April 28, 2026 • 49 mins
What’s the difference between a hernia and diastasis—and why does it matter more than you think?
In this episode of Plastic Surgery Uncensored, Dr. Rady Rahban sits down with world-renowned hernia specialist Dr. Shirin Towfigh to break down one of the most misunderstood topics in abdominal surgery.
They cover:
• Diastasis vs. hernia — thinning vs. a true hole (and why they’re NOT the same)
• Why pregnancy often leads to diastasis—and how it impacts core strength, posture, and daily function
• The real risks of hernias and when they require repair
• The truth about mesh—when it’s necessary and why it gets a bad reputation
• Open vs. laparoscopic vs. robotic surgery—and what actually matters for outcomes
But more importantly, this episode exposes what most patients aren’t told:
Why surgeon technique, planning, and collaboration matter far more than the method used—and how combining plastic surgery with hernia repair can dramatically improve both function and aesthetics.
If you’ve been told it’s “just cosmetic,” or you’re considering abdominal surgery of any kind, listen to this first.
✨ If you enjoyed this episode of Plastic Surgery Uncensored:
✔️ Subscribe on Apple Podcasts, Spotify, or wherever you listen.
✔️ Rate & Review—your feedback helps more people find us.
✔️ Follow Dr. Rady Rahban across all platforms for daily insights, behind-the-scenes, and patient education:
In this episode of Plastic Surgery Uncensored, Dr. Rady Rahban sits down with world-renowned hernia specialist Dr. Shirin Towfigh to break down one of the most misunderstood topics in abdominal surgery.
They cover:
• Diastasis vs. hernia — thinning vs. a true hole (and why they’re NOT the same)
• Why pregnancy often leads to diastasis—and how it impacts core strength, posture, and daily function
• The real risks of hernias and when they require repair
• The truth about mesh—when it’s necessary and why it gets a bad reputation
• Open vs. laparoscopic vs. robotic surgery—and what actually matters for outcomes
But more importantly, this episode exposes what most patients aren’t told:
Why surgeon technique, planning, and collaboration matter far more than the method used—and how combining plastic surgery with hernia repair can dramatically improve both function and aesthetics.
If you’ve been told it’s “just cosmetic,” or you’re considering abdominal surgery of any kind, listen to this first.
✨ If you enjoyed this episode of Plastic Surgery Uncensored:
✔️ Subscribe on Apple Podcasts, Spotify, or wherever you listen.
✔️ Rate & Review—your feedback helps more people find us.
✔️ Follow Dr. Rady Rahban across all platforms for daily insights, behind-the-scenes, and patient education:
- Instagram: @drradyrahban
- TikTok: @radyrahbanMD
- YouTube: @Rady Rahban
- Facebook: @Rady Rahban
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:06):
Welcome to another episode of Plastic Surgery and Censored. I'm
your host, Doctor Roddy Raban, and we have a fantastic
episode for you today. It's fantastic for a number of reasons.
Number one, all the episodes are fantastic, and number two,
and more importantly, we have a tremendous honor to have
doctor Sharin Toopi world renown and this one I actually mean,
(00:26):
I'm not just making that shit up, world renown hernia
specialist doctor Tophi, who has honored us to be here.
So you better listen to this episode because you guys
are you may never ever see doct Topi again. She's
so coveted and hard to find, and we're going to
tackle everything related to diastasis, hernia's, abdomen's and more. Doctor
(00:51):
Tophi and I've worked together now for over twenty years.
We've known each other for more than twenty years, and
I was just saying to her before we started to
show that I genuinely believe the patients are incredibly lucky.
When a and two excellent surgeons combine to help a
(01:11):
patient out, it's synergistic. And while that may happen on
occasion in a hospital setting, right, the neurosurgeon hires the
vascular surgeon. But in private practice to have surgeons collaborate
as we have for years is very rare, and I
just think it's really good for the patient. So welcome
(01:31):
to the show, Charin.
Speaker 2 (01:33):
Thank you for having me. I never say no when
you invite me.
Speaker 1 (01:36):
Wow, we are an honor to have you. And it's
always exciting. We did a show, I want to say,
during COVID, and we did it via zoom and it's
just so nice to see you in person less than
five feet. So let's dive in, and let's let's start
talking about anatomy, because the terminology around this is a
little confusing, and we want to make sure people understand
(01:57):
the distinction between a hernia and a diastasis. So a diastasis,
as many of you know because we talk about it
so frequently, is when the rectless muscles, which are your
sit up muscles, your eight packs sitting in the middle
of your abdomen ninety five percent due to pregnancy, that
is a massive force inside your abdominal cavity, pushing and
(02:21):
pushing and pushing and pushing out slowly and gradually pull apart.
They don't. They don't just tear apart because it's incremental
and gradually and gradually pull apart, and the normal connective
tissue that holds your two muscles together like a piece
of gum. As they pull apart start to thin. The
further your muscles get from each other, the thinner that
(02:45):
piece of gum gets because it's still the same gum,
And as a result, you get this separation between your
muscles known as diastasis. That is normal. One hundred percent
of women who have multiple pregnancies will have this. If
you don't have it, you're the unit. With every ongoing
pregnancy one, two, three, four, five, six, et cetera, that diastasis,
(03:05):
whatever percentage it was the first time, will increase. There
are women I've seen five pregnancies minimal to almost no diastasis.
I've seen people with one pregnancy and it's tensonometers. Okay,
so that is diastasis. There is no hole. It is
not a defect. It is just a weakening of the
normal anatomy that would normally hold your abdominal wall together.
(03:27):
As a result, it presents as what distension. God, I
feel like I'm like four months pregnant, I'm skinny I'm
working out, so it presents as distension, which is esthetically
visible protuberance. It presents with weakness, like I have constant
low back pain, and when I get up out of
(03:48):
my bed, I got to kind of like use my
elbow and kind of roll because your muscles are not
in the right place. It's like taking my bicep muscle
which connects to my uranius and all not to my
humors and moving its connection and putting it some where else. Well,
of course it's not gonna work. And then it leads
to other types of related issues like bladder issues and
(04:09):
bowel issues and all kinds of things. So that is diastasis.
And we've talked about that like four thousand times, and
we keep talking about it because it affects and afflicts millions,
it's not hundreds of millions of people. Then we turn
and talk about hernias. They're not the same. They're completely different.
That's like saying a Chinese person and a Korean person
(04:30):
are the same people. They're Asian, they're in the they're
in the abdomen, but they're different. So, doctor Topi, would
you tell me what you with the lay terms of
a hernia.
Speaker 2 (04:40):
Yeah, so there's good Evans showed there probably are the
same family. Yeah, of course, like your analogy earlier, But
a hernia is a hole and the risk of that
is something can fall into that hole. Usually it's fat,
but it can be intestine or another organ, and so
(05:00):
from a medical life saving standpoint, or hernia is can
be concerning. So those are usually repaired. Diastasis has always
been termed a cosmetic thing. We know that that's no
longer true, but for many many years, your specialty plastic
surgery has been treating diastasis, and my specialty general surgery
(05:23):
has been saying it's not a hernia, it's all cosmetic,
and we now know it's not true. Number one, there's,
like you mentioned, so many things that can go wrong.
And a patient that has a diastasis, they get constipated,
don't they lose their core. You need core muscles to
have good bomb movements, back pain, and ability to do
(05:43):
perform certain exercises or certain movements. So what I've seen
is our world, the general surgery world, is learning from
the plastic surgery world and understanding that not only is
diastasis relevant, but if you have some who now has
a hernia and they come to the general surgeon for
the hernia repair, it's important to also see if there's
(06:05):
a diastasis. Sure, and now we are doing a much
better job to not only repair the hernia, but understand
that diastasis repair should be incorporated as part of the
hernia repair in order to have a really good hernia repair,
higher recurrence rate if you ignore the diocese and just
treat the hernia because you're fixing a hernia within the
(06:28):
weakness and the spreading a part of the fascia. You
fix the hernia and you support that hernia by bringing
that weakness together, and you have a much better hernia repair.
Speaker 1 (06:40):
Yeah. Absolutely so for those of you listening, the distinction
is diastasis is thinning hernia as a whole. Now, you
can get that hole anywhere in your abdominal wall. You
can get it to the side of it from a
previous colostomy. You can get it in your groin in
England or hernia. You can get it in an opterator.
(07:01):
You can get it smack dab in the midline. You
can get it through your belly button, which is probably
the most common umbilical hernia, which some people even have
and are men, and they never even had any babies.
So the fact that you have a hole or a defect,
an actual opening, can happen anywhere where are two specialties collide.
Is that of the areas in which you get a hole.
(07:23):
The idea that you get a hole through a shitty
area in your abdominal wall aka thinned out a trophic
piece of tissue your diastasis, should not be surprising. In
other words, the fact that there are tons of hernias
that occur from the xyphoid, which is where your rips start,
to your pubis, which is your entire abdominal wall in
(07:45):
the middle is makes total sense. It's an area of weakness.
You are now under a great deal of pressure, often
during pregnancies, and something pops through or tears or comes through,
and so of course it is. I've been doing this
now for twenty some odd years. I've done thousands of
distasies hernia repairs, and it's just part of our surgery.
(08:05):
I get in there, I open up the abdomen to
get access to the distasis, and loan behold, there are
grape size, apricut size, grapefruit size hernia sticking in the
middle of the abdomen, and as doctor Tofi said, it
can be a number of things. Fat I've had omentum,
I've had intestines, I've had all kinds of things. So
(08:26):
normally what would happen is that, Okay, hey, doctor Tefi,
nice to meet you. I'm you know, Susie. I've flown
all the way from Ireland to see you, and I
have a hernia. And the treatment for hernias is reinforcing,
taking the thing that popped through the hole, pushing it
back in the abdomen, and then fixing the place where
the hole came through, closing the window, so to speak.
And let's for the time being eliminate and forget about
(08:48):
the midline part. But hernias historically have been addressed by
using some type of reinforcement material to bolster or repair,
because if you just close the hole and don't reinforce it,
there's a failure rate, right, a recurrence rate. As a result,
mesh and different materials have sort of become the mainstay
(09:11):
of repairing hernia's. Generally, we're going to subdivide diastasis related
hernia's for a second, So tell me a little about
how you repair hernias outside the midline.
Speaker 2 (09:20):
So I would see the United States, mesh based repair
has really skyrocketed. Over ninety percent of herneias are prepared
with some type of mesh. That's not necessarily true in
the developed world because mesh is expensive. But then you
get these kind of disasters because you have patients that
really can't get a non mesh repair and they don't
know what to do with it because they don't really
(09:42):
have good access to mesh. And then Europe is kind
of like in the middle in terms of how much
mesh they use it not. But if you think of it,
when you were a kid, I don't know if your
mom did this, but you know, if you had a
hole in your genes, there were those little patches you
aron on.
Speaker 1 (09:57):
You can't just close the I love elbow.
Speaker 2 (09:59):
Patchs elbow patches. You can't just close it, right. So
that's the same concept with mesh, which is if you
have a tiny hole one centimeter, then closing it with
stitches and no mesh perfectly good, just as good as mesh.
