Episode 81: Planning for Hernia Surgery | Hernia Talk Live Q&A

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Speaker 1 (00:00):

Okay. Hi everyone. It’s Dr. Towfigh. Thanks for joining me today. The last day of November, the 30th, 2021 on Hernia Talk Live. This is our weekly Q&A session with me, Shirin Towfigh, your hernia and laparoscopic surgery specialist. You can follow me on Twitter and Instagram at hernia doc and many of you are here on Facebook live at Dr. Towfigh or on my Zoom meeting for this session. And as always, I will make sure that this session, this episode of Hernia Talk with episode 81 will be broadcast on my YouTube channel. So let’s see what we can talk about today. I hope to talk about what’s called planning for your hernia surgery. As surgeons, we know what the best options are to optimize you for the best hernia care, for the best surgical care. And so a lot of what we’ll be discussing today will be relayed to all the steps you can take to make sure you have the perfect hernia repair.

Speaker 1 (01:11):

And whatever we learn today is most likely going to be very relevant to really any surgery you undergo. Even like tooth surgery, cosmetic surgery, any elective surgery. We know that with emergency surgeries you really can’t plan those, so it’s unclear how you can really optimize that because you’re not planning on having emergency surgery. And so that’s why a lot of emergency operations have worse outcomes than elective operations because the patients come in unprepared. However, if you know you’re going to have any type of surgery, especially hernia surgery, I’m going to share with you all my tips and tricks that we know as surgeons on how to optimize your care. I want you to have the best outcomes, the best recovery, the least risk of recurrence, the least risk of wound healing problems, the least risk of infections and the best long-term results and the lowest pain and the lowest bruising, et cetera.

Speaker 1 (02:15):

So those are all that we’re going to discuss this hour. In addition, as always, if you have any questions that you want to run by me, please just type them in either on the Zoom or Facebook Live and I’ll be monitoring that as we speak. So on that note, let’s get started. So there are multiple ways of improving your outcomes. The first is to do everything you can before surgery to make yourself the perfect candidate. Number one, and first and foremost is not to be overweight. If you are overweight or especially if you are obese for surgery especially, that is considered a poor prediction, a prediction of poor outcome. The number 40, which is 40 kilograms per meter squared, which is the B M I has been determined to be a cutoff. Pretty much no one with a B M I over 40 should undergo elective hernia surgery unless that hernia surgery is vital in any way or urgent in any way.

Speaker 1 (03:24):

And the reason for that is people with A B M I of 40 or higher, which is considered obese, morbidly obese, have everything that goes wrong with them. They’re more likely to have pneumonias, heart attacks, wound infections, blood clots, hernia, recurrences, et cetera. And so we prefer that that doesn’t happen obviously. And so we choose not to do those operations in people with A B M I affordable or over. We’ve had prior episodes of hernia attack where we discussed with bariatric surgeons like Dr. Bittner and others to really consider even undergoing something as serious as another surgery, which is morbid obesity, bariatric weight loss surgery before considering your hernia repair. If your B M I is 40 or over, if you’re able to undergo weight loss with a medical doctor, that’s more likely to be successful than doing Nutrisystem and all those other kind of ways of losing weight on your own.

Speaker 1 (04:35):

And of all the commercial ways of losing weight, weight Watchers has been proven to be the best of all of those. So many people have undergone lots of diets and tried to lose weight on their own. The best way is number one, try it with under the supervision of a medical doctor, they may even provide you with medications in addition to dietary changes to help you lose the weight. And then the most effective, especially if you’re BMI, if you’re well at least a hundred pounds overweight, is to undergo weight loss surgery. And that will not only improve your outcomes for surgery, but will dramatically improve your quality of life and your life span. We know that with bariatric weight loss surgery, you are less likely to have cancers, multiple different types of cancers. You’re less likely to have a heart attack, lung problems, asthma, diabetes, high blood pressure, and you’re less likely to die young. You’re more likely to less likely to have joint problems and knee for knee replacements and hip replacements. So weight loss surgery is considered ideal if you have a hundred pounds or more to lose or you are morbidly obese and are unable to lose the weight with regular dietary changes and exercise.

Speaker 2 (05:57):

So that’s number one. Number two, okay, so that means if you’re having a hernia repair planned electively, then I would recommend that you bring your B M I your weight down well below 40 kilograms per meter square and there are formulas online that can kind of tell you if you just put your height and weight in there, it’ll tell you what your B M I or body mass index is. Just Google like B M I calculator and it’ll show you that. And in addition, if your b m is less than 40, then the closer you are towards a normal B M I or less than 30, the better you are for sure. If you’re less than 35, that would be ideal to be at that level before having surgery. And the most help is if your weight is well controlled for central or abdominal wall hernias.

