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Speaker 1 (00:00:01):
Hi. Hi. Welcome everyone. Today is Tuesday. Welcome to Hernia Talk Live q and a. We’re here with you every Tuesday. My name is Dr. Shirin Towfigh. I’m your hernia and laparoscopic surgery specialist. We’re live on Facebook at Dr. Towfigh and on Zoom, and we’ll make sure that all of these videos from my sessions are available to you on my YouTube channel as well as on Twitter and Instagram at Hernia doc. So let me take some time today to me and so I can share with you some of what I’m learning from my patients. I actually had a patient who I’m hoping to bring on as a guest. Her name is Martine Elu. She’s an author and she wrote this amazing book on how to be a patient advocate. And she was my patient for a long time ago. She asked me to write the forward for her book, and I’ve given her book as gifts during Christmas multiple times because I just think it’s an amazing book. So the purpose of today’s hernia talk is also to talk about how you can be your own best advocate, and I hope to make a whole session about it with patients coming up soon. But let me just give you my couple hints about what I’m thinking. So patients come to me and I have a handful of patients that come to me that I’m the first surgeon they’ve seen. They’re like, I have a hernia.
Speaker 1 (00:01:40):
I did my research. You seem to fix a lot of hernia complications. So you sound like you’re the best person for my hernia parent even though I don’t have a complication. Okay, that makes sense. That’s actually really insightful. I’m very impressed by patients that go straight to the expert as their first choice. Most patients don’t do that. Most patients go to someone tells ’em they have a hernia, they go to their medical doctor, the doctor says go to so-and-so, or they end up in the emergency room and they have surgery by a local surgeon. And then either they have a pain or a recurrence or a Mesh infection or chronic meshoma or something that causes some complication. And then most often they go back to the same surgeon and the surgeon addresses that complication and for whatever reason that may or may not work out. And then they eventually start doing their search online and they reach out to me or other of my colleagues that are hernia specialists and we handle the problem.
Speaker 1 (00:02:48):
So we’re not usually the first surgery, we’re number 2, 3, 4, 5, 7, 9, whatever number surgery. So we love what we do. Those of us, there’s very few of us in the United States that choose to be that revisional surgeon. We really enjoy doing it because that’s kind of what makes us tick. But we often don’t get the first simple patient. If I get a young male that has a small hernia, I mean it’s the easiest consultation. I get really excited actually, because not very often that I get to talk about just routine consent for a regular hernia. So then the question is not just for hernia surgeons, but in general, what kind of patient doctor should you be choosing? And I’m like to bring this up because let me see, sharing is not working here. What I want to share with you some of these questions that I hope you all can kind of understand and enjoy.
Speaker 1 (00:04:00):
So that is how do you choose what kind of doctor is best? And if you do choose that, how do you know that’s the right doctor? So let me share my screen here with those of you that are watching. So for example, what kind of doctor is the best doctor? I used to think that whoever wrote the book or whoever is the chairman, for example, of the department, or the head of the university section is the best. That’s when I was a resident and I thought, oh, my chairman must be really good at what he does or she does, and that’s why I should be going to referring to that person. And as a resident training, I thought that was the right answer. I have changed my mind. I no longer believe the best doctor is the most famous doctor or the most published doctor or the head of their department because oftentimes they may be, let’s say, a good surgeon even though that’s not necessarily even true, but they’re not necessarily the best overall doctor.
Speaker 1 (00:05:13):
So, I’ve now changed all my doctors. All the doctors that I go to or my family goes to, they are the ones that listen, they’re available to you, they answer emails and return phone calls. They have a group of other doctors that they know and trust that they can refer to me. And really it’s a very different way of thinking. And now when patients ask me, oh, which plastic surgeon should I choose? Or which there’s some really good plastic surgeon around us, for example, but some of them are just horrible bedside and are just not good people to interact with, even though their work may be good. So sometimes I feel that that’s just not the right answer and I’d rather be seen, for example, by an endocrinologist that cares and thinks and doesn’t treat you like just another number and answers your questions and is very, how’s that camaraderie?
Speaker 1 (00:06:20):
And I feel the same is true to for the doctors that I refer to. So I don’t believe that you should necessarily go to the top doctor that is the most famous for their publishings or their research or their, they’re ahead of a department. I feel like there are situations where that would be the best overall doctor, but it’s not necessarily the case. And so how can you tell if you chose the right doctor? So number one, you need to be under the care of a doctor that is themself like an embodiment of what you desire and how you to be treated. For example, some people like very touchy-feely and very kind doctors officer offices that are very not very traditional. They’re kind of more warm and others like that. Very kind of rigid structure. So it depends on your personality and what you like the best.
