194. Does Age Matter?

This week, the topic of discussion was: 
-Age
-Elderly 
-Frailty Index
-Surgical Complications
-Healing
-Infection
-Tissue Repair
-Suture Choice
-Mesh Repair
-TAR Abdominal Reconstruction
-Geriatric Surgery

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 (00:00:10):

Hey everyone, it’s Dr. Towfigh. Welcome. I hope you’re all doing well. I am here to talk about a really great topic that I’ve been trying to get a specialist for but have had a hard time. The question is, does age matter? I am Dr. Shirin Towfigh. I’m your hernia and laparoscopic surgery specialist. Welcome to Hernia Talk Live. Many of you’re joining me as a Facebook Live. I’m monitoring your questions. Also, some of you’re here via Zoom. Welcome, please do follow me on my other social media platforms on Facebook at Dr. Towfigh and on Instagram and X at Herd Doc. This episode and all prior episodes are all available for you to look through on my YouTube channel at Hernia Doc or as a podcast, as a hernia doc live. And I would like to say that sometimes many of you actually message me either as on my social media or as a direct message and ask me questions which we’ve very in much detail have reviewed on one of these episodes.

(00:01:20):

So for example, I think it was yesterday, someone or the day before, I think yesterday someone asked about hernias and exercise. So can I exercise? I really want to do X, Y, and Z, and I feel like now that I have a hernia, I dual back. What can or can I not do? Guess what? We’ve had an entire episode with a trainer and Pilates instructor who understands core exercises. We had an entire episode devoted just to exercises. That was episode 55. So just go to my YouTube channel or my website or on the podcast wherever you listen to podcasts. And when you are in my site, just Google or search for the topic or the person or the surgeon or whatever and it’ll pop up. So we’re very lucky to be inching towards 200 episodes and we have tackled so many different topics within hernias that and some of them more than once from different angles with different specialists that it’s nearly impossible to come up with a question that we haven’t at least broached upon. So today, believe it or not, we have not had an actual full hour on age as a risk factor. We know that hernias are more likely in the elderly, and we can discuss why that is.

(00:02:59):

The older your age, the more likely you are to get a hernia. It’s almost bimodal. You either get it when you’re really young or you’re really old and not so much in the middle statistically. But we didn’t really talk about what to do about when you are older, like surgical risks, the risk of getting a hernia, the risk of failing a certain repair based on your age and so on. And there are a handful of what we call geriatric surgeons. So these are surgeons that are general surgeons and then they choose to do mostly geriatric surgery or at least their research is based on surgery in the elderly. And I must say that there aren’t that many. There is a push in the American College of Surgeons to include geriatrics as a worthwhile specialty within general surgery. Now, I don’t know if it will actually be an actual specialty where you can need extra training, at least probably not in my lifetime.

(00:04:15):

But from a educational standpoint, there are definitely a handful of surgeons that are very interested in geriatrics. As you know, there are geriatric medical doctors because we know that patients who are older are more likely to have complications with their medications. They may suffer from what’s called polypharmacy, where they’re given away too many different medications from different doctors, and those doctors don’t communicate. They have adverse reactions to medications that someone younger would not have. So for example, that would be things such as antidepressants, benzodiazepines, allergy medications. Those can all adversely affect someone that’s older. For example, you don’t want to give ’em Benadryl to someone who’s older because it can exacerbate certain psychiatric effects.

(00:05:18):

And elderly are a bit more frail, usually they’re more likely to fall. So you don’t want to give them medications that can drop their blood pressure and things like that. So let’s say Viagra is not usually considered a safe option in patients that are much older because it could drop your blood pressure among its side effects. There’s a lot of these little things where if you are a geriatric medicine specialist, you’re a little bit more in tune with the intricacies and the dosing and the fact that your liver and your kidney may not be as strong in metabolizing medications as you may be from let’s say a younger age. And therefore the side effects and the buildup of the medication in your system may be more or it may adversely affect your kidneys like naproxen, Advil, Aleve. Those usually we don’t like to give to the elderly or we give it at a lower dose, usually half the dose than a regular dose because it can kill your kidneys in some patients, even Tylenol, your liver may be more sensitive to it as you’re older.

(00:06:33):

So that similar kind of thought process goes on the surgical side. So we discussed kind of how a geriatric medicine doctor would think on the medicine side, but now for surgery, the question is are we in a position where we need what’s called the geriatric surgery specialty? And then how does that relate to hernia surgery? So I have multiple friends that have an interest in geriatrics, but they don’t really do hernia surgery. I’m looking for that perfect geriatric surgeon that can talk to me about hernia surgery, and I haven’t been able to recruit that person yet, but what I do know is that there’s two types of elderly patients. There’s a sick elderly patient and the healthy elderly patient. And all of the studies show once you hit like 90, and by the way, what’s the definition of elderly? So it used to be over 50 or over 55 was considered elderly. Since I’m almost there, I’m glad that’s no longer consider considered elderly. Some people started 65 as elderly, that’s Medicare age and retirement age in the United States. But the reality is most people that in their sixties are still working, at least in the United States, they are, many of them are.

