Ask Us Anything About…Hernias

Scott Gilbert – From Penn State Health this is Ask Us Anything About Hernias. I’m Scott Gilbert. Hernias are often painful and as much as we’d wish they just go away, that’s not how it works. In some cases hernias left unchecked can lead to extreme complications, and even be life threatening. The good news though is that hernias can be repaired with surgery. Today, we’re going to talk about the symptoms, causes, and different types of hernias, and those treatments available with Dr. Eric Pauli. He’s chief of the Division of Minimally Invasive and Bariatric Surgery at the Milton S. Hershey Medical Center. Dr. Pauli, I appreciate you being here today. Let’s start with some of the basics. Basically, what is a hernia, right? It’s defined as a bulging of an organ or tissue through an abnormal opening. But, you know, where does that typically happen? What organs and tissues are we talking about here?

Dr. Eric Pauli – Yes, Scott, happy to be here. I’m glad you’re hosting. You know, hernias, as I described to patients are really just a hole in the some part of the abdominal wall. All right. And those holes can be things that people are born with. So, some people have holes that just never close over the course of time or that open up. These are natural areas of weakness, like, the belly button or the umbilicus, what we call an umbilical hernia. Or, more commonly is actually growing hernias or inguinal hernias. That’s an area where there’s a natural opening in the abdominal wall, and over the course of time that area becomes a little bit more weakened, can open up. Sometimes hernias are the result of a previous surgery. If we cut or divide tissue on the abdominal muscles themselves, sometimes those holes don’t close up, and that may have to do with the size of the opening that was cut, whether somebody had an infection after the operation, or if they have specific risk factors for developing a hernia, like, smoking or obesity as a medical diagnosis. So, hernias come in all shapes and sizes, but the end result is a gap in the abdominal wall muscles, essentially, and protrusion of something from the inside and that could be the intestine. It could be some intraabdominal fat. Sometimes it’s things, like, the kidneys, the liver, the urinary bladder. So, I’ve seen hernias with all sorts of stuff in them. Fortunately, as you said, you know, not all of them are life threatening, but sometimes they can be.

Scott Gilbert – New images to show us a little bit about the different kinds of hernias. Can you walk through those for us?

Dr. Eric Pauli – Yeah, absolutely. So why don’t we look at an inguinal hernia first. So, the images we’re going to show you here, this is a CT scan of a patient who has a groin hernia, and there’s a big arrow there pointing to the side, which is abnormal. When we look at a CT scan, we’re looking from the feet up to the head, and, so, this is the patient’s right-hand side. And what we’re seeing in this particular case is a circular or an oval type bulge, and the content of that is actually this patient’s small and large intestine. So, we’re seeing some portions of the bowel inside this very large inguinal hernia. This is a very common location for a hernia, especially in men. The right side of the groin is the more common spot to get one than the left. And in this particular case, this was a very large hernia that went all the way down almost to the patient’s knee. So, it’s a pretty extreme example of how big these hernias can get. The second picture we’re going to show you is what’s called a ventral hernia. Now, this hernia here in particular is in between the rectus muscles or the six pack muscles. So, the arrow is the bulge, the arrows there, that’s a big bulge that, again, contains a lot of the patient’s small and large intestine. And, so, this patient complains that they see this very big bulge, so that’s what they’re experiencing as a hernia. When I think about a hernia as the hernia surgeon, what I’m looking at is actually the gap between the six pack muscles, and so the line you see across the screen there that goes from the right side to the left side, that’s essentially the hole that is in between the six pack muscles that represents the gap that I have to close when I’m fixing this patient’s hernia. So, this is, again, this is a very large hernia that required a complex operation to repair. Hernias come, as I said, in all shapes and sizes from very, very small, you know, little poke hole sized hernias to things like the one you see here, which is almost eight inches wide.

Scott Gilbert – And, so, that’s what the hernias look like from the inside. But also sometimes hernias are visible from the outside too, aren’t they?

