Episode 79: Variability in Hernia Surgery | Hernia Talk Live Q&A

You can listen to this episode by clicking here.

Speaker 1 (00:00:00):

Good evening everyone. It’s Dr. Shirin Towfigh, your hernia and laparoscopic surgery specialist coming to you live for our weekly Q&A every Tuesday. We call it Hernia Talk Tuesdays. Thanks for everyone who’s joining us on Zoom as well as Facebook Live. And as you know, if you miss today or if you’d like to share today’s session, this will be posted up on my YouTube channel, but you can access it through either Twitter or Instagram at hernia doc as well. So we have another great guest today, another friend of mine on the East Coast, Dr. Flavio Malcher. He is a hernia surgery specialist. He’s actually currently at NYU Langone as of this past month. So that’s really something exciting. I would like to learn from, you could follow him on Facebook at Flavio dot Malcher and on Twitter at Flavio underscore Malcher. Hi, how are you?

Speaker 2 (00:00:57):

Hello, how are you?

Speaker 1 (00:00:59):

Good. So

Speaker 2 (00:01:00):

Pleasure to be here.

Speaker 1 (00:01:02):

Thank you. Looks like you are still working. You told me that you were on call last night and you worked all day today and you had clinic and you still haven’t gone home yet.

Speaker 2 (00:01:14):

Yes. Well that’s fine. That’s our life, right?

Speaker 1 (00:01:19):

I don’t know. I don’t think it should be our life. I feel like. Yeah, that’s why surgeons are burnt out. What do you think?

Speaker 2 (00:01:25):

Probably, but maybe I’m getting old, so I was taught this way. I need to learn from the younger, how to be find a proper career. I need to have to learn. But anyway,

Speaker 1 (00:01:38):

I know I think it’s crazy that when you’re on call, many, many doctors, they’re on call and then the next day they get to go home or someone is relieving them or they have an easier day. But as surgeons, if you’re on call, then that means there are all these patients you’ve seen and new patients and possible emergencies that still need to be addressed. And in your situation, you take care of those still. You don’t pass those off to anyone, is that right?

Speaker 2 (00:02:04):

Yes. And sometimes we have different setups for surgicalist, they whatever, whoever is on the hospital take care. But maybe I’m old school again and I get attached to the patient. So once I admit the patient under my name, yes. I just want to finalize the care and stay front.

Speaker 1 (00:02:24):

Yeah. Also we say trust no one. So we like to do everything ourselves, which I think adds to the fatigue and the burnout and you have a family. So with that said, I do appreciate that you’re donating your hour with us in addition to everything else you’ve had to do today, but it’s because you love hernias so much,

Speaker 2 (00:02:44):


Speaker 1 (00:02:45):

So what is your current responsibility at NYU? You’re heading their abdominal wall program.

Speaker 2 (00:02:53):

So I spent three years of Montreal and I created, and I was running the abdominal wall program over there and then NYU make an invitation. They didn’t have a dedicated program for abdominal core health or Abdominal wall and has been my honor to try to develop this program here and try to get more dedicated care of those abdominal problems in the area.

Speaker 1 (00:03:19):

That’s fantastic. On the west coast, we don’t have that many abdominal wall programs. East coast and a little bit of the Midwest. There seems to be much more interest. I tried to build one at Cedar Sinai and there was no interest. Maybe our system’s different, but because we have a lot of private practice doctors and everyone kind of does their thing, does their own thing, and that’s kind of what today’s topic is, variability in surgery. At Cedars Sinai, also, some of the other hospitals, we have a lot of private practice doctors. In fact, at my hospital it’s mostly private practice doctors that feed the hospital. So everyone has their own way of doing things, their own idea of what’s right. And it’s a little bit frustrating for the patients because they feel like shouldn’t there be a correct answer? But I tried to develop an abdominal wall program or a hernia center many, many years ago, like 2008. And part of the problem that I hit was who’s part of that center? And in your program, is everyone part of the center? Do people do hernias outside of your center?

Speaker 2 (00:04:39):

Yeah, it’s interesting to see the growing interest on creating those programs in bigger academic institutions. And I can really see how hard it is to build that on a most private hospital driven physician hospital. But we see that more and more in academic centers. And my way to do this is every surgeon, usually every surgeon does hernia, right? So

Speaker 1 (00:05:06):

Yes, every general surgeon,

Speaker 2 (00:05:07):

Yes, should be able to do a proper hernia repair on regular day, the daily case, yes. We not let’s get out of the equation all the complexity, recurrent, and all the nightmares that we know that happen. But the regular inguinal hernias, vental, primary Ventral hernias, that should be addressed by general surgeons. The way that I build that is I don’t have the manpower to do all harness of a big institution. Back in Monty, we used to do 2,500 hernia repairs per year. In this system I only do 250, so I can do 10% of the hernias, but everyone is invited to be part of the center. I have two requirements. One, you need to put your data on our database. And I use donor health qc,

Speaker 1 (00:05:56):

But ACHQC, yeah, Ben Poulose was on our a while ago.

Speaker 2 (00:06:01):

If you hospital your hospital don’t have access to it, but create your own database. We need to track your own data, you know, need to know how your patients are doing for sure. The publication for all the groups that are very important, but sometimes they don’t translate exactly for your practice. And there’s number one and number two is you need to get together with us routinely. Maybe not every week, but at least monthly. We have a conference and we discuss and we learn from each other. So if you meet those two criteria, that’s okay and you can be part of the harness center. And that’s mainly how I do it.