If you have a larger hernia two centimeters, really the
favored repair is with mesh. Certainly anything over two centimeters.
(10:22):
For ten centimeters, you have to not only use mesh,
but even probably manipulate the tissues around to be able
to get that hole closed, and then you can put
the mesh in.
Speaker 1 (10:32):
Yeah, And the idea, of course, as everyone should understand,
is when you have an actual hole, over time it
will stretch open and there's a tremendous amount of tension. So,
like you said, let's use your analogy. You have a
hole in your genes. If you pull that hole together,
you're going to get a weird ass flattening and odd
shape to your genes. And the minute you bend your knee,
(10:53):
it's going to rip open. It's just going to rip
right open. And so the just envision the amount of
strain that your abdomen goes through from coughing, bending, sitting,
straining all that. So if you have a let's just
use a five centimeter hole and then we just try
to your kit together and put stitches. The stitches won't break,
(11:14):
the tissue will give weight. We call it cheese wiring
sort of like you know, if you hold you know,
a piece of string cheese together with cotton candy and
use a metal cable, cable's not going anywhere. The two
of the things are going to give way. So that
is why a material which globally is referred to mesh,
it's kind of a large term, is used to sort
(11:35):
of patch or reinforce it. Then within that world, there's
two things that I think are important, which is what
are those meshes? Some are really good, some are really bad.
And then within that world is do we put it
on it, in the middle of it, or underneath it.
It's a little sophisticated concept, but we have the world's
foremost expert in the world of mesh, and you guys
are not going to get this information elsewhere. And mesh
(11:59):
is the same in general surgery as filler is in
plastic surgery. Let me explain. I like that the term
mesh creates a feeling of fear in patients because mesh
was incorrectly used by a lot of people. It's a
fantastic tool when used correctly. Filler has got a bad rap.
(12:20):
Filler is a fucking amazing product, and when used correctly,
there is no substitute to it. It was just overused.
And so patients, now you say the word, I think
you need a little filler, not filler. Filler is poison.
And that's sort of how people at least when I
talk to patients and the term of mesh comes up,
it's got a bad rap. It's got this sort of
(12:41):
fear associate with. So let's let's do a few things. One,
what types of mesh are there? Just globally We don't
need to get into polyproperly, so just there's different kinds.
What are they?
Speaker 2 (12:52):
So globally it's the permanent mash and absorbable mesh.
Speaker 1 (12:55):
Right, so something that stays forever, something that stays for
while your body will eventually absorbed. My understanding is absorbable
mesh is kind of a not a really good concept
because you kind of always need you won't generate enough
scar tissue really to make up for the resilience that
the mesh is not there anymore. That's correct.
Speaker 2 (13:15):
So nothing beats permanent mesh in terms of the function,
which is to prevent recurrent hernias. But there are situations
where you either can't use the permanent mesh or you
don't really need that much mesh, so in which case
you can air on using something absorable because it's a
really small hernia. Or the patients let's say allergic too.
Speaker 1 (13:36):
Sure, so we have absorbable and non absorbable. And then
within the world of mesh, there was a lot of
because like everything, there's learning and there's a lot of lawsuits,
class action, class action lawsuits, love the word mesh. Have
you been a victim of mesh? Right? And so a
lot of that mesh problem occurred when mesh was placed
(13:59):
abudding tissue and organs inside the abdomen and as a result,
things became it heased or fibrotic or connected, creating problems.
So a lot of the old issues with mesh, if
I'm not incorrect, were as a result of not using
it the way we use it today. Is that accurate?
Speaker 2 (14:19):
Yeah, So before I was a resident, they and mesh
kind of came in kind of the seventies. They were
putting mesh directly inside and it was going against intestines.
So that was a bad idea because mesh is highly inflammatory.
It eroded and it was very stiff, it rode in
the intestine. So they learned not to do that. They're like, okay,
let's put a barrier. So now we're going to put
(14:42):
the mesh there near the valve, but then put something
that prevents the bollet from sticking to it. We know
that's also not ideal that we do it. But it's
not ideal because in the long run you have a
higher risk of bow obstructions because of it sticking to
the mesh, and a high risk of needing a reoperation
because of that issue, and risks of either mesh infections
(15:02):
or erosion in the mesh. So ideally, if you are
using mesh, the mesh should be as far away from
the intestines as possible, so it can go one layer away,
so what we call extra peranial, two layers away, so
it's retro retro muscular, extra fascil or all the way
on top of the abdominal wall, which we call it
(15:24):
on the They're all good techniques. There's pros and cons
to all of them, and depends on the skill of
the surge in the situation that the patient has right.
Speaker 1 (15:33):
So the basic gist of it is a lot of
the oh shits with mesh occurred when they were learning
to use it, and it occurred understandably because mesh is
a foreign device that's very rigid because it's giving strength,
and in many instances it's netted or it has some
if you will, some perforations in it. So that it
can bend, and as a result, organs Akabow was sticking
(15:56):
to it, creating a disaster. When you put the mesh
away from that, it's not that there's no complications, because
there's complications, it's just not the catastrophic types of complications
that really gave mesh a bad name originally. So that
I think is really really important for people to understand.
I think, just like anything else, as you said, it's
(16:17):
not so much the mesh or which mesh, like, oh,
which implant are you using, it's the surgeon who's placing
the mesh and the location of the mess and how
much undermining they do, and what type of sutures they use,
and all those things that makes a great hernia surgeon
different than a shitty hernia surgeon. Right then, there was
the advancements of laparoscopic slash robotic surgery, so there was
(16:39):
a push right in the world of getting in the abdomen.
Right getting in the abdomen was like we considered a box,
and historically we got into the box from the outside
of the box. Then all of a sudden there's this
advancement which catapults abdominal surgery into the modern era. Which
is I don't need to open up your whole abne
maka slice you open like a cadaver. I'm gonna poke
(17:00):
a bunch of small holes in, whether they're laparoscopes or
now robots arms, and I'm going to do everything from
the inside. So for the basic lay person, how has
that changed hernia repair for you? And when should they
consider the traditional approach open, slap a piece of mesh
on it, get out a dodge versus No, that's that's archaic.
(17:22):
Why would you do that? Just poke a few holes
and stick the thing from the bottom. Tell me if
you will, a little basic gist of that.
Speaker 2 (17:29):
Yeah. So the goal of all hernia pairs is to
close the hole number one and then consider whether you
should put some type of mash to bolster that repair.
That can be done through a big incision where you
access it what we call open. It can be done
through small incisions laparoscopic, or it can be done with
even more technology, which is robotic. So there's open, and
there's the laparoscopic and robotic and what we call minimally invasive.
(17:52):
In all circumstances, a laparoscopic or robotic repair will have
better recovery, less infection rates, perhaps cosmatically better that's debatable,
a lower risk of like mesh infections and so on.
But there are situations where it's open is either perfectly
(18:13):
fine or preferred right.
Speaker 1 (18:14):
And then when you stick the thing on the bottom right,
so it's the idea of patching it or plugging it right.
So from the bottom it's idea. Yeah, I had a.
Speaker 2 (18:25):
Patient patch on top of patching it underneath.
Speaker 1 (18:28):
So the idea underlaid the idea of tires. Right. If
you think about a tire, you will have a much
better repair of a tire hole. I have seven many
cars if you stick and do an internal patch, because
the patch is being reinforced by the pressure inside. So
I think from a physics standpoint, it's a better outcome.
But how do you circumvent the issue that that patch
(18:50):
is now again in intimate contact with the organs. Whereas
that was how we started this, we got in a
lot of trouble, a lot of perforations and catastrophes. We
realize as we should go outside or further away, and
now we're back to sticking it underneath. Is it any material? Well?
Speaker 2 (19:04):
I really like that you're bringing up surgical history because
you got to learn and not repeat history. So with
the open repair, we were not doing too bad of
a job. Then when laparoscop became the only way we
could do it was to put it slap underneath because
we just didn't have the skills to do it otherwise,
and that's when we saw these complications. With robotic surgery,
(19:26):
which is the next generation of laparoscopic surgery, you can
act like an open surgeon. You can go in between
the plate. There are situations where I'm never inside the
abdomen and I'm doing these minimally invasively with a robot,
so I burrow myself behind the muscle the entire time.
Speaker 1 (19:42):
Like like a vascular approach to.
Speaker 2 (19:45):
Like the end of aascular surgery, exactly as opposed to
big surgery. So you get the benefit of having the
small holes, but also you get an operation similar to
an open surgery where you can really manipulate the tissues
and put mesh in a situation where it's broad and
and very secure and you're closing the dioceses and you're
closing the hole all with very few little holes.
Speaker 1 (20:05):
Got it, Okay? So that's your four on one on hernias.
Then we shift over to where this combo occurs, which
is I am saying a ton of hernias, A ton, literally,
I did one last week. The lady came in. I mean,
she just looks like she had a like, I don't
know what, a third belly button the size of a
grapefruit above her belly mutt. So I've been doing this
for years. You and I chatted about it, and I've
(20:28):
never in twenty one years, despite doesn't matter what the
size of the thing is. It doesn't matter if it's
a twenty five sonomere, which it wouldn't because that's a
whole admin. I've repaired everything without mesh, and I swear
on my own children, I've never had a recurrence, zero zilch.
Do I have the data, No, but I would know
because a patient would be like, hey, doctor brought and
I paid you a shit ton of money, what is
(20:48):
this bulk? So that's a unique environment. And as a result,
I'm still waiting for you to publish our paper. I
need to be I need notoriety here. This is when
you and I started having this interesting dialogue, and I
think it's sort of starting to permeate, which is in
the di stasis area of the abdomen. It's a unique environment.
(21:09):
Why the defect is occurring through shitty tissue as opposed
to regular fashion. You just somehow weakened or was post
surgical or trocar site or something. And we have this
incredible anatomy there, which is there's a reason the hernia
has happened, which is they're shitty tissue. The muscle separated.
(21:29):
The gates of the mansion have opened, and you know,
everything has come through. So as I've done, and I've
told everybody the way that I always do all of
these it doesn't matter the size. As I go in,
I open up, you obviously have to be careful, right,
you don't want to plow through this hernia. As you're
opening up. I'm already there as an abdomino classes. So
in the world of access access, which I got to
(21:52):
see what the hell I'm doing, there is open surgery
and minimally invasive open surgery. In the general surgery world,
is a cut somewhere on your abdomen down the midline,
sideways something, go straight down, find the hernia, fix it.
So when you're all done and you walk out, there's
a scar somewhere in the middle of your abdomen minimally
invases a bunch of holes. This is a whole new animal.
(22:13):
I'm doing a low incision, cosmetically intended at the level
of your sea section, and I'm opening the hood of
your car, and now I see the entire world. So
from an access standpoint, there is no better access in
the world because I've literally opened up the whole box.
And then I repair that hernia, open up the sack,
(22:34):
shove everything back in, do everything I need to close
that crappy diastasis and whatever version of fascia or peritoneum
is there. And then I do my diastasis repair as
if you've never had it, and it's a very aggressive
two layer permanent suits. You're blah blah blah. And now
I have the best mesh in the entire world. I
have a biologic reconstruction of the defect that led to it.
