Episode 95: Evidence of Changing Perspectives on Hernia Surgery | Hernia Talk Live Q&A

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Speaker 1 (00:00):

All right, we are live. Welcome everyone. It’s Dr. Towfigh. Hope you’re well. We are coming to you live as we do almost every Tuesday. I’ve been out for a couple weeks and I will update you on everything I’ve been doing. I am Dr. Shirin Towfigh, your hernia and laparoscopic surgery specialist. Thanks for joining me live on Facebook. Many of you at Dr. Towfigh and also for everyone who is on our zoom. Remember at the end of this live q and a I will post this session as I do all my prior Hernia Talk Live Q&A sessions on my YouTube channel. Please also follow me on Twitter and Instagram at hernia doc. So I just want to say hi to everyone. I haven’t seen you for two weeks, and many of you may know I was in Costa Rica. We had our international hernia collaboration meeting, which is an annual meeting that we have where we take experts and bring them to surgeons, especially in countries where they’re unable to afford to travel and go to Europe or the United States for their scientific sessions.

Speaker 1 (01:14):

And it’s one of my favorite meetings. It’s the most innovative of all the meetings that I go to because, well, first I have a leadership position at the International Hernia Collaboration. So it’s kind of like my baby a little bit. It’s not technically my baby, it’s Dr. Brian Jacob’s baby. But I was one of the first believers in followers of the International Hernia Collaboration. We are almost, I think over 12,000 surgeons strong all around the world, and it is a group of surgeons that collaborates 24/7, 7 days a week, whatever questions we have huge group. We talk amongst ourselves and help each other out. And because it equivalent equalizes access to expert care throughout the world, we decide to also have an annual meeting to take meetings that are usually in the United States or Canada, or sorry, or Europe to other countries that don’t necessarily have access to all the experts.

Speaker 1 (02:22):

And this was absolutely the most successful meeting we’ve ever had. It was in Costa Rica. We had over 50% Latino and Latino surgeons, very strong support from our Latino surgeons. It was packed with experts from the United States, Europe and Latin America, including Central and South America. We had surgeons from Chile, Brazil, Columbia, of course, Costa Rica, Panama. We had Mexico, El Salvador, Guatemala. I got to practice my Spanish, which I love so much. The food was great, the culture is amazing, just a beautiful, very lovely country. We had a whole wellness part of the meeting where we discussed and promoted wellness of surgeons because as you may or may not know, surgeons are highly injured. We suffer a lot of trauma based on the kind of work that we do. And also we are emotionally and psychologically traumatized because we deal with sick patients and dying patients. And the stress of operating on someone like another human being is real.

Speaker 1 (03:48):

And we also stay on our feet for hours and our necks is down for hours and we kind of contort our bodies in ways that is not normal. And so we have a lot of injuries as part of our career. So the wellness portion of this was the first time ever, if you can believe it, first time ever that a surgical society meeting actually incorporated wellness as part of its sit down meeting. So we had people that were offering free sessions, we were offering free sessions to surgeons on anything from Pilates, acupuncture, cupping, morphing, meditation, massages, occupational therapy, physical therapy, and other types of remedies, psychological remedies as well. So that was an exciting time. And I’ll tell you, it inspired me to give this session of party talk, the title evidence of Changing Perspectives in Hernia Surgery because I’ve noticed at this meeting at last year’s American Hernia Society meeting at this year’s SAGES meeting in the upcoming European Hernia Society meeting, there’s a lot more emphasis on the patient on improving outcomes without necessarily using Mesh on reducing the overuse of Mesh, reducing chronic pain, improving a more, or promoting a more tailored approach for hernias, and also in understanding the patient’s perspective and respecting how difficult it may be for surgeons to do what they do.

Speaker 1 (05:52):

So I’m sorry for surgical patients to do what they do. So on that note, I wanted to kind of share with you a lot of what, what’s going on this past year and many of our meetings and also what’s coming up. I’ll give you an example. This year, the European Hernia Society meeting is at Manchester England, playing a big role in that meeting thanks to Dr. Aali Sheen, who was one of our prior guests on Hernia Talk Live. He’s a surgeon at the UK, very gifted surgeon. And not only are we talking about tissue-based repairs and teaching hernia surgery and all that, but we’re also have a whole session not only dedicated to the patient’s perspective of surgery, which unfortunately is very uncommon in any surgical society, but we also have actual patients and patient advocates running that session, and I’ll be involved in that as well.

Speaker 1 (06:52):

So I’m super excited to travel for this meeting later in the year, but even more excited to see how this will turn out. It’s the first time ever we’re having a session where it’s actually run by the patients and as a partnership with the surgeon. So I’m super excited about that and I hope that we kind of all learn, all US surgeons learned about this because as many of you know, it’s been my goal with hernia talk and a lot of what I do to promote the patient’s perspective, even when I talk to industry, it’s to promote them to kind of pivot and make new products and so on with the patient in mind and not so much the surgeon in mind. And I would like to say that I do see very slowly, because I’ve been doing this for 20 years and it’s finally kind of catching up, but very slow wave of change where it’s hard for the surgeons to discount the patient’s perspective and discount your voices that you know, just want better hernia repair.

