212. … and We’re Back!

This week, the topic of discussion was: 

• European Hernia Society
• New Technology
• Mesh Implant Illness
• Mesh. Removal
• Abdominoplasty, Tummy Tuck
• Hernia Repair Outcomes
• Deep Tissue Massage

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

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

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Transcript

Dr. Towfigh (00:00:23):
All right. Hello. Welcome to everyone. I’m back. It’s 2026. I’m so excited to restart Hernia Talk Live after a short hiatus. My name is Dr. Shirin Towfigh. I am your hernia surgery specialist. You all know me from my weekly Hernia Talk Live podcast, which I love that you watch and share. Thanks for everyone who follows me on Twitter or X@HerniaDoc and on Instagram @ herniadoc. Many of you are currently live with me via Facebook Live on my Beverly Hills hernia center page. You can also follow me at Dr. Towfigh. And this and all prior over 200 episodes of Hernia Talk Live are available for you to watch, share, enjoy on my YouTube channel at herniadoc and also as a podcast. I personally prefer podcasts, so I really like that you can drive or do house chores and listen to podcasts, put your makeup on as I do in the morning and I listen to podcasts.

(00:01:38):
So welcome everyone. I’m so happy to have you here. And starting 2026 with you all, it’s been a while. I took a little over a month, month and a half off because I was bombarded with patients and I really needed to focus on patient care and the days that I do Hernia Talk Live for being overwhelmed with not only patients in the office, but also surgeries. So that is why we haven’t had one for a while. And our last one was with this great hernia couple from Brazil who I love and I follow on Instagram. And I hope you all go back and listen to that last episode because they were a great, great group. My first ever hernia couple, male and female hernia surgeons in Brazil that are now a couple in real life and a partner in their surgical practice. Really awesome. They’re great people.

(00:02:43):
So hello from Portugal. Oh, hello from Portugal. Nice to see you, Fernando. I hope to see you in Porto coming soon. As many of you know, I try and use Hernia Talk Live, not only to educate you as patients that are out there, but also to share some of what we do in the hernia world. So when I go to the European Hernia Society meeting, which this year will be in Porto, I will be sharing everything that I learned from there. And for those of you that are curious to follow me as I do all of my rounds in the different surgical societies and give talks and et cetera, on the academic side, I always live tweet the meetings that I go to. So for example, this weekend is the Southern California chapter of the American College of Surgeons, and our paper is considered one of the top papers to be presented there.

(00:03:40):
I’m really excited. It’s a discussion about whether or not you should be operating on relatively sick patients, people with heart disease and high blood pressure and diabetes, and whether that actually has an effect on their hernia repair. And the answer is no. So surgeons who are skilled enough to be able to perform a safe hernia repair in our study show that at least in the United States nationally, if you are operating on a relatively sick patient, they do just as well from a hernia standpoint. And so maybe those patients should all be given the opportunity to have a better quality of life from a hernia standpoint. So I’m excited. My research fellow, Ian Kim will be presenting this on Friday. So we’re all going to be at the annual meeting of the Southern California chapter of the American College of Surgeons. And then later this year, one of the many travels that I have planned will be in Portugal.

(00:04:43):
So hello from Portugal. Thank you, Fernando, for following me and always being a good hernia friend. So it’s been a while, and therefore I thought I’d catch you up with a couple things. For those of you who follow me, you know that I finally have been granted professorship at the UCLA School of Medicine, officially called the David Geffen School of Medicine at UCLA. As you know, I train at UCLA. I currently teach at UCLA, and so being awarded the highest academic level that a private practice surgeon can attain was a milestone that I definitely was looking forward to. And to say that it was to say that it was an onerous and convoluted process is an understatement, but I’m not questioning it. I’m very happy that it happened. So thank you, UCLA for doing that. And many of you don’t know, but it’s a big deal to get to professor level.

(00:05:52):
There’s assistant professor, associate level, professor, and then professor, professor. It’s a very big deal to reach the professor level in any field, but especially in private practice, it’s almost impossible to do so. Many schools make it very, very hard for someone in private practice to gain any academic status in their medical school. So what it takes includes not only being a world-renowned doctor in your field, but also someone who donates at least 50 hours of teaching hours to their medical school, which I do. I teach the medical students as they enter their clinical years, and I teach them different surgical components like dressing changes, abdominal exam, head and neck exam, vascular surgery exam, how to place nasal gastric tubes and Foley catheters, and also how to do stitching and suturing on a dry lab, which is what we call it, which is on certain types of workbooks, but also in a cadaver lab.

(00:07:09):
So yeah, it’s a lot of dedication for free, by the way, completely for free, but I do enjoy it and I feel like hanging around young people keeps you young. So I do appreciate that after so many years of applying for it, they finally granted that. And I think I may be incorrect, but I was told I’m one of only two private practice surgeons at my hospital that were afforded this. Everyone else was denied, so I’m very grateful. Thank you very much. I appreciate it. So that was a big deal for me. We’ve had a couple of other big deals happening in 2025, which are following us in 2026. Many of you know that I have a office now in Northern California. So if you live in Northern California, you don’t have to fly down to see me anymore. Or if you’re near Northern California, so kind of Seattle, Oregon, Idaho, Nevada, Northern Nevada section, then coming to Northern California may be easier than coming all the way to Southern California.

