205. Your Outie

This week, the topic of discussion was: 

• Outie
• Innie
• Umbilical Hernia
• Incisional Hernia
• Mesh
• Rectus Diastasis
• Pregnancy
• Symptoms
• Watchful Waiting
• Mesh Removal
• Shouldice Repair
• Hernia Recurrence
• Laparoscopic Surgery
• Robotic Surgery
• Hernia Repair
• Direct Inguinal Hernia
• Chronic Pain

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.

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

Transcript

Dr. Towfigh (00:00:24):
Hi everyone, it's Dr. Towfigh. Welcome to Hernia Talk Live. I am your host, Dr. Shirin Towfigh, hernia surgery specialist. Joining you from lovely Beverly Hills. I just came back from Nashville. I'm going to tell you a little bit more about that. Many of you are joining me as a live on Facebook. Specifically this time we're going to be doing a Facebook Live through the Beverly Hills Hernia Center page. And for those of you, let's make sure that that's going on live right now. Let's see, let me just double check this before we move forward. There we go. There we are. And I'm also on Facebook at Dr. Towfigh. That's my personal page. This and all future episodes and past episodes of Hernia Talk Live our archived on my YouTube channel at Hernia Doc. But also if you enjoy podcasts, you can listen to it as a podcast, which is what I love to do when I'm in the morning putting on my makeup or driving to work. So yeah, it's been great. Can all of you hear me? Okay, let's double check that we can do that.

(00:01:46):
Yes. So you're already sending me comments, which is great, but it's distracting me. Okay, so today's topic is going to be about your outie. And I say this because, so first of all, I just came back from the American Hernia Society meeting, which is our big annual US meeting. There's also our European Hernia Society meeting, which happens around May, June, but this is our American hernias. All my friends in the US were there, but also it's quite an international meeting. It was held in Nashville this year. So he had friends from all over Central and South America, Europe, even the Middle East Australia, South America, sorry, South Africa. That was all really cool and many of my friends agreed to be guests on Hernia Talk Live. So that's kind of nice networking meeting to get more guests for you. Why did I pick your outie? So it occurred to me that most people do not know that an outie is a hernia.

(00:03:02):
So what I talking, what do I mean by an outie? You saw the picture that I posted. If your belly bind is sticking out, that's usually because it's a hernia that's sticking out. Now, you may not know you have the hernia. It may be no symptoms from it. You probably thought it was you were born this way, your belly, but always looked like that. That's fine. I'm not saying you have to get worried or you need to have this addressed, but at the very least know that you have this diagnosis. Right? So I was watching the US open on TV one day. I would like to go to Flushing New York and actually watch the US open in person, but I wasn't able to watch the women's finals because I was still in Nashville at the American Hernia Society meeting. But I was home by Sunday.

(00:03:57):
So I got to watch the men's finals and of course my favorite Carlos Raz won, which is great. He won the French open as well and lost the Wimbledon against sinner. So I've been kind of following this Raz sitter back and forth and anyway, he's really in shape all Raz and you need to have great core strength to be able to play tennis, especially with the serves and lunging and so on. Plus, in order not to have any injuries, you need core strength so you don't get groin injuries and so on. So he wins and as he's walking towards his bench to I guess get dressed for the award ceremony, he pulls up his shirt and all I could think of is he doesn't, I mean everything else from the game left my brain and all I was thinking about is this guy has an outie.

(00:04:59):
Are you kidding me? How do you have an outie and just let it be you're filled when surrounded by all these trainers and physical therapists and doctors. So I posted about it, I've done this before. I've posted about people that have outies and it's always an educational piece because technically a belly bind that's not an any is an umbilical hernia unless proven otherwise. So uncommonly, and I put this in my post uncommonly, you can scar down your umbilical cord after it's cut when you were born. You can scar down in a way that there's extra skin and that skin becomes a thickened hardened lump. And some people have that. Usually I've seen it more in males, but I don't think it matters. It's just the way that your umbilical cord scarred down and healed when you have the umbilical cord cut.

(00:06:02):
However, most people have an innie, right? So it's like a dunked in umbilical stock or they have just the extra skin. If it's a protuberant outie or if it's an asymmetric belly button, then that's an umbilical hernia. What does that mean? Well, if you have no symptoms it means nothing. It means it may look weird to some people, but most people don't really have symptoms or they don't care. In fact, they like their outie looking belly button. Cool fact, I have people who have direct messaged me asking me to make them an outie because I know it's weird, but there are people that had belly button fetishes and an outie belly bun is what they prefer. I refuse to make an outie belly bun because that means I have to make them an iCal hernia. But regardless, that's not the point. The point is to understand that. So over the years I have posted pictures of famous people that post themselves on Facebook, Instagram, et cetera, and you're like, oh, hernia. So that can include people. I think the ones the most famous I've posted about and I haven't examined them to confirm. And if I did, I wouldn't tell you due to privacy laws.

