218. Side Hernias: Flank & Parastomal Hernias

This week, the topic of discussion was: 

• Parastomal Hernias
• Flank Hernias
• Eventration
• Absorbable Mesh
• Biologic Mesh
• Prophylactic Mesh Use
• Hernia Recurrence
• Loss of Domain
• Open Surgery
• Robotic Surgery
• Laparoscopic Surgery
• Hiatal Hernia
• Foregut Surgery
• Spine Surgery
• XLIF
• Aortic Surgery

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

Guest Panelist: Dr Heidi Miller, Minimally Invasive Surgeon, Maine Health

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

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Dr. Towfigh (00:10):
Well, welcome.

Dr. Miller (00:11):
Hey, thank you. It's nice to see you.

Dr. Towfigh (00:13):
Thank you so much. Let me re-share because it's possible that no one was hearing us at all. But I was welcoming everyone to Hernia Talk Live, which we have every Tuesday. And this week you are our guest, Dr. Heidi Miller at Maine Health, very talented minimally invasive surgeon. I have a lot of questions for her because I want to know more about her life as well as the topic of today, which is going to be side hernias. You can follow her on Instagram @shutterandscalpel. She's got some pretty cool things to share about her life, both surgical and non-surgical. So welcome.

Dr. Miller (00:52):
Hi, thanks.

Dr. Towfigh (00:55):
So you're currently in Maine right now?

Dr. Miller (00:57):
Yeah, in Maine at 7:30. The sun's going down because we're so far on the East Coast, we're on the far end of the Eastern time zone, so we get early mornings and early nights.

Dr. Towfigh (01:09):
Yeah, my friends just came from there. I think they were vacationing in Maine. Montauk, is that right?

Dr. Miller (01:17):
Oh, Montauk's in New York.

Dr. Towfigh (01:19):
Montauk's in New York.

Dr. Miller (01:21):
Yeah.

Dr. Towfigh (01:21):
Where were they in Maine? Kennebunkport is where they were

Dr. Miller (01:26):
In that

Dr. Towfigh (01:26):
Region.

Dr. Miller (01:27):
Yeah, in Southern Maine. Yeah, very nice.

Dr. Towfigh (01:29):
Very nice. When I was in elementary school, our principal went to Maine every summer.

Dr. Miller (01:38):
That

Dr. Towfigh (01:38):
Was her thing. She had a house in Maine. And the pictures that I got from my friends as they were vacationing, because they did Cape Cod, they did Nantucket, they did. What's another town near Kennebunk Port?

Dr. Miller (01:53):
York is down there. Kennebunk, Kittery. Portsmouth is in New Hampshire. They might have stopped through Portsmouth.

Dr. Towfigh (02:03):
But they did mention Kennebunk Port. Anyway, I was following them on Instagram. It's just so beautiful, that whole area.

Dr. Miller (02:08):
It is beautiful. They call it vacation land because that's what everybody does and they come here for vacation.

Dr. Towfigh (02:14):
That's what they did.

Dr. Miller (02:16):
Yeah. And a lot of the Mainers have camps. They call them camps, they're like cabins on a lake out in rural Maine that they've had for generations. It's just a thing that people do. But I feel like people have some connection. My mom was a camp counselor for a summer when she was in college in Maine, and it was something she always talked about because I didn't grow up here. And so now she loves coming back to visit because it's reliving her youth a little bit, which is so fun.

Dr. Towfigh (02:48):
And you've been in Maine for how long now?

Dr. Miller (02:50):
Six years. Actually, I think I bought my house six years ago today. Wow. Yeah, so it's been a

Dr. Towfigh (02:57):
While

Dr. Miller (02:57):
Now.

Dr. Towfigh (02:57):
Congrats. And so you practice all sorts of minimally invasive surgery with, I know you have a special interest in hernias and abdominal reconstruction, so maybe explain a little bit about what your practice is like.

Dr. Miller (03:15):
Yeah, my practice is interesting because I definitely have an advanced foregut practice and then I have a complex hernia practice and I work within a group of four surgeons. There's another hernia surgeon who really focuses more on outpatient. So he's a very high volume, but more kind of outpatient. He does a couple big things in the hospital and then two bariatric surgeons. One of them does bariatric and foregut, so we all cover each other. And my practice ranges from poem for achalasia. So I do endoscopic interventional endoscopy to the big. Last Friday, I did a massive complex hernia with all the intestines on the side. Oh,

Dr. Towfigh (04:00):
Wow.

Dr. Miller (04:01):
And a 13 pound panniculectomy on the same lady because she'd lost a ton of weight and was fabulous. So that's kind of my range. And it comes out of fellowship really, because when I did fellowship in Cleveland, I had Yuri Novitsky as my hernia guy, and I had Jeff Marks as my foregut and endoscopy person. And Jeff always joked that our fellowship was funny because we did the least invasive surgery and most invasive surgery. Not a lot of in between, and that's what my practice is today. I do a lot of revisional foregut too, like redo hiatal hernias and redo Nissens and stuff.

Dr. Towfigh (04:42):
It's funny you mentioned about this humongous hernia that you fixed. Every time I'm at our morbidity mortality conference or chiming in during grand rounds, there's always a surgeon that poo-poos us fixing these really complicated hernias because they assume it's fraught with complications. The question's like how much pain was the patient in and how sick were they? Did they really need a hernia surgery? They keep making, was this a life-saving procedure? I always make the comment like, yes, there are situations where we're saving a life with hernias, but most of what we do is improving quality of life. There's tons of evidence that shows that these massive hernias should be repaired because the risk-benefit ratio, assuming the patient's healthy enough to undergo surgery, is really massive. You really improve their quality of life.

