190. Trust Issues & Hernia Surgery

This week, the topic of discussion was:
-Mistrust
-Anxiety
-Surgical Outcomes
-Complications
-Second Opinion
-Bad Outcomes
-Quality of Life
-Hernia Repair

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.

If you find this content informative, please LIKE, SHARE, and SUBSCRIBE to the HerniaTalk Live channel and visit us on HerniaTalk.com.

Follow Dr. Towfigh on the following platforms:
Youtube | Facebook | Instagram | Twitter

Transcript

Dr. Towfigh (00:10):

Hello everyone, it's Dr. Towfigh. Welcome to Hernia Talk Live. My name is Dr. Shirin Towfigh. I am your hernia and laparoscopic surgery specialist, and today is our last Hernia Talk live episode for 2024. I'm super excited. We're hitting 190 episodes almost. We've been doing this since the pandemic. I think we started this in April, or April I think of 2020. Can you believe it? We're hitting almost five years. This is so crazy. Anyway, many of you're joining me right now on Zoom. Welcome, and for those of you that are here via Facebook Live, I appreciate you following me on at Dr. Towfigh. As you know, I'm very active on Instagram at Hernia Doc and for those of you who are more academically leaning, you can follow me on Twitter at hernia doc, this and all prior episodes. We are almost at 190 episodes. Actually, I think this is 190 90th episode Will is posted on YouTube at Hernia Doc.

(01:21):

And if you prefer to listen as a podcast, then you could go to any podcast, whether you listen to Apple Podcasts like I do or Spotify, et cetera, and you can watch Hernia Talk live that way. So how should I end the year? I feel like the last episode we kind of did somewhat of a end of 2024 review. We've had some really amazing episodes. If you go on my Instagram page, I did take snippets of the ones that are really popular and reposted them so that you can get inspired to watch or listen to some of them. But I would say that it's interesting because many of you go find me on whatever social media and then when you go to either the podcast or typically the YouTube channel, what you do is then you start looking through to see what topic is exciting to you.

(02:23):

So for example, one of my patients recently said he watched seven of my episodes, which is great. And these are people that are like, these are not doctors, these are just patients that their normal life is to be a office worker, guitarist Hollywood person. Definitely nothing related to hernias. And then I have them watching seven hours of hernia discussion. That's crazy. But I am very blessed that I do have people that find what I say interesting and also informative. So what was I getting at? Oh, what I was trying to say is that people then go backwards. So for example, this patient had a certain type of hernia repair called the mesh plugin patch and he had a complication from it. So you can go to my website or my YouTube channel, whatever, and search for one of my shows specifically talking about the mesh plug and patch.

(03:26):

Or I had another patient that had mesh implant illness. He was reaching out and he said he then went online and he searched for one of my episodes on my YouTube channel or my website specifically discussing mesh implant illness. So that was very informative. You don't have to watch all 190 episodes, obviously they're titled appropriately and you can just search it. And if you'd like to listen to, I don't know, something about abdominoplasty or tummy tuck, then you can figure out which one of the episodes I had actually discussed that and use that as your inspiration to listen to more hernia related topics. Also know that I do talk about non hernia stuff. So we've talked about the prostate, the bladder, the hip, other orthopedic problems, all different types of GYN issues, pain management, the spine. So there's all that. Okay? As you know, I'm often inspired by clinical situations that I see and so on to come up with some of my topics for hernia.com and her talk live.

(04:51):

So what I want to talk to today about is about trust issues. And I will say that I feel that specifically hernia surgery requires a lot of trust from the patient in their surgeon. And I say that because we know that social media has a lot of influence on people in general. And we even published a paper showing how much social media has influenced the direction in which the FDA decisions are made. And the pelvic floor, like pelvic floor urinary incontinence meshes are now off the market in part because of patients getting a voice going on social media. But it also implies that there's a lot of negativity on social media, which we reported on specifically against mesh, but also as a broader scope against hernias in general. So there are patients, for example, that are told they have a hernia, then they go online and they are just freaked out by the fact are that that they can, they're doomed to have a life full of chronic pain. Now, that's not true.

(06:21):

There's about 20 million, I just learned this recently, 20 million hernia repairs performed annually in the world. So we don't have an epidemic of 20 million chronic pain patients a year, but there is a significant enough number of patients that suffer from chronic pain and that alone is enough to scare patients. And so there are patients that either don't get appropriate care for their hernia because of their fear based on social media posts or because of what they read. They then have lost trust in the system and feel that maybe doctors, surgeons, western medicine, whatever, is not on their site and they lose the trust. So I don't want you to make decisions that would affect your quality of life and quality of care of your hernia based on fear. And I feel that I've always made this comment to you all, which is specifically do your research.

