177. National Hernia Awareness Month

This week, the topic of discussion was:
- Hernia
-Sex Based Differences
-Hernia Prevalence
-Hernia Symptoms
-Hernia Prevention
-Hernia Repair
-Hernia Risk Factor

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 (00:10):

Hello everyone. It’s Dr. Towfigh. Welcome, welcome. Hope you are enjoying your Tuesday. Today is June 25th, I believe we are live on Hernia Talk Live on a Tuesday. I am Dr. Towfigh, your hernia and laparoscopic and robotic surgery specialist, and we are here for another Hernia Talk Live. Many of you’re joining me live on Zoom and others on a Facebook Live. As you know, this episode and all prior episodes are archived on my YouTube channel. You can watch them all and share them at hernia doc on YouTube. And if you prefer, prefer podcasts, you know that I have a podcast. So Hernia Talk Live is also available in podcast form and we’re almost caught up with all of our prior episodes. So I think we’re up to episode 177, which is kind of cool and it’s super exciting because I personally prefer podcasts. You can listen to it when driving work.

(01:15):

I do my makeup in the morning listening to podcasts. So that’s kind of like my thing to do and I think it’s kind of cool to also have hernia talk available as a podcast for those of you that cannot join live. So I just wanted to say that Happy National Hernia Awareness Month. Yes, we have an entire month celebrating awareness about hernias, and I hope to do good for you guys with today’s episode because we’re going to go through every little tidbit that you should know as someone who may or may not have a hernia or hernia similar symptoms and make sure that we spread the word that it’s not just a hernia. And hernia should be taken seriously. If you do have symptoms, what can they be? Who should you see? What can you do about it? What are preventions, et cetera. So today’s going to be kind of like an all-you-can-eat hernia episode that can give you a little bit of everything we’ve discussed in the past several years to chew on and hopefully you can share your information with others.

(02:36):

I would like to say thank you to those of you that have been following me. Some of you texted me or messaged me on social media because you thought not only should it be hernia awareness month, but also hernia appreciation, appreciating what I’m providing you. I had several patients today that said that they followed me online and they asked me some really good questions. I’m like, how do you know about obturator hernia and spigalian hernias? And they had already watched and read about my podcasts and listened to it on YouTube and so on. And watching the videos was really helpful for them. So when they came to me, they had a list of questions to get answered and concerns and really educated patients with very insightful questions. And I love that because I’m going to assume when you come to me with that, that means you’re also coming to other doctors like that.

(03:44):

And it’s just great to have patients that are educated to come in, not totally from scratch, but come in with some amount of knowledge about their disease process or potential disease process before they see me. It makes the office visit very different than someone who knows nothing about hernias and you have to start from scratch. Many of you know that I enjoy actually educating, so it’s fine by me. But if you go to other doctor’s offices, they may not have the time to sit down with you and just say, this is what a hernia is, this is what’s important about it. And I’ll do all that in the short amount of time many doctors have available allocated to each patient. I have a different practice. I don’t believe in quantity. I believe in quality time. So I am not restricted like other doctors may be, especially employed doctors who go straight to the chest, yep, you got a hernia, let’s go have surgery, or nope, no hernia.

(04:48):

I don’t see a bulge- go home. I spend a lot more time with my patients. They go over their imaging and risk factors and how to prevent it. It’s okay to go to exercise and so on. So in somewhat of a summary, today’s episode, unless you have questions you’d like me to answer, today’s episode will be focused on kind of the global picture of what it means to have a hernia. First of all, as you all know, it’s not just a hernia. It’s not just a hernia. a lot of people say, oh, that’s just a hernia. You can ignore it or it’s fine. Also, it’s not just a hernia. It could be other things that can cause your chronic pelvic pain. So I recently wrote an article that has summarized a lot of what I’m going to be discussing today, and that’s basically that first of all, hernias are common.

(05:43):

Most people either have a hernia or know someone who’ve had a hernia, right? So if you start talking at a dinner table about hernias, they may not have told you before that your friend or your neighbor, whoever had a hernia, but once you about it, they may come out and say, oh yeah, I had a hernia or my dad had a hernia, or my child had a hernia. So hernias are common. About 50% of all men in their lifetime will have hernias and about 10% of all women will have some type of hernia. Now, hernias tend to be more common in the groin in men and more common in the belly in women. And there are certain risk factors to all that. But it’s important to note that it doesn’t mean that women cannot get inguinal hernias. They absolutely can. And it doesn’t mean that men cannot get ventral or abdominal wall hernias.

