An honest question for Dr. Twofigh

[drtowfigh]

I’ve had my own share of bad outcomes. There is no perfect surgeon. We are all human. Specialists should have lower risks of complications. And when we do have complications we are usually much better at knowing what to do next.

[Watchful]

Not very clear to me – unhappy with the technique, repair not as good, but excellent outcomes?

A 5% risk just for pain caused by nerve damage in open surgery is pretty shocking. You still need to add to that pain for other reasons related to the surgery. None of the surgeons with whom I consulted shared such high numbers. Most dismissed chronic pain as extremely rare (even with open surgery), which I knew wasn’t consistent with studies. The baffling thing to me is that some of the surgeons I talked to have a very large number of on-line reviews without anyone complaining of pain, so I can’t say I understand the picture well. Maybe some surgeons are truly wizards at not causing pain.

By the way, we’ve had patients on this forum who had bad outcomes with guest surgeons: Brown, Koch, Muschaweck just off the top of my head. I know of additional bad outcomes with guest surgeons.

[William Bryant]

That’s a relief! I think it was a bit tongue in cheek but disconcerting none the less. So I feel bit more at ease now!

Would or have ever considered having Dr Kang as a guest as I know a lot of people are interested in his repair?

[drtowfigh]

I stand behind all the surgeons who I’ve had in as guests in HerniaTalk LIVE. It’s my quiet way of showing my preference for them as the chosen ones from whom you may choose to seek consultation.

Also, just because I don’t like their surgical technique doesn’t mean they are bad surgeons. These surgeons have excellent outcomes.

[William Bryant]

Dr Towfigh, I understand it was a difficult question for you about who is best to repair your hernia, I fully understand because it’s just as hard if not harder for us who will have to choose and have an answer. Could you not help us by at least giving us a short list of say 3?

It isn’t very encouraging when a surgeon says of fellow surgeons, who we patients may pick, their technique leaves a lot to be desired!

If you don’t have an answer to who you’d choose please at least tell us who had poor surgical technique!?

[Unknown Member]

Our pelvis moves everything unlike a plane crash. Dr.Iacco and Janzyck are respectful but they will do 100% and more. They care about the patient and nothing but….

[Unknown Member]

More or less we go to a general surgeon which when I walked into Dr. Janzyck and Iacco office they have a sign saying the groin is the most complex part of the anatomy which is true especially for us guys with our spermatic cord. 3dmax doesn’t need fixation buy seeing a video on YouTube it sits on a operative table folded up. That’s what liked where I went cause they said tacks always cause pain, my tacks were eroding into my pubic bone which with 3dmax aren’t needed but even with tacks that say to evaporate hernia repair is sketchy within itself.

[Unknown Member]

Just curious…if you had an inguinal hernia…how would you address it? Who in your view is the best tissue surgeon in the world…you are probably the most knowledgable doc there is about hernia surgeons having interviewed so many—if you had to choose a tissue repair…which would it be…and which surgeon would you see. I have heard you say the shouldice repair gets too tight….Desarda is unproven….Kang is doing a modified Marcy repair which only works in children…does that leave one of the German surgeons? I know its hard to get an honest answer from a doc on this…but I am trying all the same.

[Unknown Member]

Good grief…most of the studies cited say there is no difference in the risk of recurrance….and one says the risk of serious harms from lap is greater? Come on Doc….

[Unknown Member]

Thanks so much for your detailed answer…and again for tolerating dissent. Very refreshing. Sadly this “every study” stuff is commonly stated by hernia surgeons to support whatever surgery they personally perform…I looked and found studies that showed open surgery was less risky and less likely to recur…these were open mesh studies. I didnt realize i would be cathed…I didnt even realize there were real alternatives on the anesthesia front—even open surgeons were telling me they used general…I only learned later that they do this for their benefit not ours….same as catheterization…if you get a stricture or some kind of infection…from it..good luck with that— your calls will not be returned. Should i have studied this issue harder –of course…but i went to 6 doctors…and was suspicious of things i was reading on the net from attorneys. I didnt reaalize then that doctors could not be trusted at all.,I thought hernia surgeon was quick and routine…I didnt realize it was lifethreatening surgery. As watchful said he never expected to have to fly to other countries to get a hernia fixed….but that is EXACTLY what you need to do. All I ask is that what was written in the disclosure was actually said to me…Look son there are risks to this surgery…its a lot of plastic…it could get infected…shrink…migrate around your body get stuck on critical organs…if that happens taking it out may well destroy your life…but tissue repairs have issued too…you may want to explore them…do you still want to do it? If you surgeons said this to patients…you know no one would ever do lap surgery…so you hide it in some ten page fly print document. This is a typical example of the total BS I got from surgeons….20 percent recurrance rate likely from a tissue repair….and Dr Harris implies it might recur in a year….mesh is “extremely safe” citing all those large longterm studies again..https://www.youtube.com/watch?v=hGk91bXpMKU

[drtowfigh]

This is not the first time you’ve asked me to support my claims. I’ve done it before for you. I cannot force you to agree with me. Nevertheless, you asked again and I shall answer again. As you know, I prefer dealing with facts and not anecdote. So here it goes:

I interpret your situation as someone who got injured in a plane crash and is now claiming he should have driven cross country. Whereas all studies show it’s safer to fly than drive. And your focus is that flying can’t be safer or better because it causes so much emissions, isn’t carbon neutral, and isn’t minimally invasive mode of transportation.

