174. Nerve Injury and Denervation

This week, the topic of discussion was:
-Nerve Injury
-Nerve Entrapment
-Neuralgia
-Denervation
-Neuroma
-ACNES
-Anterior Cutaneous Nerve Entrapment Syndrome
-Scar
-Abdominal Wall Hernia
-Abdominal Weakness
-DIEP Flap
-Incisional Hernia
-Mesh
-Absorbable Mesh

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 (00:00:10):

Hello everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live. I am your host, Dr. Shirin Towfigh, your hernia, laparoscopic and robotic surgery specialist. Thanks to everyone who’s logged in via Zoom and also those of you who follow me on Facebook who are here as a Facebook live at Dr. Towfigh. And as always, I do appreciate all of you who follow me on Instagram at Hernia Doc. Most of the people that follow me on X are really the physicians I feel, not so many patients, but I can also be found there At Hernia Doc. I try and reserve a lot of my academic discussions to X or formerly known as Twitter. So thanks for coming everyone.

(00:01:02):

I had a conflict last week with our patient care, so I wasn’t able to do this session last week, so we’re just rescheduled for this week. No big deal. So I appreciate all of you who follow up. So a couple weeks ago we talked about complications with abdominal flaps such as TRAM flap and DIEP flap, and those are flaps that are typically done by plastic and reconstruction, sorry, plastic and reconstructive surgeons. These are surgeons that are trying to use flaps from the abdominal wall and therefore taking that flap and taking, covering another area that needs coverage. So it can be from trauma. Let’s say you got a badly damaged leg with bone exposed and just a huge crush injury. Those would be flaps of plastic surgeons to develop. But specifically for TRAM and DIEP flaps, they are primarily intended to cover missing breast tissue such as for mastectomy for either benign or prophylactic or for cancer.

(00:02:22):

So there are complications with that. The ones that I see are the ones that have complications at the abdominal wall itself, including denervation. So it occurred to me during my talk a couple weeks ago that many of you were not really comfortable with just what is nerve damage, what does denervation even mean? There’s all these terms, denervation neuralgia, nerve entrapment, nerve injury, neuroma, what do these all mean? So I thought it would be helpful to dedicate an entire session about nerves, specifically nerves that can be damaged and trapped or otherwise cause problems. If you have questions as I’m talking going through this live, please go ahead and put them on the chat box both on Facebook as well as on Zoom, and I already have one about how good is the dissolving hernia mesh? It’s not a very good question. What does you mean by good?

(00:03:30):

Is it a good product? It can be for the right patient. Is it a standard product? Currently we don’t consider dissolvable meshes or absorbable meshes standard for any type of hernia repair. There’s no good study to show that it’s any way better than non-absorbable, non-dissolving meshes because the hernia recurrence rate is significantly higher. But in some patients, they do not tolerate some of the inflammatory or potentially counterfeit permit synthetic meshes and therefore they need some type of early support of their hernia and people can use a dissolvable mesh for that. It’s not a good mesh if you want long time full support, but it may be enough for some people that need short-term support and they’re willing to accept the higher recurrence rate associated with the absorbable meshes. Alright, going back, let’s define some specific terms. So a nerve is basically something that starts in the brain, goes down to your spinal cord and then gives off branches.

(00:04:51):

So if you have sensation at your fingertips, those are because you have nerves that are functioning and giving you sensation. There’s also what we call motor nerves. So those are nerves that fall the same route, but instead of giving you sensation at the skin level, it gives you actual functions. So the nerves that allow my fingers to have the muscles contract are different than the nerves that go to my skin and my fingers to give me sensation of the skin. The same is true of the abdominal wall. So there are muscles in your abdominal wall that get nerves. Those are called motor nerves, and those nerves go from your spine out into the muscle and they allow the muscle to work to function. We often say that nerves are what carry the food to your muscle. So if you have damage to that nerve going to the muscle, then the function of the muscle is pretty much affected usually either as a weakness or a complete paralysis of that muscle. I’ve given you the examples before of someone who’s, let’s say paraplegic. Those are people who have had their nerve completely cut or transected from their spinal cord. So let’s say paraplegia, which means both of your legs.

(00:06:17):

I don’t have muscle function. There’s actually muscle there. It just doesn’t have a truly nerve function. So the nerves going to your muscles are no longer available. They’re either damaged, cut, whatever the situation may be, and so the muscles no longer in your leg. The muscles in your leg no longer get nutrition and then they stop working. You’ve seen people that are paraplegic, they’re usually wheelchair bound, but they have very thin legs. They’re just skin and bones and even though technically they have muscles, the nerves going to those muscles are not working and so therefore the muscles are not working. The same can be true of the abdominal wall. So if you have nerves going to your abdominal wall that are damaged and those are specifically the motor nerves, then the muscle, the abdominal wall will not work. And I’m going to go through some scenarios I saw actually another one today.

