198. More Symptoms You Never Knew Were from Your Hernia

This week, the topic of discussion was: 

• Groin Pain
• Hip Pain
• Back Pain
• Inner Thigh Pain
• Radiating Pain
• Neuralgia
• Ilioinguinal Neuralgia
• Pudendal Neuralgia
• Testicular Pain
• Labial Pain
• Vaginal Pain
• Pain with Intercourse
• Pelvic Floor Spasm
• Urinary Frequency
• Rectal Pain
• Perineal Pain
• Umbilical Hernia
• Inguinal Hernia
• Obturator Hernia
• Clitoral Pain
• Sciatic Notch Hernia
• Obturator Neuralgia
• Imaging
• Chronic Pain
• Tearing
• Tissue Based Repair
• Mesh Problems

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

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

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Transcript

Dr. Towfigh (00:03):
Okay, sounds like we made it. Hey everyone, it's Dr. Towfigh. Let's get this party started. I felt like last week was such a great session, so we're going to do an update of it this week. So welcome everyone. I'm Dr. Shirin Towfigh, I'm your hernia and laparoscopic surgery specialist. I hope you're all doing well on this amazingly beautiful day and you're joining me live. Many of you either by Zoom or by Facebook Live. I hope the Facebook Live is up and running and it looks like it is fantastic. So if you also like to join me in the future, not live, I do have a Facebook page at Dr Towfigh Instagram and Twitter is at hernia doc. And this episode, all prior episodes are always available on my YouTube channel at Hernia Doc and as a podcast Hernia talk Live podcast. So last week we spent a very fair amount of time discussing hernia related symptoms that you may or may not believe can be coming from your hernia.

(01:21):
And we really focused on the traditional ones and the not so obscure ones. So the traditional ones are obviously pain at your hernia and maybe pain in the vicinity where it can radiate. So for the belly button it can radiate to the either left or the right of your hernia. For some of the larger hernias, it can radiate to your back and give you bloating. And then in the groin for both men and women, the pain can radiate to your inner thigh around your lower back into the vagina or testicle and even up towards your belly button. And then lastly, there are these other symptoms that are related to pelvic floor spasm. So those include things such as urinary frequency, hold on, such as urinary frequency, pain with intercourse, pain with orgasm.

(02:20):
Let's see, urinary frequency. We talked about pain with bowel movements or enemas where you feel like you have a bowel movement but you really don't. So these are all related to pelvic floor spasm. Now after we finished last week's episode, which was a good hour, I started driving home and I'm like, wait a minute, there are all these other hernias, number one and symptoms number two that I didn't really mention. And that's after an hour of going through talking about specific symptoms that are uncommon. So I thought maybe we should do a part duh and talk about some of the symptoms that I didn't really review very well or I could have kind of expand upon. Plus many of you had questions so I'm happy to help answer your questions. In addition to support the rest of this podcast, I really enjoy the questions too.

(03:27):
As many of you may know, a lot of what I do is chronic pain and trying to figure out why people's pains occur and specifically I like to help figure out those problems. And a lot of times the reason why people are given a route away from hernia is or not clearly a hernia is because they have symptoms that are very unclear to be from a hernia. And most surgeons don't know it because it's not. In most textbooks I've written chapters on it in books, but you have to read those chapters. It hasn't yet made it to the medical school textbook, number one. Number two, women are treated differently than men in that they are treated just like men. So women have a different pelvic floor anatomy, a different pelvic nerves and so on. And yet if you ask how the medical students are taught about hernias, it's all taught in the male sexual function portion of the curriculum and it's never mentioned during a gynecologic or GYN part of the medical school curriculum.

(04:43):
In fact, a lot of gynecologists are unaware of these symptoms that can occur due to a hernia. So like I said, we went through a fair amount of them last week and I highly encourage that you share and listen to over and over again. Last week's episode, I thought it was one of my most impactful episodes and I would like to maybe do a part two today to discuss some very interesting kind of niche, a little bit not as common reasons for chronic pain that is due to your hernia that you don't even know. So one of the ones I recently had is a patient with PAD. I don't know if any of you know P ad. So P ad is an acronym for PGAD and it's persistent al persistent genital arousal disorder, persistent genital arousal disorder. And that's where the female or male feels like they're constantly having an orgasm.

