189. When to Repair a Rectus Diastasis

This week, the topic of discussion was:
-Rectus Diastasis
-Pregnancy
-Obesity
-Hernia Repair
-Incisional Hernia
-IPOM Plus
-Hernia Recurrence
-Bulging Abdomen
-Core Strength

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 (00:11):

Hey everyone. Hey, it’s Dr. Towfigh. How are you? Welcome to Hernia Talk Live. I am your host, Dr. Shirin Towfigh. Thanks for everyone for joining me. We’re winding down 2024 with our penultimate episode of Hernia Talk Live. We’re reaching almost 200 by the early 2025, so I’m super excited about that. Thanks for everyone who’s joining me live via Zoom as well as those who are here via Facebook Live. You may notice that today I have these beautiful flowers. Let me see if I can show you better. You all see that these beautiful flowers, thank you that were given to me. I love getting gifts. I love getting flowers. I’m very lucky that I do get flowers every so often from my patients and these are especially beautiful because they are kind of fresh for hernia talk, live episode, and also it’s from a very dear patient who I am hoping to be able to treat as soon as possible, so thank you for that.

(01:32):

I love it. I’m like floral, floral out today and it’s been super great. So for those of you that are just tuning in, my name is Dr. Shirin Towfigh. We meet almost every week here to talk about hernia related problems and oftentimes I am, what’s the right term? I would say that sometimes I choose my topics based on a recent patient and one of the most egregious patients I saw recently, actually two of them in the past couple of weeks have been related to tummy tuck and I like to make some comments about tummy tucks. Now, as you know, I’m a hernia surgeon, right? So I’m not a plastic surgeon, and if you really want to get a good tummy tuck, you should get it done by a board certified plastic surgeon, not a cosmetic surgeon, not a aesthetic surgeon, not a surgeon that never finished their residency and now wants to make a buck doing tummy tucks.

(02:43):

So you want to get your tummy tuck by a board certified plastic surgeon. Now, there is a trend, however, an abdominal wall surgery where we are recommending that your rectus diastasis, which means the way your muscle is put together, that we tighten that up. Now, what’s a rectus diastasis? Many of you may already know that sometimes people call it diastasis recti. So rectus refers to the rectus muscles, which is your six pack, the two sets of muscles that go to the left and right of your belly button from your rib cage down to your pubic bone. Each of those is called a rectus muscle. And if you look at a bodybuilder or a male model or even some females, you can see their six pack and that’s what they call six pack each side on the left and right is the rectus muscle. What can happen is you can get a separation in the middle between those two muscles.

(03:49):

That separation could be you’re born with it. It could be you got it because you stretched out your muscle during pregnancy. Usually it happens more often after the second pregnancy or if you’ve had twins or triplets. And the more pregnancies that go to term, the more likely you are to get a rectus diastasis. That said, the act of actually getting a diastasis is very genetic. So there are people that have had five children and still have a totally flat belly, and there are other women females that have had one child and they have a completely disrupted abdominal wall. So it is very genetic. Men can also get rectus diastasis. That’s very genetic, and if you see someone in their fifties or greater that have a rounded abdomen, that’s probably a rectus diastasis. We call that a beer belly sometimes. It’s not always a beer belly.

(04:50):

It is oftentimes a genetic predisposition to stretching of the muscles. And so you’re kind of round like what we call apple figure around the belly. We see it more often in fat people than thin people, but genetically you’ll be predisposed to it. So there are people that are in their fifties, sixties, seventies, eighties that have a completely flat belly just like when they were younger, and there are others that are still thin, but their belly’s a little bit rounded. If the belly is rounded, that’s usually because you have a rectus diastasis. That’s a trick. So if you see people at the gym or at the local pool and they have a rounded belly or when they get up from let’s say laying down position or they cough, they get a bulging in their upper belly in the middle, that’s usually what erectus diastasis looks like.

(05:47):

And what it is is it’s not a hernia. It is not a hernia, it is a separation of the bulky muscle. So the bulkiness goes to the side and then in between there’s still fascia or collagen tissue and that’s just weaker and not as bulky as the muscles. So relatively speaking, when you contract your abdominal muscles, such as with getting out of bed, you’re going to contract the left and right rectus muscles which would go in, and then relative to that, the thinner tissue between those two will bulge out. Why is that important? Well, that implies that that middle portion is thinner than the outer portions, and if it’s thinner then it’s more prone to tearing or getting a hernia. So let’s say you’re just a normal guy and you have kind of this rounded belly to begin with, but no one really diagnosed you with a rectus diastasis or diastasis recite.

