 My name is Dr. Jessica Tredo and I'm going to be talking about anguinal hernias today. Hernias is a very broad topic so there's a lot of different types of hernias and a discussion that you can have around each one but today I'm going to focus on anguinal hernias because it is one of the most common problems that we see and specifically I'm going to discuss what they are and when to treat them. So first let's discuss a little bit about how common they are. So the lifetime prevalence of an anguinal hernia in males is about 27 to 43 percent in females it's about 3 to 6 percent so although much more common in males there are plenty of anguinal hernias that are found in females as well. It is the most common surgical condition that's encountered by primary care clinicians. So 1.6 million are diagnosed every year and over 500,000 undergo operative or surgical repair every year. So specifically what is a hernia? The definition of a hernia is a protrusion or a bulge or a projection of an organ or a part of an organ through the body wall that normally contains it. So the body wall meaning the abdominal muscles that wrap around the organs. So I always use the analogy of a hole in a dry wall so the dry wall is going to be your abdominal wall that's holding everything and then the hole is going to be the hernia defect. Anything that increases the pressure behind that wall is going to cause whatever is in that room to protrude through the path of least resistance meaning through that hole or through the hernia defect. So the hernia itself is the hole and then the bulge that you may feel that's popping out of that hole are the contents behind that wall poking through. And specifically common types of groin hernias, anguinal and femoral hernias we'll discuss in a moment. So why is this important? There are certain risk factors or factors that increase your risk of developing an anguinal hernia that you can be aware of. As we discuss males encounter this more than females, there are certain age ranges that are the peak of incidence or the most common ages where you can find these but there are definitely plenty of anguinal hernias that are diagnosed between these ages. Family history in a first degree of relative has also been associated with developing a hernia in yourself and there are certain diseases that impair collagen metabolism meaning collagen is dysfunctional because of the disease and that leads to a weakness in the tissues and that causes the patient to be more susceptible to developing a hernia. Having a history of a prostatectomy or removal of the prostate especially if this is done through an open approach meaning one big incision rather than a laparoscopic or minimally invasive approach an open approach has an increased risk of four times to developing an anguinal hernia. In certain conditions that increase intra-abdominal pressure. So diseases that can cause a chronic cough such as COPD or emphysema, increased pressure, chronic constipation with frequent straining can do the same, the extra weight from obesity can increase abdominal pressure and pregnancy of course increases intra-abdominal pressure. So where are they found? Like I said there are many types of hernias that can occur in the body, specifically groin hernias, the main common, the main types are bees for here. There's anguinal hernias and within that class there's indirect and direct and I'll discuss that in a moment. There are femoral hernias which are a little bit lower in the groin and then there's obturator hernias which you can actually see from the outside it's more on the inside of the body and you can see in the bottom picture here on the left this is normal groin, the bowel is inside the abdomen and the testicles in the scrotum and eventually over time that herniac in the groin region can enlarge and then intestines can then start migrating through that hernia and that's the bulge that you feel. So as far as anguinal hernias where specifically are they? So anguinal hernias there are two main types the indirect and the direct anguinal hernias. The most common type is the indirect hernia this is most common type in males and females out of all the anguinal hernias and this is found through this where the contents or whatever is behind this abdominal wall. This is the right hip you can see here in the skeleton this is a zoomed in picture of the right side of the pelvis or the right groin and inside the body there's this canal through the abdominal muscles the internal ring is the internal opening or the opening on the inside that leads to a canal or a pathway and then an external ring where it leads down into the scrotum or the testicle and if you have a hernia that goes through this canal this is an indirect anguinal hernia and this canal is where you have this spermatic cord or the main structures that lead from the abdomen or the belly to the scrotum that houses the main vessels, nerves and also the vasctepherins this is the tube that carries sperm into the scrotum and that's where all of that goes through. In females there's a ligament in this area called the round ligament and if you have a hernia that goes through this canal that's the indirect hernia. This can develop more frequently on the right side compared to the left side for males the reason for that is because there's a later descent of the right testicle compared to the left and in females this is attributed to some asymmetry in the pelvis. For direct hernias there's a protrusion through this triangle here called the Hesselbeck triangle