Online Health Chat with Michael Rosen, MD

Monday, March 23, 2015

Description

While approximately 5 million people in the United States have an abdominal hernia, it’s estimated that only about 700,000 of these individuals seek medical treatment every year. In most patients, the cause of a hernia is not known. An injury, straining or weakness in the area may contribute. Some hernias don’t cause symptoms, but if you are experiencing discomfort and pain, you should see a doctor as soon as possible. Left untreated, a hernia can lead to more serious, life-threatening conditions. Some patients may avoid treating their hernias because they fear painful surgery. Often, however, hernia surgery is performed on an outpatient basis with a minimal recovery period.

If you reach the point where you need hernia surgery, it’s important to go to a comprehensive hernia center to get the best treatment. With expertise in both minimally invasive surgery and large comprehensive surgery, a dedicated hernia center helps ensure the operation is done right the first time. Advances in minimally invasive surgery mean that, for many patients, hernia surgery is no longer a major operation that puts you in the hospital for a week to 10 days. Patients now typically go home within a couple of days.


About the Speaker

Michael J. Rosen, MD, is a general surgeon in the Department of General Surgery in Cleveland Clinic’s Digestive Disease and Surgery Institute. He is director of the Hernia Center and specializes in comprehensive hernia care, including inguinal, incisional and ventral hernias, using minimally invasive approaches, complex open and repeat surgeries, and complex abdominal wall reconstruction. Dr. Rosen completed his residency in general surgery at Massachusetts General in Boston, Massachusetts. He then followed with a fellowship in minimally invasive surgery at Carolinas Medical Center in Charlotte, North Carolina.


Let’s Chat About Hernias

Moderator: Welcome to our chat about Hernias: What You Should Know with Cleveland Clinic general surgeon, Michael Rosen, MD. Dr. Rosen, thank you for taking the time to be with us to share your expertise and answer our questions.


Hip About Hernias

monmu: Are there different types of hernias?

Michael_Rosen,_MD: The most common types of hernias include:

  • Inguinal hernia – A type of hernia that develops in the groin.
  • Ventral hernia – A type of hernia in the front of the abdominal wall. An umbilical hernia is one common type.
  • Incisional hernia – A type of hernia that develops at the site of an incision from a previous surgery. It may develop shortly after the surgery or years later.
  • Hiatal (or hiatus) hernia – A type of hernia that develops where the esophagus (swallowing tube) comes through the diaphragm (breathing muscle).

sam500016: Will wearing an athletic supporter prevent a hernia? How do I find out if I have hernia or am at risk for it? Thank you.

Michael_Rosen,_MD: There is no way to prevent a hernia. In fact, hernias have never been linked to heavy lifting or exercise. A hernia is a hole in the muscles of your abdominal wall, and often when you perform any heavy lifting, you increase the pressure inside your abdomen and things tend to protrude out. Thus, heavy lifting makes a hernia that is there more symptomatic, but doesn’t cause it. You need to see a doctor and have an exam to confirm if you have a hernia. Often, patients feel a bulge or something moving in and out of where they have a hernia. Sometimes, patients don’t experience any symptoms related to a hernia.

Semrose: Other than wearing an abdominal binder for hernias, are there other methods of alleviating the discomfort?

Michael_Rosen,_MD: There is really no other way to relieve the discomfort other than having a surgical repair. If you are having significant discomfort relating to your hernia, you should seek a visit to a surgeon to make sure you are not at risk for progressing on to an emergency indication for surgery. We would be happy to see you for a consultation.

angelwol: Can having a hiatal hernia cause problems with digestion, and is there a minimal invasive surgery method for this type of hernia? Thank you.

Michael_Rosen,_MD: Yes, hiatal hernias can cause reflux, difficulty swallowing, nausea and regurgitation. There are several questions that must be addressed to determine if you are a candidate for hiatal hernia surgery. In particular, how well does your esophagus contract and how much acid is entering the esophagus. An endoscopy must also be done to make sure there are no other issues. Once that is addressed, the vast majority of hiatal hernias can be repaired laparoscopically with a one day length of stay.

sinaihospital: I have had a hernia since 2010. It was found during my endoscopy exam by my former gastroenterologist. Can it be caused by GERD problems? I am due for another endoscopy this year. My last endoscopy exam was done in 2010. What tests and treatments can be done for a hernia in my case, doctor? Thank you.

