Hernias are not necessarily considered an emergent condition, but they don’t usually go away on their own. Sometimes they might need a surgical repair to prevent potentially dangerous complications.
Teviah Sachs, MD, MPH, FACS discusses treatment options available for hernias and when you might need to see a physician about your hernia.
Teviah Sachs, MD
Teviah Sachs, MD, MPH, FACS received his medical degree from New York Medical College in Valhalla, NY. He completed his residency in General Surgery at Beth Israel Deaconess Medical Center/Harvard Medical School and a Fellowship in Surgical Oncology at Johns Hopkins Hospital in Baltimore, MD. He is board certified by the American Board of Surgery in both Surgical Oncology and General Surgery.
Learn more about Teviah Sachs, MD
Melanie Cole (Host): Hernias are not necessarily considered an emergent condition, but they don’t always go away on their own. Sometimes they might need a surgical repair to prevent potentially dangerous complications. My guest today is Dr. Teviah Sachs. He’s a general surgeon and surgical oncologist at Boston Medical Center. Dr. Sachs, what is a hernia and are there different types?
Dr. Teviah Sachs, MD (Guest): Yes, there are. Thanks again for having me. The hernia is basically any defect you have in the fascial component of the abdomen or diaphragm. Most hernias we refer to are inguinal or groin hernias. But they can happen anywhere in the body and there’s an enumerate number of them. Anytime you have a defect in that thin fascial covering which is almost like a ligament or a tendon that surrounds the abdominal cavity; the abdominal contents can push through those. And whether that be intestines or fat or other organs; they can become symptomatic, painful and require surgery to repair them.
Melanie: How do people get hernias? We have all heard that if lift something too heavy or even if you are on the toilet, these kinds of things can happen. How do most people get them?
Dr. Sachs: Yeah, that’s a very good point. There are areas within the abdominal cavity where there are natural hernias. So, for men, the most natural hernia is in the inguinal region or the groin. Basically, the testicles develop inside the abdomen and then during development they descend into the scrotum. As they descend, they form a natural hole in the abdominal cavity down in the pelvis and through that hole remains a couple of structures including the blood supply to and from the testicles. And the hole is very, very small but with heavy lifting, with increase of your abdominal girth, with pregnancy, with diseases such as liver failure where your abdomen can become quite enlarged, anything that increases the abdominal pressure over time can widen that space, that hole and thin it out and once it gets to a certain size; that’s when abdominal contents can come through. Another natural defect in the abdominal wall fascia is your belly button. Your belly button is obviously where your umbilical cord came in when you were in development and so just like in the groin, where the testicles descended, there are blood vessels that go right underneath your belly button through to your liver. And while we don’t use those blood vessels anymore; the hernia defect remains, and it is very small in most people. But again, with time and chronic pressure or increase in pressure; they can get larger and things can pop through them.
Melanie: Are there complications if they’re not treated? I mean if people have a hernia that could get worse over time, but it doesn’t hurt them, then is there any reason to deal with it or are there some complications that could happen?
Dr. Sachs: Yes. So, it really depends on the size and the symptoms. The smaller the hernia, actually the riskier it can be because what you have is you have a small defect and with increased pressure, a piece of intestine or other intraabdominal contents could be forced through and then when the pressure is relieved, because the hole is so small, they can’t get back in and they can’t be what we call reduced back into the abdomen. And that can actually cause strangulation of the blood supply to that intestine or other organs and they can become ischemic and die and so that is an emergency. If it’s a larger hernia; generally, those pop in and out quite often and we have what we call a reducible chronic hernia and that can happen anywhere. Those are less of an emergency, but over time; they will continue to get bigger. They don’t get smaller and so we generally recommend repairing them at an interval that is convenient for the patient, if they are suitable candidates because as they get bigger, they become more symptomatic and harder to repair in the future.
Melanie: When should someone seek medical care for a hernia? When would somebody know?
