Episode 87: All Things Hernia | Hernia Talk Live Q&A

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Speaker 1 (00:00:01):

All right everyone. Hi, it’s Dr. Towfigh. Today is another Tuesday. Hope you’re well. Glad to see all of you guys coming on board for yet another episode of Hernia Talk Live, our Q&A session which we hold every Hernia Talk Tuesday today is going to be one of my more favorite sessions because I always like the sessions where I just open it all up to you. So many of you are joining me on Facebook as a Facebook Live. That’s easy. You can just type in your questions. Also, when you’re on Zoom, you can type in your questions. I’ll answer them and thanks for everyone who has sent in their questions in advance for both through both Twitter at hernia doc on Instagram at hernia doc. And as you know, Hernia Talk Live q and a is actually an offshoot of my original website, which is available and free for all of you to use, which is called herniatalk.com.

Speaker 1 (00:01:00):

I’ve had it since 2013. There are thousand thousands of participants and questions that have been posed on that that I’ve been answering over the years and other doctors as well of mine who have joined me on the kind of staff at.com. But to be fair, this is more fun. I like this kind of interaction much more so thanks for everyone who turned in their questions. I would like to say that there was plenty, and this is really my favorite kind of all things hernia. So I will start immediately because we have tons of questions to go through and if you all have questions you want to just submit right now as I’m answering the ones that were already submitted, I’m happy to do so. I am open to any question that you may have that’s related to anything that I can answer from a hernia perspective, so let’s get with it.

Speaker 1 (00:02:05):

All right, so first question, during a tissue repair for an initial direct, not indirect inguinal hernia, using either Bassini, Shouldice or McVay technique, which is a tissue-based technique. So Bassini, Shouldice and McVay will all treat a direct, indirect, direct or indirect hernia. McVay will also treat a femoral hernia. That’s what kind of keeps it different than the other techniques. So during a tissue repair for an indirect inguinal hernia, is the internal ring reconstructed and how is this done? So yes, that is correct. The way it’s done is the internal ring is a natural ring through which it’s basically a ring of muscle or how do you call it like a hole in the muscle And through that hole is all the contents for males that goes down to the testicles. So blood vessels and nerves and all that. And for women it’s smaller hole and the round ligament, which is one of the many suspension ligaments of the uterus go through it.

Speaker 1 (00:03:14):

Not as important in women. Also a nerve goes through that usually is called the genital branch of a genital femoral nerve. So yes, the issue I have with tissue repairs, both of them except for the Marcy repair, is that you have to open up all the muscle even though you may not have a hernia through it, and then you resuture everything back together in a way to close those holes. The hernia hole and the hole that you made and the reconstruction is basically you just stop sewing at the level of the internal ring and oftentimes the internal ring hole is shifted to the side a little bit. The other technique techniques, Halsted technique, there’s a lot of different names, but the yes, the internal ring is reconstructed and by reconstructed we just mean that it’s narrowed if that’s what’s necessary. And it maybe shifted a little bit more laterally towards the side because of the way that the tissues are sewn.

Speaker 1 (00:04:18):

Well, lots of questions already live. Thank you for your kindness. How long should you expect to be in pain after double hernia repair? Any advice on dealing with it when pains actually work? Great question. So I assume when you say double hernia, you meet al hernias and the groin and they’re the left and the right side. So double two hernias done at the same time. Usually those are done laparoscopically. I don’t recommend having those performed via open Mesh or tissue based repair at the same time for two reasons. One is that’s a lot of pain control issues. And the second reason is there are studies that show that if you do open surgery left and right at the same time for the groin, the recurrence rate is higher than if you stage it. So I stage the repairs I have you pick one side, let’s say the side that’s bigger or more symptomatic.

Speaker 1 (00:05:12):

Fix that and open with Mesh or open without Mesh repair. Let that heal three weeks later, come back and fix the other side or three weeks or at least three weeks or more later. But with the laparoscopic surgery, the pain should be much, much less. And if you do have hernias on both sides, usually we do those laparoscopic. Now for pain control, I give a lot of anti-inflammatory medications because the pain is inflammatory. So no heat backs, you must use ice. Ice works really well. Use that for the first few days for sure. Tylenol works great. You have to take extra strength Tylenol, most people are able to tolerate two extra strength, so that’s a thousand milligrams three times a day. So that’s 3000 milligrams a day, not all at once. Two pills of extra strength Tylenol, which is a total of a thousand milligrams, and you take that spread out three times a day, so that’s six pills.

Speaker 1 (00:06:09):

In addition, if you don’t have any stomach issues or any [inaudible] Aleve, which is the naproxen or ibuprofen, which is Advil or Motrin or any of those type of medications, those work really well as well. I recommend you take at least two, three also three times a day. So those are typical things. The rest of the pain medications. So this, so once again, Tylenol, sometimes anti-inflammatory pill like advil or aleve, so naproxen, excuse me, ibuprofen or naproxen plus ice packs and walk around if you need more. Those are all prescription based and in my practice we sometimes give tramadol, which is a Ultram, which is a non-narcotic opioid. We use some sometimes give zanaflex or tizanidine, which is a muscle relaxant type pain medication. But those are by prescription. You have to go through your surgeon for those. I have a hard lump of hard lump to the right of my belly button, but below the Ribs and liver and it’s painful.

