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Speaker 1 (00:00):
Hi everyone. It’s Dr. Towfigh. Hope you’re all well. Today is I think the 83rd or 84th episode of Hernia Talk Live. You’re with me, Shirin Towfigh, your hernia and laparoscopic surgery specialist. I love hernias and I love talking about hernias, hence hernia talk and our weekly Tuesday Hernia Talk Live. Thanks to everyone for joining me by Zoom and also live on Facebook as a Facebook Live. You can also look at all my previous episodes on YouTube and they’re also posted on my other social media channels, specifically at Hernia Doc on Twitter and Instagram. So as many of you are aware that are joining me live, this is the kind of mid-December 2021 episode.
Speaker 1 (00:57):
I thought that I would kind of share this time with you all just individually, just me and all of you. The Christmas holidays are coming, new Year’s is coming. Many of you will be traveling or visiting away from your natural home, which may imply that you’re not in tune with everything that you enjoy doing or that’s easy for you to do at home if you have a hernia or if you had hernia surgery. You may have certain symptoms that you need to get addressed and sometimes it’s hard to do that and still have a normal life. So I thought I would spend this hour discussing tips that I can give you on how to help control hernia related pain. It can be hernia pain or hernia complication related pain. It could be groin related or abdominal wall or back. I’ll just give you my tips and tricks of all the different ways that you can think about fixing, addressing your hernia pain during the holidays. So people aren’t really doing surgery, they really aren’t operating, they’re not seeing their doctors, everyone’s out of town and so hopefully you can use that time to kind of enjoy your holidays, but at the same time not be in too much pain. So in doing so, I also would like you to give me your questions as they’re coming in. I’ll answer them one by one, but the first thing I will say is almost every hernia pain is primarily inflammatory pain.
Speaker 1 (02:35):
Hernia pain itself as you have a hernia and it hurts you, it’s because something is getting stuck or pinched that causes inflammation and the inflammation causes the localized pain. In addition, if you had hernia surgery, whether you’ve had Mesh or no Mesh, that kind of surgery causes tissue injury. It’ll heal, but that kind of injury is inflammatory in nature. Mesh is also pro-inflammatory, and so the inflammation from Mesh can cause pain. So primarily most hernia pain, whether it’s before surgery or after surgery, is inflammatory in nature and therefore biologic, anti anti-inflammatories work really well. Now what are anti-inflammatories? They’re things that reduce inflammation. They can be over the counter. They can be pills, creams, patches, pax. All of those are anti-inflammatory options. The typical anti-inflammatory we think about are what we call NSAIDs and S A I D, which stands for non-steroidal anti-inflammatory drugs Ale, Advil, which Motrin, so basically naproxen or ibuprofen.
Speaker 1 (03:49):
Those are the generic term ones for that are very anti-inflammatory. Celebrex. These are all prescription by prescription or you can get him over the counter at your local pharmacy. They have side effects people that take anti-inflammatory medications, specifically the naproxen or ibuprofen. It can affect your kidney. It may cause ulcers, it may worsen osteoporosis. There are things that they are medications you should not be on forever and you should not be on for high dose. But that said, they’re really good anti-inflammatory, very reliable Tylenol, which is a great medication as long as you don’t overdose on it. Tylenol is not anti-inflammatory. It is a good pain medication, but it’s not specifically against inflammation, so it’s not considered anti-inflammatory.
Speaker 1 (04:50):
So I usually do not recommend it as a primary mode of pain control. It can be added onto other medications as like a stepwise algorithm, but you should not be using Tylenol primarily because it doesn’t work as well. The simplest anti-inflammatory is an ice pack. I love ice packs. If you come to my office, we give away ice packs. Ice packs are great. It can be something simple like frozen vegetables or peas from your freezer or you can just, I like the old fashioned ones, like the little packs with the screw on top and you pour in the ice. Those last the longest, about six to eight hours. The ones that are not reusable, like the disposal ones where you pop it and it starts at chemical reaction and you get I guess frozen those last like half an hour. So I think it’s a waste of time and money for those.
Speaker 1 (05:50):
Even if you’re in the hospital, always ask for the non disposable ones where you pour in the ice because that lasts many, many, many hours. So ice packs are great. So if you had surgery with me, you know that after surgery you wake up with an ice pack over the area of your surgery because surgery causes tissue damage and tissue injury and then the ice packs will help reduce the inflammation related to that and reduce your bruising swelling and reduce your pain. And I recommend using ice packs for a good 48 hours after any hernia surgery. You can do it for regular hernia. So if you have a regular hernia and it causes symptoms, you can place an ice pack right over it with very little risk. The only risk of using ice packs is burning your skin from the direct contact with extreme coldness.
