184. The Perils of Watchful Waiting

This week, the topic of discussion was: 

• Watchful Waiting
• Inguinal Hernia
• Scrotal Hernia
• Femoral Hernia
• Giant Hernias
• Mesh
• Shouldice
• Laparoscopic 

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, call +1-310-358-5020 or email info@beverlyhillsherniacenter.com.

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Transcript

Dr. Towfigh (00:00:11):

Hi everyone. Welcome to Hernia Talk Live. This is another Tuesday. I’m so happy to have you here. I’m your host, Dr. Shirin Towfigh hernia and laparoscopic surgery specialist. Thanks for everyone who’s logged in via Zoom. I’m here to answer all your questions and also for those of you who are here via Facebook Live, please let me know your questions. Thanks to everyone also who has been following me on my podcast, Hernia Talk Live, and also subscribe to my YouTube channel at Hernia Doc. I really enjoy doing these every week. As you know today, I’m here for your questions and I thought that we would preface the topic for today as perils of watchful waiting. As you know, I’ve had a couple of episodes now on watchful waiting. Watchful waiting is the term that we physicians use when we’re talking about not operating on patients, but waiting to see if the patient’s disease advances.

(00:01:19):

Watchful waiting is also watchful. In other words, we don’t wish to lose you as a patient. We want you to check in with us as needed because eventually many people in the watchful waiting decisionmaking group may want to switch over to the surgical decision making group. But in general, when we talk about watchful waiting, we intend to push you into the nonsurgical arena. And then what we’ll do is we’ll watch you and if things change, then you can consider surgery, but it’s considered a safe decision. Now, watchful waiting is not only for hernias. You may have heard about watchful waiting for other diseases. Even prostate surgery has a watchful waiting situation because it’s considered typically a slow growing tumor in the prostate. And so not everyone who has a prostate cancer must have surgery. It’s definitely an option, but it’s okay to watch fully wait and see what happens to that tumor.

(00:02:30):

I guess some of them don’t grow or maybe it takes a while for them to grow or I don’t really know why you would choose to watch prostate cancer, but maybe we can talk about that in the future. But here on Hernia Talk Live, all we talk about is hernia. So the watchful waiting theory is based on the fact that not everyone may benefit from surgery, and therefore it may be beneficial to watch fully weight and see if you have more, what should I say, symptoms or signs or situations where surgery would be to your benefit. I’ll give you an example. I saw a patient today, a lovely man, he probably has had his hernia for more than six or seven years. This is based on prior imaging, but he really didn’t have any pain or symptoms until about six weeks ago. Well, and I even have patients who have pain for two days and they come in to see me.

(00:03:42):

I think you should be throwing yourself into surgery if you’ve experienced pain or symptoms for two days. That’s to me a little bit too fast of a projectile. Let’s talk about this. What are you doing to cause the symptoms? What can we do nonsurgically to help reduce your symptoms and so on. And the reason why watchful waiting is an option is because we have had two major prospective randomized clinical trials published, I believe both in 2006 or maybe 2009. I’ll have to look that up. But it’s been a while and one of them has now 10 year data. And if you look back to our multiple hernia talk episodes, I’ve had at least two episodes focusing on watchful waiting. And one of those episodes was with Dr. Robert Fitzgibbons. He is a surgeon in St. Louis, Missouri, I’m sorry, a surgeon in Omaha, Nebraska at Creighton University. And he was the original main author of the prospective randomized clinical trial through the VA system on watchful waiting.

(00:05:05):

His findings were very unique. First of all, he only looked at men. So every time we talk about watchful waiting, it really only is evidence-based in men. And what he did is they enrolled all men that were adults. This is different from the European Watchful Waiting Trial where they only enrolled men over age 50. Regardless, they’re always men and they only enrolled in the US trial. They only enrolled men that had no symptoms, so zero. They didn’t even know they had a hernia or if they saw a bulge, that’s all they had. There was no pain, twining, testicular pain, lower back pain, radiating pain, nothing. And they were active or healthy or whatever the situation was, but they had zero pain in the US trial. They also included what they diagnosed as minimally symptomatic hernias. What does that mean? That means they had symptoms that were minimal.

(00:06:16):

It did not affect their quality of life and did not affect their ability to perform things. So let’s say they were a gardener, they had a bulge in their groin, and every so often if they worked a long shift or something towards the end of the day, they would notice some swelling, but they were able to do all their gardening, go to all the different homes and do all the physical activities necessary for their job. Or it could be a young healthy male who’s a basketball player and he’s noticed a bulge and he plays his basketball perfectly fine. He can shoot the hoops, he can dunk whatever he’d like to do. He can do without any problems with the hernia. But let’s say the coach said, Hey, you got a hernia, maybe you should fix it. So these are both minimally symptomatic or asymptomatic patients.

(00:07:07):

In the European version of the Watchful Waiting Trial, they only enrolled patients without symptoms. So they had a hernia, most likely a bulge, but no symptoms. They just felt like, yeah, I don’t even know I had one or Oh, is that what that bulge was from type situation? So the takeaway message was that watchful waiting is safe in men. What does that mean? That means if you have no symptoms or you are minimally symptomatic, then you don’t need to jump into surgery. And that’s because when I was a resident, we used to book everyone for surgery. You came to the office, you had hernia, you were booked for surgery, and that really taxed the system with the county system. We had five plus year wait list in LA County of people waiting to have their hernias repaired because every single patient that we had who had a hernia we’re like, yeah, we got to get it fixed.

