Episode 80: Giving Thanks & Looking to the Future | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

Hey everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live, our weekly Q&A session for all my hernia friends. We call ourselves hernia nerds, but some people don’t like the term nerds, so hernia friends. Thanks everyone for being on Facebook Live right now where we are going to be fielding all your questions and answers, and thanks for all of you who follow me on social media at Hernia Doc, on Twitter and Instagram, and thanks for all of you who log in on Zoom. So today is going to be special and that today is our session right before Thanksgiving. This today’s Tuesday. Thanksgiving is this Thursday. Thanksgiving is officially my favorite holiday. We used to celebrate really huge. I cook so I would do a full Martha Stewart like everything from scratch menu. I’d plan it a month in advance and do all the cooking and take a whole week off of work to cook and bake and do everything literally from scratch.

Speaker 1 (00:01:10):

Even the cranberries and the pies were all from scratch. Ice cream was from scratch. We’d have two turkeys and two roasts and anyway, that was when I was much younger and had a lot more energy. We go out to dinners now, so this Thanksgiving I’m looking forward to being with my family and friends and being served a nice Thanksgiving dinner and kind of relaxing for the weekend. I have a lot on my plate to catch up with. So the theme of today’s Hernia Talk Live is giving thanks and I would just like to take this opportunity to thank all of you guys. This is officially our second Thanksgiving with you all. You may recall that I started Hernia Talk Live the Q&A session, which became a weekly session 80 sessions ago. Today is our 80th session. Can you believe that? 80 Hernia Talk Lives with all your questions being answered?

Speaker 1 (00:02:17):

And I’m super excited about it because I definitely did not expect this to become as popular as it currently is. Of course, popular is very relative. I’m not as popular as some famous person in their own world, but for hernias, we are the only one that offers answers to your questions. You may know that hernia talk.com was a website that I started back in 2013. I used to get so many questions sent to me and like patients asking me, and many of you know Sheila Yancy. Sheila is my office manager back in 2013, actually back in 2008 when she first worked with me, she would get these calls and these patients would have these stories and no one was helping them. They needed help and they would send all their information to me through Sheila and I would try and help and I would answer all as many questions as I could and I noticed that the questions were very similar and so I kept repeating answers to one person and I told myself, why am I doing this one patient at a time when I can maybe help thousands of people at a time?

Speaker 1 (00:03:36):

So in 2013, I built a website called herniatalk.com. It’s free, you can sign up or you don’t even have to sign up. You can just read through it if you want and stay private or you can sign up and post your questions or interact with others. It’s filled with I don’t know how many thousands and thousands of posts in the past eight and a half years. It’s become intense. Very good questions. We have some really active people on that website. Many of you are also on Hernia Talk Q&A, but I highly recommend that you sign up for hernia talk.com. We have surgeons that we recommend on that site. You can search by country and come up with posts that discuss these, your questions. Or just last week I had someone asking me if they knew of any good hernia surgeons in India, which of course I do.

Speaker 1 (00:04:35):

And so what I did was said, go to hernia talk.com, just search for the word India, and the post that includes the name of the Indian surgeons in the country of India will come up and they’re so gracious. They provide their email address and contact information for these patients to contact them. So it’s a great resource. I have multiple surgeons that are also on hernia talk.com that help answer your questions, but honestly, the biggest part of it is people talking amongst themselves and sharing their stories and they’ll say, oh, I went and saw Dr. So-and-so and it was a great experience. I went and saw the other doctor and I didn’t feel like they answered my question, go to this doctor because they do certain such procedure and I did very well. So it’s a very good resource and I’m very, very grateful to anyone and everyone who participates on that.

Speaker 1 (00:05:27):

And when the pandemic hit early 2020, I was shut down. The hospital was shut down because it only accepted urgent patients because we’re filled with COVID related patients that need urgent care. The ICUs were booked, the hustle was overwhelmed, and then my city, city of Beverly Hills actually shut down all patient care for I believe three weeks. So I could not even go to the office. I was stuck at home and that’s when I started Hernia Talk Live. It’s the live version of hernia talk.com and it’s been awesome. I’ve been doing this every week since. I can’t believe it’s two Thanksgivings have gone by 80 sessions episodes, 80 episodes, and I’m super excited that you all are continuing to log in and participate and so on. So on that note, I’m here to answer any of your questions. I will also address what I think is go going to come in the future, not only in my life and hernia talk live, but also the hernia world.

Speaker 1 (00:06:36):

So I’ll kind of update you. Sometimes I feel like you enjoy knowing what’s out there that I’m privy to that is able to be discussed publicly, so a little insight into our hernia community and so on. So I would like to announce that it’s because of you all that surgeons as a community are addressing hernias much more effectively, much more insightfully. I’ll give you an example. I’m giving I’m, I’m hosting a session. There’s a lot of meetings coming up by the way, I’m done for this year. I don’t have any more conferences. My most recent one was this past Sunday. Many of you were up with me at three o’clock in the morning from 3:00 AM to 8:30 AM. It was an international global hernia conference focusing on inguinal hernias. I moderated a live laparoscopic tap repair. There was a tap repair done live. We had surgeons from Israel and Belgium, India, United States and United Kingdom. We had I think over two dozen or countries that logged in and participated. It was really great.