Speaker 1 (00:07:23):

This occurred after my umbilical hernia, ventral hernia repair and both of those spots still hurt and puff out like it was never fixed. And he stitched it to No, he stitched it. No Mesh. Alright, so here’s the issue with non Mesh repair. There’s so many people that are advocating Mesh repair, which sometimes is a good idea, but it’s not pain free. In fact, it’s more pain oftentimes than Mesh based repair. So the idea of why not to use Mesh implies usually much more difficult recovery and more pain, which is why we’ve moved to Mesh to begin with. So this has a hard lump to the right of my belly button, but below the Rives and liver, it’s painful. It occurred after tissue based repair, so it could be your sutures, the knots of the sutures, depending on the type of sutures and number of knots they put in, you could feel that or you may just be tearing.

Speaker 1 (00:08:20):

If you have a tissue based repair too tight, then you can be tearing through the tissues. Your muscle is tearing like any type of muscle strain and that could be very painful. So not knowing exactly where the surgery was and where your pain is hard for me to predict exactly what’s going on. But if it’s a non Mesh repair and you’re having pain and maybe a lump, you’re feeling the suture perhaps and maybe a tear. Dear doctor is a fact or fiction when they say it’s possible to lose a leg after revision surgery, complete BS complete fiction. First of all, let me tell you this. This is not the first time I’ve heard it. I’ve had other patients come to me. One was seen in the VA system, another one was seen in a a county system. They were told for their groin mass removal, absolutely we will not remove it because you can lose your leg. They’ve also been told you can lose your testicle.

Speaker 1 (00:09:24):

Yeah, should not happen. If you are seeing a doctor that literally is telling you you may lose your leg, then you need to find another surgeon. That should not be your risk. We do. Or some people say you’ll die if I take out your Mesh. Yeah, we do heart surgery, we do heart transplants and people don’t die. So to claim that a Mesh removal surgery will kill someone is really inflating the risk of the operation. Now, there are risks with wet Mesh removal. You can have injuries to the vessels, you can have injuries to your bladder, to your intestines, to nerves, to your testicular vessels or nerves. That’s all true. Those risks should be very, very, very low and it shouldn’t be a major discussion. So I’ll give you my experience. I have removed two testicles in my career of 20 years and 80% of what I do is measurable and one of those me testicles had to be removed because it was so weird, like cancerous looking growth that the Mesh and had kind of grown around.

Speaker 1 (00:10:44):

It was very odd. The Mesh had formed an onion type tumor growth around the vessels and the testicle. I had to remove everything as one. I didn’t know what it was. It turned out not to be cancer, but that’s pretty much it. Everyone else you should be, and I’ll give you more of my experience. There have been times when removing of the Mesh involves injury to the main vessels to your leg, usually the vein, almost never the artery. I’ve had two of those again in my career of 20, almost 20 years. We’re going on to 19 years this year and it happens, but you just find the vessel and you repair it. I don’t understand why your leg needs to be chopped off because there’s injury to a vein in that region. So I would call that fiction. What do they call it? Cap or no cap?

Speaker 1 (00:11:42):

Yeah, cap. Now that the hernia has popped back out and now I have now that hernia has, let me see, what are we talking? I have horrible pain from previous left hernia surgery in 2015 with Mesh and a plug. Now that hernia has popped back out and now I have three new hernias. They want to do surgery with more Mesh and I’m scared because I’m in horrible pain every day. All right, so pain, all pain is not the same. If you had pain from a Mesh plug, that’s because you had a mass. I discuss it as you had a pebble in your shoe and that pebble needs to removed. That Mesh plug is like a mass in your groin area.

Speaker 1 (00:12:33):

That’s a plug issue. That is not a hernia repair pain where every time you have hernia repair, you should expect that pain. You should not. Now that you have your hernia recurred from that operation, which is very possible, you have hernia pain. So the pain is from the hernia, which means if you’ve hernia, that pain should go away. So don’t be afraid of having another hernia repair as long it’s done safely carefully by someone who’s very confident in going back to a previously operated area or how to handle situations like yours where patients have already failed. Prior operations. Do you have a surgeon who’s an expert in their field and has done this before? You should just have a good hernia repair to not be afraid of being in pain again because they won’t use the Mesh play. I hope that that helps you a little bit.

Speaker 1 (00:13:35):

Let’s see, I’m having inguinal hernia repair tomorrow. Great. Good luck. I’m curious what technique you’ll be having and what kind of discussions you had. Double hernia surgery was done in August. Okay, very good. So you’re saying you had your double hernia surgery in August and you still have a lot of pain That is not normal If you have a lot of a lot of pain requiring pain medication weeks to months after surgery, so definitely more than three months after surgery, that is not normal. So if your surgeon was in August, you have to see your surgeon. Just figure out why that is.

