Speaker 1 (00:00:02):
Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live, my weekly Q&A. I’m very excited to have you all today. We will be talking about some very, very common problems, but I know that a lot of questions arrive. Thanks to everyone who are joining me on via Facebook Live and also via Zoom. I’m also on Twitter at Hernia doc and on Instagram at hernia doc. And many of you know that we are, I think on episode 86, if I’m not mistaken, and all of those episodes are available on my YouTube channel and we’ve talked about so many amazing topics. So today’s topic is discussing umbilical hernias. I do that because sometimes I feel that we talk about so many rare things like Mesh infections and nerve injuries and so on, which are all very important but not common. And yet sometimes we don’t talk about the most common operations, the most common hernias.
Speaker 1 (00:01:11):
So as you may know, about three out of four hernias are inguinal. So in the groin, so the typical indirect inguinal hernia that goes down to the scrotum in males, and there’s also the direct femoral hernias. The other one, fourth of, sorry, the other one third of hernias are in the abdominal wall. Those we call umbilical hernias is if it’s at the belly button, it’s called the ventral hernia, which is a general term for anything in the abdominal wall in the front. If it’s in the upper abdomen, in the middle, we call it epigastric hernia. There are things called Spigelian hernias that are just very uncommon hernias kind of below the belly button, usually in toward side a little bit.
Speaker 1 (00:02:03):
If your hernia is after an incision, like a surgical incision, regardless of where that is, that’s called an incisional hernia. And if these terms are important because the diagnosis is important, the diagnosis is important, and also the treatment is very much related to that diagnosis. So umbilical hernia specifically refers to anything at or just right around the belly button. It’s an outtie, so if you see an outtie belly button that is an umbilical hernia until proven otherwise. I go on Instagram a lot and I feel that so often we have models and so on, and then they put themselves on Instagram, whether male or female, and my eyes go straight to the belly button because like, Ooh, that’s an outtie. Oh, that’s that’s a hernia. Maybe I should fix it. Make you look better. And then of course I get hate mail from people that are saying that I’m shaming people for having an outtie belly button, but just know it’s a hernia.
Speaker 1 (00:03:16):
It’s actually a medical problem. And even though it’s uncommon to have a lot of complications from these bellybutton hernias, some people do. And so it is actually a medical problem. So one question that’s being asked is, I have an umbilical hernia, one centimeter, but it’s not an outtie yet. Yeah, that’s very possible. So a lot of people will get imaging, maybe they’ll get a CAT scan for some other reason of gallbladder or they had a car accident or something. They get a CAT scan. And then as part of that imaging, whether it’s ultrasound or a CT scan, less commonly MRI, it will say one centimeter umbilical hernia with fat content or something else of that sort. And you never knew you had an outtie. So if you look at your belly button in a mirror, it should be an innie, so it should be stuck inside and it should be symmetric.
Speaker 1 (00:04:15):
So all around the inside of the stock of the belly bunch all look the same. If there’s one, if you look in the belly in the mirror and you see that there’s a little bit of outpouching on the side of that stock and therefore it’s not completely symmetric, then you probably have a little belly button hernia. Of course, those tend not to be a problem. I’m just saying if you want to be very, very clear about it. So someone here is saying that yeah, in fact they were diagnosed with anal hernia through a CAT scan and an ultrasound, but it’s not an outtie yet. An outtie is when the hernia is not on the side of the belly button but right in the middle and things protrude out and you get kind of like a outtie belly, but as opposed to like a sun can in umbilicus, the question is does this cause symptoms?
Speaker 1 (00:05:12):
It looks like someone already is telling us online that they do have pain and sounds like that’s why they got the symptom. The imaging, the CT scan ultrasound both confirmed a one centimeter umbilical hernia or belly button hernia. So in general, small umbilical hernias, by small I mean under one and a half to two centimeters, which means less than an inch. If you have no symptoms, most of us do not recommend it. You have it repaired because the chance of it causing you problems is low, but then there’s chance he’ll have complications from surgery. And so you don’t have to have those repaired. Now if it doesn’t look good, if it’s protruding out your swimsuit model, you may want get it repaired even if you have no symptoms. But for the smaller ones, you don’t have to get them repaired. If you’re having surgery, let’s say gallbladder surgery or appendix surgery, anything else that involves laparoscopy through the belly button, you may want to have it repaired at the same time and not ignored.
Speaker 1 (00:06:15):
Now if you do have symptoms, then that’s definitely an indication for repair of an umbilical hernia no matter what the size of it is. We don’t usually recommend repair of hernias based on size. Usually it’s based on symptoms. So what I recommend also, let’s review this, what are the symptoms? So you can have symptoms at the belly button, that’s the most common. It could also cause bloating. That’s another common symptom with a belly button hernia. However, most patients don’t necessarily have pain right at the belly button. It’s actually just the side, either just the left of it up to two or three finger breaths away or to the right of it, two or three finger breaths away. Not very far away but close by. So a lot of people, and it seems like someone who’s here online is saying that she had pain on the left side, started having pain in 2018 after lifting something heavy, but the surgeon thinks the pain and the umbilical hernia are separate.