(05:52):
What they're really having is not clitoral stimulation for example, but it's pelvic floor spasm, which they're interpreting as that because the aura is not there, it's not pleasurable. The arousal they're having is actually quite disturbing and it affects their life. They can be not working in bed, it can be painful. It's a constant pelvic floor spasm. So as we discussed last week, and I reviewed very briefly just now, pelvic floor spasm is a common denominator in a lot of patients with hernias, especially the smaller hernias. I don't know why hopefully one day someone will figure it out, but it is definitely associated. And what happens is the hernia can cause the pelvic floor spasm. The pelvic floor spasm is interpreted as a persistent genital arousal disorder and then they go see the gynecologist or urologist, usually the gynecologist or the sexual function urologist.

(07:01):
And in doing so, they're taken down usually a hormonal path so their estrogen and or testosterone is manipulated. They may be on creams and they may get blocks into specific nerves, but usually pelvic floor, well, let me rephrase, the pelvic floor may be examined, it would be quite tender or stiff or hypertonic. And then they're taken down this whole pelvic floor physical therapy line, which can be very painful as well. And then so that they get muscle relaxants, again, you're dancing around the problem. So muscle relaxants, muscle relaxants by pill, by cream, by suppository, either in the rectum or in the vagina. All of those are timely time consuming, frustrating, painful, a lot of time goes by. And then every so often I get referred one of those patients and then it's my job to figure out if there's any other reason from the abdominal wall, let's say to cause the pelvic floor spasm.

(08:24):
And then when I find an occult hernia, I get really, really excited. So the patient that I mentioned to you last week that had was a young guy and had persistent testicular pain, similar situation, he had an occult inal hernia that was the cause of his underlying testicular pain, whereas people were offering to cut off his testicle, which is completely not the right treatment, iix his hernia, which it's a little bit easier to recover from and that treated his testicular pain. So these are really, really satisfying things. That's why I love what I do because I'm not just a hernia surgeon where you see a hernia and I fix it. I try and figure out these kind of puzzles and maybe diagnose hernia as a potential cause and then try and fix it. So yeah, that's kind of the benefit of the type of practice I have, which is I tend to attract patients that were unable to get treatment by other doctors and chat GPT doesn't really necessarily figure this out.

(09:38):
I'm hoping it would be kind of interesting because I don't know how chat GPT and other AI tools capture information, but I do have information out there both on my podcast with the transcript of the podcast and the book chapters that I wrote and some research projects that we published that does address this, right? So it does address the concept of pelvic floor spasm as a result of an occult or small inguinal hernia. It does capture these atypical pains from different hernias. So I wonder if chat GPT, in fact if any of you're out there, just go put it in there. I have testicular pain. Can this be from a groin hernia or I have chronic pelvic floor spasm and urinary frequency. Can this be due to a hernia? And I wonder if they say yes or no and if they reference my papers in those, I would like to know because if it does, then I'm doing good and the AI tools are really doing well because then they capture my publications and then they can give that to a patient and you don't have to be a doctor that's read my paper necessarily because chat GPT or the AI tool will do that.

(11:11):
So I will highly encourage some of you to do that and based on your experience with the AI tools, send me a note and tell me if chat g PT says yes or no because it may say pelvic floor spasm is not typically considered associated with inal hernias. We recommend that you see your doctor for this. These are other reasons for pelvic floor spasm and they'll talk about predental neuralgia injuries and stuff. So yeah, I'm kind of curious, so let me know.

(11:50):
We did talk about a lot of the other hernias, so there are some rare hernias that you can get that can cause these enigmatic pains. A great one that I like to teach is the opterator hernia and potentially I saw one today, it's unclear if he has an opterator hernia, but opterator hernias are rare hernias. They occur in the pelvis. It's typically in patients that are kind of thin and so the ator muscle gets atrophied. Often they're sick, maybe even so sick, they're in a nursing home. Plus they have the addition of abdominal pressure, like severe constipation that pierces their bowel through this very thin opterator muscle which is in your pelvis. The hernia is very hard to see or find because it's kind of in the inner, the inside of the thigh away from the perineum and you don't see an obvious bulge. But most patients who have a severe opterator hernia will have some type of peroneal pain or kind of inner groin, inner thigh pain, but on the inside and prefer to be in what's called a frog leg position where their hip is externally rotated as opposed to an internal rotation.