Speaker 1 (06:41):
So I recommend doing it over like a light t-shirt or wrapping it in a thin towel so that you don’t get burned from too much, too much ice packs. Some people ask about ice packs versus heat pack, like what’s the difference? So if you have inflammation and inflammatory pain, whether it’s a slipped disc of your back or it’s a surgery or if it’s hernia related problem, you want anti-inflammatories and use ice packs. Heat packs actually increase blood flow to the area, which will increase inflammation and it helps relax the muscle. That’s why some people sit in a hot tub to relax their muscles. So heat packs actually worsen inflammation, but it does relax your muscle. So if you have a muscle spasm, heat pack works really well, but for surgery we don’t usually recommend heat packs because that can cause a lot of problems in terms of swelling, many of you’re coming in now and saying hello, hello from oh yes, every hi here. They’re saying that in Italy everyone has a big hernia and that is the government. I don’t understand the text. Hello from Italy here. Everybody has a big hernia and that I is the government.
Speaker 1 (08:15):
Hello from Italy. So that’s the story between ice packs and heat packs. Let’s see, we got a question here. Does failure to respond to ice placement a towel suggest non-inflammatory ideology of pain? Yes, often yes. So the other ideology of pain can be neuropathic or muscle spasm. So in those situations if ice packs don’t help you or may maybe a mechanical problem if you have a meshoma or any type of Mesh relay like balling up a functionally like a problem where it has to be physically removed, no amount of pain going to get rid of that pain. If you have nerve pain, actually nerve pain hates the ice. It may make it worse because it just stuns the area. So nerve, if you have isolated nerve pain, then sometimes heat works better than that.
Speaker 1 (09:17):
Hello, Dr. Towfigh. Hi. So the next question has to do with, oh, here’s a question. Do you recommend putting another Mesh on top of a five-year-old Mesh for recurring incisional hernia? All right, so here’s a situation. Mesh on Mesh doesn’t work. The way Mesh works is it needs to have tissue grow into it, otherwise it’s just a piece of paper. Putting paper over paper doesn’t work. So what you need to do is put Mesh against other tissue. So if you have a recurrent hernia and there’s a Mesh nearby, you can keep that Mesh and add another Mesh if that’s what’s necessary, especially if that Mesh is holding things together that you don’t want tear it apart. But in general, Mesh on Mesh doesn’t work. So I know I don’t recommend you putting Mesh directly on top of another Mesh. That definitely does not work. So other ways of doing of treating inflammatory pain are creams and patches.
Speaker 1 (10:29):
So it used to be prescription, but now in the United States we have voltaren cream in other countries in Europe and Canada is still, it’s always been over the counter. So Volter is a great anti-inflammatory cream or diclofenac is the generic diclofenac ointment or cream is over the counter. It’s basically aspirin or ibuprofen in cream form and other creams. There’s something called a flexor patch, which is also the same Antiflammatory patch, you’d like to stick it on. C B D if your state allows for marijuana use. C B D is the non hallucinogenic portion of marijuana, those THC and CBD. CBD is a part extracted that only is the anti-inflammatory portion and anti-inflammatory pain, sorry, an anti-inflammatory aspect of CBD is really, really strong. It comes in pill form, oral like liquid oil form, different types of gummies and also as a cream and patch. So you can consider creams or patches of CD as a good should ice be applied.
Speaker 1 (11:51):
Great question. So the correct answer is 20 minutes on, 20 minutes off. The reason for that is to prevent people from burning their skin and give the skin some time to get blood flow back to it basically. But what I have an injury I put on all the time, I’m just very careful not to burn myself. So get a freeze burn. So correct answer is 20 minutes on, 20 minutes off and you should do it only when you’re awake and not while you’re sleeping. Can you recommend pain management techniques for abdominal denervation? Twisting bowel sensation is quite painful. All right, so let’s move on to nerve pain. Are we done with anti-inflammatory pain? Let’s see, we talked about creams, pills. Oh, we did not talk about herbal opportunities. So as many of you know, I have an anti-inflammatory bundle which I recommend, which is completely natural, which includes over-the-counter herbal supplements.
Speaker 1 (12:58):
That includes Arnica, alpha lipoic acid, turmeric, ginger bromelain, and super B complex. These are all safe to use. The bromelain sometimes gives people nausea, it’s over the counter, it’s natural or somehow herbal or fruit derived and they’re not super strong but they work very well for most low grade inflammatory processes. So sometimes they come in creams, orating get a cream, but they’re all oral and I do recommend that you consider that there was a post about it on my Instagram saying you gave a talk and you mentioned your anti-inflammatory bundle. Where can I find it? Well, back in December several years ago, I think December of 2019 or 2017, I actually wrote up exactly what my anti-inflammatory bundle is. We also published a paper and it will be published for you all to read I think within the next month. So once that comes out I will post it as well.
Speaker 1 (14:10):
It explains the whole algorithm I have. So for people who have surgery, I recommend they take my anti-inflammatory bundle for three days before surgery to kind of reduce their inflammatory potential and then continue it for a week after surgery. So I’ve done that, that works really well and as a result I almost never prescribed high dose narcotics regarding ice packs. How many weeks of ice? So I recommend using it for a full 48 hours after most hernia surgeries. It’s a safe product so you can use it forever if you want for any other ailment. Let’s go back to the denervation nerve question. So people with nerve pain have very different needs. So nerve campaign can be because it’s being tickled by the hernia or entrapped by scar tissue or the nerve was actually injured. So those were the least extreme to the most extreme.