Dr. Eric Pauli – Yeah. Many patients will complain about what they experienced as a bulge. They’ll see some asymmetry. The bulge sometimes moves when people cough or sneeze, they may feel or see the bulbs get bigger, and they may also experience pain over that area. And that bulge that they’re seeing and the pain that they’re feeling is essentially content from the inside of the abdomen, pushing its way out when they are coughing or sneezing because those things increase the pressure inside the abdominal cavity a lot, and force additional things out into the hernia.

Scott Gilbert – You’re watching Ask Us Anything About Hernias from Penn State Health. I’m Scott Gilbert alongside Dr. Eric Pauli, from the Milton S. Hershey Medical Center. We welcome your questions for him. Just add them to the comment field on this Facebook post and we’ll make sure we get to them either live or if you ask a question on play while you’re watching this on playback, we can certainly get you an answer in the comments as well. Men versus women, how do hernias differ by gender?

Dr. Eric Pauli – Yeah. So, men and women can get the same types of hernias. There are some differences, though, in particular in women when we think about groin hernias. Groin hernias in women oftentimes present in a more subtle fashion. Oftentimes women will complain of pain or discomfort and exam or imaging has a challenge to find those types of hernias. There are people who refer to those as a hidden hernia, because they’re oftentimes very subtle. We can’t feel them. We can’t see them, but the small amounts of fat that go out in women’s groin hernias sometimes cause a lot more pain and discomfort. Women are also more prone to get femoral hernias. Now, there are three hernias that happen in the groin region, and we call them all inguinal hernias, but they are slightly different in their nature. A femoral hernia is one of those three types of hernias. And this is where fat content or bowel goes along the iliac and femoral blood vessels down into the leg, essentially. They present with pain and discomfort. They’re a little more challenging to fix, and they do affect women more commonly than men. The other hernias, though, like, umbilical hernias, hernias from incisions are pretty much equal in their rate of occurrence between men and women.

Scott Gilbert – When it comes to symptoms of hernias, we talked about some of the more obvious symptoms such as a visible bulge on the outside, but what are some of the other ones that may be more subtle, perhaps even mistaken for other medical conditions?

Dr. Eric Pauli – Yeah. You know, pain is a very common presenting complaint, and, you know, I use the term pain, but many people describe it as a vague discomfort. Many people with inguinal hernias will tell you that after the end of a long day, when they have been standing for a while, they just feel a sense of discomfort in the groin that they’re hard pressed to call it an actual pain. Now there are some specific nerves in the groin region that can get compressed and can cause very specific types of actual pain that run along those nerves. Urinary symptoms can happen with some hernias, especially if the urinary bladder is involved in those. If there is intestine in a hernia, some people will complain of nausea or abdominal discomfort after meals or changes in their bowel habits where they feel pain after meals, and it’s quite a while until that discomfort goes away. And that happens because if they have a hernia here in the abdominal wall and the bowel kind of gets up there and gets bent as intestinal content and food is trying to travel through that area, it just has a challenging time making its way through. So those are common presenting symptoms as well. Urgent or emergent emergency situations include a hernia where the bowel is stuck in it. And that can result in a bowel blockage or a bowel obstruction which presents as nausea and vomiting and failure to have bowel movements, and that that generally requires a trip to the emergency room to manage. Sometimes we can physically push the intestine back in and prevent the need for an emergency surgery. But sometimes we can’t, and we do have to take the patient as an emergency to the operating room, push the intestine back in and make sure that the blood supply is still alive, and then fix the hernia before we leave.

Scott Gilbert – So why is that such an urgent situation, you know, with regard to a possible blockage? You know, why does that pose a possibly even life-threatening situation?

