193. Redo Hernia Repair Without Mesh

This week, the topic of discussion was:
-Recurrent Hernia
-Mesh Implant Illness
-Mesh Removal
-Shouldice Repair
-Chronic Pain
-Plication
-Abdominoplasty
-Mesh Repair
-Tearing of Muscle
-Inguinal Hernia
-Ventral Hernia

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

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Transcript

Dr. Towfigh (00:10):

Hi everyone, it’s Dr. Towfigh. Welcome to Hernia Talk Live. I am your host, Dr. Shirin Towfigh hernia and laparoscopic surgery specialist. Thanks to everyone who’s joining me live via Facebook Live and also those of you who join me on the Zoom link. Thank you very much. As you know, you can share this with your friends. I have multiple social media platforms both on Twitter and Instagram at Hernia doc. But more importantly, go to my channel. My YouTube channel is also at Hernia Doc and if you like to listen to this as a podcast while you’re driving, just go to wherever you listen to your normal podcast and you can find me as her talk live. So everyone, I am so excited because I was talking to my office people, I was like, what topic should I talk about this time? Because as you know, we always try and pick a topic that is relevant to patients that I see and situations that I have because I think it makes sense.

(01:19):

It’s relevant to you all because you can probably relate to the patient and it’s a good story. And as you know, I’m all about stories and we came up with this topic specifically on fixing a hernia that was originally fixed before, usually with a mesh, but like our fixing a redo hernia without mesh. And that could be any redo hernia. It could be a redo from a inguinal hernia, it could be a redo from any abdominal wall hernia. I don’t really talk about hiatal hernias here, but it’s a similar concept. So what happens if you redo a hernia that was already repaired once the second time the surgery is done without mesh, and why is that a good or bad thing? And what are the risks and benefits of it? So we picked this topic, which was I thought a good topic. And then within several days I see patients that have exactly that or want exactly that.

(02:30):

So I have a lot of stories to share with you. So part of the reason why I picked this topic is I have a lot of patients throughout the years that have come to me, they’ve already had their hernia repaired. Now there’s either recurrence or they need their mesh removed or they need another surgery and many of them blame the mesh for their problem. And they may be right, maybe it was a mesh problem, but often it’s a technical issue or it’s not really the mesh itself, it’s how the mesh was placed and where it was placed. And we’ve, excuse me, we’ve had this discussion before where there’s the mesh itself, the material, there’s the way it’s made, like the shape or the weight, and then there’s the decision of using that specific mesh with that specific weight and quality and size. There’s how that mesh is then used and where it’s placed, and then the technique that’s used to develop those planes, et cetera.

(03:46):

So a lot of times it’s not the actual mesh itself, like the material. And so when I say mesh to my patients, I don’t mean one specific mesh. I don’t even mean two or three different meshes. There’s a wide variety of meshes that we have available in the United States and also outside the us, but it’s more widely available in the United States with one exception. And so the patients come in, they’re like, well, I don’t want mesh anymore. Take out my mesh and I don’t want it anymore. Or Can you fix this recurrence without mesh? That’s always a question. The short answer is no, it is not a good idea in general to take out mesh or redo a hernia of any sort without mesh usually not considered the best option. Now obviously we don’t always do the best option. We do. What’s the best option for that patient?

(04:54):

So if you do a population study, you’ll see that the majority of patients will do best if a redo hernia is repaired with mesh. Why is that? Well, if you’ve already failed surgery with a tissue repair, doing another tissue repair to me makes no sense. You now have even less tissue for those of you who sew. If you have a tear in your sweater or in your jeans or pajamas or socks, just closing up that hole, we will look bunched up and that outfit will be tighter than the original repair. So in areas where it’s important that you’re not tighter, we usually patch those clothing areas. So the same is true for muscle. If you’ve torn through a repair a tissue repair, you now have less tissue, less muscle to use for your tissue based repair, the non mesh repair, which means you’re going to be tighter in that area. Now, some people need that and we will go over certain patient situations where that’s necessary, but the majority of people should not get that. And the reason for that is you can tear again, that’s where you get chronic pain.

(06:24):

For those of you that follow me, you know that we’ve talked about chronic pain a lot. This study on this, and I’ve told you, chronic pain exists with mass repairs. Chronic pain exists with non mesh repairs and people think because they associate pain with mesh. And part of that is a lot of the advertising against mesh and the lawsuits that’s kind of connected like all mesh, all pain is mesh pain because that’s ingrained in people. They can’t imagine why you would have chronic pain if there’s no mesh in you. And the reason is besides normal things like there’s scar tissue and there’s nerves that could be injured, the main reason for chronic pain in patients with tissue repair is you’re trying to tear the tissue repair. The whole reason why we use mesh is to take the tension off of the repair, but if I sew you together, you’re going to be tighter a hundred percent of the time then before the surgery.

