Episode 85: Hernia Surgery and the COVID Pandemic | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

Hey everyone, it’s Dr. Towfigh. Welcome, welcome, welcome. Today is What Day Is today? January 11th, 2022. Many of you are joining us live via whatever you’re watching, whether it’s Facebook Live or through Zoom. Today’s going to be an interesting session because we’re dealing with so much. I want to share with you what’s going on in my surgical life, which may be affecting you all as well. Just as an intro, my name is Dr. Shirin Towfigh. You know me, your hernia and laparoscopic surgery specialist. Thanks for joining me on Twitter and Instagram at Hernia Doc. Many of you are here on Facebook Live at Dr. Towigh, and you can watch this and our all past episodes of Hernia Talk Live Q & A on my YouTube channel. So what’s going on? I will like to tell you that I had a bunch of operations scheduled for this week at the hospital.

Speaker 1 (00:01:07):

I operate both at the hospital and at the hospital owned surgery center, which is outpatient surgery center. And there are different reasons why I would choose one versus the other. And they canceled all my operations. So I had a bunch of patients that were scheduled, many of the doctors, many of the doctors at that work at the hospital at Cedar Sinai. And because of various issues related to the current COVID pandemic, all my operations got canceled. And this is something we’re seeing throughout the nation and possibly throughout the world. So currently in the year 2022, we are dealing still with the COVID Pandemic, but it’s a little bit different than last year. Last year around this time, we also had a lot of cancellations, surgery center, sorry, hospitals were just overwhelmed with patients. The ICUs were overwhelmed. There was overflow of very sick patients, very ill that required acute care and there just wasn’t enough room in the hospital to handle the normal volume of patients with different diseases, cancer, heart disease, transplants, surgeries, as well as the overwhelming population of patients with COVID infections.

Speaker 1 (00:02:37):

So that was last year this time. And prior to that it was even worse because not only were the patients super sick, but we had no treatment at all available, including for the doctors who were taking care of these patients. So we had a lot of, a lot of deaths, just really horrible deaths and a very, very tolling on the nurses and the doctors and the caretakers because patients were dying of infections that we couldn’t really treat very well. And yet you were putting your life at risk to treat these patients at the same time. And it was very, very sad because their loved ones could not be next to them because they would also get sick. And so many people were dying alone. That is not the current situation. Fortunately, we’ve learned a lot in the past year and a half. We do have multiple highly effective vaccinations that prevent you from being so sick and needing to be hospitalized or even dying.

Speaker 1 (00:03:36):

And even though we keep having different variants, which is the natural thing that happens with any bacteria or virus, the situation is different now. So this year we have vaccinations in the United States. About two thirds of people are fully vaccinated in about four out of five patients or people are at least partially vaccinated. And I believe about a fifth of the patient of people have received their third dose as a booster. So that’s a good thing, which means that even though we have the virus hanging around, people are not ending up in the hospital super sick. That said, they’re still exposed to the virus, which means many nurses and doctors are coming to be positive with the COVID infection. Many don’t even know they have the infection. They were just exposed to someone who did. And they’re test positive. Another fraction actually are sick with it, often mild symptoms.

Speaker 1 (00:04:49):

But because of the very high prevalence of the virus, nowadays, you’re not supposed to come to work if you have symptoms. And therefore a lot of people that are doctors, nurses and other healthcare providers or the hospitals don’t come to work, don’t come to work. You can’t run the hospital. So unlike last year where it was very high volume of sick patients taking up a lot of resources from the hospital and therefore elective surgeries and elective procedures, non-urgent procedures were being canceled this year, there’s a little bit of that. So in our hospital as well as other hospitals, we were having an increase in the volume, not like last year, but increase in the volume of patients in the hospital that are also COVID positive. Most of ’em are not in the ICU, most of ’em are not very sick, but they are taking up beds and resources and those that are sick unfortunately aren’t typically also not vaccinated.

Speaker 1 (00:06:03):

So that’s another issue we can talk about. But what’s going on is now in addition to a bed issue, we also have a staffing issue because we don’t have enough people available to staff every single resource for the hospital. And so again, similar to last year, but not as bad, we are either on a moratorium to not add extra surgeries until they can catch up. Or more recently, we are actually actively having cancellations. And if you watch, sorry if you read the news, there are multiple hospitals. I just read Rochester, university of Rochester in New York, which is a major institution. They actually completely shut down their surgery center. It is completely shut down. And all those workers that are left there are shifted to the hospital to allow for the more important, more critically ill patients, the hustle to be taken care of. That’s unheard of to have a surgery center just completely shut down.

