187. Gender Based Hernia Care

This week, the topic of discussion was: 

• Male Hernias
• Female Hernias
• Femoral Hernias
• Chronic Pain
• Mesh Injury
• Pelvic Pain
• Testicular Pain
• Pain with Sex
• Nerve Injury
• Mesh Types
• Mesh Patents
• Tailored Care

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 (00:00:10):

Why? Hello everyone. Welcome to Hernia Talk Live. It's been a minute. Thanks to everyone for joining me today. My name is Dr. Shirin Towfigh. I am your hernia and laparoscopic surgery specialist coming to you from Beverly Hills at the Beverly Hills Hernia Center. Thanks to everyone who's joining me live as a Facebook Live and also those of you who are here as a Zoom. I see you. I hear you. I'm so glad that you're here. So let me first say thank you very much for coming on board. As many of you know who follow me on social media, I have been traveling a lot and I'm going to take some of my time today to explain to you what's been going on because we're having a lot of great research and talks mostly about gender-based care and tailoring for inguinal hernias.

(00:01:09):

And I've talked to you about it before where we had presentations at the American Hernia Society meeting and prior to that at the Stages, society of American and Gastrointestinal and Endoscopic Surgeons meeting. So that was in Chicago and in, where was the other one? Blanking out on where the other one was. I've been to so many meetings. Cleveland, is it Cleveland? Yeah, Cleveland. So those were all really great. However, as the year goes by, we have more meetings. So I was at the largest meeting that we have of all surgeons. It's the American College of Surgeons. It's where the FACS belongs after my name. I'm a fellow of the American College of Surgeons. It's a great honor, a great honor to be a member of the American College of Surgeons. As a fellow member, you're vetted and have to have a certain amount of kind of prominence and pass your boards and be a good surgeon and be safe and all that valid member of the community to get that FACS.

(00:02:21):

So every year they have the American College of Surgeons meeting. It's the biggest meaning of all of 'em, it's all surgeons. So you could include neurosurgeons, urologists, vascular surgeons, cardiac surgeons, et cetera, orthopedic surgeons even. And so it's a really great way to have collaborative and multidisciplinary meetings and meetings with the people, but also discussions and topics. And so I was there to help teach a course and also be on a panel. And then just before that I was, so this was in San Francisco, which by the way is very different than the San Francisco of many years ago, unfortunately. And then before that it was the separate meeting. Completely different. No doctors there. I think I may be one of the only or very few doctors invited to that meeting. That was a med tech meeting or a medical technology meeting and robotics meeting called device talks.

(00:03:23):

There's a device talks conference, device talks. West is the one that I was invited to join a panel. So here's what's really cool. So the panel was specifically to talk about technology and inventions specifically aimed at products to meet the demands of different anatomy. So many of you may know I have a special interest in improving outcomes and treatment of hernias. So a big proponent of tailored care and part of the tailored care is when you should use mesh, what kind of meshes you should use when you should not use mesh, and how you should treat patients to minimize their complications. And one of the things that is very, very important for you all to understand is as surgeons, we are limited by the availability of products. So if I go to hospital A, they have a different inventory of products, whether it's sutures or mesh or other products, they have a different inventory than hospital B.

(00:04:40):

So for example, I operate at a different hospital yesterday than I operated at other places. Their inventory of products is different. So in some ways the surgeon is limited by what is available to them for use surgically both sutures and mesh when it comes to hernias. So what does that mean? I take it upon myself to be that person in the hospital to help determine the mesh inventory. They kind of call me. The meshes are so there's certain meshes that should be not on the market or we shouldn't be buying them as a hospital and others that I think are very good and that we should be stocking them. So every hospital that I worked at, I initially go and look at their inventory and then I start getting involved with the medical supplies people and the people that buy the materials management. And I'm like, okay, why are we buying this?

(00:05:39):

How much are we paying for it? And let's improve our inventory. So that's number one. Secondly, what is important is to know is every single product out there that is a hernia mesh for the groin inal hernia mesh has been developed with the male anatomy in mind, every single one. Why do I say that? First of all, it's still very difficult to convince people that women A can get hernias and B, that they have hernias causing their pelvic pain instead of just telling them that it's in their mind or they should just go home and drink some wine, which is what actually happens. So my whole thing has been why are women having worse outcomes from ular hernia repairs than men? Every single study you look at, women do worse, they have more chronic pain after hernia repair, they have higher rate of recurrences after hernia repair.