(07:30):

So if something’s tighter, if your clothing is tighter and I give you a tight shirt, you’re constantly trying to pull apart the buttons, the zipper, whatever the situation is. The same is true for a tissue repair. Any tissue repair, whether it’s a belly button, a ventral hernia, incisional hernia, a groin hernia, anal hernia, every time there’s a tissue pair, the tendency is to try and pull those tissues apart because you’re tighter. And that’s where the chronic pain comes from. So to already do a tissue repair once and have it fail because you tore through it, you’re just going to asking for disaster by doing the tissue repair a second time. Now, what if you had a mesh repair first? So you’ve probably heard my analogy multiple times before where mesh repair is always superior to non mesh repair when it comes to recurrences, and that’s one of the reasons why so much mesh has been used throughout the world because all the data shows that if you use mesh, your recurrence rate is lower than if you don’t use mesh.

(08:41):

That’s true for every single hernia. Now, the smaller the hernia, the less the difference between mesh and non mesh. The larger the hernia, the greater the difference and disparity between mesh and non mesh repairs. So let’s say you have a traditional hernia repair in the United States, which includes mesh and that fails. And by failure I mean you had a recurrence. And if you have a recurrence from a mesh repair, to think that a tissue repair will do better is not not based on truth. So you can choose to have a tissue-based repair, but if you’ve already shown that your body is prone to getting hernias and you tore through a hernia repair with mesh, then the chances are you’re going to do even worse with a tissue-based repair. So a lot of people come to me, all they have is a hernia recurrence. Their mesh is fine, the mesh is not balled up, it’s not infected.

(09:38):

They don’t have a mesh in plant illness, they have a hernia recurrence and they’re asking for a tissue-based repair. There’s no good reason to sway away from mesh in that population. But then you have another population where the mesh is the problem that balled up, it impinged, it, eroded, and so on. And so the mesh mechanically is the problem. And so there’s already this kind of sense by the patient that mesh at them wrong and that they’re set up for having another mesh related complications. It’s kind of like PTSD, like I already had a bad problem with mesh. Why are you giving me another mesh? In that situation? I totally understand why a patient would want to not have mesh in them again and again, I still do not like to have that conversation. I know it’s not the best thing for the patient, but in small situations, if the patient understands all the risks of a non mesh repair, if I remove a mesh that’s already balled up and so on causing the patient pain, I may consider a non mesh repair, but I will do my best to get the patient to allow for a mesh based repair because I think it’s still better.

(11:07):

The last situation, which is the most difficult situation clinically is patients who have mesh in them. The repair is perfectly fine, but the mesh material itself is inducing a problem. And that problem can be a mesh implant illness. It can be an inflammatory reaction. They may feel stiff in the area, they may be allergic to it or maybe an autoimmune disorder, whatever the situation, that material itself is not compatible with that patient’s body.

(11:44):

It is very, very uncommon. Fortunately in most patients, we do not expect mesh implant illness. If you’ve listened to me before, it tends to be in patients who already reject a lot of things in their life such as different medication, allergies, food allergies, intolerances, they may have an autoimmune disorder or an inflammatory disorder. There are many disease processes which make you higher risk for reacting to mesh. And so in those very small subset of patients where the mesh itself is the problem, you have two choices. One choice is to consider a mesh alternative. So there are meshes out there that are less inflammatory and less likely to feel stiff, less likely to cause an inflammatory or autoimmune reaction. And I tend to err on using those and we would have a discussion about that. Those are sometimes hybrid meshes, low inflammatory hybrid meshes are kind of my go-to for that. But let’s say that’s not the situation. You absolutely cannot have any mesh in you or we don’t want to risk it by giving you a hybrid mesh and then having your react to the hybrid mesh. Then and only then would I say, you know what?

(13:15):

We’re obliged to do a tissue-based repair, so we remove the mesh and now you have a redo repair of your hernia and this time it’s without mesh. And I have several patients like that. What happens to them? So let’s take the easy ones first in the belly, a repair of the belly is just sewing everything close. And often we use permanent suture for that, especially if we can’t use mesh because patients already have a tendency toward making hernias. So you can’t fool yourself to thinking that this will just heal just fine and a year later they won’t have a hernia when the suture is absorbed. So I use permanent suture for them. I have to have the patient lose a lot of weight. I cannot have my closure, the tissues being pulled together to be on any tension. You have to have a floppy abdomen. So when I put you together, I can even tighten you more.

