182. Totally ExtraPeritoneal (TEP) Hernia Repair

This week, the topic of discussion was:
-Inguinal Hernia
-TEP
-TAPP
-Laparoscopic Repair
-Robotic Repair
-Mesh
-Recurrent Hernia
-Prostatectomy
-Cystectomy
-Chronic Pain
-Recurrent Hernias

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.

Our Guest Panelist is Dr. Prashanth Sreeramoju, Hernia surgeon at Montefiore Medical Center in Bronx, New York 

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

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Transcript

Dr. Shirin Towfigh (00:00:10):

Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live, our weekly session. My name is Dr. Shirin Towfigh. I am your hernia and laparoscopic surgery specialist. You can join me for this podcast. Many of you’re here as a Facebook Live or via Zoom, but know that you can also follow me on Twitter or Instagram at hernia doc. This episode and all prior episodes will be available for you to watch and share and subscribe to on my YouTube channel at herniadoc. Or if you’re like me and you love listening to podcasts, we are also a podcast. Just find us at Hernia Talk Live. So I’m super excited because we have a new guest today. I love it when I have guests. Dr. Prashanth Sreeramoju is a hernia surgeon at Montefiore Hospital. He’s a general surgeon like me with a passion for hernias. You can find him on Twitter at Prashanth two. And we were just chatting before this episode. Welcome Prashanth.

Dr. Prashanth Sreeramoju (00:01:14):

Thank you Shirin. It’s a pleasure too and an honor to be on your podcast.

Dr. Shirin Towfigh (00:01:19):

Thanks so much. And again, you’re like some of our previous, a lot of my guests, they’re on the east coast, so while I’m here, it’s still sunny outside, 4:30 PM it’s stuffy well past your work hours, 7:30 PM in New York. So I do appreciate the time that you’re affording us and my audience.

Dr. Prashanth Sreeramoju (00:01:40):

Thank you. I’m happy to be here.

Dr. Shirin Towfigh (00:01:42):

Thank you. So we had actually quite a bit of questions for today’s session. We thought I saw one of your talks. It was really, really high quality and good. I think it was at the AHS or maybe SAGES, I’m not sure. It was about TEP, totally extra peritoneal repairs and you just did such a great beautiful dissection that said he would be a great expert to bring on. So I was hoping to talk mostly about TEP and for those of you who watch me regularly, you already know what a TEP is, but there’s TEP and there’s TAPP and that’s two distinct types of operations we can do typically laparoscopically or robotically, but also it can have open extra peritoneal repairs. So maybe Prashanth, if you can give us a little bit of a, since our audience is mostly patients, a little bit of a insight into what is it we’re even talking about.

Dr. Prashanth Sreeramoju (00:02:50):

Okay, so for the inguinal groin hernia repairs, just try to be as much as talking layman terms as much as possible so that everyone can understand. For groin hernias there are different ways of approaching the inguinal repairs, whether it could be putting the mesh above the muscle or putting the mesh below the muscle. That’s when we talk about TEP or TAPP, we are talking mostly about laparoscopic or robotic surgery. So for TEPs laparoscopic surgery, we put the mesh below the muscle about the aligning of the belly called peritoneum. So we put the mesh above it so we stay completely outside the belly so that the mesh will lay in where the muscle weakness is. So it goes exactly where it’s supposed to go.

Dr. Shirin Towfigh (00:03:53):

And the reason why we, first of all, just to clarify, all TEP and TAPP pretty much all, although there’s some exceptions, are mesh based repairs. And the reason why we make the distinction is how you approach the area where you will be placing the mesh.

Dr. Prashanth Sreeramoju (00:04:11):

That’s correct. That’s correct. So all the approaches we are talking about is mostly mesh based repairs. So you want to know where the mesh one should go visit it about the muscle or below the muscle. It’s all depends on your surgeon skill level and the patient and your type of patient you have. There are many factors involved why one would choose one over the other.

Dr. Shirin Towfigh (00:04:40):

And it used to be well before my training time that when they developed mesh and people had hernias in the abdominal wall, they would just put mesh to cover the defect and the bowel would touch it. And we learned pretty quickly that surprisingly a lot of people actually did okay with it, but in general it was not a good idea to put mesh directly against bowel, especially with no barrier. And the best barrier is your own body’s tissue. So the peritoneum is one of those and then that’s why the TEP and TAPP kind of differentiates how you access that peritoneum to move it out of the way, put the mesh and then close the peritoneum or how the peritoneum be a barrier layer between your mesh and the intestines. That’s the main reason why we do TEP or TAPP repairs.

Dr. Prashanth Sreeramoju (00:05:38):

That’s correct. I mean you say that interestingly because I was looking into literature, the history of how the TAPP started out when they started out repairing the in honeys, they started putting the mesh inside the belly. Of course they are coated meshes, but to protect the intestines, it’s quoted to protect the intestines, but still they have a very high complications just slapping the mesh in the belly have a higher rate of recurrences and complications and people try to find new ways to repair so to decrease the amount of complications. And that’s how the TEP or TAPP came into place.

Dr. Shirin Towfigh (00:06:19):

Yeah, intraperitoneal mesh was considered the standard for early laparoscopic hernia repairs for the abdominal wall and the inguinal hernia. Therefore were like, oh, we can do the same thing for inguinal. They found maybe not a good idea, but you’re absolutely right. It’s good to know the history. I gave a talk at SAGES a couple years ago about intraperitoneal only mesh and I felt like people didn’t know the history, why we do it, what’s good and what’s bad about it. And I dug through all that historical work with some of the earlier work with Ed Felix and then before that with, I’m blanking on his name, but an earlier surgeon and they actually have papers where they kind of discussed the history of how they went from Intraperitoneal onlay mesh to extra peritoneal mesh and why that was better. And

Dr. Prashanth Sreeramoju (00:07:15):

I know for me, I think it’s interesting because I feel like for the same intraperitoneal repair with the protected coating works pretty much better for the abdominal wall in the umbilical hernia or any kind of hernia. It’s pretty much the most commonly done procedure across the world perhaps. But it doesn’t work the same for the groin hernias because I think it’s maybe because of the, it’s pelvis, it’s more like a 3D three dimensional. It’s not too a dimensional, it’s more three dimensional. Your belly, your pelvic wall turns in your lateral wall. Your anterior wall. So

Dr. Shirin Towfigh (00:07:59):

Like a salad bowl. I call it a salad bowl.

Dr. Prashanth Sreeramoju (00:08:01):

Exactly. So it’s very difficult to put a mesh in a three three-dimensional intraabdominal because there are so many ways things can creep back in above the mesh.