(00:08:25):
I go there now currently only once a month, but it’s slowly increasing in volume. So for example, in January, I will be there for three days as opposed to one day. So we’ll see. I’m really excited about it. I have family in Northern California, and I kind of like the Northern California vibe. It’s very different from Southern California. I always knew it was different because Southern and Northern were always considered two different states in California because we were so different, but I had mostly experienced San Francisco, which is not that different from Los Angeles. But Silicon Valley, where my office is, very different, very, very different. It’s woodsy and homey and everything that LA is not. LA is superficial and everyone’s driving a fancy car and got plastic surgery done and there’s none of that in Silicon Valley. No fancy cars, no one with plastic surgery.

(00:09:34):
They just live their life, a lot of families, and a lot of really, really smart engineers. Everyone’s an engineer. So I love it. I kind of relate to that population myself. So let’s see. Anyone who has questions, please give me the questions. I have a couple that’s already ready from online. There’s others that have sent me questions ahead of time for today, so I will try and answer those. But if you do have any questions, I’m here for you because I haven’t been here for you for past month and a half. Here’s a comment. “Congratulations on your academic achievements. Thank you. Here’s my question. Can deep tissue massage break up scar from a four-year-old open hernia repair?” Answer is yes.

(00:10:31):
I strongly believe in deep tissue massage. There are really good examples on the plastic surgery side of how deep tissue massage can help break up scar tissue. It’s not just for early post-op. There are things you can add to it. There’s hyaluronic acid that can be added to help break up scar. That’s an injection. There is red light therapy and different types of, I think it’s called not ghrelin. It sounds like ghrelin, but it’s not ghrelin. But yes, you can definitely benefit from deep tissue massage and other modalities. So for example, we have a plastic surgery office that I share patients with and they have a whole slew of machines that help. There’s ultrasound, there’s this kind of thing that breaks up, it heats up the tissue. Anyway, long story short, if you work with a plastic surgeon that’s gifted, they may have certain machines and actually a dedicated tissue masseuse in their office that provides all these fancy ways of breaking up scar tissue.

(00:11:53):
So yeah, hyuronic acid is a good one. I had a patient who was getting that injected in London to help treat his really, really bad scarring and very, very painful scarring. I don’t know why he would scar so much, but some people scar more than others, and that can be very painful. And some patients, the scarring can entrap your nerve like the ileoing nerve or any nerves in the groin area. And so releasing the scar both by manipulation, deep tissue massage and by injection of the hyaluronic acid can be something that can be very helpful in a fraction of patients.

(00:12:33):
Okay. Here’s another question coming up. Let me share this with you. Oh, can the massage disrupt the actual repair? Good question. Depends. If there’s mesh there, unlikely. So it’s very unlikely that deep tissue massage will disrupt a mesh repair. I was just operating today with a plastic surgeon, and I value his take on things very much because he’s super obsessive, compulsive about his patients and what he does in the operating room. And we were doing a mesh removal surgery and a tummy tuck kind of combination in a patient with a belly button hernia. And I asked him what he thinks about soft tissue massage and using these massage therapists that are medically inclined, and he says he never does it. And I asked him why. He’s like, “Well, all these stitches I’m putting in, they’re going to pop all those stitches.” And it sounds like that seems like a thing that would happen, especially if it’s very aggressive, but these people who do it actually are not aggressive at all.

(00:13:41):
So if you have a physical therapist or a skilled soft tissue mastuse who understand surgery, they will know not to do deep tissue massage that will disrupt a repair. If you’ve had a tissue repair with no mesh, then yes, you’re at higher risk that deep tissue massage will disrupt the repair. But usually, usually deep tissue massages will treat the skin and the fat and nothing deeper. So it will not affect the muscle or the fascia on top of the muscle. It will focus on the layer on top, which is the skin. And so most deep tissue massages should not disrupt a hernia repair. And a lot of the hernia repairs are done deep to the muscle, so it definitely will not affect that as well. And if you have had mesh, then it will not affect it as well. All right. Next question.

(00:14:46):
Have there been any significant advancements in hernia treatment in the past five years that are not widely offered yet and may therefore elude patient awareness? Good question. I always wanted to have a session where I would invite, let’s say, five different surgeons who I respect on a panel at a time and then ask them things that they do that’s unique to them because I’ll give you an example. I’ll give you an example. When I remove mesh, especially in males. So when I remove mesh in males and I do it robotically, and it’s done specifically because they have testicular pain from their mesh placement. So normal male, you had an inguinal hernia repair, it was done robotically, which is very common right now, or laparoscopically, and they put mesh over the hernia. That mesh sometimes sticks to the spermatic cord, which is all the contents that feeds the testicle.