(06:50):

Then you get your gallbladder infected and someone says, oh, you need gallbladder surgery. And then they go in there and they take out your gallbladder and you think it’s great because you’re having a laparoscopic surgery, just four little holes or even robotic surgery with even three little holes or sometimes four holes and your you are excited because you’re like, great, very short recovery. I just have a few little holes. Well, if one of those holes or two of those holes is placed for the laparoscopic instrument, your incisions is what I’m referring to. If your incision is placed in the middle of the abdomen in the upper part where you have this thinning, you are significantly higher chance, higher risk of getting an incisional hernia or a hernia where that incision was than if you did not have erectus diastasis. That’s a little trick, but a lot of surgeons are not aware of that.

(07:50):

Another scenario is a lady who’s had, let’s say two children and has a rectus diastasis and now needs their gallbladder out or their appendix out, let’s say, or let’s say they need their colon surgery or even a hysterectomy, any incision that involves a middle of the abdomen, if the incision is made through this narrowed, this thin area in between the separated muscles, then you can get a hernia at that incision or you can just be unlucky and not only have the rectus diastasis but also get a hernia within that rectus diastasis. So that’s pretty common. There’s a lot of people that I see on Instagram that love to post their pictures or their belly and I’m like, it looks like there’s a bulge at the belly button. And some people it’s not a hernia at the belly button, it’s just the separation of their muscles, which makes their belly look more prorate, more of an Audi than it really is.

(08:59):

And in some people they always had a hernia and now you add on a couple of pregnancies and now they have a little belly button hernia. Let’s see, I just saw a question come through that includes increased risk of peri umbilical hernia if the scope is placed. Yes, so the laparoscope, which is a camera scope for both a robotic and laparoscopic surgery is often placed in and around the belly button, and that makes that space a little bit more likely to get a hernia than if you place that same camera incision elsewhere. Now the reason we put it in the belly button, besides the fact that it’s a central area and easy for us to use a camera to look everywhere, is because it looks better to have an incision hidden inside your belly button than elsewhere, more cosmetically pleasing. I would say. However, it does increase your risk of incisional hernia.

(10:01):

So many of us make the incision within the belly button but don’t actually make the muscle incision in the middle. We go a little bit, shift a little bit to the left or shift a little bit to the right to go through the muscle to reduce the risk of getting a hernia. It’s not always possible to do that, but that is a technique to do and there are a lot of techniques that I share on my attack lives, which actually probably many of you guys know now, and I’m willing to guarantee a majority of surgeons and especially those in training have never been told and may kind of learn about it later or may never learn about it at all. Okay, so that’s it With rectus diastasis, what I was getting to was in the hernia world, what can happen is we can understand that you have a hernia, but you also have this weakening or thinning in the rectus diastasis. So what we’re, now that we have more advanced technology like robotics, there’s a push towards not only fixing the hernia but also supporting that hernia repair by fixing the rectus diastasis. What we used to do, which turned out not to be the best idea, was we used to close the, we used to just bridge, just bridge that gap with mesh.

(11:31):

That ended up being fine if you’re morbidly obese because you wouldn’t know the difference. But if you’re thin and we just bridge the gap with mesh, then what would happen is you still get the bulging from the rectus diastasis, but the hole from the hernia would be covered. And so patients would be unhappy because they’d be like, wait, look it, I still have a bulge down here. And the surgeon would have to explain, well, technically that’s not a hernia, that’s your rectus diastasis. But the patient was thinking, well, but I went in there, I want to flatter belly and now I still have a bulging belly and it just paid for surgery. So that kind of made it so that surgeons were like, okay, maybe we should address the rectus diastasis. We know that people that get tummy tuck for cosmetic purposes, so usually women with a lot of thinned out skin and thinned out muscles, usually not usually, I would say, I think they looked at it like 30% of those women have a belly button hernia at the same time fixed because the surgeon goes in there to do their tummy tuck, which basically takes the separate muscles and sews ’em back together again and maybe even tighter than they were before surgery, before the pregnancies.

(12:59):

And then oh, lo and behold, there’s at least one belly button hernia that they see and they fix it at the same time. So there is a correlation between having that thinning but also having the hernia I believe. And there’s a few studies, not that many studies that kind of have looked at what can happen if you fix a hernia alone or if you fix a hernia and repair the rectus diastasis at the same time. And the thought is that dual layer where we close the hole for the hernia and on top of that support the hernia repair by bringing the muscles together and restoring a more normal anatomy that the latter, the double repair is actually a better repair for hernia then just fixing the hernia. And we no longer recommend to just bridge the rectus diastasis if possible, if the patient’s a good candidate.

