171. Surgical Meetings Update

This week, the topic of discussion was:
-Hidden Hernias
-Occult Hernias
-Patient Voice
-Hernia Imaging
-MRI
-Medical Gaslighting

Welcome to HerniaTalk LIVE, a Q&A hosted by Dr. Shirin Towfigh, hernia and laparoscopic surgery specialist who practices at the Beverly Hills Hernia Center. This is the only Q&A of its kind, aimed at educating and empowering patients about all things related to hernias and hernia-related complications. For a personal consultation with Dr. Towfigh: +1-310-358-5020, info@beverlyhillsherniacenter.com.

If you find this content informative, please LIKE, SHARE, and SUBSCRIBE to the HerniaTalk Live channel and visit us on www.HerniaTalk.com.

Follow Dr. Towfigh on the following platforms:
Youtube | Facebook | Instagram | Twitter

Transcript

Dr. Towfigh (00:00:11):

Hi everyone. It’s Dr. Towfigh. Welcome back to Hernia Talk Live. We had a kind of crazy month. I’ve been at meetings and there have been other situations. I deal with patient care and so on, and so I was not able to do my weekly Hernia Talk Live for several sessions, but that only means that we have a whole bunch of things to talk about because it’s been a while. As you know, my name is Dr. Towfigh. I am your hernia and laparoscopic surgery specialist, your host for our weekly Hernia Talk Tuesdays. Thanks for everyone who’s joining me live on Zoom and as a Facebook Live, and thank you for following me on Instagram and X at Hernia Doc and for those of you that are on Facebook at Dr. Towfigh currently. And don’t forget this and all previous episodes can be watched on my YouTube channel at Hernia Doc and now also as a podcast.

(00:01:12):

I’m super, super excited about that opportunity. So here’s the plan. I just came back from Cleveland, Ohio. I actually like Cleveland very much, but that’s the major Sage Sages meeting. SAGE is an acronym, SAGES for Society of American Gastrointestinal and Endoscopic Surgeons. And the SAGES meeting is the largest laparoscopic meeting of the year. It also involves a lot of robotic surgeons and therefore a lot of abdominal wall surgery. And what’s great about it is it’s very fun. It’s one of the more fun meetings we go to. It’s mostly younger people, which makes it more fun. It’s very technology oriented because of the fact that it does involve laparoscopy, robotic surgery, et cetera. So there’s a lot of tech involved in it. And then lastly, I kind of like it because it’s never a nice place, but it’s always in a place where you see all your friends and it’s been a while since I’ve seen my friends. So I’m super excited about.

(00:02:28):

Last week was super exciting for me and in addition to it being very exciting, it was really busy for me. So thank you all who are joining. Hello from Australia. I love it that you’re here, Australia. And I must say what I really liked about the meeting was I got to see a lot of my friends we’re interviewing for fellowship applicants. So I got to see many of the fellows that we interviewed a couple weeks ago, but it was all by Zoom, and so I got to see them in person. They came by and I felt like I met a lot of you who follow me on social media that are doctors. So whether you’re a resident in training or a fellow in training or some of you from another country, you came by at SAGES and you introduced yourselves to me and I got to get to know you a little bit about you.

(00:03:24):

I asked for some feedback from you about how I can improve Hernia Talk Live and all of my other social media outlets and talking about hernias and I am the queen, so I really like that. So I thought what you may be interested in is to learn a little bit about what I learn and if you want to know more details, if you go on X tweet, I live tweet. When I’m at surgical meetings, I sit in the front row, I take out my phone, I start taking pictures of the slides or videos of what people are doing, and I tweet it so that what I’m learning, you’re also learning. It’s my way of keeping up with talks. I also sometimes put in my own little, what’s the right term opinion or editorial about some of the talks if I agree or don’t agree with what they’re saying because it’s a science and it’s an art.

(00:04:28):

But usually I use my Twitter account, my X account for the academic scientific stuff. So most of my followers who are physicians follow me on X, and I feel like I give back by sharing with them what I learned at the meetings. Every time I go to meet, I go to a lot of meetings. It takes up a lot of my time and I wish I had more time because then when I get back everything is squished. I get to see patients that I could have seen in two weeks. I now have to see in a shorter time I back to back surgeries when I come back. So I enjoy these meetings, but I also feel bad that I’m not here clinically working to help our patients. So I thought this week I can answer some of your questions live as you send them, but also very importantly, I will review the meetings. So we had several meetings so far. Last week was the SAGES meeting, which is a big laparoscopic surgery meeting. These are all available online, by the way, if you want to just see what we talk about. So you can go to sages.org and look at what the topics were.

(00:05:45):

Prior to that was the Pacific Coast Surgical Association meeting, and prior to that was a Southern California Association, Southern California chapter of the American College of Surgeons meeting. So that’s been my 2024 so far. And I did a couple of international meetings, which I tweeted about. So that’s what I’ve been doing this past year. Two of the meetings, I actually had my fellow present art research. So research that we presented this year, I felt was very, very impactful at sages. So our sage’s topic was about hidden hernias or occult hernias. You’ve heard me talk about it before, but the topic, the title was Hidden Hernias Hurt like the Alliteration. So Hidden Hernias Hurt. Why? Because most people believe that inguinal hernias should show up as a bulge, and if there’s no bulge, there’s no hernia, number one. And number two, they believe hernias don’t hurt.

