186. Joy of Hernia Surgery

This week, the topic of discussion was:
-Research
-Innovations
-Mesh
-Non-Mesh
-Mesh Implant Illness
-Surgical Collaborations
-American Hernia Society
-International Hernia Collaboration
-European Hernia Society
-Hernia Surgeon Alliance

Welcome to HerniaTalk LIVE, a Q&A hosted by Dr. Shirin Towfigh, hernia and laparoscopic surgery specialist who practices at the Beverly Hills Hernia Center. This is the only Q&A of its kind, aimed at educating and empowering patients about all things related to hernias and hernia-related complications. For a personal consultation with Dr. Towfigh: +1-310-358-5020, info@beverlyhillsherniacenter.com.

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Transcript

Dr. Towfigh (00:10):

Hi everyone, it's Dr. Towfigh. Welcome to Hernia Talk Live. My name is Shirin Towfigh. I am your hernia and laparoscopic surgery specialist. Thanks to everyone who's joining me live on Facebook as well as Zoom. Many of you also follow me on Twitter and Instagram at Hernia Doc. We've been very active lately because I've been going to a lot of meetings and I showcase most of my meetings on Twitter. As you know, this episode and all prior episodes are archived on my YouTube channel. So do go there, youtube.com/at hernia doc. And for those of you who enjoy podcasts, we are a full podcast, almost 190 episodes. So do listen while you're driving to work or in an airplane or something. Listen to our podcast. So thanks for joining today. I thought we'd have some fun today because the topic today is called the Joy of Hernia Surgery.

(01:14):

And I picked this topic because I recently been asked to give a talk at one of our local universities at one of our local departments of surgery. And I had given talks before. These are all called grand rounds. For those of you that are unaware, there's something called grand rounds. And back in the day, I would say, well before my generation of residency, grand rounds was rounding. So they would invite a professor, let's say Halstead or someone really famous, they'd invite an important professor to the hospital, and that professor would walk around the hospital and the residents would present patient situations and cases and they would gain knowledge and energy from the gain energy knowledge from the invited guest. So let's say Dr. Let's say Halstead or someone of that nature was invited to let's say Harvard. And then all the professor, like the local residents and so on would be handpicked to surround him as he walks down of the hallways of the hospital and they stand in front of, let's say a patient.

(02:41):

And the resident that's the most junior would present the patient and would say, okay, this patient presented the emergency room with this, that and the other. And then it would be, let's say a complicated pancreas cancer or something like that. And then the invited professor would share his knowledge with his trainee audience and he would also ask questions of some of the residents to gain kind of, we call it pimping. It's not a good term anymore, but the medical term, the lay term within the medical field is called pimping, which means you ask a question of a resident to kind of seek their knowledge and hopefully they can answer the question. And if you don't know the answer, it's kind of embarrassing. That's how grand rounds used to be. It's now become a much more formal lecture series. So when you hear the word grand rounds, it's no longer rounding on patients.

(03:46):

It's actually going to a lecture hall. And anyone who's a member of the faculty of the department of surgery, for example, in my case, the residents, the medical students as well as the surgical attendings would come to grand rounds and they would listen to the lecture. So I've been asked to give grand rounds at multiple different hospitals. I've been to Texas and multiple areas in California and Arizona, and where else have I, I've been running out of Boston. So those have all been really great area Florida, where I've been invited to be a guest lecturer for grand rounds. And just so you know, this is different than the talks that I give for my research, which tend to be at surgical society meetings. And those last about anywhere from minimum three minutes to maybe maximum 20 to 30 minutes. Sometimes there are courses that I teach also usually related to a surgical society of some sort.

(04:47):

I may travel for many of those or I'm invited to give a talk. Usually those talks are 15 to 20 minutes, up to 30 minutes on a specific topic. Grand rounds is a totally different experience. You're invited by the university, you're treated like a big deal person. Often they fly you out, you meet with the, traditionally, you meet with the select people as an introductory dinner the night before. So they treat you to a really nice dinner and you get to either meet certain key faculty members that have been chosen. Utah was another one that have been chosen to kind of personally meet you at the dinner or impressionable junior residents, chief residents, whatever the situation may be. Oftentimes a chairperson is there. That's the night before. Then the morning of you are chosen to give grand rounds. That's an hour talk and question and answer session.

(05:50):

It's usually about some type of topic that is relevant to your expertise. And my expertise usually has been on hernias, although a couple of times I've been asked to talk about professionalism and social media and medicine and surgery. And also I've been asked to give talks on career advice, but usually it's a hernia talk. But in addition to that one hour, you then have a separate hour where you're part of the educational series for the residents where they have morbidity and ality conference, and often they choose a complication that's hernia related so that you as the via guests can be relevant to that discussion and share your knowledge. And then oftentimes in addition to that, there's a third hour where you're either overseeing some type of case presentations where they pick and choose complicated. Let's say in my case, hernia patients where the resident would suggest this is the situation, then they would say, okay, Dr.

