Inguinal Hernias: From Groin Pain to Hernia Repair

Dr. Scott Steele:

Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end. Hi again everyone, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, colorectal surgeon and president here at main campus in Cleveland Clinic in beautiful Cleveland, Ohio. And today I'm very pleased to welcome our guest, Dr. Kevin Wissinger, who is a general and bariatric surgeon for the Digestive Disease Institute at Cleveland Clinic, Florida. Kevin, welcome to Butts & Guts.

Dr. Kevin Wissinger:

Hi, sir. Thank you for having me. I appreciate the time.

Dr. Scott Steele:

So we are going to talk a little bit today about inguinal hernias. And before we get into that, as listeners of this podcast know, we also like to hear a little bit about our guests. So Kevin, can you tell us a little bit about your background, where are you from? Where'd you train? And how did it come to the point that you're here at the Cleveland Clinic?

Dr. Kevin Wissinger:

Yeah, so I grew up in Pittsburgh, Pennsylvania, a climate not dissimilar to Cleveland, Ohio. And from there I went to Ohio State for college, and then I went to Temple for medical school. Following that, I did residency in Orlando at AdventHealth Orlando. And then specialized training in hernia, foregut and bariatric surgery at the University of California, San Diego. And then made my way back to Florida to start a practice here in Stuart, Florida. I live down here with my beautiful wife and two young children close to family. So this was the perfect location for us.

Dr. Scott Steele:

Well, fantastic. And we're so glad that you're able to join us here at the clinic. And so today, as I said, we're going to talk a little bit about inguinal hernias. And so for listeners who have maybe not heard our previous episode on hernias, can you start by giving us just a 500-foot level overview of what a hernia is. And then talk a little bit about what specifically makes that inguinal hernia different from other types?

Dr. Kevin Wissinger:

Yeah, so a hernia at its very basic form is a defect or a hole in the abdominal wall or pelvic region. There are different types of hernias that we see as surgeons. There can be hernias at the belly button or umbilical hernias. There can be hernias of the abdominal wall at prior incisions, which we rightfully call incisional hernias.

And then we have our inguinal hernias. Those are differentiated from the abdominal wall hernias basically due to location and how they present. There can be swelling that can extend pretty significantly and follow the anatomic pathways to extend into the scrotum for males. Or can bulge out significantly in the skin around the groin area.

Dr. Scott Steele:

So how common are inguinal hernias? And if you will, who's at most risk? We know hernias can affect anyone, but are there certain populations who might see this more frequently or occurring more frequently?

Dr. Kevin Wissinger:

Yeah, so the population at greatest risk, or highest incidence, put another way, is elderly males. So about 25% of men can experience inguinal hernias over the course of their lifetime. For women, that risk is much lower in the probably 3% to 5% range if we look back at population data. The reason men are more so at risk is basically the descent of the testicles as we're growing in utero. They start around the kidneys and descend along the retroperitoneum and then into the scrotum. Areas of potential weaknesses along the way where hernias can develop or also known as inguinal hernias.

Dr. Scott Steele:

Kevin, so I got to tell you, I'm a giant sports fan and I know that groin can be a sensitive topic for patients and even for sports fans. So I hear this term out there, "he had a sports hernia or a muscle pull." And I always wonder, is this a testicular issue? Is it something? Is this an inguinal hernia? What's the difference? And how do we tell the difference symptom-wise from these conditions?

Dr. Kevin Wissinger:

Yeah, so sports hernias are a niche topic in the hernia community, and they do present differently. Again, looking at the 500-foot view, sports hernias are basically a detachment of the abdominal musculature off the pubic bone. Another name for it is pubic neuralgia. It's usually in high-level athletes. We don't often see it in weekend warriors. However, it can happen in anyone.

It's more so in athletes who are doing explosive movements, lateral movements, hockey players, soccer players. And they can present and worsen with the activities that are related to that sport. The treatment algorithm is much different. You won't necessarily see a bulge. It's more so groin pain. It can be a deeper kind of pain. And we typically reserve surgery unless it is refractory to any other sort of medical or conservative management approaches.