(14:25):

That’s a difficult decision and difficult process in most patients. They not only should not gain weight ever, but definitely should not gain weight at the time of surgery during the, because I’m a hundred percent relying on those sutures and the integrity of the closure, I don’t have mesh to support anymore. So for the ventral hernias, it’s a simple operation. You just kind of close the hole. But what I do is I apply Kate, so I do multiple layers of closures. Each layer is supporting the next layer. Even if you tear the first layer, then the second layer is there. And I’m very adamant that you lose weight in some patients. Actually, if I feel that it’s tight, I actually inject Botox. If I inject injecting, Botox will weaken, technically paralyze, but weakens the muscle temporarily and takes the tension off. People feel actually a little bit more rounded and not as flat.

(15:24):

And then once that wears off, then they have a flatter, flatter look back to normal, and they’ve done at least three or four months of healing by then. So that’s a trick that I use for that purpose. For the groin, we obviously have a lot of tissue-based repairs. There’s this Shouldice, Bassini, McVay, those are the top three. There’s the Desarda, there’s the Halsted. There’s tons of different tissue-based repairs. These repairs are a hundred percent relying on sutures in the patient’s tissue, no mesh to kind of patch the area. So oftentimes when I remove mesh inpatients, we have a decision as to what we do with that hernia. And many opts for tissue-based repair that redo tissue-based repair, it’s feasible. I can do it, but I’ve noticed the risk of chronic pain is higher probably because they already have either a hernia with missing tissue or weakened tissue from the mesh removal or something that makes it so now that or just stiff tissue, right? Because you have inflammation scarring from the first surgery and now I’m trying to cinch everything together and it becomes tight. Now, there are procedures we do during surgery called fascial releases where we kind of loosen up the tissue a little bit so that the area where we put the sutures are not too tight.

(17:13):

However, what happens is it’s not perfect and so you end up having tension on those tissues. So I’ll give you a couple of scenarios. I have a lovely patient, and by the way, these are all out-of-state patients, so it’s even more difficult to try and handle their situation. But one patient had their mesh removed because of an inflammatory disorder and mesh implant illness and then I closed his abdominal wall together. But it’s very important that he remain fit, not be too active. And the other thing is as you grow older, you may need surgery, you may need colon surgery, you may need gallbladder surgery, et cetera. People need those surgeons that are handling. You need to understand that your abdominal wall is very delicate now because all you have is just some sutures holding it together and you had a hernia before, so it’s very delicate to put it together.

(18:21):

One lady needed her mesh removed and opted not to have a hernia mesh in her anymore. There was some question of whether she was reacting to the mesh, and so we did a tissue repair and she never really felt good afterwards. It’s always like a little pull, a little twitch, a little twinge. She got constipated from bad food poisoning once and that I think pulled that pressure of straining pulled on her repair. I mean, she healed it on her own. There’s no hernia that’s recurred. If you do an MRI or other imaging, you’ll see the hernia repair is fine, but the patient just feels it like it’s just tight in that area. So I have another patient, he absolutely, he could not get mesh at the time, at the time because there was a lot of infections. So we kind of were like, alright, I don’t want to do tissue-based repair because you don’t have much tissue, so let’s wait until all the infections gone.

(19:32):

I’ll do a mesh based repair. But once I did the mesh based repair, he had a lot of missing tissue. In fact, if he needed a tissue-based repair, I’m not sure how I would’ve ever repaired him because he was missing tissue like a big hole. And something as simple as me trying to close that hole to have a better platform for the mesh alone caused chronic pain and he’s trying to recover through that where the pulling pain from the tissue repair is very debilitating. So my point is most patients who think, lemme rephrase this. In most situations I would say almost all situations with very few exceptions being mesh implant illness, if you have a redo hernia, a recurrence from a tissue repair, an open mesh repair, a laparoscopic mesh repair or a robotic mesh repair or a tissue repair of any sort, if you have a recurrence, a mesh repair is the right choice.

(20:45):

In fact, it’s the choice that will give you the least chronic pain because you’re patching an area that’s weak or loose, whereas you’re kind of tightening and therefore pulling and potentially tearing tissues if you are not doing that. So what I would recommend is that, I mean it’s great to have this discussion. My concern is some patients will go to their doctor and their doctor will not have the experience that I am sharing with you and will think it’s perfectly okay and satisfactory to just take out the mesh and do tissue based repair in most patients. And now you’re stuck with chronic pain and that’s just a horrible situation to have. So many of you are in that situation and shared with me your questions ahead of time. So I’m going to go through those questions. So here’s one, it says this is a groin hernia, inguinal hernia.