(00:06:50):

How is that possible? Almost every patient I see has pain from their hernia. So I don’t know where they got this idea that if you have groin pain, that’s not your hernia, it must be something else. And I’ve literally had people who I respect and are super big deal in the hernia world back when I was younger, stand on stage and say, if you have a really painful groin in a patient, look elsewhere, it’s not the hernia. It may be the hip or other things completely wrong. So that’s why we decided to finally take all of my data for the past 10 years. 10 years, yeah. From 2009 to 2019, we took all that data, 10 years specifically looked at occult inguinal hernias. And for those hernias we found out they’re more likely to be painful.

(00:07:49):

They show up twice as long later. So in other words, the delay in treatment is twice longer. If you have an occult hernia than irregular hernia, you’re three times more likely to have narcotics prescribed to you. Instead of actually getting your hernia repaired, it’s given narcotics, which is a horrible problem. By the way, if you could have a hernia pain that can be treated, you should just have it treated. What’s happening is, oh, did I mention mostly females, mostly younger people, mostly a little bit heavier people. But occult inal hernias is a, or hidden hernias is a diagnostic dilemma because a lot of people don’t believe in it or they’re not aware of such a thing. It’s not taught in medical school. And so typically it’s a younger female with groin pain. No one knows what the pain is from. By the way, it’s a fair number of people that are also male in our group.

(00:08:49):

But we specifically noticed that statistically it’s higher risk in females. So they present and they’re labeled as chronic pelvic pain. They get zero surgical treatment of their hernia, but they’re given narcotics. And often there what’s called medically gaslit. So medical gaslighting is a huge problem in my field because many doctors do not appreciate or recognize that there is, let’s say a hernia causing someone’s pain and they therefore do not diagnose the hernia. And the patient ends up having no diagnosis and being told it’s either all in your head or there’s nothing wrong with you, go away. You may have to live with this for the rest of your life. We can’t figure it out.

(00:09:43):

So my fellow Harry Wong, who’s a great doctor, is finishing up this year, he presented our data, and let me tell you, we had so many people interested and asking questions and supporting the fact that this is a very important topic and hopefully our paper will get published about this topic. So in essence, you have patients with somewhat atypical presentation. So they have growing pain that radiates to their inner thigh on their lower back, but there’s no obvious bulge. They typically have fullness in the groin area or tenderness in the groin area. That’s been a very specific finding. Their symptoms can be suggestive of hernia, that’s activity related pain in women, they have more pain during their period. That’s about 25% of the women that have occult hernias have more pain of their hernia during their period, but they also have activity related pain bending, sitting, coughing, lifting, pushing, pulling, those all cause groin pain, intercourse causes pain, getting in and out of bed out of a car.

(00:11:00):

These are all things that cause pain, but no one can figure out what it is. Many doctors call this a sports hernia. Now I’ve had people be diagnosed with sports hernia. They’ve never done a sport in their life. They may be elderly completely wrong. And so these people do not get a hernia repair. It’s they go through pain management, et cetera. And worst case scenario, they’re actually told it’s all in their head. So we presented our data and the goal was for doctors to understand that there it’s, oh, and by the way, they all get imaging. They all show hernia even though the hernias may be small. But our goal was to teach that not all angle hernias are the same. A very small hernia can actually be more painful than a larger hernia. The symptoms and the story is the most important part of whole diagnostic dilemma.

(00:11:57):

And then on physical exam, patients with occult inguinal hernias or hidden hernias, they’re very tender specifically over their internal ring and the groin along their inguinal canal. They may have a little bit of fullness palpable there. They tend to be more likely indirect inal hernias but also femoral hernias and less likely to have a direct inguinal hernia. They tend to be young females of slightly higher body mass index. They’re more likely to present with pain. Their level of pain is higher than the average patient with inal hernia and they’re more likely to have narcotic prescribed. Now, we then went ahead and operate on all these patients and confirmed the hernia in the patient and it was repaired. Guess what? Not only did they all improve, so everyone who had a hernia, their pain improved. Whether you had pain didn’t have pain, it improved. However, the people that had severe hernia because of their ral hernia had a much more significant drop in their pain scale, so much greater improvement in their pain after surgery than the average hernia patient.

(00:13:10):

Why is this important? Well, you may have heard that there are doctors that say that you operate on pain, you get pain. I’ve always hated that statement. I don’t agree with that statement, but it comes based on data in the past that has shown that people that have postoperative chronic pain tend to also have a higher level of pain before surgery. They also tend to be female. So if you think about it here you have a patient with a hidden hernia or occult inguinal hernia. They’re female, they have a lot of pain before surgery. They go to their doctor. They may even have an ultrasound or MRI or something that shows there’s a hernia, but their surgeon will specifically say, I will not operate on you because they have this mentality that you operate on pain, you get pain. And so what we show, which is super important, is please do operate on these patients, fix their hernia, and they will actually be much happier than your average patient.

