Dr. Lee Fleischer walks through what hernia surgery looks like for patients.
Transcription:
Bill Klaproth (Host): If you feel a bulge or a lump in your stomach or groin, it may be a hernia. Welcome to Sound Advice; a podcast from Highland Medical PC. I'm Bill Klaproth and today's topic is hernia surgery. My guest is Dr. Lee Fleischer, a surgeon at Highland Medical PC and Director of the Department of Surgery at Montefiore Nyack Hospital. Dr. Fleischer, thanks for your time today.
Dr. Lee Fleischer, MD (Guest): Well thank you for having me. Glad to be here.
Host: You bet. So let's start here, Dr. Fleischer, what is a hernia?
Dr. Fleischer: Basically a hernia is a defect in the abdominal wall through which your insides protrude to the outside that can occur in many different parts of the abdominal wall, the most common area being the groin, also known as inguinal area.
Host: And how do they usually develop, Dr. Fleischer?
Dr. Fleischer: It's not uncommon to be born with a hernia in the groin area, that we call a congenital hernia. That's usually noticed when a child is born, it's in the first- could be first few weeks or first couple of years of life. Otherwise there are ones that wind up developing as we get older and the tissues get stretched out, or certain kind of trauma to an area occurs.
Host: So is it true that sometimes there are no symptoms with hernias?
Dr. Fleischer: Very true. Very true. Sometimes the patient just presents to his physician saying, "You know, I just noticed I was coughing the other day and I have this bulge in my groin. I got scared. I wasn't sure what was going on. Can you please take a look at this?"
Host: Gotcha. Alright so for someone with a hernia, if they say, "You know what? I know what this is, or I think I know what this is. I'm just going to keep working and keep doing my thing day to day." Do they risk further damage then?
Dr. Fleischer: That's one of the fears that most people have when they come into the office to see me. A hernia, as I said, is really just a defect in the abdominal wall, and anything behind that defect can protrude when the pressure inside is enough to make it push out. Now things can occur such as incarceration or strangulation which would be more of an urgent situation, but this is a lot less common. Incarceration is when something protrudes through the hernia defect, and that's the lump that you see, and if it gets stuck and can't go back in, it's incarcerated. If something becomes incarcerated and then becomes swollen, it can actually become an emergency because that is when the blood supply to protrusion or the hernia sac is limited and you can wind up having such bad blood supply to that hernia content that you wind up cutting off the blood supply to become sick. And that will be noticed by the patient because they become sick as well. If you continue with all your normal activities when you have a hernia but it's not bothering you, odds are it's not going to become incarcerated or strangulated, and therefore not become an emergency. So if you have an asymptomatic hernia, basically a hernia that you only see but doesn't cause you any problems, you are not going to do any harm by continuing along with all your normal activities.
Host: So what's your advice for when someone should see their physician?
Dr. Fleischer: Well if somebody has a new bulge, and they don't know what that is, it may or may not be a hernia, but they should be seen by their physician to have it examined and a diagnosis can be made. If a hernia is symptomatic, that is a time that they should actually seek surgical attention so that the repair can be performed, thereby alleviating any possible problems or emergencies.
Host: So let's talk about treatment. Is it always surgery that's needed to repair a hernia?
Dr. Fleischer: Unfortunately there's not much you can do for a hernia other than fix it surgically. There's a defect - the hole that I was talking about earlier - exists, and it doesn't go away, you can't exercise to make your abdominal wall stronger because it's really just a hole, and that hole has to be fixed with surgery so that the hole doesn't exist anymore.
Host: And what are the different types of surgeries that you use to repair hernias?
Dr. Fleischer: We basically split those up into two types. One is an open approach, which is a classic approach. The other one is a laparoscopic approach, which is a minimally invasive surgical procedure.
Host: And when it comes to surgery and anesthesia, is it usually local or is the person completely knocked out?
Dr. Fleischer: That all depends upon the size of the hernia and the location of the hernia and what actually is causing the hernia, or what caused the hernia. For an inguinal or groin hernia, that is very typically done with local anesthetic and sedation. Sedation so that the patient doesn't know what's happening and a local anesthetic so they don't having pain during the procedure. That's for someone having an open approach. However, if you're going to have laparoscopic repair or minimally invasive surgery for a groin hernia, that can only be done under a general anesthetic.
