192. Balancing Hernia Repair and Your Health

This week, the topic of discussion was: 

• Organ Failure
• Liver Failure
• Ascites 
• Portal Hypertension
• Kidney Failure
• Dialysis
• Heart Failure
• Bleeding
• Hernia Recurrence
• Anesthesia
• Safety
• Hernia Complications
• Chronic Pain
• Direct Hernia
• Mesh 

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.

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

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Transcript

Speaker 1 (00:11):

Hello everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live. It’s very glad. I’m very glad to be here with you guys since we had to cancel last week. My name is Dr. Shirin Towfigh. I’m your hernia surgery specialist. Thanks to those of you that are already logged in to join me via Zoom as well as Facebook as a Facebook lot. Let me get my Facebook live app up so I can help answer your questions. All right, many of you are also following me on Twitter and Instagram at hernia doc and thanks to all of you who are subscribers to my YouTube channel and also to those of you who are watching on the podcast or listening on the podcast, I just got some of my data downloaded. You guys are doing a great job. I hope you share it with your friends and anyone who’s interested in hernias listen to the podcast.

(01:11):

I think we’re having some fun with it and as I can see from the podcast that downloads are be getting really great. So I’m super excited about that. Well, as you may know, we had to cancel last week and the reason why we had to cancel is we were in the middle of a natural disaster in California. As you may recall, many of you reached out to me. We had pretty dramatic fires and my office was not affected. We just had poor air quality, but my house was affected. I did lose my house, thank God, but we did have to evacuate and there was just a lot on my plate and I felt that doing a hernia talk live, even though most of the nation was not affected by this disaster, maybe it was not the right thing to do. And so I thank you all. Sorry about the last minute cancellation.

(02:12):

Many of you actually did reach out to me and send me great wishes either through a DM on Twitter or Facebook or Instagram, and it really, really touched my heart because I really don’t expect my patients to get involved with my personal life, but I thank you very much. We’re safe, our dog is safe, the air quality is still horrible. But for those of you, I like to hear what you know about air quality. The air quality is not good because of all the smoldering smokes and the ashes that are still in the air and I’m told there’s potentially asbestos, some plastics that have been burnt through this massive fire that was all throughout LA County, Los Angeles County. However, I was looking through the weather apps and Paris is so much worse in the weather quality than what we were dealing with even during the active fires. So I don’t know those of you that live in France, I know a couple of you are followers and are actively on here in France. Is this for real? Is Paris really that bad of air quality to the point where it’s like multiple times worse than LA during an active fire? It just seems so hard for me to believe.

(03:41):

All right, so anyway, please do go ahead and send in your questions if you want and I’ll help answer them while we’re doing this. We have multiple people who had their questions submitted last week, so I got those to answer this week. But the topic of discussion for this week that I chose is trying to balance your hernia health with your regular health. And I say this because two reasons. One is we are working on some research abstracts and what I’ve learned is that for surgeons, sometimes it’s hard for them to balance like fixing a hernia with saving a life. So there are many patients that come into the emergency room on death’s door due to complications of a hernia and the surgeon, US general surgeons, a lot of what we do is lifesaving and so they call the general surgeon. The general surgeon, whisks the patient off to the emergency room and deals with the life-threatening problem, which is usually some type of intestinal involvement. Strangulation is what we call it where your intestine is stuck in the hernia and then the hernia kind of blocks off the blood flow to the intestine and you get dead intestine and you’re almost dead. So there’s a limited time in which we can save you. Fortunately that doesn’t happen very often.

(05:22):

I don’t really take call for the emergency room anymore. I used to a lot when I was younger and I saw a lot of these patients, I don’t see them as much anymore. I’m more dealing with chronic problems than acute problems. But the teaching is still there and I tell the surgeons, go in there and save the life. Don’t worry about the hernia. The hernia is why they have the intestinal obstruction or the intestinal strangulation with the blood flow affecting it and causing dead intestine. But technically the hernia itself is not what’s causing the problem. It’s the dead intestine. So I feel that a lot of surgeons get kind of caught up in, okay, now I dealt with the intestines, now I have to fix the hernia and the teaching point to my residents and to many surgeons is disregard the hernia right now the patient’s too sick.

(06:27):

You don’t want to add an extra hour or two to do a hernia repair. It’s not going to be a good hernia repair anyway because the patient’s too sick, there’s infection and you just can’t do a good hernia repair. So just let them be, bring ’em back two, three days later when they’re not as infected or not as sick and fix the hernia then. And that’s called staging. I’m a big advocate of staging hernia repairs, especially for hernias that are difficult to repair. So here’s a comment. Glad you’re safe. Thank you so much, appreciate it.

(07:04):

And then on top of that, I got a patient that came to me to see me who was sick. He legit has a chronic illness, liver failure, not a healthy patient. And he came to me because he had a complication from a hernia repair and I’m thinking, why did you even have your hernia repaired? Was it bothering you? Not really. Did you have chronic pain from it? No. Why did you get your hernia repaired when you’re in full liver failure, you’re on the liver transplant list and he is like, well, they had the hernia. I said, I understand you had a hernia, but people live with hernias potentially operating on someone in liver failure with all the complications. We know liver failure, you have a tendency to bleed because you don’t clot very well because your liver doesn’t make all the clotting factors. You have ascites, which is fluid that collects in the belly, which adds pressure to the abdomen, which makes hernias fail and recur.

(08:14):

You have clots in your, let me back up. You have varicose veins which are just dilated, big, thick, huge veins that like big hemorrhoid veins but in the belly and around the esophagus and the abdominal wall that you can injure those as a surgeon and cause massive bleeding to the point of death. You’re higher risk for infection, you’re chronically ill and therefore can’t heal. Heal. There are all these reasons not to do elective surgery on someone that has end stage liver disease. So what part having your hernia sir trumped all these negative effects and made your surgeon kind of agree to fix your hernia. He had nothing. He had a hernia that was stuck and it was just a piece of fat that was stuck. He had no pain, he had no obstruction, he had no infection. And that’s what happens with hernias in patients with liver disease.

(09:22):

They get ascites and fluid and the hernia gets stuck as long as there’s no pain and there’s no blood flow issue, there’s zero need to fix your hernia if you’re so sick from your liver that you’re on the transplant list. That’s just, I thought it was just common sense, but apparently it’s not because he had a hernia surgery. Fortunately he had a very smart anesthesiologist and survived the surgery. Unfortunately, the surgeon decide to do this laparoscopically, which also is not a good idea because you’re blindly entering the abdomen and there are vessels like actual major veins you can consider major veins that can be injured and can massively bleed from that. And he very quickly figured out he can’t do this laparoscopically. Then he switched to open surgery. So that again, not a good idea. You have a big scar in the abdomen and that doesn’t heal.

(10:24):

You leak fluid from your ascites, it’s just a mess risk for mesh infection, et cetera. So on top of all that, just the risk of anesthesia can push your liver failure to be even worse, which is exactly what happened since the anesthesia for the hernia repair, which I felt was not indicated. He is now in worse liver failure. He had four liters of fluid taking out of his abdomen. All of that are just signs of worsening liver failure, but he’s not so sick that he can get a liver transplant because they’re sicker patients. So it’s just a bad situation and it got to, got me to thinking that maybe it’s important to kind of give a little bit of perspective. So what we do on hernia attack, all we do is talk about hernias and maybe hernia related problems and sometimes we need to stop and say, okay, fine, your hernia’s diagnosed, we know you have a hernia, but is it really in your best interest to get it repaired?

(11:33):

We’ve talked about watchful waiting. We know that it’s safe both for groin hernias and for belly button hernias not to operate on patients that don’t have pain. You also need to add on top of that the risk of surgery in someone. So if you’ve bad heart disease and you have a hernia it I may kill you if I operate on you because the anesthesia alone will be detrimental to your heart disease. So unfortunately, if you have severe heart failure for example, you’re likely not going to get a hernia repair. There are situations where I may operate on you with little to no anesthesia with just local anesthetic and I’ve done that in some patients that, especially some of that are on the heart transplant list because we have a big heart transplant group at our hospital and I’m perfectly comfortable doing that. It’s just if you go to a surgeon that doesn’t understand that, they may be like, oh, I can do this laparoscopically, I can do this robotically and it may sound great, but that’s actually detrimental because those all number one require general anesthesia, which is not good for the heart.

(12:49):

Number two, you have to fill up the belly with gas carbon dioxide, which is also not good for the heart. So there’s just a lot of thought process that needs to go through and when you’re choosing to do surgery and I thought it would be good idea to address that in today’s episode. Let’s see what questions you have. What are the risks of continuing to exercise if you have postoperative groin pain following open repair after other than just dealing with the pain? Good question. So if you have pain from your hernia repair, that should not prevent you from choosing to be active. You should still be as active as possible.

