Episode 98: Watchful Waiting for Hernias | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

Hi everyone, it’s Dr. Towigh. Welcome to Hernia Talk Live, our weekly q and a on Tuesdays. We call it Hernia Talk Tuesdays. My name is Dr. Shirin Towigh. I am your hernia and laparoscopic surgery specialist. Many of you are joining us on Facebook Live at Dr. Towigh or via Zoom. Thanks also for following me at Hernia Doc on Twitter and Instagram. And as always, this episode will be put up online on my YouTube channel so that you can watch and share with others. So I’m very excited about today’s session because I personally have tons of questions and I know many of you have already submitted your questions ahead of time. Our guest today is Dr. Robert Fitzgibbons, Jr. I’ve known Dr. Fitzgibbons well, I’ve known of him since I was a resident, but I’ve definitely known him since I’ve been in practice for almost 20 years now. He’s a hernia surgery specialist and professor at the Creighton University in Omaha, Nebraska. You can follow him on Twitter at Fitz Jr one, and if you all could, please welcome Dr. Fitzgibbons. Hi,

Speaker 2 (00:01:07):

Glad to be here. It’s a pleasure.

Speaker 1 (00:01:10):

Thank you. So I said that I’ve known you since residency because believe it or not, I train at UCLA and I was part of the LAP versus open VA trial when I was a resident. We were enrolling patients and following the up them up. And that was just a landmark, landmark trial that you were very intensely involved with.

Speaker 2 (00:01:35):

Yeah, it’s a complicated situation how that trial got going. Yeah.

Speaker 1 (00:01:41):

So for those of you that don’t know, we surgeons don’t just willy nilly operate on people. We try and do as much as we can. And there was a time when laparoscopic hernia surgery was introduced. This is after other laparoscopic operations. It said it was introduced and there was some controversy as to whether it was safe or appropriate to do laparoscopic surgery. And I know there’s a story behind it, so I’m going to have you explain it. Okay. But the VA was chosen as a center nationally to help study this. But maybe you can tell us the story a little bit.

Speaker 2 (00:02:25):

Okay. I’ll tell you the little story. It all kind of revolves around laparoscopic gallbladder surgery. Laparoscopic gall bladder surgery was introduced in the early 1990s, late 1980s and was a tremendous advance in surgery and saved patients tremendous amounts of pain, but it came with a price. The price was lots of injuries as surgeons were having to be retrained to do laparoscopic surgery. But surgeons didn’t do laparoscopic surgery before then. So I was one of the first academic surgeons that means university surgeons to do the laparoscopic cholecystectomy. And so the college American College of Surgeons came to me and said, we know that the hernia surgery is going to be the next great laparoscopic revolution because it has about the same incidence of cholecystectomy, about 800,000 cases per year. So they asked me if I would spearhead an effort to try to more orderly roll out laparoscopic hernia repair. So we said, okay, we’ll set up a trial comparing laparoscopic hernia repair to regular open conventional hernia repair. Seemed like a logical thing to do. And so we applied for an NIH grant and we didn’t get it this

Speaker 1 (00:03:55):

Very expensive. It’s very expensive to do a prospective randomized trial with follow up because you had to follow these patients out for a certain number of,

Speaker 2 (00:04:07):

So we didn’t get it. But we went back to the drawing board and we started talking to some economists at the University of Chicago and they said, well, why don’t you add a watchful waiting arm because the government would love that because they save money. If patients didn’t have to have surgery, how much money would the government save in their medical costs? So we got that together and we split the investigation into two separate trials. One was carrying laparoscopic versus conventional surgery at the VA and in the private sector or in the university sector, it was laparoscopic versus open surgery. So those two grants got funded to 6 million a piece by the VA and one side and the H and the NIH and the other side. And that’s how this all came about. That’s how all this data that we developed came about. So, and we showed that watchful waiting was a reasonable approach. It was safe in patients that didn’t have symptoms. And as you have symptoms, if you come to the doctor and you’re having a lot of pain, watchful waiting is not an acceptable option. But if you’re not having any pain, watchful waiting is a reasonable option. In pa, there’s very few problems with complications, but on long term follow up though, we’ve kind of found that almost all patients crossover eventually because they eventually developed pain. So

Speaker 1 (00:05:53):

It’s right. So it used to be that patient would get a physical examination for their job or just their annual physical, and the doctor would find an inguinal hernia and they were sent to surgeon and the surgeon would say, oh my God, we have to fix you. What if you end up with a complication like a strangulation in the emergency room? And then pretty much everyone was recommended surgery, whether they were 20 years old or 90 years old. And we didn’t have a concept of what would happen if we just watched it for a while because they probably had that hernia before it was diagnosed by a doctor oftentimes. And so that’s what was revolutionary. So half of your patients had no surgery and half of your patients had, did it matter what kind of surgery? Laparoscopic or open

Speaker 2 (00:06:48):

Either Lichtenstein or laparoscopic

Speaker 1 (00:06:51):

And then only men, correct.

Speaker 2 (00:06:54):

Only men? No. We were strictly forbid to have females in this program because obviously females because of the problem with femoral hernias, right. A much higher instance of complications. And so there was absolutely no way that they were going to allow us to enroll females.

Speaker 1 (00:07:10):

And we’ve discussed femoral hernias here before. It’s, it’s uncommon when it happens. It’s most often women, and it’s one reason why women have some worse outcomes with hernias because of femoral hernias missed or it’s delayed in the diagnosis. And then can you just briefly describe what you found? Your first trial was a short-term trial, correct?

Speaker 2 (00:07:35):

Well, yes. It was a short-term trial, yes, it was five years. And that’s when we found that it was completely safe. We had one patient with an in hernia accident, we called it hernia, either incarceration or bowel obstruction. We called that a hernia accident. And we had one patient that had that

Speaker 1 (00:07:57):

One patient out of one patient over five years,

Speaker 2 (00:08:01):

About 1200,

Speaker 1 (00:08:02):

1200 patients. That’s just remarkable.

Speaker 2 (00:08:04):

Five centers across United States and Canada that contributed patients to this study

Speaker 1 (00:08:10):

And that translate into at least a number we could share with our patients. So within the next five years, you have a 0.18% per year risk of something bad happening. And in this trial, the bad happening was the hernia got stuck or they needed urgent it, but not emergent surgery. No one died basically.