Speaker 1 (00:07:25):
I would say that’s unlikely. So if you have pain that’s activity related, like you’re saying that it’s with after lifting heavy and you have a hernia, the chance of the two are related are pretty high. And for specifically for belly button hernia, a lot of surgeons don’t appreciate the fact that the pain is not necessarily at the belly button. It can be to the side of it up to one or two, up to two or three finger breasts away from it. And I don’t know why that is. I think it may be related to the tearing effect of it, but that could be fixed by just fixing your belly button and fixing a one centimeter umbilical hernia. A very straightforward low risk operation. So if you want to consider just having it repaired and see what happens, that’s very reasonable assuming that you’re a good candidate for surgery.
Speaker 1 (00:08:23):
So we have another person online that’s saying that they also had a belly button hernia, but it was very painful and it was painful at the belly button. So that’s another way presenting too. It was very sensitive. So a really sensitive belly button, button’s not normal. You shouldn’t be super tender or red or inflamed in that area. And if the belly button is super tender and it’s red, that’s an emergency. It can be from an umbilical hernia, in which case, oh, so in which case a repair would fix it. And then every so often a burning painful belly button is that’s red, is from an infection, not from a true hernia. So that should be noted, but that’s not as common as just umbilical hernia. And umbilical hernia is more commonly seen in women, although men certainly have it as well, and it is the most common of the abdominal ventral hernia repairs. What’s a question you guys? I love it. Yeah, so the lady who was saying that her pain was just the sign of the body bottom went, had the pain undiagnosed since 2018, burning pain just to the side of her belly bottom. That’s really unnecessary if they, I’ll bet you if they had examined her, but more importantly, if they had gone imaging and read the imaging correctly because what do I say, imaging can be almost always about three out of four times misinterpreted by the radiologist. And you may have had that diagnosed earlier.
Speaker 1 (00:10:12):
She was told she should consider physical therapy. Of course, that’s not going to help it. Physical therapy will not do anything for an umbilical hernia instead of surgery. And again, a one centimeter umbilical hernia is a very low risk operation for most people. She was told that she perhaps she was overweight, which she wasn’t. So the way to note, if you’re overweight, there’s a calculator that’s BMI calculator, just write BMI calculator, it’ll come up. You put in your height and your weight, it’ll calculate something. If you’re over 25 kilograms from meter square, that’s considered overweight even though you may not think you’re overweight. And yep, there we go, man, I’m good at pres. I’ve seen so much of this. I know exactly their story. Yeah, sounds like she had a CT scan in 2019 and it was missed. What did I tell you? I’m right.
Speaker 1 (00:11:09):
You just see enough of these. It’s the same story over and over again. Is that silly? The surgeon thinks it was muscle strain. You don’t get muscle strains around your belly button. Her B M I is 24, so technically she, she’s technically normal weight. So thank you for all of that. Thank you for all of that. Okay, we have another gentleman that’s calling in or writing in saying that he had a very sensitive by his was repaired two years later and I’m curious how you’re doing it. Also, I’m curious what kind of repair, because we’re going to be discussing your repair options. There’s a lot of repair options for umbilical hernias.
Speaker 1 (00:11:54):
Okay, here’s another discussion During fistula takedown, I assume that’s enteric fistula takedown or intestinal fistula takedown. The surgeon noticed I had it on hernia and I repaired it being that I didn’t educate myself on the appropriate care of it. It recurred twice and now a third one, and I have two pieces of Mesh that you have diagnosed. They have torn away from their place and need removal and replacement of a larger Mesh. Okay, this is very important. It’s one of the topics I wanted to discuss and I’m glad that one of the viewers brought it up. So repair umbilical hernia is straightforward. However, you have to have the right repair. So what I see often is someone who has a lot of risk factors, they cough asthmatics, C O P D, nicotine user, obese, diabetic, they have a relatively small hernia, one centimeter, two centimeters, let’s say a one and half or two centimeters.
Speaker 1 (00:13:02):
They have a non mashed repair, just a couple stitches repair that tears immediately. They’re just too much tension on that repair. They’re coughing. They use nicotine, which means they’re not going to heal correctly. Their collagen is destroyed, they’re obese, which means it’s pulling on the tissues. So now that one, what started as a one or two centimeter hernia is now three centimeters or four centimeters. They go back to the doctor, they may do another tissue repair. They may ask, I don’t want Mesh or maybe they went to the emergency room and bowel got stuck to it. That’s how they knew it recurred. And so now they can’t really get Mesh. They got another tissue repair that tears and now it’s a six centimeter or eight centimeter hernia to the point where they keep and then they get a Mesh repair, but it’s done open or maybe laparoscopic but with too small of a Mesh.
Speaker 1 (00:14:03):
And so that tears, so now it’s six or eight or 10 centimeters, they go back in laparoscopic. They put in a bigger Mesh, they attack it to the first Mesh, which doesn’t work by the way, Mesh doesn’t stick to Mesh. So the, it’s like adding paper to paper unless you staple or glue it together, those two are not going to stick to each other. And then now they have multiple pieces of Mesh in them and it’s not an adequate repair to begin with. So then that recurs. So now you have 5, 6, 7 operations in. You keep losing muscle tissue each time because the Mesh never never tears. The suture never tears. It’s your muscle and your fascia that’s tearing and now you’re stuck with this huge hernia. Guess what? You’re still smoking nicotine, you’re still diabetic, you’re still obese, you still have your UN uncontrolled C O P D or asthma with the cough and now you have an enormous hernia and you’re a horrible candidate and you may come and see me because now you’re tired of it and I’m going to say, no surgery right now.