Speaker 1 (00:07:07):

And there’s other stories like that throughout the nation. So my operations that were scheduled, this, we are canceled. I haven’t heard about next week, but it’s possible that those will also get canceled. And these I have to beg and plea for some patients because they’re, they’ll be scheduled them electively, they’re not actually elective. And I have a patient with a Mesh infection that I’ll be operating on. And I was assured that won’t be canceled because that’s technically not elective surgery. But it’s hard because you’re dealing with a lot of conflicting needs of patients. And I always advocate for my own patients, but I can’t in good conscience vouch for someone who have a hernia repaired when there’s someone that has a cancer or is critically ill and he is the heart attack addressed or whatever. So that’s kind of where we are right now. And therefore I thought it would be a good time even though maybe a little bit late because we’re a year and a half into the pandemic to address the COVID pandemic its future and how it relates to hernia surgery.

Speaker 1 (00:08:27):

So currently every person who undergoes any surgery including hernia surgery, and this I believe is true for the entire United States, must be tested for COVID regardless of your vaccination status, must be tested for COVID prior to undergoing surgery. Usually it’s within 48 hours, although it’s getting a little bit more difficult to get tested so quickly because of the demand, because usually within 48 hours you have to be tested it. And if you’re negative then you can move forward and have your surgery. It used to be. The reason for that is if you don’t know if you’re in the early stages of COVID and you underwent surgery, we found this from China. The Chinese data really helped us out back in the early stages of COVID, the first stage of COVID once you were infected but didn’t really know you were infected and you underwent surgery, people that then became positive within a day or two of surgery, a large fraction of them died and they died from massive inflammatory reactions mostly in the lungs and they had respiratory failure.

Speaker 1 (00:09:39):

Those types of variants are mostly gone in the United States. We have Omicron, which is the primary variant. Delta is mostly out and the minority of the variants, and from what we understand currently from Omicron, it doesn’t live in the lungs, it lives in the nose and kind of upper faring throat area similar to the common cold. And therefore it is less likely to cause severe respiratory failure or pulmonary failure like we’re seeing in the early wave of the COVID pandemic. And therefore, theoretically, if you undergo surgery and you don’t know you’re positive or it’s early stages, you shouldn’t die from the COVID assuming you’re also vaccinated because it is as if you had surgery and had just a really bad influenza or cold in terms of a risk of dying due to the exposure to surgery. That said, it’s still a very lethal virus, about 10 times more lethal than the influenza virus.

Speaker 1 (00:10:54):

So even though it seems that the variants are getting weaker, they’re still stronger in terms of lethality than what we commonly know about the influenza virus about 10 times. So if you look at the current weekly deaths in the United States, it’s about 150 or so on average per week. And that’s increased, sorry, that’s kind of remained stable lately. That said, sorry, lemme rephrase that. If you look at the week, the weekly United States deaths from the current COVID variants, it’s about 1500 deaths a week, 1,500, whereas typically on an average year for influenza virus is about 150 per week. So about a 10th of that. So even though we’re trying to get a control of the COVID virus, the coronavirus pandemic, less people are being hospitalized and less people are dying. It’s still a pretty high death rate compared to what we’re used to, which is why it’s so important that everyone gets vaccinated so people stop dying and or become hospitalized because of it.

Speaker 1 (00:12:22):

So currently the status is you do need to be, they don’t ask for vaccination status, but you do need to be tested for COVID regardless of vaccination status prior to undergoing any elective surgery. And the reason for that is not so much to prevent your death, although that is one of the reasons, but it’s also to protect other people either in the hospital, the surgery center, other patients as well as the anesthesiologists and the surgeon from getting sick because of your virus. Because like I said, the death rate is still about 10 times that of the influenza virus. It seems that we are moving a little bit away from worrying about the positive positivity rate because record numbers of people are testing positive, but the majority of those because about, what is that? What did I say?

Speaker 1 (00:13:25):

Four out of five are at least partially vaccinated and two-thirds are vaccinated. The more majority of patients will not die, will not end up in the hospital, but may have a bad type symptoms. So that’s a size with COVID. I don’t know what’s going to happen the next year. There have been a lot of very positive sounding predictions claiming that we’re now moving from the pandemic stage to the endemic stage where pretty much everyone at some point will be exposed to the coronavirus and slowly will just kind of have that in our system. And although the variation, the variants will continue to progress, there will be weak. If you think about it from an evolutionary standpoint, the virus wants to live, say where we want to live, and the virus can only live if we live. So because it gets passed on from human to human.

Speaker 1 (00:14:30):

So the best way for the virus to live and grow is to infect each patient at a time but not kill them. And in doing so, it’ll spread and become more populous, but it’ll be weaker than the original ones. If you think about Ebola, the Ebola virus was not a smart virus. It was very, very strong. It immediately killed everyone who touched. And so it couldn’t survive in a population because their host, which was the patients died and it couldn’t be passed on. They died before the virus got passed on to a next series of patients. And so fortunately that very deadly virus and very contagious virus eventually just kind of is no longer. So that’s kind of the situation with Coronavirus, which is at this point from what we know with the Omicron, and again, I hope that everyone is very, very patient with this process.