Dr. Shirin Towfigh (00:08:13):

That’s true, that’s true. So I have patients that ask me, my patients are quite educated when they come to see me. So even this week they would say, are you doing this? Is this a tap angle hernia pair or a tap? And many years ago people would never ask me that. So laparoscopically, there’s tap and tap. Can you maybe tell me why you like to dot or tap or what are your thoughts about, do you have a bias for tap on tap for inal hernias?

Dr. Prashanth Sreeramoju (00:08:46):

For inguinal hernia, when I do laparoscopically I love to do them by TEP, by TPS rather than TAPP. I’m mostly biased because you stay completely above the abdominal cavity so there’s less risk for injury to the intestines or any other structures inside the belly When you’re doing a TAPP repair, like a transabdominal preperitoneal repair, that’s what it stands for. You try to get inside the belly first, then take in aligning the peritoneum and try to put the mesh in. But when you’re doing the extra peritoneal total extra peritoneal approach, you try to stay completely above that layer, don’t get into the belly at all. So it’s a lot more better repair in terms for many surgeons there is a big steep learning curve. But I think once you gain that, you know where you are. It could be claustrophobic initially when you’re learning because you’re in a contained space and trying to develop the planes. But I think once you get used to it, I think it’s a much more better repair than the tap repairs.

Dr. Shirin Towfigh (00:10:00):

I love that you say that because I’m also a big TEP fan. TEP think it’s beautiful. It’s a clean operation. You’re never inside the abdomen, you never see the intestines. I mean you can choose to but it’s not part of the repair. And even if there’s a situation where I have to go intraabdominal, let’s say there’s bowel I need to reduce or something, I still like to convert to TEP and not have to just do a TAPP repair. But you’re right. When I was trained in residency, the main surgeon who was doing TAPP or laparoscopic inguinal hernia repairs was this community surgeon. None of the academic surgeons were doing it and we learned from him and he was doing TEP. And to this day my approach and technique towards is very, very similar to how he taught us. And that was shoot 2000, is that right? 22 years ago. 22 years ago. Probably 25 years ago when he first taught me. But it was so new to me when people said, oh, TEP is very difficult, it has a high steep learning curve, we like to do TAPP. And I was thinking, I think tap is difficult. You have to not only take down that flap but you have to sew it back in. I thought the sewing in was just an unnecessary extra step that was more difficult. What’s your thought about that?

Dr. Prashanth Sreeramoju (00:11:31):

I mean you’re absolutely right about it. I mean the total extraperitoneal approach TEP, I think it’s just beautiful repair. You can stay completely within the space, reduce all the structures, and the biggest advantage for TEP is to, you can just lay the mesh in without any fixation. Majority of the surgeons do it compared TAPP repairs, a lot of surgeons try to sew it in. But TEPs, you just lay the mesh in and it works just lacing properly and you can see while you are taking out the CO2 deflating that space and you can see that mesh is laying nice and flat again is the abdominal wall muscle. I think that’s just a beautiful repair. And I mean it’s interesting you say you learned this 20-25 years ago, but it’s still we are striving in terms of how we do it more safely and better. That is great. As you mentioned about Dr. Felix and a few other surgeons, talk about the 10 commandments of hernia repair for groin hernia as so that we can be safe, you can decrease the as many complicated complications, any complications actually.

Dr. Shirin Towfigh (00:12:51):

Yeah, it’s very true. Very true. And when you teach your residents, do you have any problems teaching them TEP? Are they confused with the anatomy?

Dr. Prashanth Sreeramoju (00:13:00):

I think most of the times they are a little bit get claustrophobic. That’s what the best word I could think of our TEPs because the anatomy is completely looking different compared to the open approach because we are behind the muscle. You see you have a different way of it, but once they get used to the dissection, I feel like it’s a better residents can learn a lot faster TEPs than TAPPs because you have to peel down the thin one cell layer peritoneum. It’s challenging for a lot of residents to teach.

Dr. Shirin Towfigh (00:13:36):

Yeah, yeah, no, I agree. I agree. And then so of course now there’s the robotic technique and a lot of people are moving towards robotic surgery for inguinal hernias. People who weren’t comfortable with the laparoscopic inguinal hernia approach are now more comfortable doing inguinal hernias robotically, which is a good thing in that they’re offering now minimally invasive inguinal hernia surgery, whereas before they weren’t, they would opt to do open because laparoscopic was so difficult to master. But typically robotic surgery is TAPP, right?

Dr. Prashanth Sreeramoju (00:14:16):

That’s correct because just because robotic gives an extra, it’s more manual in term it can navigate yourself well transabdominally for robotic and also for robotic instruments to work on the total extra peritoneal approach. It’s a little bit, I think most of the times you end up doing something called ETEP, like ETEP, like enhanced view for total extra paternal approach, which she can do, but majority of the robotic groin hernia are done transabdominal peritoneal repairs.

Dr. Shirin Towfigh (00:14:50):

Yes. A question, what are the complications of a TEP procedure number one, and what risk factors predict the possibility of getting these complications? So what do you tell your patients about the risk of a TEP versus other approaches

Dr. Prashanth Sreeramoju (00:15:07):

For other approaches? Most of the time the comparison for the open repairs TEP repairs are in my hands it’s a lot better because you hardly see any nerves which you want to up and the mesh won’t go against the nerve because the whole purpose of hernia repair with mesh is the mesh try to create this scar plate and we don’t want to now get trapped in that scar plate and cause chronic pain. I think that’s one thing and a lot of my patients, when it get the minimally invasive surgery TEP repairs, they recover faster. Their early postoperative pain is much better than the open surgery repairs.

Dr. Shirin Towfigh (00:15:55):

Yes, true.

Dr. Prashanth Sreeramoju (00:15:57):

And the complications in terms apart from bleeding and hematomas? It’s pretty much the same for both surgeries. I mean I have my own published paper about groin hernia repairs. I have to say that, I mean it all comes down to there are three different repairs. We have a TAPP tap repair, you have TEP repairs and you have open repairs. They’re all mesh based repairs. But if you compare all three, I think the majority, most of this, there’s no real difference between all three procedures. However, TEP and TAPP do far better on patients who are morbidly obese who are BMI 35 above 35, the chronic pain and early pain is a lot better than open surgery repairs.

Dr. Shirin Towfigh (00:16:49):

Yeah, yeah, very true. Yeah. There’s a paper out there that I was involved in that looked at open lap and robotic hernia repairs for inguinal open lap and robotic hernia repairs for ventral and they took surgeons and they said, what do you do best? So I said, okay, I think I’m really good at, let’s say I’m going to make this sub laparoscopic inguinals and open ventral. They’re like, okay Towfigh, you only enroll your laparoscopic inguinals and your open ventrals in this study. And some of those surgeons says, I do a really good opening role. Okay, so you surgeon, you only enroll all your patients for the opening and then someone’s like, I like to do robotic or laparoscopic repair, that’s what I’m really good at. And then that surgeon would only enroll in that. So basically they took whatever you did best and enrolled you into that arm of the, and then they say, okay, let’s compare if you have a really good inguinal hernia surgeon, how do they do against a really good laparoscopic surgeon? It’s a great little paper because it kind of proves the point that if you’re a good surgeon at what you do, your outcomes will be good regardless of the technique.