(00:15:47):
And in some patients, it could be very pathologic the way it sticks to it. So it sticks to maybe the artery, maybe the vein, maybe the nerves that goes to the testicle and maybe to the vast deference. So specifically with the nerves, if you then have a long piece of mesh stuck to those nerves or the mesh is abnormally stuck to those nerves, you can get testicular pain and the treatment for that, you can try injections between the mesh and the spermatic cord to try and release the two from each other. So for example, the hyaluronic acid we just talked about for scar release, you can inject that between the mesh and the sermatic cord and try and release scar tissue between the mesh and the spermatic cord and help with testicular pain. Very difficult to do because getting it in the right space is hard to do.

(00:16:52):
Let’s say that doesn’t work or it’s not possible to do. The treatment is to shave the mesh and release it off of the spermatic cord. Now, what happens there? What happens there, and I’m not the only surgeon that offers it. There are maybe a dozen other surgeons in the US that do a good job of that, but I do it quite often, mesh removal. What happens though is now you have raw tissue, raw inflamed tissue, and specifically nerves and contents of the spermatic cord that go down to the testicle. So anytime you have raw tissue or inflammation, and now you want to fix the hernia with another mesh, any mesh, it could be lightweight, heavyweight polyester, polypropylene, or even biologic mesh, let’s say, or absorbable mesh.

(00:17:49):
That inflammation on the tissue will intensely stick to the mesh, which is also usually inflammatory. And those two after surgery are also at risk of the same thing happening again. So what I do is I take an anti-adhesive barrier, it’s like a sheet, it looks like this, it’s like a sheet of Kleenex tissue, and I wrap the spermatic cord with it, and that reduces how much scar forms on the spermatic cord. So then when you put mesh over it, it reduces the risk of the mesh causing any abnormal interaction with the spermatic cord, and therefore reduces the risk of another testicular pain episode. I don’t know that most surgeons do that. In fact, I’m willing to bet no one does that. I never published it. I have talked about it in my talks, but it’s not really … I mean, how many people watch my talks?

(00:18:58):
It’s not widely known.

(00:19:02):
There’s another surgeon, great surgeon, who is on the East Coast, and I learned from a rep actually, was it from a rep or maybe someone who trained with him, that he takes the 3D max mesh and he doesn’t like the way that it’s welded on the edges. So the 3D max mesh is like a braided polypropylene and the edges of it are welded and it makes it a little stiff, just a little bit enough for it to kind of pop open and stay flat. Well, he doesn’t like the fact that the bottom is too stiff. So he physically cuts out the welded portion of the mesh before he puts it in place. Never heard of that. I’m actually thinking, that may be an interesting idea to make it softer on the bottom edge. And he feels, and I haven’t discussed it with him yet, but he feels, I’m told, that making it softer and more malleable on the lower edge of the mesh before putting it in laparoscopically or robotically makes it more likely to stick down and therefore lower risk of recurrences.

(00:20:24):
Never published. I’ve never read it. I’ve actually never heard him talk about it, but it’s one of those things that maybe is a good idea. So one of my ideas was I want to have a panel of surgeons who I respect and no more than four or five, and I want them to … Each of them spew out these little things that they do that are genius. So for example, I’ve talked to you about our use of the tummy tuck to replace mesh. So basically we’re using your own tissue to function as a permanent layer over your hernia repair. It’s the same way a mesh would be a permanent layer over your hernia repair to support the hernia repair. And not a lot of patients fall into the category of needing a tummy tuck, and maybe some patients don’t want to pay for a tummy tuck, but if you are a candidate for a tummy tuck and you happen to need a hernia repair, which mesh is indicated in, you may consider getting a tummy tuck and use it and then foregoing having mesh put in you.

(00:21:47):
And we actually reported that in the European Hernia Society meeting in 2020, 2020 in Manchester. No, there was no 2020, 2021 in Manchester. And then that was very well received. And then we submitted the paper for publication. So super excited about that. I know that every single surgeon has their own little way of doing certain things. When I go to these meetings and I watch the videos that they put up, they sometimes do things that I was like, ah, that’s interesting. And I picked it up as a way of doing something. For example, neurectomy. One of the surgeons, without even thinking it’s a big deal, but no one really teaches you how to do a good neurectomy. And he was showing how he does the surgery and he happened to had to do a neurectomy. And he saw in the video that, well, everyone knows that it’s a good idea to dunk the nerve into a healthy muscle at the end of the neurectomy.

(00:22:57):
So you cut the nerve, now you have the open ends of a nerve, like cutting a wire and there’s open ends of a wire, and then those open ends need to be tied so that scar tissue doesn’t go into it and then buried into muscle to prevent it from getting scar in it. Well, there’s different ways of doing that. I was taught a certain way. This guy did a very unique way. It was like, oh, that seems really cool. Instead of dunking it in, he kind of pulls it under into the muscle. It was just a cute, simple way of doing it. And so sometimes I do that technique. My point is, yes, there are little bits and pieces of ideas and techniques that come out and the more involved you are in the Hurting Societies and the meetings and talking to people, the more you learn about these.