Speaker 1 (00:14:21):

Where are you located? I would love to come to you. I’m tired of being in pain. All my information is online. It’s very easy to find me. I’m at the Beverly Hills Hernia Center, you can see it on my shirt, which is obviously in Beverly Hills, which is in California, Southern California. Happy to see you. Are there any differences between male and female? Inguinal Mesh removals? Is one more difficult than the other? Yes, males are more difficult because they have more sensitive structures in the area that may be entangled in the Mesh, whereas for women, we don’t have testicles. There’s no blood vessel, there’s no vast, no, we do have the same nerves. The general nerve is the same in men and women, but in general it’s much easier to remove Mesh in women than a men. And number two, it’s much easier to repair hernias in women than men again, because these spermatic cord, which carries out the blood flow of muscles with testicle is not there for women.

Speaker 1 (00:15:29):

I had double hernia repair January of this year. I was not given any aftercare instructions other than no lifting over 10 pounds, but I’m so weak, tired, and have more pain. How long should this last and what can I do get past this? All right, well, anesthesia alone can contribute to this chronic fatigue. What happens is that anesthesia gets into your system, into your body fat. It takes a while for the body fat to get rid of it, and so there’s a lot of people that are just not the same for a week, six weeks or so after any type of general anesthesia.

Speaker 1 (00:16:06):

So that may or may not be related to your hernia, hernia itself and maybe related to your anesthesia. Good afternoon. Thanks for the q and a. My question is my question, is there ever an instance when the sutures are removed and the Mesh is left in on umbilical repair? Yes. Depends on why you have pain. If the pain is from where the actual suture is and you can say, right, boom, right here is where my pain is, and the surgeon knows that’s where the pain is and that’s where the suture is, they take out the suture and the pain should go away. If it’s a Mesh related pain, then you shall remove the Mesh. If it’s a hernia recurrence, you have to address the hernia. So yes, it’s totally legitimate to leave Mesh behind and just remove the suture. If the suture is the cause of the pain, the Mesh is not always the cause of the pain. In fact, most of the time the Mesh is not the cause of the pain.

Speaker 1 (00:17:07):

I’m having surgery and it will be left sided. I have pressure inside repair in 2004, I need to do an epigastric hernia repair and I’m so scared to do it. I have already waited for nine months. I have no pain. So if you have no pain from your hernia and it’s not getting bigger, you don’t have bowel, then leave it alone. There’s no need to get a hernia repaired if it’s not affecting your lifestyle, it’s not getting bigger. It’s not causing any pain, doesn’t have any bowel with very few exceptions. Another question on Zoom. Does imaging help diagnose nerve entrapment by MRI or ultrasound? All right, so that’s a tricky question. In the best of all possible rules, yes, MRI can show follow. You could follow the nerves on MRI, neurography or ultrasound and see if it’s entrapped. Most radiologists do not know how to read or interpret an ultrasound MRI for the nerves and therefore, practically speaking, it’s hard to do.

Speaker 1 (00:18:17):

There’s a radiologist who used to be at Johns Hopkins who’s now at NYU. I’d like to, I’ll probably interview him soon, who is really skilled at that. There’s a ultrasonographer at Cleveland Clinic very skilled at that, but that’s not reality in most places in the world, and so it’s very hard to diagnose it with imaging. It’s more of a clinical diagnosis If you have neurotrophin, if it removes suture fixation of a Mesh, will that increase the risk of Mesh migrating or clam shelling? Depends if it’s done after the Mesh is already integrated, it should have very little effect on folding or moving of the Mesh. If you remove the suture too early after the surgery, then the Mesh has not yet fully integrated into the tissues and really relies on that fixation. And yes, it can. It also depends on which kind of Mesh we’re talking about and where the Mesh was placed. So as an intraabdominal or between the muscles, it’s usually more secure between the muscles put up with intraabdominal and can move more. And it also depends on what it’s set against. So, that’s very helpful. I hope. I had the right side of my groin fixed in 2005 and the left is being fixed with Mesh. All right, that’s great. Very good. Glad to do that. How long does Inguinal Mesh take to integrate?

Speaker 1 (00:20:02):

Depends on the placement and the type of Mesh. So the synthetic meshes integrate the best and any Mesh is placed against directly against muscle and not against peritoneum or fascia tends to integrate the best. Also, if it’s surrounded by healthy tissue, then it would integrate better than if it’s surrounded by like scar or it’s only one side of it is integrated. If you’re talking about open repair, ultrapro is a lightweight Mesh of polypropylene. The lighter weight meshes with the larger ES tend to integrate faster because you get faster ingrowth. There’s less overall Mesh there, but if your ultrapro tends to be used for inguinal hernias, not so much for ventral hernias. And so usually that’s what we call an Onlay Mesh. So they put the Mesh on top of fascia, which is good, but it’s better if it’s put against muscle in terms of integration. But yeah, they integrate definitely within three days. It’s stuck there and it becomes strong within three to six months. I say three months.