Dr. Prashanth Sreeramoju (00:18:06):

Exactly.

Dr. Shirin Towfigh (00:18:08):

But anatomy is anatomy, right? So there’s nerves that are at risk with open surgery that are not really at risk with laparoscopic.

Dr. Prashanth Sreeramoju (00:18:16):

That’s exactly right. I mean we kind of save a lot of headache. I mean even for the news mean also in terms of the budding surgeons, the new surgeons who are coming up, they’re getting a lot more training. MIS approaches laparoscopic ts or taps compared to open surgeries. I mean I personally feel my residents are a lot more comfortable doing teps or taps than open surgeries because as my mentors are kind of retiring, I mean I’m right at the cusp. I had an advantage of getting open and laparoscopic skills. But the current residents, not many people do open repairs anymore. Unfortunately there are very few.

Dr. Shirin Towfigh (00:19:06):

Well I do open mesh and open non mesh repairs, right shoulder ice McVay. And I feel that the chief residents, especially the ones that are going into critical care trauma MIS, the ones that they know they’re going to be taking general surgery call, they all want to start scrubbing in with me towards the end of the year.

Dr. Prashanth Sreeramoju (00:19:27):

That’s correct. They

Dr. Shirin Towfigh (00:19:28):

Want to know how to do a good open inguinal hernia repair because they don’t get to see as much of it. Nowadays

Dr. Prashanth Sreeramoju (00:19:35):

I would say it’s not too far for me to say there’s an open inguinal hernia repairs almost like looking at doing a Whipple for a pancreatic surgeon because very few people do it and very limited number. It’s only certain number of cases.

Dr. Shirin Towfigh (00:19:54):

Yeah, it’s true. So I have patients that come in, they say I want a non mesh repair. Then I ask, and this is like this week, totally healthy guy, small hernia fit, wants to do all his exercise, hiking, gym, et cetera, and male, and he came to me because he was told to do a laparoscopic hernia repair and he wanted to come to me. He knows that I do non mesh repairs too and he was worried about mesh and I said, listen, you’re young, you’re healthy, you’re fit, your hernias are small, you seem to have hernias on both sides. You’re the perfect patient for a laparoscopic inguinal hernia repair and I prefer to do those TEP. Exactly. And he was shocked because he thought I would definitely say, oh no better that you don’t get mesh in you or that you can get mesh reaction. But if you look at all comers tissue repair, non tissue repair mesh, no mesh, low open lap robotic, the laparoscopic repair done well has the shortest recovery. Right? Yes. Best long-term results, lowest recurrence rate and the lowest chronic pain rate.

Dr. Prashanth Sreeramoju (00:21:10):

That’s correct. You’re a little right, because the non mesh repairs are good in certain instances they usually follow very strict criteria like you have to be the skinny person, you’re small hernias and not really highly active people. Then you obviously, but I think the best way you have to understand the pathophysiology of the hernia, especially for the groin hernia, it’s more of a wear and tear of the muscle if not developing a hernia just because of there’s an abnormal defect. I mean in some people if it is an infant pediatrics that’s totally different. They do non, but if in an adult it’s more of a wear and tear problem and your tear in the muscle getting bigger and bigger and when you start sewing the mesh with only with the tissue repair, sometimes you may not get the greatest effect. The best effect you could get is putting a mesh in and a lot of meshes out there right now. If the mesh is placed in a proper location and safely nice and flat, I think it’s the best option any person can get.

Dr. Shirin Towfigh (00:22:22):

I agree. And going back to the question, what are the complications of a TEP procedure? How do you view complications of TEP versus TAPP?

Dr. Prashanth Sreeramoju (00:22:32):

Most of the complications for the TEP vs. TAPP is mostly comes from the potential injury, visceral injury like injuries to the intestines inside the belly when you’re entering the belly itself. I think that’s the way you get into and sometimes if you don’t, so the flap, the inner line in the peritoneal flap, sometimes the tissue your intestines can creep inside and then cause mar bowel obstructions and all.

Dr. Shirin Towfigh (00:23:00):

Yeah, that’s the internal hernia of the flap.

Dr. Prashanth Sreeramoju (00:23:03):

Exactly. Internal hernia,

Dr. Shirin Towfigh (00:23:04):

That’s definitely a complication that you see with TAPP. Sorry, you see with tap TAPP and unless you have a accidental hole in your TEP repair, you should not see that at all.

Dr. Prashanth Sreeramoju (00:23:16):

Exactly. And also you are not making any cuts on the peritoneum so it decreases the chance of any additions inside the abdominal cavity. So that’s one of the advantage for the TEP. Yeah,

Dr. Shirin Towfigh (00:23:31):

Well one disadvantage is you don’t really see what’s going on in the abdomen.

Dr. Prashanth Sreeramoju (00:23:36):

That’s true, that’s true. Also, you don’t really know sometimes if you’re not careful enough how you getting the flap down, you’re doing a TEP because you’re completely above all the small intestines and colon. If you’re not careful enough in terms of how you’re using your energy devices and all, you have to be very careful. It’s not definitely, it’s not for everyone, but if you can do it, I think that you can get the very good results with it. True. I mean just to give my own experience, I mean it’d be interesting for you to know. So I had a patient one time came into the emergency room with a large bowel obstruction with basically his colon, his sig, his colon got incarcerated in the groin in the left groin,

Dr. Shirin Towfigh (00:24:30):

Left side,

Dr. Prashanth Sreeramoju (00:24:31):

Left side and came in with large very distended abdomen. So all his intestines are dilated, they’re wide and big. So first I want to see how the intestines are, so I went in transabdominal to look inside to see how the intestine is, make sure that there’s nothing is dead, they’re viable. So once I reduced, once they’re viable, once I made sure and once I reduce all the intestines are viable now I don’t have any space to repair. I thought I will just continue to do a tap repair but I don’t not able to do it because I don’t have any space to work laparoscopically. Yes. You know what I did? I ended up converting to TEP, like total extra peritoneal approach. Oh, I

Dr. Shirin Towfigh (00:25:16):

Do that all the time. Absolutely,

Dr. Prashanth Sreeramoju (00:25:18):

Exactly. You put the balloon and just create the space. Now you have a c02 two which is keeping the space open for yourself and you can put good mesh repair and that patient had bilateral hernia, I end up fixing both hernias at the same time and the patient did great. I think that’s one of the biggest advantage.