(00:23:58):
But I feel like your question is valid in that these things need to be widely distributed because … I’ll give you an example.

(00:24:10):
I try and do as many international projects as possible because we are very blessed in the United States. We have a lot of surgeons who are showing interest in hernia surgeries. We have great support systems and mentors, and many of us help each other out. But you can go to a country in South America, Central America, Asia, for sure Africa, and even Australia, there’s a lot that they can learn that we’ve already been through. We’ve been through the growing pains and the learning curve of different hernia procedures. They’re still at least 20 years behind us. So when I give talks or I do live surgery for them, I really do emphasize some of the techniques and tips that we learn not to do because I see them being done in these other countries. You can go on YouTube and watch some videos and you just want to pull your hair out because you’re like, “What are you doing?

(00:25:22):
This is so wrong. We know that this is the wrong way. You shouldn’t be holding it like this. You shouldn’t be pulling like this. You shouldn’t be cutting here.” And unless you have a good rapport and good relationship and you’re well accepted as an expert, surgeons are kind of egotistical. Can I say that where you get egotistical? We all think we do it all the right way ourselves. And so surgeons are not the best at changing or improving or following. But if they know someone that kind of talks to them … I’ll give you an example. I went to a certain country where I was invited to be in their OR and the surgeon was doing … He’s a well-respected surgeon in the hernia world and he was doing this hernia repair and I was in the room. And I’ll just say I would not have done it that way.

(00:26:29):
I would’ve spent a little bit more time developing the plane so that the mesh is perfectly flat before I said, “I’m done. This is robotic.” And it wasn’t as flat as I would’ve placed it. The space wasn’t as wide as I would’ve made it. And this is exactly why certain people get meshomas. It’s why certain patients get meshomas or the mesh gets balled up or they have complications after their hernia repair. There’s a reason why there’s a term CPIP, chronic pain, chronic post-aningual herniaphy pain. So chronic pain after inguinal hernia repair, there’s an actual term for it. So since I was there, and he was a nice guy, he was asking me, “What do I think? ” And I was honest, I said, “I would do more.” And he did. He was like, “You mean like this? ” And I said, “More.” And he did some more.

(00:27:28):
I said, “You mean like this? ” I said, “More. More on the lateral side, more on the inferior side.” And then the mesh laid flat perfectly. He’s like, “I like it. I like it. Yeah. Okay, this is good.” And then there was another patient and he had to put in a large piece of mesh. And I said, “Can I show you how I do it? ” And this is another one of these little tricks. So if you want to do something laparoscopically or robotically, but you have to put a large piece of mesh in, how are you going to get that big piece of mesh when you only have little five millimeter instruments or eight millimeter instruments? Well, there’s a way to do it. And so I have this technique where I roll up the mesh and then I clamp it sequentially to keep it fully tightly rolled up so you can then push it through this, what we call trocar, push it through.

(00:28:19):
And then as you push it through with your laparoscopic instrument, you sequentially remove those clamps. It works perfectly. So I taught him and he’s like, “Ah, I like it. We always struggle so much trying to put the mesh inside.” I said, “I know. ” And some people make the mistake of removing that trocar and then jamming the mesh through the skin into the abdominal wall, which A, increases your risk of contaminating the mesh through the skin, and B, increases your risk of getting a hernia at that trocar site, whereas you shouldn’t really get hernias from laparoscopic or robotic hernia sites. So my point is there’s so many little ways of doing things. For those of you that watch Martha Stewart or Julia Childs or Megan Markles doing these shows now where they teach you how to make soap or fix a gift wrap or bake a cake and they give you little tips and tricks like if you want to make your, I don’t know, such and such look pretty, put it in ice water.

(00:29:40):
And all these little tips and tricks that are not necessarily in a book, I wish we had that for hernia surgery because there’s a lot of these little ideas that people have that are smart and some are horrible. I’ll give you one that’s horrible.

(00:29:57):
It’s called abandoning the sock. And So abandon the sac is basically a lazy surgeon’s way of fixing a hernia and it’s fraught with complication. Before I get to that, let me answer a question and I’ll come back to my train of thought. Question, is the anti-adhesive wrapping of the spermatic cord necessary in some cases of lap hernia repair and how do you decide at the time of surgery? So everything is not without risk. So when you put anything that’s anti-adhesive, it also implies that there will be less scarring, but you need scarring to heal. So you have to be very careful if you’re going to wrap the anti-adhesive around the spermatic cord, let’s say, you have to limit it to the area of concern and not just put anti-adhesive everywhere. And you have to make sure it doesn’t prevent your mesh from adhering everywhere else.

