176. When Good People Make Bad Decisions

This week, the topic of discussion was:
-Bad Decisions
-Mesh Infection
-Hernia Recurrence
-Choosing Your Surgeon
-Second Opinions
-Life Before Hernia
-Morbidity and Mortality Conference
-Rushed Decisions
-Watchful Waiting
-Risk Factor Optimization

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 (00:00:12):

Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live. I’m your host, Dr. Shirin Towfigh, hernia and laparoscopic surgery specialist. Thanks for everyone tuning in. We have a really great show today because I’m going to share with you a lot of stories and hopefully many of you can relate to. Thanks to everyone who joins us via Zoom and also those that are here via Facebook live at Dr. Towfigh. I’m going to monitor your questions, so if you have any questions, please, please put them in the chat box and I will help answer them. Okay. Today’s talk is going to be about bad decision making and initially I wanted to make this about when surgeons make bad decisions because we’re all humans, but I also know that patients can make bad decisions. So I called it when good people make good, people make bad decisions. And I’ll go through some examples of patients that I had as early as this week actually perfectly good, reasonable people that made bad decisions and now I don’t want to say they’re paying for it, but they have outcomes that maybe could have been better.

(00:01:40):

So let’s start off by saying we’re all humans, right? So whether you’re a surgeon or a patient, we’re all made of the same kind of all humans. So it’s normal for people to make decisions that are not necessarily logical or to do things that in retrospect you’ll be like, wait, what? That makes no sense. So I’ll tell you from a surgeon standpoint, we have different philosophies that are taught to us and the philosophy that you’re taught is very much based on how you were trained, where you were trained and so on. I’ll just say for example, and I’m generalizing here obviously, but there are a lot of surgeons in the, let’s say Middle East Asia that are very confident and that confidence is instilled in them and they’re so confident that many of them are actually not that good, and yet those that are not that good are actually even more confident.

(00:02:51):

So if you think about it, there’s this great article that I still refer to. It’s called Unskilled Unaware of it, and what they did was they had medical students I think rate themselves. I think they were on a surgery rotation and they were told, okay, you just did this operation with such and such surgeon and you sewed the skin, let’s say, or maybe it was residents, they did some operation. They said, why don’t you rate yourself? How well did you do? And there were two series of patients, two series of people in the study. One series said, I think I did great, I did a great job, I sewed really well. Everything was perfect. And then there was a second group that said, I could have been faster, I could have held the instrument better, I could have been better handling of the tissues. They’re kind of more introspective and kind down themselves.

(00:03:54):

Those same people were then rated by their professors, so actual attending surgeons as to how they did. And believe it or not, the ones that rate themselves lowest actually were rated higher by their professors then than the others. So the ones that said they did great and they would not improve in any way, they just did a fantastic job. They actually were rated lower among their peers by their surgical attending professors. So the title of the paper, if you want to read it, it’s called Unskilled and Unaware of it. It’s actually like a scientific journal. And it basically showed that people that are very cocky and kind of overly confident are often not necessarily the best at what they do. And for those of you that are on social media with me, I posted a picture along with the ad for this today’s show that had a Venn diagram of three circles and I’ll bring it up just so you can see.

(00:05:12):

Let’s see if I can bring it up here for those of you that are here. Let’s see. Here we go. So it’s a Venn diagram from a New York Times article and this article was written to try and discuss why do people make bad decisions. It’s kind of a cute article and let me share it real quick. For those of you that are listening, it’s an article from October 19th, 2013. It’s an opinion page called Why We Make Bad Decisions, and they have a Venn diagram. The person was talking about how they had their own medical issue and they did all this research and went and saw multiple doctors in multiple different cities and different countries to try and figure out why they were so sick and eventually made a decision and got better. But I guess when they went through this thought process, they did some research on it and it occurred to them that you can make really bad decisions even for yourself. So the Venn diagram was one circle was who you trust. Another circle was what you want to hear. So you go to see a doctor and you want to be told that you don’t need surgery, for example. And then the third circle is whose advice to follow and then they should all converge into the best doctor for you, which is someone that you trust that tells you what you want to hear and whose advice you’ll follow.

(00:06:58):

Then in the other kind of parts that overlap is the second opinion doctors that you trust and whose advice you want to follow, but they don’t necessarily tell you what you want to hear. And then you go to on the internet who you want to trust and you try and look for things where you want to hear, but necessarily not the best advice. And then of course there’s mom and mom, you tend to follow mom’s advice and she may tell you what you want to hear, but you may not really trust her as a medical decision kind expert. So what was interesting in this article, and I’m going to read it to you, is it said that this is what they learned and it is that physicians do get things wrong and remarkably often studies show that up to one in five patients are misdiagnosed in the US and Canada.