(07:34):

It's okay that you're going to be hearing a lot of negative stuff, but do be as broad and inclusive as possible when you try to do research on hernias and then find at least one doctor, and you should always do more than one consultation. Lemme rephrase that. You should always do at least two different opinions when you're planning for surgery, but do find the surgeon that is able to answer your questions is not dismissive of you treats hernias with respect, treats hernia surgery with the attention that it's due. What I don't recommend is that you pick just the local surgeon and think it's just a hernia and then regret that when the person, the surgeon that you chose was not a specialist, didn't care about hernias, made the wrong decision and now you've need another surgery or have complications.

(08:46):

Yeah, so 10%, this is one of the posts from one of the followers, 10% MHRA, UK FFA accept this as minimum damage. Yeah, yeah, they say 10%, 12%, I think 12% for inguinal hernias, 2 million per year minimum damaged by mesh. A hundred percent. It's all about the surgeon. I agree with that. So there's good results. Sorry, FDA Oh, FDA UK No, MHRA UK FDA, except 10% minimum damage. Yeah, thank you very much for that. So yeah, the story is this, which is that all surgery has complications, all surgery has better outcome when performed by a specialist in that specialty. So if you have lung cancer, don't just go to your local doctor to get treated. You should get multiple opinions and then get surgery as needed by the appropriate surgeon if you have a hernia. The same is true. Now, obviously most people would agree lung cancer is much more complicated and critical in the decision making than a hernia.

(09:58):

But at the same time, that doesn't mean that hernia should be discounted because if you pick the wrong surgeon, if they make the wrong decision, if their technique is incorrect, you can be potentially made for your life as you can with other surgeries. So there's no perfect surgery, there's no perfect surgeon, but a surgical specialist usually will do the right thing and make the better decision. If there's a choice between two meshes, they'll pick the right choice. If there's a choice between two different techniques, they'll pick the right technique. And if there's a choice between being, often the specialists gain good reputation or a little bit more delicate with their hands and treat the anatomy, understand the anatomy better, and treat the tissues with more respect than a heavy handed surgeon. And I'm not a fan of surgeons that are heavy handed. It drives me nuts.

(11:00):

So that said, I do understand that in the population that does get hurt, whether it's a recurrence, chronic pain, nerve injury, or any other need for repeat surgery, that you kind of are in a situation where now you're afraid, you're like, okay, I should have may ask more questions with the first surgery. I should have done my research better with the first surgery and now that I'm not, then now that I didn't do that with my second surgery, I'm going to be ultra ultra conservative and do all my research and ask all my questions. Here's a question. Our colorectal surgeons trained to do hernia surgeries. All general surgeons are trained to do hernia surgeries, colorectal surgeons, all of them originally did general surgery and then they specialize in colorectal surgery. Are they hernia specialists? Typically not. There are some colorectal surgeons that do have a specialty in parastomal hernias, but UK is different. In the UK, every general surgeon is specialized and a lot of the colorectal surgeons end up, lemme rephrase this. Every general surgeon is specialized from what I understand, and many of them choose to do colorectal surgery, but because there's no specialty to take over the hernia patients, often the colorectal surgeons take on the hernia patients. In the UK, in the United States general surgery is a very well respected specialty. Most general surgeons do hernias. There are colorectal surgeons that enjoy hernias, not that many and do their own hernias, not that many.

(12:55):

So I can't say not all of them do it. And definitely there's a small percentage that do it. I still believe question. I still believe that hernia surgery should be its own principal surgery specialty. I mean, I agree with you too. That's the way that will make hernia surgery better for everyone. A hundred percent agree with that. A hundred percent. That has been true for breast surgery. It used to be breast surgery was not as own specialty and women were getting mastectomies unnecessarily. There were having too many cancer operations with positive margins. The lymph nodes were being broadly dissected and causing a lot of lymphedema and nerve injury to arms. And then breast cancer, breast surgery became its own specialty separate from surgical oncology and separate from general surgery. And now the breast care is highly, highly specialized with, they're down to the minutia as to what and very protocolized care for patients. So I agree with you, it's like emergency medicine. It used to be any medicine doctor can just go to the ER and take some call and now we have a full emergency medicine specialty, I think since the eighties or something like that. It's not very old. And now emergency medical care is very specialized. There's even pediatric emergency medical care which is even more specialized, and that all translates into more efficient and better care of patients than if let's say a family medicine or medicine doctor just shows up to the emergency room to take call.

