Top Hernia Surgeon Dr. Jonathan Yunis: Expert in Non-Mesh Hernia Repair

In the latest episode of The Glen Merzer Show, Glen sits down with Dr. Jonathan Yunis, founder of the Center for Hernia Repair in Sarasota, FL, to discuss the intricacies of hernia surgery and the different techniques available. As a leading hernia specialist performing over 700 operations annually, Dr. Yunis offers unique insights into the world of hernia repair, particularly his expertise in non-mesh techniques such as the Desarda and Shouldice repairs.

Dr. Yunis emphasizes the art and challenge of hernia surgery, pointing out that it's a highly reconstructive type of surgery requiring deep anatomical understanding. Unlike common perceptions, hernia repair is complex and demands years of experience to master. This complexity is especially true for non-mesh techniques, which, despite their low recurrence rates, are practiced by only a few surgeons in the United States.

One key takeaway from the interview is the relationship between diet and hernia surgery. While diet alone can't prevent hernias, maintaining a healthy weight can significantly reduce the risk of recurrence. Dr. Yunis points out that obesity is a known risk factor for hernia recurrence, highlighting the importance of a balanced diet.

Dr. Yunis's non-mesh techniques offer several advantages, particularly for patients like Glen who prefer to avoid permanent foreign materials in their bodies. For example, the Desarda technique, suitable for smaller lateral hernias, and the Shouldice technique, often chosen for larger or direct hernias, both boast low recurrence rates when performed by experienced surgeons. Dr. Yunis's ability to choose the best technique based on individual cases further underscores his expertise.

Another fascinating aspect of Dr. Yunis's practice is his commitment to global health. He has brought his surgical skills to underserved communities in Ghana, Haiti, and the Dominican Republic, demonstrating his dedication to making a positive impact beyond his practice in Sarasota.

As the conversation wraps up, Glen and Dr. Yunis discuss the future of hernia surgery. With increasing awareness and demand for non-mesh techniques, Dr. Yunis is hopeful that more surgeons will become skilled in these methods, offering patients safer and more effective options.

For anyone interested in the complexities of hernia surgery and the benefits of non-mesh repairs, this episode is a must-listen. Dr. Yunis's expertise and passion for his work shine through, making this an enlightening discussion for plant-based and non-plant-based individuals alike. Tune in to The Glen Merzer Show for more engaging content and remember to subscribe on your favorite podcast platform.

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DISCLAIMER: Please understand that the transcript below was provided by a transcription service. It is undoubtedly full of the errors that invariably take place in voice transcriptions. To understand the interview more completely and accurately, please watch it here: Top Hernia Surgeon Dr. Jonathan Yunis

Glen Merzer: Welcome to the Glen Merzer show. You could find us across all your favorite podcast platforms. You could find us on YouTube. And please remember to subscribe. You could find us at RealMenEatPlants .com. I have been looking very much forward to today's podcast because I'm going to be interviewing my hernia surgeon, Dr. Jonathan Yunis. Dr. Jonathan Yunis M.D. is a fellow of the American College of Surgeons. He's founder of the Center for Hernia Repair in Sarasota, Florida, where I had my surgery done. His practice is limited to hernia surgery and abdominal wall reconstruction. He performs over 700 operations annually for hernia repair or abdominal wall reconstruction. He's been a hernia surgeon specialist for over 20 years. He performs both mesh and non -mesh hernia repair. So we're going to get into that. He is an expert in hernia surgery techniques like the sholdice repair and the disarter repair that most American hernia surgeons are not trained in. Dr. Yunis has a strong interest in revisional hernia surgery, repairing recurrent hernias and surgically eradicating chronic pain from a hernia surgery.

Dr. Yunis has brought his skills to those in need in different parts of the world. He has worked with patients and different hernia specialists around the world, including Ghana, Haiti, and the Dominican Republic. Dr. Yunis, welcome to the show. 

Dr. Jonathan Yunis: Thank you for having me, Glen.

Glen Merzer: First, let me ask you, why did you become a hernia specialist? Did you go to med school saying, I'm going to repair hernias all day long? 

Dr. Jonathan Yunis: Definitely not. It's something that is now coming to many young surgeons all over the world because hernia surgery is particularly interesting in that it's a very reconstructive type of surgery. Your understanding of the intricacies of anatomy, you know, which is quite variable, really comes into play to become an expert hernia surgery. So it's something that many surgeons over years start to appreciate more than the name itself, the name itself, hernia, you know, kind of connotes a simple situation. But we've learned as surgeons that it takes many years to come experienced and expert at fixing hernias properly to minimize complications. So, you know, it's attractive because it represents great challenges, because, you know, the results from hernia surgery aren't as optimal as they should be. And it's, as I say, reconstructed. It's not just removing things, you know, we're fixing somebody. And so it's attractive for purely academic and, you know, literally people enjoy it, yeah. like myself, many people do. 