Dr. Miller (05:45):
Yeah, this lady, she's in her late 60s and she has some baseline mobility problems, so she walks with hand canes, but I am 100% certain that with her hernia fixed and without a large pannus to offset her balance, she'll be able to walk cane-free. That's huge. That's huge. And then she had lost over a hundred pounds, so to take 13 pounds of just skin, most of which her hernia was in anyways, will just help her. I mean, it helps everything from hygiene to mobility to personal satisfaction and confidence. My family will say that to all you, "Oh, she's a surgeon. She's out saving lives." I'm like, "I might not be saving lives, but I'm changing lives." There's no doubt about that.

Dr. Towfigh (06:36):
Absolutely. Yeah. And I feel some surgeons don't offer surgery because it's almost a fear that they're going to hurt the patient, not understanding the benefits, assuming the surgery's well done, the benefits for the patient. So today, we have our audience who's watching both on Facebook and on Zoom. I'll be monitoring any questions that come through, but I've never really spoken specifically about these side hernias. Everyone talks about belly button hernias, diastasis, incisional hernias. We had a couple episodes specifically on parastomal hernia and flank hernia, but not enough to talk about the difference between a side hernia versus the middle. I feel that not enough. Well, for sure the patients probably don't understand why it's such a different animal, but also a lot of surgeons, I feel, don't really appreciate incisions to the side versus the middle and the risk of doing that sometimes in patients.

Dr. Miller (07:44):
Yeah. It definitely adds some complication for both. Yeah.

Dr. Towfigh (07:52):
Yeah, absolutely. And we have some questions that have been already submitted ahead of time. I'll run through those, but it looks like we already have some questions submitted. Let's see what we have here. Okay, so one of the questions proposed is the issue of parastomal hernias. We know that about a quarter to a third of stomas, so ileostomy, colostomy, urostomy probably resulted hernias. You want to just let me know exactly. Things have changed. It used to be that you would just switch it around and then we went back and forth about using mesh the first time to prevent hernias. Now looks like we're being a bit more conservative, like only repair the ones that really bother people and don't address every single hernia. So what has been your experience with parastomal hernias, which is hernias after you perform a colostomy or ileostomy or urostomy?

Dr. Miller (09:01):
Yeah, the parastomal hernias are a losing game. The really tough thing about them. Actually, I just had a CAT scan of a patient come through today, which is a lady I did a big abdominal reconstruction on because it was all a parastomal hernia, but loss of domain, everything out in the hernia from this. And she had had rectal cancer, so it's an end colostomy, so it can't be - Permanent. It's permanent.

Dr. Towfigh (09:31):
And

Dr. Miller (09:32):
She lost weight and we got her optimized, and I did this beautiful abdominal reconstruction, but she has her stoma. And what I tell patients when you make a stoma, you make a hernia, because the definition of a hernia is bowel poking out through a hole in the abdominal wall, and that's exactly what a stoma is. So we're basically making a purposeful hernia when we're making a stoma, and so it's kind of a losing game. And we try things like how tight do you make the hole? Where do you put mesh in at the beginning? And where do you put the stoma and what kind of stoma? There's rates up to 70% even in some studies that people will get parastomal hernias. So I think that's the first thing to understand is it's just the nature of the disease and the problem, and if you don't get one, you're lucky.

(10:29):
That's kind of the starting point.

(10:35):
So that lady, actually, she came back with a recurrence and I did a robotic repair after her big abdominal wall repair with a sugar baker, so I kind of call it a mesh hammock. Then she just was back in my office a couple weeks ago and her CAT scan came through and it's back again, and it's better than it was the very first time, but it kind of looks like the second one. And so what you're getting at now is what do I do for her now? I think it really comes down to I probably have to move her stoma because I've tried this now in three places and it's time to move it to a new location and mesh up everything, but she's going to be layers and layers of mesh by the time I get done with her, and she's doing fine with them, but it's hard because they do come back and we don't have any good answers for it other than reversing the stoma.

(11:32):
If you can get rid of the stoma, that's the best way to take care of this problem.

Dr. Towfigh (11:36):
I have a question for you because you do a lot of foregut surgery, so I assume you do hiatal hernia repairs. Hiatal hernia is conceptually similar to a parastomal hernia, right? And

Dr. Miller (11:48):
My recurrence rates are the worst.

Dr. Towfigh (11:50):
Oh, no. Oh

Dr. Miller (11:51):
Yeah. I mean, that's another thing is we can't -

Dr. Towfigh (11:54):
What can we learn from hiatal hernia repairs to then make a parastomal hernia repair? Because just for the audience, hiatal hernia is a hernia where the esophagus and the stomach joint, right?

Dr. Miller (12:06):
Yeah.

Dr. Towfigh (12:07):
So there's a hole there. It has to be because that's the way you swallow down. Same way there's always a hole where you put your stoma, where you have to make a hole through the muscle to bring up the intestine. Are you able to take what you learned from years and years of doing hiatal hernia repairs to. Can you do a wrap or something? I mean, has anyone thought -

Dr. Miller (12:32):
Yeah, the wrap does. So I have actually tried that for a parastomal. I did a pre-peritoneal dissection and mesh, and then I had a big floppy piece of peritoneum, and I basically did wrap the stoma with that because I was trying to try new things that are safe, but maybe it will help. And so far, that guy doesn't have a new hernia, but we had a different complication. He had a perforated diverticulum after the repair, so we had other complications from him. With hiatal hernias, it's a similar problem because you have a hole in the diaphragm that you can't close, and I have a similar conversation with my patients for that because the diaphragm is stretchy. As we age, it gets dilated. Actually, the recurrence rates of paraesophageal or hiatal hernias is 30%. It's very similar to the parastomals. We've tried mesh, but we have a harder time up there because you can't use a permanent mesh against the esophagus.

(13:45):
It

Dr. Towfigh (13:45):
Can erode, right?