(14:36):

So yeah, specialization is very important. We find that specialization is more of a US thing. However, if you go to Canada, Mexico, most of Europe and so on, and definitely developing countries, middle East, Asia, Africa, those continents tend not to have specialists because they barely even have enough generalists to take care of the populations. So you're not going to find a hernia specialist in most of those countries. You've noticed that I don't have people that I invite from those countries often because there just aren't that many hernia specialists though it's of growing interest in the United States because we have relatively good amount of doctors in the United States compared to most countries in terms of penetration of doctors, even though overall we don't have enough doctors still in the United States. But in addition there a lot of specialists. I mean I joke about it, but I say there are times last week I did two spa gillion hernias back to back.

(15:54):

Now there are doctors that never see a Spigelian hernia. I saw two in one day and they were both on the left side and I was joking that today is left Spigelian hernia repair day. That's how specialized sometimes the care can get. So that's that. My point about it is, and today's topic is talking about trust issues and hernia surgery and that once you do have a complication from a hernia repair as a patient, you're going to have some issues with trust. You may blame the surgeon, you may blame yourself for what's gone wrong. And then you get into this anxiety mode of what if I make the wrong decision again in the second time that my surgeon now is requesting hernia surgery? And of course your personality is going to be affected by that. Some personalities are very anxious and it's almost to the point of being detrimental to their care.

(16:57):

And others are complete opposite. They're a little bit involved in the decision-making and care of themselves. So there are patients that go to the same surgeon four or five times and they keep having complications. And I'm like after number one, even number two, maybe you should consider a second opinion because you don't want to keep doing the same thing over and over again with someone. Bring a fresh eye, have another set of eyes, look at your situation and give you some feedback and maybe have a little bit of a discussion as to what's best for you.

(17:39):

But a good proportion of patients feel really broken by the complication that they have, especially for people with inguinal hernia problems, less so for abdominal wall problems, at least in my experience. And then they lose trust and that lack of trust carries with them. So I get patients in my office that have a really long list of questions, which is fine. I answer, I try and answer as many as possible. And many times these are really insightful, legit questions similar to the questions that you all ask while I'm talking in this webinar, in this podcast, and that's fine. However, some of them come with really high anxiety and questions where they've read and they've done, these are the patients they read and they've done their research, but their research is based on their worldview coloring, what kind of rabbit hole they were taken through on social media or research, et cetera.

(18:54):

And so they come to me with a set idea of what they think is going on or what should be done, et cetera. And then let's say they come to me, then I analyze their situation. I said, oh, no, no, this is a mesh problem. For example, this is not a urologic problem. This is a hernia recurrence. This is not a mesh reaction. Whatever the situation is, I'm completely going 180 to where they were headed when they came into the office. And so it's a little bit difficult for me because I have to use that part of that consultation time to steer the patient in a different direction than they were headed before they walked into the office, right?

(19:39):

It's like, how should I explain it? I gave an example to one of the patients because he was so focused on the urologic problems that he had, and I kept telling him that it's, and therefore the mesh problem that he believes caused the urologic problem. But I kept telling him his mesh is fine. Just he had the placement of the mesh is the problem, and maybe even the way the mesh was placed, but the repair, the material of the product is fine and he doesn't have a hernia recurrence and he doesn't have direct urologic injury. Let me address the mesh repair complication issue. And everything downstream from that should realize. But because of his prior kind of research and thought process, he still thought it's the mesh, it's the mesh, it's the mesh, and therefore he doesn't want mesh. And of course, he's definitely not a situation where I would do a non mesh repair.

(20:47):

He's fine. Mesh is not his problem. So I said, let me give you an example. You are driving a Mercedes down the street and you got in a car crash because another car swerved in front of you. You cannot see, therefore, I will never drive a Mercedes-Benz anymore. Your car was not the problem. The swerving of this other car in front of you was the problem. So you are blaming everything on the mesh. The mesh is not the problem. Your Mercedes-Benz car is not the problem. It's not why you got into a car crash. It's this other influence on the car such as someone swerving in front of you that induced the car crash or induced the chronic pain complication and the urologic problems that you're having.