Dr. Scott Steele:

So Kevin, you talked about the sports hernia and that being a little bit different and obviously the underlying pathology behind it. Are there different types of inguinal hernias themselves? And does that matter when it either comes to outcomes or treatment or anything? I know we're going to get into treatment a little bit later, but tell me about the types.

Dr. Kevin Wissinger:

Yeah, so there are two main types. There's an indirect inguinal hernia and a direct inguinal hernia. And this basically applies to the location of the bulge, not necessarily what's within the hernia itself. So the direct type hernias are more towards the midline portion of our bodies. And we as surgeons, when we see direct hernias, those are generally a little bit more straightforward in terms of repair.

An indirect hernia is a defect that's a little bit more towards the lateral portion or more along the pathway of the testicular structures and gonadal structures entering into the scrotum. Those hernias can get quite large, and can contain bowel. And those are the hernias where some patients, if those are left unrepaired and can grow over time, they can become quite large and encompass a large portion of the scrotum actually and be quite debilitating.

Dr. Scott Steele:

Kevin, so maybe a lot of listeners out there are a little bit worried about having to go to the doctor with a groin problem. So can you walk us through how that inguinal hernia is typically diagnosed? Is it something the provider can just examine in the office and tell what it is? Do you have to get an ultrasound or an MRI or any other imaging or any other test out there?

Dr. Kevin Wissinger:

As a general surgeon with specialty in this area, sometimes patients will come in with a full workup, certainly as you know where just everything is right there, and the diagnosis is clear as day written on an imaging study. For the vast majority of patients though, a simple evaluation in the office, a detailed history and an examination, we can elicit a bulge in the groin area, which is overwhelmingly the most common symptom. And with that, we have our diagnosis of an inguinal hernia.

Sometimes it can be a little bit more difficult depending on concomitant medical issues or prior surgeries in the area. And when patients come in and there are a few more factors that could contribute to how we would fix this problem surgically, then we'll get advanced imaging. And my go-to imaging is usually a CT scan. Unless we're talking about athletic pubalgia or a suspected bad groin strain, I'm typically not going to get an MRI.

Ultrasound has a utility in that you can sometimes do dynamic ultrasound to see if the Valsalva can elicit a more occult sort of inguinal hernia. But very rarely do we need to use those other modalities.

Dr. Scott Steele:

I want to dig into something you kind of hinted at a little bit ago. So you talked about surgery versus being able to watch it. I know that there are times when surgery is recommended; we'll go into that. But are there situations where watchful waiting is still appropriate?

Dr. Kevin Wissinger:

Yeah, so we actually have good data on the watchful waiting approach. And that's for patients who have minimally symptomatic hernias who come in with the bulge on exam. We have a diagnosis of an inguinal hernia. It's not life-limiting, and the symptoms don't appear to be worsening over time. Patients in that cohort, we can go down the watchful waiting approach.

However, in prior studies that we've done, specifically there's a study from the VA. And if you know the VA, there are a lot of elderly males, so that's the perfect population to do an inguinal hernia study on. So with the watchful waiting approach, it was safe for those individuals in that cohort.

However, in the extended follow-up, we found that about two-thirds of the patients in the trial, or two-thirds of 700 patients actually elected to undergo surgery. So over time, these hernias will get bigger and most patients will elect to undergo surgery, even if it's minimally symptomatic.

Dr. Scott Steele:

So Kevin, let's delve in a little bit more about the surgical options for... So how do you decide specifically with the inguinal hernia repair what approach you're going to do, whether it's open, laparoscopic, robotic? How do you go about this?

Dr. Kevin Wissinger:

Those three are going to be our main modalities of treating inguinal hernias. Every patient comes in with a unique set of circumstances. I'd say the majority of patients who are coming in without prior abdominal surgery, including surgery of the prostate, I think that's a very important key to elicit during a history, because that can drastically alter the tissue planes and what we're able to see surgically and safely fix the hernia.