Speaker 1 (00:07:58):

So little seemed to pride, but really great. So that was my last one and I promise you all, once that conference is available to be seen on demand, then I will share that link with you. It’s a pretty good conference. I talked about revisional hernia surgery because that’s a lot of what I do, especially inguinal hernias and we also talked about radiology and robotics and laparoscopic operations, chronic growing pain, Mesh related problems, et cetera. So it was really insightful. I would like to say that this is our busiest time, so I’m glad I don’t have any more conferences because November, December is the busiest time for most doctors, actually, most surgeons I would say especially, and what we do is kind of, I’m operating every single week between now from beginning of November till end of December, so it’s going to be busy. We don’t take time off for Christmas, Christmas except for Christmas day, and we don’t take time off for New Year’s except for New Year’s Day.

Speaker 1 (00:09:09):

So we don’t like, there’s no vacation time. So that’s going to be my life next year. A lot of meetings coming up January. There’s a Santa Barbara meeting for the Southern California chapter of the American College of Surgeons, which I used to be president of the second female president. That’s one of the societies, very dear to me. It’s also the largest chapter of the American College of Surgeons. It’s great, great meeting. There’s a Pacific Coast Surgical Association in Hawaii. I will not be attending that this year. There’s a SAGES meeting, which is a big laparoscopic meeting of the year and a huge hernia component to that meeting that’s in Colorado. I’ll be there, and I believe I have at least one session that I’m chairing that’s focusing on Mesh. We’re going to be talking about Mesh complications, Mesh reactions, updating on the lawsuits, really updating the surgeons about what they need to know, which is very unique.

Speaker 1 (00:10:04):

We were not discussing this at all four or five years ago, so you all pay. The patients have been really good at getting us to give much more attention on a society level, on a meeting level to this problem. So thank you to you. Thank you. Let’s see. What are the meetings we have in April? I’ll be in Costa Rica. We have our international hernia collaboration meeting. We have surgeons from all over the world giving talks, and we will be doing live surgeries in Costa Rica. That’s our annual international meeting that we all try to do at a country of designation that can help, can be helped by us as experts going to the country. I’m hoping in the future we’ll do Philippines. We’ve done Armenia and India in the past, so that’s really cool. We’ve got the European Hernia Society meeting. I’ll be that doing that.

Speaker 1 (00:11:00):

I think it’s October that is in Manchester. I’m really excited about that. I was recently told that I have four things I have to do, so I don’t think I’ll be doing much tourist tourism, even though I would love to because I really have only been in the UK for less than 24 hours, so I would love to get to know the country better. What else? Western Surgical Association. That’s the most elite local regional meeting that we have. I’m their chair of local arrangements. It’ll be in Santa Barbara. That’ll be kind of cool to go to. I was just there in Palm Springs this past year, so that’s going to be fantastic. And I think that’s, oh, American attorneys assign me. Of course, that’s also next year, I think September. So a lot of traveling and work hopefully will be available to do it. So I’ve been talking too much.

Speaker 1 (00:12:01):

Please let me know what you are all thankful for because I am very thankful to you. And on that note, I will answer some of your questions. So here’s a question from New Zealand. I would love to go to New Zealand, by the way. It’s on my top list of places to go. And by the way, cool T. Cool little tidbit. ovitex, which is a hybrid Mesh, which I’m a big fan of, which is a biologic like 96% biologic, 4% synthetic, which I use for a lot of my patients that have relative contraindications to synthetic Mesh is made from sheep’s stomach and guess where that sheep comes from? New Zealand. Okay, so I’m in New Zealand and going for an umbilical hernia para soon, great. It’s only seven millimeters fine. The surgeon says he can do dissolvable stitches, but it’s trying to talk me into Mesh new. It sounds like it is just easier for him to do with Mesh, but I would prefer no Mesh agreed.

Speaker 1 (00:13:04):

I also have diastasis recti by the, but they will not repair this in New Zealand as it is classified as cosmetic. I understand we have the same problem. So I just want your opinion on dissolvable stitches and whether this will work for a small umbilical hernia. Great, great question. So here’s where individualized care contradicts evidence. So if you look at evidence, all evidence, like all the studies show that all umbilical hernias one millimeter to five centimeters do better with Mesh. And by better I mean lower recurrence rates, less need for reoperation. Now you kind of have to dissect out the data. So clearly if you’re two centimeters or more in the width of your belly button hernia, your umbilical hernia, we’re not talking incisional hernia. This is a virgin area. No one’s had surgery before. So at your belly button, if you have a hernia or an outtie, we call those outties and it’s two centimeters or wider.