Speaker 1 (00:15:10):
We’ve got to control your diabetes, we got to get you off the nicotine, you have to lose weight. You may need surgery, you need to lose the weight. We got to get your asthma under control and your coughing control and then we’re going to do a huge abdominal wall with construction. But by that time you caused so much damage to your tissues. You have waste a lot of time and money and time off work probably for all these operations. So I wanted to kind of tell you that even though I always like to say on bill hernia is my favorite operation because it’s short, it’s small, it’s cute, it’s low risk. If you don’t do it correctly, it’s a disaster. And I really, really highlighted that. So going back to our original patient with that issue, he’s not diabetic and he doesn’t smoke and he did lose weight. So that’s very, very good.
Speaker 1 (00:16:11):
The weight is the most important part. And the other gentleman who had they have very sensitive umbilical hernia now says that it was repaired a couple years ago and let’s see, it was the belly button, couldn’t even touch it at the time. How can they use repair? How can they use Mesh repair or hernia if imaging is not going to show problems? I don’t know what that question means. If you can repeat that for me. My surgeons recommending PT as well. PT doesn’t do anything for abdominal wall hernias. It wasn’t, okay, so just to clarify, it was a match repair. I felt seven or so sharp poke like pains and I’ve been hurting ever since, which means you tore, tore through those sharp pains. Are you pulling suture kind of like piano, violin strings or guitar strings through your abdominal wall muscle in, you’re tearing through it and you can have a recurrence because of the sutures pulling or just chronic pain because constantly pulling.
Speaker 1 (00:17:26):
So the explanation I give is, I don’t know if any of you wear watches that have a metal bracelet to it. So comes men’s or women’s that sometimes what happens is that watch can kind of pull on a little hair on your wrist or those of you that wear glasses, the hinge of that glass can pull on one of your hairs that’s so painful. You just want to take that watch off or take those glasses off because the woo little hair is pulling. It’s the same process when you are tearing through the abdominal wall, you are cutting through it with the sutures that are cutting through this and oftentimes it’s because the repair is too tight. It’s like wearing a tight outfit, you’re going to tear through it, the buttons will pop off. So when it tears like that, depending on the reason for your repair and how it was repaired, then there’s not much you can do because it’s constantly tearing, it’s constantly pulling and it’s already on tension. So it’s not going to be taken off tension because now it’s torn through.
Speaker 1 (00:18:42):
So I thank you for liking my analogy. I love a good analogy. Yeah. Oh, going back to the second patient, we’re talking about imaging is not showing anything and the surgeon doesn’t know what to do. So the surgeon recommended physical therapy, losing weight. I would recommend getting another opinion because I’ll bet you that imaging does show something. Cause Lord I tell you, I always say imaging’s [inaudible], you got lots of questions today, which I love. So question, next question. Is it common after a umbilical hernia pair to have no belly button anymore? Usually not first. The surgery left me with two holes with a small piece of skin in between. After my recent surgery I have only a line like drawn with a pencil. It is so thin, so everyone’s belly button is different. Some people have a little extra nub of skin. It all depends on how your belly button healed after the umbilical cord was cut.
Speaker 1 (00:19:52):
But pretty much everyone can have an innie umbilicus every so often I see people with no belly button. I just saw a patient today who was operated on in Italy and I don’t know why, but they got rid of his belly button. So I can’t mean you can have a plastic surgeon recreate you a new belly button, but that’s not easy. It’s not common often doesn’t look very good. So he came to me, I’m like, where’s your belly button? He’s like, oh yeah, about that. They got rid of my belly button. He didn’t even have a big hernia. If you have a huge, huge hernia, it’s possible that your belly button is basically destroyed already the abdominal wall and it’s hard to salvage that because the blood flow of the skin is gone by the time you need your index operation. But this wasn’t even his situ, that situation for him.
Speaker 1 (00:20:46):
So I don’t know why it out as belly button anyway. So in answering your question, it sounds like you still have your belly button. It’s a stock, it has a communication with the muscle deep to it, but the skin around it has been kind of scarred down or something. So that can always be reconstructed or reintroduce. Is there a way to predict which umbilical hernias are dangerous or is the main reason to operate cosmetic? So no, the painful ones are considered dangerous because as painful because it’s being stuck or pinched. So those we recommend repair. Of course we don’t know of those people. How many of them will need emer… may undergo emergency surgery if they don’t get repaired. So that’s hard to know. There’s one cool study that showed, if you look at the imaging, the neck of the hernia is kind of the hole at the fascia level, at the muscle level, and then the head of it is how much content has protruded through the neck.
Speaker 1 (00:21:54):
So if the ratio of the neck, or sorry of the head to the neck is three to one or greater, then the chance of incarceration or something getting stuck as higher and therefore the chances of meeting urgent surgery is higher. So that’s one way to look at it. There’s plenty of small hernias. I also have that three to one ratio. So I’m not saying that that’s like the perfect scenario, but if you have pain or if you have a three to one ratio of the head and actually a amount of content that’s gone through versus the whole through which these things have gone through, if the ratio is more than three to one, then you can, I recommend you have a repair. The main ways reason is not cosmetic. In fact, the only ti, first of all, no hernias considered cosmetic surgery. From an insurance standpoint, all hernias are considered medically indicate to be repaired.