(06:39):

They absolutely can. It’s just more common in women to get belly button hernia, for example. And it’s more common in men to have groin hernias. I’ll tell you a funny story. It’s summer, so everyone’s going on vacation and all my friends are on vacation, by the way, Europe, Mexico, Hawaii, all over. So one of my friends called me from Mexico and they were I guess on the coastline, maybe Cabo or Puerto Vallarta, I think maybe somewhere around there. So he would say, what is it with these belly buttons? Why are people think it’s okay to walk around with an outtie. I literally cannot handle sitting at the poolside or at the beach, I think he was, with everyone either in bikinis or in a swimsuit like a male swimsuit with these outties, you have a good body, you also have an innie. I said, well, let me tell you.

(07:43):

I say that all the time and I would like to say that people, I dunno, don’t you, I mean is an outtie, I don’t want to knock it. I don’t want to shame people for their belly button look. But an outtie is a hernia unless proven otherwise. And if you follow me on Instagram, you see every so often I will post some celebrity that I saw on Instagram or on a video of some sort that has an outtie, and please, can you please tell them to get that fixed? Because I just think especially if it’s a female and they’re done with their pregnancies, just get it fixed Anyway. So he was like, I just want to go up to them and say that’s a hernia, right? I know somebody who can fix that for you anyway. So what do I want say? So 50% lifetime risk and then 10% lifetime risk approximately.

(08:43):

And we need to get hernias of all sorts more common in men to get a grand hernias more common in women to get the belly hernias. Now, there are certain other hernias that are very gender based. For example, a femoral hernia, which is a type of green hernia, is about 10 times more likely in female than in the male. If they do get the hernia, most women don’t even know they have a femoral hernia, but they do have it. It must get repaired. Why? Because you end up with a complication from a femoral hernia of 5% chance of dying from it, not good. So those are all really important statistics to understand. So as a female, a femoral hernia must be operated on, otherwise you risk about a 5% chance of that because that femoral hernia may cause a bowel obstruction or your testing getting stuck into the hole.

(09:38):

And because it’s not like most strenuous, it doesn’t have muscle around it, it just has bone lubricant, it’s very hard to relax the belly to reduce that hernia. It doesn’t reduce, they end up with really bad bowel intestinal injuries and that injury can cause infection, then infection can cause death. So femoral hernias are important to, especially in women who are 10 times more likely than men yet, and let just say I should not be using the words male women and men because those are gender-based descriptions. Really I’m talking about the sex of the patients, male or female. So females are more likely to have femoral hernias 10 times more likely than males and males are more likely in general to have inguinal hernias, which are a different type of groin hernia than femoral hernias. Hope that makes sense. So regardless of your gender identity, it’s really the biological sex you were born with that determines your hernia risk factors.

(10:47):

What’s not cool is the fact that we don’t know what to do with a lot of women’s hernias because no one’s really studied it. I just did a talk at the European Hernia Society, meaning on groin pain in women, and I went through what we know about it, and there’s a lot we know about groin pain being caused by endometriosis and ovarian cysts and uterine prolapse and all these gynecologic disorders. But no one really has done a good clinical trial looking at and studying women’s hernias, especially in the groin exclusively. And looking at all, there have been five clinical trials out there. Of those five clinical trials, over 3000 patients have been enrolled to study what happens for let’s say watchful waiting or different surgical operations, let’s say laparoscopic versus open surgery in men. And of those 3000 patients plus only 17 were female because of the five clinical trials, only one of them enrolled any patients.

(11:58):

4% were women. And all the other four major clinical trials that we know of where we study biology of hernias, 0% of those involved were men. I’m sorry, we’re women, all men just horrible. So we don’t know enough about women’s hernias. What we do know is the higher risk of getting femoral hernias as those that get femoral hernias of a higher risk of dying. So the European Hernia Society came up with their guidelines on how to manage inguinal and groin hernias and their consensus statement by the experts that were part of the European Hernia Society Guidelines Committee determined that of all the studies that are done, we know that women do worse, they have more chronic pain, they have higher recurrence rates, and they have higher risk of femoral hernias and higher risk of death, and therefore they do not feel it is safe to just watch a female hernia. So what does that mean? They believe that all females with hernias should have surgery and because of the high risk of femoral hernia, comparatively, all females should have laparoscopic hernia surgery, which involves mesh. Now, I don’t agree with that statement. It implies A, all women should have surgery, and B, all women should have mesh. As you know, I’m not a proponent of mesh and women and I’m not proponent of over treating hernias.

(13:28):

So I don’t agree with the guidelines in that respect because the implication is not a healthy implication. What is good about the guideline however, is the fact that they are telling people that women should always be surveyed for a femoral hernia. And because we have zero evidence about what you can do about women’s hernias in terms of safety of not operating on them, we don’t really have good guidelines like we do for men where watchful weddings considered safe. And so in men, if you have an inguinal hernia and you have no symptoms or you have minimal symptoms, maybe some discomfort doesn’t really affect your life, those patients are called minimally asymptomatic or asymptomatic, and those patients are considered safe to watch for inguinal hernias in men. And in those population where they watched ’em about 0.18% per year ended up in the hospital requiring an emergency or urgent surgery, and within the next seven to 10 years of watching them, about two thirds of them eventually needed surgery because they started getting pain.