(00:08:04):

What if we don’t fix it? This will get bigger. If it gets bigger, it’s more likely to get stuck. And all this kind of nonsense that was completely not evidence-based. So now we have with Dr. Fitzgibbons and the European trials, the US and European trials, now we have evidence. And what does the evidence show? The evidence shows that if you watch all these patients for five years, so males with or without minimal symptoms, watch them for five years, how many of them needed emergency surgery? How many of them had a complication because they waited from their hernia and so on? And basically virtually no one over the span of five years, they found that the patients that were assigned that were assigned to watchfully wait 0.1% chance per year that they would end up in the emergency room with what they called incarceration where the hernia bulge but got stuck and never was able to be put back in.

(00:09:20):

And then maybe they need surgery. And then what they found was about a quarter of the patients, and these are rough estimates, about a quarter of the patients required. Lemme rephrase that. About a quarter of the patients requested to have hernia repaired because they started getting a larger hernia or their hernia was more painful than their asymptomatic or minimally symptomatic situation. And then they were allowed to have surgery. So that was kind of the way the trial was. Interestingly, they followed the same patients for now 10 years with a good follow-up. And what they found was maybe another total two thirds of patients ended up requiring surgery. But really the number of patients that had complications were nil. People who needed emergency surgery, that was life-threatening was zero. But they did have patients that the hernias got bigger, they were tired of having the hernia, it was maybe caused them more pain, and so they wanted to have their hernia repaired.

(00:10:28):

And that’s about two thirds of patients by seven to 10 years will end up requesting surgery. So in my practice, I’m a big advocate of watchful waiting. However, it must be evidence-based. The reason why I chose the title for today’s talk to be the perils of watchful Waiting, the reason is because there are patients that are being inappropriately assigned to the watchful waiting choice and it has nothing to do with the patient’s request. As a physician, you are responsible to provide appropriate recommendations. So what I have done is I’ve seen people that offer watchful waiting to women. There’s no evidence for that, and they offer watchful waiting to people with clear symptoms. So it hurts them when they do certain activities. Also not evidence-based we believe currently. And that may change because there may be another trial that comes forward. But we believe based on the evidence that we know that watchful waiting is not appropriate if you have symptoms.

(00:11:44):

Because if you have symptoms, it implies that more content is in the hernia. Perhaps it’s being pinched more, it’s being squeezed more. The risk of things going in there and getting stuck is higher and there’s more inflammation which causes the pain. And therefore watchful waiting is not an appropriate decision. You should have surgery. Now it doesn’t mean you need emergency surgery, but the fact of let’s see what happens over the next five to 10 years is not appropriate or go home and let me know if it bothers you more when you already have symptoms is not considered safe. Let’s get into some of the questions here. Thank you for having the live talk. I’ve been using watchful waiting for two years now. Very good. I can only feel an internal lump. Oh and no pain. Perfect. So no pain means you’re asymptomatic and you would qualify for watchful waiting for groin hernia.

(00:12:44):

Sounds like ultrasound and CT scan show a 5.8 by 2.2 by four and a COA means it doesn’t have echoes. That’s ultrasound fluid collection in the subcutaneous soft tissue of the right groin. Not sure if this indicates a hernia. I will get an MRI. Seems like this is a female. If you have a fluid collection, this is very important, very, very important. If you have a fluid collection on imaging where they think you have a hernia, especially if you’re female, it may be a femoral hernia and we need to discuss this. There’s zero evidence that a femoral hernia should be watchfully weighted on or you have a hydrocele eal. And for women, a female hydrocele is called a canal of cyst. Canal of no cyst is a very benign process. It’s just a fluid collection. It doesn’t cause infection. There’s usually no pain associated with it.

(00:13:51):

If you stand, you may notice more bulging kind of like a water balloon. And then if you lay flat, the bulging will go away because that fluid will just fall back into your system. So this understanding that you have an ultrasound on CT scan, you really don’t need an MRI ultrasound on CT scan are perfectly adequate for you. And they’ve already found this fluid collection. The question is, is this a fluid collection which is a femoral hernia in which case you should have surgery or is this a fluid collection in the inguinal canal consistent with a female hydrocele? In which case surgical attention is not necessary unless the bulging bothers you or some people are thinner and you can see the ball, you can see it in a swimsuit or tights, it just doesn’t look good. So we can get those fixed. And remember hydrocele is not a hernia and should not be treated like a hernia.

(00:14:54):

So don’t let anyone say, oh, we’ll do this laparoscopic or robotically. I’m totally against that. I know many do. I don’t agree with it. I think it’s a wrong anatomical decision. Hydrocele EAL in females is like a hydrocele in males and it should be addressed similarly. Anyway. Interesting. That’s interesting, interesting comment you made. Thank you very much. So on that note, what are inappropriate watchful waiting situations? I’ll give you some samples, some examples. I had a patient that I heard about that was a female. Well, I’ve had multiple females actually, unfortunately multiple female patients that I’ve had that were seen by other surgeons and they were told, oh, you have a hernia let’s, you can just ignore it. Let me know, come back. Well, guess what? That was a femoral hernia. It was not an inguinal hernia. And what did I say earlier? There is zero evidence that we know of where femoral hernias can be watchfully weighted upon.