Speaker 2 (00:08:29):

No, nobody died. Nobody. But what we were very concerned about is that doctors would extrapolate to symptomatic patient patients or female patients, and we wanted to make sure that they understand this is for minimally symptomatic patients or asymptomatic no symptoms. They just see a bulge in their groin. They don’t have any problem with it. They play golf all 18 holes every day if they want to. But if they can only play nine holes at golf because they’re hurting and bothers them, then they got to get it fixed. They don’t qualify for this program.

Speaker 1 (00:09:09):

And your definition of minimally symptomatic was like a little twins. I just noticed it, but it doesn’t bother them.

Speaker 2 (00:09:16):

They didn’t interfere with daily activities, did not interfere with activities of daily living. If they did, if were limiting their activities at all, they didn’t. Yeah.

Speaker 1 (00:09:27):

So that was your five year trial. I loved it. I thought finally we can discuss with our patients because if it’s a fraction of a percent risk per year, 0.18% risk per year, and you’re 80 or 90 years old, so you have, let’s say 10 years of life, then that’s like a 1.8% risk of something bad happening, which means like a 98, 90 9% risk of having no issues living with your hernia. Whereas if you’re 20 years old and your life expectancy is in the eighties or nineties, you can multiply 0.18% times all those years and that’s a significant number. So back then when you had the five year data, did you tell your younger patients therefore you should have surgery or did you say therefore you can wait until you’re more symptomatic?

Speaker 2 (00:10:16):

We would tell ’em that you’re probably going to, well, after we got the second set of data, when we realized that so many people were crossing over, we told them that, you know, can delay surgery as long as you want, but you’re probably going to have to have surgery, so you should probably pick an elective time when it’s very convenient for you and just get it done. That’s kind of what we tell our patients now. It’s the data shows that on long-term follow up, the vast majority of patients eventually crossover from watchable waiting to surgery. And

Speaker 1 (00:10:54):

That was tenure data?

Speaker 2 (00:10:56):

Pardon me?

Speaker 1 (00:10:57):

Was that seven to 10 year data?

Speaker 2 (00:10:59):

Yeah, that was our 10 year follow up. And we presented at the American surgical about three years ago and showing that I think there was about 80% crossover by Kaplan Meyer estimation about 80% crossover. So the vast majority eventually developed symptoms. So that’s what I

Speaker 1 (00:11:24):

So do. Okay. That’s a good question. So at 10 years they about 80% got symptoms, and therefore the whole purpose of the trial, which was watchful, waiting in asymptomatic or minimally symptomatic, didn’t apply. And because they had symptoms, they were more likely to choose surgery than to just watch it. But do you think it makes, do you think that, let me rephrase. Were you looking in the zero to five year trial at symptoms as well, or just crossover from no surgery to, because the people that didn’t get surgery were allowed to choose surgery. You weren’t forced to stay in that arm, but most of them were fine. They didn’t, I think a quarter crossed over or something.

Speaker 2 (00:12:10):

They couldn’t be enrolled unless they had no symptoms or minimal symptoms. Symptoms that did not interfere with AC activity. So they wouldn’t be enrolled in the trial unless they had no, or some minimal symptoms that did not interfere with their activities of daily living at all.

Speaker 1 (00:12:30):

And then if they’d enrolled with no symptoms and they just got tired of having the hernia, they could choose to have surgery. You didn’t force ’em not to have

Speaker 2 (00:12:38):

Surgery? Some did. Some did.

Speaker 1 (00:12:40):

And how many of the ones that were enrolled in the watchful waiting arm, which was no surgery, had symptoms in the first five years? Do you know how that answer?

Speaker 2 (00:12:53):

I don’t remember the exact percentage. I think 80%, 30, 30% that crossed over during the first study. Five years

Speaker 1 (00:13:01):

Study? Yeah. Yeah. Okay. It’s just what do you tell patients? Because I have colleagues that say, well, you’re eventually going to need surgery, so let’s just do it now. And basically based on that data, do not offer watchful waiting. In fact, their interpretation of that data is you shouldn’t watchful wait because you will eventually have surgery. So I’m going to offer surgery to everyone. I’m more conservative. I say, we don’t know what your personal chance will be. We know the population study that two-thirds or four fifths of patients eventually by 10 years will get symptoms and want surgery. But some people don’t want surgery. Even if they have symptoms, that’s their choice. You can offer it. But to offer it to a hundred percent of the patients on day zero, I’m not a fan of. I feel like we should have that discussion. What kind of discussion do you have with your patients

Speaker 2 (00:14:00):

Counsel in that? We do. A substantial number of patients do eventually develop more pain and have to have surgery. But there is no reason to be in any big hurry to have the surgery as long as you’re not having any symptoms and there’s at least a 20% chance that you will not have to have ever have surgery.

Speaker 1 (00:14:25):

And some people are really,

Speaker 2 (00:14:26):

One little caveat in this whole thing is elderly patients, we found that to develop a new hernia are at higher risk for complications. We worry about oxygen areas that develop a new hernia. They tend to have more complications. So we tend to very liberal about operating on new hernias that develop in elderly patients.

Speaker 1 (00:14:58):

And you feel that they’re more likely to rapidly evolve into a more dangerous hernia? More likely,

Speaker 2 (00:15:05):

Yeah. They tend to act, for example, they tend to act almost like females with femoral hernia. They have a higher risk of serious complications.

Speaker 1 (00:15:14):

Got it.

Speaker 2 (00:15:15):

So if we see a patient,

Speaker 1 (00:15:16):

They’re all constipated. Why do you think that is?

Speaker 2 (00:15:18):

I don’t know. I don’t why it is. They’ll have large, why is an 80 year old all of a sudden develop a hernia? We just feel like

Speaker 1 (00:15:27):

They have, I think they’re all constipated and have enlarged prostates. That’s the problem.

Speaker 2 (00:15:33):

That’s probably it. Whatever it is, they seem to have a higher risk of emergent operation.

Speaker 1 (00:15:40):

So a question provided live is why do they get the symptoms? What’s happening with the hernia where they then become symptomatic?

Speaker 2 (00:15:53):

Let’s say a patient just has a bulge and all of a sudden becomes more painful. I just think it’s has to do with something getting into the hernia intermittently. They’re walking around, something gets into it, and they have to lay down and push it back in. And I just think it has to do with the contents of the hernia.

Speaker 1 (00:16:17):

And then this other patient had surgery in the pathology report on the fat tissue that was part of the contents of the hernia, showed reactive changes in congested vessels. What does that mean? And does it in indicate an incarceration

Speaker 2 (00:16:34):

In what tissue? Omentum the fat.

Speaker 1 (00:16:37):

Pardon? They wrote fat. I assume it was some type of

Speaker 2 (00:16:42):

This is a patient, you’re this patient you’re describing.

