel like they have armor in that one area of their body.
Speaker 2 (00:43:11):
Okay, next misinformation. Abdominal wall Mesh doesn’t affect abdominal compliance. Oh, very similar to the last one. So we don’t have perfect Mesh. We’ve discussed this before. There’s tons of different meshes. There’s synthetic, there’s biologic, there’s absorbable, non-absorbable, and a combination of those. In general, biologic meshes have more. They’re not as stiff as synthetic meshes. In general, the more synthetic the acting, the Mesh, the less compliance it has, the less give it has, the more biologic the Mesh, the more give it has in general. So it does change the compliance of the abdominal wall. Now if you put a small piece of Mesh, it won’t, but if you need a wide piece of Mesh, your abdominal wall compliance will change. And people there are like yoga instructors, ballerinas, acrobats, they need a lot of abdominal wall compliance to do back flips and weird positions and they will feel the difference and almost feel like it’s like armor in their belly and that can cause chronic pain because they can’t even really sit because of the stiffness of the Mesh. Mesh doesn’t stretch is the problem. And if we haven’t been able to find Mesh that does stretch, but then recoils back because if it stretches, it’ll just continue stretching and then you don’t have a secure hernia repair again. So no one’s been able to develop a Mesh product that mimics kind of the natural abdominal wall compliance. Maybe one day we will, it will not be me. That’s not my specialty. There’s really smart people out there that I’m sure are working on it.
Speaker 2 (00:45:03):
Here’s a myth. The reduced precision of movement of laparoscopic surgical instruments causes a greater risk of inadvertent damage to Oregon’s and tissues compared to open or robotic surgery. Not true. So it is true in every single situation, whether it’s hernias, gallbladder surgery, appendix surgery, gynecologic surgery, there is more damage risk, more injury risk with the laparoscopic approach than with the open approach. That is true even for gallbladders to this day. If you look at any study, the risk of common bile duct injury is higher in patients undergoing laparoscopic gallbladder surgery cholecystectomy than open surgery. Of course, there’s so many other complications you can have with open that no one does it anymore. And you just understand that there are ways to reduce the risk of injury. However, it is not true that it’s because of the precision of the movements or anything like that. It’s somewhat because of the way you’re looking at things and almost always because of the fact that you can’t touch. So both with robotic and laparoscopic surgery, since you can’t feel certain things, that’s, you get a lot of feedback from tactile sensation. Now laparoscopic actually has more tactile sensation than robotic surgery. So that’s one of the benefits over robotic. But again, nothing is better than touching tissue if you really want to identify something that you can’t see very well. But I can’t say it’s because of the reduced precision of the movements of the instrument. That’s not true.
Speaker 2 (00:46:54):
Question, is it dangerous to dissect the internal spermatic fascia as part of a hernia repair? Internal spermatic fascia? Do you mean the cremasteric muscle? I don’t know what. Or do you mean the fascia going down to the testicle? Beyond the inguinal canal? In general, I think dangerous is too strong of a word. You have to know what you’re doing. But we separate the cremasteric muscle all the time and in patients that do like spermatic cord denervation surgery, they open up the fascia all the time. The fascia that’s , okay, there is no fascia that surrounds the spermatic cord. There’s a muscle called the cremasteric muscle that encircles the spermatic cord. And the older you get, the less that muscle is visible and available. So no, it is not dangerous to divide that. With regard to complications of endoscopic repairs, can the bladder be injured during a tap repair? Yes, absolutely. So inguinal hernia repairs are done in the groin when you’re doing them as open surgery. Unless the bladder’s in the hernia, you can’t injure the bladder when you’re doing the hernias laparoscopically, you can injure the bladder. So I always put a catheter in the bladder to decompress a bladder and empty it, remove it out of the way. That’s not considered necessarily standard of care because not everyone, there’s plenty of surgeons that don’t put a Foley catheter. There’s no consensus as to whether a Foley catheter or urinary catheter should be placed or not.
