175. Updates from European Hernia Society Meeting

This week, the topic of discussion was:
-European Hernia Society
-American Hernia Society
--Hernia Mesh
-Autoimmunity
-Mesh Implant Illness
-Breast Implant Illness
-Tattoo
-Biologic Mesh
-Absorbable Mesh
-DIEP flap
-TRAM flap
-Incisional Hernia
-Nanotechnology
-Mesh Infection
-FDA
-MDR
-510k

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.

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Transcript

Dr. Towfigh (00:00:10):

All right. Welcome everyone. It’s Dr. Towfigh. I’m your host of Hernia Talk Live Hernia and laparoscopic surgery specialist. We are starting a brand new Hernia Talk Live today on Tuesday, we call it Hernia Talk Tuesdays. Many of you are joining me as a Facebook Live and the rest of you as a Zoom. I’m super excited to have you. And the reason for that is because I am back in town. So last week I was in Europe at the European Hernia Society meeting, and as you may know, I’m a member of the American Hernia Society meeting and a handful of US Americans are invited as guests to other hernia societies such as the Mexican Hernia Society, which I gave a talk at last year and I hope to be present at, I think, yeah, this year. And then there’s a European Hernia Society. There’s actually tons of societies.

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If there’s a Japanese, there’s the African, all the different European countries have their own separate hernia society. There’s a German Hernia Society, which is the oldest and most historic one because there’s a lot of Germans that contributed to hernias. I was invited to Swiss hernia societies, which is really awesome. I couldn’t make it though because I have two other Hernia Society meetings I’ve been invited to and the dates conflicted. There’s the World Hernia Congress, which is going on soon in Singapore, which includes the Asian Hernia Society, the American Hernia Society, the European Hernia Society, African Hernia Society, Middle Eastern Hernia Society, all in one meeting. So there’s a lot of hernia societies going on, which is amazing because that was not the case, I would say 10 years ago, years ago, 10 years ago, around 2010, 2014 is when we started to appreciate the importance of having hernia as a specialty, and societies were still young or non-existent.

(00:02:30):

And then 20 years ago, forget it. I think the American Hernia Society, if I’m not mistaken, the American Hernia Society was about 25 years old. So the European Hernia Societies are a little bit older, but all the other ones are also really young. So it’s really important to appreciate that we are evolving into having more interest academically in hernias. It’s very important. And the European Hernia Society among many hernia societies is probably one of the more academic ones. The reason for that is not only does Europe have a big history in hernias, a lot of the names that you’ve heard of Bini, well, the Americans are like McVay. Shouldice is Canadian. Basini is the most famous one for inguinal hernias in Europe, Italy, there’s chare, a lot of French doctors, Reeves Stopa, they’re all German French surgeons. So basically the Europeans are really into the hernias and because they have mostly socialized medicine and people in many of those European countries don’t really travel or leave the country, United States is a very big melting pot of mishmash of people from all over the nation, all over the world, and they tend to travel more than Europeans.

(00:04:15):

So the Swedish and the Danes both have really robust national registries. And specifically there’s the Swedish Hernia Registry. There’s a Danish hernia registry, and there’s the German called Hernia Med, which is a German hernia registry or database. And what they do is they follow you for your entire life. So we had some really amazing data coming out of those national registries talking about hernias. I’ll go over some of those. I’m going to talk to you about other things that are Lord at the European Hernia Society. If you want more details, you try to want to be a little bit more scientific, feel free to follow me on Twitter at doc at Hernia doc. And every time I go to a meeting I live tweet everything that I learned from it. So I was especially active and tired, but active at this year’s European Hernia Society meeting, which was in Prague, Czechoslovakia.

(00:05:18):

So I thought what we do today is to share some of what I learned and kind of give you a little overview of the direction that we’re going in as surgeons in the hernia world. And overall, it’s a very good direction, and if you have any questions, feel free to send them in and I’ll help answer. We already have a question here, which is, may I ask a question? Yes, of course. You can ask a question. This is a hernia live q and a question and answer session. Why does a doctor need a colonoscopy to do a reversal on a hernia or rather to take it out the mesh? I see. So there’s two reasons why colonoscopy is performed prior to a massive abdominal wall reconstruction or revisional surgery of the abdominal wall. We usually don’t do it for the groin, and that is if you’re due for a colonoscopy and you have not had a colonoscopy, you should have that surveillance of your colon to rule out a colon cancer.