Speaker 1 (00:21:31):

All right. Next question. If your initial tissue-based hernia pair was for a direct hernia, not an indirect hernia, can there be a recurrence through the internal ring? Yes. One that would be considered an indirect hernia even though you didn’t have a congenital anomaly usually associated with indirect hernia? Yes. So with tissue repairs, like I mentioned earlier, you have to open all, you have to make a hernia to fix the hernia. So whether or not you have a direct or indirect hernia, both the direct and indirect space are completely opened up and then your suture everything back together again. So if you recur from a tissue-based repair, you can recur at any position along that opening direct or indirect. And it’s hard to call it direct or indirect recurrence because it’s really an incisional recurrence from the incision made to make do the tissue repair. So yes, it can definitely be the situation.

Speaker 1 (00:22:36):

Let’s see. Next question. Inguinal bilateral hernia pair with polypropylene Mesh laparoscopically in 2015. I think that’s polypropylene, not polyester. Can both sides be taken out at once? Yes. I believe they use one path to go across and cover both unlikely, but it can happen. If not, what has appeared in between operations, we usually do them both at the same time if that’s indicated. Again, we don’t just remove Mesh because you want the Mesh removed. There has to be an indication for it because it is a risky operation. Also, does much tissue come out with a Mesh and once a percent loss of test of a testicle? So no, most tissue is not taken out. Very little tissue is left on the Mesh as you remove it, and the risk of testicular loss should be close to zero. The reason for that is the blood vessels to testicle come from five, I believe at least five different ways. One of them comes from the area where the Mesh was placed. The other four are completely unaffected. So you can actually have the entire vessels completely cut off and the chances are you will not have any loss of your testicle.

Speaker 1 (00:23:58):

I am three months post-op from a diastasis rec time muscle repair sounds like a tummy tuck. I now have a ventral hernia and a belly button. Oh, now I now have a ventral hernia at my belly button. What is a standard procedure to hopefully repair? What increase chances? What increases the chance of not having a recurrence? I’m more confused, but if you’re three months out from a diastasis closure and now you have a ventral and hernia at the belly button, I assume your diastasis closure failed. So you basically have a recurrent incisional hernia, in which case you would need to have usually a Mesh based repair because a tissue-based repair would fail yet again, and that can be done open or laparoscopically. Most surgeons would agree with me that if you have one technique failure, you should go to another technique. So if you had an open repair failure, you go to laparoscopic option.

Speaker 1 (00:25:08):

If you laparoscopic option fail, you go to open technique repair. For my left inguinal hernia surgery in 2015, the surgeon cut two nerves, the ilio inguinal and a peripheral nerve. I know which peripheral nerve, maybe [inaudible]. I had severe pain from day one. I still have horrible burning pain is the nerves that were still causing the pain candy. My doctor had a student surgeon with him for my surgery. Perfectly fine. Could he have done my surgery? Absolutely not. Do the nerves heal? They can but not this far out. So if you have burning or stinging or electrical shooting pain that’s from your nerve, if you had nerves cut, you can have nerve pain from the cut part of the nerve and therefore a nerve block in the area where the nerve was cut or more or more upstream from it can help differentiate if you have nerve pain or not. And ablation or neurectomy is sometimes indicated for that.

Speaker 1 (00:26:15):

We actually looked at our data on neurectomy. Our results will be published soon or you got accepted from publication. Yay. So I’ll post that when it’s actually physically published. But what we found was that when you incidentally cut the nerves, the risk of battery very low. But if you have nerve pain and you plan on cutting the nerves ahead of time, the risk of nerve pain after cutting those nerves is higher. And so based on that information, we try not to cut nerves as much as possible because it’s just like unnecessary injury that you have to heal from. I had an open hernia repair for an incisional hernia, so incisional hernia repair, now I want to get pregnant, should I be secured? It will recur. So most incisional hernias are done by Mesh and with Mesh. And based on that, if you get pregnant with having a ventral or abdominal wall hernia repair with Mesh, it’s possible that you may have some pain because the belly wants to expand and the area where the Mesh is doesn’t want to expand and you may have a recurrence because your belly wants to expand and the edges of where the Mesh is sewn to the muscle tears.

Speaker 1 (00:27:45):

So that’s one issue. I believe this person actually had an interstitial hernia repair without Mesh. The risk of that falling apart is actually much, much more with pregnancy than not. We don’t know what the data shows in terms of percentage. We think of somewhere around 25% risk of it falling apart strictly because of pregnancy. So in general, we don’t recommend you have any abdominal wall hernias repaired if you’re still planning on having pregnancies the same way you should not have a tummy tuck before you’re done with having a pregnancies. And I’ve seen young girls who get tummy tucks and then they get pregnant. It’s just a waste of whatever amount of money you spent on doing that operation. You’ve completely destroyed the chances of having a nice abdominal wall. Afterwards you may need to have another tummy tuck, which is not easy to do. Can nerve entrapment be associated with pinpoint tenderness or tenderness more associated with other cause of pain? Yes, absolutely. Pinpoint tenderness can be either from a nerve entrapment or neuroma where you are actually touching the neuroma. So that absolutely can happen. There’s a lot of things that can cause pinpoint tenderness. It’s usually a suture or a nerve pain, less likely like a hernia recurrence. Those have to be a bit broader in terms of where the pain is.