(00:07:38):
Justin Bieber, Kylie Jenner, Gigi Hadid, Emily Ruski, what's her name, the actress. Anyway, a bunch of actresses and actors and models that show off their belly. I'm like hernia. So there was a volleyball player that had a very obvious hernia. I texted her and she's like, yeah, I just got it fixed. Thank you. There's another singer that definitely had a diastasis with the belly body hernia and she also told me that she had hers repaired with a tummy tuck. So these things happen. However, you don't necessarily have to have these repaired if you don't have any symptoms and we'll go through a bunch of scenarios as to when you may or may not want to have it repaired both for men and women. Before I do that, I have about five questions already. So let's go through that because I have respect for those of you that come live and ask me questions.

(00:08:49):
Okay, question number one. Hi doctor. Is laparoscopic hernia surgery dangerous for those with significant bradycardia and vaguely induced atrial fibrillation due to gas inflation? No. So the reason why, okay, it's a very good question. When we do laparoscopic surgery, we have to insufflate or put gas in the belly, it's carbon dioxide and reach a pressure of about 15 millimeters of mercury to allow us space to operate laparoscopically With open surgery, we make an incision and we open up the tissues and we make that space. With laparoscopic surgery, we only have little instruments with little incisions, so we need to use gas to make our space. So in doing so, some people have been known to drop their blood pressure and or drop their heart rate down to even zero. I've seen even zero that is almost always because of two factors. One is you're dehydrated, so the anesthesiologist needs to catch up with fluids.

(00:10:03):
Maybe you haven't eaten or drunk for hours, right? You're waiting for surgery, especially if you surgery is later in the afternoon and you haven't eaten or drunk since midnight. And the second factor is that the insufflation pressure went from zero to 15 too quickly. So just because you had an episode of reduced heart rate dangerously reduced and or reduced blood pressure does not mean that you can never have laparoscopic surgery. You just tell the surgeon and you tell the anesthesiologist and the anesthesiologist will have to give you extra fluids prior to surgery to make sure your veins are filled with fluid and blood and the surgeon will have to make sure that they increase your gas slowly, not go from zero to 15 then like that because when you do that, it decreases blood flow back to your heart, it makes your heart stop. And that's an important kind of thing that people who do laparoscopic surgery need to learn about. So you all shall mention in your question about vaguely induced atrial fibrillation. So I'm not familiar with atrial fibrillation as a consequence of laparoscopic surgery. It can be that again, very rapid changes in pressure caused a very rapid differential or change in how your heart kind of fills with fluid blood. And so by doing that slowly you should still be able to undergo laparoscopic surgery.

(00:11:55):
Also what I understand is the amount of gas that's in your system, the anesthesiologist change their way of giving you general anesthesia to reduce how much gas builds up. And if you have too much buildup of gas, the anesthesiologist needs to change your respiratory rate to blow that off because if your blood has too high of a CO2 level, that can be a strain on your heart and that strain on your heart can cause atrial fibrillation and other problems. So really it's a coordination between your anesthesiologist and your surgeon knowing this problem to make sure that number one, prior to insufflation of your belly, number two, the insufflation of your belly is done slowly and not too rapidly. And number three, that your anesthesiology just keeps up with the amount of respiratory rate that they need to reduce the amount of CO2 in your system because that can be very irritating to the heart.

(00:13:02):
Alright, next question. Thank you so much for your talk. I've learned a lot. Thank you. I'm a 44-year-old male with left inguinal hernia 1.7 centimeters. I am five seven a hundred fifty pounds. Sounds like a normal height. And weight BMI is about 23 slightly over. No, that's normal. That's normal. I have mild eczema and irritable bowel syndrome. That's an important fact because irritable bowel syndrome and mild eczema together may be a sign of an inflammatory state of being also the pro grip mesh. Oh, I feel like open surgery with mesh is better for me to avoid going near my bowel. Also, this is for inguinal hernia. Also the program measures polyester, which I might have higher chance of allergenic since I'm also trying to avoid polyester clothing. I only wear cotton clothes. Interesting.

(00:14:03):
I have had patients that are allergic to polyester clothing and unfortunately did not share that with the surgeon and the surgeon put in polyester based mesh. Oh my god. And they had, there's a picture of it on my Instagram, they had a circle exactly the shape of their mesh turn red on their belly. Can you believe that? Okay, I diverge. So I think polypropylene mesh is safer for me or nothing. It depends on your hernia. Do you think everything above makes sense if you do this open repair with permanent mesh, do you usually use permanent suture for the mesh as well? Yes. Do you usually cut the ileal angle nerve deliberately when doing the open repair? No. So I don't believe in prophylactic neurectomy. I think don't mess with the nerves. There's risk with it and I don't recommend it. So I'm not one to cut your nerve.

(00:15:05):
However, I'm very careful with the technique. You may benefit from laparoscopic surgery with laparoscopic surgery if you have inflammatory bowel disease, I don't recommend laparoscopic surgery, but if you have irritable bowel disease, that's a difference process and I'm perfectly okay putting in mesh and staying extra pregnant away from the abdomen. But open repair is perfectly fine. And then you would use permanent mesh with permanent sutures. That's the technique. And in doing that technique, if you're allergic to polyester, then definitely don't use polyester mesh. Your only real other alternative is polypropylene mesh. If you're in Europe, you also have polyethylene mesh, which is called dyna mesh, which everyone really likes over there, especially in Germany, we don't carry that in the United States. And then there's hybrid mesh, which is mostly, mostly biologics. Some polypropylene suture in that is an option, sorry, not considered common but can be within standard of care.