(00:07:16):

The picture that’s associated with this today’s session is also shows someone who has a weakness of the abdominal wall due to nerve problem. Fortunately, that’s not a common problem. It’s really mostly the nerves that we talk about nerve damage for the abdominal wall tend not to be the bigger nerves that go to the muscle, but the smaller nerves that go to the skin level, those are called sensory nerves. So if you have damage to a sensory nerve, then the sensation that area will be affected. So for example, if you have a nerve cut, usually that causes numbness in the area where that nerve was supposed to give nerve sensation. So if it’s cut but it’s damaged at the it’s cut and damaged, then you get not only numbness but what we call painful numbness. So painful numbness is a type of nerve damage where it’s cut with the lack of sensation in the area where the nerve should give sensation, but it’s also painful.

(00:08:26):

It was traumatic in nature. There’s also people who don’t have numbness, actually they have the reverse. They have what’s called hyperesthesia or hyperesthesia, which means they’re hypersensitive. So very, very, very hypersensitive skin. Nothing can brush against it. They can’t wear a belt. Certain underwear, even the elastic from certain underwears is very painful in, they tend to wear skirts and not pants because brushing against any of the nerves, let’s say in the pelvis is very, very painful. So that’s called neuralgia, which means nerve pain and that can usually happen with partial damage to the nerve, usually not to complete damage to the nerve, but partial damage to nerve entrapment of the nerve. The nerve is kinked, cut, injured, stretched, whatever can happen and in reaction, the nerve like doesn’t like it and it becomes hyperactive and that hyperactivity manifests itself as hypersensitivity of the nerve and it’s very specific in that area.

(00:09:44):

We’re going to talk about motor nerve, sensory nerves and then all the different types of nerve manifestation that occur and why they can occur. And I’ll share with you some patient stories because I think that’ll help you relate some more as to what these are. Got some questions coming up. So out of respect for you as my audience, I will address them as I go. So here’s a question. I’ve been diagnosed with ACNES, which stands for A-C-N-E-S anterior cutaneous nerve entrapment syndrome after a DIEP flap, that’s the DIEP flap usually performed for breast reconstruction. I’ve been diagnosed with ACNES after a DIEP flap and attempt to fix the abdomen. Can this pain ever go away on its own? No nerve pain usually does not go away on its own unless it’s very, very minor. So technically ACNES is a different situation than nerve pain from a DIEP flap or abdominal wall repair.

(00:10:49):

So ACNES, it’s standalone. It’s an entrapment of a nerve of the anterior cutaneous nerve. It’s a relatively simple problem once it’s diagnosed, the problem is most people don’t know how to diagnose ACNES or they misdiagnose it or once they do diagnose it, they don’t know what the treatment of it is. So as the name says A-C-N-E-S, anterior cutaneous nerve entrapment syndrome, so there’s a nerve which is called the anterior cutaneous nerve. It’s anterior, which means it’s the front of the belly and it’s cutaneous, which means it gives sensation to the skin. When that nerve travels from originally from your spine, from actually your ribs down to the front of your belly, it splits and it splits right at where the rectus muscles or your six pack occurs, and then one branch goes in the front and one branch goes into the back and that branch that’s the back, which is a posterior cutaneous nerve, then runs through the middle of the muscle and then splits again to another branch of the anterior cutaneous nerve.

(00:12:01):

So at any point where these nerves split, you can get a relative entrapment of the nerve in that little tunnel into which it splits and that entrapment can cause pain. So classically, people who have ACNES either have pain where it first splits, which is right at the outer edge of the rectus muscles. So if you’re thin enough and you can see your rectus muscles, if you crunch your belly, you should be able to see the edge of your rectus muscle. So you may have pain along that edge only usually one area or you can have pain at the second place where it splits, which is kind of in the middle of the rectus muscle and that’s ACNES. That itself is unrelated to DIEP flap or any other surgery you may have. I’ve seen it in people who’ve had surgery. I’ve seen it in people who haven’t had surgery.

(00:13:04):

We don’t know why people get ACNES. It’s just something that occurs. I’ve seen it in men, women, young and old in the very thin, the morbidly obese people that are active and people that are not active. I’ve seen them with near scars and away from scars. So at this point, as far as I know, there is no clear reason why anyone would get ACNES, but because these nerves run through the muscles, therefore, and it kinks at these split areas, the pain is most when you engage your muscles. So if you cough, if you bend, if you twist, if you lift something, anything that involves crunching of your abdominal muscles, a sit up would be a good one, will kink that nerve and cause direct nerve pain. These are not functional nerves, these are not motor nerves. These are what we call sensory nerves. So it causes pain but it’s not really a functional nerve.

(00:14:07):

So in my practice you go through a series of steps with nerve blocks specifically aiming at one or two of those areas where the nerve splits and you numb the area. And oftentimes if you do that three or four times or five times over a span of a couple months, the pain will go away. I actually published on this if you want to read about it. In my experience with those patients, about a half of patients, all they need is nerve blocks and that numbs down the hyperactivity of these nerves as they run through the muscles. And then when you engage your muscles and contract your muscles in the belly, you no longer kink these and they do fine. Now what happens to the other half? We don’t really know what to do with the other half. Most of us that are surgeons offer a neurectomy.