(00:31:12):
So I personally think the mesh should be made with the anti-adhesive already on it. There’s no reason why the mesh needs to stick to the spermatic cord. It just needs to stick to the muscle. So I have patents that are available, any company that’s interested. I have patents that are available right now where you can develop mesh that has the anti-adhesive already as part of the mesh. So certain areas where there’s nerves, there’s vessels and/or there’s somatic cord contents should not be stuck to the mesh. Now, do I use the anti-adhesive in primary hernias? The example I gave you, I had to remove mesh and it was very raw. The answer is usually not unless their main symptom, unless their main symptom is testicular pain. So there are patients that basically have a lot of testicular pain, and it’s because of their upstream hernia. You fix the hernia, the downstream testicular pain goes away.

(00:32:23):
In those patients, I feel like they’re already hypersensitive with their testicle, so I don’t want to add the mesh interaction as another reason for them to get testicular pain. So yes, in really young patients, especially those who have lot of testicular symptoms, I do wrap this rheumatic cord with an anti-adhesive before putting mesh on it. And it’s just worked really well for me, and I feel like all meshes should be changed to be that. Next question. If you do a large enough dissection to allow mesh to flatten in a lap repair of a large direct hernia, does that mitigate the need for fixation with tax in a large direct inguinal hernia? It does not. Great question. So the large dissection is intended to make the mesh flat. Now, if you are choosing to upgrade your mesh to even larger mesh, so move from a 10 by 15 centimeter to a 12 by 16 centimeter, for example, then you must also make the dissection wider.

(00:33:30):
That’s a given, but it doesn’t mean that you should forego fixation. So personally, to me, it’s a physics issue. So if you have a small hernia, big mesh, great. Big hernia, small mesh, bad combination. So the larger the difference between the hernia hole and the mesh. So the wider the mesh compared to the size of the hernia, the less likely it is you need any fixation.

(00:34:00):
So I fixate almost all direct hernias because they’re almost always wide mouthed and/or very loose. So you don’t want to do a beautiful hernia repair, beautiful dissection, and put a large piece of mesh, and then your mesh will billow into the hole and recreate the hernia feeling of the patient where the mesh is falling into the hernia every time they laugh or bend or shout or whatever. So one technique is to plycate or invert the redundant transversalis fascia of that direct hernia. That’s to make the hole more flat to allow mesh to stick to it. But I also still place, I don’t rely on those stitches because those can tear because it’s just thin muscle. So I also fix it. So I do what’s called triangulation. So I always have three tacks and the three tacks are put in a triangle with a center of the triangle being the main hernia.

(00:35:12):
So if it’s a direct hernia, I put a tack below the femoral space medially above the pubic bone and superiorly above the direct hernia. If it’s an indirect hernia, that tack above the direct hernia goes above the indirect hernia. So it helps support the mesh from preventing it from falling into a direct hernia. That’s a very technical question, but thank you.

(00:35:45):
Next question. “I believe I had a hernia that has ruptured. Unfortunately, nothing is showing up on any imaging. I had major constipation for six years after a botched hysterectomy, and now it feels like my stomach is leaking into the rest of my body and damaging the tissue. Nothing is showing up on imaging. Is there any test or blood work that might show this? Okay, let’s work on some word choices. So what you’re saying in terms of the words you’re using is medically not possible. And so my concern is you’re going to go to the emergency room or to a doctor and they’re going to say,” This is not possible. We can’t help you. “What I want to be able to do is to get you to better describe your symptoms. So hernias don’t really rupture. If they do rupture, they explode. When you get a rupture hernia, it means you get this big bulging mass underneath the skin.

(00:36:46):
So if nothing’s showing up on imaging, you definitely don’t have a ruptured hernia.

(00:36:54):
Now, constipation can be something that can promote hernias. We’ve discussed this on so many of my podcasts. Constipation is a big no-no because it implies that you’re straining. Straining really increases your abdominal pressure. And when you’re increasing your abdominal pressure, you can promote hernias, especially if you’re genetically prone to get hernias. So okay, you had a hysterectomy. I don’t know why it’s botched, but let’s say you had a hysterectomy and you had major constipation, which happens with any surgery, unfortunately, and you had to strain. Now, if you had an open hysterectomy, not a transvaginal hysterectomy or a laparoscopic hysterectomy, then you have an incision that needs to heal. And if you are straining and constipated after a fresh tissue repair, fresh fascial closure, then you can pop those stitches and you can get a hernia. So that can be true.

(00:38:04):
You also wrote,” It feels like my stomach is leaking into the rest of my body and damaging the tissue. “You’d be dead if that were happening. So technically speaking, that’s not happening. Any leak or hole of any GI content is basically a death sentence and a surgical emergency. So I’m going to assume that’s not actually what’s happening, but the question is, are you bloated? Are you having cramping pain? Is it burning pain? Do you have pain in a certain area? That’s really how I would like to figure out where your problem is. And you say nothing is showing up on imaging. Well, what kind of imaging? Usually a CAT scan should be adequate for a incisional hernia, but if it’s not, it’s either misread, so it actually shows it, but the radiologist didn’t mention that it shows it. Or it’s a very subtle finding and you need something called Valsalva imaging or dynamic imaging where you push out the belly and all radiology groups can do that.