Michael_Rosen,_MD: It sounds like you have a hiatal hernia. These can certainly cause reflux-type symptoms. If your symptoms are controlled with antacids, you often do not require an operation. If you are having symptoms related to your reflux despite the medicine, we can evaluate you for minimally invasive repair. This does require obtaining information as to how well your esophagus works and how much acid is in your esophagus.

docruthful: How are femora hernias diagnosed? Can they be concurrent with other hernias?

Michael_Rosen,_MD: Femora hernias are a type of groin hernia that occurs lower down and can present with a bulge on the upper thigh. They can occur with any other type of hernia. They are more common in females. Given the higher risk of incarceration and emergency issues, we typically recommend they are repaired once they are found.

johnnnita: Speaking of CT scans, my doctor has yet to order a CT scan, and I don't have the impression that will happen. Is a CT scan optional depending on the type of hernia? I'm the one that has a direct inguinal hernia with no symptoms other than a noticeable bulge.

Michael_Rosen,_MD: Typically, a CT scan is not helpful for an inguinal hernia. We usually obtain them for ventral and incisional hernias. Most often, a history of a bulge or the physical exam is all that is necessary for an inguinal hernia to be diagnosed. The only time we obtain a CT scan for inguinal hernias is to determine if there are other causes.

ralphallen: I am a very fit 72-year-old male. I have had two right-side hernias and one belly button hernia and now a left-side hernia. I think that adds up to four! And if it is significant, I have a hiatal hernia, which I have kept in control with daily 30 mg. Prevacid®. Why am I so prone to hernias? I am athletic but very smart in how I play and workout. My first hernia was done in Toronto, Canada, at Shouldice Hospital, which was light years ahead of the US surgeries. It was done in 1977 and finally broke in 2012. Thanks.

Michael_Rosen,_MD: We do not know why some patients are prone to hernias and others are not. It probably has to do with the way your body produces collagen. It has never been linked to heavy lifting or exercise. Likely, you already had a hernia and then exercising and increasing your intra-abdominal pressure just makes them symptomatic as things bulge out. With all of those hernias, it is likely that you should have mesh now. Also a laparoscopic approach is ideal to fix hernias on both sides of the abdomen, as we can do it through the same small incisions.


Something About Symptoms

PhotoGuy: I have had my inguinal hernia for at least two years, maybe more. I can cope with pushing it back in, but am afraid of the statement, "It could become life threatening." My question is: When do I know it is life threatening? What symptoms do I look for so I know I have to take emergency action?

Michael_Rosen,_MD: The issue with a hernia becoming “life threatening” relates to what you are pushing back in. Typically, when you have a hole in the abdominal wall, it is allowing things like the intestines to poke through. These can become stuck in the hole, get swollen, not be allowed to return and then go on to lose their blood supply, and this becomes an emergency. If the hernia is truly asymptomatic, that is extremely rare. If you are having symptoms (such as pain in the area or change in bowel habits) or are having difficulty pushing the contents back in, you should see a surgeon and get it repaired. These can often be repaired using minimally invasive techniques with an outpatient surgery, and you can be back at work in less than a week.

johnnnita: What does "totally asymptomatic" mean to you? You just mentioned that. I have a noticeable bulge, but no other symptoms yet.

Michael_Rosen,_MD: Totally asymptomatic means you are not having pain in the area, your bowels and bladder are working normally, you have no limitations in your daily activities and you are able to live your life as normally as you would want despite your hernia.


Surgery Specifics

Jake87: I have two hernias, one lower left abdomen, the other in my belly button. I'm a relatively fit, 58-year-old male. Can they both be fixed at once? I have insurance with a high deductible. How can I determine what my portion of the cost will be ahead of time? How soon can it be scheduled to be fixed? Is there a backlog?