Speaker 2 (06:58):

Groin hernias, it’s also important but not as important as the abdominal wall in front of the abdomen hernias. Okay? So that’s number one. Number two, the most important I believe is nicotine use. So fortunately in LA California though we do have people that use nicotine. It’s not that many compared to some of the other states and certainly countries outside the us. So nicotine in any form patch, smoking, gum, chew vaping, all forms of nicotine have been shown to affect your collagen. And as you know, collagen is the basis of scarring and if you don’t have good scarring, you’re not going to have a well-healed hernia. So you do not want any nicotine in your system for at least six weeks before surgery, hopefully forever afterwards, but at least six weeks before your surgery something are okay with four weeks, six weeks is ideal because you don’t want the nicotine to prevent you from healing.

Speaker 2 (08:03):

So if you have a hernia repair and we’re putting sutures or Mesh or just especially if you don’t want Mesh for sure, you should not be using nicotine because that will dramatically affect how well you lay down scar and how well the tissues heal. So as with anything, you want everything to be organized. So when you have scar, you want what’s called organized scar, which means there’s a very special lattice work of scar formation that’s laid down with collagen and you want the mature strong collagen, not the weak immature collagen. When you have nicotine on board, you are less likely to have a organized scar formation. If you do have scar formation, it’s weaker. That’s why people have wrinkles because there’s less collagen in their system and then you have a poor scar formation and then you’re at higher risk for recurrence up to seven times higher risk of recurrence.

Speaker 2 (09:05):

So it’s kind of a shame to undergo a major surgery and then have it recur because you were smoking. Coughing is another big one. If you have a chronic cough because you have upper respiratory tract infection or chronic sinusitis with postnasal drip or acid reflux, those are all things that can be treated and should be treated before surgery so that you’re not coughing one cough exhibits so much more abdominal pressure that any amount of weightlifting you can do or jumping around or even obesity, the amount of pressure from obesity, so whatever you have in terms of coughing that should be treated so you should not have it surgery while you’re actively infected with like a bronchitis. If you have postnasal drip causing you to constantly like cough or clear your throat like that, that should be treated and either A, your general doctor or your ear, nose and throat specialist can help you with that.

Speaker 2 (10:14):

Usually it’s a combination of nasal washes and nasal sprays and anti-allergy medications. If you have acid reflux that’s constantly burning your throat with the acid that should be treated because those are typically patients that are constantly clearing their throat and some even have a horse horse voice because they have so much acid that’s burning their vocal cords. There’s so many excellent medications over the counter. Pretty much every excellent prescription medication that we’ve had the past 20 years are now available over the counter. Usually the prescription dose is twice the generic over the counter dose and just as long as you clear it with your doctor and it’s okay, which should be just take it over the counter and treat your reflux and figure out how you can cure your acid reflux. There’s dietary changes, weight loss, nicotine and so on. So what I do recommend is that you take this very seriously.

Speaker 2 (11:21):

A lot of people are like, oh, what’s a little cough here and there it it’s actually a big deal because what happens is the effect is you’re every cough you make, you’re taking the sutures and the tissues and you’re trying to pull ’em apart. So if I give you a shirt and it’s super tight for you and you keep coughing, you’re going to pop those buttons open. The same is true with a hernia repair. And so again, it’s quite the shame if you end up having a hernia recurrence for something due to something that’s totally treatable, and many of you that are listening to this already have had hernias repaired and are now suffering from complications oftentimes from a recurrence. So you know how difficult it is to deal with the pain, quality of life issues, the need for another surgery, it’s going to cost you extra money, you have to leave work because of it. Those are all things that are preventable if you go into surgery optimized. So that’s what the coughing. Other things that can cause coughing are obviously smoking of anything. So smoking a pipe, smoke, not so much smoking a cigar, smoking cigarette, vaping not as much, but then also smoking marijuana, lots of coughing with all of these. That kind of coughing really affects your hernia repairs. So at least during the healing stages you should not be doing any of those.

Speaker 2 (13:04):

So that’s at the issue with coughing. Going back to nicotine, I just want to mention in addition to the nicotine itself affecting collagen deposition, the act of smoking the nicotine does prevent oxygen to get to your blood, to your tissues through your blood because with the use of the tar for the nicotine and the way that it kind of burns your lungs, it reduces the ability for oxygen to reach your tissues. That’s why a lot of these patients that are heavy smokers kind of have a sallow face. Their fingers may be a little bit darker tipped. They may have vascular disease because of their smoking or their, they don’t get good blood flow to their toes. The same is true for their incision. So if you’re smoking your nicotine, then you’re not getting adequate blood flow to where you need blood flow such as to your wound to heal.