Glen Merzer: Well, followers of this podcast will know that I advocate the whole food plant based diet and the whole food plant based diet, I believe, prevents and reverses heart disease, prevents and reverses type two diabetes, prevents and reverses obesity. But it does not prevent you from sneezing your way into a hernia, which is what I did about two years ago. I sneezed, I felt some pain in my groin. I sneezed again, I felt it again. I looked in the mirror and there it was. But there is a relationship between diet and hernia surgery and we'll get to that later. But I thought when I discovered this problem that I had a hernia, I thought, it's easy. It's minor surgery, hernia surgery. And I found that it was very complex. I had a big choice to make. I went to a local surgeon who was recommended to me, who I have every reason to believe is a fine surgeon. He's a young guy, nice guy. He told me that what I had was a right inguinal hernia, and he would repair it using a laparoscopic technique using mesh. And I had already Googled mesh repair and non -mesh repair. And so I asked him why he uses the mesh and he said, lower chance of recurrence. And I said, how much lower? And he said, 50%. Now that sounds pretty significant, 50%. You could see why somebody would say, okay, give me the mesh. But I asked him 50%. Is that in absolute terms or relative terms? And he said, well, relative terms. I said, give it to me in absolute terms. He said about 1 % chance with the mesh 1 .5 without the mesh. So you could call that 50 % or you could call that 0 .5%. So using his numbers, your numbers may be different. I don't know. But using his numbers, there was a 1 in 200 chance that I would be more likely that I would have a recurrence without the mesh. So for a one in 200 chance, I didn't want to have this product in my body. And it seemed to me that it was just illogical to take that risk when I could do it without it. And there were other factors too. This statistic, whatever statistics they have on mesh and non -mesh repair, recurrence, they're based on the American population at large, right? And am I right that if you're obese, you're more likely to have a recurrence than if you're slender? 

Dr. Jonathan Yunis: Yes, that is definitely true that obesity is clearly associated in the data and in common sense of why yes, people tend to have a higher risk of recurrence with obesity. And the data is based on numerous papers and studies from not just the United States, but all over the world. And one of the problems with the accuracy of the data of these recurrence rates is many of the studies are including surgeons that are very bright and well -intended and excellent physicians. but who might have limited experience in some of these techniques. So therefore their outcomes of the surgery is not quite that valuable when they're still in the middle of a learning curve. It takes many years to get expert at many of these types of surgeries.

Glen Merzer: Yes. And so I went on the internet and looked for non -hesh mesh hernia repair and I found you. And it was well worth it for me to drive a thousand miles to have it done the way I wanted it done. As I recall, we did a telemed visit first. And as I recall, you made a comment like, Glen, even if you didn't ask for non -mesh repair, that's probably what I would have recommended for you. 

Dr. Jonathan Yunis: Right. That's correct. Yes. 

Glen Merzer: Yeah. So.I asked the local surgeon who again, as far as I know is an excellent surgeon, but I asked him how many mesh, how many hernia surgeries do you do a year? He said about a hundred. And I said, how many would you do it non -mesh? If I asked you to, he said, yes. I said, how many non -mesh do you do a year? He said one, about one. So If I'm going to get a non -mesh hernia repair, do I want to go to a guy who does one a year or a guy? I know you do about 700 hernia surgeries a year. How many are non -mesh? At this point about, about 300. Right. So I'd rather go to a guy who does 300 a year and you, I don't know what technique the local guy would do, but you do the Desarda technique, the shoulder ice technique. And are there other non -mesh hernia techniques you use?

Dr. Jonathan Yunis: There are, but at this point, the evolution of non -mesh techniques for inguinal hernia pair has led me to believe and others that these would be the two most reliable time -tested techniques that exist today. So there are other techniques of historic significance that aren't worth getting into, but this is really what I offer. And I make that decision of which one's better based on usually what I see at the time of the surgery.

Glen Merzer: Well, I'll tell you, Dr. Yunis, the moment when I knew that I made the right decision driving to Sarasota to see you. It was on the day of my surgery. I was being prepped for surgery. I was in the on deck circle or whatever you call it in a room waiting for the surgery. And you came in to see me. And I said, Dr. Yunis, I've read up about the techniques. I know there's the Desarda technique and the shoulder ice technique. Which one will I be having? And you said to me, when after I open you up, I'll know. And I thought, man, this guy is good. He's going to call an audible. He's going to he's going to open me up and do what's best for me. And that I said, I'm in the I'm in good hands. 

Dr. Jonathan Yunis: Yes.

Glen Merzer:  Is it possible to explain to a lay audience how you know whether to go with the disorder or the shoulder? 

Dr. Jonathan Yunis: Yes, absolutely. A lot of it is based on the fact that getting, again, getting back to the art of hernia surgery, that it takes many years to be able to recognize what you're looking at among very smart, excellent, well -intended surgeons, and then understand exactly what layers are which to do the right operation. So there are biases among surgeons about the techniques that they will use. And certainly, one thing that's an agreement among surgeons in general is whatever you've learned how to do best, whether it's a mesh technique or a non -mesh technique, likely you're gonna get the best outcomes because of the fact that you did it so often and you're learning what works out to be the best. So, yes, without going into the weeds about the details of why I choose a disorder or a shoulderized repair, the truth is that at the shoulderized clinic, they are excellent surgeons and they do fantastic work. but they don't believe in the efficacy of the Desarda technique. And Dr. Desarda, who's a wonderful man and has excellent results, does not really believe in the efficacy and quality of the shoulderized technique. And then people that are excellent robotic hernia surgeons or laparoscopic herniation surgeons, and those surgeries, by the way, inherently involve mesh. So, you know, those are the new modern techniques. We've been doing laparoscopic inguinal hernia repair for over 20 years. Robotic surgery is the new laparoscopy. We can talk more about that if you'd like. But the reality is is that surgeons get good at one or two techniques because the surgeons at fix hernia have to be very good at many different surgeries. And as I keep emphasizing, it takes a long time to kind of recognize what you're looking at from each one of these surgical technique perspectives. So when I get in there, I see and have a lot of experience with all the techniques and I like to pick what is gonna make my patient the happiest? I mean, it's that simple. I want it to be the least painful and last forever. So, you know, certain types of things, and this is not science, this is my sense of the stall based on years of experience and the experience of others that I pick, you know, kind of bigger hernias and hernias that are more what's called the direct space or the posterior wall of the inguinal canal. I think are much more amenable, you know, or will have better long -term results with a shoulder ice technique and kind of smaller hernias. Maybe there's less surgery in a disorder repair and that I have confidence that that will work forever. So smaller lateral hernias or what we call indirect hernias, what I often choose for a disorder approach. And when they're bigger or direct and indirect, you know, I will choose a shouldice technique. And my algorithm has in my own experience been excellent in terms of making people happy. Yes. 