Speaker 1 (00:07:25):
Some people really don’t do well with doctors that are tough and tell it to you like it is, and others love that. So you have to make sure that you’re comfortable with your doctor. If you have a doctor, where’s your medical doctor? Your internist friendly doctor, your gynecologist, your pain management doctor. If you have a doctor where you don’t enjoy going to them, they don’t respond to your needs, they don’t answer your phone calls. You need to change doctors. That is not an appropriate relationship because you are seeking care. And it’s really, I feel like that whole scenario where you are the whole scenario where there’s that hierarchy where you can’t question the doctor and you can’t ever touch or speak with a doctor and there’s all these layers and that you must just do exactly what the doctor says. I feel like in our generation currently that’s out the door. Really. You need a doctor that’s a human being that’s personable and can meet your needs. And I must say, I’ve said this multiple times in the United States, we are very privileged not to have a socialized medicine situation, which means if you don’t like your doctor, you can just change doctors. It’s not like you’re assigned a doctorate. Even people in managed care, Kaiser
Speaker 2 (00:08:54):
Permanente, other HMOs, sorry, Medicaid or Medicare, there are a wide variety of doctors that provide care within those systems and you should really choose to find the right one for your needs because it makes such a difference when you have a doctor that is really there and cares for you and helps answer your questions and reaches out to others. In fact, when we have a handful of doctors that refer to us regularly and there’s this one doctor who is so amazing female doctor, she’s just so on top of things. She follows up with her patients, she follows up with me almost like a concierge doctor, but she’s not a concierge doctor. It’s just we love it any, and so anytime any patient comes to us and is wondering who they should go to, I say go to her because she really does epitomize the ultimate point of being a doctor.
Speaker 2 (00:10:07):
So on that note, which one is better? Male or female? I would like to know your answer to that if you guys can tell me if you prefer male or female doctors. So it used to be that people wanted a male doctor because they felt the male doctors are more commanding and are more likely to know their information and treat you correctly. That’s kind of 30, 40, 50 years ago that was the thing. But now we have more female doctors and very interestingly, both in medicine and in surgery, it’s been proven actually scientifically shown that women spend women doctors, whether you’re a specialist or non-specialist, spend more time with the patient, have better outcomes, less complications, less hospitalization rates and so on. So it’s pretty amazing. And I do see that many of you’re writing in and yeah, many of you believe that you prefer female doctors.
Speaker 2 (00:11:13):
I feel like there’s enough data to support that as a population, at least in the United States, female doctors tend to give higher level care than male doctors. That said, I’m sure there are a lot of bad female doctors out there and excellent male doctors. So it is important that it’s be somewhat gender neutral as an individual, but as a population, there’s a couple studies, not just one that has shown that patients are happier, get better care, spend more time, and have lower complications and adverse events with female doctors. So I’m just going by the evidence. I’m not saying one thing over, don’t get me in trouble. I’m not saying one is better than the other.
Speaker 2 (00:12:05):
In fact, my doctors, half of them are male, half are female. So I just go for whoever’s the best. So the other point was this whole, should we go to the most famous doctor? So is it better to go to a large university or a small community hospital for your care? I believe it’s very dependent on what you need. For sure, for sure. If you have a rare problem, you need to go to a large university to get that treated. It’s a ref, it’s what we call tertiary care or kind of highly specialized care, the plate. If you need cancer, really you should be going to just a handful. If you have a very rare cancer, there’s only a handful of centers in the United States that you can go to for hernia surgery. There’s only a handful of us that do what we do on an exclusive basis.
Speaker 2 (00:13:00):
So it fits kind of that extreme. That’s rare or complicated or you have special circumstances. It really does benefit you to put your life aside and go seek care with the top specialist. And often that’s part of a large university setting. Very often that’s the situation because they’re the only ones that can have a team approach with lots of resources dedicated to a very rare problem. However, a small community hospital may very well provide you with adequate care for the majority of your needs. If you have appendicitis or anything emergency, the local hospital has it. If you broke your ankle, you know, go to your local hospital. If you want to deliver your baby, you go to your local hospital, you often don’t need specialty care for a lot of, those things. So there’s a need for the large university care, but not for everything. So for example, I live in Los Angeles, I have major universities.
Speaker 2 (00:14:04):
I have U C L A, USC, I have Cedars Sinai, huge hospital. We also have small hospitals. So if I have, let’s say a small cut and I just need a little stitch, I’m not going to go sit in a major university hospital emergency room for 12 hours to get my cut. I would go to a small university, or sorry, small community hospital and have them or emergency room and have them fix my cut. But if I’m having some complicated need for surgery, then I would definitely go to a larger university setting. So one comment somebody made, which is kind of cute, which is regarding the different sexes, both male and female, for as doctors, I’ve had both work on my initial surgery. The male general surgeon wrote me off with anxiety after complications arose. And the female plastic surgeon tried to help at first, but also wrote me off with anxiety.
Speaker 2 (00:15:12):
So oh for two, both had bad bedside manner but seemed super confident. I should have trusted my instinct. So surgeons are super confident. We’re kind of trained that way. We have a very militaristic training. And so there’s a saying that surgeons are, what’s a saying, sometimes wrong and never in doubt. So it just means that we’re always super confident about what we say and even if we’re wrong, we kind of won’t really admit we’re wrong. We’ll just kind confidently change the subject of the time. So my point is that unfortunately surgeons in general tend to be overly confident and many of us go into surgery because we don’t want that very long-term relationship with patients that internal medicine doctors have. We’re kind of cut and dry, fast, fast, fast. And whenever you see a patient that has a bit more need, usually emotional need, most surgeons, that’s not them.