(21:41):

I like to come up with these discussions. I don't know if these examples make sense to you. Question. Is it normally difficult to find surgeons who are willing to do revision surgery after you've had pelvic mesh put? Yes. It is difficult for two reasons. One is you have to find a doctor that even does revisional surgery. So we are a fraction of the population. So let's say in the world, let's say there are a hundred thousand general surgeons of that a hundred thousand, maybe 10,000, really enjoy doing hernias. I'll call them a surgeon that enjoy doing hernias. That means they respect it, they understand the anatomy, they prefer it. Other operations they do. There's a special interest in it. And of that 10,000, maybe a thousand are true hernia specialists in the world. So we went from, what did I say, a hundred thousand to a thousand that are actually revisional hernia specialists with actually not only our general surgeons and joy hernias, but they go that one step beyond and actually are skilled enough to undo hernia repairs, undo pelvic mesh and redo it. Because I was telling this to, I was telling this to my fellow in training, actually, I was operating with him. Was it my fellow? Yeah, my fellow. So he's a very skilled surgeon. He'll do great. He's going to hopefully get a job in northern California.

(23:33):

He's a good surgeon. He knows exactly what to do. So we were operating together and he was doing great operating while doing everything. And I explained to him, you're now doing a revisional surgery with me. You're board certified, you've done your general surgery residency, but I can't say you're a hernia specialist, but you're able to do this operation with me. Why was this an important discussion? Because a lot of revisional surgery is based on the decision making as to what is the right thing to do. A lot of doctors can physically do the procedure. The question is what is the right procedure to do? So for example, if you've had a hernia occur from a spine surgery in the front of the belly abdominal wall, I'll give you an example of a patient. A patient of mine had spine surgery from the front of the abdominal wall, so it's called anterior approach or alif, A LIF.

(24:49):

They had an anterior approach. So one surgeon comes in, makes an incision in the abdominal wall, and then goes all the way towards the spine from the front of the belly towards the back to the spine, and then the spine surgeon comes in, does her spine surgery, and then that surgeon that did the exposure opening the incision in the front to go back towards the spine, then closes everything up and they got her bulging after that. So this poor patient kept saying, she has a bulge. And they're like, yeah, you have a bulge, but it's not a hernia. Wrong. She got imaging. The imaging was read as, yeah, there's a bulge but there's no hernia also wrong. And she was eventually sent to me. I was like, yeah, of course you have a bulge and there's a hernia on imaging. I don't understand the question.

(25:42):

So already going to a hernia specialist means you are interpreting the clinical situation differently than the average surgeon. So that's number one. Then the question is, okay, you have this very specific type of hernia where of the three layers of the abdominal wall, they closed the top layer, but they didn't close the bottom layer two or layer three. So technically there's no full thickness hernia because the top of layer number one is there's no hernia, but there is a hernia herniation of layers two and three. And layer number three is like your inner girdle. So if you cut that, you lose your inner girdle, you lose your muscle, abdominal kind of contour and you get a bulging. So why is that? That's a hernia. You get the CAT scan, it doesn't show a big loop of intestine running through the abdominal wall. So they did not call it as a hernia because they're incorrect.

(26:53):

And she saw a regular surgeon and that regular surgeon kind of pushed her belly, couldn't stick their finger in anything, and they're like, yeah, you're just bulging on one side. Maybe you healed weird and didn't understand that there are these types of hernias. So already making that decision of interpreting the imaging correctly, interpreting what was done during surgery and now how their belly looks correctly, and then diagnosing it correctly is already half the work, right? Then other half is okay, now that you have this specific type of hernia and you're X years old and you have diabetes or obesity or whatever the situation is that it makes the surgery complicated, what is the next best procedure? Because there's a million different ways to fix the hernia with without laparoscopic robotic open, different incisions where to put the trocars, et cetera. So then I said, okay, so I believe because everything's grown wrong on the inside, let's fix everything from the inside which can be done robotically and not use your open incision again, number one.

(28:09):

And then number two, we need to kind of bring stuff closer together to close that hole. But in my, I know from my experience when you do that, it can be very tight. So Botox will help bridge that patient's pain through a better tolerated recovery and therefore I can tightening up this muscle without her being in so much pain and then tearing. So I did the repair and added Botox to it to add to her recovery. And then lastly, I knew how to do this repair and then put the mesh in a place where it doesn't affect her intestines and all that. So every single little step until the day of surgery is decision making. And that's what I was discussing with my fellow in training, which is, I mean, you clearly can do the surgery, but the key is the correct diagnosis, the correct plan of care before you actually do the surgery. So that's where it really helps to be a specialist and makes a difference. It's not only just doing the good surgery but the decision making. Let's go to more questions. Hi Sharon. I'm still in limbo, I'm afraid. Just praying something happens in the new year, but it's not looking great. Great to catch alive. Thanks for all you do for us. And Merry Christmas. Yes, thank you. Merry Christmas to you too. It's probably really cold where you live.