(00:07:54):

This is estimated at 50,000 hospital deaths each year. I believe this was from the office of OIG office of something. It is estimated that 50,000 hospital deaths each year could have been prevented if the real cause of illness had been correctly identified. So it also said that people are loathed to challenge experts. And a 2009 experiment carried out at Emory University, a group of adults was asked to make a decision while contemplating an expert’s claims. In this case a financial expert, a functional MRI scanner gauged their brain activity as they did so the results were extraordinary When confronted with the expert, it was as if the independent decision making of many subjects brains pretty much switched off. They simply seeded their power to decide to the expert. And this is where doctors come into play. As doctors, we often recommend things to our patients, often with authority, especially as surgeons.

(00:09:09):

Surgeons tend to be more confident than other specialties. We’re trained in a very militaristic way during our residency and we are learned to speak with confidence and assurity and usually usually surgeons. People don’t become surgeons if they’re very unsure of themselves or if they are a little wishy-washy in the way that they approach things. They tend to get weeded out from surgical residencies and they tend not to be attracted to the surgical point of view. And so you now therefore go and see a doctor and oftentimes as a patient you don’t know if that’s a good doctor or not. Maybe your neighbor saw the patient, maybe you went on Yelp reviews, maybe there was a doctor in your network of doctors for your insurance. Maybe you’re in a small town, you only have one or two choices. So you go to their office and they tell you, oh, you need your gallbladder removed, you need your hernia repaired and so on.

(00:10:23):

And you say, okay, and you move on. Now you remember that I always say always get a second opinion. And it’s not because I say that because I think that let’s say hernia surgery should always get a second opinion, some life-threatening operation that you should only get done by certain people. I don’t believe that. However, I do know that surgeons can often talk with authority and make it sound like you absolutely need your hernia operation. And if you don’t, you’re going to be in this horrible predicament, which may not be true. I’ll give you an example. I had a patient last week, I think it was, I feel really bad for this patient. We have certain, let rephrase this. There are certain surgeons that never say no. If a patient comes into their office, they’ll always operate on them and they always offer surgery and by always, I mean surgery is indicated, but either A, they are not an expert in that surgery, they really should give it to another surgeon that’s an expert or b watchful waiting or some type of non-operative treatment could have been another option, but they just don’t offer that to the patient.

(00:11:47):

That happens a lot. I’m not one of those surgeons. I truly believe as a surgeon that we are to consider non-operative management as much as possible and the patient should be aware that there are non-operative options. And if it’s an operation I don’t do, I’m not an expert in et cetera, I don’t do that operation because there are other doctors that are much better than me in that specialty that can do it. So this patient had a very complicated history, cancer, chemotherapy, radiation and so on. And then one day while he was still getting his chemotherapy, got this sharp pain in the side and his doctor sent him to a local surgeon and the surgeon found a hernia, pushed the hernia back in and told him he needs emergency surgery. I’m going to rephrase that. He needs urgent surgery. So this is a patient he was in, not a good mental state.

(00:12:52):

He had cancer diagnosis, cancer surgery, had to recover from that, radiation, had to recover from that and then chemotherapy and is almost done with his chemotherapy. He’s just overwhelmed with so much stuff going on and he was explaining to me that he was not in right mind to really make the right decision. And the surgeon with authority told him he absolutely needs surgery, otherwise he’ll end up in the hospital with a bowel obstruction or something very dire and the patient agreed to the surgery. Now he comes to my office now because now he’s in severe pain and he’s in worse pain than he was before surgery for his hernia repair. What went wrong? First of all, it’s kind of true that if you present with your bowel getting stuck in a hernia that you should get your hernia repaired. It’s not an emergency. This is a perfectly intelligent person that lives in a major city.

(00:14:04):

He is allowed some time to recover from his cancer and chemotherapy before you rush ’em to surgery. That’s number one. You have to, or I believe that a doctor needs to take into account the whole situation of the patient, their lifestyle, what’s going on the rest of the world, the rest of their life, number one. Number two, this patient just got pelvic radiation. What does that mean? That means he had radiation to his lower abdomen and pelvis. And when they do that, they put these little tattoo marks right over the area where every time they go get radiation, that way they can make sure they give radiation to the same exact area every time. It’s kind of like a marker. Well, as a hernia surgeon, you do not, or actually any other surgeon, you do not want to do surgery in the same area where a patient had radiation forever.