Speaker 1 (15:17):
The least extreme nerve pain can be settled with super B complex and some of the herbal medications they have anti nerve pain or kind of neuropathic pain properties. Short of that, sometimes tens machines can also help that. You can just go on Amazon or anywhere and buy a TENS machine. You put the patches on, it kind of stimulates the muscles but also really the nerves and kind of tells the nerves, no, no, no, don’t go here where your pain is go there. And so you tend to have less nerve pain. It works great for anyone who’s had any back issues. TENS machines work really great if you have nerve pain, it kind of tries to detract the nerve pain. Short of that, you really need to see a pain management specialist. There are multiple options for prescription based medications that can help you with nerve pain. Gabapentin or Neurontin, Lyrica. There are other ones. These are all prescription based nerve pain medications. And then in this specific question it says, can you recommend pain management techniques for abdominal wall denervation?
Speaker 1 (16:40):
So if you have abdominal wall denervation, typically you should not have nerve pain because it’s, there’s no nerve that’s supplying the area anymore and so you should be either no pain or numb, depends on why you have denervation. If you have denervation because the nerve was complete cut, then you should be numb and also weak in the area. If you have denervation because the nerve was injured, then you may have nerve pain but it’s uncommon to have both degradation and nerve pain. Those two don’t usually go together but if you’re having degradation where your abdominal wall is very distended and doesn’t have any tone to it and then you’re feeling the bowels kind of moving into this very weakened area of the abdominal wall, then that kind of pain is from the pulling of the intestines far away from where they’re inserted. And so the more you hold that in, the less pain you’ll have. So the we’ll talk about binders and so on, but really getting good fit so that you’re not pulling on the intestines, you’re pushing it back to where they originated from. That’s not technically nerve pain. That’s kind of bowel pain.
Speaker 2 (18:09):
All righty.
Speaker 1 (18:12):
One last thing about nerve pain. Injections can work very well. Usually a pain doctor can do it. Some of us would do hernia surgery like I do my own nerve blocks and injections, but injecting the nerve and numbing it up or adding steroids to reduce the inflammation, the area where the nerve may be active can help with pain control and then ultimately when we have to cut nerves, but usually we don’t cut nerves. That said, my goal today is to try and give you ideas of how to control your pain during the holidays when there is no doctor around and there’s no one there to inject you. So for nerve pain, it’s kind of a hard one. There are creams. C P D cream is a good one for nerve pain. There are other creams that have nerve pain medications like gabapentin in it. It’s usually done by compounded pharmacy and you can just lather that cream over the area and should help reduce your pain.
Speaker 1 (19:17):
What kind of pain do a cold hernias typically cause? Well a cold hernias by definition are hernias that you have that you don’t know you have because can’t see it or feel it but it’s there and because it’s there, a little piece of something is being caught up or pinched in the hernia and usually that’s a piece of fat that is purely inflammatory pain. If there’s a nerve nearby the and that’s being pinched with the nerve with the herniation or it’s being pushed on or irritated by the herniation because they’re both competing for the same space, you can get nerve pain but really the nerve pain is not the primary problem, it’s the inflammation. So if you treat the inflammation, the nerve, the nerve pain from a cold hernia should go away. All right, lots of questions. I love it. Good point.
Speaker 1 (20:11):
Regarding binders, it helps a lot to walk into rehab. Yes, very true. Okay, let’s talk about binders. So I like to refer ’em as in total as a compression garments. So compression garments can include binders and you really want binders that are soft that they’ll pinch. You don’t, don’t tear into your skin and so on. Everyone has a different body types. You have to find the right type of binder. Usually we prefer longer binders because they tend not to fold in and cause problems If it’s for the abdomen, you want the binder to fit you over the hips and not above, you want over the hips and that way it stop. It doesn’t slouch in For women, you want the binder to be no higher than below the breast because otherwise it could be uncomfortable to use. I like the brand C A R O M E D brand because they’re multi flap.
Speaker 1 (21:10):
The three flap 12 inch binders are very comfortable. They have a t-shirt quality against the skin. It’s lasts forever and I really like those. There are other multiple other brands that are also really good. Some are too thin, so you don’t want those that are too thin because they’re floppy. Some are super like stiff like cardboard, they’re just cheap and I don’t recommend it because they provide virtually no support. It’s like wearing a jacket, it has no give to it. Other ways of providing external compression for the abdominal wall are long underwears. For women, they are basically compression underwears that go up to the below the breast and that’s for lower abdominal problems. Or you can wear tight tank tops that are compression tank tops that come down to your waistline below your waistline. So those are two different ways of wearing compression garments without having you wear a bulky binder.