Dr. Miller (13:47):
Yeah. So it's just they're both kind of losing games, and the wraps don't prevent recurrence. There was some data a while ago that showed that they might, but there's been plenty of data that doesn't. One of the things recently that's been shown to reduce the risk of recurrence in hiatal hernias is a gastropexy when you sew the stomach up to the diaphragm or to the abdominal wall. And that's something I've tried with parastomals to tack the stoma up against the wall laterally too, and try and keep it down, but I don't know that that actually helps either. They do

Dr. Towfigh (14:26):
That for J-tubes, right?

Dr. Miller (14:28):
Yeah. Tack

Dr. Towfigh (14:29):
A long strip of the jejunum, for example, for jejunostomy feeding tube.

Dr. Miller (14:35):
Oh yeah, there's a -

Dr. Towfigh (14:37):
Right. There's a little some length of it that sometimes they tack up to the abdominal wall.

Dr. Miller (14:42):
Yeah. Yeah.

Dr. Towfigh (14:44):
But I mean, a sugar baker repair kind of forces the intestine to lay in a certain way against the abdominal wall. It just doesn't force it to be that direction.

Dr. Miller (14:58):
Yeah. And the problem with the sugar baker is there's still an opening between the mesh and the abdominal wall where your bowel goes through, right? Yeah. The recurrences I get after sugar bakers are through that. As it dilates, the small bowel usually will herniate along that bowel and over the mesh. Yeah.

Dr. Towfigh (15:23):
I teach that, that's like the Goldilocks situation where you can't make it too tight and you can't make it too loose and it's just never perfect.

Dr. Miller (15:32):
I

Dr. Towfigh (15:32):
Understand.

Dr. Miller (15:33):
Yeah,

Dr. Towfigh (15:33):
That's a tough one. I wonder if. And then tell me a little bit about, because another question that was posed was the use of just prophylactically preventing a hernia. What's the status of that?

Dr. Miller (15:53):
For parastomal hernias, there's actually really good data to say that we should be putting mesh in for prophylaxis. It's in a synthetic mesh, so a piece of plastic basically, really in any layer that you have access to is better than nothing as far as reducing the risk of getting hernias. It's something that I struggle with because the data tells us we should be doing it, but people don't do it. And it's been very hard to get surgeons to adapt or adopt that technology. It's similar in aortic patients that have big aortic surgeries. They're very high risk for hernias along their incision, and a lot of times those are side hernias, right? Yes.

(16:41):
And there's good data, very good data to say that we should be putting mesh in those patients when they're having their primary surgery, and we're not doing that either. I think because there's so much mixed bag about mesh in the petition for complications and the downside that people are afraid to use it when they don't have a true hernia to fix and not to see it as a real way where it's safe to actually prevent hernias, and that you're probably saving the patient a lot more by doing that than waiting until they get a hernia to put a mesh in.

Dr. Towfigh (17:19):
Yeah, it's probably one of those situations where if you put in prophylactic mesh and a larger majority of your patients do well, no one congratulates you, but if you have a patient that has a mesh infection or fistula or something like that, then

Dr. Miller (17:37):
They're

Dr. Towfigh (17:38):
Like, "What? You're using mesh and that has so many complications."

Dr. Miller (17:41):
That's that M&M conversation, right? "You shouldn't be doing that. You see this as wrong. No, I have 99 that did great, and the one that gets presented, it had a problem. But I do think that's part of it. Yeah.

Dr. Towfigh (17:58):
Yeah. And then what about flank hernias? Well, I used to do even more until I started educating the spine approach surgeons about how to handle these flank incisions, and I started giving talks to urologists about how to reduce how many flank incisions they make. But the flank hernias are also a problem. Those are these kind of hernias to the side. Do you see a lot of those?

Dr. Miller (18:27):
Yeah, I see my share of them for sure. They're definitely not the highest volume just because they're just not as frequent, but I see them after kidney transplants, I see them after spine surgery, I see them after aortic surgery, and I see them after some orthopedic procedures at the pelvis where they like to take the part of the pelvic bone.

Dr. Towfigh (18:52):
Oh

Dr. Miller (18:52):
Yeah,

Dr. Towfigh (18:53):
Those are difficult.

Dr. Miller (18:55):
You got to plate those.

Dr. Towfigh (18:56):
You can't just use mesh. You have to use a plate. It's so interesting

Dr. Miller (18:58):
To

Dr. Towfigh (18:59):
Have to redo their anatomy like it was before.

Dr. Miller (19:02):
Yeah. So definitely we see those. I think there are fewer because of the robotic surgery, actually. I think so much, a lot of urology has converted to robotics, and so they're not making big side incisions as much anymore. And so I do think that that has helped. And I think educating surgeons on how to close the abdominal wall helps a lot too. And so I've done some of that as well to try and help prevent them, because if you can get a good closure and avoid a hernia, then again, whether you have to put mesh in or not, that's better for the patient. Yeah,

Dr. Towfigh (19:41):
I remember the XLIF or the.

Dr. Miller (19:47):
I just lost your audio again.

Dr. Towfigh (19:55):
Mind of its own, this. But the XLIF, which is the transpsoad's lateral intercostal, or basically the fusion of the spine from the lateral approach became really popular. And we got tons of spine surgeons around where I work, and I was getting hernia after hernia after hernia. And most of these surgeons were telling their patients, "Oh, it's just some swelling. Oh, it's a seroma." But then three months later, it's still bulging. I figured out that there's a sentinel paper that described how to do this operation. You can do a much better. Let me rephrase this. A lower risk operation going transpsoas from the side than transabdominal. So spine surgeons, let's do it this way. And I read the paper, and in the paper it described closing the external oblique muscle with

Dr. Miller (21:01):
Vicryl

Dr. Towfigh (21:03):
Suture. And I'm thinking, okay, this totally explains what's going on, because number one, there's three layers of muscle there. They're only closing one layer. When I see them, they often are misdiagnosed as not having a hernia because technically one layer is still closed.