(00:14:18):

Not only do you rid of their chronic pain, which they’ve had for years and get them off their narcotics, but more importantly, this dictum that you operate on pain campaign is completely demolished by our data. We show that patients who have a higher level of pain because of an inal hernia once their hernia is repaired, have a dramatically much more improved level of pain improvement than your average patient, and therefore they’re going to be much happier and just think of all the good you can do. So my message to the doctors at this meeting was, listen to your patient. Understand that groin pain can be caused by angle hernias and repairing it even though they have a lot of pain before and you’re like, I’ve never seen this much pain from a hernia. I’m really concerned of operating on you. I don’t want to cause you more pain.

(00:15:16):

Don’t worry about it. They get better. Do the right diagnosis, get the right history, operate on these patients and they will do better. So that was our research. We presented it 500 patients almost in our comparative study, and I believe it made a big difference to those patients and we’re going to publish our results. You can all read it online once it’s published, but more importantly, the doctors and the surgeons will read it and hopefully referring doctors, family medicine, doctors, gynecologists, maybe even, hopefully definitely surgeons will learn more about hidden hernias and occult inval hernias and do a better job of not only diagnosing it but agreeing to treat it. Knowing that our data shows that this notion that you’re not going to help these patients is not based on evidence.

(00:16:11):

You don’t know how many patients I see that go to their doctor with an ultrasound or MRI or CAT scan in hand that shows a hernia. They have symptoms of a hernia. The pain is where hernia would be, but there’s no bulge and the doctor says you don’t have a hernia or they say you may have a hernia, but operating on it is going to make your pain worse. I’m hoping to completely get rid of that kind of discussion because you’re not helping the patients. So that’s kind of what we present at sages at the meeting. Super proud of my fellow because he did a really great job and there was so many questions and interest in it. I must say this year’s sages was very interesting because the president of sages, this lovely colorectal surgeon named Dr. Pat, Patricia Silla from New York, she had a vision of including what’s called the patient voice in the meeting.

(00:17:22):

Now, you’ve seen me interview several patients on the show before and some of them have shown interest in being involved in surgical meetings, and I may have told you two European Hernia Society meetings so far have included patients. And the last one I was in think, was it the, I don’t remember if it was the Manchester one that started or if it was the one in Barcelona, cis, but regardless, they actually had their own session where only patients presented. So that was really, really cool. That’s not as common in most American meetings. The American Hernia Society has started including patients, but SAGE is a huge meeting. We had over, I think 3,500 people attend. That’s a large number for a meeting only about laparoscopic surgery.

(00:18:35):

So one of the interesting parts was they picked and chose a couple of sessions and they added what is called the patient voice. Now I was the chair of a session called Hernia Get It? Hernia. It’s like the H-E-R-N-I-A, which was a session that promoted awareness of women’s hernias and how they’re different and should be treated differently. Now listen, just so you know, I treat men and women as well. I treat males and females. So let’s just say that I have a special interest in the females hernias, but I’m not exclusive to females. Just want to make that clear. There have been people that said, but do you treat males or only female? Like, no, no, no. I’m a general surgeon. I treat males and females equally. But I think because I am female, I maybe attract a little bit more a percentage of females to my practice, and I’m one of the few people that actually is talking about female hernias, and so that may also attract more females to my practice.

(00:19:55):

Now what I wanted to say is I was made chair of the session called hernia, and we talked about gender-based differences. Sorry, gender-based differences in care. We talked about the difference between the male and female pelvic anatomy and how that’s different. We talked about the difference in what symptoms females present with than males. Females tend to have less bulging and more pain. They tend to have more rating pain into their vagina down the inner thigh around their lower back, even up to their belly button. They tend to have more pain during their menses, which kind of throws people off because they think, oh, maybe it’s gynecologic and then sexual intercourse can be painful. And interestingly, they tend to have smaller hernias because their inguinal canal is smaller than males.

(00:20:51):

So we reviewed all that. We had a really great talk about transgender surgery and how the hernia surgeon is involved in that. So it was super fascinating. We had this great talk by this doctor up in Oregon Health Sciences University where they have a big transgender surgical population and the hernias surgeon there, Dr. Vaha Napoleon, who was actually a guest before on my podcast, was sharing not only how they do the surgery, but also certain factors about how the hernia surgeon can help or mess up patient’s opportunities to have these operations. For example, highly recommend not cutting any nerves. Those nerves may be used for the transgender and the operations. You talked about laparoscopic versus open surgery use of mesh and how that may or may not disturb the surgical field and all that. So really, really fascinating things. But also understanding that ultimately as a surgeon, you may be seeing a patient from a certain gender, but their sex is actually more important from a anatomical standpoint. So if you have a female pelvis versus a male pelvis, because the anatomy is different, you may want to treat them based on their sex, not based on their chosen gender.