(29:42):

I plan to be there next year. I'll see you guys in the UK next year. Okay, so that's where the trust issues then fall into play because you as a patient sometimes I'm talking about a handful of patients do their own research and come up with their own plan of care. I believe I need my mesh removed. I believe I should not have mesh. I believe this should be done open. I believe this should be done robotically. Whatever the situation is is based on your research and what you think is going on. Then you come to my office and I start dispelling your ideas. This should not be done robotically. Yes, we do need mesh. No, we should do this robotically. It is safe to do robotic surgery. I know you've read that there's even a movie about robotic complications. There's complications with anything. We really do much better with robotics nowadays than we did in the past.

(30:47):

There's all of this time I often spend trying to unprogram what you've been programming your brain to think about your situation. And then I have patients that are very, very anxious and their immediate response is to question and query. So I'm okay with you questioning my decision. A lot of doctors are not. I'm totally okay with it. I'm also okay helping you through the process to reprogram your thought process to understand why I'm recommending a certain thing. I'm also okay listening to your ideas and be like, there are patients where I would say, actually that's really good idea. Let's do that. I didn't think of it or it was an option, but I wasn't going to go in that direction. But now that you mention it, I like it.

(31:48):

What I don't think is healthy is constant questioning and not so much questioning, but doubting the hernia specialist to the point where it becomes a battle. And I've had a handful of patients like that where it's gotten to the point where I have to get to a point like, listen, I've been doing this for a long time. I'm okay answering your questions, but at some point you'll have to come to a situation where you have come to terms with my plan of care, which is a joint decision making process, right? I provide you reasons why you want to do things. You tell me why you do or do not want to do things, and we go together. You may say, I don't want to have mesh because X, Y, and Z. I'll say, okay, well not putting in mesh implies a different incision implies higher risk of recurrence implies higher risk of chronic pain.

(33:02):

And you may say yes, but or you may say, oh, I didn't know that. I would not choose that. If it has worse outcome, higher complication rate, whatever in that joint decision making, we're moving towards a plan of care. But if your ideas of what's going on are disproven by me or discussed by me, we came to plan of care and just like a rubber band, you go back to your original thoughts, it's very difficult for me to take you to surgery if you have no trust in the process. At some point your surgeon, you have to go into surgery trusting that whatever plan of care was made was done with your input and the added knowledge and expertise of your surgeon and whatever your surgeon sees in the operating room is going to be appropriately addressed by your surgeon. So I'll give you another example.

(34:18):

I saw another patient, she is had complications as well. She went to another surgeon who thought her problem was X, it turned out to be Y, so now she's seeing me. So here's a patient where actually I understand the anxiety and the questioning because she's had now two, maybe three surgeries with different surgeons and she hasn't gotten to a point where she, she's made whole, so that is quite anxious, right? I can understand trust issues there, but I'll tell you she really treated the situation well because at the end of the day, you have to trust that the decision you're making in that surgeon is one where the surgeon will take the best care of you, and then if there are different findings in the operating room, your surgeon will address it at the time and not discount it or will have the knowledge and the expertise to do that.

(35:30):

And she was very good about that. She made her decision to have me do her, no, I think third operation, third major operation in the area, and she understands that I may go in there and find other things and she's totally okay with me addressing it. In fact, that's what she wants. Well, let's get to some questions. I'm sorry. Are there any other specialists as good as you in the US East coast specifically? There are many surgeons in the east coast, actually much more than the west coast. I've interviewed many of them. I suggest that you go to hernia talk.com or my website, look up specific states, New York, let's say most of them are from New York. Actually we have a couple other, I think we have Maryland, New York, North Carolina, where else on the east coast? I think those are the only ones we have that I've interviewed, but multiple surgeons from those states and just listen to them and see if you like their train of thought.

