Hernia repair process takes patient from diagnosis through rehabilitation

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. More than 1 million hernia repair surgeries are done in the U.S. each year. What can you expect if you or a loved one are facing this procedure?

Today, I'm talking with Dr. Moustafa Hassan. He's a professor of surgery who also specializes in critical care at Upstate, and Maggie Wight, who is the Upstate Hernia and Abdominal Wall Reconstruction Program nurse coordinator. I welcome both of you to "The Informed Patient" podcast.

How many people contact the Hernia and Abdominal Wall Reconstruction Program each year, and what percent of those patients require surgery?

Maggie Wight: We typically see about 800 to a thousand patients a year on average, about 80 to a hundred patients a month. Of those new patients, 85% require surgery due to a known hernia, whether it's self-diagnosed or sent by a referring physician.

Host Amber Smith: So, Ms. Wight, I assume that as a nurse coordinator, you are probably the one speaking with all the patients. What are those first conversations like? And what sorts of information do you look for?

Maggie Wight: Our conversations begin with an introduction to the program and myself. The patient provides a brief explanation for their call, inquiring about services offered and an appointment requested. We accept self-referrals; we do not require a physician referral. I conduct a short interview with the patients gathering medical and surgical history. We discuss any recent studies obtained, such as images, bloodwork. The patient follows up with scheduling an appointment. Our location and direct patient line phone number is provided.

And the overall goal is to gather all the pertinent details so that when the patient meets with the surgeon, all the information is available and reviewed..

Before they have the physical exam, are there other tests that they may end up needing to do or have before then?

Maggie Wight: The surgeon's physical exam is of vital importance. Paired with a patient's reported symptoms and their impact on their activities of daily living, then it's determined whether other studies are warranted. Further testing may be necessary based on the complexity of the hernia with a patient's medical and surgical history. Additional testing may include CTs (computerized tomography scans) or ultrasounds. Often a physical exam may be only required.

Host Amber Smith: Now, Dr. Hassan, if I understand correctly, a hernia is when organs protrude from their cavity, such as intestines coming through a weak point in the abdominal wall.

Does this happen abruptly, like in an injury, or does it develop gradually?

Moustafa Hassan, MD: That is a great question, Amber, because a lot of patients think that the hernia was brought about by a specific incident, and in a lot of cases, that is the case. But, there are many, many kinds of hernias, and they don't all have the same etiology, or cause.

So when we talk about hernias, we always like to split them up into two main categories. One of them is the inguinal hernia or the groin hernia that most people would assume that is the case when I talk about a hernia, but the bulk of our practice actually is what is known as incisional hernias and ventral hernias, which are hernias in the abdominal wall, following an operation that the patient had in the past. So, they're very different in the presentations. They are very different in the way we treat them as well. Inguinal hernias, which are the common hernias in the groins, usually just appear; they don't necessarily have an incidence prior to that period.

Some people have a predisposition, or the way their abdominal wall is structured allows that to happen. And it only becomes obvious when maybe they cough so hard or lift something heavy and so forth. So that is for inguinal hernias. As for the other ones, which are the common incisional hernias, there has been a scar on the abdominal wall.

Moustafa Hassan, MD: This scar may not be strong enough, and it just gives way with time and allows a bulge to happen or a hernia to happen.

Host Amber Smith: Are hernias painful?

So it depends: Some people may not even know they have a hernia, while others will present at the emergency room in extreme pain and complications -- strangulation, incarceration, which means the hernia gets stuck outside and they aren't able to push it back in. So there's a wide variety of symptoms, ranging from having no symptoms at all to having excruciating pain. In the middle are people who have pain when they do specific action or when they eat something and the bowel protrudes from the hernia, that brings about the pain.

If somebody is not having any symptoms from a hernia, does that mean the hernia is not an issue that they need to see a doctor about?

Moustafa Hassan, MD: Well, I don't think so. I think a hernia is an abnormality. You don't want the first symptom to be severe pain or the complication that brings it to the emergency room.

So whenever there is a hernia, the patient needs to contact the primary care doctor or call the surgeon or just pay attention to it. Not every hernia needs an operation, but I think every hernia needs to be evaluated.

Host Amber Smith: When would a hernia be an emergency?

Moustafa Hassan, MD: A hernia would be an emergency if, basically, the intestines that stuck outside become actually stuck outside.

And there is pain, the inability to eat because the lumen (the opening or channel) of the intestine is obstructed, causing people to throw up and get distended. So that's obstruction or strangulation, which is basically a severe complication where the blood supply to that piece of intestine got cut off or twisted and cut off. So that's a surgical emergency.

Host Amber Smith: You're listening to Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, talking about hernia repair with Dr. Moustafa Hassan and nurse coordinator Maggie Wight. And I want to remind listeners they can find more information about Upstate's Hernia and Abdominal Wall Reconstruction Program at upstate.edu/hernia or by calling 315-464-1803.And now I'd like to ask you about how the surgery is done. Which patients might be candidates for a minimally invasive approach to hernia repair?

Moustafa Hassan, MD: So when we talk about operating on people with hernias, we still have to split this decision to: Is this an inguinal hernia or is it an incisional hernia?

Because it's very different, and the treatments, like I said previously, are very different. Let me start by talking about the common, uncomplicated, or even complicated, inguinal hernias. It can be done through an open incision, or they can be done through a minimally invasive approach, which is nowadays, or at least since 2016, we've been doing with a robot. Almost every time most of the time -- I won't say every time, but most of the times we do the inguinal hernias with a robot. This is a minimally invasive procedure. Three little holes in the upper abdomen, no incision in the groin. And we fix it. We put a piece of mesh there, and it's an outpatient procedure, after which the patient goes home. The procedure itself takes between 45 minutes to an hour and 15 minutes, usually.