Speaker 1 (08:09):

You want hernia surgery that is less likely to cause serious damage, and it’s just not cool. I’ve said this before in meetings, it is not cool for someone to have a hernia repair and not be able to work or sit or walk or have sex or have a relationship with their family or enjoy watching TV. Or you have patients that say they stop going out because just getting in and out of a car hurts. And so now they don’t go out anymore. They don’t enjoy their time. So if it weren’t bad enough that the pandemic has kind of curved us away from doing what we’d normally like to do, certainly should not be a situation where people should have fear of undergoing hernia surgery because there’s so much concern out there that it will get maimed.

Speaker 1 (09:09):

This a, let me show you this one thing. I just got a message on the

Hernia Talk site, and it was a patient that it’s really concerned, and here’s what they said. They basically called it a ticking time bomb. They said, how long does this mesh last? I’m kind of worried that I’m going to be getting Mesh, but I can’t travel for a surgery and all the surgeons around me want to put Mesh in place. How long does the Mesh last and what does that mean? Am I a ticking time bomb? This word, ticking time bomb should not be in someone’s mind when they are considering elective surgery. So my answer to this per patient was no a hernia Mesh is not a ticking time bomb and a hernia surgery should not be a ticking time bomb. We do perform hernia repairs with the intention.

Speaker 1 (10:08):

This is a lifelong operation that it will be with you and support you for the rest of your life. That said, we actually had this discussion at in our meeting last week. When people have pacemakers or breast implants or shoulder joint replacement, hip joint replacements, they all need to be replaced. There’s no lifelong duration of these hip replacements. The hip last I think 15 years shoulder, 20 15, 20 years, breast implants every 10 to 2010 years or so, you should replace them because they change, they constrict, they get scarred tissue, they get destroyed from overuse. And yet when we talk about hernia Mesh, the implications that it will be perfect for the rest of your life. And I must say we actually don’t know. We don’t know if this will be perfect for the rest of your life. The majority of patients actually do very well. We never tell patients, come back in 10 years, we’ll redo your hernia. It’s actually very difficult to do. So recurrent hernia repairs or revisional hernia repairs are difficult to do. That said, I don’t want people to be concerned that they have a ticking time bomb. And my response to this patient was, if you find a specialist that does hernia repairs near you or travel if you have to, if find a specialist, the risk of that hernia repair causing you problems is much, much lower. It’s not zero. All surgery has complication rates. There’s never a 0% complication rate.

Speaker 1 (12:01):

There are surgeons out there that claim they’ve never had a recurrence, never had chronic pain, never had Mesh infection ever. It is just not true. They just don’t know about their complications because I see their complications and others that do operations like me see it. So the fact that there are surgeons that claim 0% doesn’t mean that’s a real number, but it’s not a ticking time bomb in that the vast majority of hernia repair are done pretty well. They’re actually mostly done by non-specialists and that those patients do do just fine. And we tend not to recommend surgery to people if we don’t believe that it will be kind of in their best interest. So my point is this, find a specialist, get your operation performed that will ensure you have the best chance at having a good outcome, number one. And number two, always, always get a second opinion. Even if you’re going to see me or the top specialist in the world still get a second opinion and bounce it off the other people. You know what I mean? Bounce it off and see what other ideas are provided to you.

Speaker 1 (13:27):

Here’s a question on Facebook. What do you consider best practice for hernia surgeon to truly know their outcomes, pain, recurrence, et cetera, and how should patients be followed? What is the role of a quality Collaborative? Great question. So the only way to really know your outcomes is to follow your patients for life. In the United States, there is no mandates to do that. For hernia surgery, there is actually for cancer. So you are obligated to input all patients that undergo breast cancer, other cancers into a national database. And those are tracked. And as part of the hospital’s kind of quality improvement to do that so that we’re not operating on patients, let’s say with breast cancer and they all die within years, that should be a poor outcome. Same is true for cardiac surgery. Cardiac surgery is mandated that all patients and their data be input into a national database.

Speaker 1 (14:39):

Most other diseases have some type of national database that’s available but not mandated. And of recent about, I want to say five less than five years ago, three to five years ago, Dr. Ben Poulose and Michael and Mike, I want to say Cohen, sorry, Mike Rosen at Cleveland Clinic and Vanderbilt now Ohio State University, both of whom have been guests on Hernia Talk Live, both Dr. Mike Rosen and Ben Poulose got together and said, this is ridiculous. We need to know more about what we do with hernia surgery. There’s way too many surgeons out there thinking they’re doing great job and we know they’re not, and we just need to know how these patients are doing. So they develop what’s now called the ACHQC Abdominal Core Health Quality Collaborative. It is basically free for a surgeon to join. Basically, if you’re a member of the American Hernia Society, it’s free.