(13:20):
There's a sign called the how ship Romberg sign where you take the patient lying flat and you bend, you flex their hip, so their nego knee to chest and then you internally rotate their hip and that's usually painful in a patient that has an ator hernia because that action of hip flexion, sorry hip flexion and internal rotation of the hip can squeeze or pinch the opterator hernia and cause pain. That's why the patients tend to be lying flat with their hips externally rotated, which is also like what we call a frog leg, frog leg position. And so that's the ator hernia. The opterator nerve runs with the opterator hernia and so in patients that don't have severe opterator hernias, similar to other hernias that we talked about last week, the nerve can be irritated by the hernia. So you have a situation where you have fat herniating into this canal, the ator canal, the opterator nerve runs in the same canal and so now you have competing entities, you have fat and you have nerve competing against each other and that causes what's called opt rate or neurologist. So it's nerve pain and that's specifically on the inner thigh close to the knee. So it's like a tingling irritation that is or neuralgia due to an opterator hernia usually up higher, very classic kind of distal thigh, inner thigh numbness and or tingling irritation, burning sensation that is just upstream from the knee. It doesn't affect the way you walk necessarily, but you prefer to lie flat or stand and not sit. And because any hip flexion and internal rotate you don't want to cross your legs, that's a telltale sign.

(15:37):
We don't talk much about hial hernias on this show. I don't do hial hernia surgery. We've had, I believe, I believe two surgeons so far that have come and talked about foregut surgery and hidal hernias and so on, but it's a type of hernia, it's just not an abdominal wall hernia in the true sense of the abdominal wall, it's around the esophagus, but those are all hernias that can occur at the same time as other hernias and all of those give GI symptoms. So heartburn, acid reflux and bloating. In very extreme cases, your stomach can be up into your chest the same way in the groin hernia or belly body hernia. Intestines can protrude out towards the skin and it can cause weird heart attack type symptoms with chest pain and palpitations because your heart is now pumping against a space where your stomach is. You can get erosions, you can have bleeding in the area, you can aspirate and get asthma and reactive airway disease. There's a lot of things you can get from a hidal hernia and for sure if it's a big mechanically significant hernia, those should be surgically repaired. Fortunately, most people who have hidal hernias only have acid reflux and our medications are so good we don't really need surgery for most patients who get a hidal hernia surgery. So that's a good thing. Let's see, what are we missing? Talked about the groin.

(17:25):
Oh, let's talk about male sexual function. So as you know, the anatomy is as such you have a testicle with sperm in it. The testicle sperm leaves a testicle, it goes through the epidermis and goes up towards the groin via the vast deference and the vast deference empties into the prostate where the seminal fluids add fluid to the sperm and then it gets ejected out through the urethra. So that's the pathway, that pathway goes through the groin. And so if you're, there's nerves on the vast deference, so if the vast deference is competing with content in a hernia for example, then what can happen is you can have pain with ejaculation because you're competing with space in that area. Any zigzag or non-straight line towards the prostate can cause problems and then you can have obstruction, mostly the obstruction of the area I see after hernia surgery, especially with mesh.

(18:49):
So the mesh can kind of erode or kink the trajectory of the vast deference and that can be very, very painful for the patient. Let's see, what do we have? I see a question while on the topic of groin pain, how do you determine the cause and how to treat post her phy pain? Tissue repair on one side, mesh on the other when there is no recurrent hernia either by exam or good quality MRI. And how do you diagnose and address pain from stitches or mesh? Wow, that's a lot of questions. So even though that's a lot of questions, I get it almost on a daily to weekly basis because that's the type of patient population that I tend to attract and that maybe it's because I actually enjoy the puzzle solving. So let's review this.

(19:47):
You may know for those of you that follow me, the most important is your story, it's your history. So the role of the physical exam and the imaging is to support what's in the history. So if you come to me and you say, I was doing great and I had a hernia, not that much problems with it and then I had hernia surgery and now I have all these pains that I didn't have before, hernia surgery, the likelihood is the surgery, the hernia repair resulted in all those symptoms. So then you use a physical exam and the imaging to try and figure out exactly what is the situation. Is it a mesh folding, is it tearing of the tissue repair, is it a fluid or bleeding from the hernia, whatever the situation is, a recurrence. These are all situations that can occur after a hernia repair. So that's kind of where the situation is.