Speaker 1 (00:16:46):

Yeah, that’s one of the live questions presented. They already had surgery. I guess part of the fat was removed and that showed reactive changes in congestive vessels.

Speaker 2 (00:16:55):

I assume that must be omentum that was trapped in the hernia and that was removed. It could be prepared of fat too. That means fat from sort of the lining of the A abdominal wall.

Speaker 1 (00:17:08):

We just don’t see as much congestion in those. It’s usually the larger amount.

Speaker 2 (00:17:14):

I would say omentum. I mean, I did a case this week that we could not reduce the omentum. It was scrotal hernia, massive amounts of omentum. And we could now, so we had had to resect it. We got a similar pathology report.

Speaker 1 (00:17:28):

Yeah. Well, incarceration is a clinical diagnosis. We don’t usually diagnose it based on pathology. But yeah, it’s probably been there for a while. And there’s inflammation. Probably the inflammation from the incarceration causes some of the symptoms. Right.

Speaker 1 (00:17:47):

So I just want to point out, I get a lot of questions about, well, why don’t we have all this data and there’s so many thousands, millions of patients having surgery a year. Why don’t we have better data? a lot of times they want questions like, exactly what is a chronic pain rate? What is this? What is that? And your study took 6 million long period of time. I remember when I was a resident, I was very impressed by the lab versus open trial because we regularly had these nurses, a hundred percent dedicated to this trial that would bring the patients in for you to reexamine and confirm whether they had a hernia, intact hernia repair or hernia recurrence to provide that long-term data. And that’s a lot of resources. And I guess the VA was the perfect place to do it because they have the staffing for these kind of trials, but it’s so expensive. And to be able to do good quality research, that is really, really difficult. Especially in the US at that time when we had zero databases really for hernias. So you had to start from scratch.

Speaker 2 (00:18:55):

And it’s very expensive to do this type of, if you want to do it with quality control and have somebody coming in independently and source checking all of the charts to make sure the data is entered correctly.

Speaker 1 (00:19:11):

Yeah, double check.

Speaker 2 (00:19:13):

Yeah. It’s my problem with the registries that we see now. There’s not like a lot of source checking, effective source checking. And I worry that the data And are you a member of ACHQC?

Speaker 1 (00:19:31):

Right. So I am a member of the ACHQC and I hope more people would be members, but I also have my own database that we have, which is very granular down to the details for every single patient. And I’ve tried to do studies using the database from the population database from the ACHQC, and it’s very low quality. Yeah, it’s hard to do a good study on it.

Speaker 2 (00:19:56):

Yeah, I promise that there’s the hard stops where you have to Yeah. Sort of guess anyway. Yeah.

Speaker 1 (00:20:04):

Yeah. It’s really, we’re in evolution. I hope one day it’ll become a much more robust database where more surgeons are involved and more patients provide long-term care, but it’s, it’s got a lot of holes in it.

Speaker 2 (00:20:18):


Speaker 1 (00:20:20):

The next question is, does the size of the bulge serve as an indicator for surgery versus watchful waiting?

Speaker 2 (00:20:28):

No. I would say not really. More, it is pain more than the size of the bulge. Many hernias are, they just have a bulge in the groin, whereas others extend all the way into the scrotum testicle and be maybe totally asymptomatic. So it’s more pain. Pain driven would be a better answer to that question, I think.

Speaker 1 (00:20:58):

Yeah, I agree. I always tell the patients we go based on pain not by size. So sometimes they’re really small ones, they’re super painful. And the big ones are these wide open holes and not as painful, but it looks awkward but doesn’t, going back to the omentum versus pre peritoneal fat questions, the patient believes it was pre peritoneal fat. But here’s a great question that I’d like to hear your answer for. It’s about prophylactic repairs. So the question is this. My question is, I have a right squirrel hernia. One doctor I visit say said, I also have one on the other side. I have no symptoms or issues on that side. He said it, I should have that repair when he does the right side. Another doctor I went to isn’t too keen on the idea of fixing both hernias. He says, very small on the left and just wait. Any advice? The left never bulges or bothers me, but I hate to have to come back next year for another surgery.

Speaker 2 (00:21:59):

Well, that’s a very good question because I face question every day. Now, is the hernia repair going to be done laparoscopic or open?

Speaker 1 (00:22:08):

Let’s just say it’ll be done laparoscopic. We’ll start with that hypothetical

Speaker 2 (00:22:12):

Because it was done open, I would definitely not do anything on the other side.

Speaker 1 (00:22:16):

Yeah, I agree.

Speaker 2 (00:22:17):

So it’s a very debatable thing if doing laparoscopic surgery because you, it’s so easy to fix the other side because you have the same three access ports that you’re going to fix the symptomatic hernia. But the problem we have is that the small incidence of post hernia orifice, groin pain,

Speaker 1 (00:22:40):


Speaker 2 (00:22:41):

It is a real issue. It’s very rare. I mean less than 5% of all hernia repair, but a certain percentage of patients that have their hernias repaired end up chronic with chronic pain because of scar tissue or nerve injury or whatever. But they end up with pain in the groin. And in some cases it can be absolutely incapacitating. That’s unusual. Most usually it’s minor, but I just hate to take a patient that has a totally asymptomatic hernia and then turn it into where I do a beautiful repair on the hernia and then turn it into a situation where they have some pain. So this requires a very significant informed consent discussion with the patient.

Speaker 1 (00:23:36):

I agree. Before proceeding

Speaker 2 (00:23:37):

With the repair,

Speaker 1 (00:23:40):

But based on your watchful waiting data, they will have an 80% chance of having symptoms in the next five to 10 years.

Speaker 2 (00:23:51):

Well, these are, she’s, you described a non bulge,

Speaker 1 (00:23:55):

Asymptomatic non

Speaker 2 (00:23:57):

Bulge. And I don’t know if you deal with, I deal with a lot of, a lot of gynecologists who see these open internal rings and females. Yes, quite frequently. And what do you do with those? Basically that’s a hernia and don’t, what do you do with those patients? We have a very aggressive endometriosis group, and they’re doing all these laparoscopies and doing these extensive endometriosis operations and they see these patent internal rings. And I’ve come to the point, what I do with these patients is I just treat it like a pediatric hernia. I take down the peritoneum and sew it. Close it.

Speaker 1 (00:24:41):


Speaker 2 (00:24:43):

So what’s the natural history of a patient that has what looks like a hernia but clinically doesn’t have one? I’m not sure the natural history is, I don’t think we know it.