(00:06:52):

They have a higher risk of complications after hernia repair. They have higher risk of needing another operation after inal hernia repair, higher chronic pelvic pain risk as well. And they're more likely to die from their hernia. Very, very bad data. Up until recently, everyone has just been like, yeah, the research says women do worse. And they just kind of accepted it like the same way. We'll say a certain car has a higher risk of the engine, the brake's kind of not working. That's not acceptable. And I feel like until I came on the scene and now many are following me, people have just been accepting it as dogma. Now why is it dogma number one who's doing the research to see why women are having worse outcomes? We have the research that shows women have worse outcomes. Who's doing the research to look at to why?

(00:07:56):

So if you look at all the studies, it's so interesting. There have been 5- 1, 2, 3, 4, 5, major prospective randomized clinical trials on angle hernias. Well we talked about before the watchful waiting trial, the one in the United States, the one in the Europe, the laparoscopic versus open inguinal hernia trial, et cetera. If you look at every single one of these studies of the five, four of them included zero patients that were female, they were just excluded. They only looked at male patients, major prospective randomized clinical trials. The one that did include females had 17 females out of almost a 400 patient study. So 4%, 4% were females. So if you add of these five studies, almost 4,000 patients were studied to see how they do with hernias, whether the outcomes is watchful, waiting safe, is laparoscopic surgery better or worse than open surgery? Is mesh okay? Et cetera.

(00:09:10):

4,000 patients, almost 17 females, all males. So there's been no research. Now if you look at my past episodes, and I highly encourage you, go back to read them or to watch them or listen to them. On my podcast, I talked with junior surgeons to me. So younger surgeons, female surgeons actually have an interest in this. Dr. Anne Ehlers is the perfect example. She's currently at the University of Michigan and she said, you know what we do need to study. You're absolutely right. And she's given talks about this just like I have where she says we need a watchful waiting trial for women. We need a laparoscopic versus open repair trial that includes wound. We need a mesh versus non mesh Anglo hernia trial that includes wound. We don't have any of that. When I see a female patient, I can quote them statistics based on male studies, and I always have to say this is based on a male study.

(00:10:13):

Going back to the limitations, would I need mesh? Every single mesh has to date, has been designed, aimed at the male anatomy even they're not great for the males, as you know, males can get quite some complications. We had a patient advocate, Martin O'Neill, who was on my show I think a year and a half ago or so from Jersey, Jersey in Europe, not Jersey in New Jersey. This beautiful island off I think among the Channel islands, I think next to Canary between the UK and France. He is one of the major advocates saying, why are men not complaining? We have so many women complaining in the advocacy groups, why are the men shy or embarrassed? Because what happens? They get a perfectly good hernia repair with whatever mesh is available to the surgeon. And now they have testicular pain, they have chronic pain in the pelvis, prostatitis, pain with ejaculation, pain with orgasm.

(00:11:26):

They're urinating with pain, they're feeling like a sandpaper in their crotch and they're just debilitated. Many of them are no longer working. Many of them are divorced because they can't really have sex with their partner anymore. They're depressed. Many have killed themselves. I have had patients that I know of that have killed themselves, male, actually every single one of them was male that just could not tolerate life anymore. That is not appropriate. And you can blame the surgeon and we definitely need better care in the hernia world by surgeons. But you can also blame industry because they have the opportunity to make better design meshes and they're choosing not to. Why am I saying they're choosing not to? Well, I may have told you that I have developed mesh products aimed at improving and reducing all of these complications I laid out to you for males.

(00:12:33):

It's a simple tweak to what's currently out there, but it's a very important tweak. It's based on my experience in treating males and seeing male specific complications related mostly to sexual function and some to urinary function and pelvic pain. And the problem is these people, these men, they have problems after their hernia repairs and then no one knows how to fix it. So not only are we hurting the patients, they're then not able to be helped because how many surgeons like me are out there that are liking and enjoying and really want to take on these complicated patients with so many medical, surgical and psychological problems spinning out of as a result of this hernia repair gone wrong. So it's just not cool that we're in a situation right now where, for example, I've come up with mesh ideas and it's just, it's really, really complicated talking to industry because in some respects industry needs to admit that their mesh design can be improved, especially in today's world where many of them are being sued.

(00:14:06):

For them to change their mesh design may imply they need to admit that their mesh design is not ideal and that would be horrible when they're being in the middle of a lawsuit. So these lawsuits are actually in some ways counterproductive because it's forcing these for-profit companies from innovating women. There are zero meshes currently that are aimed at the women with maybe one exception. And again, if you look at my patents, we have nine granted so far. I'm very excited about them actually. They're called gender specific mesh designs for angle hernias. Why gender specific? Because I see that women have specific things they need to do that needs to be done for them to have an excellent hernia pair, their femoral hernia must be addressed. They should not have too much mesh in them.