Glen Merzer: Well, it worked for me and I'm very pleased with it. Now, again, when I got this hernia and I went to Dr. Google to determine what to do about it. I found you and I found there's a surgeon in Stony Brook who you probably know who does the shouldice repair, I believe. I think he was trained at the shouldice clinic in Canada. Where were you trained to do the shouldice repair?

Dr. Jonathan Yunis: Right from the very beginning of my career, there was a surgeon at my university hospital program, also at Stony Brook, by coincidence only, by the name of Maximo de Zin. And he was kind of a surgeon that was very early, one of the early leaders in the hernia world, you know, with the beginning of what's called the American Hernia Society, where a lot of these issues about recurrence and pain were discussed many years ago. And he taught me that operation and that's what he learned. And he had the experience as others of learning it directly from there. And then studying and then, you know, and years and years of doing it, I am extremely comfortable doing that operation. I've also been at the Sholaz Clinic twice as an observer, you know, not, you know, this other surgeon you're talking about is an excellent surgeon who actually worked there. I was trained in my residency over time and with observation in more recent times have perfected the technique. Yes. 

Glen Merzer: Well, let's talk about why there are so few surgeons who can offer what you can offer. The shouldice technique, the Desarda technique is how many, how many surgeons are there in America who do the Desarda technique?

Dr. Jonathan Yunis: I don't know that exact number, but I would say on a frequent basis, there's probably, you know, three or four, you know.

Glen Merzer:  Okay. And the shouldice technique? 

Dr. Jonathan Yunis: On a frequent basis, there's, you know, probably right now, I know for sure about three or four. 

Glen Merzer: Three or four. And then there is the shouldice clinic in Ontario, Canada, where they do many. 

Dr. Jonathan Yunis: Many, many. 

Glen Merzer: And you have a high opinion of that clinic. Is that right? 

Dr. Jonathan Yunis: Absolutely. No question. 

Glen Merzer: Yes. Yeah. So here's my question to you. The Shouldice Clinic has an excellent record. I believe something like 1 % recurrence rate. And so if recurrence is the big issue, why people get mesh? And with skilled, experienced surgeons, you could get a 1 % or so recurrence rate, which isn't going to exceed the recurrence rate with mesh. And let's factor into that if, since there's going to be some recurrence either way, would you rather have a recurrence with mesh inside you with tissue growing around it or a recurrence without mesh? I think it's obvious you're better off having a recurrence without mesh. So you have to factor that in too. So when you factor in all those factors, the fact that there are risks to mesh. I know you use mesh often and I'm not making a case that it's always wrong, but if you can do it without it, why would you want it? And so when you factor all that in and then you ask yourself, why are there so few hernia surgeons in America who do it in what I would call the optimal way?