(00:15:03):

It’s a very straightforward operation. You make a little scar over right where the nerve is being pinched at the first level, right before it separates at the level at the border of the rectus muscle of your abs and we cut that nerve, it should not have any functional deficit. You should not notice anything at the most. You may be a little numb where you used to have pain, but it should not affect how your muscle works because those are not nerves that cause any muscle function. So that’s ACNES in a nutshell. Now what you’re saying is you have ACNES after a DIEP flap. So a DIEP flap technically involves, okay, so I’m trying to figure out how you can get ACNES. The only way you can get ACNES from a DIEP flap is when they enter the abdominal muscle to get that length of vessels as your vessels for the skin flap and the skin and fat flap that they’re going to use, let’s say for your breast reconstruction that when they went through the muscle, they actually injured the nerve during that process. So that’s possible.

(00:16:33):

Yeah, that’s possible because the nerves, they catch nerves just inwards from the rectus muscle. So technically it’s not ACNES, it’s actually just a damage to the anterior cutaneous nerve. But I would recommend if you can confirm that it’s just a nerve problem, then that kind of nerve injury from a DIEP flap where they’ve cut or injured that nerve or possibly when they got out, sometimes they put a stitch in and the stitch that they put in therefore grabs unfortunately grabs a nerve and entraps it. So if they used absorbable stitches, then hopefully the suture will absorb in about three weeks and then your pain will start go away and your body will start to heal the damage. But if you came to me, I would probably do a nerve block right where the nerve may have been damaged and see how you do. If your pain is a hundred percent gone, then that means indeed you have some type of nerve entrapment or nerve damage from the plastic surgeon digging in through your muscle to try and get the blood vessels for this flap for your breast reconstruction.

(00:17:54):

And then I submit you to what’s called a serial nerve block. So every two weeks I’ll bring you in and I’ll inject you and see how you do. If you get better with each injection, then you’re done. Usually it takes about three to five injections every couple of weeks. However, if you’re not better with the injection long term, but in the short term you’re like cured, like this is great, these injections are great, then in patients like that for you, I would recommend a surgical neurectomy where we go in there, like I mentioned, make a little scar, find the nerve upstream from where the damage is and cut that nerve. No, it will not resolve on its own unless the pain is very low grade and the nerve damage is very minor. In those cases, your body will repair nerve damage, but in anything larger than that, your body tends not to be fast enough to how fast you develop scar tissue and more damage to the nerve is in competition with how fast you’re going to heal that nerve. So if it’s a very minor amount of nerve that needs healing, then it’ll heal before you get all the scar tissue and further entrapment and damage. But if it’s a larger amount of nerve that gets healed, then usually the scarring and all that overcomes the area.

(00:19:30):

So I hope that was helpful. Terminology is kind of important because then it determines who you see and what you do. Here’s another question, it’s not related to today’s topic, but it says with regard to mesh, what are the advantages of self-adhesive mesh versus anti-adhesive mesh and when would you use each? Oh, okay, totally different situation. So self-adhesive mesh. There are some innovative meshes out there that have glue on it as far as I know it’s not currently widely available and maybe still be in the development stage. But what most of us consider self-adhesive mesh are really the meshes that have these little Velcro like appendages on it on one side. So when you put it against the muscle, it kind of hooks onto the muscle. It has these Velcro like hooks and so those are used for any type of hernia repair.

(00:20:32):

The anti-adhesive mesh, you could have self-adhesive measures with anti-adhesion by the way, but the anti-adhesive meshes are the meshes where on the opposite side, not the side that you want to stick to the muscles. But on the opposite side it has this adhesive barrier of sorts though it could have an extra layer of fabric on it, it could have a film on. It depends on what the situation is, but that extra layer is intended to prevent things usually intestine from sticking to the mesh. So you would only use mesh with an anti-adhesive barrier. If you have bowel at risk for touching the mesh, you should not use it if you put it in a normal space away from bowel.

(00:21:26):

Another question, my abdomen muscles are split in two from multiple operations with a clear thin skin just connecting and holding it together. So I’m unable to do any exercise especially steps. Yes, so it sounds like you have a dysfunction of your core and you need a good surgeon who can figure out how to bring your core back to normal. I agree. You need a specialist. Okay, so let’s see. I’ll give you another example as to the question with the type pain APH for DIEP flap. So I recently had a patient, she had an umbilical hernia. It was very, very small, but for some reason the surgeon put this eight by five centimeter, actually nine by six centimeter piece of mesh by the time, oh here, sorry, let me answer this question too. Thank you for your answer On the anti-adhesive, meh, would you ever use it to avoid spermatic cord in addition to bowel?

