183. Hernia Surgery in the Elderly

This week, the topic of discussion was:
-Elderly
-Geriatric
-Frailty Index
-Surgical Complications
-Inguinal Hernia
-Mesh
-Tissue Repair
-Anesthesia
-Cognitive Dysfunction

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. Nicole Saur, Colorectal surgeon and Director of Geriatric Surgery at University of Pennsylvania, Philadelphia, PA

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. Towfigh (00:00:10):

Hello everyone, it's Dr. Towfigh. Welcome to Hernia Talk Live. Our weekly session on Tuesdays. We call it Hernia Talk Tuesdays. I am your host, Dr. Shirin Towfigh, hernia and laparoscopic surgery specialist. Thanks for those of you that are on here as a Facebook Live or coming in on Zoom. But as you know, you can also follow me at Hernia doc on Twitter X and Instagram and this and all prior episodes are available to you on my YouTube page at her new doc or now if you prefer to listen as a podcast. We are also a podcast and I'm seeing hundreds of downloads a week. So I'm really, really excited about the podcast part of our show. I would like to introduce you to Dr. Nicole Saur. She is one of the very, very few surgeons whose passion is the elderly population in geriatric surgery. She is actually a colorectal surgeon by training, but what drives her is the geriatric population. So I thought it would be fantastic to include her in our discussion today on hernia surgery in the elderly. You can follow her on X at sour Nicole. She is in Philadelphia currently and joining us probably, let's see, what time was it there? Seven 30 at night.

Dr. Saur (00:01:31):

Yep.

Dr. Towfigh (00:01:32):

So I appreciate you joining us, volunteering your time and answering our questions, and I'm super excited to have you. Thank you for joining us.

Dr. Saur (00:01:41):

Thank you so much for having me. It's an honor to be here.

Dr. Towfigh (00:01:43):

Yeah, thank you. So we have a lot of questions that have already been submitted, but maybe first you can kind of explain as far as I know. Well, I do know geriatric surgery is becoming of growing interest. There are people that are interested in geriatrics. I think in medicine, geriatrics is actually a well described specialty, but in surgery it's not. Is that correct?

Dr. Saur (00:02:09):

Correct, yep. There's been a lot of work from different organizations including the American College of Surgeons to grow the focus on geriatric surgery principles and to give us some guidance. But we don't have a particular geriatric surgery organization, which I think hopefully is in the pipeline because I do think we need kind of a home for this population and for additional advocacy, which happens of course through the ACS and the AGS, the Geriatric Society, which a lot of people are also members of. But yeah, I think that this is an evolution and a space that I hope we'll see a lot of change in the coming years.

Dr. Towfigh (00:02:51):

Well, I think the geriatric population is great. I love my elderly patients and the age of elderly always changes based on my own age, but what is considered elderly?

Dr. Saur (00:03:07):

Yeah, it's a good question. When we started doing some of this work and we were trying to write guidelines that came up a lot because of course defining the population that you're talking about is increasingly important and it really varies based on different studies and different people's protocols. a lot of people use 65 because it's Medicare age, others use 70 or even 75. a lot of times these cutoffs are sort of arbitrary based on the resources of the different institution. We talk a lot about doing universal screening for frailty. And so we say we really ideally would be screening every patient who comes in young or old for frailty, but sometimes within the system that we work in, people don't have enough resources for that. So they'll put an arbitrary cutoff, like 60, 70, whatever it is to sort of start to do some of these universal frailty tools. But I think the most consistent definition is either 65 because of Medicare age or 70 just because that seems to be really consistent in the literature if it's not 65.

Dr. Towfigh (00:04:10):

So that age is your chronological age, and then is the frailty index like your non chronological age, what your body should feel like? Is that right?

Dr. Saur (00:04:21):

So we know that age is a non-modifiable risk factor, and so it's sort of irrelevant. We talk a lot about when we present patients at different multidisciplinary meetings, usually you'll say, or even within the team, you'll say, oh, this is an X year old male or female, and really that drives a lot of conversation. So you may think, oh, should this person who's very young have a certain procedure or should we be more aggressive because they're very young and vice versa? Sometimes we say, oh, this person is older so perhaps we shouldn't give them full surgery or full chemotherapy or whatever the case may be. And that really does a disservice to our patients because we know that some patients are chronologically old but physiologically fit and young. And so having this sort of universal frailty screening can give us information that actually is useful to the physicians, but really also importantly to the patients because being able to tell someone, this is what you are experiencing.

(00:05:27):

So in your case a hernia, these are the risks of doing the surgery, these are the risks of not doing the surgery. And then this is your specific risk based on your profile of your comorbidities, your level of fitness, your nutrition, and some of that can be altered. And so you do a bit of altering and then maybe have a conversation again. But being able to give a patient that sort of patient specific information really can be game changing. And I think that empowers patients to be able to make these kinds of decisions, especially regarding elective surgery.

Dr. Towfigh (00:06:06):

So if you have a 55-year-old with a higher frailty index and a 70-year-old with a lower frailty index, you expect the outcomes to be more based on their frailty or their age.

Dr. Saur (00:06:20):

It really should be based on their frailty. And we know, I mean even the impact of malnutrition is huge and that can really be an equalizer. So they have studies where they look at patients who go to high volume surgeons and high volume hospitals saying maybe that that's the center of excellence so they have better outcomes or patients who go to lower volume hospitals and surgeons. And we see that actually malnutrition is sort of the great equalizer. So if somebody at whatever age is malnourished and even if they go to a higher volume hospital, they will have worse outcomes than somebody who has normal nutrition and goes to a low volume or a low quality, let's say. And is

Dr. Towfigh (00:07:10):

Nutrition, sorry, is nutrition a marker of how well you're taking care of yourself

Dr. Saur (00:07:17):

Could be seen as a surrogate or maybe it's a marker of some kind of inflammatory response or some kind of underlying comorbidities as well. So I think it is definitely multifactorial, but some of these things are modifiable and that's where I think the real excitement in this field is where we can take somebody who may be prohibitively high risk or may not be able to have a specific quality of life surgery because of their comorbidities, and then potentially transition them into somebody who's able to have that surgery and then potentially even better. So I think that that's the real excitement.