(13:47):

Keeping your weight in check and not gaining weight is a good way to help reduce chronic pain and keeping those muscles healthy with core strengthening exercises is also a good way to help reduce chronic pain. So therefore, if you have a hernia repair and you have pain from it, but the pain is not worse by the exercises you’re doing, which would be most situations, then by all means you should be active in exercise with little to no limitations. Okay, so we talked about liver failure, we talked about heart failure. Kidney failure is another one. So if you have kidney failure on dialysis, usually getting a hernia repair is okay because we have a treatment for, not a treatment, but some type of way to control a kidney failure, which is to perform dialysis. Now, I don’t know if you’re all familiar with dialysis. There’s two types of dialysis.

(14:56):

One is through the vessels where they clean your blood and one is through the peritoneum or the abdominal wall where they kind of clean your blood indirectly by filtering it through your abdominal fluid. And in doing so with the blood thing, you just need to make sure that the patient can clot, okay? Right? If you want to operate, you have to be able to clot so you don’t bleed from your surgery. When they do hemodialysis, which is dialysis through the blood, they often inject a lot of blood clotting, anti blood clotting, heparin and so on because the machine can’t clot the blood as the blood’s running through it, either the catheter or the vein through which they’re deriving. The blood shouldn’t clot during the process. So usually these patients are kept in a situation where they don’t clot artificially. They do that with medications, injections, and so on.

(16:03):

In surgery you want to clot, so you should have some type of discussion with the nephrologist, which is the kidney specialist to figure out, okay, at what point can we either reduce the clotting, the anti-clotting issues and prepare for surgery? And the timing of surgery is very important. The other issue which is trickier even is in people that are getting what’s called peritoneal dialysis. So the dialysis which cleans up your blood toxins because your kidney can’t do it, are done by filling up your belly with liters of flute and then siphoning it off and doing that over a matter of hours every single day. That is not as commonly performed, but some patients do prefer it or have to have it that way. And doing so, your abdominal wall expands and contracts expands and contracts. And as you know, if you’ve been following me, you know that the theory is with hernias, anything that adds extra pressure to the abdomen gives you hernias or makes hernias worse.

(17:19):

So people on hemodialysis don’t have that problem, but if you’re on peritoneal dialysis where you’re adding pressure to the abdominal wall, if you have a hernia, it’s going to make it look worse. And if you have a hernia that’s repaired, it may add pressure to the repair. So I think I had an episode in the past where we talked about risk factors for hernias and how the surgeon needs to understand lifestyle. So if you’re a construction worker or if you’re like a nurse, I had a patient who’s a physical therapist and so she carries a 50 pound bed around, you have to understand what the lifestyle of the patient is and then kind of take your surgical plan and tweak it a little bit to make sure that it addresses their lifestyle. So for example, if I am operating on an opera singer, which I have done multiple times, they generate a lot of abdominal pressure. So if you’re generating a lot of abdominal pressure and you have a hernia, either your hernia is going to get worse or if your surgeon’s fixing your hernia, you can’t do a little tissue repair that doesn’t work for opera singers or for really a big performers or singers, you really want to, for the abdominal wall, you really want a wide mesh repair to counteract all the abdominal pressure that they generate as part of their singing, for example.

(19:01):

So those are little things that go in my mind and I feel like I wish every single surgeon did the same thing. Many do of course, but some don’t really think about it. Where were we going with this? Oh, we’re talking about the peritoneal dialysis. So when you increase the abdominal pressure, that can hurt a fresh hernia repair. So again, you have to kind of track the patient’s peritoneal dialysis schedule with the hernia schedule, and then you can ask the nephrologist, don’t fill the belly with as much fluid as you normally do, decrease it, or you can temporarily put the patient on hemodialysis, which they probably don’t like to do while they’re healing from their abdominal. It all depends on what kind of hernia they have and other risk factors. Here’s another question. Thank you for your answer. What if exercise makes postoperative pain worse?

(20:09):

Yeah, if you’re doing exercises that make your pain worse, then don’t do those exercises. It’s not going to help you to be in pain. Pain is usually related to something being pinched or something going through a hole or scar tissue that is kind of hurting or pinching or whatever. You’re not damaging the hernia. So I don’t want you to think that the exercise, even if it’s causing pain, is like to a situation where, can you guys hear me? Okay, let’s just double check the microphone issue here. There we go. So I don’t want you to think that doing some type of exercise will hurt the hernia or the contents. That’s not true. In fact, there’s a question, let me find that question for you because it was, let’s see, here it is. I’ll share this question with you. It was shared by one of the viewers from her talk live from her talk.com actually.

(21:30):

And the question is this, can hernia incarceration occur suddenly with movement or physical exercise? So yes, hernia incarceration where something gets stuck in a hernia can occur suddenly, but it’s often not predictable how it occurs. And usually physical exercise is not the culprit. So most physical exercise does not increase your abdominal pressure enough to push anything through the hernia, a bad cough or vomiting. I just had a patient today actually the poor guy, he had a viral infection and he vomited 35 times in 12 hours. That averages about three times an hour and then he looks down, he is like, oh, what’s this? He has a hernia that popped out. So he probably had the hernia already didn’t know it, and then that tear just became even wider and larger with the increase abdominal pressure, let’s say from the vomiting episode. So I don’t want you to think that if you’re exercising, you’re going to worsen your hernia pain necessarily, but if you are trying to exercise and it worsens your hernia pain, that implies what’s actually happening is you are pinching something in the region. You’re not hurting the hernia, you’re not exposing yourself to incarceration or strangulation, but of course it’s uncomfortable. So if you still want to do the exercise despite the pain, that’s usually safe, but most people don’t want to cause that pain. So we just recommend just don’t do it.

(23:28):

Although if you can remain active, it’s much better for your hernia. I hope that’s helpful too. I don’t want to sound like I’m talking out of both, end both sides of my mouth, but I kind of am. A lot of what we’re preaching is without any evidence as kind of like our experience and sometimes that may not mean much. Let’s do some more questions while we’re at it. Given a flawless hernia repair, from a surgical standpoint, what factors cannot be controlled by a patient and most significantly affect recurrence and long-term chronic pain after surgery? That is a very insightful question.

(24:15):

We know from doctors Sharon Bachman and Bruce Ramshaw, both of whom I have interviewed for hernia attack live, we know from them that you can do the same operation, the same surgeon, the same mesh on two different patients, even two different sides on the same patient and the outcomes may be different. One reason for that is that surgery is a complex system and there are many factors that go into it. The other is that patients react differently to the same product. So as you know, some people keloid, others don’t the same. It’s true on the inside. So if I cut you on the inside or I put mesh on you on the inside, how you react to that, to my manipulation, to my touch, to my instrument’s, touch to even the talc on the gloves, which we don’t really have talc anymore, but even just the gloves themselves to the material that I implant in you to the suture that I use, how you react to any of those is unpredictable and maybe contributing to chronic pain, scarring, fibrosis and so on.

(25:36):

And also in terms of recurrence, it may be that at a cellular level some patients have less collagen or other proteins and enzymes that contribute to wound healing that are less strong, less sturdy than someone else. I can’t control that. So most of it are these genetic factors on how patients react to implants and sutures even and how patients heal that I cannot control now, probably not in my lifetime, but probably in the future we will have a situation where we can predict all of this with certainty. You just plug in the patient’s DNA and it’s going to say that this patient will do best with this suture and this technique and this implant. And the same way, actually the same way that they can currently do it. I believe for certain pharmaceuticals they can say this patient’s diabetes or this patient’s high cholesterol or high blood pressure will do best with this modality or this modality or this modality.

(26:54):

I know they do it for cardiology. They take your DNA somehow it predicts which type of regimen works best for you to control your blood pressure, for example. We don’t really have that in surgery currently. Not that I know of, but I predict we will at some point. How can a patient balance their doctor’s desire to wait and watch with the patient’s fear of an unexpected strangulation or bowel obstruction? I had this very discussion today, young, healthy male, he just doesn’t want to wait. And his question to me was, besides my own trepidation about why do you Dr. Towfigh, why do you not recommend surgery in me when I’m otherwise healthy? I might as well just have it. And I had told him it’s because the risk of strangulation or a bowel obstruction in a purely elective setting patient just has a hernia with little to no symptoms.

(28:01):

It’s 0.2% a year for inguinal and 0.2% a year for umbilical over a decade. That’s a very low number. The risk of me causing a complication in you, something as simple as a recurrence is higher than 0.2%. And something as devastating as chronic pain about debilitating chronic pain, about 3% for groin hernias, non debilitating chronic pain, about 12% for inguinal hernias, that’s much higher than the 0.2% per year risk of you needing urgent, not urgent, urgent surgery. So I try and kind of put it in numbers that makes sense. Would you rather not have surgery and have a 0.2% risk of needing emergency surgery or have surgery and have a 1% risk of recurrence or a 12% risk of chronic pain, mild and 3% risk of debilitating chronic pain? If you know your math, you know that the risk of surgery is higher than the risk of not doing surgery in most patients.