(00:22:33):

Okay, so that session, the hernia session was one of the four or five in the entire meeting. There are hundreds of sessions where they chose to incorporate what’s called the patient voice. And since we were chosen, I had the ultimate privilege to invite a patient of my own. I tried to find local patients, didn’t happen. I do have patients in Cleveland and in Ohio, but for one reason or another, they were not able to serve as my patient voice. I had another patient that I asked to come. She had a really, really compelling story, but she needs other surgeries and so couldn’t use her, which was unfortunate. She did send me a really great writeup that we used.

(00:23:28):

And then lastly, I have this other patient. So this patient, she flew in, shared her story, everyone cried. It was a very compelling story. She had pain for 20 years. Two zero, her child, she had pain before, during her pregnancy and it continued ever since. That child is now in college, 20-year-old. So she’s had 20 years of pain and she went through all of the trials and tribulations. She legit went to gynecologist, urologist, pain doctor, physical therapist. She had injections, she had multiple images. The images all actually showed inguinal hernia. I remember seeing images as far back as 2016 that showed inguinal hernia. She specifically was never told that there was such a finding. The doctors discounted that as a reason for her pain. Never told her that she had these hernias even though it was documented. And part of my research and also the session was to try and get this message out that you need to think a little bit outside the box.

(00:24:48):

And the doctors she was seeing were really great doctors in their box and she would have urologic problems, for example, and she would see a urologist. But if the urologist said, you don’t have a urologic problem, I know you have all these bladder issues, then they would say, there’s nothing wrong with you. To the point where they started gaslighting and she started getting PTSD because she knew every time she could to a doctor, they would say, it’s not their problem. There’s nothing wrong with her. And then you start believing that maybe I just have this very abnormal perception of what’s going on with my body and it’s not real. Anyway, long story short, she was referred to, she gave a great story. One of her friends from high school I believe became a urologist. He’s actually one of the top urologists in town, Dr. David Josephson.

(00:25:47):

If you go back, you’ve seen me interview him. Just superb. Very intelligent surgeon. So her story was that this urologist was her friend, and so everyone’s like, go see him. He is really good, but it was her friend and she had all these little female bi part issues and didn’t feel comfortable going to see this person that she knows socially about all of her kind of pelvic organ, vagina, rectal pain, bladder issues. But she finally did, and he was the first surgeon she said that actually started to think outside the box. And he said something in the order of, you want to think that this is something else besides your bladder. She has a lot of bladder issues. Maybe it’s not your bladder, maybe it’s something else. Go see Towfigh and Towfigh likes to figure these things out. Go see her. Now, of course, I’m the hernia surgeon.

(00:26:58):

I see everything through hernia lens or at least I tend to. I try not to, but I tend to, and even before I met her, the story that I got from my nurse and the imaging, I was like, oh, she got an inguinal hernia. I don’t understand what the problem is. And then she’s telling me the story and you’re telling the story and can see how you can get caught up as a patient where certain symptoms get lost in the story, like her groin pain and other symptoms get amplified like her bladder frequency and her pelvic floor spasm. And no one puts two and two together to say, okay, you have let’s say inguinal hernias causing the urinary frequency and bladder spasm, for example. I had not known her. I didn’t know this whole history. It was just very clear from the chart that a lot of people were throwing their hands up and kind of saying, it is what it is, type situation. And I felt so bad 20 years. This woman, she’s a really intelligent woman.

(00:28:10):

Anyway, so I told her it’s a Hernia, I examined her. Her pain was exactly where inguinal hernia would be. She said, really? No one’s touched her. They just review her imaging and they do all these tests for her, but no one’s actually examined her. Like I had examined her. I fixed her hernia. And I mean, she was explaining how her life has changed. She’s considering going back to play tennis and she actually was able to travel from Los Angeles to Cleveland. This would’ve been something she could never have done. She’s gained weight. She’s more energetic, she’s back to work. She has a more normal relationship with her husband who is amazing, by the way, just really, really supportive husband. Anyway, so my point is we had a great session promoting women’s hernia issues to teach these doctors, but also it was kind of part of the fact that the president of the SAGES Society has gone on to promote the patient voice that I had the opportunity to bring my patient and she could share her story.

(00:29:24):

And it was very, very, very impactful. It was unfortunately among the last sessions of the meeting on the last day of the meeting on Saturday, and we still had a pretty full house. So that just goes to show you how important that is. Here’s a question. Oh, thank you very much. I’ve had this going on for three and a half years now, all start after hernia surgery actually had mesh removal in Cleveland with no relief. Cleveland doctor says nothing is there. Toledo doctor says there is a hernia, no lump or bulge, but nonstop pain and discomfort. Doctors refuse to order an MRI. They say it will not show more than a ct. Okay, well first of all, if it’s in your groin, I definitely disagree with your doctors. We’ve literally published papers saying, don’t get CAT scans for the groin. Just skip from ultrasound to MRI.

