Episode 84: Setting Expectations for Your Hernia Surgery | Hernia Talk Q&A

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Speaker 1 (00:00):

Hello. Hello everyone. It’s Dr. Towfigh so welcome, welcome, welcome. It’s the beginning of New Year. It’s our first Hernia Talk Live Q&A session of the New Year as many of you know, my name is Dr. Shirin Towfigh. You can follow me on Twitter and Instagram at Hernia Doc. Many of you are here on Facebook live at Dr. Towfigh or and or you’ve been watching all of my Hernia Talk episodes on YouTube. So welcome. First of all, I hope all of you are healthy and hopefully back to work or whatever you enjoy doing. I’m going to start today’s session by kind of giving you a little overview. So we worked all through Christmas, all through New Years because as many of you know, the end of the year is the most, is busiest time of year for us in surgery, for sure. I did some pretty amazing cases. All the patients did very well, thank God. Some Mesh removals, some very large hernia repairs, recurrent hernias, infected Mesh operation. We did two patients with denervation injuries that I repaired. They’re all healing, doing really well. A couple patients had chronic pain after their inguinal hernia repair and then were treated by another surgeon and that was inadequate treatment. So I went there and completed that process and got them back to everything. And let me actually make sure that we’re also live on Facebook.

Speaker 1 (01:48):

There we go. We’ll be live on Facebook soon. So that’s been great. I really am so excited that all of you are, I’m super excited that all of you are joining me because there’s a lot of talk about transition from 2021 to 22. Honestly, all these years, the 2020s for me are all just, they’re all the same year for me. I’m very, very confused about all the years. I almost feel like we’re in 2023 already. I don’t know, maybe I’m just weird, but we had a great time. I really enjoy taking care of patients that do very well and it’s so nice to see them so grateful and all these different patient cases were really fun. I personally enjoyed Mesh removal operations. The infected Mesh removal was fun, and the Mesh removal for chronic pain was great. I also like the plastic surgery kind of portion of what I do. So recreating the abdominal wall, giving a nice flat closure. I do kind of like a little mini

Speaker 2 (02:58):

Tummy tuck as part of the hernia pair for the abdominal wall to give a more flat and a symmetric looks. Sometimes you do hernia pairs and the patients end up asymmetric for whatever reason. And so going back in, you try and focus on the symmetry and one patient’s like, oh this. I said, I’m going to review, revise the scars. I don’t care about the scar. I’m like, yeah, but I do. Or I’m going to revise the scar or make you look flatter. It’s like, I don’t care about that, but I dunno, I do. So I thought that we would start our year by talking about expectations. Everyone talks about resolutions.

Speaker 2 (03:40):

I personally feel like resolutions sometimes are made to be broken or not followed. And so maybe goals is another is a better way of discussing resolutions, but also expectations. And I’ll tell you this little story, which I hope will help you all because I feel like it’s a common problem, which is setting expectations for yourself as you plan for surgery. And the reason why I like to do that is the mindset by which you enter surgery has a huge impact on your outcome. And it’s not just surgery actually, it’s anything in your life. But in general, people that are positive thinkers or have a positive attitude do much better. There’s actual scientific studies that show that patients that are undergoing cancer treatment if they are evaluated before their cancer treatment and are determined to be either positive or negative thinkers. So positive outlook versus negative out outlook, their cancer outcome is actually highly correlated with whether they are a positive person or think positively or are just in general more positive about the whole experience.

Speaker 2 (05:06):

That’s really interesting. Even more interesting, I’ll give you this, it’s a paper like Israel and literature. So there’s a paper where, I don’t know where this was it, I think it was in Europe, there was a nunnery. So young women would go become nuns to vote themselves to God. And before on the day where they attended to become a nun, they had to write on a piece of paper why they are choosing to become a nun, why they’re choosing this nunnery. And over a span of I think 60 something years, they’ve gathered all of these papers of why people are state they wanted to become a nun. So they categor… after 60 years, they took all these papers, they categorized it as positive or negative. So positive would be someone who said, I believe that my mission in life is to serve God and his people or her people, and that is why I want to become a nun.