(06:55):

Towfigh, thanks for coming as your guest, we would really like your opinion as to how you would manage this patient or what we should be worried about in this patient or how we should optimize the patient. Or you sit down and almost like a boardroom type situation with residents surrounding you, mostly providing mentorship and guidance to the younger residents. Often these are either chief residents that are almost graduating or these are residents in the lab that have time dedicated to making themselves a better surgical resident and have questions about training and education and fellowship and how to find a job and those kinds of things. So last week I was giving grand rounds and of course it was a dinner. Then the morning was the morbidity mortality conference, my grand rounds talk, and also the case presentations hours. So really, really fun. I enjoy that part a lot.

(07:56):

The people in the audience sometimes know me personally in this situation, I had former medical students, former residents, former colleagues from other institutions that are now this new institution. They're all part of the audience. And I had people that aren't even general surgeons that showed up, which was really awesome because they wanted to hear me talk. Anyway, one of the talks I'd given the past, the one in one of the ones in Texas, I'd given three in Texas, different institutions was the joy of hernia surgery. And I was asked at this one from last week to not only talk about what's old and what's new in hernia surgery, which is kind of boring, but also to integrate something about the joy of surgery because my hernia surgery, because my audience are a lot of medical students, residents and junior faculty, and I thought, how cool would it be if I give you a little glimpse of what I talked about because I personally find hernia surgery amazing.

(09:06):

It's been a fantastic part of my new life and I would love to be able to share that joy with my fellow trainees and so on. So the topic that I talk about with joy of hernia surgery spanned a lot of things. First of all, I was very clear that when I was in residency, I didn't appreciate hernia surgery and the beauty of it. And it wasn't until I was in my first job at the county hospital, which I loved. It was probably my best job ever that I started to really like hernia surgery. I had a lot of patients come and see me and say, how did you get into hernia surgery? It just seems so random, and it's usually not a very female friendly or female centric specialty in surgery. Totally random. I did not expect, and I always tell my residents, you can't predict your future.

(10:12):

So I fell in love with hernia surgery because while I was at the county hospital, I saw how much I was able to improve the quality of life of my patients. I was the first to bring laparoscopic hernia surgery to the county before they were doing everything open. And then I was able to kind of bring in reconstruction with novel ways of dealing with mesh infections at the county hospital. And I'd never forget my very first patient, my very first patient as a bonafide board certified doctor at the county hospital was this lovely lady. She had a job, I dunno why she, I think it was during the time when having a job did not mean you had health insurance. And so she had a legit job. She had a complication from her, I think hysterectomy or C-section, I think hysterectomy, where she went home and her wound completely fell apart.

(11:15):

Her intestines were out in the open. So they did emergency surgery on her, and then later on she got a hernia. So then they put mesh in her, the mesh got infected and no one took ownership of her. The general surgeons didn't feel like they're responsible for this wound because it was a GYN wound. They would send her to the gynecologist. The gynecologist said, Hey, we don't deal with abdominal wall hernias. You are the ones that put mesh in her and now she's infected. They would pass her on to the general surgeons, they would send her to infectious diseases and pain management. And basically she wasn't getting the care she needed until she saw me. And I'm like, oh, mesh infection, I can do that. I know how to handle mesh infections because I was already trained in that during my residency. I felt comfortable with that problem.

(12:04):

And so I took out her infected mesh, put in biologic, recreate her abdominal wall, and she was back to work. She was working before, but because she had an infection and pus draining out, she would literally take 15 minute breaks every couple hours, go to the bathroom and change her dressing, and no one would know at her work that she had to do this. It was just a horrible quality of life and I was able to fix that. So I fell in love with just such a simple procedure. If you know what you're doing, you can help the patient. So I said, okay, now I need to learn more about what I'm doing. And I got involved with the American Hernia Society, and long story short, I'm now here where I am. So I shared the fact that not only should you discount certain specialties out of your future because you never know if you may be a hernia surgeon, but also the fact that nowadays hernias are so much more interesting, so much more exciting.

(13:11):

We have open laparoscopic and robotic approaches. We got new robots coming out. We have new technologies, new meshes, new non mesh techniques that were coming out. I shared how much I enjoy working with urologists in the operating room and gynecologists in the operating room and learning what spine surgeons do so that when the spine surgeon has a complication, they send it to me. Or if a plastic surgeon has a complication, they send it to me. And I really loved this collaboration with other specialties, which you kind of are exposed to a little bit during residency, but once you're out of residency and you go into your job as an attending surgeon, you tend to be very isolated in your own field unless you have a practice like mine, which is hernia surgery. And so I was sharing this with all the residents, right? And I told 'em, I said, listen, I hope you find joy in whatever practice that you choose, but for me in general surgery, I've been able to then be innovative, right?