Dr. Towfigh (00:07:57):

How do you calculate a frailty index or what's it based on?

Dr. Saur (00:08:02):

There's so many factors, and this is where there's always a bit of

Dr. Towfigh (00:08:06):

How objective is it,

Dr. Saur (00:08:08):

Right? So there's a bunch of different frailty tools. It seems like if you look in the press, there's been a lot of published in the New York Times in Philadelphia and the Phil Choir about saying patients who are frail may do worse from surgery, even minor surgery. And we see this in our surgical literature all the time where somebody will say, oh, I put these different metrics together, named it after myself and showed that patients who have that particular frailty index do worse with surgery. And so I have sort of called this frailty fatigue where we see in the popular press and we see the literature all the time, frailties is bad, you should try to fix it. But average surgeons who are just trying to do their job and take the best care of patients and maybe don't have a huge infrastructure in their clinic, have a really hard time assessing frailty and then don't really know what to do with it even if they find it.

(00:09:04):

And so this is where we could do a universal simple frailty screening, and it could be any number of things. There's questionnaires, there's actual walking tests, there's memory tests. What we do in my clinic is we do a nutrition score to just ask them a two question nutrition index. We also do what they call a timed up and go where the patient just walks two meters from a seated position back to a seated position, and then the mini cog, which is a test of memory and cognition. And then if those tests are abnormal, then they get referred to our colleagues in the physical therapy and also in, so a relatively simple test for a busy surgical practice can then help to identify patients who are at greatest risks and then those patients can get some kind of intervention. And importantly, we would never send a patient to a cardiologist and then just sort of check the box that they saw cardiology, of course, we would want to know what the outcome was if there were any interventions, if there's any opportunity for optimization of their cardiac status.

(00:10:12):

And that's the same for frailty. So we I think fall into this a lot of times where we say, okay, we sent them for PT check, now we go onto surgery. And they did a really brilliant study at McGill where they looked at patients who were not able to be optimized on their walking test after a physical therapy period. And they found that in those patients, they had three times higher complication rates after colorectal history than those patients who were able to be optimized. And so I think that that again is an opportunity where there has to be this intervention and then evaluation of how well the intervention worked. So I guess that was a long answer to say there's a lot of ways to assess frailty, and it really depends on what you and your teammates are able to achieve within your system. But that I think is a good thing because then there's many different options and there's even ways for patients themselves to advocate for these things.

(00:11:11):

We know that in unintentional weight loss, eating less than normal, those are risk factors for malnutrition, fatigue, noticing a decrease in your daily activity. These are things that would be red flags heading into major surgery. I had that before where you have patients who kind of have a misconception because it sort of makes sense if you're going to go do a big race, you would sort of taper beforehand. I used to be a swimmer, so you swim a lot leading up into the big competition and then in the week or so before going into the competition, you rest. And so I think a lot of times patients think, well before surgery I need to rest. But actually a lot of times what we want is for them to increase their physical activity in the weeks leading up. And so that those are some opportunities to kind of take stock in what's happening with your body and then also to advocate to have some sort of interventions before surgery.

Dr. Towfigh (00:12:12):

Yeah, I was talking to this trainer last week and we were talking about joint implants, transplants, what is it, knee replacement. And I was wondering why is it the knee replacement doesn't do as well as hip replacement? And what he was saying was a lot of these patients are all obviously older and then most people get a joint replacement and then they go into physical therapy and he said, what I do is I give them six weeks before their joint replacement and I work on them. Then they have their procedure so that he's probably improving the frailty of the patient, optimizing them for surgery by doing back loading all the physical therapy and training before the actual surgery.

Dr. Saur (00:12:57):

Yes, absolutely. We

Dr. Towfigh (00:12:59):

Don't do a good job of that in general surgery.

Dr. Saur (00:13:02):

Yeah, I think that there's little pockets like this, but you speak to some orthopedic surgeons and they say, oh, we have to save the physical therapy because there's only so many sessions that are covered, but you probably don't need to save it because if you invest some time upfront or you do some physical therapy sessions and then the chin gets some homework to do at home, perhaps that means that you won't need as many after the surgery. So I think that that's really forward thinking approach.

Dr. Towfigh (00:13:30):

Well, we used to call this the eyeball test. I don't know, do they pass the eyeball test? You kind of look at the patient and you already get a sense of whether they're older than their chronological age or if they're younger. There's also this myth that I hear maybe it's not a myth. They say when you operate on someone, they act their age. Have you heard of that? Yeah, they act their age. So if you have a 70-year-old that's fit and they go to the gym and they're like, oh, but then let's say they have a major surgery and they have a complication, then I've heard people say, oh, they still act their age. Is that true or not? I feel like sometimes there's a truth to that.

Dr. Saur (00:14:13):

Well, so it's interesting because we know that older adults can recover from major surgery. We did this large study in cancer patients just looking at different frailty tools and then how patients rated their quality of life and also what they call the functional recovery. So basically getting back to their baseline level of function. And the thing that affects that the most is complications.