(00:16:05):

Why? Because most people with femoral hernias, about a third of them will need emergency surgery if they’re not addressed. And of that one third 5% will die if they come in with an incarceration of the hernia. That’s a very, very large number to play around with. So all of these women were told to, oh, you got a hernia, you’re older, or whatever the situation was, let’s just see how it goes. And the surgeon didn’t appreciate that this is a femoral hernia. Or actually in one case I think they actually knew it was a femoral hernia and they still said watchful waiting. Completely wrong. Anyway, in one situation, the patient came back about I would say four months later, very sick, deathly ill intestine was stuck in the femoral hernia and she nearly died. Again, I told you there’s a 5% risk of death if you end up with an ignored femoral hernia where intestine gets stuck in it.

(00:17:08):

And we recently had a couple publications go to Kevin md. I have an article there we talk about, and actually Forbes. Forbes reached out and wrote a whole article about inguinal lymph femoral hernias and how they’re misunderstood. So if you want to just read something that’s appropriate for the layperson, both Kevin MD online and Forbes have these great articles where they included me in the article, but we talked about women femoral hernias do not mess with femoral hernias. That is a truly important hernia that must be repaired. So going back, the older patient, she was told to just sit on it until it gets worse. Of course, the next time she was in the emergency room, she was nearly dead. She had intestines stuck in the femoral hernia, which is a different hernia than an inguinal or groin hernia. The intestine was dead. They didn’t take her to surgery fast enough either, and they kind of did the wrong surgery approach.

(00:18:15):

Or lemme preface this, it wasn’t the wrong approach. It was something I probably would not have done. So I’m sure most general surgeons would’ve done exactly what was done, but as a hernia specialist, I know better. So anyway, time was lost and she’s very sick now. She has a bowel disease and dead bowel and the intestines had to be cut out and she had major surgery, open surgery, all these things that could have been prevented if they just fix the damn femoral hernia to begin with. And femoral hernias are very straightforward to repair. You can classically should repair them laparoscopically with mesh, but there are situations where patient’s not healthy enough for general anesthesia or they’re so thin you don’t want to use mesh or whatever the situation is. There are a lot of options. So to say you’re too old to have elective surgery is just not appropriate when it comes to femoral hernias.

(00:19:15):

Here’s a follow-up question. How would you find out if it’s femoral or a hydrocele canal of no cyst? Is there a way to see on imaging? Yeah, absolutely. So both ultrasound and CT scan should be able to show it. The problem is that they’re often misread because most radiologists don’t even know that there’s such a thing as a canal of nexus. I’m sorry to say. I’m sure most general surgeons also don’t know what a canal of NIST is, mostly because they don’t see a lot of women and they’re unaware of the variety of stuff that can happen in female groin. So yeah, I would just get a better idea. One more thing I would say if you’re a female and you are of premenopausal, so if you’re of the age where you’re still getting your period and you may have endometriosis, so this could be an endometrioma or some other reason for a fluid collection.

(00:20:12):

So if I look at it myself, I can tell you what it is. I can tell you if it’s a endometrioma canal of nexus or a femoral hernia. So I’m now actually really kind of curious. I wish we could just bring you on, bring your CAT scan up on this screen, let me read it and we’ll call it a day. But we don’t have that technology right now, but if I saw it myself, I can tell you exactly what it is and help you come up with the appropriate plan of care. But it’s uncommon for typical inguinal hernias in females to have fluid in it. That’s why I’m saying there may be a misdiagnosis.

(00:20:57):

Okay, I will try to get scans to you not close by, but I’ll try. Yeah, if you want, we can do a online consultation or something. Now I’m very curious. Okay, so one thing that is not appropriate for watchful waiting is a femoral hernia in males or females, but of course women are 10 times higher risk of having this problem. The other is in symptomatic patients. So I have had multiple patients that actually have symptoms and maybe they don’t want to have surgery or their doctor offered them watchful waiting as an option and that’s just not an option. You can delay surgery. You can say, listen, I’m a smart person. I have pain in my groin. I know that I need surgery, but my child has a recital. I have to study for exams getting married, whatever the situation is, I would like to delay it.

(00:21:59):

Can we schedule surgery for next year? That’s reasonable, right? You’re going to keep an eye on it. You understand that since your hernia is now bigger and or more painful, you’re no longer in that asymptomatic or minimally symptomatic population of men that are eligible for watchful waiting because it’s now considered safe, but you want to delay surgery, that’s totally fine. I’m okay with that. It’s the people that are told to go home, don’t worry about it. And watchful waiting was offered as an option that I have an issue with. I don’t know if many of you are familiar. There’s something called, what’s the term?