(00:15:10):

The effects of radiation are lifetime. They don’t go away with time like scar tissue that goes away with time. It gets softer. So if someone’s had surgery in one area, it’s okay to have surgery again in the same area. It just may be a little bit more complicated. But radiation’s a different beast. Radiation destroys the blood flow in that area, destroys the lymphatics in the area, decreases the ability to heal well in that region. So in general, we don’t like to operate in the same field, the same area as radiation. At the very least you’re at risk for wound complications and your wound not healing at the most. You’re at risk of injuring structure or other things that have been affected by the radiation. Now today’s radiation is much better than radiation from two decades ago. There are really able to focus the beam of the radiation to the tumor itself and not cause a lot of skin soft tissue and muscle damage in the process, but still the radiation beam needs to go from the outside to the inside and doing so it crosses the skin and the fat and the muscle.

(00:16:25):

So if you’re operating in that space, you got to understand that. So what does the surgeon do instead of offering laparoscopic surgery to this patient where the scars are nowhere near the radiation, the surgery is not where the doesn’t cross where the radiation was, he open surgery. Now in the typical patient laparoscopic or open surgery, you can debate whether one is better than the other, but they’re both considered good repairs in the right hands. But in this patient that’s already had chemotherapy and radiation, you want to minimize the risk of anything going wrong, including wound complications which increases with chemotherapy and with radiation. So he want to keep a small incision. So I would’ve recommended laparoscopic surgery and not the open surgery that he had. So he had open surgery and now he’s got chronic pain from it and it’s unclear if it’s related to his radiation or if it was just a bad hernia job.

(00:17:30):

And in retrospect, he probably didn’t need the surgery done so quickly. So now he really hasn’t had any time to recover mentally from the fact that he had radiation and chemotherapy and cancer surgery and he got plunged into another hernia surgery, which probably could have been delayed and now he’s got chronic pain, which is something helpful in a patient that has got cancer. So I really wish that that patient had slowed down, not jumped into surgery, he actually felt rushed by the surgery. He told me the surgeon was even rushed by the surgery. He got called to be told the patient said he got called to come in early because the surgeon had to catch his flight at the airport. Who does that? So that’s just to me not ideal situation, but the point is just slow it down unless you’re in the emergency room and feel like you’re like life is in danger, slow it down, get a second opinion. And even though you’re with a surgeon who’s very confident, that doesn’t necessarily translate into them being a better surgeon. You really want to know a different viewpoint and so on. So this patient unfortunately made the decision to go quickly into surgery because kind of what he was told no one else told them otherwise, and now he’s had a bad complication and maybe needs another surgery. We’re still working up on it. So that’s kind of what I am trying to help you all prevent.

(00:19:21):

As surgeons, we have what’s called m and m conference, M and M, kind of like the candies, but the M stand for Morbidity and Mortality Conference. Morbidity means when something bad happens to the patient and causes damage, mortality means when the patient dies. So every week it’s mandated. Well, it’s not mandated to have it every week. I think it’s mandated to have it about once a month I think or in that range. Most hospitals that have residency programs have weekly M and M conference where they all get together and discuss anything that happens that is a complication. If it’s a death of a patient that has to be reviewed in this morbidity and mortality conference and if it’s a complication that’s worth learning from, we also review it. So I personally love M and M conference. It’s an hour of hearing three to four different patient situations.

(00:20:28):

We go through the decision making, the surgical technique and so on, and often it’s a decision making process that is flawed that you can go over and learn from. So my dad used to always say to learn from other people’s mistakes. I think M and M conference is a perfect, perfect situation where doctors can learn from each other’s mistakes. It’s done in a non accusatory situation. We understand we all have complications that can happen and it’s really a fantastic great opportunity to learn from others. So that’s pretty much one of the beauties of surgery and the fact that it’s mandated implies that we all understand that we need to review our complications so we don’t do it again. A very common complication that I see are when doctors don’t think about other specialties like urology, the general surgeon does think about the bladder for example, and urology.

(00:21:46):

And so let’s say they do a laparoscopic procedure and they forget or don’t understand that the bladder is in the way and so they accidentally injure the bladder. I work a lot with urologists and so I’m very much in tune with that area with the pelvis and the bladder. And so I always put a catheter in, but a lot of surgeons don’t put catheters in and for some reason that’s a big deal to them to put a urinary catheter in during surgery, but it protects the bladder, moves it out of the way, helps you get a better dissection with that, injuring the bladder. And so a lot of times these complications, let’s say where they injure the bladder is completely preventable if you had placed a catheter in. So I do a lot of different procedures on patients to prevent injury during surgery. This is a United States wide m and m conference.

(00:22:47):

It’s not just in California. I’m sure it’s in most countries actually, but I feel that countries like the United States where we have a very well established educational program for medicine instills the M and M conference much more. And there are certain countries where the surgeon is considered king and you can’t question the surgeon and they’re like godlike in their hospital. I believe they usually do not have an m and m conference because how could you have any complications? And there are surgeons that come to these meetings that I go to because I go to a lot of international meetings and they say, I’ve never had a recurrence, I’ve never had chronic pain. I’m like, literally, I’ve treated many of your patients. So the fact that you’re oblivious to the fact that you don’t have any complications, it’s just a silly thought.