Dr. Eric Pauli – Yeah, it’s mostly because the blood supply to the whatever is stuck in the hernia can get cut off. As intestine gets stuck in the hernia, as maybe a little bit of additional food gets down there and it gets swollen, the amount of stuff in the hernia kind of starts to swell and that cuts off the blood supply. And, so, that section of whatever is there, it could be a section of fat or a section of intestine has the blood supply cut off and that it dies essentially. And, so, if a portion of your intestine has died, it can rupture or perforate and leak intestinal content and bacteria into the abdominal cavity. And, so, those are truly, you know, emergency situations. Our goal in the hernia clinic is obviously as in addition to alleviating pain, fixing hernia symptoms is to get to people before that is the scenario and fix them successfully. Again, fortunately, those are uncommon. All things considered, complications of hernias, but they definitely happen because hernias are so common, so common. We see that very regularly in the emergency department.

Scott Gilbert – So as we mentioned, we welcome your questions for Dr. Eric Pauli in the comments section below this Facebook post. And we have a question now from Nancy. She’s asking if colostomy wearers need to be extra careful with regard to hernias? And perhaps you could start by describing briefly what a colostomy is.

Dr. Eric Pauli – Yeah. This is a very good question. So, a colostomy is a hole in the abdominal wall that’s intentionally made, and then we deliver the patient’s colon out through this area. We sew the colon to the skin and then the person wears a bag or what we call an appliance to collect stool. A colostomy is a basically for the colon. We can also make a stoma out of the small intestine, what we call an ileostomy. Some people have had their urinary bladder removed, and so we recreate a bladder with small intestine. We call that a urostomy. These are all holes in the abdominal wall that are surgically made and a portion of the intestine is delivered through. So people who have ostomies have a much higher chance of getting a hernia. And the reason is that because there needs to be a hole in the abdominal wall for the intestine to pass through, over the course of time that hole can open up. It’s a natural area of weakness and when the hole expands, additional bowel can sneak up through alongside of the intestine that we want to be there. It’s estimated that between 50 and 80% of people who have an ostomy of any type will at some point develop a hernia. Some of them have symptoms and some of them don’t. The problem is not that people get them. We know that they happen, but that they’re challenging to repair, because most hernias that we fix, we try to close the hole all the way. But if you need an ostomy, because of previous surgeries, if you must have one for the rest of your life, we cannot close that hole all the way. Additionally, configuring the closure of the abdominal wall muscles, putting in mesh to repair hernias, which we oftentimes do, needs to take into consideration that the mesh in the bowel are going to be directly next to each other, and that there’s, you know, these ostomies essentially attach to the intestinal tract, so when we’re operating on people there is a hole that leads directly into the intestine on the operative field, and so there’s bacteria around. What I tell people is, you know, you can be as extra careful as you want to be, and you may still develop a hernia. You know, on some level these things are dumb luck. All right. Not everybody gets one, but many people do. I think what’s more important than being careful is to just be mindful of what the symptoms of a hernia are, to report them to your family doctor or whatever doctor sees you and manages you for your stoma. And then, you know, to meet a hernia surgeon if there is a hernia there to talk about, should I have this fixed now? Or should we think about fixing it down the road when I have more symptoms? So, timing of the repairs is a question that we oftentimes talk about.

Scott Gilbert – Great advice and a very important question. Thank you for that, Nancy. We have another question now from Taylor. She’s asking if a cramping, pulling feeling right below her ribs could be due to a hernia. She says she was told she had two small hernias after she had children. She’s got no other information about them since the hernias have been seen in a CT scan for something unrelated. She says it usually happens after she eats or if she coughs too hard. Those are, I know common times when these are felt. I feel like I have to stretch and it gets better, she says. And Taylor also adds, it seems to happen more and more as time goes on.