Speaker 1 (00:14:13):

All those people do better with Mesh. Doesn’t matter if you’re thin, fat, tall, skinny, male or female, all those patients do better buy a big number, a big difference. I would not offer non Mesh repair in someone that clearly would benefit from Mesh repair for two centimeter greater. Now, one centimeter or less, that’s dicey. So first of all, for one centimeter or less hernias for the belly button, again, the studies show if you put ’em head to head, umbilical hernia with Mesh will do better than umbilical hernia without in terms of recurrence. But the difference is very minimal. So maybe two or 3% better as opposed to 15 to 30% better. So in my practice, I don’t think a two to 3% benefit is worth putting Mesh in. As long as I have an honest discussion with my patient and I say, listen, we can use Mesh.

Speaker 1 (00:15:18):

I don’t recommend it if it recurs, which is very small chance of recurring, we can forgo, we can use Mesh at that time, but you have a 90 whatever percent chance of not recurring in a really small belly button hernia. So let’s not use Mesh the first time. That’s the way I approach it because the difference may be significant, but it’s like the actual number is very low. I think it’s 3%. So for any hernia, the belly button less than 1%, I recommend no Mesh. Then the question is, okay, no Mesh, what about the suture? Would you use a permanent suture or absorbable suture? And the only absorbable suture that would be appropriate I believe, would be the slowly absorbing called P D s, which absorbs fully by about eight months and starts losing its strength around I believe three or four months. Whereas the permanent suture is either ethibond, which is polyester or it’s some type of polypropylene which is permanent.

Speaker 1 (00:16:25):

So in those situations, permanent sutures always better also show that recurrence rates are lower when you use permanent suture than absorbable suture. The same way hernia recurrence is lower when you use permanent Mesh as opposed to absorbable Mesh. It just doesn’t work. The fact that you have a hernia already shows that you have a tendency towards it, and we can’t a hundred percent rely on your own tissue to heal it because by definition your tissue is not normal. It has a slightly adverse kind of ratio of collagens. So based on that, I think if you were to see me with a seven millimeter umbilical hernia, I would prefer to repair that with a polyester suture, which is permanent, but no Mesh. Now you’re adding another component, which is your diastasis. So we’ve discussed this before. Diastasis is a separation of the abdominal. In fact, I, I’m planning on bringing a surgeon who’s really, really good at diastasis, who I share a lot of patients with.

Speaker 1 (00:17:36):

There are a lot of really great surgeons. I particularly work with him because he’s very O C D and I’m a little O C D and we work very well together and he is very good with Tommy Tucks. My point is this, the diastasis is a separation of the muscles. There’s no hernia, it’s just the tissue in between the two rectus muscles, like your six pack is thinned, and if you have a hernia by chance within that thinned piece, then closing the hole alone, you’re closing thinned tissue. And the break open rate of that is significantly hard. It’s like 30% or in that range. So people who have a diastasis, now you’re dealing with not a small hernia but a small hernia with very thin tissue. So I agree that you need to do something in addition to just closing it. You’ll probably be okay, but maybe two-thirds of the time you’ll be okay if you just do tissue repair.

Speaker 1 (00:18:50):

So in my practice, of course, one option is Mesh. I don’t like to overuse Mesh. So I do a small area of two layers. So now you have two layers of closure instead of one layer of closure. And part of that is kind of bringing a little bit of the diastasis tissues together. So yes, it’s considered cosmetic, but I throw it in there anyway because I do believe that it helps the hernia repair. We’re not doing a full diastasis tummy tuck, although if you are a candidate for tummy tuck and you do wish to have a tummy tuck, then that will cure you of the belly button hernia as a side effect and will have a very good outcome without using Mesh. So I hope that clarifies things less than one centimeter umbilical hernia. The studies show that Mesh does better in terms of recurrence, but the difference is like 3%.

Speaker 1 (00:19:46):

So I don’t think that’s enough significant data to demand a Mesh in everyone. If you’re morbidly obese or you have a diastasis and you’re morbidly obese, Mesh would be a good idea. If you’re thin and have a diastasis in a small hernia, I prefer not to use Mesh in you, but that’s my preference. It’s not necessarily the most correct answer for every single patient. I hope that’s helpful and I hope when I answer these questions you understand that there’s no perfect answer for everyone. I talk about tailored approach. a lot of us that are concerned, us ourselves, hernia specialists, we follow a tailored approach. We know all the data. We don’t just kind of follow one rule. We don’t just offer one operation and therefore when we give you our advice, it’s based on all the data and you can do as much research as you wish.

Speaker 1 (00:20:48):

You still will not be able to know, and I’m not trying to be pompous about it, but it’s just reality. You will never know as much as we know, even though you’ve done your research, because we understand all the data, we have a wider view of everything. Plus we have experience in how things have occurred, and I’m going to give you a nice story about that later. Plus we have more insight into what happens when things go wrong. I have pages that come to me and say, well, I know my body well, yes, of course we all know our own body, but I know what happens when badness happens. And just telling me that your body doesn’t mean that your decision is a correct decision as to what you need for yourself. So that’s why I always say don’t go in the doctor’s office and say, I want a Shouldice or I want a robotic surgery. Find a doctor that can provide you with objective information about what your needs may be and then trust ’em to provide you with the best opportunity for care.

