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Recovering from hiatal hernia surgery requires careful consideration of dietary choices. Healthcare professionals sometimes advise against consuming chocolate post-surgery. In this blog, we explore the reasons behind this recommendation and the consequences of disregarding it. We also provide alternatives and wellness strategies for a smooth recovery. 

The Complex Nature of Hiatal Hernia Surgery

Before we delve into the specifics of avoiding chocolate post-surgery, it's crucial to understand the intricacies of hiatal hernia surgery. Hiatal hernias occur when a portion of the stomach protrudes into the chest cavity through the diaphragm's opening (hiatus). The surgery involves repositioning the stomach by moving the stomach out of the chest cavity and into the abdominal cavity.  The enlarged hole in the diaphragm (hiatus) is reduced in size but sewing diaphragm muscle together.  Sometimes a piece of mesh may be used to reinforce the hiatus repair.  Finally, an antireflux procedure such as a fundoplication (aka wrap) or magnetic sphincter augmentation (aka LINX) is performed.  Usually, the primary goal of the surgery is to alleviate reflux symptoms such as heartburn, regurgitation and chest pain.  

Dietary Considerations After Hiatal Hernia Surgery

The period following hiatal hernia surgery is pivotal for recovery.  There are two important dietary considerations during the recovery period.  

Firstly, the integrity of the hiatal hernia repair relies solely on the sutures holding the tissue together for the first few weeks.  Scar tissue and the healing process do not reinforce the repair until several weeks after surgery.  The suture repair can easily fall apart with forceful contraction of the diaphragm, leading to recurrence of the hiatal hernia or herniation of the wrap into the chest.  Retching and vomiting are the main causes of forceful contraction of the diaphragm. Consequently, dietary choices are extremely important during the recovery period to avoid retching and vomiting. This gets to the most important dietary consideration after hiatal surgery:  avoid foods that can get stuck in the esophagus.  When food gets stuck, not only will it cause severe chest pain, but it will also cause retching and vomiting.  

Typically, the fundoplication is swollen immediately after hernia surgery.  This swelling can prevent food or large pills from passing through easily.  I start patients on a liquid diet for the first week or two after surgery.  Anything that can be poured is considered a liquid.  In the second or third week, if the liquids go down smoothly, I then recommend advancing to soft foods.  I ask patients to avoid bread, rice, and chunks of meat for at least 2 weeks and until soft foods go down ok; these foods tend to get easily stuck in the wrap.  Also, just as important, is to chew well and eat slowly for a few months.

The second dietary consideration aims to prevent symptoms that could complicate recovery and increase discomfort after surgery.  After hiatal hernia surgery, chest pain and esophageal sensitivity are common from the extensive dissection around the esophagus and chest during surgery.  Therefore, foods that typically exacerbate heartburn and reflux should be avoided.  It's in this context that healthcare professionals often recommend avoiding chocolate.

Why No Chocolate After Hiatal Hernia Surgery?

While the recommendation to abstain from chocolate post-surgery might not be backed by extensive scientific studies, it's rooted in a sound understanding of the effects of chocolate on the lower esophageal sphincter and reflux symptoms.  Studies in healthy volunteers in the 1960’s and 70’s showed that eating chocolate relaxes the lower esophageal sphincter, which is the barrier that prevents gastric contents from refluxing into the esophagus.   Eating chocolate, can therefore, increase heartburn and reflux symptoms, as the barrier between the stomach and esophagus is relaxed by chocolate.  This is why chocolate is alway on the list of food to avoid in patients who have GERD or heartburn.  Chocolate also contains lipids or fats and caffeine, which can stimulate the production of stomach acid.  

The Consequences of Consuming Chocolate After Hiatal Hernia Surgery

The decision to ignore the advice to avoid chocolate post-surgery can result in a range of consequences, albeit minor, including:

Acid Reflux: Acid reflux is a common concern for individuals with hiatal hernias, and the consumption of specific foods and beverages, including chocolate, can trigger this condition.  Although the hiatal hernia repair is meant to bolster the lower esophageal sphincter and prevent acid reflux, and alleviate acid reflux symptoms, it can be difficult in the immediate post-operative period to tease out whether symptoms of chest pressure and heartburn are due to actual reflux or just typical post-surgical inflammation and esophageal sensitivity.  Avoiding such triggers, such as chocolate, is recommended to minimize these symptoms and the distress caused by these symptoms.