Here are the facts:
– every major large population database study shows laparoscopic inguinal hernia repair has multiple benefits over open repair with or without mesh, including less chronic pain, less nerve injury risk, lower recurrence risk, shorter recovery time, and so on. The more advanced we get, the stronger the data in favor of laparoscopic repair, all things being equal. These are just a handful of review papers that include a lot of references in support in addition to multiple consensus reports by the European Hernia Society.

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001785/full

https://pubmed.ncbi.nlm.nih.gov/35286471/

https://journals.lww.com/annalsofsurgery/Abstract/2021/12000/Treatment_of_Inguinal_Hernia__Systematic_Review.13.aspx

https://link.springer.com/article/10.1007/s00464-022-09161-6

https://www.sciencedirect.com/science/article/abs/pii/S0002961022003051

– the term minimally invasive commonly refers to the lesser tissue trauma and need for healing involved with lap as opposed to an open operation which involves a large cut and a longer recovery. Less cutting, less retracting, less sewing = less swelling, pain, and shorter recovery.

– not sure what you mean by “huge” number of tacks. If used, less than 5 tacks are needed. If you had more than 5 tacks per side, that is outside of common recommendations

– your tacks, if absorbable, are not petroleum based. The non-absorbable tacks are typically titanium.

– it is common to catheterize when performing pelvic surgery. Every urologist would recommend it. The risk is bladder injury if you are not catheterized. There are general surgeons who do not routinely catheterize. Most large population studies show that catheterization is otherwise riskier than not catheterizing.

https://pubmed.ncbi.nlm.nih.gov/31657302/

– 3D Max only has a tendency to ball up if the surgeon doesn’t make the space wide enough to fit it or the mesh is curled prior to placement. Analogy is putting paper in an envelope that is too small for it.

– the weight of 3D Max is 137.1 g/m2, which is heavyweight. They also have middleweight and lightweight 3D Max. It is also not microporous or macroporous. Pore size is 5×10-4 inches2.

– 3D Max instructions from the company specifically shy away from recommending no fixation. In some hernias, fixation may not be necessary. We know fixation is recommended for direct, femoral, and large indirect inguinal hernias.

– mesh fixation does not prevent balling up of mesh

– it is not true that “immense tissue injury” is initiated by laparoscopic surgery.

– it is not true that the peritoneum is “shredded” by laparoscopic surgery

– the mesh standard is 10x15cm. That is 150cm2, which is

Also know that laparoscopic surgery came after Dr Lloyd Nyhus started doing open posterior repairs in late 1950s/early 1960s. That came first. Then laparoscopic repair option was introduced.

[Watchful]

Makes sense. Would you say that there’s a certain number of years of experience when the rate of bad outcomes goes down significantly? You learn from experience how best to handle different anatomies, and how to avoid trouble. Would it be 3 years? 5 years? 10? 20? More?

[Herniated]

@drtowfigh wrote:
“For myself, I’ve always wondered who I would choose if I had a hernia. There are a lot of great surgeons out there by reputation. I’ve seen some of them operate and for some of them I was unhappy with their technique. I feel I do a much better repair and a more dainty one.”

At first glance Dr. Towfigh’s implied preference for a Beverly Hills hernia surgery experience seems self-serving. However, given her expertise with robotic surgery, self-servicing hernia surgery seems plausible, although anesthesia could be tricky 🙂

[drtowfigh]

@chucktaylor
I’d like to see which articles you are referencing that shows worse outcomes from lap vs open. Just because something is published doesn’t mean it’s a valid study. You have to analyze the strengths and weaknesses of the study.

Yes, “though rare,” as the studies point out, serious complications (bladder, bowel and vascular injury) are more likely with laparoscopic repair. That’s a given, because it’s a posterior repair. Most of us specialists have never had these rare complications and they are rare and typically associated with lack of experience. On the other hand, you have much nerve injury and chronic pain risk with open surgery because the nerves are exposed with open anterior surgery. They are much less likely to be injured with laparoscopy. So, you are comparing a fraction of a fraction of 1% risk of serious complication with laparoscopy vs an approximately 5% risk of just nerve related pain with open surgery.

How data is analyzed is very important.

For myself, I’ve always wondered who I would choose if I had a hernia. There are a lot of great surgeons out there by reputation. I’ve seen some of them operate and for some of them I was unhappy with their technique. I feel I do a much better repair and a more dainty one. So, I don’t have an answer.