(22:57):
There is no question that that's the right way to
do it in that unique subset. I don't care what
the cause is. I don't care if it's a trocar
that went through the middle. I have done people who
are men who have no diastasis but have midline hernias.
Remember our patient that I took care of the gentleman
that you said, who had a trauma and a midline
laboratorie who is phenomenally happy now and working out doing
(23:21):
like jiu jitsu and crazy things. And we did it
through an abdominal approach. So I think that's been where
the revolution and our union has occurred. Hence why I
think that when you get to doctors who are not
ego driven, mindful, thought provoking, academic, you can make really
cool shit happen. And so I think that's been very
(23:43):
exciting for me.
Speaker 2 (23:44):
Yeah, so I love collaborating with other specialties with me.
Speaker 1 (23:49):
Yes, other specialties. What the fuck? What other specialties are there?
Speaker 2 (23:56):
Honestly though, I think a doctors should collaborate general sort
of should learn what guid in college do, urologists do,
orthopedic surgeons do, certainly what plastic surgeons do, because there's
so much overlap. Instead of saying that it's like vertical right,
not my problem, go to plastics, not my problem, go
to general surgery like that, I don't I don't enjoy.
But this is where it came through because it is
(24:18):
quite common for you to do an abdominal plasty right
tummy talk in someone and then they either you either
know they have a hernia or you're like, oh, look
at that little hernia there, either from their prior surgery
or like a little belly button or epigashict hernia, And
they do great. Right, so we know for for relative
lyast months following the under four centimeters hernias, tummy tuk
(24:41):
will handle it. What we didn't know, which is what
you're alluding to, is our paper is it is incisional hernias.
Doctor Yikle of the Netherlands wrote this landmark paper that
said if you take an incisional hernia, that means a
surgeon cut took out your coalon gobblet or whatever, and
then and that was sewed and then that recurs. Right,
(25:04):
So it's technically it's a failure of a prior closure.
If you close that without mesh, it's about a fifty
to sixty percent recurrence, right minimum fifty percent. That is
a horrible number. And therefore the dictum is every incisional hernia,
not primary hernia, she must get mesh because that number
comes down to like about twenty percent. This is where
(25:26):
we started talking, right, So I said, okay, how about
you do those tummy tucks in patients that I see, right,
with an incisual hernia, I'm taught I need to put
mesh in them. But with a tummy tuck and the
right patient there their abdomble walls loose.
Speaker 1 (25:45):
Yeah, they can't be like a morbidly obese with a
massive visceral fat content. That's I mean, it's gonna faily
respect to be the right patient.
Speaker 2 (25:52):
So loose loose abdominal wall, a lot of excess skin,
so they'll actually benefit from a tummy tuck and an
incisual hernia. Where I should be put in mession. Why
don't we use the patient's own tissue so you close
it like you wo and normally, but then you take
your tummy tech as that second layer. So we talked
(26:12):
about measures. There's permanent and there's absorbable. The permanents are
always synthetic, right, I'm off the shelf. The absorables are
always can be synthetic or biologic, right, But we've never
had a permanent biologic unless you do a Tommy tech.
(26:33):
That second layer is a permanent biologic, so it's your
own tissue is permanently supporting the herding parentnerneath it. And
we did present our study as you know, in the
European Herning Society. But we've added a couple more patients
since then, so we'll get that paper dash.
Speaker 1 (26:52):
Because I think that you and I are doing high level,
high level abdominal reconstruction abdominal care. But you and I
both know that the overwhelming majority of patients are being mistreated.
And I don't mean that in a negative way. But
so what I love is like, so for example, if
I see a patient and they have a hernia. We
(27:13):
did a case where the patient had a groin hernia,
I'll refer them to doctor Trofi because that's not an
area where I can help them. When you see a
patient and you think they can benefit, you'll refer them
to me. That's the first issue. The first barrier is ego.
The first barrier is the ego of the surgeon, in
which HI, nice to meet you. You're a general surgeon. High,
(27:35):
nice to meet your plastic surgeon. High, nice to meet
you your no B I have this issue and for
them to relinquish that patient either ego what do you
mean I can do this? Or ego I'm not going
to give away this money, or stupidity. I didn't even
realize there's anything going on. So the fact that you
and I have that symbiosis. Either you send them to
me or I send them to you, or more often
(27:56):
we do them collaboratively is the key to this process.
Second is the understanding that, oh wow, I can this
person's gonna do an amazing job. So like we have
done cases where we've done I've done the tummy tuck
and the diastasis repair, the hernia was outside of that area,
so the patient benefited. While you would have done it anyways,
they could have done a laparoscopic open whatever. They're already
(28:19):
down for the count. Why would I subject that patient
to two separate surgeries. That's just such a terrible medicine. Oh,
go get this fixed and then come back, go get
this fixed. What do you mean, just fix it together.
I'm already going down one anesthetic, one recovery. It's just
a It's terrible, terrible medicine.
Speaker 2 (28:41):
So I recommend to patients to discuss where their surgeon
will put their scar. I've seen people who have a
beautiful belly button and the scar for their herneia is
way up here, whereas they could have hit it in.
Speaker 1 (28:54):
The belly button.
Speaker 2 (28:55):
I've seen people have a C section scar and there
are open hernias in decision is separate from you can
use your C section scar, you don't need to add
a second scar. I've even see patients with a scar
here and the surgeon puts a scar right there. It's
like you could have just gotten a centimeter above. So
planning is very important. And I think working with surgeons
(29:18):
like you, where you're like super intent on planning and
everything before it happens. I learned from you.
Speaker 1 (29:26):
And but that's because you're an aesthetically inclined individual. The
onus falls on the general surgeon, not on the plastic surgeon.
The general surgeon has to say wow, the same way
that OB's by force, stop doing this midline from belly
button deck. I mean we stopped. We stopped doing vertical
se sections decades ago. Why because while it's a little easier,
(29:49):
a fantas steel or a low incision is safe, effective,
and thousand times more cosmetically sound. So I cannot tell
you the number of times that I've done surgeries and
I'm like, what the fuck is this scar here? It's crooked,
it's jagged, it's ugly. I have to revise it. It's puckered,
et cetera. So bravo to you because you care enough
(30:14):
to then be like, hey, what are you doing? Oh,
this is how you do it because you're a skilled surgeon.
There's no reason why you can't do what I can
do it. You can do it, it's just you have
to want to do it. I would say the overwhelming
majority of practical medically directed surgeons, for example, is you know,
my wife's had six spine surgeries. As a result of
(30:34):
those six spine surgeries, she's had a lot of scars
as a results. A lot of those scars, some of
them were anterior abdominal okay, And I remember, you know,
one of the discussions she had. She's a young girl,
she loves her physique and takes good care of herself,
and they're like, we need to go up and down
the middle of your app and she's like hell no.
(30:54):
And then I was like, why, well, we have to
because this that the other're like, but you don't, you
can do this from the bottom. Now. She ended up
not having it, But I have subsequently done several cases
with the neurosurgeons, providing them better access, meaning they see
better than they ever did through a low incision. And
(31:14):
it's not rocket sides. It's not like I've evolved and
created some fucking unbelieva. It's just I understand you, just
you don't. It's like, I need to get this done.
I'm so sorry. It's reconstructive. Just be happy you're walking. Hey,
you know what you have a hurry? I stop bitching.
I cut it out. But these scars ugly, really, really
the scars ugly. We fix your hole, buddy, you know
(31:36):
what I mean? Like, how dare you? It's like, yeah,
but I don't like the gunshot in my abdomen. Look
you know what I mean. It's like, shame on you. You're
so vain. It's it's it's And then there's a lot
of gas lighting that occurs that a patient should not expect. Okay,
at least acceptable cosmesis in exchange for the reconstructive games.
Speaker 2 (31:56):
So I would say that it's true that I am
aesthetically inclined, but patients need to have options, which is
why I recommend every patient to get second opinion, regardless
of who they see, because it's good to get different viewpoints.
But I'll give you example. This robotic diastasis closure has
(32:18):
really taken off. It's fun. I operate it to patients
if they're absolutely not a contraindication to have abdominal paccy. However,
if you do it in the wrong patient, it's so
ugly because a tummy TAK involves the closure of the diastasis,
give your flatter belly and.
Speaker 1 (32:38):
Removing the redistribution of the skin is a separate plate exactly.
Speaker 2 (32:43):
You don't do that with robotic surgery. So in some
patients you can do a great job if you get
a cat scan to evaluate it where the muscle get together,
But now you have all this bunged up skin or
the patient really should have gotten Tommy Tech because they
already have really lose horrible skin from their multi five pregnancies.
(33:04):
And the surgeons are like, you know, they got a
good surgery, and I'm just thinking you need to offer
something else.
Speaker 1 (33:11):
Of these patients, well, they will relinquish it. They're not
gonna let go of that patient. And that is and
I think that is as I said, that's the primary
step in this process is the notion that your doctor
is going to send you to the best location for
your outcome. If someone comes and sees me and they
have something they need to get done. The first thing,
I'm like, oh, no, you need to go see an
ocular plastic guy for this. What do you mean? I
(33:32):
thought you do islids? Yeah, I do eyelids, but I
don't do that shit. That's an oculoplastic guy thing to do.
And while he's there, have him do your bleff. Do
you know how many times people have come to me
for upper eyelid surgery and in addition to the upper
eyelid excess skin I identify let's say, atosis, their lid is sagging,
or they have some other medical issue and they don't know.
(33:55):
They just think it's all eyelid skin. And I look
at them, I'm like, well, you have some mild tone.
I can take the skin out, but you're probably gonna
be unhappy because when I'm done taking the skin out,
you're gonna really identify that this eyelid is lower than
the other. To be honest with you, I don't do
tosis repair. You should. You should? You should go to
see an oculo plastic guy, and when you're there, let
(34:16):
him do your blaff. You understand. I have to let
go of them. I have to say go somewhere else,
go do it, Go get it done somewhere else and
while you're there, let him do the cosmetic part. I
think that's a big problem.
Speaker 2 (34:29):
Same with with me. When I see him, I have
to sit back and say, have you ever considered having
it just a tummy tuck? Not just a tummy tuck?
And they're like, yeah, I've always but like they thought,
that's just being vain of them. I said, you are
the perfect candid for that, because yes, you got the hernia,
(34:51):
but that hurney really should get repaired by also fixing
your diastase and putting off.
Speaker 1 (34:56):
Skin and you get access to it. That's really, really,
really important. So you know, the message here to the
patient listening is not only just in the area of
abdominal surgery, but you really One of the things that
we were talking about is doctor Tophi myself. We have
a urologist in our group. We have several specialties that
(35:17):
we've interlinked. And what's ob what's great about it is
that you're entering our network unbeknownst to you, and as
a result, you're the beneficiary of this network, and that
we can call each other up, tell each other, hey,
I think there's this the case to a urologic case
or this Obe case or whatever the case is, so
it'd be ideal. I know it's not easy to do,
(35:38):
but identify surgeons who are part of a group that
will let you go and go to the next guy
who's great or the next gal who's great. And if
you can do that with your healthcare, I think it's
really really important. I don't know that that's I don't
know if that's achievable, but certainly I think our patients
are lucky in that regard.