Speaker 1 (00:15:36):

We as physicians and scientists are constantly in a learning situation. I say that as part of hernia talk. I always say we’re talking about ASIA syndrome or Shoenfeld syndrome or some type of allergic reaction, Mesh implant illness, and we just don’t know enough about it. So when I have patients with Mesh implant illness and I discuss with ’em what I think it is, what I think the recommendations are and what I predict the outcome will be, it’s with a great, it has to be taken with a great assault because we don’t know. We don’t know if every single patient with Mesh implant illness will react to all meshes or all sutures or if they will be cured once the Mesh is removed. In our experience, most of them are cured in our experience, they’re the majority are cured within days to weeks of the Mesh being removed.

Speaker 1 (00:16:37):

And I will update you on my website. If you guys follow me, the publication of my paper, it’ll be the first paper ever describing Mesh implant illness and the results of what happens when the Mesh is removed. And after Dr. Tervaert’s paper that actually discusses the possibility of a Mesh implant illness, mine’s a second paper that actually tells you what happens when you do the Mesh removal. So I’m super excited about that, but it’s, it’s being submitted for publication and so I’ll share with you tidbits, but once it’s published, you guys can all read it. It’ll be highly informative I hope. And the more of us that see this problem and treat it and publish about it, the more we can all learn and move on.

Speaker 1 (00:17:25):

So the same is true about the coronavirus as far as we know, the current wave is more endemic. So we, there’s been discussions about talking mostly about hospitalizations and death rates and not so much the pure sheer numbers of positivity because that has not yet been, what do you call it? I believe that’s true, had a history of either autoimmune disorder themselves or some type of autoimmune. About 40% had a history of autoimmune disorder themselves or a history or family history, whereas patients without Mesh implant illness had that problem about half of them. And then we also report on the different types of meshes to which they had the implant illness. It was all different types, polypropylene, polyester, biologic meshes, hybrid Mesh meshes, as well as polyester suture, sorry, polypropylene suture and polyester suture. So it’s not just Mesh necessarily. We don’t really know if Mesh implant illness is a volume issue.

Speaker 1 (00:19:11):

So the more you’re exposed the implant, larger implants, thicker implants, higher volume of implant, if that’s what sparks it, or is it an intrinsic immunity autoimmune reaction to the product itself because of your own either sensitivities or exposures? There’s some thought that we’re seeing much more Mesh implant illness in the developed English speaking world because we are already exposed to much more plastics and other kind of synthetic products and therefore we are already somewhat sensitized. And when you put that inside our body, then we react to it. It’s a theory, I’m not sure it’s true, but the top three co countries that report Mesh number one, United States, number two, United Kingdom, number three, Australia, number four, south, South Africa. So is that just a coincidence? Is it because we don’t really read non-English journals? Are the other countries not really paying much attention to this? Like India has over a billion patients.

Speaker 1 (00:20:38):

So you would think even if it were one 10th of a percent of patients, that would be a large number of patients. I just don’t know that there’s some thought that even the chronic chronic pain is not an issue. Chronic pain is not a problem. It is a problem, but it’s not as dramatic a problem after hurting a parent in India as it is in the United States. So even if they did millions and millions of surgeries much more than the United States, even if a 0.1% of those people have a problem, you would think that would be a large number. And yet it’s not. There’s some discussion about cultural differences in complaints and pain perception and physician physicians addressing patients needs in different cultures and that maybe in the United States there’s more, how should I frame this without sounding horrible? They complain more patients maybe complain more or expect a more perfect outcome from their operations, whereas people in less developed countries tend to be much more kind of, I don’t want to use the word appreciative, maybe much more forgiving of outcomes from their doctors. And the physicians and surgeons have a much higher level of kind of hierarchy in the cultures. And so they tend not to be questioned as much. And maybe that’s why the patients would rather suffer than kind of tell their surgeon, why do I have testicular pain now? So that may be part of the problem.

Speaker 1 (00:22:30):

Just want to round out this discussion about coronavirus and surgery, talking about testing. So the more variants come up, the more important is to have a very highly sensitive test. And with time, we’ve learned the PCR testing is the best. There’s typically PCR testing and get it done at most pharmacies. There’s also the at-home test, which is called the antigen test, that has been shown to be less and less sensitive and more false negatives than the PCR test, as more variants are come about. So the rapid tests and the antigen tests are not as sorry, the rapid antigen tests and the at-home antigen tests are not as sensitive and are more likely to have a high false negative rate. And the PCR test is currently the nasal swaps, currently the gold standard and also a need for travel, et cetera. And then lastly, the PCR test can be done rapid, but that’s very expensive and I believe that’s not covered by most insurances, very expensive.