there are certain landmarks or specific structures that cause the borders of this triangle but this is due to a weakness of the floor of this anguinal canal so this is where these hernias lie. Most of the time your surgeon or physician won't be able to tell which one you have specifically at the time of diagnosis or when they're doing your exam in the office but we can tell during surgery which one it is. The other two types that we'll discuss are femoral and obturator hernias. Femoral hernia accounts for less than 10% of all groin hernias or 2 to 4% of all groin hernia repairs. Now even though an indirect anguinal hernia is the most common type in females and males when it comes to femoral hernias females have higher tendency to develop these compared to males 20 to 31% versus 1% in males. It's located a little bit lower in the groin there's this ligament here called the inguinal ligament and that is kind of the landmark or where we can see above or below that ligament we can define some of these hernias and the femoral hernias below that ligament. It protrudes through what's called the femoral ring. This femoral ring can widen with aging or following an injury are common reasons and that's why those develop. The obturator hernia is the least common type of these four types. It accounts for less than 0.04% of all hernias. It protrudes through this little foramen or canal or opening in the pelvis. This is the right pelvic bone and there's this canal called the obturator canal where a hernia can develop. Weakness may result in enlargement of the canal and some risk factors that are associated with this are profound weight loss or spinal deformities such as as you can develop an arthritis or after a fracture. So how do they develop? There's two major pathways in which the origin of a hernia can progress. So that's congenital or a result of an abnormal development either in the womb or after birth and then there's acquired reasons and these are due to alterations that lead to weakening or disruption of the tissue. For congenital or developmental reasons this is most commonly due to failure of something called the processes vaginalis to close. Processes vaginalis is just the fancy term for an outpouching of what's called the parietal peritoneum. Parietal peritoneum is the innermost layer of your abdominal wall. This picture is just showing how all the different layers of the abdominal wall tend to form this outpouching where the testicle descends from the abdomen into the scrotum as you develop as an infant and this canal or this outpouching called the processes vaginalis is intended to close after this occurs. The failure of that closure then leads to this opening that allows a hernia to develop and then females this outpouching has an equivalent called the canal of nook. For acquired reasons of developing a hernia many times this is due to an incision or previous surgery, previous scar tissue, an injury, connected tissue disorders like we discussed with the collagen diseases, chronic steroid use which leads to a weakening of the tissues, older age or smoking as smoking impedes wound healing after you develop a scar or are healing from an incision. And then due to the weakening or disruption of these tissues this allows any intra-abdominal contents to then protrude through any hernia that may develop in that area and again conditions that increase intra-abdominal pressure can increase your risk of developing a hernia through this weakened tissue. So complications what can go wrong this is what is worrisome about these hernias this is a question that I get many times when patients ask me what do I need to worry about now that I know that I have a hernia and the main complication that's worrisome is incarceration or strangulation. Incarceration is a trapping of the hernia contents within the sac or within the outpouching of where the hernia is located and if the contents protrude through the hernia and then get stuck or you're unable to reduce them or put them back into the abdomen then being stuck in that hernia defect then you have a reduced blood flow to the tissue that's protruding through the hole or the hernia and then that reduced blood flow leads to swelling of the tissue the swelling of the tissue is a negative spiral down to less blood flow the tissue gets compromised and then you that leads to strangulation or ischemia necrosis of the hernia contents meaning now the blood supply is so low that the contents within the hernia are not getting enough oxygen and the cells begin to die. So whatever is going through the hernia defect whether it's bowel, momentum, could be bladder, could be ovary sometimes that gets compromised even though this is the most worrisome complication the risk of this actually occurring is exceeding low it's 0.3 to 3% per year so that means that over 97% of the time this process does not happen. Some risk factors for this happening as we discussed females are four times more likely to have femoral hernias so although femoral hernias are the least are one of the least common type of hernia less than 10% of all growing hernias there's actually a 40% risk of presenting as an emergency with incarceration or strangulation with femoral hernias and females are more likely to have femoral hernias so that's why generally when we find inguinal hernias in females or if you're able to tell on exam that it's a femoral hernia with its location being lower in the groin then the general recommendation is to repair it. Also if you've had a hernia-related hospitalization