Speaker 2 (00:16:27):
It’s not why they went into surgery. And yet that’s what you need. If you’ve had a complication, you need that surgeon that is empathetic and sympathetic at the same time and we’ll spend that time with you. So there’s a handful of us out there that do that. And I’m sorry that as we’re all humans, there’s a lot of us that are really uncomfortable with our own emotions and therefore the emotions of our patients. And many of them tend to be surgeons, they go into surgery, they tend not to go into internal medicine. It’s just what it is. It’s crazy. I know, but just I always check it up to we’re all humans and therefore fallible.
Speaker 2 (00:17:15):
Yeah, we already discussed this. Is it better to go to a doctor in a large public practice or a small private practice? So I would consider myself a small private practice and I love what I do because since I am my own boss, I can see a patient for one hour, two hours, however long I want, I can block time off for them. It can spill into another patient’s appointment and they’ll just stop my appointment, see the other patient come back instead of saying, we’re done, go. So I feel like when you are in a small private practice, if you can provide specialty care in that setting, it’s the most ideal because you’re not bound by the principles and the dogma of a larger institution. I have worked in a large public practice as a county hospital, largest county hospital in the United States, LA county, Los Angeles County. And man, we gave really good care, but we could not spend much time with the patients. Our clinic would see 60 people, 80 people in one day. That’s just not, and it was every clinic day, that’s just not feasible for patients that are complicated or have complications. It was mostly kind of just very fast routine surgery and we didn’t really have the ability to focus on our niche, which would be, let’s say complicated hernias.
Speaker 2 (00:18:48):
Oh, here’s a nice comment. It does not seem that the general surgeons understand hernias that well. That’s very true. Very, very true. After my emergency surgery, I was informed on aftercare and what would help me to avoid getting more hernias. I feel the more information needs to be out there, what you provide to those of us that have complications. Thank you. Finally, I have an appointment this week with a specialist, but I’m being told that it will be a 20 minute appointment. So usually 20 minute appointments I feel are inadequate for a complicated situation. I set aside an hour and there are patients that need more than my one hour because they come in with a chart, this big 20 images and it would be unfair to not go through those carefully usually, however, usually if you are in a situation where the surgeon or the doctor is part of an institution is really hard for that doctor to set aside time, like an hour for a patient unless they kind of plan in advance because they often are not really in control of their schedule.
Speaker 2 (00:20:03):
So when I was at the county at LA County General Hospital, I had zero control over the clinics. I just showed up to clinic and I saw whoever came to the door. That was a county way and the patients many times waited hours just to be seen and they were very grateful to get care, but we really, really weren’t getting specialty care. It was mostly just general surgery. And then I kind of broke out in my niche in hernia surgery and I would do the hernia complications. My next job, which was at major community hospital, I was an employed surgeon and they wanted me for what I was doing, but the people that ran the office, the front desk did not report to me. They had their own boss and I didn’t really have anyone in the report. I showed up to the office, but the clinic was, let’s say I’m going to make this up.
Speaker 2 (00:20:59):
Let’s say I was in clinic on Mondays and Fridays, but then Tuesday, Wednesday, Thursday would be other doctors or other surgeons. So you shared this kind of group practice and there were other doctors at the same time that you were there. And so the people that ran the front desk had no allegiance to any of us individual surgeons, number one. And the people that made the appointment was a whole different answering service. It was like a big community practice. So my point is in the private practice, I 100% have control over who I see when I see how much time I devote to those people, I have staff that only reports to me, that staff understands now over decades of working with me that certain patient may need more time and they’ll block off that time because they care about the whole practice and the patients involved in it. And whenever you’re part of an institution, it’s really hard to get that kind of personalized care. It really is and I love it, but it’s really hard to have that happen everywhere.
Speaker 2 (00:22:15):
Another comment, I love that you and a handful of other doctors dedicate time in a virtual appointments also. Yes. So I’ve always offered what I call online consultation where you sent me all the information you have, I’ll go through all of it, I’ll review all your imaging and I will email you my thoughts and a lot of times. It goes back and forth emails after that, but it’s not really a doctor-patient relationship. You can be from anywhere in the world and send me that information and you do it through my office. I’ve always offered that because I knew that the majority of patients cannot physically fly in to see me if they choose to see me to fly in and see me as difficult. And then during the pandemic with the coronavirus, it’s even more difficult. However, because of the advent of the pandemic, insurance companies are now allowing you to see patients virtually in your own state so that you can treat them without them having to drive in or fly in to see you.
Speaker 2 (00:23:19):
And that’s been a huge help and I hope that that continues because it really has streamlined care for virtual appointments. So I really like that. Next comment, why isn’t being Mesh injured considered a disability? One would think it is common knowledge. Yeah, it is not accepted as common knowledge, but if you’re talking about disability from a legal standpoint and you want to apply for disability, I don’t see why you would have any problems making your case if you could prove all the different aspects by which you are disabled. So I have not seen anyone that’s been denied disability because it was hernia related.