Dr. Miller (21:19):
The

Dr. Towfigh (21:20):
Two layers that have given away and it gives you this relative bulge. Vicryl is not good enough because three weeks later, it's pretty much non-functional suture. You're dealing with these very thinned out flank muscles on the side, whereas the rectus muscle in the front is bulkier, and the fascia of that is even bulkier. And then lastly, all these patients are constipated, so they're Narcotics. So it's a bad combination of bad tissue, bad suture, constipated. So I started giving talks. I'm like, "Guys, I understand that's how the paper wrote it, but this is a spine doctor that wrote the paper. Let me tell you, as a hernia surgeon, don't use Vicryl. Use PDS, which lasts longer, or even proline if you want permanent, but don't use something that's so rapidly absorbable.

Dr. Miller (22:17):
Please

Dr. Towfigh (22:17):
Take all three layers in consideration when you close instead of the one layer. It's more difficult, but that's what you have to do." And we published the largest

(22:30):
Series of patients like this, but you know what? My numbers went really far down because they started listening and they changed. We haven't had a single hernia ever since we changed. So I thought, "Okay, this is a good learning experience. Let me submit a publication to the spine journals." There's two main spine journals. They both rejected saying, "This is a hernia issue. It's not a spine issue." Are you serious? We're trying to prevent the hernias. And then I submitted to a. Who did I submit to? I think I submitted to a hernia journal, and they said, "This is a spine issue, not a hernia." So I finally had to submit it to just a general surgery journal.

Dr. Miller (23:12):
But it's so

Dr. Towfigh (23:13):
Crazy that we just don't think about what we're doing and understanding that the side is so different. Yeah,

Dr. Miller (23:22):
The consequences. Yeah.

Dr. Towfigh (23:25):
What do you think about incisions? Even trocars. If you put a robotic trocar outside of the rectus,

Dr. Miller (23:35):
That's prone

Dr. Towfigh (23:35):
To hernias.

Dr. Miller (23:37):
Yeah, I've made my share of those because I do a good amount of robotic surgery too, and I like to use the longer ports to help bring the robot away from the patient when I'm doing big ventrals. And I've definitely found that because of that, it changes the torque, and then a lot of those patients have very thin lateral muscles. I've started closing those port sites because I had created some series of flank hernias by doing that. But yeah, it's hard, especially in the aging population. They just don't have the bulkiness in those muscles, and so it's a straight shot. Sometimes you put a port in, you can actually just look right through it. There's no - Yeah, you're staring

Dr. Towfigh (24:30):
At the hole right through the skin.

Dr. Miller (24:31):
Yeah. Right through the skin into the abdomen. And so those are hard, I think, and all of those. If people don't understand the anatomy with the three muscles, I see a lot of the, "Oh, it's not a real hernia," like you're saying, but two out of the three are quite wide and then stretched, and then the external bleak that's still there is atrophied and completely atonic because it just has been stretched and stretched and stretched, and it's like a thin balloon. Those are hard to fix because you have to figure out what to do with that thinned out external muscle and then try and stretch these contracted internal and transversus muscles back up to meet where they're supposed to go. But they are satisfying, and despite not being able to make people symmetrical again, that's always what I tell them is you're never going to be the same as you were before.

(25:32):
You always have some asymmetry, but at least we can get everything back together again and reinforce it with some mesh and make you feel stronger. That to me is the important part because I really feel the core is like a cylinder, and a cylinder that has damage to it loses all of its strength. We use cylinders for rockets in our shuttle and our airplanes because it's a very strong geometric shape. But as soon as there's damage to the structure, it loses that strength. I think the core works functionally like that. It's a cylinder with a roof and a bottom, and when you've got damage, all of the support to your spine and your midline, the front part of your abdomen goes away, and that's when you start having back pain and hip pain and problems walking. And so just making those hernia repairs, even though they may not be perfect, will make people more functional, and it helps their constipation, it helps their urinary symptoms, it helps their pelvic floor, it helps their breathing, and I might not be saving their life, but I'm definitely making them better by doing those troublesome hernias.

Dr. Towfigh (26:50):
Yeah, it's something that patients will never really ask their surgeon about this, but then it's incumbent on the surgeon to understand the anatomy and be cognizant of where they can place incisions, where they're least likely to cause hernias. As hernia surgeons, we think about that, but if I were, let's say, an acute care surgeon, someone who just takes care of a patient that are really sick and ill, I may not be that cognizant of the fact that placing any incision or even a trocar site from a laparoscopic or robotic surgery on the sides would cause pain. I think the issue with robotics is because of the torque that's implied, you have to go perpendicular, whereas for laparoscopic or assist ports, if I put any on the side, I really skive it. So

Dr. Miller (27:47):
Skiving

Dr. Towfigh (27:48):
It, you're not making - Straight

Dr. Miller (27:52):
Hole.

Dr. Towfigh (27:53):
It's less likely to get a hernia.

Dr. Miller (27:55):
Yeah, because then you have the overlap of the muscle you're skiving through.

Dr. Towfigh (28:01):
Do you know if there are situations where, let's say, you're only working in one direction, only in the pelvis, maybe it would be safe to skive the robotic trocars?

Dr. Miller (28:15):
Oh, I would think it would be if you had a simple. It could be something we could try with hiatals, but I don't get hernias after my robotic hiatals, which is funny because I put five ports in. One of them is just a laparoscopic five port for the liver retractor,

Dr. Towfigh (28:36):
And

Dr. Miller (28:36):
I put one on each side and then two in the middle. But I actually have never seen a port site hernia after a hiatal hernia. It's only after ventral hernias. And I think that probably is the torque and the direction because we're working up towards the head with the hiatal rather than lateral in those weaker - Yeah,

Dr. Towfigh (28:57):
There's much more movement in all directions with the abdominal wall one. I would say inguinal probably is also fine because it's always. So if you're looking straight to the pelvis or straight up to the chest, then maybe we can, if you need to put a lateral one, you can skive it. Yeah.