(00:22:51):

It’s basically a philosophy that the physician and the patient should come together and express their wants and then the decision making should include the patient. Of course, the decision making should include the patient. However, I do not believe that it’s appropriate to offer the patient options which are not true options. I’ll give you an example. There was a recent situation I saw where the patient needed surgery. Oh, it’s called, here it is. It’s called shared decision making. It’s when the physician shares the decision making with the patient or the patient shares their decision making with a doctor and that they come up with a plan of care because your views and your morals and your idea of what’s important may be different than mine. I understand that. However, I as a physician am responsible to offer you options based on true options. So I’ll give you an example. There was a patient and they needed surgery. Literally, if they don’t have surgery, they will die.

(00:24:16):

Now based on a shared decision making, they decide to delay surgery. Now, every surgeon knew that by delaying surgery, the patient is higher risk of death, higher risk of surgical site complications, higher risk of surgical site infections. So delaying surgery with the understanding that only surgery will cure them and not having surgery will kill them is not a good option. If the patient’s like, I don’t want to have surgery today. You know what? How about Tuesday and today’s, let’s say Sunday, I don’t feel like having surgery. Meanwhile, their intestine is obstructed, they have a tube down their nose and all these things. That’s not shared decision-making. You cannot say, I highly recommend surgery, but really the timing of it is up to you when the timing of it will adversely affect the patient. I don’t believe that’s appropriate surgical. However, on the flip side, there are plenty of patients that come to see me and they want open surgery.

(00:25:29):

They don’t want general anesthesia, they don’t want mesh in them, et cetera. Or they have specific requests. They want a certain type of suture used. So I’ll give you an example. If you come to my office and based on shared decision making, you come to me and say, listen, I know I have this hernia. It’s been bothering me. I understand that I need to have surgery, but I really don’t want mesh in me. I may say, sure, you’re a healthy young male. The hernia’s not that big. Although evidence shows that if you choose a laparoscopic repair with mesh, you’ll have a shorter recovery time, less postoperative pain, better long-term results with lower recurrence rate. I understand it. You don’t want mesh in you. Tissue repair is perfectly fine. It does have a longer recovery time equal or actually worse risk of chronic pain and higher recurrence rate, but I’m not going to kill you by providing this tissue-based repair.

(00:26:32):

And it’s not a bad repair. It’s legit. You’re a healthy young male with good muscles and a fairly small to medium sized hernia. Yeah, I’ll offer it to you as long as you understand you may recur. And here’s the numbers. I’ll share with you my percentages, and if you recur, you’re going to need mesh. You understand that? Yes, I do. Reasonable shared decision making. What’s not appropriate I think is something a bit more subtle, which is I don’t want mesh in me and I want you to use absorbable suture. Well, there’s no evidence that absorbable suture works for tissue-based repairs. Every single tissue-based repair, s shouldice, McVay, bini, all of them use and were described to be used with permanent mesh. Sorry, permanent suture, no mesh permanent suture. And there are good studies to show that if you replace those permanent sutures with absorbable sutures, it doesn’t work.

(00:27:34):

It’ll fall apart. Higher risk of recurrence to a tissue repair that’s already higher risk for recurrence. So no, if you come to me and you ask for a absorbable suture because that’s what you want, I’m not going to offer that to you because that’s inappropriate. It’s not part of the shared decision making. It is a decision that you’re making that has absolutely no evidence behind it. And I first do no harm, so I don’t want to cause harm by doing an inappropriate procedure. That’s a simple example. Another example would be someone with a really large hernia, and I’ve had multiple people come in to see me. They’ve been so scared of having surgery that they have chosen watchful waiting. Now, this watchful waiting choice may have been appropriate. Initially they had a hernia, it wasn’t that big, didn’t bother them that much, but now they have a humongous hernia and the hernia is down to the middle of their thigh, right?

(00:28:33):

Groin hernia down to the middle of their thigh. Now they’re in my office. Listen, this is bothering man. It’s making, it’s hard to walk now and I really want to get it fixed, but I’ve been delaying my hernia surgery this whole time because I didn’t want mesh in me and now they don’t want mesh to fix their huge inguinal scrotal hernia. Listen, I’m not offering that a huge hernia with very poor tissues, large defect, very little natural tissue to bring together thinned tissue where there is tissue is not an appropriate repair for tissue repair. It’s not even a good repair for meh repair, but it’s definitely not a good repair for tissue repair. So that’s where I think that’s where the perils of watchful waiting fall is. I sometimes see patients that have understood there’s okay to delay surgery and they legit had an asymptomatic or minimally asymptomatic hernia, but now the hernia is so big that they’re now limited in the number of the different types of surgical options that they have.

(00:29:50):

So for example, tissue repair or the hernia has been very symptomatic. I think I gave you this example. There was a great story that a colleague of mine shared. So he’s a surgeon and he had hernias and he is not a general surgeon, right? So he doesn’t know the latest and greatest about hernias, but he knows enough to know that there are people out there with complications and he’s seen them come to the emergency room when he takes call. So he knows that there are mesh related complications and he’s a fit athletic male. So he had just basically like most doctors, and unfortunately some surgeons ignored his hernia and let it grow, but he was always, it would get stuck and he would push it back in. And he had learned as a surgeon how to reduce hernias. So he allowed himself to have these partially obstructing intestinal inguinal hernias, and his whole goal was to delay the need for surgery and perhaps reduce his chance of needing mesh.

