207: Hernia Repair after Transvaginal Mesh Removal

This week, the topic of discussion was: 

• TVT
• TVT-O
• Transvaginal mesh
• SUI
• Stress urinary incontinence
• POP
• Pelvic organ prolapse
• Mesh
• Hernia Mesh
• Nerve injury
• Pudendal neuralgia
• Neuroma
• Chronic post inguinal herniorrhaphy pain
• Inguinal hernia
• Chronic pain
• Spinal cord stimulator
• Implant illness

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.

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Transcript

Dr. Shirin Towfigh (00:00:23):
All right everyone. Hi, it’s Dr. Towfigh. Welcome to Hernia Talk Live. Thanks for joining me. My name is Dr. Shirin Towfigh. I am your host hernia and laparoscopic surgery specialist. You’re joining me live on some of you on Facebook at Beverly Hills Hernia Center. You can also follow me on Facebook at Dr. Towfigh. Thanks to those of you that are actually here live as a Q&A via our Zoom. And as you know, all of these episodes we’re over 205 now. We’ll be shared as a podcast or on YouTube for you to watch and kind of enjoy. So let’s see. Let’s make sure that we’re live on everything. We’re live on Facebook and we’re live. Excellent. So welcome everyone. Today’s going to be an interesting discussion because it’s going to be a little bit controversial. The topic will be talking about patients that have transvaal mesh placement.

(00:01:32):
And as many of you guys know, that’s kind of a hot topic. A lot of patients have been named by transvaginal meshes and I see some of them now. I don’t do transvaal mesh repairs and I don’t remove transvaginal mesh. Usually those are done by urologists and gynecologists. So all I can say is, excuse me, are you a urologist and gynecologist? So all I can say is kudos to people who do take care of those patients. Very, very difficult. However, every year I would say I get maybe 20 patients, which is pretty large amount, who have had transvaal meshes, maybe more, who have had transvaal meshes. And then they come to see me. Why are they come to see me? This is very, very important. They come to see me because separate from their transvaginal mesh episode where they had it removed for whatever reason, they now have a hernia.

(00:02:41):
Also unrelated, right? Let’s say they have a belly button hernia completely separate from the vaginal mesh surgery and the removal surgery. So now I have a patient with some type of hernia and they’re freaking out because they have been so traumatized by their experience with the transvaginal mesh placement and erosion complications, infection, surgery removal, et cetera, that they are insistent on not having any more mesh in them ever again no matter what the consequence. So that’s one scenario which is you already have PTSD from complications of mesh placed because you had urinary incontinent stress, urinary incontinence, postpartum organ prolapse, et cetera. And what happens is the patients don’t ever want to go through that again. So that’s scenario number one, which is two problems. History of transvaal mesh placement with complications causing so much problems. It could be infected, it could be eroding. So pain with intercourse, it could be causing urinary problems by eroding into the urethra.

(00:04:05):
Or some people actually get mesh implant syndrome, so they don’t ever want to have any more mesh related complication, even if it’s for another part of the body. So they’re coming to me with a hernia, but they absolutely do not want mesh. So that’s one scenario we’ll talk about that. Second scenario is they have proven to have what’s called mesh implant illness or some type of systemic inflammatory reaction to a mesh product. And now they have a hernia again unrelated to the mesh removal surgery. And I can’t put mesh in them, not that I would want to, but even if I want to, I can’t. And the reason for that is they’ve already proven to have an implant illness, a transvaginal mesh implant illness, and I don’t want to be the one causing another type of implant illness. So that’s also true for women who’ve had breast implants that removed people who’ve had dental implants that were removed and therefore have other implant illnesses.

(00:05:13):
Third scenario is the one I’m seeing more of recently, which is what prompted me to do this special episode, and that is patients who have had transvaginal mesh placed, they had a complication from it and therefore they required a second surgery usually by a specialist because there’s very, very few people removing. If you thought it was hard to find a hernia mesh surgeon to remove hernia mesh, I believe it’s even more difficult to find a surgeon to remove transvaal mesh. It’s very complicated anatomy. So these patients had to go through the process of finding a surgeon, having someone skilled remove it, and now they have pain since that transvaginal mesh removal procedure. And there’s a wide range of pain. It could be directly related to the urethra and urinary pain. I don’t deal with that. It could be directly related to the vagina and the healing of the area, and they could cause intercourse or pain even with sitting, I don’t deal with that.

(00:06:24):
But they may have either abdominal wall hernia from removing the mesh because it’s often done through an incision, almost like a C-section incision to remove the mesh. Some people have abdominal wall hernias from the mesh removal that was done robotically, but even though it was done robotically, the two parts of the retropubic transvaginal meshes went through the muscles. So they took it out. There were holes left behind. And so those are incisional hernias related to the transvaginal mesh removals or they had nerve damage from either the placement of the transvaginal meshes or the removal of the transvaginal meshes and they now have aroma and so on. So I’ve seen all of these very tricky to assess because you have to separate their underlying symptoms from the mesh removal surgery and complications associated with that with an actual nerve or abdominal muscle injury from either the mesh placement or the mesh removal.