(00:16:19):
Okay, next question. Can the pressure used to inflate the abdomen or the retroactive space during laparoscopic surgery ort cause a diastasis recti? No. So many people have claimed that's the fact or their doctor has told 'em, oh, they add so much pressure in your belly. So the pressure we add is 15 millimeters of mercury. A cough is about 50 millimeters of mercury, five zero sitting or standing or bending is about 25 millimeters of mercury. So the amount of pressure that we add to the abdomen is definitely not anywhere near what you would require on a sustained basis or repeat basis to get a spreading of your diastasis or spreading of your rectus muscles.

(00:17:09):
Let's see. Next question. Does having an umbilical hernia predisposed to developing diastasis? No, but the reverse is true. So having an umbilical hernia will not promote erectus diastasis. However, having erectus diastasis, which is a spreading of the muscles seen often in women who've had two or more pregnancies or multiple babies like triplets et cetera, or in men that as they age their belly gets kind of rounded. That's usually do a diastasis that's very genetic. But when that happens, you get a thinning in the middle and what's in the middle of your belly button. So if you have an early umbilical hernia or a hernia that you never knew you had, it was clinically not relevant, not even visible, and now you have a separation of the muscles and a thinning of the tissue in between the muscles, you're more likely to have a hernia in the belly button.

(00:18:06):
And so yes, people who have outies, many of them also have a rectus diastasis. Now one category is pregnant women. So if you ask a woman or if you see a woman who's pregnant and they're wearing their beautiful dress or t-shirt and there's like a little nubbin sticking out, that's their outie, right? You get an outie during pregnancy in many women now that's because your belly gets stretched out and whatever little hole you had now is stretched out and looks bigger. Many women, once the pregnancy is done, their belly goes back to normal and they also no longer have a clinically relevant belly button hernia and no umbilical hernia, no outie. Some women on the other extreme will have everything, will have a stretching of their abdominal muscle which will never go back. They have a diastasis, which is also something that is stretched out very genetically predisposed that will never go back.

(00:19:14):
So now they have a thinning in the middle and that stretching out that they had of their belly button with the outie is now permanently stretched out and they have an outie ble. So they say I had the cutest little in belly button before my baby. Now I have two kids and I have this outie and sometimes in addition you'll have a lot of stretched out skin. So I just has a patient like that this week. So she was, she's had two kids, cute, cute, cute, beautiful children. She's still breastfeeding and she's here because she has an outie belly button, doesn't hurt her. And when you examine her, she also has erectus diastasis about two and a half finger breasts and a lot of thinned out skin. So she has a lot of options. One option is to do nothing. It's not really bothering her that much, it's more like visibly she doesn't like it but it's not like a health issue so she can just do nothing and she may want it to have another child. So wait until all childbearing is done.

(00:20:20):
Other option is just focus on the outie that she doesn't make it into by fixing her umbilical hernia and leave the diastasis and the thin skin and the loose skin alone, the most extreme option is a full tummy tuck abdominal plasty where you can address the hernia. You can address her rectus diastasis and make her a flatter belly and then you can also get rid of the thinned out loose skin and with a very large scar you can do that. And then lastly, there is a laparoscopic option. I don't think it's a good option for most people who have a lot of loose thin skin and are thin in this patient, but in other patients it is an option. So I hope that was helpful. Next question, can a te TP retrorectus dissection be performed without a balloon? Yes, so I don't necessarily use a balloon in thin patients, you almost never need a balloon. I make my own balloon sometimes, depending on the situation. And then there's what's called the Phillips technique, which is instead of staying completely extra peritoneal and making a balloon or dissection extra peritoneal, you go in the abdomen and watch yourself make that space bluntly without a balloon and you go back into the normal space. So yeah, there's a lot of techniques, lot a lot of techniques.

(00:22:00):
We have a cardiologist on here who said, I think he was referring, going back to the first, first questioner, I think he was referring to vgo mimetic, not vagal, vly induced atrial fibrillation. If you want to explain to me, so vagal mimetic means acting like it's vagal but it's not atrial fibrillation. If you can help me get that answered, I'll try and answer what vagal medic, atrial fibrillation maybe. Oh, lots of questions. I love this. Okay, let's see. Oops, question. Here it is. I had a left inguinal hernia surgery in May, the place where the hernia was low in my left pubic bone area, so that sounds like a inguinal hernia. Since the surgery I've had inner labial pain, vaginal and clitoral burning. So it sounds like you may have had a genital nerve injury. I contacted my surgeon who said that the nerve that is associated with that kind of pain is nowhere near where the surgery was inaccurate. Is it accurate? No. He said the surgery would be giving me this type of pain in this area.

(00:23:28):
I do still have some groin pain from where the surgery was to. I also am doing pelvic floor pt, so the genital and or ileoinguinal nerves can give vaginal and clitoral burning as well as labial pain. So one or both of those nerves can be injured and if it's still ongoing since May, what you need to do is temporarily just use a lidocaine patch. You can buy that from salon paws from your local pharmacy and then also go to a good surgeon hernia specialist or a pain doctor who knows what they're doing and get an ileal and a genital nerve block and see which of those is your problem. Then sometimes you just need a couple of different blocks and all you need, unfortunately, in some cases you may need a nerve ablation where the nerve is burned or frozen or a nerve neurectomy where we cut the nerve.