Speaker 1 (22:16):
I prefer maiden form for women, their highest compression products are really good. There’s also a local company here which you may also know about called yummy tummy. Yummy tummy also has a really good compression. I think the amount of compression that Spanx provides is a bit too much because you have to exert so much abdominal pressure to wear the damn thing that is almost counterproductive because you’re pushing on your hernia to try and wear that compression garment. So that’s for women. For men they have compression t-shirts that are athletic and that go down to well below your waistline and that’s good for upper abdominal hernias. For the lower abdominal hernias you should probably just wear binder and cause they don’t really make good high wasted underwear for men that are compression for her groin hernias, whether you’re male or female. Another option besides like a girdle for women would be compression underwear.
Speaker 1 (23:21):
I like the Under Armour highest compression underwears with legs for both men and women, especially the crisscross brand of it. I think that provides just enough compression to help with external compression of the hernia. And why are we even talking about external compression? Because oftentimes pain from the hernia is because it’s protruding out and that causes swelling as you’re walking gravity works against you and kind of pushes and pulls the hernia out and once you push it back in you’re like, oh, that feels so much better. So that ability to push the hernia back in so you have less pain makes it worthwhile to invest in really high quality compression garments. Talking about the underwear, so let’s talk about hernia trusses. So if you have groin hernias, there’s something called Al hernia truss. They’re very old school, they’ve been around for over a century. They look like they haven’t been invented or reinvented since over a century because they’re often very, very stiff and difficult to wear.
Speaker 1 (24:36):
Groin hernia trusses work best for men but women can also wear it. It’s intended to hold an inguinal or groin hernia in so that you can go about your daily life without any pain. It does not treat hernias and it does not improve the outcome of your hernia. There is a company called Comfort Truss, so Comfort, C O M F O R T Truss T R U S S. It’s a great small company, I hope you support them. He’s a gentleman who has a hernia himself and prefers not to have surgery and has a great Instagram page about his journey and promotes core strengthening and he developed a more modern day trust. There really isn’t anything good out there. I believe his the best in the market. You can buy online or on Amazon and the comfort truss has more of a neoprene soft quality to it. It’s not as stiff. It’s a little bit more low profile than what you can typically buy and I’ve recommended to many of my patients that they find it to be comfortable to wear.
Speaker 1 (25:47):
Oh my so many questions. Let’s see. I found that a combination of compression leggings and compression under underwear helps a lot. Great. Yeah, that’s great. So compression leggings. Here’s the issue with compression leggings. First of all, if they’re truly compression, so preferably over 25 millimeters of mercury pressure, but 18 to 25 is okay too for lower level compression. Those start the toes, have to go all the way up to the waist and they’re very difficult to wear to take on and take off. And so because of that, some people don’t wear it as much, but if you need it, it works great. The actually act of putting an on exerts a lot of abdominal pressure and that’s why I don’t think it’s good for most people with abdominal wall hernias, but groin hernias should be fine. Looks like you’re wearing the compression underwear for spans.
Speaker 1 (26:41):
If you can share which one you like, is it the one legs or the one without legs? I think the one with legs has better compression. Can a binder cause entrapment of intestines? Great question. No, it cannot. However, all binders, hernias, whatever need to be worn carefully so that you don’t So actually get good use out of it. So for example, if you have a scrotal hernia or hernia that’s coming out a lot in your scrotum to the point, it’s your scrotum. Don’t wear a truss over it directly. You got a live flat, shimmy that hernia back into place and then place the truss over it. What you don’t want to do is to be standing and pull up something compressive and say, oh, that’s great because that doesn’t help specifically for a hernia truss.
Speaker 1 (27:37):
If it’s an abdominal wall hernia, if there’s specific areas where you can push it back in and then where the binder that’s better In general, I recommend you wear your binders in bed when lying flat and then you get up and when you get up, I recommend you roll out of bed instead of bending up, just roll out bed. That’s better for your back anyway. What is the time course of postoperative pain before considering injections or other surgery? Another good question. So it depends on the severity of the pain and what was done. So if you’re in severe pain, yeah, I get an injection, why not? Why should you suffer? I don’t recommend doing more than that too early after surgery, but an injection is pretty benign. Most people do not need an injection early on and other modalities will help. I hope that’s, that’s helpful.
Speaker 1 (28:34):
How do you diagnose pain from a hernias if there’s no bulging in imaging studies are negative. Yeah, so if imagings are negative and you don’t have an hernia, it’s it’s mostly an imaging based diagnosis. All right, let’s see. Heat wraps and pain patches. Health, great. Yeah, so be careful with heat wraps. Heat wraps typically are for the back for people that have back spasm. I don’t recommend it over hernias especially, especially if you have a hernia that involves bowel. You don’t want to put heat packs on the bowel directly. Compression gum I still wear for two and a half years, remove it from rehab. Great. I’ve tried so many. Yeah, try. My favorite brands are Comfort Truss made form Yummy Tummy and Carol and Under Armor, Nike has compression short, tight, that can be worn out great. Yeah, Nike’s great too. I think all of the sports brands should have their own. The ones that I’ve tried out I found Under Armour was the higher quality one and more compression than the others for 24 years since my hernia repair, how does it migrate to my feet? I have positive pathology reports for tumor removed with S 100 mark markers for melanoma. Yeah, melanoma is not related to hernias.