Dr. Shirin Towfigh (00:25:38):

Yeah, that’s what I was saying is that even if I have to look inside, let’s say to reduce bowel, I would go back to using TEP again, but you have to close that peritoneum at the belly button, otherwise you lose some gas.

Dr. Prashanth Sreeramoju (00:25:51):

That’s correct. That’s

Dr. Shirin Towfigh (00:25:52):

Right. Yeah. Yeah. I think it’s perfect.

Dr. Prashanth Sreeramoju (00:25:55):

I know is quite interesting how you can use different planes to help yourself for the safety of the patient and also for better outcomes.

Dr. Shirin Towfigh (00:26:07):

Now one issue with TEP is if someone’s either had surgery in that space already, like a prostatectomy especially specifically open prostatectomy or if they’ve had, well, did you read the letter by David Chen that he shared his TEP complication?

Dr. Prashanth Sreeramoju (00:26:32):

Yes, yes. Open Prostatectomies anyone who has suprapubic catheter placement, anyone who has the bladder cystectomies and even more painful or the lymph node groin dissection for deep inguinal dissection, you lose that plane. In this scenario I would try to go TAPP approach like I do them mostly robotic and at the same time if the patient is not obese, I would just go open. Listen, at the end of the day you need to have all the tools in your hand so that you can do a safe and safe procedure for the patients and that’s what it matters. Being safe is a

Dr. Shirin Towfigh (00:27:21):

Good thing. Well that’s the thing is you have options. Open repair is a perfectly good option, especially in someone who’s had surgery in that area, like you said for bladder surgery, prostate surgery, which is also bladder surgery really and any type of really bad kind of lower pelvic surgery. The letter I’m referring to is this patient I guess had perforate diverticulitis or something in the past and just had the antibiotics and got better, but as a result of the recurrent episodes of diverticulitis, the colon was really scarred in to the peritoneum and then the surgeon went in TAPP to TEP and number one didn’t really know that history and went in and stayed extra peritoneal. So away from the intestines where you don’t see the intestines and did their dissection, did perfectly good surgery and then two or three days after surgery there was stool coming out out of the trocars.

(00:28:28):

So what had happened was in the dissection of the peritoneum pulling everything down, there was an inadvertent pressure pulling, tugging tearing or something of the colon which had been stuck into this area. Unbeknownst to the surgeon, he stayed away from the intestines, whereas if he had gone inside and seen or known the history, maybe this complication wouldn’t have happens. Unclear, but that’s one of the complications with TEP is that you’re not seeing at all what’s happening inside the abdomen, which is fine for most people, but if you’ve had any pelvic surgery it’s not. You got to be more careful.

Dr. Prashanth Sreeramoju (00:29:10):

Absolutely. If you need to know your patients well and sometimes a lot of patients do end up having a CAT scan and having a look at the CAT scan would also help you in terms of assessing the anatomy. Well better as it’s when I was a resident, Shirin, I have to tell you a lot of times hernia, I’ve been ingrained in my brain that hernia is more of a diagnosis. I agree it’s more of a clinical diagnosis, but the hernia surgery evolves so much that I think you need to have more than just history because ultimately we are dealing with anatomy like the muscle musculature of the abdominal

Dr. Shirin Towfigh (00:29:59):

For sure.

Dr. Prashanth Sreeramoju (00:29:59):

And having a CAT scan to tell you what, what I need to be careful of. I think it helps a great length for a surgeon.

Dr. Shirin Towfigh (00:30:10):

Oh absolutely. And it’s so important to read your own CAT scan and not just report because what the surgeon needs to get out of it is different than what the radiologist is telling you necessarily.

Dr. Prashanth Sreeramoju (00:30:21):

I a hundred percent agree with that. As a surgeon you need to know how to, I remember when I was a resident, we are going with my mentor going to the radiologist and sit down with them and talk to them like, oh, let’s review the CAT scan of this patient. That patient, right. Yes. It’s definitely a skill which you’ll need to learn because ultimately you are operating and you have the advantage of seeing the patient and you have the advantage of looking at the CAT scan and you can combine both together and that’s the man. You’ll give you a great opportunity for the patient in terms of outcomes.

Dr. Shirin Towfigh (00:31:01):

So true. Here’s another question. If you perform a unilateral hernia repair with TEP procedure, can you do a repair on the other side if a hernia develops there or can you only enter the TEP space once? That’s a good question.

Dr. Prashanth Sreeramoju (00:31:16):

It’s a very good question to be. I think you should able to still do it because most of the times when you’re doing a TEP on one side you probably two centimeters at the maximum like on the contralateral side of it, a little bit across the midline two centimeters, but you don’t entirely dissect that space. You can definitely go in that space again to fix a hernia.

Dr. Shirin Towfigh (00:31:42):

Absolutely.

Dr. Prashanth Sreeramoju (00:31:46):

The surgeon, if things too murky, you can always do a TEP repair, you go back, go in the abdominal cavity and repair, but I think you can still do it for unilaterals for sure. Yeah,

Dr. Shirin Towfigh (00:31:59):

So if you use a balloon that automatically dissects both sides, let’s say there are techniques that can reduce how much of the other side is being addressed, but let’s say for argument’s sake, the whole entire side was also exposed. It’s not that much scar tissue depends on how much time has gone by, but you should be able to access that other side fine.

Dr. Prashanth Sreeramoju (00:32:27):

Yeah, definitely. Even with the balloon dissector, it would probably dissect the space below the muscle, but it won’t entirely dissect the space. So you would still able to navigate yourself to take the hernia sac down to fix the hernia.

Dr. Shirin Towfigh (00:32:44):

Do you prefer the laparoscopic TEP or the robotic TAPP?

Dr. Prashanth Sreeramoju (00:32:48):

I mean I prefer laparoscopic. Me too for majority patients, but having said that, if I have a big inguinalscrotal hernias or morbid obese patients when they have very thick pans, I end up doing more robotic TAPPs on those patients.

Dr. Shirin Towfigh (00:33:07):

I completely agree with you. I agree with that. Let’s see if you have a significant but asymptomatic diastasis recti due to linear weakness, can a TEP procedure be performed without worsening or enlarging the diastasis?

Dr. Prashanth Sreeramoju (00:33:25):

Yeah, I don’t think diastasis would affect any patient, but most of the times for the diastasis, mostly we’re talking about the hernias on the abdominal wall. Not really for the groin hernias though, but just having a diastasis would not make the diastasis worse for the hernia repairs for groin hernias. Yeah,

Dr. Shirin Towfigh (00:33:46):

I’ve heard from some patients and some doctors have told them that it’s their laparoscopic surgery that caused the diastasis and there’s just no evidence for that.