Stomach Pain: Some individuals have heightened sensitivity to fats and caffeine. Consuming chocolate after hiatal hernia surgery can disrupt the digestive system due to the presence of fats and caffeine, potentially leading to stomach discomfort and pain.

Rocky Recovery:  Patients, as mentioned earlier, typically experience chest and abdominal pain, as well as heartburn-like symptoms in the postoperative period - even when surgery goes smoothly.  Combined with the other typical post-operative symptoms of nausea, incision pain, and general tiredness, it is reasonable to minimize activities, foods, and other environmental factors that can exacerbate these symptoms.  Therefore, avoiding chocolate and other foods that can disrupt the digestive system, is recommended.

Bottom line is chocolate will not harm the hiatal hernia repair or cause any long-term consequences if eaten after surgery.  It simply may increase postoperative discomfort during recovery and increase anxiety about the effectiveness of the hiatal hernia surgery.  Eating chocolate is certainly not as bad as retching or vomiting, which should be avoided at all cost if possible. 

Dietary Alternatives and Wellness Strategies

While the temporary exclusion of chocolate from your post-surgery diet is advised, we can explore alternative dietary choices and wellness strategies that promote healing without compromising your comfort. Here are some options to consider:

Fruit: Fresh fruits such as apples, pears, and bananas can provide a naturally sweet and satisfying alternative to chocolate. Not only are they nutritious, but they are also gentle on the stomach.  But remember, raw fruits should be avoided in the first 1-2 weeks until the swelling from the hiatal hernia repair has resolved.

Yogurt: Opt low fat yogurt, which can be a soothing option for those seeking a creamy treat.

Herbal Teas: Herbal teas, including chamomile or ginger tea, can offer a soothing and caffeine-free alternative. They are known for their calming properties and can be a delightful beverage during the recovery period.

Water: Staying hydrated is essential for the healing process. Water aids in digestion and overall well-being.

Consult Your Healthcare Provider

It's essential to remember that the decision to include or exclude specific foods from your post-hiatal hernia surgery diet should be made in consultation with your healthcare provider or surgeon. They can offer personalized dietary recommendations based on the specifics of your surgery, your individual recovery progress, and your overall health status.

Incorporating a Holistic Approach to Healing

In addition to dietary considerations, it's vital to adopt a holistic approach to healing after hiatal hernia surgery. This approach includes lifestyle modifications such as:

Stress Management: Reducing stress can have a positive impact on your digestive health. Techniques like deep breathing, meditation, and yoga can be beneficial.

Elevating the Head of Your Bed: This simple adjustment can help prevent stomach acid from flowing back into the esophagus, reducing the risk of acid reflux during sleep.

Small, Frequent Meals: Consuming smaller, more frequent meals can be easier on your digestive system, reducing the risk of post-surgery discomfort.

Balancing Nutritional Needs

While avoiding chocolate is recommended, it's essential to maintain a well-balanced diet that meets your nutritional needs during the recovery phase. Working with a registered dietitian or nutritionist can help you create a meal plan that supports your recovery and overall health.

In Conclusion

The decision to avoid chocolate after hiatal hernia surgery is rooted in the potential impact of its ingredients on post-operative comfort. While scientific studies might not conclusively support this recommendation, it aligns with a broader approach to dietary care for individuals with hiatal hernias. By prioritizing your well-being, making thoughtful dietary choices, and consulting your healthcare provider, you can contribute to a smooth and successful recovery.

Your journey towards recovery is a vital phase in regaining your health and comfort. By considering these recommendations and seeking professional guidance, you can navigate this phase with confidence and set the stage for a healthier future.

We want you to return to health as soon as possible.

We understand that being diagnosed with a hernia can be scary and stressful. You probably have a lot of questions and some anxiety. This guide is designed to help you understand hernias, common terms used with hernias, how hernias are diagnosed, what hernia surgery is appropriate and what to expect with surgery. Your surgeon will go into more detail regarding your specific situation. Our goal at The PATCH Institute is to arm you with information, provide you with the best experience, and give you the best results.

What is a Hernia?

A hernia occurs when the inside layers of the abdominal wall have weakened, resulting in a bulge or tear. In the same way that an inner tube pushes through a damaged tire, the inner lining of the abdomen pushes through the weakened area of the abdominal wall to form a small balloon-like sac.