(29:26):

And if your surgeon’s like, oh, but I don’t have those numbers, I don’t have any patients with recurrence, I don’t have any patients with chronic pain. They just don’t know their numbers. I have patients with chronic pain and I have patients with recurrence. It doesn’t make me a bad doctor. As we just discussed with the last question, there’s multiple factors that go into it. Part of it is my surgical technique and decision making. Part of it is a patient’s DNA part of it is other failures. Maybe they just bad luck. They got hit by a car or they had this neurovirus where they vomited 35 times in 12 hours. How do I control that? Let’s say they had surgery a week ago and then they have that, they’re going to come to me and say, what’s this bulge? I’ll be like, oh, that would be a hernia recurrence. They say, oh, was it because I vomited 35 times over 12 hours within a week after surgery? Things happen. So that’s the way that I try and balance it.

(30:29):

Now that said, sometimes the doctor’s choice or recommendation to weight is not based on fact. It’s based on their concern about risk for surgery. Like this patient that I would not have operated on with the liver transplant list that had a hernia that was basically asymptomatic. There may be situations where the surgeon is afraid to operate on you. I see that a lot in mesh removals. The surgeons say, oh, just give it a year. And meanwhile the patients got a big ball of mesh plug in their groin and they can’t sit. That’s inappropriate. There’s no watchful waiting for that. But a lot of patients are told to just wait the year out, see what happens often with the hope that they just go away and they find another surgeon. I think because chronic pain from a mesh, that’s clearly a mechanical problem. There’s no watchful waiting for that. So sometimes you have to figure out is it because the surgeon is thinking of your best interest and saying you’re not going to need surgery, I can make you worse. Or they were concerned about their ability to fix you and so they’re just letting you kind of linger with chronic pain. I hope that makes sense. Okay, next question.

(32:05):

While strength training strengthens muscle, can exercise strengthened fascia ligament and cartilage? I believe so because people that have achilles tendon rupture, for example, are given pretty intensive physical therapy once the healing is done to continue to heal that often fascia, ligaments and cartilages, well, not cartilage, there’s no strength in cartilage, but ligaments and fascia are often strengthened by being pushed a little bit, right? Same with muscles. You have to kind of push it, you have to stimulate it. So I believe the answer is yes. An orthopedic surgeon would have probably much better answer than me. When you have orthopedic surgery, you’re always told to strengthen afterwards. No one says, well, for achilles tendon, which is the extreme example for I think six weeks or something, you can’t do anything. But then once that tenuous repair is healed, they want you to strengthen it to continue the healing process. Okay.

(33:33):

Oh, I just got a text from my patient. Fantastic. Okay. Sorry, I got distracted. Question, can you have an occult hernia that is not inguinal? Yes. If yes, can the symptoms have an intermittent nature and how do you make a diagnosis? In this case, all hernias can have intermittent pain. It’s often related to how much content is in it, for example, or what activity you’re doing. How we make the determination is based on anatomy, so where do you have the pain and then what physical movements make it worse and then usually by imaging. Next question. It’s a question coming up that was waiting since last week. I’ll let you know which one that is. Is there anything that a patient can do to reduce scar tissue formation immediately after and in long-term following surgery? Superficially? Yes. So at the scar level, you can reduce scar tissue formation and make a beautiful scar around three weeks.

(34:46):

You want to start some type of silicone base tape or gel, and then deep to that you can break up scar tissue at around two to three weeks by massaging the wound. Any of you who’ve had plastic surgery, there’s a lot of people that believe in massaging, let’s say have a liposuction to kind of reduce scar formation and smooth everything out deeper inside. Let’s say intestinal scars. I don’t know that there’s any diet or other way to reduce scar formation. Chemotherapy is very good at reducing scar, but of course we don’t want to do that. But things that prevent healing like chemotherapy can reduce scar formation inside. There are also that we use or these methylcellulose patches and similar things that we put inside around the intestines to reduce scar tissue. So yeah, that we do do, but nothing that you can do as a patient for the inside, I don’t believe.

(35:56):

Now lemme take that back. There are physical therapists that do visceral massage. That’s basically they go really deep and they try and move your intestines around. And some patients benefit from that if they have scar tissue from their intestinal surgery. I don’t know when you’re supposed to start that or if you only do it if the patient is having symptoms. But there are visceral massage specialists, at least in la I don’t know about other places I apart from eliminating bulging and pain, what are the ways in which hernia surgery can improve your life? Very good question because again, that’s the balance of how you can improve your life versus make your life worse. So the bulging of the pain are definitely the top two reasons to get hernias repaired. However, there are certain symptoms related to hernias that may go away. For example, today I talked with my patient who was two weeks out from surgery and I fixed his hernia, not for his hernia pain. He actually had no groin pain at all, but he had bowel issues and his intestines didn’t empty correctly and he would have a lot of pain and kind of bulging in the area and then it was hard to evacuate the bowel, et cetera. And he had a recurrent hernia from a prior laparoscopic surgery and I fixed the hernia and his GI symptoms are all gone. So a lot of GI symptoms including bloating, nausea, sometimes intestinal issues can be due to a hernia. And if you fix the hernia, all that may go away.

(37:51):

Also, nausea and bloating, often nausea can be a symptom of pelvic pain. And if you have pelvic floor pain or pelvic floor spasm related to your hernia, you fix the hernia, the nausea will go away because it’s a manifestation of pelvic pain. I did not know this until I started seeing a pattern. I’m sure people who just focus on pelvic floor maybe know this, I don’t know. But you see a pattern that is back pain is another one, a groin. Hernias as well, belly or any abdominal hernia can cause back pain. And I’ve had patients that I saved from having back surgery by fixing their hernia and their back pain went away. So even if you have back issues like sciatica or other disc diseases, the higher up the pain, the more likely it’s related to a hernia. If you have a hernia, it’s worth considering hernia repair to treat your back pain. That’s definitely true. Diastasis is another one where the diastasis, because of the instability of your core, can give you back pain and we do recommend it repaired in those patients. Usually it’s in a very, very, very wide diastasis.

(39:25):

So nausea GI symptoms are, oh, urinary symptoms. So some people have pelvic floor spasm which causes urinary dysfunction and urinary frequency and urgency, but all of that is due to the hernia. So you fix the hernia, the pelvic pain goes away, the pelvic spasm goes away, and as a result, all the urinary symptoms, even the rectal pain goes away. Many people have sexual dysfunction, erectile dysfunction, it’s really pain from their hernia, giving them erectile dysfunction. You fix the hernia, the pain goes away. Now they’re okay having erections and so on. Also, pain with intercourse is due often to pelvic floor spasm. Again, inguinal hernias can cause pelvic floor spasm, pelvic floor spasm causes intercourse pain, you fix the hernia, all the downstream effects are there, including pelvic floor spasm. I’m sorry, including intercourse pain. So yes, there’s a lot of things that can be the primary complaint of a patient and then you just, that’s why, as many of you know, I get super excited when people send me abdominal pain of unknown origin because they may have, or pain of unknown origin, they may have an underlying problem no one’s figured out yet, which I’d like to figure out that’s causing something that’s causing something that’s causing what their current problem is.

(41:00):

And then you go backwards and rule those things out. So that was a very, very good question and I don’t think I’ve ever answered that in that way before. We’ve discussed symptoms of occult hernias or inguinal hernias or rare symptoms. I think we have a whole episode on rare symptoms of hernias. But to kind of look at it this way that what additional benefits can you get by fixing a hernia? Oh, another good one is we talked about bloating is SIBO or small intestinal bacterial overgrowth. If you have a hernia and a loop of bowel is stuck in it and then you get bacterial overgrowth and then you get bloating that’s pretty severe and you look like a pregnant woman, I can fix that hernia and reverse all those side effects of it. So yeah, all that’s all those things that can happen. Okay, let’s see. Here it is. Here’s a question that was submitted last week. We didn’t get to answer it. I’d like it. I promised them I would answer it today.

(42:12):

Okay. I had an indirect inguinal hernia surgery on the left side using shouldice, no mesh repair technique around April, 2024. Postoperative ultrasound done in July, found the following scar in the left lower quadrant. There is a tiny defect measuring six millimeters. This is suspicious for a small residual hernia defect. There is a small protrusion of bowel loop with Valsalva maneuvers at this defect. Findings suggest a small residual hernia. I still have intermittent pain around the incision. There is also pain when touching or pressing the incision. Shall I get a revision surgery as soon as possible to fix the small residual hernia? Can the revision surgery be done using the S shouldice? No mesh repair technique And can I wait? Okay, very, very interesting situation. Surgery was done over half a year ago and the patient has chronic pain more than six months. And ultrasound finding of sounds like a tear, you must have torn through your shoulder repair.

