Episode 8: Hernias & Abdominal Core Health | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

This is Dr. Towfigh. We’ve been doing this every Sunday so far with various guests and we’ve loved getting all your questions answered live. So here we are. Let’s start this real quick live question answer sessions. And as you know you can follow me on all this different social media outlets and this is being simulcast live on Facebook in addition to Zoom where you can register for that. And then once it’s done, I will upload it to herniatalk.com and also on YouTube. So if you guys miss it, you can always watch it. And today we are with the lovely Dr. Ben Poulose. He is a general surgeon by training laparoscopic surgeon. He is now chairman and head of the center for Abdominal Core Health at Ohio State. You can follow him on Twitter and I’m going to stop sharing my screen cause I want to say hi to my friend Ben. Hi Ben.

Speaker 2 (00:01:08):

Hi. How’s everybody doing?

Speaker 1 (00:01:10):

So you’re calling in from Ohio, I assume?

Speaker 2 (00:01:13):

I am, I am. And

Speaker 1 (00:01:17):

What’s your schedule like during this pandemic you’ve been operating or running your program? A little bit of both.

Speaker 2 (00:01:25):

Well, like most states, we just recently opened up for elective surgery and so we’ve really been taking care of a lot of the patients that we’ve postponed due to the pandemic. But Ohio actually is still recovering from the pandemic and we’re kind of doing the balancing act that many folks are doing right now.

Speaker 1 (00:01:42):

I think your state’s been pretty good. What’s your wait list? Do you know? Our hospital’s wait list is almost 3000 patients just under 3000.

Speaker 2 (00:01:51):

Yeah, we’re very similar. I think we have about 2,700 folks on the wait list and we’re kind of slowly getting through everyone who wants a surgery or procedure.

Speaker 1 (00:02:00):

Yeah, I agree. So you are a very unique surgeon in that you’re part of the hernia world. You are the current president of the American Hernia Society, which is a growing and very active society. I’ve been honored to be part of it since I started practice. The society has changed a lot. There are more young people, more women. We’ve been much better at integrating the central and South American surgeons in our society because we really, and the Canadians, because we are representing all the Americas not just the United States. So as the head of it this year, you are really kind of using that as a platform for your baby, which is core health. Is that fair to say?

Speaker 2 (00:02:54):

It is. I think it’s a fabulous opportunity and it’s an honor. First of all, it’s an honor to be here on hernia talk and I just wanted to first off congratulate Dr. Towfigh. I’ve heard about hernia talk for so long and have vaguely seen what she does and certainly seen the community that she’s built up. And I actually want to congratulate you for what I think is one of the most transformative and most useful things that we can do as hernia surgeons. And that is very simply reach out to our patients on a scale this big. I think a lot of other disease processes where people want to find answers, talk to folks with similar problems, they oftentimes have a lot of venues to do that, but hernia patients often do not. And I think this really, really addresses that. I also wanted to say everyone and least the United States a happy Memorial Day. Thanks for being here, taking some time off from your holiday weekend to be here and for any service members or families of service members. Also, again, very much appreciate the sacrifices you make.

Speaker 1 (00:03:55):

Yes, that’s very nice. That is Memorial Day weekend and we’re all kind of doing our part a little bit to make it a better country. Can I share a quick story? So Sure. My first career was very, very academic university based tenure track triple threat. And what I didn’t appreciate as much was the patient side of things. I was all into medical school and residency and fellowship and training all the trainees and getting teaching awards and stuff like that and writing all the articles that we write always geared toward the surgeon. And then in 2013 when I started my private practice, I kind of felt that the patient side was missing before I was teaching medical students. Well, I kind of still teach medical students but not as intensively. I used to run the program before, so now I’m teaching the patients and I felt I started spending more time teaching the patients than teaching the students residents and fellows.

Speaker 1 (00:05:07):

And why I started hernia attack was because it’s a free discussion forum. The audience are all patients and now that I’m during the pandemic, we started this live thing. So thank you for spending your time away from family on this Memorial Day weekend to join us but also thanks for helping promote this for me too. I know I have a lot of friends such as yourself in the Hernia Society that have been supporters of what I do because it is a little bit different than the typical surgeon goal. And so thank you for being a good supporter of it too.

Speaker 2 (00:05:50):

Well you’re welcome. And I think it’s great that you’re being an atypical surgeon because I think the world needs surgeons who are into exactly what patients need. And I think this is great. I think it’s a forum for patients to get information. Honestly, if you look at the typical interactions we have with patients, especially when we see them in clinic, it may be 15, 20 minutes and we’re expected to talk to them about their health problem. Typically hernias or abdominal core health issues, talk to them about an operation, talk to them about a potential Mesh we may or may not use in 15 minutes. That’s really hard to do to answer everyone’s questions. So I think this really feels a great gap.

Speaker 1 (00:06:37):

Well thank you enough of the love fest. Why don’t you also tell me now how you are different as a surgeon. You’re all about core health, not just doing this hernia surgery and that surgery. Can you maybe, I don’t really know your story, I don’t know your story of how this came about, why you went in that direction, what was there like an event? Did you have a dream all of a sudden, this is what I’m doing,

Speaker 2 (00:07:04):

Wasn’t a dream. Maybe it was more kind of sitting at a beach somewhere and just having a revelation. Well, it’s one of those things where in medicine often we get so narrowly focused in our own area and that’s good because we become experts in that area. But I think what happens is we lose sight of the whole patient’s experience and body function as a whole. And one thing actually, after speaking to some of my colleagues who are pelvic floor specialist, diaphragm specialist, I even have a lot of friends who are a back specialist in neurosurgery and just looking at thinking of the whole core of the body it all has to be related. And the anterior abdominal wall, which you and I spend a lot of time managing patients with, has to be related to the back, has to be related to the pelvic floor, has to be related to the diaphragm. We just think so narrowly because of our own academic divisions. I think that’s really kind of the big change.

