Episode 97: Ask Me Anything | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

Hello. Hello, it’s Dr. Towfigh, your hernia and laparoscopic surgery specialist. Welcome to Hernia Talk Live, our weekly Q&A held on Tuesdays, nicely known as Hernia Talk Tuesdays. Thank you to everyone who’s joining me on Facebook, and also for those of you that are on the Zoom, many of you follow me and I hope more of you follow me on Twitter and Instagram at Hernia doc. And thanks for those that are also subscribers to my YouTube channel because all of the sessions on this Hernia Talk Live have their own channel on YouTube and you can kind of scroll through them and search keywords and figure out what topics you’re interested in and listen to the live episode that we’ve had because we’re close to a hundred episodes. We’re not yet at a hundred, but we’re very, very close. And I’m telling you when I started this at the very beginning of the pandemic, I am so excited that you all found it just as exciting as I do because I see that our audience is growing so much more, there’s so much more interest.

Speaker 1 (00:01:17):

Hernias are cool now and I’m glad to be the one that’s trying to introduce all these topics too. Well, it’s been a while since we had a free for all, and so I thought it would be good to have just a show completely dedicated to your questions, not on any specific topic. Of course, usually I will answer as many questions as possible regardless of the topic at hand, but it’s been a while since we had just a free for all. So today you can ask me anything. Hopefully they’re all hernia related, but I’m willing to answer nearly everything. And I’ll start by saying that I hope many of you go to my website, hernia talk.com. It is a precursor to our weekly Q&A session. It’s been live since 2013. We have thousands and thousands of member subscribers. It’s completely free you just to even have to sign up to use it if you just want to lurk around and kind of see what people are asking and search the site that’s completely free to you.

Speaker 1 (00:02:32):

If you wish to ask questions or participate, then that requires a simple signing up. The reason why I bring up the website besides hoping that more of you actually participate on it, is we are planning on revamping it and updating it. And there’s so many more things you can do with these type of forums nowadays that we weren’t able to offer when I first opened the forum back in 2013. And we have updated a couple times, but I do want to make it much more user friendly, much more filled with information search capabilities, and then whatever I can do to make it the number one resource for hernias and hernia related topics. So please go to hernia talk.com, see if you like it. Those of you that are already on it, please answer my questions, which is really a survey of what do you want to get out of the website, what would you prefer to add to subtract, et cetera. And I do wish to kind of merge the two that both hernia talk.

Speaker 1 (00:03:53):

Let me know, I can help you. So many of you have already submitted questions. I love the fact that hernia talk is an international forum. Anyone from anywhere that has access to a computer or a smartphone can submit questions. And one of the questions that, and many of the questions that were submitted are by those that are international from other countries. Oftentimes they cannot be live because it’s like three o’clock in their morning for them in their country, whereas it’s 4:30 PM Pacific daylight savings time. So I’m happy to answer those questions as well as your live questions. So here’s the first live question. It says, what do you see as benefits or drawbacks of robotic versus laparoscopic stick surgery for primary inguinal hernia repair? Great, great question. So the question is, there are two ways of doing minimally invasive surgery nowadays. There’s laparoscopic surgery which has dated since the early 1990s and there’s robotic surgery, which star started probably early 2010.

Speaker 1 (00:05:07):

The outcome is exactly the same. So doing a laparoscopic repair versus a robotic repair for Inguinal hernias is exactly the same. And lemme just double check. You’re talking about inguinal surgery? Yes, Inguinal hernia surgery, I have my own biases. I’m not a big fan of using high technology like the robot for very simple, straightforward problems like an inguinal hernia. It seems to be very expensive and I personally am not a fan of the scars that you get with a robot. So I’m going to give you my biased opinion and I’ll also give you what the studies show. So the studies show there’s really no major difference between laparoscopic or robotic inguinal hernia pair. The pain rate, the recurrence rate, the recovery rate should be pretty much exactly the same.

Speaker 1 (00:05:59):

As far as we know there’s there’s no major difference. Now, there is a difference in that almost all robotic inguinal hernias are tapp T A P P or what we call R tapp. So robotic tapp T A P P. Whereas with laparoscopic repair, you can do a tap T A P P or tep T E P. And the difference is whether you see the intestines as part of your surgery or not with the tapp, the T A P P, which is done robotically and also sometimes laparoscopically you have to be in the bowel in the abdomen where you see the bowel and then you go through another layer.

Speaker 1 (00:06:35):

Whereas with the laparoscopic TEP, which is my preference, you never see the balance. So there are certain risks and benefits to doing it that way. I do use the robot, I only use it for the complicated situation. So really, really large inguinal hernias, redo, redo hernias, removal of groin Mesh, those are all highly skilled operations that are much more exact and I feel much better performed with a robot. We even published our results of Mesh removal laparoscopically versus robotically, and the outcomes were exactly the same, but surgically speaking, there was a little bit more blood loss with a laparoscopic repair and a little bit more higher risk of vascular injury because with a laparoscopic repair, because a robotic technique is much more precise. So I’m not a fan of using the robot for just plain bread and butter outpatient elective inguinal hernia surgery. It’s more expensive to the institution.