(43:42):

So the tear alone can cause pain and then as a result you’re going to have either fat and in this case it seems bowel loops going into the defect. This is very unfortunate because a SHO dice repair is four layers of tissue repair. There’s really nothing else to do if you fail a SHO dice repair. I would recommend a mesh based repair unless there’s some very dominating reason why you can’t do a mesh based repair. There’s no good tissue repair that can fix this without causing more tearing, more chronic pain. So I would recommend a laparoscopic repair with mesh. That’s kind of what I would do. Can you wait? Well, I mean there’s consequences to waiting. Number one, the hernia may get bigger. Number two, your pain may continue and cause you quality of life issues. And three, there is a risk with such a small defect that something will get stuck in it because it shows already that bowels is protruding through the six millimeter defect.

(45:00):

It’s hard to imagine, but that’s what it’s saying. And so basically I would say get another opinion. I don’t recommend tissue-based repair. If I were you, I would choose a laparoscopic repair with mesh. And let’s see why that is. If you like me to look it over, I’m happy to see you and give you my 2 cents about it. Sometimes ultrasounds are incorrect, but usually ultrasounds are very correct and since it matches your symptoms, I would believe the ultrasound, you don’t really need any other imaging in my view, but that’s kind of what I would recommend. Question in laparoscopic hernia repair for a large direct hernia, where are the fixating sutures or attacks being placed? That’s a very specific question. Everyone’s a little different as to where they put their attacks. I triangulate. So to triangulate over a large direct hernia, I place one fixation, suture or T in Cooper’s ligament immediately inferior to the femoral space.

(46:22):

I put another one straight up above medial to the epigastric vessels into the rectus muscle and I put one medially on into the rectus insertion onto the pubic bone. I hope that’s helpful for indirect inguinal hernias. I do a similar thing except I go a little bit lateral to the epigastric vessels for the rectus muscle one. And again, triangulating. So the goal of fixation is to prevent the mesh from moving or to prevent the mesh from falling into the repair. And usually when I do it, my goal is to prevent the mesh from falling into the repair because meshes don’t tend to move really if you place it correctly. So notice I only told you about three tax or three fixation sutures. You really don’t need more. Maybe up to five you can argue, but when you’re in the 10 plus range of fixation, sutures, attacks, you’re doing way too much and I don’t recommend it.

(47:38):

Okay. So anyway, that’s my 2 cents. Let’s see, what other questions do we have here? I think we had one more question that was submitted. Here it is. Good question. It has to do with postoperative recovery stuff. So the question goes as such, if you have an incisional hernia and are waiting for surgery, should you avoid exercising? No. Even with a binder, to reduce the chances of the hernia growing in size, there is zero evidence to show that exercise makes the incision hernia larger. In fact, exercise may keep the hernia from getting larger. We know that because number one, exercise should theoretically prevent you from gaining weight. Gaining weight can increase the size of your hernia. And number two, the stronger your muscles, the more likely it is those muscles are to hold everything in. And in doing so, keeping the hernia from getting too large.

(48:50):

So there are people out there that aren’t that many. To be fair, there are people out there with fairly significant hernias, like huge, like top to bottom of their belly is a hernia that are so fit that they’ve been able to maintain the muscles as close to each other as possible, even with scar tissue and prior surgeries, et cetera, because they’re just really fit and they have not allowed this hernia to display splay open. It’s pretty basic that needs a lot of core strengthening and a lot of transverse abdominis strengthening. It’s hard to do when you lose that connection between the muscles because you lose your core. But there are people that have been able to do that. So I’ll repeat again and again and again. There’s no evidence that exercise hurts. There’s plenty of evidence that exercise helps. I’ll give you an example. I’ve been doing this for 23 years now. Yeah, 23 years.

(50:00):

I have operated on one WWF patient and I think a wrestler like a Olympics level wrestler. And that’s it. No bodybuilders, no. I mean I operate on I athletes, NBA, NHL, NFL but very infrequently. They’re not the majority of my patients. A lot of those people just have a genetic predisposition. It wasn’t their weightlifting or their wrestling that caused their pain. It’s just not a factor. There’s good Danish study that shows that the people that exercise regularly are less likely to have hernias. There’s good evidence to show people that are obese are more likely to get hernia. Incisional hernias for sure. That’s a huge risk factor. And weightlifting is not considered one. We just had the Olympics in Paris because everything was not in Paris.

(51:18):

We just had the Olympics in France, I should say, not just Paris. And yeah, I was looking for hernias. A lot of people are wearing exposed bellies, right? So I’m looking like where are these hernias? And there were a handful of runners that had a hernia, just a handful. And many of them were women that had, I think they had children. So that diastasis hernia, whatever combination. Swimmers, no hernias that I saw. Gymnasts didn’t see any hernias. The wrestlers saw no hernias, bodybuilders. I think one guy had a hernia. Yeah. My point is this exercise is good. Core strengthening is good. Sit-ups, weightlifting, sports, all good for hernias. I just had a patient, he likes to do squash. How cool is that? I think squash is better than pickleball. I don’t know what you guys think, but definitely safer. Maybe actually maybe not safer. Can’t you get hit really hard with the handball for squash?

(52:44):

The squash ball Anyway. So he wants to continue his squash, which he does five days a week, hour and a half a day. I said, absolutely. I know you have hernias. Actually it was the same patient that had the vomiting episode. You have the hernias, but by all means, do your squash. Does it hurt you when you do squash? No. Great. Continue with the squash. Even the, but once I fix your hernia for a laparoscopic guard hernia, go do your squash that same day. I don’t care. No restrictions. But if you have a hurry that I have to do tissue repair on I at least two weeks, maybe at least two weeks, I get nervous because of rapid movements and squash and tennis and those kind of sports soccer, you can kind of shear and tear tissue repairs. You don’t have the backup strength of a mesh to rely on. So I get a little conservative when it comes to tissue-based repairs, even though it should be okay. But a lot of these patients get SPO hernia and SPO hernias. I kind of put in the same category as tissue-based repairs. So that’s kind of where I’m at for those. Okay, next question. Can a hernia repair here, let me show it to you guys so you can read it.

(54:14):

Can a hernia repair with mesh alter internal abdominal pressure and cause clinical symptoms? Highly unlikely. So most people who have hernia repairs, whether it’s abdominal hernias, flank hernias, or groin hernias do not have a change in their abdominal pressure. Every so often I see someone who’s in chronic pain and they say, I feel like I have a piece of armor in me. Those patients, it’s usually because of the mesh and it’s usually of the extra heavyweight mesh. Even those patients have normal pressure. However, they may not be able to generate extra abdominal pressure because they’re limited. So if you have a very thick piece of mesh in you, it’s a large piece of mesh and you want to bend down and pick up something from the ground. It may be painful if the mesh is super thick and a lot of these people just tear through the sutures that hold the mesh in place, which is why we often don’t put sutures anymore because you need a little bit of wiggle room of the mesh.

(55:33):

Here’s another question. Can introducing gas for a laparoscopic tap cause or increase diastasis recti also? No, it does not. And how many laparoscopic shortage do we do every day? So the gas is placed in a measured fashion that no more than 15 millimeters of mercury. A cough is many, many times more. Just standing I think is about 15 millimeters of mercury pressure. So the amount of pressure exerted by CO2 and insufflated for the abdominal wall for any laparoscopic or robotic surgery is insignificant compared to bending down, certainly less than a cough or anything like that. Diastasis is well documented to be a very genetic problem in males, somewhat genetic also in females, but also induced by the physical movement of the rectus muscles from pregnancy. And as you can tell the Kardashians, many of them have had multiple children. They don’t have a diastasis, they just have flat bellies. That’s a very genetically in their favor. And there are, I’ve seen women who have had one child and they still look pregnant because of a very massive diastasis erect eyes. So it can happen. It has nothing to do with laparoscopic surgery. There are people that have had laparoscopic surgery and come to me and say, ever since my laparoscopy I’ve had this.

(57:19):

It’s just not based on evidence. So I don’t recommend it or I don’t claim that that’s something that happens. So my friends, thank you so much. That was wonderful. I really, again, want to thank you all for your best wishes last week, half of last week and the week before. The whole weekend was very stressful. I got extra stressed just watching the fire come at us and then the smoke and then it caused me asthma and then so much breakage from the wind and so on. I hope everyone who’s out there that was affected by the fire is getting some type of peace from it and is able to address all the losses. People have lost their lives. It was really sad. And I really thank you all for the best wishes that you sent me through dms, et cetera. It was really, really lovely and nice.

(58:28):

And I really thank you and I appreciate the community that you are with me. And it’s not just about hernias. I do appreciate everything that you do and the love that you share. On that note, add more love. Subscribe to my YouTube channel at Hernia Doc. Go to anywhere you listen to podcasts. Download my episodes, all hundred and something, almost 200 of them are already uploaded. And you can search for a title like search for, I don’t know, risk factor or something. And then you should be able to watch those. And if you want to have some fun, because I’m having some fun with my Instagram channel, I’m adding funny stuff. You can follow me on Instagram or Twitter X at hernia doc. Thanks everyone, and I hope to see you. Let’s see, next week. Yeah, we can do episode next week. Let’s see you next week. Bye.