Speaker 2 (35:58):
Right. I would say that that the more institutionalized a
surgeon or doctor becomes, the more they lose that that
like will to call up other doctors. They're a handful
of doctors that we know, general medical doctors who are
so good at that they'll call, they'll follow for their
patient's what's the plan, what do I need to do
(36:20):
for them? Which light order for them? How can I
help you? Or I'll call you, You'll call our other colleagues,
and that especially in coordinate care. That doesn't happen enough
in the US system, And the more institutionalized and the
more insurance companies take over that ability for you to
have time to do that for every single patient. I
(36:42):
think the worst it is. So I'm glad that we
do it. I'm glad we're in a situation where our
practice well.
Speaker 1 (36:48):
We're private practitioners or excellent what we do, and we
all care very much.
Speaker 2 (36:52):
It makes such a difference.
Speaker 1 (36:53):
It's best if in the world of if you were
to put this in chat GPT or Rock or whoever,
it would spin us out, not you and me, per se.
But the way our network is built, I can get
on the phone, I can get a mammogram for someone.
By afternoon, I got a cat scan for a lady.
I don't know if you saw that intra abdominal mass
I posted. She came in for a tummy tech. She
walked in here from Texas Friday. Her surgery is Monday,
(37:16):
and I had done a skype with her. I mean,
I've done the whole thing. And I came in and
I was like, can I examine you? And she's like, yeah, sure,
And I examined. I was like, what the fuck is
this thing? It's like, what what do you mean? I
just had surgery a year ago. They did a laparoscopic
hernia repair. They were interabbed him and said, oh, there's
something really not normal here. I need you to get
a cat scan. What do you mean It's eleven forty
(37:38):
five on Friday. Surgeries Monday. I was like, just give
me a second. I'm calling everybody I know, get her
a cat scan. And one hour we come back. We're like,
oh no, no, there's a twelve to fifteen sonometer, massing
rabb likely five ORID what have you. So we have
that ability, and I think, I just I mean, I
wish that for all of my family and all of
my patients. So the last thing I think, or one
(37:58):
of the things that's really really important, and I think
there's this this notion and is the idea of scars right,
because if you do it minimally invasive, the robotic or laparoscopic,
the scars are small, but they're there because one of
the number one complaints of patients have is they come
back to me for liposuction canulus site scar revision. So
(38:21):
it doesn't matter how goddamn small the incision is. If
it looks heinous, it looks like you got puncture wounds
through your body right right right, And so a laparoscopic
port site, even if it's a five millimere trocar or
ten millimere trocar is the same all the way up
to big incisions, whether it's open gallbladder, whether it's a
open appy, whether it's a midline or anything. And I've
(38:45):
had many of these conversations with OROB colleagues. So the
areas where I think that that fails, you're already there.
You're doing it. You go down number one. I think
that when they open, and I've said this a gazillion times,
they the emphasis or the thought process is, it's really
focused on how we close. You don't have a stand
a goddamn chance if you open fucked up, like I
(39:09):
can't put this back together because the way you opened
it is such that. So when I do cases with
OBEESI I open, I don't let them open because I'm
being held accountable for your opening. The first thing they
do is they go through with the blade crooked. That's
the first thing they're literally the fucking scar's crooked at
the very least. Make it symmetrical, like it's a scar.
(39:32):
It's there, it's an ugly scar. Make it symmetric. Why
is it cock eyed? Secondly, they go through the dermis,
They go through the skin, and then there's this dermist
and they grab for the cattery. It is literally like
burning conjuct taiva or mucosa. And I asked them, what
are you doing? Oh, I don't want it to bleed.
The reason they cauterize the skin is because it's a nuisance,
(39:55):
because you have a dermal plexus and it bleeds. That's
what local is for you. Pre local every incision you
ever do, ever, so that it doesn't annoy you and
you do have any urge to burn the conject taiva.
Then they go down and they skyvee. Instead of going
straight the fuck down, they're going diagonal or better yet,
(40:17):
they take two fucking gulays, which are two retractors, put
it in the whole in just pull. It's a page
out of eighteen forty six.
Speaker 2 (40:26):
So sometimes I've seen surgeons make a tiny, tiny hole
because they want to pride themselves into having a small incision,
but they retract so much that there's so much tissue
trauma that's scars is never gonna heal nice so quick story. Yeah,
you remember we were operating together at the hospital, So
of course I had my resident and I told my resident,
I'm like play a pay very close attention because this
(40:49):
is a surgeon who usually doesn't operate with you and
you'll never have this experience ever again. So the minute
they made the skin incision, then they went to go
after the cottery, right, and you're like, stop off that
you have to go through until the you get to
the fat level. Do not use cottery on the dermis.
Speaker 1 (41:08):
Right.
Speaker 2 (41:08):
They never heard anyone tell them that before. I told
them that all the time. Know that I had you
teach them that. But it was so meticulous, like how
you approached just abdoonna wall opening. And as a surgeon,
as a general surgeon, I should say the abdoma wall
is something you have to get. It's like the front door.
(41:30):
You gotta go in and then the rest of there's
the rest of the house. So they were like, what
the hell. But they learned so much from that, and
it's so important because at the end of the day,
you can do a great colon surgery, but if your
scars ugly for the rest of your life, that's what you.
Speaker 1 (41:45):
Remember is what it's say, the shame. And I would
tell this to OB's because I work. I said, it
takes away from the joy of what you did. You
did a great job. The babies alive, they're healthy, great.
What it took to do a good closure is no more.
It's not like, well I didn't, I'm not. I'm not
a plastic sir. You don't need to be anything special.
I'm not asking for it to be pristine. I'm asking
(42:05):
for it to be basic. So you get down, they
skive like they're all jaggedy. Then they get to the fascia,
and then they get to the fascia, and then they
go straight through the fashia instead of undermining the fascia,
separating an edge of the fascia. So when you go
close the fascia, you don't pucker in the fat and
the skin and everything that's connected to it. Tucked it, okay,
(42:26):
So no one teaches us the way I understand it.
So it's like it's and this, by the way, has
not any book. It's zero to do with the closure.
I haven't done any closure. But you can if I
come in and you're like, hey, Rod, can you help
me out here? I need you to close this? And
I get there and the fascists tethered to the fucking subcutaneous.
It's skived to the side. There's an area of fat
(42:47):
that's undermined over to the side. The dermis is burnt.
If I put on a loops and a microscope, it's
still gonna look like shit. So you know that's the
key to this work. And then once you do your surgery,
as you said, you don't get any bonus points for
going through. We've gone from guide ginormous incisions to so
(43:10):
small that you can't even do the job instead of
opening sufficiently but not unnecessarily. And then you come back
and you like a seven layerer, if you see it,
put it back together. It's there. No, it's not an
important layer. It was there. It was there from the beginning.
God fucking put it there. Just put it together. Okay,
(43:33):
I'll put it together like the biggest suture you've seen,
like a harpoon. Layer one, two, three, four, grab layer
one to what are you doing, bro? You are literally
linking all these layers together. Then when the patient reaches
for something in the cabinet, there's this pulling and tugging
and tethering. It makes me bananas because at the end
(43:55):
of the day.
Speaker 2 (43:56):
Well, the user alongside suitor. I always say, as a tailor,
if you're sewing a leather jacket or you're sewing a
silk shirt, you're gonna use different threads. The same is
true for the human right. If you have really thin tissue,
you use a narrow needle and a narrow suture. They
have really thick tissue, you go up aside and now
you can never you should never mismatch that.
Speaker 1 (44:18):
And then the other thing that makes me insane is
like you go down. You're like, okay, what, thank you
for opening for me, And then they're like, cocker. A
coker is a clamp that's like a bar bear with
like a jaw. And I spent like twenty minutes being
so careful. I open up everything the fascist pristine. You
can see the vessels in the fascia and they grab
(44:40):
the most violent looking instrument and crush the edges and
reflect You're just like, oh my god. And then you
come back to close it and it's like crush And
then they're putting sutures through it and they wonder why
the thing falls apart. Oh, they're all like, how are
you a plastic? Oh but that we won't even.
Speaker 2 (44:58):
Get into that be aesthetically in glad. Oh, but you
just screwin your dissie plan.
Speaker 1 (45:03):
Yeah, So, at any rate, I think that that I
don't want to vents. Yeah, I think that one of
those things that I think is really important is that
you and I, as we do these things together, I
share it with you. You share it with your residents, your fellows,
you share with And this is what I'm referring to
as collaborative medicine. There are things about hernias that I
don't know. There's things about oh be that I don't know,
and so on and so forth. So if you guys
(45:24):
are all listening and you hear us sort of reminiscing,
it's this is what I think you should try to
identify in your clinicians. At least certainly, you should expect
your general surgeons who are doing your hernias to do
the following things. Number One, if you do better from
doing this inconjunct with a plastic surgeon instead of them,
(45:44):
they should let you go. If you could do better
in conjunction with them, that is, both you and me
work together, they should let you go. And if you're
going to be with them alone, you should expect them
to be knowledgeable. This notion that it's just a hernia
that is absolutely not true. There are hundreds, if not
(46:07):
thousands of complications associated with hernias and then it creates
misery Like me, doctor tophis probably half of her career, Yeah,
is related to revisions and complications. And that is like
when I see a patient come in for a redo
third time knows or a four time a breast surgery,
(46:27):
I cringe because it's like, what a what a travesty? Yeah,
there's a one in less than half a percent chance
of this. These are not the complications and this is
just purely bad work. And so those are what you
should hold your hernia surgeons too, definitely. Yeah.
Speaker 2 (46:48):
So I have a course coming up, Yeah, that is
intended to go through all of this. So it goes
through how to be a good surgeon, but also how
to be a good physician. Know which doctor?
Speaker 1 (46:59):
Two? I got my leucture ready.
Speaker 2 (47:03):
Doctor, refer to when to refer, whether it's a female
patient with a potential hernia or a growing pain, whether
it's it's an emergency situation, no, when to go through it.
So it's it's the growing and it's all This course
is only on growing and hernias, but it goes through
all Yeah.
Speaker 1 (47:21):
I mean listen, at the end of the day, we're
all doctors. We learn and then we learn more, and
then we learn more, and then we keep learning. So
some people are inherently astute to learn on their own
and other people need to take courses. So I think
that's fantastic, fantastic of you to do that. All right, guys, well,
I hope you enjoyed our sort of four one one
on hernias. When do you do it with mesh? When
(47:42):
do you not do it with mesh? When do you
do it robotic? When do you do it laparoscopic? When
should you go see a plastic surgeon? When should you
do it with your general surgeon? When should you just
let the general surgeon do it? So you should have
a very broad understanding of the distinctions between diastasis and
Hernia's a real, real, true understanding because I think it
is an area of massive confusion. And yeah, if you
(48:06):
have a massive hernia, doctor Tophi is an amazing surgeon
and she would be able to help you out. All right, Saran,
Where can they find you in case somebody wants to
identify you? In terms of your Instagram, your website wherever
that is.