Dr. Towfigh (00:14:40):

Complications. Patients

Dr. Saur (00:14:42):

Can undergo major cancer surgery, even major open abdominal surgery where you're in the hospital for even weeks and they can get back to their baseline function and their quality of life, but that is affected if they have a complication and it's cumulative. So if they have more than one complication, they have a bigger impact than if they just have one. And the severity of the complication also affects the ability to return. So I think that I'm not sure that it is sort of an equalizer that if you have somebody who's fit that they'll sort of be as bad off as somebody who was frail going into the surgery. But know that the idea of the prehabilitation and sort of optimizing patients is to avoid any complications that we can, and that of course, we talk about it as a bit of an airbag because if a surgeon technically does something that results in a major bleed or something that's not necessarily going to be able to be overcome by pre rehabilitation, but perhaps the patient will be better off than they would've been if they didn't do the pre rehabilitation or the F upfront.

(00:15:56):

So I don't think that it's this sort of idea of showing your age, but I do know that we have to think more about one of my favorite tools, which is the best case, worst case decision tool, and really clear with patients about, it's very easy to say, Hey, you have a hernia. It's obviously symptomatic. You could have a surgery and it will go back in and you'll feel much better. And that's obviously a very limited view of what potentially could happen. So having these discussions with patients about this is what could happen in the best case, this is what could happen in the worst case. And then also importantly, based on your risk profile, where do I think you probably would fall along the spectrum so people can have a more, I think, informed decision. And then of course, these unfortunate things happen sometimes. And so then trying to get patients through these complications I think is also easier if we have a bit more of a sort of running zone with the pre

Dr. Towfigh (00:16:59):

Rehabilitation. I feel like once they hit a complication, then the elderly patient, regardless of how fit and active and great, they tend not to bounce back as easy as maybe someone of equal fitness. But younger,

(00:17:19):

I'm going to age myself here. When I was in medical school in the nineties, we didn't really see a lot of people in their nineties or over eighties was considered really old. And actually in retrospect, so my research project during medical school was outcomes from renal transplantation in the elderly, which was considered age 55 or over. I'm hitting that number pretty soon. But my point is it was very controversial to offer knee transplants because there's a limited number of organs, and so why would you waste it, waste it on an older patient? So at that time was age 55 and older, and they actually did better than expected. And there was some theory that maybe their immune system is not as high when you're older. That was one theory why they maybe rejected less when they were older than younger. And then research started coming out on the very elderly.

(00:18:29):

So octogenarian, anogens, right, 90 year olds. And there was studies back in residency time for me where they kind of said, if you can make it to 90, this was back in the late 1990s, if you can make it to age 90 and above, you're kind of already past the Darwinian test. So you're probably a better, healthier, better health genetically than the people that are already in their fifties and sixties with diabetes and hypertension, heart disease, and therefore operating on a 90 plus year old may actually not be as bad as you think because they've kind of passed the test of life so far. Nowadays it's very common to see people in the 90 year olds, and then every so often you see someone over a hundred. It's not that rare anymore. It's uncommon, but it's not rare. Does that kind of data still make sense that if you operate on the really elderly, not someone who's very sick, let's say they're independent, but they're in their nineties, have they passed the test of life and therefore you shouldn't be that afraid to operate on a 90-year-old compared to a sicker 60 or 70-year-old?

Dr. Saur (00:19:54):

And I think it just really depends on their level of fitness, of course, because like you said, we think we are good at this eyeball test. Yeah, the eyeball test, we think like, oh, well, I don't need to be biased by age. I'll just use my own eyeballs and figure out if the patient can tolerate surgery. And it turns out surgeons aren't really that good at eyeball tests either. Okay. So really it depends on frailty. I mean, I do think that there's something biologically about, like you said, being able to live until age 90. And so probably there is this inherent level of either biology or lifestyle choices that set them up for better outcomes. But we also know that let's say somebody's 90 and they're living independently and they have sort of an intermittently annoying umbilical hernia, and then they have a surgery, they may not get back to their baseline level of independence.

(00:20:51):

So that kind of, I think information and also decision-making can be really important in those patients because although they may be able to sustain a surgery and a surgical insult, they may not get back to what they deem as an appropriate level of function or independence. And so these are some of the things I think we really have to bring to the forefront as we're thinking about it, because as a surgeon, our goals are probably different than the patient's goals. And we see this again and again as a hernia surgeon, I'm sure the goal is not having a hernia and getting back to some level of function, but for the patient it might be being able to get groceries independently or these different things that may be altered if you were not able to lift things that are heavy for a period of time. And so having a common language with the patients can be really helpful, especially in these situations.

(00:21:49):

I mean, we see in my world where they say, okay, after 75, you probably don't need to have a colonoscopy. It needs to be patients specific. So then patients will come to me and they say, well, should I have a colonoscopy? I say, well, are you going to live 10 more years? Because if you are, you probably should, right? Because we see a lot of patients who come in in their nineties and they have colon cancer because in their seventies or eighties, they stop cancer screening because they're old and now they're going to have to go through either just having the cancer or having this insult of a surgery when they could have had a much lower risk procedure. So I think also thinking about the bigger picture and what somebody's longevity is, and that often is related to their number of risk factors, number of comorbidities.

Dr. Towfigh (00:22:37):

Yes. Right, right. It's not as easy just to have an age cutoff because of everything you said. That brings us to one of the questions that was submitted related to surgery, and that is anesthesia. So there's always this concern that general anesthesia may actually push you into more cognitive problems in the elderly than in a young person. So here's the question. Is there a relationship between general anesthesia and the appearance or exacerbation of cognitive decline in older patients after surgery?