Speaker 1 (00:11):

Hello everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live. It’s very glad. I’m very glad to be here with you guys since we had to cancel last week. My name is Dr. Shirin Towfigh. I’m your hernia surgery specialist. Thanks to those of you that are already logged in to join me via Zoom as well as Facebook as a Facebook lot. Let me get my Facebook live app up so I can help answer your questions. All right, many of you are also following me on Twitter and Instagram at hernia doc and thanks to all of you who are subscribers to my YouTube channel and also to those of you who are watching on the podcast or listening on the podcast, I just got some of my data downloaded. You guys are doing a great job. I hope you share it with your friends and anyone who’s interested in hernias listen to the podcast.

(01:11):

I think we’re having some fun with it and as I can see from the podcast that downloads are be getting really great. So I’m super excited about that. Well, as you may know, we had to cancel last week and the reason why we had to cancel is we were in the middle of a natural disaster in California. As you may recall, many of you reached out to me. We had pretty dramatic fires and my office was not affected. We just had poor air quality, but my house was affected. I did lose my house, thank God, but we did have to evacuate and there was just a lot on my plate and I felt that doing a hernia talk live, even though most of the nation was not affected by this disaster, maybe it was not the right thing to do. And so I thank you all. Sorry about the last minute cancellation.

(02:12):

Many of you actually did reach out to me and send me great wishes either through a DM on Twitter or Facebook or Instagram, and it really, really touched my heart because I really don’t expect my patients to get involved with my personal life, but I thank you very much. We’re safe, our dog is safe, the air quality is still horrible. But for those of you, I like to hear what you know about air quality. The air quality is not good because of all the smoldering smokes and the ashes that are still in the air and I’m told there’s potentially asbestos, some plastics that have been burnt through this massive fire that was all throughout LA County, Los Angeles County. However, I was looking through the weather apps and Paris is so much worse in the weather quality than what we were dealing with even during the active fires. So I don’t know those of you that live in France, I know a couple of you are followers and are actively on here in France. Is this for real? Is Paris really that bad of air quality to the point where it’s like multiple times worse than LA during an active fire? It just seems so hard for me to believe.

(03:41):

All right, so anyway, please do go ahead and send in your questions if you want and I’ll help answer them while we’re doing this. We have multiple people who had their questions submitted last week, so I got those to answer this week. But the topic of discussion for this week that I chose is trying to balance your hernia health with your regular health. And I say this because two reasons. One is we are working on some research abstracts and what I’ve learned is that for surgeons, sometimes it’s hard for them to balance like fixing a hernia with saving a life. So there are many patients that come into the emergency room on death’s door due to complications of a hernia and the surgeon, US general surgeons, a lot of what we do is lifesaving and so they call the general surgeon. The general surgeon, whis the patient off to the emergency room and deals with the life-threatening problem, which is usually some type of intestinal involvement. Strangulation is what we call it where your intestine is stuck in the hernia and then the hernia kind of blocks off the blood flow to the intestine and you get dead intestine and you’re almost dead. So there’s a limited time in which we can save you. Fortunately that doesn’t happen very often.

(05:22):

I don’t really take call for the emergency room anymore. I used to a lot when I was younger and I saw a lot of these patients, I don’t see them as much anymore. I’m more dealing with chronic problems than acute problems. But the teaching is still there and I tell the surgeons, go in there and save the life. Don’t worry about the hernia. The hernia is why they have the intestinal obstruction or the intestinal strangulation with the blood flow affecting it and causing dead intestine. But technically the hernia itself is not what’s causing the problem. It’s the dead intestine. So I feel that a lot of surgeons get kind of caught up in, okay, now I dealt with the intestines, now I have to fix the hernia and the teaching point to my residents and to many surgeons is disregard the hernia right now the patient’s too sick.

(06:27):

You don’t want to add an extra hour or two to do a hernia repair. It’s not going to be a good hernia repair anyway because the patient’s too sick, there’s infection and you just can’t do a good hernia repair. So just let them be, bring ’em back two, three days later when they’re not as infected or not as sick and fix the hernia then. And that’s called staging. I’m a big advocate of staging hernia repairs, especially for hernias that are difficult to repair. So here’s a comment. Glad you’re safe. Thank you so much, appreciate it.

(07:04):

And then on top of that, I got a patient that came to me to see me who was sick. He legit has a chronic illness, liver failure, not a healthy patient. And he came to me because he had a complication from a hernia repair and I’m thinking, why did you even have your hernia repaired? Was it bothering you? Not really. Did you have chronic pain from it? No. Why did you get your hernia repaired when you’re in full liver failure, you’re on the liver transplant list and he is like, well, they had the hernia. I said, I understand you had a hernia, but people live with hernias potentially operating on someone in liver failure with all the complications. We know liver failure, you have a tendency to bleed because you don’t clot very well because your liver doesn’t make all the clotting factors. You have ascites, which is fluid that collects in the belly, which adds pressure to the abdomen, which makes hernias fail and recur.

(08:14):

You have clots in your, let me back up. You have varis or like varicose veins which are just dilated, big, thick, huge veins that like big hemorrhoid veins but in the belly and around the esophagus and the abdominal wall that you can injure those as a surgeon and cause massive bleeding to the point of death. You’re higher risk for infection, you’re chronically ill and therefore can’t heal. Heal. There are all these reasons not to do elective surgery on someone that has end stage liver disease. So what part having your hernia sir trumped all these negative effects and made your surgeon kind of agree to fix your hernia. He had nothing. He had a hernia that was stuck and it was just a piece of fat that was stuck. He had no pain, he had no obstruction, he had no infection. And that’s what happens with hernias in patients with liver disease.

(09:22):

They get ascites and fluid and the hernia gets stuck as long as there’s no pain and there’s no blood flow issue, there’s zero need to fix your hernia if you’re so sick from your liver that you’re on the transplant list. That’s just, I thought it was just common sense, but apparently it’s not because he had a hernia surgery. Fortunately he had a very smart anesthesiologist and survived the surgery. Unfortunately, the surgeon decide to do this laparoscopically, which also is not a good idea because you’re blindly entering the abdomen and there are vessels like actual major veins you can consider major veins that can be injured and can massively bleed from that. And he very quickly figured out he can’t do this laparoscopically. Then he switched to open surgery. So that again, not a good idea. You have a big scar in the abdomen and that doesn’t heal.

(10:24):

You leak fluid from your ascites, it’s just a mess risk for mesh infection, et cetera. So on top of all that, just the risk of anesthesia can push your liver failure to be even worse, which is exactly what happened since the anesthesia for the hernia repair, which I felt was not indicated. He is now in worse liver failure. He had four liters of fluid taking out of his abdomen. All of that are just signs of worsening liver failure, but he’s not so sick that he can get a liver transplant because they’re sicker patients. So it’s just a bad situation and it got to, got me to thinking that maybe it’s important to kind of give a little bit of perspective. So what we do on hernia attack, all we do is talk about hernias and maybe hernia related problems and sometimes we need to stop and say, okay, fine, your hernia’s diagnosed, we know you have a hernia, but is it really in your best interest to get it repaired?

(11:33):

We’ve talked about watchful waiting. We know that it’s safe both for groin hernias and for belly button hernias not to operate on patients that don’t have pain. You also need to add on top of that the risk of surgery in someone. So if you’ve bad heart disease and you have a hernia it I may kill you if I operate on you because the anesthesia alone will be detrimental to your heart disease. So unfortunately, if you have severe heart failure for example, you’re likely not going to get a hernia repair. There are situations where I may operate on you with little to no anesthesia with just local anesthetic and I’ve done that in some patients that, especially some of that are on the heart transplant list because we have a big heart transplant group at our hospital and I’m perfectly comfortable doing that. It’s just if you go to a surgeon that doesn’t understand that, they may be like, oh, I can do this laparoscopically, I can do this robotically and it may sound great, but that’s actually detrimental because those all number one require general anesthesia, which is not good for the heart.

(12:49):

Number two, you have to fill up the belly with gas carbon dioxide, which is also not good for the heart. So there’s just a lot of thought process that needs to go through and when you’re choosing to do surgery and I thought it would be good idea to address that in today’s episode. Let’s see what questions you have. What are the risks of continuing to exercise if you have postoperative groin pain following open repair after other than just dealing with the pain? Good question. So if you have pain from your hernia repair, that should not prevent you from choosing to be active. You should still be as active as possible.

