Episode 74: When to Remove a Mesh | Hernia Talk Live Q&A

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Speaker 1 (00:00):

Hi everyone. It’s Dr. Towfigh. How are you doing? Welcome to Hernia Talk Live, my weekly question and answer session with all you all regarding all things hernia related. My name is Shirin Towfigh. I am a hernia and laparoscopic surgery specialist and many of you’re joining me on Facebook live at Dr. Towfigh. And thanks for those that are coming in on Zoom and for all of you that follow me on Twitter and Instagram at Hernia doc and watch all my fun videos and stories that I post. And also, I hope many of you also go on my YouTube channel. I really would like to have more of you watching and sharing on my channel because all of my almost 80, almost 80 Hernia Talk Live Q&A sessions are posted on YouTube. So welcome. I just want to let you know that I really enjoy doing these and I’m balancing clinical care and surgery and doing these hernia attack life sessions with you all.

Speaker 1 (01:12):

It really forces me to stop what I’m doing in my clinical practice to sit down and answer your questions. So I do enjoy it, which is why I continue to do it. And I get a lot of positive feedback from you all. And certain things that inspire me are either questions from you or things that I am doing on my kind of research side. So I thought that we can focus today’s session on when to remove Mesh. And the reason why this is a topic that I thought would be good for tonight is first of all, I already published a paper called Why We Remove Mesh, which is a very well sought out, sought out paper. We went through all the different reasons in my practice why we remove Mesh and whether it’s abdominal or pelvic. And about three-fourths of the time, oh, sorry, two-thirds of the time it’s it’s pelvic Mesh, so it’s either inguinal femoral obtuator hernias, and about two one-third of the time it’s abdominal wall Mesh is so ventral hernias and so on.

Speaker 1 (02:24):

And then in that paper we discussed why we remove it, what are the indications in retrospect, what are the different reasons why people came to us and they ended up having their Mesh removed. And for pelvic Mesh, the number one reason was pain. So people that end up having their inguinal hernia Mesh removed is often for pain and for abdominal wall Mesh, it’s not for pain, actually it’s for infection. So the number one reason for an abdominal wall Mesh to be removed is due to some type of infection, usually of the Mesh. Sometimes it’s erosion of the Mesh or visualization and so on. Now, understand that my practice is a little bit different than the average general surgeon. So don’t think like everyone’s running around having Mesh removals or that everyone is running around having chronic pain or infections of the Mesh. Not true, it’s the minority of the patients.

Speaker 1 (03:19):

Fortunately, and even in my practice, it’s not necessarily like I see all these Mesh infection patients, but I do see a fair number mostly because I’m specialized in those of us that are special specialty surgeons, we tend to kind of attract the rare problems. So that said, we’re also really good at doing those really difficult complex situations, which is why we enjoy what we’re doing. So as a result, I was asked to give a talk at the European Hernia Society meeting. So every year we have an American Hernia Society meeting that I go to and I’m very active as a part of, but I have all these amazing international hernia surgery colleagues and the European Hernia Society is very dear to me.

Speaker 1 (04:06):

Their meeting was canceled last year. It was supposed to be in Spain. I didn’t get to go to that one. The meeting prior to that was in Hamburg and that was just an amazing meeting. And if anyone’s ever been to Hamburg, it’s now one of my favorite towns. That’s a very posh and very beautiful city. And this year it’s in Denmark, in Copenhagen. So it starts this week, actually I’m supposed to have been, I was supposed to have been there this week, but because of the different travel restrictions and work related backups from COVID, decided not to physically attend the European Hernia Society meeting this year. But I am participating 3:00 AM two or 3:00 AM I’ll be up and giving my talks and answering questions live with all my colleagues that will be physically present in Copenhagen. So one of the talks I’m giving is called When to Remove Mesh, and I thought that I would kind of take some of my talk and bring those topics to you guys.

Speaker 1 (05:15):

And I know many of you have submitted questions as well. So we’ll go through all those as today and let’s see how it goes. All right. So really quickly, there’s four reasons why Mesh is removed or one is indicated for removal, pain, hernia, recurrent pain, infection, hernia recurrence and Mesh reaction. That’s as simple as I can make it. Everything else is a byproduct of that. So if you have pain that is due to the Mesh, like a meshoma, like a Mesh is balled up, or if you have a Mesh that’s infected, that for sure needs to be

Speaker 2 (05:56):

Removed. If you have a hernia recurrence and as part of the hernia repair, there’s older Mesh in the way, you may have to have that removed. And then lastly, there are patients that we see that are reacting to the meshes and those meshes need to be removed as well. So that’s kind of the four, infection, pain, hernia, recurrence and reaction. What are reasons, what are the times when we don’t remove Mesh? First of all, I don’t remove Mesh because patients come to me and say, I want my Mesh removed. That’s just not something that I do. I don’t think that that’s appropriate and we try not to do harm. So removing Mesh is implicating risks to the patient. And so we don’t do that and unfortunately a lot of surgeons, a lot of surgeons are seeing patients that are sent by either themselves, the patients are self-referred or a law firm, the patient’s been to a law lawyer and based on either their own research or what the law firm is recommending, they are being asked or want to, sorry, excuse me guys.