(20:58):
I am not going to say, okay, you have all these symptoms and ignore your symptoms because imaging is normal, right? Because there are things that cannot be found on imaging. A nerve impingement cannot be found on imaging. For example, scar tissue and how that translates into pain. It cannot be found on imaging. Now I would like to say, let me stop here for a second. This is really, really cool information. There is a new technology which is now available in very specific areas for clinical trials only where we can image pain. Have you heard of this? So you can image pain, almost anyone can have access to this once it's completely FDA approved. So cool. So how is it? It's a PET scan, which is PET is PET stands for positive emissions technology. I think it's basically a way to look at inflammation or some type of reaction in your body. We often use it for cancer or inflammatory problems, but what people positron emission tomography. Okay, thank you. PET scan, positron emission tomography. I was close PET scan, so thank you for that.

(22:41):
Just to clarify, the thing that lights up on a PET scan we usually look for as cancer or lymph nodes and sometimes inflammation can give you a false positive because that also lights up in some situations. However, this company came up with an injection that goes where your pain goes. Now I don't know the specifics yet, I have to read upon it, I just learned about it. But there are certain pain receptors that are turned on when you have pain and those you can find them so to speak by injecting this tracer into your blood vessels and it goes to where these pain receptors are most being activated.

(23:37):
So they were talking to me, they're like, Hey, do you think this is something that your patient population would be able to be interested in? I'm like absolutely, because the people that I get sent are pain of unclear etiology. The simple ones are hernia pain and maybe hip pain and I need to figure out is it the hernia or the hip that's causing the pain and therefore do they need hernia surgery or do they need hip surgery? And I help try and figure that out, right? That's a typical orthopedic surgery consultation. The more difficult ones are the ones where let's say they've already had surgery and they need to know where is the pain? Is it the nerve, is it the mesh, is it the tightness of the sutures? What's causing the pain? Or let's say it's a patient where I can't figure out if it's coming from the spine, they've got so much spine surgery and yet they have this hernia repair or a hernia. I can't figure out where the pain is being generated from. So theoretically that patient can get their PET scan and it will localize their area of pain. I mean I kind of would want to do that too. What if I have a neck spasm or something?

(25:03):
So that's kind of like a cool thing. So the question of while the topic of groin pain, how do you determine the cause? Currently speaking? The cause is primarily determined by some theories you come up with based on the history, the story, and then you follow that up with imaging, usually dynamic imaging to help figure out whereas, and also a very careful, careful physical exam. So it's very possible. I just saw a recent patient, she had a huge ovarian cyst and she had no hernia on the side where they fixed her hernia but they said, oh, this is probably the cause of your pain. So they have a hernia appear on one side and her ovarian cyst ever got addressed and then she still has her pain after surgery. So the physical exam is very important. The physical exam from a hernia is different than a physical exam for an ovarian cyst and just because imaging shows you have a hernia for example, doesn't mean that that's the reason for your pain If the story and the physical exam don't mesh.

(26:21):
So number one is story and then depending on where the pain is, it's either a tissue repair or a mesh repair and then each one of those operations has its own special cadre of things that can cause pain, things that can cause pain and things that can cause exam findings. So just because your imaging doesn't show a hernia recurrence doesn't mean you don't have a tear because the tear will not show on most imaging unless it's a big enough to allow things to go in it. But if it's still tearing, that alone can cause chronic pain. So I hope that's helpful. Oh, here's a great question. I'm going to read this for you guys. Hello Dr. Towfigh. I've listened to dozens of your podcasts. Well thank you. Thank you for your expertise. You truly are an expert in hernias and I greatly appreciate all of your information. Appreciate it. I'm a 30-year-old male, BMI 35, non-smoker, otherwise healthy and actively losing weight. Okay, so for those of you BI up to 25 to 30 is considered overweight.