(00:39:21):
They just need to know to do that or it needs to be ordered that way where the imaging is performed with you pushing out, and that will accentuate any small hernia that is constant problem. Follow up on the question. My surgeon used permanent thread instead of dissolvable thread. Six months later, the thread was coming out and broken. So using permanent suture is perfectly acceptable. It sounds if you still had suture coming out six months later, it could be still absorbable suture because we have absorbable suture that doesn’t absorb till about eight or nine months. So I don’t understand how the thread was coming out broken, but if you have suture that got what we call spit out or coming out, then maybe you did tear or a stitch after your hysterectomy surgery and you did cause straining and then the straining pops some stitches and the stitches are now no longer in the closure and therefore you have a hernia.

(00:40:35):
So all that’s possible. It’s highly likely you had a CAT scan or some type of imaging that did show a hernia. It just was misread as not having a hernia, that happens a lot. You may have followed me on prior podcasts where I shared one of my papers, actually two of my papers, but one of them specifically on radiology and how they’re so wrong. And three-fourths of CT scans, three-fourths of CT scans, three out of four CT scans that we reviewed were wrong about hernias. They either didn’t mention there was a hernia when there was a hernia, or they said there was no hernia when there was a hernia. So that’s why I read my own imaging and I don’t trust what’s written. But to round this out, I’m happy to see you if you want to initiate a consultation with me, just call my office or go on my website or message me, whatever, and my office can get ahold of you and maybe you can send your stuff over and I can review it and let you know what’s going on because the symptoms you’re having sound like they’re not good for you.

(00:41:50):
Your quality of life seems to be, can be improved. Okay. Next question. Can you get a hernia at any surgical site? Yes. Of the abdomen.

(00:42:05):
Can it go unnoticed for decades? Yes, absolutely. And then become a problem. Also, yes. So you can have, let’s say, a small hernia and over time it grows bigger and then becomes a problem and you didn’t really know it at the time, but then as it got bigger, it became more problematic. Is an incisional hernia easier or harder to repair than a naturally occurring one? Harder. Harder, harder, harder. So an incisional hernia means you had surgery with an incision, and that could be a small incision like a laparoscopic incision, or it can be a big incision, like a big what we call laparotomy. Let’s say you had all your guts, trauma surgery, let’s say.

(00:42:47):
And anywhere in your abdominal wall, if you have had a cut through the muscle, you can get a hernia there. The national average is 11%, but that number can be higher or lower based on the location and the type of incision and your own risk factors. So smokers, diabetics, morbidly obese patients, those with constipation or these three and any wound infection, especially due to trauma surgery, all of those are higher risk for incisional hernia than a thinner patient, younger patient, non-smoker, healthy, active, non-obese. So the reason why I say it’s worse, pelvic. I meant pelvic. Sorry, just to clarify your question, you meant pelvic hernia or pelvic surgery Because incisional hernias for sure are always more difficult because A, there’s a prior incision, and therefore B, there’s lots of scar tissue, and C, it almost always needs mesh and or you’re missing tissue as a result of the hernia.

(00:44:04):
So that makes it more complicated. There’s a little bit more thought that needs to be put through an incisional hernia repair because there may be bowel stuck to it or bladder stuck to it, or whatever prior surgery was done can be stuck to the hernia and make it more complicated.

(00:44:26):
The comment about pelvic is pelvic surgery can cause hernia hernias, whether it’s a hysterectomy or bladder surgery, prostate surgery, et cetera. Pelvic hernias are different. A pelvic hernia implies hernia in your peraneum low down around your anus, around your rectum, around your vagina. Some of them are colorectoseal, cystoceles, but also some are peraneal hernias, sciatic notch hernias. Every single thing I just mentioned is very complicated. I treat them because I’m crazy and I enjoy this kind of stuff, but even pelvic surgeons don’t fix those hernias. These are very complicated. You have the bladder there. You have all the sacral nerves in the area that you have to not injure. The colon and the anus is in the way. In women with a uterus, the uterus is in the way. There are major nerves and vessels that go down into the pelvis that feed your leg.

(00:45:36):
So pelvic hernias in general are very complicated. Coccygeal tumors and coccygeal surgeries, coccygectomies, horrible. Don’t ever get your tail removed unless it’s for cancer because it’s not worth dealing with the lifetime of hell trying to get that area to not get a hernia.

(00:46:01):
And I have a couple patients I’ve had to treat and their life has just been miserable because they need one surgery after another, and it’s a very difficult area. You can’t sit down. Can you imagine not having to sit? I mean, that’s just a horrible quality of life. So yes, pelvic hernia is very complicated and I’m hoping I do a fair number of pelvic hernias. It’s not a common hernia, thank God, but I have the most experience in our area and those hernias. I don’t know why. I do enjoy it. And I think I work enough with gynecologists and urologists to be more comfortable in that space than the average general surgeon. So in some ways, I kind of want to build a better repertoire of what options are out there for people that have true pelvic hernias, not just cystocele and rectocele, but perineal hernias, coccygeal perineal hernias, sciatic notch hernias.