Speaker 2 (07:23):

I’m dealing with something over here are being asked to have the Mesh removed. So for example, a patient may do research and correctly or incorrectly know that their Mesh has been recalled, so they want their Mesh removed. To date, there has been no Mesh that has been recalled that requires removal. The reasons for recalling the Mesh were often due to packaging issues and some meshes were removed from the market, not necessarily recalled because their chance of tearing and therefore having a hernia recurrence was higher, but there’s no indication to go in there and just redo or undo that repair. So concern about a recalled Mesh is not an indication for removal. Another indication for removal seem to have been lawsuits. In fact, in the pelvic Mesh world for the vaginal motion, transvaginal motion, there have been a series of surgeons that were in cahoots with law firms that the law firms would sponsor care for the patient to go to a specific group of surgeons to have their Mesh removed, not necessarily indicated, and the patient was led to believe they had to have that done and they were severely named by this Mesh removal process.

Speaker 2 (08:52):

But in doing so, the value of their lawsuit increased. In other words, if you’re suing a company that’s selling a Mesh as part of a class action lawsuit, of which there are many and many of you’re aware of it, and we will discuss this in the future, by the way, it’s one of the topics that’s coming up, but if you’re part of a L class action lawsuit and you’re claiming that the match was defective or the company should have known that this would’ve caused pain, if you also had the Mesh removed, your value in that class action lawsuit is higher. And there have been surgeons that have collaborated with law firms to promote Mesh removal in patients for hernia, not for hernia Mesh, for pelvic and transvaginal meshes. And it was proven to be a nefarious financial decision by the surgeons and lawyers at the detriment of the patients.

Speaker 2 (10:02):

And guess what? Those surgeons are now in jail. So I think the lawyers are in jail too. I’m actually not sure, but I’m pretty confident that the surgeons were found to be guilty and therefore in jail. So that is not an indication to remove, just because you want the Mesh removed is not an indication to remove, to remove however much you think that that would be kind of a reason. So based on that, let’s go down to your questions. First one, I am a thin woman who has been having occasional nerve pain in addition to other issues since my Mesh insertion, since my laparoscopic bilateral inguinal hernia repair in 2018, the Mesh was used with a covidien progrip. How difficult is this Mesh to be removed? Is it more difficult? The Mesh is without micro hooks on the backside? Thank you very much. Great question.

Speaker 2 (11:01):

So actually the covidien progrip Mesh, which is now the Medtronic progrip Mesh, it’s a very good Mesh. The micro hooks are absorbed within matter of three weeks. It’s purely there to assist in the initial placement of the Mesh. It works really, really well. It’s kind of like Velcro. The micro hooks are really Velcro and they snap onto the muscle very nicely in terms of removal of the Mesh, it’s as easy to remove that as any other Mesh. It’s no easier and no more difficult. In general, Mesh removal is challenging and requires an excellent anatomy knowledge base. So if you do need that Mesh removed, first of all, it was already placed laparoscopically and therefore either laparoscopic or robotic. I use those terms interchangeably. The method of Mesh removal should be laparoscopic or robotic. Do not have anyone remove your laparoscopic Mesh in open fashion. You say you have occasional nerve pain.

Speaker 2 (12:15):

That is usually not an indication for Mesh removal. The question is what kind of nerve and what kind of pain and what can help it. So if it’s a specific nerve, a named nerve that we can identify as the cause of your pain, then that nerve can be blocked with a nerve block, which is an injection. And if the pain goes away, that’s all you may need is multiple nerve injections and maybe even ablation of the nerve. If the nerve is not at play, but you really have a hernia that’s recurred, but it feels like nerve pain, then what you really need is a hernia recurrence repair, which in some ways may need more Mesh actually not less Mesh or removal of that Mesh and replacing it with another Mesh to repair the hernia. So it really depends on what the true reason for that Mesh removal procedure or that is.

Speaker 2 (13:17):

The other question that was sent to me had to do with just Mesh removal in general, which is does Mesh always need to be removed and replaced at some point? So like hip replacements, they say Are knee replacements only last, let’s say 15 years, 20 years? You have to replace it after a while. Breast implants, they say after a certain mini year, I think after 20 years, 10 to 20 years, you should replace them because they start getting crunchy and not as pliable. They get cap, they get encapsulated. That is not true with Mesh. Mesh repair is considered a lifetime repair. There’s no plan to remove it, there’s no recommendation to remove it. It’s intended to be a lifetime repair without an actual expiration date. So that’s kind of the answer to that question. Let’s see who else we can help here. The other question that I get asked a lot is the timing of the Mesh.

Speaker 2 (14:25):

In other words, is it like if I remove, is it easier, easier to remove the Mesh now one or two years after surgery than 20 years from now? And the answer is no. There’s no difference in how difficult it may or may not be in removing Mesh. So patients can have their Mesh removed early or late and it’s just as easy and just as difficult to do whether it’s early or late. So that’s kind of something that we don’t really consider like a risk factor or there’s no time limit. Scar tissue is actually I important in that over time you do get scar tissue. So if you do get scar tissue over time it actually becomes less. So that does make surgery easier. However, what doesn’t make it easier is just the actual act of vest removal. I had some other questions sent to me earlier today.