Dr. Eric Pauli – Yeah. So, you know, the short answer is without looking at the CT scan it’s hard to say. If someone has a CT scan, which is a special type of x-ray study that’s very useful for looking for hernias. And someone said that there’s a hernia in that location, then sure, it could be a hernia. But what I will say is locations below the ribs are very unusual locations for people to spontaneously develop hernias. They happen, but they’re very, very uncommon. However, people do get incisions put in those locations. For example, if someone had a gallbladder surgery, those are common locations where incisions might be located. So the short answer is, yeah, those symptoms could be attributed to a hernia. But they all could also be attributed to a lot of other things. And this is why hernias can be a challenge to diagnose because the symptoms overlap with a lot of other medical conditions. And, so, not every bulge is a hernia. Not every cramp is a hernia, but a good physical examination where a hernia surgeon or a surgeon in general pushes on that area and feels what it feels like when somebody’s coughing. And then a review of the CT scan is also very helpful. One of the challenges with hernias is that imaging and how radiologists look at the x-ray reports is not always 100% correct. This is true universally from country to country all around the world. How hernia surgeons and how radiologists look at the abdominal wall when we’re interpreting it for hernias is very, very different. Hernias are a very common thing to be missed on x-ray studies. And, so, sometimes I meet people who have pain and have discomfort and symptoms like Taylor just described, and they have a CT scan that says that there is no hernia. But when we look at it, and we know exactly where she has pain and we examine and we look at the scan, we can sometimes find, you know, very small hernias that are in those locations. So imaging can be helpful, but needs to be appropriately interpreted oftentimes by the hernia surgeon themselves.

Scott Gilbert – And Taylor mentioned she did have her gallbladder removed. So that —

Dr. Eric Pauli – Yeah, and so, you know, those are locations. You know, we put little poke holes kind of under the ribs, that could be a hernia related to one of those laparoscopic trocar sites from a laparoscopic gallbladder surgery. If it was an open old-fashioned surgery, which is a big long incision under the ribs, absolutely as well. So what Taylor may have there is an incisional hernia. And, again, an exam by a hernia surgeon and a review of the CT scan to look and see if there’s hernias in those areas would be sort of the next step to manage that.

Scott Gilbert – Good question here from Amanda. She’s asking how can hernia mesh affect future pregnancies and caesarean deliveries?

Dr. Eric Pauli – That’s another — these are great questions. So, hernia surgeons, I mentioned this briefly that, you know, we oftentimes use mesh to fix hernias. The reason we use mesh to fix hernias is that hernias are areas of abdominal wall weakness. And, so, me using a mesh to fix a hernia is very much like a heart surgeon putting in a new valve if a valve is worn out, or an orthopedic surgeon using a metal rod to fix a fracture, okay? These are tools that allow us to reinforce areas of the abdominal wall. Mesh is one of the most common questions that I get asked about patients. And that’s new in the past couple of years because most people have seen a television commercial that says, you know, “Did you have mesh put in during a hernia repair? Did your hernia come back? You know, call us because there is a lawsuit.” Those lawsuits are about very specific types of mesh. And, so, saying mesh is a lot like saying car. I’ve got a car, Amanda’s got a car, Scott’s got a car. We probably all have different cars, though. And, so, the fact that my car may have been recalled because the airbag was bad, does not mean that everybody’s car has been recalled. And, so, I talk with folks about the use of mesh. Now, Amanda’s specific question is, how does mesh affect future pregnancies? The short answer is hernia surgeons don’t have a lot of literature or papers on this topic. And, so, when I meet somebody who is young, who is female, and they’ve got a hernia that we’re fixing, we talk about this topic. And if they are planning on having children in the future, we try to avoid the use of permanent mesh, because we have concerns that as the abdominal wall is trying to expand with pregnancy, that that mesh may prevent expansion. The second issue is that if somebody has a hernia related to a caesarean or a C-section, and we put a piece of mesh in there to cover the area where that C-section hernia is, we know that many people if they have another child are going to need another C-section, which means that my mesh is not only in the way of that C-section, but that somebody is going to cut through the mesh to do that delivery. And now my very nice hernia repair that I spent a long time doing is essentially gone and the risk for getting a hernia is back. And, so, what I do for women who are of childbearing age is we, if they’re planning on having children, we talk about doing a non-mesh repair, or using a mesh that absorbs over the course of time. Some hernias can be repaired without the use of mesh and just suture. That’s not the best hernia operation. But we’re not just considering the hernia, we’re considering the hernia in the patient who has plans for future children. When that individual is done having children and we can talk about doing a more definitive mesh based repair, then we do something a little more complex the next time around. Great question.