Speaker 1 (00:24:56):

Yeah. So check this out. The patient was offered bilateral open surgeries, so open on the scrotal hernia side and open on the asymptomatic, non bulging contralateral side. What are your thoughts on that

Speaker 2 (00:25:12):

That think that’s a terrible mistake?

Speaker 1 (00:25:14):

I agree. That’s horrible. Even if that side was symptomatic, there is one trial and I forget, it’s an old one. I forget who actually wrote it, which showed if you repair open bilaterals at the same time, the risk of recurrence is higher than if you stage them. And so I always stage them. It’s kind of a difficult recovery to begin with. So to do both sides at one time sometimes is too much recovery for the patient. But let’s say you had someone that had open bilateral al hernias or needed open bilateral inguinal hernias, do you do them at the same time or do you stage them

Speaker 2 (00:25:54):

Again? I kind of have a discussion with the patient on that. Yeah. Yeah. I tell ’em they’re going to be pretty roughed up if they do both at the same time. That’s true. It’s going to be hard to move and everything like that. And I kind of let them make the decision. And some say they want to go ahead with both sides at the same time. So I leave that kind of up after informed consent, I leave that up the patient pretty much.

Speaker 1 (00:26:18):

Yeah, this is true. But yeah, definitely the answer would be do not do bylaw open. If you have no symptoms on one side, leave that one. I

Speaker 2 (00:26:28):

Definitely would not do that. No way.

Speaker 1 (00:26:30):

I agree. So the next question I have for you is, let me bring this up for you, is going back to the original trial, which was a laparoscopic versus open VA trial. And that was kind of very unique. It was to be fair, in the earliest stages of laparoscopic hernia repairs. So not everyone was an expert, but the patients were randomized to either getting laparoscopic or hernia repair or open. And the data showed that pretty much laparoscopy was better if you were skilled in doing laparoscopy and maybe better if you had hernia repairs on both sides. But it wasn’t like the best surgery necessarily. If you can do just a good angle hernia repair open. Is that kind of a good interpretation, a fair interpretation?

Speaker 2 (00:27:31):

Well, I can give you a little bit more background on that if you’d like. Yeah, please. When we were developing these two trials, we wanted to do the lap versus open in the private sector and let the VA do the other study. That’s what our goal, our desire was. But the VA absolutely insisted that they do that, the lap versus open, because we knew that the skill of a VA surgeons was not up to what the skill was in the other side, but we fought it and fought it and fought it, and they just, wow. They insisted on doing that trial in the VA, which to this day is something that I worry a lot about. Cause I think maybe the outcomes may have been quite a bit different if we had the expert laparoscopic surgeons in the university setting. Yes. Where the other trial was done. I think the outcomes might have been a little different that that’s just a secret.

Speaker 1 (00:28:39):

That’s a great backstory. So how relevant do you think that data is today? Because for me, I think two things. One is we always say when you pick a surgeon, let them kind of tell you how they would like to tailor your care. Because if someone’s not good at laparoscopic surgery, you don’t want to force them to do laparoscopic surgery for you because you read somewhere that it’s better or shorter recovery time, let’s say. And the reverse is also true if someone doesn’t is really good laparoscopically and doesn’t really do too much open surgery. And there are plenty of surgeons nowadays where the reverse is now true. You don’t want to force them to do a Shouldice or a Lichtenstein if they’re not comfortable doing it because that’s just the wrong choice for that surgeon for you. Well, that said,

Speaker 2 (00:29:29):

I had to site and visit every single institution, every single VA institution mean we would not allow a surgeon that wasn’t competent at it, but they weren’t experts by any means.

Speaker 1 (00:29:42):


Speaker 2 (00:29:43):


Speaker 1 (00:29:44):

So in your practice, you were trained during open surgery, so you’re actually probably more skilled in open surgery than the average newer graduate and your career has been in laparoscopic surgery. So you’re kind of skilled in both.

Speaker 2 (00:30:02):


Speaker 1 (00:30:03):

Do you feel that, well, let me just ask, do you feel you can provide the same care for both lap and open? And if you do, the answer is yes. Do you tend to push one technique over another because you feel superior

Speaker 2 (00:30:17):

For an uncomplicated unilateral hernia? Uncomplicated one-sided hernia? I don’t see too much difference between the two by frankly. Now a lot of people would say I’m crazy and that laparoscopy is so much better. But I don’t personally in my practice see much difference. And since we can do the open operation under local anesthesia with some little sedation, I find a lot of my patients, especially the doctors, the doctor and I operate a lot of doctors, they want the open operation really, because avoiding a general anesthetic,

Speaker 1 (00:30:55):

Yes, this is true,

Speaker 2 (00:30:56):

Which is required for the laparoscopic operation, but for bilateral hernias, current hernias, there’s lots of very good indications for laparoscopy. Yeah. Females with, we know that data from Sweden where there’s this horrendous recurrence rate in females who were operated on and had direct hernias, which are almost reportable in females. So obviously it was a missed femoral hernia. So females, but females don’t tend to do as well with pain laparoscopy. For some reason, it seems like females have more pain with laparoscopic hernia repair than males. I don’t know why that is. Is that your experience?

Speaker 1 (00:31:47):

I know the data shows in general women have more chronic pain after al hernia repairs than men. It’s talking about

Speaker 2 (00:31:54):

Acute acute pain, operative pain. Oh,

Speaker 1 (00:31:56):

Acute pain. Yeah. Oh no, I don’t

Speaker 2 (00:31:59):

Notice. You haven’t seen that? Yeah. Would you just been our observation that are female patients have a lot more

Speaker 1 (00:32:06):

Acute, do you cut the round ligament?

Speaker 2 (00:32:08):

Pardon me?

Speaker 1 (00:32:09):

Do you cut the round ligament?

Speaker 2 (00:32:12):

We try not to. Sometimes you have to, but

Speaker 1 (00:32:16):

I always do. And I wonder if that helps because it allows them to kind of lay flat without having to go be tugged on, have the peritoneum tugged on. I don’t know.

Speaker 2 (00:32:26):

I mean you think

Speaker 1 (00:32:27):

That’s a factor,

Speaker 2 (00:32:28):

Isn’t there? There’s some evidence that there’s, could be possibly be some sexual ramifications of that,

Speaker 1 (00:32:38):

Not the ligament. No. I’ve actually done a lot of research on that. Every time I see a gynecologist, uro gynecologist, urologist, pelvic floor specialist, I ask about the round ligament. They’re all cut it. We don’t care about it. It doesn’t have any effect on the uterus, how it moves or any function. But women are shown, well, the women female pelvis is different and they are shown actually an anatomical stage to a higher density of nerves in the pelvis than men. So maybe that’s part of it.