Speaker 2 (15:25):

Let’s see if I can bring those up. Here it is. So next question is what are the risks of a redo open hernia pair if there’s already Mesh placed open? Okay, good question. So this is a patient that had a open Mesh removal, and then the question is, what’s the risk of a redo open? So first of all, if you have had an open inguinal hernia pair, I think this is referring to inguinal. If you’ve had an open inguinal hernia pair and you have a recurrence, the best next option for the average patient is a laparoscopic or robotic approach to the repair. It is not to redo the open with Mesh and is not to redo the open without Mesh. Those are concerned inferior because A, there’s a higher recurrence rate and B, a higher chronic pain rate. In doing so, there’s a reason why we say if you recur from an open, you do a lap.

Speaker 2 (16:24):

If you recur from a lap, you do it open in terms of the risk of requiring or redo, it’s somewhere in the 5% range. For ventrals it’s around 10 to 12% and in inguinal it’s around 5% and that includes recurrent need for recurrences and also approaching the area for pain and so on. Next question, if there is a recurrence through a hernia place anteriorly and a tap or tap cannot be performed, does the anterior Mesh have to be removed as part of the repair? Great question. Okay, this is a little bit technical. So the question is if you have an anterior hernia repair to open hernia repair with Mesh, I assume with Mesh, and now that recurred, what are your options if you don’t want a laparoscopic tela tap repair? So laparoscopic repair implies general anesthesia and sometimes people aren’t good good kids. I just saw a patient yesterday who’s elderly, not the best heart, and I really do not feel that he would benefit from laparoscopic surgery enough ward, the risks of doing it because I prefer not to do his surgery under general anesthesia.

Speaker 2 (17:58):

But exactly what you said happened. He had a lap, he had an open Inguinal hernia repair back in like 20 years ago and now it’s recurred and it’s causing him pain. So before there was laparoscopic surgery, there was what we called open pre peritoneal repair. So it’s basically open repair, different incision, and you enter a different plane. So you enter in the same plane as laparoscopic repairs. Laparoscopic we consider like behind the wall, if your hernia is a wall is through a hole, through a wall, then an open repair is from the front of the wall and laparoscopic repair repair is from behind the wall. So the major difference is open repair is a big scar in the groin and you can do it under a local anesthesia and sedation. The laparoscopic repair is smaller scars going from behind the wall, but you must use general anesthesia and the risk of bleeding is risk of serious bleeding in people that have blood clotting issues is high.

Speaker 2 (19:00):

So yes, you can perform another anterior approach to open approach if the original anterior approach failed. Usually I do that as a different type of repair, not the same anterior open Lichtenstein Mesh repair, but as what’s called a pre peritoneal repair. And in doing so, you’re operating in a more virgin field and so there’s less chronic pain, less recurrence, and less risk of nerve damage. If you choose to have another anterior repair done, I would recommend that, and it’s the same exact technique, then I would recommend complete Mesh removal at that point and that implies neurectomy and a bunch of other things, which is why I don’t recommend it. But if that is the case, to specifically answer your question, yes, that Mesh must be removed. We do not place Mesh on Mesh because it’s like putting cardboard on cardboard. Those two don’t stick to each other and we also do not leave Mesh in the same place.

Speaker 2 (20:07):

Next question is if your surgeon says no, you can’t have Mesh removed, we rebuilt your abdominal wall. It was an open ventral repair with complications such as sepsis plus two more major surgeries to remove necrotic tissue. The original opening was 39 centimeters. I felt like I was cut in half. Can I have it safely removed? Okay, the question is can I have it safely removed? Yes, all Mesh can be removed. Should you have it removed and is it the right quest? Right procedure? That’s the question. So if you had a complication from an open abdominal wall repair, in fact a patient last night called me around eight or 9:00 PM from the hospital bed trying to cancel their surgery the next day and come to see me in a totally different area of town that apparently had exactly the situation, big abdominal wall hernia, something happened, some complication.

Speaker 2 (21:10):

Now there’s like a Mesh issue. So yes, if you had sepsis and complications and the Mesh is infected, then regardless of how difficult or complicated or whatever the situation is, you should have that mess removed. It sucks. I’m sorry that that happened to you and it’s something that a surgeon needs to just kind of suck it up and do. But sure of that to kind of leave you either in pain or with chronically chronic infection or chronic sinus or chronic drainage is or chronic pain is not appropriate. So everything has its risk. This is just a higher risk procedure.

Speaker 2 (21:56):

If however, you had a complete revision of your abdominal wall and you just want the Mesh removed because psychologically you’re, you’re having issues with it, that is not the right decision that I would not support. Next question. I have a small perfect plug and patch that’s an Inguinal hernia repair with a plug and patch from 2010 when I was 24 years old. In May of this year, So 12 years, 11 years later, I started to have severe growing pain after yard work. I have been evaluated for recurrence by some of your co-experts. Can you speak to plugs and a risk to remove two of your colleagues want to remove? I am consented for ilio inguinal neurectomy with a 10% chance loss of testicle. Oh, that’s a high risk. Even though the scrotal pain is low, I’ve also had three injections which only the ilio angle provided 50% relief.