Dr. Saur (00:23:19):

So yes, the short answer is yes. The other problem is that a lot of times we don't have a good grasp on somebody's cognitive status, and so you can sort of mask even to yourself a bit of a cognitive decline for a long time until you have maybe another insult or maybe you're in the hospital and you have a bit of delirium after surgery. And so that's why part of our protocol is to do this mini cog because we can give for the surgeon, but also for the patient information about their baseline level of cognition because that can be really helpful afterward. Some of the effects of anesthesia are more short term, but we do know that sometimes patients who are predisposed to having some cognitive impairment can have long-term cognitive impairment after general anesthesia, and that tends to be affected by how long the procedure is. Got

Dr. Towfigh (00:24:14):

It.

Dr. Saur (00:24:14):

There's a lot of question about doing general anesthesia versus in some cases maybe doing sedation with spinal anesthesia. But we know that benzodiazepines also can have an effect on cognition, especially in older adults. And so that isn't always as straightforward of information as well. So there's a lot of things that we can do to try to tailor the anesthesia to the patient. So for example, if we do general anesthesia, we avoid benzodiazepines in

Dr. Towfigh (00:24:46):

Adults

Dr. Saur (00:24:47):

And thinking about the length of the surgery, trying to minimize unnecessary anesthesia time or operative time, these kinds of things can be helpful. But we do know, I think that there's more to the story that we haven't fully uncovered, but we do know that there are long-term effects that can happen from general anesthesia and older adults related to cognition.

Dr. Towfigh (00:25:10):

Yeah, I'm always worried about that. And the patients aren't worried. They talk amongst themselves when they're older. They've maybe known a neighbor or a friend or something that's had some cognitive changes after anesthesia. I've had a couple patients that had the cognitive changes. It lasted like a year or two, and then they kind of got back to normal again. See, they would come to me for their hernia, but they already had some of the procedure and you can tell they're just not fully a little bit withdrawn during the office visit. And their wife, it was a gentleman, his wife was telling me, I was like, are you sure he is okay? Yeah, ever since this procedure. And then I saw him again a year and a half ago, he was totally fine or at least seemed more involved. But that's one of the things that I don't like is that a lot of surgeons are learning robotic surgery, especially for inal hernias, and it's as if they forgot everything else they learned during residency.

(00:26:17):

And they're perfectly capable of doing open operations. And I do almost all of my open operations for the groin under IV sedation and just local anesthetic. We don't really need general anesthesia, but because they're so reliant on the robot it seems and they like it, it's a good operation, et cetera. Like 90 year olds getting laparoscopic repair. And sometimes I'm like, maybe that wasn't necessarily the best choice because you inflating their abdomen, that decreases blood flow to their heart. You're giving them a general anesthesia. I mean, it's a good repair laparoscopic, but it's not so much better that open repair is inferior if you consider the potential effects of anesthesia and a 90-year-old, do you think it same way or am I just being

Dr. Saur (00:27:07):

No, I think that's exactly right. And I think that that's the benefit of shared decision making where I could do this fancy high tech technique, but it's going to come at this cost for you,

(00:27:20):

Or we could just sort of go with the more straightforward, potentially more painful, but in other ways sort of less costly to you in terms of cogniti, other risks and of missed injury and these other things that can happen. And so I really do. I think that there are times when we shouldn't even follow the textbook. I mean, this is an example where either one would probably be deemed to be correct on an exam, for example. But sometimes in our older, especially frail population, maybe we shouldn't be following the textbook, maybe we should be offering things that are kind of outside of the box but fit into the goals of that patient. And that I think we are doing a better job of discussing more and more as guidelines come out and they talk more about shared decision making and thinking about the goals of the patients. But I'm hopeful that that will be continuing to be put into the forefront and also put more into clinical trials and saying there's different arms based on what the patient's priorities are, because I think that that's a very reasonable approach. And I think you're right. In a lot of cases, the minimally invasive approach in that patient population probably doesn't give the benefit that we see in patients.

Dr. Towfigh (00:28:40):

When I talk about the watchful waiting trials, I preface it by saying, so the watchful waiting trial, for those of you that are watching for inal hernias, it's been shown in men, not women unfortunately, but in men that if you have a hernia in the groin that has little to no symptoms, if you watch it, most patients do just fine until eventually they get pain and they need surgery. But watchful waiting is associated with a 0.81% per year per year risk of the hernia getting stuck or needing some type of urgent surgery, but it doesn't kill you, and it's usually considered a safe decision and people that have little to no pain, whereas when, again, going back to my residency times, we didn't have that trial, right? The trial was in 2006, so every patient that had a hernia, we signed up for surgery and that included a 70, 80, 90-year-old patient. And maybe we kind of slow walk. The older patients didn't book them urgently or too quickly, but now we can say, listen, you're 80 years old, you have very little symptoms from your hernia. It's not affecting your daily activities, and if we don't do anything, you have a 0.81%, sorry, 0.18, I misspoke percent per year risk of something bad happening. Best case scenario, you have 20 years to live. That's like very little. It's 20 times, it's 20 times.

(00:30:21):

What is that 3.6% risk of you ending up in the hospital? So it's worth it. And so those kind of patients, those kind of discussions we can now have because we have data to support it. Whereas before there was this worry that what if they show up with incarceration, strangulation an elderly patient, that's a lot of stress on the body. They may die, so let's fix their hernia now. And we found out that's not true. Umbilical hernia is same, right? Umbilical hernia's. Also watchful waiting is considered safe for asymptomatic hernias. So that's good data for hernia surgery. But these large hernias, I feel like age is definitely, and the frail T index I should say, is definitely something that I for sure factor in. So you're colorectal surgeon, most of your patients that need surgery, I would say a good proportion of them is due to malignant disease, cancer, even for cancer. Is there a time to consider non-operative or regardless of age, everyone for cancer had surgery?