Speaker 2 (00:33:11):

But you don’t think the innovation of the mounds, that kind of stuff means anything?

Speaker 1 (00:33:17):

I don’t know. Oh, I don’t cut the general femoral nerve wronging

Speaker 2 (00:33:23):

The wrong, but that eventually leads to the scrotum in the male,

Speaker 1 (00:33:31):

But I separate, I make sure the general nerve is not addressed. Yeah, yeah. No, I don’t touch the general nerve for sure. Sure.

Speaker 2 (00:33:37):

In the European guidelines, there was a lot of controversy about that. Yes and no. It was never settled. It was never settled. Yes. Probably it’s easier if you get rid of the round ligament, it’s It’s

Speaker 1 (00:33:50):

Much easier. So much easier. Yeah. I do it a hundred percent of the time. Okay. a lot of questions. Okay. So this is a great question about watchful waiting after recurrent hernias. So can you apply the same approach to recurrent al hernias that you do for the initial hernia? Or is there an increased incidence of progression and or postoperative pain that impacts her decision making? In other words, do recurrent hernias act similarly to primary hernias in terms of there incidents of becoming more symptomatic or incarcerate more

Speaker 2 (00:34:27):


Speaker 1 (00:34:27):

Presenter, you said?

Speaker 2 (00:34:29):

Yeah, that’s a good question. We enrolled the recurrent hernias, no problems. And we just treated ’em the same way as initial hernias. Same criteria. If that they had minimal symptoms or no symptoms, they were eligible. And so they’re in that group that had almost no complications. So I think it’s reasonable if you have a recurrent hernia and no symptoms, but commonly recurrent hernias are symptomatic much more commonly than initial hernias.

Speaker 1 (00:34:59):

Yeah. And I think the reason is now they’re dealing with all the extra scar tissue and tugging from prior surgery that may be adding to pain as opposed to a wide open virgin territory where the hernia can just go in and out without being attached to anything.

Speaker 2 (00:35:15):

That’s right. Yeah.

Speaker 1 (00:35:17):

At least that’s explain to

Speaker 2 (00:35:18):

My patients. The beauty of the recurrent hernia is that you have two options. One is open, one is laparoscopic, and so you can just do the opposite of what was done before. Yes. And then you can work in territory. That’s a little easier to deal with, so. Correct. So that’s a unique situation where if you had a laparoscopic operation, then you’re going to do it open for sure. And if you had an open operation, you’re going to do a laparoscopic for sure. So it’s a unique situation where you have a good alternative.

Speaker 1 (00:35:51):

Okay. Here’s another question. Patient with femoral hernia laparoscopically repaired with Mesh now has chronic pain ever since the patient had physical therapy, injections, anti-inflammatories, multiple scans, and nothing is seen and none of the different modalities to come. The tightness in the pain helped. What is your advice for the patient to do next?

Speaker 2 (00:36:18):

I understand, is this a female or a male?

Speaker 1 (00:36:20):

Female? Female.

Speaker 2 (00:36:21):

Female. This is a terrible problem. So he hasn’t responded to anything, any conservative measures? No. Yeah. And a triple neurectomy is not going to help because this is in a different space where where the nerves are going to help. If the pain is totally incapacitating, you’re probably going to come to try to remove the Mesh, which may or may not help, may make it worse. Again, I deal with, I have clinic tomorrow, and I’ll probably see three patients like this tomorrow, the same problem. These post hernia groin pains because of my specialty. And it is very difficult to deal with these patients,

Speaker 1 (00:37:08):

A lot of teasing out of what exactly was done and so on. So in these patients with femoral hernias, sometimes not necessarily this patient, I feel the Mesh is pulled down too low and it tends to overlap too much with the obturator space and the psoas. And that is why you said your Mesh is too low, and that kind of affects your ability to go upstairs and do a lot of hip flexion. Or sometimes I feel that the Mesh is placed too taught. So instead of allowing the Mesh to fall the natural curvature of the groin so that when you’re bending or walking get out of bed, doing normal activities, that it’s not too tight. Some people, they like for a femoral hernia, you tack it in place oftentimes, and instead of tacking it in kind of a following the curvature, they may tack it so it’s like tight. And then they feel the tightness of the repair as opposed to the actual repair being something wrong. So

Speaker 2 (00:38:09):

Often, what do you do about it?

Speaker 1 (00:38:10):

For both of those situations, you have to remove the Mesh, but there it’s not a Mesh problem. So they can still get Mesh. Again, they’re not reacting to the Mesh. It’s not like a Mesh stiffness issue or a Mesh implant illness, a Mesh reaction issue. It’s just an technically not perfectly done repair. That’ll be one of my suggestions. Okay. Here’s another question. Do groin hernias with bulges become harder to operate on the longer you wait?

Speaker 2 (00:38:43):

Yeah, that’s true. The long, these chronic hernias, I just returned last week from the Dominican Republic where we Creighton, we have a hernia emission that we go every year and fix 100 hernias in a week. And they’re all chronic hernias that have been there for years and years and years. Most of them have descended all into the scrotum, and they’re much more difficult to repair. So yes, the longer the more scar tissue develops, the longer it weights, the harder it is. It’s not dramatic for a hernia that’s just in the groin, but when they descend into scrotum, it becomes pretty difficult sometimes.

Speaker 1 (00:39:28):

Yeah. I must say though, that in the US we don’t see those really chronic ones that you see in the Dominican Republic. You may see bigger hernias, but the ones in the DR, I mean, they’ve been incarcerated for decades. Right. They’re usually actually pediatric hernias that were never repaired often. Yeah. So yeah, it’s a difficult problem. And eighties even worse what?

Speaker 2 (00:39:55):

Eighties even worse. But we haven’t been able to go there for a couple years,

Speaker 1 (00:39:58):

Haiti. I know. I know. Yeah. I would like to be involved in that at some point. Also, there’s a friend of mine who’s a Nigerian one. Yeah, it’ll be really great.

Speaker 2 (00:40:09):

Yeah, we’d love to have you.

Speaker 1 (00:40:11):

Thank you. Okay, question about epigastric cardios. So actually before we do that, you actually also looked at a watchful waiting for umbilical hernias. Is that correct?

Speaker 2 (00:40:23):

Yeah. It wasn’t a direct study, but I was involved with it with some other surgeons.

Speaker 1 (00:40:28):

So what’s your practice for people that come in with an outtie, like a belly button hernia?