Speaker 1 (00:07:39):

Theoretically, the patient is not being charged any different and the insurance company doesn’t pay any differently whether you’s done lap robotics. It’s really a extra cost to the institution, which is I think unnecessary. If it means that your surgeon’s able to provide you m i s minimally invasive surgery because they can do it robotically and they can’t do it laparoscopically, great, that’s fine. I don’t like the scars. The scars for the robot are eight millimeters. I prefer five and sometimes three millimeter scars. And I like where I can hide the scars, robotic laparoscopically. Whereas with a robot, it’s very hard to hide those scars. So cosmetically, I think laparoscopy is better, but in terms of outcome, it should be very, very similar. Next question, would you recommend a Shouldice as opposed to robotic inguinal hernia pair for someone born with an inguinal hernia and now with a very small inguinal hernia?

Speaker 1 (00:08:39):

Great question. It really depends on the patient, their lifestyle, their age, their risk factors. So patients that are great candidates for robotic or inguinal hernia or laparoscopic inguinal hernia pair are young patients, males, young males, athletic patients, heavyweight patients or patients that have hernias on both sides. People that do best with the should life repair tend to be very thin patients, very thin people who don’t have a lifestyle that involves repetitive heavy lifting and younger patients like really young, like 16, 17, 15, 14. So you don’t want to put Mesh in the young teens and anyone who has a risk of having a Mesh type reaction, which of course is very rare, but if you have an autoimmune disorder, I would kind of consider tissue repair as well. The studies say that laparoscopic repair is better for women because it tends to prevent missing a femoral hernia. So anyone with a femoral hernia also should be done laparoscopically. That’s kind of my algorithm. Now that said, I have a 80 year old patient coming up that I’m doing open Shouldice on this week, whereas usually I would recommend a Mesh based repair for someone that’s older. I had a 17 year old done today that I did a Bassini, like a tissue based repair female that’s preferred. Whereas it’s possible that if she went to, she was offered laparoscopic surgery by other surgeons, I think she’s too young and too thin for that. So it’s very, very dependent on the patient, their lifestyle and so on.

Speaker 1 (00:10:54):

Let’s see. Unable, I’m unable to create an account on Hernia Talk. You know what? DM me and I’ll try and figure out why that is. Everyone should be able to come up with a new account on hernia talk.com. Okay. Chicago has world-class hospitals, but I can’t find a hernia expert. This is true Chicago doesn’t have any, sorry, such as yourself or Dr. Brown who’s retired who specialized only in hernias. What are the key questions to ask a general surgeon for an Inguinal hernia repair? I’m okay with Mesh or non Mesh is a shouldice okay for someone in their sixties does tissue frame more with age and therefore need Mesh over tissue repair? I wish I were closer to you. I treat a lot of patients from Chicago. So if you would like to travel, I’m happy to see you. There are surgeons that do hernias in Chicago. So Dr. Shoot, I’m blanking on his name. Michael Ujiki is a surgeon that enjoys hernia repair. There’s a surgeon that actually would train it at UCLA, I’m blanking on his name, but he’s also a great laparoscopic surgeon. None of them are a hernia specialist. I wouldn’t say that they have an interest where they do a hundred percent hernia repairs or 90% or 80% or even maybe 50% hernia repairs. But if I remember the other surgeon’s name, I’ll mention it.

Speaker 1 (00:12:22):

The question has to do with is Shouldice okay for someone in their sixties? So Shouldice repair is a brand name or not a brand name, but it’s like a name, name. It’s a surgeon who came up with a very nice tissue repair, is considered the foremost tissue-based hernia repair has the most experienced long-term with it. It’s very safe, it has great long-term outcomes. I offer the Shouldice repair. You can go to Toronto and go to the Shouldice clinic or ICE hospital and actually get Shouldice hernia pair. Dr. Shouldice Jr, which is the son of the original Dr. Shouldice, just passed away last month so that we have no more Shouldice surgeons available to talk to. But their legacy does go on, especially at the Shouldice hospital. So is it okay for a six year old to have a Shouldice repair? Sure. Would I recommend it as my primary option?

Speaker 1 (00:13:25):

No. Am I going to do that this week on 80 year old? Yes. And it’s based on lifestyle preference and then the understanding that it is not the shoulder ice would not be an ideal repair for an elderly patient because your tissues are not as strong and not as healthy to undergo pure tissue repair. And the longer the older you are, the weaker those tissues are. So your risk of hernia recurrence should be theoretically higher in an elderly patient than a younger patient. So that’s kind of the caveat. But some people are willing to take that risk understanding that if they recur, they may need a hernia repair with Mesh and they’re okay to take that risk because it’s not a hundred percent, it’s not even 50%, it’s maybe 15% risk of recurrence somewhere in there. If you’re elderly that two surgeons, it’s considered too high. But to a patient it may mean they have an 85% chance of doing just fine. So that’s the discussion that I have with my patients.

Speaker 1 (00:14:35):

Let’s see. What is your opinion of Phasix Mesh? It is said to disappear and be absorbed by the body in two years living nothing foreign. So pH Mesh is a synthetic absorbable Mesh. It is manufactured product that absorbs theoretically around a year and a half. Most of us who have re-upped on patients still see the phasix two, two and a half years out. But it does kind of absorb over time. There are studies that support the idea that it works perfectly fine. However, as we learn more about these, it’s not a perfect Mesh. So it’s definitely not equivalent to a synthetic non-absorbable Mesh. So permanent Mesh and to date we haven’t figured out what is the ideal Mesh. How long do you need the support of the Mesh before you can kind of let the Mesh dissolve away and your own body will handle it? Most of us believe it’s never, so there will never be a situation where you will have absorbable Mesh equivalent to non-absorbable Mesh. So permanent Mesh will always be the standard and provide you with better long-term results based on recurrence than absorbable Mesh. And that seems to be true for sutures as well. So non-absorbable sutures, you see a higher recurrence than with, sorry, absorbable sutures. You see a higher recurrence than with non-absorbable sutures. So I don’t see why that would be any different with the meshes. However, we’re still studying so we don’t really know.