within the past year it's recommended that you go ahead and fix the hernia sooner rather than later and again hernias tend to enlarge over time as the hernia enlarges this tends to cause more discomfort more pain if the hernia is left untreated so that can be a complication of leaving it untreated. So how are they found most hernias are found on history of physical exam so when you go to the physician in their office and they do their exam that's usually where you'll find it or sometimes patients find it on their own at home and that's generally a bulge that you feel in the groin some patients may or may not have a bulge some patients may or may not have discomfort or pain they may have one of you know one or the other they may have both this can be aggravated with anything that increases abdominal pressure such as heavy lifting straining prolonged standing at the end of the day as gravity has been weighing on your body that tends to cause more pressure and then have more discomfort so that's why oftentimes the bulge is more pronounced at the end of the day rather than in the morning you've been laying down all night the hernia has a chance to reduce back into the abdomen and the bulge might disappear and then reappear later the next day because of this process again you know alleviated with lying down or cessation of straining maybe not straining anymore and then these are the symptoms that you have to monitor that may suggest that you may have an incarcerated or strangulated hernia so you may have moderate or severe pain worsening pain not getting better nausea vomiting unable to pass gas or have a bowel movement those are all signs of obstruction meaning what's bulging through the hernia defect maybe a piece of intestine that now has kinked like you you know kink a hose and now things can't move through if you have red in skin over the hernia site or fevers these are all signs and symptoms that you should present to your nearest emergency room to have it evaluated and then diagnosis may be more difficult in females or those with obesity sometimes so your clinician may order additional imaging if they feel that it's indicated so what else can it be there are certain conditions that can produce pain or mass in the groin that can mimic a hernia that's not a hernia that you can be aware of there are soft tissue masses that can occur in the groin enlarged lymph nodes there's many lymph nodes in the groin that can enlarge for certain conditions or infections a squirtle mass may develop round ligament varicostinies during pregnancy these are as a you know pregnant patient it has more volume in their veins those veins tend to dilate and they can form these irregular bulges on the veins and that bulge may be confused with the hernia sometimes and aneurysm meaning the artery in the groin for certain conditions or diseases can balloon and that balloon can then be felt like a bulge and be confused as a hernia a muscle muscle strain or tear also known as a sports hernia is actually a misnomer because a hernia isn't actually found but the persistent pain in that side of the groin can lead you to think that there may be a hernia but it's actually just a straining or a tear of the muscle and then hip problems or lumbar radiculopathy meaning pain from the nerves that come from the lower back the pain from those two conditions can radiate to the groin so sometimes you may be confused of whether there is a hernia there or not that's causing the pain or if it's just the back or hip problems so if any of these conditions are suspected then further imaging may be ordered to help distinguish between the two so when and why are they fixed there is obviously two main options either you wait or you repair it surgically the hernia is not going to go away on its own so the only definitive treatment is surgical repair the groin hernia repair is one of the most common operations performed like we discussed over 500 000 per year in the us and over 20 million per year worldwide as we discussed with hernias in females and femoral hernias these are repaired due to the higher risk of incarceration or strangulation but there's actually no evidence that physical activity will result in worsening of the hernia or incarceration so many times patients ask me you know is there anything I did to make this hernia develop or is there anything that I can do moving forward that can make this worse not that I know that I have one and I generally tell them this fact that the data doesn't show that there's anything you can do in particular with your activity that will make it worse or cause it to incarcerate or strangulate so I generally tell patients that I recommend just continuing your usual regular physical activity or exercise regimen because that's going to be more beneficial to your overall general health to continue doing those activities then to avoid them as there's no evidence to show that it will make a difference if you stop and the risk of incarceration and strangulation as we discussed is actually very very low so as far as watchful waiting sometimes this just comes down to patient preference many patients at the time that they find their hernia can't afford to take time off it's not convenient for their schedule to have it repaired or they just prefer to wait and that's okay this watchful waiting if you decide to wait and sometimes patients say it's not convenient right now but I'd like to get it fixed eventually if they have other comorbidities or other medical conditions it allows time to make those better