(00:15:17):

And the nerves, especially the IAL nerve should not be cut. And men have specific needs. Their spermatic cord should not be involved in the mesh. The nerves, especially the genital nerve should not be injured and the bladder and the pelvic floor needs to be fully covered, especially in the medial aspect more so than females. So there are all these things you can do to improve the meshes, to improve them. So I'm very happy that Dr. Anne Ehlers at the University of Michigan is seeking to do a watchful waiting trial for women. I'm very excited that there is a growing interest in gender-based tailoring of care. Many of the talks that I gave are based on that.

(00:16:15):

In fact, some of the talks that I give aren't even addressing the hernia repair. It's why don't we get better diagnosis of these hernias? My favorite, favorite, favorite paper of all time that I've always wanted to write was published last month. It's called Hidden Hernias Hurt, HHH Hidden Hernias Hurt. It's the best title I wanted to use this title for. I finally was able to publish this with my fellow at the time, Dr. Harry Wong, who's now a USC surgeon. Great, great surgeon. So what do we see with our paper? We looked at hernias that are small versus hernias that are large. And before I get into exposing all that data to you, let me answer some of your questions because they're building up.

(00:17:13):

Here's a question. How do you decide what weight mesh to use in a male with moderate size direct hernia, but who is a small or slight person and how do you prioritize and balance the possibility of pain versus the durability of repair? That's a reasonable question. So a lot of things go in my mind. So one thought is the larger the hernia, the more support you need by the mesh. The heavier the weight of the mesh, it would be I think not the best decision to use a thin lightweight mesh in a wide direct hernia, for example. So that's number one. The slight the person, and by slight I mean thin very little. It doesn't mean like small body build, it means very little fat. The thinner the patient, the more likely I am to use less synthetic product. Either no mesh or lightweight mesh than someone that's larger.

(00:18:20):

If you're both, if you have a large direct hernia and you're thin, you're going to get the heavier weight mesh. That's the way that I think about it because it's not going to work otherwise. And why do I say that? Because there's multiple studies that show actually heavyweight mesh causes less pain than lightweight mesh. It seems a little counterintuitive. You think the more the product, the heavier with the weight of the product, the more inflammation and the more pain. That's what I always thought. But why is that? There are certain studies that show that actually lightweight mesh causes more chronic pain. And my theory is that if you're using lightweight mesh without a tailored approach, so everyone gets lightweight mesh versus everyone gets heavyweight mesh, then there will be patients who have lightweight mesh in a very broad hernia and that would be inappropriate. So they feel their hernia and they feel their hernia coming back.

(00:19:21):

And so that would be the wrong decision in my mind. And so if you're thin and you have a big hernia, you need the heavier weight mesh to support that hernia because anatomy is anatomy. But in general, I prefer to use less synthetic and permanent products. So I try to air on the lighter weight meshes. Oh, here's a great question. I am a 65-year-old male with bilateral anular hernias CT scan one year ago. The pain has been very tolerable for two years. As of four weeks ago, the pain is unbearable. 99 of the pain is while in bed overnight, especially turning or rolling over. That's unusual because usually hernia pain is worse. Sorry, it's best when you're lying flat. I have been told that that is the opposite of what is normal. That is true. Does it sound like that it's something other than a hernia?

(00:20:18):

It very well can be. You may have sacroiliitis or some other back issue or even a hip problem. The other 1% of the time that I feel pain is reaching to the left with my right arm, reaching to the left with my right arm. Pain is severe, feels like testicular type pain on the left. So one thing that I recommend is to make sure your sacro iliac joint is evaluated for sacroiliitis or something called ankylosing spondylitis can give groin pain and even testicular pain. It's an unknown uncommon disease seen more often in northeastern European genetics. But that could be your problem or the back could be your issue. People who have more pain rolling over in bed can have hernias, but that's usually not 99% of the pain. Most people with hernia related pain have the pain when active. So even though you do have bilateral ular hernias, I would look at another cause of your pain specifically or spine.

(00:21:25):

Okay, let's go back to what I was discussing which was hidden hernias hurt. So what we've found in our study is that it is just so fascinating, which is that people who have smaller hernias tend to be misdiagnosed and they're told they don't have a hernia, they're told the hernia's not their problem and so on. And when that happens, they basically get pushed into this circle of no care and horrible sequela from that. I'll give you an example. Typical scenario is someone that's not obese that is complaining of some type of groin pain and it's unclear where it's hurting them, but they have a lot of associated symptoms. For example, they may have radiating pain into their groin, to the outer thigh, sorry, inner thigh into around their lower back, et cetera. They may have bloating, they may have nausea. These are all things that are going people since they don't see a big huge hernia, they'll say, oh well this may be gi, go get a colonoscopy, go get endoscopy, et cetera.