(14:20):

I would see what's wrong out there and try to make it better. I have nine patents on gender specific meshes that are, I believe are safer and more effective than the current meshes that are currently being sold, especially for women. I've invented new techniques of non mesh robotic angle hernia repairs so that you can have a minimally invasive repair without the need for mesh. I've come up with an innovative way of using a tummy tuck as a way of a hernia repair to reduce the use of mesh in patients that have incisional hernias that would otherwise need mesh for their hernia repair. Just really cool stuff. And this week we had two papers that were published both on gender-based factors, one called Hidden hernias Hurt, where we expose all the ways in which people can present with hernias besides just having a bulge. Most of it related to pain and the types of pain they can complain about.

(15:22):

So that your gynecologist, urologist, family medicine doctor hopefully will learn to ask about these topics, ask about these questions, to be able to figure out that your chronic pelvic pain is due to a hernia. Send it to a hernia surgeon, have us fix the hernia, improve your quality of life, and get you pain free instead of what we observe happening, which is a two year delay in diagnosis, mostly in young women, lots of narcotics being handed out to an otherwise perfectly curable pain, which is your hernia pain. So these things give me joy. It gives me joy to be able to go to a hernia conference like I was at two weeks ago in Chicago at the American Hernia Society and listen to talks by major surgeons that are colleagues of mine who've been very influential in the field, but then also have younger surgeons come up to me and want to take a picture with me or introduce themselves and tell me how much they're interested or even collaborate with junior faculty and residents at the meeting. And I now have two papers published with a student I've never known before, but many of you may know that I sponsor an annual research scholarship personally fund the research scholarship to promote research and discussion of females and gender specific factors in her new research. There's not enough research being done on females. And this student won the award and now I'm writing two papers with him and he's an amazing student. And hopefully soon we'll get into an excellent residency in the United States.

(17:14):

I got a lot of comments from you guys already. I need to stop talking. I can't stop talking about the joy of hernias surgery. It really has been a joy so far and the fact that I can take my little niche in the world and improve quality of care for all people, especially the young, especially the females, especially those who aren't listened to with mesh implant illness, that it's a real problem and you can't fake a rash even if people think that everything else that's psychological, you're faking. Here's a comment from one of you. Thank you Shirin, for all you do for us who can't have mesh due to previous complications. Yeah, it's a problem. Listen, we're not in a perfect world and the meshes that we have are flawed. Some of them hurt patients, some of them are perfectly good, but there are some patients that are allergic to it or react to it like any medication, like any food potentially.

(18:18):

But what really pisses me off are the companies that are allowing faulty meshes to be on the market or allowing less of medical grade meshes to be in the market. And as you may know, patients ask me, what is this mesher putting in mean? I'm like, oh, it's polypropylene. What is that? Is that like plastic? And I said, well, it's like medical grade plastic. But honestly, I can't even say that anymore because it used to be medical grade plastic when it was called Marx, and it was made in the United States by Chevron Phillips in Texas, and there were some standards to which the FDA had already tested this specific type of polypropylene. But there's new evidence that shows that oftentimes companies have chosen no longer to use the same exact distributor manufacturer from Texas, and they're going overseas often to China according to some of these evidences found in the lawsuits that many of you know about against the mesh companies, and they're buying less than medical grade polypropylene.

(19:34):

So the fact that I'm trying to tell someone is medical grade is really not honest. I can't really say that anymore. We don't know that it's medical grade plastic anymore. It's a little bit different than what the FDA has already approved. So at some point, this will all get corrected. Us surgeons, we surgeons are just a little helpless because there's not much we can do to influence the companies that are making these products, but it's just a problem. Here's the question. What are your thoughts on Surgimend bio mesh as in the uk it was recalled due to major complications. Yeah, a lot of the companies, including SME products and others, how should I say this? So companies are trying to come up with a better form of mesh, so they're moving away from the pure synthetic meshes and they're moving into the biologic world. We know from AlloDerm, which was a high quality cadaveric product, but anything lesser than being high quality, the body sees as being very foreign.

(20:49):

And so even though it's biologic, it's absorbable. If it's not a high quality product, then what you can see is the body sees it as very foreign and it's highly reactive to it. There's a big inflammatory reaction to it. The foreign body reaction to it is much more, and therefore it's not as effective. You might as well use synthetic mesh and they don't absorb. By the way, a lot of these meshes do not absorb because they're very synthetic, because they're overly processed. And the more you process a product, the cheaper the product. It is really hard to develop a very high quality product. Making it pure is much more expensive than making it just zap it with chemicals.