(00:06:24):

Because what you don’t want to do is to have a perfectly great well done hernia repair or a very delicate mesh removal, tenuous abdominal repair, and then have someone say, oh, by the way, you have this colon cancer, we need to take out your colon. And then they have to go through that abdominal wall reconstruction to actually fix, address a life-threatening problem, which is your colon cancer. So you don’t want that to happen. So if there’s any reason to need abdominal surgery, usually unusually appendix or gallbladder, if you’re of a certain age, then it’s better to get that cleared out of the way before you commit to a major abdominal wall reconstruction or revisional surgery that may involve mesh removal. You just don’t want someone to mess that up. Again, it’s the same as true of a tummy tuck for you women who’ve undergone multiple pregnancies and then want to have a tummy tuck because now you have a very thin skin, very loose skin, very stretched out abdominal wall. Well, guess what? You should not have a tummy tuck unless you’re a hundred percent sure you’re done with future pregnancies. If you feel you may want to be pregnant or you may accidentally get pregnant, if you’re fertile, you should not be getting a tummy tuck because that will destroy the tummy tuck. So the same is true of hernia repairs. We don’t want you to have a, let’s say for a female, a massive abdominal wall reconstruction and then you get pregnant two months later. That’s not considered the best option.

(00:08:18):

And then for males, you want to make sure that you follow the natural guidelines, the guidelines for preventative things such as colon cancer and prostate cancer, which may affect your abdominal wall. That’s the reason why. So that’s your answer. So what did I learn at the European Hernia Society? First of all, I’m very excited to say that we are as a society, moving away from just giving lectures on how to use mesh and repairing everything without the patient in mind. And the European Hernia Society meeting two years ago in Manchester was probably the lead meeting in involving patient advocates specifically. They not only paid for sponsored and invited patient advocates, they also had a specific session which was run by patient advocates patients themselves. This year in Czech Republic, we had a handful of patient advocates that were part of the meeting, excuse me, that were part of the meeting, and they were sprinkled throughout the meeting as either speakers or moderators and commentators mostly to give the patient viewpoint or represent the patient viewpoint. So for example, I had had two talks. I moderated three sessions and my fellow gave a talk. So it was a busy meeting. One of the sessions that I chaired was on autoimmunity, again, very new. The Manchester meeting two years ago was a first European hernia Society meeting that I went to that actually included autoimmunity as a full session, and that’s continued ever since. So this year is a full session on autoimmunity that we had two surgeons, myself and Dr.

(00:10:49):

Moki, pardon me if I pronounce that wrong, German who also, and we also had fantastic patient advocate from the UK. So that group, oh, and by the way, the European Society actually has their own patient committee, and from what I heard, they’re coming up with something like this, kind of like hernia talk. I don’t think it’s live, but I may not be incorrect, but they’re having a patient run podcast or something like that. So I will post about it myself to promote them because a really great thing that they’re doing to help promote the patient side and improve patient involvement in surgical meetings, which is kind of cool.

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Anyway, what I wanted to say was at the autoimmunity session we had, let’s see, we had not only surgeons talk, but we had a physician talk who was like a rheumatologist and a immunologist, and then we had a biomaterials specialist. She was really cool. She went to medical school, but then she decided she wanted to be a scientist and not a clinician. So she does all this stuff about biological materials. And then we had another doctor, he was not a physician, he was from Czech Republic actually, and he talked about technology and how to make meshes and so on. And Aaliyah even had a session with industry for industry to kind of talk about meshes. So really cool stuff. Basically there’s a little bit of an issue in terms of making mesh where the scientists say it’s so easy to just make mesh smarter. So because of the way mesh is made and it’s kind of got these interstices a great way to latch on nanotechnology, how cool is that?

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And that nanotechnology can be anything from antibiotics antibacterials to reduce or prevent mesh infection to things that can give you information about the body. They’re like, it’s so easy to tack on technology and what they were saying, it was in the lab, it’s really easy to do, and this is things that don’t affect the actual mesh because a nano level, but it can provide you information about how the patient’s doing. However, from an industry standpoint, you can’t do that. So let’s put the cost aside. Let’s say cost was not even a matter, which of course it’s a big matter because right now measures already expensive. To add nanotechnology to mesh is super expensive, but let’s say cost was not an issue. Just the regulatory ability to bring technology that’s not currently out there and start a new is very difficult. So in the United States, we have the 5- 10k process, and so if you have a mesh that’s similar to prior meshes, you can get that approved.