(13:57):

We do recommend that that separation be closed as an extra support of a hernia repair before putting mesh in place. So I did that a couple of weeks ago. There was a patient that had clearly a wide hernia about four centimeters, and that four centimeter hernia was sitting within a five or six centimeter with erectus diastasis. So just closing that hole and putting mesh would not have been adequate. He probably would not have been as happy because he’ll still have a very bulging belly. So we did what’s called a robotic etep, ETEP, which is we go in there, we find the hole, which is the hernia, we remove all the fat, and then we close the back layer in one layer we put mesh, we close the front layer and another layer which includes erectus, diastasis, and then the actual hernia is closed as well. So three layers of closure plus a mesh is a much more sturdy repair for this kind of situation.

(14:57):

What I was kind of impulse to talk about is all these things where you should not do the tummy tuck repair. Alright, patient number one, not thin person, geez, obese, BMI. I think in the mid to high thirties, which is technically obese, 25 to 30 is considered overweight. Anything over 30 is obese. She carries a lot of her weight in her belly. She has a very rounded abdomen. So she goes in and I don’t understand the situation and again this is going to be a common scenario, but I don’t know what they were thinking, but they said, let’s do a hernia repair and a tummy tuck at the same time, I think robotically or laparoscopically, I think robotically, I don’t have the opera report, it’s done in different country. So that surgeon had never done this operation before. They brought in a visiting surgeon and that visiting surgeon, I don’t even know if they were there or not there, but she is wondering if the surgeon came and went or what the situation was.

(16:16):

Anyway, long story short, they closed the hernia, they closed the muscle layer, but only in one layer. Usually for tummy tuck we do two layers because these are on tension. She’s already obese, so she wasn’t the best candidate to have those separated muscles brought together anyway. And then she does something simple. I think she pulled up her pants or opened a door or did something very simple and she felt a pop. And now she looks horrible because the upper part of her muscles completely tore and she now has what looks like an alien growing out of her upper abdomen. It shows underneath all the shirts besides it looking ugly, it hurts her. She’s got liver, stomach, intestine stuck in this hole. It’s technically not a hernia, but it’s an unraveling of her tummy tuck repair, which she should never had done because she was not a good candidate for it.

(17:26):

And when it was done, the correct in my interpretation, it wasn’t the best repair performed because she didn’t even have imaging before to see how wide the repair was. The surgeon said it was five centimeters wide. Right now she’s about eight centimeters wide. I doubt it was five centimeters. I wonder if they thought it was five centimeters wide, they’d never imaged her before and then they closed five centimeters, but really it was eight centimeters wide. So instead of getting the thicker fascia on the sides where the muscle is, they took the thinner fascia in the middle and just sewed that. I already told you that closing, that sewing that for example for hernia repair will fall apart. So just bad situation, wrong technique, wrong choice of patient for the technique and done by a surgeon who was not skilled in doing it and actually had never done it before.

(18:28):

So she now needs to have it redone. But like any surgery, a redo is not as good as the first time because now we’re dealing with torn tissues because the suture never tears. It’s always the muscle that tears. And so just bad situation. Patient number two, this one I don’t understand at all either this patient, hold on, what’s going on? This patient needed some type of non-elective surgery involving the colon, which by definition is no longer a clean operation and it’s not technically elective because there was infection and abscess and all that. And for some reason someone decided that the same time as a non-elective colon surgery with pus that they would do a tummy tuck at the same time with liposuction and a bunch of other things. I am still aghast that such a decision was made. It breaks the rules of acute care surgery, which is do not mix elective surgery in a situation of non-elective surgery.

(19:47):

So if you need a gallbladder surgery at the same time, don’t do your boob job. If you need appendix surgery for infection, don’t fix your hernia. At the same time, you don’t want to mix some type of important non-elective surgery where you don’t want more infection than is reasonable. You don’t want to prolong the operation time more than reasonable. You don’t want to mix that with an operation you can do at a different date. Electively in a clean and controlled situation. That is number one dictum of acute care surgery. And it’s so interesting how so many surgeons do not follow that. They think they’re helping the patient, Hey, so you got some extra skin, why don’t we just take care of that too while we’re on it? You’re going to have surgery anyway, but the surgery is your colon. If you’re having a boob job and a tummy tuck, that’s different.

(20:49):

Those are both elective, they’re both clean operations, a controlled setting. Some people don’t even combine those together because it’s too long of an operation and therefore increases your risk of blood clots and wound complications including infection. But now you have a contaminated or a situation where we’re operating on the colon in a patient that’s had an abscess and infection and we’re adding a cosmetic procedure, which the patient would not have benefited at all from a colorectal standpoint. So anyway, as you can imagine, a lot of problems, skin problems, et cetera. And then complications from that. So in a patient that’s a smoker, let’s say patients that’s obese, a patient that’s diabetic, poorly controlled or anything else that would affect wound healing that has a wrong patient to choose for a tummy tuck. And by tummy tuck I mean any form of closure of the diastasis recite.