The weakness may be present at birth, can be caused by wear and tear of daily living, or by surgeries.

Men, women and children of all ages can get a hernia.

A hernia does not get better over time, nor will it go away by itself.

What causes a hernia?

The wall of the abdomen has natural areas of potential weakness. Hernias can develop at these areas.

Anyone can develop a hernia at any age.

Surgeries that require cutting through the abdominal wall can also create weaknesses and hernias.

How do I know if I have a hernia?

The common areas where hernias occur are in the groin (inguinal), belly button (umbilical), and the site of a previous operation (incisional).

You may notice a bulge under the skin.

You may feel pain when you cough, lift heavy objects, strain during bowel movements or urination, or during prolonged standing or sitting.

Some hernias do not cause pain or a bulge, and may be discovered during CT or MRI, or during routine physical exam.

Do I need to have my hernias fixed?

You should always have a hernia evaluated by a doctor. The doctor will help you determine if surgery is necessary and if surgery is safe in your situation.

You should have surgery if the hernia is enlarging rapidly, causing pain or limiting the activities you do normally.

You should have it fixed, if you’ve had an intestinal blockage due to a hernia.

Hernias that aren’t causing pain, intestinal blockage and aren’t enlarging can sometimes be observed. Consult your doctor.

How are hernias fixed?

A hernia repair usually involves two steps:

  1. Closing the hole or weakened area
  2. Applying mesh to reinforce the repair

Repairs can be accomplished with open, laparoscopic, robotic or a combination of techniques. Each technique has its pros and cons. Usually repairs using small incisions, such as laparoscopic or robotic, lead to faster recovery and less complications.

Larger or recurrent hernias can be very complex and require a hernia specialist to obtain the best results. The hernia specialist will have more knowledge, tools, techniques and skills to tailor the best operation to your situation.

RECOVERY AFTER HERNIA REPAIR

Most patients undergoing hernia repair for the first time can safely and comfortably go home the same day. Patients who need an abdominal wall reconstruction for large hernias or have advanced medical conditions will remain in the hospital.

The rate of recovery is dependent on many factors.  The type of surgery, pre-existing pain, cultural expectations, personal pain threshold and complexity of surgery all play a role in the pace of recovery. At The PATCH Institute, we focus on these factors as it applies to you, and develop a multi-pronged Enhanced Recovery and Comfort (ERC) Program to help you recover as quickly as possible. Our ERC Program focuses on the 3 stages of surgery: pre-operative, operative and post-operative.

Pre-Operative Pain Management

Studies have shown that medications and nerve/field blocks can blunt the pain signals transmitted to the brain. This is called pre-emptive analgesia. By blunting the pain signal transmission, patients usually experience less pain during and after surgery. With our ERC Program, we can utilize several medications including (oral or IV) acetaminophen, Cox-2 inhibitors (e.g. Celebrex), gabapentinoid (e.g. Lyrica) and/or opioid-receptor agonists (e.g. Tramadol). 

Operative Pain Management

One of the best ways to improve the speed of recovery is to perform surgery through small incisions using laparoscopy or advanced robotic surgical systems. As part of our ERC Program, we usually perform nerve or field blocks prior to incision or early in the surgery to blunt the pain signals.  Our anesthesiologists are trained in performing advanced nerve and field blocks such as TAP (transversus abdominis plane), Quadratus Lumborum, or Rectus Sheath blocks.

Post-Operative Pain Management

Most patients are concerned about experiencing too much pain after surgery. We will ensure that you are comfortable after surgery, but it is important to remember that pain is a way for the body to guide you. Pain will tell you when you need to rest or take it easy. Pain will tell you when you’ve overexerted yourself after surgery. Pain will tell you when you are potentially harming the repair. We do not want to completely eliminate pain. Also, to completely eliminate pain after surgery would require narcotics that can lead to severe constipation, dizziness and nausea. Constipation after hernia surgery is usually worse than the incisional pain itself.

The most important thing to do after surgery is to rest. After most hernia surgeries you will need 2-3 full days of rest. When you get home after surgery, plan to sleep a lot or rest on the couch. Over the next 2 days read a good book or watch some good movies/shows. You will be able to walk around the house or in the yard but focus on relaxing and resting. Many patients find herbal teas to be very soothing and relaxing also. Icing the incisions during the first 2 days is also recommended.