(00:23:01):

So all of that basically delays their care. Now, if you had come out to me and said, I have these symptoms, I'll ask you more questions. And I understand the concept of hidden hernias. This concept of hidden hernias or occult inal hernias is not new. Back in the 1970s, sorry, sixties, I think there were papers published on it of usually women that present with chronic pelvic pain and so on. So what we did was we looked at all the patients with occult hernias and we looked at almost 500 patients and about a little over half of them were male and they're kind of like medium weight to slightly overweight. And about half of those patients had occult hernias and the other half did not have occult typical hernias. So we're like, okay, how are they different? How are people with occult hernias different than non occult hernias?

(00:24:03):

Because in my mind they're the more complicated ones. The occult hernias, they're the ones that don't get the right care and get delayed. And that's exactly what we found. We found that the occult hernias are more typically female. They are more typically thinner. So their BMI is much lower and they typically have much more pain before surgery. Now for some reason, surgeons in the United States have this dictum, you operate on pain, you get pain. So if a patient comes to them with a lot of pain, they tell them, oh, I can make your pain worse if I operate on you. And I never agreed with that because that was never my experience. I take on patients with pain, most of my patients have pain, I don't make them all worse. That would be a horrible business practice and a horrible doctor if every single one of my patients in pain got worse after I fixed them.

(00:25:02):

So that ideology I think comes out more out of fear by the surgeon than reality. And we use this study to specifically discount that. And I'm so excited that our data was able to prove it. So okay, looking at the occult versus non occult. So the people with a hidden smaller hernias with the more obvious hernias, the people with the smaller hernias had more pain, 91% versus 70% presented with pain. So almost all of the ones with a smaller hernias had pain, whereas the people with the bigger hernias maybe just have a bulge with not necessarily too much pain and their range of pain is worse, right? They're much higher level of pain, both when they came to see me and during their normal life, then we looked at, okay, how long are these people suffering? And these people suffered almost three times longer than the average patient.

(00:26:02):

So on average, someone who comes to see me has had pain for about 14 months, whereas those who come to see me with an occult hernia 39 months, 39 months, I had one lady who had pain for 22 years, I think that's my record, 22 years of chronic pain. Everyone told her it's in her head. She was limping, she had so much pain. And I tell you this story because I get very emotional about this one story. Its an older lady, she had 20 years of pain. She was in her seventies when I operated on her, which means she was in her fifties. She was like my age when this pain started and they kept telling her she just has to live with it. There's nothing to do. And after surgery, her son started crying because he said this was the first time, lemme rephrase this.

(00:26:59):

He told me he had forgotten what it was like to see his mom walk without limping. I mean, that just should not happen, especially in the United States where we have such excellent healthcare. We should not be telling a woman that everything's in your head and your pelvic pain is not treatable. Many of them have hernias that are treatable. They're just this hidden hernia. So what's horrible is that many more patients that fall into the occult hernia are taking pain medications versus typical patients who have hernias. But here's the clincher. We specifically asked about opioid use and opioid use was 8% in the typical non occult hernia patients, 24%, three times more opioid use in the occult hernias. So what the society is doing is they're telling these patients, it's all in your head. You're going to suffer for months and months and months unnecessarily. And you know what? There's nothing else to do for you. Here's some narcotics. And now we're wondering why we have an opioid crisis because you're exposing people completely unnecessarily to opioids when they can just have surgery and get cured.

(00:28:21):

So let's go to the results. So we then operate on these patients and we said, okay, how many of them got better? Well, guess what? Not only did the patients with the occult hernia that started with a higher level of pain end up having lower pain, they also had a greater, I'm sorry, not only did they have a greater reduction in pain, but it was significantly more improvement in pain than the typical inval hernia patient. Does that make sense to you? Complete opposite of what the dictum is, which is you operate on pain, you get pain. No, no, no. You operate on pain and the pain goes away because you're the good doctor that figured it out and gave them a chance to cure. Now it's true OC call hernias are a little bit of a difficult diagnosis to handle because not everyone has it.

(00:29:29):

You have to understand the different symptoms and all that. But come on. And it's mostly women that are being told it's in their head because diagnosis is not right. So not only are we not optimally surgically treating al hernias based on your gender and we don't have the right meshes out there to provide optimal care, but in addition, we're not even diagnosing them well either. We can't blame industry for that. Here's a question. Sorry, I'm getting all angry. I get like this at the meetings too. It's crazy because people ask questions and sometimes the surgeon's like, oh, and then I get all animated and I start answering the question, okay, how do female hormones play into hernia repair? Two questions. Number one, I had a left angle hernia repair with mesh when I was breastfeeding and the surgeon said it should not make a difference, but I know breastfeeding hormones includes relaxing.