Dr. Saur (00:31:42):

Oh, no. I mean, we have, in rectal cancer, we have evolved a lot. So it used to be that you would do surgery and then there would be this very high chance of having a recurrence of the cancer in the pelvis. So the disease treatment really evolved into including chemotherapy and radiation in addition to surgery. Now, sometimes even in younger patients, we don't do surgery if the tumor goes away completely with the chemotherapy and radiation. I think rectal cancer is sort of the best example in our world of where we can really use adapted care. So some patients, if they're very fit and they have, let's say a relatively early rectal cancer, they probably would go for surgery to remove the cancer and the lymph nodes and then do some kind of either bowel connection or ostomy back. And then along the spectrum, maybe they'll get chemotherapy and radiation as an attempt to try to avoid.

(00:32:40):

But if somebody is very frail and they're becoming symptomatic, maybe we just do an ostomy, which is sort of an easier to tolerate the shorter procedure. So a lot of different options that can be accomplished based again on what is the disease process, what is the level of frailty of the patient, and then of course the goals and having that kind of discussion. So rectal cancer management is becoming increasingly complicated. And then of course, it's even more complicated if you think about all these different ways that you can adapt care. But again, I think that that is really, I hope what we're going to be doing for all types of treatments, benign and malignant, thinking about what are the sort of dogmatic principles that we've been really focusing on for all of this time in surgery and where can we make different adaptations based on the goals of the patient and the functional status and the ability to tolerate that surgical stress.

Dr. Towfigh (00:33:44):

The issue with hernia surgery as opposed to some of the other operations is I don't think the colon wall changes that much with age does it, but definitely the abdominal wall and the muscle is really thin out, and so the quality of the fascia on which to base your surgery on is different, and therefore the outcomes are a little bit different for men versus women. I mean, based on your age as well as other factors. But age is definitely a major one. So that's kind of where we are. Here's a question. Have you ever considered functional care? I don't know what they mean about functional care. Do you know what functional care implies? I don't know what I

Dr. Saur (00:34:29):

It means in that context.

Dr. Towfigh (00:34:31):

I don't either. Maybe they can respond while we ask more questions. Another question is, does age affect the capacity of the groin and inguinal canal tissues to remodel and stretch if necessary from an open hernia repair? I see. So what they're asking is since an open hernia repair maybe too tight from the mesh or no mesh is used and the tissue repair is tighter, can the fact that you're more lucky to stretch out, I guess, be a positive thing for hernias? No, that just means recurrence. It doesn't mean you're going to loosen. I dunno. Do you have any other insight into that? No,

Dr. Saur (00:35:16):

I think that that's a good question because like you're saying, we don't really talk about that much. In my world. The bowel tends to heal similarly despite age. I wonder if is that related to age or is it more related to obesity and other factors that are more universal?

Dr. Towfigh (00:35:35):

No, I mean, doesn't elastin collagen, isn't that less in the tissues as you grow older? I think so. That's why you get wrinkles and ay face. Here's the next question. What age related factors as opposed to chronological age itself most significantly impact the risk of hernia repair surgery? I guess the tissues, right?

Dr. Saur (00:36:11):

Yep. And then I think kind of does

Dr. Towfigh (00:36:15):

Hormones? No, the hormonal changes of the elderly? No,

Dr. Saur (00:36:23):

I don't know. Not necessarily from a surgical risk that I know of.

Dr. Towfigh (00:36:28):

Okay. Okay. And I would assume, well, I mean, I guess when you grow older, you're more likely to have other diseases like atherosclerosis and blood vessel vessel diseases that reduce blood flow maybe to your tissues and make them less likely to heal. Well, I don't know. Okay. Next question. What measures can be taken to optimize an old patient's condition before surgery, such as physical exercise, nutritional status, and do these measures impact postoperative outcomes? You kind of addressed that earlier.

Dr. Saur (00:37:09):

Okay, go

Dr. Towfigh (00:37:10):

Ahead.

Dr. Saur (00:37:12):

No, so what I was going to say is that, yeah, we do multimodality, like you say here with the physical exercise and nutrition. So there's a lot of different ways that you can do this sort of term of prehabilitation. So

Dr. Towfigh (00:37:28):

Rehabilitation

Dr. Saur (00:37:29):

Ready for surgery, but the sort of most important tenets are evaluation and optimization of functional status. So if the patient has a slow walking test doing physical therapy that's targeted for them, nutrition evaluation and optimization with when appropriate, a consultation with a dietician. Smoking cessation is a huge one, which I know is huge.

Dr. Towfigh (00:37:56):

Smoking, that's a big

Dr. Saur (00:37:57):

One. Hernia surgery

(00:38:00):

And treatment of anxiety and depression. So those are the main tenets of the prehabilitation. And we do know that those affect postoperative outcomes. Sometimes it's not easy because a lot of these outcomes, thankfully, are quite rare, these sort of poor outcomes. So you'd have to do a lot of surgery to be able to demonstrate the impact of some of these interventions on a specific outcome like cornea recurrence for example, or infection or something, because it's just not all that common. And then it's hard to pinpoint the effect of each piece of this sort of multimodality

Dr. Towfigh (00:38:46):

Way. But we

Dr. Saur (00:38:47):

Do know that it impacts the ability to get back to patient's functional baseline. It impacts their quality of life. And so I do believe that we're just not able to statistically show all of these different outcomes, but I do think that it is making an impact on the different outcomes. And then indirectly, again, on recovery and quality of life and things that patients and physicians and hospital administrators care about, time in the hospital chance of coming back into the hospital kinds of things. Because we focus on these things also because they matter, I think to patients and also to surgeons, but they also give us an opportunity to say, Hey, we need a dietician in our hernia center, for example, because if we can improve our patient's nutrition, then they have a 50% less chance of coming back through the emergency department, which is better for the hospital, and then everybody kind of wins. So using some of this information to be able to grow the resources that are available to patients is really important because a lot of times in the US care from a dietician isn't reimbursed by insurance, and it can be difficult for patients to access these resources outside of a cancer center or a bariatric program, for example.