Speaker 1 (00:29:20):

How long does Mesh last? Okay, good question. So Mesh, that synthetic is made to last forever. They’re made from either polyester, polypropylene or goretex like EPTFE and poly vinyl dye something. So P V D F in Europe is also available. These are all synthetic, they’re all permanent and they will last as long as you last. There are biologics which last around eight months. There’s some synthetic absorbable meshes that last theoretically around one and a half to two years, sometimes longer. And then there’s all these hybrid meshes. There is a biologic called Michael that lasts about three weeks or so.

Speaker 1 (00:30:15):

Let’s see. Do you do a lot of tissue based repairs with abdominal hernia repairs? I do depends on your risk factors, the size of the hernia, the quality of your tissues and what repairs you’ve had in the past. So if you have a one millimeter to 15 millimeter or one and a half centimeter hernia in the abdominal wall, that’s not a hernia from a prior surgery, then yeah, those are perfectly good for tissue-based repairs. If you have a massive amount of reactions to everything and can’t have Mesh. There are ways to do tissue-based repairs for ventral hernias. Usually it’s a, it may involve a component separation and the plastic surgeons are really the ones that mastered that. Dr. Ramirez and his Ramirez operation really kind of showed the anterior tissue repair for that. The recurrence rate for that is just under one third. So it’s not the perfect repair.

Speaker 1 (00:31:19):

But yeah, of course I do offer almost every option you may have for her repair. How long can inflammation from Mesh persist after removal from Mesh implant illness? Unknown. So that’s an incorrectly stated question. It’s not the inflammation from the Mesh, it’s the reaction of your body to the inflammation. So once the Mesh is removed, many patients I think in, I’d have to look at our data cause we’re actually publishing on that. I think 40% had immediate response and another 40% took about a year to get better and the others just never got better after a year. So that’s my data. I don’t know many other people that even have any data to look at it. We should look at the breast implant illness data as well to see if that is something that is worth kind of comparing for meshes. But the expectation is once the Mesh is out the trigger for all this problem is gone and now you’re finally to learn to settle down and not be pushed into this inflammatory state.

Speaker 1 (00:32:34):

And for some people it’s immediate, for others it it’s never. And for the rest of them somewhere within a year. Do you ever recommend arnica cream? And if you are familiar with it, what is a hypothesis mechanism by which it relieves pain? Is it a natural form of Novocain? Yes, I’m a huge fan of Arnica. We actually put most of our patients for a low risk outpatient surgery on arnica, the pill, pellets that go underneath your tongue before surgery and after surgery. It helped a lot with inflammation and swelling and bruising. Arnica cream is also very good topically it can help with it’s a good anti-inflammatory. That said, nobody understands how it works. It is. And so the thought is that it just has an anti-inflammatory properties, but it is not a natural form of Novocaine. Novocaine is a numbing medication used for nerve pain. Arnica does not address nerve pain at all.

Speaker 1 (00:33:47):

Let’s see, what’s the best and strongest synthetic Mesh? Yeah, there is no best. Polypropylene is good, polyester is good. Most of us don’t really use E P T F D anymore except in really rare situations. So they’re all equally strong. There’s actually, you don’t want Mesh that’s too strong because if the strength of the Mesh is way beyond the strength of your natural abdominal wall, then you’re going to feel like you have armor on and that can be very painful. So it is a misnomer to think you want the strongest Mesh. You want strong Mesh but not really strong Mesh because it can be too stiff and cause like a feeling of armor is what people say.

Speaker 1 (00:34:38):

There was a time when we had meshes that were even stronger, two layers, three layers, double layer, and we would put them in patients thinking, oh, this would be so strong, you’ll never have a recurrence again. They’re like, oh, I feel like they feel like the tin man like a robot. And that’s not good because you want some flexibility in the Mesh. You want to be able to bend over and tie your shoelaces and pick something up from the ground. And if you have super strong Mesh and that is also very stiff and heavy, so you really don’t want that necessarily.

Speaker 1 (00:35:28):

Okay, next question. My grandma, I love this. My grandma is 82 years old. She has a colostomy and it gets obstructed due to a hernia. What can she do? So this is what we call a colostomy hernia or more commonly a parasoma hernia. The stoma is kind of the hole in the muscle. Almost everyone who has a colostomy will have a hernia around it because you’re actually making a hernia if you think about it. So you’re making a hernia by cutting the intestine and sticking it through the abdominal wall and that hole through the abdominal is a hernia. You’re making it and it’s really hard to prevent that from becoming bigger over time. The larger the hole that you make, the higher the risk of you getting a hernia. And about I believe a third of people who have colostomies end up having colostomies that really affect their ability to function during the day.