(00:07:40):
And the reason why I bring this up is as general surgeons, I’m willing to bet most general surgeons have never even seen a transvaginal mesh placed, let alone seeing them be removed. So the anatomy is not familiar. There’s the optuator canal, which we don’t really operate in. There’s a lot of nerves in the area that people are unfamiliar with, and a hundred percent of the patients that I’ve seen have had their imaging misread. So they weren’t even told that they have these problems such as incisional hernia or neuroma from their mesh removal procedure until they came and saw me like we don’t know what to do. So it can get complicated. So because at least it is in the United States, I’m not sure about Europe and other countries, but because the situation is such that our training is in silos, so general surgeons get trained, neurosurgeons get trained, they don’t interact.

(00:08:46):
Gynecologists get trained. We don’t interact. Urologists have certain training we don’t interact at the most during our first year, which is called internship, year of residency, we do rotate through different specialties and kind of get a taste for what a urologist does, a neurosurgeon does, orthopedic surgeon does if you do a rotation with them. But if you don’t, you’ll never know. And as far as I recall, I don’t believe there are any residencies that have the surgeon, the general surgeon rotate into gynecology. We just don’t do that. Our primary connection to a gynecologist is often when they call us in the operating room asking for help. So we usually don’t operate together. Now I do, but certainly during residency that was not the situation and that’s true for most of the United States and probably throughout the world. So we don’t have this kind of broad education that we used to. It used to be a urologist was actually a general surgeon who chose to then focus on urology, and it used to be a gynecologist was also a general surgeon that then did gynecology. That’s not true anymore. Each of these specialties have their own residency now, and many of them do not interact at all with each other in their different departments.

(00:10:22):
I say this to show you how disparate our education training can be and unless we have colleagues or referral base or a practice like mine where we interact pretty closely with other specialties, I mean I choose to go into the operating room and watch my friends operate and I ask questions, they probably want me out, get out of here, we’re operating. But I learned from them, I’ve been in the OR where transvaal mesh has been placed and I’ve been in the OR and have colleagues that have spoken to me about how they remove the transvaginal meshes. So TVT, transvaginal tape meshes and TVO. So transvaginal tape, trans opturator meshes are the two most common types of meshes used. They’re all referred to as slings, and the sling is basically like a sling, what do you call it?

(00:11:26):
What word? Kids forgetting the name like a swing. It’s kind of like a swing or a hammock. And what it does is your bladder emptys out through the urethra and it’s kind of a wide open with not much muscle around it because of the muscle’s been stretched out or affected by let’s say multiple pregnancies. So what is done to prevent stress? Urinary incontinence, every time you lift something or cough or laugh, you’re urinating, they try and add a little bit of extra pressure on the tube, the urethra to prevent it from constantly leaking urine. And they decided before, I think there was a surgery for it where they would just tighten the muscle around the area.

(00:12:21):
And it wasn’t until hernia meshes came out that they’re like, oh, well maybe we can use hernia mesh for this kind of problem. And it turned out that was not a good idea. The mesh is placed in an area that’s very thin and very sensitive that needs to move, which is called the urethra and the vagina. And whereas in the groin or the abdominal wall, there’s not as much like movement and it’s not very sensitive area. So the same way we don’t put mesh over the intestine, they should have known you should not put mesh against the vagina or vaginal mucosa actually, or the urethra. Well, they learned the hard way. So unfortunately tons of women got named from this procedure.

(00:13:14):
So if you were someone who’s had transvaginal mesh, either a transvaginal tape mesh, which is kind of like a V or up, which is more like a U placed and you have chronic lower abdominal pain, groin pain, et cetera, you should see a hernia specialist to see if they can help you. So I’ll share some stories with you of our patients. So I had one patient that had severe, she kind of had groin pain ever since the mesh was put in, and then when the mesh was put out, the groin pain actually got worse. So interestingly what they did was the mesh that goes like a V over here’s a urethra, it goes like a V to pull up on the urethra. The two tails of this what we call tape, this mesh goes up and is brought up through the rectus muscle and then cut. And so the rectus muscle scars in on the mesh and holds it in place without you need to do any suturing.

(00:14:28):
This one, the mesh was placed too wide, too lateral, and so the nerves that give sensation to your groin, if the nerve is coming over and the mesh is cross dissecting it, transecting it particularly the nerve is now injured by the mesh placement even though the mesh is not that wide, it’s just very unlucky. And the further wide they put, the more likely it is to cause nerve injury. That’s just a technical error that should not have happened. It probably also implies that the surgeon to understand that there are nerves in the way and the more you bring the mesh in towards the middle, the less likely you are to injure a nerve. So she had a neuroma, big, huge neuroma and we had to cut it out and we sent it to pathology. So that burning constant pain that she had was resolved. Now she’s numb over the area, but that neuroma resolved. So now she can wear clothing, the underwear over the area doesn’t burn and she can wear clothing with a waistline and not just wear a skirt all the time or a dress and that chronic pain was resolved.