(00:24:33):
Okay, going back to the other question, vagal mimetic atrial fibrillation is just a more clinical name for the same disorder as vaguely induced atrial fibrillation. Okay, I learned something new. So if I were to see you in the office and you explain to me what your symptoms are, I would have to put in my notes to be most accurate. Vag mimetic, atrial fibrillation, not vaguely induced. And for the cardiologist who's watching, do you agree with my assessment of why people can get bradycardia and or VGO mimetic atrial fibrillation when undergoing laparoscopic inguinal hernia surgery? Okay, next question. Thank you so much. Some surgeons told me he might cut some nerve during open inguinal mesh repair to avoid long-term pain. Do you think that makes sense? What can happen if my nerve is cut? Okay, I don't think it makes sense. There are papers, however that don't agree with me.

(00:25:38):
There are multiple papers that show if you have specifically ileal nerve cut, then chronic pain after hernia repair will be reduced. In my mind, that's assuming that you're injuring the ileal nerve or the mesh is too involved with the ileal nerve postoperatively and therefore in my mind that will only get rid of ileal nerve pain. It doesn't affect any other reasons for pain after hernia surgery of which there are many. So I don't agree with it. I don't think you should touch the nerves. I feel like just have a good hernia repair and you'll be fine. When I was a resident, we used to dissect out the ileal nerve and clamp it out of the space, do our surgery and then bring the nerve back there. That should never be done and it's possible that these studies were done a time when that was a technique and so of course if you gut the nerve then it'll get rid of your ileal neuralgia because I'm sure people were getting nerve damage from this technique, which we should never do anymore.

(00:26:58):
So that's my answer. Okay, to the cardiologist, you are brilliant even outside your specialty. I agree. Okay, great. You agree? Thank you so much. Appreciate it. Okay, next question. Dr. Towfigh, you are a smart surgeon. Thank you. Do you provide hernia surgery using natural tissue repair? No mesh? Yes I do. September, 2025, ultrasound found right direct neck, 1.6 centimeter sac 2.6 by two by 2.5 centimeters. Characteristics contains bowel. Okay, so you have a pretty large hernia. You have a direct hernia almost two centimeters wide, 1.6 centimeters and it includes bowel, it's reducible, it changes with Val Salva obviously. Can I watchfully Wait if there are minimal symptoms? Yes. The watchful waiting trial and I interviewed the lead author of those watchful waiting trials, Dr. Robert Fitzgibbons, go backwards and listen to it as a podcast or as a YouTube video. So watchful weighing trial was done specifically in patients like you, healthy inguinal hernia, minimal symptoms, and they watched you for five to 10 years.

(00:28:23):
They found a 0.2% per year risk of incarceration and they found that one year about a third of patients had symptoms and required surgery, I'm sorry, five years and at 10 years, two thirds of patients required surgery, which means one third of patients were still doing fine. So it was considered a safe option. I do not wish to use mesh well. I do recommend mesh for you actually, how long can I wait? What size of hernia will be too big for no mesh repairs? So you're already on the too big size sounds like for not doing well with a tissue repair. So in general, direct hernias don't do well with tissue repairs and you have a much higher risk of recurrence, but also chronic pain if you choose a tissue-based repair for a direct hernia. So mesh based repair is much better either open or laparoscopic.

(00:29:18):
That would be my recommendation for you. If you wait even longer it'll be even larger. So what's not important is the size of the sac. It's important as the size of the defect and 1.6 centimeters is already too big plus you have bowel in it. So I do recommend repair, especially for you're getting symptoms. If you don't have symptoms, you can wait but you will need mesh. I don't recommend a tissue-based repair. You'll just blow it out and you'll be miserable and you'll hate your surgeon. Okay, which may be me, which no, I won't be offering it to you. Okay. For testicular pain there could be damage or irritation to the genital nerve for testicular pain. No genital femoral nerve does not give testicular pain. It can give scrotal skin pain but not testicular. Testicular pain can often be due to vasal nerve pain. So the vas deferens, a branch of this nerve known as a genital branch supplies a scrotum.

(00:30:24):
That's right. There could also be injury or irritation to other nerves that innervate the scrotum including the anterior posterior scrotal nerves. Additionally, irritation or injury to the specific spinal nerves or pelvic nerves can lead to scrotal pain. This sounds like a chat GPT answer are the above information correct? Yes, but we are not injuring spinal nerve roots or pelvic nerves as part of a hernia repair. So if you were fine and then you had testicular pain, it's not from a scrotal nerve, those are not also part of the hernia repair. Will an MRI of the lower spine and pelvis with a focus on the scrum and testis be useful? Only if you think you have a hernia recurrence or a mesh problem, it's usually not otherwise helpful. Rather an ultrasound looking for nerve injury and or nerve blocks would be much more helpful. Here's another question. I love you guys. You gave me so many questions, I'm trying to go through 'em as fast as I can because there's a lot of them. I still have more to talk about, but you're outie, okay.