Speaker 2 (22:57):

Are plug removals the most gratifying? Yes, they’re the most gratifying. It’s like taking a pebble out of your shoe so gratifying. It’s like the best thing ever. So yes, if you have, so first of all, why do you need the Mesh plug removed? Is it because the meshoma causing pain or more likely, I’m willing to bet, not a lot of money, but I’m willing to bet. I’m willing to bet that you just have a recurrence. You’re 12, you’re 11 years out from surgery. If you haven’t had plug meshoma type pain, which is an indication for removal, we discussed that earlier in the hour. Then you don’t have meshoma and you have a hernia recurrence. Meshomas occur early. It’s not like you had a pebble in your shoe for the past 11 years and just now you have pain. So here’s a situation. If you have a hernia recurrence, then that hernia recurrence should be addressed. It should be addressed however it needs to be addressed. Most likely the plug needs to be removed, but the whole plug and patch system does not need to be taken down.

Speaker 2 (24:13):

The 10% risk of testicle loss is super high. I would reconsider surgery by a surgeon who has a 10% testicle loss risk. That’s really high. I’ve had to remove two testicles in my career and it’s been since 2002 and one of them was for because there was cancer involved. So you know, you shouldn’t be removing testicles. It is a risk but it’s a very low risk. Secondly, it is tricky to remove the meshoma, the Mesh plug. It can be stuck to the bladder, to the general femoral nerve to the less commonly to the ilio inguinal nerve and it can be stuck to your external iliac vein, which is a major vein that drains your leg and the epigastric vessel. So it can be stuck to a lot of things potentially and your sort of needs to really understand the anatomy to do that for you. So good luck and I hope there are people that we spoke with on Hernia Talk Live because I stand by their technique and their knowledge and skills base.

Speaker 2 (25:36):

Next question, did you say scar tissue is less over time? Yes, I did scars remodel. So if you look at any scar that you may have had on yourself, it looks ugly the first couple weeks to a month and then by the following year it looks much better and in two to five years you don’t even notice you have a scar. So yes, scar tissue including wounds and the scars inside do remodel on their own as part of the process that everybody undergoes and it does reduce overtime. Also, are there statistics on removal of resorbable Mesh? Not really. Most resorbable Mesh resorbed by the time people find out that there’s anything wrong with it, the longest Mesh available now is 18 months and most absorbed between three weeks to eight months. So we usually do not have to remove resorbable Mesh unless they don’t resorb.

Speaker 2 (26:42):

What is the best imaging that will detect adhesions and scar tissue that may be causing chronic pain? Not much good imaging. It’s really a good radiologist. So sometimes ultrasound and sometimes MRI can identify that can adhesions and new scar tissue cause chronic pain? Usually not. It’s very overrated how much adhesions and scar tissue can cause chronic pain. Is there a way to confirm with imaging that Mesh was totally removed to make sure the surgeon did what he or she was supposed to do? Yes and no. So if there’s a lot of Mesh left behind, usually an MRI can pick that up. If there is a very little Mesh left behind, usually MRI will not pick that up. CT scan most likely will not show it to you in a really, really talented ultrasonographer. Maybe can find that up. But usually not.

Speaker 2 (27:41):

I have pretty severe inflammatory response, but most surgeons think it’s in your head, well then you shouldn’t go to those surgeons. That’s like my answer until we start learning more about it and getting that message out more, then find a another surgeon. Is it possible to remove pig skin Mesh or does it absorb into your tissues if you have a recurring hernia after pig Mesh? How was it repaired? Great question. So pigskin Mesh was one of those that supposedly absorbed around eight months. It tends to be, depending on the brand, they tend to be more synthetic acting than other meshes. So they may take longer to resorb. But yeah, within the first year, definitely two years it should not even be visible to remove. If you have a hernia recurrence from a biologic Mesh, which is a very high chance, it’s over 50% chance that you will get a hernia recurrence.

Speaker 2 (28:43):

If it’s used as a bridge, not if you actually have a tissue repair in addition to it, then you have a lot of options just like any other person. You can have synthetic Mesh, you can have hybrid Mesh, you can have another better surgical technique for the tissue repair with biologic Mesh. So there are options. Thanks for that question. If a patient had an open ventral or incisional hernia repair extending from the Mesh, the Mesh extending from the hip to hip and rib cage to pubic bone, okay, that’s like your whole abdomen with the component separation repair with oblique muscle reinforcement, how difficult is it to implant the Mesh? Very, very, very difficult. Probably the most difficult of all the options out there. Will the oblique muscles place on top of the Mesh be sacrificed upon X plant if they’re integrated into the Mesh? So the goal of Mesh removal is to minimize how much tissue is sacrificed, but you do lose some integrity of the me of the soft tissue.