(00:31:04):

For example, I don’t know. He didn’t want to get chronic pain. So remember this is a doctor themselves, their surgeon themselves. So they already, they should know more about chronic pain and what causes chronic pain. So I’m listening to this story and in my brain I’m like, the more you’re ignoring these multiply recurrent episodes of obstruction, the more you’re going to risk chronic pain. Why is that? So every time you have a hernia that BULs out and it hurts you and you try and push it back in, the reason why it hurts is because it’s getting stuck or it’s too big for the hole or something’s getting pinched, but that causes inflammation. Inflammation causes pain, but it also causes scarring. So every time over the past 10 or 15 years or however long it was that he decided to ignore his hernias, these multiple episodes of pain and blockage and scar and inflammation, he’s been scarring down the area.

(00:32:14):

And what can happen is you can actually scar down the neck of the hernia so badly that it will never reduce because now you’re stricted down this canal that was naturally open where things can go move in and out and you could push your hernia back in. You’re not pushing it in anymore. So it gets stuck more. So as he was telling his story, my brain was like, you’re doing exactly the wrong thing. If you want to reduce your risk of chronic pain, you should repair your surgery before you’re having all these inflammatory bouts. Hence, once you choose watchful waiting, if your symptoms change and now you have pain, swelling, obstruction, incarceration where things get stuck, those are all indications for need for surgery. It may not mean you need emergency surgery, but you definitely need surgery. Here’s a question. I’m a 39-year-old male located in Toronto with an inguinal hernia that my daughter described as excise.

(00:33:24):

Everyone calls it hernias, excise. I have only had it for a few months and I have no pain. Great, so sounds like a healthy male with an asymptomatic inguinal hernia. I have seen two surgeons about getting it repaired. The surgeon at my local hospital recommended a laparoscopic repair with mesh. I also saw a surgeon at the Shouldice hospital who suggested I was a good candidate for a shouldice repair. Would you recommend going forward with surgery? If so, which surgical method would you recommend? So I’m not a fan of electively repairing hernias that don’t bother you if you have no pain and the hernia sounds is either small to medium size, otherwise the Shouldice hospital would not have offered you surgery If you have a small to medium sized hernia and you don’t even know that, you don’t even have pain from it. My personal recommendation is watchful waiting is safe and you should consider it.

(00:34:21):

Now does that mean you’ll never need surgery? No. Two thirds of you who will fall into this category will have surgery within the first seven to 10 years, but a third of you may never have surgery. And if you’re fit and you don’t have higher risks such as tissue disorders, nicotine use, chronic cough, constipation with straining enlarged prostate with straining or a job where you’re doing repetitive heavy lifting movements. If you don’t have any of those, you can do fine and delay your surgery. So would you recommend going forward with surgery? I don’t feel strongly about that. Choosing no surgery would be a perfectly safe method, safe option. Now, let’s say you’re tired of having abul. It’s visible. You’re of a personality where you’re constantly thinking about your hernia, and so even though it’s not bothering you, it psychologically is affecting you and you can’t concentrate on things or you’re tired of seeing the bulge, whatever. If you then do choose to have hernias, most patients will do better with a laparoscopic repair with mesh if the surgeon is a specialist in doing that. So if the surgeon is gifted surgeon, talented surgeon has had multiple, many, many years of experience doing laparoscopic surgery with mesh as a male, you’ll do best with that. Now that said, I have had a great episode with one of the shouldice hospital surgeons, Dr. Spencer Netto, who unfortunately has now left the S Shouldice Hospital, but the SHO ice repair is a very, very good repair.

(00:36:11):

It’s a tissue-based repair. It’s perfectly done at the Shouldice Hospital, the surgeon’s there. That’s pretty much all they do, and you should have a very good outcome. It’s not perfect. Don’t expect a perfect operation anywhere you go, whether it’s the laparoscopic repair or the shoulder ice repair, you can always are at risk for recurrence, you’re at risk for chronic pain and so on. I personally don’t like going in anteriorly, which is the front with a scar in young healthy males. I think it’s just too much risk of nerves and stuff getting even in scar tissue. It gets stuck in scar tissue. So if I were you and I were a 39-year-old male with an asymptomatic hernia, I would delay my surgery until I have symptoms. And when I do or if the hernia starts getting bigger, I would choose a laparoscopic with mesh. But if there’s any reason that you don’t want mesh or you feel like you have an autoimmune disorder or you’re okay getting the shouldice repair with the wrist that you may need a laparoscopic repair if it fails, you can’t go wrong. You live in Toronto, you have the best of both worlds. So best of luck too for all that, but I would just focus on exercising and making sure you don’t have a chronic cough or constipation and reduce any of the treatable risks that are there for hernias getting worse. So that’s kind of what I want to talk about, which was the perils of watchful waiting, which is that if you let your hernia grow too big, then you reduce your chances of having a lot of different options.