(00:15:46):
Once the mesh is removed. There are different techniques. There’s the open technique where you use a C-section scar and you find the edges of the mesh from the transvaginal mesh and you go work your way down. Or there’s the robotic approach where you go from the inside out and find the mesh as it comes out and you pull it down. Either of those situations can cause what’s called an incisional hernia. So basically in the groin where the mesh comes out behind the pubic bone, when they remove that, the mesh, remember it is stuck to the rectus muscle and therefore also to the fascia. So if you pull it, you can leave a defect in the rectus muscle or the fascia, and when they do that, that can cause a hernia herniate because it’ll gape open. Now in some people they just scar that down, but if you are obese, chronically coughing, constipated use nicotine or unlucky, or if the surgeon has to cause more injury by cutting out more tissue, then you can have a defect in your muscle down below there.

(00:17:06):
That’s a very odd place to have a defect. Most people don’t get regular hernias there. So that’s why I call it an incision hernia, not a groin or an ral hernia. So I have had patients where the surgeon is like, yeah, you got a hernia there, or they had imaging and the radiologist or the surgeon did not appreciate that the location of this hernia is actually more inward and more cephalad, more inner and higher up than a typical angle hernia. And so they call it called an inal hernia and the surgeon didn’t know. So the surgeon took the patient and did an open inal hernia repair, completely missed the hernia. So now you have a patient who had a transvaginal mesh complication required the transvaginal mesh removed. After that complaint of groin pain goes to the surgeon and the surgeon’s like, yeah, you have a hernia and things that say and regular typical standard inguinal hernia, right?

(00:18:10):
So groin hernia. And she said, remember they come in with PTSD and complicates with mesh. So often the patients come like, we don’t want any more mesh in me. So she goes to a surgeon who says, yeah, I can do an inguinal hernia repair, no mesh. Of course, that’s McVay basini, shouldice, desarda. There are all these techniques that are without mesh. So unfortunately she had that hernia repaired, but it wasn’t the hernia that was her problem. She had an inguinal hernia repaired and it’s unclear if there really was an inguinal hernia or kind of looked like maybe there was an inguinal hernia, but the hernia for which she saw the surgeon, which was more inward and closer, higher up than where the surgeon was, was completely missed. So she wakes up with a scar in her groin and the same exact symptoms.

(00:19:12):
That is a situation because general surgeons don’t understand what is done by urologists and gynecologists and all they can see is what they know which is inguinal hernia. It didn’t occur to them that she could be having this problem related to her transvaginal mesh removal. So she had a tissue-based repair, which was great, but of a hernia that she didn’t need fixed because they totally missed the incision hernia from the mesh, removal from the transvaginal mesh. So one was nerve injury, one was an incisional hernia that needs to be repaired. So I am seeing more patients with incisional hernias from transvaginal mesh removal. Why is that important? Number one, they’re often not diagnosed with the hernia. They’re told they have chronic pain, they need nerve blocks, they need more pelvic floor pt. Some are told they need a spinal stimulator, whereas an incisional hernia is a mechanical problem.

(00:20:26):
There’s a hole and through that hole you can get fat with pain or you can get intestine with pain. Usually it’s fat because the bladder is there, so it’s usually not related, but interestingly because the bladder is nearby, they may say my pain is worse with a full bladder, and that’s because their bladder will fill up with urine and now add pressure to the area of the whole, the hernia, and when the urinates, that pressure is gone so they have less pain in either case. The situation is such that there they fall into this gap, they fall into this gap and I didn’t even know anything about this stuff, but as you guys already know, I’m very inquisitive and so I’m learning. I’ve learned how these transvaginal meshes are placed and how they’re being removed and I talk with my gynecology friends and urology friends and I know people who do this procedure and so on.

(00:21:33):
But most importantly, you know who you really are, who’s really your friend, your pelvic floor or physical therapist. I will tell you the majority of patients that are referred to me with some type of complication after transvaginal mesh removal is not the urologist that did the transvaginal mesh removal and not the gynecologist that inherited the patient. It’s the pelvic floor physical therapist that figured it out. That said, I don’t think this is a transvaginal mesh problem. This is not a pelvic floor problem. You have pain and swelling exactly in this area where your incision is. You should see Towfigh. I love my pelvic floor PT people because they touch the patients, they talk with the patients. It’s a very intimate interaction with them. And doctors, I’ve told you this before, doctors for some reason just don’t spend the time and don’t examine patients like they used to.