(00:08:19):

So the concept of elderly is changing as we grow older, I definitely would consider seventies, eighties, nineties, hundreds in the elderly category. But what’s unique is there have been multiple studies that show that the Darwinian principle and that principle is if you’ve hit 90, the chances are you are in better shape than someone with multiple medical problems in their sixties. So if I operating on a 90-year-old, that patient may actually do better than operating on a 70-year-old or 60-year-old with diabetes, high blood pressure, COPD, et cetera. And that’s kind of like survival of the fittest. That patient in their sixties that has all these multiple medical problems is unlikely to make it to 90, whereas the healthy 60-year-old that’s still running marathons or has a trainer et cetera, is likely or skis and plays pickleball is more likely to hit 90. So operating on a 90-year-old sometimes is actually safer on average than operating on a 70-year-old or late sixties person.

(00:09:48):

And there’s really good data to support that. There’s trauma papers and other surgical papers that looked at how patients do based on age. And on average, if you’re over 90, the chances are you’ll do better than in that kind of 60 to 70, 60 to 80 range because you’ve met a lot of those milestones and you’ve shown that you’re healthy enough to get to 90. Most people in their nineties are not like that. That’s sick compared to there’s a lot of people that are in their sixties and seventies that are still sick. So that’s kind of interesting. I had friends whose parents were in their nineties and they needed emergency surgery and they did perfectly fine. Everyone’s worried about them, but they did perfectly fine. And it’s kind of remarkable how the body is like that.

(00:10:55):

So the question is, as a surgeon, if I see someone who’s 60, 70, 80 or 90 or a hundred, do I offer surgery to them? Are they more likely to require a certain type of surgery or do poorly or do well from a surgery and therefore, what’s the plan of care for someone and should I even consider their age? Some people think, oh, age is just a number and therefore if they’re healthy, why does it matter that they’re 50 or they’re 90? I will tell you, we do have a dictum amongst us surgeons that we say once you get sick, you start, or even once you operate on people, patients act their age, quote, act their age. So if I have a perfectly healthy 90-year-old and I’m operating on them and something goes wrong, there’s a bowel injury, they need emergency surgery or whatever, their reserve is not really there once they get sick.

(00:12:10):

Intensive care need a lot of people that you go into surgery thinking, wow, they’re so healthy, they’ll do so well. If they have a complication, they don’t do that well. It takes longer for them to stay intubated. They’re less, they just don’t have the reserve that maybe someone younger has. It’s harder for them to get off the ventilator. It’s harder for them to get discharged. They’re more likely to need physical therapy or inpatient physical therapy. They’re more likely to end up in a nursing home or some type of aftercare to get them to a point where they’re independent, they’re less likely to get out of it independent and they have a dramatic drop in their quality of life. There’s a concept in quality of life assessments called frailty. In fact, there’s something called the frailty index. And the frailty index or frailty relates to multiple factors and it has to do with your lifestyle, your ability to take care of yourself independently and also your medical reserve.

(00:13:34):

So for example, someone who still works, there are plenty of 80, 90 year olds still work at Walmart. You see them, Kmart, the greeters, or they work at your local grocery store and you’re like, man, they’re like, they’re standing on their feet and they have the mental acuity to do all the computer stuff or eight hours of work, whatever. That’s a good sign if someone can do all that and not be destroyed because those are difficult jobs to do. Are they able to, do they drive still? Do they regularly exercise? Can they weight bear? Are their joints able to kind maintain their weight? This is all separate from evaluation of their heart and lungs and the normal surgical evaluation that we do, it has to do with how frail are they? If something goes wrong, what is the likelihood that they will recover from it as opposed to ending up either in a prolonged hospitalization or a need for aftercare.

(00:14:46):

And the frailty index is often a stronger predictor of whether a patient will be a higher risk for poor outcomes than let’s say their heart disease or blood pressure, well controlled chronic illness, let’s say diabetes or high blood pressure. So that’s kind of the way we think about it. I think before we came up with this formal frailty index that is measurable and can be assigned to a patient, it also has to do with their nutrition and how good they take care of themselves. But before we’re able to come up with that, we all had what’s called the eyeball test. So if you look at a patient and you’re like, oh, he kind of failed the eyeball test, it just means you look at the patient and as a physician you can kind of assess their ability to be a good successful surgical candidate just by looking at them.