Speaker 1 (00:23:46):

But typical PCR test, there is a law now that must be covered by insurances, at least in the California, I don’t know if it’s a federal law. If anyone knows the answer to that, you can let me know all. So a couple questions have been sent to me through my different social medias, so I do highly encourage that you send me questions. So for the next half of the hour, we’ll go through your different questions. One of them is about umbilical hernias and whether you should lose weight. The question is this specifically it’s asking about, let’s share screen for those of you that are online. So should I wait to lose? Should I wait W A I T to lose weight W E I G H T for an umbilical hernia? The answer is yes. Every hernia surgery will do better if you are not overweight and you are not obese.

Speaker 1 (00:24:51):

In fact, there’s a cutoff at a BMI or body mass index of 40 kilograms per meter squared, which means you’re at least a hundred or so pounds overweight, you should not have any hernia surgery. If you want to have any surgery, you should be weight loss surgery before you attempt any elective hernia surgery. The problem is this, and I have a couple patients out there that have seen me who I love and they’re amazing people and they’re hundreds of pounds overweight, and I beg them for their own health, but also for their hernia health to lose the weight. And I beg them to get weight loss surgery, it’s nearly impossible to lose a couple hundred pounds on your own. You need help. That help is almost surgical In some situations. You have to hire someone, either a physician or a trainer to get you down, but they’re, it’s really, really, really difficult to lose that much weight in a reasonable time on your own. So weight loss surgery is really the only method to move forward. We’ve had two surgeons I believe so far that have come on board. We’ve talked about weight loss surgery, Dr. Green, did I have Dr. Greenberg and Dr. Bittner?

Speaker 1 (00:26:22):

I dunno if I haven’t had Dr. Greenberg, it’s time for him to come on board. He’s currently in Georgia, so yes, you need to lose weight. Please consider weight loss surgery. There is a little bit of a stigma against getting surgery for weight loss. I hope you all understand. Most of these people that you see that are famous, whether they’re politicians or actors or singers that all of a sudden lost a lot of weight, 90 pounds in several months or a hundred pounds or 60 pounds within a year, that’s all weight loss surgery. They’re not telling you they’re having weight loss surgery. I’m willing to bet, bet money. And I know many of them for a fact because I live in a city where these are all done had weight loss surgery. It’s just not public knowledge. So I don’t know why they don’t just come out and say, yeah, I tried for decades just to lose my weight and I can’t lose the weight.

Speaker 1 (00:27:27):

And I did weight loss surgery because that stigma needs to go. Patients with who undergo weight loss surgery have higher life expectancy, less risk of needy hip replacements and knee replacements, less risk of heart disease, less breast cancer risk, less colon cancer risk. I mean it’s pretty amazing. And most recently there’s a paper that came out and looked at not only the fact that overweight people are more likely to be sicker and or die from COVID, from the coronavirus, but the minute you have weight loss surgery, you re reduce your risk of hospitalization and death from COVID. The minute you have surgery, you don’t even have to lose a hundred pounds. So this is really, really important. Please consider weight loss surgery if you’re about a hundred or so pounds more, or if you just haven’t been able to bring it down. And if you are someone with a really huge hernia, I have a lot of patients waiting for a surgery, I haven’t offered it to them yet because I need them to lose the weight. It’s going to be really hard with a big hernia to also be active enough to lose the weight in addition to changing your diet. And so what I need you to do is to get the weight loss surgery to help you get there faster. Even if you do diet in exercise, it’s going to take years with the weight loss surgery much faster. And then you can have your hernia surgery, but I would not recommend hernia surgery when you are obese.

Speaker 1 (00:29:06):

Next question. Can you please speak to incisional hernia? Sorry, incisional healing. I had an abdominal wall reconstruction in hernia repair. December 2nd, 2021. I’m having four areas that continue to seep. Oh, interesting. Abdominal wall reconstruction. Okay, I was told today it is due to so many abdominal surgeries and this happens. Can you tell me if they should be covered, left out to air or put anything on them? Very, very good question. I’m very happy to answer that. It’s an excellent question. So in general, you should heal wounds. If you’re not healing wounds, something is wrong. Often it’s because your nutrition’s not good. So anyone who undergoes surgery should eat and drink a lot of protein.

Speaker 1 (00:29:59):

You start drink, drink, drink, drink, protein shakes, your wound will heal. So that’s number one. So if you need to help with your wound healing, drink and add protein to your diet. Number two, if you’re diabetic or have a tendency to high sugars, make sure your diabetes is well controlled during surgery and after surgery because of blood sugar being high will prevent wound healing at a rate that is acceptable. That’s number two. The rest of it has to do with your surgeon or your surgery and what was done. So if you had a lot of skin removed or a lot of muscles moved around, that can affect the blood supply to your skin and muscle and therefore part of that edges of the wound may not get the best blood flow because it’s the furthest away from everything else you’ve done from where the blood vessels originate.