(00:30:20):

So they need to do some education of their own. Or maybe you can send them my paper that shows how poor CT scan is for angle hernias papers online. You can just download it, number one. Number two, these things can be very subtle. I just saw a patient who had a hernia repair. Now I don’t agree with how the hernia repair was performed, but she did fine for 14 years and she has new groin pain. Now, anyone who did fine for 14 years and now has groin pain, has a hernia recurrence until proven otherwise. That’s my motto. I stand by it. It’s a very good rule. However, she went to her doctor and her doctor was like, oh, you must have scar tissue from your surgery.

(00:31:16):

Okay, hold on 14 years and you have scar tissue. If you had scar tissue would’ve been 14 years ago. People do not suffer from scar tissue issues 14 years later when they have 14 years of great success. So that was the wrong idea. They sent her to physical therapy. It actually hurt her more. So I’m looking at her imaging and knowing the kind of hernia repair she had done. I had a little inkling. So she had what’s called a keyhole repair. How can I explain the keyhole repair? If you have a piece of mesh, you put a hole in it that’s a keyhole repair. That hole allows for this spermatic cord to go through. Now she doesn’t have a spermatic cord and her round ligament was cut, but they still use a keyhole mesh. It comes precut. You’re not supposed to use those for women if they have no round ligament. There’s no spermatic cord. We don’t have testicles. So you just use a flap piece of mesh. This one, they use a precut one with a circle. So it seems to me the surgeon put in a mesh with a circle in it. And if you look at the imaging, she’s got a MRI, by the way. MRI, she has a very subtle little piece of fat trying to poke through that little hole in the mesh. It shouldn’t have been there.

(00:32:40):

Listen, she’s very tender on exam exactly where a hernia would be, but she doesn’t have a bulge. She’s very thin. So if she had a bulge, you would’ve seen it. And so everyone’s told her, oh, it’s just groin pain. Or you have a sports strain or something like that. So that’s wrong. The imaging, which is the MRI, shows it Now, she didn’t even have the correct MRI. She had a regular MRI. What I would’ve liked is if she had what’s called the MRI pelvis with the val Salva, which is a bare down view where you push out through that area. She didn’t have that. But even not having that, even not having that, she still shows a little bit of fat booking out. I guarantee you, if she had the same imaging with the area looked at with her pushing out, you would’ve seen the mesh with a little hole in it, a little piece of fat going right above it, I’m sure. Anyway, she has a hernia recurrence. We’ll fix it for her.

(00:33:42):

Here’s a question I was told. There was bow stringing of sutures on my inguinal floor done during my tissue repair. Bow stringing, the sutures were tender and may be contributing to my postoperative pain. Have you heard this term and what it might mean? Yes. So bow stringing, it implies that your suture is on tension. So if you think of a guitar or I guess it comes from an arrow, right? Like a bone arrow that string for the bone arrow that you pull on. But you can also think of a guitar or violin or something. So you want those strings taut. That’s where you get the musical feedback and also how you get a really good bow and arrow kind of projection. However, you do not want that taut during any type of surgery. You never want bow stringing of your suture because it will be very taut, whereas your tissue needs to be flexible so that you can bend and put your pants on and cough and sit and stand and pick up your dog or child or whatever.

(00:34:59):

So bowring is not a good idea and I don’t know why, but some people they put sutures in and they really pull it really hard. Makes no sense to me. If you ever wear a hoodie and you know how the hoodie has that little draw string inside the hood, most people who wear hoodies don’t use the hood and they use the hood loosely. So you never pull on those strings. But if you did, you can see how the hoodie, if you put it on yourself, it could kind of scrunch around your face. You don’t, don’t even do that for clothing. Why would you want to do it for your abdominal law? That never made sense to me. But I really enjoy phasix and I am kind of a nerd about phasix. So I think logically about these things and some people they think if they’re pulling, they’re tightening it really tight and making that mesh border or the mesh to the ligament may be waterproof.

(00:35:59):

I don’t know. Doesn’t make sense to me. So that’s the bow stringing. Now you say that you have suture pain. It may not be suture pain or maybe it could be it’s just a too tight of a repair would be a more clarified discussion. I want to show you something cute that happened during the sages meeting. For those of you that are here, video based, do you all see this is a pin and this pin was given to me by Dr. Jenny Shao. She was a guest on Hernia Talk before. So it’s a pink pin and it says hernias. The N is a cute little bulging hernia and the first three letters of hernias is capitalized to promote her part of hernias and is pink in color. So this was passed out and it was kind of cute because it was designed by her and the purpose of it is to promote awareness of hernias among women.

(00:37:15):

And it kind of caught on. A lot of people wore it and wore it proudly. And we actually had a session called hernias with the HER being prominent. And our research topic was on hidden hernias hurt, which is a gender-based kind of problem usually. So it’s kind of cute that we all did that. Now what else do we talk about? The meeting tons of topics. You can go online and read about it. Many of these will be available on YouTube. They eventually make it to YouTube and are free for you to watch usually a couple years after the meeting, maybe one year after the meeting. But we talked about, let’s see, what did we talk about?