Speaker 2 (00:24:03):
All right. I have some really insightful questions that were sent in guys, so well let’s go through it. Regarding hernia surgeon, why is a specialized hernia surgeon so important? And I didn’t make these up, these were sent in to me. Why is a specialized hernia surgeon so important? Okay, I’ll just start by saying that every general surgeon that graduates from a residency should be able to perform a hernia surgery. It is part of our training, it is part of our oral boards, our written boards, our board certification. You should be able to repair it. Now, as with any operation, a specialist should be able to perform it better than a non-specialist. That could be true for heart surgery, pancreatic surgery, liver transplant. If you go to someone that does it for a living and does a lot of it for a living, you’re more likely to have a better outcome than if you go to a generalist that dabbles in that specialty.
Speaker 2 (00:25:05):
And that has been, that’s proof proven lower hospitalization rate, lower complication rate, better outcomes when any procedure is performed by a specialist as opposed to non-specialist. And the true same must be true for hernia surgery as well. And I feel that the reason for it is we see all the complications, you learn, you learn. It’s almost like forensics. It’s like forensically. You get to figure out why did this go wrong? Did they choose the wrong Mesh? Did they choose the wrong technique? What did they do to cause this problem? And oh, by the way, let’s make sure that I learned from this myself and not repeat it and do it over again. So that’s kind of the reason why I feel a special specialist even in hernia surgery are super important and we tend to have better outcomes. And so the next question is what are the most common mistakes made by general surgeons that you have to fix?
Speaker 2 (00:26:08):
This is a great question. I’ll just tell you today, today’s office visit. So I had a bunch of patients today, most common mistakes made by general surgeons that you have to fix. First of all for ventral hernias. So that’s umbilical incisional. Any abdominal wall hernia, not groin, the most common mistake is they don’t close the hole. So you, it’s best that you close the hole and then put your Mesh. They don’t close the hole. The second most common mistake is they don’t use a wide enough Mesh coverage. So smaller is actually not better. So that, no, the third reason is the third most common sake is they make it too tight. So just like an outfit, if I give you a shirt and too tight, you’re going to pop some buttons. The same thing will happen to a hernia. If I have you wear a shirt, if I have you undergo a hernia repair that’s too tight, you’ll pop that hernia, you’re going to get a recurrence.
Speaker 2 (00:27:08):
So those are the top three reasons for ventral hernias. For inguinal hernias, I feel number one, the surgical technique chosen is wrong. They use a Mesh plug and patch. We don’t really like to do three dimensional meshes anymore. So that’s one mistake. The second mistake is choosing the wrong type of Mesh for that patient. So for example, they put a heavyweight Mesh in a thin female or they do a tissue repair on a morbidly obese male that’s a coffer and a smoker. So those are the wrong match. You’re matching the wrong operation of the wrong patient. And the third most common problem is laparoscopically and open. They use the wrong size Mesh and wherever they put the Mesh, it’s not perfectly laid flat or they make it too tight. So again, too tight of a repair is a problem and I feel that surgeons kind of forget that if you’re a tailor or a carpenter, if you make things too tight, it doesn’t work, it’ll tear or it’ll break.
Speaker 2 (00:28:14):
But for some reason people forget about that when they operate. So those are kind of the most common situations that I repair. So going back to today’s, so today I saw a lady who’s had two hernia repairs already and I don’t know what they did because the operative report is still pending. She wasn’t able to bring it with her, but the hernia hole was open and the Mesh had just completely fallen into the hole. So she has bulging and she has pain and the colon is stuck to the Mesh because they did an Intraperitoneal Onlay Mesh or IPOM. So now she also has chronic constipation and guess what? We know if you have chronic constipation and you have a hernia, that hernia’s going to get bigger or more symptomatic or pop. So of course now she has five hernias and I’m going to fix four of them for her.
Speaker 2 (00:29:08):
The other patient is a chronic pain patient and that is one who had a Mesh plug-in patch. He had a direct hernia, which means it’s wider than a regular indirect hernia. So if you want to use a plug-in patch, which I don’t recommend, but if a surgeon chooses a plug-in patch, you have to choose a right plug. And according to the obtuator report, they use a small plug, what did I say earlier? A smaller is not better. So the plug comes in a small, medium, large, extra large for direct hernia. The correct size is the extra large. What he put was a small. So now here’s an athletic eye with a piece of Mesh in him, which bothers him to begin with. The plug and his hernia is not appropriately fixed because that plug is not enough to plug a large wide direct defect. And so that combination has him in a lot of pain every single day.
Speaker 2 (00:30:04):
He doesn’t sleep very well because even tossing and turning wakes him up because of the pain. Sitting just in my office bothers him. He’s athletic, but every time he exercises he’s reminded about his pain. He can’t wear slacks or pants or jeans because of the pressure on the groin area. He has to always wear athletic clothing. So when he has to be in meetings, it’s kind of very uncomfortable for him because it’s not appropriate to wear short exercise shorts or sweatpants to a business meeting and it just really screws up his life and he kept going to other doctors, oh, this is another one. What’s most common is once there is a complication, especially for inguinal hernia, they go to a general surgeon and the general surgeon says one of two things, it’s your nerve, let me block it. Or it’s not the Mesh, go to a pain doctor.