(14:42):

However, we don’t know what happens if the same exact situation happens with women. You may remember Dr. Annie Ehlers from University Michigan was one of my guests, I’m going to say almost two months ago. And she did an excellent, excellent job of pointing this all out. And even more importantly, she is getting national federal money to study what happens with women to try and repeat the clinical trial that Dr. Fitzgibbons did. Also, a prior guest, I think over a year ago on Hernia Talk Live, he was the inventor of the watchful waiting trial and the main author of it. And so now I’ve got Dr. Ehlers and Dr. Fitzgibbons talking to each other so that she can learn from him as to what kind of problems he ran into developing this clinical trial. So she doesn’t repeat the same problems and therefore hopefully we’ll have a successful watchful waiting trial and I hope to be one of the surgeons who helps enroll patients in that clinical trial for women.

(16:01):

So I’ll tell you, I just recently spoke to another patient. She was very anxious and to begin with, and she has an inguinal hernia. It’s minimally symptomatic. And she said, oh, now that I know I have a hernia, I want to get it fixed. I said, okay, that’s fine. That’s probably good idea because she’s young, so she’ll eventually need surgery. And then what she said was she came back and saw me and she was very different, very nervous, unsure, afraid to have surgery, afraid to go back to her trainer and exercise, really concerned because she wants to get pregnant. And I tried to explain to her, listen, you don’t have a femoral hernia, so that’s good. You have an inguinal hernia and you should have your surgery when you’re ready, both physically and psychologically, mentally ready to undergo surgery. It is surgery. I don’t want to operate on you

(17:12):

if you are coming into surgery very unsure and unhappy and anxious and thinking everything bad is going to happen. Well, what she said is actually the reason why I’m so nervous is because I went to my medical doctor and I showed some reticence about surgery and I wasn’t really comfortable moving forward yet. And he said, why are you having surgery? You don’t need surgery. Look at me, male, look at me. I have inguinal hernia. I haven’t had surgery on it. Just ignore it. Okay? That threw her into a spiral because now she’s saying, I have a surgeon who told me I have a hernia. I read all these risks of problems with it, but now I have this my own doctor that says, don’t do surgery. Listen, that is an inappropriate statement to say to a patient because what you’re telling her is factually incorrect. You are equating your male inguinal hernia that has no symptoms.

(18:17):

You are asymptomatic with a female young, so older male, asymptomatic inguinal hernia, with a young female with a symptomatic inguinal hernia, not the same. The fact that you’re equating, it just shows that you have no idea about the biology of hernias and or nor would the guidelines show. So as a female, you cannot be encouraged to do watchful waiting, especially unless you’ve had a femoral hernia ruled out. There is no evidence to show watchful waiting is safe for females. There’s also no evidence to show that watchful waiting is safe for females. If they don’t have femoral hernia in men, they typically don’t get femoral hernias. So watchful waiting has been considered safe based on two major clinical trials, one of which follow patients up to 10 years. However, to equate that with women, especially young women, especially young women that are at risk for femoral hernias, especially young women that are prone to femoral hernias and have symptoms in their hernias is completely wrong because that male is a male older asymptomatic with an inguinal hernia that is watchful waiting is safe with those patients. It is inappropriate to equate his situation with his female patient situation. So I was kind of unhappy to hear that her medical doctor made these comments and it’s just not cool to scare your patient. And then now your patient inaccurately believes that she should not have surgery and is even more scared of surgery now than she was before.

(20:14):

All right, so how do you know that you have any hernias? Oh, here’s a good question. Can you explain why thin people are more likely to have pain after open hernia surgery and is one centimeter of subcutaneous fat adequate to prevent increased pain? So the data on thin people having more pain after open hernia surgery is specifically for open hernia surgery with mesh it, it’s not necessarily with non mesh hernia repairs. So thin people who have open hernia surgery with mesh will have mesh on top of their muscle and on top of the nerves without much fat to buffer the inflammation from the mesh and without much fat to prevent you from feeling the mesh from the skin area and without much fat to buffer the feeling of the mesh itself underneath the skin. So that’s why I believe that can happen. Is one centimeter of subcutaneous fat adequate to prevent increased pain?

(21:23):

We don’t know. There’s never been any study on actual BMI or even fatty tissues, but we do know the fatter you are, the less pain you have with the, sorry, open mesh based repair because the mesh is on top of the muscle and the next layer is a very thin fascia and then fat and skin. So if you don’t have much fat, all you have is skin thin layer of fascia, then muscle then mesh, then you’re going to feel the mesh from the outside. You can see the mesh. Sometimes you can see the sutures even and the knot of the sutures. So that’s kind of why.