Speaker 1 (00:22:06):

All right, next question. I have recurrent hernias of a tissue repair on one side and anterior Mesh only on the other. This sounds like inguinal hernia. The surgeon wants to do an open repair to inspect some other I issues like nerve entrapment. If you have failed a tissue repair like a Bassini, how could a surgeon reuse tissues like the conjoined tendon or transversus to repair a failed tissue repair? Likewise, how can a small defect on that side with a Mesh be repaired open without removing or replacing the entire Mesh? There are other issues that require an anterior open Mesh. So the patient has a recurrent hernia after a tissue repair on one side, an anterior Mesh. Okay, okay, so I understand there’s hernias, left groin, right groin, both have hernias. One had a Mesh repair, one had a tissue repair. So regardless of whether it’s a Mesh or tissue repair, if you had an anterior approach, which sounds like was a Lichtenstein on one side and some type of Bassini repair on the other side, so Mesh and a tissue repair on the other side, the best repair, lowest recurrence, lowest chronic pain rate, best long-term outcome, best short-term recovery best in every single aspect is a laparoscopic repair with Mesh.

Speaker 1 (00:23:33):

If you have nerve entrapment, that’s a different problem than hernia recurrence. Your surgeon should be able to identify the difference between nerve entrapment and hernia recurrence and the symptoms are just different. Hernia recurrences are usually not burning, usually not radiating along the dermatome of the nerve. It’s usually worse when you’re standing better when you’re lying flat, you don’t have sensitivity to touch if you have nerve entrapment that a nerve block should cure you of the pain. Whereas if you get a nerve block, you will not get cured of your inguinal hernia recurrence pain. So those are all data and information that should be addressed before committing to surgery. And if it turns out that you don’t have a pain from a hernia recurrence, but you have pain from a nerve entrapment, that nerve entrapment occurred early, did not, it occurs within the first year of surgery.

Speaker 1 (00:24:38):

It doesn’t occur years after the surgery. So given the story and the exam and the imaging you should be and maybe a nerve block, your surgeon should be able to come up with a better idea than I just want to go in there and take a look because you should be able to predict what’s going on before taking a look. I absolutely disagree, in general, with going anteriorly to do a tissue repair after a failed tissue repair or going in anteriorly to do a tissue repair after a failed Mesh repair. Those are just not considered standard and they are not necessarily in your best interest. I would probably offer you a laparoscopic bilateral inguinal hernia repair if I can rule out a nerve problem. And really now the nerve problem has to do with when did your nerve pain start? If it was years later, then it’s not a nerve problem, it’s a hernia problem.

Speaker 1 (00:25:35):

And do you respond to a nerve block? If you’re cured with a nerve block, then it’s a nerve problem. But if you’re not cured with a nerve block, then it’s a hernia problem. So these are the things that I feel surgeons need to really think and not just kind of knee jerk going there because you can cause a lot of damage if you’re unnecessarily exploring someone in an area where there’s lots of scar tissue and the nerves can be injured as part of it. So here’s the next follow up question to the same patient from the same patient. I’m afraid there is a possibility of both painful recurrences and nerve entrapment and also cord lipoma, which he does not feel he can get out from the posterior approach. Also, issues also, I have issues from prior abdominal surgery with adhesions. So prior abdominal surgery with adhesions usually are not a contraindication to laparoscopic or hernia repair because we’re extra peritoneal.

Speaker 1 (00:26:36):

We’re not in the bowel, we’re not with the bowel, we’re extra peritoneal usually. Now that said, you can also have an open posterior approach. If you absolutely have a disaster of an abdomen and no one wants to go in there laparoscopically, you can get an open posterior approach. So that’s kind of old school, but definitely an option that is available to you. So it’s still a posterior approach going anteriorly and offering a tissue repair is not the best option when you’ve already had an anterior approach. Second thing is you’re afraid of possibility of painful recurrences. So painful recurrences do not occur as often with laparoscopic repair or a posterior approach repair. It is the best recovery and the least amount of pain is with the posterior approach, not the anterior approach. Cord lipomas, they should be able to be addressed from a posterior approach.

Speaker 1 (00:27:43):

If you have a hernia, things went through. So same way they went through, they can be pulled out. There should be very little issues of removing the cord lip lipoma with a posterior approach. If not, you can add a cord lipoma, incision anteriorly without having to do the whole thing anteriorly. So you can have a laparoscopic posterior approach or the open posterior approach. By posterior, I mean behind the hernia hole, whereas usually we go in front of the hernia hole, you could think of the abdominal wall as a wall with a hole in it and anterior is working in front of the hole and posterior is working behind the hernia.