(00:31:37):
My throat is dry. I had a left inguinal hernia surgery in May. The place where, oh, I already did that. Okay, I already did that. Right. Great, great, great, great. Let's see more questions. My atrial fibrillation. Oh, this is the patient with the atrial fibrillation after the laparoscopy, my atrial fibrillation was always caused by cold liquids and foods. Also postural changes in abdominal pressure. Sounds like you have a very sensitive heart because the cold foods and liquids are going down the esophagus, which is abutting the heart in the same cavity and so you're a little bit of cold fluid touching your changing the environment near your heart is giving you atrial fibrillation. That's interesting. Thus my concerns about gas pressure issues. Also postural changes in abdominal pressure such as a tight belt and bending of the waist, et cetera. Yeah, it sounds like your atrial fibrillation should be controlled with some type of rate controlling medication. A cardiologist should be the person to determine that, but I wouldn't say that you shouldn't get laparoscopic surgery if that would be a benefit to you because there's a lot of factors to that and there are ways to help reduce your risk. But yeah, if there are options for open surgery, I would take it. If your discussion with the surgeon is that it's just as good, but if you're going to have a major benefit from laparoscopic surgery, they can always convert from laparoscopic to open if you're going to an abnormal rhythm.

(00:33:28):
Okay, left indirect inguinal hernia on ultrasound, non reducible contains fat. Does this hernia need surgery? We only go by symptoms. So if you don't have symptoms, I don't care what the ultrasound shows for anal hernia, can I watchfully weight? Like I said, watchful waiting is considered safe for patients. Men specifically, we don't know what it's like in women, but men with inguinal hernias that have none to minimal symptoms. I had an angle hernia surgery in April, 2024 using the shouldice technique. Is this a recurrence? Oh, I see. See, okay. Well you should start with that first. You already had hernia surgery, now you have an ultrasound which shows a hernia. Yeah, by definition that's a recurrence. You had a hernia surgery. April, 2024, September, 2025 you get ultrasound, which shows a hernia. Hence that's a recurrence. Yes, and that's a good point, which is that there's so many people that come to me and they come in with the mentality of I just don't want mesh, but that's just the wrong way to look at.

(00:34:48):
They should say I want the best repair for me, the least recurrence or the least chronic pain or whatever's important to you. And if you want to say I prefer not to have mesh, then we can have a discussion. I can say, okay, in the patient with a large direct hernia with bowel inate, I would say, I understand you prefer not to have mesh, but you need mesh because it's not feasible to perform a tissue-based repair and expect an equivalent outcome or similar even outcome because you're going to have a higher risk of recurrence and chronic pain. Now going back to your outie, which is the topic of today's talk, okay, here's the answer to I do not wish to use mesh. I'll rather have a recurrence than using mesh, which can cause disabling chronic pain. I'm thin built, can I use natural tissue repair again?

(00:35:49):
Oh, you want another tissue repair after shoulder eyes, what are my options? Will you provide natural tissue for hernia which is repaired using shoulders? I would not. I would not. So the mistake here is you're equating mesh option with chronic disabling pain. What you're not understanding is that a recurrence can also give you chronic disabling pain because you're constantly tearing through the tissue. The way that recurrences occur with the tissue repair is you're tearing through the tissue and that can cause chronic disabling pain. So it's not like tissue repairs this amazing repair that doesn't cause any problems except maybe a recurrence and mesh will cause you chronic disabling pain. That's not true. Also, there's various types of meshes and there's different places we can put meshes. So if you were to see me, you're a thin patient, I understand thin build is usually a good candidate for a tissue repair, but you have to understand if you have recurred from your tissue repair, then you need to get a mesh based repair and that repair will be laparoscopic.

(00:37:00):
So you would need a laparoscopic repair with mesh. Now we can use lightweight mesh, we can use a lower profile mesh, we can use a less inflammatory mesh. Those are all options. But to think that you fail the tissue repair and repeating some type of other tissue repair is going to somehow give you a magical result When you just had the best known tissue repair with the best outcome and you failed. That is not right. So I would not offer you a tissue-based repair if there's a problem with med, is it hard to fix? No, I mean it depends on the problem. What's the problem with a mesh worst case scenario? It's infected low risk but or I'm saying worst case scenario or it's crumpled up, it was poorly placed. That can be redone. So we actually have, you can do a lot more. Most of what I do is revising hernia repairs and redoing hernia repairs or dealing with recurrences. So I No, you can undo the repair whatever. Is it true that inguinal hernia mesh done in open, it's easier to remove? Oh no, than the mesh done laparoscopic. Okay, so very good question. All mesh removal procedures should be done by a hernia specialist. Do not venture with a doctor in your neighborhood who doesn't do these for a living because they can cause serious damage. Now both open and laparoscopic meshes can be removed by open or laparoscopic techniques.

(00:38:44):
Both have risks. The anterior, the open repair mesh removal has a higher risk of chronic pain because there are nerves that are involved. So you higher risk that you will need a neurectomy as part of your mesh removal procedure and higher risk of damage to the blood flow to your testicles. In males, the laparoscopic MES removal is technically via the technique much more challenging because it can be involving the bladder, it can be involving the major blood vessels to your leg, however much less risk of nerve injury and much less risk of chronic pain. I personally, if I had to choose which one is better for the patient, less risky and open or laparoscopic repair, I would say laparoscopic because I do a lot of it and I'm really good at it and I really enjoy doing it. But it's a very challenging technique. Most surgeons do not know even how to do it. And if someone's offering it to you that's never done it before run because that is not an operation you want to be their first or second patient with.