Speaker 2 (29:54):

It’s just kind of the problem depends on where the Mesh is placed and how thin the Mesh was and the technique. But yes, a lot of that tissue will have to be sacrificed and it’s very difficult because it’s basically sandwiched. It’s sandwiched inside the tissues. It’s like taking mayonnaise off of a sandwich. It’s really hard to do that. It kind of grows into the bread. The bologna’s easy, but then the mustard or the mayonnaise is hard. Next question. Love you guys for sending me so many questions. It’s been a while since I’ve been here alone answering your questions. I think the topic is really something that you enjoy. Next is remodeling of scar includes thinning and a reason for recurrence of open repairs. No, that’s not correct. Remodeling of the scar just reduces the amount of inflammatory cells in the area and is not a reason for recurrence in open repairs.

Speaker 2 (30:56):

Is it normal to feel the Mesh through your skin? I’m a very thin woman and it often feels almost lumpy at times. Could it be scar tissue that is causing the sensation so thin patients may be able to feel the Mesh without actually touching it, like you kind of feel like there’s something stiff inside your belly or groin. If the Mesh is placed on top of the muscle, we call that an Onlay repair. If the Mesh is on top of the muscle and therefore deep to the skin and soft tissue, the fat, then if you touch your skin and fat and you have very little fat, you may be feeling the Mesh or even the sutures of that Mesh. But if you’re feeling lumps, that’s usually not the Mesh and it just may be a consequence of having had prior surgery in certain parts of your fat diet.

Speaker 2 (31:49):

Let’s see. For women with breast implants who have B ii, which we discussed last week, I don’t know if you were there last week, but we discussed B ii, which is breast implant illness and trying to figure out how much these plastic surgeons know about breast implant illness and how much we can learn from them when we’re dealing with hernia. Mesh implant illness for women with breast implants who have breast implant illness in order to have a significant recovery, they need full on block capsulectomy if the scar tissue and the capsule are left behind the women’s day sick. Is the same true for patients with Mesh implant illness or a syndrome? Does the Mesh and all the scar tissue around have to be explanted in order to heal from the Mesh implant illness? Yes, that’s correct. So we don’t really encapsulate because our Mesh is more similar to like the textured breast implants, whereas the most of the breast implants are not textured. So they do encapsulate because of fluid.

Speaker 2 (32:51):

You don’t get ingrowth of the fat into it as much. Whereas we place it over mu within muscle and you get better ingrowth into the Mesh. So we usually do not have encapsulation. But yes, all of the Mesh and its soft tissue, it’s sutures informed by must be removed for patients with any type of Mesh implant illness. I have a comment about please answer, but I feel like I’ve answered all these questions so I’m not sure what it is you’d like me to answer. If you have had the same incision cut three times and now you have more surgery, does that lead to hernia and problems with chronic pain from the repetitive incisions? So no incisions alone or just skin and soft tissue. If you have muscle incisions and they go through the same scar multiple times, in some patients that may increase your risk of incisional hernia. What could a surgeon do that may have caused muscle damage? Could the stretching or some surgical technique cause chronic problems? If the area was injured due to surge’s bad technique during surgery, what causes do you know that can likely be cause of injuries? So that’s kind of a vague question. What is muscle damage?

Speaker 2 (34:16):

I don’t know what that means By muscle damage. Do we retract and open up areas in the abdominal wall? Yes. Can that retraction cause pain? Yes. Does it cause damage? Usually not. If it’s like a nerve damage, then that could be from very aggressive and very long operation that can kind of impinge on the nerves for a long time. Usually not in the middle of the abdomen. That’s more on the sides where the nerves are. There are no nerves in the middle that it can be injured in that matter. So it’s hard to answer this question not knowing the details, but surgical technique is very important. I think that the kinder you are to the tissue, the more delicate you you’re handling, the softer you’re touched, the less inflammation and bruising you get and the less pain the patient has after surgery, the nice, the scar heals, et cetera. What if pieces of Mesh were not totally removed and that is causing the pain? How do you dress that? Well, that’s actually one of the reasons why I completely removed Mesh. There’s very, very, very few patients, maybe less than three, where I’ve left pieces of Mesh behind in my entire career. And the reason for that is I’m very aggressive in removing the Mesh and I don’t want to second guess whether that last piece of Mesh that I left behind is the cause of pain or symptoms or not.

Speaker 2 (35:49):

I’d rather just deal with it during surgery. And then if there are any issues after surgery, I know that one piece of that puzzle is ruled out being the Mesh and now we got to deal with other things that may be causing pain. How do you detect nerve problems? Is there any imaging that shows nerve damage? Good question. So there are studies with ultrasound or MRI that can specifically look at nerves. There are also electrograms, myelograms and nerve conduction studies and nerve velocity studies that can identify and study nerves. We usually don’t use those. It’s usually not very helpful and mostly we go by the clinical diagnosis such as where’s your pain and what type of pain do you have? And then if we think or if we identify a certain nerve to be the problem, you can block that nerve, especially if it’s a sensory nerve. So it’s a pain issue. You can block that nerve with a nerve block agent, some type of anesthetic and see if the pain goes away. And that’s a very good test. So if you have nerve pain, then blocking that nerve should get rid of the nerve pain, even if that’s a short-term solution. At least it’ll give you your answer.