(27:47):
Over 30 is called obese over 35, morbidly obese. So he is BMI 35, that's kilograms per meter square, non-smoker, 30-year-old meal. Otherwise healthy, I had a less than one centimeter of fat incarcerated umbilical hernia. This was repaired using open surgical technique from MA general surgeon in Canada, less than one centimeter open without measure. Okay, that sounds fine. I'm four months and I have recovered well. However, I have a small seroma confirmed by ultrasound last week, which seems to cause slight discomfort at times. Okay, seromas occur. So if you have a bulging hernia and you have any surgery that gets rid of the bulge, the area where the bulge was is now empty and when that area is empty, your body will naturally fill an empty space usually with a little bit of blood because you had surgery and mostly fluid and that we call seroma and that's what this patient had. I have a small seroma, which seems to cause slight discomfort at times. My surgeon thinks we should just leave it alone. I agree. Do you usually let small seromas resolve on their own? Yes, I do. Should I be worried about encapsulation for the small ones? Usually not. Is it normal to have some discomfort for months post-op?

(29:16):
Depends on what you mean by some. A tissue repair will always give you some type of nudging, pulling, burning, tugging sharp pain. It should be low level, one out of 10, two out of 10, maybe three out of 10 and get better over time. The more pressure is on the repair. Let's say because you're morbidly obese, a lot of abdominal fat, let's say coughing, constipation, those are all pressures. The more there is of that, the more pain you'll have from a tissue-based repair because you're pulling on the tissues. Also, if the tissue repair is done too tightly and the tissues are way too tight the same way if you tie your shoe laces in your shoe, your tennis shoes way too tight, that can also cause pain and be another reason for pain.

(30:25):
Do you usually let small syringes resolve on their own? Yes. Should I be worried about encapsulation? Usually no. Is it normal to have some discomfort four months post-op? That's what I was mentioning. Some, yes, not much. I only sometimes feel discomfort after doing activities like cleaning or carrying groceries. It's usually towards the end of the day. Okay, that makes sense. I'm scared to start lifting again due to this discomfort and I'm terrified of a recurrence. Okay, that makes sense. So the more, because it's a tissue repair, you are a hundred percent relying on your own tissue. The recurrence rate is higher than with a mesh repair and the chronic pain rate may not be any different. This is where I like to make sure you're all understanding. I'm not saying you should have had a mesh repair. Usually A BMI of 35, I would put mesh maybe if it's less than a one centimeter, that would be the only time I would not use mesh.

(31:23):
Anything over one centimeter. In a morbidly obese patient I would use mesh. And the reason is the abdominal pressure is very high compared to the average patient. So if you have a lot of abdominal fat, your abdominal pressure will be higher than the average patient and therefore will be constantly tugging on the tissue. So if I give you clothing with buttons and I force you to wear one size too small and so the buttons are on intention, you may not pop a button, but those button holes are going to look distorted over time and not look good and you may even tear through. It depends on how strong your muscles are. Now the fact that you're losing weight is a good thing. People who lose weight will have lower abdominal pressure and less tension on their stitches and therefore less chronic pain. So for every five pounds that you lose, you should feel a little bit better and I highly encourage that you exercise to get those muscles strong.

(32:35):
So if you're having any ripping or tearing of the muscles because of the suturing or stitching being too tight or because your weight is pulling on it, then by losing weight and strengthening those muscles that pain can go away. So in most patients, I don't recommend the seroma or the fluid collection to be removed. I do recommend that they lose weight and become active and that combination will help reduce the tension on the tissue. All in all of that will reduce your risk of recurrence. Your risk of recurrence is so much higher because of your weight than any amount of grocery shopping you can do. So focus on abdominal core strength and fitness and don't stress about any of your activities causing a tear. Okay, follow up question. You mentioned the possibility of tearing. Yes. Can both sutures on the side with the tissue repair and mesh on the side causing tearing?

(33:38):
Yes. How do you manage, this is about the al hernia question before, how do you manage once you remove stitches and mesh? Do you need to do lap repair first? It all depends. So in most patients who have a tissue repair that's being tugged on, I usually recommend a mesh repair deep to it to offset the pressure on the tissue repair and allow it to kind of be supported a little bit. I did have a recent patient who already had mesh repair and during their mesh repair they got a tissue repair bad situation. And so in that patient I just redid the tissue repair because they already had the mesh to support. They just had torn through the tissue repair. And by the way, that patient imaging did not show a hernia recurrence because the match was placed laparoscopically and was behind the muscle. So technically there was no hernia recurrence.