Speaker 1 (00:06:39):

So you, it’s okay to have multiple levels of hernia care provide in the same center

Speaker 2 (00:06:45):

It is, but they need to get together and they need to discuss what they’re doing and everyone does a little bit different and that’s okay. And that’s how we learn. Maybe your way to do is better than mine, but I don’t know your way so you can get together. We going to learn together and we going to show ourselves our data because you can say that you have the best results, but maybe when you really follow up your patients things are a little bit different.

Speaker 1 (00:07:13):

So if they don’t want to follow that, those rules, they don’t want to put their database in, they don’t want to meet. Can they still do hernias at your hospital?

Speaker 2 (00:07:23):

I think they, yes they can, but they are not hernia surgeons. So on the website and our faculty list, they are listed at general surgeons, but they’re not listed as hernia surgeons.

Speaker 1 (00:07:36):

Okay, got it. Okay, that’s really good to know. Yeah, it was really difficult because those were all roadblocks that we’re thinking as hernia surgeons, we have certain ideas, but there’s a lot of hernias that are done in Los Angeles. We really don’t have an abdominal wall program. David has his Lichtenstein hernia clinic, but even that is not a comprehensive hernia program with a lot of members. You know what I mean? USC has one a name to it, but it’s mostly run by plastic surgeons and they don’t

Speaker 2 (00:08:11):


Speaker 1 (00:08:11):

A lot of MIS or chronic

Speaker 2 (00:08:14):

Even on a big system. Our faculty department of surgery and Montreal who have over 30 faculty and we have three on the hernia center because sometimes the surgeons, they don’t really want to give time or invest time on this. Got it. And that’s, that’s okay, that’s okay. We’re not here to say that our way is the right way. We just want to learn together.

Speaker 1 (00:08:35):

I think when I showed up in 2008, they looked at me like hernia, we invest in transplants and cancer and heart. Why should we invest in hernia? And yet now around me, there’s so many private practice, private practice centers that are marking themselves as also being a hernia center. So what I’d like to do is kind of go through a little bit about variability in surgery. And what I mean by variability is I get this a lot. I have patients that go and see multiple doctors, they go and see you, they see me, they see other people and they have one problem which is let’s say a ventral hernia or a recurrent hernia or a growing pain, whatever, and they get multiple recommendations for what to do. So that’s one issue, which is variability of recommendations or practices. And then the other issue is I see a lot of patients that say, I want the Shouldice, I want the Lichtenstein, I want the Rives Stoppa, I want a TAR, whatever I want robotic.

Speaker 1 (00:09:46):

I always say don’t choose the technique, choose your surgeon and then allow your surgeon to determine what’s best to tailor for your needs. So that’s where I see kind of variability because not every surgeon does the same Shouldice or does the same Lichtenstein or the same laparoscopic repair, even though you’re looking for someone to do laparoscopic repair. Surgeons vary in how they do it and what they’re really good at. So I feel like it’s a better way to deal with it for surgeons, for patients. So not so complicated is pick your surgeon and then kind of rely on the surgeon to guide you.

Speaker 2 (00:10:32):

But sometimes speaking a surgeon not easy as well. So the way that I see it is if I can make a very simple parallel, how can I get to LA from New York? I can have a direct flight, I can have a direct flight, the business ticket, I can have a cheaper flight with one connection, I can have a red eye, I can have a daytime. So if I get to LA safely really doesn’t matter how I got there, but there’s different ways you can even drive, take a train, whatever you choose. But the point is you get it safely. And sometimes mention is not mathematics. We don’t have the same thought process together, the results that we all want. So true. And the patient needs to understand that. And sometimes I have a old professor that said that a man with one watch knows what time it is. A man with two watches will never be sure. So

Speaker 1 (00:11:35):

Oh that’s a great one. Is that ion?

Speaker 2 (00:11:37):


Speaker 1 (00:11:39):

I love it. Yeah. Well how do you say in Portuguese?

Speaker 2 (00:11:46):


Speaker 1 (00:11:49):

I love it.

Speaker 2 (00:11:50):

Yeah, I I don’t want to make the idea that just go to one person and they have all the answer. No, but you should search for more opinions. But without open mind. Sometimes the patient, they want a specific answer and until they get that answer they keep trying to find another surgeon. I completely agree with your statement that we choose the surgeon, not the procedure, but yeah, it’s not choose a surgeon, let him or her decide the procedure. Okay. It is share decision. So yes, you need to pick a surgeon that you trust after a few interaction and then say, okay, what is best for me and why? I like patients that come with a Google search and they have opinions and they have questions and that’s okay, but they need to come with a open mind. Sometimes they understand what they read over. There is not everything. And if a person comes well-informed, great, but needs to come with a open mind to be open to listen what we have to say.

Speaker 1 (00:13:01):

Yeah, I totally agree with that. I love patients who do some research because in some ways they’re already ahead when I discuss because I discuss anatomy and techniques and so on and they already know. But as you mentioned, it can be very, the stuff on Google can be very misleading, especially a lot of the groups where patients who are injured or have had complications tend to be very vocal, which is good in that it alerts people that it’s not just a hernia repair, they can have problems and complications, but it certainly is not the majority of patients that have complications. Otherwise we wouldn’t be doing these operations. People need to understand that we like risks in the point less than 1% range, maybe the less than 5% range. We don’t do operations that have 90% complication risks. That just doesn’t happen. So I feel like there’s a little bit of loss of trust there in doctors thinking that we’re out there to main people or something.

Speaker 2 (00:14:09):

And I have a good one on statistics for you as well. Yes. And I have a old professor of biostatistic on my mastery in science. They statistic they don’t apply to individuals. So when you just said that we do operation, they have 2% of complication rate. I cannot say that that patient Smith will have 2% of rate of complication because it’s a completely different case. And if that happens to her or him is a hundred percent, they don’t care. But 98%, but for me it’s a hundred percent because if it was true, if you put your head on the fridge and your back part on the oven on average, you’ll be comfortable And that does not happen.

