 What is a hernia and are there different types? A hernia is a hole in the abdominal wall through which the organs will protrude. And if we think about it, we all have an abdominal wall coat or layers of abdominal wall muscle which hold our organs in place. If a tear develops in the abdominal wall muscle, eventually that will get larger and a hole will develop. And what can happen is pieces of intra-abdominal fat or intestine can pop in and out through that hole and create a lump. The danger with a hernia is something goes through that hole and gets caught, then it can become an emergency. So if one of those pieces of fat come through and get caught there, or if the intestine gets caught there, then the blood supply can actually get choked off and it can become what we call a strangulated hernia. There are different types of hernias and there's basically two types that we classify them. One is what we call a congenital hernia and the other is an acquired hernia. Congenital hernias are hernias that we're born with and most children when they have hernias, those are congenital hernias. Adults on the other hand usually have acquired hernias and people can acquire hernias for several different reasons. The most common reason is people have increased intra-abdominal pressure. So women, when they get pregnant, they can develop hernias. People have fluid in the abdomen or what we call ascites. They can be prone to hernias. Cough, this is another reason that people develop hernias. So people who smoke, people who have what we call COPD, they are prone to hernias. But really anything that increases the abdominal pressure. So straining for constipation, people who chronically strain to urinate, people who do a lot of lifting or do a lot of heavy physical work, these people are prone to hernias. We then kind of further classify hernias based on their location. And hernias develop along natural weak spots in the abdominal wall. And we know there are certain weak spots where hernias are more prone to develop. So an umbilical hernia is a belly button hernias. And we know that the belly button is an area that the umbilical cord pierced through the muscle when we were infants. And this is a natural weak spot through which the muscle can tear and we can develop a hernia in that location. A groin hernia, we will call an inguinal hernia. And this is a weak spot where in men the spermatic cord pierces the muscle. And in women the round ligament pierces the muscle. Another important hernia to note is what we call an incisional hernia. And when people have surgery on their abdominal wall, the surgeon makes an incision and then sews the muscle together with sutures. That muscle heals with scar tissue. And that scar tissue is never as strong as the native muscle. So about 20% of the time after patients have had a midline scar on their abdominal wall, they'll go on to develop incisional hernias. So it's really a pretty common problem that we're faced with every day. How do I know I have a hernia and how would it be diagnosed? Most of the times when people have a hernia they present with a lump or sometimes they'll have pain. But the most common symptom is that of a lump or a protrusion. That occurs where the hernia is located. So they may have a lump in the groin or a lump in the belly button. And if intestine has gone through there, often when they press on that, they'll hear like a squishing sound because they're pushing the intestine back into the abdominal cavity. But sometimes they won't feel a lump and they may just have pain. So a common presentation of an umbilical hernia, especially if someone's a little bit heavy and they don't really notice the lump, is they may be leaning up against the kitchen counter or leaning up against the counter and they'll feel some pain or discomfort in the belly button. So if you have these symptoms it's important to go to a medical profession and get examined. And usually the way a hernia is diagnosed is by physical examination. So 90% of the time a doctor can perform an examination and that'll be diagnostic of a hernia if one is present. Sometimes hernias can be difficult to diagnose on physical examination. And then we'll use some adjuncts to physical examination, such as radiologic imaging. And the easiest imaging to do is what we call an ultrasound. And that's just taking a little probe and some jelly and kind of putting it over where the symptoms are. If an ultrasound shows a hernia then that's diagnostic. But the problem with ultrasound is it's very user dependent. So if the ultrasound technician misses it then it doesn't mean it's not there. If ultrasound still doesn't give us an answer then we'll move to what we call three-dimensional imaging. That's meaning a CAT scan or an MRI. And these are a little bit more involved but still they're not horrible procedures to go through. You basically lay on a table and with a CAT scan you kind of go in and out of this giant donut where an MRI you kind of go into the machine and it makes a lot of loud noise. But the advantage to three-dimensional imaging is it's very precise and it gives us a lot of detail on the abdominal wall anatomy. And almost always we can find a hernia if one is present. The wall hernias need to be repaired. Generally the answer to that is yes. All hernias should be repaired. However, if the hernia is small and asymptomatic sometimes that hernia can be watched. Regardless it's a good idea to go and see a specialist if you've been diagnosed with a hernia because sometimes the specialist or the hernia surgeon will be able to examine you and identify characteristics of the hernia that may put you at higher risk for developing problems such as incarceration or strangulation. So what do I mean by that? Sometimes the hernia neck or the opening in the muscle can be quite small but the hernia sac or the area that things will protrude into can be rather large. So in that instance you're more prone to having something go through there with a big cough or strain and then get stuck in there. So in that instance the surgeon may recommend surgery even though the hernia is not symptomatic. The other problem with watching hernias is that usually when we watch hernias they become more symptomatic over time. So in instance where a patient is very sick or very feeble and not able to undergo surgery when we put those patients into what we call watchful waiting, usually within a couple of years 40% of the time they'll come to