(00:47:17):
These are all really complicated, even obturated hernia, really complicated pelvic hernias that are not well-recognized. Imaging often misses them. That’s why I read it myself. One lady was told she has a tumor and sent to a spine surgeon because she told she had a tumor on her sciatic nerve, turned out to be a hernia. So these are all little things that I enjoy, but I’m kind of in the minority. The pelvis is a difficult part of the body to master. I’ll tell you, if you go to the typical hernia surgery specialist in the United States, even outside the US, but this is particularly a US issue, the majority of them do really good ventral hernias. So they do abdominal wall hernias, incisional hernias, component separations, ETEP, TAR, RevStopa, all these names, SCOLA, REPA, all these names. Give them a groin pain patient, they don’t know what to do.

(00:48:28):
And it’s just because it’s more complicated. There’s a lot of urology and gynecology involved. There’s a lot of neurosurgery involved, and in general, they’re uncomfortable with the pelvic area. They don’t know what to do with women. Most surgeons are not comfortable treating women in that area because they’re unaware of all the other pathologies involved.

(00:48:53):
And so they’re really good with ventral hernias, but not so good with the groin. And so sometimes patients are attracted to go to those surgeons because they have a big name and hernia surgery, but really their big name comes from a subset of hernia surgery, which is the ventral area, which they do a great job on. But you go down to the groin and there’s groin pain and groin complications, those are much more complicated and they often don’t know what to do. There are surgeons that think that you should always cut the nerves. Not true. For sure not true. Highly don’t recommend cutting nerves all the time. There’s certain surgeons that are afraid to cut the brown ligament. 100% should always be cutting the brown ligament. That really helps the patient. So I’ll just say that all hernia specialists are not the same. And pelvic hernia is definitely one of those sub, sub, subspecialties.

(00:49:54):
Your comment here is there really don’t seem to be any options besides you for even information on pelvic hernias. And that’s true. There’s no book on pelvic hernias. There’s no good chapters written. The chapters are often written by people who’ve never even done these operations before. They just read another book chapter and write a book chapter. So it’s unfortunate. I’m surrounded by a lot of really good colorectal surgeons in LA. They don’t do pelvic hernias. They don’t do peraneal hernias. All those get said to me. So it’s kind of interesting. I don’t know why that is. It’s kind of a gap. Maybe in the US we have these verticals. So colorectal surgeons deal with the colon, but not near the colon. The gynecologist deal with the gynecologic, but not near the gynecology stuff. So the pelvic floor is kind of like no one owns it in a specialty.

(00:50:56):
The physical therapists are good about it, but they can’t do surgery. So it’s kind of a problem. Okay. Next question. At what point in a patient’s journey of post-inguinal herniography should the patient give up and go for spinal cord stimulator or should all surgical options be exited? Yes. I am not a fan of spinal cord stimulator at all. The reason is because most patients who see me who have been told they need a spinal cord stimulator have not exhausted their options and have a medically or surgically treatable problem. And you’re not treating the problem with a stimulator. If you go for stimulator, you have said you have some type of nerve issue that can no longer be treated medically or surgically, and all that’s left is to just get you symptomatically better. But there are plenty of patients that have treatable problems. They have a neuroma.

(00:52:02):
They have a meshoma. They have a hernia recurrence. The fact that a patient has a hernia recurrence and no surgeon or doctor has been able to diagnose that and they told them to just get out of my office and go get a spinal stimulator is beyond me. That’s just horrible. So those are the type of patients that I see. Are there patients that benefit from the spinal cord stimulator? Yes. Is it part of the armamentarium of trying to treat post-anual herniography pain? Yes. Should the majority of patients need it? No. Most people have a treatable problem, which is why I say I do offer online consultation, so you can just help me help you type situation if you can’t physically come in to see me. Okay. Oh, lots of questions here. Hello. Thank you for answering our questions. I have seven minutes. I had one MRI done.

(00:53:04):
It showed no hernia. I also did five ultrasounds. One showed tiny umbilical hernia.

(00:53:16):
Another ultrasound showed pre-umbilical hernia. Three ultrasounds showed no hernia. Two surgeons evaluated me. One said there’s no hernia, but there’s a ventral hernia. Another surgeon said there’s no hernia. He even told me if I have it, it is smaller than the MRI or his evaluation could see. The form of my belly button has changed. It looks like a small mole. Since I’m in another state, you kindly looked at my MRI and my ultrasounds, but not my last ultrasound that showed that I have a pre-umbilical hernia. What should I do? My pain subsided. Do I need a surgery? Should the mesh or no mesh be used? What type of surgery should be used? What anesthesia should be used? Local or general and what exercises are safe? So exercises in general are safe for any hernia. I’ve discussed that forever. The type of surgery you need … Well, whether you need surgery or not is purely dependent not on whether you have a hernia, but on whether the hernia is causing your symptoms.

(00:54:22):
And the type of surgery is a discussion between you and your surgeon based on the size of the hernia, your own risk factors for hernia recurrence, and your risks or benefits of having either stitches or mesh put in you and so on. And what type of that? So that’s kind of where that discussion should go. What exercises are safe to do for osteoporosis if I possibly also have a hernia?