(00:22:38):

So, very good question. I actually am a big fan of using adhesives around the spermatic cord so that the spermatic cord does not touch the mesh. In fact, I have some patented meshes that I would like some company to actually invest in that has exactly, that means this is a mesh product wherein the area where this spermatic cord can interact with the mesh is covered with anti-adhesive. There’s absolutely zero reason for anyone to need their spermatic cord stuck to the mesh. So I actually have a design for that that’s been patented. And if you know of any mesh companies, they actually care about their patients and don’t want them to get testicular pain, you let them know that they can call me because it’s really frustrating trying to convince companies to help patients. How’s that? It’s just the weirdest idea anyway, but on my experience, there’s a lot of men out there that have testicular pain and part of the reason for their testicular pain is because the mesh is sticking to their spermatic cord and concrete kind of holding this spermatic cord in place.

(00:24:02):

Whereas you want to have this hematic cord mobile. And so the design would be to have anti-adhesive. So yes, thank you very much. Companies should flock to my idea, but as you know, companies are more interested in making a buck than actually helping patients often and sometimes admitting that your mesh product is actually hurting patients may cost them millions. So they sometimes choose not to improve their products because that admits that their original product was not the best. So I digress. But yeah, it’s based on my own experience where I was removing mesh off of these spermatic cord areas. And so in my current practice I actually do take an anti-adhesive barrier and wrap the spermatic hoard, especially in people that already have testicular pain or and need the mess removed. So that really helps.

(00:25:09):

It’s not a well-known technique. I’m teaching you my secret sauce because I’ve had so many operations, my inguinal organs are stuck together, especially my bowel and bladder. I’m full of adhesions and was told no further surgery can ever be done again. Well, that’s not correct. It’s always possible to have more surgery. I had left inguinal hernia surgery nine years ago with mesh and a plug. I’ve had a horrible pain since then. Now I have horrible burning pain on my pubic bone. I was told in Arizona that my mesh and plug had moved over to my pubic bone in Minnesota. The doctors say the mesh is still in place. I’m confused. Most likely the mesh is still in place, but that doesn’t mean it’s not causing you the pain. Okay, going back to this week, I had a patient that I had known for a while. So she had a minuscule umbilical hernia and instead of just putting a stitch in the hernia and this otherwise thin lady, they put this relatively large nine by six centimeter mesh and they put it on top of the hernia and then they took a stapler and they went staple, staple, staple staples. They put 13 staples in her.

(00:26:28):

Horrible. So needless to say, she had pain from not only having a piece of mesh very close to her skin, but also all these staples. So I recommend that she have the mesh and staples removed. She went to another surgeon and they did a perfectly good job removing all the staples sutures and the tuck or the, so that part she got better, but she had this one area to the left of her belly button that was very painful and it wasn’t clear why she had the pain. So she came back to see me and I saw her and I said, okay, what could have happened is one of two things when they took off the mesh as part of your mesh removal surgery and they took off the attacks and so on, you could have had a little tear in your fascia, which was, it’s the strength tissue just below where the mesh was placed and that could have caused pain, but it didn’t show it on any fascial tear on the imaging, but it’s possible. And when I examined her, she had a really, really tight rectus muscle. It was really, really spasming. And I said, well the other problem is it could be a nerve issue. So how is this a nerve issue? It’s possible that the clips that they put in were near or around a nerve. And then at the time they were lucky and when they did staple staples stapling the mesh into the muscle that they didn’t actually have a, what do you call it? They didn’t actually have injury.

(00:28:08):

They didn’t actually have injury. They didn’t actually have injury to the nerve. However, let me make sure I got my microphone okay here. However, what can happen, okay, there we go. Is my microphone okay? Yes, it’s however, what can happen is the process of removing the clips, you can tear some muscle and there may be a nerve in the muscle. And now that’s what happened. So her pain was in the area of where you would see ACNES type pain, but technically it, it was a nerve injury from a clip removal in a patient that needed a bunch of fixation clips and her mesh removed from the abdominal wall. So that’s the situation.

(00:29:19):

So she came and saw me, I said, let me numb this up. If it’s a nerve problem and you numb it up, all your pains should go away. If it’s some other problem, the pain should not go away. In fact, the pain may get worse. So let’s say if there’s a hernia there and I numb it up, the pain will actually be worse. So I numbed them up, I numbed her up and add some little steroids and the pain was a hundred percent gone. And guess what? She only needed one. Remember I said you can do three to five injections. She needed one, which means what? A, it means it was a right diagnosis and B, it means her nerve injury was minor. So the combination of me numbing it up and adding some steroids and her own body remodeling and repairing that nerve, that combination made that she’s been pain-free for a long time. My belly is hard as hard. Is this from my belly button? Hernia mesh, it depends on where your mesh is. So if you’re thin and you have mesh on top of the muscle, or if you’re thin and you have mesh that’s heavy weight deep to the muscle, you can feel hardness. But that doesn’t necessarily mean it’s from your mesh.