(00:15:50):

Of course, very crude way of doing it. It has many assumptions. It’s not easily testable and measurable, but it is something that we gain a gift of being able to look at someone and be like, I’m not sure I’m going to even offer you surgery. I’ve had people come into my office. It’s like there’s the two daughters with their mom. Mom comes in with a wheelchair. I can’t examine her in the examination bed too frail, frail to get up from her wheelchair to go onto the bed, and I have to examine her while she’s in the wheelchair. She’s completely dependent on her children. She’s a widow, she’s widowed, doesn’t work. They have help at home assistance for showering and moving her around, et cetera. She mostly sits, and that’s her interaction. And they’re like, look at this big hernia. Let’s say she had emergency general surgery.

(00:17:05):

Her intestine needed surgery, they fixed that. They saved her life and now she’s got this huge hernia. So the question is, I mean, I would love to fix that hernia, but I can kill her if I fixed a hernia or in some ways worse, I can make her completely debilitated because it would be, let’s say an operation with lots of general anesthesia, which could affect her dementia. It could be an operation that will fix the belly, but now she’s stuck in the hospital even more dependent and needs to be moved to a nursing home. She can’t even be taken care of by caretaker at home. There’s a lot of these things that go through our mind. You currently have a functional mother that’s somewhat disabled because she’s completely dependent on you and can’t really walk on her own. For example, is that better with a hernia or a mom you can’t even talk to anymore. She’s got advanced dementia or had a stroke during surgery who now has a perfectly well fixed hernia. That’s kind of the decisions that need to be made and the discussions that we need to have.

(00:18:27):

We haven’t even discussed physiologically how the abdominal wall and the groin muscles and fascia are affected by age. Sometimes we operate on patients and you can kind tell their age based on the quality of their tissues. For example, when we close an abdominal wall, we use sutures, which is basically a needle and thread that has to go through muscle and fascia to bring things together. In elderly patients, you can have poor quality tissues. So when you’re sewing things together, everything tears, it doesn’t hold suture. You’re going to need to use a different set of sutures than you would someone younger because their tissue is so frail. A thicker suture will just rip right through the tissues and not hold. They may be more likely to need mesh or a wider piece of mesh than a tissue-based repair. And I’ve had patients, I’ve had patients, I’ve had an 83-year-old I think, who want a tissue-based groin repair. I performed it on him. He gardens every day. He has got a huge orchard that he takes care of. He had good quality tissues for an 80-year-old and the hernia was not big. So a lot of those things kind of go through my mind.

(00:20:02):

In addition to the tissues, the skin even of someone who’s older can get very, very thin. So what can happen is your skin thins, right, becomes paper thin skin and the dermis, which is the thick layer beneath the skin, which gives you a little bit of tur and tension also is non-existent in a lot of the elderly patients. Every so often we’ll operate on someone younger and we’ll be very surprised that their skin quality, their dermal dermis quality and even their muscle or fascia is older than it should be, right? It feels like you’re operating on a 70-year-old, but you’re operating on a 50-year-old or 40-year-old. So that happens every so often. I recently operate on a patient, I think she was was early forties, and her peritoneum, which is a layer of the sock that kind of holds the chitlin site, the intestines in was paper thin.

(00:21:18):

I would rephrase that because paper can be thick. It was like one cell layer. It was see-through. That’s how thin it was. So it wasn’t paper thin. It was more than paper thin. It was completely see-through. I can see the intestines on the other side with no problem. I felt if I tugged a little bit more than it would tolerate, the whole thing would rip open. That’s how delicate her tissues were. And in general, when I went in to operate on, her tissues were kind of loose. It didn’t have the tur that you expect for someone 15 years younger than me. So it was kind of interesting to me that someone so young would have older acting tissues, and of course she got meshed, and I’m glad that I did not recommend a tissue-based repair for her because it’s very possible that the same tissue that I saw in the abdominal wall, the belly button, et cetera, and the peritoneum being so thin and super see-through almost it’s possible the same is true in her groin. And then could you imagine having to sew that together? Even if I pick the thinnest most delicate suture and needle to use, it probably would not hold very well, would tear apart.

(00:22:43):

So that’s my take on age. I would say that age does matter, if that’s the question for today, does age matter? It does matter. Is it the only factor? No, but it is a very big factor. I may change the type of surgery I offer you based on your age, but when I say age, it often implies everything else that comes with age. So your frailties, your comorbidities, maybe the medications you’re on. If you’re older, you may have already had a heart disease, you may be on blood thinners. That significantly changes what I offer you than someone who’s not on blood thinners. For example, in my practice, I do not like offering laparoscopic surgery to patients who are on blood thinners. I just feel like the risk of critical bleeding is just not worth it, and I don’t recommend it because you can do a perfectly good open surgery without laparoscopy for the groin and not risk the massive critical bleeding that would not stop if you’re on a blood thinner doing it laparoscopically.