(36:43):

Okay, if you have pain following a complicated repair of a recurrent hernia by a specialized groin surgeon, should you and how do you trust that surgeon to perform revision or if they make a recommendation for spinal cord stimulator? Okay, I'm not a fan of spinal cord stimulator. Almost every patient with very few exceptions that I've seen who recommended a spinal cord stimulator were incorrect and the patient had a surgically treatable problem. So this is where I say get a second opinion. So yes, if you've had a complicated repair of a recurrent hernia by a specialized groin surgeon and now you have problems because they say there's nothing else to do for you, go get a spinal cord stimulator. Go see a second. Even third, what do you call it? Surgeon for another consultation or opinion. Okay. Let's see. Do you know anyone in Northern California who is a hernia specialist?

(38:02):

Not really. Not in the true sense of there are hernia surgery doctors who are really good at hernia surgery. In my mind, a hernia specialist is one who can handle every single complication and revisional problem, and we really don't have that in northern California. In the Kaiser system. There's a David Wynn and I should probably interview him at one of these sessions, who is the go-to person in the Kaiser system for this, but that's pretty much it. There are good doctors like Dr. Rockson Liu in Northern California that are just good hernia surgeons, but do they do chronic pain and neurectomies and all that? They do not. And a lot of them are really good with the abdominal wall, but not as comfortable with treating complications related to the groin. So I would recommend, again, go to my website or YouTube channel at hernia doc and look up Northern California, like your city of San Francisco, Oakland, whatever.

(39:10):

And you'll see I've interviewed multiple surgeons, actually. Is it multiple? I think it's only one surgeon. No, no. I take that back. Multiple surgeons from Northern California, I think Mary Hahn and others, and see what you think, see how you like the way that they answer questions and so on. I always like to say that the surgeons that I interview are somewhat vetted by me already. I know them, I've worked with them. They have good reputation, et cetera. And so I think very highly of them. And I'm kind of like Costco. Do you guys all shop at Costco? If I need a vacuum, I'll just go buy it from Costco. I don't usually need to do my research. And every time I do the research, Costco is the Costco actually carries the top rated vacuum, for example. Or if I need, I don't know, maybe something a blanket or some type of electrical electronic problem thing.

(40:23):

Usually Costco or pots and pans. Usually Costco has done its research already and they typically stock the best of whatever it is you need. So I feel like Hernia Talk Live, it does that because the guests that I bring on are pre-vetted by myself and I stand behind their work and we usually pick a topic that is relevant to their specialty and discuss it, and I don't bring on people for that. What is your opinion of Dean Matsuda and his endoscopic repair of sport hernia? Okay. Dean Matsuda, he's a great surgeon. He was in Hawaii. Is he still in Hawaii? I think he's still in Hawaii, and I don't know what you mean by endoscopic. If you mean laparoscopic, then he's really just doing a hernia repair. There's no laparoscopic repair of a sports hernia. They're almost always done for open repair.

(41:27):

Yes, it is cold. Yeah, the UK is cold. I know. You're the only doctor I've seen that gives me complete trust. Thank you so much. Let's see, at some point you got to trust someone. Exactly, true. And I feel like there's a handful of patients that are stuck and they'll never trust anyone, and I feel that really affects their ability to recover well from surgery. I do not recommend you go into surgery with a high anxiety level or a mistrust of the process. I trusted Dr. Mwe implicitly and still do because like the lady answered my questions with knowledge and honesty, and I did interview Dr. Mwe. We'll discuss more over to you one day. Okay. I actually look forward to it. Have a fantastic day, and like Ursula said, thanks for all you do. Thank you. You're welcome. Next question.

(42:25):

Hi, Dr. Towfigh. I'm curious whether hemp is being tested as a form of surgical mesh. It would not be. And hemp is. I mean, I think it's biodegradable. No, my understanding is hemp could be biofilm resistant and would be interested in your views on hemp being used in hernia pairs. I mean, I've never heard of it. If you have any papers or articles where they've used hemp inside the body for any reason, I would love to read about it. I think it's a fiber, right? I know hemp based on C-B-D-T-H-C, marijuana, so there's hemp. You can make an oil out of it, a paste out of it, but can you make it into a permanent mesh? I think it absorbs too quickly. Next question. I'm afraid that surgeons I've seen since the first are afraid that I want to sue the first surgeon. Oh, and don't want to get involved. Yes, that's true. There are a lot of surgeons that specifically never want to be that surgeon that does the revision surgery because they don't want to deal with potentially suing patients. And I have that situation as well. There are just patients that are litigious or angry and they just want to sue.