(22:00):

That could be a classic tummy tuck by a plastic surgeon where they make a huge incision in the lower abdomen from left to right or it can be a robotic or laparoscopic operation by hernia surgeons such as us where we actually physically go in there and minimally invasively close that fascia gap. Patient number three, this patient had a tummy tuck by someone that doesn’t do tummy tucks. So what did I say earlier? You want to have a board certified plastic surgeon, number one, and then within that you want a board certified plastic surgeon that does tummy tucks. So if you’ve got someone who does mostly nose jobs or boob jobs and they do maybe a tummy tuck a year, you don’t want them doing your tummy tuck. A lot of things can go wrong.

(23:07):

And as a hernia surgeon, I see a lot of complications from tummy tuck. What do I see? Number one, the scar looks horrible. So one reason is you’re not the right candidate, you’re a smoker, you have uncontrolled diabetes, you’re morbidly obese, bad situations for tummy tuck, you should not be getting a tummy tuck second because you’re going to have a wounded complication, wound necrosis and or wound infection number one. Second situation is the scar is not correctly. So you are paying for a cosmetic operation and therefore you should have a cosmetic outcome. What does that mean? That means that your scar should not only heal well, it should be close to invisible, but it should be not visible to the average eye. So when you’re wearing a swimsuit or booty shorts or a midriff exposing tank top, you should not be seeing your scar. So the scars involved with a tummy tuck in the traditional sense are a very wide low transverse scar, which most good surgeons dip it down into the bikini line so that it mimics what kind of swimwear you would wear.

(24:34):

So the really, really, really good ones will say what kind of underwear do you wear? What kind of swimsuit you wear? Because some people like to wear different types, boy shorts, et cetera. And then kind of tailor the area of the scar to match that. So you can hide it in a bikini, let’s say, or your normal underwear. Sometimes I see them there’s too high, so it’s way close to the belly button where the scar is. That would be a bad ugly looking tummy tuck. The other incision, which is super important and if you ever want to get a true high quality tummy tuck, the key giveaway of most tummy tucks is how your belly button looks and you need to find a surgeon that makes pretty belly buttons. I can tell if someone’s had a tummy tuck. If I see their belly button, that’s a dead giveaway for most people.

(25:34):

So you want to get the tummy tuck that most nicely, most nicely hides your belly button in a natural way. So those are the two ones that I think are got to be important. Some people make the belly button really wide and big, you don’t want that. You want a tiny tucked in belly button but not too tiny where it’s hard to clean it and it can get chronically infected. So then the techniques are different types of sutures and all that. So this patient had a tummy tuck, I believe from a surgeon that doesn’t really do tummy tucks but for some reason was recruited or available to do a tummy tuck item for this patient. And what he did was just a novice mistake. So if you look at your belly, the upper belly and lower belly are distinctly different in the upper belly, the muscles are attached to your ribs.

(26:42):

So the bottom edge of your ribs are attached to your muscles. So I can only pull your upper muscles inward so much without pulling your ribs. So I’m limited by how tight I can make your belly in the upper abdomen if I make it too tight. Either you’re going to have chronic pain or it’s going to tear or you’re going to look very round and you don’t want to look around. You want to look flat. So the upper abdomen determines how tight you can make the rest of the lower abdomen because the lower abdomen except for the really lower part really isn’t stuck to anything. It’s stuck to your spine. So I can tuck in the waistline part as much as I want, but I don’t want to do it too tight because it needs to match the tightness from the upper abdomen. So the other one I saw this week was the patient barely had a tummy tuck in the upper abdomen, barely. It was very little.

(27:53):

And then below the belly button it’s super tight. So first of all, that causes chronic pain. So the patient feels like there’s a belt or tight waistline in the middle and when the patient kind of sits or bends, he feels like it’s just like the cinched vs around his mid waist. Secondarily, it looks weird. So the lower abdomen looks flat and tight. The upper abdomen’s bulging it around, so it looks really ugly. It looks ugly without clothing. It looks weird with clothing. So this is where you do too much of a tuck in the middle and lower abdomen and the upper abdomen is somewhat loose. Now once that happens, it’s very difficult to address it and fix it. I have a patient out there who unfortunately had I think something similar where the tummy tuck was done too aggressively in one area and not as aggressive in the other area. And everyone’s a little different. Some people their rib cage goes all the way down and you can’t do too much of a tummy tuck. Others, they have a very short rib cage and so the upper abdomen of their lower abdomen are very disparate in terms of how lax their muscles are for this tummy tuck.

