Speaker 1 (00:00:00):
Hey everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live, our weekly q and a session held every Tuesday. We call it Hernia talk Tuesdays. I’m Dr. Shirin Towfigh, your hernia and laparoscopic surgery specialist joining you live from the Beverly Hills Hernia Center. Many of you are joining me via Zoom, some of you’re here via Facebook Live from at Dr. Towfigh. And thanks to everyone who follows me on Twitter and Instagram at Hernia doc. So I’m really excited about today’s session because it’s all about your stories and those of you who’ve been following me and know I love stories, I feel that the beauty of what I do is partly because of all the stories that I hear from you all. And you may know that I have a podcast that I co-host as the official podcast for Sages a Society of American Gastrointestinal and Endoscopic Surgeons.
Speaker 1 (00:01:09):
It’s a great podcast if you want to listen to it. It’s called Sage’s Stories. And the reason why we named it Sage’s stories, because I feel everyone’s story is so important, and that specific podcast is focused on surgeons’ personal stories as they relate to sages and their like laparoscopic endeavors, but also their personal stories. But specific to you all, you may have heard me say that the story is the most important factor of whatever medical diagnosis you’re coming to me for. So when you come to me, I’ll just give you a scenario. You come to me in my office, if you come to see me in person, you meet my front office, you check in, you get your vital sign, et cetera, and then you meet my nurse. She is the number one nurse in the world, Belle- nurse Belle, many of you already know her.
Speaker 1 (00:02:05):
She is the most skilled hernia specialty nurse in the world for real. That’s all she does. She knows so much, but she gets your story in a lot of your intake and comes to me first before I see you. And I often know exactly what’s wrong with you before I meet you, before I see you because of your story, you tell me your story and that is very telling as to what your diagnosis is. And mind you, my practice, as you know, is highly specialized in not just hernia repairs but reduced but treating hernia related complications. So most patients come to me with prior surgeries or prior imaging, prior consultation with other doctors. It’s not just a straightforward, oh, look at this B hernia, come and fix it. And despite that, the story itself is so helpful. Patients come in with stacks and stacks of CDs, of CAT scans, MRIs, ultrasounds, multiple operations, but it’s really of all those that information your stories is the most important.
Speaker 1 (00:03:20):
I kind of had a very rough week last week. I would say the last two weeks have been pretty rough because the stories that you’ve shared with me, whether it was via in-person consultation or what I call online consultation where it’s a less interactive but equally effective way to reach me, they really affected me and I felt that there was so much sadness in these stories because I was talking with patients I knew immediately based on their story what was wrong or at least what needed to be done. And yet these were mostly young patients, some of them older with some of them decades of chronic pain, unsolved medical mysteries, no reason for their symptoms been told there’s nothing wrong with ’em. And so for years they are in pain. Some of them are in school and cannot go to class. They have to do their Zoom classes while laying in bed. Many of them had to quit their jobs. Some of them are married and the problems affected their relationships. I have construction workers that can no longer work and are on state disability.
Speaker 1 (00:04:49):
One patient came to me wheelchair bound and that story has really affected me and I desperately hope that I can cure that patient and get them back walking again. It’s just been a rough two weeks. The stories were just so heartbreaking. And I just want to share with you some common themes. The most common theme is there’s really something wrong with a patient. There’s a reason for their symptoms or their pain or their their symptoms, and they go from doctor to doctor and they’re told there’s nothing wrong with ’em. They’re told they have to live with it.
Speaker 1 (00:05:34):
There’s imaging isn’t all normal, not true. Their exam is normal, not true. They didn’t get the right exam, they didn’t get the right imaging, and they’re told nothing wrong with you, nothing we can do. Oftentimes the patients get this full gas lag, so then they start thinking, it’s all my head, maybe there really isn’t anything wrong with me. I’m just feeling things. And that’s a situation you should never be in. What my impression is, and we’ll go through some of your stories because many of you have shared your stories, so I will definitely respect the time for that. But I feel that the common themes are patients that are legit going to their physicians, whether they’re doctors or surgeons or some of their PAs or nurse practitioners. And they are told that what they’re feeling or what’s going on with them either doesn’t exist. It’s mis, it’s misinterpreted by them.
Speaker 1 (00:06:42):
They may be lying about it. That’s not as common. Fortunately, nothing to do. It’s all in your head. You got to live with this for the rest of your life. Here’s some medication. I mean, I literally had a teenager who was told there’s nothing to do. Here’s some gabapentin, which is a nerve modulating medication, which A has side effects, and B, makes you very drowsy and just take it. And the implication is you have to take this for the rest of your life. She’s a teenager. I mean, how ridiculous is that? Athletic could no longer do athletics, couldn’t go to school. So this is a situation where fortunately, most of the people that came to me are their own best advocates. Even some of them have been told for years there’s nothing to do, and yet they still follow their gut. They know deep down there must be something wrong and they reach out. And I’m so glad that they did because there are probably multiple times more patients out there that lose hope. They feel that there’s nothing they can do. They’re they believe that scenario that nothing can be done or there’s nothing there and they live with it. I have, I think the one who broke the record was 22 years. 22 years of pain.
Speaker 1 (00:08:13):
They just gave up and once I cured them, this was a someone, elderly lady, the son just broke down and couldn’t stop crying because he had forgotten what it was like to see his mom walk without a limp. That’s how bad the situation was. And she had a femoral hernia, by the way, uncommon hernia, but definitely one that women are more prone to. You’ve heard me talk about femoral hernias a lot on this show, and I fixed her, her I diagnosed it, fixed her hernia. She’s normal now, and the sun just lost it in front of me, literally had forgotten what it was like for his mom to walk normally just it was their new normal.