Speaker 1 (00:14:53):

Right. Is that another Brazilian story?

Speaker 2 (00:14:55):

Yes, he was back in Brazil with my professor. So I don’t create stories but I like stories and it really, I love it. But in average you are comfortable and that doesn’t happen. Yes. So patient needs to really understand what is going on and we’ll be honest. I know that one in a million happens if happens to you, it’s a hundred percent you don’t care about the other 999,000 that didn’t happen is you?

Speaker 1 (00:15:23):

Yeah, yeah, that’s very, very true. Now you guys know more, I like to hang out with Flavio because he is very informing. He is very fun to be with.

Speaker 2 (00:15:32):

Thank you.

Speaker 1 (00:15:33):

So Flavio, you are the author of now two articles that I know of that deal with variability in surgery and you’re trying to help gear surgeons towards some sort of minimal standardization of what would be the best type of inguinal hernia repair. And I’ve read your articles, we’ve talked about it with the residents, we teach it and so on. But even in your article there’s controversy as to whether the steps that you mentioned really should be done in every single hernia repair. Can you just briefly tell us what your nine and 10 commandments Sure. Check notes are.

Speaker 2 (00:16:14):

Yeah. So why

Speaker 1 (00:16:15):

You did it and what the feedback has been from other surgeons.

Speaker 2 (00:16:19):

Yeah. Variability is expected in life and imagine as well. So another phrase is not mild, this is very common, but justice is not treating everyone equally, but it’s treating the unequal unequally so you don’t treat everyone the same. You need treating different people on different ways to give justice. So the same thing happens in our cases. We don’t do the same procedure for all harness because we need to adapt to specific situations. But at the end of the day we should have some principles to create a standardization and say searching safety for the patient. And that all began with the laparoscopic cholecystectomy with the initiative of a critical safety. And then some surgeon got the idea, so why don’t we replicate this safety measurements to another procedures? And one of them is a very common procedure will be laparoscopic lyse repair. So yes, and they published the what you mentioned, nine commandments in our group.

Speaker 2 (00:17:24):

We were working on how to teach in a easier way this procedure with an anatomic review and very simple stuff. But became, we learned that it was very easy to another trainees to learn that way. And we got the idea why don’t we merge the commandments, the steps of the procedure with an atomic review to make it more visual. So we invite HO and Ed Felix to write a conjoint paper. Professor Felix join us and we create what we call the 10 golden rules. So we don’t want to say that everything needs to be done that way, but if you follow those rules and they’re not very, very, very specific, it just does major step of the procedure, probably you’re going to avoid some complications or some missing issues on the surgery. But that is so controversial that we just wrote another follow up. Yes. Challenging the 10 golden rules because people challenge and we need to learn from challenge and the idea is just to give surgeons a checklist. And I heard different surgeons telling me that, oh it’s so helpful now I print and I live on the side of my tower and it’s kind of a checklist. So I checked those and I know that I’d probably be safe and I like that.

Speaker 1 (00:18:46):

Yeah. So just for the audience, there was a paper by Dr. Edward Felix and Jorge Dais who wrote, it wasn’t a scientific paper, but they wrote a nice little letter that was published that said these are the nine steps we think every surgeon should take minimum to do a safe operation where you’re identifying everything accurately before putting in your repair laparoscopically. And we called the nine commandments because there’s nine steps to it and you’ve increased it to 10. So we did have video. Did you hear about this? We presented I think at sages I think we presented, so we took the 50 top laparoscopic or robotic Anglo.

Speaker 2 (00:19:33):

I saw it and is unbelievable. Unbelievable, horrible.

Speaker 1 (00:19:41):

We rated them from zero to 10 and I think four of them scored zero of the, it just scored zero. Many of the 60%, something scored like well below 50%. So the average surgeon is not doing a lot of what we experts think should be done. So do you think that expert hernia surgeons provide better care and lower complications? Is that something that you believe? We know if for cancer and other operations that if you go to an expert you have better outcomes. You believe that’s also true for hernia surgery?

Speaker 2 (00:20:21):

I think this is true for everything life. So if you drive once every three months, you’ll not be the expert driver. If you drive three hours every day, you may be best better. But the problem is I don’t get it when a surgeon says, ah, I’ve done this a thousand times. Yes I know how to do. You could have done a thousand times wrong. Yes. So that’s why I keep telling that we need to talk with our colleagues and keep learning together. But definitely as much more you do of the same procedure, you kind of master that. And as we know, we all know the 10,000 hours rule for different activities in life, but that I think that’s applied and that’s a few papers showing different results when you go to expert. That does not mean that all hernias need to be deal by experts. But definitely if I have a hernia, I probably not look for my heart transplant surgeon. The guy is a star, but probably he’ll not be able to do a hernia as good as a me, myself or not a hernia surgeon. And the opposite, the same. I can do azo ectomy. I haven’t done one for 10 years, but I know how to take out the zag. They’ll not be the best person to do it.

Speaker 1 (00:21:36):

Yeah, no, I totally agree. Are you a history B, do you know much about history?

Speaker 2 (00:21:41):

A little bit.

Speaker 1 (00:21:44):

Iran had a Shah, remember the Shah of Iran?

Speaker 2 (00:21:47):

Oh yeah.

Speaker 1 (00:21:48):

And he died. So he actually died of a surgical complication. People think he died of cancer. He actually died of a surgical complication. And there’s a great documentary called a Dying King and it kind of takes the medical aspect, interviewed all the different surgeons that took care of the Shah. So because he was a Shah and this, we see that a lot with VIPs or important people, prominent people, they picked the best surgeon and they picked DeBakey who is a very, very gifted, well respected surgeon for the heart. He’s a great heart surgeon, but he needed his spleen taken out. So they had to basically do the splenectomy and he injured the pancreas and the surgeons that were there, this was done Egypt. The Egyptian surgeons actually said, Hey, watch out for the pancreas. And he’s like, oh I’m DeBakey. And anyway, the injury went unaddressed.