Speaker 2 (00:40:36):

I think it’s pretty much the same. It turned out to be same, pretty much the same. If they’re not having any symptoms, they really don’t have, there’s no urgency to get it repaired. But when they start getting skin changes, a lot of times they’ll build with hernia patients, when it gets big, they start having skin changes, then you worry about ulcerations

Speaker 1 (00:40:54):

Thin. It gets thin, right? Yeah. Yeah.

Speaker 2 (00:40:57):

Because the lyse is pretty thin to begin with. And so once they start getting skin changes, that’s when something needs to be done.

Speaker 1 (00:41:05):

So this is a question about epigastric hernia. So it’s higher up than a bellybutton hernia is an epigastric hernia that is not bothering you. Does that need surgery?

Speaker 2 (00:41:16):

That would really be the same as the umbilical hernia. If it’s not bothering you probably don’t need to do anything about it. They do. Sometimes they can get very large though. So you don’t want to get too large before you do something because sometimes they can really get big.

Speaker 1 (00:41:38):

So is it fair to say that in general, and of course femoral hernia is a big major exception to it, but in general, if you have a primary abdominal wall hernia that’s not bothering you. For most people it should be considered safe to just to watch it. Whether it’s belly bone, epigastric, groin, that sound about right?

Speaker 2 (00:42:01):

Yeah, I think that’s a very good, but do not extrapolate to femoral hernias and females, they are dangerous hernia. They need to be fixed.

Speaker 1 (00:42:09):

So those actually the one break in the rule, even if they don’t even know about the femoral hernia. Let’s say they got a CAT scan for their, I don’t know, gallbladder and they happen to catch the groin area. If they found a femoral hernia, they should be advised to have that repaired.

Speaker 2 (00:42:26):

Yeah. Because we know that at least 40% of patients of females will end up with in the emergency room of strangulation

Speaker 1 (00:42:35):

Eventually. And is there a time span that you recommend when you talk to your patients about that?

Speaker 2 (00:42:41):

I don’t tell ’em. It’s not emergent. They shouldn’t dillydally. They shouldn’t wait two years, but it’s not emergent. But they should find a time that they can fit it into their schedule or they can be off work for a couple of weeks and we’ll fix it.

Speaker 1 (00:43:01):

And then let’s talk about the really, really big harness, because you were telling me before the, we started that your practice really evolved to dealing with these enormous abdominal wall reconstructions and you’ve looked at these patients to see is it really worth it to fix these huge operations. And maybe you can tell us a little bit about what interesting finding you found.

Speaker 2 (00:43:25):

Well, we do deal with these huge hernias that are really so much, are so incapacitating to the patients and the nurses and the residents tell me, I have the most grateful patients in the hospital.

Speaker 1 (00:43:40):

Oh yes,

Speaker 2 (00:43:41):

They’re so grateful. And even in the immediate postoperative period when they’re having their postoperative pain, so mean some of these huge hernias that seem to have loss of domain can be so symptomatic and so much influence, quality of life for our patients that we just have to fix ’em. That we deal with two huge problems with these patients. One is morbid obesity. So many of these patients are morbidly obese and we like to have our BMIs less than 35. It’s very hard to get that nowadays. And then smoking, so many of these patients smoke and that can be a huge problem with incisional hernia. Although we have data from the ACHQC, we we’re just in the process of publishing a paper based on a ACHQC data showing that active smoking really did not make any difference as far as recurrence rates we’re concerned. What the problem was is people that smoked smoking for a few months prior to surgery. So if they smoked all the way up to the surgery or they quit years ago, that was good. But the people that did the worst were those people that tried to quit within this a couple of months of surgery. It’s very, yeah, and it’s a huge database.

Speaker 1 (00:45:15):

Is it because they were eating,

Speaker 2 (00:45:18):

I don’t know what they were gaining weight. I don’t know what I, sugars

Speaker 1 (00:45:21):

Were high.

Speaker 2 (00:45:23):

We cannot explain it, but the people that did the worst were those that tried to quit smoking within a few months of surgery. That’s

Speaker 1 (00:45:31):


Speaker 2 (00:45:32):

Large recurrence rates are concerned.

Speaker 1 (00:45:34):

What we did show is that the quality of life is significantly improved, even though these are very big complicated operations that are sometimes risky even. And they have their own set of complications. But overall, despite the general anesthesia, long operation, long recovery time, risk for infection or wound complications, they actually have a much improved quality of life.

Speaker 2 (00:45:58):


Speaker 1 (00:45:59):

Mean, with these big hernias,

Speaker 2 (00:46:00):

They come into my office and they’re just so grateful. They’ve dealt with this huge thing sticking out and painful and cosmetically a disaster. And yeah, they’re just so grateful.

Speaker 1 (00:46:16):

And do you have them in binders? Do you use abdominal binders after their surgery?

Speaker 2 (00:46:22):

I know a lot of surgeons do, but I don’t think there’s good evidence that binders prevent any complications. But if the patient’s more comfortable with a binder, I’ve certainly a lot of, but the problem is you can’t see the wound, you know, got to take the binder off and then you got to put it back on and it’s painful for the patient in the immediate postoperative period. So I’m a big study from France a few years ago that showed that really binders didn’t make any difference. Correct. And we offer the patients a binder if they want, but I’m not a big fan. I like to look at the wound at least to them while they’re in the hospital.

Speaker 1 (00:47:04):

Okay. Next question is on the similar line is the previous question about how difficult the operation will be if you wait. So as a hernia grows bigger with time, can watchful waiting make the repair more difficult or cause the formation of adhesions or make a hernia that could have been treated by pure tissue repair, less desirable and you have to treat it with Mesh?

Speaker 2 (00:47:29):

Well, that’s certainly true. If the hernia gets to be a huge size that the recurrence rate with a pure tissue repair would be much, much higher. So if you are interested in a pure tissue repair and many patients are many, I would say maybe 5% of my practice, the patients will say, I don’t want Mesh, I want, then you should get that hernia repaired when it’s small as possible because the tissue repair, population based studies have shown that over time tissue repairs will fail in about 15% of patients. It sort of wears out the tires on your car. With Mesh, it’s more like 1% failure over time. But there’s many patients that are willing to accept those odds, and that’s perfectly fine. If that’s what they want, then I’m glad to do it. We, we tend to do a classic Bassini Bassini with the triple layer type repair. That means that we do a repair that Bassini originally described, which when the operation

Speaker 1 (00:48:44):

Original Bassini, not the modified, the original

Speaker 2 (00:48:46):

Bassini. Yeah. When it was important to the United States in the late 18 hundreds, it was greatly modified to not be nearly as effective. And it works well. It works well, but we just have,

Speaker 1 (00:49:01):

So you interrupted sutures, you don’t run,

Speaker 2 (00:49:04):

It interrupted and we open the trans vessels. Fascia, we developed the triple layer internal by transverse transversesalis fascia and suture to the ligament just like Cindy described.