Michael_Rosen,_MD: Yes. Often we can fix two hernias at the same time, particularly if they are at the belly button and in the groin. This can often be done on an outpatient basis laparoscopically through three very small incisions. We do have financial counselors who can address the cost with you. We would be happy to reach out to you after the chat. Typically, these cases can be scheduled within a few weeks of the initial consult.

johnnnita: I am scheduled soon for hernia surgery (this month). Which anesthesia method would be best for this type of surgery? I have one direct inguinal hernia on my left side just above the scrotum. It was initially diagnosed about 15 years ago, but only a few months ago did a bump/bulge appear. I'm not in any pain, though. I understand it will be an "open" surgery (not laparoscopic). My second question: is open surgery any safer/better than laparoscopic? Oh, by the way, I did have mitral valve repair surgery at Cleveland Clinic in January 2007, and I understand that I shouldn't be concerned about any anesthesia (other than normal). I've been fine ever since that time.

Michael_Rosen,_MD: Yes. Open inguinal hernia surgery can be performed under local anesthesia. It typically involves a mesh being placed to repair the hernia. In an experienced surgeon’s hands, it is a perfectly appropriate technique with excellent long-term results. Laparoscopic inguinal hernia repairs are also widely performed, and you would likely be a candidate. The downside of laparoscopy is that you must have general anesthesia. The advantage of laparoscopy is that it does result in less short-term pain and has been associated with lower rates of long-term chronic pain when performed by an experienced surgeon. Ultimately, the most important factor in getting a good repair is to have a surgeon that is skilled in the operation that you are having.

Semrose: After emergency abdominal surgeries four years ago, I have two large hernias. I was told then that I needed to lose weight before having them repaired. I don't think I can ever lose enough weight because I have tried. (I am 230 pounds.) Can the surgery ever be done on a heavy 54-year-old woman like me?

Michael_Rosen,_MD: While we can certainly operate on patients who are overweight, there are clear risks associated with being overweight during hernia surgery. Patients who are overweight are at a higher risk for wound infection, mesh infection, recurrence and overall postoperative complications. We have a very comprehensive team that tries to assist patients in losing weight. We have a medical and surgical weight loss team that can address and tailor an approach for you to be successful. It is worth a consultation to determine the anatomy of your hernia and set some reasonable goals to achieve prior to your hernia repair.

brockington: Dr. Rosen: I am obese (BMI >40) and have a ventral hernia of about 15 cm in diameter next to an incision from prostatectomy. Can I be a candidate for surgery in my present condition?

Michael_Rosen,_MD: As mentioned in my prior post, obesity is clearly linked to worse outcomes after hernia repair. We have a comprehensive approach to medical and surgical weight loss that has been very successful for many patients. I would strongly encourage you to come in for a visit and start this process, as your hernia is already quite large and the natural history of hernias is to slowly increase in size.


Road to Recovery

Semrose: With surgical hernia repair, what can I expect for a length of hospital stay? (I have two large abdominal hernias.)

Michael_Rosen,_MD: The approach and expected recovery will depend on how "large" your hernias are. Some hernias can be repaired laparoscopically and can have a short one- to two-day length of stay. Others can require complex open repairs with longer hospital stays up to seven to 10 days. Typically, this can be determined by physical exam and review of a CT scan.

Semrose: After abdominal hernia repair, how long must I recuperate before resuming exercise like swimming?

Michael_Rosen,_MD: Exercise resumption can vary depending on the size of the hernia and the type of repair. For most hernia repairs, we ask that you do not immerse the incision underwater for the first two weeks to prevent healing issues. However, most patients can return to vigorous activity within four to six weeks.

Jake87: How soon to resume normal activities like exercise, playing golf, yard work, washing the cars, etc. after the procedure?

Michael_Rosen,_MD: Four to six weeks.

Juanitarievley: My husband has an umbilical hernia that looks painful, but he says it isn't until he touches it. I want it "fixed." What does the surgery involve and how much recovery time will there be?

Michael_Rosen,_MD: If it is a small hernia, it often can be fixed as an outpatient procedure. Typically, we make an incision just below the belly button and either just stitch it up or use a mesh. Patients are able to go home the same day, are sore for about a week and then return to normal function. It is probably best to set up a visit to be evaluated and have a conversation with your husband.


Questions About Complications

turt21: Greetings. I am a pre-lung transplant patient. I was on the active list after having been on a ventilator three times and one time having had a tracheostomy. I have pulmonary sarcoid diagnosed 23 years ago and have been on prednisone the whole time. Having bounced back, I am presently on the “inactive” list although I have been on supplemental oxygen for five years. The last time I was on a ventilator was three years ago, and I came away with two hernias, one is umbilical and one is where a feeding tube was located. These have become quite ugly, albeit not painful. My GERD is getting worse. My question is whether it’s dangerous for me to have these corrected due to the mesh that is used and my long steroid use. Looking at these every day is painful. This isn't the belly button I was born with. Do you think these two can be dealt with safely? Thank you.