(00:37:58):

If you have symptoms, you are not a candidate for watchful waiting. That’ll be inappropriate and too many doctors maybe are inappropriately recommending watchful waiting. And if you’re a female, there’s no rule for watchful waiting. Now the good news is, as you may have watched one of my past episodes with one of the surgeons over at Michigan University of Michigan, they are talking about starting a watchful waiting trial for women. That’s exciting. Very, very badly needed, but I will give you more information on that as I hear it. Here’s another question. My angle hernia is small in a bladder hernia, not the intestines. Okay, so that means your bladder is involved in your angle hernia, which can happen. Is there less risk of strangulation with the bladder? So the issue, the short answer is yes, strangulation is typically only with small intestine, infrequently with colon or fat and almost never with a bladder.

(00:39:08):

So if you have a small inal hernia and there’s bladder in it, usually that’s a direct hernia. It’s uncommon to have bladder involved in an indirect angle hernia with the bladder involved in the hernia, you sometimes trap some urine in that hernia, and so when you empty your bladder, you’re not really emptying your bladder, it’s getting stuck some fluid in your hernia. And so some people have recurrent urinary infections because you have urine that stays there. That’s one risk of not addressing your hernia. And the second is that have, what do you call it, just pain with a full bladder. People get full bladders every time right before the urinate. So it could be that you’re getting recurrent episodes of pain daily because as your bladder fills, your is filling and therefore you’re getting more groin pain. Those are very important to get addressed by a specialist because you don’t want them to go in not understanding that the bladder is involved in the hernia and then they accidentally injure the bladder while trying to approach the hernia or sew the hernia or close the hernia or dissect out the hernia. The bladder can be there. Now, one thing to remember is if you’ve had surgery before and that surgery involved removing mesh or something like that and you have now a hernia, sometimes the mesh removal process and then the closure of things in the area can pull the bladder into the scar tissue near the hernia as opposed to you actually having a true bladder hernia.

(00:41:12):

I hope that makes sense. I don’t know how better to say that, but if you have robotic or laparoscopic revisional surgery and you’re removing mesh, sometimes the bladder can scar into the hernia. It looks like there’s a bladder hernia, but it’s not really the problem. This should not be confused with what we call cystocele, which is a pelvic floor hernia, not an inal hernia where the bladder falls into the pelvic floor and makes it difficult to urinate because as you want to urinate, it’s kind of like kinked at the bladder usually in the females. Oh see, look it. He just responded. He says, yes, thanks. I did have mesh removal. Okay, so if you had mesh removal laparoscopically or robotically at the end of the procedure, they then close the peritoneum, which is the layer and the bladder can get pulled towards your groin, but that’s different than actually having a natural hernia into which the bladder falls.

(00:42:18):

So if you have imaging which shows your bladder just pulled to one side or pulled into a hernia, that’s a different story. And usually it’s not a hernia unless you actually have a hernia now, but if you have a hernia that implies you had mesh removed, but the hernia was not repaired unless you had a mesh infection, usually, usually we repair those hernias at the same time unless the plan is to do what’s called a stage repair. So we take out your mesh, let’s see how you do without the mesh, and then once that is healed, then we’ll discuss how to now repair your hernia because we’ve confirmed that the mesh removal got rid of all the pain that you had from the mesh. Does that make sense? I hope that makes sense. Okay. Sometimes they can get complicated. I’ll tell you, it’s so funny.

(00:43:15):

I enjoy, as you know, I enjoy, what do you call it, puzzle solving. I enjoy it when people see, there we go. He just responded. Yes, exactly. I don’t even know your situation. And guess what? I exactly figured it out. It comes from experience. My friend comes with experience, but every so often I have these situations, people call me and they ask me these half questions. They only tell me half the story and they ask me a question and I’ve already figured out the other half. They haven’t told me because I’ve seen the situation before. Or I would say, oh, I bet blah, blah, blah. And they’re like, yeah, that’s exactly what it was or exactly what happened. And so yeah, that’s the, who was it someone recently, it was a surgeon in I think Mexico who reached out to me and had some questions and I helped answer those questions and he wanted to do something that I’ve already done multiple times and it’s failed and I’ve learned from my experience.

(00:44:23):

He said, well, don’t you think if I should try? I said, listen, you can try, but I’ve already tried. It doesn’t work. So if you want to personally that fine, but if you’re asking me, I wouldn’t not redo that. Again, I’m trying to think what the situation was. If I look in my text, I’ll tell you what it is, but simple things like don’t put mesh on mesh or don’t leave part of the mesh behind in a mesh infection situation and or put a drain in when you use a biologic mesh. These are all things where people think they’re reinventing the wheel and those of us that are older have already done it. We’ve experienced the problems. Just don’t do it. It’s so important. It’s so, so important that people like me and others publish and give talks and educate people around us so that they don’t repeat the same problems that I repeat.

(00:45:23):

So many times I see either at conferences or other things that people will make mistakes that those of us that have been through the ring, we totally know that that should not have been done because that’s a clearly not going to be a good outcome, but they do it because they don’t know. Here’s a question. Can a hernia ever be missed laparoscopically during the operation? Can the hernia hide? Well, good question. Yes, laparoscopic surgery can miss a hernia. How is that? If your surgeon goes in laparoscopically and they say, I’m going to go in there and take a look, which I’m totally against, by the way, there’s enough information from imaging not to have to go in there and take a look with no plan.