Speaker 1 (00:09:05):
So kudos to everyone who shared their stories with me and kudos to everyone who believed in themselves and didn’t take no for an answer. In Hollywood. You know, I’m in Beverly Hills, so this is Hollywood. In Hollywood there’s a saying that no means not today, not yet. And you have to keep pushing and being resilient. And a lot of the movies we see and books that are published or projects that go through, went through because of persistence and let’s say a screenwriter in Hollywood for example, continues to push their screenplay until finally gets a contract with some major production company. So you have to be the same. You have to be persistent, and if your doctor locally can help you, great. If they cannot go outside your system, go outside your state, go outside your country. I see a fair number of patients both outside the state and outside the country.
Speaker 1 (00:10:13):
So it’s definitely something that I highly recommend because I feel that it’s just not cool to live with the way that I, some people think it’s appropriate live. The other thing I wanted to make sure you understand is oftentimes if you’re told there’s nothing to do, it means that doctor cannot provide you with the care that you need. Doesn’t mean you can never get the care that you need. It means that specific physician, surgeon, whoever doesn’t know the answer. So you have to keep searching and that’s what I recommend that you do. I highly recommend everyone get more than one consultation. Many of you know that I offer what’s called online consultations. So that is when I don’t necessarily, I don’t see you, I don’t examine you, but you send me all your story, you send me your story and ah, these stories are just amazing.
Speaker 1 (00:11:15):
So I do want to share some of the stories. I know some of these patients myself and I feel that I know I have some insight into their stories, but I’m glad that some of them shared it. I will share some of the stories from the past several weeks that have really affected me that I hope you understand, I may change some details in it so it’s not exactly the same, the one patient or two patients that I saw with that story, but I hope it resonates with you. So I see that many of you’re coming on live. Thanks for all your questions.
Speaker 1 (00:11:55):
Great topic. Thank you. We will be helping you. How many Mesh excisions are performed per year? That’s a good question. We don’t know the answer to that. I know that a million hernias are repaired each year, but I would venture to guess I had to estimate Mesh excisions are probably less than 20,000, maybe even less than 10,000 a year. So less than 1%, you’re one of the 5% that will always feel pain from the surgery. Some people are more prone to complications than others. Can I do core exercises if I have epigastric hernia, that doesn’t hurt or bother me. Yes, and we’ve discussed this before, that exercises are excellent for hernias and are not only protective, they should not make your hernias worse. So let’s move on to some of your stories. Some of them are educational, some of them are still in the process and pardon me, I’ll be reading a lot of these, so got to pay attention.
Speaker 1 (00:13:04):
Okay, this all started with a foolish lifting accident that led to what was diagnosed as multiple injuries in my groin causing pain and discomfort, including having had successful hernia repairs many years later. Number one, left incisional or indirect hernia through a reconstructed deep inguinal ring. Number two, attenuation of the floor of my previous multilayer inguinal canal repair. Usually we call that a direct inguinal hernia. Number three, recurrence of a previous right-sided Mesh repair due to tearing of the medial attachment. Number four, all accompanied by loud disruption of a pre pubic aponeurotic plate. So one thing I want to suggest is these are all very complicated things we’re talking about, but there’s a difference between a sports hernia and a regular hernia and we have had at least two prior Hernia Talk Live sessions, one with the Sera Institute and Dr. Poor talking about sports hernias and sports hernias specifically are not your traditional inguinal hernia.
Speaker 1 (00:14:09):
A sports hernia has to do with disruption of the natural attachments of the muscles to the bone or tearing of the muscles, whereas hernias occur in naturally occurring parts of the body such as the inguinal canal or the transversesalis fascia, and those tend to be different in nature. Their symptoms are often different. The reason why you get it is different. The type of patient that gets it is different, et cetera. So many times I see a housewife or elderly patient diagnosed with sports hernia, it’s just not possible. You just can’t, don’t have muscle strength or the force to get a tear like that. You must be in sports, so athletic in some way and have the structure to be able to tear it. Also, I must say that the diagnosis of sports hernia is often incorrect because they don’t see or feel a typical hernia. So the default is, oh, it must be a sport hernia, but you have to have some logic to this. How do you get a sport hernia or a tear if you don’t really have muscle tissue that’s that strong or you didn’t do any activity like that. The one exception is trauma. You can get traumatic hernias. Those are very different. People that fall tend not to get sports hernia type symptoms, but a big car accident can cause traumatic hernias. Again, that’s different from a sports hernia.
Speaker 1 (00:15:53):
So after intense research, which I must have gotten wrong, I underwent a bilateral repair that consisted of resecting herniated adipose tissue. Okay, that’s a hernia coming through previously reconstructed internal ring, okay, that’s a recurrent hernia and timing of loose previously reconstructed internal ring. We usually do not do that because tighten of a internal ring unless it’s part of a tissue repair, does cause tearing and chronic pain. Number two, implication of we can previously reconstruct a left inguinal four. That’s basically a direct inguinal hernia plication. So if you have a direct angle hernia, you’d be placated closure of the right-sided hernia defect using a small piece of ultrapro Mesh, okay? The fact that it’s small is not a good thing. You need to have the standard size of Mesh. Smaller meshes are more likely to be tight and cause recurrence. The Mesh was fixated to Cooper’s ligament because of attenuation of the inguinal ligament.