Speaker 2 (06:20):

That was considered positive. There was another subset of patients that said, I have a miserable life. I’ve been abused. I’m poor. I’m just a horrible life and I feel that becoming a nun will give me a sense of self-worth or happiness or something that I currently lack. So that was considered negative and they found that the patient, the nuns that had a positive sentiment in their note actually lived 15 years or something longer than the people that put in a very negative sentiment as to the reason why they wanted to become a nun. So that’s a pretty fascinating story that was published scientifically studied, really interesting. And I hope that whatever your baseline is that you do choose to enter your journey with hernias with the positive light. Many of you know that I run a discussion form called hernia talk.com.

Speaker 2 (07:36):

It’s actually the precursor to our Hernia Talk, Live q and A sessions. The website is free for everyone. You can just go through it and be a lurker and just read people’s stories and responses. I Rives, I respond to many of them. We have other stories that respond to them, but it’s mostly a patient-based discussion forum talking about anything related to hernias. And you can see that there’s a subset of patients that are very negative. All their posts talk about how horrible their experience was, how they hate their surgeon and that they’ve been maimed and so on. Now, all those may be true, they probably are true, but 99% of their focus is on the negative. Whereas there are also another fraction of patients that go on hernia talk.com and explain that they understand that this was a complicated situation or they’re not blaming X, Y, and Z, but they’re here to look for help and they try and come up with a much more positive way in handling their situation.

Speaker 2 (08:58):

Now understandably, most of the people that come on hernia talk.com have a hernia or a hernia related complication. And so they’re not there just because they’re having fun all day. That said, it’s very clear how some are very negative, others are very positive or try and be positive or at least be objective about their scenario. And I’ll tell you the people that are more positive I guarantee will have a better outcome. And this kind of falls into another discussion we’ve had on hernia talk.com, which is it all on your head. Doctors were kind of pushing towards mental health in addition to physical health prior to surgery and there’s was a discussion hernia talk.com, that this is all BS, that this is just doctors trying to deny that they did anything wrong and kind of say it’s all in your head. It’s not though scientifically has been shown through that cognitive behavioral therapy, psychotherapy treatment of any depressions treatment of any anxiety and all of that can very much help you become a more effective patient and also therefore much have a much better outcome from your hernia surgery.

Speaker 2 (10:23):

So that’s what I really would like to focus on, which is expectations. And just to kind of share with you where I think we’re going is for one, what should you be sending your expectations for on just determining who you going to see or the doctor. So sometimes people go into doctor’s offices and they feel like it’s going to be a perfect experience. The reality is as long, how do I explain this specifically for US medical system, I would say that the medical system in the United States is not framed in a way that will make your experience optimal. Most doctors that you will see are employed, which means they are not their own boss and therefore they must follow the rules and regulations of their employer, which is usually a large institution, maybe a university which makes things much less personal. They may be part of a group, they may be sharing call or sharing practices.

Speaker 2 (11:35):

They may be bombarded with tons of patients that they have to see based on whatever they are being asked to do clinically as part of their employment contract. So just there alone, most likely they don’t have control their schedule or over who answer the phones or how many minutes are provided for your consultation. So it’s one reason why I switched out of that system and went into private practice. However, that’s not reality for most doctors. So when you go to your doctor’s, please understand the expectations that you need to have, which is that you’re dealing with other people potentially other patients are there with similar problems as you that want the same time and attention of the physician. There may be people that run the front desk and have no idea what a hernia is or how much pain you may be in or how long it took you to be able to get to this appointment. So be courteous to that staff because they’re also human beings and want to lead a as much of a normal fruitful life as you do.

Speaker 2 (12:52):

What I see doesn’t work is patients that have expectations that their surgeon have all the answers or at the front desk kind of be able to do everything perfectly. That’s just not reality. When you see your surgeon, it’s very, very good to come with actual list of questions. When I see my own doctor, I actually email her a list of like, this is what I plan to come in and these are the questions I have. I do the same for my family when I go to their doctorate business with them. So that’s kind of something good to do. But setting your expectations is key when you’re dealing with your surgeon. If you’re dealing with a general surgeon who’s not a specialist, it sometimes is not adequate to expect them to have the same experience or knowledge of an expert. It’s that’s not their role. It would be great if they would refer you to an expert if that’s what you need. But that’s really kind of where I think I feel like a lot of people get very frustrated because they go see someone that maybe has been labeled as a hernia expert, they’re really a general surgeon and don’t spend more than half of their time during hernia related problems and operations. And you go in there wanting all these answers and they’re just not giving it to you.