(00:54:52):
So in general, for osteoporosis, weightbearing exercises help the most. And so weightlifting and certain exercises where your weightbearing really help with osteoporosis. Hernias are not a contraindication for any of those exercises. My physical therapist suggested to lift heavy weights for osteoporosis, and that is how I injured it. Lifting weights did not cause your belly button hernia. I will guarantee you that. So if symptoms subsided, I don’t need surgery, correct. That’s usually correct. Yeah. For most hernias with a few exceptions, if you have no symptoms, there’s really no good reason to fix it. Most hernias can be watchfully weighted on in the belly button and in the groin. And there’s some exceptions. We’ve talked about this in other podcasts, specifically the rare pelvic hernias and a spegalian hernia or a femoral hernia. But short of those, most ventral hernias can be ignored until you have symptoms.

(00:56:03):
So what you really should do is to understand what you have, understand when you should act on it, what are the right symptoms to think about, and then review all the risk with your doctor, review all the risk factors that you may have that would maybe increase your risk of having your hernia advanced or become more symptomatic, and then take that information, relax about it, and move on with whatever the best plan of care is. There are patients that have little ETBT ventral hernias that aren’t bothering them at all. They want it fixed. As long as they understand the risks and benefits of that, I’m okay fixing that for them.

(00:56:51):
So it all depends on how good of a candidate you are for surgery. Do you respond to email inquiries from patients who have seen you in consultation several times or is repeat online consultation needed? Depends on the question. If you’ve seen me for problem X, whether inpatient or online, and I provide you with care or recommendations, I’m happy to follow up with you. If you then went on and had a procedure or your situation has changed, so now it’s a different situation. I have to review a whole new set of your new operative report, new imaging, new symptoms, that’s considered another new online consultation.

(00:57:48):
Do I need a CT scan to understand if I have a hernia or do I need to do nothing if I have no pain? Yeah, like I mentioned, if you have no pain, there’s no need to act on it. So there’s no need to keep getting … You’ve gotten five ultrasounds and at least one MRI. That’s way too much. You don’t need a CAT scan in addition in my opinion. So where was that with my earlier story? We’re going to have to figure that out. Okay. 2026, I will be gone already. It’s like the second week to Santa Barbara for the Southern California chapter of the American College of Surgeons. Please follow me on X to see what I learn and watch my student give this excellent presentation on severity of illness and hernia outcomes. And I have a couple of more. This year’s going to be interesting because I’m trying to shake it up a little bit and not go to the same meetings every time.

(00:58:59):
So oh, I forgot to tell you this. Last year I was invited similar to the year before, to the actual American College of Surgeons. So there’s two American College of Surgeons situations. One is the local chapter, which is the Southern California chapter, of which I was a first female president, very proud of that, and which is the largest and most active chapter of the entire American College of Surgeons. Then there’s the big American College of Surgeons meeting. It’s the largest, biggest surgical meeting in the world. It is all surgical specialties, neurosurgery, urology, general surgery, head and neck surgery, cardiac surgery, transplant. They’re all gather in one place. And this year it was in Chicago, thousands and thousands of people, tons of sessions.

(00:59:47):
I developed a session called Challenges in Hernia Surgery, and of all the sessions, all the specialties, myself Session was ranked number one. Number one. Why? Excellent topic. We picked really interesting subtopics and I invited the best of the best to come and give their talks. And we had a fantastic Q&A session at the end to encourage questions from the audience of this fantastic faculty. And it was so awesome that we got voted as the number one most highly rated. I mean, we had the largest ballroom assigned to us and it was standing room only. So that’s happened to me a couple times where we had a really good showing for some of my sessions and this has been great. So for those of you who are new to hernia talk live, we do this almost every week. If I’m out of town or if I’m operating, I can’t do it.

(01:01:00):
But it’s every Tuesday, 4:30 PM to 5:30 PM Pacific Time. If you follow me on any of my Instagram, Facebook or X accounts, or if you’re on herniatalk.com, you will see me posting the link to this. I will answer your questions for that hour. I am devoted to getting as many new guests this year as possible to also help answer your questions, and we’re going to have really interesting topics to talk about, and I’m super excited. So for those of you who have been so lovely to me, I just want to say thank you.

(01:01:47):
I love the fact that you are following me and come to my hernia tox sessions and listen to hernias for an hour. And with that, I hope you follow me and I’ll see you … Let’s see. Am I in town next week? Yeah, I’ll see you next week, Tuesday, 4:30. See you then. Bye everyone.

(01:02:11):
That concludes another fact-filled episode of Hernia Talk Live, the only weekly podcast that helps answer your hernia-related questions. Today’s program was produced by Dr. Shirin Towfigh. For more details about today’s episode, look at our show notes. Remember to follow Hernia Talk Live on Apple Podcasts or wherever you listen, and please give us a five-star review. It really helps us spread the word that it’s not just a hernia. See you next week for another great episode.