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But if you come up with a mesh that has antibiotics on it or antibacterial on it, let’s say antibiotics, that is a drug. It’s no longer a device. So because it has a drug, it goes through a separate drug pathway, not a device pathway. And as you may know, pharmaceuticals and getting drugs approved is much, much more difficult and much more time intensive, but also expensive than the device market. That’s one issue. So putting a drug onto a device, it’s not going to happen because you can’t sell a piece of mesh that’s currently being sold at $300. You can’t sell it for $3,000. It’s just not possible. Then there’s a question of adding nanotechnology to the mesh and that no one even knows that’s basically starting all the way from the beginning and you can’t use the 5-10k process. So it’s not going to be fast, going to take 7-8 years to go through the process, and in doing so, you’ve already outdated and too much money and so on.

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So it was very interesting to hear the scientists say, it’s so easy to make better mesh, and then the industry is saying, fine. But from a financial standpoint and from a regulatory standpoint, it’s pretty much impossible to make these fancy meshes. It’s very fascinating, and the reason is, as a scientist, you’re dealing with products that don’t need to go in someone’s body. That’s why we have great technology for trucks and cars and airplanes and all that. That’s not going in your body. But once it’s something that’s now FDA regulated because it gets implanted and the purpose is to implant it forever, then all the regulatory processes come. Now, what’s even more interesting is it used to be that US was a problem. The FDA was a problem, but now FD is much easier than getting into the European market. So the European markets have an extra layer of protection for the patient, which is that you must include human trials on every product you put out.

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So they started from scratch several years ago. They said, listen, I know you’re already on the market. We’re going to take you off the market. You’re going to show us human clinical trials, and you must follow patient outcomes forever before we bring you back on the market. So newer meshes are now easier to come and be added to the US market through the FDA via the 5-10k process than to be added to the European, I think it’s called the MD through the European Commission to be approved there because you have to provide not only all the safety data, but actual human clinical trials data in addition to follow up.

(00:18:02):

It was just fascinating. Let’s see. Can I ask, what’s your favorite mesh for a complex abdominal wall repair? Another thing, what if the surgeon isn’t giving you a choice, they insist on using whatever they favor. Well, yes. So as a surgeon, you have certain products that you have access to. It’s whether you like it or not. The people that determine what meshes are available to the surgeon are not the surgeons. Usually it’s whoever is the buyer for the hospital. It’s like if you go to Nordstrom’s or Bloomingdale’s, you as a buyer do not choose what clothing is available in that department store, and the people that work there do not choose it. It’s some buyer outside that you don’t even know who they are that decides I’m in Bloomingdale’s and Beverly Hills. This is my type of client and these are the type of products we’re going to sell at Bloomingdale’s.

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So the same is true for Meshes, kind of sort of, which means they have a buyer, and that’s partly the hospital employee that is in charge of buying. And part of that buying involves understanding how much it costs and approving buying that product because the cost is acceptable. There are hospitals where the surgeons have a lot of power to help influence what is bought. Let’s say from the mesh standpoint. Let’s say there’s a surgeon say, I want such and such mesh, and the hospital says, no problem, because they want to make sure that surgeon is happy and the surgeon gets what they want. That’s not very common anymore. That’s hospitals are going bankrupt because they’re appeasing to surgeons, and really surgeons are appeasing to the reps and the reps are there to make money. So basically there is some type of balance between a hospital trying to get mesh products, let’s say, that are not too expensive and are good enough, or at least negotiate a possible better price versus what a surgeon believes is the right mesh for their use.

(00:20:32):

So what do I use? I don’t have favorites. I prefer simpler meshes. I don’t like fancy meshes that have all these extra things attached to them, which is just purely made to make them more expensive. And so a typical flat, polypropylene based mesh or lightweight, polyester based mesh is usually fine for most abdominal wall reconstructions. I do like the pro grip meshes that have the grips on. It does make life easier for certain operations, not for all operations. So when you go in and you see a surgeon, you should not be telling the surgeon what mesh to use or what technique to use. That would be the wrong thing to do. It’s like me telling, I’m ordering Uber and I’m telling an Uber driver, I don’t like this car. I want you to go drive a truck. Well, they don’t drive trucks. They drive their Tesla or their Prius.

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So you need to allow the surgeon to use the mesh they’re most comfortable with. There’s a learning curve to every single mesh product out there, and you can do harm if you’re forcing a doctor to use a mesh product that they aren’t using because there’s a learning curve there. There’s some training and education with each type of mesh. I’ll give you example of why it’s important to know the Meash products. Actually, I’ll give you two examples. So one example, when I first started one of my jobs, they knew I was coming in as the hernia expert, but of course there’s tons of surgeons that do hernias. So one of the residents caught me and said, Hey, do you mind seeing this patient? I went and saw this patient and the patient had stool coming out of their incision, their abdominal wall incision. I’m like, what happened here?