Speaker 2 (14:24):

Looks like some questions are coming in quickly. Go to some of those. My colorectal surgeon tells you I post stoma hernia is too high risk. It’s the size of a five pin bowling ball, it’s five pin bowling ball. How shall I treat it? Is that the like a small bowling ball? So regardless of what or how big your hernia is, we had a whole discussion on really large hernias and optimizing your treatment for it. So actually this is a good question to move on to. Expectations about planning for hernia surgery. So many people go to their consultation like this person online who was told that her hernia repair is too high risk and the hernia is too big. So what does that mean? Oftentimes it doesn’t really mean that your hernia is not fixable. It just means you as a patient are not a good patient.

Speaker 2 (15:32):

Undergo whatever hernia surgery you need. You may be a smoker, a nicotine or a user of nicotine. You may have diabetes that’s not well controlled. You may have C O P D or asthma with a chronic cough that’s not well controlled. You may be obese. Most people in the United States are not normal weight. So if you have any bit of obesity, definitely that should be treated before during the hernia. So setting your expectation of planning for surgery includes understanding that maybe right now is not a good time to have surgery. I recently had a patient who is more really obese and had a huge hernia. I mean I could fix hernias, give me any hernia, I’ll fix it. But you want to fix a hernia with the intention of getting it to be a secure repair.

Speaker 2 (16:28):

You do no service to the patient if it recurs within a month or three months or whatever. So I always make sure I maximally optimize the patient and that means the weight loss needs to occur. And some people are very resistant. They don’t want to have weight loss, they don’t want to pay for some type of plan, whether it’s Weight Watchers or a medical physician who kind of oversees their weight loss or they don’t want to undergo weight loss surgery. You know what? That’s not the decision I would make for you. But if that’s your decision then you’re not going to have the hernia surgery and you can’t have both at the same time. So it’s very important to know why your hernia is too high risk. It’s a too high risk because at the state you are currently in, the hernia will fail once it gets repaired because you have a higher risk of infection or recurrence because of obesity or diabetes or nicotine use.

Speaker 2 (17:29):

Or is it a high risk because that specific surgeon cannot fix it, in which case you would need to move it, kick it up a notch and go to a surgeon who is a hernia specialist and does those for a living because those hernias can be repaired when in the hands of an expert surgeon. All right, now let’s set the expectations for the day of surgery. So that can be very stressful. Make sure that you have everything set up, you know, want to be with someone. So we need to bring you in and take you home. Hopefully someone that cares about you and you can get that kind of taken care of. But the day of surgery, you want to wear comfortable clothing and make sure that you take the appropriate medications given to you but not the ones that you were told to stop a day or a week before. Get there early. Don’t rush. We live in Los Angeles. We always have traffic. So you have to make sure that you take it into account how much traffic there may be and so on. So you don’t want to be rush or stressed out the day of your surgery.

Speaker 2 (18:44):

I think you should expect to see your surgeon the day of surgery before you get taken into surgery. So that’s the expectation that I have and I think you should have too because any little questions before surgery should be addressed prior to being wheeled into surgery. And then make sure you have everything you need for after surgery. So do your grocery shopping, make sure you have ice packs available, whatever medications there are, get those filled If you need Tylenol or Advil or something, don’t eat anything spicy. Make sure your bed’s well made and you have extra pillows and so on. So those are kind of expectations that I think simple things to prepare for your surgery afterwards. Many of you could come to see me or travel. So you end up either being in an Airbnb or a local hotel and it’s still important to go to your local store and stock up on water and tea and anti constipation pills and warm clothing and comfortable clothing and so on.

Speaker 2 (19:54):

And make sure that all that’s addressed so that once you have your surgeries go home and everything’s ready for you or whatever your hotel is. All right. So see as I predicted the surgeon that told our friend here that her stoma is too high risk is mildly obese, is a nicotine smoker, and has a acute bronchitis. I mean I guessed it. So if you stop your smoking, you lose the weight and your bronchitis is treated, that may not be a high risk hernia repair anymore. And I would get a second opinion from an actual hernia surgeon because colorectal surgeons do do hernia repairs, especially from a stoma, but most of them do not do them as well as a hernia expert. So I would get a second opinion, but focus, focus, focus on your health. Many people talk about new years resolutions, it’s always about their health and I must say that it really needs to be about your health. Nowadays we’re even more in tune with how important it’s to stay healthy.