Speaker 2 (37:10):

Briefly, what are the basic techniques for removing or revising Mesh place and truly or view open procedure? Well, I’ve actually published on this, so you can look at and watch the video as part of the article of, it’s called a step-by-step guide on how to safely remove retroperitoneal Mesh. But anatomy is key. You have to respect the anatomy. You have to understand before surgery what you’re going through. You have to know the opera report and identify exactly what was done with what kind of Mesh. Get imaging to identify where the Mesh was placed, confirm that the opera report was accurate, and identify where the Mesh is in relationship to important structures like the bladder, the vessels in your legs, potentially the nerves and the spermatic cord. And then go about it very delicately and very carefully and respect the anatomy. I think the best surgeons are the ones that really understand anatomy.

Speaker 2 (38:10):

Next question. I’m flipping back from Facebook Live and Zoom. This is great you guys. Yes, thanks. You totally answered. No, it’s not psychological at all. Still having infections, inflammatory responses, et cetera. Hopefully I can get an appointment with you in the plan of action. Yeah, happy to help. Absolutely. Also have obvious new hernias. Okay, just add that to the list. We’re happy to take care of all that For women with breast implants, if we’re going to talk about that, please answer. Okay, now finally we’re getting the question that they want me as my Mesh was taken out, why do I have pain right there where my sutures were? Groin surgery, sports hernia. Right there where sutures were. I have two small bumps. Okay, that’s very difficult for me to answer without knowing what surgery you had done for what purpose and where exactly these bumps are.

Speaker 2 (39:12):

But bumps can be scar tissue bumps can be suture nuts. Bumps can be areas where fat necrosis where the fat has died in the area or you had bleeding and it caused scar tissue locally where the bruising or the bleeding was. So if you have pain in the area and you’re early after surgery, you have to wait and kind of massage the area and see what happens. If you’re months to years after the surgery, you still have pain, then you need imaging and a good examination to help identify the area of the pain and a good history to figure out like what brings on the pain, is it purely touching it or do other activities, bring it on because it may be due to a hernia recurrence or a nerve issue or tearing trying. If you’re trying to tear through the tissue, are you open to consult with my current surgeon about my particulate upcoming surgery?

Speaker 2 (40:11):

Sure. Just you have to call the office to request a consultation yourself. And then I’m hap any patient that I work with, I’m happy to work with their surgeon or doctor or pain doctor or anyone else to provide my 2 cents about it. Next, what is the likely cause of inflammation type of nagging pain or soreness that gets worse with weather change such as rainy or cloudy weather? That sounds very rheumatologic, so I would check to see if you have any rheumatologic problems. Yeah, not sure what else to say about, we don’t have anything in the medical books that says a certain type of disease process besides joint inflammation gets worse with weather. You recommend Kara binders in the past for flank hernias or Deni beta abdominal wall. I found the Velcro to be short-lived. Do you have any other recommendations on how to support the flank when surgery is not advised?

Speaker 2 (41:16):

Oh, that’s a great question. I should do a good binder post on my Instagram. Maybe on my TikTok. That’ll be fine. So yes, I think the pyramid binders, the two flap and three flap ones are really good. Their velcros tend not to be short-lived. We have patients that are still bringing them to the office. But if you want other brands, I think the tank tops work really well. If it’s a male, some of the compression tank tops that are made by some of the activity activewear brands, if you’re female, then yummy tummy and made form have good compression tank tops or the long underwears that cause that have extra compression also by yummy tummy or made form I think are good options. I was wondering if you recommend Dr. Yunis in Florida. I have not found any interviews with him on any of your hernia talks, so I was wondering if he is good and if you recommend him. Well, I recommend you look deeper because I have absolutely interviewed Dr. Jonathan Yunis. I think he’s a great surgeon and a great resource in Florida.

Speaker 2 (42:34):

All right, next question. If tap or tap cannot be done, how do you revise a failed open hernia? Plus? I already answered that question. So that would be by an open pre peritoneal repair. What are the basic techniques for removing or revising match? Oh, I answer that one too. Be very careful and respective of the anatomy and, okay, next question. What are the risks of removing some or all Mesh placed in an open hernia pair? Are there risks bowel perforation? So most open hernia pairs are performed anteriorly so from the front and never extend posteriorly in the back and therefore there’s zero risk of bowel perforation. There are a handful of meshes that extend posteriorly that are placed anteriorly. They include the perfect plug-in patch, the ethibond, P H S prolene hernia system, Mesh, the bard or BD kugel patch, which I believe may or may not still be marketed. Those are the three ones that tend to have a posterior component and therefore removing it potentially has theoretically a risk of bowel perforation. Although that risk should be very close to zero because it’s almost always placed away from the bowel ie pre peritoneal and therefore not close to the bowel and therefore removing it. You should also stay pre peritoneal and away from the bowel.