(21:51):

So Serge and others similar to it, phasix, many of these companies are trying to try to say Mesh what? Meh, we don't sell mesh. We sell this amazing absorbable product, synthetic absorbable product or a biologic absorbable that's very synthetic. And so like I said, we're not in a perfect world and therefore the products that are out there are not perfect and they're not so egregious that they're actively hurting a big swath of patients, but we definitely have patients that are being not helped by certain meshes. Another question, what are the potential causes of pain from a laparoscopically placed mesh that is fixated with tax? Wow, that's like a full lecture, but I'll run through it really quickly. Laparoscopic mesh repair with fixation with tax can be a perfectly good, good technique. You can have a hernia recurrence, you can have mesh infection. The mesh may be placed too tightly, which will cause you pain.

(23:07):

It may be too loose or inappropriately placed, so you'll get a hernia recurrence or the mesh will fall into the defect. You have to close a lot of those defects. If it's ventral, you got to pick the right size mesh and appropriate weight mesh for the patient's type of hernia and body habitus and the place where you're putting it, you can get pain from attacks, the attacks can pull through or you can put it in too tight and those can cause either pain or tearing of the muscles. But if you use too many attacks, that can cause a lot of muscle spasm. I mean, there's a lot, and there's a reason why we are promoting a hernia surgery specialty because most general surgeons do not know the gamut of complications that any one procedure can be at risk for. And they don't understand that putting a heavyweight mesh in a thin lady or a lightweight mesh in an obese male can have consequences and they can just think there's mesh. There's literally situations where I am told people are just ask, well, what mesh does to if I use, and then that's the mesh they use, not understanding that I may use different types of meshes for different types of situations. And when the nurse says, okay, doctor, are you ready for your mesh? And the doctor says, yeah, give me the mesh. They go, which mesh do you want? Because we have a whole inventory of meshes out here. And they say, well, whatever Towfigh uses, that's not the right answer.

(24:45):

That's just crazy to me. Here's another comment. I wish all hernia surgeons were as honest as you think. I think surgeons are afraid to say what's on their mind and they're afraid of being exposed. We, for those of you that listened to our Hernia Talk episode last week with Dr. Collins, she's great, by the way. She's one of my favorite people. We talked about a New York Times article that exposed the practice of many surgeons who are not skilled and or don't really have the experience of doing certain types of complicated procedures. They go to a conference, they may watch it on YouTube, they may go to a course even, and then they start doing this very complicated procedure on their own. And the problem is you can name a person by causing nerve injury in many of these patients and the New York Times for some reason, decide that's a good topic to talk about.

(25:54):

And let me tell you, so many hernias surgeons took offense to this article. I don't know why. If you're doing a good job, then you're doing a good job. But if you're part of the problem, you need to look at the world not from your own point of view, but from the patient and or public's point of view. So you may think you're doing the right thing, but if patients are out there and what they're thinking is, wow, you're basically putting videos out there with no caveats saying this is how you should do hernias. And surgeon's like, okay, I'm just going to do this hernia, and you're not part of the process of holding courses, teaching, or as a society, you're not part of the process of teaching and so on. Then maybe you should be a bit more, have more of a caveat when you give a talk.

(26:55):

So I give talks for example, about robotic ular hernia repair with no mesh, right? You may think, wow, that's like, that's it. I'm going to go and give all my patients this procedure. It's minimally invasive and I don't need to use mesh wrong. Every time I give a talk about it, I say, this is not a good procedure for the majority of patients, you must be non-obese, non overweight. You must have a small, indirect or direct inal hernia. So small, you can't see the hernia from the outside, but you are symptomatic from it. Do not apply this to a large hernia, big hernia, visible hernia, obese patient, et cetera. I say this every single topic, why? Because I don't want to be promoting a technique that's inappropriate for certain patient population. I want to make sure it's understood and it's written in my paper and it's written in anything that I talk about transcribed in anything that I talk about with this topic. You must only reserve this technique on thin patients with small hernias. Listen, it's a tool in the toolbox. I'm not here to invent a product that everyone can use necessarily, but if it can help a handful of patients that are thinner and are mesh reactive, have a small hernia, why not put mesh in those people? Why put a huge piece of mesh, someone with a four millimeter hernia? That just makes no sense to me.