Dr. Prashanth Sreeramoju (00:33:55):

No, definitely not. We are not destroying the abdominal wall. We are just taking the innermost lining and we are not destroying anything at all. Yeah,

Dr. Shirin Towfigh (00:34:04):

Agreed. Here’s another question comparing TEP to TAPP, is the mesh placed in the same tissue plane?

Dr. Prashanth Sreeramoju (00:34:11):

That’s correct. It’ll be placed in the same exact issue. Plane? Yeah, same exact. The line,

Dr. Shirin Towfigh (00:34:16):

Yeah. I just did a robotic TAPP on an incisional hernia in the lower quadrant, left lower quadrant. It was an anterior approach to a spine surgery and they closed the anterior layer but not the deep layers, so she had a bulging where the internal oblique and the transverse abdominis had pulled away, so I went in and did a TAPP. Right. So I basically had to, but I explained to the patient that I started in the abdomen and then I went outside the abdomen and that plane and she was like, well, I don’t understand. Why couldn’t you just stay outside? Right. So what do you think about robotic TEP procedures?

Dr. Prashanth Sreeramoju (00:34:57):

I think robotic TEPs I think is perfectly good. I think there is a learning curve for it for sure. Not many surgeons do it because just because the instruments are still bulkier, you need to have that enhanced view. I don’t think any T regular TEP procedures are done for robotic. I think most of them are EAPs, which is enhanced view, total extra petal approach. We start a little bit higher, but it’s totally doable. I think Dr. Flavio Malcher from NYU has published his first series of robotic TEP repairs on that, so I think it’s doable, but I think because robotic instruments are so in terms you have more wrist motion, all this, so it just makes it a lot more easier to do tap repairs robotically than TEPs.

Dr. Shirin Towfigh (00:35:56):

Yeah, the arms need more space to move around and so your typical TEP, you cannot do robotic, but an ETEP, which it’s basically extended or enhanced where it’s a much wider space, larger space you can consider doing. It’s just not worth the time and effort of it.

Dr. Prashanth Sreeramoju (00:36:17):

I agree on that for sure.

Dr. Shirin Towfigh (00:36:20):

Here’s a question about mesh complications and device complications. What resource database do your practices use to check on problematic mes? I’m aware of a database named device events. This patient I think is from Australia, which is designed in detecting and informing specialists of problematic medical devices. Obviously for mesh procedures to be successful, specialists should be aware of any medical devices that use becoming flagged as problematic. Is this something that you use and if not, what are your views on this being mandatory for all specialists to receive alerts about device problems? The database is at least 10 times larger and much more detailed than the FDA’s mod device. I have not heard of device events,

Dr. Prashanth Sreeramoju (00:37:11):

No. Yes, I agree. From the patient perspective, it’s a big thing. Whenever we say mesh repair, a lot of red flags goes on the patient. I mean, I’m not going to every single patient I talk, Hey, I’m going to do the mesh repair, but I tell them, listen, the standard of care for hernia repair is a mesh repair. That’s a standard no matter what. It’s all depends on how well the mesh placed and where exactly it’s placed. It’s not the mesh is the problem. Having said that, to answer the question, there are definitely databases, which industry does follow FDA. European has a database also. Whenever I did some medical writing for company consulting for basically every single surgical instrument or anything, they have basically post server, post-marketing surveillance data. They look into all the literature, if any. The

Dr. Shirin Towfigh (00:38:16):

Industry has

Dr. Prashanth Sreeramoju (00:38:17):

It, industry has it, and it’s mandated by the FDA and also European Union CC. They have, every country has its own database collection to make sure that they’re doing the right what they’re supposed to do. Unfortunately, they high complications rates for some reason, they’ll pull out, I mean there are certain measures which are pulled out in my surgical industry. It’s not like we are just working in a silo. I think everything single thing will be monitored

Dr. Shirin Towfigh (00:38:51):

Virtually.

(00:38:53):

The problem with MAUDE and some of the FDA based devices is anyone can make a claim and it’s not clear what if a patient has a recurrence? Is that really a device issue or a surgeon technical issue? Their lawyers out there that are suing for hernia recurrence, it’s not clear how they’re going to prove that it’s the device and of course the mesh companies will say, it’s not the device, it’s the surgeon and vice versa. So it’s difficult to know each of those different reports, how vetted they are because I’ve gone through that MAUDE, M-A-U-D-E, that MAUDE database, and there’s a lot of notable reports in there, so it’s hard to differentiate what’s real, what’s not real. I think that’s what’s going to be true for any database that tries to track complications.

Dr. Prashanth Sreeramoju (00:39:55):

That’s true. You are a hundred percent right, but I guess

Dr. Shirin Towfigh (00:39:57):

It’s similar to car crashes, right? If you log every single car crash, is it the driver or was it the faulty brakes? How do you know?

Dr. Prashanth Sreeramoju (00:40:06):

Yes. I mean I think your analogy fits right in for sure, because when you have a complication, is it related mesh or is it because surgeon? I think it’s different. I mean, as I say, the mesh majority of the times, whenever the patients talk to me about, oh, mesh, is it bad? I said, listen, mesh itself is an inert material. It doesn’t cause any bad mesh. They talk about there’s a lot of infection. It’s sterile mesh never get, mesh won’t get infected unless there’s infection spreads to it, but by itself it won’t cause infection, so it’s just a matter of having more awareness. I think that’s important for us. Hernia surgeons. It’s our responsibility to teach, talk to the patients about what to expect and everything.

Dr. Shirin Towfigh (00:41:02):

Yeah. Yeah. Mesh infections are pretty bad complications. You never want a mesh infection that’s just, that destroys a patient’s life for many years.

Dr. Prashanth Sreeramoju (00:41:13):

That’s true. I agree. And on the average, every mesh infection would undergo a patient would undergo at least two, three procedures to clear off the infection.

Dr. Shirin Towfigh (00:41:24):

Yeah. Yeah. It destroys your life for several years. Yeah, absolutely. Okay, next question. After you deflate the space, the end of a tap, can you go back in if the mesh is not lying appropriately or the floor is still floppy?

Dr. Prashanth Sreeramoju (00:41:41):

Oh yeah, absolutely. I think it’s a great question. If you’re not satisfied the way how the mesh laid in, you can inflate that space again and reorient your mesh. As long as you’re still there, you can absolutely reorient it.

Dr. Shirin Towfigh (00:41:58):

Yeah, for sure. For sure. What kind of mesh do you use for your TEP?