Speaker 1 (00:16:32):

Let’s see. I’ve had two hernia repairs the second with Mesh in 2016. Now I have, I’m having a third surgery for recurring incisional hernia with Dr. Mary Hawn at Stanford. Excellent surgeon, how many re and she’s chairman at Stanford. How many repairs can I still have? I am 70. Oh, okay. Well I think forensics is necessary here. So you’ve had two hernia pairs a second with Mesh. I’m, I’m going to assume that you had an umbilical hernia. That sounds like the typical scenario. You have a little belly bun hernia, it recurs, they fix it. Sorry, you have a little belly bun hernia. They fix it with a couple stitches, it recurs and then you have a recurrence. That recurrence, they say, okay, maybe we should use Mesh this time, but now that’s rec recurrence. The question is why did it recur? You are 70, but I assume if you’re having a third surgery that you’re healthy enough to undergo a third surgery.

Speaker 1 (00:17:34):

This, okay, it seems like the hernia was after a ruptured appendix on a cruise ship. So was that hernia done? Was that appendix surgery performed laparoscopically? And did you have the hernia from the belly button? So if you had surgery and then you had a hernia from that surgery, that is not a hernia that should be repaired without Mesh. The first time it should have been repaired with Mesh. Now you’re in this horrible so cycle where you keep getting the wrong operations. So you had a, oh, sounds like you had a five hour open surgery for ruptured appendix and you got a hernia from that. That should have been repaired with Mesh. The fact that it didn’t get repaired with Mesh means you tore and now your hernias bigger, then they put Mesh in and for some reason you have another hernia repair. So the question is how big is a current hernia?

Speaker 1 (00:18:31):

Why did it recur? Was it the Mesh too small? Are you constipated or have a chronic cough or you’re lyse putting Mesh at risk? Was it the wrong technique? Did they use a wrong weight Mesh? Was it heavyweight Mesh or lightweight Mesh? So these are all part of the forensics that needs to go on before you commit to your third surgery or at least have that discussion with your surgeon as to how are they doing this surgery different compared to the last surgery to prevent another recurrence. Because at age 70 you shouldn’t have to deal with multiple, multiple recurrences. That’s just unnecessary extra risk for your body. All right, next question. Are there two types of chronic regional pain syndrome?

Speaker 1 (00:19:23):

Okay, we’re really shifting gears here. So it’s complex regional pain syndrome, C R P S or we call it Crips sometimes like the BR bloods and the Crips. I’m from LA. Okay, so CRPS, C R P S, complex regional pain syndrome. Are there two types? One and two. And what are the differences in terms of causes and presentation? Patients still see the face. I don’t know what that means. Okay, so I’m not sure about the different types of complex regional pain syndrome. I do know that it’s a horrible disease and in most patients that have that or are at risk for that, you don’t want to operate on the patient because that’s extra trauma that will instigate more nerve in layman’s term, more nerve kind of activity and it can be very, very debilitating. What’s the recurrence do you give to patients who have to have Mesh removal for various hernias?

Speaker 1 (00:20:28):

Umbilical ventral angle. So when I talk to my patients about recurrences, I try and discuss the data. So the data shows blah, blah, blah, blah. In your case, I believe you’re higher risk or lower risk. Let’s say when we look at data, we look at a population and if there’s a population study, it takes old people, young people, males, females, athletes, non-athletes, obese, thin, and it’s very hard to provide individual data because we don’t have a database that can say, plug in your information here based on your age, your height, your weight, et cetera, your risk will be X. We don’t have that data in any database. So what I do is I understand that if you’re thinner, you’re going to have a lower risk. If you have C O P D, you’re going to have a higher risk. If you’ve failed two or three operations, you’re going to have a higher risk.

Speaker 1 (00:21:34):

If your process is enlarged, you have a higher risk. If you’re an athlete, you probably have a lower risk. So I will, when I talk to the patient, I give them kind of what the data shows and then I give them what I think their risk would be based on their additional risk factors or lack of risk factors, smoker, age, et cetera. So for most umbilical hernias, just a primary repair without Mesh, the… see, I can’t even answer that because if you do a primary pair on a big umbilical hernia, you’re going to have a higher risk than if you do a smaller hernia. So it’s hard to give that the correct answer. For most al hernias that are allow, that are Mesh based experts should provide less than 1% risk of recurrence for most umbilical hernias experts, if doing it correctly with the right technique, Mesh, no Mesh, depending, whatever, also the risk should be less than 5%. And for incisional ventral hernias, it should be around 10%. So that’s kind of the ballpark numbers. So less than 1% for inguinal is about 5% for umbilicals and 10% for incisional. That said, everyone’s risk factors will kind of increase or decrease those numbers. Next question. I got a hernia after pregnancy, I just got it repaired last week, sounds like, and they use Mesh and I’m having a lot of pain. When will the pain go away?