(00:30:40):

Which imaging could show a fascial tear? Hernias not only happen are there hernias that only happen to fascia without a hole in the muscle. So yes, you can have fascial tears if the fascia tears and muscle and or nerve herniates through that fascial tear, that could be painful. Most of these are not visible on imaging. However, even on ultrasound, like this patient, I ultrasound her, I couldn’t see it. Okay, so that’s one thing about the sensory nerves. So there are other, let’s talk about the motor nerves because there’s a gray picture that I have on the advertisement for this on social media of a patient of mine that has a really bad spinal problem and she had spine surgery. And ever since her spine surgery she has had this bulging of her right abdomen. And if you look at it, she’s super thin so you can kind of see everything.

(00:32:00):

She has really thin skin and no fat. So you can see the bulging, but it’s like a hot dog shaped oblong bulging. It’s only on one side of her abdomen and that each level of your back, so whether it’s usually your thoracic, but sometimes your lumbar has a specific level where the nerves kind of feed the muscles in the front. So in her, I think it was a T 11, I think that’s a T 11 injury. So it’s a 11th intercostal nerve that was damaged as part of her spine surgery. And then this is not reversible. In fact in her, I’ve taken pictures over the years because she’s not ready for surgery yet, but every year this bulge gets bigger and bigger. I saw a similar patient this week, so also fairly thin lady, and these are often in thin people, you can’t really see it as much in an obese patient and it has to be pretty large to see in a normal weight patient.

(00:33:21):

But I also saw another lady today. She’s like, I was having this weird kind of back pain and I was just fidgeting and trying to move my back around. I was having back pain and then all of a sudden I see this bulging in my right abdomen. So she was sent to me to figure it out. They couldn’t figure out if it’s a hernia or what it is. I looked at her and based on the shape and the location, I knew it was a nerve injury from her spine and not a hernia. So hernias tend to be kind of round holes, especially in the groin or in the abdominal wall. And if they’re oblong it’s because it’s following let’s say the inguinal canal. But this was nowhere near the inguinal canal. So she had a bulging very similar to the picture that I have for today’s episode, but not as big.

(00:34:21):

And I’m looking at her, I’m like, you kind of have it on both sides. The left side is a little bit less than the right side and when you press on it, it doesn’t feel like anything. It just feels like a soft bulging, like a balloon. It’s usually not painful. It starts to get painful the larger it gets because it starts to get heavy. And the reason for that is if you lose muscle function, that one area where the nerve would be, then what happens is your abdominal muscles kind of weaken and spread and your intestines are just pushing out. So in most people they have normal abdominal walls, they have a flat belly or kind of supported belly and someone like this, they actually have no function to that muscle, so just start spreading. And so I actually sent her not for, well, I sent her for a pelvic MRI just to look at her abdominal wall muscles and with valsalva or pushing out to look at, but specifically I sent her for a spine MRI.

(00:35:32):

So I’m looking for T 12 or L one in that region. Some type nerve impingement. Now mind you, that’s actually quite rare. It’s very rare to have a lower thoracic or upper lumbar disc problem, but it’s not unheard of. And I see a handful of patients like this every year and no one can figure it out. They haven’t seen it as much. And in retrospect, I should really write this up because no one really knows about it, but it’s a very, very hard to diagnose problem because no one’s seen it before. In fact, I’ve actually, so going back, the treatment for this is to release the pressure on the nerve. So interestingly, most of these people don’t even have back pain. It’s pressure on just the motor nerve just enough to make that a muscle weak but not enough to cause pain because it’s no obstruction.

(00:36:40):

But I have a great neurosurgeon spine surgeon who I work with who’s treated these patients. So I send the patient to them and they then operate and release the pressure on the nerve and then that muscle regains function over time and goes back to normal. That has to be done within the first several months of impingement because if you have nerve impingement for too long of a time, you start losing muscle function. So early diagnosis is very important because the alternative is not very good, it’s very hard to treat those. Let’s see, I had 44 0 operations to rebuild my abdomen and a partial mesh removal, my scar burst open and was left that way to heal, but no operation to rejoin my abdominal muscles. Okay, well your name sounds familiar, but I’m not sure that I’ve seen or met you before because your story doesn’t sound familiar, but if you want me to help you figure this out, I’m happy to entertain a online consultation if you want to sign up for one and help me figure it out for you. But pretty much everyone, 99.9% of people with any type of abdominal wall problem are usually fixable. And you just need an innovative surgeon who understands what has happened, analyze what happened, why did it take 40 operations to rebuild your abdominal wall, where were the mistakes made, how are the factors that are pushing you towards all this failure? What are we missing here? And then go from there.