Speaker 2 (44:15):

All right, next question. I had a bilateral AL hernia repair laparoscopic with Mesh one and a half years ago with a barb 3D max. That’s great. I’m riddled with chronic pain and nerve blocks don’t seem to help. I have pain in the ankle region. If I take deep diaphragmatic breath, I also have burning pain in my thigh. What’s my best course of action? Okay, so your surgery was one and a half years ago if you did well for the first year, year and a half. And this is more of a recent problem than the number one cause of your problem is a hernia recurrence. You may also have a folding of the Mesh and that can cause a hernia recurrence in addition to what’s called a meshoma or a balling above the Mesh. So if you have pain that is co, that is so, and let me tell you this, nerve blocks is a complete waste of time.

Speaker 2 (45:16):

If you have laparoscopic Mesh, the chance of having nerve injury after a laparoscopic Mesh placement is very, very, very low. Hernia recurrence, erosion folding up of the Mesh impingement on the spermatic cord are significantly more common than any nerve injury. So in general, I’m not going to say never, I did say never, but a waste of, well, I said it was a waste of time, but in general, nerve blocks are a waste of time when it comes to laparoscopically placed Mesh because the nerves are not injured. It’s not a place where you can get nerve injury. So the question is why do you have the pain? If you have pain with a deep inspiration or a diaphragmatic breathing, then you have probably a hernia recurrence. If you have pain that’s radiating into the inner thigh, that’s also probably a hernia recurrence. So it’s not a Mesh problem per se, it’s a hernia recurrence problem.

Speaker 2 (46:17):

So you need to find a surgeon that can help work that out for you to identify whether or not you had a Mesh, sorry, a hernia recurrence. When a patient is having infections, quote infections, does that mean just in the Mesh area or can the patient have infection in other parts of the body? For example, if there is an infection in another part of the body because of inflammatory response from possible infected Mesh can these infections because from the infected Mesh area. Okay, so not sure we try to ask. It sounds a little confusing. If you have a Mesh infection that is a local infection and would not cause infection elsewhere in your body, like you’re not going to have a ear infection, a intestinal infection or bladder infection because you have a Mesh infection. It’s possible though improbable that if you have a major infection in your body like a tooth abscess, perforate appendicitis or diverticulitis per rectal abscess, so a severe infection that bacteria may run around in your bloodstream and land on your Mesh and even decades after hernia repair cause a Mesh infection, unlikely.

Speaker 2 (47:41):

But I’ve seen situations where that happens. The inflammatory response itself of your just sneeze there for you, the inflammatory response itself of the Mesh does not cause infections. So are they really infections or why are they labeling these as infections? I’m not sure. I hope that helps answer your question, doctor. I think you were awesome. Oh, I think you’re awesome. So I’ve been wanting to get a consult, but unfortunately the consultation fee is a bit too high. I want to see, but it’s preventing me from a consult with you honestly. Well, I don’t know how to answer that. I spend a lata time and effort for each of my patients over an hour sometimes. Plus we answer all your questions, go through all the information, get you a plan of care and help get you better. So if that’s worth a consultation fee for you and you’d like to save up, I’m happy to see you. Otherwise. There are plenty of other doctors that I interview here on hernia talk and that I’ve helped promote because I believe that we need more hernia experts in town. So happy to have you see them as well.

Speaker 2 (49:05):

All right. I have esophageal spasms with dysphagia. Oh, okay. So that’s, that’s a abnormality. I have had a gastric sleeve in 2011, which is not a good combination to have if you already have esophageal spasm with dysphagia. And now I’m being told that I need a gastric bypass. Will that help the spasms? No. I am also having abdominal pain where I had incisional hernia repaired with Mesh. One doctor said that the Bard Mesh is rolling into my bowel. I had a colonoscopy that did not see the blockage. It would not, new doctors seem more concerned about my hiatal hernia, but has not tried to see where my abdominal pain is coming. So you should find doctors that can identify your abdominal pain for you. So if the ones that are currently working for you find another doctor, there’s plenty of doctors in the United States or wherever it is that you’re, you’re coming from.

Speaker 2 (50:01):

So that’s the good news. And then if you have abdominal pain, the esophageal spasms and dysphagia is usually not the cause you have two problems. So you may need two doctors that can coordinate with each other in that respect. Do you have a hernia expert in South Texas area that you can recommend for me? Unfortunately not. As you can tell, I haven’t yet to interview anyone from Texas. And there’s just a paucity of people that deal with like truly deal with hernias in Texas. You can go on hernia talk.com. There’s a handful of doctors from Texas that we’ve talked about and that patients have seen. You can also go onto the American Hernia Society website. It’s just american hernia society.org, I believe, and look up doctors in Texas to see if you want to see any of them. But there’s very few surgeons that even do hernia specialty and very few of them handle chronic pain in all the complicated situations.

Speaker 2 (51:11):

I’ll try and find you someone in Texas that I can interview, but for now it’s a little bit difficult. All right. Let’s see. What are the questions we can answer? So that’s kind of been our situation so far. I think that this topic of when to remove Mesh and kind of why to remove Mesh seems to spark a lot of your interest. So I really like that more questions are coming in. Any hernia removal specialists in the New England area? Yes, I’ve interviewed multiple ones. So you can go on hernia talk live and look those up. Also, you can go to hernia talk.com to look at the different doctors that patients have seen and been happy with on that patient. Discussion form is all free. You can also go to the American hernia society.org website and look up whatever state you’re interested in and see if there are any surgeons in that state that can help you.