Speaker 1 (00:23:09):

What can I do to not get the hernia back? Should there anything? Should there be anything I shouldn’t be doing? So in women that have hernias in the abdominal wall, I assume this is abdominal wall and not groin. You should wait until you’re done with all pregnancies before you commit to a hernia repair. The groin is different. You can have inguinal hernia repairs and have pregnancies without really any consequence. But for the ventrals, so abdominal wall hernias and the belly button for example, I don’t recommend the hernia be repaired unless you’re spun with fertility. The reason why people have pain for ventral hernias, abdominal wall hernias, umbilical hernias often is because either the surgery was highly traumatic, so a lot of pushing and pulling the tissues or it’s too tight of a repair.

Speaker 1 (00:24:05):

You only, you just had surgery less than two weeks ago. So it takes about two to three weeks for a ventral hernia pair to be pain free. But if you’re in a lot of pain, a binder works that helps take the tension off of the sutures to help reduce the pain. And then afterwards, the risk factors that help reduce risk of heart recurrence include no more coughing, no more no smoking of nicotine or use of any nicotine, no constipation, no straining, and then exercise and don’t gain weight. Those are the top, top, top ones. Okay. What’s the price difference between Shouldice and robotic surgery for someone paying all out of pocket? Okay. Depends on where you have it done. Usually patients who undergo surgery at an outpatient surgery center give a, get a better deal in the United States than those who go to a hospital because the cost of running a surgery center is lower than the cost of running a hospital.

Speaker 1 (00:25:16):

So the time effort is lower. Also, a Shouldice repair repair should be less expensive than a robotic surgery, not for the surgeon but for the facility. So when you get a cash package, you’re paying for the surgeon, the anesthesiologist and the facility. The facility costs include the surgical tech and the time in the operating room, the sutures, the Mesh, whatever, and the robot robot’s a 2 million plus product. So oftentimes if you don’t need any of that and your anesthesia’s minimal, so to Shouldice you don’t have Mesh, that’s less cost. Your anesthesia’s not general anesthesia, that’s less cost. Surgery time may be the same, so that should be different cost. And then the cost of all the technology is lower with the Shouldice. So technically speaking, the facility part may be lower for a Shouldice than for robotic surgery. Technically speaking, especially if you do it at an outpatient surgery center. However this is screen, the codes are very similar. So the code for an open hernia repair is almost exactly the same as for the robotic surgery repair. And so

Speaker 2 (00:26:43):

If they only go by code and don’t really look to see what type of surgery you’re having and they code you a cash price, the code for a robotic surgery actually pays less to the surgeon then for open repair. It’s just a weird funky code thing. So highly variable, but theoretically it should be cheaper to have a Shouldice repair at an outpatient surgery center than a robotic surgery at a hospital. Okay. Question about scars from a robotical hernia repair. If the incisions for the robotic surgery are larger than laparoscopic surgery, does that mean there’s a higher risk of an incisional hernia later? Yes. Not by much, but yes. And what is a price difference between, oh, I answered that.

Speaker 2 (00:27:41):

If you do a should eye surgery on someone and it fails, what would be the fix? Great question. So if you fail a tissue repair, then you should commit to a Mesh based repair after that makes no sense to redo you’re you’re pretty much, you’re pretty much, what do you call it, burnt that bridge once you fail a tissue repair and you should get a Mesh based repair. So whenever I talk to patients that I really do not want to promote a tissue-based repair, let’s say elderly patient, definitely morbid obese patient, but they are willing to undergo that risk, then they must, before I commit to that surgery, they must commit to the idea that they will need a Mesh based repair if it fails. And like I said that those are, that’s the discussion I have in people where I feel the failure rate is higher than expected. If you have Mesh removed, doesn’t that leave the original hernia hole with a certain need to suture the hole left by the Mesh removal if they’re not replacing the Mesh?

Speaker 2 (00:28:52):

Yes and no. Depends on how big the original hole was. Oftentimes we remove the Mesh. First of all, if we remove the Mesh for infection that holds like sealed shut with inflammation so you don’t see the hernia usually if you remove standard Mesh and the hole originally was small, then scar tissue may have covered the hole and you can remove the Mesh and leave everything alone and then commit to fixing the hernia if and when it recurs and they mostly do recur. I had a morgagni hernia repair on Friday and I’m still having pain and soreness. How long will this last? How is morgagni hernia? You were the first person to talk about morgagni hernia. Congratulations.

Speaker 2 (00:29:47):

For those of you who don’t know, Dr. Morgagni is Italian surgeon. He coined the term morgagni hernia because it is a uncommon but developmental hernia in the diaphragm, it’s not an abdominal wall hernia, so we don’t usually talk about it here. Repair of it is done laparoscopically or thoracoscopically usually not open and it should not be painful. So if you have pain, it’s probably at the level of the actual incisions, in which case ice pack should help anti-inflammatory should help. We’re really going through rapidly through these questions guys. I hope you’re enjoying it. I have tons of questions that were pre-submitted. I think in reference to those people who cannot join us live, I should go through those really quickly just to be nice. I did promise I would address this and I’ll go back to your questions live. Okay. After open right inguinal hernia repair two years ago, I have pain reading to my testicles.