Speaker 1 (00:23:03):
That said, the true indication for repair for most hernias is if you have symptoms. So if you don’t have symptoms, you can do what’s called watchful weighing. I no longer have a belly button. The best removal surgeon said saving it would increase the risk of a failure. Is that true? Okay, so saving a belly button sometimes causes skin and tissue necrosis and failure of the wound to heal. But no, it doesn’t cause you to have a higher risk of herniations. I don’t agree with that statement. Can you Mesh to Mesh instead of glue or staples and how is that effective? When you said you cannot place Mesh to Mesh, so if you are in there for the first time or for the original time and you have a fresh piece of Mesh with another fresh piece of Mesh and you sew that together because your hernia is so huge that you need two meshes together, which is nearly never, then that will work.
Speaker 1 (00:24:16):
Understanding that that it only works because the way Mesh works when you put it in, it causes an inflammatory reaction. When it causes that reaction that inflammation kicks in and scar tissue kicks in and your body starts growing into this Mesh. My point is, if you’ve had Mesh before, after it’s already gone through its initial inflammatory stage, it’s no longer inflammatory. It’s just sitting there like a piece of cardboard or a piece of paper, it has no more potential to stick to anything anymore. So then you bring another piece of Mesh in because now it’s a second or third operation. If you want that Mesh to overlap with this Mesh, just know that the first Mesh has no reaction left to it anymore. It’s done, it’s burned out. You’re introducing a new Mesh, which works again with inflammatory reaction and wants the nearby tissue tissue grow into it.
Speaker 1 (00:25:18):
Well, if the nearby tissue is meshed, it won’t grow into it no matter what you do. And if you try and so Mesh to Mesh in an overlapped way, so on top of each other, that sandwich will not heal. It’ll just get be at risk for having bacteria there or fluid there, which will then get bacteria in it. So my point is if you have Mesh in you, we tend not to put Mesh onto Mesh. We can just remove the old Mesh and put in a larger piece of Mesh. By doing that where you’re adding Mesh to other meshes it, it’s uncommon and often causes problems such as fluid collections and poor healing.
Speaker 1 (00:26:08):
Must the comorbid diastasis also be operated on or can a hernia repair? Oh, that’s a good question. Okay, so haven’t talked about diastasis yet. a lot of people that have umbilical hernias have it within a diastasis that complicates things. So diastasis is a thinning of a tissue and a separation of the tissue between your two muscles. Everyone has a little bit of tissue between your left and right six pack or rectus muscles. That’s normal. It’s it’s millimeters to maybe a centimeter wide. If it gets to be more than one and half to two centimeters wide, that’s a diastasis. You may have seen men that have kind of rounded beer belly. That’s a diastasis. You have seen women that used to be flat and had a couple kids and now they’re kept a rounded belly. That’s a diastasis. So since that middle portion is thinned out, it’s a higher risk to getting a hernia there, especially at the belly button level. So what do you do in that situation? a lot of options.
Speaker 1 (00:27:16):
The simplest option is to ignore the diastasis and just fix the hernia. So that’s doable, but you can’t fix it like a regular hernia. You have to do is called the mayo repair. And the mayo repair involves like a two layered repair because you’re dealing with thin out tissue, you have a hole now not near nice thick tissue but in a thin disease tissue. So you need to do an overlapped repair called a mayo repair. But it is doable. The recurrence rate is always higher regardless of what technique you use. If you don’t address the diastasis and you just fix the hernia, but it’s an option.
Speaker 1 (00:27:59):
The most drastic option is to get a tummy tuck are what we call abdominalplasty, which addresses the hernia and the diastasis. It’s also the best repair for any type of hernia that’s within a diastasis. Now, true abdominalplasty or tummy tuck involves removal of skin. So if you don’t have skin, then what we do is we do our laparoscopic or robotic plication of a diocese and a hernia. So that’s kind of my 2 cents on it. What kind of me and I believe we’ve discussed diastasis repairs with and hernias and abdominalplasties with two of our prior surgeons. One with Dr. Fisher and one with Dr. Oh, maybe three. One with Dr. Yanis and one with dr.
Speaker 1 (00:29:02):
So three plastic sugars we have so far, we’ll have more plastic surgeons coming up this year. And the discussion has been on abdominalplasty and hernia repair related to that. So it’s a good question, but again, not everyone needs to have a tummy tuck. Not everyone’s a good candidate for it and therefore there are other options. It’s just what’s the risk benefit ratio? What kind of measure you use for umbilical hernias? What is your preferred placement? So another good question. Really, any Mesh can be used for a medical hernia repairs, especially if it’s permanent Mesh. There’s a trend towards absorbable Mesh, which I haven’t really fallen into yet because the data still is not where I want it to be. So depends on the size of your umbilical hernia and your past medical and surgical history. But you can do an excellent repair, you can do a laparoscopically, you can do it robotically, extra peritoneal, you can do it on repair.