(21:44):

I had a redo anterior tissue repair of a recurrent direct hernia. Let’s say that it was a shoulder D repair, I don’t know, ace shoulder dice, something like that originally done open one side mesh. The other side tissue, I now have inguinal, which is chronic groin pain. The etiology or the cause is unknown, but it’s expected that I have tightness of the repair. And what I’ve said earlier is usually unless there’s a nerve damage, chronic pain after a tissue-based repair is due to it being too tight and therefore trying to pull. And classically a direct hernia is going to be more tight of a tissue based repair than an indirect inguinal hernia typically. And so it makes sense that you had a direct hernia, that you had tissue repair and now you’re telling me it’s a redo of a recurrent direct hernia. So you are doing exactly what I said you should not be done, which is you had a recurrence of a redo, you had a recurrence of a direct hernia and they did a tissue based repair, big, big risk for chronic pain.

(23:06):

So now you have chronic pain and the etiology is unknown, but suspected tightness of repair, I agree with that. Can a posterior repair with mesh relieve the tension anteriorly? Yes, yes. Or our two procedures required laparoscopic bench repair followed by open repair to remove anteriorly placed sutures. So I absolutely would recommend if you have a tight repair, it’s not always tight because it’s naturally tight. It’s tight because the minute you stand or bend or do any activity, you’re adding pressure, abdominal pressure to this repair and therefore trying to pull it apart. Whereas if you lay flat in bed, it shouldn’t feel tight. That’s most situations. I don’t know what this situation is. That’s most situations. So when you’re lying flat, if it’s not tight and it’s only when you’re up and about and active after first let’s say half an hour or so of getting out of bed, that’s something that can be relieved by adding mesh. The question you’re posing is should you also remove the tissues, the sutures?

(24:18):

I would not do that as a single stage procedure because the majority of patients will not need that second procedure. I would do the mesh based repair posteriorly where it sounds like no one’s been yet. So it’s normal tissue, low risk of any chronic pain, low risk of injury, any nerves and get that repaired. Now remember, the mesh itself cannot be placed like just a stick. You need to add a little bit of tension to the repair to take the tension off of the next layer, which is the muscle. Then if your pain is cured, which let’s say 80% of the time, 85% of the time your pain will be cured, then you’re done. Why do I say do it staged? Because in that 15%, let’s say, or 10% who may need to have something done anteriorly, then it’s worth doing it. But if you do it on everyone going in anteriorly and what sounds like now will be the third time puts you at significantly high risk of nerve damage and therefore chronic pain and in males, you may lose your testicle because now it’s the third time someone’s manipulated the blood flow to your testicle by operating in that space.

(25:50):

And so that’s a complication that can absolutely be prevented by just not going there. Here’s a comment from one of my favorite followers. He writes, doctor, irrespective of tissue or mesh repair is increasing the slack through weight loss essential for optimal outcomes. Yes, absolutely, yes. So all hernias are prone to rupture failure tear. If you add tension to them, whether it’s a meh repair or a tissue based repair, the less tension you add to that, the less risk of tearing or chronic pain or recurrence. Losing abdominal weight can be a major way of reducing tension onto that area, and if you have strength your core, that will actually also relieve tension on the repair by supporting the repair, by having good core strength. So losing abdominal intraabdominal weight and gaining core strength as a combination is the best option to either reduce hernia recurrence, reduce chronic pain, reduce any failure of your hernia repair. That’s a very good question, but yes, you’re right.

(27:13):

Next question. You discussed rectus muscle plication as a way to repair incision hernia without using mush. What are the advantages, disadvantages, and limits of application for this process? Good question. I didn’t mention it yet, but I will now that you bring it up. So plication is what you do with a tummy tuck. You take your loosey goosey abdominal wall from a lady who’s had five babies and you tighten it close and do it usually two layers. That’s called a plication where you take something loose and you tighten it by folding it and sewing that fold in. You can do that for hernia as well. And I do do that for most of my abdominal wall reconstructions. I do plication because I feel like it smooths out the contour similar to a tummy tuck and it also supports the main repair. I would also suggest that if you do need your mesh removed because that’s what we’re talking about today, or if you do need a redo repair or you have an incisional repair or something like that as relatively small, you can consider using the plication, that extra layer of muscle as your support of the first repair.