Scott Gilbert – Yeah. And as you’re talking about surgery here, a very logical next question from Matt, who’s asking, what is the typical recovery like from surgery?

Dr. Eric Pauli – That question is entirely dependent on what hernia we’re talking about, and what type of hernia repair we’re doing. And it ranges from a couple days to about a month. When I fix kind of routine groin hernias and routine belly button hernias, you know, those are day operations. People come in the morning they have their operation and they go home. Those patients do not require narcotic pain medications, they can get away with Tylenol and ibuprofen alone. And, you know, many of them are done minimally invasive or with just very small incisions. And, so, people can go to work in a day or two, you know, depending on what they do for a living. For my more complex hernias, we showed that ventral hernia, which was a very large one, that patient will be in the hospital for, you know, three and a half days on average for my types of surgeries. And it’ll be about a month before they’re back to, you know, kind of regular activity without abdominal discomfort that limits what they do. So hernias range vary greatly in their configuration and size. And, so, the operations vary quite greatly as well.

Scott Gilbert – Makes good sense. I’d love to know what Matt’s dog is drinking out of that glass, by the way.

[ Laughs ]

Scott Gilbert – Maybe you could tell us in the comments. You’re watching Ask Us Anything About Hernias from Penn State Health. I’m Scott Gilbert alongside Dr. Eric Pauli from the Milton S. Hershey Medical Center. Obviously he knows his stuff on hernia, so now’s a great time to put your questions in the comment field below this Facebook post and we’ll pose those questions directly to Dr. Pauli. Steve’s question is up next. He’s asking what is the average length of surgery with someone with an ostomy?

Dr. Eric Pauli – Again, another good question, and it depends a little bit on the complexity. You know, as I said earlier, repairing hernia around an ostomy is exceptionally challenging. In 2020, surgeons still do not understand the optimal way to fix one of these hernias. We have a variety of options, which we can exercise, but there’s no one size fits all repair for these types of hernias. The number one type of repair that we like to do for these goes by a doctor’s name whose name is Sugarbaker. So, it’s called a Sugarbaker Repair. The reason that that repair is favored is that when we put the mesh in, the mesh comes down, over, and across, and that lets the bowels swing around and go up. That lets us widely cover the area where the hernia is located around the stoma without making any cuts in the mesh. The reason we don’t want to cut the mesh is that when you cut mesh and the body starts to grow into it, it contracts and it opens up the area where the hole is located. So, if you put a mesh in and you cut a hole, the hole will eventually open up, and that lets the hernia come back. And, so, Sugarbaker Repairs can be done laparoscopically. And, so, those are shorter stay operations with little poke hole incisions. They can be done also robotically. Same thing, these are minimally invasive operations. But a lot of people who have ostomies have hernias not only at the stoma site, but maybe a hernia in the middle where they had an incision that was done to give them the stoma, so they have more than one hernia. And in those cases, the repair becomes a lot more complex. These are multiple hour operations to free up all the scar tissue, fix all the hernias that are there. And then to carefully configure the mesh in the bowels so that they swing around each other successfully, to widely cover the repair. And those are patients, who as I said earlier, they’re on the longer end of the spectrum in the hospital, you know, three-and- a-half days or so, maybe four days sometimes. Then a longer recovery, you know, upwards of a month until people are fully back to regular activities. But, again, even with those operations, whether it’s minimally invasive with a Sugarbaker Repair, or whether it’s a big open operation and a Sugarbaker Repair, there’s still a chance that the hernia around the stoma can come back upwards of 14 to 20% in the long term, so still a challenging type of thing to fix.