Speaker 1 (00:31:06):

So if you see any black in the skin or sloughing off like layers of skin kind of sloughing off, that can be a sign. You’re not getting good blood flow to your wound. There’s not much you can do with that. There are some people that take you to high, what’s it called? I want to say bariatric oxygen, but it’s not the oxygen chambers. They put you in the high pressure oxygen chambers and that tends to push blood flow out further so that you can get better healing. The other option are there special creams that can help increase blood flow and decrease bacterial load. And in doing so it can help your healing. So things like sine cream, which is a prescription based sulfur based cream, if you’re not sulf allergic, you can use hyperbaric. Thank you. Thank you. I love that you’re watching this. Thank you.

Speaker 1 (00:32:13):

Hyperbaric oxygen chamber, not bariatric. Couldn’t remember anyway. Thank you very much. Yeah, hyperbaric chamber, which is a sulf phase cream is very good at promoting healing and reducing the back by reducing the bacterial load in the area. In general, if your wound is not healing and it’s open and it’s seeping first, see what it’s seeping. If it’s more of like a yellowish tinged or sometimes yellowish brownish tinged, that’s okay. It just is what your skin and fat starts seeping. If it’s green, that’s not okay. If it’s thick tan color, also not okay, that’s a sign of an infection needs to be addressed surgically. If your skin and soft tissue is not healthy, that’s going to die. And then bacteria loves to eat that dead tissue. And so your risk of infections higher. So assuming it’s not infected, the vessels to keep the wound moist. And what do we mean by moist?

Speaker 1 (00:33:21):

Not water, but the same way you moisturize your skin, so you should keep it moist. I like to use either one of two options, either kind of over the counter cream like cetaphil cream or prescription celandine cream. So those are really good to put over. Aloe is also good, can keep it moist. So that’s what we mean by moist and moist and cupboard. So you put a clean, dry gauze or other type of dressing over it and daily clean the wound. And by cleaning you can do soap and water. That’s totally okay. Soap and water is a great antibacterial. And then you dry it and you put a nice layer of cream on it. Either the prescription celandine cream only on the open area or a cetaphil over the counter cream, and that should work just fine. There’s another one too, I’m, I’m trying to remember, starts with an A. That’s also a good skin kind of cream. a lot of the plastic surgeons use it. If anyone remembers the term starts with an A, it’s just over the counter cream.

Speaker 1 (00:34:48):

Yeah, do not leave it open to air if it’s aquafor. Thank you. I love you guys. Yes, aqua aqua four is great. It’s very watery, like aqua four. And so D does keep it moist. It’s all, it’s not antibacterial in any way, so don’t expect it to kill any bacteria, but it does keep the wood moist as it’s healing. And also very good for lips. Yes, correct. Very funny. Love you guys. Yeah, leaving wounds open to air while they’re trying to heal, just dries out and dried. Doesn’t work very well. It’s like putting your bread, you know, want it covered and kept moist. Otherwise it’ll get not as tasty. So very, very good questions. Next question. At 65 I have my first femoral hernia with a bowel loop. And I’m really scared because it sounds like I can only have a mesh repair. This is true.

Speaker 1 (00:35:55):

I want a tissue repair. Not the best. I’m a 5 foot 8, 150 pound female. The hernia is four by 11 millimeters at the neck and the sac is 55. Yeah, we don’t care about the sac. Will a tissue repair have a 50 50 chance of holding? If not, which is the best of the worst Meshes. Two surgeons in Montreal want to use a plug. Oh no. But I know what you think of those. Yeah. Okay, so here’s my thought on femoral hernias. Excellent question. Another excellent question. So femoral hernias can be tissue repair. It’s called a McVay repair, or Shouldice has a femoral hernia variant that was described. So there’s a femoral hernia variant of Shouldice, but more commonly there’s also the McVay repair. Those tissue repairs are both not good. Yes, it’s better than 50 50, but not by much. And in addition, because it’s such a high tension repair causes a lot of pain in the area.

Speaker 1 (00:37:03):

So chronic pain effort, tissue repair for femoral hernia is a significant problem, number one for sure. It is a femoral hernia, you have to get it repaired and there’s bowel involved. So a hundred percent you have to get it repaired and don’t delay it because the more you delay, the more likely you are to end up in the emergency room. You need an emergency surgery. And then who knows who your surgeon will be And what options are you available to you by then? So if you are in Montreal, okay, so the gold standard is not a plug repair. In fact, we’re moving away from plugs. The reason why we’re moving away from plugs is the plugs that are used for femoral hernias by definition will be stuck against the femoral vein. And that is not a good place to have Mesh. Number one, it could cause vein obstruction.