(00:22:39):
I have doctor friends are like, why do we need to examine the patient? It’s obvious what’s wrong with them? There’s a hernia. Why do I need to examine that? Well, for this very reason, the second patient I told you about had a hernia, but that wasn’t her problem. The pain was cephalad up and more medial inward than her hernia. So if you had examined her, you would’ve known that her pain is, the pain is toward the middle and her hernia is to the side. So where she’s complaining about cannot be explained by the hernia that she has is a different problem. And to top off onto on top of that, for some reason a lot of doctors and surgeons do not look at the imaging themself. They believe radiologists. That’s their specialty. So if they can’t figure it out, how am I supposed to figure it out? But I would disagree. I would say as a surgeon, the more you read your own imaging or even sit down with a radiologist, make friends with your radiologist, sit down with them and go over the imagings that you ordered, especially for your complicated patients and you’ll learn so much, you’ll learn so much about ’em.

(00:23:58):
Let’s see. Do you have any questions? I’m happy to respond to ’em. I have a feeling I’m going to get a lot of comments out for this show because this is such a difficult topic to digest for some people. But I hope I can impress upon you the importance of experience and time and energy on this topic and also persistence if you can’t figure it out or not getting the right answers, be persistent. See more people get second, third and opinions because that’s really what you need to get the help that you need. Let me just share with you some questions that were sent to me.

(00:24:59):
Let’s see. What are the current treatments offered for POP and SUI? So SUI is stress urinary incontinence and POP is pelvic organ prolapse. Is mesh implantation of any form still preferred or the first choice approach? Yes. So there’s still transvaal mesh being used. Most of the companies in the United States are no longer marketing their meshes and or no longer selling their meshes. Some companies went bankrupt because they just got bombarded with so much I lawsuits. However that said, it’s still available and I know that people are still getting transvaal meshes placed. An alternative is the use of not synthetic mesh, but absorbable biologic meshes. It’s unclear how effective the quality of these is.

(00:26:02):
And lastly, what they’re doing is a very old fashioned technique using your own tissue called tensor fascia or TFL where it’s a scar in the lateral thigh area where they take a strip of your tensor fascia lata and use that as a autologous biologic mesh for placement. Oh, here’s a question. Let’s see if I can help answer this. I had an ankle hernia surgery on the left side, April, 2024 using shoulder dice technique The following year, January, 2025, the ultrasound found a recurrence left indirect inguinal hernia. It contains fat reducible changes with Valsalva in September. So a couple weeks ago, the ultrasound found the same recurrent hernia. This time it’s not reducible and contains fat. The hernia has changed from reducible to non reducible. Do I need to see a surgeon urgent to do a hernia surgery? No. So we don’t go by whether it’s reducible or non reducible, we go by symptoms.

(00:27:15):
So if you have symptoms, you should get it repaired. If you don’t have symptoms, if it’s incarcerated chronically, that’s what we call chronically incarcerated. That means the fats are stuck in there forever. There’s no need to have urgent surgery. We really go by symptoms. So that’s a very good question. I don’t know that we’ve ever talked about incarcerated hernias before. We may have long, long time ago we had a whole episode on incarcerated and strangulated hernias very early. I think it was pandemic time. I think it was pandemic time. Okay, thank you for that. Next question, why is transvaal mesh removal concerned so difficult that only a few experienced and special ed surgeons are able to perform it safely and effectively? Good question. So I did allude upon the fact that transvaginal mesh removal surgeons are not common and they’re probably more difficult to find than hernia mesh removal surgeons. So these tend to be urologists or gynecologists. I’m willing to bet most of them are urologists because the mesh mesh needs to be removed in a plane between the vaginal wall and the urethra, which means you don’t want to injure the urethra because then you can’t urinate and you don’t want to cause any injury to the vagina, although it’s more difficult to do because that’s a very vascular one because that could cause a lot of quality of life problems and definitely make it so it’s difficult to have intercourse.

Speaker 2 (00:29:04):
So on that note, excuse me,

Speaker 1 (00:29:15):
It’s a very, very tenuous operation and the reason for that is you can imagine the mesh is sandwiched between two major organs and so you have to remove the mesh without injuring those organs and yet make sure you don’t cut a hole in either of the two organs and then the rest of the mesh can be in a tricky position as well. More difficult than trans is the trans opturator mesh because those meshes, I can’t believe why anyone would do this, but they came up with it. Those meshes go out to the side like a wide U up against along the pelvic floor, out against through the opturator muscle and what’s through the operator muscle?