Speaker 1 (30:08):
Yes. Under Armour, I am four foot level with no waist large ventral, what would you suggest? Okay, good point. So if you’re really short, if you have a very narrow waist and wide hips, those are actually the most difficult because of the binders kind of don’t follow the hips very well. But if you’re four 11 with no waist, then most binders tank tops, compression tank tops or long underwear should work for you. You just have to use a shorter binder. So nine inch instead of the 12 inch. Excellent tip. Thank you. I had left, I had left inguinal hernia surgery in 2015 with pain from day one. Now I have a right inguinal ventral incisional and epigastric hernia plus one doctor says left inguinal hernia popped back out. I refused more surgery with Mesh. What garment? Okay, great question. So first of all, if you don’t have symptoms, don’t worry about it.
Speaker 1 (31:10):
You just because you have a hernia doesn’t mean you have to address it. That’s the same for compression garments. So compression garments are intended to, for two reasons for the groin is only intended to treat that dull boring pain you may get with standing. And so if you have to stand, let’s say you’re security guard and you have Inguinal hernia, a truss will probably help you because standing for such a long time may cause more bulging of a hernia and there’s more like dull aching pain. But if you’re just a regular Joe Schmoe and you have a hernia in your groin and you have no symptoms, there’s no reason to wear, no reason to wear a truss does for the abdominal wall. It has two purposes if you have symptoms because the hernia, like the one of the guests here, one of the viewers said she has a here he has a abdominal wall denervation.
Speaker 1 (32:00):
Things are always pulling out. That’s very painful. If you have a bulging abdominal hernia and you want more support because it helps your back or it helps your front or came from the front, then that a binder or and or compression tank top or long underwear will help. However, the second purpose of binders or some type of compression garment for abdominal wall of hernias is the following. If you ignore your hernia for a long time and many people do, and if you have no symptoms, it’s okay. The things that are pushing out are pushing through a hole in the muscle and the next layer is fat and the next layer is skin. Over time that fat will start moving away and thinning out. So you basically have hernia and then skin and many of you can actually see your bowel just like moving up and down underneath your skin. That’s how thin the skin gets. You want to prevent that. Number one, you want to maintain as thick of a skin flap over your bowel and hernia as possible for multiple reasons. One is it’s safer, second is it’s better for you in terms of whatever you need your surgery. And third is this as this bowel or whatever it is pooches out of your hernia.
Speaker 1 (33:31):
Abdominal hernias. Now in the abdominal wall, as the bowel pooches out and goes towards the skin, it pushes towards the skin and thins out the skin. You’re also big basically a budding bowel to skin. So the normal abdominal law, you have skin fat, fascia muscle, more fascia than bowel. So if I poke your belly or even try and stab you, I have to go a long ways before the bowel could get injured and the bowel is often not injured by a typical poke or a seatbelt or whatever. If you lose all of that, if you lose the fascia and the muscle and the fat thins out, all you have is skin, then your bowel is within the millimeters of outside. If you have a scratch or a rash or a belt that irritated your belly or you bumped against something, that skin can get injured and guess what’s just due to a belt and even more extreme cases, the longer there’s pressure on that skin by this extruding bowel, the poor, the blood flow at that skin and just like how people can get decubitus ulcers because they’re relying on their back all the time like in a nursing home and you get poor blood flow to that pressure zone In the sacrum, the same thing you can get decubitus ulcers are what we call pressure ulcers on the skin overlying a hernia because the bowels constantly pushing against it and you get low blood flow eventually breaks down.
Speaker 1 (35:17):
You get these open sores. That is dangerous because if you get an open sore of skin right over a bowel, if that doesn’t heal then you have bowel and bowel does not like the open air and it will open up and you get a fistula. This is what we call a fistula from a hernia and that’s a horrible complication. It takes a lot of surgeries to fix those and it really ruins your quality of life because you’re having stool coming out of your hernia. So I just want to express how important it is to maintain skin health, moisturize the skin, make sure you don’t get dry skin because that’s easy to crack open over your hernia and then to maintain the hernia in as much as possible with these compression garments to reduce this kind of ultimate problem end stage problem, which is a fistula.
Speaker 1 (36:17):
Let’s see. You are describing mine exactly. Oh my, yeah, let’s not get there. I wish I could come to you for repair. I mean I’m here and I’m not taking any time off during the holidays. We are booked to the rim until New Year’s, so that’s my situation. Can you clinically distinguish neuropathic and nociceptive pain based on type of pain? Yes, so good question. Neuropathic pain is nerve pain. It’s often burning hot poker, hot electrical, shooting pain. Nociceptive pain pain is all the other types of pains. Dull, sharp can radiate but not necessarily SW swelling type pain, but really it is the nerve pain is much more specific. I wear a binder 24 7 with an exception of showers due to thinning muscle in the lower out. Very good. My PT wants me to start weaning off, but every time I do go longer without it, it causes severe pain.