Speaker 1 (00:08:10):

So you just define what the core is. Can you define again, very distinct terms? What are the boundaries of what you call the core?

Speaker 2 (00:08:18):

Sure. So it’s the diaphragm up on top, it’s the pelvic floor on the bottom, the back behind, and then the abdominal wall in front. And the concept is that because everything is related operations or diseases like hernias that are on the front will affect the back, can affect the pelvic floor and vice versa. And I think we as physicians have just kind of narrowly put things in little bins to make it easier for us. We often kind of lose out on the fact that we’re operating on a whole patient and it may affect our operations or the diseases we help address can affect other areas, not just what we’re talking about.

Speaker 1 (00:09:02):

So we know that umbilical hernias and inguinal hernias can cause lower back pain or back pain, a radiation to the back. I’ve had many patients that were set up for spine surgery, you fixed her hernia like oh my back pain is gone. Yes. Yeah, I mean that’s a very unappreciated kind of side effect of hernias can cause back pain.

Speaker 2 (00:09:26):

I think he really hit upon this and back pain is one thing that think all of us as surgeons have really noticed that there’s some link between hernias, repairing hernias and back pain. And I think you know would find many patients who would pretty readily agree with that. The other good example of this is in women’s health as well. In women who have really functionally problematic, postpartum diastasis after they have a baby multiple pregnancies, they can often have a weakness of the anterior abdominal wall, a diastasis. And unfortunately I think we do a disservice to a lot of women by just dismissing them and saying, oh well it’s just a cosmetic thing. It’s not a cosmetic thing, it’s a functional problem. And in fact, one of our colleagues, I dunno if Andres Olsen in Sweden, he actually made a link between repairing diastasis and improvement of pelvic floor function. Oh wow. Yeah, and it’s absolutely amazing because he presented that a couple years ago at the European hernia side meeting and it was the first time we’ve had evidence that there’s a link between fixing something on the anterior abdominal wall and it improves something on another part of the core.

Speaker 1 (00:10:40):

So one other thing that I noticed that inguinal hernia can cause pelvic floor spasm. So these patients, a lot of them are women. I see a lot of women. So I kind of see a little bit of a skewed population. I see men too, but I’m kind of like 50 50 instead of 10 to one. So these women, they go, they have growing pain or chronic pelvic pain, they go to the gynecologist because it’s down there and then they say, okay, we don’t think you have any problem, you must have. Or they may do vaginal exam and they’re very tight. Oh yeah, pelvic floor spasm. They go to the pelvic floor physical therapist and like, oh yeah, you have really bad pelvic floor spasm. That must be why you have growing pain or whatever. Or pain with sex, sexual intercourse. And they undergo pelvic floor physical therapy.

Speaker 1 (00:11:34):

It’s very painful. Those women end up having hernias. I fix the hernia, the pelvic floor spasm goes away and then sexual intercourse and all the other things that go along with it are also gone resolved by the hernia repair. And what’s really cool is a small fraction get urinary frequency. They’re like 10 times in one night, something ridiculous and they go through the whole interstitial cystitis and bladder things and urologists, et cetera, and you fix their hernia and their urinary frequency goes away. And I tried to figure out why. So I called on my, spoke to all my female urology specialist and they said, oh, maybe it’s because the hernia, like you said, effects a pelvic floor and pelvic floor goes under undergo spasm and that gives you sexual pain, it gives intercourse pain, it gives you urinary frequency, which I see also in men. And some people get a anal, like a tenesmus, like a anal spasm and then you fix a hernia that goes away. So there’s so much that we don’t, that’s not in the books that we don’t know. So I’m really excited that you’re going to figure out a lot of these questions for us to your center.

Speaker 2 (00:12:57):

I don’t know if I’m going to figure out a lot of these questions, but I think you hit upon one of the major points and that is we need to really rethink how we approach diseases of the pelvic floor, the anterior abdominal wall, even back pain and what those abdominal core health framework does. It just kind of takes a step back and resets all these disease processes that individually we may have pretty reasonable treatments, but these kind of links I think open up an entire new avenue of research, open up an entire new avenue of how we think about this. The second thing you mentioned in terms of rehabilitation, I think is a really critical aspect of abdominal poor health. If you think about hernia disease and the things we do to operate on patients with hernias, even pelvic floor or diaphragm issues, these are some of the most mobile areas of the body that you can think of. And they’re used all the time 24 hours a day. And we don’t even think about it when we have an operation for a knee or an elbow in orthopedic surgery. Everyone knows you coupled that with physical therapy. Exactly. And everyone knows that physical therapy is an important component of that. How come in surgery or abdominal core surgery that we operate on patients, we send ’em home goodbye, don’t bearing 10 pounds crazy. There has to be,

Speaker 1 (00:14:20):

No one has come up with the physical therapy that’s appropriate all the time. Are you going to send me a physical therapy? I’m like, no. But

Speaker 2 (00:14:30):

An answer for that one. Finally, for the past three years actually, we’ve been working at my former life at Vanderbilt, but most recently at Ohio State. And one thing, and this is a shameless plug for Ohio State. Sure. Because of the athletic program we have here, mainly football and basketball we have a massive amount of help with our physical therapists, our physical medicine and rehabilitation groups here. And they have really done a fantastic job of taking this idea of physical therapy for the core and developing targeted physical therapy regimens for that. And it’s available free for all patients and all surgeons right now on the ah AHSQC’s website.

Speaker 1 (00:15:14):

Oh, okay. On that note, I want to share with people what is the AHSQC. Let me go to that slide because this is very important. This is something that is important not only for patients, for doctors, but also for patients. So I hope everyone sees this. This is the website for the AHSQC. It stands for American Hernia Society Quality Collaborative. And there’s so much interest out there for people to know what happens to these patients. How come my surgeon doesn’t follow up with me after two weeks and now I’ve got this complication or whatever. This is it. This is the only hernia based data collection set in the United States. Is that correct?