Dr. Jonathan Yunis: That's a very, I mean, that's an excellent question. And I think that's going to evolve that, that in my experience and in others experience and in the demand from the, from the world that will change. Okay. So, you know, you know, the, so why we can talk about that, but I am, I am confident that over time that non mesh techniques, shouldice to Sarda and others will gain traction and will be performed better and better over the years, you know, all over the world. So So why is it? Well, again, it keeps going back to this thing that I keep saying, which is that it's a little known fact and an underappreciated thing. When people think about what it must mean to become a brain surgeon, a neurosurgeon or a heart surgeon, these are two amazing, intricate, high level responsibility fields with very intricate anatomy and so on. But a lot of the things that you look at, even for these complicated kind of... you know, major open heart surgery, when you go in and you look and see what it is, it's recognizable, you know, and the quality of the outcomes there, there's a lot of importance about how it's approached and how the surgery is done, hand -eye coordination, where exactly do you cut? But with hernia surgery, it takes so long for the learning curves of what you're even looking at. that surgeons are taught over the recent past, these techniques that we get pretty good results with, which is laparoscopic. You know, right now, the most common ways to fix an inguinal hernia, we're specifically now talking about hernias in the groin, inguinal hernias, inguinal and femoral hernias are fixed with mesh, either with an open technique through a small cut, just like a non -mesh repair, or laparoscopic or robotic, where a mesh is put on the back inside wall of the abdominal cavity in a very safe place. And when surgeons get expert at doing laparoscopic and robotic mesh placement, the incidence of a mesh problem is extraordinarily low. An expert putting, doing this, what we call posterior mesh repair. So not all mesh repairs have the same risk of complications that you were trying to avoid. So when an expert does a laparoscopic or robotic repair, and they've learned this well as a young surgeon and then in their career and they're getting better and better, it's a good choice. They have a low risk of recurrence, close to one or 2 % as an expert and the risk of a mesh problem is under 1%. So that's why it persists because an expert robotic or laparoscopic hernia surgeon will say, I hardly ever have a mesh problem. And that's true. but it definitely occurs in about 1 % of people. And you made a very good point, which a lot of people don't think about, which has to be factored into this is that inguinal hernias are not a cancer. So if you can fix that inguinal hernia in what I am now considering the true least invasive minimally invasive approach, which is an old fashioned cut at least this big over the groin going in and putting no materials in and not even going in the abdomen. To me, this is much less invasive and you can fix that in a less invasive way and the hernia comes back. You're absolutely right. The safety of the surgery in the acute phase is safer than a laparoscopic or robotic repair in terms of something terrible happening, meaning it's not that much risky. And then if as you say, you get a recurrence, people get recurrences with a laparoscopic or robotic repair, even though they're very durable. You're absolutely right. You need an expert to fix your recurrent hernia. I mean, this is not something talked about when you have a laparoscopic or robotic repair and I go in as an expert to fix these people. And, you know, I often do them open from the front, whether I use mesh or not is not relevant right now. But that requires a lot of experience to fix that properly because the mesh complicates the anatomy in the recurrent situation. So everybody's different. I don't want my patient's hernia to ever come back again, but you're correct. If your hernia ever came back again, even a very minimally experienced nice young surgeon could fix that hernia as if no one was ever there before. Why is it, you know, I'm showing you that the history of teaching surgeons, you know, is that you learn a particular technique because these surgeons also had to be learning how to do sick, take gallbladders out, do small bowel obstruction surgery, do colon surgery. There's many things that fall within the realm of what's known as the general surgeon who fixes hernias. And another note on that is a lot of people it's just a general surgeon. Well, that it's a little bit of a misnomer. General surgeons are trained from anywhere from five to seven years. And, you know, this is my training and others to be expert at everything in the abdominal cavity, including hernias themselves, you know, so it's not just like being a general practitioner. These are expert surgeons, but their responsibility is fixing many different things, you know, in the abdomen. So, you know, it's all about experience, learning curves, et cetera.

Glen Merzer: Let me make an analogy to the subject that's often the subject of my podcast, which is diet. 30 years ago or so, there were very few physicians who recommended the whole food, low fat, vegan diet. It was Dr. John McDougall and Dr. Michael Klaper and just a handful. You said there are just a handful of surgeons like you in America who do the, shoulder ice and to Sardar repairs. There was just a handful of doctors 30, 40 years ago telling, practicing nutritional therapy, telling their patients, stop eating meat, stop eating dairy, stop eating sugar, go on a whole food plant based diet. There is now the American college of lifestyle medicine. There are thousands of doctors doing this. Thousands of doctors, still a minority, but thousands of doctors. telling their patients with heart disease, well, you could have a statin and an angioplasty and a heart bypass, or you could eat fruits and vegetables. So do you see this coming that more doctors will be trained in shouldice and the Sarda and there's the shouldice clinic. Are they training more and more shoulder ice surgeons up in Canada? How will this transformation happen?

Dr. Jonathan Yunis: That over time people are gonna appreciate the safety of this operation and that the efficacy of it, meaning that the recurrence rate is not terribly high. And so over time, the leaders of the academic world that teaches young surgeons will be gaining expertise by observing others. I'm having, for example, a very highly critically acclaimed a hernia surgeon is gonna come observe me in about a month all day doing these operations and he is bringing his surgical fellow. So it'll be over the next five years that I think that the academic community will start to appreciate it. And from teachers teaching teachers to teaching students, the evolution will likely be what you've thought before others as you did with your you know, with your concept of what's the proper diet, I think it's gonna evolve that, you know, yes, even at university hospitals, this will be offered and even emphasized, correct?

Glen Merzer:  Is there an economic force militating against that hope?

Dr. Jonathan Yunis: That's a very interesting question and this is an opinion. That among surgeons, I am very honored and very lucky to be in a profession where the Hippocratic oath is celebrated of first do no harm. We do it for others, for not our own gain. And it's pervasive among my peers. I'm very lucky. There's true honesty in this field of surgery that I'm in, of what's right. Let's do what's right for the patient. So among my peers, no, there's no profit motivation of any of these operations, but there is a huge industry that makes mesh all over the world. And that is, I don't have the exact number, but it's in the billions on an annual basis of the mesh industry. And there's huge competition and huge, obviously marketing and things that go along with it, that this may be what's influencing the history of hernia surgery and the near future, you know, in terms of it going the other way, you know, and I want to just take a time out here just so our audience is clear on this. We today are talking about repairing inguinal hernias without mesh and those techniques being the shouldice and disordered techniques. There are many other types of hernias at the abdominal wall. you know, that include, but aren't limited to umbilical hernias, epigastric hernias, and what we call ventral hernias, ventral incisional hernias, hernias of the abdomen that occur after having other surgeries. So, you know, many patients, you know, have these very complicated hernias and it gets a little confusing that they're looking for non -mesh techniques. And some of these bigger surgeries that require very significant operations that we perform that sometimes take three to five hours. you know, with robotic technology or open, demand mesh is my point. And I think that will always be necessary to be clear. And when done expertly, don't forget, even in these big hernias, the risk of complications from mesh from these big complicated hernias in expert hands is extraordinarily low. So it's becoming an issue.