(28:43):

Also, the tummy tuck situation, it is great to be able to offer a tummy tuck and the appropriate candidate and use the tummy tuck as their permanent biologic reconstruction of the abdominal wall without using mesh only. So far, we've shown it to work for up to four centimeter hernias, and it only works in people that are candidates for tummy tuck. So don't bring a morbidly obese patient with a lot of intraabdominal fat with a diastasis to get this procedure. It doesn't work. You have to have an appropriate cosmetic candidate first, and then if they also have a hernia that usually requires mesh such as an incisional hernia, then you can apply it. So again, put restrictions if there are restrictions to your type of procedure. I personally have been seeing way too many people get abdominal reconstructions robotically or open tar. You've heard the word tar.

(29:42):

TAR stands for trans versus abdominals release. Everyone's doing it. What the hell? You don't need to do it. I had an argument with a surgeon who had the balls to tell me that it's totally okay to not close all the abdominal wall layers. I'm like, no, you have to close the posterior layer in addition to the anterior layer. And he was arguing with me that he never closes the posterior layer. And I'm like, but why not? If you can close it, you should be able to close it. The whole purpose of closing it is to give. If you don't close the posterior wall and you only close the anterior wall, A, you're lazy if you can close the posterior wall. And B, what you're causing is a patient to have more of a square abdomen instead of a rounded abdomen because you're releasing the lateral edges while at the expense, you're closing them the front at the expense of releasing the inner girdle.

(30:38):

Don't do it. Guess what? Now everyone's saying, ah, maybe we should consider closing the posterior layer. Hello. I've been telling this to you guys. So it's just ego, man. I don't know. I feel like people are just, they're, I mean, surgeons are already egotistical, but sometimes it's just too much. There's another thing in fashion right now called abandon the sack, right? So don't reduce the hernia sac when you're doing guard hernias. Just cut it out and then close the hole. Listen, we did that when we were doing open surgeries. It only works if you do it for really, really big hernias where there's a consequence to removing the sack, which includes bleeding. And then in those cases with the open procedure, we were doing these what we call marsupialization of the sac, which reduces the risk of hydrocele or fluid collection and bleeding in the area.

(31:45):

You're forgetting surgical history. Why are you reinventing the wheel when we did this 30 years ago when before you were born? And we know that doesn't work. So the fact that surgical history has gone, oh, by the way, I did include surgical history in my joy of hernia surgery talk because I really do enjoy the history of hernia surgery and we can learn so much why you keep repeating history. Anyway, so many comments you guys. Let's see what you're saying. I'm searching for a surgeon who knows how to remove bush. Yeah, there's a bunch of us. Go to hernia talk.com and we can help you. Do you think surgeon skill plays a major role in hernia pair? A hundred percent. So I'll tell you this. I give talks. I have friends of mine that give talks. There are plenty of really good stories out there giving talks.

(32:36):

Some of them, they also put out really good videos and you're like, wow, they're such amazing videos, and then I'll inherit one of their patients. And it turns out, no, they were cherry picking the video that they're showing. They're very heavy handed surgeons. They don't care to be cosmetically pretty. They don't, they're not careful about how they're putting their mesh, where they're putting their sutures, what kind of incision they're using. You really, I think you really need to be a careful surgeon that not only knows your anatomy, but it's very careful about it and thoughtful and has a soft, delicate touch and doesn't cause a lot of tissue damage that I've inherited some patients of other surgeons where I'm like, are you serious? Were you even in the room when this happened? How did this happen? Why did you ignore this aspect? And it just shows to me that sometimes when people give talks, it looks better than what they actually do in real life.

(33:52):

How do you balance the decisions about mesh type weight, tightness of placement, and any other decisions related to balancing the risk of pain and durability of the repair of laparoscopically placed mesh in patients who combined with a combined large defect of the inguinal floor, but is also relatively light or small or has poor collagen based on direct hernia recurrence? So for angulo hernias, you never put in a tight mesh. That just doesn't work. It's like giving you a tight shirt. Your tear out of it so tight is never good for anything. The weight of the mesh is a combination of your body habits, but also what the demands are on the defect. So a wide defect or a thinned out tissue may require, or a large person may require a heavier weight mesh. So these are all decision types that experienced surgeon makes. Pain is not directly related to any of those. The higher risk, the tighter you make the repair, the more pain, the more unstable the repair, the more pain, the more durable the repair, the less pain. So those are all just the, it comes with experience. It's like asking Leonard Da Vinci, how do you make your strokes to make sure that you give the right contour shading to the Mona Lyse it's experience. And yes, I did just compare myself to Leonard da Vinci and the Mona Lyse.

