Hernia & Abdominal Wall Reconstruction

Podcast Transcript

Dr. Scott Steele: Butts and Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end-to-end.

Hi again, everyone. Welcome to another episode of Butts and Guts. I'm your host, Dr. Scott Steele, the president of Main Campus here at Cleveland Clinic in beautiful Cleveland, Ohio. Today I'm super excited to have Dr. Eric Owings, a general surgeon at Cleveland Clinic Tradition Hospital in Florida. We're going to talk a little bit about something that we have maybe touched base on a little bit in the past, and that's hernia and abdominal wall reconstruction.

Eric, thanks so much for joining us here on Butts and Guts.

Dr. Eric Owings: Scott, thanks for having me. I'm just excited to be on the podcast with you today.

Dr. Scott Steele: Fantastic. As listeners to our podcast know, we always like to start out with a little bit of background for you. Where are you from, where did you train, and how did it come to the point that you're at the Cleveland Clinic?

Dr. Eric Owings: All right. I am originally from High Point, North Carolina. Did schooling at the University of North Carolina, and then the University of Louisville. Then I did all my surgery training at the University of Tennessee in Knoxville. It was there that we had some really amazing hernia people that taught us all sorts of tricks and trade of hernia repair and abdominal reconstruction.

After Tennessee, I joined with what was originally Martin Memorial, and then turned into Cleveland Clinic I want to say about four years ago. I've been out about eight years here. We're in Port St. Lucie, Florida. We're at Tradition Medical Center, where we have a pretty robust hernia, abdominal wall reconstruction program.

Outside of fixing hernias all the time, I have a wife and three little boys. We do all sorts of fun stuff. Pretty avid kite-boarder, fishing, all sorts of stuff like that, living an outdoor Florida lifestyle outside of that. That's a little bit about what we do down here.

Dr. Scott Steele: That's fantastic. We're so glad to have you here.

As I said, today we're going to talk a little bit more about hernias, and also about abdominal wall reconstruction. Can you share at a very high level what a hernia is and how it affects the body?

Dr. Eric Owings: Sure. A hernia is a defect. It's a defect typically in the muscle and the fascia through which something is able to then eventrate or squeeze. We typically think of it as an abdominal wall hernia. The abdominal compartment is made up of layers of muscle and fascia, and it's one main compartment there. If you think of what a hernia actually is, it's a defect in that. Akin to if you were to have a hole in a side of tube of toothpaste, and you were to squeeze that tube of toothpaste and something squeezed out the side. That same principle happens when you have a hernia, basically. In short, it's a hole, it's a defect, and it comes in all different shapes, and sizes, and locations.

Dr. Scott Steele: Piggyback on that. What are the most common types of hernias that patients listening to this should be aware of?

Dr. Eric Owings: The most common types of hernias that we see are inguinal hernias or groin hernias, which are lower abdomen in the groin region. Bilaterally usually, on both sides. Other common weak spots are the umbilicus. The way the abdominal wall is built, there's some places that are just naturally weak spots, whether it be the umbilicus because we were plugged up there as babies from your umbilical cord. Your inguinal canal is a naturally weakened spot as well, where there's really limited and no muscle there from an inguinal canal, which is actually a little tunnel. It's not supposed to be there, but it's a weak spot in our abdominal walls as well.

The other main type of hernia that we see real frequently, just in terms of abdominal walls, is from previous surgeries. We call those incisional hernias. Incisional hernias happen very frequently. As you can imagine, the etiology of that is from previous surgeries. We see a fair number of that.

Inguinal hernias, umbilical hernias, and ventral hernias. A ventral hernia is a catch-all term for anything on the front side of the abdominal wall.

Dr. Scott Steele: I know you said that the hernias occur in various places on the body. Can you talk a little bit about what type of symptoms patients would experience?

Dr. Eric Owings: Yes. Oftentimes, the hernia may not have distinct symptoms. They may have some mild dull pain, but often times you'll really see a problem from what gets squeezed through the hernia. Whether it be a loop of bowel which causes a real problem, or fat that gets squeezed through there. The way hernias develop is they typically will slowly enlarge in size, and people will feel more pressure, and then a bulge that can follow that.