Dr. Sachs: Well if you ever notice a new bulge or a painful bulge anywhere in your groin, in your abdomen, elsewhere that you can see on your side, or if you have had a previous surgery and you notice where the incision was or near that incision, you notice a new bulge or an enlarging bulge; you should be evaluated by a physician and most commonly by a surgeon to see whether or not it requires a surgical intervention and what options exist for that intervention.
Melanie: What would surgery be like? Because some people would want to put it off if it’s asymptomatic or think oh it’s not going to get any bigger because they worry about what that surgery would be like, but you are doing them laparoscopically these days, yes?
Dr. Sachs: Laparoscopic surgery has been around for a few decades now, but it’s really only in the past ten years that we have really started to expand its use for hernias more commonly. The laparoscopic approach is usually done with small incisions, usually about the width of your finger, five to ten even twelve millimeters at the most. And through these small incisions we can operate within the abdominal cavity and fix the hernias without leaving large incisions and generally getting patients back to their normal self and their normal daily activities much quicker. The other option would be open surgery which is more classic type of repair. Sometimes we can’t repair things laparoscopically either due to prior surgery or other reasons that would prevent a patient to be a suitable candidate for laparoscopic surgery. And in those cases; it’s usually a larger incision, but the repair is just as sturdy and generally patients do well from that as well.
Melanie: You used the word sturdy. So, once you have fixed a hernia; does it come back or is that a pretty strong situation that you have set up again and might a hernia come back above or below the spot that you just made stronger?
Dr. Sachs: Well if you repair a hernia appropriately; the risk of recurrence is rather low. The real risks that come with the recurrent hernias are if patients basically do a few things that they shouldn’t after surgery. So, we generally recommend the patients avoid any strenuous activity or heavy lifting for up to six weeks after surgery to give that area time to really heal in. and those first six weeks are the most important. We also generally use mesh and we like that mesh to add strength to your repair and as long as we place that in a suitable position where there is good coverage of the hernia defect; generally, hernias don’t recur although there is about a 5-10% chance of recurrence. Other things that can increase the risk of recurrence would be things like smoking, diabetes, increased weight gain or doing things that might increase the abdominal girth. So, in patients who have had hernia repairs who then become pregnant, sometimes those hernia can come back. But generally, hernia repair is a safe option and very durable.
Melanie: What are some other common surgeries that you can treat laparoscopically these days?
Dr. Sachs: Well the most common are gallbladders and appendix operations. The gallbladder operation is a particularly important because prior to laparoscopic surgery, the operation on the gallbladder was a very big operation requiring a big incision in the right upper quadrant underneath the rib cage and now we can do it through four very small incisions, removing the gallbladder through a relatively small incision about the width of your thumb right above the belly button. The other operation would be appendix for appendicitis or for under appendix problems and again, through about three different small incisions removing the appendix with the patients getting back to their normal daily routines sometimes leaving the hospital the same day or the day after.
Melanie: Then wrap it up for us what you would like the listeners to know about laparoscopic surgery and hernias and when they should seek medical attention.
Dr. Sachs: Yeah, I think that patients should understand that laparoscopic surgery when appropriate is a very safe alternative to open surgery and patients should always ask their surgeon if the operation that they are being – that they are discussing with their surgeon can be approached laparoscopically. Because there are certain types of operations that are very feasible, and the patient should really be an advocate for themselves in terms of seeing if laparoscopic surgery is appropriate. I think that for hernias, patients should seek medical attention whenever a new bulge or a painful bulge is seen either in site of a prior incision or in an area like the groin or the belly. And those should always be evaluated by a surgeon to make sure that they are safe either for surgery or for nonoperative management and observation.
Melanie: Thank you so much Dr. Sachs for being with us today. This is Boston Med Talks with Boston Medical Center. For more information you can go to www.bmc.org that’s www.bmc.org . This is Melanie Cole. Thanks so much for listening.