Dr. Prashanth Sreeramoju (00:42:03):

My go-to mesh is mostly 3D max mesh and ledge measure. Out of the times, I have a standard way of doing it. Almost all my patients get a large extra large. Very few patients get large mesh. It’s all about having proper mesh overlap. You have to getting down to the basics of hania repair, make sure you have enough overlap, make sure we have good mesh mesh nice and flat and all those things.

Dr. Shirin Towfigh (00:42:33):

Here’s an insightful question. It says that we understand that mesh based repairs may be the standard of care, but once you have a complication, what is the standard of care for that? How do people know about what to do with mesh removals? How do surgeons follow, what standard of care do surgeons follow for mass removal due to complications? From my experience, the standard of care has been, well, it’s unfortunate this happened, but we don’t know what to do and here’s a number to a pain management doctor. Good luck. Good point. Honestly, we do not have a standard of care for how to handle complications after hernia repair,

Dr. Prashanth Sreeramoju (00:43:12):

And there’s

Dr. Shirin Towfigh (00:43:13):

A lot of people out there that require whether it’s a, we do have a standard of care for recurrence, right? We do know what to do with a recurrence. Do you want to review that?

Dr. Prashanth Sreeramoju (00:43:22):

Yes. Yeah, definitely a standard of care for hernia recurrence, so that’s one of the complications of hernia surgery. So if you have a hernia recurrence from an open repair, the best way to fix those repair recurrence is to go posterior repair, which is like TAPP or TEP repairs. But if you have a hernia recurrence from a posterior approach, it depends upon the skillset. Their recommendation is mostly to go anterior approach like open repair or if you’re skillful enough, it depends on who did the surgery. If the mesh was nice, small or it’s mood, then you can go back and I mean there are instances I’ve went back and posterior approach repairs like TAPP, I went back in and looked for a TAPP repair because the mesh basically got folded on its own and clamp shelled and opened up the honey space. Or in some cases the mesh was small for the hernia recurrence. Yes. It’s pretty standard the way how we approach when it comes to the chronic pain. Yes. Then that gets a little bit difficult because every patient is different.

Dr. Shirin Towfigh (00:44:36):

Very true.

Dr. Prashanth Sreeramoju (00:44:37):

I would tell you it’s interesting to get the bottle, your car analogy, if you’re fixing a car, one thing is fixed. You just fix that and that’s it. Because every single carb is made exactly the same exact lens, same thing. But we are here, we are not fixing cars. We’re helping patients and every single person is different. We heal differently. Like I heal differently. If I get a hernia repair by you, I heal differently than by someone else. It’s totally different up. So chronic pain is something which is very subjective in terms of it. Having said that, to answer the question, yes, when it comes to complication of a hernia pain, then we need to figure out whether hernia pain, the chronic pain is related to the nerve pain or is it related to mostly a somatic pain related to the mesh. So sometimes some surgeons use plugs for the open surgery, which I don’t like it.

(00:45:45):

I hate them because I end up removing a lot of them. So if that is a situation once you, for my standard way to make it short, my standard way of approaching these chronic pains is to, I do a pain map first I determine whether it’s a nerve pain versus a nonna pain. If it is a nerve pain, then I send him to, it’s a multimodal multidisciplinary management. You give a trial of gabapentin, Neurontin pain management nerve blocks and see if it improves. If that improves, that means that you’ll have a higher success rate in terms of doing a surgical procedure called neurectomy and potentially also removing the mesh at the same time because at this point you want to deal with what is most bothering for the patient. You need to take care of the pain, not really worry about the hernia recurrence if it hernia comes back, but once you fix the pain, if the hernia comes back later on, yes, we can go back and fix it, but first you need to take care of what is the most imminent problem for the patient. Yeah.

Dr. Shirin Towfigh (00:46:55):

Most patients who have chronic pain after hernia repair do not need their mesh removed.

Dr. Prashanth Sreeramoju (00:46:59):

Yes.

Dr. Shirin Towfigh (00:47:00):

That’s one thing, and most also do not need nerves cut. It’s usually a hernia recurrence or a folding of the mesh or something or a single nerve which may be injured. So in my practice, my practice, it is mostly that. That’s where you kind of have to be the detective to figure out what exactly do they need and what can you just not do and still have the patient do well. So if the mesh is perfectly flat and it’s clearly neuropathic pain, just deal with the nerve. If it’s vice versa, nerves are totally normal. The mesh is folded, don’t touch the nerves, deal with the mesh. So that thing, I feel like some patients, they go to surgeons and the surgeon just wants to do everything. Let’s take all the mesh out and cut all the nerves and that’s not their problem. Let’s say it could just be a recurrence or some surgeons, it’s always nerve pain, right? So they go straight to pain management and they can’t. What bugs me the most is when they have a laparoscopic repair and they get sent to pain management for nerve blocks, there’s no nerve that’s being injured.

(00:48:12):

You can’t technically injure the genital nerve or the lateral femoral continuous nerve. It’s so uncommon. So you have to be really in the wrong space to do that. So we just don’t see that very often and those that are never nerves, that pain management knows how to inject anyway, right? Yes. So that really bugs me, but for the patients to understand that this person’s correct, there is no good algorithm. We have a great book. It’s actually here, let me just show you the sage’s manual of groin pain. It’s a fantastic book. Patients can read it, but it’s not meant for patients, it’s meant for surgeons. I highly recommend it for anyone that does anything related to the groin or inal hernias because it goes through orthopedic gynecologic, chronic mesh pain, nerve pain, everything you can imagine, but it definitely tells you to tailor to the patient.

Dr. Prashanth Sreeramoju (00:49:13):

I agree. I mean you’re a hundred percent right about saying that Not every groin pain is related to the hernia repair. Sometimes I had a patient just mean, it’s interesting you say that. I had a patient with groin hernia repair and with the same groin pain again few years after saying that it could be like, then we are like, oh man, is it related to nerve pain or not? But you have to ask the good history and physical when is the pain? He’s saying mostly pain happens when he’s getting into the car, coming out of the car on hyperextension of his leg. So then you know what? Let’s get an MRI and it shows that sure enough, he has a tear in his muscle, one of the muscle, which makes it when you bring your completely

Dr. Shirin Towfigh (00:50:01):

Unrelated,

Dr. Prashanth Sreeramoju (00:50:02):

Totally unrelated. Exactly. So you have to having a good history and pain mapping, all those things would help in siphon out basically identifying what exactly is the problem. Is it the nerve or

Dr. Shirin Towfigh (00:50:18):

Anything? So true. Here’s another question. When do you use fixation in TEP versus no fixation, and how do you gauge the size to use for mesh in a small patient?

Dr. Prashanth Sreeramoju (00:50:32):

Majority of the, I never use the fixation device for TEP repairs because it’s in the right exact space where I created, it’s not going to move or anything like that. I think some surgeons use fixation mostly for themselves. I personally feel because I mean listen, what

Dr. Shirin Towfigh (00:50:52):

About a really large direct?