(35:35):

Here's a comment. I was joking to myself recently that the surgery I'll be having with you soon needs to go live. I mean, we can do it live if you want technology possible. Then I've seen you actually did do a live surgery. Yes, I did. Which is awesome. How did that come about and how did more, how and how have you done more or plan to? So there's a company called Glib. It is a company that is like the YouTube for the medical world, and it's all medical videos, so it's usually surgical. They ask me to do their very first ever live surgery with live q and a. And in virtual reality 360 degree had never been done before. We had 90 countries log in and ask questions. People were able to use those 3D Google glasses to watch an immersed view into the operating.

(36:44):

It was totally cool. So I've worked with that company a couple times since then. They said, well, we would like to have a video on tissue-based repair. So I did one with them. We like a video on mesh removal, so I did one with them. So that's how it happened. Of course, the patient must consent to having the video recorded. But yeah, if you want your video to be recorded and live, I'm happy to call GLI and have them come and film you. It's a total production, by the way. It was kind of cool. Would you agree that binders and abdominal strengthening are key in incisional hernia recovery? Yes. So I do require my patients not to be obese prior to surgery, lose the weight and be as fit as possible. So I encourage all forms of core-based exercise before surgery, after surgery. I'm very reliant on binder. In most patients, there is a risk with using the binder. Usually that's not that bad. The main purpose of using a binder is to hold external pressure onto the repair of the abdominal wall while you're healing, until you're healed. And that external pressure also reduces bruising and swelling and takes a little bit of the pain away. I don't use a binder in patients where I'm worried about blood flow to their skin flaps and the extra pressure from the outside may reduce blood flow even worse and make it a much more complicated situation.

(38:26):

Let's see. Herbal treatment. Jesus, why do you come to my site and give me spam? Is watchful waiting a correct stance for a small fat inguinal hernia and a woman? We don't know. We don't know. We do know in men, watchful waiting has been studied in both the United States and in Europe, and both have shown it to be safe. 0.2% per year risk of incarceration of the hernia. If you wait up to 10 years, about two thirds of patients at 10 years will end up having surgery because their hernias get bigger and are more symptomatic. Men tend not to get femoral hernias and femoral hernias we know are not situations where you should watchfully wait, but women do get femoral hernias about 10 times more frequently than men. And therefore the risk with watchful waiting in women is that you're actually watchfully waiting on a femoral hernia or missed femoral hernia.

(39:31):

And during those five to 10 years of weight, someone may die because there's a risk of death with femoral hernia. If you're unaware of it, then you end up with an intestinal obstruction and so on. So that's the current philosophy. There is no watchful waiting trial ever done that included a single woman in the trial. It was all restricted to men. That may change. It may take a while before the study starts. I'm hoping to be part of that study. But the University of Michigan is looking into that, and I spoke with several months ago with one of their main surgeons from the University of Michigan where we talked about women's hernias and research done in women's hernias, and she is hoping to recreate the watchful, watchful waiting trial in females and desperately needed because we don't know the answer to that. That said, there are a lot of patients out there that have femoral hernias, femoral hernia. What did I just say earlier? There's zero evidence that any patient that is safe for any patient to have watchful waiting for a femoral hernia because you can die from a femoral hernia. But I've seen multiple patients myself in the past year alone, that have femoral hernias and we're told, oh, that's a small hernia. You could just sit on it or, oh, it doesn't bother you that much. Yeah, just a lump, just push it in. Not a big deal.

(41:12):

Totally wrong because every single one of those, except for one, ended up in the emergency room almost dying of the ones that I knew I should say. And the one that I know did come to me and saying, I just didn't like the answer, and then it still seems to bother me. And then am like, no, you have a femoral hernia. We can't sit on this. And I repaired it. So watchful waiting is definitely not a, there's no evidence to do that. What complications externally do you see in umbilical hernias in men? So all hernias, especially umbilical hernias can start growing. And as they grow, they push out and the skin overlying the belly button will start stretching out. And then lastly, start thinning. And the more you let this go, the thinner that tissue gets, and now all you have is skin and bowel deep to it.

(42:20):

Usually bowel is the risk, not as much of a risk with fat. And as it's pushing out, you start getting reduced blood flow to that skin. Or as it thins, because it's a protran skin, you can scratch it, maybe your belt will catch on it, your cat will scratch it, something like that. We may burn it in front of a stove so that skin, if anything happens to it, you'll now expose your bowel. Best case scenario, if the bowel is intact, worst case scenario, you're now pooping out through your skin. So that is a horrible complication. I tell patients who have protuberant belly buttons, always keep the skin moist, wear some type of soft T-shirt over it so that whatever else is on the other side like a belt or a binder or a shirt or zipper, doesn't excoriate the skin If it's pretty stretched out, I do recommend external compression with either a tank top that's compression based or a binder that can hold it in to reduce how fast the skin thins out. And then once it's pretty thin, even if you have no symptoms, you absolutely should get that umbilical hernia repaired. We know that there's something called watchful waiting, and watchful waiting is considered appropriate in most umbilical hernias that are asymptomatic. So no symptoms similar to the groin hernias. It's a 0.2% per year risk of incarceration. So that's considered safe men and women, by the way.