Speaker 1 (00:22:57):

There was no drain place. He was neutropenic from the cancer chemotherapy, he got infection, salmonella infection and got two liters of ascites of pus and so on and then died. But people were trying to give him the best surgeon, but DeBakey probably had not done a splenectomy for 20 to 40 years. I forget how old he was when he had the thing. But yeah, I can do a splenectomy but it’s been maybe 10 years since or 15 years since I’ve done his splenectomy. So probably not the best person to do it and I would not do it.

Speaker 2 (00:23:38):

And we see that a lot. So sometimes patients they search for the chief of surgery or the chairman of the department. And those positions are very important and usually very smart people and very good people, but maybe are not the specific problem that the patient needs the care. And there’s another side of that problem is when you have a very, very recognized or senior surgeon, maybe the juniors will not speak up and maybe they will not stop the senior. And that has a good history on aviation. I think it was in Korea or Japan on the eighties. And they have this huge accident with 747 and then they were reviewing the problem and the pilot makes so many mistakes, but he was instructor of flying on the company and super well respected and the co-pilot did not say anything and it was so clear. But for you on the Asia on you have the sole respectful, yes as a cultural issue as well that he died but he rather died than speak up that, oh oh stop doing this, we’re doing wrong. And after that they change rules on aviation. Now some decision needs to be shared between the pilot and the co-pilot and don’t rather don’t really matter the level of severity of those. And the same thing happens. We just talk about the commandments and critical of your safety. The critical of your safety should be confirmed by all surgical members, not only the surgeon itself. So that’s all a safety net that sometimes you need to create to try to avoid complications.

Speaker 1 (00:25:26):

Very true. We have a couple questions. What do you know about Lichtenstein and the Mesh placement? Specifically, the question is, is there any data from the Lichtenstein hernia repair prior to [inaudible]? So [inaudible] was the one that really took what you and others have done for laparoscopic inguinals. He did it for open inguinal saying this is the Lichtenstein, this is how to do a perfect Lichtenstein hernia repair, put your suture here, dissect like this, et cetera. So one of his commandments was do not put a suture into the periosteum because that can cause chronic pain. So just grab the fascia over the bone but not the actual covering of the bone as part of your open angle hernia pair with Mesh. Do you remember what the history of that is? And that was based on his own experience because he was doing a lot of chronic pain. But is there any data to support not putting suture into the periosteum that you were aware

Speaker 2 (00:26:31):

Of and probably not. And at need to remember 30 years ago or 20 years ago, they’re much less DR data driven than we are we right now. And you can see those names Lichtenstein and whatever show guys McVay today, we don’t have Towfigh procedure or Malcher procedure. No, we have obturator or total expert cause we believe that we should share the data and understand what is the best procedure. But 23 years ago that was not the way and that would come back to the variability of the procedure. Everybody say that they do Lichtenstein, but I bet the 90% of those are not really true Lichtenstein procedure. So I understand what Dr. Amid mean with that, but I don’t know. For me it’s almost impossible to caliber my hand. Oh I’m taking only the fascia, I’m not taking the periosteum. I don’t think that is an objective way to say that. You took the periosteum or to just the fascia. Yeah, I believe that you need to securely fix the Mesh on that area because I just operated two recurring hernias yesterday from open Lichtenstein years to years ago. Yes. And I don’t think that’s a is a techno failure, but clearly the recurrence was medial close to the pubic. So we know, we all know that’s the area that the recurrence occur.

Speaker 1 (00:27:57):

Yes, yes. The next question has to do with Mesh Biodesign. Mesh. I think that’s the cook biodesign, right? I think yes, that term Can biodesign Mesh be removed?

Speaker 2 (00:28:10):

Probably not Biodesign. Mesh is one of the earliest biologic Mesh for AB wall. And as far as I know, I may be wrong, but it is out of the market because not as because of problems because did not deploy good results. Long term is a very pliable and make no harm. But I don’t know if they create enough scar to hold and is absolvable Mesh. So after a period of time you don’t have any residue of it.

Speaker 1 (00:28:43):

If this per member is referring to the cook biodesign. Cook no longer sells Mesh except for hiatal hernia, I guess they’re surge is biodesign but they’re out of the Mesh market for hernias. On a similar note is kind of looking at market changes. So you may know that the same polypropylene Mesh that we used for hernias was being used transvaginally for stress urinary incontinence and pelvic organ prolapse. And as far as I know there’s currently no company that actively sells anymore transvaginal meshes. And the question here is can you please tell me why Mesh is no longer used in the vagina but it is with hernias

Speaker 2 (00:29:35):

Because it’s completely different position and the nearby structures are completely different. What happened with the Mesh of the vagina, it was very close to the mucosa, was just under the mucosa. There’s a thin layer and the vagina is a very dynamic area. So you have sex, you have urine, you have other fluids going through that area and you have your day by day movements. When you put a Mesh on the ab wall, you are not close to any mucosa and depend on the position. You are between muscles very far away of any viscera. And for those specific Mesh that go inside the cab, they’re close to viscera, they’re coated to create that protection layer. So the difference is different positions, position close to the mucosa on a very dynamic area.