(00:46:19):

You should know if there’s a hernia or not based on imaging, but let’s say you’re a circumstance, I’m going to go in there and take a look. Well, let tell you this, you can miss hernias if you just put a camera in and take a look. Why is that? So what is a hernia? A hernia is a hole through the muscle. What’s in that hole that will cause the pain, fat or peritoneum or bowel? So if you have bowel in your hernia, you also have peritoneum and maybe fat if you have peritoneum in the hernia. And then when you go inside with laparoscopic, you’ll see a loop of intestine in the hernia. That’s clearly a hernia. If the bowel is not involved and you just have the peritoneum bulging into the hernia, when you go in laparoscopic, you’ll see that it’s like a dimple. You dimple of you see a hole with a dimple of peritoneum going into it.

(00:47:20):

However, and this is very important for females, especially in some very thin patients or any younger, if you do not see a dimple of that peritoneum, that does not mean on the other side of the peritoneum there isn’t fat that is inside the hernia causing symptoms. And this happened to a recent patient who was quite young and she had laparoscopic surgery. And what I say, female, young, those patients tend to have smaller hernias and usually fat in there. So what you really have to do if you suspect a hernia is in addition to going in with the laparoscopy and just taking a look, you have to actively remove the peritoneum off of the muscle, look at the actual muscle hole, not the covering on it, which is the peritoneum, and see if there’s a hole and if there’s content such as fat inside that hole.

(00:48:23):

Because if there is, that’s a hernia and that’s how those hernias can get missed because all you see is from the inside perfectly normal peritoneum, and you don’t see what’s on the other side, which is fat going into the hole. So that’s really, that comes with experience, that comes with knowledge of anatomy. That comes with thinking outside the box. This poor girl, she was bounced around because she had exactly the situation and no one could figure out why she had so much pain and it’s because they missed the fact that there’s fat on the other side of the peritoneum in the little hole. And there were some surgeons that were even offering her triple neurectomy, which I think is just nuts to do in a young girl, but she just had a small hernia that required repair.

(00:49:17):

I’ll tell you something interesting. I was having lunch with some friends and I live in my own little bubble, right? So I think I come here every week and I talk about hernias and how they can cause pain. And if there’s no bulge, doesn’t mean there’s no hernia. And if you have testicular pain or pain with sex, sexual function and orgasm or vaginal pain or pain with your menses, a pain that goes through your inner thigh around your lower back bloating, these are all potential causes from an inguinal hernia. Or what about urinary frequency, right? But what I keep getting reminded is not everyone listens to this podcast. It would be great, but they don’t, not everyone reads my papers. Not everyone shows up to the conferences that I give talks at and not everyone cares. So there are tons and tons of doctors throughout the world that are currently mislabeling patients as having chronic pain, chronic pain, interstitial cystitis, predental, neuralgia, vulvodynia. And these poor patients go through all these different diagnoses and they don’t know that all they have is a hernia that’s been missed similar to the concept that we’re talking about here with this one patient. Okay, going back to the patient that had the bladder hernia, I had a bladder inguinal hernia. I had systemic symptoms because of the mesh. It was removed by Dr. Brian Jacob. Okay, great. I live in Paris.

(00:51:09):

I had also lost my ejaculations because I was born with only one testicle on the mesh side. Okay? The mesh was obstructing the spermatic cord. Jesus, are you serious? That’s horrible. You have helped me with this so much during these talks. Oh, so glad I got my sexuality back. Thanks to mesh removal, I now have a small recurrence along with a spermatic cord lipoma given the trauma I went through with mesh, should I wait or have a SHO dice as quickly as possible? I’m weary of surgery now as I felt emasculated once already. Dr. Jacob did not fix the hernia. It was not visible during the removal. Thank you so much for all your guidance, which helped me decide on removal. Okay, this is a very interesting situation. Typically, I would say, yeah, you had a bad outcome with mesh. You now have a small hernia recurrence that’s bothering you and you wanted a shoulder ized repair.

(00:52:13):

It’s not standard, but I understand it and I would support you getting a shoulder. However, this is a big however in your situation, you have one testicle and if you want to keep that one testicle, you have to do as much as possible operations that will not risk blood flow to that testicle. And how do you reduce that? By doing everything laparoscopically or robotically, doing an open repair, even by a very good surgeon, Shouldice technique puts you at higher risk of complications with that one testicle than if you did everything posteriorly, the laparoscopically or robotically. So if the hernia’s not bothering you, I would leave it alone. And if it is bothering you, I would seriously consider laparoscopic or robotic laparoscopic or robotic surgery with some other type of mesh, even the hybrid mesh.

(00:53:30):

What’s important is to make sure you don’t have any blood flow issues to your testicle. Okay, so important to tell this person about the blood flow. Yes. So the blood flow to the testicle comes from multiple different areas, like five different ways, but the most proximal way is laparoscopically or robotically. But if you completely disrupt the blood flow laparoscopically robotically, you have so much other blood flow further down towards your testicle. That doesn’t matter. However, if you have surgery further down the road like open surgery closer to your testicle and you disrupt blood flow in that space, then you’re at serious risk of having blood flow issues to your testicle, which can have effects on your sexuality because you need blood flow to the testicle to make testosterone. You don’t have a second testicle to make up for the testosterone of the other side. And putting fertility aside, just the testosterone itself is an issue. So I would have serious discussions. Having multiple operations posteriorly, robotically doesn’t affect your blood flow as much as having even one operation anteriorly, which is like a shouldice repair. So I would just put it out there. Since your situation’s unique in that you only have one testicle, it’s on the hernia side, and I assume you’re young enough that well, you need testosterone and it’s not cool to have your one remaining testicle have poor blood flow to it.