Speaker 1 (00:49:17):

Yeah, yeah. It’s a great repair. Yeah. I sometimes use that for women who I go in to do a Marcy because they clinically have a really small hernia, but symptomatic may have been one of those patients that the gynecologist saw the small internal ring opening, but their symptoms match perfectly what an inguinal hernia would be. And they have it a small one, but you go in there and it’s too big for a Marcy, which would be a single stitch. So I do a Bassini on those. That triple

Speaker 2 (00:49:50):

Is obviously a good, also good. I don’t feel I’m experienced enough with Shouldice to really get it. I, I’ve been to Toronto and observed the Shouldice surgeons and I just don’t quite think I do better with the Bassini personally.

Speaker 1 (00:50:10):

Yeah. I’m doing a Shouldice tomorrow on a 83 year old male who does not want Mesh. So it’s all about understanding the risks and benefits, benefits of that.

Speaker 2 (00:50:23):

You going to use wire?

Speaker 1 (00:50:26):


Speaker 2 (00:50:27):

That’s what they do in Shouldice.

Speaker 1 (00:50:30):

Yeah. I should do the original Shouldice with wire. But you’ve been to the Shouldice whole wire issue is a totally financial decision. It’s not like they basically have women in the back putting together wire into a needle making their own, which is cheaper than if they bought polypropylene suture.

Speaker 2 (00:50:56):

I didn’t realize for

Speaker 1 (00:50:56):

Real financial decision. Here’s another question. Apart from the very low risk of incarceration and strangulation, are there any other disadvantages of watchful waiting? The European Watchful Waiting trial did hint on what if you have a heart attack or a stroke and between the time of diagnosis of hernia and when you really should get it repaired. So maybe repaired early. What are your thoughts about that?

Speaker 2 (00:51:26):

Well, I think you’re probably referring to the United Kingdom trial, correct? Yeah, that’s

Speaker 1 (00:51:32):


Speaker 2 (00:51:32):

Because there’s another one that was done by Yeckel and Holland. There’s been three big trials, three big watchful waiting trials. I just completely disagreed with the interpretation of the United Kingdom trial. It

Speaker 1 (00:51:46):

I agree. I think

Speaker 2 (00:51:47):

It didn’t make any

Speaker 1 (00:51:48):

Sense shy to say, yeah, it was too shy. I think they were uncomfortable to say it’s totally safe to do watchful waiting.

Speaker 2 (00:51:55):

Yeah, well they were saying yeah, that you shouldn’t do watchful waiting because you might get a heart attack and that had to be worse operative candidate. Well, that was a pretty weak argument I felt,

Speaker 1 (00:52:06):


Speaker 2 (00:52:07):

Since you could fix the hernia they local anyway, so I thought their data showed exactly opposite of what their conclusions were that I thought they showed that watchful waiting. The other two trials, the Holland trial in our trial really confirmed that watchful waiting is very safe.

Speaker 1 (00:52:29):

Yeah, agreed. Quick technical question. Is there such a thing as a running interrupted suture,

Speaker 2 (00:52:37):

Running interrupted suture? Well, that’s two different types of surgical techniques. Yeah. Running means you take a suture and you tie on one end and you just suture to the other end and then tie it up. The other end course interrupted. You use individual sutures and tie each one as you go. And there’s,

Speaker 1 (00:52:58):

I’ve never heard of a running interrupted suture. I guess this was in their operative report. Maybe a typo. I’ve never heard of such a

Speaker 2 (00:53:07):

Thing. Well, yeah, there would be never, yeah, do either. And it’s just surgeon’s choice. Some people, like some surgeons prefer interrupted sutures, some surgeons like running. I tend to running. Yeah,

Speaker 1 (00:53:19):

Yeah. Okay. Can watchful waiting be viable for large or recurring incisional hernias?

Speaker 2 (00:53:29):

Well, it can be, but it depends upon, but these tend to be very symptomatic. Large incisional hernias tend to be very symptomatic and they’re not. They’re painful and they’re also, they’re cosmetically, the patient can’t go on the beach without seeing this big thing sticking out. a lot of times with the kind of hernia,

Speaker 1 (00:53:51):

Where’s a beach in Nebraska? You guys have a beach in Nebraska,

Speaker 2 (00:53:54):

We have swimming pools. But anyway, so those are reasons why the patients really want to get them, have ’em fixed.

Speaker 1 (00:54:10):


Speaker 2 (00:54:11):

So what we’re waiting is if their patients asymptomatic and they’re willing to, and of course we have the problem of morbid obesity and smoking. And if you go to B M I of 50, in other words, you’re weight 300 pounds and you’re five foot five tall,

Speaker 2 (00:54:28):

The chance of success of repairing that hernia is lyse zero. Then we have to counsel the patient for bariatric surgery. We, in our abdominal wall reconstruction unit, we have a bariatric arm. I don’t do it myself. We have a bariatric arm in. And so we tend to shuffle these patients off to the bariatric surgeons and try to get it approved by their insurance company. And what we do is we do the bariatric surgery, they lose the weight, drop their B M I to 35, and then we fix the hernia. Some people will fix the hernia at the same time they do the bariatric surgery, but we don’t think that’s the way to do it. We think, yeah, we don’t do the bariatric surgery and then fixed her knee.

Speaker 1 (00:55:08):

Yeah, I agree. And then that’s really good that you have that arm because it’s hard to find a bariatric surgeon that’s comfortable doing laparoscopic surgery when there’s a huge hernia in their face. You know what I mean? I have two that I rely on that are really skilled and not afraid, and they’ve done excellent for these patients. But it’s a specific skill to be able to operate when there’s a huge loss of domain or big hernia or something in the area where you’re typically go in for this operations.

Speaker 2 (00:55:42):

Yeah. Well these bariatric surgeons are directly attached to the abdominal wall reconstruction program. So they They’re used to dealing with it just like you’re talking about.

Speaker 1 (00:55:53):

Yeah, exactly. And you have a fellowship to train people as well?

Speaker 2 (00:56:00):

No, we don’t have a fellowship considering developing one, but we’ve always, we at Creighton, we’ve resisted fellowships because we want our residents to get an optimum experience.