Speaker 2 (14:11):

So you’re a higher risk for wound complications because you’re not healing and therefore also high risk for wound infection. And many of you not only is a wound infection a big deal, but if there’s Mesh in there, then you get a Mesh infection and that’s just a disaster. You do not want to get a Mesh infection. You want to reduce every single possibility that you get a Mesh infection. So we got weight loss, nicotine cessation and cough suppression or treatment. The second, the fourth one is constipation. The number one reason in the states why people have hernia exacerbation is constipation. That means straining. So if you’re straining to have a bowel movement, you are at risk of having hernias become exacerbated and if you have a surgery for hernia repair, actually if you have any surgery of the abdominal wall, you’re at risk of getting a hernia because of the straining and the abdominal pressure that you make from that straining.

Speaker 2 (15:25):

So basically with the straining, what you have is increasing the abdominal pressure and wherever you have sutures that are or things are sewn or things are placed, they’re being put under pressure and you will have a high risk of recurring from that hernia. This is actually kind of important because first of all, the United States constipation is endemic. There’s so many people that are constipated. Just go to your local pharmacy and the largest section of your pharmacy is kind of constipation, medications, fibers, laxatives, stool softeners, enemas, whatever you can think of are available over the counter like the whole wall is filled with constipation, treatment regimens, CTs, et cetera, which means that any surgery you undergo of the abdominal wall, maybe it’s a hysterectomy, maybe it’s your prostate cancer, maybe it’s your gall bladder surgery. If you’re constipated going into that surgery and then after surgery you’re straining, you will increase your risk of having a hernia from any of those operations.

Speaker 2 (16:35):

We call those incisional hernias. Interestingly also, as you may know, constipation can occur from actually having surgery. Often the narcotics that are used during anesthesia or prescribed after anesthesia for your hernia pain or your surgery pain can promote pretty bad constipation even if you don’t naturally already have a predilection to be constipated. And so it’s very important that before surgery you, you’re not constipated to begin with and start at a better baseline and then we’ll talk about how to prevent constipation for after surgery, but that’s really important for any surgery that you have, especially hernia surgery. Constipation is the enemy of hernias. It’s the number one enemy of hernias. Okay, so we’ve got weight loss, nicotine cessation, cal suppression and constipation prevention. The rest of the things that I’ll just be discussing are really related to just not preparing for surgery the long term weeks and days, months before but rather the day before surgery for example, or the week before surgery.

Speaker 2 (17:56):

So in most situations we don’t want you to be taking anything that will cause you to bleed during surgery. There’s already a risk of bleeding with any operation. With hernia surgery, the risk is usually low, but even the slightest amount of bleeding or oozing can cause adhesions. It can cause swelling and pain after surgery. It may show up as bruising of your incision and in some cases may look, make your scar look ugly and in rare cases you need surgery to treat the bleeding. So whatever you can do before surgery to prevent being prone to oozing or bleeding is good. So fish oil should be stopped at least a week before. There are other certain herbal medications that tend to thin your blood that you should stop if you are taking aspirin, usually we like you to stop that aspirin one week before surgery. In my practice, I don’t recommend stopping the aspirin if you are dependent on it.

Speaker 2 (19:04):

So if you have a horrible, horribly diseased atherosclerosis of the heart and you’re dependent on that aspirin to not have have a stroke or not have a heart attack, then personally I’d rather you not have the stroke or the heart attack during surgery and we buy a little bit extra bruising and I’m just a little bit more careful with the he what we call hemostasis or prevention of bleeding during surgery. So I’ll say keep your aspirin because hard before hernia and then after that just understand that you’ll be more bruised than the average patient during surgery. Aspirin usually does not cause significant bleeding. It’s more the bruising If you are a fish eater, so someone just wrote, I ate fish, can I eat fish the day before surgery? Really the effects of fish will last about a week. If you’re a daily fish eater, yes you can, but if you take fish oil in particular, that’s a very kind of potent amount of fish oil and it can keep your you a little bit more thinned.

Speaker 2 (20:23):

If you’re a pescatarian, all you do is eat fish, then you’re more likely to have bruising and even bleeding during surgery. So I prefer that you don’t eat fish for the week before surgery if you really want to be very careful about it. But more importantly is the fish oil capsules. That’s a lot of concentrated fish oil that you take daily in terms of other things that can cause bleeding. So related to aspirin are the what we call NSAIDs, the non-steroidal anti-inflammatory drugs. They include ibuprofen, naproxen and things like ale and Advil. So in those situations we recommend you be off them for three days, not a whole week but three days because their effect lasts about three days, whereas aspirin stays in your system for about a week. So prefer that you but Tylenol is okay. Tylenol does not cause any problems with bleeding if you are on a blood thinner like an actual blood thinner, it could be warfarin, it could be any of the commercial products for the heart.