(44:09):

But I think men and women, yeah, I think the study included men and women. However, the minute that skin gets thinned, you absolutely should have it repaired. Otherwise you'll go straight from no problems to major problem with skin death, bowel sticking out and needing emergency surgery, and that's no longer a clean situation, and therefore you're going to have a major complication. So getting a fistula from a hernia is a big deal. Definitely do not want to fall into that space. Talking about belly button hernias, there was, I don't know, if you go on TikTok, there's videos every so often of people dancing. It's usually a female dancing and they have this hot dog looking protuberance of their belly button sticking out and people wonder what's going on there? And what, I'll tell you what that is. So I think there's a fetish about it, honestly.

(45:14):

I think it's a fetish. But these women are often doing some type of essential dance with their skirt or pants just underneath the belly button, this phallic looking belly button sticking out. So what's going on with without those are, these are chronic belly button hernias. These are hernias where the patients had it as a child, it's a belly button hernia as a child. So it never got bigger. It just, the skin just elongated longer and longer. And these are often in countries, happens in countries where there's not easy access to healthcare. And so as a child, you never got that belly button hernia fixed and it never reduced on its own clothes on its own after birth. And then you just kind of lived with it as an adult, and it just grew longer and longer and longer. And I don't know why they think it's good, why not just get it fixed?

(46:12):

But the access to healthcare is not the same in the United States as it is in other countries. So these are often in people from lower at-risk countries that don't have good healthcare access, especially electively who just basically have a hernia, but it's a chronic hernia where the defect is not big, it's just contents have flown through it over time. They're often thin people. They're not thick people, so there's not a lot of content in it. It's just over time it, and it looks really, really weird. I'll tell you that. It looks like a phallic kind of look to it. So I don't know if it turns people on or why they put these videos on TikTok, but it's very weird and people don't know what it is. I'm like, it's just an umbilical hernia, but it's different than an adult umbilical hernia. An adult umbilical hernia just grows and becomes wider.

(47:06):

It's original tear, whereas as a child, it's a stable hole and it doesn't get bigger over time. So yeah, that's how it is. I've been talking a lot, but as you can tell, I enjoy talking about hernia hernias. Let's see. Going back to joy of hernia surgery, some of the other things I talked about was the joy of doing research, the joy of innovation, the joy of comradery and with different specialties as well as this growing and very lovely new hernia world. There's something called the Hernia Surges Alliance. And if you go on TikTok, sorry, if you go on Twitter or X or Instagram, it's Hernia S Alliance, hernia Surgeon Alliance. And it's really a new group of young female surgeons that have gathered and said, we really do need to have more push to promote female hernia surgeons, which is great to promote the study of female hernias and to improve the research done about it.

(48:11):

So I'm a huge proponent of that. I'm glad that they launched their alliance this past two weeks ago in Chicago at the American Hernia Society. And then I talked about the joy of all these hernia meetings. So I told you we were in Chicago, that was great. I had four more meetings by the end of the year, I think six. So I'll be up in San Francisco at the American College of Surgeons where we'll be showcasing two of our research projects, one on round ligament handling and the other one on I think female factors. And I'll be giving a talk on handling of emergency angle hernias. It'll be course that I'll be teaching on emergency surgery. And prior to that I'll be at a device talk conference also in Northern California, more just south of Sacramento where, sorry, south of San Francisco where I'll be talking about developing medical devices that are focused on the needs of females.

(49:31):

So I'll be promoting my mesh, my patented mesh products for inal hernia and females. After that, a couple weeks after that or a week after that, I'll be in Acapulco. So the American College of Surgeons meetings is coming first, and then after that I'm going to be at the Mexican College of Surgeons meeting where they've invited me to give several talks mostly about handling of hernias, emergency hernias and so on. And then mesh. They want to give me a mesh talk and then I'll be in, no Colorado, I'll be in Colorado. Our research got accepted in Colorado, so super excited about that. I'll post all these on social media so you can read about them. So I'll be in Broadmoor Resort in Colorado. Super excited about that because that's a nice place, but it's just so cool to go all these meetings. And then I'll be at the International Hernia Collaboration also in Mexico this year was an international meeting. All the top surgeons are there.