surgery because of worsening symptoms or the hernias gotten bigger and more troublesome. Fortunately urgent problems in patients we put into watchful waiting are not as high as we think. So if someone is very sick and unable to have surgery and we recommend watchful waiting usually they won't present as a surgical emergency. But that is the big problem with putting them into watchful waiting is if that does happen the outcomes often aren't as good. How are hernias repaired and are there different types of procedures? That's a great question. A lot of times patients will ask this question because they think their hernia has gone away. And really there's no way that hernia can go away without surgery. So the only way to fix a hernia is with surgery. There's no exercises you can do. And the short is there's no non-operative approach that will make her hernia go away. When we fix her hernia the goal of fixing her hernia is to do as little damage to the tissue as possible but still get the best results. And the goal is to get the patient back to health and back to full function as quickly as possible with the best long-term results. There's really three steps to fixing her hernia. And the first step if you think about it is just to reduce the contents back into the abdominal cavity. In other words we push whatever has came through the hole back into the abdominal cavity. The second step is to repair the hole. And we do that basically by closing the hole usually with sutures. The third step is then to reinforce the repair. And generally we like to reinforce the repair with something called a mesh which is a synthetic material. It kind of looks like a window screen but it gets implanted in the muscle. And we know that by putting a mesh our recurrence rates are much lower. There are different procedures that we use to repair hernias. We can use mesh techniques. We can use tissue repairs or non-mesh techniques. We can use minimally invasive approaches such as laparoscopic or robotic approaches. And we can use open approaches. Tissue repair is repair without using mesh. And the problem with tissue repair is it's plagued with a very high recurrence rate. Really there's one repair that a lot of people speak about that has a very good recurrence rate and that's called the shoulder ice repair also known as the Canadian method. People have heard a lot about this and we get a lot of people asking about the Canadian method because there's a lot of fear about using mesh today because of a lot of misinformation in the media. The problem with the shoulder ice repair is it does give very good results with recurrence rates maybe two to three percent. But the problem with it is you have to select your patient properly in order to get a good result. And I think the reason they have good results is because they're super selecting their patients. They're selecting good candidates, patients who aren't very obese, patients who they have to have a specific what we call height to weight ratio. And the shoulder ice clinic will only perform surgery on these patients. Patients who are heavier, patients who have larger defects, patients who have complex recurrent defects. These patients may not be candidates for shoulder ice repair. So most hernia surgery in the U.S. and throughout Europe is done with mesh. And the reason being is because mesh repairs give us the best long-term results. Mesh repairs, especially in the groin, recurrence rates are less than one percent. And then we kind of can do laparoscopic versus open techniques for hernia repair. The big advantage to laparoscopic techniques or minimally evasive techniques is that's a quicker recovery. There's less cutting, less manipulation of tissue. So that affords several benefits. Healing is quicker. There's less pain involved. And we know there's often less wound complications with minimally evasive approaches versus open. How do you decide which technique is best for repairing a hernia? This is a common question that we get is how do I know if I'm a candidate for laparoscopic surgery, robotic surgery or should I have open surgery? And the way we decide that is really based on patient factors and hernia factors. So what do I mean by that? Well, every patient's a little bit different. Some are at higher risk for undergoing surgery. And also each hernia is different. The location of the hernia is different. The size of the hernia is different. The complexity of the hernia is different. So this will kind of dictate how we do the repair. Let's take groin hernia, for instance, and see how we would decide whether a patient's a candidate for laparoscopic or open surgery. There's really no difference between a unilateral or one-sided inguinal hernia repair, whether it's done laparoscopically or whether it's done open. It's true, there is a little bit quicker healing and a little bit best match pain, but not that much. And the important thing to note is that the long-term results are gonna be the same. The recurrence rates are usually 1% or less with open or laparoscopic surgery in the groin as long as we use mesh. What are the benefits to having my hernia repaired laparoscopically? The advantage to laparoscopic surgery comes into play when there's more than one hernia, or if there's a recurrent hernia where the prior hernia has been done with an open technique. So what do I mean if there's more than one hernia? In other words, if somebody comes in and they have a right-sided groin hernia and a left-sided groin hernia, and then maybe they also have a belly button hernia, with a laparoscopic technique, we can repair all three hernias at the same time, and the healing would be the same as if you had one side done with an open technique. So this is really the advantage of laparoscopic surgery, is bilateral or more than one side or recurrent hernias. By the same token, the advantage to open surgery is that usually we don't need general anesthesia. There are some patients when they come to our office, they're elderly, they're feeble, they have a lot of comorbidities, and they're not good candidates for general anesthesia. Laparoscopic surgery pretty much always is gonna require general anesthesia because we need the muscles relaxed, and we need to work on these very fine, delicate structures. With open surgery, if we have someone who's 90 years old or may not be the best candidate for general anesthesia, we can often repair that groin hernia by giving them a mild sedative and