(00:24:03):

So those are little things. The Lichtenstein kind of inguinal hernia pair, which is a very, very commonly performed operation, very well studied. I personally don’t like to use it in younger patients unless it’s a huge hernia, but I do prefer it for older patients because it’s a good sturdy repair and I don’t need to give general anesthesia for it. I can do it under local anesthesia with sedation or even without sedation. So in a patient that has dementia or doesn’t want general anesthesia because they’re older or risk for Parkinson’s or any of these kind of neurologic disorders where maybe anesthesia could make it worse, an open mesh based repair called the Lichtenstein, a perfectly good repair for someone older. A, you don’t need to use the iv. The general anesthesia reduce the risk of that, and B, you need the mesh because the tissues are not strong enough for a tissue-based repair.

(00:25:11):

So let’s go through some questions and see how we can answer those. Since many of you have turned in questions, and I’m going to try and run some through some of these, we have I think about six questions that were pre-sent in. Okay, here’s a question. The elderly, those who are elderly may have thinned fascia. Yes. Smaller musculature, well, I won’t say we have smaller musculature, but definitely more thinned or weaker musculature relative to younger patients. Is this a factor when doing hernia surgery? Yes. What precautions can you take in the elderly when doing dissections to prepare a landing spot for mesh when fixating the mesh or suturing tissue together for a tissue-based procedure to achieve a pain-free and durable outcome? Well, in general, I do not tend to rely on tissue repair as my mainstay for elderly patients. Their tissues tend to be thinner, tend not to hold suture very well, tend not to be strong enough to handle a tissue-based repair.

(00:26:19):

And remember, unlike a mesh repair, a tissue-based repair is a hundred percent reliant on your own tissue. And having had a hernia, we already know by default that you do not have normal healthy tissue. You have tissue that has lower collagen and other things than the patient who does not have a hernia, and therefore I’m not dealing with normal healthy tissue baseline. And you add the age to it makes it more complicated. So I personally do not recommend a tissue-based repair. For most patients who are elderly, and by elderly I mean I would say over 70 on average. There’s obviously exceptions to everything, but even Jack Mulane, for those of you who remember who Jack Le is, if he came to me in his eighties or nineties, I probably would’ve offered him a mesh based repair. Now, what precautions can we take though? Well, number one, very careful tissue handling because the tissue tends to be more fragile, more likely to bleed or bruise, more likely to bruise, and all of that can make healing worse and affect healing number one. Secondly, the suture and the needle that attach to that suture comes in various sizes.

(00:27:48):

I personally use a 2 O’s, which is a standard for most groin hernias, but you can also do that for abdominal wall 2 Oh’s, and it’s really, oh, so we call it two oh, a lot of surgeons who trained that when I did still rely on thicker, larger sutures, oh, number one, number two, that’s just kind of how it is. We moved away from that. I teach my residents to move away from that. The thicker the suture, the stronger the muscle that has to match it. So that’s number one. Second is the needle that’s attached to that suture needs to match the suture. So you don’t want a big thick needle on a really thin suture and the manufacturers for the most part do the matching for you. But there are situations where the needle is thicker than the suture, and so you have to match a thin suture with a thin needle, and the thinner the needle, the better it goes through thinned tissue because it causes less of a mark.

(00:28:57):

For those of you who’ve used a sewing machine or you’ve done sewing yourself, you know how important it is to match not just the color of your thread but the quality of your thread. So whether it’s polyester or cotton or silk, and match that to the fabric that you’re sewing. And then the delicateness of the fabric that you sew also needs to correlate with the delicateness of the needle that you use either for your sewing machine or for your handheld sewing. So it’s very important that you don’t have huge gaping holes in your silk shirt where your silk shirt has been sewn. The same is true for the abdominal wall as you want to match your suture and your needle to the quality of the tissue. So one thing that you can do is in an older patient use a thinner suture. I also do that for some of the thinner patients.

(00:29:57):

Here’s a question. H can also affect the way a body could resist an infection. That’s true. Could there be a confusion sometimes between age or symptoms related to mesh and a biofilm infection inside the mesh like a staph? Would it be recommendable to systematically do a bacteriological testing like a gram coloration of explanted mesh in patients that present chronic fatigue after their hernia surgery? And does infected mesh necessarily show on standard blood work? So this idea of biofilm and infection, from my understanding, we don’t have a good clear line between Asia, which is a SIA autoimmune or inflammatory syndrome induced by adjuvants. We don’t have a direct line from Asia to biofilm or mesh infection or what we call a subclinical mesh infection. Biofilm also is poorly understood. That term is used very commonly inappropriately. Everyone has biofilm, every implant has biofilm, et cetera. Some people allege, but what actually is biofilm is unclear, and is biofilm always associated with bacteria or not?