(00:38:03):

Emergency hernias. So they wrote hernia with the ER part of it capitalized, so it’s hernia with the HER. So we talked about emergency problems with hernias. We had a whole imaging session about hernias. We didn’t really talk about mesh implant illness and I felt the imaging session was a little bit weak. No one talked about MRIs. They only talked about CAT scans. And I must say most hernia surgeons are very comfortable, the abdominal wall and not so much with the pelvis and the groin and maybe that’s why. So I don’t know, that’s maybe the situation, but that was kind of cool. Here’s a question that was submitted about the meaning apart from the anatomy, differences of the relative rarity of angle hernia in women. Are there any other reasons at the basis of the difficulties that women face to access hernia treatment? For example, are women disadvantaged even in accessing incisional hernia treatment?

(00:39:06):

Yeah, that’s a good question. So actually women are more likely to have hernias, especially ventral hernias. So umbilical hernias, it’s just the groin where the men tend to be more common and groin hernias are more common than umbilical hernias in general. So that’s kind of the difference. The disparity number one is for the groin is actually diagnosing it. Okay, so we did discuss that in our research about hidden hernias and also how women have a lot of stuff going on in the pelvis including the ovaries and the uterus, and therefore oftentimes there hernias are discounted as a reason for pelvic pain because they’re seen by their gynecologist who’s not aware of angulo hernia as a problem.

(00:40:00):

A second problem we discuss about women not getting maybe timely care is pregnancy. So pregnancy can promote umbilical hernias or we can just have a ventral or umbilical hernia, but you’re of childbearing age. So if you’re pregnant or can be pregnant or wish to be pregnant in general, we don’t recommend a definitive hernia repair in the abdominal wall like belly bin. Groin is different. You can have your hernia repair in the groin at any time. It’s not affected by pregnancy or delivery. However abdominal wall hernias are. Now the question was how bad is it to repair an umbilical hernia at the time of pregnancy or before pregnancy? It’s not that bad. So sometimes perhaps we are overstating the effect of pregnancy on umbilical hernias. The congenital consensus is if you have a belly body hernia and it’s not bothering you, then don’t repair it until you are done with all forms of pregnancy. If it is bothering you, then you can get it repaired without mesh. Preferably if it’s big enough that you need mesh and you can’t wait, then it’s perfectly okay to fix those two.

(00:41:23):

There is a higher risk of maybe pain during pregnancy or recurrence, but apparently it’s not as high as we think. So one thing where women maybe to be disadvantaged, they’re not offered care because of their risk of getting pregnant and therefore their quality of life is lower with a hernia. And lastly is we had a huge discussion. I’d love to hear what you guys think about which is disparity in care and the obese. So people that are obese, we don’t recommend hernia repair on, sorry, we don’t recommend elective hernia repairs, elective hernia repairs and the obese because the outcome is worse, higher recurrence rate, higher chronic pain rate, higher surgical infection rate, higher wound complications, higher mesh infection rate. Now is it that much higher?

(00:42:20):

Depends on the situation. We’re not talking about 700 pound patients here. We’re talking about maybe a 200 pound patient who’s five five. So the question was is it fair that we are denying hernia care to patients of a certain body mass index BMI Understanding that number one, the same body mass index for a male is different than for a female because a female will carry much of it in her hip and chest maybe and the male would carry in his belly where the hernia repair would be and therefore maybe you can allow for a higher BMI in a female patient than a male. Whereas right now we’re not and therefore we are maybe denying adequate ventral hernia or abdominal bowel hernia repair care to women. Number two, we understand and everyone knows that people that are obese tend not to be of, tend to be of lower socioeconomic class.

(00:43:29):

It’s cheaper to eat junk food. Access to healthier food is more expensive, access is lower and it’s more expensive. So is it fair to deny hernia repairs to the morbidly obese understanding that they tend to be of lower socioeconomic costs or basically denying care to people because of their economic class and there wasn’t a good consensus about that because you also don’t want to destroy these people’s lives. I agreed with Dr. Naski who is in New York, who’s a very smart surgeon, who is seniors like me and has seen what’s happened over the years in terms of fistulas and mesh infections and pulmonary complications and heart attacks and wound complications, mesh infections and bad recurrences with loss of domain in failures because you chose to operate on a very obese patient. The younger populations seem to think, well by the time they lose the weight, they’ve lost a lot of time and potential income.

(00:44:53):

There’s no good access to weight loss medications. They tend to be expensive. And why are we providing disparate care? And I would say that our victim is first do no harm. And it’s true that many of these people that are morbidly obese end up in the emergency room and now you’re stuck with a very complicated abdominal wall in an emergency setting with let’s say bowel obstruction or dead intestine. That’s not good either. But the answer is not to I think and may disagree with me. The answer is not to do a potentially harmful operation because you’re trying to give equitable care when you know that the data shows it’s not as good I of a repair and I’m not claiming everyone needs to have perfect her repair, but it’s really not cool to have someone have stool coming out of the wound, which is very, very damaging when they also could have had a better outcome with a lower rate.