Speaker 1 (00:17:00):
That’s also not standard. I don’t understand why you would do a retroperitoneal Mesh when you’re doing an anterior approach. Fixate the pubic plate down to the deep pubic periosteum. That’s to address a sports hernia, which I’m not sure this patient had suturing of a lateral border, the rectus muscle to the GUI ligament and tenotomy of the abductor longest consisting of multiple incisions. Again, these are multiple operations done for a typical LeBron James type sports hernia, which very likely this patient does not have Following my surgery, my pain has been more intense. I told you because multiple things have been done, which cause increased pain, the tightening of the internal ring, the closure, the use of a small piece of Mesh. The ultrapro is a very, very lightweight Mesh that often doesn’t work, especially if you have a direct hernia. I will need more extensive workup to determine the cause of the increased pain and whether another surgical in intervention maybe appropriate.
Speaker 1 (00:18:08):
So usually these require either undoing of the prior repair to make it looser and putting in a retroperitoneal Mesh or just treating a reconstruction, a recurrent hernia. The patient’s story also includes cryo radiofrequency and surgical neurectomy. I don’t hear anything in the story that tells me there’s any nerve pain going on. So that’s another thing I’d like to talk to you about. Nerve pain. So we’ve had two pain specialists come on. We have another one coming up really, really soon, which will be an amazing discussion. But when you have nerve pain, there are multiple modalities to treat it, but pain is not always nerve pain. In fact, most growing pain is not nerve pain and I see so often a surgeon sees a patient, oh, you’ve got pain. Go see the pain management doctor. Pain management doctor understands nerve pain, they do a spine disorders, et cetera, and they keep doing nerve blocks and cryoablation and surgical recommend surgical neurectomy or pudendal nerve stimulators for the spine. But the pain is because your hernia is recurred or the Mesh is folded or it’s too tight of a repair. Your tearing so has nothing to do with a nerve. So please, please do not touch your nerves if there’s nothing wrong with them.
Speaker 1 (00:19:38):
Okay, here’s a question. How do you repair defect in the fascia as opposed to a hernia? So if you have a full thickness defect in the fascia, which includes the full muscle, et cetera, communicates a front from the back, that is that by definition of hernia and you do a hernia repair, if you actually just have a tear of the fascia and the muscle underneath it’s intact. That’s usually a sports type injury and we just close the fascia and rare rarely need to use anything like Mesh. Got some more stories for you. So here’s an example of a patient that is being given all this information and makes it sound like this complicated situation was going on, whereas probably what they had was an inguinal hernia that required repair and yet there’s all these pubic plate epi neurotic plate and things were tightened and implicated and it’s giving a lot of complexity to otherwise simple situation. And now that they have pain, they think it’s also a complicated situation. Often it’s not.
Speaker 1 (00:20:57):
Here’s another story. I had a femoral hernia that Dr. Towfigh diagnosed great. Without her help, I believe I never would’ve gotten a true diagnosis, which led me to have a femoral hernia repair. Nice to hear. I lived with horrible growing pain for 10 plus years. That is horrible. 10 plus years of growing pain and now I am 85% better. Since having had surgery, I would’ve still been suffering had I had not found Dr Towfigh. Okay, so thank you for that story. Femoral hernias are classic for this. People cannot feel femoral hernias. It is a rare problem to begin with. Most doctors don’t even think about it as a diagnosis. It’s more common in women, it’s often misdiagnosed and in people who have it, they may have another hernia as well. So they have a regular hernia repaired and they totally do not get the femoral hernia repaired, and so after surgery, they still have chronic pain.
Speaker 1 (00:21:54):
It’s actually the number one reason for women having chronic pain after a routine hernia repair is a missed femoral hernia. So that was in the day before laparoscopic surgery. So yes, femoral hernia should always be in the differential diagnosis. I also see some really very unique, really rare hernias. So there’s these perineal hernias, the rarest of which is a sciatic not hernia, and I’ve, I’ve repaired those before. There’s perineal hernias and obturator hernias and these weird posterior lumbar hernias. So I think they’re cool because I get to operate on them very, very, very, very rare incidence, like a fraction of a percent in the world.
Speaker 1 (00:22:49):
But because I have that experience, every time I look at an imaging, I also look for those you never know. Maybe their pain is from that. In fact, I’ll give you a story. Okay, great story, lovely lady. Many, many years of pain to the point where she can’t sit. It’s just difficult even to sit. She has to use a donut and she has this kind of pulling pain in her lower abdomen and she gets some bloating with it. Anyway, long story short, she has multiple doctors even goes to these major institutions, Mayo Clinic, et cetera, and they tell her nothing wrong with you, maybe it’s your back. It’s not your back pelvic floor. It’s not pelvic floor. Anyway, so because I have this experience where I treated these really rare pelvic hernias, when I saw her, I looked at her imaging and in addition to looking for hernias, I looked for these really rare hernias and guess what?
Speaker 1 (00:23:52):
She absolutely had one perineal hernia. So perineal hernia, the very rare hernia in the muscles of your pelvic floor. It’s often there because you’ve had a very pregnancy, but not necessarily it can actually occur spontaneously. I’ve not seen any in men. They’ve always been in women and I believe it would be super rare for a male to have it, and her imaging didn’t really show it except for one imaging. I’m like, listen, you need to get imaging with Valsalva. Bear down imaging because how do you get most of your imaging? You’re lying flat. What’s the best way for hernia pain to go away? You lie flat. So we don’t really do standup imaging. There are standup MRIs but not very high quality. So to reproduce the gravity pull of standing and abdominal pressure of standing, we have you do bear down views. Bear down during the imaging.