Michael_Rosen,_MD: Steroids can affect wound healing and certainly can complicate any elective operation. However, many patients with hernias are on steroids, as they have also been linked to the cause of hernias. We have much experience operating on patients taking steroids, and there are certain things we can do surgically to reduce the risk of infection. We can often perform a minimally invasive or laparoscopic approach, which significantly reduces the risk of infection. If you are not a candidate for a laparoscopic approach, newer meshes placed under the muscle also resist infection. However, your operation will require general anesthesia, and we will have to make sure your lungs can tolerate the procedure.

Chappell: At age 83 and in good health, I have an inguinal hernia that causes me no pain and that I can still "push in." If surgery would offer me relief from this "nuisance," without any radical complications, I would consider repair. How common is damage to the inguinal nerves during surgery for a hernia? How serious are the complications? Can damage be avoided? Can damage be corrected? How good is the mesh repair? How often must it be replaced? What other factors should I consider? Or, at my age, should I just live with the nuisance? Please discuss. Thank you.

I am reluctant at age 83 to have my hernia repaired because:
1. Abdominal surgery has been known to cause damage to the pelvic nerves creating severe pain and possible disability.
2. The mesh patch material is not a permanent fix and often requires replacement.

Michael_Rosen,_MD: I would agree that it is always important to carefully consider the risks and benefits of surgery, particularly at age 83. There are many factors that go into whether we take an operative or a nonoperative approach to a hernia. Depending on where it is in the abdomen and if there are symptoms related to the hernia such as pain, changes in bowel habits or skin issues. If the hernia is totally asymptomatic, it can be observed. If it is bothering you or affecting your quality of life, I do recommend repair. We have newer, minimally invasive approaches to repair hernias that significantly reduce nerve injury and chronic pain. While no mesh is perfect, the risk of removing a mesh is rare.

Tiant: For inguinal hernia in a male, if you are a candidate for laparoscopy, should you choose it over traditional? Are there fewer chances for subsequent nerve pain? I am already suffering from RSD nerve pain as a result of foot surgery in 2011. Thank you.

Michael_Rosen,_MD: The most important predictor of a good outcome after inguinal hernia repair is to make sure the surgeon is an expert at the operation, whether laparoscopic or open. There are many studies that suggest that laparoscopy does result in less chronic pain, when performed by experts. It sounds like you are at high risk for chronic pain, and I would advise that approach if you are a candidate.

frou11: I have what is probably a large incisional umbilical hernia. I hear there can be serious post-op problems with mesh. Is pledgeted repair an option and do you use it?

Michael_Rosen,_MD: Large incisional hernias can be very complex operations that have serious potential side effects and risk of postoperative complications. While mesh is certainly not perfect, there really are no other alternatives to result in a durable long-term repair. However, with new innovative surgical approaches and newer meshes, the risk of mesh is continuing to decrease. I am not familiar with a pledgeted repair.


Problems with Prior Surgery

gm3: I had open surgery for an abdominal aortic aneurysm in October 2013. The entry incision was made on the left side, and above the incision line I have bulge that will not go down. The operating physician is advising that this is crust area with laxity in the abdominal wall and will eventually go down. A second physician opinion advised that I have an incision hernia, and the only way to correct it is through a surgical procedure. My last CT scan reflected that the bulge area did not "appear" to be a hernia. (1) Is there a procedure that would determine exactly what is causing the bulge, and if the bulge is due to abdominal laxity will a strong exercise routine eventually reduce the bulge? (2) If bulge is an incision hernia, what is the procedure to repair the same? Your response would be appreciated.

