Jul 25, 2019

Announcer: Health information from experts supported by research. From University of Utah Health, this is thescoperadio.com.

Interviewer: Hernias are extremely common and millions of people have them, and symptoms can vary from men to women. They also vary depending on the type of hernia you have. And if you have one, you should get it treated.

Dr. Rodney Barker is a surgeon and hernia specialist at University of Utah Health. And let's start out with a very basic thing here as we go through our journey. What is a hernia?

What Is a Hernia?

Dr. Barker: A hernia is a defect in the abdominal wall. Some people call it a hole in the muscle, but it's more complicated. There's muscle. There's connective tissue that holds muscles and tendons together. When we get a defect there, it allows something that normally belongs in the abdomen to protrude through that defect, and that is the process of herniation.

Interviewer: And is it a genetic reason that I would have this defect? Does everybody have the defect?

Dr. Barker: It's genetic to the human condition, but there are natural weak spots where they typically occur.

Interviewer: All right. So everybody has the possibility of getting a hernia?

Dr. Barker: Correct.

Interviewer: Nobody is completely immune.

Dr. Barker: That's correct.

Hernia Symptoms

Interviewer: All right. So you've mentioned one of the symptoms I think, is there is that weakness in the abdominal wall and all that tissue, the more complicated version, and something kind of pokes out. Is there a noticeable bump?

Dr. Barker: In most people, yes. That's what they first notice. But if someone has a very small hernia and they're large, they may not feel or notice the bump themselves.

Interviewer: Okay. I've heard kind of the classic way is you go to pick something up or you're lifting something or pushing some weight and you feel a pop. Is that kind of the traditional way most people would experience . . .

Dr. Barker:That's probably a minority of the patients that I see. It is still fairly common, but most people are in the shower or they're doing something and they incidentally find this bump.

Interviewer: Okay. And didn't even realize, at the time, that they did anything.

Dr. Barker: That's correct.

Hernia in Women vs. Men

Interviewer: All right. So I was told that hernias are a little different in men than they are in women. How is that?

Dr. Barker: Most hernias are the same. Inguinal hernias, which are the commonest type that we fix, tend to be more noticeable in men and easier to diagnose because of the difference in anatomy. In women, they don't get the same degree of outward bulging. It's not often as easy to palpate or feel it.

Interviewer: And as a result, are there more women that are walking around with hernias that don't realize it than perhaps men?

Dr. Barker: No way to know that.

Interviewer: Okay, fair enough.

Dr. Barker: Probably not. Men are more prone to getting inguinal hernias than women.

Interviewer: All right. So you could have a hernia and not even know that you have a hernia.

Dr. Barker: That's correct.

When to See Your Doctor

Interviewer: Yeah. So then could it possibly heal on its own?

Dr. Barker: No, it won't heal on its own, but if it's there and it's not bothering you and you don't know about it, it's not a dangerous problem.

Interviewer: Okay.

Dr. Barker: It's not something you need to worry about or run and see your doctor and say, "Do I have a hernia?"

Interviewer: So if it's something that it's not giving you any sort of complications, you're not feeling any . . . like, what would be an indication that this is actually a hernia I should be concerned about?

Dr. Barker: So if you feel the bump or the bulge or you're having discomfort or you're questioning that, that's something to get checked, and you could see your doctor and check for that.

Is a Hernia Dangerous?

Interviewer: Are there any dangers of not treating after you realize that there's a bump there or you have some discomfort?

Dr. Barker: The danger of a hernia, and I use that word literally, danger, is that you can get bowels stuck in it. Incarceration is what we call it. That bowel can sit there long enough, swell up, and strangulate. It sounds terrible. It is terrible, but it's very rare. Most hernias will not go on to incarcerate.

In my training, when I first started years ago, we would tell people with a hernia, "Boy, you should get that fixed because, you know, it could strangulate on you sometime." These were hernias that were often found on routine physical exams in totally asymptomatic patients.

Since then, we've learned that the rate of incarceration in a totally asymptomatic small hernia is very, very low. And we don't rush all those people to surgery anymore.

Interviewer: So do you have a lot of patients that come in with kind of initial hernia symptoms and then you just kind of watch them?

Dr. Barker: Not too many, because most of the time by the time they're seeing me, they've made that decision. But I've seen patients who have had a hernia for 10 years and they've just been watching it and now it's growing and becoming symptomatic.

Your Options For Hernia Treatment

Interviewer: Got you. So let's talk about how you treat a hernia. I understand there are three different ways. Two of them you kind of use now. One of them not so much anymore. Explain what those are.

Dr. Barker: Correct. The first we've talked about. We call it watchful waiting. And I use those words carefully when I talk to patients. I don't tell them, "Hey, we're just going to ignore this. Go away. Don't worry about it." We're going to watch it and we're going to wait.