Speaker 1 (15:55):

You have to input your patient data on every patient that you operate on that has a hernia, and those patients are followed for life. Great, great idea. Lots of questions to answer. What suture did you use? How many sutures? What tax, which type of tax? What Mesh, what size Mesh, which type of Mesh, which brand of Mesh? Where’d you put the Mesh? What was the size of the hernia? Where was the hernia? As well as demographics of the patient age. Are they smokers? What’s their weight and height and all that stuff. Very, very detailed data information.

Speaker 1 (16:31):

And the goal is to develop a database that patients are followed for the rest of their life. See what happens in Europe. There are many countries like Sweden, Denmark, a little bit, Germany, not so much, whereas it’s highly socialized medicine. And the country has a very good idea of exactly what has been happening to you from a medical standpoint. And so there is a Swedish and a very strong Swedish and Danish hernia database, and lots of studies have come out of that. Now, the database is not very strong in terms of the breadth of information that they capture. They don’t necessarily capture all little details, what suture and whatever did you use for the hernia repair? But they know every single patient that underwent hernia repair a hundred percent of patients, not just a fraction of the population. And they track those patients for life.

Speaker 1 (17:31):

So we have 10 year data or longer on patients with undergo hernia surgery. And it’s a mandatory database. Every time a patient ends up in another hospital or another clinic in the country, their data gets updated. So if they’re admitted for a bowel obstruction and they had hernia surgery 10 years ago, that’s captured that. There’s now a bowel obstruction related to the hernia repair. If you leave the country, we don’t get that data, you lose the data. But Denmark, Sweden, pretty stable countries. Most people stay there. It’s not a major problem. So a lot of the data that we have is from long-term patient population studies in Denmark and Sweden, a little bit from Germany, from the hernia med registry, which is not as robust, but still better than what we have in the United States. And in one very unique example, there was a Mesh by Ethibond called Physio Mesh.

Speaker 1 (18:36):

It sound like a great idea. Very lightweight, tons of anti-adhesive there. So it doesn’t erode into bowel. It’s lightweight, so you’re not going to feel it. It’s very soft knit, so patients won’t feel it, it won’t burn, it won’t cut it. Great idea. And because of the data, and I think it was from the Swedish hernia database, I may be wrong, they found that it was actually way too lightweight and patient surgeons were using it to bridge, which means they have a hole and then you just kind of cover the hole instead of closing the hole. So there’s a part in the middle of the Mesh where there’s a lot of tension on it, and it was splitting where it was bridging the hernia defect. That’s all good. They were seeing patient after patient before even the company knew the hernia database. People knew that there was patient after patient coming in around the country with splitting of this Mesh.

Speaker 1 (19:42):

And so the ethibond, which is a j and j company, actually proactively just removed the Mesh off the market. It wasn’t technically recalled. It was just considered to be too lightweight for the way that surgeons were using it. Now that said, it could have been a very good Mesh if surgeon would just stop bridging, but we lost a very lightweight Mesh because surgeons were not using it necessarily correctly, not really understanding the product very well, and I guess poor knowledge and education by the industry to teach the surgeons how to use the product. And long story short, it got removed, but it got removed purely because it’s database. So we’re hoping in the United States that the ACHQC quality Collaborative have a role like that. Unfortunately, the number of surgeons that have volunteered to sign up is a very small fraction of the number of surgeons that actually do hernia surgery, number one.

Speaker 1 (20:51):

So I’m part of it, I love it, but it’s one of few. And number two, the strength is not only up to have a lot of surgeons input the patient data so that it can be followed, it’s for the patients to then answer the questions after 30 days at three months and six months and one year and two year and five years and 10 years and whatever to report how they’re doing. And the patients are not reporting. They’re treating the emails and follow through as if it’s spam. And the percentage of patients that actually respond to provide long-term outcomes data from their hernia surgery is very low. And it’s very possible that only those patients that have problems respond in the patients that don’t have problems don’t respond soon. We are going to getting skewed data. So the way it’s currently being done in the United States is a good start because we’ve never had a hernia database before, but it’s incumbent on more surgeons buying into the process, which is extra work and more patients buying into the process, which for them is also extra work. So I hope that answers the question. I do believe the quality Collaborative is definitely necessary, but everyone needs to want to be part of it. It’s like living in a dorm. Everyone needs to keep it clean. You can’t just have one person clean up after everyone else. Everyone needs to pitch in.

Speaker 1 (22:28):

Let’s see. Yeah, good question. It seems most surgeons only take follow-up for three months and if there are complications, some surgeries referred to pain management before then and discharge a patient is very, very correct. So from an insurance standpoint, the payment that a PA surgeon gets for the surgery technically covers 90 days of post-operative care as well. So if you have a stitch problem or pain or whatever, and it’s well within 90 days, you go see your doctor and you use insurance to pay for your surgery, you cannot usually be charged for those office visits for 90 within the first 90 days. So you’re correct. Most surgeons don’t follow up with their patients unless a patient comes back and certainly most do not act for three months, which is again, another problem. All of this takes coordination, office phone calls, patients agreeing to come in, surgeons wanting to see them and ask questions as well.