Speaker 1 (00:36:29):

So if you know anyone who has had a colostomy, it’s basically you’re pooping out of your skin on the abdominal wall. The colon is attached to your skin from the inside out and there’s a bag that’s pushed, pushed. There’s a bag that’s put on top of the colostomy called a colostomy bag that catches the stool. Instead of pooping out your rectum, your anus, you’re pooping into a bag. That bag needs to fit on your abdominal wall. So if you have a hernia, that bag will now be on a hill of some sort instead of on a flat abdominal wall. And so some people have problems with their stoma appliance fitting very well because it’s not on a flat surface. It’s trying to attach to a curved surface and it’s very difficult in this situation. It sounds like the hernia is creeping next to the colostomy and distorting the colostomy and making it so that it doesn’t empty.

Speaker 1 (00:37:33):

So there are nonsurgical ways of handling that you can put in kind of stiff tubes in the colon to prevent it from twisting on itself or bending on itself. It’s not the best option. You can wear specific belts and girdles that can hold the hernia in so it doesn’t keep obstructing the colostomy or just bite the bullet and have surgery and get it fixed. And don’t do anything fancy you don’t want in an 82 year old, assuming that they’re even healthy to undergo surgery, don’t want to do a perfect six hour operation. You want to get in and out, just fix the hernia good enough so that their hernia appliance fits nicely and they can get along with their kind of daily activities. When do you recommend P R P for post hernia surgery? Chronic pain by chronic groin pain after repair with polypropylene Mesh.

Speaker 1 (00:38:35):

A surgeon told me PRP doesn’t work. Yeah, PRP is not intended for chronic pain. It’s intended to heal tears. So if you have a tear from a tissue repair, you can consider P R P. If you have a sports hernia, you can use P R P. P R P is plasma ridge protein. It’s okay. The doctor takes your blood, spins it down through a centrifuge so it separates all the kind of fantastic great nutrient proteins from everything else and takes that concentrate and sticks it into an area where you’ve been injured and it’s supposed to accelerate healing. It will not touch nerve pain, it will not touch Mesh related pain. P R P in general is not much of what we do for chronic pain that’s related to heart repair unless it’s from obturator. In fact, I know I just said we don’t use it, but today I recommend it for one of my patients is a young male that had a tissue repair and he’s got a little bit of pain and the repair is perfectly fine except for this one little area that’s like fairly a millimeter, maybe two millimeters where the little piece of fat is trying to work its way.

Speaker 1 (00:39:52):

And so he’s at the very, very, very early stages of a hernia recurrence. So all he feels is pain in the area. So I don’t want to operate on him because he would need Mesh and it’s not bothering him that much. So I told him to go to physical therapy, which he has, and there they do shock therapy and ultrasound and red light therapy to help improve healing of that tear as if he had a sports injury or groin strain that’s not really a tear from his tissue repair and maybe he can scar that down. He’s gotten much better over the past month to the point where he’s able to drive and work. He’s not released it for exercise. So I said, you know what? Maybe you should consider P R P. Let’s treat this like a muscle tear. Let’s have you the pain doctor inject P R P into that area and kind of hasten the healing of this area.

Speaker 1 (00:40:52):

And then I’m basically doing my best to try and prevent him from having surgery that you may have made on need. Alright, I’m just doing a lot of questions today guys. I told you this is always my favorite, but it’s a bit much, but I like it, so thank you. What do you believe caused a difference in results between incidental and prophylactic neurectomy and attempted therapeutic directed? Okay, so you’re talking about the study that we presented at stages, the annual laparoscopic meeting and has been accepted for publication where we show that people do better if the neurectomy was done incidentally then if it were done therapeutically. So prophylactic versus the therapeutically, we don’t know why and I think it has to do with the status of the patient at the time and therefore the status of the nerve at the time. So we just don’t know enough.

Speaker 1 (00:41:55):

The risk of having a therapeutic neurectomy go wrong is about 4% in our study. It’s about 5% in most other studies. So we’re about the same as most other studies. And the risk of an incidental or prophylactic neurectomy going wrong was 0% and we follow these patients 10, 12 years, some of them. So I think the reason is the baseline. So if your baseline is high, high nerve activity, high nerve injury, you already have a neuroma, you already have nerve injury and that’s why you’re having the neurectomy, then yeah, you’re going to get high risk for that nerve reacting and not doing well with the hysterectomy. That said, it’s possible that it’s not 0% for prophylactic, it just happen to be 0% in our database and if we did another hundred patients that it wouldn’t be 0%, but the reality is it’s much, much lower as healing takes place on the incision. When the Mesh has been used, can the area around the incision get harder and tight any? It has nothing to do with the Mesh. It has everything to do with surgery, inflammation, scarring and so on. So yes, Azure, you’re healing your wound will get high. Sorry, harder and tight. I do recommend massages to my patients just to have a massage themselves and that helps make your skin scar look nicer and your wound becomes softer.

Speaker 1 (00:43:36):

My doctor had me go in for a shot in my nerve and pain from my ankle and hernia surgery. The person used an ultrasound good and couldn’t find the area to give. The injection not so good. You can only see one layer of my abdomen. He said the nerves are between second and third layers. Where are the other two layers of my abdomen? So yours may have been narrowed or it may have been scarred and so it’s hard to see the different layers. What they need to do is go out further away from the area of surgery and find normal tissue and then find the nerve in that normal tissue is between the second and third layers and inject it there. It’s not like a entire abdominal wall is destroyed, it’s just the area where the original surgery may have been. Do I have to go to my doctor to know if my epigastric screen is getting bigger? I mean no. You should be able to notice if your party is bigger or not. Can I go swimming if I have an epigastric hernia? Yes.