(00:22:38):

Like, oh, we just did surgery three days ago and all of a sudden stools coming out the incision. I’m like, well, okay. First of all, this is not appropriate. You have to take the patient back to surgery. Do you need my help? Yes, we do. Thank you very much. So I take the patient back to surgery with the original surgeon, and I see that they put a specific mesh. This mesh was very popular. It’s called the composit mesh. Technically it was a composix kugel, but they changed the name around a little bit because Kugel became a bad name. So they called it the composites mesh, and it was two layers of polypropylene and one layer of PTFE mesh.

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Now that third layer, which is a PTFE mesh, was placed strategically to prevent intestine from sticking to mesh and also prevent mesh from eroding into the bowel. That was the whole purpose of it. You’re not supposed to cut that mesh because if you cut the mesh, that third layer is now no longer the protective layer, and it exposes the two layers of polypropylene that are not protecting the bowel anymore, and you can cause bowel fistulas and adhesions and so on. So of course the surgeon did not know that. That’s like a learning curve thing. This is the one type of mesh you cannot cut. So I went in surgery, I’m like, wait, did you cut this mesh? And he is like, yeah, of course I did. I said, no, no, no. You can’t cut this mesh. This is not mesh. You’re allowed to cut. I explained to him the way the mesh was made was to make it safer. They add a third layer of PTFE, basically goretex, which is very soft, does not stick and is intended to protect the bowel from the other meshes, which is a polypropylene.

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You’re not supposed to cut it. What they did was they got this mesh. The mesh was pre-made sizes. They thought, oh, this is too big. So they cut it, and now you have these razor edges of the polypropylene that are no longer protected that are like razors. And within a few days, the bowel was just being filed down by this edge of the mesh, and he now got a fistula. Now, the poor man, I actually don’t know what happened to him because it wasn’t my patient, but I helped had to resect bowel. We take out the mesh, he has a hernia, he has intestinal surgery that needs to heal. He needs to get rid of the infection, he’s going to have a hernia and he needs to come back to have yet another hernia surgery. That’s just disaster. And that was purely because the surgeon did not understand that there is how to use that specific mesh.

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My second story is there was a session at the European Hernia Society meeting about disasters. It was a great one. It was so good. Surgeons went up there pre-prepared their talks on disasters that they were involved in. Now, just so you all understand, we’ve all had disasters as a surgeon. The motto is, if you’ve never had a complication, that means you’re not operating. All surgeons who operate have complications. It’s like saying you’ve never had a problem with your car. When you drive a car, you’re either going to have a flat tire, once someone’s going to hit you or going to have a ding, you’re going to get out of a car accident. Something will happen. If you say you’ve never ever had a car complication, including a ding, then means you’re not driving a car. Same situation with surgeons. So it’s very humbling to be up there and share your story.

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And they shared their complications. And in that complications session was a surgeon who operate on a fellow surgeon. And that surgeon somehow was involved in designing a mesh or I don’t know, liked some type of mesh, which the other surgeon had never used before. And there were friends. So he is like, Hey, when you do my hernia repair, this is the mesh I want you to use wrong decision. And so he did, but he had never used that mesh before. In fact, their hospital I think didn’t even carry it. They had to order it special or something like that, which he did. And I mean, it went fine I think, but you should not be doing that. So if a surgeon shouldn’t do it to another surgeon, then definitely a patient should not ask it of another surgeon. So I hope that helps answer that question.

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Here’s another question. What would be your wishlist for what nanotechnology could add to mesh? It’s fascinating. So one thing that we discussed was to alert. So one thing is it could tell you about tension, the same way that when you drive a car, there’s so much technology, it tells you if your trier pressures are high or low or whatever. It can also give back to you information what’s going on at the abdominal wall level, tension level and so on. There are people that have recommended using meshes as an implant to improve your health, right? So it’ll tell you what your blood levels are. They can look for cancers because all the tissues you’re exposed to, your it’s to your blood and whatever’s in your bloodstream other than a technology would be antibacterial or anti-infective strategies where it’ll tell you the pH of the area and so on.

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So there’s just a lot. There’s a lot you can do with it. And what we were saying was that was kind of a joke. There was a surgeon there that I think is late sixties, I think maybe early seventies, I think late sixties. And he kept saying, in my lifetime, in my lifetime. So we’re all joking, okay, everything was relative to in Mark’s lifetime. But the point was that in the next 20 years, we probably will not be having such technology, maybe the next 40 to 50 years that technology will make it, but not in the next 20 years.