(28:49):

It’s a very small population of patients that fall into that category, but if you have a very small hernia and you’re not obese, you can consider plication as an alternative to mesh. It’s not considered standard, it’s not performed by most people. You have to be a good candidate with no abdominal tension or fat. I saw a patient recently very fit, like this guy had abs of steel, but his belly was so round. Those yoga balls that you sit on, that was his belly purely genetic. The guy’s not fat at all. This is just intraabdominal fat that’s accumulated very genetically, potentially due to medications as well. He works out five days a week, hour and a half a day at a major weightlifting like where all the bodybuilders go, but he just genetically has this very protruded abdomen. If you touch it, it was literally rock hard.

(30:03):

The guy is in great physical shape but just doesn’t have a flat belly. It’s very round. That is a horrible, highly tensile, highly tense abdomen. If I just take a scalpel and just cut it, it’s just going to pop because there’s so much tension pulling his abdomen apart, and the more it pulls apart, the more it pulls apart and he gets this rounded look with rectus diastasis. So that’s a situation where there is no give, I can’t close you in multiple layers. And so if you have a hernia in that situation, you don’t want someone to go in there and put a bunch of holes because all those holes will pop open. You want to do the least amount of surgery as possible and just patch, don’t close, just patch because any closure is going to fail. So that’s kind of the situation. Next question.

(31:07):

Can rectus plication be combined with other techniques such as component separation or botulinum toxin injections to improve its effectiveness in recurrent incisional hernia repairs? Okay, we did briefly just mention Botox. So Botox is a toxin. It paralyzes your muscles. You’ve seen what happens if you put it on your forehead, you can’t raise your eyebrows and therefore you’ll have less wrinkles. We do use Botox in the abdominal wall and that basically makes your abdominal wall loose and then it makes it so during surgery I can really kind of tighten up the abdominal muscles without too much tension and buys me about three to four months of recovery.

(31:58):

In some patients where they’re in a chronic pain because of a tissue repair that is pulling apart, sometimes I use Botox in the first patient’s question. Botox may be a good way to temporize your pain. It’s not a cure, but I’ve had patients who have had just way too much surgery. They’re busy people, they can’t have so much downtime, and I’ve treated their chronic pain from a tissue repair after a prior mesh removal procedure by injecting Botox and after about four or five series or cycles of injections, their muscle loosened up enough that they didn’t have chronic pain anymore. That’s another technique to do if you don’t want surgery. Here’s another question. What’s the difference between the surgical techniques of implication and plication? So I’ll tell you my definition. So plication means you take the two edges and you close it and then you take, let’s say a centimeter out from the other edge and then you close it. So you’re basically closing a hole. I implication means you have a laxity or a bulging that you then grab that redundant tissue, you don’t close the hole, you grab the redundant tissue and that’s now pooched out and you bring it inwards you, I implicate it inwards and you bring it in. So for example, an implication would be like a hat, like a men’s hat. If you just push it in and out, that would be in implication. Whereas apply case would be actually closing.

(33:57):

Plication would be actually closing a hole in multiple layers. Next question. Oh, so the follow up to this question is can the rectus plication be combined with a component separation? So component separation, we’ve had multiple shows on that, is when you take your muscle abdominal wall muscle and you break it up into different components and move them across a horizontal plane to be able to close a hole. So you only use component separation if you can’t close the hole primarily together because it’ll just pull or tear apart. So you need to loosen it. We talked about chemically and loosening with Botox. You can physically, mechanically loosen it by causing releases of tissues upstream to allow the hernia downstream to be repaired. In general component separations weaken the area where the component was separated and we prefer not to do it unless it’s necessary. Is it a technique? Yes. Should it be done in every patient? No, it’s just another tool in the toolbox. But know that a component separation will weaken the abdominal wall, if not perform with mesh to strengthen the abdominal wall. I don’t know if that makes sense.

(35:34):

All right. Next question. What kind if any of resorbable mesh would you consider for patients with mesh implant illness at high risk for reacting to any kind of material? I just don’t recommend it. All of the fully resorbable meshes that are synthetic are highly inflammatory, and that’s exactly what you don’t want in a patient with mesh implant illness or an MII. So you can’t use the synthetic absorbable meshes nonsynthetic or biologic absorbable meshes. Most of them are so processed and might as well be synthetic. Technically it came from a cadaver and not a lab, so it’s considered biologic, but some of them are so poorly made that they’re basically synthetic and their body sees it as synthetic and they’re highly inflammatory. There are a handful of brands that I believe are very well done in terms of the quality of their process of making the biologic.