(22:02):

So I would say anyone who has a bulging in any area should be ruled out for a hernia. Any weird abdominal pain that you have or groin pain or pelvic pain, you should be ruled out for a hernia. And for example, I saw a patient who, oh, let me add additional symptoms to a hernia besides possibly bulging and pain include nausea, bloating, pain that radiates to your back in the groin. It would be increase in urinary frequency, pelvic floor pain, pain with sitting, bending, coughing, reading, pain down to your inner thigh into the vagina and females into the testicle in males, pain with sexual intercourse and females pain with any type of sexual function in males.

(23:04):

Pain that gets better when you’re lying flat, worse when you’re standing in upright or activity based and so on. So in those types of situations, you should be ruled out for a hernia. It doesn’t mean you need to have surgery. It’s just good to know why do you have the pain? Is it treatable? Because all hernia pain is treatable with surgery and there are other reasons for pain. So you got to make sure what your diagnosis is and then at least now that you have a diagnosis, you can come up with a plan of care that is considered safe and appropriate that may or may not be surgical. I had a patient who went to the ER twice within six months each time vomiting and had pain and swelling, AKA bulging from a hernia both times, each time the doctors, I’m not even sure if they examined her because on my exam she had serious known like a firm, I could feel like a ball, kind of like those jaw breakers, kind of the size of a large jaw breaker or a medium sized jaw breaker.

(24:13):

But she had a CAT scan, it was misread as normal and then she had a second CAT scan six months later also misread as normal, normal. And she actually had five hernias. 1, 2, 3, 4, 5. I reviewed her pain, two of the hernias in the groin, she had no pain from two of the other hernias she actually had pain from is where she pointed her pain to be from and is why she went to the emergency room. So it’s very common for these hernias to get missed on imaging. So just because you have imaging that’s normal doesn’t necessarily mean you don’t have a hernia. Another patient same day came in, also had imaging where he was told it was normal, it wasn’t, it was a hernia. He went and saw a surgeon. The surgeon said you don’t have a hernia. Imaging was normal and he kind of felt around but didn’t feel a hernia. And of course he had a hernia, so it was small. Granted it was small, but I knew he had a hernia just by his symptoms. Pain was sitting and bending fullness in the area that radius down into his inner thigh better when he’s lying flat or not as active, difficult getting in and out of it a car. The story is what’s important. I always tell you guys it’s the story and then secondarily it’s the physical exam and then the imaging will help support the story and the physical exam findings.

(25:57):

It’s even worse for women because the women have all these gynecologic organs and it’s all like, oh, it’s your endometriosis. That’s why you have pain with your periods Not true. 25% of women with hernias will have worse pain during the periods. Oh, it’s your ovarian cyst that ruptured. Oh, it must be your fibroids. None of those cause radiating groin pain or specifically with hernias, activity related groin pain. So the fact that gynecologists urologists don’t know enough is really disturbing to me and I’m going to be spending a lot of time this year hopefully reaching out to that population to get them to understand. I got a call today from a urologist telling me that a patient has pelvic floor dysfunction. I said hernias can give pelvic floor dysfunction and pelvic floor spasm. He’s like, oh, really? Okay, I didn’t know that. It’s true. Most doctors do not know that, but the patients that have pelvic floor dysfunction will come with groin pain, but also your other pelvic floor problems.

(27:10):

So pain with urination, urinary frequency where they’re urinating a lot. I always ask if how many times they go to the bathroom at night. Often it’s more than twice and that would be abnormal, possibly pain in the rectum with a bowel movement, pain with sexual intercourse, vaginally, and then also pain with orgasm and in men, pain with ejaculation. So these are all symptoms of pelvic floor dysfunction or chronic pelvic floor pain and spasm due to chronic pelvic pain. But really what it’s due to is an inguinal hernia. And the inguinal hernia is usually small. It gives pelvic floor spasm and then they get pains.

(27:56):

What’s interesting is I gave you the data, but really there’s a good group of doctors including general surgeons including medical doctors, including gynecologists that don’t believe that women can get groin hernias. I was first introduced to that when I had my second job, the first job, different job, my second job, I was interacting a lot with a different specialist and one reason why I gave grand rounds at our OB GYN department was because I would get patients who would come to me and say, yeah, I went to some gynecologist and I asked also about a hernia because I listened to your hernia talk podcast or I listened to, I watched, I read an article that you wrote and they said, oh no, women don’t get hernias. And at that time, actually, I had the New York Times article that interviewed me and did this whole session about hernias and women and how it could be their silent pain diagnosis and the patient would physically take the New York Times article to their gynecologist let’s say, or their medical doctor and say, read this article.