(00:30:38):

And does that affect hernias or hernia? Actually it does number two. Okay, let me just answer number one first. So yes, we do not like to operate while a patient's breastfeeding. In general, we recommend that three months of either pregnancy or breastfeeding is over with whichever is latest. So if you're pregnant and then you're breastfeeding, finish everything you have to do and then give yourself three months. And that is how long you need for the progesterone to reduce and the relax and to go away because both of those cause your muscles to be very thin and very lax. And you'll notice while you're breastfeeding your belly, it feels like it's all mushy and it has not gone back to normal because their hormones are not back to normal. So we want to operate on you as close to your normal state of muscle as possible.

(00:31:43):

So we don't like to do elective surgery when you're pregnant and we don't like to do elective surgery immediately post-op postpartum, and also not when you're breastfeeding. It has nothing to do with anesthesia or pain medication or anything. It's purely the fact that the relaxant, progesterone, et cetera are elevated and your muscles are not at their peak level of performance. And so sewing it together or patching it or whatever is not going to give you the best outcome. Okay, number two, I have chronic left groin pain after the surgery and I noticed that one of the things that affects my pain is my menstrual cycle. It hurts more right before and in the beginning. Why might that be? Okay, that is also hormonal. So the estrogen peak and trough contribute to pain and during menstruation all pains are worse. And so if you have pain from whatever, let's say your hernia repair, it will be worse during and right after your menses.

(00:32:55):

So your men, it's not like it's necessarily a hormonal thing causing the pain, but the fact that you have pain, it will get worse during gram menses. So what you need to focus on is see why you have the chronic left groin pain. I hope that's clear. Here's some more questions we can get to. Does the caveat about relaxing in women apply to PROSCAR in BPH and men with BPH? I don't believe so. So the hormonal difference related for pain is related to estrogen and for postpartum and for breastfeeding is related to progesterone. So that should not be affected by proscar in men. With respect to 22 years of pain, can chronic pain be improved even though changes occur in the nervous system and centralization? Maybe once you hit nine months of chronic pain, I am told by the pain doctors that that's when you start centralizing.

(00:34:06):

Now that doesn't mean that everyone's doomed to chronic pain if they didn't treat it within the first nine months. That's not true. But it may mean that you are at higher risk of not having full resolution of your pain because your body's now used to having pain. It may mean that your postoperative recovery is longer. You may need a larger variety and quantity of pain medication for a longer time. And it may be that if it's so too severe and you have PTSD even related to your chronic pelvic pain or chronic surgical pain that either before surgery or after surgery, you may need adjunctive therapies to detox you from all the stress. And that may include microdosing or ketamine therapy. So it depends on how severe your pain is. It doesn't mean you're doomed and everyone's a little bit different.

(00:35:22):

Alright, so let's go to my MedTech talk. I thought it was really fun. So often I get invited to a nonsurgical conference this past week was one of 'em. I was at the device talks conference up in Silicon Valley. If you haven't been to Silicon Valley, it's quite the treat. First of all, it's beautiful Northern California. It's just beautiful. Second of all, it's so cool to drive around and it's like that's Apple, that's Google, that's Intel. Everything that you use, they have a building there, it's so cool and it's just filled with engineers of all different shapes and sizes, ages and all that and experiences. So, oh, here's a comment. Ketamine therapy has been very beneficial. Yeah, yeah, I'm glad you chimed in on that because it is one of a couple of different ways that we can help reprogram the brain and your interpretation of pain to kind of change the neural communication. Ketamine tends to do that.

(00:36:40):

Okay, device talks. So it's a MedTech conference and they already knew in their world that I am an inventor of some gender-based based mesh designs for the anal hernia. And so they had a whole session dedicated to inventing products to address various anatomies like different anatomies. So as you know, the pelvis and males and the pelvis and females are very different. The shape is different, the structures are different. The amount of nerves, concentration of nerves in there is different and so on. And therefore I believe the surgical technique should be different. And if you use mesh, the shape and the type of mesh should be different. So that's part of my patents. I have, I dunno, 18 or more different designs for different types of mesh products and none of them so far have been granted and we're really excited about it. So I gave this talk. So I was on this panel, it was great, and the other people on the panel were scientists and entrepreneurs and engineers and all that. And they were just aghast at the fact that someone hasn't figured out that women A, get hernias just as much as men and B don't do as well. And therefore maybe we need to improve the technology out there. It's crazy.