(00:29:57):

So we talked about autoimmunity. That was really cool session, and we learned a lot. So one thing I learned a lot was we talk about mesh and plant illness. Oh, let’s talk about oex. You want to talk about oex. And oex is also a very good mesh. It is a hybrid match. It comes into both a permanent and absorbable hybrid. And if you put the bowel, the biologics, absorbable side against the bowel, it should not stick. Yeah, the bowel does not stick to it. What was I saying? Oh, the autoimmunity talk. So one thing that I learned was in addition to, and I kind of knew it, but I learned more. So there’s breast implant illness, mesh implant illness. These are all part of the Asia A SI, autoinflammatory and autoimmune syndrome induced by adjuvants. So the adjuvant can be covid vaccine or even covid infection. It can be the breast implant. It could be the mesh implant, but it can be things as simple as tattoos. So tattoos are a permanent implant. So there are all these people that get tattoos, and we’re seeing a fair number of people coming up with autoimmune disorders that are sprung by the tattoo ink. And personally, I don’t know how you get rid of that. I think you have to do those anti tattoo kind of lasers. But also recently I saw malignant lymphoma can be a risk factor with tattoos. That’s kind of crazy.

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We know the breast implants have been associated with malignant lymphoma. So these are all other adjuvants, and people with autoimmune disorder tend to be higher risk. But there’s also a thought that these implant illnesses can trigger an autoimmunity disorder. And then we also talked about non-surgical ways to treat it. So steroids has been one and immune suppression medications or the other. But really mesh removal or the implant removal is the treatment of choice because it’s in many times less risky to do that than to put someone on steroids for the rest of their life. And then lastly, we talked about the fact that we just don’t know enough. There are people that are cured in our study, 60% are cured once their implant is removed, but 40% in our study are not cured. And many people get better, but they don’t really get better. And there’s no way for us to know ahead of time who’s going to be at risk for these mesh implant illnesses and vice versa.

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We don’t know These patients who have mesh implant illness, what percentage of them will get cured by removal? So by definition, Asia syndrome implies that the adjuvant causes the autoimmune and therefore removal of the adjuvant should cure you. But it seems it’s much more complicated than that, and we had a long discussion about it. It’s kind of interesting. Women with autoimmune that cannot have mesh, what kind of hernia repairs available to them? Well, it depends on the type of hernia to begin with. So almost everyone has, almost everyone has a non mesh option. So for inguinal hernias, there’s different named types of repairs. The Marcy McVay, the Shouldice, Basini, these are all types of tissue. We talked about desarta at one of the meetings sessions. So those are all tissue repairs. If you have a ventral hernia repair, there’s different surgical techniques that can help augment repairs.

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The smaller the hernia, the more likely it is that you can do a good job with a tissue repair. There are just not enough really good tissue repairs for large ventral hernias or large hernias of the abdominal wall. There just aren’t. But there was, for example, this new technique, it’s called the R-T-L I think it was called. I’d never heard of it before, but they presented their data as a clinical trial from Sweden. There’s a Swedish clinical trial where they use a specific surgical technique to close the abdominal wall. And they found that using this technique as opposed to the routine technique had a three times lower risk of hernia recurrence. So the original technique was just taking a slowly absorbable suture and suturing it. And then the second technique, which was really just an RTL I tell you about was taking a permanent suture and running it up and down the edges of the same and then tying it at the end as a second layer. And that took incisional hernia risk from 12% down to 4%. That was amazing. Never seen that before, but apparently one of my good friends from Latin America, Dr. Edgar Losado, which I should bring over as a guest. So he’s like, oh yeah, I do that all the time and actually report it as a trial before the Swedes did. So I think I’m going to bring him as a guest to review that. I thought that was kind of cool.

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Okay, here’s another question. Women who had TRAM or DIEP flaps with autoimmune disorders, what choices do they have? I have many women with multiple sclerosis and mesh isn’t an option. So MS, I think I’d have to look up MS. I think technically is not an autoimmune disorder, and so mesh may be an option for them. I’d have to look that up to double check, but I believe you’re talking about people with TRAM flaps or DIEP flaps that have incisional hernias. That is definitely a complication. In fact, I just saw a lady today who had a pretty random epigastric hernia after a deep flap, and it looks like it was part, it was not specifically from the deep flap donor site, it was from the abdominal wall plication. They did as part of the reconstruction of the abdominal wall once the deep flap was removed and used for breast reconstruction.

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Anyway, so the answer is most women with MS or other autoimmune disorders will do just fine with mesh. As far as we know, the percentage of people, women with autoimmune, women without autoimmune that have this kind of reaction to meshes is very low. We don’t know the actual number. That’s a major problem, but it’s low and considered to be less than 1% because we put in about a million, let’s say 7 million meshes annually. So it’s true, 1% of that would be 70,000 people. Sorry, 7 million. Yeah, 70,000 people a year, which is a lot of people, but it’s about 1% or lower. So we don’t know however who that person would be. So it’s possible that you can say maybe slightly more than 1% if you have autoimmune disease, we don’t know. So one is you can gamble and just do the mesh repair. The second is you can start with a biologic mesh and a high quality one.

