Hernia repair: A common reason for surgery
Worldwide, more than 20 million hernias are repaired every year. Half of those surgeries are done in the United States, where up to 10 percent of the population develops some type of hernia in their lifetime.
General surgeon C. Jeffrey Siegert, MD, FACS of Cape Cod Surgeons in Falmouth has seen plenty of hernia patients over the years he has practiced medicine. Repairing hernias are one of the things he loves about being a general surgeon because not everyone has the same type of condition. All of the different nuances means he tailors treatment to what will be the best option for each individual patient.
“The simple description of a hernia is a hole in the muscle that allows one body cavity to move outside into another or to move outside the body,” he explained. “So basically, anywhere that you have muscle layers as partitions to organs you can have a hernia. The most common hernias out there are inguinal hernias, which are groin hernias. Inguinal is the Greek word for crease to the groin. The reason why that is so common is that there are already holes in the muscle there.”
All hernias, including inguinal hernias, occur because of the way the human body is designed. In the case of an inguinal hernia, Dr. Siegert compared the “holes” to submarine hatches. They exist because in the embryonic stage of pregnancy all humans’ genitals are located behind the heart. Hormones that develop between nine and 12 weeks of pregnancy cause the gender-specific organs to develop.
In females, the sex organs drop down to the pelvis to become ovaries. In males, they drop down through those hatches into the scrotum because male sperm has to be cooler than body temperature to be effective in reproducing. Both males and females have a tether attached to their sex organs. In females, the tether becomes a nonfunctional ligament. In males, the tether is called the spermatic cord of the inguinal canal.
“Those little hatches are trouble because over time they can dilate and stretch out and so then it’s not just your little tether to your testicle or your spermatic cord that is going through there,” Dr. Siegert said. “Other things are coming through to ‘herniate.’ Usually, it’s fat inside your belly or the actual intestines themselves squeeze through those holes and then what the patient sees is a bulge.”
How Dangerous are They?
The seriousness of the hernia is determined by whether it can be reduced easily. In other words, can the doctor gently press it back in when the patient is standing? If it is stuck or hard as a rock and the doctor can’t get it back in, it’s called “incarcerated.” Those cases need to be operated on within a day or two, Dr. Siegert said.
If the hernia is really stuck and losing its blood supply, it’s called “strangulated.” A strangulated hernia is a surgical emergency. That patient needs to be in the operating room within six hours or a piece of bowel could get stuck in there.
“Unfortunately, I have seen people die from that,” Dr. Siegert said.
Heavy lifting can cause or exacerbate a hernia, but the two most important independent factors that cause a hernia are weight gain and smoking. Both behaviors can not only cause a hernia, they can also make it worse. They can also make a hernia repair fail.
Smoking is bad for hernias because it hampers healing. Also, if a patient develops COPD from smoking, it changes the anatomy of the chest. The chest wall has to increase in size to keep oxygen in the lungs. That pushes the belly and diaphragm down, which increases abdominal pressure. A chronic increase in abdominal pressure causes hernias.
It’s important for the surgeon to take a thorough medical history because other factors can also affect hernias, including constipation caused by rectal cancer and bad prostate enlargement, which also puts increased pressure on the pelvis.
Different Types of Hernias
Although inguinal hernias are the most common, a hernia can occur anywhere on the abdominal wall. Other hernias include umbilical hernias, hiatal hernias, periesophageal hernias, femoral hernia and a Amyand’s hernia which involves the appendix. Hernias are also more common if a person has had a previous operation on the abdomen, because once you access the abdomen surgically, it is just inherently weaker, Dr. Siegert said. Inguinal hernias are more common in men, although women do get them too.
There has been a lot of controversy about using mesh to repair a hernia. Most of the controversy has been unnecessary, Dr. Siegert said. But it has resulted in making the meshes better. Whether a surgeon simply stitches up the hernia or uses a mesh is dependent on the size of the hernia. Any hernia larger than about one and a half centimeters will get a better repair with a mesh.
“We use mesh to help take the tension off,” he said. “The reason why mesh is used is the recurrence rates when you use mesh are so much better. Without mesh, it’s like a 30 to 40 percent chance of recurring at five years, versus with mesh it’s like a four to five percent of a chance of recurrence. So, it’s like 10 times better.”
He compared the mesh to a patch on a pair of jeans. If you just stitch up the hole in the pants, you have a small straight line of an inch taking on all the tension. If you stitch a patch in place, you spread the tension over six to eight inches around the patch.
One of the other questions about hernia repair is whether to do it from the outside in, or from the inside out laparoscopically.
“If you have two hernias at the same time, I find that the laparoscopic works better because it’s a lot less painful because you can fix them both through the same three little incisions in the belly,” Dr. Siegert said. “There is definitely a big difference with the pain with a bilateral incised inguinal hernia. There’s not much of a difference on a one-sided hernia, so if someone comes in with a one-sided hernia, basically it is up to the surgeon. I personally enjoy doing it both ways.”
Hernias don’t go away on their own, so about 79 percent of all hernias end up getting repaired. But for some patients who have other comorbidities or medical issues, there are certain hernias doctors just watch to make sure they aren’t getting worse, because it might not be worth the risk of putting the patient under general anesthesia. Dr. Siegert advised those patients to wear support garments to hold the hernia in when they do chores such as yardwork.
“But I make sure to tell them that they can’t smoke and they have to lose weight,” he said.