(29:23):

This is what I have, these are what the symptoms that I have. And they’ll be like, no, that’s not medical literature. It’s quack stuff, it’s quackery. So it’s hard to change people. It’s hard to convince them about your experience as a surgeon to try and teach them. But to be fair, I did give the grand rounds, this is many, many years ago. I’m going to say it was 2000 and somewhere 2009, 2010 maybe. But I gave a grand rounds, which is like a lecture series at the department, obstetrics and gynecology at my hospital. And I explained how women are different in the type of symptoms they have and they can present with all these symptoms that are not consistent with what you hear from a men. So the women are more likely to have no bulging but still have pain in the groin. They’re more likely than men to have radiating pain such as into their vagina, their inner thigh or around their lower back. Didn’t know any of this. And I was bombarded after I was done with the lecture, I was bombarded with surgeons that came up to me and said, I’ve seen maybe three other patients like this in my office this week alone. And show was good because I kind of taught them to consider hernia for these women and I felt like I did good with that lecture. That was a very worthwhile lecture to do. So that was good. I’m glad I did that.

(31:09):

All right, so we talked about the prevalence of hernias based on your gender and the types of hernias. We talked about watchful waiting, whether it’s appropriate or not. We didn’t talk about watchful waiting for the umbilical hernias. That is also considered safe if it’s small and they have no symptoms. The larger ones or the ones that have symptoms we should repair and women if they are pregnant, want to be pregnant at risk for being pregnant. We prefer not to fix those hernias until after they’re done with pregnancy. Usually within three or more, usually after three or more months after they’re done with pregnancy or breastfeeding, whichever one is longest. Why is that? Because both with pregnancy and with breastfeeding, your progesterone levels are really high and those prevent you from getting your muscle strength back. You kind of have a floppy belly still and you want to have your surgery with as much of a normal abdominal wall as possible.

(32:26):

That’s why I strongly recommend against gynecologists recommending or providing umbilical hernia repairs at the same time as a c-section because your belly is very floppy and everyone that I’ve seen do that has had a recurrence, so it’s not right. Okay, and then we talked about symptoms and watchful waiting. So what we did talk about was prevention. So prevention of hernias is a big favorite topic of mine I try and talk about with almost every single patient that I see because getting rid of risk factors that you can control for hernias will a improve your current hernia status. And if you ever have a surgery in the future, then that will also reduce your risk of hernia recurrence. So genetics you can’t do anything about. That’s a major risk factor for hernias is genetics. There’s not much you can do with that. So it’s best to just let it go and it is what it is.

(33:37):

But things that are correctable or constipation, chronic cough, weight gain, nicotine use, these are all factors and good glucose control. These are all factors that can contribute to hernias getting worse. And also if you have a hernia repair, these are all factors that would address reduce, will significantly increase recurrence of your hernia unless they’re treated early. So I always say treat that chronic cough. If you have covid and you’re coughing, do treat the cough, don’t ignore it. If you’re straining to have a bowel movement, take whatever medication over the counter or change your diet as necessary to control and treat that constipation do not gain weight. In fact, if you exercise and you lose weight, you may notice that your bulging will get smaller and your hernia will be less symptomatic and you’ll have a better lifestyle. In addition, nicotine use disrupt your collagen. People with hernia problems already have a disrupted collagen, so it may make you more likely to have a progression of your hernia faster.

(34:44):

And also if you have surgery, then you will have a poor healing and therefore higher risk of recurrence because your body will not lay down good, healthy, strong scar tissue if you’re a nicotine user. Here’s some more questions. I don’t want to ignore you guys. This is absolutely why hernia surgery should be its own principal surgery. It truly isn’t just a hernia. It’s so true. It is vastly more complicated surgery than it is made out to be. Still working hard on this. I totally agree with you. We don’t have enough people yet to be hernia specialists, but let me tell you, pretty soon in the United States we’ll be having a formal hernia fellowship separate from other fellowships where all you do is abdominal wall and hernia surgery. And that’s really good because we need people to do better job fixing hernias. Most unfortunately, most of these hernia specialty clinics are not good at a revisional surgery and b inguinal surgery, they like the abdominal wall a lot.

(36:00):

They’ll do all these fancy robotic surgeries, but if it’s a redo or if it’s a chronic pain, a mesh problem or any groin pain, they’re not good at it. So eventually we’ll get there. I’ve always wanted to have my own hernia fellowship, but we have a really great surgical residency program and I don’t want to take the experience away from our surgical residents by having a fellowship, so we’re not ready to do that yet. Do you know if gynecologists or urologists learn about pelvic hernias in women in any of their standard curriculum? I actually asked about that. The answer is no, they do not. So gynecologists pretty much deal with all women’s things. So they do a little bit of breast, but a lot of pelvis. And the pelvis includes a uterus, ovaries, round ligament, vagina, labia. Those organs, they know a little bit about the pelvic floor and no one teaches ’em anything about hernias.