(00:55:13):

We didn’t talk about ventral hernias. So abdominal wall and umbilical hernias, and I would say that umbilical hernias, watchful waiting is considered appropriate for those similar to ular hernias. If you have symptoms, you should not operate on typical umbilical hernias unless you are a model. You don’t want to have an Audi. And there are multiple models out there, by the way, who do have Audis, you need to call me because I can fix it. But typically for belly button hernias, we would recommend watchful waiting as well. If it’s not bothering you, I do offer those belly button hernias to get fixed if they are planning on having another surgery and the hernia is going to be in the way, let’s say laparoscopic surgery. And then there’s one question which I thought was sent in which was really insightful and I’ll share it with you. And it’s this one, let me share it with you real quick.

(00:56:19):

And it was, are there any situations, are there size limits besides beyond which you no longer recommend watchful waiting despite the patient being asymptomatic or middle asymptomatic? So for angulo hernias, we recommend that once you have the hernia extend to the scrotum, that’s way too late and you should really get your hernias repaired before they reach the scrotum because once they do hit the scrotum, hernia repair, risk increase complications, increase recurrence increases the patient’s already uncomfortable at that situation, and then your options for surgery are also decreased. So chronic pain is higher, all that. So it’s a better hernia repair if you don’t wait until you have a scrotal hernia. Now what about the belly? What’s interesting is there are patients with really huge hernias in the belly that have no pain. It’s just enormous. And there’s a study also by Dr. Fitzgibbons that looked at hernias nine centimeters wide or greater.

(00:57:33):

So these are giant hernias and found that the quality of life is so much better in these patients once this is repaired that it’s worth repairing. I want to say this again, it’s not that they’re saving lives necessarily, but the quality of life, even with just the big operation and the reconstruction, the long recovery and the pain and all that. Patients with these deforming nine centimeter or larger abdominal wall hernias are so much happier, have a much more productive lifestyle, are more active and are healthier after their hernia repair, that it’s worth offering hernia repairs to these people who actually don’t even have symptoms because many surgeons actually don’t offer surgery, mostly because they don’t want to be the one doing these big complicate operations. They’re like, oh, well, it doesn’t bother you just wear a binder. I see these patients a lot. They’re told, oh, just wear a binder.

(00:58:50):

And I’m like, yeah, but the patient’s skin is so thinning and they’re at risk for serious complications. But we actually now have studies that show nine centimeter or greater hernias, you should get those repaired. It really will make you a better position. What are the risks of having an incarcerated or strangulate hernia? And can a hernia become strangled without first becoming incarcerated? So we don’t know. We don’t know. What if you first have to incarcerate and then strangulate, or do you go straight from normal to strangulation With femoral hernias, often it just goes straight to strangulation because it’s such a small hole. But we don’t have enough evidence to support the trajectory of hernias. But we do know for ular hernias, there’s a 0.18% per year risk of incarceration for asymptomatic or minimally symptomatic hernias. So it’s a small number while undergoing watchful waiting for a hernia. What symptoms demand seeking urgent medical attention, we reviewed that basically pain, sometimes bloating, vomiting for sure.

(01:00:04):

And of course, I would say getting as it gets bigger, there’s another question in addition to pain, discomfort and bulging, which I just talked about. Should functional limitations such as having to wear a binder or restricting some type of physical activities, be considered as a sufficient reason to recommend surgery as opposed to watchful waiting? So the answer is yes. Like I just mentioned in the really big hernias, nine centimeters or greater where they do have to wear a binder and they’re restricted in the type of activities they can do, they can barely bend down, for example, to tie their shoelace. It’s very heavy to pull around this heavy weighted bulging. Then yeah, you really do improve their quality of life. The same is true for angle hernias. So if you have anular hernia that is reaching down into your scrotum, that’s also very, very uncomfortable and of discomfort, and I would suggest that you get those repaired to improve your quality of life.

(01:01:11):

So that’s kind of my 2 cents about that. So that’s it. I think you guys did a really nice job of hanging in there with me and I hope I was able to answer all your questions. That was really fun. Free to talk live episode, the perils of watchful waiting. Thanks everyone for joining me on Hernia Talk Live, another great Hernia Talk Tuesday. The sun is shining in beautiful Beverly Hills. I hope you can see it on screen. For those of you that are watching, you can go on my YouTube channel to watch this and all prior episodes at Hernia Doc. Don’t forget to subscribe and that will allow more people to find me on YouTube, but also on my podcast. So go to the podcast and listen. In fact, I had a patient, was it yesterday, who called and she was listening to the podcast. I really liked episode number 82 with one of the nurses who was a patient of mine and was asking about a book that we recommended in that episode. So I believe it’s in the show notes regardless. Thanks for watching. Thanks for sharing, and thanks for following. Talk to you guys later.