Speaker 2 (48:21):
You can google me, doctor Schirinopi. I'm on Instagram. My
website is Beverly Hills Hernia Center dot.
Speaker 1 (48:27):
Com, Beverly Hills Hernia Center dot com. And TOPHI is.
Speaker 2 (48:33):
T O w F I g h. Yes. But if
you just Hernia dot or.
Speaker 1 (48:38):
Just google me world renowned the best hernia surgeon, you'll
find her.
Speaker 2 (48:44):
And I have a practice a Beverly Hills, and I
also see patients in a Silicon.
Speaker 1 (48:47):
Valley up north northern California. Awesome, all right, guys, that's
a rap. I hope you enjoyed that episode. I certainly did,
and I always do enjoy our episodes with my colleagues.
As always, I have two partying request. Number one, if
you enjoy the show, forward this. Just forward this to
like five people, you know, because the next time you
see a friend, they're like, Oh, what's wrong with you?
(49:08):
Why are you limping? Oh? I just had groin surgery.
You had groin surgery. You're gonna say, God, I wish
you would listened to this episode. And then secondly, if
you like our show, which I hope you do, then
go write something nice, Go write a review. We really
appreciate it. It helps with a ranking. It makes everybody
feel good. There's a lot of people who put time
and energy on the weekends to do this show. All right, guys,
(49:29):
until next time, I'm your host, Doctor Rody Raman signing off.
Welcome to another episode of Plastic Surgery and Censored. I'm
your host, Doctor Roddy Raban, and we have a fantastic
episode for you today. It's fantastic for a number of reasons.
Number one, all the episodes are fantastic, and number two,
and more importantly, we have a tremendous honor to have
doctor Sharin Toopi world renown and this one I actually mean,
(00:26):
I'm not just making that shit up, world renown hernia
specialist doctor Tophi, who has honored us to be here.
So you better listen to this episode because you guys
are you may never ever see doct Topi again. She's
so coveted and hard to find, and we're going to
tackle everything related to diastasis, hernia's, abdomen's and more. Doctor
(00:51):
Tophi and I've worked together now for over twenty years.
We've known each other for more than twenty years, and
I was just saying to her before we started to
show that I genuinely believe the patients are incredibly lucky.
When a and two excellent surgeons combine to help a
(01:11):
patient out, it's synergistic. And while that may happen on
occasion in a hospital setting, right, the neurosurgeon hires the
vascular surgeon. But in private practice to have surgeons collaborate
as we have for years is very rare, and I
just think it's really good for the patient. So welcome
(01:31):
to the show, Charin.
Speaker 2 (01:33):
Thank you for having me. I never say no when
you invite me.
Speaker 1 (01:36):
Wow, we are an honor to have you. And it's
always exciting. We did a show, I want to say,
during COVID, and we did it via zoom and it's
just so nice to see you in person less than
five feet. So let's dive in, and let's let's start
talking about anatomy, because the terminology around this is a
little confusing, and we want to make sure people understand
(01:57):
the distinction between a hernia and a diastasis. So a diastasis,
as many of you know because we talk about it
so frequently, is when the rectless muscles, which are your
sit up muscles, your eight packs sitting in the middle
of your abdomen ninety five percent due to pregnancy, that
is a massive force inside your abdominal cavity, pushing and
(02:21):
pushing and pushing and pushing out slowly and gradually pull apart.
They don't. They don't just tear apart because it's incremental
and gradually and gradually pull apart, and the normal connective
tissue that holds your two muscles together like a piece
of gum. As they pull apart start to thin. The
further your muscles get from each other, the thinner that
(02:45):
piece of gum gets because it's still the same gum,
And as a result, you get this separation between your
muscles known as diastasis. That is normal. One hundred percent
of women who have multiple pregnancies will have this. If
you don't have it, you're the unit. With every ongoing
pregnancy one, two, three, four, five, six, et cetera, that diastasis,
(03:05):
whatever percentage it was the first time, will increase. There
are women I've seen five pregnancies minimal to almost no diastasis.
I've seen people with one pregnancy and it's tensonometers. Okay,
so that is diastasis. There is no hole. It is
not a defect. It is just a weakening of the
normal anatomy that would normally hold your abdominal wall together.
(03:27):
As a result, it presents as what distension. God, I
feel like I'm like four months pregnant, I'm skinny I'm
working out, so it presents as distension, which is esthetically
visible protuberance. It presents with weakness, like I have constant
low back pain, and when I get up out of
(03:48):
my bed, I got to kind of like use my
elbow and kind of roll because your muscles are not
in the right place. It's like taking my bicep muscle
which connects to my uranius and all not to my
humors and moving its connection and putting it some where else. Well,
of course it's not gonna work. And then it leads
to other types of related issues like bladder issues and
(04:09):
bowel issues and all kinds of things. So that is diastasis.
And we've talked about that like four thousand times, and
we keep talking about it because it affects and afflicts millions,
it's not hundreds of millions of people. Then we turn
and talk about hernias. They're not the same. They're completely different.
That's like saying a Chinese person and a Korean person
(04:30):
are the same people. They're Asian, they're in the they're
in the abdomen, but they're different. So, doctor Topi, would
you tell me what you with the lay terms of
a hernia.
Speaker 2 (04:40):
Yeah, so there's good Evans showed there probably are the
same family. Yeah, of course, like your analogy earlier, But
a hernia is a hole and the risk of that
is something can fall into that hole. Usually it's fat,
but it can be intestine or another organ, and so
(05:00):
from a medical life saving standpoint, or hernia is can
be concerning. So those are usually repaired. Diastasis has always
been termed a cosmetic thing. We know that that's no
longer true, but for many many years, your specialty plastic
surgery has been treating diastasis, and my specialty general surgery
(05:23):
has been saying it's not a hernia, it's all cosmetic,
and we now know it's not true. Number one, there's,
like you mentioned, so many things that can go wrong.
And a patient that has a diastasis, they get constipated,
don't they lose their core. You need core muscles to
have good bomb movements, back pain, and ability to do
(05:43):
perform certain exercises or certain movements. So what I've seen
is our world, the general surgery world, is learning from
the plastic surgery world and understanding that not only is
diastasis relevant, but if you have some who now has
a hernia and they come to the general surgeon for
the hernia repair, it's important to also see if there's
(06:05):
a diastasis. Sure, and now we are doing a much
better job to not only repair the hernia, but understand
that diastasis repair should be incorporated as part of the
hernia repair in order to have a really good hernia repair,
higher recurrence rate if you ignore the diocese and just
treat the hernia because you're fixing a hernia within the
(06:28):
weakness and the spreading a part of the fascia. You
fix the hernia and you support that hernia by bringing
that weakness together, and you have a much better hernia repair.
Speaker 1 (06:40):
Yeah. Absolutely so for those of you listening, the distinction
is diastasis is thinning hernia as a whole. Now, you
can get that hole anywhere in your abdominal wall. You
can get it to the side of it from a
previous colostomy. You can get it in your groin in
England or hernia. You can get it in an opterator.
(07:01):
You can get it smack dab in the midline. You
can get it through your belly button, which is probably
the most common umbilical hernia, which some people even have
and are men, and they never even had any babies.
So the fact that you have a hole or a defect,
an actual opening, can happen anywhere where are two specialties collide.
Is that of the areas in which you get a hole.
(07:23):
The idea that you get a hole through a shitty
area in your abdominal wall aka thinned out a trophic
piece of tissue your diastasis, should not be surprising. In
other words, the fact that there are tons of hernias
that occur from the xyphoid, which is where your rips start,
to your pubis, which is your entire abdominal wall in
(07:45):
the middle is makes total sense. It's an area of weakness.
You are now under a great deal of pressure, often
during pregnancies, and something pops through or tears or comes through,
and so of course it is. I've been doing this
now for twenty some odd years. I've done thousands of
distasies hernia repairs, and it's just part of our surgery.
(08:05):
I get in there, I open up the abdomen to
get access to the distasis, and loan behold, there are
grape size, apricut size, grapefruit size hernia sticking in the
middle of the abdomen, and as doctor Tofi said, it
can be a number of things. Fat I've had omentum,
I've had intestines, I've had all kinds of things. So
(08:26):
normally what would happen is that, Okay, hey, doctor Tefi,
nice to meet you. I'm you know, Susie. I've flown
all the way from Ireland to see you, and I
have a hernia. And the treatment for hernias is reinforcing,
taking the thing that popped through the hole, pushing it
back in the abdomen, and then fixing the place where
the hole came through, closing the window, so to speak.
And let's for the time being eliminate and forget about
(08:48):
the midline part. But hernias historically have been addressed by
using some type of reinforcement material to bolster or repair,
because if you just close the hole and don't reinforce it,
there's a failure rate, right, a recurrence rate. As a result,
mesh and different materials have sort of become the mainstay
(09:11):
of repairing hernia's. Generally, we're going to subdivide diastasis related
hernia's for a second, So tell me a little about
how you repair hernias outside the midline.
Speaker 2 (09:20):
So I would see the United States, mesh based repair
has really skyrocketed. Over ninety percent of herneias are prepared
with some type of mesh. That's not necessarily true in
the developed world because mesh is expensive. But then you
get these kind of disasters because you have patients that
really can't get a non mesh repair and they don't
know what to do with it because they don't really
(09:42):
have good access to mesh. And then Europe is kind
of like in the middle in terms of how much
mesh they use it not. But if you think of it,
when you were a kid, I don't know if your
mom did this, but you know, if you had a
hole in your genes, there were those little patches you
aron on.
Speaker 1 (09:57):
You can't just close the I love elbow.
Speaker 2 (09:59):
Patchs elbow patches. You can't just close it, right. So
that's the same concept with mesh, which is if you
have a tiny hole one centimeter, then closing it with
stitches and no mesh perfectly good, just as good as mesh.
If you have a larger hernia two centimeters, really the
favored repair is with mesh. Certainly anything over two centimeters.
(10:22):
For ten centimeters, you have to not only use mesh,
but even probably manipulate the tissues around to be able
to get that hole closed, and then you can put
the mesh in.
Speaker 1 (10:32):
Yeah, And the idea, of course, as everyone should understand,
is when you have an actual hole, over time it
will stretch open and there's a tremendous amount of tension. So,
like you said, let's use your analogy. You have a
hole in your genes. If you pull that hole together,
you're going to get a weird ass flattening and odd
shape to your genes. And the minute you bend your knee,
(10:53):
it's going to rip open. It's just going to rip
right open. And so the just envision the amount of
strain that your abdomen goes through from coughing, bending, sitting,
straining all that. So if you have a let's just
use a five centimeter hole and then we just try
to your kit together and put stitches. The stitches won't break,
(11:14):
the tissue will give weight. We call it cheese wiring
sort of like you know, if you hold you know,
a piece of string cheese together with cotton candy and
use a metal cable, cable's not going anywhere. The two
of the things are going to give way. So that
is why a material which globally is referred to mesh,
it's kind of a large term, is used to sort
(11:35):
of patch or reinforce it. Then within that world, there's
two things that I think are important, which is what
are those meshes? Some are really good, some are really bad.
And then within that world is do we put it
on it, in the middle of it, or underneath it.