Speaker 1 (00:30:15):
These are all different techniques. The best repairs based on the size of the hernia, what’s going on inside your belly. For example, if you have a Crohn’s disease, I would not do a laparoscopic or robotic hernia repair. I just don’t want to be inside your belly when you have inflamed intestines. Whereas if you have a smaller hernia, let’s say three centimeters, you need Mesh, then that’s a perfect laparoscopic repair. So it depends on your body size, your risk factors, your medical history, and also of course your surgeon’s skills to do all those. All right, let’s go back to more questions. Can you recommend a surgeon in Chicago? So all of those questions can be answered on hernia talk.com. You can just search for Chicago and see those surgeons that pop up.
Speaker 1 (00:31:14):
Second opinion surgeon doesn’t see anything defended as well, recommends pain injections. So pain injections may be useful because if you’re tearing and there’s no actual hernia, so this is a situation where belly bone, hernia very sensitive, is repaired with Mesh two years, two years later, it’s very painful, but the imaging doesn’t show anything. So if it’s torn but there’s no actual hernia, then you may have to just plicate the pain with injections. If it’s still torn, it is too tight of a repair and that’s why you have pain. You can consider Botox. So it’s kind of a unique way to address it, but Botox will loosen up those muscles and therefore you won’t feel the tightness of the repair anymore and give yourself a little bit of a breather and if that works, then just do Botox a couple times and that should loosen up the abdominal wall a little bit. That said, Botox is not covered for this. You’ll have to pay cash for it usually.
Speaker 1 (00:32:25):
Yeah, my surgery recommended pain management injections two, except you actually having umbilical hernia. So no amount of pain injections will help an umbilical hernia. Okay, so sounds like I have an umbilical hernia that can cause referred pain on the left side. That’s true. It’s a one time hernia based on imaging, correct? I am an ex-smoker, like occasional, have not had a cigarette since the summer. Can I still do the surgery? So we don’t like you to be exposed to nicotine for at least six weeks before surgery and preferentially not at all after surgery. So if you can do that, you’ll have the best outcomes.
Speaker 1 (00:33:14):
Not ahead, any smoke or just social. Yeah, but the problem is that the nicotine kind of messes up healing and for hernias it’s something like seven x or something where the recurrence rates like and complication rates are seven times higher than the average patient. So you don’t want to mess with that. Is Mesh better or suture for a one centimeter hernia repair? So that’s an interesting question. What’s your definition of better? If you look at all the data that’s been published on hernias, every single one I’m, I don’t know of a single data point that doesn’t show Mesh to be better from a hernia recurrence standpoint. So even a one millimeter hernia does better for recurrence than with Mesh than without Mesh all the way up to vigor woods. That said, the recurrence rate is really low for one centimeter hernias. And so if you come to me and you’re not overweight, you’re not an active smoker, you’re not diabetic, you don’t have a chronic cough, you’re not immune suppressed.
Speaker 1 (00:34:12):
In other words, you’re a low risk patient and one centimeter hernia. I would do that without Mesh for sure, even up to one and a half centimeters. I would push that envelope because there are risks with meshes. You can get a Mesh infection, you can have chronic pain from it. It just complicates things. What if you need another surgery in the future for gallbladder or appendix or you get colon cancer and you need surgery, that Mesh is going to be in the way. So I’d rather not do it for a small hernia, even though technically the risk of recurrence is higher without Mesh.
Speaker 1 (00:34:51):
Next question. I have a 12 by 12 I assume centimeter Mesh put in place for a ventral hernia has been causing lots of problems. The main one being pain. My doctor who put the Mesh and now wants to take it out. Should I trust that seeing doctor take it out? Well, if it’s any of the doctors that I’ve been interviewing, I would trust ’em because I only picked the best. And I don’t just willy-nilly interview anyone. I interview people that are well known in the hernia community are well established in their knowledge base and technique. That said, I would always get a second opinion regardless. It’s surgery and in your case it’s repeat surgery. So even patients that come to me, I encourage ’em, go talk to another surgeon and get another opinion. Run that by me if you want to kind of have a bit more insight into your disease process.
Speaker 1 (00:35:50):
So yes, do see a second opinion, and then the question is why is it causing the pain? Is it causing you pain because it’s balled up? Take it out if it’s causing pain because you’ve fix a recurrence, it’s not a Mesh problem if it’s causing you pain because it’s put in too tight. That’s a technical problem. That’s not a Mesh problem, but you do have to undo the type repair and redo it if it’s causing you pain because you’re somehow reacting to it, of course, take that up. But in most cases, pain alone is not an adequate diagnosis. I need to know what kind of pain and what situation and then based on that make her decision food collection and what I don’t understand that question. Thanks so much for your video. It’s so nice to hear someone. Real knowledge, experience. Oh, well thank you.
Speaker 1 (00:36:51):
I do have real knowledge and experience women doctors rule. Oh, I like it actually. Based on that, did you see the new paper that came out where it looked at men, doctors, women, doctors, male patients, female patients, and it showed that basically if you’re operated on by a female patient, sorry, by a female surgeon, regardless of you’re sex, you’re going to do better. But if you’re operate, if you’re a female being operated on by a male patient, you’re likely to do worse. Did you see that? It kind of supports that women should be surgeons. Okay, hernia talk.com. Yes. Yeah. Okay. So going back all those injections, if nothing, that makes sense. Okay. And yes, you don’t want, you agree to stop smoking forever. That’s great.