Speaker 2 (21:10):

In fact, you have read that there’s a good evidence to show that not only is being obese a risk factor for having hospitalization so on from this coronavirus pandemic, but people who undergo weight loss surgery actually do better even in the first year of their weight loss surgery in terms of outcomes than if they were were obese but before their weight loss surgery. So really interesting studies coming out. All right, next thing we can talk about are setting expectations for your recovery. So first of all, you had surgery. So even though we all want you to have the least amount of pain possible, most often surgery is not pain free. Now you shouldn’t be rithing in pain, but you should expect to have some amount of pain. Most hernia surgery pain is inflammatory and so anti-inflammatories work really well. Ice pack is a great anti-inflammatory.

Speaker 2 (22:21):

Put a heat pack over your hernia surgery because that can promote more blood flow and therefore more swelling and inflammation. So you want an ice pack, usually all the anti-inflammatory pills, either over the counter prescription or prescription work really well. So those are all really good to do. You want your recovery to be smooth, so don’t plan on traveling for fun or going on some major athletic event too soon after your surgery. Trust me, I have patients who are like, oh yeah, I have to travel for 20 hours next week and I need to go on some marathon that I scheduled ahead of time. Yeah, that’s not a good time to have your hernia surgery for either of those situations.

Speaker 2 (23:15):

You really don’t want to mess up with surgery and the recovery is very important. Constipation we talked about, it’s very important not to be constipated before surgery and especially after surgery because the straining that you do can put those fresh sutures at risk and then activity is very important. So do walk around and be active because you don’t want to get blood clots or get a pneumonia cause those are two risks after surgery. And then lastly is work. Some people have to go back to work early, which is fine, just get up and about so that you’re not so sore. So every hour you should get up and about that said, do not freak out if you have pain or stabbing or burning or something after hernia surgery. You’ll have swelling, you will have bruising, you’ll have a lot of purplish colors potentially in the area.

Speaker 2 (24:13):

All of that swelling and so on will adversely affect your recovery because you’ll be like, oh, what’s that? I’m not. I was never this bloated. I look pregnant. Why is that? Well, because you had a bunch of work done inside your abdomen, your belly is just reacting to all that inflammation on the inside. This is this weird numbness and swelling I feel. Yeah, you’re very swollen from the surgery and I can give a little bit of painful sensitivities in the area. So you’re, your body will change around the time after surgery and don’t necessarily think that what you’re feeling now is how you’re going to be for the rest of the time. Just be very kind of cognizant that surgery is, it does change your body for what it’s worth. Here’s another comment. Positive results will sure help with positive thoughts, five surgeries later and a recalled Mesh and guts full of coils, chronic infection and every type of surgery, open lap and robotic.

Speaker 2 (25:21):

Obviously I don’t want to be blaming anyone for further complications. That’s not why I’m here. But I would like to say that in general, if you compare people with a positive attitude versus an negative attitude even with complications, so take all the people with complications, which can happen and happens to me too and look at the outcomes from from people that are positive or attitude. The people with a negative attitude will have more surgeries, more complications, more redos, more problems. So that’s where I’m getting at is all things being equal, you’ll do better with a positive attitude.

Speaker 2 (26:05):

Here’s another comment. I found a CT scan report that was taken in 2018, three years after my left inguinal hernia surgery, which I had horrible pain from day one. The scan showed a suprapubic hernia that was previously repaired with Mesh and it says a Mesh intact, I only had left inguinal hernia surgery. Can both hernias be done at the same time? It was never told. I was never told I had a suprapubic hernia until this year. I’m confused. So your surgeon should tell you what they saw and what they did. But yes, you can repair a suprapubic hernia at the same time as an inguinal hernia if it’s done laparoscopically or robotically. So that is correct, that can be done, but yes, you should. I highly recommend everyone get a copy of their opera report. You should have that in your files and a part of your medical records. So many medical records are now online on your smartphone. You can just make sure you keep it there because you may need another surgery for another reason or get pregnant or you have a trauma or something and people need to know what was done inside you.

Speaker 2 (27:19):

Another comment, can complex or prolong surgery affect colonic motility? If yes, how much time is typically needed to complete recovery? That’s a good question. So yes, colonic motility can be affected for up to several days after a complex operation. Usually after the first few days it should be back to normal. Some people, however, I’ll give you, however, if you get antibiotics as part of your operation, that sometimes can change the bacterial population. So let’s say you had 20% of one bacteria in 80% of another, it may make it reverse and that change in the balance may change the consistency of your co colon stool, which is mostly bacteria anyway to be more diarrhea or more constipation.