Dr. Towfigh (00:40:12):

Yeah. Because hernia is not considered a specialty like that. That's really interesting. Does age affect the pulmonary status of someone?

Dr. Saur (00:40:26):

I think not directly. It was all this data coming out in the early days of minimally invasive surgery talking about the effect of putting carbon dioxide into the abdomen on patients' complication rates from a pulmonary perspective and saying, oh, okay. Older patients shouldn't have minimally invasive surgery because it's quote unquote too stressful. And in colorectal surgery, there's multiple randomized control trials saying that there's no worsening in cardiac complications in older patients. And in fact, they tend to do better with minimally invasive surgery than they get even more benefit with minimally invasive surgery than their younger counterparts. So I don't think

Dr. Towfigh (00:41:09):

That there's, oh, that's interesting for colorectal surgery,

Dr. Saur (00:41:13):

Right? Because there's this idea of the stress of the surgery versus the stress of the perioperative period. And in a lot of times, like in colon surgery, the stress of the surgery may be more imminently invasive surgery, like what you're saying of the hernia surgery. But in our world, the alternative is this sort of large, big operation incision that causes to have a harder time breathing because you're sort of splinting and you're in pain, and then that translate into more chance of getting pneumonia, but not because of your age really because of this sort of painful stimulus that you have. And so sometimes in those cases, patients actually have a benefit of having minimally invasive surgery, even though the stress of the surgery is more. But in the case that you said That's so interesting.

Dr. Towfigh (00:42:01):

Yeah.

Dr. Saur (00:42:01):

Really make, if it's a hernia surgery, which is otherwise

Dr. Towfigh (00:42:04):

The opposite,

Dr. Saur (00:42:05):

Broken an outpatient, you can't really make up this huge differential between minimally invasive and open in that same way. Yeah.

Dr. Towfigh (00:42:13):

That's so interesting. I've never thought of it that way because for you're absolutely right. So a big operation, big incision in the abdominal wall in an elderly patient is much more difficult to overcome than multiple small holes doing a lot on the inside already with both surgeries. Whereas for us, at least for the groin or some abdominal wall, the incision's not that big and it's further away from the lungs and pulmonary, and it's reasonable. It's reasonable to do it open and still do it outpatient. Right?

Dr. Saur (00:42:53):

Yeah, because I think you don't make up that benefit on the backend the way that you do from a major abdominal surgery.

Dr. Towfigh (00:43:00):

Yes. Yes, that's correct. How does thinning of fascia muscle affect surgical approach and outcomes? I mean, definitely a thinning of fascia and muscle affects outcomes from all hernia surgery. So I would say usually we rely more on mesh in patients that have really weak fascia and muscle. But at the same time, you don't want to overwhelm the system. So if everything's really weak, you'll want to put something like a really heavyweight mesh because it'll just tear right through. You kind of need to match the quality of the tissues with the quality of the mesh. So big muscular guy, you can get away with probably a heavier weight mesh if they need it, whereas a thinned out tissue, the heavy weight mesh is just too much. It's like a armor and it'll overcome the tissue quality and just rip through. That's the way I think about it.

(00:44:06):

Here's an interesting question. Sounds like a personal question asking for a friend. If there's a question of bladder outlet obstruction in an elderly male that has mild to moderate, that is mild me bladder outlet obstruction in an elderly male that is mild to moderate, not requiring intervention, if you think of Foley may be necessary, is it best to place on the table prior to operating to prevent intraoperative bladder dilation preemptively, or to wait to see if the patient can urinate after surgery in recovery to determine need for Foley? Do you use urinary urinary catheters for most of your colorectal operations and why? We do

Dr. Saur (00:44:54):

For abdominal surgery, but in my practice for anal rectal surgery,

(00:45:02):

We don't use a catheter because they go home the same day, but we want them to urinate before they go home. Because of the same question that you're alluding to, I think of saying, is it better to be a bit proactive or a bit reactive? Yes. So I think in our practice we try to give people the benefit of the doubt that after an intervention, so for us, we give a nerve block that can sometimes make it difficult to urinate. So if you already have a bladder outlet obstruction, you probably will be more likely to have difficulty urinating. But some people are able to. But what we'd want to avoid is having this situation where you have to come back through the emergency department and you're very uncomfortable and you can't urinate. So what we do is we try to limit the amount of fluid so we don't overwhelm the bladder during the procedure. And then after the surgery we make sure that they're able to urinate before they go home. And if they can't, then we do put in a catheter in that situation if we do very

Dr. Towfigh (00:45:59):

Similar to my practice. And then can you explain why you use a Foley catheter or a urinary catheter during your abdominal approaches?

Dr. Saur (00:46:08):

Yeah, because the surgery is usually several hours long, and so we want to have information about how much urine the patient is making so we know how much IV fluids we should be giving because that can affect, if we give too much IV fluids, then that can make the bowel swollen and make it harder for the patient to have bowel function and it kind of slows everything down. So we try to be very stingy on the fluids, but then we have to make sure we're not being too stingy with the urine output. So we usually keep the catheter in for a day or so after major surgery.