It's a little sophisticated concept, but we have the world's
foremost expert in the world of mesh, and you guys
are not going to get this information elsewhere. And mesh
(11:59):
is the same in general surgery as filler is in
plastic surgery. Let me explain. I like that the term
mesh creates a feeling of fear in patients because mesh
was incorrectly used by a lot of people. It's a
fantastic tool when used correctly. Filler has got a bad rap.
(12:20):
Filler is a fucking amazing product, and when used correctly,
there is no substitute to it. It was just overused.
And so patients, now you say the word, I think
you need a little filler, not filler. Filler is poison.
And that's sort of how people at least when I
talk to patients and the term of mesh comes up,
it's got a bad rap. It's got this sort of
(12:41):
fear associate with. So let's let's do a few things. One,
what types of mesh are there? Just globally We don't
need to get into polyproperly, so just there's different kinds.
What are they?
Speaker 2 (12:52):
So globally it's the permanent mash and absorbable mesh.
Speaker 1 (12:55):
Right, so something that stays forever, something that stays for
while your body will eventually absorbed. My understanding is absorbable
mesh is kind of a not a really good concept
because you kind of always need you won't generate enough
scar tissue really to make up for the resilience that
the mesh is not there anymore. That's correct.
Speaker 2 (13:15):
So nothing beats permanent mesh in terms of the function,
which is to prevent recurrent hernias. But there are situations
where you either can't use the permanent mesh or you
don't really need that much mesh, so in which case
you can air on using something absorable because it's a
really small hernia. Or the patients let's say allergic too.
Speaker 1 (13:36):
Sure, so we have absorbable and non absorbable. And then
within the world of mesh, there was a lot of
because like everything, there's learning and there's a lot of lawsuits,
class action, class action lawsuits, love the word mesh. Have
you been a victim of mesh? Right? And so a
lot of that mesh problem occurred when mesh was placed
(13:59):
abudding tissue and organs inside the abdomen and as a result,
things became it heased or fibrotic or connected, creating problems.
So a lot of the old issues with mesh, if
I'm not incorrect, were as a result of not using
it the way we use it today. Is that accurate?
Speaker 2 (14:19):
Yeah, So before I was a resident, they and mesh
kind of came in kind of the seventies. They were
putting mesh directly inside and it was going against intestines.
So that was a bad idea because mesh is highly inflammatory.
It eroded and it was very stiff, it rode in
the intestine. So they learned not to do that. They're like, okay,
let's put a barrier. So now we're going to put
(14:42):
the mesh there near the valve, but then put something
that prevents the bollet from sticking to it. We know
that's also not ideal that we do it. But it's
not ideal because in the long run you have a
higher risk of bow obstructions because of it sticking to
the mesh, and a high risk of needing a reoperation
because of that issue, and risks of either mesh infections
(15:02):
or erosion in the mesh. So ideally, if you are
using mesh, the mesh should be as far away from
the intestines as possible, so it can go one layer away,
so what we call extra peranial, two layers away, so
it's retro retro muscular, extra fascil or all the way
on top of the abdominal wall, which we call it
(15:24):
on the They're all good techniques. There's pros and cons
to all of them, and depends on the skill of
the surge in the situation that the patient has right.
Speaker 1 (15:33):
So the basic gist of it is a lot of
the oh shits with mesh occurred when they were learning
to use it, and it occurred understandably because mesh is
a foreign device that's very rigid because it's giving strength,
and in many instances it's netted or it has some
if you will, some perforations in it. So that it
can bend, and as a result, organs Akabow was sticking
(15:56):
to it, creating a disaster. When you put the mesh
away from that, it's not that there's no complications, because
there's complications, it's just not the catastrophic types of complications
that really gave mesh a bad name originally. So that
I think is really really important for people to understand.
I think, just like anything else, as you said, it's
(16:17):
not so much the mesh or which mesh, like, oh,
which implant are you using, it's the surgeon who's placing
the mesh and the location of the mess and how
much undermining they do, and what type of sutures they use,
and all those things that makes a great hernia surgeon
different than a shitty hernia surgeon. Right then, there was
the advancements of laparoscopic slash robotic surgery, so there was
(16:39):
a push right in the world of getting in the abdomen.
Right getting in the abdomen was like we considered a box,
and historically we got into the box from the outside
of the box. Then all of a sudden there's this
advancement which catapults abdominal surgery into the modern era. Which
is I don't need to open up your whole abne
maka slice you open like a cadaver. I'm gonna poke
(17:00):
a bunch of small holes in, whether they're laparoscopes or
now robots arms, and I'm going to do everything from
the inside. So for the basic lay person, how has
that changed hernia repair for you? And when should they
consider the traditional approach open, slap a piece of mesh
on it, get out a dodge versus No, that's that's archaic.
(17:22):
Why would you do that? Just poke a few holes
and stick the thing from the bottom. Tell me if
you will, a little basic gist of that.
Speaker 2 (17:29):
Yeah. So the goal of all hernia pairs is to
close the hole number one and then consider whether you
should put some type of mash to bolster that repair.
That can be done through a big incision where you
access it what we call open. It can be done
through small incisions laparoscopic, or it can be done with
even more technology, which is robotic. So there's open, and
there's the laparoscopic and robotic and what we call minimally invasive.
(17:52):
In all circumstances, a laparoscopic or robotic repair will have
better recovery, less infection rates, perhaps cosmatically better that's debatable,
a lower risk of like mesh infections and so on.
But there are situations where it's open is either perfectly
(18:13):
fine or preferred right.
Speaker 1 (18:14):
And then when you stick the thing on the bottom right,
so it's the idea of patching it or plugging it right.
So from the bottom it's idea. Yeah, I had a.
Speaker 2 (18:25):
Patient patch on top of patching it underneath.
Speaker 1 (18:28):
So the idea underlaid the idea of tires. Right. If
you think about a tire, you will have a much
better repair of a tire hole. I have seven many
cars if you stick and do an internal patch, because
the patch is being reinforced by the pressure inside. So
I think from a physics standpoint, it's a better outcome.
But how do you circumvent the issue that that patch
(18:50):
is now again in intimate contact with the organs. Whereas
that was how we started this, we got in a
lot of trouble, a lot of perforations and catastrophes. We
realize as we should go outside or further away, and
now we're back to sticking it underneath. Is it any material? Well?
Speaker 2 (19:04):
I really like that you're bringing up surgical history because
you got to learn and not repeat history. So with
the open repair, we were not doing too bad of
a job. Then when laparoscop became the only way we
could do it was to put it slap underneath because
we just didn't have the skills to do it otherwise,
and that's when we saw these complications. With robotic surgery,
(19:26):
which is the next generation of laparoscopic surgery, you can
act like an open surgeon. You can go in between
the plate. There are situations where I'm never inside the
abdomen and I'm doing these minimally invasively with a robot,
so I burrow myself behind the muscle the entire time.
Speaker 1 (19:42):
Like like a vascular approach to.
Speaker 2 (19:45):
Like the end of aascular surgery, exactly as opposed to
big surgery. So you get the benefit of having the
small holes, but also you get an operation similar to
an open surgery where you can really manipulate the tissues
and put mesh in a situation where it's broad and
and very secure and you're closing the dioceses and you're
closing the hole all with very few little holes.
Speaker 1 (20:05):
Got it, Okay? So that's your four on one on hernias.
Then we shift over to where this combo occurs, which
is I am saying a ton of hernias, A ton, literally,
I did one last week. The lady came in. I mean,
she just looks like she had a like, I don't
know what, a third belly button the size of a
grapefruit above her belly mutt. So I've been doing this
for years. You and I chatted about it, and I've
(20:28):
never in twenty one years, despite doesn't matter what the
size of the thing is. It doesn't matter if it's
a twenty five sonomere, which it wouldn't because that's a
whole admin. I've repaired everything without mesh, and I swear
on my own children, I've never had a recurrence, zero zilch.
Do I have the data, No, but I would know
because a patient would be like, hey, doctor brought and
I paid you a shit ton of money, what is
(20:48):
this bulk? So that's a unique environment. And as a result,
I'm still waiting for you to publish our paper. I
need to be I need notoriety here. This is when
you and I started having this interesting dialogue, and I
think it's sort of starting to permeate, which is in
the di stasis area of the abdomen. It's a unique environment.
(21:09):
Why the defect is occurring through shitty tissue as opposed
to regular fashion. You just somehow weakened or was post
surgical or trocar site or something. And we have this
incredible anatomy there, which is there's a reason the hernia
has happened, which is they're shitty tissue. The muscle separated.
(21:29):
The gates of the mansion have opened, and you know,
everything has come through. So as I've done, and I've
told everybody the way that I always do all of
these it doesn't matter the size. As I go in,
I open up, you obviously have to be careful, right,
you don't want to plow through this hernia. As you're
opening up. I'm already there as an abdomino classes. So
in the world of access access, which I got to
(21:52):
see what the hell I'm doing, there is open surgery
and minimally invasive open surgery. In the general surgery world,
is a cut somewhere on your abdomen down the midline,
sideways something, go straight down, find the hernia, fix it.
So when you're all done and you walk out, there's
a scar somewhere in the middle of your abdomen minimally
invases a bunch of holes. This is a whole new animal.
(22:13):
I'm doing a low incision, cosmetically intended at the level
of your sea section, and I'm opening the hood of
your car, and now I see the entire world. So
from an access standpoint, there is no better access in
the world because I've literally opened up the whole box.
And then I repair that hernia, open up the sack,
(22:34):
shove everything back in, do everything I need to close
that crappy diastasis and whatever version of fascia or peritoneum
is there. And then I do my diastasis repair as
if you've never had it, and it's a very aggressive
two layer permanent suits. You're blah blah blah. And now
I have the best mesh in the entire world. I
have a biologic reconstruction of the defect that led to it.
(22:57):
There is no question that that's the right way to
do it in that unique subset. I don't care what
the cause is. I don't care if it's a trocar
that went through the middle. I have done people who
are men who have no diastasis but have midline hernias.
Remember our patient that I took care of the gentleman
that you said, who had a trauma and a midline
laboratorie who is phenomenally happy now and working out doing
(23:21):
like jiu jitsu and crazy things. And we did it
through an abdominal approach. So I think that's been where
the revolution and our union has occurred. Hence why I
think that when you get to doctors who are not
ego driven, mindful, thought provoking, academic, you can make really
cool shit happen. And so I think that's been very
(23:43):
exciting for me.
Speaker 2 (23:44):
Yeah, so I love collaborating with other specialties with me.
Speaker 1 (23:49):
Yes, other specialties. What the fuck? What other specialties are there?
Speaker 2 (23:56):
Honestly though, I think a doctors should collaborate general sort
of should learn what guid in college do, urologists do,
orthopedic surgeons do, certainly what plastic surgeons do, because there's
so much overlap. Instead of saying that it's like vertical right,
not my problem, go to plastics, not my problem, go
to general surgery like that, I don't I don't enjoy.