(34:44):
They just had torn through the tissue repair because the technique that was used was the incorrect technique and it was too tight. You can't close, you should not be closing a direct defect for example. You should be plicating it. There's a difference. Plicating means you take the extraneous extra and bulge out tissue and you flat it out tightening it or closing a defect is you're taking a wide hole and you're closing it and that's not the right thing to do. So depends on what kind of tissue repair, how it was done and where your mesh is. But usually you don't need to do that if the tissue repair was done adequately. You just need to add mesh deep to it to help support the hernia.

(35:45):
Alright, these are great questions. So let's see, what was another one that a recent patient I had with hernia pain that I figured it out. I tell you what I do is I get so excited when I figure things out. To me it's like, I don't know if any of you do New York Times the crossword puzzles and they also have a whole list of games you can play like world. The words that you find with the Spana Graham, the mini puzzle and what's that new one they brought out besides BU bumblebee? Oh, it's you have to match four. What four are the same. I just get really excited with those and so when I get sent a patient to just figure it out, a lot of people, my office says, okay, we're happy to make you an appointment.

(36:48):
What are you here for? What kind of hernia? They're like, oh, it's not clear if I have a hernia. They just said Dr, to if I can help figure this out. So yeah, I basically help figure it out and then they ship it to the specialist that can help that. Okay, going back to this question about the belly body hernia. Thank you, that was very helpful. Are there any exercises to avoid for my one centimeters umbilical suture repair? Not really. Sit-ups encouraged all core exercises encouraged. Let's see. Weightlifting encouraged, squatting does increase your abdominal pressure a little bit. Maybe don't do squatting. Jumping, also like trampoline stuff. Also discouraged. That does increase abdominal pressure. That probably includes jumping jacks and jump rope. However, I, oh and therefore my personal bent is I don't like CrossFit. I feel like CrossFit involves a lot of squats and a lot of jumping and those are two things we don't like to do because it's been shown to increase abdominal pressure.

(38:05):
But everything else you should do, of course safely do it safely. I was considering starting physiotherapy. Great. Regarding the seroma, is there a reason why we avoid draining it? So usually we avoid draining seromas because it's a sterile fluid collection and sticking a needle through your skin can infect the fluid collection. It's a big no-no if you have mesh in the area because then you can infect the mesh and the mesh needs to be removed and now you have a hernia, then you'll need a third surgery to fix the hernia after you resolve the infection after the meshes are removed. In patients that don't have mesh like yourself, you can aspirate it. If it hurts the patient, lower risk of infecting a tissue-based repair, you still can get an infection of the fluid and that will weaken the sutures and the muscles through which the sutures are going and increase your risk of hernia recurrence. So that's the main reason why we don't recommend aspirating a seroma. Now if the seroma is big, bulky, it's pushing on the skin, you can consider as sterile as possible, removing the seroma and then pushing the area in with an external compression, either like a sock or gauze or something and a binder on top of that. Those are my tricks for that.

(39:37):
The other option, you're saying it's a small seroma, it's just massage it, massage the seroma and that will increase blood flow to the area and the blood flow will absorb the fluid and then you're done. So massage it daily, multiple times a day. There's no science behind it, just as much as you can massage it. And you'll notice over time that that will reduce in size because your body is handling this seroma on its own. Okay, going back to the postoperative pain after the groin hernias, how successful is offloading ingle floor with laparoscopic mesh in the case of tissue repair without the need for removing sutures? Pretty good. Again, depends on the technique of what kind of tissue repair was done. If it's a traditional tissue repair or if it's a repair that causes just a little bit of tightness and you just need a little bit more support to it, then that should work.

(40:40):
Now, if it's a poorly done tissue repair where they actually close the hole that shouldn't be closed without releasing other tissues nearby, then that should be undone and no matter mesh is going to help you. So I can't answer it in your situation specifically, but if there's a tissue release or more formal tissue repair, then mesh can help offload that. If it's too tight, because that's a temporary problem and not a severe problem. If it's a tissue repair without a fascial release or a closure of a direct defect without truly plicating the defect, then that could be tearing and therefore you would benefit from the mesh or suture bearing removed as a part of it. Hello and thank you for this info. Oh, you're welcome. I hope it's all helpful. Thank you very much. Let's see, what else were we talking about? Oh, a lot of people don't know that bloating is a common symptom with hernias and they always ask why. And it seems bloating is a reaction to pain. So if you have pain, either the pelvis or from your hernia, if you're bloated, it doesn't mean there's intestine stuck. It just means that you have pain in the area.