(13:47):

Keeping your weight in check and not gaining weight is a good way to help reduce chronic pain and keeping those muscles healthy with core strengthening exercises is also a good way to help reduce chronic pain. So therefore, if you have a hernia repair and you have pain from it, but the pain is not worse by the exercises you’re doing, which would be most situations, then by all means you should be active in exercise with little to no limitations. Okay, so we talked about liver failure, we talked about heart failure. Kidney failure is another one. So if you have kidney failure on dialysis, usually getting a hernia repair is okay because we have a treatment for, not a treatment, but some type of way to control a kidney failure, which is to perform dialysis. Now, I don’t know if you’re all familiar with dialysis. There’s two types of dialysis.

(14:56):

One is through the vessels where they clean your blood and one is through the peritoneum or the abdominal wall where they kind of clean your blood indirectly by filtering it through your abdominal fluid. And in doing so with the blood thing, you just need to make sure that the patient can clot, okay? Right? If you want to operate, you have to be able to clot so you don’t bleed from your surgery. When they do hemodialysis, which is dialysis through the blood, they often inject a lot of blood clotting, anti blood clotting, heparin and so on because the machine can’t clot the blood as the blood’s running through it, either the catheter or the vein through which they’re deriving. The blood shouldn’t clot during the process. So usually these patients are kept in a situation where they don’t clot artificially. They do that with medications, injections, and so on.

(16:03):

In surgery you want to clot, so you should have some type of discussion with the nephrologist, which is the kidney specialist to figure out, okay, at what point can we either reduce the clotting, the anti-clotting issues and prepare for surgery? And the timing of surgery is very important. The other issue which is trickier even is in people that are getting what’s called peritoneal dialysis. So the dialysis which cleans up your blood toxins because your kidney can’t do it, are done by filling up your belly with liters of flute and then siphoning it off and doing that over a matter of hours every single day. That is not as commonly performed, but some patients do prefer it or have to have it that way. And doing so, your abdominal wall expands and contracts expands and contracts. And as you know, if you’ve been following me, you know that the theory is with hernias, anything that adds extra pressure to the abdomen gives you hernias or makes hernias worse.

(17:19):

So people on hemodialysis don’t have that problem, but if you’re on peritoneal dialysis where you’re adding pressure to the abdominal wall, if you have a hernia, it’s going to make it look worse. And if you have a hernia that’s repaired, it may add pressure to the repair. So I think I had an episode in the past where we talked about risk factors for hernias and how the surgeon needs to understand lifestyle. So if you’re a construction worker or if you’re like a nurse, I had a patient who’s a physical therapist and so she carries a 50 pound bed around, you have to understand what the lifestyle of the patient is and then kind of take your surgical plan and tweak it a little bit to make sure that it addresses their lifestyle. So for example, if I am operating on an opera singer, which I have done multiple times, they generate a lot of abdominal pressure. So if you’re generating a lot of abdominal pressure and you have a hernia, either your hernia is going to get worse or if your surgeon’s fixing your hernia, you can’t do a little tissue repair that doesn’t work for opera singers or for really a big performers or singers, you really want to, for the abdominal wall, you really want a wide mesh repair to counteract all the abdominal pressure that they generate as part of their singing, for example.

(19:01):

So those are little things that go in my mind and I feel like I wish every single surgeon did the same thing. Many do of course, but some don’t really think about it. Where were we going with this? Oh, we’re talking about the peritoneal dialysis. So when you increase the abdominal pressure, that can hurt a fresh hernia repair. So again, you have to kind of track the patient’s peritoneal dialysis schedule with the hernia schedule, and then you can ask the nephrologist, don’t fill the belly with as much fluid as you normally do, decrease it, or you can temporarily put the patient on hemodialysis, which they probably don’t like to do while they’re healing from their abdominal. It all depends on what kind of hernia they have and other risk factors. Here’s another question. Thank you for your answer. What if exercise makes postoperative pain worse?

(20:09):

Yeah, if you’re doing exercises that make your pain worse, then don’t do those exercises. It’s not going to help you to be in pain. Pain is usually related to something being pinched or something going through a hole or scar tissue that is kind of hurting or pinching or whatever. You’re not damaging the hernia. So I don’t want you to think that the exercise, even if it’s causing pain, is like to a situation where, can you guys hear me? Okay, let’s just double check the microphone issue here. There we go. So I don’t want you to think that doing some type of exercise will hurt the hernia or the contents. That’s not true. In fact, there’s a question, let me find that question for you because it was, let’s see, here it is. I’ll share this question with you. It was shared by one of the viewers from her talk live from her talk.com actually.

(21:30):

And the question is this, can hernia incarceration occur suddenly with movement or physical exercise? So yes, hernia incarceration where something gets stuck in a hernia can occur suddenly, but it’s often not predictable how it occurs. And usually physical exercise is not the culprit. So most physical exercise does not increase your abdominal pressure enough to push anything through the hernia, a bad cough or vomiting. I just had a patient today actually the poor guy, he had a viral infection and he vomited 35 times in 12 hours. That averages about three times an hour and then he looks down, he is like, oh, what’s this? He has a hernia that popped out. So he probably had the hernia already didn’t know it, and then that tear just became even wider and larger with the increase abdominal pressure, let’s say from the vomiting episode. So I don’t want you to think that if you’re exercising, you’re going to worsen your hernia pain necessarily, but if you are trying to exercise and it worsens your hernia pain, that implies what’s actually happening is you are pinching something in the region. You’re not hurting the hernia, you’re not exposing yourself to incarceration or strangulation, but of course it’s uncomfortable. So if you still want to do the exercise despite the pain, that’s usually safe, but most people don’t want to cause that pain. So we just recommend just don’t do it.

(23:28):

Although if you can remain active, it’s much better for your hernia. I hope that’s helpful too. I don’t want to sound like I’m talking out of both, end both sides of my mouth, but I kind of am. A lot of what we’re preaching is without any evidence as kind of like our experience and sometimes that may not mean much. Let’s do some more questions while we’re at it. Given a flawless hernia repair, from a surgical standpoint, what factors cannot be controlled by a patient and most significantly affect recurrence and long-term chronic pain after surgery? That is a very insightful question.

(24:15):

We know from doctors Sharon Bachman and Bruce Ramshaw, both of whom I have interviewed for Hernia Talk Live, we know from them that you can do the same operation, the same surgeon, the same mesh on two different patients, even two different sides on the same patient and the outcomes may be different. One reason for that is that surgery is a complex system and there are many factors that go into it. The other is that patients react differently to the same product. So as you know, some people keloid, others don’t the same. It’s true on the inside. So if I cut you on the inside or I put mesh on you on the inside, how you react to that, to my manipulation, to my touch, to my instrument’s, touch to even the talc on the gloves, which we don’t really have talc anymore, but even just the gloves themselves to the material that I implant in you to the suture that I use, how you react to any of those is unpredictable and maybe contributing to chronic pain, scarring, fibrosis and so on.

(25:36):

And also in terms of recurrence, it may be that at a cellular level some patients have less collagen or other proteins and enzymes that contribute to wound healing that are less strong, less sturdy than someone else. I can’t control that. So most of it are these genetic factors on how patients react to implants and sutures even and how patients heal that I cannot control now, probably not in my lifetime, but probably in the future we will have a situation where we can predict all of this with certainty. You just plug in the patient’s DNA and it’s going to say that this patient will do best with this suture and this technique and this implant. And the same way, actually the same way that they can currently do it. I believe for certain pharmaceuticals they can say this patient’s diabetes or this patient’s high cholesterol or high blood pressure will do best with this modality or this modality or this modality.

(26:54):

I know they do it for cardiology. They take your DNA somehow it predicts which type of regimen works best for you to control your blood pressure, for example. We don’t really have that in surgery currently. Not that I know of, but I predict we will at some point. How can a patient balance their doctor’s desire to wait and watch with the patient’s fear of an unexpected strangulation or bowel obstruction? I had this very discussion today, young, healthy male, he just doesn’t want to wait. And his question to me was, besides my own trepidation about why do you Dr. Towfigh, why do you not recommend surgery in me when I’m otherwise healthy? I might as well just have it. And I had told him it’s because the risk of strangulation or a bowel obstruction in a purely elective setting patient just has a hernia with little to no symptoms.

(28:01):

It’s 0.2% a year for inguinal and 0.2% a year for umbilical over a decade. That’s a very low number. The risk of me causing a complication in you, something as simple as a recurrence is higher than 0.2%. And something as devastating as chronic pain about debilitating chronic pain, about 3% for groin hernias, non debilitating chronic pain, about 12% for inal hernias, that’s much higher than the 0.2% per year risk of you needing urgent, not urgent, urgent surgery. So I try and kind of put it in numbers that makes sense. Would you rather not have surgery and have a 0.2% risk of needing emergency surgery or have surgery and have a 1% risk of recurrence or a 12% risk of chronic pain, mild and 3% risk of debilitating chronic pain? If you know your math, you know that the risk of surgery is higher than the risk of not doing surgery in most patients.