Speaker 2 (28:17):

They may also make it so that you are more bloated and more gaseous because the type of bacteria and you now make more gas. That problem is called SIBO. S I B O. We actually had a session with Dr. Leo Trayzon, a gastroenterologist, and we discussed SIBO I think a year ago and almost exactly a year ago. And what we discussed is that SIBO, which is stands for small intestinal bacterial overload, can be induced by antibiotics and surgery often gives at least one dose of antibiotics. So separate from just anesthesia causing motility problems for the first few days after surgery, antibiotics can also induce that. Next question, how sorry, how should the pain subside in a successful groin surgery if it’s a redo? All right, good question. Everyone’s different. For almost everyone, the pain should be gone within the first three months. For the majority of people, the pain should be gone within the first six, six weeks.

Speaker 2 (29:32):

If you’re lucky, you wake up with no pain. So it’s a wide range, depends on what was done and what the pain was and how long you’ve been dealing the pain and in what manner you’ve been having the pain. It also helps if the nerves were involved or not involved. In my experience, when nerves are involved, the recovery is much more difficult than when nerves are not involved. Also, why you have the redo surgery. Did you just have a hernia repair that need to be redone or did they have to remove Mesh? So the more operation is done, the more extensive the operation, the longer the operation, the more inflammation, the more inflammation, the more pain and swelling and the longer the recovery.

Speaker 2 (30:19):

At the end of the podcast, can you refer me to a Calgary, Alberta Canada hernia specialist for a second opinion? Okay, if you go to herniatalk.com and search the word Canada, there’s a search function. There may be some Canadian surgeons you can talk to and see in I think Ontario, there’s a surgeon called Dr. Hari Kumar, but Hari Kumar, you can kind of look it up. He’s a great surgeon, he should be able to help you. I think he’s in Ontario and then in Montreal there’s at McGill, there’s some really great hernia surgeons, but that’s pretty much it. There’s not much going on in Canada in terms of hernia specialists unfortunately.

Speaker 2 (31:14):

Let’s see, is just, oh, I just had abdominal wall reconstruction and bench hernia pairs with 12 by 12 Mesh. I have great pain in my Rives. How long should this last? Well, depends. So if it’s abdominal wall reconstruction and it’s a really wide hernia and they had to put Mesh to overlap your Rives or sew Mesh to your Rives, which I don’t recommend, but I’ve seen it done, that is possible that that will be a permanent problem because the Mesh is permanent. The sutures, the Mesh are permanent and it kind of cements the muscle onto the Rives and it gives problems such as combing your hair, reaching up for upper covered stretching out in bed. So that’s kind of a, that can be a situation. However, if you had abdominal wall reconstruction with what’s called component separation and they had to go wide and release some tissue, will they operate near your Rives and by operating near your Rives, you may just feel some tension in that area or pain in that area and that should get resolved within the first six weeks.

Speaker 2 (32:39):

The next question is how can you determine if postoperative pain is due to sutures impinging on nerves as opposed to generalized inflammation? Well, number one, did they use sutures? Sometimes we don’t use sutures. Number two, where were those sutures placed? So if it’s done by a hernia specialist, usually we know where the nerves are and therefore do not place any sutures where the nerves can be. And if it’s abdominal wall, usually it doesn’t involve any nerves that can be entrapped, but if it’s in the groin, that’s a huge kind of potential for nerve entrapment. Okay, there’s some comment that says why can’t I find 20, but I dunno what you mean by that sir. Oh, here it’s terrified of male inguinal Mesh removal. I have been running a study online looking for male patients who have had removal with positive results, meaning their life is substantially better.

Speaker 2 (33:45):

I have found two sort of one who never speaks just his wife, another one from Europe. I’ve had many males contact me with negative results with different sets of problems with including pain and unable to have sex. Why can’t I find 20? So the reason why I can’t find 20 is they’re not like on these online. There’s very few patients of my own that I know of that that start going back to these online posts to engage. It takes a lot. I’ll tell you, especially with today’s culture, a lot of these online discussion forums and I would have to say with hernia tech.com, it’s not as bad, but it’s also not perfect, but it’s definitely not as bad as the other online forums. There’s a lot of negativity and once you’re done, you’re done. You don’t want to go back to these discussion forums. Some of them go, some pages go back and start explaining how well they did.