so if they have high blood pressure it allows time to get that under control their blood sugars are not under control it allows time to optimize that if weight loss is you know indicated for their general health it gives them time to do that if their smoker smoking impedes wound healing it increases complications with wound healing or infection risk after surgery so it gives them time to potentially attempt to quit smoking as well so it allows for those other things to make the outcome of the surgery much better for the patient also but during this time you have to continue to monitor for those warning signs that we discussed and if they develop present to the emergency room as far as managing symptoms during this time there is something called a trust this is a picture of an example of what that looks like you can find it at the you know at your local drug store but the data shown that this may or may not help to be honest but I always tell patients you know if it's causing you significant discomfort and it's something that you want to try you know it's it won't hurt so you can go ahead and try that and just see if it helps you and then surgical repair is the other option this is my recommendation I realize I'm a surgeon and this is what I do but the reason why I recommend it at your earliest convenience as we discussed is because the natural tendency of these hernias again is to enlarge over time as it enlarges the hernia gets bigger it gets more complex and more difficult to repair frankly so I generally recommend to fix them when they're smaller when the patient's younger it allows for you know a less complex repair less operative time less time under general anesthesia and get it fixed now when you're younger and healthier whereas later in life you may develop other comorbidities that can affect the outcome so how are they fixed the current practice right now there's two general approaches to hernia repair the traditional or open approach is when it's repaired from the outside of the body or in front of the hernia so the top picture here is an example of the incisions you would make for an open approach the minimally invasive approach either laparoscopic or robotic are smaller about one centimeter incisions for laparoscopic you can see here there's usually one at the umbilicus or the belly button and two below for robotic there's one at the umbilicus and one on either side you may or may not have an additional incision and the minimally invasive approach provides numerous benefits over the open approach it allows for a diagnosis of the contralateral side meaning if there is a hernia suspected on the other side the other groin as well you'll be able to find that during the time of the surgery and potentially repair both at the same time even though the long-term outcomes between open and laparoscopic approach are the same meaning you'll still get a quality repair in the long-term either way uh it does laparoscopic or robotic has a quicker recovery time after surgery and it's associated with less pain after surgery so that's why generally I only recommend an open repair if there's a contraindication to doing it minimally invasively meaning the patient can't undergo general anesthesia for whatever reason which is required for a minimally invasive surgery so a little bit about the mesh um why is it used I get many questions about the mesh you know you see a lot of commercials about complications with the mesh and compared with a non-mesh repair mesh repair it has a lower recurrence rate meaning a much lower risk of the hernia coming back um compared to open or compared to a non-mesh repair with equal or lower risk of postoperative pain actually and then the complications of that come from the mesh are actually very rare it's and it's not a common occurrence that you have a complication related to the mesh the thing that surgeons need to be cognizant of is placing the mesh um in the proper position in the groin and making sure it's a sufficient size for that repair um so many times you know even if there is a complication with the mesh although it's uncommon it's usually not due to the mesh material itself which is a common selling point for these commercials but it's actually the way that it was used and where it was placed and the technique that was used to do the repair and then of course there are situations where a non-mesh repair is indicated such as in a scenario where you may have an infection or risk of contamination such as bowel perforation and then uh just a little bit about robotics um i am a robotic fellowship trained general surgeon um i did a year of extra training in robotic general surgery and then the reason why i prefer it is although there are similar similar outcomes in the literature compared to laparoscopy and robotics um in the end you will get a quality repair either way but um the data suggests there's no difference but i suspect that um that's because the data is actually very uh young if you think about it robot the robotics platform is much younger than laparoscopy and the learning career to robotic surgery um requires um you know time for you to develop those skills using robotics so um it may just take time for the literature to show that but the reasons why i prefer it is because compared to laparoscopy there's much better articulation or rotational movement of the instruments you can see an example here on the top of a DaVinci robotic system you have the patient here on the table near the blue drape and then you have the robot connected to