Speaker 1 (00:38:02):

Number two, it’s a very bulky thing to put right where your groin crease is. And so if you’re thin and you’re not thin, you seem to be average body weight. But in thin patients, if you bend at your hip or move your legs and you have this full thick thing right in the groin crease, that can cause pain and prevent you from doing a lot of activities. So absolutely do not. If you have a choice, do not choose the Mesh plug. Laparoscopic repair with Mesh is absolutely the gold standard. It’s an excellent repair. It has the lowest risk of chronic pain, the fastest recovery, and the lowest risk of recurrence if done by a surgeon. You have excellent surgeons in Montreal that can offer you, at McGill, can offer you a laparoscopic repair. Go see Dr. Vassiliou, she’s Melina Vassiliou, she’s an excellent laparoscopic surgeon and she should be able to repair you laparoscopically with Mesh. I don’t recommend the tissue repair, especially since you’re not super thin. So the chance of you having a recurrence and chronic pain is significantly higher. So if you’re worried about Mesh because of chronic pain and other issues, then do not choose the tissue repair. In fact, the Mesh repair is the gold standard. So I hope that’s helpful to you. All right, so what’s the more questions?

Speaker 1 (00:39:37):

How long after inguinal Mesh removal should, what kind of where oh should where you’ll be for the long-term outcome? Good question. So it depends on how long you’ve been in pain and what your kind of pain threshold status is and what was done and if it was done open or laparoscopic. And if nerves have to become also why was a Mesh remove? Was it due to chronic pain or Mesh reaction? Was it a meshoma or not? So in general, most people should feel different after the Mesh remove will. Almost immediately they should have pain, but they can tell you, I have pain, but it’s different than the pain from before surgery. That’s a good sign. It will take weeks to months for you to feel back to normal, but you should feel looser in the area, less pulling and tugging.

Speaker 1 (00:40:37):

There will be swelling and bruising. Once that’s gone, which can take four to six weeks, then you’ll start feeling better. So it is not necessarily immediate depending on the reason for the mass removal, but you should definitely feel different after surgery. Next question. What’s the current situation with non-emergent surgeries happening at Cedar Sinai with the current COVID spike? If you need a non-emergent surgery, but surgery would be better happening sooner rather than later, is it within the best interest of the patient to wait a few weeks if possible? Nice question. So at currently Cedar Sinai up until last week had a moratorium on scheduling new cases that are elective and non-emergent, non-urgent. That policy changed this Sunday. They’re actually actively canceling patients because of the spike in hospitalizations and the dramatic number of staff that are unable to work because they’re symptomatic from COVID. So based on that, we are not scheduling the question.

Speaker 1 (00:41:46):

Second question is, and I explained earlier today, the onset of the hour that my patients have all this week, I’m not operating at the hospital, they all got canceled. The second part of the question is also important, which is if you want hernia surgery, should you have surgery during this pandemic? And I would say yes. I don’t believe that the current pandemic is affecting patients who need elective surgery. You all have to be tested for COVID within two days of the operation. You must be negative for that. And fortunately, the current variant is such that even if you do get it, it does not cause inflammation of your lungs like the previous variants had. And so the chances of you having a horrible outcome after surgery because now there’s like COVID in your lungs is very, very low. So most of the hospitals are doing excellent job of keeping patients safe.

Speaker 1 (00:43:01):

We’re not having patient to patient transfer of diseases. Everyone is very good at wearing their mask and following appropriate precautions with hand washing and alcohol. What’s changed in the operating room is another question is this, we’re much more cognizant about the respiratory issues and so early on we could not even be in the room when the patient was being intubated by the patient, by the anesthesiologist. Whereas now we are in the room, we all wear masks, but some people now wear more of a N 95 mask, whereas before we were not wearing N 95 masks.

Speaker 1 (00:43:51):

The sanitation has significantly increased and become more prolonged than before in the operating rooms. Still to this day, we’re not allowing extra visitors in the room. So it used to be that you can have medical students and visiting surgeons from other countries and reps from the industry in the rooms, that’s pretty much no longer allowed. So we are limiting the number of people in the room. So I cannot take my residents to certain surgery centers because of those regulations. I do those operations alone without a resident help. And I have two countries where they want, the surgeons have been asking to come to observe me doing certain types of operations they’d like to learn from me, which I’m happy to have. And cedar side of the hospital is happy to happen. Not right now. Unfortunately because of the COVID pandemic, we are not allowing any visiting surgeons, especially from other countries, actually from anywhere to come into the operating room to kind of observe because we’re limiting the volume and number of people that are available in the operating room and putting patients at risk.

Speaker 1 (00:45:09):

All right, back to more questions. How can you tell if your hernia’s back if you have a Mesh? Yeah, these are really insightful questions. So your question is right in that it’s implying that a hernia recurrence after Mesh repair is going to look and feel different than a hernia repair prior to, than a hernia, prior to a Mesh, any hernia repair because now you have Mesh and scar tissue over the area where you’re going to have a hernia recurrent. So before when you had a hernia, whatever is going through, whether it’s bad or intestine will kind of eat its way through tissues, maybe push on the tissues, expand on the tissues, you may see a bulging. Those are all typical symptoms of a groin hernia or abdominal wall hernia. If you add Mesh, first of all, you had surgery, so you’re going to have scar tissue and then you have Mesh, which is a covering over it.