Speaker 2 (00:31:01):
Both of those are incorrect answers. First of all, do not just punt the patient over to a pain management doctor. I never do that. If the patient would benefit from seeing a patient management specialist, great, I’ll have you coordinate. I’ll coordinate care with that patient pain management doctor, but I say, oh, stay away for me, not my problem. Go to pain management. Because pain management specialists know their specialty and they usually just know spine really well, maybe some orthopedic injuries, but they don’t know hernia, they don’t know Mesh. And often what happens is the patients get thrown into this kind of cycle of pain doctors giving them pain medication and doing blocks and nerve blocks and then eventually getting these spinal stimulators and ablations, what all they needed was a hernia repair redone or their Mesh removed. But if you don’t have that collaboration between a pain doctor and the surgeon, you don’t end up getting the care you need. So this patient that I was talking to you about had multiple nerve blocks over years. Of course none of them really worked, but they’re like, well, sucks to be you. If it’s not nerve blocked, doesn’t help you, then we really can’t help you. And really all he needs is his plug to be removed and the hernia repaired. So I’m planning on doing that for him, but that’s kind of where we are.
Speaker 2 (00:32:32):
Okay, good question. How does sitting and wearing dress pants rather than sweatpants aggravate groin pain? So if you have a very sensitive groin area for multiple reasons, either you have nerve damage or you have a bulky Mesh, what we call meshoma, which means a ball of Mesh, sometimes people who undergo a plug and patch repair, that plug really functions as a ball. Then anything constrictive over the lower abdomen feels horrible. So the classic question is, can you wear jeans? Because jeans are always a little stiff and they’re like, oh no, I can’t do jeans. It has to be sweats. I’m in yoga pants. Women say I’m in yoga pants all the time. Men say I have men, I get home, I wear sweatpants. Or they buy really baggy pants because they can’t wear a belt to a conforming belt and they can’t really wear regular pants because the tension around the lower abdomen is too much for them and it, it’s too painful by the way, if you have that, you either have a hernia that’s recurred or you have a meshoma or you have both. That’s just a little tidbit. Okay.
Speaker 2 (00:33:52):
What are the most valuable skills of a surgeon that can be assessed by a patient before and after surgery? Okay, I know you’re looking for surgical skills, but I’m going to tell you it should be person skills because a really caring surgeon is super necessary even before being a very skilled surgeon, I think I don’t like to go to doctors or refer to doctors are just not good people, but are really good with what they do. So if you’re talking about surgical skills, I would say that surgeons that have a very light touch are really good. And that means by light touch. I mean for example, I have a strong grip when I shake hands, but that’s on purpose because I feel like that I don’t like that lamp handshake. I would just kind of raised that way, but I have a very light touch.
Speaker 2 (00:34:57):
I’m constantly dropping my phone cause that’ll hold it very strongly. And so it’s always has a case and I feel that when I’m, because in surgery I’m really gentle with the tissues and I’ve learned to do that because I’ve noticed that the more gentle I am on the tissues, the less pain and swelling and bruising the patient has after surgery. So that’s just the way that I was trained. So kind of see how dingy they are and the way they handle things. If they’re, I don’t know, I feel like the more obsessive compulsive the surgeon sometimes the better If they’re like everything’s clean and straight in their office versus a surgeon that has files everywhere and their jacket is all crooked and their hair is disheveled, maybe they’re not the best surgeon either. I don’t know. I don’t want to make up stuff, but I feel that surgeons that are clean cut and their offices are clean and their nails are clean and their hair is well kept and they’re just overall well kept tend to also treat their wounds and their surgery in a very respectful way as well.
Speaker 2 (00:36:15):
So I hope that’s a nice little clue. Going back to that other question that was asked about the pants, what about sitting, how does that aggravate groin pain? So sitting increases abdominal pressure. So if you have a hernia that’s recurred or you have a meshoma or balled up Mesh, oftentimes sitting and bending increases abdominal pressure and therefore increases pain from your hernia. So that’s what the whole kind of sitting a aggravating pain comes from. How does a patient determine the course of action when a surgeon and physical therapist provide different guidance? Oh, good question. It gets confusing and patients most definitely don’t want to do anything to jeopardize their health further. That’s a good question. Doctors say one thing, physical therapists say some other thing. It is really kind of hard to know which one’s correct because there are some really amazing physical therapists out there that are probably right and the doctor is wrong and there are super smart doctors out there and the physical therapist is not knowledgeable enough about a certain topic. So that’s a hard one. I would have to say go with your gut and follow both guidances and see which one works best for you. That’s a hard one to answer.
Speaker 2 (00:37:40):
Next question. Can these skills be nurtured by a surgeon who operates in a volume-based context? Yes. So I think what you mean by volume-based, so I don’t consider volume-based a negative thing. There are surgeons that are certainly volume-based practices. I am, I used to be volume based practice. I’ve chosen not to because my, what do you call it? My interest is in really rare diseases and difficult to diagnose problems and chronic pain and those patients really cannot be treated in a five to 10 minute or 20 minute interval and their operations tend to be long. So I prefer not to have a volume based practice, but certainly there tons of excellent surgeons that are volume based and the good ones are the ones that have a team that can fill in the blanks where they’re unavailable. So that great nurse practitioners, other surgeons in the practice that can meet the needs of writing notes and gathering all the paperwork and preoperative workup for the patient.