the instruments and then the surgeon is sitting at this console controlling the instruments right next to the patient this bottom picture on the left shows a zoomed in picture of what the surgeon sees so through these lenses you can see the instruments inside the body doing the you know uh the instruments are used during the surgery and then the surgeon is controlling those instruments from the console with his or her hands and then you can see on the bottom right the natural uh 360 rotational movement that you get in your wrist is actually mimicked by the end of the instrument and it can do um you know 360 rotational movement that allows for a much more precise um operation and when you're manipulating the tissues um and then you have the 3d hd visualization that you get in robotic surgery that is much more advanced in laparoscopy so that is those are the reasons why i prefer it and why i do robotic surgery so with that that comes to the end of my talk um that was just a little bit about inguinal hernia specifically how they develop why it's important to diagnose them and how we can treat them so with that i'll close and i'll transition to any questions you may have thank you so much dr. Taito um there are a couple of questions that came through the q&a um one question is if the hernia does not hurt can you leave it alone uh certainly um as we discuss there is that option of watchful waiting um again you know if it's not hurting you it's not bothering you then you can just monitor for those concerning symptoms um but over time it will likely enlarge so whenever it's at your early is convenience um i recommend fixing it before it gets very large and complex to repair but i leave it up to the patient if it's not something they're interested in then it's definitely reasonable to wait and then i see here can pregnancy result in the reemergence of a corrected hernia um you know it's always possible um but the reason why we repair the hernia especially with mesh um is to reduce that that risk of the hernia coming back um so likely if you had a quality of repair the risk of it uh reoccurring is is low and then i have here how is the robotics machinery maintain sterilized storage to prevent infection etc it's just like any other instruments so the actual robot arms um are actually covered with a sterile uh dressing or plastic so during the surgery we're not ever touching the actual robot because it's covered with that sterile dressing just like we put sterile sheets or dressing on everything we use and on the patient um so once you take off those dressings the actual robot was never touched and then the instruments that we do use during the surgery get sterilized with the same process that any other surgical instrument goes through and then what percentage of hernia is return you know it's been quoted anywhere from you know one to 15 percent depending on the technique so that varies based on what type of hernia you you have what type of repair that you use to fix the hernia and whether you use mesh or not but mesh placement is definitely been shown to significantly reduce the risk of recurrence um how about um the benefits of robotic surgery post-op um so the benefits post-op you know obviously um i'm biased in the literature literature hasn't shown this yet but like for the reasons that i discussed i think that it's a much more uh precise repair um i'm able to do a much more precise um you know surgery manipulation of the tissue is um because of that precise motion i don't have to be as aggressive with the tissue and i believe that it it allows for less trauma to the tissue you know after surgery um but i do other things that um help with postoperative pain as well that aren't necessarily uh related to the robot such as using um local medication during the operation in the muscles to help with the pain so that the patient doesn't have to use um as many narcotics post-op so that helps with the pain um but i think the less manipulation less trauma to the tissues is definitely beneficial to healing after surgery and then i have here how does age affect the decision to do repair versus watchful waiting that hasn't enlarged in over three years are remaining small i'm 82 no corbidase it's a very controlled hypertension so this is a perfect example of um you know a situation where you can wait if it's a small hernia it's not causing you any discomfort and hasn't enlarged over three years um you know the risk of you having a complication from this um is is really low so it's definitely reasonable to just wait um and then you won't have to undergo the risks of surgery but again monitor um those symptoms so that you know when something's wrong if you've already had a C-section does that impact surgery or outcome not necessarily you may have a little bit of scar tissue um you know in in the pelvis but that doesn't really um increase much risk per se um it may make the surgery a little bit longer if those uh adhesions have to be lice for whatever reason but um it shouldn't affect your your outcome and then recovery time after surgery um so every patient's different i always tell patients um you know it's patient specific but generally after about a week or two you're back to doing your normal activities at home i always uh recommend a restriction of heavy lifting um more than about 10 to 15 pounds for about four to six weeks after surgery to allow the the tissues to repair properly um and heal well but usually i tell patients after two weeks you can go back to aerobic exercise like cycling