But this is where it came through because it is
(24:18):
quite common for you to do an abdominal plasty right
tummy talk in someone and then they either you either
know they have a hernia or you're like, oh, look
at that little hernia there, either from their prior surgery
or like a little belly button or epigashict hernia, And
they do great. Right, so we know for for relative
lyast months following the under four centimeters hernias, tummy tuk
(24:41):
will handle it. What we didn't know, which is what
you're alluding to, is our paper is it is incisional hernias.
Doctor Yikle of the Netherlands wrote this landmark paper that
said if you take an incisional hernia, that means a
surgeon cut took out your coalon gobblet or whatever, and
then and that was sewed and then that recurs. Right,
(25:04):
So it's technically it's a failure of a prior closure.
If you close that without mesh, it's about a fifty
to sixty percent recurrence, right minimum fifty percent. That is
a horrible number. And therefore the dictum is every incisional hernia,
not primary hernia, she must get mesh because that number
comes down to like about twenty percent. This is where
(25:26):
we started talking, right, So I said, okay, how about
you do those tummy tucks in patients that I see, right,
with an incisual hernia, I'm taught I need to put
mesh in them. But with a tummy tuck and the
right patient there their abdomble walls loose.
Speaker 1 (25:45):
Yeah, they can't be like a morbidly obese with a
massive visceral fat content. That's I mean, it's gonna faily
respect to be the right patient.
Speaker 2 (25:52):
So loose loose abdominal wall, a lot of excess skin,
so they'll actually benefit from a tummy tuck and an
incisual hernia. Where I should be put in mession. Why
don't we use the patient's own tissue so you close
it like you wo and normally, but then you take
your tummy tech as that second layer. So we talked
(26:12):
about measures. There's permanent and there's absorbable. The permanents are
always synthetic, right, I'm off the shelf. The absorables are
always can be synthetic or biologic, right, But we've never
had a permanent biologic unless you do a Tommy tech.
(26:33):
That second layer is a permanent biologic, so it's your
own tissue is permanently supporting the herding parentnerneath it. And
we did present our study as you know, in the
European Herning Society. But we've added a couple more patients
since then, so we'll get that paper dash.
Speaker 1 (26:52):
Because I think that you and I are doing high level,
high level abdominal reconstruction abdominal care. But you and I
both know that the overwhelming majority of patients are being mistreated.
And I don't mean that in a negative way. But
so what I love is like, so for example, if
I see a patient and they have a hernia. We
(27:13):
did a case where the patient had a groin hernia,
I'll refer them to doctor Trofi because that's not an
area where I can help them. When you see a
patient and you think they can benefit, you'll refer them
to me. That's the first issue. The first barrier is ego.
The first barrier is the ego of the surgeon, in
which HI, nice to meet you. You're a general surgeon. High,
(27:35):
nice to meet your plastic surgeon. High, nice to meet
you your no B I have this issue and for
them to relinquish that patient either ego what do you
mean I can do this? Or ego I'm not going
to give away this money, or stupidity. I didn't even
realize there's anything going on. So the fact that you
and I have that symbiosis. Either you send them to
me or I send them to you, or more often
(27:56):
we do them collaboratively is the key to this process.
Second is the understanding that, oh wow, I can this
person's gonna do an amazing job. So like we have
done cases where we've done I've done the tummy tuck
and the diastasis repair, the hernia was outside of that area,
so the patient benefited. While you would have done it anyways,
they could have done a laparoscopic open whatever. They're already
(28:19):
down for the count. Why would I subject that patient
to two separate surgeries. That's just such a terrible medicine. Oh,
go get this fixed and then come back, go get
this fixed. What do you mean, just fix it together.
I'm already going down one anesthetic, one recovery. It's just
a It's terrible, terrible medicine.
Speaker 2 (28:41):
So I recommend to patients to discuss where their surgeon
will put their scar. I've seen people who have a
beautiful belly button and the scar for their herneia is
way up here, whereas they could have hit it in.
Speaker 1 (28:54):
The belly button.
Speaker 2 (28:55):
I've seen people have a C section scar and there
are open hernias in decision is separate from you can
use your C section scar, you don't need to add
a second scar. I've even see patients with a scar
here and the surgeon puts a scar right there. It's
like you could have just gotten a centimeter above. So
planning is very important. And I think working with surgeons
(29:18):
like you, where you're like super intent on planning and
everything before it happens. I learned from you.
Speaker 1 (29:26):
And but that's because you're an aesthetically inclined individual. The
onus falls on the general surgeon, not on the plastic surgeon.
The general surgeon has to say wow, the same way
that OB's by force, stop doing this midline from belly
button deck. I mean we stopped. We stopped doing vertical
se sections decades ago. Why because while it's a little easier,
(29:49):
a fantas steel or a low incision is safe, effective,
and thousand times more cosmetically sound. So I cannot tell
you the number of times that I've done surgeries and
I'm like, what the fuck is this scar here? It's crooked,
it's jagged, it's ugly. I have to revise it. It's puckered,
et cetera. So bravo to you because you care enough
(30:14):
to then be like, hey, what are you doing? Oh,
this is how you do it because you're a skilled surgeon.
There's no reason why you can't do what I can
do it. You can do it, it's just you have
to want to do it. I would say the overwhelming
majority of practical medically directed surgeons, for example, is you know,
my wife's had six spine surgeries. As a result of
(30:34):
those six spine surgeries, she's had a lot of scars
as a results. A lot of those scars, some of
them were anterior abdominal okay, And I remember, you know,
one of the discussions she had. She's a young girl,
she loves her physique and takes good care of herself,
and they're like, we need to go up and down
the middle of your app and she's like hell no.
(30:54):
And then I was like, why, well, we have to
because this that the other're like, but you don't, you
can do this from the bottom. Now. She ended up
not having it, But I have subsequently done several cases
with the neurosurgeons, providing them better access, meaning they see
better than they ever did through a low incision. And
(31:14):
it's not rocket sides. It's not like I've evolved and
created some fucking unbelieva. It's just I understand you, just
you don't. It's like, I need to get this done.
I'm so sorry. It's reconstructive. Just be happy you're walking. Hey,
you know what you have a hurry? I stop bitching.
I cut it out. But these scars ugly, really, really
the scars ugly. We fix your hole, buddy, you know
(31:36):
what I mean? Like, how dare you? It's like, yeah,
but I don't like the gunshot in my abdomen. Look
you know what I mean. It's like, shame on you. You're
so vain. It's it's it's And then there's a lot
of gas lighting that occurs that a patient should not expect. Okay,
at least acceptable cosmesis in exchange for the reconstructive games.
Speaker 2 (31:56):
So I would say that it's true that I am
aesthetically inclined, but patients need to have options, which is
why I recommend every patient to get second opinion, regardless
of who they see, because it's good to get different viewpoints.
But I'll give you example. This robotic diastasis closure has
(32:18):
really taken off. It's fun. I operate it to patients
if they're absolutely not a contraindication to have abdominal paccy. However,
if you do it in the wrong patient, it's so
ugly because a tummy TAK involves the closure of the diastasis,
give your flatter belly and.
Speaker 1 (32:38):
Removing the redistribution of the skin is a separate plate exactly.
Speaker 2 (32:43):
You don't do that with robotic surgery. So in some
patients you can do a great job if you get
a cat scan to evaluate it where the muscle get together,
But now you have all this bunged up skin or
the patient really should have gotten Tommy Tech because they
already have really lose horrible skin from their multi five pregnancies.
(33:04):
And the surgeons are like, you know, they got a
good surgery, and I'm just thinking you need to offer
something else.
Speaker 1 (33:11):
Of these patients, well, they will relinquish it. They're not
gonna let go of that patient. And that is and
I think that is as I said, that's the primary
step in this process is the notion that your doctor
is going to send you to the best location for
your outcome. If someone comes and sees me and they
have something they need to get done. The first thing,
I'm like, oh, no, you need to go see an
ocular plastic guy for this. What do you mean? I
(33:32):
thought you do islids? Yeah, I do eyelids, but I
don't do that shit. That's an oculoplastic guy thing to do.
And while he's there, have him do your bleff. Do
you know how many times people have come to me
for upper eyelid surgery and in addition to the upper
eyelid excess skin I identify let's say, atosis, their lid is sagging,
or they have some other medical issue and they don't know.
(33:55):
They just think it's all eyelid skin. And I look
at them, I'm like, well, you have some mild tone.
I can take the skin out, but you're probably gonna
be unhappy because when I'm done taking the skin out,
you're gonna really identify that this eyelid is lower than
the other. To be honest with you, I don't do
tosis repair. You should. You should? You should go to
see an oculo plastic guy, and when you're there, let
(34:16):
him do your blaff. You understand. I have to let
go of them. I have to say go somewhere else,
go do it, Go get it done somewhere else and
while you're there, let him do the cosmetic part. I
think that's a big problem.
Speaker 2 (34:29):
Same with with me. When I see him, I have
to sit back and say, have you ever considered having
it just a tummy tuck? Not just a tummy tuck?
And they're like, yeah, I've always but like they thought,
that's just being vain of them. I said, you are
the perfect candid for that, because yes, you got the hernia,
(34:51):
but that hurney really should get repaired by also fixing
your diastase and putting off.
Speaker 1 (34:56):
Skin and you get access to it. That's really, really,
really important. So you know, the message here to the
patient listening is not only just in the area of
abdominal surgery, but you really One of the things that
we were talking about is doctor Tophi myself. We have
a urologist in our group. We have several specialties that
(35:17):
we've interlinked. And what's ob what's great about it is
that you're entering our network unbeknownst to you, and as
a result, you're the beneficiary of this network, and that
we can call each other up, tell each other, hey,
I think there's this the case to a urologic case
or this Obe case or whatever the case is, so
it'd be ideal. I know it's not easy to do,
(35:38):
but identify surgeons who are part of a group that
will let you go and go to the next guy
who's great or the next gal who's great. And if
you can do that with your healthcare, I think it's
really really important. I don't know that that's I don't
know if that's achievable, but certainly I think our patients
are lucky in that regard.
Speaker 2 (35:58):
Right. I would say that that the more institutionalized a
surgeon or doctor becomes, the more they lose that that
like will to call up other doctors. They're a handful
of doctors that we know, general medical doctors who are
so good at that they'll call, they'll follow for their
patient's what's the plan, what do I need to do
(36:20):
for them? Which light order for them? How can I
help you? Or I'll call you, You'll call our other colleagues,
and that especially in coordinate care. That doesn't happen enough
in the US system, And the more institutionalized and the
more insurance companies take over that ability for you to
have time to do that for every single patient. I
(36:42):
think the worst it is. So I'm glad that we
do it. I'm glad we're in a situation where our
practice well.
Speaker 1 (36:48):
We're private practitioners or excellent what we do, and we
all care very much.
Speaker 2 (36:52):
It makes such a difference.
Speaker 1 (36:53):
It's best if in the world of if you were
to put this in chat GPT or Rock or whoever,
it would spin us out, not you and me, per se.
But the way our network is built, I can get
on the phone, I can get a mammogram for someone.
By afternoon, I got a cat scan for a lady.