Speaker 2 (00:16:02):

That’s correct.

Speaker 1 (00:16:03):

Okay. And this is work that you initiated in collaboration with the American Heart Society. So I’m going to leave this up so the patients can look at it, but can you just briefly tell us what the AHSQC is and how this is relatively important for patients to know about not just doctors?

Speaker 2 (00:16:25):

Sure, absolutely. So the AHSQC is very simply a way for surgeons and patients and also industry and also the FDA to improve what we do in hernia care and improve the quality of what we do. One of the problems in our healthcare system is that our healthcare system really isn’t geared to have someone have a patient, any one of us undergo an operation and then follow you long term to see how you do. Our healthcare system would rather do the operation check, make sure you’re okay one time and just kind of wave you on by as you continue on your journey. But that’s not how hernia should work because oftentimes we’re recommending the implantation of products that are going to be with you arguably for the rest of your life. So we should have some responsibility as surgeons and as industry members and even as the FDA to see what happens to you over time. It’s a very simple concept, but it can be very hard to do that in our healthcare system. And so the AHSQC helps with that, what it offers to you as a patient. If you’ll, can you scroll down a little bit, Shirin?

Speaker 1 (00:17:30):

Yes. A screenshot.

Speaker 2 (00:17:32):

Ah, screenshot. Okay. So whenever you guys go to the website, at the bottom right when you look at the mobile app, you as a patient can download the mobile app directly to your smartphone. There’s both an Android version and an Apple version. And on that app is contained several. There we go. Materials. Oh cool. There we go. Great. So you can download the iPhone version, download the Android version, and it will have two things. It will have a risk calculator that can be used to calculate your risk for undergoing particular types of operations and particular types of medical profiles. And you can also download the abdominal core surgery rehabilitation part of it, which takes you through directed core exercises developed by 16 physical therapists across your country and can really help you recover from your surgery.

Speaker 1 (00:18:21):

So that’s free on the app?

Speaker 2 (00:18:23):

It’s free on the app. Free for surgeons. Free for patients, yeah.

Speaker 1 (00:18:27):

Okay. Well, I’m going to, I didn’t know that.

Speaker 2 (00:18:30):

Yeah, really?

Speaker 1 (00:18:31):

I didn’t know that’s new. I didn’t know you guys at that because I’m a member of the AHSQC. Every single patient that sees me gets logged in. We encourage them to continue to provide feedback on the site so we can get long-term results data not just about my repair, but also we’re really interested in also other things like the Mesh implant and how that if there are any problems with that in long term we don’t have enough data. Product depend product exclusive. I didn’t know you guys had that. Okay, cool. So I’m going to use that. Yeah. Is that something that is downloadable to, or did it go on the app?

Speaker 2 (00:19:18):

It’s easier on the app because it’s much more easy to navigate on the app and the app actually has videos coupled to the exercises that show you exactly how to do the exercises. There is a downloadable version on the website too. It’s a pretty thick amount of papers, but still that can help if you don’t have a smartphone.

Speaker 1 (00:19:41):

Okay. Let’s see. I’m going to ask some questions for you because we’ve got people on Facebook and Zoom with some questions. So if you don’t mind, I’m going to ask, have you answer some questions while you’re here.

Speaker 2 (00:19:55):


Speaker 1 (00:19:56):

Okay. So okay, one, we have someone here from, looks like from Canada making some comments how this will never happen in Canada. <laugh>, what are some long-term relationships? Oh yeah, long-term relationships. This is a common long-term relationships between the patient and doctor is critical. And I think for cancers, the patients have long-term relationships, but for hernias we would love to have long-term, but it, it’s not something we see commonly. Do you agree with that?

Speaker 2 (00:20:36):

Yeah, I agree with that. And the reasons for that are many. I think the cultural connotation of cancer evokes many more emotions in patients as opposed to hernias. Although hernias can certainly be very impactful events to patients. And in fact, we have a lot of patients who have hernias after cancer operations. That’s true. But I think part of the problem is though, is that as kind of a society, we tend to think of hernias less of a problem than cancer. And so if you’re doing okay, why should we even follow up 3, 4, 5 years afterwards? And I think that’s where we need to get the message out. That is actually quite important because if you are doing well with a particular Mesh in a particular repair, we would certainly want to know that. And just like a patient undergoing colon cancer 3, 4, 5 years out of their colon cancer operation, we would certainly want to know that they’re cancer free. So very similar, we’d want to know that

Speaker 1 (00:21:36):

Talking about cancer, there was one who patient who had a sarcoma sounds like, and then they had a hernia and their sarcoma was addressed, but now they still have a hernia. It’s unclear though, if the hernia was related to the sarcoma. I actually had a patient that presented with a hernia and I forget why I imaged him. It just didn’t feel right. It felt a little firm and it was actually huge retro cranial sarcoma that extended into the organ.

Speaker 2 (00:22:06):

Wow. Yeah, that’s unfortunate. And that really goes back to abdominal core health. What we do as we limit ourselves to a definition of hernia surgeons, 25% of my practice is abdominal wall oncology. And so it goes back to this idea of we’re not just hernia surgeons, we’re surgeons that take care of a very dynamic organ, really the anterior abdominal wall as part of the core.