Dr. Miller (29:17):
Yeah. And when I think about it, the way we put our ports in on the lateral side for the hiatals, I do kind of skive them because I aim them up towards the hiatus anyway. I hadn't really thought about that before, but it's true. I have not seen a port site hernia from a hiatal hernia repair. Yeah.

Dr. Towfigh (29:38):
Okay, let me share a screen here. One of the questions that we had, we already answered, which was, "Why don't surgeons just use mesh for the stomas? The risk seems low and the benefits are high." Are there people that are using the fully absorbable Meshes for parastomals?

Dr. Miller (30:03):
Yeah, for parastomals and I think for when they make the stomach

Dr. Towfigh (30:08):
Unfortunately,

Dr. Miller (30:10):
I do think yes. I think people still are using biologics that are fully absorbable. People are using some of the newer biosynthetics that last a little bit longer, and I think that data still is remaining to be seen. I don't have any good data behind that yet. And then some people will use just a permanent mesh as well. From my experience, the fully absorbable meshes for parastomal hernias just have almost a hundred percent recurrence. You need that structure. What about the

Dr. Towfigh (30:50):
Hybrid meshes? They have a little bit of synthetic woven into them?

Dr. Miller (30:54):
Yeah, I don't know that I've had any experience with those for parastomals.

Dr. Towfigh (31:00):
That

Dr. Miller (31:00):
Makes

Dr. Towfigh (31:01):
Sense.

Dr. Miller (31:01):
But it's definitely an interesting idea to give a little bit of structure left, to have a little structure left behind even when the absorbable portion is gone. And I know also recently the mesh suture that's come out on the market, people have been using it for parastomals and trying different things, whether it's like a purse string where you make a circle around the stoma with it, you can get that from dilating or just closing the defect with it. But I've heard mixed reports on outcomes for that, and I don't think it's actually been on the market long enough to know what the recurrence or complication rates are.

Dr. Towfigh (31:43):
Do you just take the mesh suture? So mesh suture, it's a cute idea. It's like a thicker, it's a little bit more inflammatory suture, I should say. And therefore the thought is it's a little bit bulkier, but a little bit more inflammatory and therefore it causes more scarring and hopefully therefore less hernias. I think that's how it works, right?

Dr. Miller (32:08):
Yeah. So it's actually a proline mesh basically that's just rolled into a roll and then attached to a needle. And so the idea of it is that it just gives you more area to grow into because you have not just one small suture, but kind of a bunch of sutures that are interwoven. And so the idea is that there's more scaffolding for the body to scar into the way we think of mesh. And it will be interesting to see because I've used it and I think it's a great idea for some things, but when you sew with it, it all gets bunched up. So then you just end up with a big bunch of suture.

Dr. Towfigh (32:52):
And

Dr. Miller (32:52):
I know some people have been posting, people have used it on a hiatus and still get recurrences for hiatal hernias and going back in there, it's really just a mess of scar tissue to deal with. But with the parastomals, I've heard people, I've used it to close the defect, to tighten the hole up around the stoma, and then also reinforce with the mesh just as one more added thing to try and help. Other people are using it and sewing in a circle around the stoma and tightening it up like a purse string to see if they can make it dilate. So

Dr. Towfigh (33:36):
Do they take the muscle and then they just sew the edges like you would

Dr. Miller (33:44):
Put the edge

Dr. Towfigh (33:44):
Of a shirt, like a collar or something?

Dr. Miller (33:47):
So if you wanted to take a collar but pull it tight, like a drawstring, and so you're sewing around that circle, but then you're pulling that tight so you're squeezing it up and in. Got it,

Dr. Towfigh (34:04):
Got it, got it. Okay.

Dr. Miller (34:05):
Yeah. But there's not good data or outcomes yet to know whether that is helping or not. Yeah.

Dr. Towfigh (34:15):
Next question. We already talked about it. What do you think of the absorbable meshes for parastomal hernia? So for a definitive hernia pair, it's out. Absorbable mesh is not considered a good option. And for preventative, is it still

Dr. Miller (34:36):
Out? I think it's a reasonable place to use a long-lasting absorbable mesh in a primary, if you're making a stoma and putting a mesh in as a preventive measure. Those absorbable meshes definitely leave some scarring behind, which potentially could help prevent hernias in the future. The data shows that synthetic fully permanent meshes are safe and the most effective. So I don't think absorbable meshes are out, and I think it's a reasonable thing to try and that we should study those outcomes. But in comparisons, the synthetics are as safe or the permanent ones are as safe, and so I don't see a benefit to using absorbable ones. Plus they're more expensive. So you're adding cost and then

Dr. Towfigh (35:31):
Not

Dr. Miller (35:32):
Really adding benefit.

Dr. Towfigh (35:35):
Yeah, I agree with you. I completely agree with you. Okay, next question. If I have a side hernia, can I ask for no mesh repair?

Dr. Miller (35:45):
You can always ask for no mesh repair. The conversation I would have with you is that it really kind of depends on where and why you have a hernia, because there are certain places where I know if I just sew it back together, it's coming back, especially where the anatomy of the abdomen, a lot of those side hernias happen in between the six-pack muscles and the side muscles. There's just thin fascia there. And I'm pretty sure that if I were to just sew those together with a suture that goes away, that hernia is just coming back because there's no muscle, there's nothing to structure or scar in. But there are other places where maybe it's a hernia where you have a couple muscle layers that are still there and strong that we could potentially try it. But I would warn people away from no mesh on side hernias because I really think that's a place where you need some structural support for the scar tissue to grow in.