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So not something that causes a high inflammatory reaction. There are high quality versus highly processed biologic meshes. So pick the biologic mesh that has a least processing, and then that could be something of use. But I have had people that also react to biologics. So that’s a crazy problem because everybody’s a little bit different. And then there’s this hybrid mesh where it has some polypropylene in it, but it’s not a hundred percent. It’s more like 4% polypropylene, let’s say by area. And so does that work? In some people it works really great. In fact, in my research shows that the majority of people did just fine with that specific mesh that’s waiting to be published. I’ll let you know when that’s published, where we looked at different types of meshes after removing mesh from mesh implant to see how people reacted, including suture alone. So the reality is we just don’t know there are enough patients that we can learn from. There are a lot of patients, we just don’t have enough to learn from them, and there aren’t any good studies out there to look at it. Here’s a comment. I got autoimmune after I got my me. Yeah, so there’s a lot of you out there, and it’s unclear why, if it’s a environmental problem, is it we have more autoimmune people? Are we being exposed to a lot more implants than before?

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And we talked in the autoimmune session, it tends to be a lot more in first world countries, English speaking countries, so uk, Australia and United States and a little bit of Canada. We just don’t know why that is. Are the meshes more counterfeit than they used to be? And therefore we’re exposed to much more impurities than we were before? No, basically no one knows. No one knows. We had a great session on sportsman’s hernias and I met some really fantastic surgeons that are very involved with soccer teams and how much the Europeans like their soccer or football as they call it. So really, really great surgeons, lots of great protocols on physical therapy and injections and this and that. So I will bring at least one of them to my podcast to discuss sports hernias and the whole philosophy behind who HSC should it be orthopedic surgeon, should it be a general surgeon, how we treat these growth with the different algorithms and come up with a really good hour on sportsman’s hernia.

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So I think that’ll be really good. I’m super excited to bring some new surgeons. I met some really great surgeons that are doing great stuff out there, and hopefully they can all contribute as guests on my podcast because I’m really enjoying the podcast and I hope that you guys are enjoying it too. And the whole process of getting guests, I think it has been really cool as well because I enjoy the interaction with them a lot. So that’s been really cool. Let’s see, what else did we talk about? We had a whole session called hernia, HER capitalized hernia. And that was a session that I gave a talk on groin pain in women. As you know, I’m an editor of a book on groin pain, and we had a great, great chapter written by a very smart duo of gynecologists where they talk about groin pain in women that’s not due to hernias. And they went through endometriosis and pelvic congestion syndrome, ovarian cyst, ovarian remnants syndrome, pelvic floor spasm, et cetera.

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And so I went through all of those. I went through how the hip can cause scoring pain in women and should consider that all the GYN issues, urologic problems, and so on. And then I went through individually how each one of those can cause different symptoms. So for example, a hip disorder may cause groin pain in both angle hernias and hip problems. Both of them can cause groin pain. However, a hip disorder, you’re probably going to have a lip, maybe a hip click, and also pain in the buttock as well. Whereas in the groin, groin pain for angle hernia, the groin pain can radiate into the inner thigh around the lower back. But when you lie flat, the pain usually goes away. So little tips and tricks on how to come up with that.

(00:44:37):

And I mentioned that my fellow presented our hernia score data. So what we’re doing, and I hope it comes out soon, I was hoping it would come out at the beginning of the year, but we’re delayed because we’re trying to add more data to make the database stronger. But hernia score is a predictive tool that where we use machine learning, basically it’s a type of AI or artificial intelligence called machine learning, and it takes data that I’ve gathered since 2008 to help determine if your groin pain would be cured by inguinal hernia. So how do you know as a patient if your groin pain is because you have appendicitis or diverticulitis, a groin pull or some type of muscle strain, a hip disorder or a spine problem or an inguinal hernia. And this will help you determine the chance that your groin pain is due to an inguinal hernia and therefore maybe instead of being given just pain medication because no one can feel that inguinal hernia or you’re a female, they both don’t believe it can be inguinal hernia because women can’t get hernias of course, which is completely false statement, but I still hear it, believe it or not.