Speaker 1 (00:22:33):

I agree. How is the sports hernia related to the core? Is that that’s not really part of the core or is it,

Speaker 2 (00:22:43):

I would consider it a part of the core. And if you think about the complexities of the pelvic region, certainly I know you’re very, very well familiar with this area. And if you think about all the different forces that are applied to that area, certainly there’s, just because we can’t see something and precisely identify something on an MRI or a CT or an ultrasound, you and I in our field makes this simplistic assumption that, well, there must be not anything there to it. Well, of course it’s not that simple. It’s much more complex than that. And so I think our healthcare system, especially surgical disciplines, have a real problem dealing with problems that can impact patients that might not show up on a CT scan or an MRI or an ultrasound. I do think there are patients with several types of non hernia, non-class hernia type of pain in the inguinal region that can be due to a multitude of problems. I think the idea of a core muscle injury or a spurts hernia I think is a real one. The question is what do we do about it? And to me, I think what’s a little simplistic is thinking that our hernia operations automatically should fix that. No, I mean if hernia operations are for hernias and I think we need to really investigate that much further, are there other tailored interventions which could include physical therapy of various forms that can help that? It’s a whole area that we need to look into.

Speaker 1 (00:24:11):

So one question we have on Facebook Live is if you had multiple hernia repairs, right, presumably many with Mesh in and out, take out Mesh, maybe researcher or recurs, et cetera abdominal wall hernias, how does that affect your core and should you be worried that you’re weakening your core or does a repair not weaken your core? What do we know about that?

Speaker 2 (00:24:35):

I think this is one of the biggest thing problems we really, really struggle with as hernia surgeons. The hernias that come back, especially in patients multiple times over, if you look at the information that we know about, especially fixing anterior hernias or hernias in the front part of your belly, not necessarily inguinal hernias. Yeah, if you wait long enough, they will come back to some degree. So I really think what we need to do is shift our thinking away from it’s a one and done type of thing where we fix it and we expect it never to come back. It’s a super dynamic area and if you look at over time what happens, they likely will come back if you just wait long enough. And so I think we need to really change our focus to thinking of these problems as more of chronic diseases as opposed to just a simple thing that we cure. So the bottom line is sure, it absolutely does affect your core strength and the more hernia repairs that you have very likely weakens it. We certainly need to develop some measures to help measure core stability and core strength kind of as the whole unit. But absolutely that will definitely affect your core strength overall.

Speaker 1 (00:25:46):

Okay. Another question. How will my umbilical hernia repair affect my athletic abilities after recovery? As someone who experienced two pregnancies, I was left with a diastasis recti and now a Mesh repair. Will that help close the gap from diastasis to strengthen the core more so than it would without the repair?

Speaker 2 (00:26:06):

Great question. Whenever you have an umbilical hernia along with the diastasis, it can be really challenging to help figure out what the right thing to do is. I think certainly you can have some discomfort from the umbilical hernia itself and repairing the umbilical hernia should help with that. Whether or not it helps also with the function of your core. In terms of the diastasis, that’s a little bit more difficult to figure out. I think it really probably won’t affect the diastasis much and the core strengthening exercises you do in the physical therapy can have some impact. But I’ll be honest with you, it’s just an area that we really need to spend more time investigating because I personally don’t think just telling a patient that, well, I’ll just do some physical therapy and exercises for a diastasis this big is going to help. I do think there are some surgeons that will consider repairing it, but we definitely need more information to see if that repair is actually going to help patients long term.

Speaker 1 (00:27:02):

But the reverse is not true. Right. Can her, can abdominal hernia cause lumbar disc disease or just pain

Speaker 2 (00:27:10):


Speaker 1 (00:27:11):


Speaker 2 (00:27:12):

We don’t know. And I think this is where we need a large area of investigation. If you’ll take a little bit of a back step, why is a lot of the answers that I’m giving you or that Dr. Towfigh is giving you all is, I don’t know. We’re not sure. Well, unlike a lot of things that we deal with, cancers, low back pain, things like that where there’s been a lot of research funding put forth through it for years and years and years. Hernia and abdominal core diseases don’t have a lot of research funding and we need to have some more support for these things to answer these questions. Definitely.

Speaker 1 (00:27:50):

Another question is related to can a diastasis recti so can you have one core problem? Cause another, can an inguinal hernia cause a diastasis recti?

Speaker 2 (00:28:03):

Yeah, I think those two things are probably separate. Certainly they’re two things that affect the abdominal core. My kind of initial thought is that they’re probably unrelated in terms of what causes the other, but certainly they add up together in terms of how they affect your core. And that’s a really cute poodle that really wants your attention. You

Speaker 1 (00:28:27):

See that?

Speaker 2 (00:28:30):

I mean,

Speaker 1 (00:28:30):

Hey, can’t be on this

Speaker 2 (00:28:32):

Live. I think he won the show. <laugh>,

Speaker 1 (00:28:36):

You bothering me this whole time here. Come on in here. Come on. All right. Okay. I have some questions that have been presented. So let’s see. Oh, what do you have to say about nuerectomies? We do nuerectomies for pain. Some people do nuerectomies just for prophylactically, for anal hernias as you know, and we’ve discussed this on hernia attack before, if you have a very proximal, so the closer you get to the spine, the more likely you are to lose. Not just sensation, which is the purpose of most nuerectomies is to reduce chronic pain, but the muscle function is gone as well from that. So what are your thoughts about neurectomy or are there ways to reverse it or gain, it’s such a horrible complication when you get this denervation sometimes with kidney surgeries you get nerve that’s caught aorta surgeries. What is your answer to that besides don’t do it

Speaker 2 (00:29:44):


Speaker 1 (00:29:45):

Kind of reduce complications or what in meantime<inaudible>?

Speaker 2 (00:29:50):

Yeah, I definitely think that during the course of surgery, especially inguinal hernia operations we need to basically leave the nerves exactly where God put ’em as much as we can. There’s a reason they’re there. They’re a reason why they exist in that space. We kind of have this almost arrogant attitude that we can move them around, cut them and people will be fine. Well no, sometimes they’re not fine. And so I think as surgeons, especially with inguinal hernia operations, we need to be very careful and not necessarily divide nerves, section nerves. We preserve them as much as possible a hundred percent as far as nerves being injured and causing other bulges and other problems after other operations. And you mentioned one of the most common ones when you have a kidney operation or any kind of operation where you have a cut on the side of your abdominal core or your abdominal wall, it can lead to asymmetries and bulges and weaknesses there. There’s not a whole lot we can do about it surgically. I do think though that is one instance where physical therapy does help quite a bit. And the other thing that I think that probably needs to have more investigation is does targeted stimulation of that area help out at all? And those are areas that we really need more answers with.