Speaker 1 (37:34):
Should I continue attempting to wean off or resign myself to wearing it forever due the condition of muscle loss. So your PT wants to wean you off because a PT is focused on core strengthening and they are probably working to help your back and your front have core strengthening and if you’re externally supporting it, then you’re not internally supporting your abdominal wall and your back. Now if they’re working with you and you truly are able to get good core strengthening, then no matter how thin your muscle is, if it’s strong, you should be fine. The issue sounds like you have thinning muscles due to either diastasis or due to prior surgery. So if you’re actually missing muscle or you have herniation or diastasis of your muscles, then no matter how much core you do, you’re not going to be able to regain that. So I don’t disagree with you about wearing the binder or some type of compression, external compression.
Speaker 1 (38:40):
What is the time course of postoperative pain before considering injections or other surgery? Oh, we already discussed that. Would you mind repeating the compression values that work best? The compress? Oh yes. So for the leg, the stockings or the compression leggings are rated mild, moderate high compression. So you definitely want it over 18 millimeters of mercury. So it’s usually 18 to 25 is the required rate. Anything above 25 is better. So 25 to 35 is considered pretty good. And then for people that have a lot of legged next leg problems, varicose veins, non-healing venous ulcers, they usually want like 30 or 40 millimeters of mercury. But in my book, anything over 18 is good.
Speaker 1 (39:33):
With regards to post-operative pain, at what point should you begin to expect a problem as opposed to a healing process that may resolve with time? Everyone’s very different. It’s not a science, it’s an art. So it depends on what surgery you had, how much injury and inflammation was caused from the actual act of the operation and you know what your history is. What happens when you go into surgery and what is kind of like your experience before. Everyone’s very, very different. It’s hard to tell. I mean sometimes I do these really complicated hernias and I tell the resident man, I hope this patient does well, but they may have a lot of need for pain medication and so on. They’re like, oh, I’m just fine, everything’s fine. This was better than my first surgery. It’s very unpredictable per patient, so it has to do with the types of pains you have and the surgeon will know what they did and try and correlate your symptoms with what you are giving, feeding back to them and figure out what that is.
Speaker 1 (40:44):
Let’s see. Could I call your office to schedule a visit? Everyone can call my office absolutely. And I have the nicest office. Is it possible to do surgery while I’m there? Yes. For our out-of-state patients, we do recommend that you initiate a consultation before you come to see me if possible, to determine what you need and make sure that you’re in the best shape for surgery and make sure what the plan of surgery is. If you decide that surgery is the next step, we’ll give you a surgery date and then a one or two days before surgery I have to see you and physically see you, but we can do it so that during that week you see me, you get your COVID test, you get the surgery, all that gets done at the same time.
Speaker 1 (41:25):
I went in for a numbing injection on my nerve for pain from the left inguinal hernia and the man couldn’t give me the injection because he had only seen one layer of my abdomen and the nerve he needed to inject is between the second and third layer what happened to the layers of my abdomen. Okay, so that sounds like a tap block or an ilio inguinal gastric block. You still have those layers. He just needed to go further lateral to find them. That’s the problem. a lot of times the pain doctors don’t understand what we do for surgery. So if we put Mesh in it, it signals a lot of those layers together and that they don’t understand that that’s what happened. So if you’ve had surgery before, it does change your anatomy a little bit, but you just go more towards normal anatomy, so more laterally and then you work your way in. That’s what I do them myself because I know exactly what’s going on. Can you refer me to a surgeon outside Boston? If you go to hernia talk.com, we’re Hernia, Talk, Live, but this all started with a page and discretion form that I started back in 2013. Call hernia talk.com. So on that forum we have tons of doctors that have the patients have had good experience with just search the word Boston and you’ll see choices come up. What is your view on Mesh for large incisional hernias?
Speaker 1 (42:54):
Large incisional hernias absolutely need Mesh. That’s my view. They need heavyweight Mesh. You can’t just do lightweight Mesh. Can a recurring incisional hernia by the naval be repaired at the same time as fixing the jejunum with narrowing due to [inaudible]? Absolutely not. Nope, nope, nope, nope. Do not mix a clean elective operation with a contaminated or clean, contaminated or dirty necessary operation? No, don’t let them do it. You’re going to get, no. Here’s what happens. Just so you understand, you are going to undergo a necessary operation. Sounds like you need your jejunum operated on, you need your jejunum operated on and that’s necessary for sounds like an adhesion or narrowing so you can get normal bowels. That operation, first of all has risks. Wound infection is a major risk. Non-healing, bowel obstruction, ilias, vomiting, bloating, those are all risks of that operation from a hernia standpoint.