(00:30:24):
You have the opturator artery and vein, you have the ator nerve, and you also have branches of the ental nerve nearby the peroneal branch, excuse me, of the pudendal nerve. So there’s a lot of stuff you could injure just placing the mesh and then removing the mesh means even more likely that those structures will be injured, which can be quite consequential, specifically the ator nerve and the perineal branch of the pudendal nerve. And when I operate, I can see the ator canal, but I’m usually deeper than where the trans ator meshes placed. So usually I’m not able to address any of those problems in my specialty. Usually the transvaginal retro pubic where it doesn’t go laterally through the opturator canal, it goes up behind the pubic bone through the rectus, is much easier to address. Sometimes it is stuck to the bladder and so you have to make sure when you remove the mesh you don’t injure the bladder and so on.

(00:31:47):
But oftentimes it’s just really tricky, the pelvis, it’s like the brain. There’s so many critical things going on there. You’ve got your bladder, the rectum, all these weird nerves that no one really learns about the sexual function in the area, the vagina uterus, there’s so much going on down there and it is really, really tricky. Most general surgeons, with the exception of the colorectal, I’m sorry, I’m going to rephrase this. With the exception of well-trained colorectal surgeons are very uncomfortable and do not really understand most of the pelvic organ region. As a general surgeon, we’re really happy in the abdomen. The pelvis is really, it’s complicated. So I’ve had to learn a lot and thank God I’m surrounded by a really smart gynecologist and urologists many of whom I’ve interviewed. So I would say that it’s just really difficult to operate in that area. So now you have a surgeon, either urologist or gynecologist who chooses to be that person, which means you’re inheriting, check this out, you’re inheriting a patient population that’s already depressed, suicidal has PTSD from all the downside effects of transvaginal metric.

(00:33:31):
They can’t have sex, they’ve lost their spouse, they’ve lost their job, they’re dealing with infections and their whole body is messed up. Then you have to go in and do this very critical operation which has filled with complications. You can cause fistulas, poor healing injury to the urethra, the bladder, the patient may not get better after the mesh removal. Now you have all these other risks associated with the mesh removal. So it’s quite a difficult specialty to have and for most surgeons, it’s not like a lifestyle they want to have because it’s a combination of maim patients, difficult operation, a lot of intensive work with patients. So I personally like it because I feel if you can help the patients, it’s very, very satisfying and it’s really good to be able to be that person. I’m sure the urologists or gynecologists that choose to be in that field feel similarly, but there’s not that many of us.

(00:34:43):
I’ll give you an example. As you may know, I have a lot of hernia friends and some of them are really good surgeons but not that good at interacting with patients. So if I give them a hernia to fix, they’ll do an excellent hernia surgery. But if I tell ’em to go talk with a patient because the patient has another half hour of questions, they’ll be like, yeah, no, that’s not happening. And it’s just, I don’t know if it’s a personal issue, if it’s a God complex that some surgeons have just you have to just agree that everything I tell you is what you need to know and everything else is on need to know basis only, and I don’t care to tell you anything more or they’re uncomfortable being questioned because they interpret questions as a way of being disrespectful or questioning them. But the patient just want to know.

(00:35:49):
It’s unclear why some surgeons are that way, but those are persons you should see for a big hernia, let’s say, but not a person who you should see for revision surgery. So if you have a complication and you need mesh removed or something like that, that’s probably not the best person for you to see because they just don’t have the personality to sit down, answer your questions, be available and handle someone with lots of anxiety, let’s say. So the same is probably true for gynecologists and urologists. So there are urologists that are phenomenal urologists and let’s say you have prostate cancer or you’re a gynecologist and patient has let’s say fibroids and they’ll do great surgery, but they’re just not present for you for the downstream questions and complications, et cetera that you may have. So I personally, when patients ask me for referrals, I try and keep that in mind so at least I know the hernia surgeons well to know this surgeon’s great for your type of hernia surgery or this surgeon’s maybe a gifted surgeon but not the best, most thoughtful person and not the one that’s going to sit down and think about your problem because that’s just not their forte.

(00:37:18):
So I hope that clarifies.

(00:37:22):
Here’s a follow-up on the patient about the recurrence after ROIs. Dr. Tofa, you are a great surgeon, thank you member. That’s very nice. After I had the anguinal hernia surgery in April, 2024, that’s the first repair. The pubic bone area has always been tender, which happens with shoulder dice or any tissue repair, especially if your hernia was a direct hernia. That area, it tends to be the toughest to heal from because it’s usually the tightest area. I always had the mild or moderate pain near the pubic bone area when crust, I also had mild bearable pain near the inguinal canal area. So this is a chronic pain associated with tissue repair that we’ve talked about in past episodes. So many people say, I don’t want mesh because I don’t want chronic pain. And that correlation is that correlation is not accurate because studies show you can have just as much chronic pain with a tissue repair. For those of you tolerate my cough, I don’t know why my throat is so dry today, but I do have my glass of water, so excuse me. Basically there’s an equal risk of chronic pain with tissue repair as there is with me repair. And the reason for the chronic pain with tissue repair is you’re constantly putting pressure and tension on your stitches, and in some patients that implies micro tears and eventually tears of your muscle, excuse me, and those