Speaker 1 (00:30:34):

Going back to the history of how things are developed, the patients that underwent hernia repairs early in the Mesh world where we didn’t have barriers. Cause barriers I think occurred in the eighties when the seventies people were putting Mesh directly on bowel and then they learned very quickly that’s not a good idea. So similar to putting Mesh around the vagina, there were complications putting Mesh directly on intestine and those two both have mucosa and very similar in their response to a foreign body. So we don’t do that anymore as a abdominal wall Mesh, we have Mesh with barriers for the vaginal Mesh. It’s not the barrier itself, but it’s like you said, it’s put against a very mobile structure that can cause a lot of problems including infection, erosion and chronic pain. So we’re learning, we’re constantly learning about everything we do and that’s where the variability is.

Speaker 1 (00:31:40):

We just got rejected for this potential abstract and hopefully I can present somewhere else, but we looked at our 10 year data and we followed actually not 10 years, 20 year data. And we followed the cases I was doing 20 years ago to now and they’re different. The amount of robotic and laparoscopic that I do is higher. The amount of open with Mesh is lower, the amount of open without Mesh is higher. It’s kind of went like this as one type of case went down, other type of case went up. So there’s variability in what I offer now, the same patient that I saw 20 years ago, perhaps I would treat differently. Nowadays I have new techniques and tar and all these other new techniques that I didn’t know about in the early two thousands. So there’s variably even within a practice as to what we offer.

Speaker 2 (00:32:38):

And that does not mean that what you were doing 20 years ago was wrong. I mean that happens everywhere in life. You can probably buy I iPhone four, somewhere is not wrong to buy iPhone four, you may even work. But nowadays you have the 13 that much better. So you are offered different stuff. You can buy a very classic 1970 car and drive around. But what is safer to drive that car or to drive your car with airbags, abs, and all that. So it is not about being right or wrong, things change. Technology comes in all means of life including medicine. Thanks God. Yes. And that’s the beauty of the variability to the surgeon to be able to adapt and continue to learn. And then I circle back on my vision that we cannot learn by ourselves. We need to learn by others by sharing experience. If I only have my experience, I’m limited to my numbers. If I share everyone’s experience, I can have a much bigger reach. So I mean is the one that does not learn from their own mistakes. I intelligent one, it learns from its his or her mistakes, but the whys learn from others mistakes. So we should try to be wise, at least intelligent but possibly wise.

Speaker 1 (00:34:05):

Yeah. I’d like to know your experience in South America because you’re a big deal in the Latino world. You’re a big deal American world too. Like US world too, but

Speaker 2 (00:34:18):

Big anywhere.

Speaker 1 (00:34:19):

But you’re huge. You’ve been president of their societies and very well respected. So I went to China, this is 2010. And the Chinese surgeons were very gifted, talented surgeons and they don’t use that much Mesh, it’s just they have what, a billion and a half patient patients, potential patients. And it’s just not feasible in their economy to use Mesh for everyone. But in the bigger centers, they’re starting to use a lot of Mesh and newer meshes and they were giving us case studies of look at these patients that we did showing us pictures. And I’ll tell you some of us were sitting there going, oh I wouldn’t have done that. And they were showing us look at all these great cases we’re doing, but they were about 10 to 15 years behind US delegation and European delegation. I was there and it occurred to us that their learning curve and their exposure is about 10 to 15 years before us. So we’ve learned not to do what they were showing us. They had an open abdomen, they used a E P T F E Mesh. We’ll never do that. And what do you see in your experience in Latin America in central and South America?

Speaker 2 (00:35:40):

I can really see what you’re saying. I’ve been to China twice for work and they have this huge hospital. I mean a thousand bad hospital is a small hospital. Yeah,

Speaker 1 (00:35:53):


Speaker 2 (00:35:54):

It’s unbelievable. And the hospitals are so big with so big faculty, they are their own societies and they have their own social living and learning on that close organized group of physicians. And there’s a lot of respect. So to challenge a senior surgeon is much harder than happens here in the us. Latin America. I think that is much more close to us here in US than actually the Asia type. We have the traditional surgical school of Latin America was Argentina until the sixties more or less. And then Argentina become a very problematic country regarding economic economy and everything. And on other hand, Brazil improve a lot. So nowadays, and I, I’m biased because I’m Brazilian, but travel along, I see the Brazilian surgery bypassing the other countries. I’m not, don’t take me wrong, it’s just because we are such a bigger country and we have a decent economy for the last two decades that we were able to accomplish some improvement.

Speaker 2 (00:37:06):

I give a quick example. Brazil has over 50 robots and you talk with Argentina and they have four or five. So it is that kind of disparity. And don’t get me wrong, healthcare in Brazil can be very, very bad. But we have this eager to learn and we learn on some not perfect conditions. So we adapt a lot our variability. So we are more creative in how to adapt and always remember you showing the adapt for tap procedures. Yes, yes. And that’s a typical thing that a Brazilian surgeon will do to be I use it. Use, yeah. Yes. But it’s not common in us to see that. Right. You need to agree with me for sure. And that’ll be absolutely normal in Brazil or in Argentina or in Chile. But the surgeon, lifetime surgeon in Latin America has improved a lot. The problem is the access to technology.

Speaker 2 (00:38:02):

So maybe we don’t have the latest match or the latest robot or access for people to have that kind of access. And coming from Latin America, coming from Brazil, I see Americans complaining a lot and they don’t have the perspective what is a bad healthcare system. They really don’t have a perspective what is a real bad health. I’m not saying that we are in the perfect world here, but things could be a lot worse. And bringing that perspective, my practice is very interesting because I can see the difference and be grateful for what we have here.