When you have something else that starts to squeeze through there, what gets squeezed through depends on the symptoms. Say if you did have a ventral hernia, which is a hernia on the front side of the abdomen, and a loop of small intestine gets stuck through that like a kink in a hose, if it were to get stuck through a small hole, it can cause a bowel obstruction which elicits symptoms of nausea, vomiting, and severe abdominal pain. That's really the most significant and severe symptoms that I would be concerned regarding patients.

Dr. Scott Steele: How is a hernia typically diagnosed? Is this physical exam? Is there specific tests that you order?

Dr. Eric Owings: A little bit of both. Inguinal hernias, typically we're able to pick up almost all with a physical exam. They always happen in specific locations. A standard inguinal hernia typically does not require more advanced, intense imagining there. We know where it is. Unless there's something complicating that, we usually don't get a CT scan. However, a CT of the abdomen and pelvis is the roadmap for any major operative planning. We do CT scans for anybody with a recurrent hernia, anybody with a larger hernia, or anybody that has any uncertainty about that diagnosis. CT of the abdomen and pelvis really turns on the lights on everything inside the abdomen. It's really great for hernias specific. We rely very heavily on CT scans. Less so on ultrasounds, but really CT scans of the abdomen and pelvis are the main roadmap for guidance with major hernia repairs.

Dr. Scott Steele: You also talked a little bit about abdominal wall reconstruction being a variation of this hernia repair. Can you describe a little bit more about what that is and what situations might that be necessary?

Dr. Eric Owings: Abdominal wall reconstruction, it's hernia surgery, but it's a different type of hernia surgery in that you're fixing typically a defect that is much, much larger where you're having to basically rebuild the whole abdominal wall. Think of it as a standard hernia repair would be patching a wall. You have a hole in drywall and you're going to patch that hole. Sometimes we use a number of techniques to be able to achieve that. Abdominal reconstruction would be like building a whole new wall.

That becomes necessary when you have such large hernias, and typically these are from a ventral incisional hernia in a recurrence or some severe infections that have led to lack of any real integrity in the abdominal wall.

Dr. Scott Steele: Is this a worse-case type scenario when it comes to treating hernias? Are there other treatment options that are available?

Dr. Eric Owings: It's all along a scale. Small hernias typically require a more straightforward or simpler approach. But when you get into the realm of abdominal wall reconstruction and recurrent hernias like that, you really have to pull out some advanced techniques to be able to fix these more complex problems. Abdominal wall reconstruction is really the last major surgery that we would have to be able to fix somebody's abdominal wall. I would say yeah, it's pretty severe when it comes to the point of requiring an abdominal wall reconstruction.

Dr. Scott Steele: Truth or myth, truth or myth. Hernias can heal on their own without any medical intervention.

Dr. Eric Owings: Myth. Myth. We're not like lizards and regrow another tail. A hernia itself is a defect. It's a hole in the abdominal wall. Whether it be the muscle, the fascia, or some combination of layers of the abdominal wall because there are layers of muscle as well. If you have a true hernia, it's not something that gets better. Typically, hernias will enlarge over time. The reason they do that is that you have radial forces that act on these. A hernia is a circle if you think about it. As people go throughout their normal day, you have an increase in inter-abdominal pressure. That constant increase in inter-abdominal pressure slowly enlarges this small circle, or this hernia if you will. Those are the radial forces that we talk about there.

The other thing that we worry about with folks is that, as people age, the integrity of their collagen and their connective tissues also diminishes. Like anything else wears out, the strength and integrity of your abdominal wall also is not as strong. That's another thing that portends to lead to hernia enlargement.

Dr. Scott Steele: Can you talk a little bit about when do you decide to use mesh and when do you decide to use just the patient's normal tissues to fix the hernia?

Dr. Eric Owings: Sure. It's mainly a size factor. If you break it down between ventral hernias and inguinal hernias, we can talk about inguinal hernias without a mesh-based repair in just a minute.