Speaker 1 (00:37:50):
Wow. If I could affect you just by talking to you and have you stop smoking, that’s great. But you know, just have to know. I see people with such preventable problems that if they just didn’t smoke, they would’ve healed. They wouldn’t have occurred. They wouldn’t have had the wound breakdown, that little fluid that comes out that it got uninfected, now they have a Mesh infection and so on. So you’re doing the right thing. My surgeon said he wouldn’t know if he has to use Mesh until he opens me up. I would get a second opinion. I will, I will. You always know because you have imaging and if it says one centimeter, why? You should just know in your practice if it’s a one centimeter hernia, do you use Mesh or do you not use Mesh? If there’s a diastasis, some people prefer to use Mesh because it’s so thin tissue there. So all of that’s available on imaging.
Speaker 1 (00:38:55):
You’re finishing up with your comments on diastasis. Yes. So diastasis is different than an umbilical hernia. And I say that because I say that because a lot of people they mistake having A is having a hernia. It’s not. A hernia is actually just a weakness, a hernia as a whole through which things go through. So it makes you higher risk for having a hernia there and it makes you high. A diastasis makes you higher risk for having a recurrence of your hernia, but it’s not an actual hernia. All righty, having a really hard time finding a surgeon here. Well, here’s what you need to do, do what’s called a telehealth consultation or online consultation. Many of us offer you an opportunity to do a consultation even though you’re not in our town or not in our state even. So that’s really what I need you to kind of focus on is I at least get a second opinion either in your state or outside of your state so that you can get a little bit more direction. Next question, do umbilical hernia parents take longer to heal than other ventral hernias elsewhere? No, pretty much not. If you do not, in fact the reverse may be true. Umbilical hernias repair really well. Yes, in your question, I am available for online or telehealth consultations. Just contact my office, all the information’s on my websites.
Speaker 1 (00:40:46):
Next question. If you do not overlap old, old and new Mesh, but rather just send them together, is that viable to avoid trauma of removing old Mesh place years ago? No, it is not my 12 and don’t be worried about the trauma of removing Mesh. There’s not that much trauma in removing Mesh. In extreme case, if there is, then they would leave the Mesh alone. But usually, at least in my case, I don’t do that. I don’t leave old Mesh in and just do a crappy repair around it. My 12 by 12 Mesh has caused me a lot of pain, but after several weeks it’s getting better. I was told it would take about three months. The rib pain is the worst. Okay, so rib pain from a Mesh repair has to do with the fact that most likely they put the Mesh, they sewed the Mesh to the Rives. You’re not supposed to do that.
Speaker 1 (00:41:45):
There are certain situations where I would do that. Hernia repair is not one of them. So in some situations people put Mesh directly over the Rives and what happens with that is if you take a deep breath in, it hurts. If you raise your hand to brush your hair or to shower and wash your hair, it hurts. If you raise your hand to go pick something up from a cabinet or hurt, it hurts. So those are all situations where you’re trying to expand your Rives and the Mesh will let it happen. Also, the muscles over your Rives are trying to move and the Mesh won’t let it happen.
Speaker 1 (00:42:22):
So because of all of that, it hurts. Now in many situations will get better. I do agree that by three months you should feel better than it seven weeks. So it’s obviously I would not jump into removing your Mesh very quickly. How do you safely undo a suture repair if it’s too tight? Okay, so if the suture repair is too tight and you have too much pain, you likely are tearing, in which case you would have to go in there, undo the sutures and maybe add Mesh because you and the Mesh will take some attention off or do some other type of tissue repair. Going back to the Rives patient, if the Mesh is sewn to the Rives, is Mesh sewn to the Rives from abdominal Wall reconstruction? Usually not, but I’ve seen it and in those cases where it is sewn to the Rives, it can cause pain. So that’s my sit situation.
Speaker 1 (00:43:32):
All right, let’s go back to my slides. I had some questions pre prepared for you all to see if it can help you. So what is an outtie? Did we discuss this? So an outtie is a protrusion in the middle of the belly button as opposed to an any. There was some discussion a couple years ago how to spell outtie. Is it O U T I E or O U T T I E? I was spelling it with two Ts for the longest time and I just feel like it should be two Ts, but I’m told it’s only one T. Do all umbilical hernias require Mesh? So the answer is no. In my practice it has to do with the patient and the risk factors and the size of the hernia. So in umbilical in my practice an umbilical hernia under and half centimeters, I typically do not put Mesh anal hernia outside of a over one and half centimeters. I typically do put Mesh. If you’re super thin, I may take that number up to two centimeters.
Speaker 1 (00:44:45):
So I wouldn’t put Mesh for hernia up to two centimeters. Understanding that that decision is actually giving you a higher risk of hernia recurrence than if I did put Mesh in. But I’m buying that risk against the risk of having Mesh related problems and complications Is laparoscopic better than no, but I thought someone would be asking me that, but no one did. So no laparoscopic repairs not better than open. A good laparoscopic repair and a good open repair are both great. A good laparoscopic repair is better than a bad open repair. And a good open repair is better than a bad laparoscopic repair. So it all has to do with the size of the hernia, your own body habits and also your medical history and whether or not there’s a diastasis and some of the factors to determine whether you should have something done laparoscopically, robotically or open surgery.