Glen Merzer: Right. And I'll note that even at the shouldice clinic, apparently about 1 % of their hernia repairs use mesh. They use it when they believe it's necessary and appropriate. Yeah. Now, as I said, when I got the hernia, I thought, this is easy. And so, you know, simple hernia surgery. And I realized how complex the choices were. It's not just a choice of mesh or non mesh. There's also the open laparoscopic and robotic repairs. And the open repair means you cut me in the groin where I had the problem. The laparoscopic repair involves making incisions in the abdomen and going through that space downward towards the groin. And the risks there, and they are much smaller and capable hands like yours, but the risks there are that the bladder or other organs can be affected, right? 

Dr. Jonathan Yunis: Correct. 

Glen Merzer: Yeah. So I said to myself, again, I tend to go on instinct when it matters matters health. I said, well, I have a problem in the groin. I'd rather be cut in the groin and repaired in the groin than go through my belly. So I asked around different people, what's the risk to getting open surgery right in the groin where I have a problem. I was told more pain. So I want to tell you, Dr. Yunis, Yunis, how much pain I had. from your surgery. Because I was worried about the pain because frankly, I can't swallow a pill. So I, before the surgery, I got, I think, two bottles of liquid Tylenol. I've never taken this stuff in my life. But two bottles of liquid. I wanted to be prepared for this terrible pain. You know how much pain I had? I didn't have to take an aspirin. I had zero pain. You're a good surgeon. I guess you didn't. hit a nerve. Is there a nerve that's cut with the shouldice repair?

Dr. Jonathan Yunis: Potentially there is, and that decision is made on an individual basis. I have a personal philosophy where I don't cut any of the nerves. They're easily seen. There's three major nerves running through that area. But in terms of your experience and what you heard from others, I just want to kind of go back on what your experience was and why other people would say that. Yes. you know, an excellent laparoscopic robotic surgeon who's gotten really good at would say, you know, I don't wanna say kind of prejudicially, but what they've heard or from their experience of doing, you know, of doing open surgery that it is less painful to have a laparoscopic or robotic repair. So let's just start with that. I think it's important. And the answer is not just your experience, you know, my experience with, you know, thousands of patients. that there is no increased amount of pain from either an open non -mesh repair, laparoscopic repair, robotic repair. So it's kind of an old prejudice because when an open repair, usually with mesh gets done in a less professional or accurate way, it hurts. So as that surgeon gets better and better with time, with getting past their learning curves with any of these surgeries, including the open surgery, we're also making it a less painful experience. Not just, it's safer and it's not gonna come back again, but the more I and others understand the subtleties of the anatomy, not just, it's not about cutting a nerve, it's about how we handle the nerves, how we handle the tissue, how we expose what was years in development of your hernia, separating everything so we can see it perfectly and then do the shouldice repair. It's here where damage happens in a subtle way that is why people historically had a lot of pain from an open repair or even a laparoscopic in inexperienced hands or robotic inexperienced hands, it could be very painful. So experience again is also making it less painful. And as a fact, there is no statistically higher risk of pain with what you had versus the other operations. And I feel strongly about that, yes. 

Glen Merzer: And I just want to make it clear to the audience, when I say I had zero pain, That is absolutely correct, but there was what I will call soreness, and I'm going to make a distinction between soreness and pain. If somebody tells me that they injured their wrist last week and I said, are you in any pain? And they say, only if I do this. Well, don't do that. But that's what it was with the surgery. There was no pain. Literally the evening I came home, the next day. I could walk around, no pain. I could sit and read a book, no pain. I could watch television, no pain. When I was lying down at night in bed and had to get up in the morning, there was soreness as I engaged my abdominal muscles. Of course, there was soreness. My wife had to help me the first night or two to get out of bed. There was no pain during the day after the surgery. I was walking around downtown Sarasota. I was not in any pain. So only when I engage my abdominal muscles, there was soreness. Soreness to me is to be expected and is not what I mean by pain. 

Dr. Jonathan Yunis: Yes.

Glen Merzer: Let me ask you this. You use mesh often. How has mesh evolved over the course of your career as a hernia surgeon? 

Dr. Jonathan Yunis: Well, fortunately now it's evolving in a positive direction because of this awareness about potential mesh related complications. So the, you know, the materials mesh has been used also, you know, the audience should understand that hernia mesh has been used for inguinal hernia surgery, you know, for 50 years. So it's not new. And it's not like all of a sudden we're finding out about how terrible it is when the mesh is not put in a perfect technique or the mesh, you know, you're asking me a question about, you know, how the mesh has changed. You know, we used to use thicker meshes and. You know, there was confusion about what was necessary. And now with proper technique, we're using not always, but typically lighter weight meshes, you know, materials that are less dense. And when we talk about mesh, this is usually in 2024 polypropylene, which is a type of plastic or polyester. There's also polytetrafluoroethylene. And these are lightweight plastics that are woven. you know, in a way thus the word mesh where little fibers are woven to each other. And so mesh has evolved where the fibers are becoming smaller, you know, with less weight and the pores, the openings in the mesh, in the weave are bigger. And these things have led to improved outcomes or lower risk of mesh complications over time. And we're understanding that pretty well. And then how to put the mesh in and where to put it in, also is what's improving. So it is all getting better. There were many kind of meshes from the old days that were clearly culprits, things that are kind of thicker, like kind of big objects that thin muscular people like yourself would feel every time you moved even more. So these are some of the bigger problems with mesh is just some of the designs of the shape, but not necessarily the chemical comp. So polypropylene has been used for about 50 years. And even though there are some signs that some people that study it and point to bad things about it, that is really not the problem. It's the bulk of it. And that bulk is getting less and less over time, less dense, less material. 