Speaker 1 (00:31:16):

Yeah, that’s a good one. If we could figure that one out that can save or really affect, improve the quality of life of so many

Speaker 2 (00:31:23):

People. And actually one of our patients here just mentioned that it really affected everything they do a hundred percent. It really does. These can be very disfiguring, these can be very impactful on your function. And one of the most frustrating things I face as an abdominal core surgeon is seeing patients who are in your condition like that and basically telling them, we don’t have a whole lot we can offer you because and again, to me that’s all we can do now, but that’s unacceptable. We have to investigate these things and figure out how we can help patients better.

Speaker 1 (00:31:55):

Yeah, totally agree. All right. Some more questions for you. Actually, there’s a question that came back that came to us a couple weeks ago. I’d like to ask you the same question. I forget who, I don’t know if it was Brian that we asked. It was a pretty insightful question and here it is. Why are there so many in different interpretations of watchful waiting? So they’ve been to different doctors and then each surgeon kind of said, oh, well watchful waiting means you should have surgery. The one said, well watchful waiting means you shouldn’t have surgery can you? Okay, maybe you tell me what your take is on the watchful waiting trials and how you interpret those results in your practice.

Speaker 2 (00:32:47):

Sure. I’ll start by asking everyone here on a question. So if you asked 10 surgeons how to take out an appendix, yes, how many answers you think you would get and put your answer on the chat if you can. So if you have insurgents, how many different ways you would take out an appendix, how many answers would you get?

Speaker 1 (00:33:08):

I mean it’s like laparoscopic open. I would staple it, I would clip it, I would use the harmonic, the port need to be this way, then the ports need to be that way.

Speaker 2 (00:33:18):

You’d probably get about 20 different answers from those 10 surgeons. And so washable waiting. I think the generally accepted definition or interpretation of that is to make a decision not to do an operation and follow and see how you do. And so that actually may be a very reasonable thing to do for two reasons. Number one, the benefit of the operation may not be something that in that surgeon’s experience and in the knowledge we have that would provide you much benefit as a patient. And the second component of that would be you may have a situation where the medical problems you have the difficulty or the anticipated amount of how difficult the operation would be would, it’s just too much and it would be better to make a decision not to do an operation. And I know a lot of you are in very, very difficult circumstances where you want something done because you’ve had so many things happen to you, it’s affected your life, it’s affected your family’s life, maybe it’s affected your finances.

Speaker 2 (00:34:26):

When you reach a surgeon at the end of all those trips you make to different physicians and surgeons who thinks about your situation very carefully, talks to you for more than 20 minutes, looks at all your tests, cares about what your situation is and recommends watchful waiting or not an operation, you need to hug that surgeon and really seriously. And we really need to appreciate that because that surgeon sounds like they’re making a pretty good decision on your behalf. I know it’s probably not what you want her to hear cause you want that fixed, but what they’re recognizing also is limitations we have as surgeons and even in their own skill set. And that’s an important judgment point is to sometimes you just shouldn’t do an operation.

Speaker 1 (00:35:15):

Yeah, I agree. I agree. The other question is this was about someone’s boyfriend who has a bulging naval umbilical hernia. What can they do in terms of exercises and activities? What’s safe to do and what shouldn’t they do? Do we know enough to be able to answer that question?

Speaker 2 (00:35:37):

I think we’re learning more actually. Yeah. We used to say you shouldn’t do anything. Don’t lift anything over five pounds, you’ll you’ll stress the whole thing out. One of the colleagues of myself and Dr. Towfigh, Dr. Henneford, I’m sure many of you’ve heard of, did I think one of the most fascinating studies several years ago where he and his research team looked at what are the activities that a human being can do that really stress the anterior abdominal wall? And we often think it’s jumping, doing activities, exercises, core strengthening stuff, running, all those things. The two things that were the most impactful activities were coughing and sneezing more than anything else. And you think if you were a patient with hernias, you know this just by being who you are because you know that when you cough and sneeze, it’s a huge amount of pressure over a very small amount of time. And so my answer to this would be do whatever activities make you happy and do it. Activities that you can tolerate that doesn’t aggravate the hernia in terms of pain. And if you can do particular activities mostly oftentimes aerobic activities. That’s okay.

Speaker 1 (00:36:50):

Yeah, I agree. So do you tell your patients, I tell my patients prevent coughing or if they catch a cold of some sort, don’t let that cough later for two, three months, treat that early and then constipation’s a big one, the straining. But do you let them do and planks and weightlifting?

Speaker 2 (00:37:13):

I do in general. I do. It’s a little bit different. If I’m talking to someone who does orange theory on a daily basis and does us very high impact, high intensity, high frequency type of exercises, then we have a more frank conversation about what specific activities you can and can’t do. Another good example are in power lifters, in bodybuilders who will easily lift 400 pounds with many, many different type of act. Those kind of things you got to modify. But I think short of all those activities in general my recommendations are do what you can because that’s what makes you healthy. And if you really have pain in the area of your hernia when you’re doing an exercise, you just got to modify things.