(00:23:43):

I’ll give you another example. So we talked about a morbidity mortality conference. a lot of times I show up to it because other specialties are talking about their complications and I’m there because there’s a hernia related problem that was by another surgeon and one of the things I always teach the residents and also the surgeons is don’t try and be a hero, right? So why do I say that? a lot of people believe that when they go in for surgery, they do everything. Let’s say let’s say you go in and you try to save a life, right? So a patient has a serious problem, bowel obstruction. Let’s say they’re deathly ill. You take ’em to the surgery and you find out the bowel obstruction is from an intestinal adhesion from prior surgery. Oh, there’s also a hernia here. Okay, leave the hernia alone. You are there to save the patient’s life.

(00:24:55):

You’re not there to be the perfect surgeon that does everything at the same time. In fact trying to do everything at the same time. We’ll probably be more likely to hurt the patient than get you a cookie for being a great surgeon because you did everything. So leave the hernia alone, deal with a bowel obstruction. What if the bowel obstruction is due to a hernia? That’s always something that the trauma surgeons are struggling with. How do we deal with the hernia when we have a deathly ill patient with a bowel obstruction? My advice to them leave the hernia alone, let me fix it later. Or maybe you can bring them in later when they’re not so sick. You can’t do a good hernia repair when the patient’s septic has an overwhelming infection is about to die on. You needs intestine surgery, there’s contamination in the area, et cetera.

(00:25:51):

So leave it alone. Fixing the hernia is not going to save their life. Fixing the bowel obstruction or the dead intestine or the strangulation or the sepsis will save their life. Save the life and when they’re better, we can fix the hernia life before hernia. So it’s one of those things where you don’t want to burn bridges. Also, I just saw a patient this week. I saw a patient this week. So the patient had a really bad trauma, huge accident, chest injury, abdominal injury, forklift had basically pierced and he even recalls seeing his intestines outside his body while on the field. Crazy, right? So they saved his life and in doing so they caused a hernia because he was so sick that when they opened him up in his belly, everything was so swollen. Well, they tried three times to try and close his belly and they couldn’t.

(00:26:51):

And in doing so, they did kind of sort of release some tissues to try and close it. But listen guys, just give it up. This is a sick patient. You saved his life. He did colon surgery, spleen surgery, pancreas surgery. His diaphragm was torn. He had chest injury, lung injury, leave the hernia up to me, I’ll fix the hernia when he’s healthy, stable when there’s no infection, right when he’s up and about and will have good nutrition and is mobile and is healed. Do not be a hero and try and fix a hernia, which is an elective operation at the time of someone who’s still in trauma. The guy was in the hospital I think three months and it’s unfortunate that he now has this humongous hernia, but guess what? He’s alive and I’m happy to fix the hernia six months to a year after this trauma and I’ll do a really good job that I promise, but in the meantime, let him recover, get on with his life. What I don’t like is when good people make bad decisions. When you have a surgeon that wants to now do a component separation, put mesh in, do these fancy operations that they see all of us talk about now they want to do it in a patient that’s sick, infected or otherwise not suitable to have a hernia repair. That’s when that’s just a bad decision.

(00:28:34):

Okay, doctor? Oh, here’s a question. I had a recurrent hernia repair combined with a sports hernia repair. You already know how I feel about that. It’s very uncommon and unlikely that you have a sports hernia and an inguinal hernia at the same time. The surgeon told me there was no advantage to doing a hybrid procedure, which I discussed with him. IE open for sports hernia followed by lap hernia repair, but he said there’s no advantage if the inguinal canal is already dissected. I now have severe life-altering pain. Yes, for revision surgery. Do you recommend doing a lap repair first followed by removing the sutures and mesh anteriorly or do you address anterior problems first followed by lap placement of mesh? So in your situation, since I know the situation, my recommendation has always been to fix your hernias. You have inguinal hernias, you don’t have sports hernias.

(00:29:33):

That’s always been the red herring where you got diagnosed with this by people that didn’t understand your anatomy and your lifestyle. So you did have an angle hernia. You still don’t have a good hernia repair. You’re trying to tear through a tissue repair you should not have had, I recommend just focus on your angle hernia, get that repaired laparoscopically and reassess. Again, I don’t want to be a hero and do all these operations on you at the same time, you may only need a laparoscopic hernia repair and then all the pain will go away because that repair will take the tension off of your tissue repairs that you had. Now if your tissue repairs are the problem and remain a problem after the hernia repair, we’ll reassess after the hernia repair, give it some time to heal and see how you do. Then we can focus specifically on any sutures or problems that you have that were done that need to be undone and that would be an open anterior approach.