Dr. Prashanth Sreeramoju (00:50:54):

Oh, if it is large direct, yes, I definitely did for those thing where you don’t want to even rate the mesh, don’t want to bow out of the abdominal wall, yes, but if it is the only cases, but other majority times I always end up using either large or extra large, I’d never go below large. I think if you’re doing it’s, if you go below large, that means that you did not create good enough space to put the mesh in. That’s my way of looking at it. It’s

Dr. Shirin Towfigh (00:51:25):

Very uncommon for me to use a medium. I have had maybe a handful in my career, really tiny Asian females, super tiny, very petite, small, small built, almost pediatric in size. There’s no benefit to using smaller meshes usually. Next question, how long does it take for a scar plate to form and can that healing be enhanced in any way by the patient, such as with compression underwear?

Dr. Prashanth Sreeramoju (00:51:56):

That’s an interesting question, Sharon. I would say that I think the healing maximum takes up to two months and after that it’s mostly a strengthening After two months, there’s no real healing happening up there. I don’t think the compression would have any affect underwear effect on healing process, healing process, all about your body, how we heal with the mesh and the surgery and no hematomas or fluid collections. It’s all depends on that, but it’s nothing related to the external devices.

Dr. Shirin Towfigh (00:52:32):

Yeah, agreed. Although I’m appreciating more and more the benefit of massaging the area. Yeah, that can help. Next question, are meshes used in robotic repair different than those for laparoscopic meshes?

Dr. Prashanth Sreeramoju (00:52:48):

No, they’re exactly

Dr. Shirin Towfigh (00:52:50):

The same. They’re exactly the

Dr. Prashanth Sreeramoju (00:52:50):

Same.

Dr. Shirin Towfigh (00:52:51):

There are some meshes that are more difficult to place lap for tap, TEP, in my opinion, the program meshes are more difficult to use because you have a smaller space and it tends to stick to everything and some of the meshes are more difficult to put through certain trocars than others, but in general it’s the same.

Dr. Prashanth Sreeramoju (00:53:12):

Yeah, I agree. Shirin mean mean program meshes are the, which has a grips to it. So basically you can, Velcro again is the wall muscle and you don’t have to use a fixation device kind of thing, so it basically gets stick to the area, so it’s good.

Dr. Shirin Towfigh (00:53:31):

Alright. Next question. Assuming proficiency in all hernia repair techniques, what are the factors that influence the choice of technique of a specialized hernia surgeon, especially between TEP and TAPP. Since you and I are both TEP surgeons, like we prefer TEP. When would you go for TAPP?

Dr. Prashanth Sreeramoju (00:53:50):

I would go for TAPP mostly when a patient, as I mentioned earlier, if there’s a big large inguinalscrotal hernia, yes in males or a very big hernias or if there is a patient who has, as you mentioned, a patient who just discussed about diabetic colitis. If there is some very bad history, which you don’t know about, which you need to be careful about, you want to see everything, you want to make sure that you do the safest. Those are the cases, and if the patient is morbidly obese, those are the patients I would go for tap. Otherwise TEP works great in every other patient.

Dr. Shirin Towfigh (00:54:30):

Yeah, I agree. Next question. Is the effort involved in maneuvering the surgical instruments in a more restricted space? The only reason for which TEP is considered more difficult than TAPP,

Dr. Prashanth Sreeramoju (00:54:44):

It’s not really the effort, it’s just the manner about the way, how you place your trocars, your incisions. I mean it’s interesting. There’s huge variance in how we surgeons do TEP. I’ve seen surgeons doing three small holes straight, a straight line in the middle.

Dr. Shirin Towfigh (00:55:03):

That’s how I do it.

Dr. Prashanth Sreeramoju (00:55:04):

Yes, I’ve seen surgeons doing two in the straight line and one a little bit on the control lateral side once they develop that space. So every surgeon has a different way of doing it. Ultimately, you triangulate the instruments so that you can fixate the repair, right? So you triangulate onto your point of surgery if your hernia is in the groin, basically your three instruments in triangulating, which includes the trocar. So to have the best efficiency,

Dr. Shirin Towfigh (00:55:33):

I think why people think TEP is more difficult is the anatomy is more difficult to appreciate and understand. I’ve done so many TEPs to me it’s memorized in me all the different relationships between where the pubic bone is and therefore where a femoral would be and therefore where the epigastric would be and therefore where a direct would be and therefore where indirect would be like, to me, as long as I know where the pubic bone is, I know where everything else is. Anatomically the pelvic anatomy is, it’s like a map. I mean I can be blind and still know where everything is, but I think for a trainee it’s difficult to learn that anatomy. In fact, I remember, I think it was like 10-15 years ago, there was a talk given by I think either Yekel or one of his underlings in the Netherlands and they said that they would make their junior residents scrub in and hold camera for a thousand inguinal hernias before they were allowed to operate.

Dr. Prashanth Sreeramoju (00:56:41):

Wow.

Dr. Shirin Towfigh (00:56:41):

Just to hold camera for a thousand. I’m like, wait a minute, how many hernias are you guys doing? But yeah, it’s because the anatomy is so complicated. Whereas when you do a TEP, sorry, tap TAPP, people tend to be a little bit more comfortable with that anatomy because you can kind of, I don’t know, they’re more familiar with it. It’s easier look to look

Dr. Prashanth Sreeramoju (00:57:07):

At. I tend to agree on that for sure, because when you’re doing a TEP versus TAPP, when they’re doing TAPP, you’re basically, you saw the broader view and you’re trying to peeling it down. That gives you some sense of comfortness for you to, but in general, it’ll be the same anatomy no matter whether you’re doing a TEP or TAPP with TEP or TAPP, it’ll be the same anatomy for the patient because both are posterior repairs, right? Yeah. So it’s just a matter of getting comfortable in that zone or in that box fixing it. Yes, definitely. As you said, you always start with TEPs because that anatomy is always constant, like your bone, your pubic bone, your rectus muscle, everything is pretty much constant. Yeah.

Dr. Shirin Towfigh (00:57:58):

Off topic a little bit, have you been told, let me rephrase, have you seen patients with complications after a TRAM flap or a DIEP flap? DIEP?

Dr. Prashanth Sreeramoju (00:58:11):

Oh yeah. a lot of them.