(00:31:27):

Also unclear. So is our world’s complete sterile? No, but the body is theoretically sterile and if you have an infection, if you have a clinical infection where your white blood cell count is elevated or you have other factors that are elevated, there’s no kind of argument you have an infection. But if there’s negative cultures, negative blood tests, negative CAT scan, negative pathology, it’s hard to argue that that is biofilm or that’s an infection just because you want it to kind of fit a box. And so that’s a problem that I have with biofilm and infection, which is like you said, would it be recommended to systematically do a bacteriological testing of what you can’t bacteria, bacteria logically test the mesh that’s inside the body. It’s technically sterile if you try and biopsy it or you’re actually potentially contaminating it yourself. So you can indirectly test it, but those tests are almost always normal, so it’s a problem. I think we’re going to have to learn more over time about this idea of biofilm and infection and maybe, you know what? This gives me a good idea. I think I’m going to look for a specialist that can maybe discuss this in a much more educated way than I can for all of you. Okay. Here’s the next question.

(00:33:14):

What about if using tacks for fixation of mesh can you match tacks size to thickness of rectus muscle and fibrous tissue to a pubis and structures to which the mesh is fixated? No, we don’t have variable sizes of meshes. We have different companies that make different fixation devices that are either screwed on or kind of punched into attacks. So if someone who has really, really thin tissue, you can still use attacks into their bone. So two out of three of those would for angle hernia, for example, would not go into the muscle would into ligament or bone. But the third one, you just have to be very, very gentle with it and you cannot fixate very deeply in very thin muscle tissue, or you can just forego a fixation and or use sutures instead of fixating where you can control the quality of the suture and so on.

(00:34:22):

Alright, these are good questions. Let’s go to the next question. The elderly may have not as robust of stem cells. Oh, I want to mention this other question. When you talk about age can affect the way a body can resist an infection, the thought is the older you get, the more likely your immune system reduces. So you’re correct, but it’s a two-way street. You are less likely to be able to fight off an infection because your immune system is not as weaker as you age, but because your immune system is also lower, you’re less likely to react to a foreign body like an age Asia syndrome type thing. So I just wanted to make that clear theoretically. All right. Next question. The elderly may have not as robust stem cells growth factors as younger patients, are they less likely to have good incorporation of a mesh into the surrounding tissue?

(00:35:29):

Yes, especially for mesh put into serve as a scaffold for a bulging inguinal floor in a patient with a large direct hernia, or will tissue incorporation be delayed such that only non-absorbable attacks can be used as fixation to prevent the Fluor from bulging? I’m not a fan of non-absorbable attacks. I’m also not a fan of non-absorbable sutures, so that’s my bent. If you feel like you need tacks or any type of fixation, I believe it should be permanent. And there’s some studies that show that if you follow patients far enough absorbable sutures and therefore absorbable tacks would lead to higher risk of recurrence. However, to specifically answer your question, yes, the elderly in general, the older you get, your healing is affected by your age because you just don’t have as robust stem cells and growth factors like you mentioned. So any type of surgery, even just the skin doesn’t heal as well, doesn’t scar, and also you don’t make as much scar when you’re older with when you’re younger. So scar is often something that is good because it keeps the mesh together, it keeps the sutures together, it holds them up. It makes the mesh in the muscle, for example, scar in if you’re a suture base, it allows the sutures to hold the tissues and scar in strongly. The scars made by elderly patients tend to be weaker and not as robust as that and younger patients, and therefore you’re more likely to have hernias after a surgery in an elderly patient that will be called an incisional hernia than in a younger patient.

(00:37:19):

These are all really good questions, by the way. Let’s go to the next question. Are the elderly more susceptible to mesh or wound infections and do you need to do anything beyond your usual procedure to reduce the chance of infection? Okay, the global answer is yes, they’re more likely to have a surgical site infection, but not by much. Not by much, and that’s because the hernias that we do electively are always clean. It’s a clean wound class. There’s four wound classes, clean, clean, contaminated, contaminated and dirty, and hernias usually fall into the clean selection, and so the numbers are always really small. It’s like 1% or lower, so you can’t really find a major difference between the young and old in terms of wound infections and therefore mesh infections. However, if you have a major surgery, let’s say perforated diverticulitis, you need a colon resection, the chances of wound infection in that dirty class four wound would or contaminated wound would be much, much more disparate where an elderly person would be less likely to be able to fight off the infection no matter how much antibiotics you give them because they’re T-cell, B cells, whatever their immune system is, it’s just not as strong.