Speaker 2 (34:51):

And I’ve seen that they get shamed by others saying, well that was your experience, but that wasn’t my experience. And don’t go telling people it’s perfectly okay to have this surgeon or that operation or this procedure done because I had a bad opportunity. And so they get shut down by people that have bad experiences. However, we publish our studies, we publish our experiences and we definitely have more than 20 patients that have done very, very well after Mesh removal. It’s just a question of whether they’d be willing to talk to you and share their experience. I do know that what you expressed to me in general as you would like more patients, I did have one patient last year that came on as a guest. I will have more patients for you. I will have patients that have had, let’s say hernia repair or Mesh removal, mushroom removal or neurectomy to come on and explain to you about the recovery. I don’t know if we could talk a whole hour with that patient. I guess we can, but that’s definitely something that I’m planning for all of you for 2022. Next question.

Speaker 2 (36:18):

What is the difference between anterior and posterior component separation? Does one of them predispose you more than the other to recurrent or new lateral hernias? So both of them are in the sense a movement of the different muscle compartments against each other to lengthen the abdominal wall to be able to close it in the middle. The difference with the anterior and posterior component separation is where that lengthening is done either anteriorly or posteriorly. And the anterior tends to give more of the lateral hernias unless you kind of really screw up a posterior repair, which can also cause lateral hernias. The la both of them need really good technique and very careful identification of the anatomy and both of them can be botched to the point where you would get lateral hernias. So yes, in terms of recurrent hernias, I believe the posterior component separation has less recurrences than the anterior component separation because it offers more laxity.

Speaker 2 (37:27):

Next question. I love these. My hernia surgery was open surgery. I had it done June, 2015. Then another surgery did, another surgeon did exploratory surgery in December, 2015. So what was that six months later in the same incision? In the same incision and remove the Mesh and plug but replaced both. Neither surgeon told me about a suprapubic hernia, then just found out about it. Now how has my Mesh migrated? No, Mesh does not migrate. I need people to stop focusing on Mesh migration. The only Mesh that may migrate is the plug and that’s only if it’s not fastened correctly. But pretty much all of the Mesh stays put where we put it and does not migrate. So no Mesh is not migrated. And I need the law firms and the online discussion forums to stop talking about Mesh migration because it’s not a thing. It just confuses patients. I have so many patients that tell me that the Mesh migrated and I’m like, it’s putting Velcro on you and having a migraine just doesn’t do that. All right?

Speaker 2 (38:40):

Yes, exactly. Online forums can be so hard to be a part of because you get torn apart no matter what your experience. That’s very true and I’ve seen that. I feel like people with good experiences are almost shamed because they’re being told they’re the minority and which we sort of know is not true. And it’s just a very distorted, distorted environment online. I would have to say that’s true for everything, not us, but it is true. All right, I’m post three months laparoscopic and ventral 12 centimeter Mesh surgery. I’m experiencing burning when I exercise this normal. Should I wear a support belt? Should I back off? Thank you. So it sounds like you had a laparoscopic al hernia repair with 12 centimeter Mesh. Usually it’s 12 by 16 centimeters. So if you have burning when you exercise, depends on where your burning is and how the Mesh was placed.

Speaker 2 (39:43):

Are you burning in the testicle? Are you burning in the groin? Are you burning at your scars? I would go back to your surgeon and kind of have ’em double check that wherever it is you’re burning and see if it’s related to the hernia repair. And if so, thank you to an injection or get an MRI or something like that. How successful is single nerve neurectomy versus triple neurectomy? How do you determine which nerve is involved and can a diagnostic injection be done into the gentle nerve with ultrasound? Excellent question. Okay, so I’m a big fan of not touching the damn nerves. I’ll just tell you that right now. Don’t touch it and if you do have to touch it, do the least amount of disturbance of the nerve. So I am not an advocate of doing triple neurectomies on everyone. Quite the opposite. I either prefer not to do any neurectomy or if you do get a neurectomy, I do what’s called selective neurectomy.