(42:11):
Did you guys not hear me? No, I think you can hear me now. Yeah, so it's kind of interesting that, oh, I feel like the Facebook stopped for some reason, but I'm still here. Okay, yeah. So that's kind of the situation with the bloating as a cause of pain. I'll tell you, there's some patients that have syndromes that can make them more prone to hernias and that includes things like aler delo syndrome, which is a collagen deficit. And what can happen is you can have an undiagnosed or maybe diagnosed Aler Danlos syndrome and when that happens, this is so weird, lemme just double check the Facebook for some reason it's okay. No, it looks like it's okay, it's back.

(43:16):
So what can happen is the fact that you have the Aler Danlos syndrome, for example, can then mean you have not only are prone to hernias, but there are all these other things that you're also prone to like pots, which is postural orthostatic tachycardia syndrome where you need to constantly hydrate, otherwise you pass out SIBO or sibo, which is SIBO, small intestinal bacterial overgrowth, which is a situation where you're bloated very severely, you wake up the morning, you do fine, you brush your teeth and then you drink water, you become this big bloated mess. Then the cycle starts again with each meal and then settles down once you sleep. Again, endometriosis also associated with these syndromes. So then you can get chronic pelvic pain with your periods and everything else that comes with that and the endometrial implants. And then lastly, MCAS. So it's mast cell activation syndrome.

(44:26):
By the way, I never learned any of this in medical school or in residency. I had to learn all of these by treating patients like you, which is why most doctors don't know it because they don't treat patients like you. But MCAS is mast cell activation syndrome. You get a lot of allergies, rashes, highly sensitive to foods and therefore usually I can't put mesh in these in patients like this because they tend to react to anything inflammatory like mesh. So yeah, it's so interesting how one thing interacts with another. Okay, let's going back to the post-op pain, apologies I do not understand. Which tissue repair characteristics distinguish favorable response to unloading floor with mesh as opposed to the need to remove meshes, remove sutures. Sorry, I could not fall, but it is complicated than novice. Okay, so there's a traditional way to do hernia repair. Let's say a shouldice or a McVay or a bini, these are all named after surgeons who came up with tissue-based repairs or even a Marcy.

(45:38):
Each repair is intended for a specific type of hernia and when performed, it's a very tight repair. They figure it out, it's tight. This was figured out in the 18 hundreds and mid 19 hundreds. So therefore on top of doing a tissue repair, you then have the surgeon then does what's called a fascial release. So distant from where the hernia repair is, where everything is closed and usually above it, you loosen up the fascia there to allow that to drop down, to take some tension off the stitches. Otherwise it's very painful and therefore has a higher risk of tearing and therefore hernia recurrence. So in order to reduce the tension in this tension repair closure of the hernia, we do a fascial release. The fascial release, if done perfectly, will help reduce chronic pain tearing and recurrence from your tissue-based repair. If you don't do a fascial release and I believe at S shouldice they don't necessarily do a fascial release every time they do it as needed, then you're at higher risk of tissue tearing, pulling, tugging, being too tight and hernia recurrence.

(46:57):
Also, you're at risk of doing what's called an incomplete fascial release, which is you do a little bit but not enough to completely take the tension off the suture line. So if you had a tissue repair that's still too tight, despite doing a perfectly good tissue repair and a fascial release, then adding mesh to help support that tissue repair like a hammock, like a hammock or sling behind it, that usually helps If you lose weight and you lose abdominal pressure onto that tissue repair, that will also usually help. What it won't help is patients wear. It's just way too tight. If I give you a clothing and it's a little tight on you and I just release the seams a little bit, that's doable. But if I put a tourniquet around you, no amount of seam on the tourniquet will allow you to get better.

(47:59):
I hope that analogy makes sense. So if you have a tissue closure like a Marcy or some type of primary closure of the direct hernia that is done so tight, not anatomically, not application, you're asking the marsy repair to do too much, then that is too tight of a repair, too tight of a closure and is just tearing through the tissues, which is often very painful and mostly burning pain. No amount of mesh can undo that because your tissue is torn already. You can put the mesh to help support that tissue. But in those patients, often you also have to remove the old sutures to give the pain, give the patient a little bit of reprieve from the tugging. I don't know if any of you wear watches or have worn glasses where your hair gets stuck in it. In the hinge, that's very painful and often you either have to have to cut the hair out of the watch wristband or the glasses because that's the only way you can get rid of the pain and that's the reasoning behind going in and removing the stitches.