(36:50):
I

Dr. Towfigh (36:50):
Agree. It's really hard. There's very thin fascia laterally in the midline, around the midline. It's nice thick fascia at least. And even those, the non-mesh repairs have a pretty good size failure rate. It's even worse when you go further laterally. Question for you. So do you think these side hernias are best done open or laparoscopic or robotic? I

Dr. Miller (37:18):
Think it depends. I do them both ways. Well, laparoscopic or robotic can be very beneficial for some of them because I can basically peel down the inside layer of the abdomen and then all the way down to the retroperitoneum, so to the fat behind the kidney, create a lot of space there. And then I can sew the muscles back together and put a big mesh and cover that up with that layer. And I can do that both laparoscopic or robotically, depending on how big it is. If it's big and bad, then I'll use the surgical robot. But for spaghelion hernias, which is a side hernia, I love that as a laparoscopic case and there are some others that work for that, but there are definitely times when an open side hernia is the way to go. If you've got big floppy external oblique and then a big hole and you need to be able to plicate muscle and put it together in the right layers, then that's better approached.

(38:20):
If they're really big and you have lots of domain through there, you probably need to do it. And then the other time I will go for open is if there's excess skin or stretched out skin that needs to come off, because you get a much more cosmetic and I think functional repair too, if you take that skin at the same time and tuck everything back into the right proportions.

Dr. Towfigh (38:44):
Yeah. Going back to what you said earlier about in your fellowship, we had the foregut surgeons doing everything minimally invasively and the hernia surgeons ending up doing so much maximally invasively. I feel that over time as you become more experienced with hernia surgery, you move away from laparoscopic robotic surgery a little bit because you understand that there is a role for open surgery, whereas maybe early on you're like, "I want to do everything laparoscopically and it's the way to go." But then with experience, you understand there are benefits to doing something open, whether it's cosmetically, getting a better repair or skin issues and so on. So yeah, I totally hear that in what you're saying, which is it's not always better laparoscopic or robotically.

Dr. Miller (39:37):
I think I'm definitely one. I don't have huge robot numbers. Some people will be like, "Oh, I've done thousands and thousands of robotic cases," because I choose to use it for very specific things. And so I use it for my revisional surgery for gut and the rest I'll do laparoscopic and I use it for complex hernias that I feel are appropriate, but I don't think everything is appropriate. And it's funny, when I was a fellow, we actually, that was the year we did the first robotic TAR. We were growing that year and learning it and it was becoming popular. So it's been funny. It's been interesting to watch it explode

Dr. Towfigh (40:24):
And

Dr. Miller (40:25):
Cause problems. But then now also slowly, like you're saying, people are learning from that going away. But I also do panniculectomies because, and I was just looking, I did one today, which is getting rid of excess skin in patients mostly after weight loss. In Maine, something like 60% of people are on Medicaid or MaineCare. It's a very large number. That was

Dr. Towfigh (40:54):
A big deal with your recent political campaigns. Yeah. Yeah.

Dr. Miller (41:00):
And the plastic surgeons in this state, most of them won't see patients who are on Medicaid, and so they don't have any access for this. So it's become one of my little niches, and our bariatric patients will come to me and I'll do them, and I enjoy them. So I also enjoy that part of the open hernia surgery as well, is the plastic surgery part of it where I get to make it lysis. And you reduce the risk of seromas or fluid collections by getting rid of the excess skin, and you're reducing the risk of wound infection by getting rid of old scarred tissue. So I think there's a lot of benefit to open surgery. And I think I also say an open lysis of adhesions is my zen. That's where I find my flow state, which is interesting. Yeah, I

Dr. Towfigh (41:59):
Agree.

Dr. Miller (42:00):
I agree. I like a robotic lysis of adhesions too, but it's not the same. No,

Dr. Towfigh (42:07):
No. It's like needing bread versus putting it in a bread machine that you want to do. That part is, I agree with you. It is very zen.

Dr. Miller (42:18):
Yeah. Yeah.

Dr. Towfigh (42:20):
And then what's your experience with these nerve injury abdominal wall where the side really pooches out? Have you seen

Dr. Miller (42:31):
Those? I've seen those. I think about other people ask me too, "Do you repair them?" And I talk to patients about it and it really depends. And I've done some research or read some of the research about it too, and there are some case series that show good benefit from a pain or a functional standpoint of basically plicating the muscles, so kind of scrunching it up and sewing it back, tightening it up for people. But I actually personally haven't done it. I've talked to patients about it, I see it, I explain the problem, and then I send them for physical therapy first because that would be my first line treatment. And either they don't come back or we just decide not to go forward with surgery. I always have concerns about causing worsening chronic pain by doing it because of the muscles and the nerve structures that go through there, and then you're scrunching them up and sewing them into suture.

(43:30):
And so it's something I think is an interesting idea, and I will placate those muscles if I'm fixing a hernia. There's a hole, but then there's also stretched out muscles. I'll tighten them up to give it natural or tension,

(43:47):
But I've not done it really without a true hernia.

Dr. Towfigh (43:52):
Yeah. Going back again to vascular surgeons who resect a rib to try and gain access, whether it's for thoracic surgery or spine surgery or for aortic surgery, and also spine surgery. So I have my fair share of patients that have this, what we call eventration. It's like a laxity of the muscle. It's very deforming looking,

Dr. Miller (44:21):
And

Dr. Towfigh (44:22):
The muscle just doesn't get good nutrition from the nerve. So it starts loosening up and you get this asymmetry where you're like an alien's coming out from your side and there's no good way to make it go back because the nerve is injured, directly transected or stretched out or something like that. So I did my first one, I'm going to say maybe 20 years ago, where I collaborated with a plastic surgeon. He seemed to be like, "Oh, it's just like a tummy tuck. We'll just do a tummy tuck on that side." And I learned from him that just plicating alone is not enough. You have to really plicate it, tighten that muscle really more than you're comfortable doing as a general surgeon.