Speaker 1 (00:24:52):
So she had a bear down imaging. Lo and behold, little piece of colon got stuck in this little itsy bitsy hole in her perineum and it got missed actually by radiology. So I called the radiologist like, Hey dude, buddy, I don’t want to tell you how to do your job because I respect you. You’re a radiologist, you’re really great, but I’m looking at image series. I’m going to make this up. Series nine, image 54, doesn’t that look like a perineal hernia? He said, you’re absolutely right. Oh my God, do you need a job? I can can hire you in her radiology. You literally told me that. Of course he was joking, I have a job, so I diagnosed it. Now she’s from out of state. It’s hard to have surgery in a different state. I understand that. So she went back, I hooked her up with one of her surgeons near her, asked in advance, have you ever treated these?
Speaker 1 (00:25:58):
Yeah, we’ve done this before. Honestly, I’m not so sure. Because she saw that surgeon, that surgeon completely said, Nope, don’t think that’s it. Maybe it’s a nerve, which of course it’s not. And took her down this whole rabbit hole of nerve pain. She called me back, I said, ah, no, no, no, no, it’s all about your story. This is not a nerve issue. It’s you can’t sit standing up for a long time bothers you and it affects your bowel movements. This is a perineal hernia. Call the doctor again. Hey buddy, listen, I want to tell you how to take care of your patients, but look at this imaging, look at this here. Listen to her story. This is a perineal hernia. You told me you know how to fix these. Guess what? She’s scheduled for surgery. So the point is, it’s all about the story and not really being able to see or examine the patients and get that story is not helpful. All right, next question.
Speaker 1 (00:27:10):
You know my story, growing pain that became abdominal bloating, pressure edema and cold burning sear sensation up my spine all due to nerve damage. Yeah, so I’m happy to help you. We’re going to reassess everything you, you’ve, I know you’ve been talking to Nurse Bell, so I’m happy to help figure this out for you. Next question, what kind of Mesh did you use in that femoral repair and what was the size of the Mesh? Okay, good question. So the gold standard for femoral hernia repair is a laparoscopic repair with Mesh. The type of Mesh you use is not very relevant, depends on the patient. You can use lightweight Mesh, you can use heavyweight Mesh, you can use mid-weight, mid-weight Mesh. It really doesn’t matter unless it’s a huge femoral hernia, which it almost never is in the really huge hernias. You maybe use a more of a mid-weight or heavier weight Mesh not such as a small weight Mesh. The typical size of Mesh depends on the size of the patient’s pelvis. It usually starts at 10 by 15 centimeters or I say it’s about the, it’s like size of my hand and that’s the Mesh because you not only fix the femoral space, but you also fix all the other areas we call the MPO or myopectineal orifice and includes future inguinal hernias.
Speaker 1 (00:28:34):
Another question, what type of imaging shows the Mesh and plug used in the left al hernia surgery? So all imaging should be able to show those ultrasound, CT and MRI will show you a match plug. However, if you really want to get the best information in planning for surgery and evaluating that repair, I recommend an MRI without contrast. Okay, let’s go through another story that was sent to me. Oh, going back to this femoral hernia situation. So I posted on this multiple times and shared some stories. In fact, I dunno if any of you guys are follow Beverly Hills Housewives of Beverly Hills, but Denise Richards had a femoral hernia, which I repaired and she also had a problem getting diagnosed for a really long time. She was really great at sharing her story. So not everyone gets femoral hernias, but it’s definitely something to look out for if you have enigmatic or mystery growing pain.
Speaker 1 (00:29:45):
Okay, here’s another story. I was implanted with pH st Mesh. So that is a synthetic absorbable Mesh and the ST stands for separate film technology, which implies an anti-adhesive barrier, which means this is an abdominal wall hernia. So I was implanted with pH st Mesh for hernia and muscle repair. I was disabled from it from day one with pain and autonomic nervous system dysfunction that usually means pots, postural orthostatic tachycardia syndrome. I did not want synthetic Mesh and the implanting surgeon agreed to use biologic, although technically this is not biologic, it is synthetic. I’ve since learned that pH is a hybrid that has polyester in it, not exactly accurate. pH is not a hybrid. It is a synthetic absorbable Mesh. Hybrid Mesh is imply there’s a synthetic, I’m sorry that there’s a absorbable and non-absorbable component. This is purely absorbable, but it is synthetic and it doesn’t have polyester in it, but it does have a type of product in it which is closely linked to polypropylene, but it is absorbable from high functioning.
Speaker 1 (00:31:01):
I wound up bedbound. I had developed a small bulge in the lower flank that was, I was told was a hematoma that would resolve. Four months later Mesh was removed, but the damage had been done. I now have full-blown dysautonomia pots and m a. So POT stands for postural orthostatic tachycardia syndrome. M a stands for mask cell activation syndrome. They often come together. Some people also have Ehlors Danlos syndrome and little tidbit. In a couple weeks we’re going to have a specialist on all of these discussing how they’re interrelated for you all to learn from it. Some women also have endometriosis as part of this syndrome. So just so that you understand why this is relevant. So patients that have Mesh in them, that’s synthetic and I don’t care what kind of synthetic, absorbable and non-absorbable, there is an inflammatory process as a result from it.