Glen Merzer: Is there a choice between absorbable and non -absorbable mesh? 

Dr. Jonathan Yunis: Yes, there are many different types of absorbable meshes that have been out there, biological and synthetic absorbable meshes. But in inguinal hernia surgery, so it gets a little confusing here for our audience because absorbable mesh is very popular for some very complicated large ventral hernias. So these inguinal hernias that occur in the groin and the inguinal canal where the abdomen kind of meets the leg, there's very little role based on good recent evidence for absorbable meshes in the inguinal canal. So a good non -mesh technique. you know, is as good as a mesh technique, you know, with an absorbable mesh. You know, actually the recurrence rate's probably gonna be higher. So, you know, the expense of not, the expense of these absorbable meshes, so they're often much more expensive, and the fact that there's, that there's no proven efficacy or quality of using it in the growing England region is why it's really not a great option and really shouldn't be offered and is rarely offered by most of my colleagues. 

Glen Merzer: Now at the Shouldice Clinic where I've never visited, but you have in Ontario, they apparently do hernia surgery as a three day event. In Sarasota where I visited you, you did the surgery and I think it was about four or five hours later that I went home. Is there some case for keeping patients for three days? Why do they do that? 

Dr. Jonathan Yunis: Well, one of the beauties, if I can again support and speak highly of this amazing institution, the Shouldice Clinic, which is now about 60 plus years old, is that they have been studied as an institution of quality because they designed an operation, they designed a technique and a process and an algorithm that they've been doing well and teaching others well for over 50 years. And in doing so, they're getting great outcomes. And there's a lot of little steps of the surgery that they do, materials that they do. And part of what I'm talking about now is that historically, they kept people in this facility, a beautiful facility for three days. And so in the old days when things were not, we weren't really worried 30 years ago about how much money we were spending about someone staying in, there was less emphasis on these things. Even a patient would say, hey, they're watching me that much closely. I had surgery. So for safety reasons, so there's no risk of, if bleeding occurs, you're at the facility, they can guide you with certain stretching things and walking around and you know, and just kind of support even with low grade medicines for your pain, that the fact that they've been doing this for so many years, they decide that that is part of their process, that they don't want to eliminate even little things because that's why they're so successful with such great results. I, as a very experienced surgeon myself, know that I do not need to keep people in for three days. It is absolutely not necessary at all. In fact, to me, it's the safest way to fix an inguinal hernia. I have to do a safe operation, but I feel extremely comfortable with people leaving the outpatient surgery center in as little as two hours after the surgery is over and leaving Sarasota within two days. So, you know, I think that's a good explanation for you that I applaud the Shouldice Clinic for sticking with something that works, which is, you know, part of their formula. But I personally and other surgeons would say it's not necessary in 2024. 

Glen Merzer: Now, another potential difference, if what I understood from reading their website is correct, they often use local anesthesia. I had under your hands, I had a general anesthesia. Talk about that. 

Dr. Jonathan Yunis: Yeah. That's a very big concern of many patients. Yes, at the Shouldice Clinic, part of their routine is to do these almost all, not every single one, but 99 percent of them under a type of local anesthesia. I also do that on a frequent basis you had general anesthesia, but a light general anesthesia. So again, there are things that are not perfectly understood by society about words that we use like general anesthesia and local anesthesia. So anesthesia itself is a cookbook of many little things that help a patient have no pain and have safety during the time of surgery and have the ability to walk out of a facility after the surgery. So general anesthesia, we refer to it, we say you had general anesthesia, but you did not have a type of general anesthesia where we do the same thing, say, when we have to do a robotic inguinal hernia repair, we have to do it under general anesthesia where we put a tube through your trachea, what we call intubation, and we paralyze you. We use paralytic agents in part of that general anesthesia. And these are kind of the bigger parts of general anesthesia. Again, where the lay public doesn't have words to understand the difference between your general anesthesia and the other general anesthesia. So you had a very light one where we use what's called the LMA, laryngeal mask airway, that we're breathing for you, but we're not paralyzing your body. You're able to kind of breathe on your own a little bit, but we're breathing through. We're not putting something all the way down there. We're putting something kind of in your pharynx, in your mouth. You know, we're using much less drugs, you know, than the other type. We have a very high predictability of you feeling great when you leave. Again, going to the shouldice clinic and I do, or my clinic say, I do local anesthesia, because some people demand that that's what they want despite this explanation, or some people that literally wouldn't be able to tolerate general anesthesia for certain reasons. And I use an ultrasound guided nerve block from the surgery. I do this myself. that makes it where, yes, I potentially can do that open surgery with an incision this big without giving you any anesthesia by doing the proper nerve block. So why not do it that way on everybody? Because some, you know, it's just the general anesthesia that you have, this light LMA anesthesia is so well tolerated that it's just fine to do it that way. You know, that I don't think, you know, for a healthy man, that there's any benefit to local anesthesia. So it can be done either way, but there are variations to sum it up of really what we call different types of anesthesia. And so I don't think there's any big benefit of doing it strictly under local or general. 