Speaker 1 (00:38:44):

Yeah, I mean even, what was it, two weeks ago I think I got a patient that flew in from Canada because they felt they weren’t getting care in Canada. They saw me on Monday. I said, yeah, you have a hernia but you seem to have a spine issue. Did your doctor talk to you about spine? They’re like, I’m supposed to get a MRI maybe in two weeks, something like that. I’m like, well let’s get MRI today. So they got MRI Monday night, I got the report from the radiologist Tuesday morning, Tuesday afternoon they saw a spine surgeon, he diagnosed them with severe spinal impingement with motor dysfunction et cetera, and abdominal wall laxity from it. And by Friday they had surgery. That’s the United States. Things happen. Other countries, the care may be good, but the, there’s nothing compared to the US healthcare no matter how much people

Speaker 2 (00:39:43):

Can. And the other side is how much it costs. And I understand that the amount of money that is expand on healthcare here is probably not sustainable and we need to find a way. And I see a lot of waste as well, not because we have a good healthcare that we can make it better and less costly. Cause I have so much waste to improve that.

Speaker 1 (00:40:12):

So going back to the patient that asked about the cook biodesign. So apparently they’re from the UK because in the United States you cannot get that Mesh, but it sounds like they’re selling it in outside the United States because this patient had surgery nine months ago for a rare sciatic notch hernia that included

Speaker 2 (00:40:31):

Surgery mens? Oh sur

Speaker 1 (00:40:34):


Speaker 2 (00:40:35):

Oh biodesign, okay. Yeah.

Speaker 1 (00:40:37):

So they had a rare sciatic notch hernia, which usually can involve the ureter, but they said that it involved their bladder wall and now they’re in agony. So I would venture to say, cause I’ve done sciatic notch hernias it, it’s very complicated because the nerves are there and the ureter is there and there’s some major vessels in the area and you don’t want to injure any of those or have Mesh kind of erode into the nerve or the ureter. So I agree with using some type of less toxic Mesh, but if you’re an agony then that’s not a Mesh problem. That’s probably a surgical problem. Here’s a patient that had their Mesh ripped in two and it stuck in her and has ruined her life. What do you recommend for that?

Speaker 2 (00:41:29):

So it is a very rare situation to have a mash rip out. A Mesh is much stronger than the muscle usually. So to get enough strength or forces or pressure on the area with the me and does not burst the muscle themselves and then the mash is very unlikely. We saw, we start seeing this with a very lightweight mash on maybe on the late nineties, early 2000. Yes. And then that’s why surgeons after decade change back for a little bit heavier me, a little bit stronger mash. But that can happen. So once that happens, we need to figure out if, usually the problem is not the me that is wrapped, it’s the recurrence that now happens and that needs to be addressed. Correct. And during that reoperation, the surgeon may or may not be indicate the removal of the old, the cases, the old Mesh is not really the problem. The problem is the failure of the repair.

Speaker 1 (00:42:38):

So there’s two what we call ultra lightweight meshes in the market. And the other one was physio Mesh, which was basically ultrapro with a barrier. And those are deemed to be ultra lightweight and really I believe should be reserved in very low-risk patients. So no one obese known with a large hernia, you should not use it as a bridge. It’s just not strong enough. And oh here she wrote, okay, it was ultrapro Mesh, but sounds like it was done for an inguinal hernia broke in two pieces to my pubic bone. What I’d like to kind of emphasize is all of these problems are treatable. If you have hernia recurrence, a Mesh that tore a Mesh that pulled whatever attached to your pubic bone, et cetera, that’s a treatable problem. Do you treat patients like this?

Speaker 2 (00:43:31):

Yeah, so on the inguinal area, when the patient come with pain, after a procedure of a surgery is crucial to understand or have any idea what is causing the pain. Different causes demands, different management sometimes is a nerve that was pinched or trapped or something happened that we call have a neuropathic pain. That is the cut nerve. You pinch a nerve and that is a pain using burning shooting on the certain area of the lower abdominal type. The other cause is a recurrence. And maybe that’s the case that you’re saying the Mesh maybe not rip away but they’re detached from the pubic bone and it would just comment. That’s probably the most common recurrence mechanism that we have in open artery repair. And now the recurrence is the cause of the pain and there a bunch of others cause of the pain of tenitis is all confused on that area. You need to search for a little bit more experience and manage that kind of pain to first of all try to identify, not sometimes easy, but try to identify what may be the cause of the pain and the treatment may be injection, maybe treatment may be physical therapy and the surgeon may, may be a surgery with mass resection with no mass re removal. So it’s very variable.

Speaker 1 (00:45:02):

Yeah. So it sounds like she was first misdiagnosed as a nerve problem, but then when they found went in there, they found out that the Mesh had torn away and then she had the Mesh remove and sutured. So it’s an interesting idea. So the Mesh tour, but then they did a suture repair. So if the Mesh to either that was a surgical technique problem or the hernia was too big to withstand the forces of for the Mesh to be with forces to be withstand or it was too tightly put in. So now you have a tissue repair. I would like to know, do you now have more pain because now you have a really tight tissue repair that you’re trying to tear through the same way you tore through your Mesh And maybe that maybe a non Mesh non tissue repair like a Mesh repair would’ve been a better thing because your problem wasn’t the Mesh, it was the choice of the Mesh or the surgical technique. That was the problem. Question though for you, since you mentioned it twice now, what do you mean by medial failure of an inguinal hernia or recurrence and what structure is disrupted or torn?

Speaker 2 (00:46:13):

Yeah, so the media recurrence is we have some pediatric vessels. It’s just a landmark that we have on that area. If the recurrence is medial, so to the center of the abdominal we call median recurrence if the recurrence is lateral. So the side of the pediatric vessel is a lateral recurrence and the most common recurrence area after an open repair with Mesh is the medial very close to the bone because it’s hard to attach the Mesh to the bone area

Speaker 1 (00:46:43):

And the bone doesn’t stretch

Speaker 2 (00:46:45):

And is a pulling force. And we need to understand the pubes is a area where the abdominal muscle insert from the top and the tie and the hip muscles insert from below. So there’s a lot of forcing pulling the pubic bone. And if you put a Mesh there, it may dislocate or torn or whatever you want to call. So that’s what we mean as a recurrence.