Speaker 2 (00:39:30):
Tears

Speaker 1 (00:39:31):
Can translate into a hernia recurrence. Okay, let’s see. Do I have to do the hernia surgery urgently? No, I am worried about strangulation incarceration that’s chronic does not necessarily result in strangulation. What are the chances of strangulation for an incarcerated hernia with fat? So the risk of strangulation for an incarcerated hernia with fat is very low. It’s usually the risk we see with intestine and if you have no symptoms, it’s close to zero. I do not wish to have a hernia surgery for the incarcerated hernia with fat if possible. That’s fine. Can I wait for a few years? Sure, you are right. The left side inal hernia is indirect. Okay. I meant direct. So if you have a direct hernia, your risk of pubic bone pain and hernia recurrence after a tissue repair is higher. So I tend not to recommend tissue repair in patients who are good candidates for mesh repair if you have a direct hernia.

(00:40:38):
Okay. Next question. Can recurrent hernia cause pain over the pubic bone as opposed to the inguinal canal? And how can you explain that anatomically just what I mentioned. So we’re talking about inguinal hernias. If you had a tissue-based repair or a mesh based repair, the recurrence risk is highest by the pubic bone and that’s because you’re either tearing the tissue of the pubic bone or you’re pulling on the pubic bone area. So in order to assess that, you would get imaging, for example. But yes, hernia recurrence is always more common medially by the pubic bone than laterally and for tissue-based repairs is because it’s just tighter in that region. And for mesh based repair, it’s often because there’s not good enough overlap by the surgeon in that area. Okay. Next question.

(00:41:40):
What strategies do you adopt to prevent pelvic organ prolapse or stress earning contents from returning after transvaginal mesh removal? So I’m not the best person to answer this. We have had a couple of surgeons, Dr. Hibner was one of them who were guests of ours that regularly do transvaal mesh rules. But I think what I’ll do is I’ll include in the future a surgeon was specifically only addressing transvaginal mesh and they can best answer as far as I know, there are tissue, old fashioned tissue-based repairs where they just cinch, they pull up and cinch, they do tummy tuck, but around the level of the urethra. So that I know happens. I’m told that those stitches usually don’t hold and they do a pull up where they stitch the muscles up to the pubic bone. I’ve seen those syringes done before. They often don’t help. So they may help or maybe temporary, but there are options. They’re just not I long-term.

(00:43:06):
What are the short and long-term complications after transvaginal mesh removal that patients face most commonly, I think we answered that. How do you envision the long-term care of a patient who needs to have a transvaginal mesh removed? Yeah, so it’s really a balance of what you’re willing to live with and how much surgery you’re willing to undergo. So as far as we know there’s good pelvic floor physical therapy that can help strengthen the muscles. I think there’s been some advances with regard to electromagnetic stimulation, DNS and those kinds of things. Weight loss always a good one because weight gain can add a lot of pressure and cause more pelvic organ prolapse symptoms.

(00:44:02):
I don’t know that there’s any good garments to help with this. And then lastly, because there are binders, but there’s no good garments. I have been told that a tummy tuck oddly can improve pelvic floor function. So some people who’ve had pelvic floor dysfunction get a tummy tuck for other reasons and then their pelvic floor functions improve. I think it’s all part of the core. And then what’s your appetite for having another surgery and having maybe a biologic or autologous biologic tends to fascia lata graft place to help with your urinary incontinence? It’s unclear. It’s unclear if every patient’s a little bit different, right? Some people are younger or they’re very incontinent. Those patients need something whereas others are willing to work or we’ll never have surgery again, that area is just really traumatic for them. Next question. Have you ever had any chronic pain postal hernia patients that you have not been able to help and had to do either neurectomies or refer to spinal cord implant? Yes, of course I have.

(00:45:23):
The most difficult of my patients are the suicidal ones. I have a handful of patients, maybe two or three, one in particular who is actively suicidal and unfortunately that also colors and affects his ability to see doctors and get care and follow through with therapies and so on. There are other patients that have a lot of centralization of their pain and no matter how much therapy is done at the endpoint, they have very centralized pain and need some type of spinal cord stimulator. I have reported on my outcomes from neurectomies, so we have 0% neuroma rate in people who have what’s called prophylactic neurectomies or pragmatic neurectomies, and we have a 3%, 3% or 4%, I think 3% risk of neuroma in patients with prior neuromas that required neurectomy. That’s very similar to the reports by others of about 4% risks. I think those are always very difficult. I think about many of those patients because I no longer see them and I’m very controlling. So I usually like to follow my patients and have them see me often. But there are patients that are, some of them are just resolute. They’re okay with just dealing with how they are currently and don’t want any more therapies even though they’re not perfect, they’re just okay being where they are in their life. And spinal cord stimulator can be a lifesaving procedure for many patients.