Speaker 1 (00:46:13):

And so that’s going to be different in your sensation. You may or may not see a bulge, you will be pulling on the Mesh potentially as things are trying to eek their way through the hole. I just have a patient this week that had just a tear of their Mesh off of one of the sutures. So that made an unstable repair. And so part of the Mesh is flapping in the wind and then because of that, it’s no longer adequately covering the hernia. And then over time he started having fat E back into the hernia. But the symptoms were different than before surgery. Obviously if the symptoms were same, then that’s pretty clear cut. But many times the symptoms are different because now you are pushing into a tighter area that has scar tissue. The nerves are around. So if you’re pulling on the Mesh, you may be pulling on nerves, whereas before the nerves were not an issue.

Speaker 1 (00:47:10):

So you may get more nerve type pain, you may get sharper pain as opposed to dull pain. And it may be more difficult to diagnose because on examination there’s no bulging and it’s covered with scar and with the Mesh. Whereas imaging is much, much more helpful in those patients. So in patients there’s not obvious imaging is super helpful. And this patient that I’m talking about, unfortunately his imaging was misinterpreted, but when I read it I could see that the Mesh would be supposed to be flat. But in him where his pain was, the Mesh just pulled away just slightly ever so slightly just pulled away a little bit and that was enough to give him pain because it’s trying to recur through the hernia Mesh.

Speaker 1 (00:47:58):

So that’s why it’s so important to not only get the right imaging but also have that imaging appropriately reviewed because for whatever reason people, well lemme tell you this, I kind of cheat because I as a surgeon see you and examine you and then look at the imaging. So I kind of already have an idea of what I’ve, I’ve plan to see and I’ve also reviewed prior operative reports, for example, so I know what’s in you or what’s been done. And so then I look at the imaging with so much more information. Most radiologists do not interview their patients prior to surgery and aren’t aware of the different types of Mesh, different types of repairs and have no understanding of what the patient’s pain is or where their pain is. And so they cannot correlate what they know from the patient and their history with the imaging.

Speaker 1 (00:49:01):

So they’re just going to read what they see. And like art radiology can, two people can see the same thing. Sorry, look at the same image and have a different interpretation. And if you talk to the radiologist, which I have, they’re like, you know, can say all this stuff because you interpret the imaging understanding what’s going on behind the scenes. So we may be getting an imaging for a patient with appendicitis and you’re going to say, well look at that hernia there. Well yeah, except everyone has maybe a little bit of fat. How do we know that that’s a hernia that’s symptomatic or not? Or if they’re right. Lower quadrant pain, let’s say is from appendix. And so do you want us as radiologists really to tell you every single little piece of fat that we see anywhere that could potentially be a hernia that’s going to dramatically increase the number of hernias we diagnose and potentially expose a much larger number of patients to unnecessary hernia surgery. Because unfortunately, there are plenty of surgeons out there that offer hernia surgery to completely asymptomatic patients. And as you know, I don’t believe in that. I don’t believe in operating on every single hernia. We used to do that and now we are stuck with a very high chronic pain rate, which potentially could be lower if we only operate on patients that truly needed their hernia repair based on their symptoms.

Speaker 1 (00:50:47):

If that, and if that means delaying your surgery by a couple years until it becomes symptomatic, that’s what I recommend. I know a lot of surgeons don’t agree with me, they interpret the watchful waiting trial, which was done in 2006. They interpret the watchful waiting trial as not as it’s safe not to operate. But look at all these people that all end up needing a surgery. About 70, 80% need surgery within five to 10 years. So why don’t just do the surgery now? Well, I’ll tell you why. Because you don’t know who those 70, 80% are. And so you are, you’re putting 20 to 30% of the people at risk for chronic pain from hurting repairs or complication or nerve injury or Mesh infection or something. Or they never needed it. So to me that is not how I practice.

Speaker 1 (00:51:46):

But it’s very possible that if the radiologist reports every single little piece of hernia anywhere that will trigger the referring doctor and be like, oh, hernia go to surgeon. Surgeon will be like, oh, hernia, go to surgery. And then you may never have needed. I have plenty of patients that have come to me with, I just had testicular pain or a growing pain and I went to the surgeon, he said I had a hernia and I fixed it. And I’m like, yeah, but none of your symptoms sounded like hernia symptoms. That sounded like a hip or it sounded like a testicular problem. Yeah, but now they have a complication for the hernia repair and by the way says the hernia wasn’t causing the symptoms. Now they have still the symptoms from before surgery, which was the hip or the testicular problem. So my point is this, I don’t believe it’s kind of a problem in that are you over, I don’t want radiologist necessarily to over-diagnose hernias either.