(50:41):

I help set up that meeting. So all the topics are relevant, modern, it's in Mexico, half of our faculty are Mexican or from the region. And our goal with the International Hernia collaboration is to always take our meetings to countries where the local surges will benefit the most as opposed to just having it always in the United States where it's expensive and most people outside the United States can't get to it. So that's going to be my year. And then I have all these operations to do while I'm in town and I don't like to operate and leave. So often it's hard balance between going to all these meetings, A to teach B, to learn C, to kind of mingle mentor, spread the joy of hernia surgery. But also I need to make time for you all because as patients, you all need my help to figure out your situation and then offer you surgery and work with your schedule because you're all busy too and so on. So I would like to say that I love what I do every Tuesday. Here's the question. How many procedures do you typically do you do typically an or day? Well, it depends on Wednesdays. I'm usually at the hospital and depending on the type of surgery, it can fit between one and three operations. And then on Thursdays I'm usually at our surgery center, and those are usually less complicated or less critical operations. And so with those I can usually do, I'll do between one and three operations, one to four operations depending on the situation.

(52:35):

But my body is also aging, so don't expect me to do 10 operations in one day, although I guess it would be nice to be able to do so many, but it's very tolling on the body. I don't know if you have friends that are surgeons, but we're all have aches and pains and it's hard to be on your feet with your head looking down, focusing for hours on something without moving around, without having time to sit down with no bathroom breaks, no liquid breaks, and just you go into your zen mode, complete zen mode. It's kind of, it's a fascinating situation, but it depends on the length of the operation. I have operations that I can finish in half an hour and I've done operations that's taken more than 12 hours. It all depends on the situation of the patient and what they need.

(53:31):

And the hospital's always available. As you know, I also work out of St. John's hospitals, so Cedar Sinai is my mainstay, but many of you are more on the west side of town. So I have the availability at St. John's Hospital. Some of you live on the east side of town or don't care. There's a beautiful hospital called Huntington Hospital in Pasadena that I also offer care in. So it's fun. The joy of surgery includes the joy of going to the operating room and operating in teaching residents and interacting with medical students. And the hospitals are like our offices. So it's kind of nice because you go there and you meet with new people and you have a full team. And just surgery in general is very fun. We have a new research fellow now, I hope he becomes a surgeon because he's really a great, great student and is studying and doing the MCATs and he just got his very first abstract accepted for research.

(54:36):

So will be presenting that next year in Santa Barbara. Just a lot of really great research coming out of our lab, and I'm very proud of what we do. And I'm really glad that during this meeting where we had the whole hernias female hernia session at the American Hernia Society meeting, I got a shout out for two reasons. One is for my life dedication towards improving her knee care, especially among females, but also for personally funding a research scholarship to promote research in female factors with the goal of promoting research and per female factors. If you can't believe it, the first year came out, we barely found a paper that was even eligible.

(55:29):

There was only one paper that included females at all and they won the award. And then the next year was a couple papers were eligible and now we have a whole slew more. Here's another question or comment. Will you continue your work on mesh implant illness complications? Yes. So thank you for asking that. Give me a second. So I gave a talk on mesh implant illness, multiple talks. One of 'em was at this last grand rounds as well to expose people to the idea, they're warming up to the idea about it, but we still have our implant survey. We presented the results of 815 patients who responded to the implant survey, and that paper will hopefully get published soon.

(56:25):

The results were fascinating. There were 21 items of mesh, sorry, implant illness reactions, but specifically for the mesh implant, I am gathering more data on my own patients as I treat more patients with mesh implant illness. However, our implant illness survey is still open. So if you go to my Instagram page, right pin at the very top of the reels is the implant illness survey. You can go to my bio on Instagram and click on the link for the implant illness survey. Do spread the word, anyone who has a dental implant illness, a breast implant reaction, whatever you feel you're reacting to your hip implant, et cetera. I really hope that you respond to the survey and increase our ability to learn from your experience. So that's the answer to your question. So yes, I'll continue my work on mesh implant illness complications because we still have a lot of naysayers and people who don't believe it, but major institutions like Cleveland Clinic are now agreeing that such a thing exists and offering treatment to their patients. How many hours does a patient typically recover in holding area of outpatient center following a laparoscopic surgery? And is it different for patients requiring preoperative FO catheter for history of outlet obstruction? So they're there as long as you need to be. Most people stay about hour to hour and a half, and you should be able to urinate within that hour to hour and a half.

(58:12):

So that's it, my friends, it's been wonderful. Thank you so much for joining me and sharing my love for hernia surgery and hernia care. And it's really been a joy to be the host of your weekly Hernia Talk Live episode. Do go to hernia talk.com if you have any questions. Might try and interact as much as I can. And you guys are all just fantastic and I hope that I see you next week for even another wonderful Hernia Talk Live session. Thanks everyone. Bye.