(00:45:59):

But potentially you could go as a patient, be empowered, go online, put your symptoms, it’ll spit out a score. It’ll say you have an 83% chance that of curing this groin pain with an inguinal hernia, in which case you may want to go see a hernia specialist. Or you can put in your data and it says you have a 13% chance that having a hernia repair will cure your groin pain. In which case maybe you should go see an orthopedic doctor or a spine doctor or a gastroenterologist or a gynecologist, urologist, physical therapist, that kind of thing. So that was it. There was a great study that someone presented. It actually won the award for the best breast presentation. There were many awards given up, but it was a clinical trial that took patients that had groin pain, had occult al hernias, and by occult that meant they had groin pain and an ultrasound which showed a hernia, but the physician couldn’t see or feel a hernia.

(00:47:13):

What do you do with those? Is that something worth operating on or not? They randomized them to two sets of patients, I believe this was from the Netherlands, and they saw that, okay, first of all, that was all the information you got groin pain, no obvious hernia on examination ultrasound, which prove that shows there’s an inguinal hernia. So first of all, just because you have an inguinal hernia doesn’t mean that you inguinal hernia is a cause of the pain, right? You could have other reason. So what they did was they randomized them into two groups. Half of them got physical therapy and some watchful waiting, and the other half went straight for surgery. And what they showed was of the group that went into physical therapy, what was a percentage, a good percentage, somewhere between let’s say almost half between 40 and 60% were cured, showing that their groin pain was not due to the angle hernia, but rather due to let’s say constipation, ovarian cyst that ruptured diverticulitis, whatever hip disorder. So physical therapy is now in by the Netherlands group, considered a good adjunct to people with occult inguinal hernias to prevent the need to fix hernias that are not symptomatic basically. So that was kind of a good one. If you go to my Twitter page, I will have already posted on that. So you can look up occult inguinal hernia on my Twitter page at hernia doc and see if you can find that. It’s kind of good study, kind of good study.

(00:49:16):

We had a lot of, there’s a lot of awards given out for best paper, best video, best this, best that. And then I got an award because as part of the evening dinner, they had a welcome dinner for everyone who was there. By the way, 1500 people attended this meeting. It was a big meeting. So as part of the things to do, they came up with something called hernia homes like Sherlock Homes, but it was hernia homes. They’re European English, not their best language. So it’s called hernia homes. And it was a series of puzzles you had to solve. So they gave you a bunch of puzzles and it was word puzzles, number puzzles, game puzzles, and some check related stuff. So you had to get all those questions. And then they gave you a puzzle to solve, which was kind of like a story, a storyline about, it was like a murder mystery.

(00:50:37):

So there was a quote murder at the time of the dinner, and it was the present of the European party. Society was murdered, and then you had to then solve the mystery as to who killed the president of the European site. Anyway, guess who wants that one, right? As you know, I love solving mysteries. I love solving problems. And while everyone was busy drinking and getting their party on, I was like, wait, puzzle mysteries to be solved. I’m on it. So we had to play work in teams. So we just got in and we did all the numbers puzzle. We got the first stage really quick, and the last one I was like, it’s this one, this is the right answer. And my team was like, no, I don’t think that’s the right answer. I’m like, listen, trust me, A plus B equals C. I’m doing it.

(00:51:37):

I know this stuff. So we turned in our answer and we won the award. I won the award for hernia Holmes murder mystery at the European Society meeting. Anyway, I thought that was fun. I actually enjoyed that part very much, even though I’m sure people weren’t into it as much. Some people didn’t care. Let’s see. You discussed your favorite mesh for ventral hernia. What about for large direct inguinal hernia? Thank you. Good point. So large direct inguinal hernia. Let’s break this down. First of all, direct inguinal hernia usually requires a heavy weight mesh. A large hernia usually implies a heavier weight mesh. So a large direct angle hernia should, in my recommendation, need a heavy weight mesh. So what type and what’s made of is not as important. I prefer slightly curved meshes for the laparoscopic or robotic and flat meshes for the Lichtenstein open repairs.

(00:52:53):

But tissue repair is usually not a good choice for large direct inguinal hernias and using a mesh, it should be on the heavier weight side because you need a lot more support than typical meshes for that. We had a boat race as part of this meeting, they have what’s called dragon boats, and it’s basically like rowing. If you see, these crews are the surgeon who was the chair of who ran the meeting, she was like a world champion kayaker and rower, and there’s a great river that, I think it’s the river Danu, right? That runs through Prague. So what do we do? We all got into our teams. We had team USA, so there was like five teams, 10 people per team, and you had the drummer, the front of the, that kind of gets you coordinated. Then you have two rows of rowers. I don’t know why, but we were horrible.