(00:38:30):

Okay, I going back to this issue, the alternative is not good because once you’ve lost the muscle function, then treating the bulge is not like a hernia repair. Oh, that’s how I know you. You are the founder of the hernia mesh victims of Ireland. Yes, that’s how I know you well. I’m very sorry that you were one of the victims, but again, if you have not gotten enough help, I would be happy to look into it for you if you want to send it for an online consultation. Let’s see, I had a right angle hernia done three months ago. The surgeon placed 15 metal staples to secure the mesh. 15, I have an allergy to metal. I am experiencing pain, the hernia with laparoscopically performed. Yeah, that’s way too many staples. And here’s the problem, let’s talking about nerves again. So if you have 15 staples put into this one small area where your groin hernia is number one, that’s way too many staples and you can cause severe muscle spasm just from the staples alone.

(00:39:52):

Number two, the risk is that they may actually catch a nerve as part of this problem. So depending on where those staples are placed, the more staples you have in you, the higher the risk of catching a nerve and damaging a nerve. And there’s a great paper I believe from Dr. Heniford, I’m not sure who used to be one of our guests on Hernia Talk Live that showed, I think it was, if you have over five, I think the risk of chronic pain increases directly with the increased number of staples or fixation used for hernias. Let’s see, going back to this gentleman who is congratulations, founder of hernia mesh victims in Ireland, we only have general surgeons doing all the hernia operations. Yes, I heard about this. I’m asking the government to employ qualified hernia surgeons who can only qualified hernia surgeons who can only use mesh.

(00:40:58):

So I heard about this. So as you know, I’ve fallen in love with the UK and I plan to be there visiting London and looking into ways where I can expand my practice to help patients like yourself in the UK and other international patients because I have a fair number of international patients and I have actually quite a bit of patients in the UK itself. So what I learned about the British system is unlike the United States where we have general surgeons as well as subspecialists subspecialties within general surgery, because Great Britain is such a, sorry, because the United Kingdom is such a small island relative to let’s say United States, but with a very large population, then you have a large number of people that are subspecialists like colorectal surgery, urology, surgical oncology, et cetera. And so they focus on their subspecialty and then they quote dabble into general surgery.

(00:42:07):

So when people are dabbling, they’re doing their subspecialty, let’s say breast, colon, vascular, and then they see a hernia in addition to their normal practice. So there aren’t really people that are doing, so there’s no hernia specialists for example, in the United Kingdom there are surgeons who do hernias, correct me if I’m wrong, but that’s kind of what it was explained to me, that you don’t have anyone that will specialize. It is not considered a specialty number one. And then because of the way that the national healthcare system health system is made, there’s no role for specialists within just general surgery. You have to be a name specialist.

(00:43:02):

I dunno, correct me if I’m wrong. Oh sorry, you’re in Ireland, not uk. My bad. Well, it may me the same. I don’t know. I did meet a really great surgeon in Ireland who is, let’s see, I have his name. He’s an older surgeon practicing in Ireland who actually asked me to come over to Ireland and help with their practice there, which I would love to do one day. But I have a feeling the system is similar in that you don’t have specialists in hernias. There’s not enough to go around maybe or there’s no incentive to do that. But I would like to visit Ireland because it’s a beautiful country and one day I will do that, but not this trip.

(00:43:56):

I think the gentleman that I met, the surgeon was head of the hernia Society of Ireland at some point. I don’t remember. Okay, let’s go back to what are we talking? We talking about ACNES, we talked about deep flops. My patient with the only mesh removal that had the nerve injury. My patient with the probable spine injury causing the nerve impingement with the bulging. Oh, let’s talk about some more nerves. So oh, here’s another good one. I recently saw a patient, this was actually an online consult, so I don’t actually see the patient, but the story is good enough to share because I’m trying to figure out her diagnosis. So this is a patient, let’s see what she have. Anterior approach. Flink. Ah, she had spine surgery but for some reason, so there’s different ways of doing spine surgery. You can do a posterior approach, which is in the back.

(00:45:13):

They make an incision. The mid back, there’s the anterior approach, which is a midline abdominal wall incision. There’s a flank approach which is nine degrees to those two, which is from the side. And then there’s a lateral approach which is the in between the flank approach and the anterior approach. So this patient for some reason had a lateral approach. And from what I understand working with spine surgeons and trying to understand what they do, which is very important, it’s somewhat surgeon preference whether they want to do it from the front or from the side or in between what’s called laterally. Anyway, long story short, the risk of the lateral approach which this patient had is you’re actually cutting through the oblique muscles, whereas with the anterior approach, you’re not cutting through any muscles. You’re actually in the middle where there’s no muscle. So on the lateral approach, they cut through the anterior approach and fix her hernia and now she has this bulging.

(00:46:26):

So the question is why does she have the bulging? So she sent me her pictures to me. So they told her, there’s nothing for you, nothing to do for you. Go home, sucks to be you. Just be grateful. Your spine surgery went fine. But she’s like, yeah, but you left me with this bulge. I’m like a normal body. Now I have this asymmetric alien coming out of me and I’m like, just do some physical therapy, it’ll go fine. Wrong answer. By the way, physical therapy never helps any of these. But I looked at her imaging and her imaging specifically shows that what they did was when they cut through the muscles, they didn’t so them as they were coming out, there’s three layers of muscle. They only sewed one layer. So what happens is the one layer is still fine, but the two layers beneath are pulled away.