Speaker 1 (00:32:05):
The more synthetic the product, the more inflammatory and that can in very few patients, but in some patients that are prone to it, spark a autoimmune or inflammatory syndrome of light of sorts. We call that Asia syndrome or Shoenfeld syndrome. We’ve had Dr. Tervaert in the past talk about it and we have upcoming guests who are also specialists in this process and came up with this diagnosis to talk about with you all. But it’s unclear if POTS and M C A S, which is mass cell activation syndrome, which are both autoimmune and or inflammatory disorders, it’s unclear if that is sparked by the Mesh or if people have that and they get a reaction from the Mesh. So in this situation with this story, the timing of it seems like they were doing normally fine and the Mesh sparked this problem.
Speaker 1 (00:33:14):
The thought is that once you remove the Mesh that this will go away, but sounds like it hasn’t. So she also has a denervated abdominal wall that seems not right. I’ve spent the last two and a half years trying to regain some functionality and have seen many specialists and have discussed surgical intervention for the abdominal wall. So here’s the issue here. The pods of the M C A S prevents you from having any synthetic Mesh, absorbable or non-absorbable, so you’re relying on a non Mesh repair in some situation you can have a biologic, high quality biologic that’s low in inflammatory potential used to augment your tissue repair. I would like to know if you also have Ehlors Danlos syndrome because that goes with the two and then the question is why do you have this denervation? Because if you have denervation, even if you have a tightening of that loose muscle, it will fall apart as a very difficult situation with not that much, not that much you can do about it.
Speaker 1 (00:34:24):
Very, very difficult situation. You’re one of two patients I know with this problem. Next question, when you do laparoscopic surgery, how many tags do you use and where do you place it to avoid pain but still keep the Mesh in place? Great question. First of all, if you don’t always have to use tacks number one tacks or are some type of fixation, whether it’s a curly queue or the suture or something, they’re either absorbable or non-absorbable. I prefer the non-absorbable because there’s little no evidence that an absorbable is any better, but we do know that it’s long-term results are better with obs, non-absorbable fixation. So where do you put it? First of all, you use as few as possible.
Speaker 1 (00:35:15):
I had a patient, she had I think 19 tacks placed just in one groin alone. You should have between, you should have three. Anything over five is definitely egregious. 19, I just don’t understand. And this was for a groin hernia laparoscopic. She was dragging her foot, her leg, I should say she was dragging her leg after surgery for three weeks. She went to her doctor and the doctor was like, yeah, it’s fine, you’ll get better. Just keep walking it out. And she’s like, I literally cannot walk it out. Eventually her leg function improved but she still could not totally bear weight on it and she had severe right lower quadrant pain and she saw me and I I’m like, you have 19 tags and guess what? Many of them were placed incorrect places, so you don’t want to put any near the nerves. She had multiple around the femoral nerve, which is completely incorrect placement. You should not put any near any nerves. In fact, we call the area, the nerves a triangle of pain. So the ilio iliac, epigastric, genital genital femoral and the lateral femoral cutaneous nerves should not be anywhere near those fixation areas. You should not put it into any critical structure like a vessel, extra iliac vein, extra iliac artery, epigastric vessels or the bladder. Don’t put it through the bladder.
Speaker 1 (00:36:53):
But other than that, it’s pretty safe to put through muscle and we don’t like to put it too deep in the muscle because that can be too tight or too painful and there are nerves in the muscles. So there’s a delicacy to use using fixation. You don’t, don’t overuse it and use it in correct places and when you place it, place it delicately. Let’s see. Oh, why no contrast for the MRI because it doesn’t help you. The contrast has no, there’s no indication we’re using MRI with contrast for patients with soft tissue problems. Next question. I believe my Mesh has pulled in at least seven suture points on the right side of my umbilicus. Is removing just those sutures a good fix or should the Mesh be trimmed or reattached or just have it all removed? It is a four and a half centimeter patch.
Speaker 1 (00:37:47):
Let’s see, four and a half centimeter patch over the belly button, at least seven suture points. That seems like a lot for four and a half centimeter patch. So depends if the pain is exactly where the suture is, you can just take out the offending suture. If the pain has to do with two-ten for repair overall, then you need the release of all the Mesh and the sutures from that area. My surgical report says the ilio inguinal nerve was not preserved. Could that be causing all my pain? Depends again. So if you already had ilio inguinal nerve problems and that nerve was cut, there’s a risk that you’ll, you’re going to have recurrent problems in about 5% of the time. If you had no problems with the ileal nerve and it was cut prophylactically in our study, surprisingly we showed no problems with that. 0% had chronic pain or any risk in doing so, but you would maybe be numb in the area. But in order to figure that out, it’s all part of your story. Where do you have burning pain, hot pain, hot poker. Is it in the same direction as the ilio inguinal nerve? If it is, then probably the nerve is could be causing your pain.
Speaker 1 (00:39:09):
Again, it’s all about your story. Can the rectus muscle fascia should be a source of painted sutures or placed in the rectus muscle? Full thickness? Yes, it can be. Yeah, the muscle tends to tear as opposed to fascia. So if you’re tearing, oftentimes it’s not the suture, it’s just the tearing effect. So a lot of people come in and they think, oh, they got nerve pain or something. They just have too tight of a repair and the repair is trying to tear and it’s that tearing sensation, that tearing effect that causes their pain. So what do you have to do? You got to fix it. Either take the tension off, undo the repair, or more importantly just do a better hernia repair to take attention off the original repair.