(49:26):
So I hope that's helpful. Trying to think if there's anything else that we're missing in terms of, oh yes, I want to mention this. We did talk about rare pelvic hernias causing pain. The most interesting one is called a sciatic notch hernia. So sciatic notch hernia is exactly what it said. There's a notch or a hole in the pelvis called the sciatic notch. It's called the sciatic notch because the sciatic nerve goes through that hole to go down your leg. It kind of comes out in the buttock. So therefore if there's a hole there, you can get intestine or a fat going into that sciatic noch hernia. So typically a patient comes and they don't like to sit down and they have buttock pain and if you feel it, you can feel like a little bulging or they can feel bulging as a sciatic hernia, very difficult to repair. I've done a couple of those and 99% of surgeons will never see a sciatic notch hernia.

(50:37):
What's interesting is they get sciatica and sciatic nerve pain, so then they go down the whole spine surgery route out number one and number two, the ureter, which is what empties your kidney into your bladder. The ureter gets trapped sometimes in these sciatic no hernias and they can have symptoms of urinary problems and be sent to the urologist. The urologist will treat them like a kidney stone or something like that or a ureteral spasm without understanding the actual cause of the pain. So very interesting situations all not clearly due to hernias. And I just love sitting down sometimes with some of my friends and they mentioned, yeah, I got this patient with something that they had no idea, could be a hernia. And I said That could be a hernia. And then they say, wait, what? Oh, and then I'll explain to them and say, yeah, so you get this and that causes the nerve irritation or it causes the pelvic floor spasm or the bloating and then blah, blah blah.

(51:54):
So there's some patients that GI sends me because they know they are learning that bloating is a symptom of hernia and no amount of antibiotics. Probiotics, endoscopy has been able to cure their bloating and then I fixed the hernia, which was really small but inconsequential and maybe even didn't hurt them. But then the bloating goes away. So interesting stuff. Hernia live is great. Well thank you. Ultrasound found solid appearing abnormality towards the left groin, which does not appear to definitively communicate with the abdominal canal. This appears fairly homogeneous, no obvious vascularity with some adjacent vessels. Findings could represent a lipoma additional, more fairly typical left anal hernia. A CT scan may be helpful to better assess the anatomy. What is a lipoma? Do I have a recurrent hernia and shall I do a CT scan or MRI? Great question. Okay, so number one, you have a lipoma which implies fat in the inguinal canal, which is a hernia.

(53:06):
The fact that they're calling it lipoma is just to confuse you because they don't want to commit to inal hernia. But what you have is what's called pre peritoneal fat going into Ular canal, which is the most common reason for a hernia anyway. I don't know why people don't understand that, but some feel like it's not a hernia unless intraabdominal contents go through like intestine and even peritoneum. But in your case it's a smaller hernia which only has pre peritoneal fat in it. I don't think you need a CT scan or an MRI because I don't think either one will be necessary since your ultrasound already confirms an inguinal hernia. However, if you had to choose the MRI pelvis using my hernia protocol is a much more sensitive study and more likely to be considered positive than a CAT scan than. And the CAT scan and MRI should both be done with Valsalva, which is bare down views.

(54:06):
Go to my website, go to my channel, all of those have my MRI hernia protocol available for you. I think on my Facebook page, maybe it's the Beverly Hills Hernia Center one or the she Towfigh one. Dr. Towfigh one. I think I made the MRI hernia protocol pinned. I think it's pinned to the page. So that may help you. I hope that's helpful. That was really fun. We did a nice job, guys. I love it. Thank you so much for joining me on another hernia attack live. It's so beautiful outside. I've been, go check up on my patient now. We did a big operation. I didn't get home until almost 10:00 PM last night and it was the most satisfying hernia repair on a very deserving patient. So I'm going to go check up on them at the hospital. I just got notice while I was doing this podcast. The patient's doing great. I'm going to go look at them and hopefully he can go home pretty soon. Until then, I will see you guys next week. See you guys. Bye.