Speaker 2 (52:13):

All right. Have you removed Mesh from a patient suffering from Asia syndrome or autoimmune diseases? Yes. Who doesn’t recover only to find out their allergies? That’s from titanium alloy, mixed metal clips, staples, or other metal use during the initial hernia surgery? No, because I remove all of that as part of the hernia. You have to remove all foreign body because you don’t know what it is that they’re, they’re reacting to. Do you ever do Collaborative surgeries with any surgeons who explant metal clips at the same time as a Mesh explant? Usually I’m the one doing that, but I do do Collaborative operations in complex patients who have sensitivities to plastic and metal. How do you stop blood vessels and excess bleeding during surgery? And what types of sutures do you use in these patients? These are usually not bloody operations, so it’s really not a problem, but careful technique is important. The two doctors you said I need, would that be a gastroenterologist and a bariatric surgeon? No, it would be a forgo specialist or bariatric surgeon and a general surgeon. There are a handful of bariatric surgeons. There are also hernia and abdominal wall surgeons. Dr. Bittner was one where I interviewed a while ago, but usually you have to coordinate between a forge or bariatric surgeon. Usually forge surgeon and a general surgeon.

Speaker 2 (53:39):

Have you had others that have chronic regional pain syndrome from Mesh? And would you recommend moving, removing Mesh in this case? So no, chronic regional pain syndrome is usually not due to Mesh. It’s usually due to a nerve, chronic nerve pain or nerve injury or nerve problem, not from the Mesh itself. We did talk about chronic complex regional pain with Dr. Vahedifar, one of the pain management doctors who treat a lot of these patients and will probably do more about that in the future because it is kind of a difficult diagnosis to go about. But that’s a nerve problem, not a Mesh problem.

Speaker 2 (54:19):

Our silk sutures are more likely to have complications like fistulas. Yes, silk sutures are considered somewhat inflammatory and they’re also somewhat permanent. So inflammation plus permanency equals potentially infection and then maybe also fistulas? Yes, you’re correct, Brian Jacob also does hernias and bariatric surgery. So he would also be another person that I would recommend. That’s absolutely correct. All right, everyone, it’s been real. One more question. Do bariatric surgeons know more about abdominal problems? No. Would it be worth it to pay a visit to one? Yes. Would you recommend someone like Mark Bessler? I’m not sure I know Dr. Bessler. Or someone who’s not just a general surgeon in the abdominal area. I’ve tired of general surgeons just talking about hernias, no offense, and wanting to put more Mesh in every time. Yeah, you just sounds like you just haven’t found the right surgeon for your needs, but you have to really find that one or two doctors that are able to help you.

Speaker 2 (55:26):

What would you provide for those who have experienced neurological or autonomic issues following incisional hernia surgery with Mesh, neurologic or autonomic issues following incisional hernia surgery with Mesh? So first I would make sure that I’m not missing another diagnosis separate from the Mesh and then potentially we would just remove the Mesh if that’s the inciting implant lasts upon you, doctor. Thank you. I personally have had chronic revisional pain since the Mesh was put in. Sorry to hear that Dr. I had sports hernia surgery. I had to h sports hernia surgery, but I have pelvic pain if sitting. What do you think? Is there any relation with groin injury and perineum pain? They think I don’t have

Speaker 3 (56:22):

Dental nerve. I’ve seen a few doctors but no answers. Pain with sitting is either due to spine hernia, recurrence and sometimes your hip. So I will look at the all three of those to help figure it out. Could a plastic surgeon help if there’s no hernia but rather chronic pain coming from another source? Usually not. Usually not. That’s usually not what they do. And finally, which bariatric surgeon do you recommend in the East coast in Europe? There’s several of them. I don’t know enough of my bariatric surgeon colleagues to recommend any one bariatric surgeon. Sorry about that one. Okay, well that was fun. I feel like we went through so many questions. Let’s see. Did we miss any?

Speaker 3 (57:12):

Here’s another one. Let’s finish up the question that were submitted because I feel like I owe it to you guys. Are there any systemic issues? Our systemic issues are reason to remove Mesh? The answer is yes. And should my recalled Mesh be removed? The answer is no. All right. It’s been real. It’s been lovely. You guys have been great. I feel like we did a lot today. We’ve just went through question, another question, every question. That was a lot of questions. We’ll do this again. What do you think? I have some more guests coming up, so I hope you guys are coming back next week. Tuesday, hernia talk. Thank you everyone for joining me. Don’t forget to follow me. I really want more people to be on my YouTube channel watching it and sharing it. Thanks to all of you who follow me on Facebook at Dr. Towfigh and on Twitter and Hernia doc. At Hernia doc. I’ll make sure this is downloaded and uploaded for you on social media so you can all watch it and enjoy it because ah, wow. Tons of information tonight. Thank you all. Have a good evening.