Speaker 1 (00:40:01):
More questions. I had two hernias when I had surgery. I have chronic pain, heart problems, pulmonary problems, intestinal problems, kidney problems, et cetera. They would not do removal surgery on me. Mine was put in 2001. So obviously the repair, sorry, the Mesh removal surgery needs to be performed without killing you. It’s definitely a risk benefit ratio that your doctors will have to take. So if they feel that the operation is way too high risk for the symptoms that you’re having, then that’s the decision between you and your surgeon. Next question. What are the symptoms and cause of pain after prior tissue repair that you see in your practice? Good question. So there is a lot of risk with chronic pain after a tissue repair. The most common is the tissue repair falling apart doesn’t fall apart, it tears apart. So you’re actually tearing your muscles and your tissues as part of the recurrence and when you’re tearing, that implies that it’s going to be very painful.
Speaker 1 (00:41:12):
So the same way LeBron James’ rectus muscle tears very painful or groin strain is very painful. A tissue repair tearing has a similar pain and that’s why people have symptoms. So I just recently operated on a patient, no one could figure out why they had pain nerve injections. Finally they said, got to do a stimulator. Guess what? The nerve injections never helped. So the two options are if you’re tearing through muscle, use some Botox and relax that muscle. If you can relax the muscle and the pain goes away or is better, then it’s too tight of a repair and it’s trying to tear through. Sometimes imaging will actually show you the tear and also show you that there’s a hernia that’s trying to recur. As a result of that. Tear my incarcerated painful hernia about one and a half inches, even a line down, but was reduced after three weeks to about size and only can be noticed with Valsalva.
Speaker 1 (00:42:12):
I don’t know how, but do I still need surgery even if it’s ought to reduced? So I highly recommend that you listened to last week’s episode with Dr. Robert Fitzgibbons, Jr. From Omaha, Nebraska at Creighton University. He is the author and father of the watchful waiting trial and that is where we discussed the risks and benefits of surgery and how okay it is to just not operate on hernias, especially if you have no symptoms or minimal symptoms, whether it’s incarcerated is not as interesting. Next question, can tearing pain ever ease on its own or does scar tissue keep growing and tearing repeatedly? Yeah, tearing keeps continuing. It doesn’t stop. It doesn’t stop my story story with a femoral hernia repair and the story continues. Happy that Dr. Towfigh is part of my story too. Yes, I know and I can’t wait to fix you. I don’t know how I’m going to fix you, but I can’t wait till that day can a very deep infection near the area, okay, is a term for the impingement of a very specific nerve.
Speaker 1 (00:43:33):
The nerve is called the lateral femoral cutaneous nerve. It runs under your inguinal ligament, which is like a wire. So in some people when you stand, it kind of cuts on and impinges on the nerve. When you sit it’s better. So if you have true that is an impingement on the nerve. Now usually the impingement on the nerve is from the inguinal ligament, but in some patients it can be impinged on by scar tissue and yes, a deep infection near the area can cause scar tissue and the scar tissue can cause symptoms of your lateral femoral cutaneous nerve. She goes on to say I’ve had the pain and tickling and unable to lift my left my leg high as to get in a car. I have been told a large ventral or incisional hernia as well as an oh, I’ve been told I have a large ventral or incisional hernia as well as an umbilical hernia. Okay, so you may also have an inguinal hernia, and this is not related to your level from femoral cutaneous nerve at all, but again, part of their story. So where is the pain? What is affected getting in and out of a car? That’s usually inguinal hernia. Is it worse when you’re standing than sitting? That’s usually neuralgia paraesthetica. All these little details in the story are very important. Let’s do another story.
Speaker 1 (00:45:02):
Oh, it’s a long one. My name is Carol. In 2016 I had 12 inches of colon removed due to a perforation. During the surgery they repaired an umbilical hernia. I was unaware of that to begin with because I was experiencing issues with the colon surgery. Oh, because I was experiencing issues with the colon surgery, I was unaware I even had it umbilical hernia, nor had I been educated on exactly what I had happened to me. I recurred the incisional hernia repair. Okay, so she had an umbilical hernia. It was fixed during her emergency colon surgery and it fell apart. Actually, you had emergency colon surgery, which implies you’re already at higher risk of an incisional hernia from the incision that they did to get to your colon. Very high risk. I think 30 40% risk of just an infection and infections can cause hernias. In 2017, which is one year later, I need my gallbladder removed.
Speaker 1 (00:46:02):
So the surgeon repaired the incisional hernia at the same time and placed a small piece of Mesh inside me. Again, small is not better. Again, I was not aware of the Mesh, nor was I given any education on self-care. So small is not good. When people say, oh, I just had a little small little hernia Mesh put in, that implies usually that the Mesh is too small and therefore you’re at higher risk for a hernia to occur. Recur, okay, she goes on. So of course I recurred again. There you go. See just from the story, I can tell you the next step of what’s going to happen next. But my regular doctor and ER doctors told me that I was experiencing gastritis and to take Tums and antacids. Again, if you had a recurrent hernia and you get abdominal pain and it’s worse when you’re standing and bending, that’s not because you have acid reflux.