Speaker 1 (00:28:20):

But that’s kind of my thought process about it. I’d love to know why there’s a hesitation and I just don’t understand that. Okay, so it sounds like the New Zealand is looking for a two layer CLO closure. So one technique which is a two layer closure for people without a diastasis. It’s called the Mayo repair. The mayo repair is a two layer closure of an umbilical hernia that helps you forego the need of her of Mesh. But in people with a true diastasis, I just do a local closure of the diastasis on top of the hernia and that seems to provide good results. Alright, so I just wanted to also let you know that many of us are super busy with surgeries during the last two months of the year. And so consultations tend to be a bit more difficult to get. But I read some notes online.

Speaker 1 (00:29:19):

There was some confusion about online consultations and out-of-state patients and telehealth and so on. So as you may know, almost all, pretty much every surgeon offers in-person visits. So that’s like the traditional, you go to the patient’s, the surgeon’s office and you do your consultation. They examine you and talk everything over with you. In addition, many of us offer telehealth. This whole issue of telehealth is not new, but during the pandemic, most insurance companies, including C M S, which is Medicare and Medicaid, have agreed to pay for these telehealth visits before insurance companies were not paying for telehealth visits, or if they were, it was like five or 10 bucks or 20 bucks something minimal. So surgeons were not offering it. So now insurances are supposed to be paying the same rate for telehealth as they are for in person. So many of you’re able to stay at your home and do your consultation with your surgeon while at home.

Speaker 1 (00:30:30):

The caveat is during the heat of the pandemic, there were laxity in regulation. So this whole interstate health was not as regulated because they didn’t want people. Let’s say I have a patient from Colorado who wants to come see me under normal circumstances. It says I don’t have a medical license to practice in Colorado. I cannot treat a patient in Colorado. They have to come to California to see me. Same with New York, same with Florida. I have one state license for medical practice and that’s in California. Now, if I had a license in Colorado, then I can treat someone in Colorado, but I don’t. And most surgeons have a license usually in one state during the pandemic, the heat of the pandemic when travel was either impossible or advised against the regulations were eased. And so I was able to do telehealth with someone in New York or Florida or Texas or Oklahoma or Nebraska or Illinois or Idaho.

Speaker 1 (00:31:52):

They would make an appointment as if they were an inpatient in-person patient, but they weren’t. They were at their home in their own home state and they would do a telehealth visit with me. I can no longer offer that because the regulations are now stricter again and they’re back to usual. So I am not able to provide, and not just me, surgeons are not able to provide telehealth appointments to their patients if the patients live in a state outside of wherever the medical license is. So some surgeons are now demanding that you come to see them. And that kind of pisses off some patients like, well, why don’t you offer me telehealth? Well, because you don’t live in my state and I have a medical license to practice outside of my state, and you’re, since you’re technically out physically outside my state, my medical license and malpractice, et cetera, does not cover opportunity to provide care for you.

Speaker 1 (00:32:54):

Which is weird because I have a lot of out-of-state patients and I do surgery on them and they go to their home state. So I just did operation yesterday on a patient from Ohio. So today they flew back to Ohio. So since they’re my patient and I operate on them and I saw them physically in California though now they’re in Ohio, I can give care to them because it’s considered continuity of care, but you can’t initiate care. So it’s weird. I can write prescriptions for them, they can call me and do a telehealth with me if they have a wound problem or a question, but that’s because they’re already my patient somehow that’s okay. So I don’t really understand, but if anyone’s a lawyer or anything, you let me know cause it makes no sense to me. So what I’ve done is I offer what we call online consultation.

Speaker 1 (00:33:54):

So online consultation means you’re not really my patient. This is not something I’m going to be billing insurance for. This is not a medical, a doctor-patient relationship. I’m just providing you my expert opinion based on data that you sent me. So you can send me your images and a write up of your problems, maybe pictures if you want by email and or by mail. And then I’ll respond to you by email, but I don’t get to see you. I don’t get to examine you. There’s no doctor-patient relationship. But as much emailing back and forth as you wish is possible. So I have patients from Singapore and Italy, India and a lot of nearby states, a lot of us states that have chosen the online consultation opportunity. And it’s I think a good deal because you get a lot of interaction from me and I get to really think and kind of about you and provide you with my expertise.

Speaker 1 (00:34:57):

It also helps give you some guidance. So if you are in Washington state and you can’t come to see me, but you’re not necessarily getting all of your information that you need from your doctor, you don’t have to fly in to see me, we don’t have the opportunity to do telehealth. And at least this way I can give you some guidance and I’m always very generous about not only giving you advice but also leading you and reaching out to specialists near you to get you the care that you need, assuming there’s someone that I know near you who can provide you that care. So I saw online was some anxiety and unhappiness that some surgeons were not. Were only offering people to be seen in person. That’s why it’s not like they’re being lazy or not helpful. They just legally cannot see you if you live outside of your whatever state they are.