Dr. Towfigh (00:46:40):

Exactly the same for hernia surgery. So abdominal approaches, anything laparoscopic. I personally put catheters in for one of two reasons. One is like you mentioned, it's going to be a long operation, so it's not fair to the patient to just have their bladder fill up during surgery and then get to an extreme situation. The second is operating down in the pelvic region. You don't want the bladder in the way and therefore potential risk for getting injured. So you need for the catheter is to get the bladder out of our way and away from the area of dissection, which I think is also true for your lower rectal colorectal sigmoid operations. Right,

Dr. Saur (00:47:25):

Exactly.

Dr. Towfigh (00:47:26):

And then for outpatient surgery, and that don't necessarily require a catheter because it's going to be relatively short. Those patients, we try not to put catheters in if they don't need it, but because hernia surgery is similar to your rectal surgery, does somehow stimulate a risk for postoperative urinary retention. I do require that they urinate after surgery before they go home. Yeah, I would also say if you have mild to moderate bladder outlet obstruction, you may not require surgical intervention, but you definitely should be on medical intervention because straining to urinate against obstructing prostate is a big risk factor for hernias. Don't do it. Here's a question. Can laparoscopic surgery be done without using the belly button for access?

Dr. Saur (00:48:30):

Yes.

Dr. Towfigh (00:48:31):

Yes. Thank you. In your

Dr. Saur (00:48:34):

World too, I guess because yours is in our world

Dr. Towfigh (00:48:35):

Too, you don't have to use it. It's nice to use it to hide an incision, but you don't have to use it.

Dr. Saur (00:48:41):

I had a patient once when I used to do my extraction for my colon, resections would make kind of like a C around the belly button. And I had this young patient once who said, I had this friend with this really ugly scar. And I said, oh, well what did it look like? And she drew it and I said, oh, that's so funny. Because our dogma was, oh, it's better to great scar round the umbilicus because you're hiding it. And she said, it doesn't hide it at all. It kind of makes it look like a C instead of a straight line. And so she totally challenged my impression that we're sort of hiding this in the belly button.

Dr. Towfigh (00:49:23):

Oh, they're totally right. And I would say there are some countries where they go straight through, I think Mexico, they go straight through straight line. It's old school. For some reason, we switched over to going around the belly button as if we shouldn't go through the belly button with your incision.

Dr. Saur (00:49:42):

Yeah. But yeah, it's so interesting. So now I usually do a fanin steel now that bikini incision, but otherwise I'll just do a small underneath the belly button incision and it looks so much better. I don't know why I thought it was better to go around.

Dr. Towfigh (00:49:58):

Well, I'll tell you, I love doing little belly button hernias and I experiment with different types of scars. The up and down scar, just the inferior portion from the stalk down heals so well, I don't understand people that put a big scar like transversely below the belly button or through the belly button and it looks horrible. Anyway. Here's a cute question. What if a patient is obesity yet handsome by losing weight before as well as after? Can the long-term prognosis significantly improve, especially for hernia recurrences?

Dr. Saur (00:50:42):

Yes. Right.

Dr. Towfigh (00:50:43):

Yes. Well, yeah. The long-term prognosis will definitely improve with losing weight before and after the handsomeness may also improve. It depends. Everyone's different.

Dr. Saur (00:50:57):

The eye of the beholder, right? Eye

Dr. Towfigh (00:50:59):

Of the beholder, yes. Okay. Next question. Let's see. Do you need to get the bladder out of a way for a tap only or tap and robotic the prayer, all of it. Same area. Same area. Okay. Let's see. Oh, this is interesting. So there's something called mesh implant illness similar to breast implant illness. It's basically a autoimmune or inflammatory reaction to implant. I don't know if you've seen, I treat a fair number of patients with it, but it's considered higher risk in patients that already have an autoimmune or inflammatory disorder like rheumatoid arthritis, lupus and so on. So here's the question. Assuming that systemic inflammation is an integral component of mesh implant illness and inflammation increases as we age, have you seen a higher rate of mesh implant illness cases in the elderly compared to the general population? I have not, but I don't think it's true that inflammation increases as you age. Doesn't it decrease?

Dr. Saur (00:52:13):

Yeah, I was going to say the inflammatory response I would think is less as you age.

Dr. Towfigh (00:52:18):

Yeah, I think the immune response and the inflammatory response both decrease. So you should see less mesh implant illness. I personally have not seen it in elderly patients. They tend to be younger. So that, remember my medical school project with the transplantation, the elderly, they did better. They did better, less rejection. Does the formation or reformation of adhesions after surgery increase with age? That's a good question. Probably decreases no,

Dr. Saur (00:52:59):

But I think along those same lines, probably less because that again is sort of an inflammatory response,

Dr. Towfigh (00:53:05):

Less inflammatory

Dr. Saur (00:53:05):

Response. But I can't say I have any true data on the degree of adhesions.

Dr. Towfigh (00:53:13):

Yeah, I never paid attention to it, but I don't know if anyone's ever studied that. It's interesting question. Less adhesions. Well, what about their scar? I think their scars tend to be aggressively thickened, right? Younger people have more thickened scars. How does age affect incorporation of mesh into the tissues and scarring into the mesh? And overall, how does age affect adequacy of scar formation? And does this affect your decision making?

Dr. Saur (00:53:52):

Have you ever had that in your algorithm?

Dr. Towfigh (00:53:56):

I mean, I would say that make us as thick of a scar when you're older. That's maybe why you have higher risk of hernias when you're older. No, I would say that's why your outcomes are worse. Your collagen, alas and all that framework is not as strong and not as aggressive.

Dr. Saur (00:54:21):

And like you were saying, maybe having, if there is such a thing, having a specific type of mesh, maybe for these types of, I'm imagining maybe for the older women that have femoral hernias, is there something specific that you do differently because of the quality of the tissue?