(37:05):

It’s not part of their curriculum. They’re not taught that women can get hernias. Many, many, many gynecologists do not believe women can get hernias. It’s just something that supposedly is taught to them. I think I asked urologists now, back in the day when I was a resident, there were urologists that did hernia repairs and I thought that’s fine. It’s kind of in the groin area, you’re operating around the spermatic cord and therefore you don’t want to injure the testicles. That’s probably a good thing. And people of my generation urologists know about hernias, many of them perform ular hernias still most of them open, some of them laparoscopic or robotic with mesh. Now, almost all of them are not up to date as to new technology and they’re continuing to do what they did when they were a resident. And so us general surgeons who are hernia specialists typically are more aware of what to do.

(38:10):

So if they were into a problem, they usually refer to me because that’s beyond them. I did ask the urology professors that run the urology residency program specifically if they teach hernias, the answer is no. There’s no requirement by the urology board, our board of urologic surgery, something like that to know anything about hernias. There’s no questions on their exams about hernias. There’s no part of their curriculum that mandates teaching hernias. There may be programs out there because of the type of urologist that’s on their staff and faculty where residents may get exposure to hernia repairs or even learn how to do hernia repairs, but they’re not expected to know anything about hernias in terms of surgical repair in the community once they graduate. So it used to be, but it’s no longer part of the curriculum to teach urology residents about hernias. What are your thoughts on vascular compression, post hernia repair causing things like pelvic congestion? So there is a concept called pelvic congestion syndrome. PCS Pelvic congestion syndrome is one of many diagnoses people should think about when considering chronic pelvic pain, especially in women, it’s caused by a variety of things. Part of it can be because you’ve had surgery and the surgery either compresses the vein or the blood flow or the surgery contributed to narrowing of the vessels causing pelvic congestion. Hernia is not one of those operations.

(40:10):

I’ve never conceptually, I can’t even figure out why you would equate hernias with pelvic congestion syndrome, but there’s no nerves that can be compressed with, I’m sorry, there’s no veins that can be compressed with hernia surgery or even with hernias. The things that can be compressed will be tumors or other growths by the kidneys. Or if you are born in a weird anatomy where your vein is compressed either between the spine and the aorta or behind a renal artery, can obesity increase the risk of mesh complications? For example, pain infection? Absolutely. That’s a very good question. So yes, obesity is correlated with higher risk of tearing of the muscle from hernias, higher risk of recurrence significantly, and also higher risk of surgical site infections and therefore mesh infections. Do you call it a hernia if it’s a bulge caused by nerve denervation? But these tissues are not poking through the muscles?

(41:17):

No. So there is something called denervation injury that can occur for a variety of reasons. Usually surgical, let’s say you had an operation and they damaged the nerves. We see that with the DIEP, the DIEP flaps, DIEP flaps for breast reconstruction. We see that with kidney removal surgery, a large aortic surgery where they cut through the muscles and therefore the nerves. We see that with lateral approach, lateral approach, spine surgery where they can injure the nerves. That’s a permanent injury. There’s no way that muscle’s going to come back. That muscle is fed by those nerves. So if you injure those nerves, what happens is the muscle will start getting thinner and lose its strength compared to the surrounding muscles. So for example, if you tuck in your belly, that’s really engaging the muscles and there’s strength to it, but if there’s one area that just doesn’t tuck, that’s just a terrible complication of these multiple operations.

(42:30):

Those are not hernias though. There’s actually no hole. You’re going to feel a fullness and a heaviness in the area over time, but there’s no hole and therefore there is no risk of let’s say bowel getting stuck in there. Do physicians who do deep procedures, those are plastic surgeons learn what to do if a nerve is affected causing a bulge. They do not. So they don’t know what to do with it. B, they don’t even know that they’re at risk for it because they’re obviously damaging these nerves as part of identifying and harvesting the vessels for your flap. See, there’s not much literature in the plastic surgery papers to even tell you that it’s a problem. I may have to do that paper. I try to do that for the spine surgeons telling them that, listen, you’re causing nerve injury and hernias both problems with your lateral approach surgeries, and they would not publish my paper.

(43:39):

I would go through journal, a journal and they would say, this is not our problem. This is a general surgeon’s problem, even though they’re causing the problem. I was trying to prevent the problem, not teach you how to fix the problem, but it was a problem. I had understood that you do repairs on women with nerve denervation from deep. That is correct. So I’m not a plastic surgeon. I’m a general surgeon hernia surgery specialist. So in patients who have had denervation injury for whatever reason, so denervation means the nerve has been injured to the muscle and now you have a bulging of the muscles, and that can be for all these different reasons, which like I explained, including after a deep flap, then I do offer a procedure. It’s not a good one to be honest. You’re basically taking that loose muscle and you’re folding it in kind of like you would taking in a jacket to give it a nicer waistline and then you’re using a wide piece of mesh to hold it in place because that muscle is not healthy. It’s an open operation. We use the same scar as your deep flap scar. Sometimes I bring in a plastic surgeon to make sure that that flap is remained healthy.