Speaker 1 (23:37):

We have a database that we maintain, and so I try and follow up with my patients. A lot of the research that we do is based on our follow up that we do with our patients and the ACHQC database issues, but it’s a problem. And even worse is what you just mentioned, which is once it gets beyond what they’re comfortable helping you with, let’s say you have pain, they send you to pain management, which means they’ve completely lost the patient oftentimes. I hate that. I hate the fact that so many surgeons just send patients to pain management and pain management has no clue what you did as a surgeon oftentimes. I work very closely with my pain management doctors, but they don’t know what suture you use, what technique you use, where is the Mesh, what is the Mesh, how are the different meshes, how are the different sutures or the different techniques?

Speaker 1 (24:39):

This could have been a Mesh that’s folded up. Pain management doctors are mostly dealing with nerve pain, so they’ll do a nerve block, but that’s the Mesh that’s folded, not a no amount of nerve block is going to help you. And then when it doesn’t help you, they give you narcotics and medications that kind of numbs your brain. And when that doesn’t work, they, they’re like, well, let’s do a spinal stimulator. And it’s, it just bugs me. I tell my patient, do not get a spinal stimulator. This is a mechanical problem. You have a hernia recurrence or you have a Mesh folding or Mesh erosion or something, and you should not be getting an implant into your spine because I want to call it bandaid, but it’s not even a bandaid because doesn’t help with anything. It’s just an invasive procedure. But that’s a comfort zone for a lot

Speaker 2 (25:27):

Of pain doctors.

Speaker 1 (25:30):

Here’s another question. After 22 years of

Speaker 2 (25:32):

Living with Mesh, I’ve had chronic pain for the last 10 years on my side, hip, leg and foot, and it seems to be pointing at my right ankle repair from 2000,

Speaker 1 (25:41):

Okay, I’m going to stop you right there. If you had surgery in 2000 and you were fine for 12 years, and now you have 10 years of pain, that is a hernia recurrence until proven otherwise. I don’t even know who you are or any details from your surgery, but if this is a hernia related problem, you have a hernia recurrence. The only other option is less likely a Mesh infection or a neuroma, which is a nerve that was originally injured. It took 10 years to get to a point where it builds enough scar tissue to get symptomatic neuroma, and those are much, much less common. So let’s move

Speaker 2 (26:24):

On with your question.

Speaker 1 (26:27):

I’m waiting to be seen by the head

Speaker 2 (26:28):

Neurologist at University of Miami. My neurologist sees nothing neurological that would cause my chronic pain. What are the chances it is the Mesh and what tests can be done to confirm

Speaker 1 (26:38):

It? Very, very, very, very low chance. It’s the Mesh. Mesh related complications occur within the first weeks, months, maybe a year. At most two years, you will not have a normal situation and then have pain 12 years later if it’s a Mesh problem. Those implants cause their problems early and not late with one exception. That’s a Mesh infection, which can occur at any time. My medical records were destroyed, so I dunno what Mesh was implanted in 2000. I hope I could find some interest soon. So imaging such as a MRI can demonstrate where your Mesh was placed and what the Mesh looks like. Is it flat? Is it two layers? Is it, it can tell the difference between PTFE and polypropylene or polyester meshes? It can show you how thick the Mesh is. So imaging can provide a lot of information as to what the Mesh may be and what technique was used as part of your operation if you don’t have the medical records?

Speaker 1 (27:49):

That’s a great question. I have neuromas removed in my feet. That’s why they’re thinking this. Yeah, so neuromas in your feet are unrelated to neuromas from surgery. People who get neuromas in their feet, it’s a totally different process and it doesn’t make you any more likely to have a neuroma from surgery, but you have to see what kind of repair you had done. Was it open or was it laparoscopic? What is typically done about Mesh infection is removed. So the standard of care for a Mesh infection is removed. The Mesh, the implant must be removed in very, very, very, very slim circumstances, less than 1%. You can try and salvage the Mesh with antibiotics and partial removal, but it almost never works. So you need full removal of the Mesh to treat a Mesh infection.

Speaker 1 (28:50):

Next question. I was told I have a hiatal hernia with part of my stomach. Second side. Does that need surgery and can it be arthroscopic? So the reason to treat a hiatal hernia is based on your symptoms. So I would defer to your gastroenterologist and foregut surgeon to determine what kind of symptoms you’re having and whether they can be managed medically or not surgically. But yes, if you do need surgery, they can’t be done laparoscopically. The pathology reports from neuroma has come back as an amorphous material. Yeah, amorphous material needs Mesh probably. I don’t know what else that means.