But of course it could be more complex, and it can take longer, or it could be more simple and take less. So that is for the inguinal hernias, either a robotic approach or an open incision, a robotic approach. The other big category, which is the incisional hernias -- these are different. These are big, big, abdominal wall incisions and reconstructions, after which the patient may stay in the hospital for a few days. Sometimes we have to remove a piece of intestine, if necessary. So it's a big undertaking. The smaller ones, the simple ones, can be still done robotically, a minimally invasive approach. The big ones are most commonly done through an open incision.

Moustafa Hassan, MD: Not every patient is the same, and not every hernia is the same. So that decision is decided with the patient after viewing images and exploring the options and talking about what is a durable repair, which would restore function, comfort, good cosmetic appearance

Host Amber Smith: Is synthetic mesh, always used in hernia repair?

For the most part, I would say, whether it's an inguinal hernia or an incisional hernia, we use meshes. This is the cornerstone of the repair. This is the way that we can increase the durability of the procedure and prevent hernias from coming back. They are not necessarily all synthetic meshes. There are some other products that work well, but the choice of mesh is very critical. It's based on the hernia and the patient and the situation itself. But most hernias are fixed with mesh unless they are really small.

Host Amber Smith: Do hernias ever recur after they've been repaired?

Moustafa Hassan, MD: Oh, definitely. There is a recurrence rate for the hernias, and this depends on the original hernia, was it fixed before, and also depends on the technique used, it depends on the experience of the hernia surgeon, and most importantly depends on the patients. So it's more common in people who are overweight, more common in people with uncontrolled diabetes, smokers, people who are immunocompromised, and then a few conditions that would predict whether the hernia would recur or not.

We actually do have a calculator that would predict the complications, including hernia coming back, and we would discuss this with every patient in our practice.

Host Amber Smith: So they know before they go into this what they may be in for.

Moustafa Hassan, MD: Very important to set the expectations, so people understand what they have and why the hernia they have is different from the neighbor's or the little tiny hernia of the groin that was fixed, never came back. So we have to really explain why not all hernias are equal and that the expectations also are not equal.

Host Amber Smith: Well, we've talked a lot about hernias. What is abdominal wall reconstruction? When would that be necessary?

Moustafa Hassan, MD: So basically it was very large hernias that had been fixed several times with subsequent loss of muscle tissue and so forth. We need to do more than just put a mesh in and close. We do an extensive, more extensive procedure if necessary, of course, to bring all the muscles and move them from the sides of the abdomen to cover the hole and bring them back together, reconstruct the abdominal wall.

Sometimes we have to move this large pad of fat that some people would have either had before, or they've lost a lot of weight and we still have that fat, or that is created by the hernia pushing over a long period of time. So we do a combined operation sometimes with with the plastic surgeons, who remove the fat, and we repair the hernia. It's more than just a hernia repair, so we call it abdominal wall reconstruction, but realistically speaking, you can call any large hernia repair an abdominal wall reconstruction.

What is recovery like for someone who has a hernia repair? How soon do they anticipate they can get back to normal activities?

It depends on the kind of hernia, and, Maggie actually runs a rehabilitationprogram, an after-surgery rehabilitation program, and she can elaborate on that.

Maggie Wight: Our team has developed a successful prehabilitation and postoperative rehabilitation program to prepare for surgery. We focus on optimizing physical and life preparation to improve function and health before repair. We provide access to a free mobile app and website, which breaks down our programs into three categories: before surgery, surgery and after surgery. Familiarizing yourself with tips that will help develop good habits that can promote healing, improve flexibility, teach proper breathing techniques and safe ways to bend and lift are among a few of the benefits.

Our program focuses on including self-care for healing and recovery, stretching activities of daily living, exercises to enhance your repair and impact your recovery. As well as weight loss, smoking cessation and blood sugar control. As the nurse coordinator, we work in close contact to monitor your progress and success and ensure your preparedness for surgery.

Patients are instructed to call with any questions or concerns or changes in their symptoms before surgery. And then we will move forward with scheduling. As far as recovery, our postoperative rehabilitation program is designed to maximize a complete recovery and healing process to regain their independence and ensure durability of their repair.

After being discharged from the hospital we encourage that you'll be able to go upstairs, that you walk frequently and stay very active. We ask that you avoid any heavy lifting for about three to four weeks for an inguinal groin hernia, and about six to eight weeks for an abdominal ventral hernia.

Maggie Wight: We typically don't like to put a number on weight limit restrictions because "heavy" varies from individual to individual. Therefore, we ask that you use your good judgment and avoid any unnecessary abdominal strain during that time frame, which can happen even without lifting anything, simply by bending over or transferring positions incorrectly, which is why it is imperative that you participate in our prehabilitation program so that you understand these tips beforehand.

We ask that after surgery, you take over-the-counter medications, such as Tylenol or ibuprofen, if not contraindicated, for first-defense pain control and reserve prescribed narcotics for breakthrough pain. That, paired with our exercises and the knowledge that you gain from the rehabilitation program, sets you up for success, through recovery.

Host Amber Smith: Well, I appreciate both of you making time for this overview.

My guests have been Dr. Moustafa Hassan, a professor of surgery in the Upstate Hernia and Abdominal Wall Reconstruction Program, and the program's nurse coordinator, Maggie Wight. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York.

Find our archive of previous episodes upstate.edu/informed. I'm your host, Amber Smith, thanking you for listening.