For the first 2 days, we recommend alternating Ibuprofen and Tylenol. When you get home start by taking Ibuprofen. Then 3 hours later take Tylenol. Continue taking each medication every 6 hours. This way every 3 hours you’re are taking a pain reliever. With this regimen narcotic pain pills are not necessary.

BELOW IS THE EXPECTED RECOVERY FOR EACH TYPE OF SURGERY


LAPAROSCOPIC OR ROBOTIC INGUINAL, UMBILICAL, & SMALL VENTRAL

COMFORT

Almost all patients are discharged home the same day. Ibuprofen and Tylenol work well together. Placing an ice pack over the incision during the first 48 – 72 hours also help. Remember, the goal is not to have zero pain, but to be comfortable at rest and with movement. Focusing on resting is very important.

Constipation is very common after surgery. You should have a bowel movement by the 3rd day after surgery. Take stool softeners and drink lots of fluids after surgery. If necessary, take an over the counter laxative such as milk of magnesia or use a fleet enema.

SHOWERING

If your incisions are dry, you may shower 48 hours after surgery. If your incisions are seeping or if you have a drain, ask your surgeon.

ACTIVITIES & RESTRICTIONS

You will be able to walk and use the stairs right away. Do not perform chores or drive for at least 1 week. Most patients can return to normal activities, including non-strenuous work, about 1 week after surgery.  If you perform strenuous work or activities, your surgeon may restrict those activities for up to 6 weeks.

OPEN INGUINAL, UMBILICAL, & SMALL VENTRAL HERNIA REPAIRS

COMFORT

Almost all patients are discharged home the same day. Ibuprofen and Tylenol work well together. Placing an ice pack over the incision during the first 48 – 72 hours also help. Remember, the goal is not to have zero pain, but to be comfortable at rest and with movement. Narcotics may be needed for the first few days. Focusing on resting is very important.

Constipation is very common after surgery. You should have a bowel movement by the 3rd day after surgery. Take stool softeners and drink lots of fluids after surgery. If necessary, take an over the counter laxative such as milk of magnesia or use a fleet enema.

SHOWERING

If your incisions are dry, you may shower 48 hours after surgery. Dressings should be removed before showering.  If your incisions are seeping or if you have a drain, ask your surgeon.

ACTIVITIES

You will be able to walk and use the stairs right away. Do not perform chores or drive for at least 1 week. Most patients can return to normal activities, including non-strenuous work, about 2-3 weeks after surgery.  If you perform strenuous work or activities, your surgeon will likely restrict those activities for 4-6 weeks.

LAPAROSCOPIC, ROBOTIC OR OPEN INCISIONAL HERNIA REPAIR

It is more difficult to describe an expected recovery pathway for this group of surgeries since incisional hernias can range in size from as small as a pea to larger than a watermelon.  Your surgeon will give you more details before and after surgery.


DIAPHRAGMATIC (HIATAL, PARAESOPHAGEAL) HERNIA REPAIR

Nausea and difficulty swallowing can occur after these repairs. Therefore, most patients are observed in the hospital overnight. An UGI – an x-ray where you swallow contrast dye – may be performed the following morning before you are discharged to examine the condition of the esophagus, tightness of the wrap and to rule out any leaks.

COMFORT

You will be given liquid pain medication or medications that come in very small pills. Because there will be swelling in your esophagus and the wrap, larger pills may have trouble passing the first week or two after surgery.

Retching and vomiting can cause serious problems after surgery. It may cause the wrap to slip or the repair to fall apart. You will be prescribed anti-nausea medications after surgery.

Liquid Ibuprofen and Tylenol work well together.  Icing the incisions during the first 48 – 72 hours will help.  Remember, the goal is not to have zero pain, but to be comfortable at rest and with movement. Focusing on resting is very important.

Shoulder pain is very common after diaphragm surgery. Frequent gentle shoulder/back massages and/or warm compresses help. Narcotic pain medications do not help for the shoulder pain.

SHOWERING

If your incisions are dry, you may shower 48 hours after surgery. If your incisions are seeping or if you have a drain, ask your surgeon.