(00:38:33):

I gave some statistics there. It was kind of fun. And there were people in the audience that had hernia repairs themselves. Some of them did very well. Others knew like their friend or neighbor, whoever had a complication and much it affects their life and so on. Others are like, oh, I know someone that was telling me how much pain they're in, et cetera. And they're just told it's in their head. So people were relating to it. Why? Because inal hernias are one of the most common diagnoses in general surgery and one of the most common operations done in general surgery. And at the same time there's a lot of discussion about industry and their role in improving care and how to balance the importance of addressing various anatomies versus how much money they can make. And it was just really interesting because then you go to the meeting, then I go to the American College of Surgeons and they're the companies there that actually make the product and sell it.

(00:39:42):

So if you go to the med tech conference, these are all people from idea to execution and then you go to the surgical conference, it's from execution to marketing, right? They're selling the product. But the in-between is what I experienced at this med tech conference, which is really, really cool. And I got to speak with some really interesting companies that their whole job is to get you from idea to execution. And yeah, we talk a lot of really good things. I have so many ideas. Honestly, if I were a surgeon, my day job would be to just spit out all these ideas and start developing products. But I do have a day job and that's to treat you guys. And it's my pleasure to do so, and it's one of the reasons why I love what I do because I really enjoy the thinking process.

(00:40:40):

I'm really good at the surgical process for sure. But I also enjoy the pre intraoperative thought process and it really bugs me when I see that doctors just are like, okay, just doing the run of the mill and not think about the fact that this patient had a tummy tuck. Maybe you shouldn't operate the way you are in this patient compared to this thin athletic male compared to this morbidly obese elderly male. Each patient, this one had a prostatectomy. We can't do the same hernia pair in that as the patient who has a C-section. So it just boggles my mind that there's not more thought into daily surgery and part of it is our fault, right? We need to educate better. I'm going to different residencies now and helping to teach them about hernias. And I teach the medical students at UCLA. So one of the, I said, listen, so when do you guys learn about Anglo hernias in medical school? You know what their answer was during the male reproductive system talk.

(00:41:58):

So already you're only talking about hernias in a male context, which means no one knows how to ask questions of a female, examine a female or learn the anatomy of a female as it relates to hernias. They don't even understand it or know it. And it starts in medical school when gynecologists never are taught about hernias. How do you expect the typical non gynecologists to even know about hernias in women? It's just crazy. That said, I'm very lucky because I'm surrounded by surgeons that I work with and collaborate with. And this week alone, this week alone, what's today? Tuesday, I've already had one patient sent to me by an orthopedic surgeon who knew better and thought that this patient's chronic pelvic pain is related to a hernia. I had a plastic surgeon send me a patient who felt that this patient's abdominal wall pain is not related, is related to a hernia.

(00:43:05):

And I had a urogynecologist, basically urologist who sent me a patient who felt that their chronic pelvic pain and urinary symptoms are due to a hernia. That is amazing. The fact that urologists orthopedic surgeon and plastic surgeon, none of whom treat hernias, all had the forethought to send me a patient thinking that there may be a hernia. And this weekend even I saw a patient who didn't even have a hernia, but the doctor that referred the patient to me understood that I enjoy, I'm kind of weird, right? I enjoy puzzle solving. So in doing so, sometimes I just get consults of we can't figure this out, Towfigh, can you just figure it out and let us know what to do? So didn't have a hernia, very abnormal abdominal wall, a lot of complications and pain problems and it's probably a medical problem and definitely does not need surgery by me.

(00:44:11):

But I was happy to sit there for a long time to help figure out. It's a very complicated story of why this patient's having this engorged abdominal wall and to treat them because as I like to think critically and figure things out. Let's see. We've had some questions submitted to us. Here's another one. What are the differences in shape and geometry of mesh between men and women? Is it better to use flat or 3D type anatomic mesh when treating pre direct hernias or thinned thinning below angle floor that has not developed a defect yet? Sort of a Gilmore groin? Okay, good question. So let's get the first part. What are the differences in shape and geometry of mesh between men and women? Women have a broader femoral space. So for women, they would benefit more if there was better coverage of the femoral space. Men are more likely to get direct angle hernias, so they would benefit more if they had a broader coverage of the direct space. A company just came out with a mesh, I'm like, what were you guys thinking? This has no coverage of the femoral space, poor coverage of the direct space, and it's just too narrow. Who decided that was a good idea? I assume you guys put millions of dollars into this product design. You can't just come out with a product and that's not cheap to do. It just boggles my mind. How do these people, who do they talk to when they come up with these products?

(00:45:53):

Honestly, no wonder some of them are not doing well. Okay, is it better to use flat or 3D type anomic mesh for the groin? And if you're putting it muscular, so in the pelvis where it's kind of rounded the anatomic or kind of curve, I prefer a little curve to the mesh. You don't have to have curve. There's no study that shows curved or flat is better on the front there. I've never seen a curved mesh and it's not really curved. It curves a little bit, but lemme take that back. The amid modification of a lattin hernia mesh does take a flat mesh and kind of curves it and it does kind of follow the shape of the groin a little bit better. That's a technique that I use.