Speaker 1 (44:18):
Now you have let’s say a hernia at the same time. If you can have the surgery and just ignore the hernia, that would be choice number one. For example, laparoscopic hernia, laparoscopic approach may be one. If you have to go through the hernia to fix the jejunum problem, then your surgeon should do something minimal. Nothing that burns any bridges. Don’t put Mesh in there. It can use something absorbable to temporize your herniation so it doesn’t cause any problems after surgery. And then sometime down the line when everything is better, you can undergo a more definitive hernia repair. If you choose to combine an elective clean operation for your hernia repair with a necessary non-clean operation of your intestines, your wrists are the following wound infection with Mesh infection, Mesh infection, vomiting, bloating, which causes another recurrence of the hernia, abscess or any other kind of fluid contamination of the Mesh or failure of the hernia because it was done under non-optimal situation.
Speaker 1 (45:38):
So no, don’t recommend it. Nope. So many people call me into the operating room saying, Hey Towfigh, so we just did this major operation, now we got this big hole. Can you come and do your fancy surgery, the hernia? I’m like, Nope. We’re going to do a very non fancy surgery. We’re going to claw back to 1950s and how we used to just close skin sometimes over these and deal with the hernia later because anything I do now will hurt, will number one, recur and or number two cause more complications and therefore number three, prevent a good hernia from being repaired later on your program for out-of-state patients. Wonderful. Oh, thank you. We have a lot. I would say about 40% of our patients are out-of-state or out of, definitely out of southern California. Can IBD contribute to inflammatory pain from hernias?
Speaker 1 (46:38):
No. Is ultrapro a dangerous Mesh? No. ULTRAPRO is a, what we call ultra lightweight polypropylene Mesh. It is very lightweight. In fact, it’s so lightweight, we don’t recommend it for most hernia repairs. It’ll just tear. It was originally invented for groin hernias to reduce the amount of kind of total volume of Mesh being used is pretty good for groin hernias. I think it’s still a little bit too lightweight for most patients for groin hernias, but no is not a dangerous Mesh. Let’s see. Okay, what are you talking about? No, jejunum. So this patient’s question was I need jejunal surgery. Jejunal surgery on jejunum, which is the second part, the middle part of your small intestine.
Speaker 1 (47:43):
Okay, going back to the injection question. I went to see someone else for the injection and she injected me in my hip. This was three weeks ago and I still have horrible pain. Why was it put in my hip instead of the groin for left or hernia surgery pain. Okay, so was it actually put in your hip joint, in which case that’s for like a hip problem. Maybe they think your hip is causing a pain or was it put where you think your hip is, but it’s not really your hip, it’s it’s really in the abdominal wall, but it’s towards your hip. That’s a better place because you want to catch the nerves somewhere between your spine and where the pain is. So anywhere along that line from your spine around your abdominal wall to the groin is fine. So if it’s close to your hip, that spine, that’s the actual pipe where they were able to find more normal anatomy.
Speaker 1 (48:32):
Scotland has a bill to not allow Mesh insertion. What will happen if all Mesh is not allowed? Okay, very good question. That will not pass because there’s no alternative for patients to be treated. What we do know is the European Union, that there’s a law that you cannot allow Mesh to be used if there’s been no validated prospective human trials. And so this whole concept of, well, we have this Mesh, so this other Mesh is similar to the Mesh. Mesh B is similar to Mesh A and so let’s just introduce that in the market that’s being kaboshed by the European Union in the United Kingdom, there are a lot of initiatives of banning Mesh or limiting Mesh. So far for pelvic Mesh, there’s been some areas of the world where pelvic Mesh has been banned that has actually limited doctors from treating a lot of patients for hernia Mesh. Yeah. If you ban hernia Mesh, then we’re going to go back to the early 19 hundreds and how we were treating patients or like China, how they treat patients in China or Africa. If you go there, you’ll see patients have these enormous hernias and they just live with it. And that’s typically not the type of lifestyle that we expect in the first world.
Speaker 1 (50:05):
All right, let’s go on to, oh, I wanted to share this with you. There’s some talk online on hernia talk itself, hernia talk.com. There’s been some multiple articles that have come out on the brain body access. So multiple studies show that people that have a positive outlook, positive attitude, positive personality, have better outcomes. And that’s true for cancer. If you’re a positive person that’s concerned a positive personality and positive outlook, you’re more likely to get a cure from your cancer. Believe it or not, the same is true for surgery. So people that come into surgery without depression, the positive outlook are more likely to have excellent recovery and less likely to chronic postoperative not on hernia talk. The discussion was, well, that’s just BS. That’s just doctors saying we need to focus on your brain. There’s something wrong with your groin or your Mesh and they’re just blaming the patient and trying to deflect away from the surgery the patient really needs.