Speaker 2 (00:30:52):

My surgeon asked for an ultrasound, am I wasting my time? I just get an MRI. Great question. So if you had a hernia repair, now you have testicular pain and you think it’s from the hernia repair, then you either have a hernia recurrence or the Mesh is somehow entrapping or eroding into your spermatic cord. And so usually we don’t look at that in an MRI would be the next best step to evaluate your hernia repair to help rule out a hernia and evaluate where the meshes in relationship to your hernia. If you didn’t have Mesh as part of your repair, then at the very least you may have a hernia recurrence. In which case again, MRI I think is with Valsalva is best. However it seems your surgeon asks for an ultrasound as a testicular ultrasound to rule out any primary testicular problem, epididymitis traumatic cord cyst and so on.

Speaker 2 (00:31:55):

So that is a reason for the ultrasound. It’s perfectly appropriate to move on with testicular ultrasound to evaluate the testicle before looking at the hernias that causing her pain. But the hernia should repair, should also be looking for that. I have a sports hernia. I also have back pain, difficulty breathing tight pelvic floor. I cannot engage my core. Is that common? Yes. What other musculoskeletal symptoms do people present with her present with hernias? And do these get better after hernia repair? Yes. Great. Great question. So the sport hernia concept, I’m willing to bet you don’t have a sport hernia and you actually have an inguinal hernia. It’s just a small one and it can, small anal hernias can cause testicular pain, pain to the inner thigh around the lower back, nausea, bloating, a tense pelvic floor, which can cause urinary urgency, frequent urinary frequency, anal pain and pain with a bowel movement.

Speaker 2 (00:32:58):

Pain with intercourse. Athletes or people that are really in tune with their core may also notice that they can’t really engage their core as much anymore. And that is very interesting because then when you fix the hernia, all those fall into line, your pelvic floor is relaxed, you’re able to engage your core again. Everything seems to go back into place. The lower back pain is gone, the testicular pain is gone. It’s no longer painful to have intercourse. The you don’t have painful bladder and urinary symptoms go away and you can have normal bowel movements. So there is hope. Please talk about postoperative side effects such as testicular swelling in men. So again, sounds like we’re talking about inguinal hernias. I feel like we talk a lot about inguinal hernias and not so much ventral, so we can talk about all of ’em, but inguinal seems to be of most interest.

Speaker 2 (00:34:01):

So testicular swelling in men, any inguinal hernia repair, whether it’s open, laparoscopic or robotic, has a risk of bruising. And in men, since they’re standing upright, the bruising will go south and if it goes south, they may get bruising along their penis skin. More likely they will get swelling in the scrotum, not the testicle, the scrotum and they may get bruising in their upper thigh. So that’s one of the side effects. Other side effects can include seromas, which is a fluid collection, bleeding, which is a hematoma. Those are the most common side effects we see. Swelling will go away. All these are reversible swellings and reversible symptoms. What are the complications of how you Mesh? In most people there are no complications. Some people however can have erosion folding and pain from it. Some people can react to it. We call that Mesh implant illness.

Speaker 2 (00:35:04):

M we just submitted a paper where we discussed this new concept of m i. There’s a lot of talk about Mesh migration. That was an issue with the plug. It’s really not an issue with any other Mesh and so I feel online there’s a lot of chatter about, oh, my Mesh has migrated. I even had a patient come to me with kind of right upper quadrant pain in the chest area and the patient thought, I think my groin Mesh has migrated to the, I mean that just doesn’t happen. So the issue of Mesh migration is really overblown. I see it in the lawsuits. I see it in the discussions online. It’s really not a thing unless you’ve had a plug and patch repair.

Speaker 2 (00:35:56):

All right. Let’s see. You said that abnormal collagen metabolism plays a role in the development of hernias. Yes. Does it also affect adhesion’s formation after surgery? Not that we know of. How can you be sure that you have Mesh implant illness before undergoing Mesh removal surgery? Dude, if I knew that answer man, I would be saving so many patients we don’t know. In my study, the majority 80, over 80% of the, and hopefully I think it’s getting published, over 80% of the patients who had Mesh implant illness had some sort of autoimmune disorder or family history of autoimmune disorder and or a laundry list of allergies. Whereas if those who didn’t have Mesh implant illness, I think only like 15% or something had one of those. So that tends to be maybe a risk factor, but it really is not something that we can definitely say, aha, you will have it and you will not. It’s just a relative risk. So even those patients that have symptoms such as like let’s say you have full-blown autoimmune disorder, even those patients do not tend to have a hundred percent at risk of Mesh plan illness.

Speaker 2 (00:37:34):

Okay. Is there anything you can do to lower your chance of recurrence after Mesh removal? Yes. So we did discuss this before and that is that, hold on, where am I? We did discuss before and that is that people who have, let’s say a constipation, chronic obstructive pulmonary disease, chronic cough, anyone who uses nicotine, people who are morbidly obese, non-athletic, non exercising people, these are all people at higher enlarged prostate constipated people who are straining. Those are all increased your risk of hernias and therefore preventing all that will also improve your risk of reducing your risk of recurrence after Mesh removal are recurrence, chances of pure are recurrence chance of pure tissue and Mesh reinforced repairs influenced by the age you have when the hernia is repaired? Yes. So younger patients theoretically have healthier tissue and will develop a stronger scar and a more secure hernia repair as opposed to older patients who would not have that. Is there a relation between chronic inflammation and hernia development or recurrence? Not that we know of.