Glen Merzer: If I had had the local anesthesia, then I would have been conscious during the operation, right?

Dr. Jonathan Yunis: Well, there's different variations of that. So people say, I had it done under local and we give you sedation is what we call it at the same time. So there's a type of, so these again, you know, I'm not sure exactly how to communicate it. You know, you could ask more questions just to, I think this is an important point for you, is that local anesthesia is often misconstrued in the lay public because I could do a straight local, like I described to you, where I can use an ultrasound, guide my nerve block right around these group of nerves. I can cut in, be talking to you the whole time. It's awesome. Then I can supplement little areas with local anesthesia around where I'm working. But the reality is, is some people will require some type of sedation because of their anxiety. And some people will be told they had it done under local, but we're giving you what's called propofol, which is a light intravenous medicine, or Versed, or narcotics. So these are all... things that are part of local anesthesia or local anesthesia with sedation. And so it spans the gamut from being completely awake to where you really had a type of general anesthesia, we just didn't breathe for you. So most people tolerate all of those and modern anesthesia in 2024 is much safer than the history of what we've attributed problems to And a lot of the cognitive dysfunction that people are worried about from general anesthesia, in a one hour operation or less done with an LMA, with minimal medicines has an extraordinarily low or potentially no risk of cognitive dysfunction. A lot of that gets confused again, with very bright people that have problems with the way they think about anesthesia is say, let's look at the extreme of open heart surgery. you know, coronary bypass, your blood goes through a cardiopulmonary bypass machine while the surgeon is fixing your heart. This is under general anesthesia. And this is where a lot of people, even in expert hands can have some loss of memory or, or strokes even. And, you know, so it gets kind of blamed on general anesthesia, but it's general anesthesia with open heart surgery that's going on here, you know? So, so, So it's the terminology that gets a little bit confused, but it can be done with either technique and anesthesia people do very well from with inguinal hernia repair. 

Glen Merzer: Well, I remember you had a terrific anesthesiologist. I forget his name, but he was a lovely guy. And as he was starting to put the mask over my face, I said, wait a minute, wait a minute, darn, you're going to sing a lullaby first? and he got a lullaby on his cell phone. And my last memory was his dropping that cell phone on my tummy before I was out. 

Dr. Jonathan Yunis: That's great. 

Glen Merzer: So tell us about your trips to parts of the third world to volunteer your services to help people.

Dr. Jonathan Yunis: Yes, it's not something that people think about, but there's are in many third world countries or areas historically where even hernia care doesn't get done, and people suffer and young people are out doing physical things like farming all over the world with hernias that are just getting more and more in the way or potentially causing emergencies. So.So I was part of both faith -based and non -faith -based missionary work in these countries, in Ghana, Burkina Faso, Haiti, and Dominican Republic, multiple times in my earlier career. And they were extraordinary experiences, culturally and so on. And one of the things that really comes true there is that when you're doing this volunteer work, in another country in often very difficult conditions of heat and light that's not great, anesthesia that's not great, sterile conditions that aren't great. You have to be even more expert at this surgery, given the ethics that this is a human being that you're operating on. You might be doing this out of the kindness of your heart, which is what you're doing, you're giving to people. But the challenges of doing missionary type of surgery or hernia surgery in other countries requires even more expertise. And I learned a lot from that as well. Yes.

Glen Merzer:  Did you go, I assume, as a member of some team? 

Dr. Jonathan Yunis: Yes. absolutely. Yes. 

Glen Merzer: And so how many such trips have you made? 

Dr. Jonathan Yunis: Four of them. Yeah. 

Glen Merzer: Wow. Which countries? 

Dr. Jonathan Yunis: So it was Burkina Faso, Ghana. Dominican Republic and Haiti. 

Glen Merzer: Well, kudos to you for doing that work. Before we finish, I want to get back to the subject that's usually the subject of this podcast, which is diet. Clearly, hernia surgery is easier for you to do, isn't it, on somebody like me who's at my high school weight than somebody a hundred pounds overweight?

Dr. Jonathan Yunis: Very much so. And it's not about me. Your outcome will be better because of that. And it's because when I expose a man's or a man or woman's anatomy that is thin and muscular, that's the initial challenge where the reconstructive technique as described by Shouldice or Desarda is it's necessary that you've isolated the anatomy perfectly and obesity distorts that anatomy. We see even what we call fatty replacement of muscle in people. It's an extraordinary thing that really comes to light as a hernia surgeon. You see that more where in the inguinal canal where these groin inguinal hernias occur, it's a potential natural space where we become more upright, gravity is pushing through you know, these muscles, your oblique muscles and rectus muscle in the groin where there's these potential openings that are allowing say, you know, the round ligament in a female to come through or the spermatic core that goes to your testicle come through that in, you know, in these areas that we expose the anatomy is distorted, you know, with obese people. And one of the reasons why you'd have higher risk of recurrence is the tissue doesn't hold as well because there's fatty replacement of it and the surgeon's not recognizing it. It requires even a greater learning curve to operate on someone who's obese, so you really know what's what. So these are higher risk of recurrence. The Shouldice Clinic is extraordinarily picky about not operating on people over a certain BMI. And they have that ability because people are coming from all over the world. The demand is extremely high for them. So people that are as little as 15 or 20 pounds overweight get turned down by the Shouldice Clinic. One of the reasons 

Glen Merzer: - 15 or 20 pounds overweight. 