(00:47:24):
I don’t really understand how it works. We did have a little bit of discussion with it of our pain doctors, both doctors, Simi and Leilani in particular in past episodes where we talked about this. So I would say it’s necessary for some patients, yeah. Okay. Next question. One surgeon said, ultrasound is not an accurate modality for hernia based on what? Go read my paper. So also the surgeon said they will not operate on a hernia if there’s no protrusion, stay away from that surgeon. What does this mean? So that surgeon needs to A, read my papers, B, read other people’s papers that completely refuse what they say. First of all, protrusion is not a requisite for a hernia. There’s something called occult inguinal hernias. Most people with occult hernias where there’s no protrusion, if you actually palpate the area, you will feel the hernia. It’s just not large enough to smack you in the face with it, in which case you don’t need to be a smart surgeon to operate only on those patients.

(00:48:35):
So that’s completely incorrect. Secondly, ultrasound is very accurate for modality if it shows a hernia. So our study shows that the true positive rate of a ultrasound is a hundred percent. So if you have a ultrasound and it shows a hernia, you have a hernia, it’s hard to, what else could it be? Whereas the false negative rate is 50%. So half the time if you have an ultrasound and it says it’s negative half the time, that’s true, and half the time that’s false. That’s a 50% false negative rate. So if you have, it’s called triple concordance, right? You need three things to be true, the history, the physical exam and the imaging. So if you have someone with a good history for an anal hernia and you have someone with a physical exam, let’s say suggestive of a hernia and you have an imaging that doesn’t show a hernia, let’s say your ultrasound, then you should move on to an MRI CAT scan is horrible for small anal hernias.

(00:49:50):
You need to do either an ultrasound or an MRI. We have a whole algorithm of it published in our paper. You can go Google me and write Towfigh imaging in our papers are there. So we have an algorithm as to what algorithm you should follow for imaging of occult hernias. So this is very interesting because you are the same patient that just wrote, you had two ultrasounds, both confirm hernias and now it’s showing those worse. In which case I would not understand why a surgeon would say that an ultrasound is inaccurate when you had two back to back that support each other and you have pain.

(00:50:34):
What’s so difficult about this here? This is what really irks me, and I see this every single day. I have a group chat with my friends and I feel like every day I want to write and scream about a situation I see because it makes absolutely no logical sense. The only reason that I would say any doctor would see a patient who’s had a hernia, has had chronic groin pain from the hernia repair and has two ultrasounds that show hernias and they’re going to ignore all of that. Your history, probably your physical exam and your imaging and just say ultrasound is not accurate. And if there’s no bulge, there’s no hernia that’s complete BS complete, yes. I just dunno what to say to this. All I can say is that is not the surgeon you should be going to for any of your treatment because either they’re just saying this because they don’t want you as a patient or they’re not a very logical person, which means they’re not going to be making smart decisions when it’s important to make smart decisions. So that’s how I feel about it. It really irks me. It really irks me when patients like you are getting ultrasound after ultrasound pain after pain and you’re basically not being treated for it. It really bothers me.

(00:52:06):
Next question. Does the pudendal nerve provide any of the sensory innervation for the lower groin and lower or inferior pubic bone area? So the groin, no, but the midline structure structures, yes. So clitoris certain parts of the pannus, perineum rectum, those areas, yes, but I would say groin, no, not that I know of. Same question. After shouldice inguinal or hernia surgery, there may be scar tissues. Will this affect ultrasound finding? Yes, it’ll affect ultrasound findings. I usually don’t recommend ultrasound if you already had surgery because the scar tissue can confound it and give you false negative, but you have a positive fighting still despite all of the scar tissue, they still see a hernia. How does the hernia look? It’s the fact that goes in and out of a hole. They’re seeing that the fact that they’re seeing the hernia despite all of those findings is even stronger. Reason for you to believe that there’s a hernia finding, plus you have symptoms suggestive of it, plus your exam is probably showing that you have a hernia there. So this is why logic needs to, needs to come first and they’re literally measuring it. Neck 0.4 centimeters, sock 1.3 by 0.4 by 1.3 centimeters. They’re literally giving you as much information as any excellently done.

(00:54:02):
Ultrasound would show. They say it’s an indirect hernia lateral to the inferior epigastric vessels. That is a really good description. You’re lucky you’re getting high quality ultrasound. You’re unlucky with your surgeon and you should move on to another surgeon. That surgeon may be great to do your first repair, but they’re very uncomfortable handling the subsequent situation, which is common by the way. Let me give you another story. We’re almost done here. So I have a patient, let me backtrack. There are surgeons in our area that are highly gifted. If I had a hernia or my mom had a hernia, this surgeon may actually be someone that I would refer to. Very gifted surgeon like everyone knows he’s amazing. However, I would not send a patient to the surgeon for a chronic pain situation after angulo hernia repair. I just wouldn’t. They just don’t know the algorithm.