(00:40:06):
So that's my thought on it. It's much more, you cause much more damage by removing an angle mesh that's done open you cause less damage by removing a laparoscopic mesh laparoscopically. However, if something happens bad like a bladder injury or a vessel injury that's much worse can be life-threatening in some patients. It's just the risk of that it's really low when performed by a hernia specialist. Next question, do you ever have to inject the genital nerve diagnostically for chronic pain? If so, how do you do that? Yes, absolutely. So the genital nerve can be injured in two separate areas, either distally away at the mesh repair anteriorly if an open repair and beyond or in the retroperitoneum posteriorly from a robotic or laparoscopic mesh repair. So you have to inject the genital nerve where the injury is to get the best diagnostic answer. Most pain doctors are okay injecting the genital nerve in the front.

(00:41:29):
Usually they go by the pubic bone and they inject it there. It's usually effective. What they are very uncomfortable doing is injecting the genital nerve further upstream, posterior deep to the mesh in patients who have that injured from a laparoscopic or robotic repair. I do that with ultrasound guidance because you don't want to, because the nerve is very close to the large external iliac artery and extra iliac vein. And when that happens you don't want to accidentally injure the extra iliac artery or vein with your needle and cause bleeding or put local anesthetic into the major blood vessels.

(00:42:17):
And also you can't put too much volume there because your femoral nerve is also nearby in the same space. So if you flood the area with local anesthetic, the patient can't walk because because they're femoral nerve which controls all the muscles from the groin and below to your leg, we'll stop working and you can't get up, you can't stand. So it's a tricky way, but yes, diagnostically we do use, we do perform genital nerve blocks. Let's see, will the inguinal hernia with non reducible fat mentioned before be strangulate unlikely. This is my major worry for my left and right hernia. So your, let's see which side was which. Your left side, which is a recurrence from the shouldice has fat in it and seems to be small. If it's asymptomatic, you can ignore it until it becomes more of a problem and it's very unlikely to cause strangulation.

(00:43:22):
You already have scar tissue there so things don't move too much on the right side. You have the larger direct hernia with bowel and I'm willing to bet, check this out, this is how sure I am. I'm willing to bet that the hernia you had on the left side is exactly like your current hernia on the right side with a large direct hernia and therefore higher risk for chronic pain. And what'd I say? Hernia recurrence, which is exactly what happened on the left side. So you probably had a large direct hernia on the left side and you had a tissue repair, which is not ideal for that specific type of hernia. And you got a recurrence as expected. And on the right side you have the same exact problem. Direct hernia this time with bowel in it unlikely for you to get bowel obstructions. Usually direct hernias, they don't do that. The neck is usually wider than an indirect hernia and if you're asymptomatic or minimally symptomatic, again, more reason that more very unlikely you'll have an incarceration episode or strangulation.

(00:44:36):
I understand the left side recurrence is now indirect, but your original hernia, I'm willing to bet was a direct similar to your right side. And so the right side, what should be repaired when you're symptomatic? I hope that's clear. I don't know, maybe I'm wrong, but usually people are symmetric, so if you have one type of hernia on one side, you usually have that type of hernia on the other side. So I understand that you now have an indirect anular hernia recurrence from your shouldice, but my bet is that your original left was a direct Okay.

(00:45:28):
Original left was also indirect. Okay, well I was wrong then, but that's usually a marker for recurrence is a direct hernia for the tissue repair. Okay, let's see. Okay, let's continue our talk about your outie. So now we have a Carlos Raz. Thank you. You are a great surgeon, very knowledgeable, I appreciate it. So now we have Carlos Raz. He's won multiple grand slams and he has an outie umbilical hernia. Should you get that repaired? No, I haven't asked him if he's symptomatic, of course if he's symptomatic he should get it repaired, but I would not touch him surgically if he's continuing to win tennis with a small outie right now some people have outies and they don't know they have an outie or umbilical hernia and then have symptoms. It's usually pain either at the belly bin or to the left or to the right of the belly button.

(00:46:37):
Some people get bloating and some people have pain that radius to their upper back. So if you have any of those symptoms and you have an outie, you may have pain due to your umbilical hernia and therefore an umbilical hernia repair would be good. And we have some questions here that were submitted prior. Let me share the screen with you because it's a good series of questions in terms of how to evaluate someone with an outie. So question number one is how can you distinguish between an umbilical hernia and a naturally convex navel Just by looking without relying on physical examination or imaging studies.

(00:47:27):
If it's asymmetric, usually that's a hernia. If it's perfectly symmetric and looks like a cinnamon roll right in the middle, sometimes that's just a thickened tissue and not a hernia, but you definitely need physical examination. If it's something that can stick back inside that's a hernia. If you can't stick it back inside, it doesn't have any loation to it, then it's probably not a hernia. And then of course imaging will help. I will say that I have so many people that directly messaged me because I have a friend, he went on a vacation with his family to Italy with a bunch of his friends and he's like, Towfigh, there are so many patients here that need to come see you. I am tired of seeing outies at this beach in Italy. Everyone that has an outie and people that follow me on Instagram often they direct message me about, do you think this person has outie?