(29:26):

And if your surgeon’s like, oh, but I don’t have those numbers, I don’t have any patients with recurrence, I don’t have any patients with chronic pain. They just don’t dunno their numbers. I have patients with chronic pain and I have patients with recurrence. It doesn’t make me a bad doctor. As we just discussed with the last question, there’s multiple factors that go into it. Part of it is my surgical technique and decision making. Part of it is a patient’s DNA part of it is other failures. Maybe they just bad luck. They got hit by a car or they had this neurovirus where they vomited 35 times in 12 hours. How do I control that? Let’s say they had surgery a week ago and then they have that, they’re going to come to me and say, what’s this bulge? I’ll be like, oh, that would be a hernia recurrence. They say, oh, was it because I vomited 35 times over 12 hours within a week after surgery? Things happen. So that’s the way that I try and balance it.

(30:29):

Now that said, sometimes the doctor’s choice or recommendation to weight is not based on fact. It’s based on their concern about risk for surgery. Like this patient that I would not have operated on with the liver transplant list that had a hernia that was basically asymptomatic. There may be situations where the surgeon is afraid to operate on you. I see that a lot in mesh removals. The surgeons say, oh, just give it a year. And meanwhile the patients got a big ball of mesh plug in their groin and they can’t sit. That’s inappropriate. There’s no watchful waiting for that. But a lot of patients are told to just wait the year out, see what happens often with the hope that they just go away and they find another surgeon. I think because chronic pain from a mesh, that’s clearly a mechanical problem. There’s no watchful waiting for that. So sometimes you have to figure out is it because the surgeon is thinking of your best interest and saying you’re not going to need surgery, I can make you worse. Or they were concerned about their ability to fix you and so they’re just letting you kind of linger with chronic pain. I hope that makes sense. Okay, next question.

(32:05):

While strength training strengthens muscle, can exercise strengthened fascia ligament and cartilage? I believe so because people that have achilles tendon rupture, for example, are given pretty intensive physical therapy once the healing is done to continue to heal that often fascia, ligaments and cartilages, well, not cartilage, there’s no strength in cartilage, but ligaments and fascia are often strengthened by being pushed a little bit, right? Same with muscles. You have to kind of push it, you have to stimulate it. So I believe the answer is yes. An orthopedic surgeon would have probably much better answer than me. When you have orthopedic surgery, you’re always told to strengthen afterwards. No one says, well, for achilles tendon, which is the extreme example for I think six weeks or something, you can’t do anything. But then once that tenuous repair is healed, they want you to strengthen it to continue the healing process. Okay.

(33:33):

Oh, I just got a text from my patient. Fantastic. Okay. Sorry, I got distracted. Question, can you have an occult hernia that is not inguinal? Yes. If yes, can the symptoms have an intermittent nature and how do you make a diagnosis? In this case, all hernias can have intermittent pain. It’s often related to how much content is in it, for example, or what activity you’re doing. How we make the determination is based on anatomy, so where do you have the pain and then what physical movements make it worse and then usually by imaging. Next question. It’s a question coming up that was waiting since last week. I’ll let you know which one that is. Is there anything that a patient can do to reduce scar tissue formation immediately after and in long-term following surgery? Superficially? Yes. So at the scar level, you can reduce scar tissue formation and make a beautiful scar around three weeks.

(34:46):

You want to start some type of silicone base tape or gel, and then deep to that you can break up scar tissue at around two to three weeks by massaging the wound. Any of you who’ve had plastic surgery, there’s a lot of people that believe in massaging, let’s say have a liposuction to kind of reduce scar formation and smooth everything out deeper inside. Let’s say intestinal scars. I don’t know that there’s any diet or other way to reduce scar formation. Chemotherapy is very good at reducing scar, but of course we don’t want to do that. But things that prevent healing like chemotherapy can reduce scar formation inside. There are also that we use or these methylcellulose patches and similar things that we put inside around the intestines to reduce scar tissue. So yeah, that we do do, but nothing that you can do as a patient for the inside, I don’t believe.

(35:56):

Now lemme take that back. There are physical therapists that do visceral massage. That’s basically they go really deep and they try and move your intestines around. And some patients benefit from that if they have scar tissue from their intestinal surgery. I don’t know when you’re supposed to start that or if you only do it if the patient is having symptoms. But there are visceral massage specialists, at least in la I don’t know about other places I apart from eliminating bulging and pain, what are the ways in which hernia surgery can improve your life? Very good question because again, that’s the balance of how you can improve your life versus make your life worse. So the bulging of the pain are definitely the top two reasons to get hernias repaired. However, there are certain symptoms related to hernias that may go away. For example, today I talked with my patient who was two weeks out from surgery and I fixed his hernia, not for his hernia pain. He actually had no groin pain at all, but he had bowel issues and his intestines didn’t empty correctly and he would have a lot of pain and kind of bulging in the area and then it was hard to evacuate the bowel, et cetera. And he had a recurrent hernia from a prior laparoscopic surgery and I fixed the hernia and his GI symptoms are all gone. So a lot of GI symptoms including bloating, nausea, sometimes intestinal issues can be due to a hernia. And if you fix the hernia, all that may go away.

(37:51):

Also, nausea and bloating, often nausea can be a symptom of pelvic pain. And if you have pelvic floor pain or pelvic floor spasm related to your hernia, you fix the hernia, the nausea will go away because it’s a manifestation of pelvic pain. I did not know this until I started seeing a pattern. I’m sure people who just focus on pelvic floor maybe know this, I don’t know. But you see a pattern that is back pain is another one, a groin. Hernias as well, belly or any abdominal hernia can cause back pain. And I’ve had patients that I saved from having back surgery by fixing their hernia and their back pain went away. So even if you have back issues like sciatica or other disc diseases, the higher up the pain, the more likely it’s related to a hernia. If you have a hernia, it’s worth considering hernia repair to treat your back pain. That’s definitely true. Diastasis is another one where the diastasis, because of the instability of your core, can give you back pain and we do recommend it repaired in those patients. Usually it’s in a very, very, very wide diastasis.

(39:25):

So nausea GI symptoms are, oh, urinary symptoms. So some people have pelvic floor spasm which causes urinary dysfunction and urinary frequency and urgency, but all of that is due to the hernia. So you fix the hernia, the pelvic pain goes away, the pelvic spasm goes away, and as a result, all the urinary symptoms, even the rectal pain goes away. Many people have sexual dysfunction, erectile dysfunction, it’s really pain from their hernia, giving them erectile dysfunction. You fix the hernia, the pain goes away. Now they’re okay having erections and so on. Also, pain with intercourse is due often to pelvic floor spasm. Again, inal hernias can cause pelvic floor spasm, pelvic floor spasm causes intercourse pain, you fix the hernia, all the downstream effects are there, including pelvic floor spasm. I’m sorry, including intercourse pain. So yes, there’s a lot of things that can be the primary complaint of a patient and then you just, that’s why, as many of you know, I get super excited when people send me abdominal pain of unknown origin because they may have, or pain of unknown origin, they may have an underlying problem no one’s figured out yet, which I’d like to figure out that’s causing something that’s causing something that’s causing what their current problem is.

(41:00):

And then you go backwards and rule those things out. So that was a very, very good question and I don’t think I’ve ever answered that in that way before. We’ve discussed symptoms of occult hernias or inal hernias or rare symptoms. I think we have a whole episode on rare symptoms of hernias. But to kind of look at it this way that what additional benefits can you get by fixing a hernia? Oh, another good one is we talked about bloating is SIBO or small intestinal bacterial overgrowth. If you have a hernia and a loop of bowel is stuck in it and then you get bacterial overgrowth and then you get bloating that’s pretty severe and you look like a pregnant woman, I can fix that hernia and reverse all those side effects of it. So yeah, all that’s all those things that can happen. Okay, let’s see. Here it is. Here’s a question that was submitted last week. We didn’t get to answer it. I’d like it. I promised them I would answer it today.

(42:12):

Okay. I had an indirect inguinal hernia surgery on the left side using shouldice, no mesh repair technique around April, 2024. Postoperative ultrasound done in July, found the following scar in the left lower quadrant. There is a tiny defect measuring six millimeters. This is suspicious for a small residual hernia defect. There is a small protrusion of bowel loop with Valsalva maneuvers at this defect. Findings suggest a small residual hernia. I still have intermittent pain around the incision. There is also pain when touching or pressing the incision. Shall I get a revision surgery as soon as possible to fix the small residual hernia? Can the revision surgery be done using the S shouldice? No mesh repair technique And can I wait? Okay, very, very interesting situation. Surgery was done over half a year ago and the patient has chronic pain more than six months. And ultrasound finding of sounds like a tear, you must have torn through your shoulder repair.