Dr. Shirin Towfigh (00:58:15):

There’s a Facebook group that has a very large number of women with complications from the TRAM flap or DIEP flap. Sometimes it’s a true hernia sometimes because they’ve injured the posterior space, but sometimes it’s a denervation injury. So it seems the question here is we have a lot of patients in our support group for ladies with complications from tremor, DIEP flaps and surgeons are approaching these laparoscopically. These approaches do not hold either because the mesh is adhering to organs, they may have weight gain, the mesh seems to tear or not expand. I have my own thoughts about this, but what are your thoughts about

Dr. Prashanth Sreeramoju (00:59:05):

Okay, my thought about, I mean I have seen and I repaired a whole bunch of the TRAM flaps and DIEP flap repairs causing hernia. I personally feel DIEP flaps are a little bit better than TRAM flaps because it’s mostly because what happens is when you’re doing these flaps, they get the denervation basically and the muscle gets atrophied in that area and you get this hernia. It mostly looks like a very big large diastasis, and I have repaired prepared a bunch of them, and I always end up going robotically. In those cases, I take the peritoneum down plicate because you don’t really have the muscle up there. You have to plicate the disastasis portion of it and put a mesh, a wider heavyweight mesh to prevent. But I always end up telling my patients, listen, you lost the muscle. The muscle is the one who gives the shape for the body for your abdominal wall.

(01:00:11):

Once you lost the muscle, you can put your new, I can fix that hernia with a mesh, but in future it might look great for the first couple of years, but it might bulge out. It’s like if you take a rubber band, you keep pulling out after sat in time, it’ll slack, right? That’s what happens. The scar tissue is not like elastic. It won’t come back once it gets stretched or because our abdominal cavity mean people underestimate the abdominal wall muscle, but they’re working constantly 24 7, just like your heart. They’re constantly working, you’re coughing, laughing. They put a lot of strain on those muscles, so it’ll put a lot of strain on that scar tissue and eventually in future it might blow out. But if it happens, we can always do other ways of fixing it. So

Dr. Shirin Towfigh (01:01:01):

Here’s my take on DIEP and TRAM flap complications. So if you have a denervation injury, which is a large proportion of them, that is a horrible complication because any operation that’s performed has to be done with the understanding that at the local area, that nerve, that muscle is mush. There’s nothing you can do with a tissue repair ever. You have to use heavyweight mesh and it’s an anterior problem. It’s not a posterior transversesalis fascia problem you have to do. So I’ll do all those open. I just use their same tummy tuck type incision and I do very tight plication. It has to be super tight and then put a very, very wide mesh, and it has to be super wide. You can’t just treat it like a hernia. It has to go to only healthy tissue and tissue that doesn’t move. So pubic bone, pelvic bone, inguinal ligament, ribs, that’s how extensive it is.

(01:02:07):

And even those operations still don’t hold perfectly. My problem that I see is that people address these hernias and they like to do robotic hernias. For example. I’ve seen people do robotic TARs for TRAM and DIEP flap complications and I’m like, that’s not the problem to do. A TAR completely ignores. It may look good from the inside, but completely ignores what’s going on from the outside. So I think what they’re saying, which is laparoscopic repairs are not holding, it’s not so much that they’re not holding, it’s the wrong approach. I’m trying to think of what would be a good analogy. Like saying my roof is open and it’s leaking, and you’re like, okay, no problem. We’ll just put a tent inside. If you’re in the tent, that’s fine, but your house has still got hole on the roof and the house is destroyed. So to put a tent inside the house does not solve the problem of the big hole in your roof.

Dr. Prashanth Sreeramoju (01:03:14):

That’s it. Definitely. I think that’s a great analogy you pointed out. I mean definitely I agree. I’ve done both ways. Majority of the times the patient end up going to the plastic surgeon because of the bulge and because it’s in the same area of their operated and they’re always like, and I’ve done this, Hey, I’ll lift up the skin flap and you fix it. Once they lift up the skin flap, yes, I will definitely fix it anteriorly. I would not go posterior at all. But if they’re not, the plastic surgeon is not doing anything, Hey, I cannot do anything anymore, then I just create the pre peroneal space and plicate the muscle, then put the mesh. I’m not doing tars on these patients at all because as you said, it’s not a problem where the muscles tore apart. It’s just a matter of denarration problem rather than anything else.

Dr. Shirin Towfigh (01:04:07):

I mean, you could have legitimate hernias. Right. And those hernias, especially with the TRAM flap, some of them are now called, I just saw one last week. It’s a small pedicle tramp flap, so they take a central pedicle. Most of the rectus is intact. They take a central rectus pedicle with the vascular pedicle small piece of BTUs, and then the rest is basically like a deep flap. So technically it does include the rectus, hence the term trim. But those people that actually get hernias and even those hernias still, it’s an anterior problem and I feel that it’s not a hernia to approach it like a hernia. It lacks the understanding of what the problem is, and that’s why these people that just go like intra peritoneal mesh, they put a mesh in. I have another patient that was referred to me recently from a deep flap complication, and they went in there and they did a perfectly good good, she actually legit had a hernia, and it’s just very difficult to get those really tight posteriorly and anteriorly. You can do a very tight tummy tuck posteriorly, it’s not good tissue and you can’t do really good tummy tuck and it doesn’t give you the contour that you need and that these patients expect anteriorly. So I just suck it up and do it anteriorly.

Dr. Prashanth Sreeramoju (01:05:32):

I think you have a great point by saying that because when you’re doing these repairs anteriorly, when you’re plicating them, it gives you a better contour than posteriorly because you are inverting that laxity of the tissue when you’re doing the posteriorly, it kind of gives you a bump because you’re tightening. That gives you the bump that I can see that what you’re saying.

Dr. Shirin Towfigh (01:05:58):

Okay. That was a great, great. More than hour. I’m sorry to take so much of your time. It’s 8:36 your time. It’s time for you to go home.

Dr. Prashanth Sreeramoju (01:06:11):

I know it’s so much fun discussing about hernias. I think. I hope a lot of people benefit from this talk. I think it’s always a pleasure to have you

Dr. Shirin Towfigh (01:06:21):

Agreed. Thank you for your time. I really appreciate it. And for those of you who joined us, this has been a great episode. Please go to my YouTube channel. This will be up in the next 24 hours. Go to add Hernia doc, subscribe, share like if you’d like to listen to podcasts, leave us a little comment so that other people can also find us on the podcast on Hernia Talk Live. Thanks everyone. Follow me on Instagram at Hernia doc and I’ll let you know about our next session next week with another great guest. Until then, thank you again, Dr. Prashanth Sreeramoju. Thank you again for your time. It was fun. I hope to see you at, are you going to be at the American Hernia Society meeting?

Dr. Prashanth Sreeramoju (01:07:05):

Yes. I will be. So I’ll see you back in Chicago again. Guess we’ll

Dr. Shirin Towfigh (01:07:09):

See you in Chicago. Alrighty. Thanks everyone. Bye. Bye. Bye.