Speaker 2 (21:38):

If you have a heart stent in for exam for example, any of those, you can have to run that by your cardiologist or medical doctor who prescribes it to you. The reason for that is there must be a reason why you’re on it. You may have had a stroke, you may have had a heart attack, you may have had a heart stent in place or you have aortic aneurysm. There are multiple life threatening reasons for which you are on a blood thinner. Maybe have some weird heart rhythm. That’s a very common one. So if your cardiologist says it’s okay for you to be off of those medications before and after surgery, great, but if they say it’s not okay, then you should just not be undergo surgery until it’s okay to be off of that. All right, we got some questions coming up. If I can just go through those real quick and then we’ll go through these preparations. Before surgery, I’ve had four anal hernias till this day. Every time after the surgery I have terrible pain until I get to urinate. Why does that happen? Is it common and after I urinate, the pain is tolerable. Okay, that’s really interesting. So it’s a good thing to talk about which is your prostate. So men have prostates. Women do not have prostates. The prostate is there to take the sperm and then add a bunch of semen to it basically and help in that process.

Speaker 2 (23:19):

What is important to know is that as you grow older, your prostate can enlarge. It sits right on the top, the base of your bladder at the outlet of the bladder. And you can think of it like a collar, like a neck tie or a neck piece around the base of the bladder. So the larger the prostate, the more it’s compressing the outlet of your bladder, which is called the urethra. And so you have problems completely emptying your bladder or your urinary stream is slow. You may wake up multiple times at night to urinate, you may dribble, you may feel like you’re urinating frequently or urgently. Those are all symptoms in large prostate. If you take medications to take medications to shrink that prostate, that’s great because then after surgery you will be able to continue to have that shrunken prostate and that outlet is wide open for you to urinate.

Speaker 2 (24:29):

If you are unable to urinate after surgery, your bladder will get bigger and bigger and bigger and then you will have problems emptying the bladder if it gets too big. So the question is, I’ve had multiple hernia surgeries for the groin four times each time I have severe pain until I can urinate. Well, it’s possible that during surgery your bladder, you kept baking urine, right? You’re getting IV fluids and your bladder’s getting bigger and bigger and bigger and it can, if any of you have ever held your urine, it can be very painful to have a full bladder and your bladder is filling up during surgery, so you can’t willingly urinate until you wake up and then you have so much pain and then you empty your bladder and you feel better. So that may be one scenario. Many surgeons don’t use fully catheters or urinary catheters during surgery, and so they’re the bladder’s at risk of enlarging too much as you’re making urine during anesthesia.

Speaker 2 (25:35):

I tend to err on using the Foley catheter during my pelvic surgery, so any laparoscopic al hernia repairs, but not for the open, I usually have urinate before you go. If you have prostate issues, you’re at risk of having problems urinated after surgery because the anesthesia will kind of get you all relaxed and it will relax everything including your muscles, including your bladder, and usually you need that bladder pressure to overcome the tightness at the prostate level to urinate. But then if you wake up and you don’t, you’re still kind of woozy and your bladder function has not completely come back yet to overcome the high pressure zone at the prostate, then you may not empty your bladder at all and then someone needs to put a catheter in before your bladder B bursts. So it’s very important. I’ll add this to the list. It’s very important if you have any signs of prostate enlargement that you get that treated before your hernia surgery.

Speaker 2 (26:45):

I routinely ask this for all my al hernia patients, especially if you’re over 50, which is when your prostate issues start to become a problem. Mostly it’s in the seventies and eighties, but it definitely starts around age 50. So if you have, you’re a male, you don’t have a urologist or you do have a urologist and you’re not optimized for your prostate because you wake up more two or more times at night to urinate, your urinary stream is slow, it dribbles or it sprays. You have to strain to empty your bladder completely. You have frequent urination or urgency to urinate. I think I mentioned slow urinary stream that all of those are symptoms associated with an enlarged prostate that must get treated usually medically, usually with medications before your hernia surgery or you will have a high risk of not being able to urinate after surgery again.

Speaker 2 (27:43):

Why would you want that to happen? Why would you want to end up with a catheter in you which you have to go home with? Very uncomfortable for men when you can prevent that by just getting that treated. Alright, it makes sense. I identify with the different scenarios. Thank you. You’re welcome. Next question. I have a right inguinal hernia, recurrent left inguinal hernia. Okay, so the right side primary inguinal hernia left side is a recurrent inguinal hernia and a ventral incisional hernia and an epigastric hernia. Can all the hernias be fixed in one surgery and how many pieces of Mesh would I need? I still have horrible pain from the left inguinal hernia surgery six years ago with both a plug plug and Mesh. I’m scared to have surgery. Okay, so the short answer is yes, all of those can be treated at the same time.

Speaker 2 (28:37):

However, I personally do not like to mix more urgent problems with elective problems. So if you have chronic pain and you have a Mesh plug and that needs to be addressed rather we just focus on that first and then not slap some Mesh elsewhere in your body. And then now we have four issues to deal with, but usually, usually it’s one Mesh and one groin, one per groin and then one Mesh for the eventual incisional combination hernia. Do you find that binders help patients from hernia from their hernia surgical sites when they cough or sneeze? Yes. For ventral hernias, abdominal wall hernias, I’m a big fan of binders. I think that the binders initially help stabilize the abdominal wall adds external pressure, it reminds you had surgery, it adds external pressure to help reduce the tension that will be on your abdominal wall and your hernia repair.