I don't know if you saw that intra abdominal mass
I posted. She came in for a tummy tech. She
walked in here from Texas Friday. Her surgery is Monday,
(37:16):
and I had done a skype with her. I mean,
I've done the whole thing. And I came in and
I was like, can I examine you? And she's like, yeah, sure,
And I examined. I was like, what the fuck is
this thing? It's like, what what do you mean? I
just had surgery a year ago. They did a laparoscopic
hernia repair. They were interabbed him and said, oh, there's
something really not normal here. I need you to get
a cat scan. What do you mean It's eleven forty
(37:38):
five on Friday. Surgeries Monday. I was like, just give
me a second. I'm calling everybody I know, get her
a cat scan. And one hour we come back. We're like,
oh no, no, there's a twelve to fifteen sonometer, massing
rabb likely five ORID what have you. So we have
that ability, and I think, I just I mean, I
wish that for all of my family and all of
my patients. So the last thing I think, or one
(37:58):
of the things that's really really important, and I think
there's this this notion and is the idea of scars right,
because if you do it minimally invasive, the robotic or laparoscopic,
the scars are small, but they're there because one of
the number one complaints of patients have is they come
back to me for liposuction canulus site scar revision. So
(38:21):
it doesn't matter how goddamn small the incision is. If
it looks heinous, it looks like you got puncture wounds
through your body right right right, And so a laparoscopic
port site, even if it's a five millimere trocar or
ten millimere trocar is the same all the way up
to big incisions, whether it's open gallbladder, whether it's a
open appy, whether it's a midline or anything. And I've
(38:45):
had many of these conversations with OROB colleagues. So the
areas where I think that that fails, you're already there.
You're doing it. You go down number one. I think
that when they open, and I've said this a gazillion times,
they the emphasis or the thought process is, it's really
focused on how we close. You don't have a stand
a goddamn chance if you open fucked up, like I
(39:09):
can't put this back together because the way you opened
it is such that. So when I do cases with
OBEESI I open, I don't let them open because I'm
being held accountable for your opening. The first thing they
do is they go through with the blade crooked. That's
the first thing they're literally the fucking scar's crooked at
the very least. Make it symmetrical, like it's a scar.
(39:32):
It's there, it's an ugly scar. Make it symmetric. Why
is it cock eyed? Secondly, they go through the dermis,
They go through the skin, and then there's this dermist
and they grab for the cattery. It is literally like
burning conjuct taiva or mucosa. And I asked them, what
are you doing? Oh, I don't want it to bleed.
The reason they cauterize the skin is because it's a nuisance,
(39:55):
because you have a dermal plexus and it bleeds. That's
what local is for you. Pre local every incision you
ever do, ever, so that it doesn't annoy you and
you do have any urge to burn the conject taiva.
Then they go down and they skyvee. Instead of going
straight the fuck down, they're going diagonal or better yet,
(40:17):
they take two fucking gulays, which are two retractors, put
it in the whole in just pull. It's a page
out of eighteen forty six.
Speaker 2 (40:26):
So sometimes I've seen surgeons make a tiny, tiny hole
because they want to pride themselves into having a small incision,
but they retract so much that there's so much tissue
trauma that's scars is never gonna heal nice so quick story. Yeah,
you remember we were operating together at the hospital, So
of course I had my resident and I told my resident,
I'm like play a pay very close attention because this
(40:49):
is a surgeon who usually doesn't operate with you and
you'll never have this experience ever again. So the minute
they made the skin incision, then they went to go
after the cottery, right, and you're like, stop off that
you have to go through until the you get to
the fat level. Do not use cottery on the dermis.
Speaker 1 (41:08):
Right.
Speaker 2 (41:08):
They never heard anyone tell them that before. I told
them that all the time. Know that I had you
teach them that. But it was so meticulous, like how
you approached just abdoonna wall opening. And as a surgeon,
as a general surgeon, I should say the abdoma wall
is something you have to get. It's like the front door.
(41:30):
You gotta go in and then the rest of there's
the rest of the house. So they were like, what
the hell. But they learned so much from that, and
it's so important because at the end of the day,
you can do a great colon surgery, but if your
scars ugly for the rest of your life, that's what you.
Speaker 1 (41:45):
Remember is what it's say, the shame. And I would
tell this to OB's because I work. I said, it
takes away from the joy of what you did. You
did a great job. The babies alive, they're healthy, great.
What it took to do a good closure is no more.
It's not like, well I didn't, I'm not. I'm not
a plastic sir. You don't need to be anything special.
I'm not asking for it to be pristine. I'm asking
(42:05):
for it to be basic. So you get down, they
skive like they're all jaggedy. Then they get to the fascia,
and then they get to the fascia, and then they
go straight through the fashia instead of undermining the fascia,
separating an edge of the fascia. So when you go
close the fascia, you don't pucker in the fat and
the skin and everything that's connected to it. Tucked it, okay,
(42:26):
So no one teaches us the way I understand it.
So it's like it's and this, by the way, has
not any book. It's zero to do with the closure.
I haven't done any closure. But you can if I
come in and you're like, hey, Rod, can you help
me out here? I need you to close this? And
I get there and the fascists tethered to the fucking subcutaneous.
It's skived to the side. There's an area of fat
(42:47):
that's undermined over to the side. The dermis is burnt.
If I put on a loops and a microscope, it's
still gonna look like shit. So you know that's the
key to this work. And then once you do your surgery,
as you said, you don't get any bonus points for
going through. We've gone from guide ginormous incisions to so
(43:10):
small that you can't even do the job instead of
opening sufficiently but not unnecessarily. And then you come back
and you like a seven layerer, if you see it,
put it back together. It's there. No, it's not an
important layer. It was there. It was there from the beginning.
God fucking put it there. Just put it together. Okay,
(43:33):
I'll put it together like the biggest suture you've seen,
like a harpoon. Layer one, two, three, four, grab layer
one to what are you doing, bro? You are literally
linking all these layers together. Then when the patient reaches
for something in the cabinet, there's this pulling and tugging
and tethering. It makes me bananas because at the end
(43:55):
of the day.
Speaker 2 (43:56):
Well, the user alongside suitor. I always say, as a tailor,
if you're sewing a leather jacket or you're sewing a
silk shirt, you're gonna use different threads. The same is
true for the human right. If you have really thin tissue,
you use a narrow needle and a narrow suture. They
have really thick tissue, you go up aside and now
you can never you should never mismatch that.
Speaker 1 (44:18):
And then the other thing that makes me insane is
like you go down. You're like, okay, what, thank you
for opening for me, And then they're like, cocker. A
coker is a clamp that's like a bar bear with
like a jaw. And I spent like twenty minutes being
so careful. I open up everything the fascist pristine. You
can see the vessels in the fascia and they grab
(44:40):
the most violent looking instrument and crush the edges and
reflect You're just like, oh my god. And then you
come back to close it and it's like crush And
then they're putting sutures through it and they wonder why
the thing falls apart. Oh, they're all like, how are
you a plastic? Oh but that we won't even.
Speaker 2 (44:58):
Get into that be aesthetically in glad. Oh, but you
just screwin your dissie plan.
Speaker 1 (45:03):
Yeah, So, at any rate, I think that that I
don't want to vents. Yeah, I think that one of
those things that I think is really important is that
you and I, as we do these things together, I
share it with you. You share it with your residents, your fellows,
you share with And this is what I'm referring to
as collaborative medicine. There are things about hernias that I
don't know. There's things about oh be that I don't know,
and so on and so forth. So if you guys
(45:24):
are all listening and you hear us sort of reminiscing,
it's this is what I think you should try to
identify in your clinicians. At least certainly, you should expect
your general surgeons who are doing your hernias to do
the following things. Number One, if you do better from
doing this inconjunct with a plastic surgeon instead of them,
(45:44):
they should let you go. If you could do better
in conjunction with them, that is, both you and me
work together, they should let you go. And if you're
going to be with them alone, you should expect them
to be knowledgeable. This notion that it's just a hernia
that is absolutely not true. There are hundreds, if not
(46:07):
thousands of complications associated with hernias and then it creates
misery Like me, doctor tophis probably half of her career, Yeah,
is related to revisions and complications. And that is like
when I see a patient come in for a redo
third time knows or a four time a breast surgery,
(46:27):
I cringe because it's like, what a what a travesty? Yeah,
there's a one in less than half a percent chance
of this. These are not the complications and this is
just purely bad work. And so those are what you
should hold your hernia surgeons too, definitely. Yeah.
Speaker 2 (46:48):
So I have a course coming up, Yeah, that is
intended to go through all of this. So it goes
through how to be a good surgeon, but also how
to be a good physician. Know which doctor?
Speaker 1 (46:59):
Two? I got my leucture ready.
Speaker 2 (47:03):
Doctor, refer to when to refer, whether it's a female
patient with a potential hernia or a growing pain, whether
it's it's an emergency situation, no, when to go through it.
So it's it's the growing and it's all This course
is only on growing and hernias, but it goes through
all Yeah.
Speaker 1 (47:21):
I mean listen, at the end of the day, we're
all doctors. We learn and then we learn more, and
then we learn more, and then we keep learning. So
some people are inherently astute to learn on their own
and other people need to take courses. So I think
that's fantastic, fantastic of you to do that. All right, guys, well,
I hope you enjoyed our sort of four one one
on hernias. When do you do it with mesh? When
(47:42):
do you not do it with mesh? When do you
do it robotic? When do you do it laparoscopic? When
should you go see a plastic surgeon? When should you
do it with your general surgeon? When should you just
let the general surgeon do it? So you should have
a very broad understanding of the distinctions between diastasis and
Hernia's a real, real, true understanding because I think it
is an area of massive confusion. And yeah, if you
(48:06):
have a massive hernia, doctor Tophi is an amazing surgeon
and she would be able to help you out. All right, Saran,
Where can they find you in case somebody wants to
identify you? In terms of your Instagram, your website wherever
that is.
Speaker 2 (48:21):
You can google me, doctor Schirinopi. I'm on Instagram. My
website is Beverly Hills Hernia Center dot.
Speaker 1 (48:27):
Com, Beverly Hills Hernia Center dot com. And TOPHI is.
Speaker 2 (48:33):
T O w F I g h. Yes. But if
you just Hernia dot or.
Speaker 1 (48:38):
Just google me world renowned the best hernia surgeon, you'll
find her.
Speaker 2 (48:44):
And I have a practice a Beverly Hills, and I
also see patients in a Silicon.
Speaker 1 (48:47):
Valley up north northern California. Awesome, all right, guys, that's
a rap. I hope you enjoyed that episode. I certainly did,
and I always do enjoy our episodes with my colleagues.
As always, I have two partying request. Number one, if
you enjoy the show, forward this. Just forward this to
like five people, you know, because the next time you
see a friend, they're like, Oh, what's wrong with you?
(49:08):
Why are you limping? Oh? I just had groin surgery.
You had groin surgery. You're gonna say, God, I wish
you would listened to this episode. And then secondly, if
you like our show, which I hope you do, then
go write something nice, Go write a review. We really
appreciate it. It helps with a ranking. It makes everybody
feel good. There's a lot of people who put time
and energy on the weekends to do this show. All right, guys,
(49:29):
until next time, I'm your host, Doctor Rody Raman signing off.
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