(00:46:05):

Let’s see. I feel like there’s a lot of comments on this. Let’s see. Here’s some comments. Thank you for your comprehensive answer with regard to the case of my bow stringing, the repair was done as pure tissue repair without mesh. I was told suturing of the inguinal floor with prolene was done to flatten a bulging inguinal. Can I get relief from removing bow stringing sutures or would it make me worse? Could laparoscopically place posterior mesh alone, relieve the pressure and tissue cutting caused by the bow stringing sutures or do the sutures have to come out? Both are potential options. So if you’ve had a tissue repair and you have chronic pain from it, if it’s a really tight repair, I usually I give Botox to those patients. I don’t offer surgery, just get some Botox and see if you get better. The second option is if it’s slightly tight, if it’s tight.

(00:47:01):

And the laparoscopic repair of a tight tissue repair doesn’t always work. Depends on the original hernia. If the original hernia was a big hernia and you’re tearing through the tissues, yes, a laparoscopic mesh will help. But if it was a small hernia and you just have a tight repair, laparoscopic buttressing of that will not usually help. And the last case scenario, to remove the sutures, I’ve personally never had to remove sutures. Usually Botox is adequate for that situation. Now going back to your other question, I have scar tissues and adhesions in the nerve issue. I’m in pain with an inal hernia that needed repair because the mesh broke and stuck to my pubic bone and suture up. I’m in a lot of pain. Nobody will listen. Is there a surgery that I can have? Well, I mean we’re listening to, you can’t say no one would listen, so you need to see a specialist or someone who will listen.

(00:48:09):

Let’s see, mesh removal went fine for me, but the discomfort and pain is exactly the same. There’s definitely something they’re missing. Yes. So if mesh removal didn’t work, then it wasn’t the mesh or whatever they did did not address the main problem. Maybe you have a nerve problem, maybe you have a hernia recurrence, maybe there’s a tear somewhere that they missed or maybe you have a hip disorder or something completely or a sacroiliitis or something completely unrelated to the groin. I’ve had patients like that where you think it’s the groin but it ends up not being, and you don’t really know until you go through the process of taking out the mesh and then reevaluating patients and then see what they do with the nerves, for example. So those are all things. So yeah, this is kind of cool the whole hernias, but I’m curious what you all think about disparity in care.

(00:49:04):

I may have to do, I think I may have to do a whole session on it and I would like it to be more interactive with you all, which is do you think is appropriate for a surgeon to provide a potentially harmful operation and definitely an operation that’s inferior to what they would provide if you had lost weight or would you prefer the doctor insist on you losing weight? And that could include surgical weight loss or medical weight loss. There’s tons of medication for right now. Surgery is very doable in patients, but that implies you’re going to have another surgery, which is a weight loss surgery, let’s say, and then a year later you have your hernia repaired. It’s more of an investment into a long-term. Great result. I personally prefer that I’m not all about quick fixes, but some doctors, they just feel wrong saying no to you and they take you to surgery.

(00:50:13):

And I’ve seen a lot of disasters when people offer surgery to patients who are not what we call optimized. And part of the optimization may be your weight loss. It may be you’re stopping your nicotine. It may be correcting that constipation or a really enlarged prostate that you have. I believe in optimizing all that before having surgery. People don’t need hernia surgery everywhere. People can live with their hernias and I’m not a fan of ruining someone’s life or lifestyle because just to do an extra hernia repair, many of these patients have what’s called regret decision. Regret. In fact, there was a whole session about decision regret. It’s kind of a whole session on decision regret from hernia repairs, specifically looking at people with really large hernias that, and I think inguinal hernias, I forget, I need to look at the data that looks at decision regrets. So they were told they’re going to have a certain surgery, they had the surgery and then now they’re living with the consequences of the surgery. Many people do well, but as you know, there are complications. They can have a recurrence, chronic pain, mesh infection, whatever.

(00:51:34):

Then especially if they have no symptoms before and they have the surgery, there’s a fair number of what’s called decision regret. And some of the patients happen to be complications from prior surgery that then commit to mesh removal and neurectomy and all that. And they review the idea of decision regret. And that’s something that I think right now as surgeons, we don’t really talk about decision regret. In fact, many sort are like, this is what you need, it’s what I recommend, get it done. Whereas others, such as myself, we tend to sit down a little bit longer with the patient and kind of review their plan of care and so on and expectations a little bit and go through options. But this whole idea of decision regret is good because it’s based on the patient’s point of view. So I may think I had a great hernia repair on you, but you may be like, I don’t know, I was kind of flat before. I’m not as flat as I wanted to be, or I barely had a hernia before and now I’ve got this bulging seroma or things like that. So I would say the stages meeting was a good one. We talked about a lot of different topics.

(00:53:04):

There’s more hernia surgery sessions coming up. I’ve got a lot of travel this year. So next month I’m going for the European Hernia Society meeting. Last year it was in Barcelona. This year it’s in Prague. How cool is that? In fact, the very true story, the very first European Hernia Society meeting I went to, I presented at that one. I presented our research about sacroiliitis as a unrecognized cause of groin pain and it was in Prague, and guess what? It was in Prague the same day as Czech Republic. As Czechoslovakia became the Czech Republic and part of the European Union. And we were witness to the whole town was celebrating. It was kind of cool back when all these countries were becoming EU and the EU was like a thing.