(00:39:03):

How does age impact wound healing and the adoption of mesh in the elderly? Does mesh use become inevitable for all kinds of hernias and their recurrences as you age? I don’t want to say inevitable or a hundred percent, but yes, as you grow older, your chances of needing support for a tissue repair such as the use of mesh will be more because your tissue are just not as strong. Here’s another question. If your skin heals well and normally in general, is that an indication of how well you heal internally as well? Yes, it is. It absolutely is. Some people heal, they heal perfectly. It doesn’t scar too deeply. You can barely see their scar, their skin’s not wrinkled.

(00:39:59):

If they bumped against something their skin doesn’t tear off. Those are all good signs of someone who has a good healing, but if someone bruises all the time and the minute anyone touches them, their skin kind of tears off and so on, they have a lot of wrinkles that implies lower collagen and therefore poor healing. It seems more and more young and strong athletes are turning to simple sutures for angle hernias without mesh, like the technique in Germany developed by Dr. Wick. Why is it because a sports hernia is more easily repaired using sutures? Also, is there less risk to the spermatic cord without the use of mesh for inguinal hernia in men? Good question. Let’s take one at a time. Why would someone who is a very major athlete that’s young and strong want to opt for a tissue-based repair? Usually those are an athletes that require a lot of flexibility like a ballerina gymnast.

(00:41:15):

What’s another good one? Certain dancers, they need a lot of flexibility or they’re super thin and they don’t want the mesh to prevent them from having that same flexibility. Also, there are a handful of athletes that have been maimed by mesh, whether it’s the soccer players, tennis players, they’re in the news if you read about it. Some have actually lost their ability to perform at a professional level because of a mesh complication, and so that has not been lost on us. And so someone who’s making millions of dollars a year does not want to lose that option because of a freaking mesh. So that may be another reason why they personally feel that they should not have a mesh based repair. That said, in certain patients who have a lot of tension, sorry, let me rephrase that. In certain patients who are likely to have a lot of tension onto their wound, their scar, whatever, I would recommend a mesh based repair.

(00:42:34):

I’ve done several NFL players, NBA players, NHL players. That’s by the way, basketball, football, and US football and hockey and soccer players, they tend to do better with mesh. I’ve done some soccer players that prefer the tissue-based repair, but it was mostly because they had a failure or a problem with their mesh repair. I personally prefer all of these people who need to work out and they do things that’s very rapid and fast or they need that kind of extra support, otherwise their belly is so tight that any little incision will pop it. I feel like patching those are as much better option than trying to cinch those clothes than risk them tearing apart, tearing it apart. Also, sports hernia by definition is not a hernia unlike the name, and so a sports hernia would benefit from a tissue-based approach and usually and not a mesh based approach.

(00:43:42):

Next question, I’m 74 years old with a 28 centimeter incisional hernia. I have consulted a surgeon and he has recommended a TAR. That’s transversus abdominal release. Also, when you say 28, is it 28 centimeters long or 28 centimeters wide? I would suggest it’s probably 28 centimeters long. At this time I’m not in any pain and I’m able to carry on. He said that the quality of life is an important factor and I believe that the tar would decrease my abilities. It should not. I have another appointment in April. What suggestions or recommendations would you suggest? Okay, good question. So abdominal wall reconstruction comes in many different forms. The wider your hernia, the worse your quality of life. Anyone with a hernia nine centimeters wide or greater would benefit in having their hernia repaired because it will dramatically improve your quality of life. That’s a paper that we discussed with Dr.

(00:44:44):

Fitzgibbons in one of my prior episodes that he published as part of his follow up to many of the watchful waiting trials where if you have a hernia of a certain size, actually watchful waiting is not recommended even if you have no symptoms because your quality of life will be improved if you repair a nine centimeter or greater hernia of the abdominal wall. Now the question is how will the reconstruction affect your abilities? The Cleveland Clinic, I believe, and Oregon Health Science University as well as others, including some in Europe, I believe in the Netherlands, have looked at the ability to perform daily activities as well as certain physical activities after major abdominal wall reconstruction. So if I take your muscles and I move them across from each other and kind of reshape your abdominal abdominal wall in order to close a very wide defect, how does that affect your ability to get out of bed, bend over to pick, tie your shoe laces, get in and out of a car, do a sit up, and so on?

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So remarkably, since all of these are done with release and then a big wide mesh is placed, they didn’t really find a major difference in abdominals wall strength and the ability to perform certain activities like the ones I mentioned, which is fascinating to me because you’re technically making your abdominal wall thinner and you’re changing the physics of the abdominal wall so that the direction in which certain tissues were meant to be are now changed. But everyone who’s had a TAR or other similar abdominal wall reconstruction who underwent this study where they tested you before and after, showed a dramatic improvement in their ability to actually do these activities and have an improved quality of life. Next question, are you able to move freely between T and sutures with a tap? Yes. If you decide tissues are inadequate for tap or do you have to switch to tap?