Speaker 1 (00:46:57):
It’s all about the story. Not until I was literally riding on the floor in pain and we call an ambulance, did they do a proper imaging and saw that not only I had recurred, but now it was strangulated and strangulated means usually bowel is stuck in the hole. This was in 2019, so it sounds like you were probably having intermittent obstruction or bowel stuck in the hernia causing you the pain. It was dismissed. I was told I’d need to have my small intestines resected. Luckily my colorectal surgeon had them wait and after four days of lying in the hospital, my intestines popped back in and they repaired me and sewed me up. I had a second piece of Mesh placed. Again, no one told me about it, but that is part of the repair. Not until July of 2021 that I learned about hernia groups on Facebook and people there instructed me to gain access to my medical records where I discovered that an I indeed had Mesh inside of me an I indeed had recurred a hernia yet again.
Speaker 1 (00:48:01):
Wow, that’s three hernia repairs. 1, 2, 3. Two of them with Mesh. I have since dropped 53 pounds. That’s good because if you are overweight or obese then that’s a major risk factor for these hernias coming, falling apart and I’ve been able to consult with a few surgeries including you, Dr. Towfigh. Yay. I hope I can help you and I’ll be making my decision soon as to the next course of action. I have drastically modified my day-to-day habits of movement and also switched my sleeping position to back sleeping only. See, this is what a lot of people don’t understand. It’s you have to change so much of your lifestyle to have to deal with these hernias. I squat instead of bending and I’m taking big steps overall to not aggravate my current situation. Because having strangled once and now that recurred you may be at higher risk than the average patient from strangulating again.
Speaker 1 (00:48:57):
I’m thankful I don’t have any big pain and I’m praying this next surgery can remove the next, the two piece of Mesh I have inside and I can have a repair without more Mesh and it will be the last surgery I have. Okay, not to poop on your party, but if you’ve already failed three hernia repairs, you’re definitely not going to have a tissue repair performed. But the question is, where are these meshes? How were they repaired before? Can we do a nice, beautiful repair with just the right amount of Mesh and just the right placement? Just the right area to get you to a point where there’s your last operation. You don’t need any more surgeries and part of it is to go through your story and understand why, walk you through the story to understand why you recurred each time. Did you recur because you had a chronic cough and was constipated or were very overweight or did you recur because a surgeon used the wrong technique, the wrong size Mesh and the wrong thickness of Mesh? Again, it is all part of the story.
Speaker 1 (00:50:08):
Next question. Let’s see. I’m 62. I’ve had a very big hernia at the bottom of my stomach for years. I have colitis two, so it hurts even to Ben. It hurts. The doctor doesn’t think I’m healthy enough to have surgery. I need to lose a lot of, can anything happen if I don’t have surgery? It’s very big and hard on both sides of the hernia. So the size of hernia is not as much of a factor as your symptoms. So if you have symptoms related to the hernia, you do need surgery. But before embarking on any surgery, make sure that you’re not constipated, you’re not straining, you are not overweight and you’re not using nicotine and you don’t have a chronic cough, then you should have your hernia surgery. Do not try and just get it done just to have it done because as you heard from this last story, should have three hernia surgeries and looking for a fourth. You don’t want to be that person.
Speaker 1 (00:51:09):
All right, when you have a patient with terrible pain from badly plate Mesh and the Mesh needs to come out, do you call the surgeon from the original surgery to let them know so they can understand their results? Okay, great question. So yes and no. I used to always call the surgeons and say, Hey, so just let you know I’m seeing your patient. I feel that this is a problem and I’m going to fix it. Just want to let you know. And eight out of 10 times I got nasty attitude. It was like they basically said, you’re wrong. There’s no way that my hernia recurred. There’s no way that my Mesh is causing the pain. There’s no way I did anything wrong and it was just the worst interaction. And so if the patient asks me to call their doctor, I do, but no, I do not call.
Speaker 1 (00:52:02):
I don’t routinely call those doctors. If I know the surgeon personally and we have a rapport, I do, but I don’t call ’em anymore. It just gives, it’s just horrible interaction. I hate to say this, but in my experience, people, and I’m a nice person. I’m not telling them you. If these things happen, I’ve had my own patient, I would like to know if any surgeons out there that has my patient, please let me know because I want to know what happened, what they were do, et cetera. But I feel that’s that’s not the case for most people. I do want to share another story of someone who’s been on a very active person on Hernia Talk.
Speaker 1 (00:52:45):
You’ve heard me. I have very few patients that I publicly talk about. Some of them have asked to come on or asked to share and be involved with their stories. The Patient RN, the at patient RN who came on around Christmas time, she shared her story and also kind of how she was able to navigate the system to advocate for herself. I have a recent patient that man his life kind of really got screwed up after Mesh was put in and he went to doctor for doctor chairman, department head of surgery, whatever they all told him is like nuts. It’s all in his head. There’s nothing wrong with him. He finally reached out to me again online consult. So it’s a great way to initiate a consultation. He’s not from this country and I think he wants to move back to not move back, to move to the United States based on his very positive experience.
Speaker 1 (00:53:49):
But I performed the operation he thought he knew he needed, needed his Mesh removed. He had a very significant Mesh reaction. Mesh implant illness is what we like to term it now, and all of his symptoms pretty much have resolved. He’s able to go back to eating normally. All of these weird rashes he had and the joint pains and the brain fog, inability to concentrate are all gone. His energy is up. He has attitude about life is up. So people just didn’t believe that he had a Mesh reaction and they told him, not only did they tell him he was wrong, there’s nothing wrong with you, but they also told him there’s nothing to do and then no one can do it, which was totally wrong and gets rid of hope for patients. I’ve had patients been told, you can’t have this Mesh removed, you’ll lose a leg.