Host: Dr. Fleischer, with the advancements in minimally invasive surgery, are you doing most hernia repairs with minimally invasive surgery now?
Dr. Fleischer: Probably about a 50/50 proportion. Minimally invasive surgery is used obviously in patients that can undergo general anesthesia. If someone is not physically fit for general anesthetic, it has to be done under a different type of anesthetic, and therefore laparoscopic repair cannot be performed. For somebody with a single-sided non-recurrent hernia in the groin, the recommendation is usually to have it done using the open technique under local anesthetic and sedation. The reason is multi-fold, but basically in a simple format, for someone with a unilateral or single-sided non-recurrent hernia, the risks and benefits are the same whether you do it laparoscopically or using the open technique, therefore the only difference would be the anesthesia that's used for the procedure. If you can perform a surgical procedure to repair a hernia under local anesthetic and sedation, as opposed to a general anesthesia with the same risks and benefits, the benefit to the patient would really be to perform it under the local anesthetic sedation. It's basically having something done with less anesthesia. For the same benefit. If somebody has two hernias, in other words one on each side of the groin, that's a bilateral hernia, and the benefit is actually for minimally invasive surgery because recuperation risks and benefits are less if you do it laparoscopically.
Host: Okay, got it. And when it comes to the repair, do you use mesh then to make this repair?
Dr. Fleischer: Meshes have been used for probably well over forty years now, and they really do aid in decreasing the risks after having surgery for hernia repair. One of the main risks would be a recurrence, and a recurrence rate is drastically reduced if we include mesh during the repair. Also the pain after the surgery is much less if we use the mesh because basically you can perform the surgery with less tension and less tissue disruption if you're going to include a mesh for the repair. Therefore it leads to less pain afterwards, less swelling, and the patient feels better recuperates quicker. So yes, most of the time mesh is used for a hernia repair, unless the hernia is so small that there's really no benefit to adding the mesh.
Host: Right. So let's talk about recuperation. How long will someone usually be out of work, and what is the typical recuperation period like?
Dr. Fleischer: Well, if we take a single-sided or unilateral inguinal hernia repair, a patient that does not do physical labor can go back to office work in one week. They're not going to be 100% normal, but they're going to be 80% or maybe a little better than that when they return to work, and since they don't do any heavy lifting, they're not going to aggravate their groin and they can actually manage to get a full day of work. If somebody does have manual labor, we do extend the recuperative period a little bit longer. For somebody who does heavy duty manual labor, I may personally keep them out of work two or three weeks until they're feeling a little bit better before they put too much stress and strain on the hernia repair.
Host: And can people resume normal activities then eventually? Somebody that's a laborer that's a lifting heavy things, will they be able to do that then after the recuperation time?
Dr. Fleischer: Oh absolutely. That's a very common question I get in the office. People come in afraid that now that they have a hernia, they really can't do anything for the rest of their lives. Really what I tell them is before we do the hernia repair, you can continue doing whatever you've been doing. After the hernia repair and after the recuperative period is done, you can get yourself back into all your normal activities. That means a pipe fitter can lift heavy pipes and do their manual labor, or even sports enthusiasts can go back to running marathons, people can climb mountains, whatever they were doing before once the recuperative period is over.
Host: Well that's really good news, and last question then, can a hernia come back?
Dr. Fleischer: Unfortunately they can, but given the newer techniques these days and with the help of the mesh, the recurrence rate is actually a whole lot lower than it used to be. For example, somebody with a unilateral or single-sided. Non-recurrent hernia, the first repair gives them a typical recurrence rate of 1% to 3%. That's nice and low, and life goes on after that. For somebody with a recurrent hernia though, their recurrence rate does go up higher. So that's why I usually tell my patients the first repair is the most important repair, and please put in the time for recuperation afterwards, therefore we will not have to do this again in the future.
Host: Right, well that's really good information, and Dr. Fleischer, thanks so much for your time today in talking with us about hernias and hernia surgery. For more information, please visit www.HighlandMedicalPC.com. That's www.HighlandMedicalPC.com. This is Sound Advice; a podcast from Highland Medical PC. I'm Bill Klaproth, thanks for listening.