(00:30:42):

I do not recommend a hybrid approach in addressing your current complication because you’re mixing things. So I see this a lot. I see people who have, let’s say one problem, let’s say it’s a meshoma and maybe nerve problem and then they have the other side fixed at the same time or they have a mesh implant illness or something and they get the mesh removed and they want another hernia repair at the same time. I’m like, listen, these are complicated situations. You got to break it up. You don’t want to do everything at the same time and it’s just not appropriate. You’re asking for more complications and even though time-wise, it’s seems better decision, that can’t be your decision, which goes to this thing I want to talk to you about for patients. Sometimes I feel that patients make the wrong decision because to them it’s very important for example, to have an operation done in this two week time that they have off from work or this, they feel like they have to have it done really quickly and so on.

(00:32:03):

So do not rush into any surgery. Do not consider time an important factor in surgery if you can. For example, I had a recent patient, his reason for going and signing up for surgery within days after seeing a surgeon was he just wanted to get it over with. And he’s just one of those guys that just like to do things quickly. Listen, that’s not necessarily the best idea. If you have a hernia, slow it down, slow it down. If you feel you only have a two week time interval because of or whatever, don’t jump into surgery because one surgeon can do it. Then another surgeon who maybe have been better surgeon couldn’t do it in that time period. I have some patients that come and see me, I give them one thing to do and then they go to a surgeon who’s not an expert because that surgeon can fit him in at a certain time period or a certain hospital.

(00:33:03):

And now they come back to me saying, I wish I had done it with you because now they have a complication from the other surgeon. I also see that a lot of people make decisions based on financial needs. Now of course it is definitely an important thing to consider and if you have had two consultations and they both say similar things and you’ve done your research and one surgeon is cheaper than the other, but they’re equivalent in quality, fine. But don’t choose the cheaper surgeon that’s never done the surgery before offers you inferior diagnosis. Inferior because they’re cheaper because in the long run you’ll save much more money if you go with an experienced skilled surgeon that does the right thing than with an inexperienced or unskilled surgeon that’s very confident that then performs an operation and now you need CAT scan, MRI, ultrasound, you can’t go to work, you’re debilitated.

(00:34:14):

You need nerve blocks. You have to see a pain management doctor, another MRI and another surgery to undo everything, which is now going to make it much more expensive. So invest in your health, choose the right doctor, get a second opinion and don’t use financial as a major decision point. Next question, follow up to the first question. I never meant simultaneous hybrid procedure. I understand I may need two surgeries. I’m just checking on the most correct sequence for lap followed by second, reopen, repair if necessary, or to address possible anterior pain triggers followed by a second surgery with lap repair to address the hernias. No, like I said, you need to do your hernia repair first. That’s always been your problem. Then you reassessed to see if how much of your pain is addressed by the hernia repair. Just because you have pain doesn’t mean the pain is necessarily triggered by the anterior open repair.

(00:35:23):

You’ve had pain from before, which was unaddressed by your anterior repair or you’re tearing through it. So get the hernias repaired first, then reassess. You may or may not have pain. If you do have pain now it’s going to be a more focal pain because you took the hernia pain out of the picture. Then you can have a better second operation after the laparoscopic hernia repair to address exactly what you need. So you minimize unnecessary operations. And I’m a big fan of minimizing unnecessary operations and I am a fan of doing things in a staged manner. Now it’s very important talking about stage procedures. So there’s a trend right now in many of our surgical societies to talk about two things. One is patient regret, and in Michigan they ask patients about patient regret. And women and younger patients often have regret from their hernia operations and the regret is usually linked to a higher risk of chronic pain or hernias going wrong.

(00:36:33):

So there’s also a trend of surgeons feeling like they are discriminating against people that are morbidly obese and by not offering them surgery. So it’s true that obesity tends to be in the United States, a disease of people that have poor access to healthy foods, which include fresh fruits and vegetables and high quality foods, and they tend to eat more processed foods, fast foods, cheap foods, and therefore the higher obesity rate. Now, it’s not true of all patients, but overall that seems to be the consensus. And therefore, if a patient who’s morbidly obese comes to your office with the hernia, the right thing to do is have them lose weight first and then fix the hernia, which means a large percentage of people that are morbidly obese will not get their hernias repaired either ever because they just won’t lose the weight or in a timely manner. So then they’ll end up in the emergency room with a complication now, and that’s a much worse situation with more wound infections, more mesh infections, not as good of a hernia repair than if they had done it electively. So the question that us surgeons have, we surgeons have is are we doing society a favor by refusing to operate on patients after a certain weight because we know they’re going to have more complications, more hernia recurrences, more wound infections, more mesh infections, more chronic pain?