(45:00):

But yeah, there’s opportunities to make you look and feel better, but it’s not a perfect operation. Those operations have much worse outcomes than any hernia repair that I do because I’m not dealing with unhealthy tissue with hernias, but I am with these denervation injuries. Let’s see. Are there reasons to operate on diastasis rectocele beyond physical appearance? Yes. So there’s multiple reasons to operate on diastasis recti. Just to confirm, a rectus diastasis is a separation of the rectus muscles from each other. It’s often very genetic or it can happen after two or more pregnancies or really huge multiparous like twins and triplets where your belly is really stretched out. So when that happens, you have a thinning of the tissues in between the two muscles. When you get a thinning in that area, you’re prone to hernias. So if you have a hernia within a diastasis, one way to fix that hernia is also to operate on the diastasis.

(46:05):

That’s one option. The second option is you don’t have any hernias, but you have a really wide rectus diastasis that’s giving you constipation because you don’t have good core and back pain because you don’t have a good core. So restoring the core by closing the very huge rectus diastasis is another reason to operate on patients. Those are the top two. All other purposes for diastasis recti repair will be cosmetic. Now I remember a long time ago I did have one lady, she had her liver edge that would catch into the diastasis recite. Very, very uncommon problem. So you have this valley in between the two muscles and unfortunately her liver was of a certain shape where it kept getting caught in this valley along the edge. It wasn’t incarcerated or trapped in any way. It’s just depending on how she bent forward, got out of bed or did whatever the edge would get caught on the lip of the edge of the muscle that was pulled apart. Very, very painful and she required surgery for that.

(47:22):

Let’s see. I do you agree that if you do not have pain in the perineum but only have pain in the groin and pubic area that you do not have Pudendal Neuralgia. Must you have pain in the perineum to make the diagnosis of Pudendal Neuralgia? It’s actually more than that. Pudendal Neuralgia does not give perineal pain. It typically gives clitoral or penile pain and it can give rectal pain or anal pain I should say. So you can get coccygeal pain, anal pain and penile or clitoral pain, but not specifically necessarily the perineum itself. So yes, if you have no pain in the perineum and you have pain in the groin and pubic area, that is not Pudendal Neuralgia. That is true.

(48:28):

I have three more hernias, but I’m afraid to have another hernia surgery because I’ve been in pain for nine years after angulo hernia surgery with mesh. I want to come to Minnesota to do, okay, I want you to come to Minnesota to do surgery on me. I mean I would love to. I actually have, I’ve told you this before, I have delusions that I will be able to travel all over the world and do hernia surgery and I just love to travel and every time I travel, there are patients that I know in those areas that could benefit from my operations and at least my consultation and care. But it’s not physically possible to do so. Let’s see. Did I talk about everything you need to know? We talked about prevention, surgical options. The reality is we’re doing much better today than we were before.

(49:16):

In terms of surgical options. We have open laparoscopic, robotic with mesh without mesh and our meshes are a widely variant. So based on all of that, I believe that we’re doing really well with hernia repairs nowadays, definitely better at abdominal wall repairs than before. We can definitely improve more with Ingle repairs than we had before. We are starting to reteach tissue-based repairs. We are hoping to start decrease overuse of meshes and educate our surgeons internationally and nationally about tailoring the care of the patients to their needs. So obese patient needs a heavyweight mesh. Direct hernias need a heavyweight mesh thin patients prefer not to use mesh or use a lighter weight mesh. Women try not to use mesh in the groin or if they need mesh, try and use thinner, a lighter weight mesh. Patients with autoimmune disease, try not to use mesh in them and things like that.

(50:20):

So we’re learning more every year. What I know now is different than what I knew five years ago or even three years ago. Definitely different than what I knew a decade or two ago. We’re always learning, we’re always educating ourselves, we’re going to conferences and so on. So as you know, I’ve been a couple of conferences so far. I still have some more to go. I have got the American College of Surgeons meeting in San Francisco, the American Hernia Society meeting in Chicago, the Mexican College of Surgeons meeting in Acapulco and the Mexican Hernia Society meaning or Association of Mexican Hernia Surgeons in, no, I don’t have that this year.

(51:07):

Oh, the International Hernia Collaboration meeting in Meida. I was invited to the Swiss hernia days in Switzerland, but I just couldn’t fit it in my calendar with everything else going on. And next year I hope to be invited to the European Hernia Society meeting in Paris and I lac my French. I’m a big Franco file, so I’m excited about that. So we’ll see how it goes. Like I said, I love to travel. I do a lot of it for these meetings and maybe one day I’ll be able to travel all around the world to do hernias. It’s just not possible currently. And that’s too sad because I would love to do it. So I’ve got some really cool articles coming out. Pretty soon I’m going to write an article about National Hernia Awareness Week. I already turned that in hopefully that get published, but I have another one that I’m preparing on autoimmune disorders and women and how to address them in the face of a hernia.