(43:42):

So the tear alone can cause pain and then as a result you’re going to have either fat and in this case it seems bowel loops going into the defect. This is very unfortunate because a SHO dice repair is four layers of tissue repair. There’s really nothing else to do if you fail a SHO dice repair. I would recommend a mesh based repair unless there’s some very dominating reason why you can’t do a mesh based repair. There’s no good tissue repair that can fix this without causing more tearing, more chronic pain. So I would recommend a laparoscopic repair with mesh. That’s kind of what I would do. Can you wait? Well, I mean there’s consequences to waiting. Number one, the hernia may get bigger. Number two, your pain may continue and cause you quality of life issues. And three, there is a risk with such a small defect that something will get stuck in it because it shows already that bowels is protruding through the six millimeter defect.

(45:00):

It’s hard to imagine, but that’s what it’s saying. And so basically I would say get another opinion. I don’t recommend tissue-based repair. If I were you, I would choose a laparoscopic repair with mesh. And let’s see why that is. If you like me to look it over, I’m happy to see you and give you my 2 cents about it. Sometimes ultrasounds are incorrect, but usually ultrasounds are very correct and since it matches your symptoms, I would believe the ultrasound, you don’t really need any other imaging in my view, but that’s kind of what I would recommend. Question in laparoscopic hernia repair for a large direct hernia, where are the fixating sutures or attacks being placed? That’s a very specific question. Everyone’s a little different as to where they put their attacks. I triangulate. So to triangulate over a large direct hernia, I place one fixation, suture or T in Cooper’s ligament immediately inferior to the femoral space.

(46:22):

I put another one straight up above medial to the epigastric vessels into the rectus muscle and I put one medially on into the rectus insertion onto the pubic bone. I hope that’s helpful for indirect anular hernias. I do a similar thing except I go a little bit lateral to the epigastric vessels for the rectus muscle one. And again, triangulating. So the goal of fixation is to prevent the mesh from moving or to prevent the mesh from falling into the repair. And usually when I do it, my goal is to prevent the mesh from falling into the repair because meshes don’t tend to move really if you place it correctly. So notice I only told you about three tax or three fixation sutures. You really don’t need more. Maybe up to five you can argue, but when you’re in the 10 plus range of fixation, sutures, attacks, you’re doing way too much and I don’t recommend it.

(47:38):

Okay. So anyway, that’s my 2 cents. Let’s see, what other questions do we have here? I think we had one more question that was submitted. Here it is. Good question. It has to do with postoperative recovery stuff. So the question goes as such, if you have an incisional hernia and are waiting for surgery, should you avoid exercising? No. Even with a binder, to reduce the chances of the hernia growing in size, there is zero evidence to show that exercise makes the incision hernia larger. In fact, exercise may keep the hernia from getting larger. We know that because number one, exercise should theoretically prevent you from gaining weight. Gaining weight can increase the size of your hernia. And number two, the stronger your muscles, the more likely it is those muscles are to hold everything in. And in doing so, keeping the hernia from getting too large.

(48:50):

So there are people out there that aren’t that many. To be fair, there are people out there with fairly significant hernias, like huge, like top to bottom of their belly is a hernia that are so fit that they’ve been able to maintain the muscles as close to each other as possible, even with scar tissue and prior surgeries, et cetera, because they’re just really fit and they have not allowed this hernia to display splay open. It’s pretty basic that needs a lot of core strengthening and a lot of transverse abdom strengthening. It’s hard to do when you lose that connection between the muscles because you lose your core. But there are people that have been able to do that. So I’ll repeat again and again and again. There’s no evidence that exercise hurts. There’s plenty of evidence that exercise helps. I’ll give you an example. I’ve been doing this for 23 years now. Yeah, 23 years.

(50:00):

I have operated on one WWF patient and I think a wrestler like a Olympics level wrestler. And that’s it. No bodybuilders, no. I mean I operate on I athletes, N-B-A-N-H-L-N-F-L, but very infrequently. They’re not the majority of my patients. A lot of those people just have a genetic predisposition. It wasn’t their weightlifting or their wrestling that caused their pain. It’s just not a factor. There’s good Danish study that shows that the people that exercise regularly are less likely to have hernias. There’s good evidence to show people that are obese are more likely to get hernia. Incisional hernias for sure. That’s a huge risk factor. And weightlifting is not considered one. We just had the Olympics in Paris because everything was not in Paris.

(51:18):

We just had the Olympics in France, I should say, not just Paris. And yeah, I was looking for hernias. A lot of people are wearing exposed bellies, right? So I’m looking like where are these hernias? And there were a handful of runners that had a hernia, just a handful. And many of them were women that had, I think they had children. So that diastasis hernia, whatever combination. Swimmers, no hernias that I saw. Gymnasts didn’t see any hernias. The wrestlers saw no hernias, bodybuilders. I think one guy had a hernia. Yeah. My point is this exercise is good. Core strengthening is good. Sit-ups, weightlifting, sports, all good for hernias. I just had a patient, he likes to do squash. How cool is that? I think squash is better than pickleball. I don’t know what you guys think, but definitely safer. Maybe actually maybe not safer. Can’t you get hit really hard with the handball for squash?

(52:44):

The squash ball Anyway. So he wants to continue his squash, which he does five days a week, hour and a half a day. I said, absolutely. I know you have hernias. Actually it was the same patient that had the vomiting episode. You have the hernias, but by all means, do your squash. Does it hurt you when you do squash? No. Great. Continue with the squash. Even the, but once I fix your hernia for a laparoscopic guard hernia, go do your squash that same day. I don’t care. No restrictions. But if you have a hurry that I have to do tissue repair on I at least two weeks, maybe at least two weeks, I get nervous because of rapid movements and squash and tennis and those kind of sports soccer, you can kind of shear and tear tissue repairs. You don’t have the backup strength of a mesh to rely on. So I get a little conservative when it comes to tissue-based repairs, even though it should be okay. But a lot of these patients get SPO hernia and SPO hernias. I kind of put in the same category as tissue-based repairs. So that’s kind of where I’m at for those. Okay, next question. Can a hernia repair here, let me show it to you guys so you can read it.

(54:14):

Can a hernia repair with mesh alter internal abdominal pressure and cause clinical symptoms? Highly unlikely. So most people who have hernia repairs, whether it’s abdominal hernias, flank hernias, or groin hernias do not have a change in their abdominal pressure. Every so often I see someone who’s in chronic pain and they say, I feel like I have a piece of armor in me. Those patients, it’s usually because of the mesh and it’s usually of the extra heavyweight mesh. Even those patients have normal pressure. However, they may not be able to generate extra abdominal pressure because they’re limited. So if you have a very thick piece of mesh in you, it’s a large piece of mesh and you want to bend down and pick up something from the ground. It may be painful if the mesh is super thick and a lot of these people just tear through the sutures that hold the mesh in place, which is why we often don’t put sutures anymore because you need a little bit of wiggle room of the mesh.

(55:33):

Here’s another question. Can introducing gas for a laparoscopic tap cause or increase dias erect eye also? No, it does not. And how many laparoscopic shortage do we do every day? So the gas is placed in a measured fashion that no more than 15 millimeters of mercury. A cough is many, many times more. Just standing I think is about 15 millimeters of mercury pressure. So the amount of pressure exerted by CO2 and insufflated for the abdominal wall for any laparoscopic or robotic surgery is insignificant compared to bending down, certainly less than a cough or anything like that. Diastasis is well documented to be a very genetic problem in males, somewhat genetic also in females, but also induced by the physical movement of the rectus muscles from pregnancy. And as you can tell the Kardashians, many of them have had multiple children. They don’t have a diastasis, they just have flat bellies. That’s a very genetically in their favor. And there are, I’ve seen women who have had one child and they still look pregnant because of a very massive diastasis erect eyes. So it can happen. It has nothing to do with laparoscopic surgery. There are people that have had laparoscopic surgery and come to me and say, ever since my laparoscopy I’ve had this.

(57:19):

It’s just not based on evidence. So I don’t recommend it or I don’t claim that that’s something that happens. So my friends, thank you so much. That was wonderful. I really, again, want to thank you all for your best wishes last week, half of last week and the week before. The whole weekend was very stressful. I got extra stressed just watching the fire come at us and then the smoke and then it caused me asthma and then so much breakage from the wind and so on. I hope everyone who’s out there that was affected by the fire is getting some type of peace from it and is able to address all the losses. People have lost their lives. It was really sad. And I really thank you all for the best wishes that you sent me through dms, et cetera. It was really, really lovely and nice.

(58:28):

And I really thank you and I appreciate the community that you are with me. And it’s not just about hernias. I do appreciate everything that you do and the love that you share. On that note, add more love. Subscribe to my YouTube channel at Hernia Doc. Go to anywhere you listen to podcasts. Download my episodes, all hundred and something, almost 200 of them are already uploaded. And you can search for a title like search for, I don’t know, risk factor or something. And then you should be able to watch those. And if you want to have some fun, because I’m having some fun with my Instagram channel, I’m adding funny stuff. You can follow me on Instagram or Twitter X at hernia doc. Thanks everyone, and I hope to see you. Let’s see, next week. Yeah, we can do episode next week. Let’s see you next week. Bye.