Speaker 1 (00:36:05):

So the question is, does that continuity expire after three months? No, continuity of care does not expire after three months. If you have surgery, the payment for the surgery by insurance or the yourself or whatever includes three months of care, 90 days of care. So let’s say I do an operation, my patient from yesterday, Ohio will call him Ohio person. So if Ohio person saw me and had surgery yesterday, the clock starts yesterday for 90 days. So today is day one, okay, for 90 days, whatever question he has, whatever appointment he wants to make, however many times he wants to see me, if he has wound problems, if he needs any other related procedure is covered by that first surgery. So it’s like it includes a 90 day continuity of cure. That’s for most operations, small operations like lumps and bumps. It’s either zero days or 10 days of continuity.

Speaker 1 (00:37:15):

But most major operations, it’s 90 days. That doesn’t mean that your surgeon can’t see you or can’t treat you after nine days, but then you’re considered a established patient or maybe even a new patient after two or three year. I think after three years you’re considered a new patient but not a established patient if you haven’t seen them for three years. But it’s not related to continuity, it’s just related to how much is covered by your insurance. Oh, here’s someone else they said, I’m looking forward to my online consult with you. Thank you so much. I’ve got a whole bunch that I have to do this weekend. So in addition to stuffing my face on Thursday, which I’m very much looking forward to, I have several online consults that I’ll be typing up and I like I’ve mentioned, I have, I’m a little bit obsessive compulsive about my reports and my dad was a writer and that kind of like writing is really in my genes.

Speaker 1 (00:38:19):

So you’ll see when I give you your reports and your email, the emails that I respond to you all, it’s very detailed, very comprehensive and excellent resource if you want to take that to your next surgeon or learn from it. And I encourage a back and forth in a question answer session. So looking forward to online consults. Next question is, I see a lot of people talking about seromas. Why or how do seromas have happened and what are the thoughts behind draining or not draining them? Something some think it’s dangerous to drain when Mesh is present because it may further infection. Okay, so seroma means ball. Seroma means ball of serum. Hematoma means ball of blood. meshoma is kind of a acute cute term, which means a ball of Mesh. So seroma is a fluid collection. Usually your body does not like empty spaces. And if you had a hernia that filled up a space and now you had the hernia repaired, that empty, that space is not scarred down yet.

Speaker 1 (00:39:35):

And we will fill up with fluids. Sometimes there are techniques that you can use within the first several hours two weeks after surgery to reduce the risk of that space filling up with fluid because once it does, it is potentially painful because of the pressure of the fluid, it’s potentially discomforting. You can see it under your clothing sometimes depending on where the seroma is and how big it is and so on. So in general, we do not touch hematomas and also we do not touch seromas. They were almost always absorb. Hematomas especially will absorb and scar down in that area and very little happens as a result. If you’re really unlucky, the seroma or hematoma can be underneath the Mesh and lift the Mesh off of the repair. And yes, that can disturb a repair, but usually that’s not the case. Usually the serum or hematoma is not around the tissue of is the fatty areas where the hernia was pushing on.

Speaker 1 (00:40:53):

So you’re correct, we don’t like to touch them. Massaging the area can help your body increase blood flow to the area and take the lymphatics and macrophages and eat up that fluid or blood and take it back to your heart and make that seroma or hematoma get smaller if it’s big and not going away. We can very carefully under sterile technique, stick a needle in and take out as much fluid as possible and then put some type of compression dressing or compression garment on to prevent that space from growing again, understanding that every time we do that you’re increasing the risk of introducing bacteria in an otherwise sterile field. And if you do that and you get an infection and meshes right there, that’s a disaster. So oftentimes it’s not worth it to go after unless the patient is very much uncomfortable or the Mesh is far away from the serum or hematoma. So I hope that helps. As a follow-up question, can an untreated hematoma cause nerve damage? The answer is no. Nerve damage has to be physically performed. They either have to be burned or cut or stretched, but no, a hematoma would not be able to do that.

Speaker 1 (00:42:25):

We’ve had some really interesting patients lately. So one patient came in referred to me by a fertility specialist. So it’s a male and he’s trying to get pregnant with his wife and they had been unable to have a baby. I think they had one but it didn’t come to fruition. Very sad story. So during the fertility workup, his sperm motility was found to be suboptimal. And by the way, he’s got this humongous hernia sitting on his testicle. So they sent him to me and said, maybe if you fix the hernia, his fertility will improve. So here’s my data on that regarding fertility and hernias, because I believe we discussed this when we were with Dr. Paul Turk last year, who’s he’s a urologist and fertility specialist. So patients who have hernias should not like as a population. If you look at everyone who has a groin hernia, male, they should not have any difference in fertility if they have a hernia or not have a hernia.