(00:54:12):

It was a, we tried and we tried to coordinate too, and I don’t know what it was where we came in dead last. I can’t even tell you how embarrassing it was because we actually were the first out in the water and they put this check steer behind it to make sure we go straight. So there was that. We did go straight, but we had so much fun. They said these dragon boat racers and rowing in general is a very social, it’s a very social sport, and they’re very true. We had so much fun, but we all got wet in this nasty water that smelled like fish, and we were rowing so hard. So the first they had us do a practice run, and then they said, okay, for the next 200 meters you’re going to race. And so we raised and we were so far behind. It was so embarrassing. And so in true American fashion, we just claimed that we won.

(00:55:22):

And they’re like, wait, no, but you didn’t win. I’m like, no. Yeah, we won. Yeah, we won. Of course we were joking, of course. But as when you go as an American to these non-US meetings, it’s hilarious because you take with you all of the kind of stuff that Americans are known for. So we’re usually not as formal as the Europeans or the Asians. We are a little bit more rowdy, a little bit more extroverts. We’re a little bit louder. I mean, I dress very formally and I’m very cognizant of the importance of maintaining formality and respect. I speak multiple languages. I come from a different culture already, so I get it. But in general, the stereotype is that the American is a little bit, is very kind, but tends to be louder and not as formal and tends to dress a little bit more disheveled compared to the Europeans.

(00:56:37):

And of course there’s the American politics everyone knows about. So we just decided we’re just going to pretend like we won, came in first where we were for sure dead last. They were just weighty for us to even, we didn’t even know we would reach that, the end point anyway. Here’s another question. In a recurrent inguinal hernia, what role does the external oblique play and how it is closed impact patient’s symptoms? Oh, how does closing it? Okay, so for recurrent angle hernia, the external oblique does not play much of a role in the actual hernias, usually to the transverse abdominis, which is deeper in the intra oblique. The external oblique has, okay, there’s something called the Halstead technique. The Halstead technique is very old, right? Halstead, you guys should all know about Halstead. If any of you watched, was it Nip Tuck? It was one of those HBO Showtime shows, which had Halsted as a character.

(00:58:03):

Anyway, he suggested that if you have a very weak abdominal wall, that you should use the external oblique as an extra layer of closure. So the Halsted technique is unique in that the spermatic cord in males is not talked in the inguinal canal deep to the external oblique, but rather the external leak is closed and then as another layer of closure for the hernia repair, and then the spermatic cord is laid on top of it. So there is some thought that you can use the external oblique as a buttress to your repair. So the dasarta technique, which we described alongside who was the surgeon? We talked with Dr. Lawrence, the Ralph Lawrence, because he does the dasarta technique. If you go to that session when he was my guest, the dasarta technique relies on the external oblique as kind of like an onlay mesh. You can think of it. So kind of like a Lichtenstein repair, but a very narrow strip of it. The problem with that is the external oblique , A neurosis is very thin fabric that can be torn easily. So it’s not considered a great standalone repair. But in patients that have a typical, typical recurrent inguinal hernia, the external oblique is closed like any other hernia, it is not considered a significant part of your recurrent hernia repair. I hope that makes sense.

(00:59:54):

All right. We had a lot of questions too. I’m so sorry we didn’t go through it. Let me quickly see these questions. Yeah, we talked about MRIs and CAT scans. I gave a talk on the purpose of the MRI versus CAT scan. Basically MRIs better for the groin and pelvis and then CAT scan. And if you’re worried about tumors, MRI is better. And then CAT scan is really good for the abdominal wall. I also went through using MRI for infection. I have a patient today I saw who may have a mesh infection, chronic one. Her surgery was in 2009. So I’m curious what what MRI will show that infection. And let’s see. Okay, so I hope you guys enjoyed this. Please do go to my Twitter page at hernia doc and follow me. I have a lot more meetings coming up towards the end of the year. I have the Mexican College of Surgeons, the Mexican Hernia Society, the International Hernia Collaboration, Western Surgical Association. All that’s still left with meetings to go to. Sometimes I wish I could just go to meetings and not have to work. I really enjoy it. But anyway, thank you for hearing my story. I did have a lot of fun.

(01:01:31):

Friends are amazing. I love the Europeans. We had the Indians come, we had our South American and Central American friends were there, Canadian surgeons were there. It was just a great, great international meeting. I really enjoyed it and I hope you enjoyed some of my discussion of what we did there. So I will see you all. Let’s see, not next week. I’m teaching at the medical school, so the following week, I’ll see you back in two weeks and I have a great lineup coming up this summer of guests, so stay tuned for that. In the meantime, please go to my podcast. Do rate me and like me and do whatever you like so that more people can watch or listen to Hernia Talk Live as a podcast. Thanks everyone.