Speaker 2 (00:39:00):
Their surgeons are run that run multiple rooms. They operate two patients at one time and they have a team that starts one operation, they work there, then another team starts another operation. Once they’re done with their surgery, they go the next patient to have surgery and then this one, the first one is cleaned up and closed by a closing team. So there is that. What do I think about that? Well, I must say volume is good because, well, it’s potentially good. Volume is potentially good because if that means that you’re doing more and therefore getting really good at what you’re doing great. But if you’re a bad high volume surgeon, that’s horrible. If you’re just a high volume surgeon because all you do is take call everywhere and you’re always on call and just operate, operate, operate. You may be the jack of all trades are really master of done and that’s not a good thing I think especially if you’re looking for specialty care. So I don’t think volume is bad or good, it really depends on your knee. Next question, no pun intended, but I find that surgeons are dishonest and only care about money and won’t help you after surgery when you run into problems. Yeah, I don’t agree with that.
Speaker 2 (00:40:20):
I don’t agree that surgeons are dishonest or only care about money. I think there are people that are dishonest in every specialty, whether it’s healthcare or not, and there are people that are interested in making a lot of money. Certainly most of us would would’ve made more money if we didn’t go into medicine, believe it or not, because we come out with half a million dollars. I think the average is over half a million dollars in debt and you really don’t start working until you’re over 30, close to 35. So you would’ve made more money not doing all of that in your lifetime. So I know there’s a lot of that and if you have come across surgeons and doctors that gave you that impression, I’m very sorry and you really should not go to those doctors because most doctors are very, regardless of how their personality may be, and unfortunately I feel that surgeons tend not to have the best personalities compared to let’s say a pediatrician or a family doctor or even your local endocrinologist or orthopedic surgeon.
Speaker 2 (00:41:39):
I would say that if you are seeing people that are dishonest or are only in it for the money run, go see another doctor, you really should not be in that relationship with your doctor at all. And I feel very strongly about that because there are very few doctors that I know that are only in it for the money or are dishonest, very few, very, very few and just have to find the right doctor. That’s kind of why I’m spending this time here because I feel that so many people feel at a loss and they seem like overwhelmed by the fact that they’re not getting an answer by the doctor that they’re going to, they feel like they don’t have any other options and I’m here to tell you, you own your own healthcare needs, you or your own best advocate, switch doctors. If you don’t like doctors, go get a second opinion or third opinion and take your own healthcare in your own hands.
Speaker 2 (00:42:44):
Next question. I say the same about engineering still paying loans after PhD. Yeah, education is not cheap in the United States. I must say though, let me tell you this. So there’s a trend towards building institutions that are kind of paid for and there’s a new medical school in Los Angeles that just opened. So when you’re a new medical school, you’re going to get tons of people to come, but you really don’t want to start on a bad footing. So you start small and you only accept like creme de la creme. So this medical school, first of all, it’s free only 50 students, everything is paid for. You get a stipend to live in Los Angeles, you get an Uber or Lyft card, so you don’t have to own a car or pay for gas to go from hospital to hospital or clinic to clinic. During your rotations, you get a free iPad, a free iPhone, I think a computer paid for just basically these kids are going through medical school, a new medical school.
Speaker 2 (00:43:55):
So there’s hiccups in that. I think they’re going to come out basically with no loans, which for those of you outside the United States, that’s probably normal. I think most of the world education is higher, education’s free or almost free. Whereas in the United States it’s super expensive, super expensive. Like I said, I think it’s a little over half a million dollars in debt when you come out of medical school. So yeah, how awesome would it be to do medicine and not have to worry about paying your bills and you can just focus and do whatever specialty you want to do because that’s what you enjoy. Okay, yes. Also, don’t forget of the excellent hernia nurses. Yes. So like my nurse Bell, she is probably the only, I want to say the only, she may not be the only, but I think she is the only hernia nurse specialist.
Speaker 2 (00:44:57):
There’s no one that knows hernias, no nurse that knows hernias like she does. She knows everything you need to know about hernias, hernia repairs, hernia complications, recovery, medications, outcomes, what to expect, et cetera. She is an amazing, amazing nurse and it makes a huge difference because oftentimes I go see my patients like, oh, nurse Bell already answered all the questions, my work is done. How crazy is that? I’m very blessed to have a great nurse. This is true. Thank you for that comment. Let’s see, next question. Hi doctor. If you have a small fat filled umbilical hernia on the right side, is it possible to experience pain on the left side from that hernia or would that be unrelated? Also, does hernia pain typically decrease when you lay flat? Classically, classically, classically, yes, hernia pain goes away or re is best when you are lying flat.