ACTIVITIES & RESTRICTIONS

Continue walking often. Do not perform chores or drive for at least 1 week. Most patients can return to normal activities, including non-strenuous work, about 3-4 week after surgery.  The diaphragm is a very strong sheet of muscle and is used in strenuous work, vigorous exercise, coughing and sneezing. Since the repair involves suturing the diaphragm, any strenuous activity can damage the repair. Your surgeon will likely recommend avoiding heavy labor and sporting activities for several months.

DIET

As mentioned above, post-operative swelling can make swallowing large items difficult and potentially dangerous. Most patients will be required to start on a liquid diet for a week or two. If there are no swallowing problems, the diet is then gradually progressed from soft to regular food. Large chunks of meat, bread and rice can easily get stuck in the esophagus. 

The success of hernia surgery is frequently determined by how you prepare for surgery and what condition your body is in before surgery.  Many complications after surgery can be prevented by modifying risks factors before surgery.

Rehabilitation before surgery

The medical term "prehabilitation" comes from combining "pre" and "rehabilitation."  "Rehabilitation" is what we do after surgery to speed up recovery.  "Prehabilitation" is what we do before surgery to speed up recovery.

Great News!

Preparation before surgery can ensure success like giving an important presentation or running a race. Many complications after surgery can be prevented by you.  Taking an active role in your own care is very important for a fast and smooth recovery.

My Commitment

We don't just offer hernia surgery.  We are serious about prehabilitation.  We will work closely with your family doctor and the preop anesthesia clinic to improve your medical condition and overall health before surgery.

Smoking

Cigarette smoking and nicotine use in any form will reduce your ability to heal, and increases your risk of complications such as infections, wound separation, heart attacks, pneumonia and stroke. You should stop smoking at least 4 weeks before surgery.

Weight

Obesity increases complications. We measure obesity by the BMI (body mass index). A BMI of 30kg/m2 or less is ideal for hernia surgery. A BMI over 35kg/m2 is associated with more complications. If obesity makes surgery too risky to proceed, we will ask you to work with your medical doctor or dietitian to lose weight.  In some circumstances, we can offer weight loss surgery before hernia surgery.

DIABETES

Poorly controlled diabetes is a major reason patients have complications with surgery. If your HgA1C is above 7.5%, surgery should be postponed.

NUTRITION

Eating a healthy balanced diet is good for your overall health, but it also helps your body heal faster after surgery.  Increase fresh fruits and vegetables, and reduce processed foods and sugary drinks.

OVERALL HEALTH

Major hernia repair surgery is like running a marathon. The success of surgery frequently depends on your physical and mental condition going into surgery. Regular exercise and learning stress-reduction techniques before surgery will reduce your risks of complications.

The PATCH Institute offers all options

The general scientific knowledge of hernias has grown exponentially in the last few years. Advancements in technology have also greatly increased our surgery options. The surgeons at The PATCH Institute are experts in utilizing the latest knowledge, techniques and technology to repair your hernia with the smallest scars, quickest recovery and lowest complication rate. During the consultation, your general surgeon will determine the best surgery option for you.

OPEN SURGERY

This is the traditional approach with a larger incision at the hernia bulge. This type of surgery is still preferred when the hernia is either very small or very complex. For example, many inguinal and umbilical hernias are many times best performed open. Open surgery is sometimes better in complex hernia repair when there is mesh to be removed, when intestine needs to be resected or when there is a lot of skin/fat that needs to be removed.

LAPAROSCOPIC SURGERY

A form of minimally invasive surgery introduced in the 1980’s. Laparoscopic surgery uses small incisions away from the hernia bulge.  It frequently leads to less complications than open surgery. Today, it is used for hernia repairs that don’t require advanced robotic surgical systems.  It has several limitations:  the surgeon uses straight instruments that may limit the precision of surgery, it is difficult to place mesh outside the abdominal cavity, more surgeon fatigue due to poor ergonomics, and it requires sometimes painful fixation tacks and sutures.

ROBOTIC-ASSISTED SURGERY

A form of minimally invasive surgery through small incisions. It utilizes advanced robotic surgical systems such as the daVinci robot. The robot is not autonomous. It is simply a more advanced surgical tool and is FULLY controlled by the surgeon. The robotic platform offers the surgeon fully wristed instruments and a 3D high-definition camera with 10x magnification. As a result, the repair can be done with more precision, and complex hernias can be fixed with small incisions. Furthermore, the robot doesn’t get tired and the surgeon sits during surgery, so there is less surgeon fatigue. For the patient, this translates into quicker recovery, less pain and less complications. This is the preferred approach for medium to large hernias and many inguinal hernias as it combines the best of open and laparoscopic surgeries. Also, the surgeon is more likely to be able to sandwich the mesh between layers of the abdominal wall to keep the mesh from coming into contact with the intestines.