Speaker 2 (29:42):

It will maybe help your wounds heal nicer because they’re not being stretched open. You may have less bruising and less swelling from the external compression. So there’s a lot of things that can help. It can help with, I feel that most patients enjoy having the binder on in the early phasix. Some of them don’t want to take it off afterwards. So I’m a big fan of abdominal wall binders. However, what’s key is you must make sure that the binder is soft and it’s it’s your size so you don’t want it to pinch you or fold or roll. a lot of women have relatively narrow waist with a very wide hip and it’s really difficult to get a good binder because it’ll just fall into the waist and then fold up from the hips. So sometimes the softer or the longer binders help or in women’s cases you can buy long underwear that comes up to the breast line or compression tank tops that come from above.

Speaker 2 (30:48):

And that’s a good point. You may or may not be provided a binder by your surgeon, but it would be something to consider going online and reading about to find binders and have ’em in the house. Maybe you want multiple binders so you can wash them and you and wash ’em. Wear in between as part of your recovery. Just get prepared for surgery. If your surgeon has special binders they like, you should ask them. I personally like the caromed C A R O M E D caromed brand, the triple binder, the 12 inch triple binder. I think that’s really soft and easy to wear on your own. It’s like a t-shirt type texture. There’s some other ones by prolene, which are okay also for the long tank tops and underwears. I like maiden form for women and yummy tummy. They tend to have good quality products. I’m not a big fan of spanks. That tends to be too tight for surgical patients. Are binders effective in inguinal hernia surgery as well? No. So binders are not adequate or effective for inguinal hernia surgery. I do recommend if you have a large hernia that you wear a compression garment to help reduce scrotal swelling after surgery. Specifically I like the Under Armour high compression athletic underwear, the ones with the crisscross pattern to it. Those tend to be good quality, affordable and I like the men’s athletic compression for under armor that are mid thigh length. So that tends to add good compression and for

Speaker 3 (32:38):

Women they have make women’s girdles again made form I think is a good option for that. I wish they would sponsor the show. I just call them up, Hey maid inform, or Kara you want to sponsor my show? Maybe Under Armour wants to sponsor it. It’ll be kind of cute. Maybe we can give away how giveaways. I don’t know. All right, moving right along. What else can we discuss? Okay, so we talked about blood thinners and obviously if have you’re over 45 you should be getting an EKG and if you’re have any heart disease you should be risk assessed for your risk of anesthesia. Blood tests are typically normal, although if you’re young and healthy you don’t necessarily have to have blood tests. Depends on your surgeons and your anesthesiologists comfort level. I do check urine tests in some patients because if you have an active urinary infection and you have U, what do you call it, bacteria in your system, then that can cause a Mesh infection.

Speaker 3 (33:54):

So I prefer that that get treated. a lot of people are running around without really knowing that they have bacteria in their bladder, but that’s not necessarily routine and that’s pretty much it for before surgery. You want to make sure, again, you’re not morbidly obese, you’re not using nicotine. Any cough is treated or suppressed. Any constipation is absolutely taken care of before surgery you’re not on anything that could increase your risk of bleeding and if you’re a blood thinner, you should not be having surgery. If you do need the elective surgery, you have to work with your hematologist or cardiologist to figure out what to do with the blood thinner because that’s super important. I’ve had a couple patients that have actual blood clotting problems and so they have to be on a blood thinner and so they really can’t be off the blood thinner or they’ve had problems like blood clots to their lungs and so on, which is a life-threatening problem. And so you work carefully with them to get them blood thinned as close to the surgery as possible, but not during surgery and then you restart the blood thinners afterwards oftentimes with injections, lovanox. So lot to think about. Here’s another one. Is it a good idea to hydrate with something like Gatorade the day before surgery? Not really. Gatorade has a lot of sugar in it and most of the sports drinks are not really necessary. If you just have a normal diet and water intake, you should have

Speaker 2 (35:36):

Normal minerals and so on in before surgery. Most people do get a blood test to make sure their potassium’s normal and sodium is normal and so on. And then in terms of anesthesia, there are these commercially available drinks that are like, what do they call? They’re like electrolyte drinks which are recommended to be taken the day of surgery actually, which is kind of weird because we’re saying don’t eat or drink anything before, before your surgery, minimum six hours and yet this is allowable. So the reason why we tell people not to eat or drink before surgery, it’s because during anesthesia you may, if you have a full stomach or have anything in your stomach, it may reflux up either because you’re refluxing or because you’re having laparoscopy or belly’s being bloated with gas and that may increase your risk of refluxing or it could just laying flat anyway.