Bill Klaproth (Host): If you feel a bulge or a lump in your stomach or groin, it may be a hernia. Welcome to Sound Advice; a podcast from Highland Medical PC. I'm Bill Klaproth and today's topic is hernia surgery. My guest is Dr. Lee Fleischer, a surgeon at Highland Medical PC and Director of the Department of Surgery at Montefiore Nyack Hospital. Dr. Fleischer, thanks for your time today.
Dr. Lee Fleischer, MD (Guest): Well thank you for having me. Glad to be here.
Host: You bet. So let's start here, Dr. Fleischer, what is a hernia?
Dr. Fleischer: Basically a hernia is a defect in the abdominal wall through which your insides protrude to the outside that can occur in many different parts of the abdominal wall, the most common area being the groin, also known as inguinal area.
Host: And how do they usually develop, Dr. Fleischer?
Dr. Fleischer: It's not uncommon to be born with a hernia in the groin area, that we call a congenital hernia. That's usually noticed when a child is born, it's in the first- could be first few weeks or first couple of years of life. Otherwise there are ones that wind up developing as we get older and the tissues get stretched out, or certain kind of trauma to an area occurs.
Host: So is it true that sometimes there are no symptoms with hernias?
Dr. Fleischer: Very true. Very true. Sometimes the patient just presents to his physician saying, "You know, I just noticed I was coughing the other day and I have this bulge in my groin. I got scared. I wasn't sure what was going on. Can you please take a look at this?"
Host: Gotcha. Alright so for someone with a hernia, if they say, "You know what? I know what this is, or I think I know what this is. I'm just going to keep working and keep doing my thing day to day." Do they risk further damage then?
Dr. Fleischer: That's one of the fears that most people have when they come into the office to see me. A hernia, as I said, is really just a defect in the abdominal wall, and anything behind that defect can protrude when the pressure inside is enough to make it push out. Now things can occur such as incarceration or strangulation which would be more of an urgent situation, but this is a lot less common. Incarceration is when something protrudes through the hernia defect, and that's the lump that you see, and if it gets stuck and can't go back in, it's incarcerated. If something becomes incarcerated and then becomes swollen, it can actually become an emergency because that is when the blood supply to protrusion or the hernia sac is limited and you can wind up having such bad blood supply to that hernia content that you wind up cutting off the blood supply to become sick. And that will be noticed by the patient because they become sick as well. If you continue with all your normal activities when you have a hernia but it's not bothering you, odds are it's not going to become incarcerated or strangulated, and therefore not become an emergency. So if you have an asymptomatic hernia, basically a hernia that you only see but doesn't cause you any problems, you are not going to do any harm by continuing along with all your normal activities.
Host: So what's your advice for when someone should see their physician?
Dr. Fleischer: Well if somebody has a new bulge, and they don't know what that is, it may or may not be a hernia, but they should be seen by their physician to have it examined and a diagnosis can be made. If a hernia is symptomatic, that is a time that they should actually seek surgical attention so that the repair can be performed, thereby alleviating any possible problems or emergencies.
Host: So let's talk about treatment. Is it always surgery that's needed to repair a hernia?
Dr. Fleischer: Unfortunately there's not much you can do for a hernia other than fix it surgically. There's a defect - the hole that I was talking about earlier - exists, and it doesn't go away, you can't exercise to make your abdominal wall stronger because it's really just a hole, and that hole has to be fixed with surgery so that the hole doesn't exist anymore.
Host: And what are the different types of surgeries that you use to repair hernias?
Dr. Fleischer: We basically split those up into two types. One is an open approach, which is a classic approach. The other one is a laparoscopic approach, which is a minimally invasive surgical procedure.
Host: And when it comes to surgery and anesthesia, is it usually local or is the person completely knocked out?
Dr. Fleischer: That all depends upon the size of the hernia and the location of the hernia and what actually is causing the hernia, or what caused the hernia. For an inguinal or groin hernia, that is very typically done with local anesthetic and sedation. Sedation so that the patient doesn't know what's happening and a local anesthetic so they don't having pain during the procedure. That's for someone having an open approach. However, if you're going to have laparoscopic repair or minimally invasive surgery for a groin hernia, that can only be done under a general anesthetic.