(29:25):

What happened to this patient, which is awful, I believe she’s had upward of seven, maybe more than 10 operations to try and fix the problem. So what she had was two loose, sorry, somewhat tight of the upper abdomen and very tight in the lower abdomen, like super tight. It just looks abnormal. It looks like a cardboard, how a cardboard folds, that’s what she looks like. So then instead of, okay, so if you look at it relatively speaking, it looks like the bottom is too tight, the top is too loose. So what are your options? You can loosen the bottom or you can tighten the top. Well, the mistake is to tighten the top because that tight top will just pull on the ribs and cross. Chronic pain will tear in the middle too tight or it’ll kind of make your belly come to a point in the middle because your ribs are pulling it apart.

(30:29):

As your ribs are pulling apart, you’re not flat, you become more like a tent. So she kept having instead of having the lower abdomen tightened, I mean loosened, excuse me, she kept having the upper abdomen tightened to the point where they even started cutting out muscle, which to me is nuts, but I know it’s a thing that is done in plastic surgery and she actually went to legit plastic surgeons, but I’m not sure she went to plastic surgeons like we have in Beverly Hills where all they do is cosmetic surgery. She went to some surgeons that were in academic centers and sometimes they’re not the best because they don’t deal with these kind of problems. They deal with patients with cancer and so on. Let’s ask this question. Can suture closure of a small peri umbilical hernia done at the type of a laparoscopic hernia repair hold and sewn with rectus diastasis?

(31:31):

It is just a matter of risk. So it’s significantly higher risk for a patient who has erectus diastasis to have a simple suture fall apart than someone without erectus diastasis. So we recommend that the technique be modified in patients that have a rectus diastasis to reduce that risk. Everything is a risk. It’s not a hundred percent and that was kind of my point, but once it does tear and becomes bigger, then now you need another surgery. And all the ramifications of a second surgery and dealing with now torn tissue potentially have been a bigger hernia than you had initially and so on. So that’s the problem. So yeah, this is the problem. So this new patient that I have with this botched tummy tuck, really what the patient needs is the lower abdomen loosened and don’t touch the upper abdomen. Now the upper abdomen actually technically probably can be made tighter.

(32:41):

I recommend don’t mess with it. Enemy of good, right enemy of good is better. So the upper part is fine and not as kind of bulging, would not look as bulging if they only just loosen the lower abdomen. So that’s kind of my recommendation. Of course, I’m not a plastic surgeon, I can just make recommendations. I would not be the one doing that operation even though I’m knowledgeable, I’m not board certified and therefore if there’s complications it would not be up to me to treat it. So my theory is if I can do something better than an expert, that’s fine, but if there are experts out there that do this for a living, really you should go to them. And I have a lot of patients that are fans of mine and they’ve had prior surgery with me and they really would like some other surgery that I can technically do. They want some other surgery to be done by me, but I often say no because just because I can do something doesn’t mean I should be the one doing certain operations. It has to do with what’s right. I have plenty of patients that need my expertise. I don’t need to dabble in care of patients that I can refer to a surgeon that does whatever they need for a living. So for example, I don’t do hiatal hernia repairs. I can, I am trained to do them.

(34:19):

I used to work at USC, which was the center, the hub of hiatal hernia repairs. It’s technically not an abdominal wall repair, it’s a foregut process. There’s a lot of endoscopy and pH monitoring and manometry testing that can be done and there’s different techniques that are out there. I’m just not one that does that on a regular basis. And so you should not have your hiatal hernia repaired by me. And if you come to me with a hiatal hernia, I will say I have a lot of good friends that know how to do good hiatal hernia repairs in Los Angeles that were trained at USC are the greats in world and I recommend you go to them, not to me. And I hope that that surgeon that doesn’t really do much mesh operations and so on does refer. Oh, another patient. So patient number four.

(35:23):

This is a sad one. Again, like I said, I don’t know what was going on in their mind or what. So this patient, so sad. This patient had a hernia repair with mesh and seemingly the repair was just fine, no hernia recurrence. So the patient, excuse me, I’m going to make up some of these details. The patient had surgery, let’s say 12 years ago and six or seven years later got sick. You can’t figure out why. If someone told him it’s the mesh and he was fainting or something like that, completely unrelated to the mesh and they took out the mesh, it’s not clear. I think he had some hormonal problem. It’s not clear. Anyway, he now has a hernia on the other side and so he goes to other surgeons and he says, I want a hernia repair but I don’t want mesh. And he finds a surgeon near him, not around here. He finds a surgeon near him who says, I’ve done this once before and if you’re okay with it, I’ll do it for you too. For some reason the patient decides that’s a good idea, I’m just going to go to a surgeon who’s in his lifetime only done one operation like this before in his life. Now mind you, this is not a small town that this guy lives in. He could have found someone who is an expert or at least has done more than one, but for whatever reason he did not.