Speaker 1 (00:47:11):

There’s another question regarding retro rectus Mesh. This is now abdominal wall Mesh, not groin Mesh have many patients experienced complications when Mesh is placed in the retro rectus space.

Speaker 2 (00:47:25):

Complications that can happen with any position. They are very rare in any position. But what we learned that retrorectus position probably is the safest position of the Mesh. That does not mean that other positions are dangerous or should not be done. But because of the anatomy, the vascularization, the death of the plane regarding the skin, the protection from the visa, there’s a lot of good reasons to use a space. So complications are not common in any space, but even less common on that space. But they can happen like a hematoma or seroma or something.

Speaker 1 (00:48:07):

It has a lowest risk of infection. It has the lowest recurrence rate. When Mesh is placed in the retrorectus space, it has the lowest likelihood of chronic pain. Mesh, erosion fistulas, adhesions are pretty much zero because it’s not against anything but muscle and fascia. So yeah, we all prefer in fact, trying to think, have they ever need to remove a retrorectus Mesh, I don’t recall ever having to remove retrorectus. Mesh.

Speaker 2 (00:48:38):

Yeah, I think I probably one or two cases with a bad infection that went all the way down and not remove the whole Mesh but pieces of the Mesh they were not integrating and we need just kind of Deb debris that

Speaker 1 (00:48:51):

Yeah, maybe infection and that was it. This one is also about laparoscopic inguinal hernias. Here’s a question. Do you and Dr. Malcher recommend affixing Mesh laparoscopically? If there’s no self-adhesive, do you do it to Cooper’s ligament, pectineal ligament? Are there any concerns about periosteum being invaded with the suture or the tack?

Speaker 2 (00:49:16):

I guess this is about harness. Yeah. Yeah. So we should not fix anything to the bone itself on the way that we position the matches behind the bone. So we don’t need as much fixation if we put behind the bone because the pressure will press the measure against the bone and will fix it in place. Yes. So one option is non fixation. Another when you do want to do a fixation, sometimes it’s necessary because a bigger hernia, recurrent hernia on other factors, you should not tack or suture the bone itself. But the Cooper’s ligament as mentioned, yes. So the Cooper’s ligament is not periosteum, you’re not functioning the bone itself. So it is a safer place to tack or suture your Mesh.

Speaker 1 (00:50:10):

Yeah, I agree. And I show them to my residents because they think they come in like okay we’re going to talk into the bone. So here’s another, this is variability. So your resident comes and they’ve seen now four or five surgeons do it, do the same laparoscopic inguinal hernia pair differently. And I try to reeducate them and kind of make them unlearn some things that they do and fortunately they listen to me so that’s good. But they don’t really have that much power to go to another surgeon say, let me show you how it’s done because they’re still in training. But yeah, so I teach them too. So for the coup we don’t for the pubic tubercle region, I tack if I need tot I also practice non fixation, but if necessary for a large or direct hernia, then I tack onto the rectus insertion onto the pubic bone, not to the pubic bone itself and then onto Cooper’s ligament not to the bone. Yeah, totally agree with that. Question is what is attack and how does it appear on MR imaging?

Speaker 2 (00:51:24):

Most of the attacks are not metal. So they will not show on an MRI or x-ray or even a CAT scan cause there are some plastic absorbed material. But we still have metallic attackers that sometimes are necessary. So they will show in a CAT scan or a x-ray as metallic instruments. And it’s important to disclose this with the patient. I never forget, maybe 20 years ago I did a laparoscopic cystectomy. The patient came back, have a good relationship and said, oh doctor I I’m I’m embarrassed and that’s okay. I know that happened but you forgot something inside of me and she got x-ray and she could see the clip and somebody said your certain certainly forgot a piece of a needle or a metal inside. So we frequently forget to disclose to the patient that they may see the tack on a x-ray and they no problem on TSA. That should not be a problem TSA. But they shouldn’t MRI maybe those are very small tanks. They are not really a big problem MRI and, but they can bright up and if you want sometimes a more refined image around the tack can be a problem. But they just show up. It’s not a big thing. It’s not hard to see them.

Speaker 1 (00:52:45):

The tacks that are opaque on most imaging are the spiral tags that are metallic. I believe they’re almost either a hundred percent titanium or some may have a little bit of nickel in it on MRI on I think it’s a fat SAT images. Sometimes you can see the non-visible to based on the distortion scene on MRI. So you can imply that maybe there’s a attack there but you don’t actually see the attack itself. Here’s a young man, he had bilateral inguinal hernia repair with Mesh in 2008. He had severe groin and nerve pain and muscle spasticity in 2017. So what is that? Nine years later he had the left Mesh removed and replaced with dissolvable Mesh. In 2018 he still had severe nerve pain and groin in the groin and the left pelvis and the left leg and now he has back pain level of five to six. Any thoughts as to what is making me have chronic pain issues four years out now from his left groin Mesh removal and replacement with dissolve Mesh, I’m going to assume this was done either laparoscopically or robotically for both cases.