Speaker 1 (51:27):
I don’t agree with that for sure. If you are not mentally and psychologically ready to undergo surgery for whatever reason, there’s trauma in your life, there’s a lot of things going on in your life or you’re just severely in pain and depressed and have P T S D from prior surgery experiences, then you should not undergo surgery until you’ve come to a much more stable psychological state. Dr. Bruce Ramshaw, who’s one of my favorite people, he is one of the first people that I interviewed for Hernia. Talk. Live is really championing this, which is getting the body to the mind to help control what happens with the body. There’s something called cognitive behavioral therapy. There’s a lot of different processes out there that help patients control their thoughts and their reaction to stuff in effort to have a better outcome. It doesn’t mean you’re not going to have your hernia surgery.
Speaker 1 (52:34):
It doesn’t mean you’re not going to get the treatment that you need. It may delay it. That’s very true. It may delay it and that’s sometimes it’s what’s necessary to get a good outcome. I’ll give you an example. If you have a patient that’s morbidly obese, 300 pound patient has a hernia, I’m going to tell you, you need to lose weight and I will not fix your hernia until you’re down to a more normal weight. And that may involve dieting, it may involve pills, it may involve surgery for the weight loss and not surgery for the hernia. Am I delaying your surgery? Yes. Will you be pissed off at me? Possibly. Will you have a better outcome from your hernia repair if I did that? Absolutely. All the studies show that. So the same is true about the mental state. It will involve delaying surgery potentially.
Speaker 1 (53:33):
It doesn’t mean you’re not going to have your hernia pair, but it does mean I’ve had multiple patients that have gone through cognitive behavioral therapy and then they’re like, actually, I’m good. I don’t have any more pain. I’m life is good. Do I need to have the hernia surgery? Like no, if you have no pain, no need to do surgery. So do not discount this. The fact that surgeons are finally understanding this is a good thing. Oftentimes surgeons are like to cut, is to cure. And it’s not always to cure because if you’re cutting out the wrong patient, that patient may be destroyed. I’ve know so many patients that are destroyed from hernia surgery, not because necessarily that they got butchered, but they just, their personality is also one that it’s not allowing them to heal because they’re holding on to some anxiety and depression that has never been addressed.
Speaker 1 (54:27):
So please do not think that if a doctor or medical doctor or surgical doctor recommends cognitive behavioral therapy or anything else that focus on the mind that they are discounting or don’t want to treat what’s going on in the body. This want you to get the best outcome. And every single study has shown that. That said, I was introduced to the CALM app. I don’t know if any of you guys have used the CALM app. I was introduced to it this week. I’ve seen the ads on it. I’ve seen LeBron James promoted on tv. I have a friend who’s very debilitated, who is getting a lot of help with her chronic pain through the Calm app. And maybe that’s something you guys need to do. Go to the app and download it. And if you’re having a lot of pain and issues, take some of those classes and courses on it and listen to some of their lectures and meditations during the holidays for sure. It may be hectic. There’s so much going on in this world and maybe something like the Calm app is another way that you can help. You can consider getting some type of pain relief during the holidays when there’s no one else around. And I also want to share this, I mentioned this before, it’s the ACHQC abdominal core health quality Collaborative. You can log on as a patient to ACHQC dot org.
Speaker 1 (56:06):
This is a national database in the basically United States where many of us, I’m one of the members, looks like there’s 457 surgeons so far, log in all our patients and they get followed prospectively. But if you go on the ACHQC website, there’s a patient’s tab. And in the patient’s tab is a patient information page. In addition to a patient information page, there is a rehab guide. And that rehab guide can provide you with certain exercises and ways of managing your core, your abdominal kind of strength before and after surgery, specifically for ventral hernias. But it’s got great ways on how to focus on posture and abdominal, your daily activities, how to roll out of bed and go from sitting to standing, and then focusing on your core surgeries and what’s safe and okay to do after surgery. So I do recommend that you consider reading some of that.
Speaker 1 (57:13):
And lastly, thank you. Thank you. I need to calm my mind and remind myself that I’m a PMA type A person. Yes, yes. And unfortunately, high pay people don’t do that well when you get a curve ball and pain is definitely curve ball. So on that note, I will say goodbye. This is mid-December. I’m super busy operating on the rest of the next two weeks, so I won’t be able to host any webinars until the new year. So I hope all of you guys have a great Christmas and New Years, spend the holidays with friends and family, stay safe, please and send me by social media any feedback you have on how we’ve been doing in the past almost two years, a year and a half, almost two years of Hernia, Talk, Live, q and a. And if you have any cool topics or doctors and surgeons and specialists you want me to interview for a year 2022, let me know, drop you a note and appreciate it. Love you guys all. Thank you so much. Happy holidays to you. And yes, my deep breathing helps. Very good, very good. Appreciate your time. Thanks everyone. So keep it safe. Keep it safe. I hope you guys all do really, really well. And on that note, I will say goodbye.
Speaker 1 (58:50):
Oh, don’t forget, I will be sharing all of this on YouTube for you, and if you want to spend some time listening to my YouTube over the holidays, that would be helpful too. See you guys. Bye everyone.