(00:46:52):

Then it says, yeah, is there a difference in treating a thinned below ular floor that has not developed a defect yet? So not all hernias have a defect. A direct hernia typically does not have a defect. It's a, like you mentioned, a thinned billowing ular floor. The goal is not to patch that floor. The goal is to plicate that floor so that you have a foundation onto which the mesh can go. You should not just randomly patch it and think that and leave the thinned direct space alone. I hope that clarifies things. Alright, there's another question that was sent to me. Let's see if we can get to that. Are the anatomical differences between men and women so profound as to require the development of a completely new hernia treatment techniques for women? Listen, maybe. Maybe it's just not cool that women are dying of inal hernias because there is a femoral hernia and the femoral hernia was missed and therefore they need to get a second operation because a first operation to address their femoral hernia and or their femoral hernia was never treated because they were told watchful waiting is appropriate, which is not, and then they die.

(00:48:25):

So is there a rule for just treating the femoral hernia in patients that are women? Do you need to prophylactically treat their angle hernia? We don't know the answer. If I see a patient that's female who I know has a lifetime risk of femoral hernia, but at the time of surgery has no femoral hernia, do we need to prophylactically cover that femoral space? We don't have good studies to tell us one way or another. So for example, the shouldice repair perfectly good repair does not cover the femoral space McVay does. So is it appropriate to use a shouldice repair in women or should all women who do not get mesh should they all get a McVay repair? We don't know. So these are all questions that need to be answered, that needs to be funding for this. I actually gave a talk at the European Hernia Society, meaning about growing pain in women.

(00:49:23):

And I showed that there is serious, serious lack of funding in NIH grants and there's only been one NIH grant that has funded actual hernia repair. And that was the one, the laparoscopic, the watchful waiting trial, basically the laparoscopic versus open trial that then also conferred to a watchful waiting trial. So that's it. And that was like in the nineties. So yeah, they need to fund it and we're hoping that the University of Michigan gets that study and I am hopeful that I can be involved in that study to recruit as many of my female patients to learn these questions, to understand what is appropriate for. So yes, that may be true that we have to radically change our technique to address specifically women's hernias. You explained that hernia treatment historically focused on men. What are the disadvantages for women of an approach that ignores our specific anatomical differences?

(00:50:37):

Well, what we know is that there's higher rate of chronic pelvic pain, higher rate of chronic pain after mass repair. Is that because the mesh that we use is too heavy for women? Is it because the shape of the mesh we use is inappropriate for the female pelvis? Is it because we're missing femoral hernias and they're getting chronic pain from a missed femoral hernia? We don't know. We don't know because we don't have databases that are very a transparent and giving us the nuances of the decision making behind that. Is it because women just have more nerve endings in the pelvis than males? We just don't know. So that is something that needs to be addressed. I really don't like it when women are treated like men in certain factors such as ileal neurectomy. There are some surgeons that do what's called a proactive ileal neurectomy.

(00:51:33):

They cut the nerve in every single patient and they believe that cutting the nerve will reduce the risk of postoperative groin pain in their hernia repair. Complete BS by the way, just don't mess up the nerve or put some anti-adhesive over the nerve. That's one of my mesh designs. So in women that's a big deal. You do not want to cut the ileal nerve in women because they may get or the genital nerve in women because they may get numbness of the moms and that's not good for sexual pleasure. So for men who routinely cut the ileal or genital nerve in women, you're just not understanding what that does for women. So don't do it.

(00:52:28):

I feel like I'm angry today. I don't know why I'm not naturally angry person. Okay. Can you mention some cases where not adapting hernia treatment to the patient gender was the sole cause of serious complications? Yeah, very, very good point. There are plenty of situations where doing a anterior tissue repair or an anterior open mesh repair, Lichtenstein repair has resulted in a missed femoral hernia and therefore either for either chronic pelvic pain because of the hernia or need for a second surgery or death because femoral hernias are the deadliest of all hernias with a 5% risk of death if you have a bowel injury or a bowel stuck in the hernia. So yeah, that's a very common one. Others are more worsening quality of life with higher risk of chronic pelvic pain. Many women are smaller build and you're using larger pieces of mesh. The typical MeSHs, the size large.