(00:55:13):
They’re not comfortable with what questions to ask, what kind of physical exam. They can’t interpret imaging or an MRI. There’s don’t do injections. There’s just no good algorithm. I’ll give you another example. We had a joke about this in the office because it’s so ridiculous. Triple neurectomy. So triple neurectomy is one of many tools we have to treat chronic post angle or hernia if pain, but most people do not need triple neurectomy. I know that my nurse knows that. I’m willing to bet. If you were to take all the general surgeons in the US and you said, I have a patient with chronic postal, her neuropathy pain, what’s the treatment for it? And you gave ’em three options and triple ectomy was one of the options. They would choose triple neurectomy. Not true. Most patients don’t need a neurectomy, let alone a triple neurectomy. If you’ve had a laparoscopic repair, you definitely don’t need a triple neurectomy. That makes no anatomic sense. And yet I have patient after patient that come to me with chronic pain after their inal hernia repair and somewhere along the line of the multiple surgeons that they’ve talked to, most of whom are not specialists, they were offered a triple neurectomy, which would’ve been a horrible thing to do because their nerves are totally normal.

(00:56:53):
Okay, I’m sorry. I get so pissed off when I see so much misinformation pedaled to patients which can hurt the patients. Okay, can isolated lower pubic bone without bone pain without rectal or peroneal pain because by pudendal neuralgia, usually not. There is a dorsal clitoral nerve. I believe there’s a dorsal penile nerve, but that’s not pubic bone pain. My pubic bone pain improved with diagnostic pubic nerve injections, but I do not have the peroneal rectal or penal pain, right? You don’t have to have all the ental nerve pain. So you can have a branch of the ental nerve but isolated pubic bone pain. It’s usually not perineal in any way because if you’ve had a hernia pair, the ental nerve, this branches should never be part of the injury. So you’re just getting distracted. One surgeon examined me at the end of May and oh, this is going back to the S shouldice patient with two ultrasounds showing hernia recurrence.

(00:58:12):
One surgeon examined me end of May, and another surgeon examined me early July. They both said, I have no hernia on the left side. What shall I do see a hernia specialist? I don’t know how much more to stress this. If you have two ultrasounds that show hernias, then their exam should be abnormal. Your exam, sorry, their examination of you should be abnormal because you have pain in the area. You should have somewhat of a swelling in the area. And this week I had a patient who has been told over and over again by the same surgeon that they have no hernia. Now my nurse would’ve known that that’s completely incorrect. The patient had surgery over a decade ago. They did fine for a decade and then recently has groin pain. So they’re like, oh, it’s your mesh. Oh, you need triple no. If you had a hernia repair over a decade ago and you were doing fine until this year and now you have pain, I hope you all know the answer. What’s the answer?

(00:59:28):
Recurrence ular, hernia recurrence. So I said, send me your imaging. I’m willing to bet my house that you have a hernia recurrence. So he sent me the imaging, guess what, hernia recurrence both sides. So he’s like, what do you mean hernia recurrence? I’ve had CT scan, MRI ultrasound, they’re all negative. Nope. I reviewed all of them. They all showed hernia recurrence. And I said, I’m willing to bet if I examine you that you’ll be tender over the area. And so I look forward to examining him and offering him hernia repair. It’s just crazy. I don’t know. I dunno what to say. Is it safe to inject the gentle by injecting into this spermatic cord?

(01:00:18):
That’s usually, I mean, yes, answer is yes if they know where they’re injecting, yes. Okay, sorry, I get pissed off sometimes when I see patients are being given the wrong information and they’re just being given the runaround and then image after image keeps showing the same thing, but it’s misread and they go to surgeon after surgeon who really shouldn’t be treating these patients. What they should do is say, you know what? I don’t really know how to do this or I’ve never done it, or it’s really outside of my skillset. You need a specialist the same way if you had a liver cancer or a pancreatic cancer and that surgeon will probably refer you or do you liver transplant? That surgeon will refer you to a specialist. They should do the same thing for these hernias because it’s really a disservice and I just don’t understand.

(01:01:11):
Anyway, thanks for rallying me up. Now I have to go do a house call on a patient. So hope you guys do well. I’m going to continue working after I say goodbye to you all. So thanks for joining me. I’ll see you again next week. We have I think that, and then I have another meeting to go to the following week. So don’t forget, I live tweet when I go to surgical meetings. So follow me on X if you like to hear what we do during surgical meetings. I’m at Hernia doc, I’m also on Instagram at Hernia doc where all my fun stuff is. If you want to have a laugh about hernias, that’s the place to be. I’m a little bit more serious on Facebook at Dr. Towfigh and at Beverly Hills Hernia Center. And remember, if you like podcasts or if you like to watch things on YouTube at Hernia Doc, all of these are all my hernia talk live sessions are available for you. And on that note, thank you and goodbye.