HYBRID SURGERY

Sometimes the best option is to combine multiple techniques. We call this a hybrid technique because we may perform part of the operation robotically and another part open.  Hybrid surgery is frequently performed for complex or unusual hernias, and ones that require skin or soft tissue removal.  

Experience Matters

Regardless of the option that is right for you, the surgeon's experience is probably what matters most.  Using the latest robotic technology does not guarantee great results.  Frequently surgeons will promise a laparoscopic or robotic approach but have a high conversion rate to open surgery.  At The PATCH Institute we are experts at minimally invasive hernia repair, and have an extremely low conversion rate.

What is mesh?

Mesh is a sheet of material designed to reinforce a hernia repair. It can be called a "screen" or "patch" also.

Material

Mesh can be divided into synthetic or biologic, and permanent or absorbable.  Biologic mesh can be made from human, pig, sheep or cow tissue.  The newest meshes are made with a combination of synthetic and biologic material.

Safety

Mesh is safe when implanted properly. It has been around for almost half a century and has been implanted in millions of people without problems.

Choice of mesh

There are many factors that determine which mesh your hernia surgeon will use. Most hernia repairs utilize permanent synthetic meshes that are made with either polyester or polypropylene.

Surgery without mesh?

You developed a hernia because of weakened tissue. Just sewing the weakened tissue with sutures is usually not enough to prevent a future hernia, so mesh is needed to reinforce the repair.

Dissolving mesh

Dissolving mesh can be derived from biologic or synthetic sources.  There is no benefit in using these meshes in most situation.  A hernia specialist at the PATCH Institute will be able to guide you with the choices.

What is the evidence regarding mesh and chronic pain?

The best available evidence shows that using mesh for hernia repairs does not lead to increased chronic pain. However, using mesh decreases recurrences significantly compared to not using mesh. Below are 2 good quality studies in the surgical literature:

van Veen RN, Wijsmuller AR, et al. Randomized clinical trial of mesh versus non-mesh primary inguinal hernia repair: Long-term chronic pain at 10 years. Surgery, Volume 142, Issue 5, 695 – 698.

In this study 300 patients were randomized to open repair with mesh and open repair without mesh. This is the gold standard method of performing a comparison study in surgery. After the surgery, the patients were followed for a median of over 10 years. The patients whose repair did not utilize mesh had a 17% recurrence rate (i.e. 17% failed over 10 years). Patients whose repair utilized mesh had a 1% recurrence rate. The authors also found “that mesh repair of inguinal hernia is equal to non-mesh repair with respect to long-term persistent pain and discomfort interfering with daily activity.” In other words, patients who had mesh did not have more pain or discomfort than patients who didn’t have mesh repair. 

Scott N, Go PM, et al. Open Mesh versus non-Mesh for groin hernia repair. Cochrane Database of Systematic Reviews 2001, Issue 3.

This study is from Cochrane. It is a non-profit, non-government organization formed to organize medical research findings to facilitate evidence-based choices about health interventions faced by health professionals, patients, and policy makers. Cochrane includes 53 review groups that are based at research institutions worldwide. 

This review by Cochrane examines the evidence from studies comparing different types of open surgery for people with groin hernia. They included only randomized studies comparing methods using synthetic mesh versus methods without mesh. There were 20 studies comparing mesh with non-mesh repair analyzed in this study.

Based on their analysis, there was strong evidence that fewer hernias recur after mesh repair than following non-mesh repair. There was a suggestion that people had less persisting pain after mesh repair, but results were only available for nine out of 20 trials. Open mesh methods were shorter to perform than Shouldice procedures (an open non-mesh repair) but took longer than other types of non-mesh repair. They found no clear differences between mesh and non-mesh methods for operative complications and persisting numbness. Overall, people spent less time in hospital and returned to their usual activities quicker after mesh repair.

The leading minimally-invasive general and hernia repair surgeon on the West Coast, serving patients in the greater SF Bay Area. 

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