swimming jogging things like that um and so the recovery time you know especially with a minimally invasive approach is is um about a week or two what are the limitations during post-op period so i discussed this briefly just now my main thing is the heavy lifting no heavy lifting four to six weeks um aerobic activity after two weeks but other than that i want you to be up and walking the day of you know the night of surgery uh walking has actually actually been shown in the literature to enhance recovery um so walk as much as you can as much as your body allows um and then just you know if you're having more discomfort or pain slow down but walking is good i have diaphragmatic hernia without obstruction we're getting green do you have some any suggestions as to what to watch for diet or activity advice um so i would definitely um monitor that um as far as a diaphragmatic hernia there's different types so there are diaphragmatic hernias meaning there's a whole in the actual diaphragm or the breathing muscle and then sometimes diaphragmatic hernias can be confused with what's called a hiatal hernia which is where the stomach starts migrating into the chest um with diaphragmatic hernias that's something that a thoracic surgeon would monitor for to make sure that there's no complications for that so i would have an evaluation if you have that um but if you have a hiatal hernia um uh there are you know i would recommend getting an evaluation um if it's causing you any symptoms to see if it's symptoms from the actual hernia versus another gi uh process because there's a workup that needs to be done to figure out there's other ways other medications that you can take to help with the symptoms that you may be experiencing um hiatal hernias are similar in that they just tend to get bigger over time so i would just continually monitor with your physician or if you've seen a gi doctor or surgeon that if your symptoms um progress or get worse or you feel like you know it's to the point where it's now large enough where it's not allowing you to eat and things like that then a repair is definitely um indicated and recommended how long is the procedure typically uh for inguinal hernias usually it takes about an hour and a half two hours if it's a large one um that's usually the operative time it is an outpatient procedure you go home the same day um it's undergeneral anesthesia it's minimally invasive um and yeah it is outpatient how would i know if the hernia is obstructed so it is those uh those signs and symptoms those warning signs and symptoms that we discussed if it's obstructed or it's stuck um then you would have increasing and worsening pain you may have nausea vomiting unable to pass any gas or stool um meaning the intestine could be obstructed within the hernia um you know really red painful bulge fevers those are all signs um that you could have an obstruction or incarceration and you should present to the local emergency department i think that's all the questions does anybody have any additional questions while we have dr curto right um do you want to put your contact number in the chat so that people can reach out to you yes another question so i'll do that while you answer this question okay after my surgery the surgeon recommended in the future avoiding any heavy lifting as well as sit-ups on their third year in the site yes and immediately post-operatively that's also my recommendation no heavy lifting for four to six weeks and then um you know sit-ups are going to increase your abdominal pressure and put pressure on the on the repair so i'd also wait on that as well but as far as aerobic activity that's you know jogging cycling um i generally recommend that you can you know progressively increase that again after two weeks where can i see the uh where can i see the recording of this meeting i'll i'll leave that to kailyn to give the details on that uh kailyn if you could tell everyone where to find the recording of this meeting thank you um yes we are going to email it out to everyone who registered for this so you will receive it via email and it will also live on youtube and then what is the recurrence rate of a hernia um as i said they it's been quoted anywhere between one and 15 percent but that um that is dependent on the type of repair that's used and whether mesh is used and again you know mesh repair decreases the risk of occurrence and then does diastasis recti impact surgery too so diastasis recti um is not a hernia it's a widening of the rectus muscles or the the ab muscles the muscles that run up and down the center of the abdomen when those muscles widen there's still tissue in between those muscles and um so there's no actual hole but that tissue tends to bulge with any pressure that's inside the abdomen so that bulging when is visible to the patient when they're you know especially doing crunches or sitting sitting up from lying down so that bulge looks like a hernia but it's just the tissue bulging out because now it's not behind muscle because the muscles have separated um so that's related more to uh ventral or abdominal wall hernias uh whether that is um repaired or not that if you just have diastasis recti that's a cosmetic procedure um but if a patient has a hernia as well i uh when i do the hernia repair uh if they have abdominal wall hernia when i do the repair the abdominal wall hernia um if it's indicated um there are instances where i will try and re-approximate the muscles or bring them closer back together if i think it'll augment the hernia repair