Speaker 2 (36:46):

If you are not awake or with it, then you may reflux and that reflux may that acid or food can go into your lungs, which in some cases can be lethal or at the very least you may get a pneumonia. So what I recommend is that you follow the directions of your anesthesiologist. Usually it’s they say don’t eat a drink after midnight, but the number is really six hours, somewhere between six and eight hours is safe to have not had anything major to eat or drink. However, if you’re diabetic, that’s something you should work with. So let’s say you have a after. Usually we operate on diabetics earlier in the day and non-diabetics later in the day. I personally, personally don’t think it’s fair if you have a 2:00 PM surgery for you not to eat or drink after midnight because that’s like what, 14 hours without any water or food.

Speaker 2 (37:55):

However, I would recommend that you talk to your doctor if you’re like, oh, as long as eight hours we’re okay then if you have a 2:00 PM surgery that subtract eight hours so you can have breakfast at six, 6:00 AM or something like that. So that’s kind of something that you may want to talk to your doctor because it’s kind of not cool to just starve and be dehydrated all day because of this one rule of nothing to eat or drink after midnight, your medications should be taken otherwise regularly. And if you take ’em at night, that’s fine. You take anything in the morning of your surgery date, definitely your blood pressure medication, you have to take it. Usually your diabetic medication we have you take half dose because you’re not eating or drinking. So we don’t want you to bottom out. We don’t want you to skip your diabetic medication because then you’ll show up with a sugar that’s super high and dangerously high and then we have to actually cancel surgery because of it. So usually we allow your you to take your medications with a sip, a sip of water.

Speaker 2 (39:06):

Next question. How about a low fiber diet after surgery? Okay, we’ll talk about after surgery. That’s a totally different situation. Let’s kind of finish up everything preparing for surgery. So a lot of questions about bathing. So at the very least you should bathe before surgery. That’s super important to reduce the dirt and any bacteria in your body on your skin because we have to cut through that skin and we don’t want to drag that dirty or bacteria from your skin onto it. What’s even more interesting nowadays is we often recommend Hiba cleanse, which is chlorhexidine gluconate. It’s a chlorhexidine-based soap or lotion or like liquid soap that is antibacterial. So really any antibacterial soap and pretty much all soap is antibacterial pretty much is fine, but specifically the hospitals talk about hiba cleanse or chlorhexidine. So that has been shown to in scientific studies, to dramatically reduce the amount of bacteria on your skin so that when we cut the skin and we start doing our surgery, we don’t drag bacteria into your wound because that is a risk. Some places recommend taking a hippo cleanse or chlorhexidine shower the night before and the more morning of some hospitals, including my hospitals have CHLORHEXIDINE wipes that they wipe you down in addition right before surgery. And then during surgery we do wash you up with usually chlorhexidine or Betadine Prep solutions to reduce the bacteria that naturally lives on your skin. What I really highly encourage is please clean your belly button.

Speaker 2 (41:16):

People forget they have to clean inside their belly button and some people have really deep belly buttons and if I can just tell you some of the stuff that we find in belly buttons, you would puke, it can be super gross and there can be so bacteria that grows in this deep, moist, dark part of your belly button and people forget that once you shower, you also have to clean inside the belly button. So if you have a deep belly button, you may want to use a Q-tip before surgery. If you don’t have a deep belly button, just use your finger soap and water is adequate, but please, please, please clean your belly button before surgery. Highly, highly recommend it. One patient says that their surgeon also had them put bacitracin in their nostrils, so that’s related to what’s called MRSA or mrsa. Mersa or MRSA is stands for Methicillin-resistant Staphylococcus aureus.

Speaker 2 (42:23):

It’s a highly bacterial resistant, sorry, antibiotic resistant bacteria. It is also the bane of our existence when it comes to infections because once you’re infected with M R S A, it kind of harbors in your body and may pop up again in future surgeries. So if you’ve had surgery before or you’ve been in the hospital a long time, it’s very possible that you have M R S A. I probably have M R S A just because I’ve been working in the hospital for half my life. So if you have had a R S A infection in the past, you’re at risk of having an M R S A infection again. And so one of the places where the M R S A harbor is in your nose, believe or not. So most hospitals survey you for M R S A regardless of why you’re there. By sticking a tube in your nose and checking for M R S A. If you’ve known to have M R S A in the past, they may give you antibiotics to put inside your nose to reduce how much R S A is in your system and therefore less likely to, what do you call it, like infect your wound and et cetera.

Speaker 2 (43:41):

So yes, shower before and morning of. And then if your surgeon or your hospital may want you to use bacitracin or some other antibiotic appointment into your nose to reduce the risk of M R S A at the day of surgery, one thing you should not do is shave the area of your incision. You are not doing us any favors by shaving ahead of time. And I’ll tell you why. When you shave, whether it’s with a razor or a blade or clippers, you are causing micronics on the skin and those micronics now expose the skin to bacteria. If you are now opening up your skin to bacteria because you shaved for us the night before,or day off and then you show up to surgery, you are already exposing your skin and wound to bacteria and therefore an infection. So people who shave ahead of time are at higher risk of having a wound infection.

