What is a hernia?
At its broadest definition, a hernia is a weakening in a tissue plane through which other tissue can protrude. You can herniate a disc out of your spinal column, and that might pinch a nerve and cause pain. You can herniate your brain out of your skull, which is a pretty devastating injury to have. You can also herniate your stomach up through your diaphragm, which can make you susceptible to reflux. But I fix abdominal wall hernias, the most common of which by far is an inguinal hernia.
What is the tissue that’s protruding? Can it be dangerous?
Worst-case scenario, it could be intestines, but even then, that doesn't mean doom. A lot of times it's just fat. But when it's intestines, that's where you can start to get more symptoms. The true danger of a hernia is that whatever tissue is protruding into the space starts to look like a mushroom cloud, meaning the hernia opening is small relative to the size of the bulge. It’s hard to push the tissue back in, in that case, and that's usually way more symptomatic. It can cause digestive issues and even a full-on bowel obstruction.
Even worse, it can cause strangulation, where the tissue that’s stuck can start to swell because that's what tissues do when they're inflamed. And it can start to slowly cut off its own blood supply if the hernia is small enough relative to the amount of tissue. But it’s important to note that hernias don’t rupture or explode.
Are they painful?
In some cases, yes. When they first form, the tissue that now has the defect has either torn or weakened. That's an acute change, and that can really hurt. They often settle down because those tissues are no longer tearing, but the damage is done. The bulge is there, and it causes discomfort. In some patients it will hurt every time they do anything that increases intra-abdominal pressure — straining, lifting, coughing, sneezing, grunting, jumping, and landing. All those things can cause a hernia to hurt.
How are they treated?
If it's an inguinal hernia, there are lots of studies that have shown that watchful waiting is safe and OK to do if the patient has no symptoms or very minimal symptoms. Education and reassurance are sometimes all I provide when I see someone for a recently diagnosed inguinal hernia that doesn't bother them. This is only in males — women with groin hernias are more likely to have a femoral hernia, which occurs a bit lower down than an inguinal hernia and has a higher chance of tissue entrapment. Typically, females with groin hernias, even if asymptomatic, should be evaluated for repair.
The literature shows that over time, almost every hernia slowly gets bigger because we constantly have pressure in our abdomen. Even with watchful waiting in men, sometime over the next several years, the hernia is going to get bigger and carry a slightly higher risk of one of those emergency problems like obstruction or strangulation. At some point you're going to raise your hand and say, “Hey, this bothers me now; I want it fixed.”
When is a hernia belt used as treatment?
A hernia belt, or truss, basically serves to hold the bulge in. In many instances it can help relieve or sometimes resolve symptoms, but it doesn't treat the hernia. It's not a substitute for repair, but it can be helpful in some instances. For example, I've seen a patient with a recently diagnosed hernia who has booked a trip to Spain to do a hike, is going sightseeing in Italy, or has a work project to do, and it's not a great time to get it repaired. I bring out the hernia belt, they put it on, they say, “With this on, I'm able to do more, I'm having more comfort. I'll have the repair when I get back or when the project's done.” A hernia belt can be useful as a bridge to surgery, but in terms of an alternative to surgery, that's really reserved for the patient who truly has prohibitive medical conditions that make surgery way too dangerous.
What about the surgery? How complicated is it?
Inguinal hernia repair is the most common general surgery procedure done worldwide. Epidemiologists have estimated that 30% of the men on the planet will get a hernia on one side or both at some point in their lives.
There are two general approaches. There's the open approach, which is the long-standing version where we make an incision that hides below the waistband or the belt line. That scar overlies where the defect is, and then we put a piece of mesh into the defect so it's no longer a hole. Things can't bulge out anymore. In some patients, I can do that surgery with just lots of numbing medicine that I inject. The anesthesiologist would be there monitoring the patient, but we wouldn't have to give general anesthesia, meaning they wouldn't have to intubate them. They can give them heavy sedation as if they're undergoing a colonoscopy. But it takes certain circumstances to be able to do it that way. Otherwise, it's a general anesthetic outpatient procedure that is considered a low-risk surgery when it comes to heart or lung health.
Then there is the minimally invasive approach, which involves fixing the hernia defect from the underside. We use small incisions, a telescope camera, and specialized instruments that fit through the small incisions. Typically, an inguinal hernia repair done laparoscopically would involve an incision at the belly button and one on either side. As of the past five years, a newer minimally invasive approach that has been growing in popularity is using the Da Vinci surgical robot. The reason I prefer it is because the camera is markedly better. On the robotic camera, there are actually two cameras in the same telescope stick, and it creates a three dimensional view. It's a little bit crisper of an image. The other advantage to the robot is that with a laparoscopic instrument you only get four degrees of freedom: In-out, up-down, side-side, and twist. But when I control the robot with the console, it has wrists, so you get seven degrees of freedom, which is what we humans use. You can do more, and you can do it more swiftly. You can sew more easily; you can see better. The robot makes it a lot less stressful for the surgeon.
What should people be aware of as far as signs they have a hernia?
They are often discovered in a routine physical, but some patients might come in and say, “I was lifting something, I felt a little pain, and then a few weeks later, I looked down in the shower, and I noticed that this right groin area sticks out more than the left. For some patients, it's groin pain. If you ask any primary doctor what's on the potential list of causes of groin pain, hernia is always there. They can present in a variety of ways, either a bulge, a sensation, asymmetry, pain, or any combination of the above.