(00:38:31):

Is that higher risk of recurrence outweighed by a higher risk of not operating on these patients ever or in a timely fashion and therefore having them either have a poor quality of life because they’re living with a hernia that may be causing them pain or preventing them from working or submitting them to need for emergency surgery. So I struggle with that a little bit, but not a lot because you still have to do the right thing and it’s just not cool to offer surgery to a morbidly obese patient over 300 pounds, let’s say patient and submit them to potential complications as a surgeon knowing that if they had lost the weight, they would do better purely because you feel guilty for saying no to a patient. Now, there are surgeries out there we know that do offer surgery to patients that are not optimized. Their diabetes is out of whack, they’re morbidly obese.

(00:39:43):

They may even have uncontrolled hypertension, they have a chronic cough, they’re constipated, they have a large prostate, they’re strained strain to urinate and they operate, and I inherit a lot of these patients and I tell ’em to stop your complication was because you had a risk factor for a bad outcome, which includes diabetes, chronic cough, poorly controlled asthma, constipation, a morbid obesity, enlarged prostate, and that should have been treated before you had your hernia. Otherwise you wouldn’t have had as high of a risk of getting these complications. And now that you’re with me, I’m not going to repeat the same problem twice. I am going to push to make sure you’re optimized.

(00:40:32):

There are some surgeons that offer these operations to the patients and it’s a bad decision, but they do it because of financial reasons. I’ve heard them say it’s horrible to say, but they say, Hey, if I don’t offer this surgery, they’re going to go down to the surgeon down the hall or down the street and have the surgeon with that surgeon. So I’m basically losing a patient. You know what? That surgeon shouldn’t be doing it either. And so it’s not a better evil to kind of say, well, I’ll just do the surgery because I’m a better surgeon than the other surgeon and if I say no, they’re going to go to that other surgeon and so I’m going to prevent that from happening to me. That’s not a legitimate argument, but I hear it a lot. The other situation is surgeons just, there are surgeons that never say no, I just saw a patient that had a hiatal hernia repair by a surgeon who’s perfectly able to do the repair, but I can do a hiatal hernia repair.

(00:41:41):

I was trained to do it in hiatal hernia repair during residency. I worked at USC. I learned a lot about hiatal hernias there, but that was really the mecca for a lot of Foregut surgery. And yet I don’t offer hiatal hernia repairs because you really need to know what you’re doing. You can cause a lot of serious quality of life problems by doing a diaphragm or hiatal hernia repair in a patient. You can prevent them from swallowing and burping and eating, and that’s exactly what happened to this patient. So I think that if it’s, now, if I were a rural surgeon in Montana or Idaho and or in a region of the world where there’s no good access to specialists, then my practice will be different than it is now, and I would be doing breast surgery and hysterectomies and fixed fractures and do colon surgery and hiatal hernia repairs, gallbladders, et cetera.

(00:42:54):

There was a time in my life when I was the emergency surgery doctor called the acute care surgery doctor at the largest county facility and I was just there to save lives. People came to the doors through the emergency room dying extremely sick. I saved their life. Was I the absolutely best surgeon in everything I did? Not necessarily, but I was a really good surgeon, I would say, and my goal was to save a life. My goal was not to do the very absolutely best cancer operation, for example, because that was not my specialty. Those I would refer out. My point is this, sometimes a decision to do surgery is not based on the best optimal decision for the patient is because the surgeon always says yes, doesn’t turn away patients, doesn’t refer patients out to those two are specialists and so on. So unfortunately, I see patients from the surgeons that are maybe not the best decision, right? You can’t say it was a wrong decision because there’s a hundred ways to do a surgery. There’s so many different standards of care and so on in the community, but would I have chosen what they did? No. Would I put a mesh plug in a thin female? No. Is it okay to do? Yes. Do we have any strong data to show that a certain mesh or a certain technique should not be done in a patient? No, we don’t. That’s part of our problem, but that’s where I think it’s important to get second opinions.

(00:44:54):

Let’s see. I took some notes to make sure. I will tell you another thing. There’s certain trends that come and go. So for a while, there are patients that I, sorry for a while, there were surgeons that said, Hey, there are situations where there’s contamination, there’s intestinal surgery, there’s gallbladder surgery, et cetera, and therefore there’s bacteria in the body system. At the time of surgery. Over time we decided, you know what? Mesh can get infected when that happens. So let’s not put mesh in at the same time of a contaminate or kind of dirty operation. Then there were certain countries, Turkey, Algeria, Egypt, where they publish papers saying, you know what?