(36:49):

AlloDerm was the original one. Flex HD seems to be pretty good. These are very low inflammatory compared to their competitors. Some of the competitors actually were taken off the market. They were so synthetic, they never resorbed your body, saw it as like cardboard and then never resorbed. So I would say in general, I do not recommend any resorbable mesh. There is Vicryl mesh, which will last about three weeks. I’m not sure three weeks will help at all. So I’m not a fan of using it. That’s a synthetic absorbable, but it resorbs so quickly, I doubt it’s going to cause any problem. And then lastly, I do have one patient, I don’t know. I would just say once you’re diagnosed with MII for real, that I would stay away from even certain sutures like you can react to them. It’s kind of crazy, but the state that we’re in right now. Okay, question. Are there any researchers or companies working on absorbable sutures that last longer than PDS? Yes, that’s they are allowing the use of absorbable sutures in certain situations. Yes, there are companies looking at sutures. So PDS will last about eight months. There are sutures. I mean technically silk is a suture, but it loses it’s tensile strength very technically. Silk is an absorbable suture, but it loses its 10 cell strength much sooner than it’s absorbed. So it’s not worth using and it’s highly inflammatory.

(38:43):

But yes, there are companies that are trying to come up with sutures that last about two years. I’m not a believer. I feel you’re just shifting that curve of when the recurrence will occur out to two years instead of whatever, nine months. So I’m not a fan. Sorry, I’m negative about that. Let’s see. Next question. What can be done to reduce the chances of incisional hernia recurrence? Oh, a lot of MII questions. I guess actually I understand why you would have a lot of questions or mesh implant illness questions because that is a classic situation where you need to do a redo hernia repair because you had to remove the mesh and you cannot use mesh again. So that’s a classic situation and unfortunately it’s a very difficult situation for most patients because it’s not ideal and we don’t have a good absorbable mesh as this last question was alluding to that would be safe enough to be used without risk of reaction in these patients.

(39:59):

Next question. What can be done to reduce the chances of incisional hernia recurrence in an MII patient who after minimally invasive mesh removal must undergo open surgery? So one is to find a surgeon who can perform your surgery without open surgery because you’re undoing what was done for you, what could be done to reduce the chances. I mean, I guess one could be add Botox to buy yourself some time. The second is don’t be stupid. Don’t treat the patient exactly like every other patient and use an absorbable suture. Don’t take big bites that can tear through. Take small frequent bites that’s been, that’s through the stitch trial. A lot of good evidence in support of the importance of surgical technique and the needle you use to match the suture size. Don’t use big sutures. I use a two oh suture, not any bigger. Use a SH needle, not any thicker because that’s more likely to match the two oh suture.

(41:14):

Take small frequent bites, be very careful, minimize how much open incision you need for the surgery. Potentially lose weight and or use Botox three to four weeks before surgery in preparation for the operation. There’s a lot of little tricks. Surgical technique is very important as well. The surgeon should be yanking on the tissues and causing inflammation or tearing or clamp the tissues. You just have to be very, very careful and quite respectful of the tissues. Form mesh plant illness. Patients can preexisting autoimmune illnesses. Autoimmune illnesses such as ulcerative colitis or autoimmune thyroiditis affect wound healing and risk of recurrence after tissue-based hernia repair, not in and of itself. So people with ulcerative colitis or autoimmune thyroiditis should heal normally as do other patients. However, if they are on an immune suppressing medication, for sure, that will affect wound healing and risk recurrence after tissue-based hernia repair. Of course, this is a very interesting discussion because most of the patients, we found about 80% of the patients in our study who did have mesh implant illness or MI had some type of autoimmune disorder or tendency. And therefore this is very relevant because some of those autoimmune disorders do affect your ability to heal.

(42:58):

But usually unless you’re on a medication that will prevent healing, you should be fine. It’s a long question, long question in MII. Patients can tar trans versus ADOS release TAR or any other kind of component separation techniques be used to provide reinforcement to a recurrent incisional hernia repair whose width would not strictly require these techniques? Yes. If yes, what is the risk of the abdominal wall derivation in the hands of an experienced general surgeon who does not specialize in hernia repair high? And how does it compare to that of a specialized hernia surgeon? Much lower. Okay, very good discussion. So component separations, there’s anterior posterior different ways of doing it. AAR as a posterior component separation, very well known, well-respected technique in patients that need their hernia closed without tension and their hernia is too big to do it and they need a component separation technique. Just a typical situation, you have at least a one third chance of recurrence. That’s based on Ramirez. His paper where he was the first to really, he was a surgeon, Dr. Ramirez, he was the first to kind of come up with this idea of component separation and his publications showed about a third recurrence. The bigger the hernia, the more need for component separation, the higher the recurrence rate.