(00:48:30):
Is this a hernia? And it would be like someone's doing some type of Instagram pose with their belly out and I'd be like, yeah, good call. So I made it like my life to dedicate to hernias. But I feel like so many people that follow me are equally amused by this option of checking out hernias. Even my mom has done the same. Okay, next question. In managing a patient with post angle hernia pain, after you have done your very best revision, either hernia repair or removal of mesh, do you ever have to recommend a neurectomy even in the apps of neuralgia in such, how do you decide which nerves are transect? Yes, that is an issue. So if you have no nerve pain and you go into surgery or revisional surgery, what would be the situation which you would need? A neurectomy? Number one is if the surgery that I'm planning for you would cause nerve injury.

(00:49:43):
Mesh removal is a great one. If you're removing mesh and the mesh is stuck to a nerve, you're going to injure that nerve. It's like taking Velcro off of a cashmere sweater, it's just going to destroy the sweater. So instead of leaving that damaged nerve behind and having the patient wake up with nerve pain, we do cut that nerve. We call it pragmatically. So that is one situation. The other situation is if you go in there planning to do a revision repair and you're like, oh my god, I did not expect this. And it's either the nerve is stuck with a bunch of scar tissue or the nerve has what's called a neuroma and the neuroma is basically something that needs to be addressed surgically and can explain the patient's symptoms. So those are the two situations in which that would happen. How big of the central hole size of your TEEP laparoscopic repair for small inguinal hole mesh repair, usually how big of the central hole size of your laparoscopic repair for small inguinal hernia mesh repair usually, I don't know what you're asking. Are you asking what size mesh do you need? Most patients, even for a small Anglo hernia, need a 10 by 15 centimeter repair mesh. If you're a bigger person or a bigger hernia, we go up to 12 by 16 centimeters. If you're a very small person, very small, we may go down to an eight by 10 centimeter mesh, but that's usually really petite people and not the case in most people, at least not in the United States, maybe Asia more likely to have people that are very small build.

(00:51:39):
Alright, let's keep moving. Next question. When from a patient's perspective, should you suspect an umbilical hernia? If you have a protruding navel but do not experience any symptoms? So one would be see a doctor if it bothers you if you have a belly, but pain, pain to the left or right of your belly button, bloating of uncleared cause because that could be through the hernia or radiating pain to your back. If you don't have any of these symptoms and are just curious or you don't like how your belly button looks, then you can also see your surgeon to see if that can be fixed surgically. Assuming comparable hernia width, is there any difference between the techniques used for the treatment of umbilical and incisional herds? Absolutely. So for those of you who've watched my episodes, the incisional hernias are a completely different animal than umbilical hernia.

(00:52:43):
Umbilical hernia, you're born with it or developed over time and it's what we call a primary repair incisional hernia. It was caused by an incision and that opened up and that usually implies sometimes surgical technique goes wrong, but usually it implies that you have collagen issues that failed irregular closure. And so we need to address that usually with mesh. Now, if your incisional hernia is like less than a centimeter, I probably won't put mesh in you, but usually incisional hernias are most likely to need mesh and are more likely to benefit from a laparoscopic robotic approach than your typical umbilical hernia.

(00:53:31):
Next question, should I have any concerns having bilateral inguinal hernia repair with mesh after a hydro seal surgery in 2020? No, that's a great, great plan. You probably had a hernia at the time of your hydrocele. Could the surgery cause a recurrence? The surgery should not cause a hydrocele. No hydrocele could have been due to a hernia and they fixed the hydro seal but missed your hernia. That can happen. But regardless, you had a good hydrosectomy sounds like, and now you have a hernia and a laparoscopic repair is a great option. Next question, do you ever have to do a neurectomy if the revision doesn't resolve pain and use the neurectomy is therapy. Okay, so that would be planned if you have neuropathic pain, so pain due to a nerve then blocking that nerve should make the pain go away even temporarily.

(00:54:39):
I would not just go in there willy-nilly cut a bunch of nerves just because I can't figure out why you have nerve pain, explain why you have pain. That's not how it works. You can't just keep cutting and hoping that eventually you'll get the right answer. You should figure out what the right answer would be and then go after it. So no, I don't recommend that you go in for neurectomy if you dunno why else there's pain because you should only do a neurectomy if there's either an obvious neuroma or scar tissue involving the nerve and that nerve kind of helps explain the pain. Or you've done your due diligence prior to surgery and performed nerve blocks and you've narrowed it down to certain nerves. Now there are surgeons, and even in hernia institutes that strongly believe in triple neurectomy. This is based on the fact that if you look at all patients who've had triple neurectomy back in the day, research by Dr.