Host: Dr. Fleischer, with the advancements in minimally invasive surgery, are you doing most hernia repairs with minimally invasive surgery now?
Dr. Fleischer: Probably about a 50/50 proportion. Minimally invasive surgery is used obviously in patients that can undergo general anesthesia. If someone is not physically fit for general anesthetic, it has to be done under a different type of anesthetic, and therefore laparoscopic repair cannot be performed. For somebody with a single-sided non-recurrent hernia in the groin, the recommendation is usually to have it done using the open technique under local anesthetic and sedation. The reason is multi-fold, but basically in a simple format, for someone with a unilateral or single-sided non-recurrent hernia, the risks and benefits are the same whether you do it laparoscopically or using the open technique, therefore the only difference would be the anesthesia that's used for the procedure. If you can perform a surgical procedure to repair a hernia under local anesthetic and sedation, as opposed to a general anesthesia with the same risks and benefits, the benefit to the patient would really be to perform it under the local anesthetic sedation. It's basically having something done with less anesthesia. For the same benefit. If somebody has two hernias, in other words one on each side of the groin, that's a bilateral hernia, and the benefit is actually for minimally invasive surgery because recuperation risks and benefits are less if you do it laparoscopically.
Host: Okay, got it. And when it comes to the repair, do you use mesh then to make this repair?
Dr. Fleischer: Meshes have been used for probably well over forty years now, and they really do aid in decreasing the risks after having surgery for hernia repair. One of the main risks would be a recurrence, and a recurrence rate is drastically reduced if we include mesh during the repair. Also the pain after the surgery is much less if we use the mesh because basically you can perform the surgery with less tension and less tissue disruption if you're going to include a mesh for the repair. Therefore it leads to less pain afterwards, less swelling, and the patient feels better recuperates quicker. So yes, most of the time mesh is used for a hernia repair, unless the hernia is so small that there's really no benefit to adding the mesh.
Host: Right. So let's talk about recuperation. How long will someone usually be out of work, and what is the typical recuperation period like?
Dr. Fleischer: Well, if we take a single-sided or unilateral inguinal hernia repair, a patient that does not do physical labor can go back to office work in one week. They're not going to be 100% normal, but they're going to be 80% or maybe a little better than that when they return to work, and since they don't do any heavy lifting, they're not going to aggravate their groin and they can actually manage to get a full day of work. If somebody does have manual labor, we do extend the recuperative period a little bit longer. For somebody who does heavy duty manual labor, I may personally keep them out of work two or three weeks until they're feeling a little bit better before they put too much stress and strain on the hernia repair.
Host: And can people resume normal activities then eventually? Somebody that's a laborer that's a lifting heavy things, will they be able to do that then after the recuperation time?
Dr. Fleischer: Oh absolutely. That's a very common question I get in the office. People come in afraid that now that they have a hernia, they really can't do anything for the rest of their lives. Really what I tell them is before we do the hernia repair, you can continue doing whatever you've been doing. After the hernia repair and after the recuperative period is done, you can get yourself back into all your normal activities. That means a pipe fitter can lift heavy pipes and do their manual labor, or even sports enthusiasts can go back to running marathons, people can climb mountains, whatever they were doing before once the recuperative period is over.
Host: Well that's really good news, and last question then, can a hernia come back?
Dr. Fleischer: Unfortunately they can, but given the newer techniques these days and with the help of the mesh, the recurrence rate is actually a whole lot lower than it used to be. For example, somebody with a unilateral or single-sided. Non-recurrent hernia, the first repair gives them a typical recurrence rate of 1% to 3%. That's nice and low, and life goes on after that. For somebody with a recurrent hernia though, their recurrence rate does go up higher. So that's why I usually tell my patients the first repair is the most important repair, and please put in the time for recuperation afterwards, therefore we will not have to do this again in the future.
Host: Right, well that's really good information, and Dr. Fleischer, thanks so much for your time today in talking with us about hernias and hernia surgery. For more information, please visit www.HighlandMedicalPC.com. That's www.HighlandMedicalPC.com. This is Sound Advice; a podcast from Highland Medical PC. I'm Bill Klaproth, thanks for listening.
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