So patients who are coming in without prior abdominal surgery with an inguinal hernia virtually any size, I will typically recommend a robotic inguinal hernia repair with mesh. The discussion that we'll have in office goes something like this. So the procedure is a same-day surgery. You'll come in about an hour and a half to two hours before the surgery to get checked in and get prepared for the procedure itself. The robotic inguinal hernia repair surgery is usually about 45 minutes to an hour. And then that timeframe will depend on the other factors associated with the size and characteristics of the hernia. And from there, they'll recover in the PACU area and then go home the same day. And that's my typical interaction in clinic if we're talking about robotic repair.

An open repair would be kind of my second choice or my alternate approach. If a patient has had significant abdominal surgery, where I would prefer to stay in the tissue planes that are outside of the abdominal cavity. That's for patients with prior either prostate surgery; open prostatectomy are kind of the main indications. Severe prior surgical history, radiation in the past, things like that can all disrupt the normal intra-abdominal tissue planes, and would make me lean towards an open inguinal hernia repair.

Unless there was some sort of contraindication in my head in terms of if we were concerned about bowel that could be infected leading to a mesh-related issue, I always recommend mesh. Because that gives us our highest rate of success and lowest rate of hernia recurrence, which would be less than 1%.

Dr. Scott Steele:

So Kevin, you mentioned mesh and I know basically TV has it, the mesh this, mesh that. So mesh is a word that patients often hear in relation to not only heart surgery, but they can have their own thoughts about mesh. So can you explain a little bit deeper the role of the mesh, and what role does it play? And maybe address some of the concerns that patients may have heard about it, and has this and how has this evolved over time?

Dr. Kevin Wissinger:

Yeah, so mesh is a topic that's brought up frequently in my office. But going back to basics and actually the utility of mesh and inguinal hernia repair is really to prevent recurrence and to bolster our repair. So a tissue-only repair or not using a mesh for an inguinal hernia repair, that recurrence rate can be 10% or higher if we're doing a first-time hernia surgery.

If we're talking about utilizing mesh for a first-time surgery, the recurrence rate, like I said, is less than 1%. So that's the utility in utilizing a mesh. The mesh that I typically use in inguinal hernias, be it a open inguinal hernia or a robotic inguinal hernia, is a polypropylene-based mesh. It's interwoven polypropylene with little absorbable microtines on it that allows it to adhere to the tissue and bolster our repair.

A lot of the concerns with meshes, these were typically in patients with pelvic organ prolapse disease. The older commercials that used to be shown on TV were pelvic organ meshes that had led to erosion into surrounding structures, bladder, urinary issues, etc. Those meshes have certainly fallen out of favor and technique has changed since then. And one of the reasons that the meshes caused so much issue in patients with pelvic organ prolapse was that the meshes were fixed at a couple of different points to prevent the prolapse. But the structures in this area are very hypermobile, and so that would lead to erosion. A fixed mesh with mobile organs led to issue.

For inguinal hernias, we're placing the mesh on a very natural area in the body that kind of contours along the curvature of our groin and pelvic region. It's a very natural pocket that we make for the mesh. And so it's very well tolerated. The risk of mesh-related issues, including infection, mesh fracture is much, much less than 1%.

Dr. Scott Steele:

Kevin, there's two other terms that patients may have heard about in terms of hernias, and that's incarceration or strangulation. Can you tell us for the listeners who may not be familiar, are these serious? Are they not? How often do they occur? What do you do about them?

Dr. Kevin Wissinger:

Yeah, so incarceration and strangulation, some patients will think they're synonymous terms, but they're not. These are when hernias become dangerous, be it in the inguinal region or in the abdominal wall region. And most commonly when we are concerned about these hernias is when there's bowel within the hernia. So if there's small intestine or large intestine within the hernia, and it's stuck or fixed within the hernia and can't be pushed back in, that's when a hernia is incarcerated.