(00:53:43):

There are some women that can't have a large or people are now used to using with robotics, they're putting even larger pieces of mesh extra large and they think that's great. What they don't understand is female pelvis may be wider but not as narrow and they may need a smaller mesh because they don't need that much direct space overlap, but they need better femoral space overlap, et cetera. So there's a lot to that where the mesh sizes should also be different the same way the mesh gloves, I mean the gloves sizes are different to in a typical female surgeon versus a male surgeon. And yet all the instruments we use are made for a male hand. I remember I was at my new job and a company came to show us all their new stapler systems and you it's got this, it's a stapler, so you got to to deploy the stapler.

(00:54:45):

Nowadays they're all electronic, which is really interesting. It's much more expensive too. But back in the day it was a manual grip. And in doing so there were a handful of female surgeons, including myself, and we're like, this is really hard to do. And it's not that we were weaker, it's just our hands did not fully grasp the product like the men's did. And we had some Asian females which had even smaller hands in mind. I had I think normal or to large hands for a female and it was definitely, they had to use two hands. So it's not appropriate for a surgeon to have to let go of their left hand holding whatever other instrument to use two hands to help deploy a stapler, for example. That's just a bad design. The same is true for a hernia mesh design, which is these sizes that are maybe too big for the female pelvis.

(00:55:42):

How do you decide when to use anti-adhesive mesh to protect this spermatic cord in male lap hernia repair? So you should not be using anti-adhesive mesh for male laparoscopic hernia pairs unless you have a problem with the peritoneal flap and you're afraid bowel will be touching it. I do use anti-adhesive sometimes around the spermatic cord. And one of my mesh designs includes that design, which is to use anti adhesives specifically in the areas where the mesh is more likely to touch the spermatic cord. So especially my redos where I remove mesh and that causes a lot of scarring and inflammation of the spermatic cord, then I do wrap the spermatic cord with anti-adhesive to reduce the risk of the cord getting very much entrapped, eroded, or impinged by the mesh. But in general, we don't use anti-adhesive mesh because that means all of the meshes, anti-adhesive.

(00:56:51):

I think the new meshes should have strategic strips of areas with anti-adhesive on it. But no one listens to me. I feel like I'm a lone wolf out there coming up with ideas and then 10 years later someone's like, aha, I have an idea. I'm like, I literally told you that 10 years ago. Okay. What kind of meshes have you designed for women and how do they differ from meshes that are already on the market? Thank you for asking. So I have a whole booklet full of mesh designs, many of the patent pendings, several of them patented.

(00:57:36):

I've been working on it for over 10 years. And the products are aimed at reducing gender specific complications. So in men, the complications that I see are related to testicular pain, nerve pain, erosion of the mesh around the spermatic cord injury to the spermatic cord by the mesh. So the mesh design is made to provide optimal coverage, especially of the direct space for men, and then reduce the risk of mesh erosion, impingement and adhesion to the nerves and the spermatic cord by strategically placing anti adhesives where the mesh interacts For women, the issue is the nerves and the femoral space. So I specifically developed meshes that have a much broader femoral coverage than the typical mesh, and therefore better than the current meshes because since they don't have very broad coverage of the femoral space, sometimes you have to press bring the mesh even lower than you would like.

(00:58:47):

And that involves having too much overlap of the mesh with other critical structures like the vessels down to your leg, the spermatic cord and males or the psoas muscle, which helps your hip flex. So to reduce the risk of having pain going up and down stairs or bending or sitting pain or catching of your spermatic cord with painful sex, painful orgasms and higher risk of chronic pelvic pain and pelvic floor spasm and or nerve injury, I developed mesh that kind of preferentially covers the femoral space without adding extra mesh to the lateral parts of the product and therefore reducing the risk of interaction of mesh with critical structures. So the beauty of it would be to combine all of that together, right? Good for men, good for women, but specifically specific addressing their gender specific problems.

(00:59:51):

So I hope that was helpful to you. I really enjoyed giving this talk. It's the most passionate about is this idea of improving hernia care equally for both genders. And do I regularly, so you use regular mesh, but add an anti-adhesive wrap in the male lap hernia repair pending your product coming to market. Yes, that's what I do and it works really well. Let's see. Any more questions before we leave? Let's see. Looks like that's it guys. It was lovely. I missed you all. I'm so sorry. It was like a long month of travel and every Tuesday I was dedicated to, I was sick on one of those Tuesdays and then I had patients or I had to travel. And guess what? It won't get better next week. We have two more meetings coming up, the Western Surgical Association where we will be giving another more of our research and I'll update you on that on social media. So please do follow me on Instagram, Twitter, wherever you like, because post mostly on Twitter, post my research products and talks there. And then we have the great international hernia collaboration and then we hope to end the year in the bang. So follow me and I'll keep you up to date with everything we're doing and hopefully you'll enjoy it as much as I enjoy it. And hopefully all of this would mean we'll all get better hernia care at the end and hopefully sooner than later. Thanks everyone. Bye.