Speaker 2 (00:39:13):

Okay. We kind of went through those really fast. Meanwhile I see all these questions adding up on the chat. Okay, let’s see. Let’s go to the live questions. Dr. Yunis removed Mesh from top repair but got a large varicocele since the orig original surgery. How can a hernia repair cause a varicocele? Can this be causing chronic pain? I was told the Mesh was tight on the cord. Okay, so varicocele is like varicose veins of the scrotum. So there are veins that go down to your scrotum. If there’s any problem with the actual vein, you would like people who have varicose veins or if there’s an obstruction at the level of the hernia repair where there’s backflow of the veins, then those are called varicocele. I’m, I’m assuming you don’t have a hydrocele but you have varicocele. Hydrocele is much more common after hernia repair.

Speaker 2 (00:40:08):

Varicocele is very uncommon after hernia repair and even if you have a really tight spermatic cord, you still should not get a Varicocele because you should still be able to drain the veins through multiple different avenues. But if you do have an obstruction at the internal ring or if you’re not like a straight shot, it’s kind of angled, then I guess you could theoretically get backflow and have a varicocele. I would look talk with the urologist to see most varicoceles do not need surgery. It may affect your fertility, so if that’s an issue you can get addressed or may cause like dull scrotal heaviness, in which case they can get addressed and there are surgical options for that.

Speaker 2 (00:40:56):

What are my options when I’ve had umbilical surgery repair? No Mesh, four permanent sutures and one of the sutures is just about poking through the skin. It is so painful. If it pushes into my skin, I can see it’s purple and feeling like a fishing nylon, well just take it out. Would you open the whole thing up again and would you have. No, I would just take out the one suture. And would they have negative consequences? Would it be best to wait or have it done sooner rather than later? Otherwise I’m healing well in New Zealand. Yeah, if depends on when your surgery was. I assume the surgery was a while ago, so a while ago, maybe months ago. Otherwise just take it out. They can do it in the office and if you had multiple sutures then theoretically you don’t need that one suture because you’ve already scarred in that one area theoretically.

Speaker 2 (00:41:50):

I think you perform TEP. I do. I prefer laparoscopic T E P. Are TAPP and TEP equally good techniques? Yes. Or is the theoretical advantage of not entering the abdominal cavity with TEP? The key thing I believe it is, but many disagree. Other factors that make one better or are both about equal. So there’s no study to show that there’s any clinically significant difference between TEP or TAPP. I think it’s unnecessary to be in the abdomen for most inguinal hernias. So why be there and risk bowel injury, postoperative obstruction and exposure of the hernia Mesh to the abdominal wall potentially. That said those risks are really small. Also T E P is considered a more challenging technique than TAPP, which is why most people do TAPP. I prefer TEP, even though it’s more challenging, I find it actually much more pleasant.

Speaker 2 (00:42:54):

You have to be really good at making a wider exposure and know your anatomy much better. People find it much easier to know your anatomy with a T A P P. So if you’re going to do a better surgery TAPP because you can see your anatomy and you’re more comfortable, that’s good. If you understand the anatomy better and you’re willing to be working in a little bit restricted space but never be in the abdomen using TEP, that’s good. It should not be a reason to choose a surgeon. Today had a pain stimulator placed on me for a seven day trial. Okay, hopefully you need it. Otherwise I feel a lot of people are incentivized to get these pain stimulators and they don’t need it. They’re like actually have a treatable reason for their pain. Why don’t doctors request an MRI for hernia repair and or Mesh removal?

Speaker 2 (00:43:48):

Don’t MRIs give a clear picture than any other imaging? They don’t request it for two reasons. MRI is considered of highly higher level type of radiology. So either you need to be able to read the MRI or the radiologist need to be able to read it or both. Most general surgeons are not comfortable reading an MRI and are much more comfortable looking at a CAT scan so it doesn’t make sense for them to order an imaging study that they can’t read or evaluate. It also doesn’t make sense to order a imaging study if their radiologist has no idea what they’re looking at either. I just had a patient from New York, I think it was New York and they had MRI. It was completely misinterpreted and I’m looking at it, I’m like what about this? And they said they actually did a comment on it in the radio.

Speaker 2 (00:44:43):

So I called the radiologist in New York to have that person reevaluate with me on the phone and honestly they gave me some BS answer. So I knew the answer was incorrect and it sounded like the radiologist didn’t know what they were talking about because I challenged them on a question and they were like giving me some, oh that’s a scar tissue. No, I think it’s an infection of your Mesh. So I took the same image to my own radiologist who read all my imaging and I’ve learned a lot from them and I said, could this be scar tissue or is this infection like no, this is inflammation or infection. You’re absolutely right. It is not scar tissue, it should not look like this. So it’s a problem with MRIs which is you need to have someone interpret it correctly, you know can have the highest level technology.

Speaker 2 (00:45:33):

If you it’s get an answer from it, then it’s of no use. So PE doctors do what they’re most comfortable with. Most doctors don’t even know that MRI is appropriate. I have noticed since we published our papers, I think it’s almost 10 years now, that when our first paper got published that over time there’s been a much more interest in getting MRIs and my MRI protocol has become really popular for hernias. And so that said, insurances still don’t approve it as easily as they do other studies, which is so stupid. They’re just, they’re behind the times. I had anal hernia surgery in 2015 with Mesh and a plug. I’ve had pain since day one. Is it safe that I have a spinal stimulators? So I’m not a fan of spinal stimulators if you haven’t exhausted other options for your pain. So if you have a neuroma, that’s a surgical problem.