Speaker 1 (00:38:00):

Yeah, I agree. I think the people that are doing very careful exercising that’s safe for their back is probably also safe for their belly. Whereas the people that I see that they weights in the gym, you’ve seen those people, that’s

Speaker 2 (00:38:22):


Speaker 1 (00:38:24):

But they’re like, they’re throwing and it’s like, I mean that’s just that kind of quick jolty rapid movement I feel is not right. Before this whole pandemic, I signed up with a new trainer. He’s amazing. He’s 72 years old and yeah, exactly. And he is so fit and so good. And he is been around the block forever and so knowledgeable. So knowledgeable. And I’ve had two spine surgeries. Oh wow. That’s good To him, I’m like, listen, I’ve had spine surgery. I don’t trust the average trainer who barely has any. I know more than that person to train me, but I really need to get back to a normal person. He is so good. And he walks around the gym and I go to Golden Gym, which is the Arnold Schwarzenegger gym with all the Bible and it’s like little me and this 72 year old guy, but he knows everyone there and he points out to me all these people that are doing everything wrong. So it’s bad for your back, it’s bad for your core, it’s bad for your potential hernia. Yeah, there’s a lot to learn.

Speaker 2 (00:39:41):

This is a great discussion. So you can imagine how your trainer when he is walking through there and pointing out doing it wrong, doing it wrong for good reasons, because it stresses your body in bad ways. So you can imagine now how critical it is after an operation making sure you’re doing the right exercises calibrated to your operation. Yeah, I think it’s a fascinating thing. It is really an area that we need to understand more as surgeons.

Speaker 1 (00:40:11):

Yeah, I wish he actually has an interest to do some work like that to learn because he gives me books to read and articles. He’s very scientific about anything which I appreciate. But I mean he’s so good and the fact that he’s so much older than everyone and so fit. But he basically tells you if you want to work on your abs, let’s say there’s a good way and a bad way to do it. You don’t have to stress your back to work on your apps, things like

Speaker 2 (00:40:40):

That. If you forget everything about this hernia talk session, planks are the best

Speaker 1 (00:40:46):

Planks, but there’s different types. So he’s telling me there’s different types of planks, there

Speaker 2 (00:40:52):

Are different types of planks

Speaker 1 (00:40:54):

Anyways. So there’s different ways to do things without stressing your cause I had cervical and lumbar. He doesn’t want to stress my neck either. Anyway. I love him to death. He’s great. Okay, remember, are you ready for the next question? Sure. Okay I plan to have children, but I don’t want to get a diastasis recti. Is it possible, is that even possible or am I doomed to lose my flat abs from the baby?

Speaker 2 (00:41:20):

Great question. And again, I think every mother should be thanked for <laugh> having to undergo this and not know what you’re going to come out on the back end in terms of your abs. So I think again, we just don’t have an information to really to answer that with any real authority. But I would say that you can do some things to minimize the effect of the diastasis. I do think that if you think about what happens during pregnancy as you’re pregnant with your baby, everything stretches out, including your skin, your muscles, the coverings of the muscles

Speaker 1 (00:42:02):

First open in some people.

Speaker 2 (00:42:04):

Yeah, absolutely. And then we expect something very amazing to happen after you deliver your baby. And that is everything come back to normal after that. And it’s amazing that most of the time that does happen. But when it doesn’t happen, especially how multiple pregnancies, yeah, there’s no question it can be a big impact on your life. I do think that there is some benefit after your pregnancy to start targeted core exercises. And I think that’s probably one way to build up your muscle again and also build up the strength of your fascia, the collagen layer covering the muscle. So I would actually suggest doing that as much as you can after the pregnancy. Again, it’s hard to do that because you’ve got a baby, you may have other kids and other things to do, but I do think that that would be one thing within your control that you can do. But it’s hard.

Speaker 1 (00:42:54):

So I think they should wrap. There’s been no good studies. Well, there have been studies, but there have been no great studies looking at diastasis recti postpartum. But what we do know from one study is that wrapping and doing transverse abdominus exercises can reduce the diocese by one centimeter best case scenario. But what I don’t see gynecologists or obstetricians tell their patients is to wear some type of hernia belt in their third trimester to reduce some of the pressure on the pelvic floor. And also second is to wrap themselves early postpartum to kind of encourage the while it’s still fresh so to speak, and not scarred down for the diastasis, the rectus muscles to get back to the midline. Those things don’t hurt may help. And I think it’s very genetic, isn’t it? Genetic, the whole diastasis concept

Speaker 2 (00:44:01):

In some men, right? I’m pretty sure there’s a genetic component to it. Your points a really good one when you really have, I think a finite amount of time to recover your core muscles after a pregnancy or after any kind of operation, if you think of it that way, where the muscles and the collagen coverings and the muscles still have the ability to be programmed basically. And I think your point’s a good one. Yep.

Speaker 1 (00:44:28):

Yeah. Okay. Looks like we may have another question, another pregnancy question, 20 weeks pregnant and have an Anglo hernia. What concerns should I have and how should I treat it while pregnant? And then will it grow? Will the hernia grow as my body grows during pregnancy?

Speaker 2 (00:44:49):

Well, first of congratulations on your baby. Exciting time. And certainly having a baby and a hernia is not a fun experience. I think if the hernia is not really bothering you much, I would recommend just not doing anything about it during the pregnancy. And if there is a situation where it starts becoming more impactful to you start having pain from it on a more regular basis, then it certainly would be good to talk to a surgeon to get your opinion on whether or not something should be done about it. A lot of times in women who are pregnant and have inguinal hernias, oftentimes you can talk through it and figure out what activities are really triggering the pain. Certainly as your baby grows that one of two things will happen. Either in my experience, some women actually have less symptoms later on because the baby just kind of occupies that whole area and it just kind of helps push things off to the side. But some women do get worsening symptoms from it as the baby grows inside your abdomen and push forces more things through the hernia. The biggest concern anyone would have is that an emergency scenario arises with the hernia while you’re pregnant. That’s very, very rare overall.

Speaker 1 (00:46:08):

Yeah, very rare.

Speaker 2 (00:46:10):

Very, very rare. And so I think you can take some comfort knowing that that situation is very rare where something really needs to be done on an emergency basis. And if you have any concern of that, obviously seek out your doctors. But overall I think we like to not repair hernias while you’re pregnant. If you do have symptoms while you’re pregnant, oftentimes just modifying your activity can help minimize those symptoms.