The majority of people that have hernias will eventually get them fixed. One study showed that within a year, 30 percent. By five years, 70 percent, 75 percent are going to have it repaired. And that's because the hernias get bigger and they become more symptomatic or the patient changes their mind to say, "Yeah, this really does bug me. I want to get it taken care of." So watchful waiting is most of the time a temporary treatment.

The second option, and the most common thing, is we operate on them. We repair them. That is the standard of care for symptomatic hernias.

The third option is not used much anymore. I see it more in elderly patients. But 30 years ago when I started, I saw it much more frequently, and that is to wear a truss. Trusses are like little belts with a pad or a ball on them that pushes in on the hernia. And the idea is that keeps it from coming out.

The problem with trusses is they don't work very well. They are uncomfortable for most patients, and we rarely see them anymore. And I don't ever prescribe them. If I have a patient who says, "I want a truss," they can Google it and find some vendor that sells it and buy it if they want to.

Interviewer: Sure.

Dr. Barker: It's pretty rare, though.

Hernia Surgery

Interviewer: And as far as surgery is concerned, what type of procedure is this? Is it a laparoscopic, you know, that small incision surgery, or is it an open surgery?

Dr. Barker: It's both and it depends on the hernia type. It depends on is it a brand new hernia or a recurrent hernia? And it depends on the preference and skill of the surgeon that's doing it.

Most hernias are still repaired with an open approach, where they make a single incision, cut through the layers, sew it up usually with a patch, get out.

Laparoscopy is done frequently. I'm primarily a laparoscopic surgeon when it comes to hernias, especially inguinal hernias. In that, we make three little incisions and go in with a camera and long skinny instruments. There's less cutting and sewing of the natural tissues. It does require a patch to be put in there to block the hole, but it works very well and it has a very acceptable recurrence rate.

Hernia Repair Recovery

Interviewer: And after a hernia surgery procedure, what type of recovery would a person expect at that point?

Dr. Barker: So the average laparoscopic repair that I do, most people within a week are back to their regular activities or close to it.

Interviewer: Wow.

Dr. Barker: I don't put any restrictions on after that first week.

Interviewer: Got you.

Dr. Barker: It's either fixed or it's not, and the patch is well set up or it's not, so lifting is not going to make any difference.

Interviewer: What about the more open type of surgery? Does that take a little bit longer?

Dr. Barker: It does. And it depends, again, on how it's done. If you bring tissues together and put stitches in them, you need to wait for that to heal. And that can take up to six or eight weeks.

It also depends on whether mesh was used or if it's just a straight-up suturing. Without any reinforcement, if we just straight up suture, I tell people six weeks of limited activity so they don't pull that apart.

Interviewer: But they can go back to work if it's not an active job within a week, two weeks?

Dr. Barker: Yeah. It depends on the job and how they feel.

Interviewer: Got you.

Dr. Barker: I have, you know, experience over this with part of it is their job. If you're a guy who hates your job and it requires physical activity, I won't get you back for a month. If you're a self-employed accountant and it's tax time, you'll be in the office the next day.

Interviewer: Yeah, I bet. All right. What's the bottom line when it comes to hernias, in your mind?

Dr. Barker: Well, I've done a lot of them, so it's . . .

Interviewer: That's good.

Watching Hernias Before Fixing Them

Dr. Barker: You know, they're very common. It is one of the most common operations done in the United States. About a million of them a year are repaired here. It is the most common surgical procedure I've done over the years, thousands of them.

We've changed in 30-some-odd years from fixing every single one we see because, "Gosh, you know, you're going to get incarcerated," to, "Well, let's watch it if it's not bothering you." We still fix all the hernias that are bothering people or that are at risk for incarceration.

Hernia Mesh: A Surgical Debate

I think the biggest controversy now or the biggest question we have is, "What's the role of mesh?" When I started, we rarely put it in. We sutured tissue together. We then switched to mesh, and now, in the 80s and 90s, almost all hernias are repaired with mesh since then and people are starting to blame the mesh for various things.

A lot of these people don't remember what I do in the pre-mesh days when we were seeing people come back with their fourth hernia at the same spot and we had no idea how to fix it because the tissue was gone. There was just nothing you could do for these people.

So I think mesh has done a lot to reduce recurrence rates, but there are questions about it. You know, it's a foreign body. Is it causing more pain? Is it causing other issues? And I think those questions need to be studied and answered.

Interviewer: What's your take on that, then, if a patient came to you and said, "I would rather not use mesh"?

Dr. Barker: We have a very frank discussion. I say, "We can fix your hernia without mesh." If it's a small umbilical hernia, we'll do it anyway without mesh. If it's a groin hernia, it's a longer discussion.

The vast majority of patients, once they hear the science behind it and once they hear their options and why we do it, opt for mesh repairs. We can do repairs without mesh, but most of us nowadays aren't that good at it. I trained doing them. I still do occasional ones, but it's not what I would choose for myself. If I had to have a hernia fixed, I would have it done laparoscopically with a mesh patch.

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