Speaker 2 (00:46:38):

You don’t need to have a stimulator in. If you have C R P S complex regional pain syndrome then maybe a ST nerve stimulator is your health. But I think spinal stimulation should be done as last stitch effort and not first stitch. So often I feel that people are not getting the right diagnosis or the right treatment and they’re sent into a pain management doctor. The pain management doctor knows what they knows what they know which is nerve pain and they don’t understand that the nerve pain is treatable as opposed to untreatable and they recommend a spinal stimulator to treat the nerve pain but there’s a treatable cause for the nerve pain. I have a patient from Iowa and he had a neuroma and he was told he needs a pain stimulator. So I’m like no, let me just block the nerve and his pain went away. So why would you implant something in your spine if you can have nerve blocks done every so often to get rid of the pain and then eventually maybe even have the nerve cut? I mean it just doesn’t make a sense to me. I’m glad he came to me and didn’t get that.

Speaker 2 (00:47:52):

Okay, let’s see. Oh let’s go back to the more ganglion hernia. I love that term more. I was not born with the more ganglion hernia. The doctor found it on x-ray and compared it to previous x-rays which and it did not show it there. The surgeon said it’s super rare he’s only worked on two and 20 years. Any idea how I could have gotten this? There’s no car accidents or trauma. So a true morgagni hernia is like any other hernia. There’s a predisposition for it. You probably were born with it and just didn’t know until it got to the point where you could be seen on imaging. Other reasons for diaphragm hernias include being stabbed in the chest or having had a bad car accident. So if those did not happen then it was probably something you were born with even if they didn’t see it until before.

Speaker 2 (00:48:46):

Let’s see, looking at imaging, mine didn’t show squad. I fought hard to get an MRI approved and nothing. What does that mean? That means you tried to get it approved and they didn’t approve it or you tried to get the MRI approved and didn’t show anything because I see stuff, I just saw a patient from Mayo Clinic that they totally missed the hernia. It was actually, to be honest, it was very rare hernia. My own radiologist missed it. I saw it in the office called my radiologist like oh yeah, you’re totally right. So they changed their report and then we sent it to Mayo Clinic. A Mayo Clinic agreed with me and so now she has a diagnosis for her chronic pain that she’s had for years that no one could figure out before. Let’s see, my Mesh from ultra ultrapro broken pieces, okay, I don’t understand this but it sounds like she had Inguinal hernia pair with which is the lightest weight Mesh available on the market.

Speaker 2 (00:50:01):

It seems to have torn, which is the problem because it’s extra lightweight, especially if it’s placed in someone who’s not super thin or it was a large hernia that it can fall apart. Nobody works lisen mines was removed and sutures. Okay, sounds like the Mesh was removed and you had a suture repair of your hernia and no one would operate. So if I’m happy to see you or send in your contact my office and have them start what we call an online consultation where they provide you with, well you provide me with all your records and I’ll figure out what I can help you with because all these pains are treatable, you just need someone to do the forensics part of it. Also with TAPP repair, again we’re talking laparoscopic or robotic TAPP inguinal hernia repair, bowel habits changed significantly. I e lots of bloating, constipation, acid reflux since none of which I had before it shouldn’t.

Speaker 2 (00:51:03):

If you do have any of that, the Mesh may be exposed or you may have an internal hernia from the top. Number one that SH can be easily identified on most imaging. The other thing is surgery in general, we give at least one dose of antibiotics and that dose of antibiotics can mess up the bacteria in your gut and in doing so, give you SIBO, S I B O which stands for small intestinal bacterial overgrowth. If you go to your GI doctor or your gastroenterologist, they can TR test you for S I B O, which stands for small intestinal bacterial overgrowth to see if the bacteria has changed since surgery and then you get treated for that. And we actually did a whole episode on SIBO and other reasons for abdominal bloating and pains with Dr. Leo Trayzon early on in Hernia Talk Q&A. I think over a year ago and learned a lot about, you know, just have a regular surgery, you’re doing fine and now after surgery you’re bloating a lot and it’s like intensive bloating, maybe acid reflux and some change in bowel habits and that could be just from one dose of antibiotics and it’s a medically treatable problem.

Speaker 2 (00:52:30):

Let’s see, I’ve asked for MRI of my abdomen, no one will order it. Well abdomen is different. Mostly for the abdomen. We don’t need MRIs. CAT scan is adequate or an ultrasound but for the pelvis, which is like where the inguinal hernia is, it’s very helpful. What is a rate for chronic pain in the hands of a world class hernia Laparoscopic robotic surgeon on primary hernia? It’s very low, it should be less than 3%. There are so many population studies but they never have studies, just the top experts. That’s true. Now that said, there is a study, I have to see if it’s published yet because I was part of it. It looked at expert surgeons that did open laparoscopic or robotics. So whatever they felt was each surgeon got assigned their favorite operation. They felt they did the best and they were followed prospectively to see if you to a surgeon and they just did their best repair.