Speaker 1 (00:44:40):

You know how to swim. Let’s see, more questions. That’s a cute one here. Let’s look at this one. Is it okay to do pushups with the hernia? Yes. So all exercises are considered safe if you have a hernia regardless of where the hernia is. That includes pushups, sit-ups, pull-ups, weightlifting, including deadlifts and overhead lifts and bench press, cycling, running. The two types of exercises that have been shown to increase abdominal pressure and therefore perhaps not the best idea include jumping. So things like trampoline or certain exercises that the CrossFit people do, number one and number two, squats. And I believe the squats were measured as without weights. We don’t know if lunges are the same, probably not. It’s kind of unclear why squats increase your abdominal pressure. It probably does add a lot of pressure in the pelvis. So in general, all exercises are healthy and good and people who exercise have been statistically shown to have less hernias in general than people who don’t exercise. So do exercise, maybe don’t do as many squats or jumping sizes, but everything else should work.

Speaker 1 (00:46:24):

Bilateral Mesh surgery 2015. Recently I thought I had a recurrence on both sides on scan it shows no signs of recurrence if that would be very uncommon to get recurrence on both sides. But I’m in the same pain if not more as I was from my original hernias. What are your thoughts on this again? What kind of pain? Is it testicular pain, growing pain is only when you’re active. Is it back pain associated with it? Could you have pain from an intestinal problem? What does the imaging show? Does imaging show no recurrence? Great. What about the Mesh? Is the Mesh folded? Is a Mesh in good position? Is what kind of hernia did you have repair? Was it direct hernia and they used lightweight Mesh or too small a Mesh where yeah, you don’t have recurrence, but every time you bend or a shout and talk loudly or cough, you have pain in which cases it’s more of a unstable repair.

Speaker 1 (00:47:20):

Those are all really important details that I need to know. And again, if any of you want me to look over your stuff, I do do online consults so you can just contact my office directly, all the information on all the what internet sites. Send in your stuff. I’ll look it over and kind of give you my 2 cents of what’s going on, even if you can’t physically come in to see me. Can hybrid Mesh stretch after successful integration? No. If you have post operative pain in general, how long can you wait before developing peripheral and central subsidization and complex regional pain syndrome, how do you balance allowing adequate healing and reduction inflammation versus risk sub complex regional pain syndrome and centralization? That’s a really tough question and a very important question. So when I operate on patients, I understand that I’m not just operating on their hernia, I’m operating on them on their body. And so some people are at higher risk of having significant complications, especially if their baseline is highly inflammatory, highly autoimmune, highly nerve pain, you’re going to have more problems after surgery. So complex regional pain syndrome is a difficult one. That is a complication you do not want to ever have and we don’t understand it very well.

Speaker 1 (00:48:53):

We think that people that have a hyperactivity in the nerves or have nerve pain that’s been unaddressed for a long time are at higher risk for getting this very, very difficult to treat. Very debilitating problem. What I’ve heard from my pain management doctors is that if you have unaddressed pain for at least nine months, then that’s when you start getting centralization of pain. And centralization refers to the fact that your brain gets kind of reprogrammed to always feel like it’s in pain even if you’re not in pain anymore. So if you have years and years uncontrolled unaddressed pain and you come to me and I fix the problem for the pain, you may still be in pain afterwards because your brain is still telling itself it’s in pain even though it’s not getting signals from the, let’s say the groin or the abdomen anymore, telling it to be in pain and complex regional pain syndrome is different than centralization.

Speaker 1 (00:50:05):

It’s really a peripheral nerve hyperactivity, again, probably sparked from all the nerves talking to each other. I’m trying to stay this on and I’m trying to do this all in as much layman terms as possible. Fortunately, most people who have most people with complex regional pig get better after about three years. So there is some hope, but it’s a miserable several years, so nine months, that’s the number that that was quoted to me as kind of when you start being at risk for having centralization. I really wanted to come to see you this winter so you could help my hernia surgery pain and do surgery on my three new hernias. We were snowbirds in Arizona from Minnesota, but someone broke into our Arizona home this summer, burn it to the ground. So we’re now stuck in Minnesota. Wow. I’m 79, my husband’s 83 with severe health issues, so we’re unable to come to California. Can you come to see me in Minnesota?

Speaker 1 (00:51:15):

That would be kind of cool if I would. I should be a traveling hernia surgeon. I’ve actually considered it because I have a lot of patients, not so much in Minnesota, but in Florida, Texas and Michigan. I’m sorry, Florida, Texas and Chicago and northern California that I would love to be able to help and it would be so cool if I could just travel around, but based on medical license, that’s kind of hard to do and malpractice insurance and all that. Plus I would hate to operate and run because what if you need me afterwards and I need to fix something. So that’s kind of also difficult. I do recommend we did interview Dr. Archer Roboswami, who is a surgeon in at University of Minnesota. So you can go see her. She’s great. She’s a great hernias surgeon, laparoscopicly talented. She was one of my guests on here, so just look her up and that should help.