Speaker 1 (00:45:43):
Going back to the patient with the rib pain, you mentioned improving from seven weeks of three months postoperatively, what happens during that time period that leads to improvement in pain? So what is it loosens up the interaction and the scar tissue between the Mesh and the Ribs loosen up a little bit and you end up not pulling on it as much. Can a laparoscopic operation for appendix result in an umbilical hernia repair? Yes. Any laparoscopic operation that involves a scar in your belly button can cause a hernia there because that actually is no longer an umbilical hernia. It is what we discussed earlier and incisional hernia. Incisional hernias are different. All incisional hernias except for super small ones, all of them should be done with Mesh because you already failed a primary closure or suture repair, which was presumably done at the time of your operation.
Speaker 1 (00:46:47):
So yes, appendix, gall bladder, ovary, surgeries, all of those involve an incision through the belly button. Sometimes that incision is not closed at the fascia level, so you have a higher risk of hernia there. Sometimes they’re removing something, they remove the prostate, the appendix, the gall bladder, the ovary, the uterus through that incision and that can make the incision higher risk for a hernia. How common are umbilical hernias compared to or we discussed that earlier. Two-thirds to three-fourths, almost three-fourths actually of hernias are inguinal, the rest are ventral and the majority of those are umbilical that rest of that one quarter. The majority of those are umbilical and the umbilicals are more common in women than in men.
Speaker 1 (00:47:42):
Yeah, excruciating pain with the Rives. My surgeon did not offer laparoscopic. So if they didn’t offer at all, if you asked for and they said, oh yeah, I offer laparoscopic but not for you, then that’s kind of a tailored approach. For whatever reason your repair was deemed to be better done, not laparoscopically. But if they didn’t offer because they don’t know how know to do it, then you should get a second opinion. Because in my opinion, if you’re not able to do laparoscopic robotic and open surgery, then you really can’t consider yourself to be a specialist in hernias because you should be able to offer all options. Mesh, non Mesh, you should be well-versed in a variety of ways of doing things. So you should definitely seek a second opinion. I’ve had nephrectomy in the past and bladder removal. Both were done laparoscopic. Okay, good.
Speaker 1 (00:48:35):
I’ve also had appendectomy age seven nephrectomy later years. So I oddly had gotten the hernia. Oh yeah, yeah. Okay. So this is the one centimeter umbilical hernia in patients that’s had a laparoscopic nephrectomy, laparoscopic appendectomy. Laparoscopic is actually hundred percent it’s from your laparoscopic surgery. Yeah, for sure live. And 99% if the Mesh is by the sternum, the Rives and was unbearable first a little bit better. Now 15 months later, if nonactive, should I still seek removal or repair or leave alone? Well, depends on your lifestyle. If your lifestyle is an inactive lifestyle and you have no more pain, I leave alone. But if it’s preventing you from doing things that improve the quality of your life that you enjoy, then I would get it addressed. And Mesh removal is not a big deal over the Rives.
Speaker 1 (00:49:35):
I mean all surgery’s a big deal, but in the grand scheme of things, it’s not that big of a deal. A month after my umbilical Mesh was placed two years ago, I developed hip size and nerve weakness in my legs. The Mesh was removed after seven months. The symptoms have been chronic and finally diagnosed with L five S one nerve weakness. Recently at the MRI shows a bulging disc seeing that symptoms start within weeks after the Mesh. Are there any way these things are related? No. I treat a lot of patients with Mesh related complications. Sciatica, L5 spinal disc problems and hip bursitis are not related. Two hernias or two Mesh related problems.
Speaker 1 (00:50:21):
Does having umbilical hernia increase your risk for other types of hernias in the future? So having any hernia indicates that you already have a predisposition towards hernias. We’ve discussed before how hernias can be genetic, has to do with the collagen ratio in your body and so on. And therefore, yes, if you have an umbilical hernia and the chances are you may also get an inguinal hernia or if you have surgery, you will have an incisional hernia. Thanks for all your info. So important for those who can plan this, who can to plan their surgery? Yes, that’s true when going to the emergency room, they do not use Mesh and you have one surgery after one another until you get the Mesh.
Speaker 1 (00:51:10):
Okay, let me break down what this viewer’s trying to tell you. Remember my story earlier about belly button hernias and how it’s important that it gets done well the first time. If you ignore the belly button hernia and every time you have surgery it’s because you ignored it and now you have a stuck in it and it’s an emergency, you’re never going to get the best repair and that’s going to recur. The chances are you won’t get Mesh because you have bowel injury or you won’t get a surgeon who does not do this for a living as you won’t get the best repair and you probably aren’t ready yet for surgery because your nutrition’s not optimized. You’re still smoking and you’re maybe overweight. So all of those scenarios make it so that people that undergo umbilical hernia pairs emergently do horribly compared to patients who get it done electively.
Speaker 1 (00:52:03):
Cause they will get recurrences when complications need a second operation. So I’m not saying everyone should have surgery, but if you have a higher risk hernia such as one that’s tender or painful, don’t ignore it, get it done electively so you don’t end up having it done emergently. I had new Mesh sewn to old Mesh. What complications do I need to look for in the future or should I have a revision before complications? So what’s done is done. You should never prophylactically undo a hernia repair because the chance of you having a complication are not a hundred percent just wait. Typically the scenario is you either get a recurrence number one or you get a fluid collection between the meshes which can cause pain and or that fluid collection can get infected. In which case you’d have to act upon any of those three scenarios.