Speaker 2 (00:53:27):

Doesn’t matter if it’s done laparoscopic, robotic or open for anal hernias and for ventral hernias, the author is Dr out of New Orleans. Blanking on his name, but I’ll look for it and see if I find it I’ll, I’ll send it up to you guys. Very large study, very complicated and pretty unique because it’s not pitting one, study one against the other. It’s pitting like best surgeon versus best surgeon and see if it matters. So if you just go to your surgeon and say he says or she says, I recommend this surgery and does that mean it’s inferior because it’s not laparoscopic. Even if they do a good job open. Usually not. Usually not. Oh boy guys, it’s a lot of questions.

Speaker 2 (00:54:27):

Okay, how do you answer patients? Sorry? How do you address patients who have chronic pain following an open incisional hernia? Parent? Can you explain how patients can tell if the it’s nerve related or adhesion related? incisional hernia pain is almost never adhesion related. Those who usually will cause intestinal obstructions. Adhesion related pain is oversold. Often chronic pain after open inguinal hernia repair is often because you’re tearing and you have a hernia as it relates to it. That’s the most common. Most patients with incisional hernia impairs do not have chronic pain. They’ll have Mesh folding Mesh infection, Mesh hernia recurrence. But chronic pain unrelated to those is really uncommon. So there’s almost always a reason for it.

Speaker 2 (00:55:17):

Dr T, two and a half years, I’m two and a half years passed bilateral al hernia repair with Mesh laparoscopic tap T A P P. At this point I got sore with lots of activity and field pulling during workouts. It’s always better with rest and almost perfect after resting standing for prolonged periods of time. Also makes it sore. Do these symptoms justify mushroom given the wrist? So it’s possible that what you have is too tight of a repair. Sometimes surgeons don’t appreciate that the pelvis is like a bowl, it’s like a circle. So putting in a straight piece of Mesh, you need to have it follow the curvature of your body. And when they’re in there they kind of put it really tight and that’s too tight and so you can feel pulling and so on. First you have to figure out why you have the pain and for a lot of laparoscopic for open surgery, sometimes I give Botox and that loosens the repair a little bit.

Speaker 2 (00:56:20):

It doesn’t help as much for laparoscopic repairs. So I can’t say that that’s a good test to do. You could try and get a dynamics imaging study to help see if the Mesh is too tight and then see if you have tacks, if you’re too tight. Usually they use tacks. If they didn’t use tacks, it’s uncommon for it to be too tight. So maybe it’s a tack issue. I’d have to know your full story before answering that. I had a CT scan and the doctor says the measures laying flat but doesn’t like the permanent tacks and where they were placed. Okay, I don’t know what the question is. Okay.

Speaker 2 (00:57:11):

How do you decide when to surgically intervene for chronic postoperative inguinal and pain syndrome and how do you balance the timing of allowing the postoperative inflammation to subside versus the risk of peripheral and central sensitization? Great question. So unaddressed pain starts becoming at risk for centralization, central sensitization after nine months. So you have some time to figure things out. I’m not someone that says, oh, give it a year, come back. That’s almost never the answer. And it depends on the type of pain, what instigates the pain, where is the pain and how you correlate that with what was done. So it’s a lot of forensic puzzle solving and trying to figure out what’s going on in terms of, what do you call it, the kind of trying to put the whole puzzle together and that’s really, really important. It’s what I love to do. I think any of you follow me or listen to me.

Speaker 2 (00:58:16):

I love the puzzle solving. I’ve always loved to solve puzzles since I was a kid, so I’m really excited. That’s kind of part of my job now, but I hate to say this, I feel like most people do not like puzzle solving. Why are you in my office? Go home, go to pain management. So based on that, I feel that you really need to find a surgeon who’ll like figure it out for you. And then once you have a plan of care, then you can follow it. But there are times when it’s just inflammation and you just have to let your body handle it. But that’s usually the first three months. That’s usually not after three months. The imaging and tacks force was some more information to my prior question. Oh right, right. So if your Mesh is too tight, they must have used tacks because using, doing a repair without tacks does not make it be too tight.

Speaker 2 (00:59:11):

And therefore removing the tacks alone however, will not get rid of the pain because your Mesh is now stuck in that tight position. So you have to unstick it. So I would just undo the repair and redo it again. I hope that’s helpful. Okay, I think we’re out of time. How fast was that? So many questions. Please come to California. I want to come to you from Minnesota, but I’m 80 and my husband’s 84. Well just, you know what, continue with the online consultation, that’s really the best. I offer so much information when you email me for these online consultations, so that’s what I highly recommend. And therefore, thank you everyone. That was so much fun. Please, please follow me. I need more subscribers on my YouTube channel so I can continue populating it with all these hernia talk q and As. So subscribe when you’re not available to come out live on this.

Speaker 2 (01:00:14):

You could always watch it again on YouTube at any time. If you’re interested to make this a podcast, let me know. I’m interested to see if anyone has any interest in a Hernia Talk podcast. And then thanks everyone. Thanks for being with me on Facebook as a Facebook live at Dr. Towfigh. I’m also the Her at Hernia Talk. Sorry, hernia doc on Twitter and Instagram. And I love you all. I love what I do. I’m so blessed and I really thank you for everything and hope that you all have an excellent, excellent, excellent, excellent evening. Thanks for joining me. I will see you next week. We do have a great, great guest. Next week we’re going to talk about watchful waiting and all the data that’s out there in its favor and laparoscopic versus open surgery, et cetera. So see you next week. Bye.