Speaker 1 (00:56:14):

That’s how UCLA

Speaker 2 (00:56:15):

In my career, I think I’ve, one of my biggest progressives that I never developed a minimally invasive fellowship, but we did that on purpose. That was a purposeful decision to keep the red so the residents would have the total experience.

Speaker 1 (00:56:29):

That’s how my training was at UCLA. We only had a vascular fellow, but pediatric surgery and colorectal surgery, all those specialties for gut, it was all the residency, which was great. It was great for us. And I think even vascular surgery, the hierarchy was the chief resident and then the fellow, as opposed to most programs where the fellow has a hierarchy. So it was a very resident friendly training hierarchy, which was really good. And so you have clinic tomorrow, you’re going to have all these patients now call you. And

Speaker 2 (00:57:05):

Wednesday’s my big clinic day and I kind of dreaded, I enjoy Monday through Monday, Tuesday where I operate Wednesday and Thursday. But

Speaker 1 (00:57:14):

Yes, we’re discussing earlier these two important comments. One is hernia surgery, especially the type that you do a lot of which are these open reconstructions are very tolling on the surgeon’s body. It’s a very physical operation. You’re standing for long periods of time. There’s a lot of tissue that you’re manipulating and a lot of people in the operating room to help with retraction so on. So I want to make that comment for the audience so they understand how hard we work for these hernia repairs.

Speaker 2 (00:57:46):

And some of ’em take five, six hours

Speaker 1 (00:57:49):

Or more. I had one that was 12 hours. And man, I now take micro breaks as I told you, 10 seconds. Every hour and a half of stretching, every hour and a half of surgery. I stretch out with the whole team for about 10 seconds. But yeah, once you’re done with that, it’s you go into your zen mode. Do you go into your zen mode? I kind of forget everything. I have no bladder like sensation. My thirst sensation’s gone, everything’s gone. I’m just focusing on surgery. And then when it’s done, you’re like, oh, I really dehydrate.

Speaker 2 (00:58:26):

I’m the same way.

Speaker 1 (00:58:28):

Yeah, yeah. I kind of like it. It’s a nice little, it’s like our little country club, the surgery operating room and so on. Okay. Let’s see. There’s one or two more that are coming in of questions. Is cryo ablation or radiofrequency ablation equivalent for surgical neurectomy? Do you do any nerve trans surgery?

Speaker 2 (00:58:49):

I do, yeah, I do triple neurectomies. Open. Yeah, open. Yeah. Yeah. And our pain guys will sometimes do the cryo ablation or the radiofrequency or other modalities.

Speaker 1 (00:59:03):


Speaker 2 (00:59:04):

I don’t see too much success with it, but we do it, I mean in part of our, we kind of a five step program for management of these chronic pain patients. And we never go to surgery until a service has seen them to offer an opinion.

Speaker 1 (00:59:24):

Okay, very good. Yeah, I, I’ve noticed. So for neuromas, those are very resistant to anything but surgery and you have to go in there and actually physically resect the neuroma. But if it’s nervous entrapped in scar or if it’s minimal, I try not to do neurectomy. So we looked at our own data, we presented at SAGES this past year and we looked at all the neurectomies we did for all different purposes. And some were targeted neurectomies because the patient had Neuralgia like nerve pain and others or neuroma and others were prophylactic. So you go in there, let’s say to take out a Mesh and they didn’t have any nerve pain, but the nerve is now stuck to the Mesh and removing the Mesh is going to injure that nerve. So we do a prophylactic hysterectomy. And what we found was prophylactic neurectomy was very safe.

Speaker 1 (01:00:15):

We had zero complications from that, no neuromas or postoperative chronic pain. But if you go in there to treat a nerve type pain surgically, there’s a certain risk of getting a neuroma again or having chronic pain and Neuralgia, we need more injections and so on. And in doing this research, we looked at the risk of the same happening with cryoablation or radiofrequency ablation. And again, similar to surgical neurectomy, not that much data out there. But I do try and reduce how much surgical neurectomy I offer based on our own data. Because we have had two patients that have advance onto having complex regional pain syndrome. And there’s some thought that the less invasive you are with a nerve, the less likely you are to get that complication. So I can’t say it’s equivalent, but it does have a its role.

Speaker 2 (01:01:17):

So you’re not a fan of triple

Speaker 1 (01:01:20):

I do not do triple neurectomy unless all three nerves need to be addressed. I do selective neurectomy. Yeah. And I think the reason is in talking with [inaudible] about it, he’s like the godfather of triple neurectomy who kind of introduced the whole idea. I think if you sit down and really, really try and predict based on the symptoms which nerve needs to be addressed selectively, you can reduce the need of doing triple neurectomy. Because if you always do triple neurectomy, the chance of you being successful always higher. But for sure I, I’ve stopped doing laparoscopic or radical triple neurectomy because that can cause a lot of denervation. So I try and do the neurectomy as close to the side of injury as possible. Yeah. So I remember

Speaker 2 (01:02:09):

You used to be a big fan of that.

Speaker 1 (01:02:11):

I was. And then I started seeing patients with denervation injury and we presented the first three patients for that. And then I did a whole at stages, and then I did a whole anatomy lab. We did 200 cadavers where we mapped out the whole retroperitoneal plexus. Because as I was doing these operations laparoscopically, I was like, this is not like netter, this is not the anatomy’s different with each patient. So we learned a lot from that. But yeah, that denervation injury is very, very difficult to treat, basically not treatable. And the further distal you cut the nerve, the less likely you are to risk that. Yeah. And the more selective you are, the less likely. So that’s kind of been my practice as a result.

Speaker 2 (01:02:56):


Speaker 1 (01:02:58):

All right.

Speaker 2 (01:02:58):

Interesting. I didn’t realize that.

Speaker 1 (01:03:00):

Yeah. Yeah. I’ll have to publish more of that. Thank you, Dr. Fitzgibbons. That was fantastic. I appreciate your time.

Speaker 2 (01:03:08):

Well, I’m glad to be involved and I hope the audience learned something.

Speaker 1 (01:03:13):

I love that a lot of people are really thanking you for your expertise. Okay. So thank you for your time and everyone, thank you for joining me for another week of Hernia Talk Live, our weekly Q&A. We have more guests to come every week. Please watch my YouTube channel to watch this episode and catch up on prior episodes. I believe this is episode number 98. Can you believe that?

Speaker 2 (01:03:38):

Is that everybody?

Speaker 1 (01:03:40):

Good night everyone. Thanks Rob. Bob, talk to you later. Bye-Bye.

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