Speaker 2 (44:50):

So do not shave for us. We will shave for you to limit the time between shaving and making the incision. So we will have clippers, not even shavers or clip electrical clippers, which cause a least amount of skin irritation. We will shave the hair. We may or may not shave the area of your surgery to reduce the hair because the hair also harbors a bacteria. And immediately afterwards we will wash your belly or groin or whatever it is with antibacterial solution, which is called a… So I do not recommend that you do any clipping or shaving the area of your groin or belly. We’ll do that for you because that will provide you with a lower risk of infection one viewer is mentioning. You can actually also bathe too hard, maybe like loofa too hard and cause nicks in your skin. That’s true. It’s not common.

Speaker 2 (45:54):

I don’t see that commonly. But yeah, don’t, don’t use a really aggressive loofa the day before surgery either. So what else are we missing? Oh, I want to talk to you about ERAS. Let me explain to you what ERAS is you may have heard of eras. So ERAS is spelled E R A S like Sam and it stands for this acronym. It’s enhanced recovery after surgery. So enhanced recovery after surgery is a whole system of algorithms and recommendations to help improve your outcome. Usually as part of the ERAS system, it talks about what to do during the operation and then after surgery for the patient. And that can include multimodal pain therapy, use of local anesthetic use of reduced use of narcotics cleansing and all that. And then after surgery doing, taking all efforts to resume bowel function. What’s important is making sure that you as the patient are optimized before surgery so that the ERAS or the enhanced recovery after surgery is optimal optimalized for you.

Speaker 2 (47:15):

So if you come in constipated, then ERAS is going to have a lot of catching up to do to prevent constipation after surgery. If you come in infected, then no matter how much antibiotics they give you after surgery, you’re already kind of behind eight ball. So a lot of today’s episode is focusing on planning for your hernia surgery because we want to make sure that you as a patient do as much as you can so that your surgeon and anesthesiologist can take over on the day of surgery onwards to provide you with the best care. One question is, can you take a sleeping pill the night before surgery? Yes, you can take narcotics even up to the night of surgery. We don’t recommend you take any anxiolytics, Valium, Xanax, the day of surgery. We do not recommend that you take any sleeping pills. Obviously the day of surgery, we oftentimes do not recommend you take any antidepressants the day of surgery, there’s a lot of things you can just not take for one day, which is fine. Even like you can miss your thyroid medication for one day, it should be okay because that’s already in your system.

Speaker 2 (48:34):

The other thing I want to talk to you about, about is this anti-inflammatory bundle that I use. It’s not common. I don’t want you to go around telling all your doctors why aren’t they using it. It’s not considered standard of care. So yes, you can take Xanax the night before. You can take anything the night before, just not the day of. So I strongly believe that we have to prep your body to be in as low of an inflammatory state as possible because surgery cause is basically trauma to your body. It’s inflammatory trauma. And so the lower your inflammatory state before surgery, the better you’re going to recover after surgery with less pain, less bruising, less swelling, less involved because you have less inflammation. So what I recommend for my patients is an anti-inflammatory bundle. And that bundle is the following. They take Arnica, these are, and I start these three days before, that includes Arnica, bromeline and I believe alpha-lipoic acid and those you can take before surgery without any consequence.

Speaker 2 (49:46):

And I continue that after surgery, Arnica in particular. And then after surgery we do those three plus turmeric, ginger, beta, superbee complex, and I think that’s it. So arnica, alpha lipoic acid, brom, superbee, complex ginger, turmeric, yeah, six pills. I’m in love with the arnica. So arnica is a natural homeopathic herb. It reduces bruising, reduces inflammation and swelling. And I learned for the plastic surgeons, for people that get facelifts or nose jobs, the less swelling they have, the less bruising they have, the better the cosmetic output outcome and the less pain. So plastic surgeons and E N T doctors actually give arnica before surgery. So I’m like, why shouldn’t I give RN before surgery? And I did, and patients do so well. So obviously you need to clear it with your surgeons. They don’t freak out. You’re taking some homeopathic medication. However, I’m a big fan of RN and I highly recommend you take it.