(52:11):

So I’m really excited about that. It’s going to be a fun rest of the year and I really appreciate all of you guys who follow me on Hernia, Talk, Live and on social media because it’s going to be kind of a fun rest of the year doing a lot and got a lot of good researchers out. We did get our paper accepted, I think it’s our round ligament survey about how to handle the round ligament in women. And we’ve got a couple more papers coming up. So as I get them accepted and going to different meetings to talk about them, I will continue to update you all. I feel like you do enjoy that part.

(52:59):

You are beloved by many. Thank you so much. I appreciate you. Although you’re anonymous, I accept anonymous compliments. Thank you. What are attacks made of? Can you have MRI with hernia attacks? Depends on, so yes, all attacks are MRI compatible. The metal attacks are titanium and therefore you can have an MRI. The plastic attacks are usually polypropylene based or PDS PolyOne based because they’re absorbable and those are basically plastic. So that’s okay to have MRI if you’ve had a attacks. I’ve never realized how hard it is to find a specialist to fix a peroneal hernia with colon in the space. Why is it so challenging to have colon in the space? I’m trying to find a doctor I know. Well, I do that surgery as you know because discussed this before. You are the greatest. So thankful for your care. I appreciate you. Thank you for that.

(54:04):

So peroneal hernias are kind of those hernias that no one wants to touch because they’ve never been trained in it. So colorectal surgeons who deal with colon surgery do not know how to do peroneal hernias typically because I’ve called them to help out and they’re like, we send them to you to tophi. And then gynecologists don’t do that surgery even though they know about stuff in their perineum urologists who deal with perineal hernias in the midline such as uterine prolapse, they do not do the hernias when it’s toic suicide, which are the peroneal hernias. I do those. So there’s a handful of general surgeons who know how to do it. It’s very uncommon hernia to begin with. And so even those of us that do it don’t do that. Many of those I do maybe one or two a year, but that’s kind of a large number compared to most general surgeons who do zero.

(55:03):

So, well, I’m sorry, let me rephrase that. Do zero in their lifetime in their career. So I enjoy doing it. I think it’s fun. It’s not that difficult to do it. You just have to know your anatomy. It is a risky operation. You just have to know your anatomy. But yeah, it’s really hard. Please do fight to get me. It says I’m still fighting to get you. Please do. I’m happy to take care of you. I love doing these operations. I think it will really help you very much. And definitely if you can figure out a way to fight the dam insurance companies and get them to approve an actual specialist and fix your specialty hernia, that would be ideal. Otherwise, otherwise it’s just a waste of time and resources to keep bouncing from one doctor to another. And it’s a waste of time and resources for the insurance company too. Why should you pay for all these failed operations and repeat images and multiple specialists when you can just send them to the specialist that can do the operation and have them take care of it all themselves?

(56:18):

That’s why I never understood is why put the patient through the rigamarole. I think sometimes, and it’s very cynical of me to say this, but it may be true. I think sometimes the insurance companies are just, hope you just go away. You change insurances or you just give up and just think, I’m just going to have to live with this on my own and save them money from, prevent them from having to send you to a specialist they would have to actually pay for. So the Affordable Care Act mandates that if an insurance does not have in-network, a doctor who can meet your needs, they must be able to offer you care. You’re paying for the health insurance. They can’t see, oh, we only offer health insurance for these things. That’s not cool. So they have to be able to offer it to you. So if that means traveling miles and miles and hundreds of miles away or seeing a doctor that isn’t in the network of the insurance, so be it.

(57:27):

But most insurance companies don’t want you to know that. Number one, because that empowers you. It also may be higher charges and higher cost to them. And that was not the spirit of or the letter of the law when it comes to the Affordable Care Act. And so as patient, you should fight to get the best care you can. And if you can show that there is no good specialist or no surgeon nearby and you have to travel, then your insurance will have to agree to make some type of contract with an outside physician or surgeon to actually make it happen and get it done. So on that note, I wanted to just thank everyone. It’s been a pleasure as always. You’ve been great. Don’t forget, go to my YouTube channel at Hernia doc and subscribe or go to my, if you like podcast, go to listen to Hernia Talk Live on any place you’d like to listen to podcasts.

(58:31):

And if you could just leave me a review, that would be great because then more people will understand where it’s coming from that will understand that they can go see this podcast. And if you enjoy more medical stuff, you can go to my Twitter page at Hernia doc on X, or if you prefer fun and funny stuff, that’s all of my Instagram at Hernia doc. And then the Facebook page has turned into more of a serious one where it’s not as funny as Instagram. But either way, I’m available to you. Thanks everyone. See you next week. Am I teaching next week? No, I think that’s the following week. I’ll see you next week and thanks everyone. Till later. Bye.