Scott Gilbert – I like what Barbara said in the comments, and that is, “good question, Steve.” Thank you. And thanks to all the others who’ve asked questions today. You know, I think we often think of lifting heavy objects improperly is a leading cause of hernias. Can you talk about how that factors in along with even other lifestyle factors, for example, proper diet, exercise and that type of thing?

Dr. Eric Pauli – Yeah. So if you think about a hernia as an area of the abdominal wall that is weak, it’s kind of like a tire that has a little blister in it, if you’ve ever seen that before. Anything that increases the pressure inside the tire, or in this case inside the abdominal cavity, is going to make that blister kind of bulge and get bigger and bigger and bigger over the course of time. And, so, coughing. So, people who maybe have lung diseases where they cough, you know, people with COPD or smokers. People who maybe have allergies who sneeze a lot. People with obesity who carry a lot of weight inside their abdominal cavity. Or people who maybe strain for urination because they have enlarged prostate, or strain with bowel movements because of constipation. These things all increase the pressure inside the abdominal cavity, some a lot more than others. Lifting when you stabilize your abdominal muscles to lift something, can also do that. So, it is a risk factor for increasing the abdominal pressure, and if you have a hernia or have any area that is intrinsically weakened going to become a hernia, then, yes, those activities over the course of time, we think, can lead to the development of hernias. But you also have to realize that there are lots and lots of people out there who lift heavy things, and maybe they do it wrong. Okay. But they don’t develop hernias. So, there’s some genetic factors here as well. Some people have collagen or connective tissue that is just a little more prone to get hernias than others. Again, these are kind of some of the mysteries of hernias that we haven’t really figured out 100% yet. Hernias as a kind of subspecialty of surgery are new. Ten years ago, any general surgeon, any colorectal surgeon, any vascular surgeon who made a cut, and gave kind of gave you an operation, if you developed a hernia, they would be the ones fixing it. It’s really only in the last, you know, 10 years or so that we see people who have specific advanced training in hernia repair and who focused their entire surgical career on, you know, on fixing hernias, and that’s kind of my practice.

Scott Gilbert – Yeah, sure. As we begin to wrap up here, I want to address a possible misconception people may have that, no. Yeah, I see this hernia, I feel this hernia, but maybe it will go away on its own. Do people often think that mistakenly?

Dr. Eric Pauli – Yeah. A lot of people ask if they’re, you know, will it go away over the course of time? Are there exercises that I can do to help make it go away? You know, do I need to have surgery? So, first off, not every hernia requires an operation. I meet many people who have hernias who have no symptoms, it was found incidentally. And it’s okay to follow those patients, so long as, you, the patient, and the surgeon are kind of actively aware of, you know, what their symptoms are. But what I tell people is hernias don’t go away over the course of time. They can’t really heal themselves. They can remain stable over the course of time. They may slowly get worse over the course of time, and as they’re getting worse we just want to know, how is it getting worse? Are you having more pain? Is it just a little larger, or are you developing other symptoms that might be a little more worrisome, which now kind of tip the balance, right? Operating on a patient with a hernia is about risk and benefit. If you have no symptoms from a small hernia, I’m hard pressed to make you better. But if your hernia is interfering with your lifestyle, if there’s a risk for a bowel obstruction because there’s bowel in the hernia, then, yes, we impact you, and so we want to talk about fixing those hernias.

Scott Gilbert – Great. And I just want to let Nancy know that we will definitely get to her follow up question in the comments after this interview. But it is time for us to wrap up. So I want to thank you very much for your time, Dr. Pauli. Some great information here. And also thanks to all the folks who tuned in and asked questions. Like he said, a lot of really great questions that added some additional insight here into this program, which is Ask us Anything About Hernias. Dr. Eric Pauli is chief of the Division of Minimally Invasive and Bariatric Surgery at Penn State Health Melton S. Hershey Medical Center. So you can find more information about him and his division on our website at hmc.pennstatehealth.org. We’ll also put a link in the comments below this Facebook post as well. Dr. Pauli, thank you for your time and thanks to all of you for watching Ask Us Anything About Hernias from Penn State Health.