Speaker 1 (00:52:54):

Either because that will lead to overtreatment as well. And so that’s kind of a problem. Next question is TEP, which is totally extra perineal, is TEP placed Mesh easier to remove than TAPP placed? No TAPP and TEP Mesh are placed in the exact same position and they just get to it differently, but in the same exact position. So no, the removal of TEP versus TAPP is exactly the same. And by the way, removal of TEp and TAPP is both done versus via TAPP, transabdominal pre peroneal. Does the general femoral nerve always have to be cut when removing Mesh? Almost never. Almost never to relieve ongoing chronic pain. It’s not easy to injure the general femoral nerve, not by repairing a hernia and not by removing the Mesh for laparoscopic surgery. And the reason for that is the me the nerve though it’s nearby, it’s actually underneath this kind of sheath and often not kind of floating in the wind and open to being injured. So you really have to be very deep where the Mesh has to dig very deep for the general femoral nerve to be injured and therefore need to be cut. So no, I almost never have to touch the general femoral nerve during inguinal Mesh removal after the Mesh was placed laparoscopically in a temp or a tap.

Speaker 1 (00:54:29):

So I hope that’s helpful. Next question, what is the best test to find out if you’ve ever heard? It depends on the type of hernia for the abdominal wall. CAT scan or ultrasound are both good for the groin and MRI or ultrasound are excellent or both excellent. And CAT scan is not as good. It would be a second or third grade for me. The reason why ultrasound and MRI are better is because they’re much more sensitive and you can differentiate hernias from other things much better, whereas CAT scan everything that looks gray. But for the abdominal wall, the anatomy is more flat and not as curved as a pelvis. And so it’s a little bit easier to identify hernias and if you drink oral contrast that can differentiate bowel from the abdominal wall and it’s often difficult to get a good MRI image on the abdominal wall. So that’s kind of how it goes.

Speaker 1 (00:55:31):

The last thing I’d like to kind of end this hour with is I hope that all of you are safe and COVID free and staying safe. I have a feeling that over the next two weeks, some reports that by kind of mid-February this surge is going to reduce. And that’s based on UK and Israel data that shows that the Omicron kind of pandemic has is very short-lived. It kind of spikes and then comes down, goes up really fast and comes down really fast. And so I’m hoping that not only will all of you be safe because there will be less of a prevalence of this variant, but also the hospitals will open up and that we can provide care. Again, I’m very fortunate that our surgery center is open and has been open and providing excellent care to everyone who cannot get care at the hospital.

Speaker 1 (00:56:41):

And the hospital is actively transferring as many patients to the surgery center for their care as possible to offload the hospital. So Cedar Sinai has an excellent job and for those of you who visit me, I have a very beautiful office in Beverly Hills in the best building in Beverly Hills. It’s a plus rated, I don’t know what that means, but it is a great building, high security and very clean. And we have two surgery centers in this building. I’m very happy to announce that our surgery center was voted number two in the nation, all of the United States. We were number two for surgery center as a Sears Sinai partially own surgery center that we share with for your reference number UCLA’s outpatient surgery center. So the top two surgery centers in the nation outpatient are in Los Angeles. That’s pretty cool. Although technically or in Beverly Hills, but LA County, Los Angeles County. And we just give really excellent care. Many people that I know love have had surgery here and it’s just very well done, very well run. And they have been godsend in a savior for my patients and others who are being canceled at the hospital.

Speaker 1 (00:58:07):

Question here is if you’ve had COVID, how long should you wait before considering surgery? Depends on the variant. So back in the early stages, I believe the recommendation was eight weeks before you should have surgery. That is no longer the case. Currently, as long as you’re COVID negative, you are allowed to have surgery because the current variant, which is omicron variant, resides in the nose and upper pharynx and not in the lungs. And so your risk of having surgery while still recovering from your infection is much, much lower because the lungs are not affected. So I believe the answer is five to 10 days. That said, you’re, you may still be positive on your COVID testing and therefore you have to get antibody tested, not just PCR tested. If you’re PCR positive, but five to 10 days has gone by, you should probably get antibody tested because you may be falsely positive after you are no longer infectious

Speaker 2 (00:59:20):

From the COVID testing. So it’s been fun. I’m super excited about this year. I feel that it’s going to be brighter, lighter, less depressing. I’ll do more operations. I’ll continue with my hurry talk you guys. All guys will all be very much safer and healthier. And I planning on going on a lot of trips for meetings and so on. I have a lot of meetings coming up, which I will share with all of you. So I’ll see you next week. This ends for me, Hernia Talk Live Q&A with Dr. Thanks for everyone for coming in on Zoom and Facebook Live and do share from my YouTube channel. I want more people to go on my YouTube channel as I’m filling up for you. So thanks everyone. Peace out.