Dr. Jonathan Yunis: Correct. Correct. 

Glen Merzer: That's most people in the United States. Right. 

Dr. Jonathan Yunis: That's right. So they operate on, I mean, so sometimes they might look at, that's not fair to say 15, 20 pounds and they won't operate on you. What I'm getting at is depends on the distribution of your fat. So, I don't know exactly what their cutoff is, but it's kind of a gestalt thing for me too. I agree with them. So when there's a lot of fat distributed in the abdominal wall or a lot of what we call male visceral fat with a big belly on the inside, there's gonna be more pressure on the area of the repair. The anatomy will be distorted. These people will have a higher risk of recurrence and should not be operated with that technique. And I often will choose to offer these people a robotic or laparoscopic mesh placement surgery or that they may be motivated to go on a weight loss plan. So you are absolutely right. It's a big factor in long -term outcomes in the. 

Glen Merzer: Do you ever say to patients, I won't do the surgery on you until you lose 50 pounds. 

Dr. Jonathan Yunis: If they're demanding that I do a non -mesh repair. Absolutely. I say that, you know, because I know I believe in what the shouldice is clinic believes in that. Yes. you should lose the weight, but some people would say, okay, doc, I'm not gonna lose the weight. I'm happy being 50 pounds overweight. Just fix me the way you think is best. And I can fix someone who's 50 pounds overweight with a robotic approach, fairly readily and easily with a low risk of complications. It is an amazing technique as well. So that is an indication of this robotic surgery is obesity. It helps it a lot.

Glen Merzer: Well, you'll find on my channel an interview with the great Dr. Alan Goldhamer, who has the True North Health Clinic in Santa Rosa, California, where he puts people on supervised water only fasts. And then as they come out of that fast, he puts them on the diet that I practice, a whole plant food diet. And if you have patients who need to lose weight, you can suggest they look into that because that's an excellent way to lose weight quickly.

Dr. Jonathan Yunis: Excellent. 

Glen Merzer: Finally, let me read to you what is on the website of the Shouldice Hospital in Ontario. They say, although there are inherent risks in any surgery, there are no risks in natural tissue hernia repair comparable to where mesh has to be peeled off a bladder, colon, spermatic cord, or major blood vessel. Would you agree with that? 

Dr. Jonathan Yunis: I agree with that. 

Glen Merzer: Right.

Dr. Jonathan Yunis: But that doesn't mean that mesh should never be used. 

Glen Merzer: So as they agree and they agree to that. 

Dr. Jonathan Yunis: Yeah, I agree. It is the you know, I'm going to just go back to one other thing that, you know, a lot of there's a lot of brilliant young surgeons all over the country right now that are becoming hernia experts. You know, it is really a force of I have some great colleagues that are in this field and And the reality is, is that as they get better and better with mesh placement, the risk of mesh problems is decreasing. 

Glen Merzer: Well, that's good to know. And I certainly wouldn't, and I am not an expert in this field as you are, but I'm certainly not making them the case that mesh is always a mistake or that mesh should never be used. But what seemed to me to be clear is that for me, There was absolutely no reason to use mesh. I just needed to find a surgeon who was experienced and knew how to do it without mesh. And what was remarkable was how few such surgeons there are in the United States of America. And there should be more. There should be more surgeons like yourself, given that there is something like a million hernias a year that get operated on with a million hernias being operated on a year, we should have more than three or four surgeons doing the shouldice technique and the Desarda technique because for me it was a no brainer.

Dr. Jonathan Yunis: Yeah, that'll change. 

Glen Merzer: OK, I hope I hope it will. I'll point out to that your clinic is in Sarasota, Florida. Why did you choose Sarasota?

Dr. Jonathan Yunis: because I grew up in the New York metropolitan area. My father was a very successful physician that offered me an area where his big group could be referring to me. And I decided to make it on my own and just started with a job in St. Petersburg to kind of make it on my own. And I'm still there and moved a little bit further south into Sarasota. It's a great town and. It's easily accessible and I have a great medical community, so I'm very happy that I chose it. 

Glen Merzer: Yeah. Well, it's one of the most beautiful towns in America and it's where I went to college. And there is a stretch of land at the Ringling Art Museum. If you walk from the Ringling Art Museum to Sarasota Bay, where there's Khadzan, the house of John Ringling, that was right next door to where I went to college and I used to...walk there all the time thinking, this is pretty. Well, 50 years later, I now feel it's still the most beautiful plot of land in America. There are banyan trees and palm trees and the view of Kadzan and the Bay. It's just gorgeous. So for me, I called it my hernia vacation because it was just lovely to stay there for 10 days. I didn't have to stay there that long, but I wanted to.

Glen Merzer: Dr. Yunis, it's been a pleasure seeing you again and people can find you at the Center for Hernia Repair in Sarasota, Florida.

Dr. Jonathan Yunis:  Correct. 

Glen Merzer: Thank you for joining us. 

Dr. Jonathan Yunis: Thank you for having me.