(45:20):
And then of course the muscles are not healthy and as we discussed, they're kind of thin on that side. So then you put a really wide piece of mesh to cover that whole area, but you have to basically wrap the patient with mesh and you have to sew the mesh to bones, so to the pubic bone, inguinal ligament, pubis, ribs, around the back, cross the midline. And for the smaller ones, it works pretty good. Works pretty good. I also sew the mesh to the suture line. For the bigger ones, I feel like the muscle just still gives way. Maybe the area where you sew it to the bones holds, but in the front it still just gives way because all you're attached to is the other muscles.

(46:12):
And it probably helps them in that if you didn't do it, it'll just continue to grow and just become very heavy and painful. But I tell my patients, this is the worst operation I offer in terms of outcomes. It's the least likely to be perfect. It's a big scar, it's a lot of mesh. And I don't know, I don't think we've figured out the best way. I've seen people that have offered robotic lycation, and I think that doesn't work at all because you need to make it super tight and you can't make it super tight robotically because you just don't have the space and you just can't put enough mesh to wrap it around. You're just basically treating it like a hernia, but it's not. So I think robotic is a wrong decision, but I don't know how you feel about that.

Dr. Miller (47:11):
I mean, I think that it still remains to be seen. I do think as we've gotten better with the robot, I can do such a massive dissection with it and really open up the same kind of space and get all the way back to the spine and up on the diaphragm and down to the psoas. But I think that where you're saying the tightening of it, you're working under tension because you've got the patient insufflated

Dr. Towfigh (47:39):
And

Dr. Miller (47:39):
I always decrease my insufflation, so I decrease the pressure that I'm working when I'm closing hernias. But you have to have enough space to work in,

Dr. Towfigh (47:48):
So you

Dr. Miller (47:48):
Have to have some, and then you're working in a place that already has tension. So if you can have them paralyzed in a. I mean, they're paralyzed for robotic surgery, but they've stretched out, but paralyzed and truly relaxed with an open repair. And maybe that's a place for hybrid. If we can do the dissection and place a big mesh robotically without having to do that giant sit and then somehow maybe do the plication open, I think there's probably still some innovation that can be had there. I've tried to send some of those patients to physiotherapists for EMG therapy and stuff, and I have had no luck. They always - Yeah, it doesn't

Dr. Towfigh (48:36):
Work. EMS. Well, in LA, EMS is really caught on where they put these suits on you and it just kind of.

Dr. Miller (48:46):
Oh.

Dr. Towfigh (48:48):
They're like, "Oh, you can do a thousand sit-ups worth of exercise." So I've asked those people to see if that will help regenerate some muscle or something. But so far, I mean, it's worth studying, but that doesn't work.

Dr. Miller (49:06):
Yeah.

Dr. Towfigh (49:06):
Yeah. I have a inguinal hernia question that's being posed, if I can read it to you. Yeah.

(49:12):
It says, "Despite inguinal hernia surgery guidelines, it seems to me that even now there are still many publications that either combine the information from prior studies like a meta analysis or studies that look at previously operated patients from one or more hospitals retrospectively regarding how best to reduce pain following surgery. Some of the comparisons are the type of surgery, like open tissue, open mesh, shoulder, slap, others. Other comparisons include mesh weight, poor size, whether the mesh needs to be fixated, how the mesh is fixated, and seems to me sometimes the articles don't necessarily reach the same conclusion. So given that, how do you decide what and how you perform your repairs?

Dr. Miller (50:05):
I think that chronic pain after inguinal hernia comes down to technique, so that's why I think the data is - Technique

Dr. Towfigh (50:13):
Or decision making or both?

Dr. Miller (50:16):
Well, I think it's - Is

Dr. Towfigh (50:17):
Technique part of the decision? Yeah, I

Dr. Miller (50:18):
Think technique is part of the decision. But I think it's being aware of your anatomy, knowing where your nerves are and how to avoid them, not over dissecting and not putting mesh directly on nerves. And so I think it's really technique and decision making, which I think is why that the data is so confusing because there are studies that tell you that heavier weight mesh causes more pain, and then there's newer studies that tell you that it doesn't matter if it's midweight or heavyweight.

Dr. Towfigh (50:49):
It doesn't

Dr. Miller (50:50):
Matter if it's open or lap, it doesn't matter. And I think one of the things that's been consistent is if you use more than 10 tacks, you're hiring. Yes, that's the Hennepin paper.

Dr. Towfigh (50:59):
Yeah.

Dr. Miller (51:01):
Because I think no one's actually looked at it again probably because we don't use tacks that much. So I think it really comes down to technique. So the decision on how to fix an inguinal hernia for me is a shared decision discussion with the patient. And I do more laparoscopic than I do open, but I do plenty of open inguinal hernia repairs too. And

(51:28):
I think a lot of the reason I do more laparoscopic is because if they have bilaterals, I prefer a laparoscopic for bilateral because it's same incision, a little more surgery. And the data and my experience has been that people get back to activity faster. People play tennis and golf and fishing or lobstering as they do here within two weeks of a inguinal hernia repair laparoscopically. If it's a unilateral, so just on one side hernia, then I will often tell them I don't know that there's a benefit to laparoscopy. And one of the great benefits, and I think you and Dr. Blake talked about this last week too, of an open repairs, I can do it under local anesthesia. You don't have to have even MAC, you don't have to have sedation. And some people really like that idea. And so I really have a discussion with the patient of these are the options, and this is maybe my recommendation or this is what I do more frequently in your case, but we'll come to a decision together on how to do that.