Speaker 1 (00:43:47):

So population studies have never shown a correlation between inguinal hernias and fertility. However, we do know that if the testicle is not within the scrotum, it’s higher up towards the abdomen, it’s warmer and therefore the warmer temperature of the testicle affects sperm motility and sperm function and can cause infertility. And if your testicle is bathed in a lot of blood vessels called like varicose veins, which are called varicocele seal, those varicose veins, which happens in some males, those varicose veins can heat up the testicle more than if there were no varicose veins because the testicle is in the scrotum and that’s outside the body where it’s cooler relatively speaking. So the increased temperature from the varicocele seal can cause sperm problems, motility problems, and treating those varicose veins can return the patient to have better fertility. So the thought was if you have a huge amount of intestine like colon, small intestine fat, whatever from inside the body where it’s hot sitting outside the body in on top of an intestine where the tester prefers to be in a cooler environment, does this humongous hernia change the testicular environment enough to heat it up enough that it’s contributing to this gentleman’s fertility?

Speaker 1 (00:45:37):

The answer is we don’t know. No one has looked at scrotal hernias, patients with scrotal hernias to see if that subpopulation has infertility compared that is worse than the average patient. All comers, no difference. Squirrel hernias, we don’t know. So it was a huge hernia, a young male, so it was worth repairing anyway. And so I will hopefully have more information because in about four months he can have a new set of sperm available. I think every three to four months you get brand new, a hundred percent brand new, a repopulation of sperm. So it would be kind of cool to know now that his hernia is repaired and he looks like a totally new patient, how his sperm count and motility will change. So I’ll report that back to you because that’s kind of a cool little detail of something that we haven’t seen.

Speaker 1 (00:46:47):

Yes. So patient is asking me, I had a telehealth visit with you in the past, am I entitled to continue to email you with questions? Of course, yes, I believe so. Why not? Happy to answer your questions. Another patient that I saw, I just wanted kind of express to you that not all groin pain is hernia pain. So I saw three patients all in the past two weeks, two weeks, maybe two and a half weeks. They were all sent to me for different reasons, but they were all labeled as having inguinal hernia or hernia pain. And I just want to tell you, because we’ve discussed this before, we’ve had orthopedic surgeons on, we’ve had sp, we haven’t had spine, we’ve had pain doctors, but I think we need to get a spine doctor, they’re so difficult to talk to.

Speaker 1 (00:47:48):

So usually neurosurgeons or orthopedic surgeons that wanted to be neurosurgeons. So I find a good spine surgeon who would entertain you guys on this show if any of you knew of one. I know some great spine surgeons, but sometimes I wonder how good they’ll be able to answer questions live. They’re just really good at what they do. My point is this one guy came and said, oh, I’ve got, I had growing pain. And he’s like young, healthy, athletic, he’s big soccer player. They said, oh yeah, you got a hernia, let’s fix the hernia. Well, they missed the fact that he had no symptoms from his hernia. They were all related to his hip and maybe a sports injury and not to a hernia. So they fixed his hernia that put Mesh in a guy that probably didn’t need it. Guess what? Now he is got complications from the hernia Mesh and he barely really had a hernia and they missed the fact that he has a hip problem.

Speaker 1 (00:49:01):

So that’s one where it was so easy to blame it on the hernia and yet when the hernia was fixed, his pain never went away and now he has additional pain from the hernia repair. So it’s so important to get a good story. The second patient has known sciatica, so he is got known back problems and he’s got this horrible groin pain, but the groin pain, it radiates to his lower back and his exam was totally normal. I’m like, you don’t have a hernia at all, but it has my hernia. Maybe it’s a cult hernia or hidden hernia. No, no, no. Let’s look at your back. Looked at his back and actually they came from flew in from another country if you can believe that because they were unhappy with the care in their country. So they came to me for hernia because they didn’t think people, they were giving them the right information.

Speaker 1 (00:50:06):

I got them an MRI. So they saw me on a Monday. He had a bulging of his flank and he had the severe groin pain. And I said, okay, this is not a hernia, that’s a spine compression issue causing nerve damage where the muscle is no longer has nerve being feeding it and the groin pain is from your back as well. Let’s get an MRI. So he saw me Monday, I got him an MRI Monday night, I reviewed it Tuesday morning with the radiologist. He confirmed that I was correct, no hernia. And in fact he has a very bad disc, T 11 I think, or T 12, T 11, 12. That was Tuesday morning. Tuesday afternoon he saw a spine surgeon. I called that in for them by Friday. He had surgery, he had emergency surgery on his spine and he was living with us for over three months and everyone else was like, Ooh, maybe it’s a hernia.

Speaker 1 (00:51:14):

No, no, no, this was a spine injury. And the longer the spine injury, the more likely he is that he will have irreversible nerve damage and this bulging and this growing pain will not go away. So he actually needed his surgery weeks prior. It was completely missed by his other doctors. And the other surgeons, he actually saw some people, I think a general surgeon, his medical doctor, I think he had a pain doctor for his spine, but he never saw a spine surgeon or orthopedic surgeon. Anyway, long story short, yeah, not every groin pain is a hernia. So I could have been like, oh, let’s just go in there and take a look and maybe we’ll find something and put it in Mesh or did a repair and cause damage from that. And then his original problem would not go away. And I just say these things because if you’re a hammer, everything can look like a nail, right?