(37:11):

So the patient has his hernia repair without mesh and he claims the hernia never got better. The bulging never went away and now the bulge is even bigger. And he comes to see me. I don’t know why he didn’t just see me from the beginning, but that’s fine. So now he comes to see me and he wants a tissue repair. I said, hold on, you already had a tissue repair, it’s already failed and this is a pretty big hernia. Now I’m not going to offer you the same repair over again, right? That’s the definition of insanity, trying to do the same thing over again and expect a different outcome. So during this time I said, well, let me see what was done for you. So I asked for the op report, check this out. I’ve never seen this before. So I asked for the op report and I’m reading the op report.

(38:07):

I’m like, okay, so where’s the hernia repair? That’s weird. They explain how they found the hernias. They called the quite large hernia and then they found the sac and they cut out the sac, there’s nothing in it. They sewed it up and they push it back in place and then they’re closing. And I’m like, okay, so when they do the hernia repair, no hernia repair. So I don’t know if the surgeon chose not to do a hernia repair. They thought just pushing the hernia sac back in place is going to stay because it actually works for children, which are a totally different situation. Children tend not to have a enlarged or patulous internal ring, and it’s more of a developmental problem than a actual collagen based deficit for which they have a hernia. And so a technique called high ligation can happen for children. And if you want to go back, I forget which episode it is, but there’s a episode with Dr. Todd Ponsky that I did.

(39:17):

Dr. Polsky is a very well-respected pediatric surgeon in Ohio, I believe it’s in Cincinnati Children’s Hospital. And he is someone who advocates using high ligation and has tried to study it to see if high ligation with nothing else. You just close the hernia sac and push it back in if that is something that can happen for adults. And so far his study has shown it cannot be done in most adults, whether it can be done in like 20 year olds as opposed to 60 year olds. It’s unclear, but it is not considered standard of care for an adult. You have to do some type of tissue based repair or mesh based repair to actually address the hernia itself. In adults, this surgeon decided to do I think a high ligation. Either that or he forgot to do the hernia repair or he did do some type of hernia repair, but he didn’t put it in the notes and he just signed the note knowing that he just didn’t do it.

(40:28):

It’s totally unclear to me. I’m going to give him the benefit of the doubt and say that he did no hernia repair because he was doing some type of high ligation surgery. So no shoulder eyes, no McVay, no Bassini, no, he did no tissue based al hernia repair. What the hell? Of course the patient’s going to show up with the bulls never going away and now even larger. I think that he had to make the whole bigger just to be able to push everything back in. I don’t know. I’m going nuts because the last couple of weeks I’ve been bombarded with patients, which is great. I’ve done a lot of operations, which is also great, but the stories that are coming with these patients is crazy. I mean, who if you’re going for a non mesh repair, that doesn’t mean you go for a non-air.

(41:25):

Does that make sense? Just because you’re not putting mesh in doesn’t mean you do everything up to the point of putting in mesh and just don’t put the mesh in. That’s not how it works. You have to close the hernia somehow. And there’s a lot of techniques that you should have learned in medical school or could have learned in medical school or even read a book or watch one of my videos or something. And there’s, if you’re board certified surgeon, you should know about Shouldice or McVay or Bassini or Desarda or some type of tissue-based repair. So the fact that you thought a non mesh repair just means everything you do with a mesh repair, just don’t put the mesh in. I don’t know. Some of these stories, I’m like, how? Oh, and check this out. This is even sad. So why does this patient not want mesh?

(42:22):

Because he went to some clinic that told him he’s got cancer from the mesh, which by the way cannot happen, has never been shown to happen. There’s not a single report of mesh causing cancer. And then I looked into it because he was sold hundreds of thousands of dollars of supplements to holistically cure this cancer. No joke, this is a real story. And then this patient who is not of significant means by the way, used up all his savings to pay this quack center. That’s not even a doctor I think. I don’t think an MD was treating him. And they’re like, see, they repeated his labs. I’m like, see, there’s no cancer now it’s because of all these supplements. And I’m like, I don’t believe this. Send me your labs. So he sent me his labs. First of all, there’s no cancer. What he had done was some blood testing that looks at circulating tumor marker cells.