(44:49):

However, these are very tricky operations. There’s a reason why it was a plastic surgeon who came up with this procedure because plastic surgeons understand blood flow, they understand wound healing, they understand where the neurovascular bundles are. You don’t want to injure the nerves to the muscles when you are making these planes because the nerves run up and down and the planes might go left and right. So you have vertical bundles and you have horizontal muscles. So if you’re going horizontally out to the edges to release these tissues, you can’t injure the bundles that are going vertically. And if any of you’re interested, there’s actually an article about this by the New York Times. And listen, if you’re wondering why the New York Times is doing an article on hernia repairs, it’s exactly this, that there are plenty of surgeons out there that are not specialized who perform these tars because they saw them on video or they saw them at a conference or the patient came to them and said, can you do this procedure?

(46:04):

And they dabbled in it and they didn’t understand this anatomy of the neurovascular bundles and how important it’s to know your anatomy. If you don’t know your anatomy and if it’s a redo revision situation, certainly that’s a problem because your anatomy gets a little bit distorted by that from scar tissue and everything else. And so what they showed is, and they showcase in this article, I highly recommend you read it, multiple patients, I believe they were all female by chance. I’m not sure. Multiple patients in this New York Times article actually had horrible complications where the nerves were slashed, the muscle tissues were inappropriately cut, and they ended up having this very abnormal, asymmetric bulging abdominal wall and there’s nothing to do for it. There’s no surgery to reverse the effects of these. And so they’re maimed by often well-intended surgeons that just didn’t know what they were doing because they didn’t have the experience AAR or other components separation.

(47:18):

Absolutely, absolutely, absolutely must be done by someone who’s experiencing it. Now, everyone needs to gain experience. Obviously you don’t want to go to that person, just don’t. It’s not worth it. And if you are an MII patient, you already have all these other problems. You should not dabble in getting your abdominal wall messed around with by someone who doesn’t understand the intricacies and all the complications you can have. I always tell my residents, the more you experience you gain as a surgeon, the more worried you should become as a surgeon. It’s the junior surgeons, well first year in residency where they don’t really understand the whole gamut, the whole scope of complications that can occur with every single thing we do. Every operation I do, all the complications are in my mind about everything from simple things like bleeding and infection to complicated things like injuring bowel, injuring nerves, naming the pain, chronic pain, et cetera.

(48:26):

I go through that process with every single patient every time I operate and then until I see them for their post-up, I worry about it. The more senior surgeon you are, assuming you have a conscience, obviously the more you worry about all these complications. Now, if you don’t know that much about the procedure or you haven’t done enough of them, you may not be aware that there are all these different complications. So like I said, a junior resident first year in training hasn’t experienced all these potential problems you can get from a hernia. Whereas a chief resident in their last year of residency has had five or more years of seeing complications, revisions, sick patients, patients die even. And that’s part of the learning experience. So I always say a good surgeon becomes more worried the further along they get in their residency, the more experience they get.

(49:28):

So if you go to a surgeon like, ah, it should be fine. Everything’s okay and they’ve done one or two tars their entire life that you should sway, just leave. Don’t do it. If they say, I know how to do it, I do one every couple months. I mean, maybe that’s better. You really don’t want to go to someone that’s never done it. Or I had a patient knew that the surgeon had only done one of this operation in their entire life and it was a senior surgeon. I’m like, yeah, that’s fine. They were okay being patient number two. And of course they had a complication. So yeah, if it were me, I would not mess with it. Next question, have you heard I mesh implants causing sarcoidosis? I have not, which has caused lung nodules due to severe inflammation from a mesh reaction. I know there are studies linking breast implant illness, which we call BI, with the development of sarcoidosis.

(50:43):

That would make me think the same thing could happen with hernia mesh. So I have not seen or heard of it. I would like to read any article that claims that there’s a direct relationship between breast implant illness and sarcoidosis. I, it’s hard to make these statements because people can get sarcoidosis for a variety of reasons and to make the correlation, the time correlation, like they were fine, they got the breast implant and then they got sarcoid. Doesn’t necessarily mean it’s a causative effect. So I’m curious where this data is linking it now, autoimmune disorders, it’s a much better, by the way, autoimmune as a whole, not a specific autoimmune disorder as a whole is a little bit better researched. But even that, we still don’t have an actual cause and effect that we can say definitively, this rheumatoid arthritis, this lupus or this ulcerative colitis was caused by this mesh implant.