(43:54):

In my heart, I still want to help the patient, but I've been burnt by patients that are litigious. Am I crazy for feeling this way or is my hernia truly so called that they don't believe me? Well, I mean, keep asking questions, keep seeing specialists until you get the right answer. Clearly, if you're seeing surgeons that don't want to help you, then they're not the right surgeon for you. And maybe after multiple people seeing multiple people, et cetera, you may get to a point where maybe someone will figure out exactly what's wrong that's completely different than what you were thinking, and that could be a good thing too. I've had patients where I just couldn't figure it out and I finally, and it was bugging me. They didn't come back to see me. I don't remember how I would, some of them actually would reach back and be like, remember when I came to see you and I had all these symptoms and no one could figure it out, and you were stumped as well?

(45:04):

I'm like, yeah, did you figure it out? I figured it out. It was this weird diaphragm hernia on one of 'em, another one. It was all eventually treated by what's CBT, behavioral therapy, CBT, cognitive behavioral therapy and so on. So I learned from these situations, and I highly, highly encourage when I see patients where I haven't figured it out or I send them to another specialist, let's say urologist, orthopedic surgeon, whatever. I always say, if they figure it out, out, please let me know because I will learn from that process and hopefully the next patient that I help treat is going to benefit from you. Sharing your knowledge with me. Do you know any Australian hernia specialist that would be interested in being invited your platform? It would be great to hear Australian specialists treat patients in comparison to other countries. Yes, I do. I have multiple friends in the Australian hernia world. Some of them are gaining given more notoriety and interest in hernia surgery. So I'm hoping, yes, cognitive, thank you. So I'm hoping that maybe 2025 would be a good time for me to get them to come on as guests. The timing of the Hernia Talk Live is going to obviously be changed because of the change in time zone, but yeah. Yeah, for sure. Australian surgeons are on my list. Don't you worry. I have not forgotten about my Fran down south.

(46:59):

Okay, well, these are great questions. I really thank you all for these. So if you're highly anxious, do not get surgery until your anxiety is under control. Needing revision surgery, having chronic pain, being maimed, having your quality of life destroyed because of a prior surgery will cause you anxiety. But whether it's something you can do on your own or whether you need medications, do not get surgery while you're in a heightened anxious mode. You need to get that under good control because otherwise it will seriously affect your recovery and you want to be in the best mental state to undergo your surgery. So that's number one. Number two, do get multiple consults and opinions and do not just say, oh, well, he was the closest to me or whatever, you need to invest in your health and wellbeing. You'll be burnt if you choose a surgeon based on convenience and not based on what's your best interest.

(48:19):

I'll give you an example. So I have some friends that live in one part of the state and they're just not getting based on my opinion. They're not just not getting the right care where they are, whether it's because the doctors they're choosing is not right or they don't want to pay out of pocket and they're trying to stay in network and the doctors that are in network are just giving them appointments six months out, four months out, and then they don't see the doctor, they see a nurse practitioner, and then the nurse practitioner doesn't understand that their patient, that this patient is a bit more complicated than your typical system, whatever the situation is. And now it's been like five years that they're not getting the appropriate care. Five years of their life is ruined from this medical disease and it's affecting the family, and they're just wasting away.

(49:23):

They're now down to less than a hundred pounds, not eating, et cetera, just completely horrible quality of life. Now, my recommendation was listen, at some point you have to see what's happened in the past five years and understand it's not helping you. You're not getting the care you need. No one's listening to you, et cetera. I know someone who is excellent at what they do will help you, will treat you with utmost care. And attention is knowledgeable, is very caring, but they're not where you live. They're where I live. I have a really great list of doctors about different specialties. You need someone who will take personal care of you. And by the way, unfortunately he's not in your network. You're going to have to pay cash.

(50:18):

And to this day, they're still not there yet to agree to kind of nip this, the bud and understand what they're doing the past five years has not helped, and they should just suck it up, come near me where I know the doctor and I can help with the process and just get your life back to order. A lot of patients like that, there are a lot of patients that for whatever reason, do not feel like they should have to travel for their care. Meanwhile, years have gone by hundreds and thousands of dollars have been spent on care that was completely wrong or ineffective to me with my personality. I can't accept that. I just go root of the problem, get it one and done and move on. And this idea that you should just waste away and just complain about your situation when there are alternatives to me, doesn't make sense. Okay, question. I was able to find the following information on hemp. Oh, cool. Okay. Let's see. This is for international purposes only for medical advisor or diagnosis consultant professional. Okay, that's our whatever. Okay, that's our disclaimer anyway. Hemp itself cannot be directly used as an implant material. However, research is being conducted on using cannabidiol, CBD, cannabidiol, CBDA compound found in hemp to create biocompatible polymers for potential use in medical implants.