(43:35):

If I do that on anyone, you’re going to have some positives because these are not actual tumor marker cells specific to a tumor. Any amount of inflammation or just baseline anything can make these numbers positive. So I think what happened was he had this test, it showed these positive tumor markers. They told him he has cancer. They sold him hundreds of thousands of dollars of like vitamin C infusions and coffee enemas and red light saunas and supplements, which reduced his inflammatory state in his body and then repeated the test. And of course those tests are now going to be lower because the inflammation, his body is lower, but they label him as a cancer patient now in remission. What the hell? Like, oh by the way, I looked up this place medical board after them FDA after them, and yet this poor patient now thinks he’s got cancer from mesh and therefore doesn’t want mesh in him anymore and thinks he has cancer in remission where he never had cancer.

(44:45):

I mean, it’s just, I’m so saddened by the story because the power of selling voodoo can be so strong and they sell ’em things like, oh, of course, as western medicine doc types would not tell you the real truth. Not true. So not true. Okay, here’s a question. I have a medical question if you have time. The pathophysiology of a metabolic syndrome, which is much more common in men is believed to be the inability to store extra calories in the subcutaneous space such as fat that can be liposuction and superficial to the muscles, but rather these calories are stored in visceral space including omentum, and the intraabdominal space is deep to the muscles.

(45:47):

Have you noticed in men with diastasis recti that this type of fat distribution exists due to the metabolic syndrome? Are the men who get diastasis recti more commonly? Yes, that is correct. So the apple type belly where it’s rounded and most of the weight is stored in the midsection is often associated with more intraabdominal or visceral fat and less fat underneath the skin. That is true. Are these men more likely to have diabetes or high cholesterol or other findings of metabolic syndrome? I have not looked at that. I’m sure there’s plenty of literature that supports that, whether rectus diastasis is more, it’s true that rectus diastasis is higher in patients with a genetic predisposition and in obese patients, I would say, and or in obese patients. However, I don’t know if the metabolic syndrome is also correlated with higher risk of rectus diastasis that I don’t know.

(46:57):

It does correlate with higher risk of, let me rephrase that. Metabolic syndrome does correlate with higher risk of obesity and obesity is associated with a higher risk of diastasis recti. So if A equals B and B equals C does A equals C, I don’t know. I don’t know if the metabolic syndrome is associated with higher risk of rectua diastasis, rectus diastasis because it’s a collagen disorder, not a metabolic disorder. Good question though. I don’t understand what you meant by doing mesh repair without mesh. Okay, so when you do a mesh repair, you dissect out the hernia, you push the hernia back where it belongs or you close the sack, you sew in the mesh and then you close all the tissue layers.

(47:48):

So this guy did everything but sow in the mesh. He dissected out the hernia sac, he cut out the extra hernia sac and pushed it back where it belongs, didn’t do anything else because in a tissue repair you would have to do a tissue repair where you sew the muscles together to close that hole and then just close the skin. That’s what I mean by doing a mesh repair without the mesh. So he followed every single step he would’ve done for a mesh repair and just didn’t put the mesh in, which as you recall, mesh repair is the patch for inguinal hernias. So he just didn’t patch the hole. He didn’t even close the hole because you don’t close the hole with inguinal hernias, you just patch it in a tissue repair, you close the hole so you never close the hole. He just pushed the hernia back where it belongs.

(48:38):

But of course it comes back out. Anyone that has a groin, hernia, nose, you push it in and comes right it back out and then he woke the patient up. It makes absolutely no sense to me. I am just flabbergasted and I feel really bad for this patient and I hope that he listens to me. Yes, that’s right. He did not sew any tissues together. Yes, that’s exactly what I’m saying. And I read the operating report multiple times. I was hoping that maybe it’s a misprint and the surgeon dictated it incorrectly. But I have a feeling based on the patient’s history where he woke up with a bulge and he continues to have a bulge and it’s bigger now than before surgery. I think he did exactly that where he did not sew any of the tissues together. He just reduced the hernia and went home.

(49:28):

Which to me, I mean it’s so beyond standard of care. I just don’t understand how that can happen in modern day United States. First world country, developed country. I just don’t get it. And this is not a junior surgeon, this is a surgeon. I think he knew too much. I think he knew there is this technique of high ligation which we use for children and thought it would work for this guy and maybe told him, Hey, I’ll try it. I’ve never done it before. So he only closed skin, but not the hernia defect itself. Yes, that’s correct. See, even you can’t believe it. I went to the same stages. I’m like, wait. So he literally went from pushing the hernia back in and then deciding to do nothing else, no mesh place, no hernia closure, no tissue-based closure, nothing. And he closed the skin and that was it.