Michael_Rosen,_MD: It sounds like they repaired your aneurysm through a flank incision. If that is the case, then in order to do that, you have to cut through the muscles and nerves, and the muscles can atrophy and weaken over time. This can present as a bulge, and often on the CT scan we can see that the muscles are thinner than the other side. Unfortunately, there is not much we can do to improve that surgically. But, luckily, it will not cause any long-term risk for bowel issues. While exercise will help build up the other muscles of your abdomen, they won't improve the denervated muscles. Alternatively, you can have a hernia, which means a true hole in the abdominal wall. This does predispose you to risks of bowel issues and should be repaired. This can be determined by physical exam and review of the CT scan. We will be happy to reach out to you after the chat to set up a consultation.


Particularly Problematic

beggingforhelp: I have had a large growth next to my navel for at least one to two years. Only one CT scan out of eight ever found my small hernia in my navel. Now, for a year, I have suffered and begged the doctors to do open surgery. This is causing bowel blockages, shortness of breath, nausea – torture! They said I needed an MRI and an MRA, but they never ordered it. Finally they did, but three times in a weak they cancelled my MRI. They said they only do MRI on organs, not lumps or growths. I am going to die from this. How do we find this growth when there is no CT, etc. to find it? It is as large as my hand. Can robotic surgery fix this knot? My gynecologist wants to do endo abolition at the same time – does not want to put me to sleep twice. Please help me. Thank you for this website.

Michael_Rosen,_MD: Sounds like this is a very challenging problem. I think the best thing to do is come see me for a full consultation so that I can examine your belly button and look for a hernia myself. I can also review the CT scans and see if I am able to see a small hernia. Often, it is very difficult to review the CT scans and actually identify small hernias. We will reach out to you after the chat.

Stolly6819: Please refer these questions to Dr. Rosen, as he performed hernia surgery on me back in 2008 and stated I should seek his attention if further issues arose. Dr. Rosen, I sought medical attention due to a severe pain that goes down my leg, which the doctors keep thinking is my back. I asked them if this could be from my hernia pushing back onto my spine. The doctors look at me like I'm crazy. Is it possible for this to happen? I know that I have had leg pain in the past but not as severe. They have given me injections to see if it is my sciatic nerve causing the pain in my back. Dr. McCollister did a CT scan and, yes, the hernia has begun to come back. He has tried to email you to ask you if this is possible. I have been sent to pain management to see if that would help, and they keep saying it’s my back. They gave me more injections and also have done a nerve scan, which came back normal. Now he wants to put in a stimulator. I have many more questions – I need to know answers.

Michael_Rosen,_MD: Sounds like you have several things going on and certainly a hernia can cause some of these symptoms. I'm glad you've found me, as I've moved to Cleveland Clinic. We can set up a visit for you to see me, and I can examine you and review your CT scan. We can then come up with a plan to make you better. Take care, Dr. Rosen.


General Questions

SteveRose: Why should I come to Cleveland Clinic Hernia Center?

Michael_Rosen,_MD: At Cleveland Clinic Hernia Center, surgeons perform more than 2,000 hernia repairs each year, from the routine to the most complex cases, at 16 convenient locations in northeast Ohio. Our center is designed so that patients receive individualized care, undergoing a comprehensive evaluation with a board-certified surgeon to determine the best surgical procedure for their specific type of hernia, which helps avoid recurrent hernias and complications. You can call 866.709.5935 to schedule an appointment.

Stolly6819: Is there a way to speak with you on the phone due to living several miles away?

Michael_Rosen,_MD: Yes we can speak. It is worthwhile to call my office first and let us collect information about you and determine if we need any imaging studies so we can have an informed discussion. Our telephone number is 216.445.3441.


For Appointments

Hernia treatment is available at Cleveland Clinic Main Campus and at 16 regional locations. To make an appointment with Dr. Rosen or any of the board-certified specialists in Cleveland Clinic’s Hernia Center, please call 866.709.5935, ext. 47000 (toll-free). You can also visit us online at www.clevelandclinic.org/hernia. Same-day appointments are available.


For More Information

Cleveland Clinic

At Cleveland Clinic’s Hernia Center, surgeons perform more than 2,000 hernia repairs each year, from the routine to the most complex cases, at 16 convenient locations in northeast Ohio. Our center is designed so that patients receive individualized care, undergoing a comprehensive evaluation with a board-certified surgeon to determine the best surgical procedure for their specific type of hernia, which helps avoid recurrent hernias and complications. This comprehensive center is the first of its kind in Northeast Ohio and one of only a handful of such centers in the nation.

Cleveland Clinic Health Information

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