(52:09):

Oh, I think this is as like implanting a drug not necessarily using as a implant like a sheet. These CBD based polymers have shown promise in preclinical studies due to their potential biocompatibility antioxidant properties and potential for controlled drug release. Yeah, this is what they're talking about. It's implanting a drug onto an implant. However, more research and clinical trials are necessary to fully evaluate their safety and efficacy for use in human implants. So there are things that are put in your body that are intended to give direct local drugs, either antibiotic antibacterial, anti-inflammatory toward estrogen, testosterone, whatever as an implant. So I think what they're talking about is, let's say you have, I'm going to make this up. Let's say you have a piece of mesh and you infuse CBD as an inflammatory, sorry, as an anti-inflammatory onto the polymer, the mesh polymer. And therefore when you put the mesh in, you also have an anti-inflammatory effect locally to help reduce pain and reaction to the mesh. I'm totally making this up, but the mesh is still a permanent implant and then the CBD is used as a drug to implant it.

(53:43):

Okay. Well, thank you for including your Google search, which is studies on hemp as a medical implant. So what they're trying to show is hemp as a drug or CBD, which is a much more refined version of hemp chi quality, more potent than hemp, as a drug being used as an implant as opposed to hemp. The fiber being woven in a way to function as a mesh barrier for hernias. I think that's what it is. Okay, next question. Hello doctor. I have an in mesh removal. I have had an inguinal mesh removal tap, initially robotic for the removal because of systemic mesh reaction. I now have an even larger bladder hernia, two centimeters. Is a sized tissue repair still an option now, or should I consider that I have too much more scar tissue for a neurosis? So I would have a look at your imaging. It's not only the size of the defect, but also the quality of the muscle left behind. But I'd have a look to see what your original mesh was and how much muscle damage was placed. But the short answer is yes, a Shouldice is doable, and sometimes you can do a Shouldice plus a biologic to help support the Shouldice. At least in the healing stages, you must have what's called a relaxing incision to help reduce that tension on the Shouldice repair. But yeah, the short answer is yes, but there's a lot of caveats to that.

(55:45):

Okay, well, we're getting a lot of questions answered. I'm super excited about this. I would love to hear from you all if what you think about trust issues. I don't want to come off as a surgeon that says my way or the highway, and you just have to trust what I say and move on. I don't believe in that. But I do know that there are some patients, and maybe my experience is different than most surgeons because I do attract patients that are already have a complication. They have chronic pain, they're often out of state, they're often having lots of anxiety associated with this. It may have affected their job or their family life, et cetera. So all that baggage comes with them, and therefore the type of patient that I see may be a little skewed. I don't think the average surgeon sees patients that are mistrusting of the situation, but at some point, one of the people watching right now says, Martin, at some point, you have to start trusting the person that you're doing it with.

(57:03):

And don't kill yourself if that trust is not there initially. But it has to be there before the day of surgery and it's good for you. It's good for your doctor. You want your doctor to feel like you're appreciating and they're doing everything they can to help you. And honestly, if you're in a situation where you don't trust that doctor, just move on. No one's forcing you to be with that doctor. There's no, pretty much everywhere in the world, you can go see another doctor. You may have to travel, but no one's putting you in jail and saying, you have to use this doctor. So use your own judgment. Find a doctor that you do trust, and if you can't find that doctor, move on and find another doctor. That's kind of my parting words. I don't know how much better to say that without really sounding too haughty, but that's just the way that I am thinking.

(58:07):

And I hope that today's discussion on trust issues is relevant to you all. It's so important that you treat any anxiety you may have and find the right match for yourself before moving on with surgery. Especially if it's revisional. You do not want to have the wrong revisional surgery. It can definitely burn a lot of bridges. So on that note, thanks everyone for joining me. I hope you have a Merry Christmas. I believe Hanukkah's coming up. So happy Hanukkah. The New Year's going to be amazing. 2025 is going to be super, super exciting. I will have some Australian surgeons on board. I will get you some northern, I'll try and get some more Northern California. There aren't that many Northern California. What do I do about that? Oh no, the Dr. David went from Kaiser Permanente. I will do that for you. And yeah, we're really busy. I'm working through Christmas. I'm working Christmas Eve. My office has me working all those days, but hopefully I'll get some time off and we'll see you all in January, 2025. So excited. See you soon. Bye.