(00:47:19):

So now you don’t have the girth of three layers of muscles holding on to the abdominal wall. You have two layers that pulled apart and now a hernia. But then the third layer is preventing a full thickness hernia. So it’s a partial thickness hernia. For those of you that watch me regularly, you may have heard me mention a Spigelian hernia. It’s like a rare hernia, but it’s exactly what I described, which is a partial hernia through two layers of muscle and the third layer is intact. Dr. Spiegel German surgeon came up with spa hernia, orian hernia, and it occurs naturally, not in most people, it’s kind of a rare hernia, but it can occur naturally In this patient. She has a Spigelian type of hernia because of the three layers. One layer is intact and the other two have the hernia. However, it was made by a surgeon.

(00:48:22):

It’s an incisional type of hernia, but it’s also speaking only hernia. Anyway, long story short, most likely what she needs is a hernia repair. So I said, listen, I can fix your hernia. It’s doable. Don’t let them tell you otherwise. Definitely don’t wait. Waste time with physical therapy. She sent me multiple imaging. You can see it went from 1.6 to 2.7 to 3.4, almost now four centimeters wide, this hernia. So every time she gets another imaging it gets wider. Why would you wait for that? That said, the imaging was always no hernia. No hernia, which of course is incorrect. However, what I told her, what I’m telling you is whenever you have spine surgery, you’re always at risk of having damage to the nerve. You’re there to fix the nerve, but you can also damage the nerve by retraction, by pushing on it, by cutting whatever the situation is.

(00:49:18):

And for the abdominal wall, most people think of damaged nerves like for your arm or leg. This is for the abdominal wall. Most people don’t understand abdominal wall nerve pathology, but part of the bulging that she has may be a second problem, which is nerve damage to the muscle itself. And I’ve operated on many patients who have had both. That means you fix the hernia, you’re like, okay, there’s clearly a hernia, let me fix your hernia. And then you fix your hernia like, well thanks, this bulging is gone. But now in the front I have more bulging. Why is that? Because they had the hernia and the nerve damage and the treatment is very different. The hernia is treating any other hernia. It’s a hole in the muscles. You bring the holes together, you patch it with mesh. That’s the scenario for most hernia repairs.

(00:50:13):

If your nerve is damage and causing muscle weakness and like a flad muscle, there’s no hold to close. It’s just a weakening, like a billowing out of your muscle. So the only way to do that is to counteract that by tightening the muscle and just tightening the muscle also doesn’t work because your muscles weak and will just loosen up again. So you have to use a very wide piece of mesh to cover it. It’s not the best operation we have to offer. It’s not the best surgical technique is open. You must use mesh. There’s no non mesh alternative. So it’s unfortunately a somewhat debilitating disabling complication and you won’t know that you have that unless you fix the hernia first and then see what the abdominal contour is like afterwards. So we talked about this two weeks ago with a DIEP flap where you can get muscle damage, nerve damage to the muscle causing the bulge. We’re talking about it with spine injuries and spine spinal problems where you can have nerve impingement or pressure on the nerve or nerve damage from the spine surgery, which also causes bulging of the abdominal wall.

(00:51:34):

So I just want to get that out there. There’s not much written about it. It’s really hard to get anything like this published because there aren’t enough patients to say, okay, I have a series of 5,000 patients and here’s what they look like. That’s what the journals want. I have maybe three to five patients a year that I see like this and not all of them get surgery, so it’s hard to follow up with ’em, but it’s at some point to write this up and find a journal to accept it. Here’s a question in the mesh repair with mesh for nerve damage in the mesh repair with mesh for nerve damage. Oh god, in the hernia repair with mesh for nerve damage, what prevents the mesh from below along with denervated muscle? Nothing. So that’s why it’s a horrible operation. So the technique that I’ve come up with is sewing the mesh to things that don’t bulge out.

(00:52:37):

So I sew it to the hip, right? The anterior super iliac spine that’s bone, I do it to the inguinal ligament. That’s a type ligament. I sow it to the contralateral abdominal wall where it’s normal. I sew it to the ribs, the rib margin where that’s bone and it basically becomes almost like armor and still, still it’s not perfect. Still despite doing a very tight repair, that area will bulge a little bit asymmetrically. So we do our best. It’s still not perfect or good enough. It’s not the best cosmetic outcome. It’s better than it was, but it’s maybe 60, 70% better. It’s never a hundred percent better. The best ones I’ve done, they’re like 90% better and the patient’s perfectly fine because it’s better than it was. And at least it takes off the pressure of the bulging and that heaviness that they feel that’s very difficult and they don’t look so abnormal under clothing. But other than that, those are really hard operations to perfect. And most surgeons actually tell you to go home. There’s nothing to do. It’s not a hernia. Go do physical therapy, lose some weight, do some sit ups, and none of those work. None of those work.