Dr. Towfigh (00:54:42):

Yeah, I mean femoral hernias, right? You should be repaired with mesh in the appropriate patient population. Every so often, someone doesn't want mesh or they're so thin or they've had problems with implants before. But yeah, tissue repair is not a good idea in most elderly patients. I had a patient who was in his eighties, I'm going to say 86 or 87, he was not thin. He was active. He had a orchard and did a lot of gardening. He came in specifically, he knew that I also offered non mesh hernia repairs. And I'm like, yeah, but you're in your eighties. Why are you worried about hernia problem mesh problems? He is like, I did my research and I just don't want mesh. So I did it because it wasn't that egregious of a decision. But I said, listen, if you recur, you're going to be higher risk of recurrence than a young healthy person having the same repair without mesh. You're going to need mesh if you recur. He's like, I'm okay with that. He's like, what's the risk? And I gave him risk like five to 7% of his money. He's like, that's fine. I have a 90 plus chance of doing just fine without the fish. And he did fine. It's been like four or five years so far. So yeah. How does surgeon overcome this problem of less scar?

(00:56:17):

I mean, it is what it is, right? I don't know. Do you have any options, any answers?

Dr. Saur (00:56:25):

Well, it's interesting. I think in hernias, of course, like you were saying, you sort of want some scarring to keep everything in place, but in a lot of areas of surgery, you really don't want scarring because you're going to potentially have the bowel obstruction or other kinds of complications related

Dr. Towfigh (00:56:40):

Right in your field,

Dr. Saur (00:56:42):

Plus minus,

Dr. Towfigh (00:56:43):

Yeah. If you sew two bowels together, it scars down. It could obstruct, right?

Dr. Saur (00:56:49):

Or they could be adhesive bands causing blockages and things like that. So yeah, in our world, we usually think about less. We want less scarring. So in that case, having less scarring is better. But I guess in the hernia healing, you want potentially more. So it's interesting. Maybe plus minus.

Dr. Towfigh (00:57:06):

Yeah, plus minus. But as far as you know, there was no obvious difference in outcome of doing bowel surgery in the elderly versus

Dr. Saur (00:57:17):

No.

Dr. Towfigh (00:57:17):

No. Right. Yeah. Not that different. Yeah. Okay. Alright. Are there any options for older patients who would need to have an AL or incisional hernia repair but cannot tolerate mesh? Yeah, I mean, it's all a risk benefit ratio. If we can do it without mesh and it's a good repair, it's an option. But if you have poor tissues, it's just not cool to do a repair that's going to bust open the next day. There needs to be some reasonable opportunity to heal and do well for many years. But to do a repair just because you don't want mesh or if you can't have mesh, there are other options. Then just straight pure synthetic mesh. So there's options. You don't have to freak out over that. Let's see. There's just a question here. I already answered that question. Cool. I think, are we done with questions? I think we're done. Let's see. Yep. I have no more questions unless someone else has questions. Here's what I just saw. Oh, they removed it. I just saw one about a deep flap. So I know that for breast cancer, people use flaps from the abdominal wall, but they also use flaps from the abdominal wall for anal rectal cancers or even benign disease sometimes where you,

Dr. Saur (00:58:49):

Yeah,

Dr. Towfigh (00:58:50):

You need to use And what do you use? You use abdominal wall.

Dr. Saur (00:58:56):

I try not to because that tends to be pretty morbid in our population, especially if they have to have an ostomy, which is usually the reason that we're doing flap for full of the rectum and the anus. So I try to do, if we need, well, I really try to just do omentum and then close the skin if I can. But otherwise we try to do thigh based or buttock based flops more than wall.

Dr. Towfigh (00:59:22):

But

Dr. Saur (00:59:22):

You do them if needed.

Dr. Towfigh (00:59:24):

Yeah. We're just seeing a lot of abdominal wall flap complications for breast cancer, denervation, as well as hernias or a combination, which is horrible. They have a hernia and a denervation, and there's not enough people that understand the anatomy and understand what was done by the plastic surgeon. The plastic surgeons don't really understand how to fix these things. So it's a bad combination of not having the right thing. Let's do one last question. If you cannot use heavyweight mesh in a large, direct hernia, is what you use as an alternative at increased risk for ular Fluor flopping. Again, you don't have to use heavyweight mesh for a large direct. It's preferred, but it's not a must is what I would say. In fact, I learned a couple of days ago that the original Amid Lichtenstein technique used ultra lightweight mesh even for direct hernias. So I guess it was good enough for them to do it. It should be good enough for us to do it. We got the experts doing it. Alright, well that's it. Thank you so much. Look at this. We're all done.

Dr. Saur (01:00:42):

Thank you so much for having me. This was great.

Dr. Towfigh (01:00:44):

Yeah, an hour went by so quickly. Thank you so much to Dr. Sauer for joining us. It's already late her time, east Coast time, but I do appreciate you spending time with us, answered a lot of really cool questions. We plugged in some colorectal surgery here and there, which we don't often do on Hernia Talk Live. Thanks everyone for joining and for adding through the questions. Go ahead and subscribe to my YouTube channel so that you can watch this and all prior activities and episodes or go on wherever you like to listen to podcasts and write a little review. If you like our podcast, Hernia Talk Live. I will join you all next week for another great guest, an episode. But thank you all and thank you again, Dr. Saur. I will see you next week and I'll see you Dr. Saur in Long Beach in Sages next year.

Dr. Saur (01:01:38):

That's right. I'll be there. Thank

Dr. Towfigh (01:01:40):

You. Looking forward to it. Thank you very much. Take care.