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You do not with robotics. If that decision has made on table now you can suture tap ep. You mentioned going into the pubic bone as a third fixation point for tap placed mesh. If you find poor tissue quality in a greater than 70-year-old, is this a contraindication to standard teaching of trainees to fixate into fibrous tissue rather than inter periosteum for a hernia repair? Would you have to use suture anchor? No, it is not a contradiction when you laparoscopically. So when I place my laparoscopic tacks, I usually put it in Cooper’s ligament, but not into the bone under the femoral space and into the rectus muscle attachment onto the bone pubis bone, but not into the bone. But the majority of surgeons are taught and still do place the tacks into the bone, and orthopedic surgeons put tacks in the bone all the time. So no laparoscopically. It’s not considered a contraindication to do that. And if you already have poor tissues, it’s a good alternative to aim directly for the bone because those are areas where tacks and sutures hold best.

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Alright, couple more questions. Beyond cardiopulmonary issues, which could make general anesthesia problematic, are there any other factors that could limit the option of hernia surgery for patients of advanced age? Are there any other factors that could limit the option of hernia surgery for patients of advanced age? I think so. So yes, general anesthesia may involve some cardiac or lung problems that you won’t necessarily imply in a non general anesthesia or kind of IV sedation scenario. However, in addition, there are some concerns about the effects on the brain. Does dementia get woken up or accelerated in patients who undergo general anesthesia after a certain age? That’s kind of one of the main questions that I think is very patient specific. I think in people who already have dementia or have poor blood flow to their brain because of atherosclerotic disease, some may consider are general anesthesia risky and higher risk of promoting dementia.

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What is the incidence for the elderly of cognitive dysfunctions, exacerbation or appearance after surgery, both short and long term? Yeah, that’s exactly the question answer I was trying to get. We actually, I highly recommend you go back one of our earlier episodes with Dr. Edna Ma. She was an anesthesiologist and we talked about the risks of anesthesia. In general, modern day general anesthesia is very, very, very safe. The risk of actual primary anesthesia related complications is quite low. The question remains though about the elderly and how certain anesthetics can, and usually it’s the IV muscle relaxants and so on, and maybe some of the benzodiazepines and how they can affect cognitive function. So there is a concern, for example, by some patients that, oh, I’ve had two general surgery operations of serum already. Is the third one going to push me over the edge? It’s too much general anesthesia back to back, bad for you and so on.

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I would love to kind of go back and listen to Dr. Edna Ma because we did discuss this in general, anesthesia alone is not considered a risk factor for cognitive dysfunction. It’s often related to the type of surgery. So if you have a surgery where you’re about to have a lot of changes in your, let’s say, blood pressure or higher risk of bleeding and things like that, then those can contribute to differences in blood flow and fluid in the brain and therefore risk like a stroke or cognitive dementia. However, in general, I think most people are okay with it, and I personally err on not using general anesthesia if I can, but I would never say, oh, you shouldn’t have general anesthesia after a certain age because I don’t believe that there’s evidence to support that. Will taking collagen supplements help strengthen tissue and muscle and prevent hernia from getting bigger? Not that we know of.

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There are certain collagen supplements such as BioSil and others that are precursors to collagen that have been shown to be good for hair and nails, but I don’t believe there’s anything that’s been shown for muscles. But one day, I think one day we’ll get there and then I’ll be out of a job and I’ll see you at the beach. Actually, not at the beach I burn, so maybe south of France or something. Okay. The surgeon trained at the Cleveland Clinic and has done many tar. What questions should I ask? What complications can happen with watchful waiting? So we actually interviewed the main surgeon from the Cleveland Clinic, Dr. Mike Rosen as one of our prior guests who probably was the person who trained your surgeon and therefore I highly recommend that you watch his episode or listen to his episode as a podcast. Dr. Mike Rosen, he’s one of our earlier guests from the cleaning clinic. Dr. Rosen’s actually moved on just very recently in the past month or so to Northwestern in Chicago. So we finally have a major, major name for hernia surgery in Chicago. But yeah, I recommend you just go and listen to that episode. It was a great episode.

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Next, apologies. I was not sure from your answer whether for the pubic fixation you’re going into bone or not. The other fixations go into Cooper’s ligament and superiorly into the rectus muscle. So technically when people say they’re in Cooper’s ligament, they’re often just going into the bone deep to the Cooper’s ligament for the pubic fixation, most people go straight into the bone. I’ve changed my technique and I put it into the rectus insertion onto the bone and not necessarily onto the bone, but if I feel like I have to, I will put it in the bone. I don’t have any problems with doing that. Okay, let’s see. Any more questions for you all? Yes. Are there any extra precautions that you adopt when operating on patients of advanced age? Oh, we already had that question. So yes, a lot of things, even little things. For example, as you grow older as a male, you’re more likely to have enlarged prostate.