Speaker 2 (40:40):

We just published and I by just, I mean yesterday, published a peer review article of our experience with neurectomies, and we looked at what happens when you do a neurectomy. Like how do patients, do they suffer, they get better, do they need more operations? How many get neuromas and so on. So I highly recommend you read the paper. I will post it on my social media this week with a link to the article. However, in patients that need pro that do not need neurectomy and happen to get a neurectomy, which is what we call prophylactic neurectomy, we found that they all do find in the most, they just get a little bit numb and they have zero additional pain and zero complications from that. In patients with known nerve problems, whether it’s a neuroma or nerve injury, a nerve entrapment and the nerve is planned to get cut, they don’t do as well. Number one. And the reason for that is, I forget the numbers, I have a re-review the paper cause it’s been a while, but a good fraction of them, I’m going to say about a quarter will need some other procedure because they’ll still have some residual pain from the neurectomy. The original paper on triple neurectomy advocated triple neurectomy showing that people that got triple neurectomy had a more successful outcome in addressing their pain than those that got singular double neurectomy.

Speaker 2 (42:13):

The thought was, well my thought is the reason for that is it’s kind of like a big whack. You can just get rid of all the nerves whether you need it or not. So that if, as opposed to if you do what’s called selective neurectomy and you were wrong and you had to cut another nerve once you didn’t, then you would have poor outcome. My theory is spend more time with the patient, do diagnostic injections and yes, you can do a diagnostic injection of the genital nerve under ultrasound. I do it in my office all the time. It’s tricky though. It’s very tricky.

Speaker 2 (42:57):

If you do a good enough examination and history of the patient, you should be able to narrow it down to what nerves are the problem and then use your judgment during surgery so that you’re planning for these neurectomies before surgery and not just do a triple neurectomy. I feel like more people are siding with me over time as opposed to triple neurectomy. But triple neurectomy has become the standard for a lot of patients who need chronic surgery for their chronic pain. Next question, is inguinal Mesh removal more difficult than other places for exams? The abdominal wall? Yes. How is recovery for inguinal Mesh removal patients i e recurrent are really, really good. In fact, my experience, the majority of patients say that their recovery from their Mesh removal surgery was better than their recovery for recovery from their original hernia repair. Now I definitely have a very good number of patients that have a lot of pain swelling and just takes a long time for them to recover. But that said, almost everyone recovers really, really well. 85% or so are cured of all their symptoms and about 20 12% or so need some extra work and the remaining one or 2% actually get worse and are very difficult to.

Speaker 2 (44:33):

Next question, postoperative pain is due to sutures placed deeply into the periosteum. How urgent is a removal following surgery in terms of permanent trauma? Not urgent, I would say. And let’s move on to my last little question about surgical setting expectations, which is your future after hernia surgery. So once you’ve had any operation, it could be a skin mold or it can be major spine surgery or it can be hernia surgery. You are no longer going to be the same as you were before. You either have a scar, you’re going have inflammation, the nerves may go out of whack, your alignment of your body may be different. There’s a lot of things that happen with surgery. So do not expect to be perfect like you were before ever period. Now will you be maimed? No, obviously not. But what I want you to kind of have the mindset is that you did have surgery, something actually happened to you.

Speaker 2 (45:41):

Your natural body is no longer exactly as you were when you were born. So those changes in you hopefully are for the better, but don’t expect anything perfect. Now you can do a lot to make sure your outcome is the best possible. So for the rest of your life, do not use nicotine for the rest of your life. Do not gain weight for the rest of your life. Do not ignore a chronic cough. Coughing can add a lot of stress on your repair and cause a hernia recurrence a hundred percent for the rest of your life. Do not get constipated. Drink more water, have prunes or dried apricots or MiraLax every day or magnesium, recce, whatever it is you like or all of those combined. Straining is the number one enemy of hernias in hernia surgery. And the main reason why people in the United States have hernia problems is because of their genetics.

Speaker 2 (46:43):

But then secondary, because of constipation, please treat your constipation. And by the way, people that treat their constipation are less likely to have hemorrhoids, cancer of their colon, diverticulitis or diverticulosis, and many, many other anal fistulas or fissures and many, many other problems that are completely prevented if you prevent your constipation. So that’s a super, super important part of your world. And then I’m not saying you should baby your hernia at all. In fact do not like exercise is great, but do be cognizant. The fact that you’re not, your body is no longer perfect. You have a repair in you, you have sutures, you have a change in your anatomy and so please take care of that so you don’t have a second and third appointment. You get the cycle and the cycle is just not good at all.