Speaker 1 (00:46:36):

Yeah, absolutely. I think in general, well for abdominal wall hernias, we try not to repair them until you’re done with all your pregnancy plans. And then for inguinal, like you said, it’s the very low risk for an ever to cause a problem during pregnancy. This is a good question. Does diet play a role in recurrence of an Anglo hernia or in core health?

Speaker 2 (00:47:05):

Great question. We don’t know the short answer. We do know that. I know I’m embarrassed to say we don’t know all these things. There are some things that I think we can think about and kind of figure out how it plays into core health. We know that your diet in terms of how it impacts your overall health can then impact core and impact hernias especially if you’ve got a bit of extra weight on you over time. We know that that has an impact on hernias and repairs. Now, what’s really something we don’t understand really well is how diet affects collagen formation, how diet affects muscle regeneration, muscle healing. I think our nutrition colleagues are really, really starting to begin to understand how different diets can affect those type of things and something that’s just still pretty brand new.

Speaker 1 (00:48:02):

Yeah. Can you explain that? When people get a six pack, they have their AB right, it’s, it looks like there’s cuts between

Speaker 2 (00:48:12):

See mine, they aren’t there, I need to do more planks.

Speaker 1 (00:48:20):

How does a abdominal wall hernia or Mesh repair affect that? That’s one of the questions is after umbilical hernia repair does a Mesh form to your gabdominal wall? And if so, does that mean it’s possible for the abdomen to become flat again and regain the six pack?

Speaker 2 (00:48:38):

So the six pack, if you kind of think of what gives you the effect of a six pack, it’s the way the rectus muscles, which the set of muscles on the front part of your abdomen are set up, they basically look like blocks stacked up on top of each other. And when you have a smaller hernia, if you already have a defined six pack smaller hernia, like a small umbilical hernia, you should be able to still maintain that look of the six pack and you’ll still be able to continue that. Now if you have larger hernias that actually expand out into the actual six pack muscle itself, for example, this happens in patients who undergo cancer operations or other operations that really affect the core there. And when a hernia forms there, it can be more difficult even after a repair to recreate that. But what I have found is that in patients who are fairly healthy, have even sizable hernias you can get some of that effect back as you fix the hernia and you reapproximate the muscles together. It’s not nearly as pronounced as it would’ve been before a hernia operation, but you can work on it and get at least in the direction of a six pack.

Speaker 1 (00:49:51):

All right. So we have 10 more minutes. I’d like to touch upon a little bit of what your interests are in terms of post-marketing surveillance and so on. But before we do that, just to recap maybe explain how care or the approach is different in your center for abdominal core health compared to the average kind of general surgeon’s office that you go to and why that’s important or why you feel that’s important.

Speaker 2 (00:50:20):

Sure. So our center for abdominal core health at Ohio State really takes a very holistic view as a patient, as are several other centers for abdominal core health kind of popping up around the country. And just to explain what that means what it means is we are thinking more in terms of the function of your abdominal core and trying to tailor therapy or a treatment plan specifically for the core itself. For example, you might have pelvic floor problems and you might have an inguinal hernia and you might have lower back pain problems. Well, if that’s the case, you come to our center predominant core health and we try and arrange that whole for you to see those specialists all in a pretty close time frame. So we make it easy for you to really get information about all your problems. And then we tie it all together also with physical therapy. And we also include other alternative therapies that are even beyond surgery or traditional medicine. We incorporate our inner center for integrative medicine, therapeutic yoga acupuncture, mind mind, body therapy as well. And that really, really helps because I do think that thinking of these areas is much more of a holistic type of functioning unit, is far beneficial than thinking of it very narrowly.

Speaker 1 (00:51:47):

As we discussed earlier, the AHSQC, which has been spearheaded by you in which you spent a lot of time and effort on is the only opportunity that we have as surgeons and as a population in the United States to look forward after hernia repair and see what happens with time in one year, two years, 10 years, 15 years, 30 years, lifetime of the patient basically. And that’s kind of also the direction of the FDA, I think, and the patients would like industry to go. So what can you tell us about the future of hernias, hernia, Mesh products the role of the FDA, how we can learn from what’s happening in the European Commission? What are your other thoughts?

Speaker 2 (00:52:35):

Sure. So I think it really is very, very simple. And that’s the following. If we as a society are allowing implants to be placed, meshes to be placed in patients, we have a responsibility to see what happens to patients over time, period. That is a very difficult thing to make happen, especially in our healthcare system. As we mentioned earlier, it’s just very difficult to follow patients long term, but we’ve got to find a way because it’s clear right now the system that we have is basically nonexistent. There is actually a surveillance system that we have, but it’s voluntary. It’s not very well thought out. It’s really more to just kind of check a box to say, we have a surveillance system, but we don’t, it doesn’t work. So as a surgeon actually, the reason why we came up with this was that I actually had one of my first patients when I was in Nashville ask me, Hey, if you’re going to implant that in me, what’s the 10, 15 year consequence of having that Mesh product placed in my body?

Speaker 2 (00:53:43):

And it was like, crickets, <laugh>, we don’t know. And to me that’s really unacceptable because if we’re designing these products to be placed in patients long term, we have a responsibility as surgeons, as industry, even as patients, and as the FDA to make sure that they’re safe and we follow them effectively. And right now, I mean again, outside of the QC in this country, it’s not happening. And so we often experience patients who have, again, most patients do well and that’s good, but there are patients who don’t do well and have serious problems associated with their repair. And we need to find out why that is. We need to figure out as best as we can. Is it the product? Is it the technique? Is it what exactly is going on there? The interesting thing is you mentioned in the European Union, they now require the mandatory following of these products over time.