Speaker 1 (00:52:16):

What tests will show the Mesh in my body? So ultrasound and MRI, MRI is the best test to look for meshes and what’s happening to them. Ultrasound is possible, but just give you that much information. And CT scan sometimes can show it on for abdominal wall, but it’s not so much for groin. For groin, how many Mesh removals would you say a surgeon have performed to be concerned Experience? I would say that they should at least be doing half of their career should be hernia based because you want them to understand hernias and just anatomy. So at least half of their practice should be based on hernias. That would be something to consider. And then they should be doing a couple, one or two a month. So at least a 10 a year. I would say minimum. There just aren’t that many of us out there.

Speaker 1 (00:53:20):

But that’s a really good question. Can you have, if your pain gets better with arnica and lidocaine cream and even after lying supine during sleep, can you have sensitization of if your pain gets better, less likely? Yeah. So if you have good control of your pain, then yeah, the sensitization should be less of a risk. Did you say that the effects of anesthesia medications may cause postoperative pain for months after surgery? No. They can cause fatigue for months, for weeks after surgery up to six weeks. If you’ve had general anesthesia, you can have fatigue, not pain from your anesthesia.

Speaker 1 (00:54:07):

Going back to that question about how many, so I of course only do hernia stuff, so I’m a little bit biased, but I understand that not everyone can see me and not everyone has access to highly experienced hernia specialists, which is why I say that if they do at least half of their career at hernias and at least a couple, one or two, maybe at least one mesh removal a month, that should be enough insight to know what they’re doing. Ideally, you want them to only do hernia surgeries and the majority of their practice to be mesh removal. So for me it’s 80% of what I do is revisional surgery every so often. Get a young college student with a belly hernia, it’s like, wow, that’s so easy. I don’t know what to do with my time. He schedule you for a full hour consultation and I have you the simplest, the easiest patient in my office.

Speaker 1 (00:55:13):

So we kind of high five with those because it’s kind of nice to relax and not have a patient come in with a thick booklet of the 17 operations they’ve had before. I mean I enjoy it, but every so often it’s nice to have just a young healthy person with a small hernia. What is a long-term recurrence risk after incisional hernia Mesh removal If a recurrence was not present at the time of removal, that’s high. So if you have Mesh removed and your surgeon said, oh, good news, I took out the Mesh, it’s all scarred in your tissue’s, all scaring, no hernia, there’s nothing for me to repair. There’s about an 80% chance that you’ll get another hernia because all you’re relying on is your own native scar tissue and your own native scar tissue is not adequate. Now when will that occur? Can occur months to years later, not longer than that.

Speaker 1 (00:56:25):

Can you reduce that risk? Yes, you can focus on core strengthening, make sure you’re not overweight, no constipation, no chronic cough, much, much focus on core strengthening, no nicotine use that can help reduce your risk of the hernia coming back. But you’re just relying on your own tissues. And I would do the same if I removed Mesh, there was no hernia. I would not fake a hernia repair at the time because it’s unclear what the risk of the hernia recurrence is, but it’s close to the 8%. Is there a classification or name for someone like you who publishes so much out of private practice? Oh, thank you. So thanks for asking that because I am in private practice, but I have a very academic practice, which means I do teach research and I’m clinically active. So if I had the same practice at a university based place, I’d probably be a tenured professor because that’s what they want. They want what’s called the triple threat publications, ie. Research, education, i e teaching and clinical practice and clinical kind of.

Speaker 1 (00:57:47):

But what they do is they, when they call people academic surgeons, they usually refer people academic surgeons as surgeons that are employed by university or an academic institution. And the reality is nowadays a lot of these employed surgeons at university hospitals are employed to do surgery and they don’t do a lot of teaching or a lot of research and they’re not very active in that. They’re really mostly clinical, but they’re so called academics. So I like that you brought that up because I feel that the term community surgeon, which is what they would call me, is not representative of what I do. I consider myself an academic surgeon in private practice. But thanks for that.

Speaker 1 (00:58:40):

I just got out of the institution because I feel like I’m more productive as my own boss than thank you, than being having a boss that kind of tells you where my career should go. Okay. So that’s it guys. That’s it. We finish an hour and I think we did like a hundred questions. No joke. No joke. So thanks for that. That was fun. I enjoyed it. Thanks for everyone for joining me. We’re going to call it a day, so we got some really cool people up. You’re going to like all of them, lots of variety coming up. And my guests, I’ll get ready to come on to hernia talk. So please thank you for joining me and I love that you’re all here and log in and ask so many questions. Please do follow me. I need more subscribers to my YouTube channel where all of Hernia Talk Live is posted all 87 episodes so far. Thanks for everyone who follows me on the different social medias. Yes, the hour definitely went by really fast. I’m at Hernia, I am at Hernia Doc on Twitter and Instagram and Dr Towfigh on Facebook. See ya next Tuesday. Bye guys.