Speaker 2 (51:02):

It’s three times a day before surgery for three days and then for at least a week after surgery, again, three times a day. As you know, Arnica comes in cream forms and in addition to pellets, but in specifically I recommend this and then prior to surgery, the last comment I’m going to make is you’ll need to make sure that everything is set up for your recovery at home. So make sure your refrigerator is well stocked. Have as much anti constipation things available as possible, whether you like figs and fruit juices or fibers or laxative, mineral oil, milk of magnesia, MiraLax, any of those magnesium based products. Work, have them stocked. Ice packs. I’m a huge fan of ice packs. Just your old fashioned screw top. Stick the ice in the bag, ice packs, those can last six to six to 12 hours. Have some ice packs available and just slap it over your wound and that will help reduce inflammation and pain, swelling. And it’s a great adjunct to regular pain medication. If you need to buy a binder, if you need to wear some comfortable clothing, get all that prepared. Obviously you need to have someone drive you home because you’re not allowed to drive home alone or leave the surgery center or hospital alone. Someone needs to be there. Every so often. Patients are alone, they have nobody to drive them. And there are medical transports. In fact, I think Uber.

Speaker 2 (52:51):

Uber offers medical transportation. What that means is they don’t just pick you up and drop you off. They have to physically get out of the car and walk you into the house and assure that it’s a safe environment before they leave. And that’s something to consider. I do not recommend heat packs. Heat packs are not your friend when it comes to any surgery. It increases inflammation and swelling and may even increase bleeding. So ice packs and anything cold works much better. Oh yeah, like my slap it on the wound coming, slap it on the wound, gently place it on the wound, put your ice packs and gently place it on the wound. 12 hours, sorry, 20 minutes on, 20 minutes off, or as long as you can tolerate, honestly, as long as you don’t get a burn, an ice, ice burn.

Speaker 2 (53:50):

And then yeah, clothing. So your comfortable shoes, comfortable outfits don’t wear things that are tight, especially first a couple days you’ll be swollen and or bloated and so on. And then have some food available, either readily made or delivered to you. You don’t want to, the first day of surgery, you don’t want to eat anything spicy or greasy because the anesthesia, who knows how you’re going to react to anesthesia. And last thing you want to do is be all drowsy, then want to vomit. Oh no vomiting. Because vomiting similar to coughing and sneezing generates enormous abdominal pressure and you can’t control how much you re and how much abdominal pressure you develop because of it. So yes, I do not recommend you taking anything that can increase your risk of vomiting and therefore usually spicy and greasy foods are among that because the anesthetic that’s in your system doesn’t help that. Someone mentioned that there should be a layer or towel between a your wound and the ice pack and just like a t-shirt should be okay. A towel can be fine. It may be too thick to actually get the benefits of the ice packs. Just be careful not to burn yourself and use your own judgment.

Speaker 2 (55:21):

Okay, so someone’s thanking me already. Gosh, I wish I could have heard all of this prior to my first surgery in 2016. I was so on how to take care of myself. Yeah, well you know what? I didn’t know these in when I was a resident. I just learned how to operate and then all of a sudden I have all these patients that need guidance and I myself have had surgery before, so I understand how important it is for the aftercare in addition, but definitely to optimize yourself before surgery. Yeah, a t-shirt or a piece of fleece works well between your ice pack and the wound Last comment. This is fantastic. Thank you. Are you able to do post-surgery talk? I have a few questions. Yes. I think we’re pretty much out of time for this hour to talk about planning for surgery. What I’ll do is I’ll do another one later in the year on after surgery.

Speaker 2 (56:24):

We’ve already had a couple guests in the past, especially our bariatric weight loss surgery friends, Dr. Bittner, I recall specifically where we discuss how important it is to have good weight control before surgery and after. And then I believe with Dr. Trayzon who’s a gastroenterologist, we talked about constipation and other ways to help thing like ideas on how to prevent constipation after surgery. But I do agree. Thank you for all this. Everyone’s thanking me. I love your comments. I do agree that we should do another hour, but just talk about post post-operative and I’ll, I’ll get to the nitty gritty eventually. We should get a frequently asked questions brochure. Sure. Actually go to my website, beverly hills hernia center.com. And we do have a brochure on pre-op and post-op optimization. So pre-op instructions brochure actually has most of what I discussed on it already. So again, it’s my website, www.beverlyhillsherniacenter.com.

Speaker 2 (57:37):

Under the patient section patient instruction section, we have pre-op instructions, so that should be all of it. Do you do virtual visits? Because I live in Minnesota. Yes I do. We provide online consultations to anyone outside of California. Can you discuss ventral hernias later? Yes, actually, we’ve discussed ventral hernias a lot and with multiple different surgeons. If you go on the YouTube, my YouTube channel and just on my channel, just search for the word ventral hernia or incisional hernia, you’ll see which posts, which episodes, include those comments. And yes, if you visit any of my social media pages, you’ll see how you can contact my office for an online consultation if you’re out of California and any other telehealth visit if you’re within California or you can come visit me and I’d be happy to see you. Thanks everyone. I appreciate it. Enjoy your evening, make sure you’re not constipated or coughing and hope you all have a great, great time going through. Oh, you know what, we didn’t talk about glucose. Make sure your blood sugar is normal. And that is the end of it. Thanks everyone. Bye to you later. Bye-bye.