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Well, guess what that means? You’re also more likely to have urinary issues after your hernia repair or actually after any surgery. And so I’m more likely to ask questions like, how often do you wake up at night to urinate and do you feel that you have urgency to urinate because you’re not completely emptying your bladder after you go? Do you take medications for your prostate? And with all of those questions, I gauge the risk of ending up with urinary symptoms after surgery. And so I will tell the anesthesiologist, please minimize the amount of fluids that you give the patient. Because any fluid over 400 milliliters for a typical inguinal hernia has been associated with higher risk of urinary retention. I will make sure that the patient is followed very closely after surgery so they don’t get too much fluid so that they don’t end up filling their bladder before they’re ready to urinate.

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I personally do not like to discharge my patients from the surgery center until they’ve urinated so that when they don’t go home and say, oh yeah, who’s on call? I haven’t urinated. It’s been eight hours since surgery. So these are all little things. There are medications you can give to promote urination in people with enlarged prostates, other little precautions. It’s very possible that because of your age, you’ve already had prior surgeries and you have other scars and therefore you may have scar tissue from your prior surgeries or adhesions bowel obstruction. Risks going into certain areas may be riskier because you’ve had another surgeon in that area for a different reason, let’s say for your hysterectomy or your colon resection. So these are all little factors. You’re more likely to have an incisional hernia as a elderly person. Then the question is how important is fixing the incisional hernia?

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Is it small, large? Is it 28 centimeters like this patient I was saying, or is it an ETB T one that we can ignore? And one thing I’d like to mention before we leave is this issue of watchful waiting. So there’s two watchful waiting trials and we discussed them in our episode with Dr. Fitzgibbons Robert Fitzgibbons. It was a great episode on watchful waiting. He was the author of all of the watchful waiting trials, both for the groin and for the abdominal wall there. He was a counterpart of his Dr. Oyer who did it in the UK. The one in the UK specifically looked at men 55 and older. The one in the United States looked at men 18 years and older. And what’s important is the one that looked at 55 years and older thought it was important to determine if we should forego doing hernia repairs on elderly males.

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And the benefit of it because up until that time in 2006, the dictum was, if you have a hernia, you should get it fixed, otherwise you’ll die or something bad will happen, you’ll have an intestinal obstruction or something. However, that was never really proven. And some people would come to your office that let’s say I’ve had this hernia for 20 years. I didn’t know I had it. I just thought a bulge was normal, maybe we should fix it. And people were scratching their head, oh, well people are living with hernias for 20 years, maybe we don’t need to repair every single one. And who is the person that should be repaired in that paper? They looked at five years of not fixing hernias in men over 55. And during that time, no one ended up in the emergency room requiring major hernia emergency, but patients did die of heart attacks, strokes, and so on.

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And you could argue that means you don’t need to fix someone’s hernia because they did fine from a hernia standpoint. But elderly people are more likely to have heart attacks and strokes. Or you can say, wow, look at this population. They’re getting heart attacks and strokes. Good thing I wish I had fixed their hernia earlier when they were not as sick. So the authors took the latter argument saying You should fix ’em to prevent fixing a hernia after someone’s had a heart attack or stroke. But the reality is fixing the hernia doesn’t prevent the heart attack or stroke. So it was perfectly safe to not operate on these patients. So that’s one other consideration, which is for going, if you’re 80 and your frailness is to the point where I don’t think you’re going to live another five years, then we know from the studies it’s a 0.2% per year risk of incarceration of your hernia. So five years times 0.2, that’s like a 1% risk of not operating on you. I’m going to take that risk. I’ll be like, yeah, just live your life.

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Whereas someone in their twenties, 0.2% times another 80 years is like a big number, 9% or something, or 16%. So I would say the watchful waiting trial was most relevant to these elderly patients because now you can have an evidence-based discussion regarding actual data as to why it’s safe to undergo that. And with that, my friends, I know many of you have also added questions, but we are going to save the questions for next week because it is now time to finish Hernia Talk live. I got carried away with all your questions. So thanks everyone for joining me on Hernia Talk Live. Come again next week. We’re planning on some great guests and you’ve shown me I have a couple extra topics that we can discuss that I haven’t been thinking of before. See you all on my social media at herniadoc on Instagram and X. Follow me on Facebook at Dr. Towfigh. Please subscribe and follow and like my YouTube channel at herniadoc, and listen to me as a podcast. See you later.