(52:43):
Granted, we don't always get to know what happens to our patients, but I can think of two or three inguinal hernia repair patients they've had that have had chronic pain after their repair, and all of them have resolved. But in two out of those three cases when I did their surgery, they had some sort of acute inflammatory event going on. So one of them, it was an older gentleman who came and he had a kidney stone, and it had happened the week before. He was still looking for it, but he desperately wanted his inguinal hernia repair. And so we talked about it in pre-op and I was like, "I don't think this is a good idea." And he was like, "I want to do it anyways." And so I did it, and we both suffered for it because he was in my office for six months with very severe chronic pain that eventually did, it slowly started to get better.

(53:40):
And then I have another one, I can't remember what the exact problem was, but it was an acute thing. It happened right before the hernia repair. Oh, I

Dr. Towfigh (53:48):
Get it. Yeah.

Dr. Miller (53:50):
Yeah. So I think that's the other piece of it, is if there's something about the patient where there's an acute inflammatory event going on, that chronic pain piece just is much easier to come to because you're already highly excited. The nerves are excited, the immune system is excited, and so that's a lesson that I've learned. I mean, I tried to avoid those situations, but kind of forced into them, but I will be more strict about that when I talk to patients

Dr. Towfigh (54:21):
Experience. Quick question. As a follow-up, does bilateral laparoscopic hernia repair versus repairing only one side in a patient that only has symptoms on one side, does that double the risk of chronic pain? My patients actually asked that. Am I doubling my risk of chronic pain if you're fixing both hernias, even though I only have pain on one side? What's your practice? Do you offer that?

Dr. Miller (54:48):
I offer. I do it based on, that's another shared decision making. I tell them we can or we don't have to. I think more often than not, patients will choose to have the bilateral done because the idea of having another surgery later on is worse than the idea of a potential complication from that side. But I definitely have other people that say, no, just do the one that's bothering me. And if the other one starts, I'll come back and do it there. I'm open to that. Whereas my partner will fix the bilateral all the time. It's just practice. Yeah.

Dr. Towfigh (55:32):
If you yourself had bilateral hernias on imaging, but only one side hurt, what would you do?

Dr. Miller (55:41):
I would probably have both done.

Dr. Towfigh (55:42):
Really?

Dr. Miller (55:43):
But I would also be in a surgeon's office who I really trusted,

Dr. Towfigh (55:47):
Number

Dr. Miller (55:47):
One.

Dr. Towfigh (55:49):
I

Dr. Miller (55:49):
Would

Dr. Towfigh (55:49):
Not. I would probably be like, "Don't fix a side. Th doesn't bother me."

Dr. Miller (55:53):
I know I'm very active. I lift heavy. I run it. I go to the mountains. I do things where the idea of having a potential complication from a hernia that could be prevented to me would push me into that because at some point I'll be skiing across Antarctica. I don't need to have a hernia.

Dr. Towfigh (56:14):
I love it. Okay, so you have to explain to me because you got some pretty cool Instagram

Dr. Miller (56:19):
Profiles.

Dr. Towfigh (56:20):
Tell me a little bit more about your non-surgical self. Yeah, explain the name of your Instagram page.

Dr. Miller (56:28):
So the Instagram that you put up there is Shudder and Scalpel, and actually I started that I think as a resident. It's old, but Shudder is for photography and then scalpel obviously for surgery. When I started, I had this idea of my dream job is to be a photojournalist for National Geographic. That's my dream job, going into deep, crazy places and taking beautiful pictures and telling stories about the world. I think I had a dream that I would be able to do some of that and be a surgeon, and I try a little bit. I'm not - Friends that do that.

Dr. Towfigh (57:06):
Not National Geographic, but they do a lot of photography on their spare

Dr. Miller (57:11):
Time. Yeah. So that's that. And then I have another Instagram called Buzzing Wanderlust, which is my travel business. So I'm a travel agent or a travel advisor, and I have a travel business, so I can plan trips and book your next vacation for you.

Dr. Towfigh (57:31):
Can you help me with Africa next year?

Dr. Miller (57:34):
Oh, yeah. And Africa is a place in my heart, because I live there in the Peace Corps, and I travel almost every year. I'm going to be

Dr. Towfigh (57:42):
Gone

Dr. Miller (57:42):
In October. All right.

Dr. Towfigh (57:43):
I owe you a phone call. Well, are you going to be in Denver at the

Dr. Miller (57:46):
American - Yeah, I'll be there. I'm even tomorrow.

Dr. Towfigh (57:48):
Yep. Okay. Yeah, we can talk about that.

Dr. Miller (57:50):
Thursday, I'll

Dr. Towfigh (57:51):
See you there.

Dr. Miller (57:52):
Okay. Yeah.

Dr. Towfigh (57:53):
Okay. Well, this has been great. I really appreciate your time. You've been awesome. I'm really looking forward to seeing you in Denver at the American Hernia Society meeting later this week, and I will have to be calling you for my

Dr. Miller (58:08):
Africa

Dr. Towfigh (58:09):
Trip next

Dr. Miller (58:10):
Year. I'll bring you a card so you'll have it.

Dr. Towfigh (58:13):
I love it. I love it. Okay, everyone. Thanks very much for joining us. This was yet another wonderful guest with us on Hernia Talk Live. It's becoming biweekly Q&A. It used to be weekly for five, six years. Don't forget, if you go on YouTube at herniadoc, this and all prior episodes are archived there. You can watch it, share it, like it, subscribe, whatever you like to do. And please follow us on Facebook, Instagram, and X at herniadoc and Dr. Towfigh. I will see you hopefully next week. See you all. Thank you so much.

Dr. Miller (58:54):
Thank you.

Dr. Towfigh (58:55):
Thanks again. Have a great

Dr. Miller (58:56):
Rest of your

Dr. Towfigh (58:56):
Day. Bye. See

Dr. Miller (58:57):
You in a couple days. Yes.

Dr. Towfigh (58:58):
Bye-bye. Bye.