Speaker 1 (29:35):

Lots of questions, guys. Oh, great. Question about cognitive behavioral therapy. Is it effective for severe chronic postoperative pain? Yes, it is very effective in many patients. There’s actually Dr. Ramshaw who we brought in early on almost two years ago now for Hernia Talk as a guest where we discussed cognitive behavioral therapy. We also discussed it with I think Dr. Vahedifar. I think we discussed it with him as well. And we will be having a great guest who does cognitive behavioral therapy coming up in a couple couple months on Hernia Talk live. However, yes, severe chronic postoperative pain can be controlled with cognitive behavioral therapy, assuming there’s no mechanical reason that can be surgically addressed. So it has to be more than just a mechanical problem.

Speaker 1 (30:38):

Those are usually done fixed surgically. Next question is high dose prescription capsaicin. 8% not over the counter. Capsaicin is effective for chronic postoperative pain. So capsaicin is like black pepper, so it’s like pepper, and you can think of it as like a pepper cream. a lot of people do it because it causes like heat and helps, and I’m using very lay terms here, causes heat and helps with local pain. Capsaicin in general doesn’t help hernia related pain or hernia related chronic postoperative pain. Mostly things that can help most chronic pain are anti-inflammatory or anti nerve type pain medications or pain creams. So capsaicin doesn’t usually do that. So no, I don’t think so.

Speaker 1 (31:42):

After Mesh removal, how long disorders only wait to lay another Mesh? Okay, so that’s based on that question about Mesh infection. So depends on the type of surgery that you need. So the options are take out the Mesh and just let the scar tissue go in there and the chances are there’s so much inflammation from the Mesh removal, from the Mesh infection that Mesh removal alone is all you need. You’ll never need Mesh again. The other option is that this is actually a very big deal. We’re taking out the Mesh and leaving a huge gap, which will not heal from scar tissue alone. In those cases, you have two options. One is a tissue-based repair, which is no Mesh or combined tissue-based repair with some type of non-synthetic biologic type Mesh, which will absorb and has a higher risk of recurrence. But really you don’t put other meshes in if you choose to have regular synthetic Mesh put in at a later date. So weeks to months to years later, it’s risky. You can do it because the risk is, but it’ll still have some bacteria left behind. There’s not causing infection. But once there’s an implant there, it will sit on the implant and start your eating weight. But what you can do is use a very lightweight multi monofilament macropores, which means big holes, very lightweight, very little synthetic to reduce your risk of another Mesh infection.

Speaker 1 (33:20):

Okay. Oh, so here’s a question about, oh, let’s do this one and then we’ll go to the question about specialists. Is there a way a patient will know if they have Mesh folding? So what’s relevant is if the Mesh folding is causing your pain. So if you cannot, if it’s in the groin and you cannot sit or bend, then you must be ruled out for what’s called a meshoma or a Mesh folding. Or if the Mesh is folded and that’s why you have a hernia recurrence that’s relevant. But just to look to find if you have a Mesh folding, we don’t do that.

Speaker 1 (34:00):

Okay, so the next question is a follow up to this. What I saw sent into me before, and it has to do with specialists, and the question is this, do you think that general surgeons should not be hernia repair, should not be doing hernia repairs because they’re causing more harm than good? And it’s a follow-up question. As a follow-up question, how many surgeries were a hernia specialist seasoned and well past the learning curve need to perform per year to keep their skills up at a high level? Is there a balance between getting burnt with too many operations and not doing enough to keep up the skills? So excellent questions. The reality is that the vast majority of surgery on hernias in the United States as well as around the world is performed by general surgeons as part of our general surgery residency training. Hernias are taught you have to do a certain number of hernias to be able to graduate and sit for the boards to be board certified.

Speaker 1 (35:08):

And there are competencies related to that. So it’s unreasonable at this moment to feel that all hernias should be performed by specialists. There just aren’t that many of us out there. It would be great, but there just aren’t that many of us out there. The good news is there’s more of us out there now than there used to be. So when I started this about 20 years ago, there were maybe four, three or four of us out there that really wanted to do hernia surgeries, and then now there’s maybe 50 so, or maybe 30 to 50, somewhere in that range in the United States. And so there’s definitely more interest. I have residents that want to do it. So that’s all really great.

Speaker 1 (35:58):

We do know, as you alluded both your questions, that if you are a specialist, your outcomes will be better in all operations that you’re a specialty in. So if you have breast surgery, your operation will be better if done by a breast surgeon specialist than by a general surgeon who’s trained in breast surgery as well as hernia surgery. If you need heart surgery, well, that’s a bad one. If you pancreatic surgery, we’re trained in general surgery to do pancreatic surgery, but really the best outcomes are performed by people who do pancreatic surgery as a specialty. So the same is true about hernias, but again, similar to breast surgery, most breast surgery in the United States is done by general surgeons. Most hernia surgery is done by general surgeons. So do I think they shouldn’t be doing hernia repairs at this point? No. Ideally do I think hernias should be prepared by a specialist?

