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Hernias are often thought to occur in older patients – people in their fifties, sixties, seventies, and that’s true. There are patients that develop these over time. However, it’s also quite common to see hernias occur in infants – even newborns. When we see these, we are not alarmed. We just take care of them, operate and fix them, and patients recover fine.
People often ask me if heavy lifting can cause a hernia. I would say that in general, patients usually already have the beginnings of a hernia or a weakness in their abdominal wall and when they lift something heavy, that increases the pressure inside their abdominal cavity enough to cause either some intestine or some fat to bulge out of that hole or that weakness and develop a hernia. But it’s not so much the heavy lifting that causes a hernia. It’s just that the heavy lifting allowed you to manifest the hernia which was already there.
Hernias come in all different shapes and sizes. Small hernias that don’t have anything bulging out are generally fairly safe and don’t carry much risk. However, as hernias become larger and you find that contents are bulging out (especially if it’s your intestine) then they can become quite dangerous and even life threatening. So there’s sort of a wide spectrum of what you can find with hernias.
Patients often ask me if they need to have surgery to repair their hernia. Generally my answer is that at some point you will need surgery to fix your hernia. Hernias don’t get better on their own. They generally just get larger over time. So a small hernia may take a long time to develop into a larger symptomatic hernia, but usually at some point a person will need a repair to fix that hernia to prevent further complications from occurring, like developing an incarceration.
It’s important for a patient to have their hernia repaired at some point because hernias can either cause an incarceration (where a piece of intestine gets stuck inside of the hernia) or their hernia continues to get larger and larger and larger, and you can have large amounts of your intestine come out of the hernia and cause a very disturbing visual defect.
In order to have a hernia operation, the patient has to be in relatively good health. Anyone who has a severe illness may want to consult with their physician and consider whether or not they should actually have surgery, as surgery may actually be more dangerous than the hernia itself.
In preparation for hernia surgery, patients are generally asked to not eat or drink anything after midnight the day before the operation. On the day of the operation, the patient arrives and the operation itself typically takes about an hour for the average hernia. After surgery, patients will usually spend about two hours in the recovery room prior to going home. It’s important to note that most of these operations are done as an outpatient basis where the person will usually go home the same day of surgery. In terms of pain after surgery, patients usually have pain for about 2-3 days where they may be taking pain medication. By about one week after surgery, most patients feel pretty good and are able to be up and around and even go back to work.
Laparoscopic surgery means that rather than making a large incision (which we used to in the old days), we make these small incisions – usually three incisions – and insert a video camera and we perform an operation using very small instruments through these small incisions. Robotic surgery is a variation of that where we still make the small incisions, but rather than my hands holding these instruments, we have large robotic arms that are holding these instruments. I sit at a console that’s about 10 feet away from the patient and look through a 3D high-definition viewfinder. I move my hands in virtual space and that controls the robotic arms and allows me to perform the operation without actually standing next to the patient. People often ask why we would do that and it’s because the robotic instruments have not only a great deal of dexterity and finesse, but they also have what we call wristed instruments. Meaning that the instruments themselves, rather than just opening and closing, they have wrists on them like your hands and when you can swing them around and rotate and move around, that allows you to do some really fine motion and it makes operating that much easier.
Minimally invasive surgery (which includes either laparoscopic or robotic surgery) has several advantages over doing what we call an open operation. So if we are specifically talking about hernia surgery, even today in 2017 the vast majority of people when they have an inguinal hernia repair, for instance, that’s a hernia that is located in your groin – most people have the traditional open operation where you have an incision made over the area where your hernia is and a piece of mesh is placed in there to sort of bolster the abdominal wall and create the hernia repair. What we do is perform the same type of operation, but rather than doing it from the outside, we are performing it from the inside. So we use these small fine instruments and we go inside of the abdominal cavity and repair the hernia from the inside. We place a large piece of mesh on the inside to cover the hole. A hernia really is just any hole that is in a wall that is supposed to be holding contents in. The analogy for this repair is having a flat tire. The cheap way to fix a flat tire is to plug it from the outside, but the better way to fix a flat tire is to actually remove the tire and place a large patch on the inside to cover the hole. That is exactly what we are doing when we perform the laparoscopic or robotic hernia repair. Now this repair is better in that it results in smaller incisions. Therefore, you have smaller scars, you have less pain, quicker recovery time. It turns out that the complication rates are actually lower when you use this technique, as well. When it comes to how durable the repair is, doing it laparoscopically or robotically is equally as effective as doing it through the standard open technique.