Speaker 2 (00:45:56):
That is classically the case. So yes, that’s very common, number one. Number two, belly buttons. Hernias are usually in the middle or to the left or to the right, but their pain could be to the left of that or to the right of that. So yes, what you said is correct. There’s also another question that was submitted which I’d like to read and answer and it’s, it’s an unfortunate situation, but this patient she wrote I have, or maybe he, I don’t remember. I have a 7.7 centimeter incisional hernia, a 5.5 centimeter umbilical hernia below the and another umbilical five centimeters. So these are usually when we talk about, usually when we talk about size of hernias, we talk about width. We don’t talk about length, we talk about width. The length we don’t care about as much. It’s the width. So sounds like maximum 7.7 centimeter hernia and two other hernias, five and five and a half centimeters wide.
Speaker 2 (00:46:59):
So about half my belly is open, I’m unable to withstand surgery. What kind of life can I live like this? Okay, first of all, a very difficult life I must say because these are fairly large hernias, which means that most of your intestinal and abdominal contents are either through it or will potentially be through it. This is what we call loss of domain. So over time, because it’s easier to go through those holes and out towards your skin than stay inside a tight belly, these hernias will become bigger and bigger and bigger to the point where it’s what we call giant hernia and it really dramatically affects your quality of life. Walking becomes difficult, sitting becomes difficult, bending becomes difficult. Moving around in bed is difficult. People tend not to leave their house because their abdomen looks so abnormal. The best solution is of course, surgery.
Speaker 2 (00:48:03):
The next best solution is to make sure that all other risk factors are addressed. You should not be even forget obese, you shouldn’t even be overweight. You shouldn’t be normal weight. You should exercise and maintain the muscle strength. You should make sure your skin is kept healthy so that the skin doesn’t erode underneath those hernias. You make sure that you wear a binder to keep those intestines and other contents inside. Prevent them from pushing outside. Do not smoke nicotine, do not be constipated. If you are, make sure it’s treated so that you don’t strain in it and push these things even further out of the hole. Do not strain if you’re urinating or having enlarged prostate. If you have a chronic cough because you’re a smoker as meta, use marijuana or have acid reflux or C O P D aggressively treat that cough because you really can’t have surgery sounds like. And if you can’t, then you have to do the best that you can in treating every single other underlying problem so that you don’t get worse. It’s not a nice way to live. It’s a very difficult way to live and I don’t know why you say that surgery is not possible. Is it because you were so ill otherwise that your surgeons felt that you may die from surgery? If that’s the case, then really follow my advice and make sure every other risk factor with hernias is addressed by you. Next question.
Speaker 2 (00:49:42):
So I have a situation, the doctor was supposed to do exploratory surgery, in quotes, exploratory surgery to find out the cause of pain and only remove Mesh and nothing else. First of all, I don’t agree with that. We have so much technology now, both your story, your physical exam and imaging should provide you with enough information to have a plan and not just do exploratory surgery before you go into surgery. Let’s see, to find out the cause of pain and only removed Mesh and nothing else, and now the surgeon says I may have diastasis and wants to send me for a CAT scan and wants to charge me when I had the same pain and it wasn’t addressed with Mesh removal. Why are there so many unnecessary costs and runarounds and is a CAT scan the best to diagnose diastasis? And does diastasis cause chronic pain on one side of the rectus abdominus? Okay, so diastasis usually does not cause pain. CT scan is the best way to diagnose hernias, Mesh problems of the abdomen and diastasis.
Speaker 2 (00:50:50):
And why are you getting the runaround? Well, it sounds like your situation’s not clear cut. If it were, you wouldn’t need so many different attempts at figuring out what it is. So you are a puzzle and we have to figure out this puzzle. Not everyone can figure out a puzzle on one setting. They went in there sounds like with not much of a plan, I like to plan these a little bit more, but in going in there they removed Mesh. But if you still have pain, then maybe there’s a missed hernia. Maybe there’s adhesions that need to be addressed. Is there, is the repair too tight? Is your abdominal wall not even the issue and you have a back issue for example. These are all things to look into and there’s in my patients before they go to surgery, there’s a lot of workup. It’s not like they show up. I’m like, oh yeah, this is great. I’ll just fix you. No, they need CAT scans, MRIs, injections, nerve blocks, medications, various exercise modalities, all of these you’re trying to figure out what is going to help you.
Speaker 2 (00:52:00):
Okay, so what kind of exercise can you do with hernias to lose weight? Anything you want. There is no contraindication to any exercise you can do. Pull-ups, weightlifting, cycling, any sports, whatever that you can physically do, you should do. If you have a hernia, there is no evidence that any of these exercises make your hernia worse. In fact, people who exercise are less likely to have hernias. There are two exercises that we think do increase your abdominal pressure and those include squats and jumping, like trampoline type jumping or squats and jumping, kind of like CrossFit. That said, honestly, those are probably safe to do too. Probably it just does increase your abdominal pressure. Next question, what type of groin injuries are associated with the exercise gluteal bridge or pelvic bridge? Yeah, it depends on how you’re doing them. The gluteal bridge or pelvic bridge is intended to strengthen and engage your gluteus muscles and your abdomen needs to be engaged as part of it.