Speaker 1 (37:02):

Yes, but that’s the best of all possible worlds and we don’t live in that voltarian kind of world. So then the question is fine, what are the criteria? What do I ask? And we’ve actually had a whole session of Hernia Talk Live dedicated on the hernia specialist and what to look for. So number one is should I think they should not, these are my ideas. A hernia specialist is one who dedicates at least 50% of their time to do hernia surgeries. Surgeon will do a colectomies gallbladder surgery, breast surgery, butt surgery, colon surgery and so on. So that’s okay. But if at least half of their time and operations are dedicated to hernia surgeries, likely they have an interest in hernias. That’s number one. Number two is a number. So for laparoscopic anal hernias, we believe somewhere between 200 and 500 cases is the learning curve for open inguinal hernia surgeons, we don’t really know that number.

Speaker 1 (38:23):

I think it’s a hundred or 150. For robotic surgery, it’s lower. It’s something like 50 to a hundred cases. So you can ask your surgeon how many years you’ve been doing this, how many do you do? I do not believe that high volume surgeons are necessarily better. You can do a lot of cases, a lot of operations that do them all really poorly. And we certainly have a lot of surgeons that are very busy and not that good. And so I don’t believe volume like, oh, this surgeon operates a thousand cases a year, this one does 150 year. I don’t believe volume is a good indicator. And if any of you follow me on Twitter, we had a whole discussion about volume, volume surgery, and I made some pretty strong comments in the same line as this. So in terms of number of cases, I’m not sure it’s important that they be super busy surgeons, but they need to care.

Speaker 1 (39:27):

So I’m not a high volume surgeon. I don’t do 1,000 operations a year, but a hundred percent of what I do is dedicated to hernias and hernia related complications. And I’m busy enough, but I have really complicated patients. I don’t want to do a thousand cases a year because that means I’m never going to be able to really sit down and focus and come up with a good tailored approach with every single patient. It’s just there are only so many hours in a day to sit down and talk with patients and figure things out. So that’s kind of my spiel about that.

Speaker 1 (40:03):

Let’s see. Next question. I’ve been to several hernia specialists and I feel like I’m a conflict of interest to them and they, it’s like they push me away and I’m doing what my doctors tell me to do. I now have three hernias and I’m afraid I don’t know what to do. Well, I’m sorry to say this. You’re seeing the wrong people. You’re just seeing the wrong people. It’s like dating. If you define the right surgeon that will listen to you and kind of buy into your story and help you, there’s plenty of us out there. I’m happy to help you if you want. There are other surgeons that I’ve interviewed on hernia talk that may be closer to you. I don’t know where you live. I do offer online consultations, so at least I can help guide you without actually physically seeing you if that’s something you would like, but you just haven’t found the right surgeon.

Speaker 1 (40:58):

I say this because I have tons of family members and friends that call me all the time asking for advice, not necessarily for hernias, but about anything possible, knee pain, ear pain, weird vision changes, stomach problems. And they’re very frustrated because they don’t get the time of day from their doctor. And it’s like, I’m not even the specialist, but I’m trying to help them. And then I try and find the right doctor to meet their needs. Someone that listens, someone that’s caring, someone that’s thoughtful, it makes a huge difference. Let’s see. Have nerve grafts ever been performed in conjunction with hernia repair to correct abdominal walls?

Speaker 1 (41:47):

Depends on where the injury was. If the injury is very much at the front, no. If it’s in the back, yes. And there are very few surgeons that do that. Dr. Greg Dainian is one in Chicago. We have a Dr. Seruya here in Cedar Sinai, S E R U Y A, who may be able to help with that idea. It has to do with one specific nerve and also where area was injured. Next question. I’m in Florida have been told about Dr. Yunis here in Florida. I I agree. Dr. Yunis is a great surgeon. I had him on as a guest at on Hernia Talk Live as well. So it’s a resource for you. I am here to provide you opportunities to test out these doctors and help you get the care that you need. So you can watch Hernia Talk Live with Dr. Yunis.

Speaker 1 (42:53):

Let’s see. How widespread among the hernia operating profession do you think are best practices like the critical view and 10 commandments? Wow, these are really good questions. Or avoiding plugs in open surgery. And are these best practices showing up better patient results nation or are the staff not yet changing? Great questions. So the question has to do with many of us coming up with standards of care, like at the minimum when you do this hernia repair, you have to do the following nine steps in order to reduce the risk of missing a hernia, damaging organs, causing extra pain, having a higher recurrence rate.