(51:53):

In most patients, there’s a tendency already to have this disease. Like I said, 80% of our patients had an autoimmune disorder themselves or in their family. And so you have that tendency and potentially the mesh is waking up that tendency and you’re either getting diagnosed earlier or more likely to get diagnosed with it, whereas it may have been dormant if you weren’t exposed to the implant. But whether it would cause it, I’m not sure there’s any study that could claim the causation, but I’ll look into it. I’ll look into it because I’m also interested to know, I just had a patient who came to me because his rheumatologist felt that his abnormal blood tests were due to the Sion plan, and there’s nothing to show that a low testosterone is due to ESS plan or that abnormal cholesterol levels are due to Sion plan. There’s just none.

(52:58):

And so I was curious why the rheumatologist was saying that I reached out to them to see what they’re looking at. But it is very easy to blame the mesh and there’s certainly lots of reasons to blame mesh, but I would say we have to be very cautious about coming up with a direct cause and effect or to say that, yeah, it’s been shown, but I will look into it. I’ll read whatever article is out there about sarcoidosis and breast implant illness. It’s the same thing as me implant illness. For the most part, all of these are part of Asia or the autoimmune or inflammatory syndrome induced by adjuvants, hence the acronym Asia A-S-I-A. And it’s one of those things that we’re kind of in the learning status of it, and I welcome anyone to share their information with me so I can read more about it.

(54:11):

But as far as I know, I’m not aware that anyone has reported it. I have not seen it in my patients. Sarcoidosis is not a very common illness to begin with, so that’s not necessarily a reason to discount it. And I’d like to see if there were just a single case report or what, because there’s some articles out there written by people that don’t really understand Asia or mesh implant illness or breast implant illness, and they just wrote an article to have published an article and you read it and you’re like, this is nothing. This claims nothing but how it got published under peer review. I don’t know. Okay. Next question, but thank you for asking. Assuming a surgeon who is equally skilled with different tissue repair techniques and an ideal match of the chosen technique to a patient’s characteristics, what tissue repair techniques are most effective in minimizing recurrence and chronic pain risk?

(55:18):

So great question. The reason why Schulze, for example, has become the elite repair and other repairs like Bassini, Desarda, Halsted, all the others are lower on the risk is because shouldice has four layers and the surgeon understood his anatomy and used strength in layers and tissue layers and releases to get you to a position where it’s really hard to break through four layers and you can tear through one, you have multiple other layers to support you. The same is true of plication, where you’re plicating multiple layers like a tummy tuck. It’s why tummy tuck holds, even though they don’t use mesh plastic surgeons are often like, why are you guys using mesh so much? We do tummy tucks all the time. They don’t fall apart. Well, you’re dealing with people that usually have normal tissues and just got stretched by pregnancy, not due to herniation.

(56:24):

That’s one reason. But also the multiple layers of tissue and the careful decision as to what suture, what needle type of technique to use is very important. So the key is to use multiple layers, not a single layer. The other key is to use permanent suture and not absorbable suture. The third key is to make sure your suture size is not large, so you don’t leave large holes in your muscle and fascia and your needle is not large. Lastly, you want to take careful bites of the tissue so you don’t tear through the tissue. And all of that is kind of like a package deal.

(57:13):

Okay, next question. For posterior mesh to relieve tension in a painful, open tissue repair, do the tissue and mesh need to be incorporated with each other by scar tissue? They will be, there will not be empty space. There’s no such thing as empty space in our body, but you don’t want the mesh to fall into the tissue repair. You want it to be a little bit of a trampoline to pull away to kind of take some tension off of the tissue repair. Hopefully that makes sense. Alright. Let’s see. Any more questions? Nope, that’s it. I, that’s it. I love it. All right, everyone. Well, that was fantastic. Lots of good questions. I do appreciate you joining me. I think, yeah, next week we’re on on for another episode of Hernia Talk Live next week. You have any interesting topics you want to share or you want me to address?

(58:22):

Please let me know. If you have surgeons you want me to, or other doctors you want me to talk with, let me know. In the meantime, do follow me. Subscribe to our YouTube channel at Hernia Doc and make sure you don’t miss any of our episodes. We’re hitting almost number 200. We’ll have to celebrate at number 200. And yeah, share this with everyone. Well listen to me as a podcast. Please. If you do listen to podcasts, may I please ask you to leave a comment. If you leave a comment, it’s more likely that people will be able to find my podcast, and so I appreciate that. Until then, bye bye.