(00:54:09):

I’d have a look at the exact date. I want to say it was around like 20, maybe 2004 or 2005 around then. So that was kind of cool. And then this year’s going to be in Prague. I’ve got, I want to say four, maybe five talks. I have talked about imaging. I have a talk about women’s hernias. I’ve talked about mesh removal and groin pain, chronic groin pain after hernias, repairs. What else? I talk, oh, I have a bunch of talks about mesh and plant illness and there’s a whole section on autoimmune disorders and mesh and trying to understand that whole thing. So that’s going to be really, really exciting. Yeah, it’s going to be a great meeting. The European her society meeting is in May and they have a dragon boat race. I don’t know what it is, but I think it’s like a rowing thing.

(00:55:07):

But I’ll be participating in a dragon boat race. So we’re going to have different teams. So maybe I’ll wear my hernia pin to celebrate it. Oh, I have another pin. Let see if it’s here. Oh, here it is. This wasn’t for the prior hernia surgery. It was a big H, kind of like a Superman, but it’s like hernia surgeon superpowers. I should start wearing these on my stuff. What do you think? Is that too cheesy? I mean, hernia stuff is cheesy anyway, so it would be really weird to bust out all these pins like Jill wine banks and her pins every time she’s on tv or I don’t know. I feel like just the fact that all I do is hernias. It’s already on the funny side, but can I just be Superman but superwoman with my H emblem? No. Oh, guys, sometimes I feel like I enjoy this more than you all do.

(00:56:17):

I don’t know. Will me know? Yeah, please send me a question. We’ve got a couple more minutes if you would like. Okay. The rest of the year is going to be interesting. I’ll be in Mexico twice. So there’s the Mexican College of Surgeons meeting. I think I have four talks for that point. They’re really taking advantage of me. I have the international hernia collaboration also in Mexico this year. I make that program myself. So that’s not a no talks for that or no, I’m giving a talk. I’m giving a talk on the treatment algorithm for chronic al pain after hernia repair. Just today I got invited to Swiss hernia. It’s called Swiss hernia days, but it conflicts with my Mexican College of Surgeons meetings, so I can’t do that. Going back to the Botox. Botox does not help with bow stringing. Botox relaxes the muscles, so the strings do not bow as much, if that makes sense.

(00:57:23):

The bow stringing is because it’s too tight of a repair. So if it’s too tight of a repair, you can artificially relax those muscles and see if your pain will go away and make it less painful. One of the means are there’s the American College of Surgeons meeting is this year as well. We just submitted our research on round ligament handling because people don’t know what to do with a round ligament in women. So hopefully that will get accepted and we’ll be in San Francisco for that. And it’s a lot of meetings. I think that’s it. Yeah, I couldn’t go to Switzerland. That would’ve been cool, right? Swiss hernia days. Go to Switzerland, two European trips in one year. I don’t know. I feel like I need to work harder, let’s say. Is watchful waiting bad for an extended period of years, such as two and a half years as far as the thinning rectus muscles when needing an incisional hernia repair?

(00:58:23):

Well, the watchful waiting trial was not based on incisional hernias, but ventral hernias without incisions. We don’t believe there’s any data to support watchful waiting for incisional hernias, but most of us do it anyway, and that data is like five plus years. So as long as you have no symptoms, and to me, most her news can be watched even if we don’t have data for it. Well, my friends, it’s been lovely. Thanks very much. This was fun. I hope you guys enjoyed it. Got a little insight as to what we do. What I didn’t tell you. Okay, hold on. Before we say goodbye, I’m tell you my story. So what I didn’t tell you is this is a very low key. This is a very not uppity meeting, the sages meeting. So Saturday is the last day and they decided everyone tends to leave Saturday and they take their flight out. So it kind of sucks to wear a suit for your talk and then have to go on a flight in your suit. So let’s make sure we call it now casual Saturday, which is very weird for surgeons. That means no heels, no tie, no suit, athleisure. They said wear athleisure. So guess what I did?

(00:59:47):

We’re in Cleveland and I’m a big Lakers fan, so I wore a Lakers sweater, sorry, Lakers, sweatpants. Lakers, LeBron James Jersey, Lakers jacket, which completely blinged out Lakers in the front. So when I was up there in the session, the lights shone. I was sparkling Lakers and tennis shoes. My mom actually wanted me to take a Lakers cap too, but I think that made me too much and I had to fly through Cleveland Airport with that outfit through Denver Airport. Those of you who know the LA Lakers are now playing Denver Nuggets in the first round of the playoffs. Denver airport with my Lakers outfit, and I finally landed in Los Angeles home Sweet Home. Okay, enough of me. Thank you everyone. This was lovely. I enjoy it very much. It was good. It was really good. I have some really great guests coming up. I hope you join me. Don’t forget, subscribe like YouTube at Hernia Doc and my podcast. Please rate me. Thank you. See you next week. Bye.