Speaker 1 (43:38):

The reality is most of us that are specialists already know this information and follow it anyway. That’s the impetus for publishing is to educate those that are out there, number one. Number two, those that are in training are likely also exposed to these best practices, critical view, nine commandments, et cetera. Those are already out there in practice. The majority of doctors and surgeons do not go to national meetings, do not read articles, are in their own world and maybe completely clueless as to what’s out there that’s new and treat you the exact same way. They were taught to be trained in residency, which can be 10, 15, 20, 25 years ago. Lastly, I’d like to make a comment, cause this may sound awkward, but there are a lot of, so ego is an issue with surgeons, and surgeons kind of fake it a lot. And it’s not until you actually watch them operate that you can say, oh, great surgeon, or Ooh, wow, I can’t believe that surgeon just did that.

Speaker 1 (45:00):

So I have literally been asked to be on these meetings, but zoom based meetings and in some cases live like in the operating room, but the surgeons doing the operation, they’ve asked me to kind of help be part of the meeting to discuss for the audience what’s happening in the surgery and educate them either live or by Zoom. And let me tell you, there have been a handful of operations where I’m like, wow, that was really great, did it great follow the best practices. But the majority of ones that I’ve done, I still have PTSD from them. I just look and it’s kind of awkward for me because I want to take over the operation, but I’m in a different country, for example, or it’s not my operation. And I’m not saying they’re naming the patient, they’re not actually hurting the patient, but they’re definitely not following these commandments, which means potentially the patient can be at risk, but the surgeon is providing their expert care again, as ego.

Speaker 1 (46:10):

So I would be like, oh, so maybe Dr. So-and-so you can explain to the audience, the viewing audience, what you’re doing now. Because in my brain I’m like, because I have no idea that I think you know what you’re doing right now. Oh, so maybe you can point out the anatomy right now and the nurse, because in my mind I’m thinking, oh shoot. Like I don’t think he understands the anatomy because the way he’s operating, he doesn’t see that there’s a nerve here. He’s this or hernia or whatever. So my point is there’s a very wide range of talent out there and ego is a big part of it. So these surgeons, they want to show how great they are and some are really, really amazing. Great. Dr. Belyansky is one of them, just an amazingly talented surgeon, and he was a guest on Hernia Talk.

Speaker 1 (47:06):

And yet others you’re just like, oh my God. Okay. Note to self, they talk the talk, but they don’t walk the walk. I even wrote an article with two friends of mine, one from University of Washington, Dr. Andrew Wright, who was a guest on Hernia Talk, and another one was Dr. Hakan Gök, who is a surgeon in Turkey. And we reviewed the top 50 most popular inguinal hernia operations on YouTube. So we looked on YouTube, we searched for Inguinal hernias, and we ranked the top 50 based on views. And then we scored them based on what you were mentioning, which is best practices, the nine commandments. Let me tell you, you guys need to read that paper. I still, and I’m talking about PTSD because every time I was watching another video, I was freaking out because I’m watching these operations that had gotten like 50,000 views and I’m thinking, how the hell did they think that was appropriate to post this on YouTube? Because some of these people got zero out of nine points from the nine commandments and nine best practices steps for the critical view of the inguinal hernia, for example. Read my paper guys. It is crazy, crazy, crazy.

Speaker 2 (48:28):

Oh, what to say.

Speaker 1 (48:30):

But there’s just a wide range of surgeons

Speaker 2 (48:33):

Out there. Let’s see. Some well-known surgeons still completely will measure removal lap without the robot. That is true. I do that as well sometimes. What would be an indication for this type of removal versus robotic? I like the placement and size of the trocars with just a lot better because of my body size and possible diastasis recti above my belly, which would be where one of the robotic trocars will be directly placed. So laparoscopic and robotic

Speaker 1 (49:03):

Options are there for Mesh removal in the groin

Speaker 1 (49:07):

In patients, I offer both. We actually looked at our data on the patients that had robotic versus laparoscopic, and they did just as well with both operations. The patients that had the robotic surgery in our data and we published this, had less bleeding. And that was really the major difference. There’s less injury to vessels with the robotic approach, but they’re perfectly good approaches. There are surgeons that offer both, but robotic is easier. And so I actually like the robotic approach better. That said, you do not need any trocars above the belly button. So if that’s your surgeon’s technique, that’s your surgeon technique. I never use anything above the belly button. And so I don’t know why you’re being offered that.

Speaker 2 (49:56):


Speaker 1 (49:58):

What are continuing

Speaker 2 (49:59):

Education requirements to keep a license? Are there specific or are they specific or concerned to topics not in their realm? So very good question.

Speaker 1 (50:11):

I don’t remember the exact numbers, but you do have to nor to maintain your medical license, you have to have a certain number of hours in order of continuing education, including on medical ethics. And in order to maintain your board certification, you need even more number of hours over a span of several years. I think it’s 50 hours or something. I always exceed it cause I go to so many meetings and they all account. In addition, you need to get quizzes and answer the quizzes and get those questions. All right. There’s questionnaires, et cetera. So it’s multifactorial the, they used to have it, so you have to know everything. So in addition to getting the continued education hours, which can be from your own specialty, you do have to take an exam every 10 years. That includes, like for me, I would include breast surgery, kidney transplants, pediatric surgery, heart, heart, heart and lung surgeries, liver, stomach, colon, all the different cancers, all the different endocrine diseases, et cetera. They’ve changed that a little bit because it’s not fair for a trauma surgeon to be up with all the different cancer modalities and tumor markers. It’s not fair for a breast surgeon to know how to run a ICU ventilator and critical care management. So they have in the past several years changes so that you can be a little bit more narrow in your test taking and quizzes that you have to take. But the hours can be within your own specialty hours don’t matter.