But for ventral hernias or any hernia along the abdominal wall on the front side, it's a size-based thing. Plain and simple, if it's two centimeters or smaller, it's an option to use a primary tissue-based repair, which means sutures along, to be able to fix those. When you're really talking about larger than two centimeters, there's a couple of other factors that come into it. But when you really are talking about spanning a larger hernia and trying to close those with suture alone, the data doesn't really support a primary repair because there's too much tension on those sutures, there's suture pull-through. Your hernia risk of recurrence of that hernia run very high, about 60, 70 percent depending on a couple of other factors. The larger hernia almost always require some mesh-based or synthetic repair for ventral hernias.

The common question that we also see with inguinal hernias is, "Can I have my inguinal hernia fixed without mesh?" The answer is a little more complex. If you have somebody who is fit, trim, keeps in good shape with a BMI of low 20s, and it's a small hernia, then often times, yeah. Often times we can do a couple of techniques to be able to decrease some of the inguinal region to be able to achieve a primary tissue repair is what that's called. But if somebody really has a large defect in the groin, not optimal body conditions, not optimal tissue there, then trying to fix a large hernia when you don't have enough extra tissue to be able to bring together without an unnecessarily high amount of tension, it really results in a failure. For inguinal hernias, it's sometimes yes, it's possible. But the patient has to be the perfect patient, has to be fit, has to be a relatively small hernia. And has to understand that the risks of a permanent tissue repair are oftentimes a little bit higher, just in terms of risk of recurrence of that hernia.

Dr. Scott Steele: What can patients then expect during the recovery period with or without mesh after the abdominal wall reconstruction, as well as after a groin hernia?

Dr. Eric Owings: Typically, a groin hernia is something that we're going to be fixing as an outpatient basis. It's done relatively efficiently, home the same day with limited downtime. We fix them either laparoscopically, robotically, or in an open approach. The recovery time often looks very similar with a permanent tissue-base repair versus a minimally invasive approach with a mesh. If you're talking about a minimally invasive approach, it always does require a mesh-based repair. That recovery is pretty fast. Most folks are getting back to normal activity really within the week or so. We still say no heavy lifting or strenuous activity, but the guiding principle behind a lot of hernia recovery is just common sense. If it hurts, don't do it.

Now when we start talking about ventral hernia repairs and recovery there, that can take a significantly longer time. You're using your abdominal wall for all sorts of things throughout your day. Getting up, going to the bathroom. Anything you're doing is moving your abdominal wall. We're fixing abdominal walls, and we're bringing the muscle and the fascia back together, so you typically feel that. The level of pain is a little bit higher with those hernia repairs from any modality, whether it be an open primary tissue repair, or it be a laparoscopic or robotic approach. There is more pain associated with that.

When we start talking about recovery time for abdominal wall reconstruction, it does depend on, again, the size of that hernia. If we're doing a true abdominal wall reconstruction, which often times what we do is a posterior or a transversus abdominis release, which is a very effective and definitive repair. Really, it takes a number of weeks to be able to recover just to be back to normal functionality, because we really do have to do a couple of maneuvers that allow us to be able to close the abdominal wall without tension and rebuild that abdominal wall, reinforcing that with mesh. That really does require a longer recovery time obviously. It's a little bit of a patient-by-patient basis though, too.

Dr. Scott Steele: Yeah, that's great. I know you mentioned earlier the risk of recurrence. Can you talk about the risk of recurrence after treatment?

Dr. Eric Owings: For standard hernias, the risk of recurrence when it's repaired well is very low. For an inguinal hernia, my hernia recurrence rate is about 0.5%. It can happen, but it's very, very rare for those standard hernias that we fix all the time to actually reoccur.

The chance of a ventral hernia to reoccur is a little bit higher. Though I think there's a significant advantage today with using, whether it be a robotic approach or a laparoscopic approach, with a mesh-based repair that the chance of having a ventral hernia recurrence is very, very, very low. It's not 0.5% low, but it's very low still. Two to five is what I would estimate that at now.

Dr. Scott Steele: How are hernias treated at the Cleveland Clinic? Do you do them robotically, laparoscopically, the old-fashioned open incision? Does it matter on the site?