The complications that can occur with hernia surgery are: some of the generic ones which are bleeding and infection, injury to other organs or complications from general anesthesia. Specifically with hernia surgery, the main complication that we worry about is a recurrence of the hernia or the hernia coming back. Fortunately the recurrence rate is very low – it’s about 1%.
It’s important to know that hernias can’t really be prevented from occurring. If it’s something that you are born with (as in the congenital types of hernias) then it will develop regardless of what you do. I would say that in general, there really isn’t a way to prevent you from forming a hernia.
At the Hernia Institute of Beverly Hills, we focus on performing the latest techniques in hernia repair by utilizing robotic and laparoscopic technology. At the Hernia Institute of Beverly Hills, one of the main advantages we have over other centers is that we actually have our own da Vinci robot. The da Vinci robot is the universal platform that is used around the country and around the world for robotic surgery. Traditionally, this robot can only be found in large hospitals as the equipment itself is quite expensive. At the time that our center purchased this robot, we were only the second outpatient surgery center in the entire country to have their own da Vinci robot. What that did is it allowed us to move many of the operations that would require you to go to the hospital to have done and allow you to have those done in an outpatient setting where you can come in, have surgery in a nice, clean, uncrowded environment, and then go home after surgery rather than having to stay in the hospital.
A common question that I get from people is: What is a hernia? A hernia really is just a hole that is in any wall that is supposed to be holding something in. You can have a hernia that occurs in your chest, in your head, in your abdominal cavity – sort of anywhere where you have a cavity. Specifically, when we’re talking about the abdominal cavity, there are multiple places where you can develop a hernia. The most common places that you would see a hernia would be in the groin region, either on the right side or the left side or also in the belly button region or the umbilicus. Those are common areas because they are areas where people are actually born with these hernias. They are congenital defects. So if you think about it in terms of your belly button, we are born with an umbilical cord that travels through our abdominal wall and therefore we’re naturally born with an umbilical hernia. Now, after you are born and the umbilical cord is cut, that hernia should close up and seal up so that you don’t actually have a hernia later on in childhood or adulthood. In the groin, we have the same situation where during our development as a fetus, there are structures that pass through the abdominal wall in the groin and as they do that, they leave holes in the abdominal wall. These holes are supposed to close up as we continue to form as a fetus. Occasionally, they don’t completely close and as a result, patients end up developing hernias that they see either in their childhood or later on in adulthood. Hernias can also occur at other locations of the abdominal wall where you may develop a weakness. Another common site for a hernia is from a prior incision. So in patients that have had either open or laparoscopic surgery, they could have had a large incision, they could have a really small incision – but those incisions (because they are slightly weaker than other parts of the abdominal wall) can actually open up and become hernias themselves.
There are all different types of abdominal wall hernias. These can include things like inguinal hernias (which are hernias located in your groin), ventral hernias (which are hernias that occur anywhere around your abdominal cavity), umbilical Hernias (which are hernias in your belly button), there are incisional hernias (which are hernias that develop from a previous incision). When you look at all of those, they’re all generally the same in that they are defects or holes in the abdominal wall, and the hole is allowing something to bulge out and either cause pain or to cause a visible bulge. There is a different type of hernia called a hiatal hernia, which is a completely different entity from the other hernias that I’ve mentioned. This involves the stomach and the esophagus and heartburn and reflux and has nothing to do with the typical hernias that we talk about when we think about a bulge from our abdominal wall. The most common symptoms of a hernia (regardless of the location) are usually pain or discomfort or a bulge that is visible.
Hernias are typically discovered either by the patient who notices a bulge (generally while they’re taking a shower and they don’t have any clothes on) or they go in to see their doctor who performs an annual exam and says, “Hey, by the way, did you know that you have a hernia?” They are usually visible and usually what you see as a bulge. Occasionally hernias can be smaller and they don’t have a bulge, but they do cause pain. Under further examination – either with an ultrasound or an MRI – we can tell that a patient has a hernia.
Hernias are quite common but are definitely more common in men than in women. In men, about 20-25% of men will develop a hernia during their lifetime. For women, it’s about 9-10%. Specifically we’re talking about groin hernias or inguinal hernias, as those are the most common types that we treat. Nationwide, as a country we perform somewhere around 800,000-900,000 hernia repairs a year.