Speaker 2 (00:54:02):

So my mom was a chronic pain patient. Okay, yeah, this, they’re a very difficult patient to manage and they suffer a lot because it is bad to have pain but when you have pain every day for a week, a month or year is something drives you crazy. Yes. And what something that shouts out in my head is the patient has in 2008 and he got it removed in 2017. So nine years after what happened in those nine years, he suffered pain for nine years before a surgeon decided to do something or he got a few years that everything was fine and then five, six years after the procedure some pain came. Cause those are some clues of why they has pain. But now the mass is removed, we understand that probably the whole mass is removed and the Mesh should not be there anymore. Back pain usually is not related to the groin pain, but back pain can be a reason for the groin pain as well. And chronic pain has the very interesting factor that even if you remove the cause of the pain, the patients still fuse the pain. Yeah. Because your brain, your center nervous system is so to feel that even when you remove the stimuli you still feel it. And that’s the parallel that I make is the patient that lo lose the limb, they can feel pain on a limb that they don’t have it. Yeah,

Speaker 1 (00:55:45):


Speaker 2 (00:55:45):

Because as it is always a very hard patients,

Speaker 1 (00:55:50):

So one of my pain doctors told me if you have nine months or more of unaddressed pain, usually nerve pain, then you start centralizing after nine months, it takes that long. So if you have it early on, you get treated, that’s fine. But after nine months, that’s when you start getting the risk of centralization. But I would recommend for this patient to get some type of dynamic imaging because it’s possible that the pelvic pain, the back pain, the leg pain and so on is just a hernia recurrence because you did have absorbable Mesh. We know that that doesn’t work for growing hernia repairs or really most hernia repairs at risk of recurrence is fairly high. And obviously what you said about chronic pain is these are very difficult patients because you have to be able to differentiate what is surgically treatable and what is not surgically treatable, number one.

Speaker 1 (00:56:49):

And number two, am I going to make their chronic pain syndrome actually worse by now offering even more surgery because you’re adding more trauma. If it’s a nerve surgery, you can push them into this kind of C R P S, the complex regional pain syndrome and so on. And there are subsets of patients that are just more prone to these complications than others. Another question has to do with when people come to see you, do you have patient experience with patients that have Ehlors Danlos syndrome, POTS, which is postural orthostatic tachycardia syndrome, mast cell activation syndrome, or anything else that makes them more prone to foreign body reaction or complications from hernia pairs?

Speaker 2 (00:57:36):

No, I don’t have experience with those syndromes and I’m always learning that always something new popping up and okay, we need to respect that. And again, we go back to statistics, we put a hundred masks, nothing happens, but there’s one patient that reacts differently and that’s the problem with MES is we can have the best product, but once we put on the patient, every patient reacts differently and then we go back to variability as you start talking.

Speaker 1 (00:58:06):

Yeah, so my practice is very different from Flavio’s. I see patients like this all the time. So I actually have a whole protocol for POTS patients and Ehlors Danlos. Patients I think should be treated differently than the average patient because they’re, their tissues just not normal. It’s very lax and you actually have to make ’em extra tight and do more than the average patient to get the best outcome and they present differently. And patients with mast cell activations, I don’t tend to occur with pots. I don’t know, I don’t understand the correlation, but I’ve seen them a lot together and patients don’t do well with Mesh. If you have mast cell activation, they just, it’s, it puts them down this spiral of chronic pain and inflammation and swelling as a reaction to the foreign body.

Speaker 1 (00:58:59):

So going back to the original patient that talked about the Mesh that got torn off the pubic bone and then suture repair, it seems like her left groin is still tender and numb with stabbing pain three years after surgery. So that’s too long to wait to heal. I would recommend looking to see if something was missed, if you now a nerve issue or recurrence or entrapment or something else that can be tweaked. And I dunno what you tell your patients, Fabio, I beg them, please be patient with me. This is a long-term process. We have a long-term relationship. I’m going to have to do imaging procedures, some things will work, some things will not work. But I’m here to figure out your puzzle, but I need your patients with me to follow through multiple steps as we go through figuring it out.

Speaker 2 (00:59:55):

So what I usually say to my patients, I may not know all the answers, but I can guarantee all my support and transparency and sometimes, as you said, the solution is not a surgery, but I refer you to somebody, but please come back. I don’t know if that work and I want to try to keep you with you all the way until we find out what is happening and what kind of solutions. If I don’t know the solution, let’s ask more people. Let’s ask different people how we can make your life at least less worse.

Speaker 1 (01:00:27):

And that’s not a weakness. You want surgeons that know each other and collaborate and talk to their friends. I do that all the time and you see me on some forums asking questions. And also I get called for questions. So I think it’s great if you have surgeons that are asking their colleagues and running cases by them because they’re curious. You want us starting this? Curious. Always waiting to alert. Alright, well the time has come, doctor. Thank

Speaker 2 (01:00:59):

You. Alrighty.

Speaker 1 (01:01:01):

Told you it runs fast.

Speaker 2 (01:01:02):


Speaker 1 (01:01:03):

Yeah. We have great audience to ask. Great questions and time flies very quickly, so thank you for your time. Your, I hope, what time is it now? Eight 30 right now. At your time? Yeah. Yeah. You need to go home in rest. You poor thing.

Speaker 2 (01:01:23):

Okay. But we should do that again. Again next time.

Speaker 1 (01:01:28):

Yes. And I look forward to being with you hopefully in Costa Rica next year.

Speaker 2 (01:01:31):

Sure, sure thing. Yes. Thank you Shirin.

Speaker 1 (01:01:34):

Thank you everyone for joining me. This ends our hernia talk session for today, Tuesday with Dr. Flavio Malcher at NYU Langone Health. You can contact him through the NYU system if you’d like to see him in New York. He’s an amazing surgeon and great friend and thank him for his time and I will see you all next week on yet another session of Hernia Talk Live. Follow me on Twitter and Instagram at Hernia doc on Facebook at Dr. Towfigh and I will post the link to the YouTube video for this so you can watch and share with all your friends. Thank you.

Speaker 2 (01:02:14):

Thank you. Bye.