Speaker 1 (52:02):

I wanted to go through, oh wow, look, all these questions. Is Dr. Dasarda method comparable to Shouldice technique for a indirect hernia? No, not even close. Can prolene be used to repair hernia tissue repair without causing postoperative pain? Yeah, of course. That’s actually the most commonly used suture for tissue repair. Are most surgeries taped and available for the patient to see? Nope, they are not. Does the size of suture used for a growing or hernia repair impact? The incidence of post pain, for example, is not rated ethibond more likely to cause pain because of its size? Great question. The short answer is we don’t know. There is a tendency towards using double O suture as opposed to single O suture because double O is thinner, but triple O is even thinner and that’s too thin. So it depends on the patient’s tissue and the needle that’s used and the size suture that’s used.

Speaker 1 (53:09):

So it’s more than just suture and graded versus monofilament is also other things to kind of take into consideration. But we tend to go more for tissue repairs and fascia and bustle closure. We tend to use two or double O suture with a narrow needle in order to reduce trauma to the tissues. Have you personally ever been a patient who sutures who? Have you personally ever had a patient who sutures placed with sutures placed in the periosteum determine the cause of their pain by workup and then address issues surgically? How do you perform the surgery? Was it successful? I have not had any patient recently who has had sutures in the periosteum that caused their pain. I have had patients who have had the anterior Mesh placement with sutures in the periosteum and it’s unclear why they had the pain, but we did remove the sutures from the periosteum as part of their pain workup.

Speaker 1 (54:15):

Best clarifying. That was like a, ugh, okay, here’s a crush that was submitted and it has to do with age, which I thought would be interesting. And that is this, can hernia Mesh be removed in an older woman? Yes. And what are the odds of a good outcome? Usually 70 to 80% in by most hernia specialists, but it depends on the reason for the pain and what’s being done. So a plug in patch removal typically has a much better outcome, 90 plus percent benefit than like a nerve type injury pain, which has a worse outcome. Is age a big factor in revisional surgery?

Speaker 1 (55:01):

Yes, but mostly because of the time of surgery and anesthesia involved. I am 68 years old and had a hernia repair with Mesh nine months ago. I developed severe arthritis within days of surgery. Okay, well that’s very interesting. If you had severe arthritis within days of surgery that you did not have before your Mesh placement, of course you need to full work up to see why you have this arthritis because your age can definitely be a factor and it could be a coincidence that you also had hernia Mesh. However, it’s some patients and it’s usually not an elderly patient. It’s usually in younger patients you can be reacting to the Mesh in inflammatory meth, an inflammatory way, and that is causing your arthritis. But you need a full workup to be able to figure that out. You can’t just say, oh yeah, Mesh arthritis, therefore it’s the Mesh.

Speaker 1 (56:01):

That doesn’t necessarily occur and I don’t recommend that you have, let’s say, Mesh removed based on just that information. Okay. Here’s another question, a good one, which is related to that, which is how is allergy testing to polypropylene Mesh performed? Is it a patch test? Yes, it is. Do you use the actual Mesh? Yes, I do. Does the allergist request a sample? Yes, they do. From the surgical Mesh manufacturing? Yes, they can. Or you can find on eBay or I’m a surgeon, so I have access to meshes, especially expired meshes that we can use for the allergy testing. So if you can share, if your surgeon can share with you with the allergist, that’s the best kind of collaboration. But there are other options which you can kind of buy it on eBay or somehow work with your hospital to get a sample.

Speaker 1 (57:09):

One more minute guys. Can you provide umbilical hernia recovery advice? Yes. Ice packs Ice. Ice ice, Tylenol and naproxen or a leaf, Advil, ibuprofen. Ice, ice, ice. I don’t recommend any activity restrictions, but that’s highly variable based on the type of hernia had and your surgeon And I do recommend that we use anti-inflammatories because all the pain is inflammatory in nature and that my friends is the end I’ll party talk today. We have a great guest next week. Hope you join us again next Tuesday. This is the end of party talk. Live q and a. Thanks to everyone. You guys have been great. More questions. I’ll try and answer them offline if I can. If not, we’ll post them for the next week. See you next week. Go on YouTube by YouTube channel. Please subscribe that way every time, or I’m done with one of these. We’ll get a notification that there’s a new Hernia Talk Live Q&A for you to listen to and learn from. Thanks for following me on Facebook at Dr and on Twitter and hernia and Instagram at Hernia doc. See you all later.

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