Speaker 2 (47:53):

Regarding, oh, what should, regarding to their symptoms, what should Asia patients expect short-term and long-term after Mesh removal? Great question. We’re actually publishing our paper on that specific question, which is what happens to Asia patients after Mesh rule. Now Asia is an acronym, A S I A for some type of syndrome called Shoenfeld syndrome. And the A S I A stands for autoimmune and or autoinflammatory syndrome induced by induced by adjuvants, A S I A. It’s basically, I like to term it Mesh implant illness. It’s a systemic reaction to the Mesh. If you remove the Mesh from the offending implant, your symptoms should go away. What we notice is about 40% of our patients have resolution of their symptoms within the first month and then the other others, it’s a little bit weird. It takes some people years, others fall, this long spiral of a lot of autoimmune disorder disorders that just don’t get better.

Speaker 2 (49:04):

So we don’t know is the short term. We do know that mesh removal helps. We don’t know what percentage or which specific patients are cured with vegetable and what other percentage will have the repercussions of their autoimmune disease kind of prolong and continue forward. So from an academic point of view, you’re extraordinarily prolific. Well, thank you. I’m an academic surgeon at heart. I must say I’m in private practice. Most people in private practice are not academically inclined. I didn’t start in private practice. I ended up here because I got somewhat dismayed by the type of care I can give while employed as an institution, like a university. But I started a tenure track academic and was doing really, really well. But there’s things called glass ceilings and politics and other things that I just didn’t like and it tended to hinder my career. So thank you for noticing that.

Speaker 2 (50:21):

I do pride myself in having a research team and studying my outcomes, giving talks on it and educating surgeons and residents and fellows. And this year is going to be interesting because obviously I will continue with hernia talk, but there’s multiple weeks where I will be out of the country or out of town because there’s the American Hernia Society meeting, the European Hernia Society meeting. There’s a new meeting called Tugs I’ll be involved in. There’s National Hernia collaboration meeting, sages, American College of Services. I’m giving talks to all of them that I’ve already committed to. So it’s going to be a busy year and I’m hoping that we can continue to do all these meetings in person. That’s kind of my hope. And one of my dreams is to be able to spend a whole year being able to travel and see my friends, but also give talks. And so thank you for noticing that. I do, I do love the fact that I get to publish. Many of you saw my post at the end of the year. So I do come from a strong family lineage of writers and my dad was a really great one and writer and editor and he always wanted me to be a writer.

Speaker 2 (51:53):

So now I write about surgery. That’s kind of like my homage to my family is I write about surgery and I do enjoy writing. I enjoy operating more. But if I were to retire, I probably would do a lot more writing than I do. So let’s see what, one of my last comments, my last comments to you are all are to just thank you for following me. It’s been, it will be soon, a year and a half. Sorry, it’s been a year and a half. It’s going to be soon. Two years. I’m doing great talk live. You guys have been amazing to follow through. We’ve got some really cool speakers. We’re going to be a little bit out of the box this year and not just focus on surgeons as much as we’ve had before. And we are going to go a little bit more international this year with our guest speakers. And I hope to recruit a couple of patients to come in and be my guests and share with you their experiences with Mesh removal. And I hope that those will be really good. So on that note, I thank you very much. Please do like and subscribe me on my YouTube channel. I really want to grow that and soon probably dump all of these episodes onto a podcast so you can listen to them more easily than on other scenarios. And on that note, I

Speaker 3 (53:24):

Will say my goodbyes. I will see you again next week. Oh, we have a question. Okay, quick question before I go. What are your recommendations for managing post-operative pain during that three month period when you are waiting and determining whether you have chronic posting or hurt pain in need of revision to get through this difficult period? Okay, so if it’s nerve pain, you can use lidocaine patches, which are now available over the counter in the United States. Outside the United States. It was always available over the counter. You can try ice packs if it’s inflammatory pain. There are different medications including gabapentin that can help with the pain control. Your Dr. May include injections to the area to see if that will help reduce the pain in the area or the inflammation of the area. So those are all opportunities to help quench the activity and pain that you have in reduced swelling or to nerve nerve activity and hopefully get you to a point where you’re more stable. So my friends, on that note, I will leave you. We will see each other again on Tuesday. This is Dr. Shirin Towfigh signing out. Thank you for joining me in 2020. I really appreciate all that. You guys. Take care. Bye.