(00:45:58):

We don’t have the resources to take care of some of these patients and have ’em come back and so on. We put meshes in these patients. You know what they did fine. Guess what? They did fine. So some of the surgeons in the United States are like, huh, it seems that in some of these countries with poor resources, they are putting mesh into their patients and patients seem to be doing fine. Let’s study that. They studied it and they found out actually they’re doing okay. Right? So you can have a situation where you have a bowel injury or bowel surgery or gallbladder surgery, stomach surgery, anything that has bacteria in it, and then at the same time fix the hernia or end use mesh. And statistically they do well. Now were there patients that had infections of their mesh? Yes, there were. Where there a lot of ’em?

(00:46:54):

No, they were not. However, if you ask me, and if you’ve asked many surgeons, what can happen is you’ve now changed this patient from having an acute infection to being at risk of having what’s called a chronic infection. So two years later they’re going to feel kind of sick, a little fatigued, maybe some hot feeling hot. They may have some redness over their hernia repair with a mesh. They may have a mesh infection, they may just not feel good. And these are patients that have chronic mesh infections. They have this inflammation in their body and they just feel sick. They’re not so sick, they have to be in the hospital, but they’re sick enough that they can’t function as well as they used to as a mom, as a office worker or staff person. So just because you can quote, get away with putting mesh in a contaminated field, which against the instructions for use of those meshes by the way, doesn’t mean it’s the right thing.

(00:48:09):

And so cutting corners or trying to do things one way, I talked to one surgeon and I said, when I was at the big county, I learned a lot about how to handle mesh infections and I’ve now perfected the situation. It worked perfectly. So based on our data, which we presented at the Pacific Coast Surgical Association, we had two arms of patients. We had a single stage in this multiple stage, and the single stage was you had a patient with a mesh infection, you took out the infected mesh, you put in a biologic mesh, and you did all these wound cares. In the multiple stage, you took out the infected mesh, gave them antibiotics, did a lot of wound care, decreased the bacteria load, then you put the biologic mesh in and the hernia recurrence rates were much higher, almost three times higher, no, two and a half times higher in the two and a half, 19% to 42% I think it was.

(00:49:14):

Yeah, a little bit more than two times higher in the single stage. So I now do a multiple stage thing. I was talking to surgeon, Hey, you guys do a lot of mesh infection patients. Do you guys stage your patients? And you know what the answer was? I didn’t like this answer. The answer is yes. Ideally we would stage the patients because like you said, sherin staging, it allows the patient to go from an infected situation to one where antibiotics and wound care has reduced the infection. Now you have a very, very low bacterial count and therefore a better operation with better healthy tissues. But I’m a busy surgeon. I don’t have the time to do a staged operation. I have so many cases to come to do, and I’m sorry, but that is just the wrong answer. It’s not okay for you to perform.

(00:50:19):

Okay, lemme rephrase this. It’s not okay for you to know there are two options and one option is better than the other. And for you to choose the worst option because you’re a busy surgeon, that is just ego talking and I don’t believe in that. If you’re such a busy surgeon, then you can afford to hire another surgeon and do the right thing for the surgeons. So this is a situation where good people make bad decisions and their decision is not based on what’s good for the patient because they believe it’s good enough for the patients, good enough. And yes, they do have wound complications. They just deal with it. And yes, they do have patients that get mesh infections after that again, and they just deal with it.

(00:51:05):

They’re making that decision because from an administrative system-wide standpoint, it works better in their system to do a single stage. I see this a lot in less in countries where there’s less opportunity for advancement in technology, they do stuff because they have limited resources. Now, if you don’t have an option, that’s fine, but when you do have the option, I don’t think that’s a cool decision. Let’s see. I’m looking at my notes. I want to make sure that I, yeah, so that’s where I really don’t like it when surgeons either put time or money into the factor of what they do for the patient. I think you should always do what’s right for the patient. If that means it’s going to take longer, more trips to the operating room, more use of your resources, or if the decision not to operate means you’re not going to make money on that patient or you’re going to lose money, then so be it.

(00:52:19):

I don’t think as physicians, we should be making decisions based on financial motivation or like a system type system-wide resources decision. Here’s a question. Hello doctor. I have an Anglo hernia on the right side, small to medium. I’m 45 years old and 165 pounds. In your opinion, would you recommend open surgery or robotic surgery and with mesh or no mesh? And what type of mesh, hybrid or polyester? And what are the benefits and negatives? Okay, your question is asking for a full surgical consultation. So I’m not going to answer your question personally to you because that would be inappropriate. I need to know much more about you, your examination, your lifestyle, the size and type of your hernias, what you’ve had before and so on. But in general, males with little to no symptoms from their inal, hernias are perfectly okay to wait until they have symptoms.