Speaker 2 (00:48:39):
I operate with urologists all the time. They can’t imagine ever having any pelvic surgery without a catheter protecting that bladder. So I respect that and I follow their lead. A tap repair or a tap repair, both of them are laparoscopic approaches to Inguinal hernia pairs. In both of them, you have to dissect around the bladder in the tap. It’s more blind. I’m using that in quotes, more blind than in tap repair. So tap repair T e p is more blind than tap T A P P mostly because a lot of people use the balloon and the balloon dissection alone can injure the bladder. It’s almost always never a problem if you know your anatomy. And the only major risk is if someone’s had bladder surgery such as a prostatectomy that causes adhesions and sometimes thinning of the bladder in the area of the adhesion. And then if you tug on it, you can pop it or tear it. Fortunately, most bladder injuries are very treatable. They can be treated at the time that’s identified and does not necessarily complicate things as much as you would think. The bladder is very forgiving structure. Fortunately, unlike the pancreas, which we respect the pancreas for sure.
Speaker 2 (00:50:16):
Okay. Is it true that loss of haptic feedback and robotic surgery can be compensated in order to prevent unintentional tissues organ image? Yes, that is true. Those of us that do robotic surgery understand there is zero haptic feedback. In other words, you can press on something and not even know you were pressing on it. However, which means that if you poke a loop of intestine and didn’t know you poked it, you could cause a hole and never even know. And that’s one of the risks with robotic surgery. What you learn to do is don’t move those instruments unless you’re seeing them in your view. And if you’re seeing them in your view, you can see how the instrument distorts. If you press against the bone, you’ll see the instrument kind of push away. That’s somewhat haptic feedback, but it’s really a visual feedback. It’s not haptic by definition. And so we learn as robotic surgeons to get a lot of, the visual cues specifically from what we see, not to do any operations outside of our field of view because you can’t see what you’re touching outside that field of view. And then that really compensates for the visual, the haptic feedback that you’ve lost. There are companies looking at making haptic feedback. Even intuitive surgical has dabbled and it to date, no one’s been able to come up with haptic feedback. That’s good enough. And so we’ve just so far learned to just adapt to that.
Speaker 2 (00:51:55):
Can repeated or prolonged anesthesia increase your risk of future neurodegenerative disorders? Man, that’s a good question. So there’s some studies on that. I’m not up to date with like the most newest studies in general, anesthesia can kill some brain cells and we see that many people that undergo anesthesia that are older make have some changes in their memory, et cetera. It’s not common. It’s oftentimes related to blood flow and other things related to the surgery, not necessarily anesthesia itself, but to actually increase your risk of neurodegenerative disorders like let’s say Alzheimer’s or something that I’ve never seen or heard of. So I’m not sure that that’s true. I would have to defer to any of you if you know of you guys know of any of that data. If adhesions tend to lessen with time, why can they cause an obstruction decades from surgery? That’s a really smart question.
Speaker 2 (00:53:08):
So there is some studies done population based in Europe. I think it’s the Denmark population study, which looked at patients up to 10 years after their hernia repair for ventral hernias with Mesh and found that a decade down the line they’re going to have a fairly significant incidence of adhesions, obstructions, Mesh infections and so on. So the question is, if you get less scar tissue over time, why do you get a higher risk of having obstructions and so on over time? Well, I don’t know the answer to that. I think the right answer is that obstructions and so on do not necessarily occur because the entire area is adhesed. In fact, it doesn’t occur when the entire area is ahesed. It occurs when one area is adhesives and then all the rest of the area, for example, that’s now normal and no longer scarred will then wrap around the one last adhesion that’s left. So I think that’s the reason why.
Speaker 2 (00:54:14):
All right. What are the causes of abdominal pain in Asia syndrome patients? So ASIA syndrome stands for autoimmune or autoinflammatory syndrome induced by adjuvants. It talks about syndromes. We see some of it’s called breast implant illness. We have Mesh implant illness. We have a whole slew of other implants like hips and stone that you can react to. And it’s a systemic reaction to these meshes that causes weird things like headaches, chronic fatigue, dizziness, insomnia, joint pains and swelling, numbness and tingling in the fingers and toes, weight loss, hair loss, ringing in the ear, double vision, weird rashes and so on. So these are people that were totally normal. And then after they get an implant, they start getting a fraction of those symptoms as a syndrome. Abdominal pain is not a common one. Abdominal pain is not usually a syndrome of Asia syndrome. Bloating can be, but I have not seen abdominal pain as a cause of Asia syndrome. It’s usually due to more of a mechanical problem. What is meant by core and form Mesh?