Speaker 1 (00:54:45):
Never happens. You’ll lose a testicle. Almost never happens or shouldn’t happen in most situations. You’ll never be the same again. Operating on pain causes more pain, all completely false. If you know the story and get the right history and come up with a very solid plan with the right doctor that has the experience, you should have a good outcome. And I’m not able to solve every single medical mystery, but I must say pretty damn good, pretty damn good with a lot of these. I kind of enjoy it. I really do enjoy it to be honest. In fact, my patient today said, I heard you like mysteries. You like to solve mysteries. That’s why I came to you. I’m like, yep, love mysteries, medical mysteries. Next question, next story. I had a colon resection on July of 2020. During the procedure, my small intestine was nicked and they close it.
Speaker 1 (00:55:42):
Okay, that’s a problem. It can happen for sure, but if you have any intestinal injury, the risk of you getting sick from it, fistula infection is very high. Several days later I became septic, which is a very deadly infection. A second surgery was done to fix it. So after three laparoscopic surgeries using my umbilical area, this resulted in a very large ventral and umbilical hernia. I’m still waiting repair. What could happen if I don’t fix it? Okay, so this is a good question. In general, if you have no symptoms, we discussed, this is a great, this should all from last week. This should have been last week’s question. We talked about watchful waiting last week. So the answer is this. If you have zero symptoms, watchful waiting is considered safe and including for ventral and abdominal wall hernias. Are incisional hernias in the same category?
Speaker 1 (00:56:42):
We don’t really know scientifically, but likely they are. Although incisional hernias usually apply more scar tissue than your typical umbilical or ventral hernia. So if you have minimal symptoms, it’s often and you live in like a country where you have easy access to emergency care, it’s often safe not to do anything about it until you start getting symptoms. But once you do have symptoms, and Dr. Fitzgibbons was very clear about this yet last week, once you do have symptoms, it would be not the right decision, especially for ventral hernias to, and especially for elderly to just ignore it because the symptoms are indication that something is getting caught in there and the risk of problem is higher.
Speaker 1 (00:57:28):
Next question. How can you determine whether a tissue repair is too tight and is tearing clinical exam imaging? Would that be the telltale signs to you? So it’s your story. It’s how to put was seen, what was done, and what your symptoms are now together. Oftentimes imaging is not a good way of assessing it. However, you can have Valsalva imaging like MRI with Valsalva and see if there’s not enough bulging, natural bulging from a tissue repair or if it just like rock hard stays there from a Mesh repair. So that’s sometimes helpful, but not usually. It’s all about the story.
Speaker 1 (00:58:16):
Keep saying it. All right, let’s do a couple more questions before we’re done today. After my trial with the D R G pain stimulator, I have not been able to have a normal bowel movement without digital stimulation. What can cause that? Is it something to be concerned about? That’s weird. So you should be able to have normal bowel movements because the pain stimulator is way up high. It’s not sacral in nature, but potentially you may be on narcotics or other reasons that may be causing constipation and difficulty emptying. Your pelvic floor should also be able to be unaffected by the stimulators because that’s also sacral nerves and that’s usually not where D R G pain stimulators are placed. What are your thoughts on getting nerves burnt to stop pain after inguinal hernia repair? I don’t believe in burning nerves for all inguinal hernia repair because most inguinal hernia repair pain is not nerve related.
Speaker 1 (00:59:22):
So if it is nerve related first I block it. Oftentimes it’s all you need is blocking. Or if it’s involved in scar tissue, kind of doing a hydrocele dissection with hyaluronic acid. I had my plug-in patch removed at the cleaning clinic in December after 10 years. See, good job. I didn’t have unbearable pain until 2021 and no one could figure it out. It’s been five months and I have done PT for eight weeks. Plug pain is gone. Yay. But now I get pain around the adductor insertion and pubic tubercle after activity. I did have a flat sheet put back in because I’m active and live with mush for 10 years almost pain free. No nerves were taken. What do you think can be causing this new pain? It still prevents me from being active and pain free. Okay, so if you have, let’s see, pain around the adductor insertion of pubic tubercle that may be ilio inguinal in nature. So an ilio inguinal nerve block may be helpful. It’s uncommon not to cut any nerves during a Mesh removal, especially if you had the plug and the patch removed. Just to remove the patch alone can cause ilio inguinal nerve injury. So first start with a nerve block to see if it’s your ilio inguinal nerve.
Speaker 1 (01:00:43):
One more and then we’ll see you next week. Okay? I went back to my implanting surgeon and he said to go to pain management. I knew right then I was screwed. Yeah, I agree. They just won’t admit they messed up. I’m praying Dr. Fitzgibbons will help me. I was referred to him. Great. Still have tacks, my pelvis and possibly leftover Mesh. It’s been five years since my removal and my pain is still off the charts. So bets of luck to you Definitely see the specialist that I have confidence in and we’re only the only ones that I bring on these shows. So good luck to everyone I think. I hope that this has basically been helpful, have so many more stories to share. You can’t imagine how many stories I hear every week. It’s just something that I love to hear and I feel it really is a great part of what I do every day. So in summary, be your own best advocate. Share your stories, make sure your doctor hears your story and never not believe in yourself because you’re often right. On that note, let the guys, thank you everyone. I will see you next week. We have a really great, great series of people that we have lined up for the next month. Talk to. See you then. Bye.