A ventral hernia is any hernia that occurs in the abdominal wall, which we call the ventral side of a person. A femoral hernia is a variation of the inguinal or the groin hernia. It occurs right next to the blood vessels that are exiting your abdominal cavity and going into your legs. This would be the femoral artery and vein, and you can develop a bulge right next to it. It’s something that we don’t see very commonly in men, but we see it more commonly in women.
An inguinal hernia is a hernia that occurs in the groin region that can either be on the right side or the left side and is the most common type of hernia that we see.
An incarcerated hernia is a hernia that has allowed the contents within the abdominal cavity to bulge out and actually get stuck in that hole. That can either contain fat or it can contain your intestine. When that occurs, it’s a quite concerning condition and generally requires immediate surgery to fix. The one thing that we worry about the most with hernias is for the patient to develop an incarceration. By that I mean having their intestine come out through the hole and becoming stuck in that hole and becoming incarcerated. What that does is that it tends to kink off the intestines so that nothing can flow in and out. Worse than that is that the blood flow to the small intestine can also be compromised and if it’s not treated within the first 4-6 hours of first becoming noticed, that piece of intestine can actually die and results in much more serious complications.
Although less common, inguinal hernias can occur in infants or young children. It is treated in the same fashion as in adults in that it requires an operation to repair, although typically we don’t use mesh in the adolescent population. If your child does develop a hernia or is born with a hernia, it’s not anything that you should be alarmed about. It can be treated easily and after the child recovers, they should have no other consequences from that.
A hiatal hernia is quite different from all of the other abdominal wall hernias in that it involves a loose area or a weakness of the diaphragm, which allows the stomach to actually bulge up into the chest. So that’s a completely different entity from all of the other abdominal wall hernias that we typically think about.
An epigastric hernia is another type of ventral hernia and is just specifying the location of the hernia. The epigastric region is in the upper abdomen, so any hernia that occurs in the upper abdomen is something that we would call an epigastric hernia.
Sports hernias are an interesting finding. There isn’t actually a great definition for a sports hernia but generally speaking, when an athlete develops pain (and the classic example is a hockey player who strains their leg or their groin – they develop pain, a sharp pain that occurs in their groin) and when you run all these tests, you often can’t find anything that’s wrong. You can’t feel a hernia. When you do an MRI or an ultrasound, you don’t see a hernia. But in fact, they continue to have pain. Oftentimes what you find is that the insertion of the muscle that is onto the bone has become torn and that’s what’s causing the pain. That is often what we consider a sports hernia, which is different from a traditional hernia.
An umbilical hernia is a weakness that develops in the middle of the belly button (which we call the umbilicus) and typically what you see as a bulge coming out from the belly button. People often like to call this an “outie”, but an outie really is an umbilical hernia.
When you talk about hernias, there are various classes of hernias aside from where they might be located. Hernias can either be congenital (meaning that you were born with it), they can be acquired (meaning that you developed it possibly because of strenuous activity, maybe you were lifting weights or lifting something heavy), or they can be a result of a previous incision. With those three hernias, it really doesn’t matter which type it is because the repairs are generally all the same in terms of how we fix these hernias. Many of the hernias are either fixed primarily – which means we just close it with sutures and that’s what we do for small hernias. For larger hernias, we try to close up that hole but in addition, we reinforce that repair with a piece of mesh, which is generally a piece of woven plastic, which we call polypropylene.
If a patient is at home and they start to notice some discomfort either in the belly button or in the groin region or anywhere else on the abdominal wall, they might want to think about seeing their doctor to be examined to see if they have a hernia. Now, if that person is at home and they happen to notice a bulge that comes and goes, then they definitely need to come in to see a hernia surgeon and may actually need to have that repaired relatively soon. It’s important to note that in general, hernias should not be ignored. If you have any suspicion that you might have a hernia – whether it’s discomfort or bulge – it’s important for that patient to go in to see their doctor to be examined and make sure that they don’t have a hernia, or if they do have a hernia, to go on to see a surgeon and have that repaired.
One of the main risk factors for developing hernias is obesity. Patients that are heavier (and especially those that are quite heavy) have so much more pressure on their abdominal wall that they have a higher likelihood of developing hernias.
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