(00:55:48):
Parid showed that they did a much better, they had a much better outcome in terms of pain relief than if you only did what's called selective neurectomy. But if you analyze the paper, what they really did was basically some people had selective neurectomy, others had triple neurectomy, and it's possible the selective neurectomy was done with not as much insight into the patient. So if you cut all the nerves, then you'll be right at least one third of the time because there are three nerves. So I don't subscribe to the triple neurectomy theory. I think it's best that you sit down with a patient for a very long time, help figure out which nerve should be addressed and then carefully plan the surgery. But the idea of triple neurectomy is certainly very commonly accepted and is a known way of treating chronic groin pain.

(00:56:52):
I just don't like it. We did a whole session on neurectomy. I published on Ectomies. There's risks with neurectomy. You can get neuromas, you can get chronic pain, you can get Crips, which is complex regional pain syndrome. Horrible, horrible complication. You don't want to be that patient. That's my theory. Let's see if the small anular hernia done by open well the mesh size be smaller than the laparoscopic 50 by 10. How big is the mesh for open repair? So the open repair is four by six inches. Some smaller people three by six inches, but that's the standard repair. We don't decrease or increase the shape of the mesh based on the size of the hernia because then the mesh is supposed to cover all potential hernias. So if you just address one hernia, the other hernia will, then you'll come back with a hernia next door to it, number one. And number two, your mesh is best when it's up against healthy tissue. So you don't want to just cover the small hole, you need to cover the small hole plus a width or a radius around it, abnormal tissue. And the standard size, which has been shown to decrease the risk of recurrence is three to four inches by six inches for the open and 10 by 15 centimeters for laparoscopic.

(00:58:31):
Can the penal nerve supply innervation to the groin area? No, the pedal nerve does not supply innervation to the groin area. It does to the pannus and to the clitoris, but that's as close as it gets to the groin. All right, we have a couple more minutes, so if I can just share some more questions. These were really insightful questions. Let's see. Is the permanent mesh complication risk of umbilical hernia repair negligible when compared to that of ular hernia repair due to the lack of delicate abdominal structures in close proximity? In the former, yes and no. So if we're putting mesh away from the intestines, there's really no nerves you can injure with umbilical hernia repair. So that's one advantage over angle hernias where there's tons of nerves, but depending on how you fixate the nerve, if you go too far out loud, you can injure nerves.

(00:59:37):
I have seen that. And if you put the mesh intraabdominal where there's bowel, you can cause serious damage including bowel obstructions and fistulas or injury to the bowel. So that's a horrible complication considering minimally invasive and open umbilical hernia repair. By the way, the original ular hernia repairs laparoscopically was mesh place intra abdominally, like the umbilical hernia repairs that were done. But we quickly moved away from that. That has not been the case for the umbilical hernias. We still, not we, but many surgeons still routinely place the umbilical hernia mesh inside against the bowel because it's easier. It takes a bit more skill to do it the other way around. So anyway, there is that serious issue. Next question. Considering minimally invasive and open umbilical hernia repair, so laparoscopic and robotic versus open umbilical hernia repair, what are the feasible anatomical planes for mesh placement of those, which one do you prefer?

(01:00:48):
So most umbilical hernias do not need mesh. They tend to be less than one to 1.5 centimeters. And those routinely don't need mesh over 1.5 centimeters and certainly over two centimeters they should have mesh placed. And it really depends on the risk factors of the patient. So if you have a situation where you're doing it with mesh, either laparoscopically or open robotically or open, we prefer to have the mesh behind the rectus muscle. But you can have the mesh anywhere, you can have it on top of the fascia underneath the fascia, outside the peritoneum, inside the peritoneum. The preference is to put the mesh retro rectus. That would be my preference. But it all depends on what surgery they've had before, if that space is available, how difficult it is to access that space and so on.

(01:01:44):
And let's see. When repairing an umbilical hernia as a minimally invasive approach, always best. No, no, it's not. So the best approach is a one that is tailored to the patient's need. I can't think of how putting in three incisions to fix an incision to fix a hernia, a small hernia that's the size of one of the incisions is useful. So I offer plenty of open umbilical hernias, no mesh. Usually in some patients they may need mesh. And it's a balance between whether you want to be intraabdominal or extra abdominal, you mesh or no mesh, how big is the hernia? Is there a diastasis involved or not? So there's a lot of factors to consider and that's really the gist of it. We think umbilical hernias are just cute little things and there's, there's a lot of thought process that needs to go into it.

(01:02:58):
What's their risk factors? Are they an opera singer, which I had a couple of weeks ago? Are they a trombone player or are they in construction? These are all patients that have increased abdominal pressure. Who do they have recently that had severe increase of bowel pressure? Oh, some people have what's called ileoinguinal pouch, so they can't have a bowel movement without straining. That's a lot of bowel pressure. So that's one category of patient. Then you have another category super thin, you have another category, wants to have more pregnancies or has had multiple pregnancies. So all of these people have a different risk factor, different cause of their hernia and should get a different type of repair. And it's all part of that shared decision making with the patient. So on that note, I really, really, really appreciate all the questions from you guys. It's my favorite Hernia Talk episode when I am bombarded with questions. I really like that. On that note, I was in Nashville last week, such a cool city. And if you're interested to see what I did and what I learned, it was the American Hernia Society meeting I posted because I live tweet these meetings on Twitter. So that's where you can find me on X at hernia doc.

(01:04:28):
And until next week, I will. Thank you very much for being my guest. Thanks everyone.