Speaker 2 (00:54:38):

And actually Australia just did that too. And it has to do with how we classify our Mesh products. We haven’t done that here in the United States, so we do the best we can. And so I also think though that industry doesn’t want to make a bad product. I mean, it’s just kind of bad business for that to happen. And so we’ve worked with industry because largely that’s the only group that will fund us right now in terms of helping us follow patients long term. And so we here in the United States, work with industry, work with our patients, work with the FDA to ultimately meet that goal of trying to figure out what happens long term.

Speaker 1 (00:55:17):

All right. Well we’re almost done, I think. What kind of core activities are you doing during this pandemic?

Speaker 2 (00:55:24):

<laugh>? Right. Well, my 10 year old daughter and I she’s been forcing me to do my plank work. And so

Speaker 1 (00:55:31):

The planks on your hands or your elbows or

Speaker 2 (00:55:35):

Elbows. So I do one minute elbows. Yeah, one minute side, one minute side, one minute straight up. And I try to repeat that with two additional sets.

Speaker 1 (00:55:47):

Do you do Pilates?

Speaker 2 (00:55:49):

I don’t do Pilates. I’ve just started getting into a little bit of yoga. I should be more into yoga given my background. No, I don’t do Pilates.

Speaker 1 (00:55:58):

I must say Pilates was the one thing that Sammy from injury, and I am a huge Pilates fan, I have a great Pilates instructor because she’s very intelligent and for whatever reason, knows exactly what kind of day I had. If I was operating late at night or came back from a trip overseas or something, she knows exactly which parts of the body to stretch out and balance out. But I feel like Pilates much more than yoga even. It’s great for core. And I’m telling you, the first time I had an injury, I tore like a ligament. You could barely see it on MRI and I could barely sit or stand up because of the pain. And after that I just did Pilates. And I’m telling, lemme tell you, I never got back pain anymore. Never had neck pain after that. I mean it’s for surgeons, I think it’s the best thing.

Speaker 2 (00:56:56):

<laugh> Pilates,

Speaker 1 (00:57:01):

It really helps with our, I we’re so prone for occupational injury,

Speaker 2 (00:57:06):

I’ll have to get on my Pilates.

Speaker 1 (00:57:11):

I’m just a big fan maybe cause I have an excellent Pilates instructor, but I see some patients that are, I almost got injured doing yoga, but I’m just not flexible like that. You don’t need to be flexible with Pilates, everything is smooth and it works on, it really does the core. It really does. It

Speaker 2 (00:57:28):

Does deal

Speaker 1 (00:57:29):

With all the core muscles

Speaker 2 (00:57:32):

And Pilates, bar yoga. Those are activities that really, if you think about it, they really center around the core concept and that’s what it really is all about. And in terms of the balance and the movements and yeah, they’re definitely beneficial exercise in the relatively low impact too.

Speaker 1 (00:57:53):

But I think CrossFit not so much. What’s your thought on CrossFit?

Speaker 2 (00:57:58):

Oh yeah. Tell you a little story. CrossFit. So I went to CrossFit on a dare. Again, not to <laugh> talk down any CrossFitters who are on this, but I went to CrossFit on a dare three years ago and I was at the one time we’re surgeons, right? We’re like, we’re going to do it a hundred percent. So I was that guy throwing the thing everywhere and all that stuff. I couldn’t move for two weeks after that. So I think a lot of people benefit from CrossFit. You got to be careful though, because you can’t injure yourself unless you do it correctly. And with the right training,

Speaker 1 (00:58:31):

I feel it’s a lot of fast movements and jerky movements. It’s a lot smooth and kind of low impact. It’s a little bit high impact. And I don’t like CrossFit. That’s like my thing. I tell, I’ve had a lot of patients come after P 90, what’s it called? P

Speaker 2 (00:58:48):


Speaker 1 (00:58:49):

P90x. And there’s another one too, infinity or Xfinity, some crazy name which sounds like very raw <laugh> extreme exercises and they’re very CrossFit based and they come and enter and I feel that insanity. Thank you. Marcy Insanity. Yeah. And

Speaker 2 (00:59:12):

You really want to do an exercise called insanity.

Speaker 1 (00:59:15):

I know. And so I kind of say, no, don’t do that. Yeah, they’re the people as p90x,

Speaker 2 (00:59:22):

<laugh>, maybe P90X was. So I

Speaker 1 (00:59:25):

Made a comment about that on Twitter that like, oh, I’m against CrossFit and Yuri Novitsky got so pissed off as if I hurt his feelings about it. Or I’m somehow negating all CrossFitters out there. I don’t know. But I feel like the world can do without CrossFit from a core health standpoint,

Speaker 2 (00:59:47):

<laugh>, right? It’s high impact.

Speaker 1 (00:59:50):

<laugh> a little high impact. All right. Dr. Polls, thank you so much for this. I’m going to no longer take up so much of your time because it’s been fantastic. So usually we end with me saying goodbye with this slide because I just want to remind everyone that I will post the actual final video on YouTube. And you can also watch it right here where you are on Facebook Live. And however, I think even more importantly, we need to share this page, which is Dr. Poulose’s and the American Hernia Society’s Quality Collaborative. And for all of you, it’s a h s qc.org. There’s a free mobile app, which includes not only information related to for hernia patients, but also some free links and rehabilitation programs, diagrams, videos et cetera. So on that note, thank you, Ben. I really appreciate it. It’s been lovely. I would love to talk with you more. I hope to see you again soon. Whenever that is. A HS is in September, American Society annual meeting is in September.

Speaker 2 (01:01:15):

That’s right. And thanks for having me. This has been a lot of fun. And thanks everyone for your attention. And again, kudos, Dr. Tofi for hernia talk. I’m a big, big fan. Thank you very much.

Speaker 1 (01:01:26):

Thank you. Thanks for everything you do. Take care of yourself and for everyone out there, happy Memorial Memorial Day weekend and peace out. Thank you. Bye.

Speaker 2 (01:01:34):

Thanks folks. Bye-bye.