Dr. Eric Owings: All of it does. We offer everything. We have open primary tissue-based repairs. We have a laparoscopic-based repair. We also have a robotic approach. We have a number of tools in the toolbox to fix different types of hernias. It takes some experience, in terms of knowing when to use which technique for different hernias because it is a highly variable field, if you will. It's user-dependent, it's patient-dependent. A lot of the surgical literature will say, "You should offer the patients the approach that you are the best at." It really benefits the patient if you're good at all of these different modalities.

It's not just you take a seven-iron to everything. It's you want to be able to operate well robotically, laparoscopically, and then still be able to do an open hernia repair and abdominal wall reconstruction, which oftentimes is open. But sometimes we are pushing that envelope a little bit more so now, with doing some robotic abdominal reconstructions.

Dr. Scott Steele: Are there any other advancements on the horizon when it comes to the treatment of hernias or in the abdominal wall reconstruction field?

Dr. Eric Owings: Yeah, there really are. We do a large volume of abdominal reconstruction through open surgery, which obviously requires a big open incision. That's required because you're really starting to dissect all the way around the abdominal wall, transecting through different fascial planes in terms of being able to increase the capacity of the abdominal wall. Classically, we're doing that from an open approach. As robotics has really advanced and progressed, we're able to translate some of thus open techniques onto the robot so that we can tackle larger hernias through these robotic abdominal reconstructions.

Now it's a selective number of patients that you can achieve that with, but it is a growing patient selection that I think is really the next big frontier for hernia repairs.

Dr. Scott Steele: Now it's time for our quick hitters, a chance to get to know our guest a little bit better. First up, what was your first car?

Dr. Eric Owings: Oh, a 1999 red Jeep Wrangler.

Dr. Scott Steele: What was the best trip that you've ever taken?

Dr. Eric Owings: I just got back from Wyoming and Idaho for two weeks, where I spent the first few days fly-fishing on the south fork of the Snake River. It was incredible fly-fishing and caught some really awesome fish. Then I actually drew a Wyoming elk tag, so I had an archery elk hunt in the Wyoming back country and was able to get a really nice five-by-five bull elk on day five of this six-day trip. It's an easy answer, that was the best trip that I've ever been on because it was such an incredible experience.

Dr. Scott Steele: Number three, what's your favorite food?

Dr. Eric Owings: Lobster.

Dr. Scott Steele: Then finally, give me a 15-second ad for why the Florida coast is the best place to visit.

Dr. Eric Owings: Well, in the wintertime it's amazing particularly when the first cold front comes through, and you actually have a reprieve from 100-degree heat. I find it to be a really, really amazing place because outdoor opportunities abound, and it's just a matter of what you want to do. Whether or not if you want to be out on the boat and go fishing, you can do that. I enjoy kiteboarding, and it's really windy down here all winter long. That's what I spend my free time doing, outside of repairing hernias and spending time with my family. I love that. It's an amazing family community as well. The Treasure Coast is where we call home. I'm a big fan of the area. Summertime gets a little hot, I'll say is the only downside.

Dr. Scott Steele: That's fantastic. Give us a final take-home message to our listeners regarding hernias or abdominal wall reconstruction.

Dr. Eric Owings: I would make sure that the person who's fixing your hernia has ample experience in doing that, and has ample experience in each one of thus techniques, and be able to offer multiple options in terms of fixing those. Not just a, "Hey, here's how we fix every single hernia." But it's a patient-specific approach, and it's also a surgeon-specific approach. That you want to be able to see somebody who really enjoys fixing hernias, does a large volume of them, and can offer a number of different types of repair.

Dr. Scott Steele: Well, that's fantastic. To learn more about hernias, abdominal wall reconstruction, or to schedule an appointment for treatment at Cleveland Clinic Florida, please call 877.463.2010. That's 877.463.2010. You can also visit clevelandclinicflorida.org/digestive for more information. That's clevelandclinicflorida.org/digestive.

Eric, thanks so much for joining us on Butts and Guts.

Dr. Eric Owings: Scott, thank you very much for having me.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.