Speaker 1 (00:52:14):

So if you’re a general surgeon, you see a hernia, you fix it, but does that help the patient’s pain if it’s nerve pain from the back or the spine or if it’s a hip disorder or some other endometriosis or something like that. On that note, I’m super excited. We will be coming up with a scoring system as an app for you. So you can just plug in all your data and it’ll spit out the percentage chance that you would benefit from a hernia repair in the groin as a cause of your chronic groin pain or chronic pelvic pain.

Speaker 1 (00:52:57):

I can’t tell you much more about it, but once it comes out, I’ll let you know. Next question. I had anal hernia most of my life after getting the repair I have have longtime pain two years later plus a diastasis should I get relieved with abdominalplasty? So abdominalplasty will address your diastasis, it will not address your anal hernia. And if you need anal hernia pain addressed, I would get that done first. The reason is this, once you have an abdominalplasty, you don’t want anyone else messing up with that beautiful cosmetic repair, a flat abdomen, beautiful scars, blood flow is an issue. So if you need any surgery in the groin, if it’s laparoscopic, do that first. If you need any surgery in the groin that’s open, do that first, get all that ready and make sure your surgeon’s aware that you may choose to have an abdominalplasty afterwards, three months to one year afterwards, usually about a year because an abdominalplasty will pull on your inguinal area because if it is being tightened and it gets tightened this way and it gets tightened this way.

Speaker 1 (00:54:14):

So if you’re being pulled this way, your inguinal area may get pulled. So whatever operation need to get done needs to be done with the thought process that in the future you will have an abdominalplasty, which will tighten up the area even more than whatever they need to do for your groin pain. So that’s where that kind of 360 patient care comes to play. And I love it because I work with plastic surgeons, I work with urologists, gynecologists and urogynecologists and pain doctors. So spine surgeons, I have insight into what they do. Orthopedic doctors like technically during residency, you get a little snippets of what these surgeons do, but you don’t really know.

Speaker 1 (00:55:02):

You don’t really know what they do if you’re not working with them closely. And I love that aspect of my care because I can talk to my patients about their testicle and their ovary and their spine and their pelvic floor even though I don’t do any of those operations because I have fantastic doctors that I work with. So I’m very thankful for them for that. Next question. Do you think there is such a thing as a Gilmore hernia, i e attenuation of the posterior wall, of the inguinal canal without a defect, along with possible avulsion of the conjunct tendon causing pain due to pressure on the nerves? How can that be treated like a standard hernia? So there’s a question of whether there’s laxity of the groin from tears or from natural laxity due to genetics. Most often, especially an older male or someone who’s not an athlete, those are all laxity and should not be treated like a sports injury or sports pain. No stretching of the growing canal does not cause nerve pressure or nerve pain. If you do have a hernia that’s poking and there’s a mass effect, that mass effect can push on and irritate the nerves, but the nerve lays on the muscle and it moves with the muscle. So just stretching of the muscle itself should not give nerve pain.

Speaker 1 (00:56:37):

So on that note, I would like to say that I hope you guys all give me a little bit of your insight as to what you’re thankful for. We’re at episode 80 today. I’m very thankful to all of you who continue to join me and ask all these wonderful questions. I’m thankful to everyone who listens and learns is able to learn from these sessions and maybe educate your friends and family and refer. I had a patient who came today and said, I looked you up and then there were these YouTube videos and you did a really good job and you answered this question about urology and that’s pretty cool. I thought that was really great. I’m like, thanks.

Speaker 1 (00:57:26):

She had no idea who I was before that. She was referred to me by one of her doctors who used to be my intern when I was a chief resident. I was a very close friend of him of mine. So my point is this, without me even knowing your sponsorship of this by participating has allowed me to do to 80. I will definitely go to a hundred. Let’s see if I’ll last beyond episode number 100. But I’ll definitely go to 100, which will be till spring or fall or spring or summer. We’ll see. And I have a lot of really cool people coming up. I have a patient coming up as a guest in December. You’re going to love it. It’s going to be one of the most inspiring episodes we’ve ever had because she is a patient and she is the ideal patient. And I hope you all can learn from her because being a chronic pain patient is not easy.

Speaker 1 (00:58:37):

Navigating the medical system is not easy. And I think she’s done the best job of anyone that I know. I’ve had some amazing patients, I love them also dearly. One of them made us some shortbread cookies today. I think I ate three and I’m going to take the rest home and not leave them from my office because they were so good. But that said, even though I love it when you guys feed us and you’re very grateful to all of you, this one patient has been very special because she’s had such a difficult and complicated situation and she’s done such an excellent job of keeping her calm and navigating through the system. So on that note, thank you for coming. I hope you all have a very, very happy Thanksgiving. It’s my absolute favorite time of the year right now. If any of you are around to visit my office, just come and visit it like it’s completely Christmas out, down to the smell like we’ve got point set and candles and wreaths and every room has something special. And it’s all because my office staff loves Christmas as much as I do. And on that note, thank you very much. Have a great, happy Thanksgiving. Enjoy it with your family, and hope to see you again next week. Bye everyone.