Speaker 1 (00:53:03):
But I would not prophylactically undo anything if the old Mesh was described as incorporated into the external bleak. What does that change? Does that change the equation as to whether new Mesh can be sewn into this incorporated? Actually no, it must be incorporated because that’s how Mesh works. What you want is the new Mesh to incorporate and if you put it against other Mesh, it will not incorporate because Mesh does not incorporate unto Mesh Mesh. It’s a tissue that incorporates into the Mesh. So if you don’t put the Mesh against tissue, it won’t incorporate the issue isn’t the first Mesh. The issue is trying to get the second Mesh to work. So you don’t need a third Mesh.
Speaker 1 (00:53:49):
Let’s see, lots of great questions. What is this question? Okay, my belly button, little hernia, which is after her laparoscopic umbilical appendectomy, append, appendectomy, colectomy and nephrectomy. The belly button did not start bothering me until 20 18, 7 years later. Yeah, that’s true. That’s the natural nature of all hernias. You get it and you don’t know you have it. And then months, years, decades later, it’ll cause symptoms and maybe will never cause the symptoms seven years later. So not from lifting, but lifting could have caused it to get worse? Possibly, most likely not. It’s just a matter of what’s going on with the rest of your symptoms. If you have a chronic cough, if you’re constipated or if you’re overweight or using nicotine, those are more likely to make making it worse than any sort of lifting. So if the laparoscopic related to the repair with Mesh or suture and laparoscopic or open surgery. So if it’s incisional hernia and it’s one centimeter, I would use Mesh in that because otherwise the recurrence rate is almost 50%.
Speaker 1 (00:55:11):
With regard to Texas, I live in Texas. Do you have any colleagues you can recommend? Thank you sir, very much while you do, you’re welcome. Again, go to hernia talk.com and just search the word Texas or your city and see if anyone’s recommended surgeons there or if you like any of the surgeons. I honestly don’t know that many surgeons in Texas. There’s maybe one and it all depends on what you need. So Texas I I’ve actually considered going to Texas to do surgery, but I’d rather you guys come to me because I have my whole team here and it’s a bit more difficult for me to travel and see you for a week. And then let’s see you afterwards.
Speaker 1 (00:56:03):
Pregnancy, no one talked to you, to me about pregnancy. Can I still have pregnancy after umbilical hernia repair? The answer is yes. If you’ve had an umbilical hernia and it was repaired before you’re done having pregnancies, obviously I’m talking about women, then there’s a higher risk that your hernia will recur. And if you had a Mesh repair, it’s a higher risk that during pregnancy you’ll have chronic pain in that area. Of course it’s not a hundred percent, but it’s something to be wary about. So if you’re a female and you have a adult hernia and you plan to get pregnant and you don’t have like no symptoms, don’t get your hernia until you done with pregnancy. That’s the safest. Do you use staples or sutures for incisional hernia? I do not uses or staples. I do suture my incisional hernia.
Speaker 1 (00:57:06):
Should I wait to lose weight for a local hernia? This is a leftover question from last week or two weeks ago. Yes, as we discussed earlier, you don’t want to have a poorly done on local hernia because the domino effect will make you have a giant hernia because you’ll keep tearing through it and each time you tear the hole is bigger, you end up with a more difficult hernia to repair because first the hole is bigger. Secondly, the tissue is missing so you have less healthy tissue to deal with. And third, you probably still need to lose weight. So yes, absolutely lose weight before you get any envelope for hernia repair.
Speaker 1 (00:57:50):
Come to Texas. Yeah, I should come to Texas. You guys come to me. Will you come to Chicago? I have come to Chicago for meetings and Texas for meetings, but not to start to operate. It was really heavy and started feeling about the next day. All right, couple more questions you guys. What if I don’t repair my umbilical hernia? So that’s a good question. Watchful waiting is considered safe for umbilical hernias. We don’t know about that for ventral hernias. However, we know for really big hernias, if they’re nine centimeters or larger, people have a much better improved quality of life if they just have a damn hernia repair. The smaller hernias, we also feel the reverse. If you don’t repair the really smaller hernias and they’re considered low risk, then you should just consider non-surgical approach. And don’t be constipated. Don’t, don’t have a chronic cough. Don’t smoke nicotine. Correct your diabetes and get your weight under good control and exercise. So if the hernia, however, is symptomatic, which means you have burning, sharp, dull any type of pain in the area, then you really should get it repaired because the chances are that the pain is telling you that there’s something stuck there. And if you don’t address that, that thing that’s stuck will cause a lot of symptoms and pain that obstruction and you’ll need emergency surgery.
Speaker 1 (00:59:37):
It was fun. That’s very quick hour. Super quick. Tons of questions. I love that so many of you were involved. I knew sometimes you kind of forget talking about such simple questions like on bill hernia, but I knew this would be a hot topic. You guys went through some amazing scenarios. I love answering all those questions. Many of you’re looking for surgeons near you, so please go to hernia talk.com to look for surgeons that we talk about or go through my kind of list and see who I’ve interviewed on Hernia Talk Live. Also the American Hernia Society has its own website, which has a series of list of doctors that you can go find a surgeon. So thank you for joining me. Come back next week every Tuesday, Hernia Talk Tuesdays. I will be here and we’ll answer a lot of your questions. Thank you so very much.