When we talk about strangulation, that's really the overall evolution of a chronically incarcerated hernia that can cut off blood supply to the region. That's how we characterize a strangulated hernia. These hernias, when seen in office, if I can't reduce it in the office, I'll have the patient go to the emergency department. If I see the patient in the emergency department, they will get an urgent surgery once they are medically optimized and safe to undergo general anesthesia for the surgery.

Dr. Scott Steele:

Kind of wrapping up here, are there any lifestyle changes, whether it be diet, exercise, weight management, how you lift things, belts, that can reduce the risk of developing a hernia in the first place? Or lower the chances of one returning after surgery? I do know some patients are like, "God, I don't want to exercise and lose weight because I can pop a hernia." So what are your thoughts there?

Dr. Kevin Wissinger:

Yeah, I like to keep the discussion about activity with the presence of a hernia very common sense. I tell patients I have no restrictions prior to a hernia repair. They should live their life and do whatever they typically do. If a hernia is becoming more symptomatic to the point where it's limiting their lifestyle and they're not able to do the things they love, then we should discuss repair.

Really in hernia repair and in life, it's all about pressure forces and gravity, right? So over time, if the more intra-abdominal pressure that one has, that can worsen the effects of a hernia in the groin or abdominal wall. Intra-abdominal pressure can be in the form of gaining excess truncal obesity or weight. It can also be in the form of constipation, usually of the chronic variety. It can be something as simple as doing an activity that you don't typically do. Or overdoing something is I've seen patients who like to garden frequently and that led to a hernia.

There are patients who come in with work-related different aspects of their work that led to hernia formation, certainly lifting. And patients with asthma-type symptoms, COPD, chronic coughing - those can all lead to hernia formation or worsening of hernia-type symptoms. So losing weight is probably one of the main things. As well as, if a patient comes in and they are a smoker, obviously stopping their smoking habit as soon as possible to give them the best chance of success.

Dr. Scott Steele:

Okay, so now it's time for our quick hitters, a chance to get to know our guests just a little bit better. So first of all, salt or sweet?

Dr. Kevin Wissinger:

Oh, sweet, absolutely.

Dr. Scott Steele:

What's your favorite sport to watch?

Dr. Kevin Wissinger:

Favorite sport to watch is football and the Pittsburgh Steelers.

Dr. Scott Steele:

And then what was your first car?

Dr. Kevin Wissinger:

First car was a Honda Accord, actually. That was the first car.

Dr. Scott Steele:

And finally, if you could have a superpower, what would it be?

Dr. Kevin Wissinger:

I would say being able to go back in time. I'm a little bit of a history buff, and I'd like to see some events with my own two eyes. Yeah, that's what I would say.

Dr. Scott Steele:

Fantastic. And so take us home. For our listeners who are out there and maybe have a little groin discomfort and they've been ignoring it. Or maybe they do have a full-blown hernia, what's your final take-home message?

Dr. Kevin Wissinger:

Yeah, so I always tell patients it's never the wrong answer to be seen in the office by a surgeon with any sort of groin pain or bulging. You can be unsure if you have a hernia; you can know you have a hernia. And we can have a very nuanced discussion about all the reasons to fix it or not to fix it, the ins and outs. And basically just a very understanding environment of why you should fix it, why you shouldn't. How can we get you to that place of getting back to your normal lifestyle, and getting over the symptoms that are afflicting you?

Dr. Scott Steele:

Fantastic. And so for more information on the Digestive Disease Institute 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.

And if you happen to be located here in Ohio and want to schedule an appointment for hernia treatment at Cleveland Clinic, call 216.444.6644. That's 216.444.6644. You can also visit clevelandclinic.org/hernia for more information. That's clevelandclinic.org/hernia. Kevin, thanks for joining us on Butts & Guts.

Dr. Kevin Wissinger:

Thank you. I appreciate the time, Sir.

Dr. Scott Steele:

That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.