Speaker 2 (00:55:40):
I don’t know what core and form Mesh is. I know some meshes are referred to as core Mesh or form Mesh. That’s just the name that the company has addressed it, but I have not heard of core and form Mesh. If anyone else knows the answer to that, maybe you can help. Is it true that when undergoing surgery for pre peritoneal Mesh removal, the peritoneum is covered, that is covered by the Mesh is sacrificed? Yes, that is true. So peritoneum is very thin. It’s like, I don’t even know how many cell layers, but it’s very thin and the Mesh is a hundred percent stuck to the peritoneum if it’s placed in abdomen and in removing it, a hundred percent of the area where the peritoneum is involved will be removed with the Mesh, which is okay because peritoneum grows back. So even if you cut out peritoneum, it will grow back within days to weeks. So that’s not really one of the things that we worry about. We don’t care if peritoneum gets stripped in any way. In fact, I tend to strip the peritoneum when I do any Intraperitoneal Mesh placement to allow the Mesh not to stick to peritoneum, but to stick to the muscle and the fascia, and then the peritoneum will grow over the Mesh and be a nicer repair.
Speaker 2 (00:57:07):
Yeah, I’m sorry, I don’t know what corn form Mesh is. If you message me later about where you’ve heard about Core and form Mesh, I’m happy to figure that out for you. Other than avoiding damage to nearby organs and delicate structures, what is the most technically difficult part of Mesh removal? I would like to say that every time I do revisional surgery, I want to make sure that the patient has a good outcome in recovery. And I feel that good pain control is multifactorial and how I handle the tissues is very much part of that multimodal pain control. So as a surgeon, if you go in there and you’re like, ah, you’re pushing and shoving and poking and pulling and tearing tissues, that patient will hate you. You’ll be bruised, you’ll be really swollen and so on. However, if you take your day little instruments and you move things around and you try not to overstretch or over push anything, then the tissue will be less swollen and you’ll be less bruised after surgery and therefore you’ll have less pain.
Speaker 2 (00:58:22):
So after any revisional surgery, I feel like it’s so important not only to be technically proficient and carefully removing the Mesh, for example, off of the vessels, the nerves, those are the top two, the vessels and the nerves, and then also the bowel and the bladder and then the muscles and the fascia. But I think also it’s super important to do all that while being very gentle on all of the tissue. I actually prefer to do a lot of, my Mesh removal surgery, not under general anesthesia. For that very reason, I feel that if the patient is placed under IV sedation, then that forces me to be even more delicate because a patient somewhat, they’re not awake, but their body’s like not fully paralyzed from the medications they give. And so I will be much more delicate in my procedure by force,
Speaker 4 (00:59:21):
And so the patient will have a better outcome. I love it. I love it when patients say, oh, the recovery from this revisional surgery was so much better than my first surgery. I mean, I don’t love it because I wish they had bad outcome before. No, I love the fact that even though my surgery was revisional, so technically the recovery should be worse, more swelling, more bruising, and worse than the first surgery, which was virgin, virgin area. It means that I was doing well in my technique, in being as gentle with the tissue that’s possible and really getting it to the point where the patient has a really good outcome and basically, don’t hate me, don’t hate me, because you don’t want to inflict pain on patients. And when they’re recovering much better with less swelling and bruising than the original surgery, that’s like feels great because that kind of tells you that what you did was, so the time has come everybody. Thanks for joining me. Oh, here it is. Surgeon noted, housed, housed six by 10 core and four Mesh when he changed colostomy to ilio and remove the rectum.
Speaker 4 (01:00:47):
Oh, that’s okay. So just to quickly answer this before I leave you all, that’s Endoform core Endoform Mesh. It’s a specific brand of, I believe, absorbable Mesh. And it has to do with him or her dictating the opera report and not fixing the typo in the opera report after it was done. So that’s endo form. Just look it up on Google. Alrighty, on that note, it was a pleasure as always, thank you guys. I’m going to run to surgery right now, right after this. So hope you all have a good evening. I’m going to go to the operating room and help a patient, and I will see you again next week. Bye-bye.