Speaker 2 (00:53:12):
You’re not supposed to overextend the pelvis so you can get rectus tears and less frequently add extra tears with those exercises. But usually it’s a rectus tear. I want to add that this was done by a so-called expert or we’re going back to the exploratory surgery. I want to add that this was done by a so-called expert, expert in exclamation points and then he says, I may have to live with the pain when meanwhile before surgery, he said he will help me to have better quality of life. A bunch of lies. It’s like they do one thing, ignore another, and then it’s a cycle and then I have to live with the pain. Anyway, the whole point was so that I don’t live with pain and I can live a normal life. They do not realize it’s hard to live with pain. Okay, first of all, you’re a hundred percent correct.
Speaker 2 (00:54:12):
Living with pain is horrible. Absolutely horrible. I’ll give you an example. I just got my booster shot for the COVID vaccine and I had this chronic, this fatigue as I was walking to my car one day later and it occurred to me that there are people that have this pain, this chronic fatigue their entire life. Absolutely crazy. Very, very potentially disabling. And I understand it. I totally get it. So in your situation with your expert surgeon, a, they may be self described as expert and not really experts. Lemme tell you the minute I open, I opened up my Beverly Hills hernia center, like 15 hernia centers opened up around me. It’s just marketing from almost every, there’s no real hernia expert around me except for one person, which is on the other side of town. So for these other 12 people around my block to have be hernia experts and have hernia centers, it’s purely for marketing.
Speaker 2 (00:55:22):
They’re just trying to gain the patient population. They’re not really experts, so they may be self-proclaimed expert. If they’re not, then they’re just not the right match for you. They haven’t figured out, they haven’t sat down to really figure out what’s wrong with you and they’re picking at straws. So instead of complaining about what’s happened to you, use that energy to find another surgeon and be patient and know that it’s a journey that no one can figure this out for you on the first go. Maybe they can, maybe they can’t. I’m happy to see you if you want.
Speaker 2 (00:55:56):
I do do zoom consults and if you’re in California, I can do zoom consults because I’m practicing California. But otherwise I can do online consults for you if you’re out of state and happy to figure it out for you, but do not give up. You really need to be your own best advocates. The whole purpose of this session, okay, going off the prior questions, are there any exercises to do or to avoid with thinning abdominal wall? No, absolutely not. It’s the same situation. Sorry, I had to add this to your response about back pain. Yes, I suffer from back pain as a result of the damage in the abdominal wall from surgery, but no doctor will tell me what injury was caused to my abdomen. It’s very frustrating when they don’t admit to anything. I found the surgeon from your talk show live actually. Yeah.
Speaker 2 (00:56:51):
So I think that surgeons that I bring on, my talks on my hernia talk are excellent and give great outcomes for their patients. But if it’s not working out for you, find another surgeon, go to another surgeon. I have my own fair share of patients that maybe are unhappy with the care that I give. I can’t please a hundred percent of my patients. But that said, you really should seek out another surgeon if this one doesn’t work for you to get you the care that you need and it’s all part of your course. If you lose abdominal fall function because you have a hernia, you’re going to lose your core stability. So you may get back pain and breathing is going to be difficult. You’ll be constipated your PE with pelvic floor issues. So it’s all related. Next question. Oh, I’ve got these other questions here.
Speaker 2 (00:57:47):
I’m a 33 year old female with a right angle or hernia pair three months ago. Okay, with more standing or bending or exercise. The bulge comes again, it’s hard to sometimes it’s hard sometimes and soft sometimes. My general surgeon can’t find anything on physical exam. We didn’t find anything on CT scan, but the bulge comes and goes, could this, what could be the reason? So bulges that come and go are either fluid or a hernia. So if you have fluid from your hernia pair, like a seroma, that should be seen on CT scan. If you ever hernia recurrence, it may or may not show on the CT scan because CT scan just has you live flat without any pushing. You need an ultrasound or an MRI to identify that better. So if you had your hernia repair three months ago, likelihood is it’s a good repair and that nothing happened to it. And you may have swelling or a seroma fluid collection from the hernia repair, which can happen and that usually goes away over time. However, if you have a hernia recurrence, a lot of your symptoms will also come about. And it’s usually painful after hernia repair to have her early hurry, recurrence, and then an MRI. I usually get an MRI in those situations and that my friend is the end of Hernia Talk. We had so many questions left. I feel like we only went through
Speaker 3 (00:59:20):
A handful, but this was fun. So I’m getting back on track with more guest speakers. We’re going to have some amazing guest surgeons and doctors coming up in the next several months by the end of the year. So I’m super excited about that and I have a great set of patience that I’m going to bring up. So you’re welcome. Thank you so much. I hope you enjoyed this. Does m I show scar tissue sometimes? Yes. I, I’m really excited that you all like this. I felt like some of you were engaged in today’s session on how to find the right doctor. I just can’t stress enough how important it is that your doctor matches your needs. One doctor who’s great for one patient may not be the best match for another patient. So on that note, thank you for choosing me as your hernia talk, doctor on hernia talk, live question, answer session. Go to my YouTube channel to watch this and past issues we’ve had over 75 I think so far. So I’m really excited about that. Thank you for following me on Facebook at Dr. Towfigh and on Twitter and Instagram at hernia doc and I will see you again next week. Bye everyone.