(00:53:26):

Once you do have symptoms, and that’s called watchful waiting. Once you do have symptoms, hernia repair is indicated. Almost all patients have an option of open or laparoscopic or robotic surgery, open surgery with or without mesh. And the laparoscopic and robotic surgery is almost always with mesh and the mesh. Doesn’t matter what it is, what type of mesh it is, I prefer the flat meshes and not any meshes that are like no mesh plug, for example, and so on. So pick the surgeon, don’t pick the type of surgery, go to a surgeon that you trust, get a second opinion and ask the right questions. And then based on that, decide whether you want surgery or not. That’s what I tell everyone I there’s risk with surgery. So if you’re doing fine with no pain and no symptoms, there’s really, I can’t make you feel better. I can make the bulge go away, but I can’t make you feel better. So you’ll be very unhappy if you unfortunately have a hernia surgery that has even a twinge of pain afterwards because you didn’t have that before surgery, which is why I’m not an advocate of repairing hernias if the patient has no symptoms.

(00:54:45):

But what technique and all that is very much based on your surgeon and what’s good. You can have a perfectly good open surgery by a highly talented surgeon that does really good open surgeries. You can have a horribly gone wrong robotic surgery by someone who doesn’t understand how to do anular hernias just because you read something that robotic surgery is good or whatever. Okay? I want to share with you a quick story. When I worked at USC, I had a mentor there named Dr. Thomas Byrne. His father was chair of the department for many years. He himself went to undergraduate school, medical school and residency at USC and was basically at USC for 50 years. He was a genius surgeon, so well regarded, just safe, intelligent, very talented, pretty much had seen everything.

(00:55:43):

Now, Dr. Byrne was also a very humble surgeon, and this is kind of going full circle when I said it early on, the cocky surgeons tend not to be the best surgeons. Actually, the surgeons are a little bit unsure, not to the point where it affects their decision making, but to the point where they start questioning their decisions in a positive way is very helpful. Dr. Byrne was one of those. He passed away the same year. My dad passed away. So multiple very important men in my life passed away in the same year, 2017. Dr had a philosophy as a surgeon, you need to be a compulsive pessimist. What does that mean? That means when your patient says, doc, I got a little, I have this pain here after my surgery. You can’t say, oh, that’s fine. I’m sure it’s okay. You have to worry.

(00:56:45):

You have to worry about your patients. When you operate on patients, you have to worry about them. Where you don’t want to be is that doctor that never worries, never cares, never thinks twice. I think about my patients all the time. I did, lemme tell you this, I had the simplest operation last week. I had a patient who had a little dimple where he had a prior robotic surgery, so I did a full abdominal wall reconstruction, looked beautiful, but he had this one little dimple that didn’t look the best. So I offered to fix that little dimple For him, it was a nothing burger compared to the actual operation that I did on him, which was full abdominal wall reconstruction. And I worried about it. I wanted to make sure that the dimple would be as close to looking good as the rest of his incisions did.

(00:57:36):

And even my residents who operate with me worried about him, which is a very good sign. You always want your trainees to worry, and the older they get, they have to worry more. And this whole idea of compulsive pessimism is a really positive one because it teaches you that you’re not infallible that make mistakes. The worst is the surgeon who doesn’t worry, they don’t have a conscience, they think they’re God and nothing can ever go wrong. And those are the surgeons that are always late. They act late, they delay any intervention for the patient. The patient suffers and sometimes has a bad outcome. And then we discuss it at Morbidity and mortality conference called m and m conference. So that’s kind of my spiel.

(00:58:30):

I hope you learn from it. I try and teach my residents this all the time. Be humble, make good decisions, run it by other people, especially when you’re younger, and that will help you make good decisions. Always worry. And on that note, and oh, quick question, can mesh become infected many years after surgery from a systemic infection occurring years later? Yes. Or does a mesh plastic endothelial lights or become covered by fibrous tissue or totally integrated into surrounding tissue? That can happen as well. By the way, what is this tissue integration of mesh actually mean? It means that the mesh is enmeshed in the tissues. So you now have a tissue mesh complex. But yes, any foreign body can get infected. Let’s say you have tooth abscess, that bacteria is now in your system and it can land on your mesh and cause a mesh infection.

(00:59:36):

We discussed a while ago, and it’s kind of one of those things where maybe we should be giving antibiotics to people each time. But on that note, thank you for joining me on Hernia Doc Live. Please do follow me on YouTube at Hernia Doc where all of these are there. And also we have a podcast. Now, Hernia Talk Live is a podcast, so please follow and like the podcast if you like podcasts, and I will see you in a couple of weeks. I believe I’m teaching at the medical school next week, so I may not be able to join you, but if I can, I will see you.