(00:54:11):

And it takes a lot of time and energy to do good repair for these question, does the pain related to nerve damage have some unique symptoms and features differ from other pains? Oh yes. Thank you. So one thing we did not discuss is what’s called neuralgia, which is nerve pain. Not everyone that has nerve damage has nerve pain, but neuralgia and also just because you have nerve pain doesn’t mean your nerve is damaged. It could just mean your nerve is irritated. You can have neuritis where there’s inflammation of the nerve. You can have neuralgia due to a hernia, right? You can have, I’ve told you this and multiple, multiple times when we’re talking about occult angle hernias where groin pain sounds very nerve and it is in the distribution of a nerve, but it’s really from your hernia. But people are told, oh, you have an ileal nerve or nerve entrapment and they’re taking down the wrong path.

(00:55:17):

They need to be taken down the path for hernias. So the typical nerve pain is a burning pain. Some people call it a hot poker. You may also have a hypersensitivity in the area. Other things are called paresthesias where you have kind of like a tingling sensation. You may feel hot in the area, direct pressure over it may be very hypersensitive and so on. So it’s usually not sharp and it’s usually not dull. It’s usually burning in sensation. But there’s a spectrum. So there are people that have dull pain or achy pain that have it from nerve pain. There are people that feel cold in the area or it’s not constant pain. But classically nerve pain is a heat like hot poker, like burning sensation in the distribution of the nerve that’s being affected. And that nerve may be entrapped in scar, maybe entrapped in suture.

(00:56:26):

I have a patient, very dear patient who had just a routine inguinal hernia repair, just routine and damn surgeon put a stitch. So here’s your nerve, but stitch right there. I always teach you all, and I teach my residents, before you commit to putting mesh in or sutures and or sutures, you must identify the nerves. And every time they operate with me like, wow, Dr. Towfigh, you really spend a lot of time looking for these nerves. And they tell me when they operate with the other surgeons, that doesn’t happen. It’s really a shame because I don’t know how more clearly we can publish guidelines that tell you you have to identify the nerve because if you don’t, you’ll put a suture where their nerve is and entrap that nerve. So this poor patient is a big deal guy in Hollywood. He had a routine open inguinal hernia repair with mesh by one of our general surgeons and he put a stitch.

(00:57:32):

First of all, he put a stitch where he shouldn’t have, which is lateral to the inal ligament. You should not put any stitches lateral because that’s where the nerves are. So he did that wrong. Secondly, he put a stitch right around the ileal nerve. So this poor patient, check this out, this poor patient could, you know where you take a shower, you walk into a shower, there’s like a little ledge, you have to step over a little ledge to get into your shower. He had so much pain from this damn nerve being entrapped by a stitch that he had a hard time raising his leg, that extra two inches off the ground to put his foot in for the shower. How sad is that? Completely preventable. It should never have happened.

(00:58:25):

Anyway, long story short, I went in there, I found the nerve, I found the stitch, I took care of it. He’s taking, this patient is cured. He is taking showers now, no problem. But he was told, oh, give it some time. Oh, come back in a year. All completely bs because when you have a nerve that’s entrapped, no amount of waiting time is going to prevent that suture from entrapping the nerve after you’ve already entrapped the nerve question. I had my gallbladder removed and got a hernia. Can this be fixed with mesh? Yeah, of course, absolutely. Let’s call it incisional hernia. Depending on where the hernia is, it may be tricky if it was open or laparoscopic. Usually the open hernias are more difficult.

(00:59:10):

Sorry, the open gallbladder surgery hernias are more difficult. Question, I’m in Eastern North Carolina. Would you kindly recommend a surgeon in North Carolina or southeastern Virginia to remove the metal staples? Well, I recommend that you follow me because I have had multiple surgeons from both North Carolina and Virginia with whom I have interviewed. So just go to my site on YouTube at Hernia Doc and you’ll be able to find a bunch of surgeons that I interviewed or just go to hernia talk.com and to search for Virginia or North Carolina. And you should see the videos with the surgeons that I interviewed who I respect. I tend to only invite surgeons who I respect. Otherwise you’re not invited. Okay, so on that note, I would like to thank you all for hanging in there with me. This was kind of cool. It was a very kind of a niche talk, right?

(01:00:15):

Talking about nerves and all that, neuria, neuroma and neuritis, denervation and all that. But I think we did a good job. I really appreciate all of you coming, joining me, asking me questions. Do follow me on YouTube at Hernia Doc. That’s where this and all prior episodes are all stored. You can also listen to me as a podcast. So if you like the podcast version, go to Hernia Talk Live as your podcast, wherever you listen to podcasts. And thank you very much and please take care. See you all in a couple of weeks. I will be out of town next week.