then injecting the area with a local anesthesia, and they'll go home the same day with minimal discomfort. So the open technique is often advantageous in that scenario. Another scenario where open surgery might be good is if someone has a very, very large groin hernia because sometimes with laparoscopic surgery, we can't reduce that entire sac laparoscopically and they can wind up with a chronic fluid collection in the groin, which can be uncomfortable for a patient. Are there problems with repairing hernias with mesh? I'm glad you asked that question because this is a common question we get asked in the office. A lot of patients are fearful for having mesh placed because they've heard through legal advertising or through misinformation that hernia mesh is bad. The important thing to note is that if we don't repair hernia with mesh and mesh is necessary, the hernia is gonna come back. And hernia mesh has decreased the risk of recurrence dramatically and definitely mesh reinforcement is a superior repair to open technique and that's been proven time and time again. A lot of the misconception comes because they started using hernia mesh for other applications such as pelvic floor reconstruction and these can be difficult problems to deal with. So they started using mesh for uterine prolapse or for, and they would suture the mesh to the posterior wall of the vagina or for urinary leakage. They would suture the mesh around the urethra and over time what was happening, the mesh would erode into the vagina or to the intestine and there were a lot of problems with this. So unfortunately people kind of started associating that with hernia mesh where hernia mesh, when the mesh is implanted upon the muscle, the likelihood of that eroding into the intestine or to other organs is pretty much zero. So what problems can we have with hernia mesh? Well, like any foreign body that's implanted, rarely the mesh can get infected or rarely people can get chronic pain but by and large mesh is safe and it's effective. Will I develop chronic pain after surgery and if so, what can be done? Chronic pain after hernia surgery is something that rarely occurs and there are a few different types of chronic pain. What does occur after groin hernia surgery about 10 to 15% of the time is a chronic pain that we call an inflammatory type pain and this pain usually goes away within a few months to a year. So what do I mean by that? Well, people, you might be doing fine and then you might go out and do some heavy snow shoveling or some heavy exercise and have some discomfort in the groin and that gets relieved with some stretching or non-steroidal medication and you may go through this cycle a few times and eventually that inflammatory pain tends to just burn out and go away but there are rare patients who will develop a chronic debilitating type groin pain and this can occur for a few different reasons. Groin pain can occur from over healing or contracture around the mesh or from mesh folding, something we call a meshoma or it can occur from nerve entrapment. When patients develop this type of chronic debilitating groin pain, there's treatment can be very difficult and very challenging. Usually we'll try and distinguish whether something is a chronic inflammatory pain or whether the pain is stemming from what we call nerve entrapment or a problem from a nerve being conically trapped or encased in scar tissue and then we'll alter the treatment based on whether it's what we call neuropathic pain or inflammatory type pain. Sometimes we can treat this with exercise, sometimes we can treat this with different medications, sometimes we'll treat this with injections into the nerve, sometimes we'll treat this with nerve ablation or sometimes we'll actually have to go back and remove the mesh in order to relieve the pain. So chronic groin pain after hernia surgery may occur, it's rare, but there is treatment for it. What's different about the NYU Winter Purnia program and why should I go there for my surgery? The doctors at the NYU Winter Purnia program have a lot of experience with hernia surgery. It's a high volume center, we do a lot of hernia surgery and we like doing what we do. So there's a big advantage to that because we're not just rushing through surgery, we look at each patient individually, we have a lot of experience, we know how to treat different problems and we're also very interested in patient outcomes. We track our data, we look for new techniques, we teach new techniques to the residents, we have, we're kind of innovators in different fields and our goals are to have the best outcomes with the least impact upon the patient's life so they can get back to a quick and speedy recovery. We've developed ERAS protocols, stands for Expedetti Recovery After Surgery. We like to limit narcotic usage, there's a lot of problems with prescription narcotic usage today in the state and in the country. At NYU Winthrop, we have a monthly multi-disciplinary hernia conference, this is not only a teaching conference, but we also discuss very complex and difficult cases, maybe cases that are outside the standard realm of what we've seen, patients who've had complications from surgery, patients who may have had surgery elsewhere and had a less than optimal result and we discuss these patients, we go over the images with radiologists, we have hernia specialists there, we have plastic surgery there, we have orthopedics involved if necessary, we have radiologists available to review images and we come up with a specialized treatment plan for these complex cases so that we can have better outcomes. Additionally, we have some services here that a lot of institutions don't offer, so for patients who have chronic pain after surgery, we have a pain management team that we can work with, we have techniques that we can do surgically if pain management fails to remove mesh, this is something that isn't done at a lot of institutions. We can also offer surgical nerectomies, removing nerves if they become entrapped and another huge advantage of the NYU Winthrop hernia program is an abdominal wall reconstruction. Most of the time, abdominal wall reconstruction for these giant abdominal wall hernias is done with an open technique. Here at NYU Winthrop, the surgery is done almost always robotically, which has some tremendous advantages. For more information on the NYU Winthrop hernia program, call us at 866 Winthrop or visit us online at NYUWinthrop.org.