(50:19):

Like, what the hell? Yeah, we’re good. So now he’s like, what do you, I said, well, I recommend laparoscopic surgery. Why? I said, well, because you already had surgery in the front. So now the nerves, everything is scarred in for me to go back in through the front. No matter what kind of repair mesh, no mesh repair, whatever you want, I’m at risk of injuring your nerves Right now your nerves are not injured. You just have a hernia recurrence. So if I can go in laparoscopically, I can go into a virgin space where no surgeon’s been, there’s no scar tissue. There’s actually very little nerves that can be injured and I can do a good mesh based tissue repair, I’m sorry, mesh based Anglo hernia repair and just do a routine hernia repair with mesh. He’s like, yeah, but I don’t want mesh. I’m like, listen, you don’t want mesh because you think you got cancer from mesh.

(51:14):

First of all, you don’t have cancer. You were sold this diagnosis of cancer in remission based on hundreds of thousands of dollars of treatments that had nothing to do with your cancer. And you already saw what happened when you went to a doctor that doesn’t know what they’re talking about or doing. And now you’re not going to force me to do a procedure that I think is the wrong procedure for you. Now, if I thought you had mesh implant illness, if I thought that you had an autoimmune disease, if I thought that your hernia was so big that a laparoscopic repair would not be good enough, if there’s any other reason why I think an open repair, putting your nerves at risk is worth it, I would’ve recommended that. But that’s not my recommendation. And I’m not going to be forced into doing an operation on you that I think is not as good.

(52:07):

It’s inferior and may actually cause chronic pain in you. You don’t want chronic pain. I’m going to give you a good laparoscopic repair with mesh, a lower risk of chronic pain. And I kind of left it at that and I feel really bad. I feel like the patient left with so much hope coming in because he has these preconceived ideas of what’s right, and I kind of dispelled some of them, but it was way too much information for one visit, I think. And once he sent me all of his labs and I reviewed it, I was blown away by how much this poor patient was taken advantage of. And I don’t know, I hope he listens to me, but wow, there’s a lot of history there that needs to be reprogrammed. And I don’t know if the patient’s up to it or how much time we need to do that.

(53:11):

And it’s so sad that that’s the story. But I like to share my patient stories with you because I think that it gives you sheds some light because now I have this patient from another country completely deformed her tummy tuck that was done incorrectly and now she’s got this bulging abdomen, it looks like an alien coming out. I have the other patient who had an unnecessary operation during a non-elective operation that ended up with wound complications and chronic pain and never needed a tummy tuck to begin with this other patient that had the wrong technique use and now he’s deformed and upper abdomen’s bulging and lower abdomen’s flat, and he actually makes his living on his abs and it looks horrible now. And then this poor patient here who was told he’s got cancer in remission by some fake cancer center, a doctor didn’t even see or treat him.

(54:17):

Certainly not a board certified doctor and definitely not a doctor that’s a cancer doctor. And I get sad because there’s so much preventable disease out there. And yet these are patients that have work to do, they’re retired and have fixed income, they can’t have a job anymore. They’re in a situation where some of them don’t even live in this country. There’s so much complexity on the social side in addition to their medical issues that I need to address that it’s just, if I can just tell you that this past two weeks have been quite exhausting from a mental standpoint, I hope you can hear it in my voice because every single one of these patients, this is only four patients that I’ve seen in the past two weeks, maybe in the past one week, honestly. And just how is this possible? How is it possible that so much wrong is done to well-meaning people in a fully, I mean some of these operations were done at major famous institutions. It just boggles my mind, it boggles my mind. I just don’t know what to say.

(55:52):

What I have to say is that’s all for what I have for today. I hope some of these stories stick with you because it’s not just a hernia. And it’s very important to get second opinions no matter what kind of hernia you plan to have. Even something simple and do your research. I know many of you do. You wouldn’t be on this podcast if you didn’t. And I hope that some of these episodes I do kind of get the message out, but it’s just nuts some of the stuff that’s done. And I’m just one person. I can’t fix everyone.

(56:38):

Maybe you all can help spread the word about the need to see good doctors invest in your health, get second opinions. But until then, I’m just going to have to come every week and do another episode of Hernia Talk Live and keep feeding you with stories until I make an impact. So on that note, thank you for joining me tonight. My name is Dr. Towfigh. As you know, I come here every week as much as I can. I share with you my stories and today’s topic was a good one. So go to hernia talk.com to continue the conversation. If you want to watch this or past episodes, go to YouTube at Hernia Doc or to my Hernia Doc Live podcast, wherever you listen to podcasts. You can find me on Facebook at Dr Towfigh and on Twitter and Instagram at Hernia doc. And I look forward to our last episode next week. See you later. Bye-bye.