Understanding Abdominal Wall Hernias and Options for Reconstruction
Understanding Abdominal Wall Hernias and Options for Reconstruction
Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive surgical health from end to end.
Welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the chairman of colorectal surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio.
I'm very pleased to have Dr. Ajita Prabhu here. Ajita is an Assistant Professor of Surgery at Cleveland Clinic Lerner College of Medicine. She's got a lot of things that are going on. She's also the Associate Program Director for our General Surgery Residency here at Cleveland Clinic. She's the Director of Surgical Simulation for the entire Cleveland Clinic enterprise and she's the Vice Chair of Quality and Safety for the Surgical Operations. Ajita, welcome to Butts & Guts.
Ajita Prabhu: Thanks so much for having me.
Scott Steele: One of the things we like to start off with is getting to know our guest. Tell us a little bit about where you're from, where you trained, and how did it come to the point that you're here at the Cleveland Clinic?
Ajita Prabhu: I'm originally from South Carolina, where I was born and raised. I grew up there. I did my medical school training and my undergraduate school there. I moved to Portland, Maine, where I did my residency training in general surgery at Maine Medical Center. Following that, I did two years of GI and advanced minimally invasive surgery training at Carolinas Medical Center in Charlotte, North Carolina. After that, I moved to Denver where I was in private practice for almost three years.
At that time, I decided to make a change and transition into academic practice. My friend, Mike Rosen, called me and asked if I wanted to come work with him. So, I was recruited to Case Western, where I was at University Hospitals for about two years and then transitioned over here after that.
Scott Steele: Well, we're very glad to have you here at Cleveland Clinic. Today, we're going to talk about a couple of things. The first thing we're going to talk about is hernias, in general, and specifically focus on abdominal wall hernia. For our listeners out there, this is a term we hear all the time, but what is a hernia?
Ajita Prabhu: A hernia is a hole, specifically in the abdominal wall musculature. The muscles of the abdominal wall come apart for some reason. Sometimes from an operation, sometimes just naturally over time with pressure. But, there's essentially a hole in the abdominal wall that allows something to stick out that doesn't normally stick out.
Scott Steele: I tell my patients all the time since I make some of those holes, that on these more complex ones we have an abdominal wall reconstructive team. There's not many places in the world that have that, but we're lucky enough to have that here. So, what's abdominal wall reconstruction?
Ajita Prabhu: Abdominal wall reconstruction is probably a catch-all phrase that is a phrase that refers to the repair of large and very complex hernias. Essentially, the larger the hole gets, the harder it is to fix. The goal of abdominal wall reconstruction is to get the muscles back together over a big piece of mesh and reinforce that entire repair.
Scott Steele: So, I'm a patient. How can I tell that I have a hernia on my belly wall that would need some type of repair?
Ajita Prabhu: Most patients describe either feeling a bulge, or sometimes they say they feel something sticking out that doesn't belong out. Others will come into the office and describe it as an alien baby. That's one of the more creative terms that I've heard used to describe it.
Scott Steele: Do all hernias need to be repaired or have an abdominal wall reconstruction?
Ajita Prabhu: Not necessarily. I do think that when a patient discovers that they have a hernia or their doctor discovers that, it's a good idea to go see a surgeon about it and get an opinion. Not every patient is symptomatic from their hernia and not every patient requires a repair. But, I do think that somebody with experience should evaluate it and give the patient a good idea of what their needs might be.
Scott Steele: One of the common questions that a patient may have is, "What would happen if I don't get it fixed?"
Ajita Prabhu: That's a great question and there's definitely a lot of fear-inducing type of material on the internet about this.
The biggest fear is that a loop of intestine or some fat may go out of the hole and get stuck there and be unable to return back to the abdomen and then the worst complication of that can be that that loop of intestine could lose its blood supply. That can be catastrophic and that's called strangulation. If you look on the internet there's certainly a lot of material out there about the fear of strangulation. For the majority of patients, if whatever is sticking out can be pushed back in easily and there's not pain from that, then I tell them, "You really probably can go along living your life and we can plan an elective operation to fix that problem." But, that's the biggest thing that I think people get worried about.
Scott Steele: I want to make sure that our audience really understands some of the terminology. So, hernia versus abdominal wall reconstruction and then groin hernia versus abdominal wall hernia or an incisional hernia or a parastoma hernia.
Ajita Prabhu: So, hernia versus abdominal wall reconstruction. A typical hernia repair may involve either an operation through small incisions, or it might be an open incision where there's a larger incision made on the abdominal wall. It may be a simple operation where a piece of mesh is placed to reinforce the abdominal wall.
When we start to talk about abdominal wall reconstruction, we're now talking about additional procedures that may involve cutting some of the abdominal wall muscles to release the muscles back to the middle of the abdomen. It basically gives us the ability to get the muscles back together again and we don't need to do that in all patients.
Scott Steele: What kind of cases or what kind of people do you predominantly see that might require an abdominal wall reconstruction?
Ajita Prabhu: It's usually the patients that have had multiple operations. They have very large defects. Many of them have a major quality-of-life effect in a negative way from their hernia. They may even be immobilized from the size of the hernia. It's usually very large defects and it's usually multiply-operated abdomen. Sometimes they've had multiple failed hernia operations themselves as well. Those are usually the typical types of patients we see for that.
Scott Steele: As a patient, walk us through a little bit about an office visit with you for a presumed abdominal wall defect or hernia in the abdomen.
Ajita Prabhu: When patients come in, the first thing I want to know is a little bit about their experience, what they've been through to get them there. The majority of patients that come to our office, particularly with a complex hernia, have been through something quite catastrophic, or that's at least a very common thing that we see. So, I'd find out some about their background, what types of operations they've had in the past. Then I found out how the hernia is affecting their lives, what is it that bothers them about the hernia and do I think that I can meet their needs with an operation.
The next thing we talk about is whatever their medical conditions may be that may favor or drop them out of favor for a hernia repair that time and then what things we can work on to get them ready for surgery. If they're a candidate for surgery, we then talk about what their options are for the operation itself, and then we talk about the risks and benefits in detail, and then what I think is going to happen. I talk about what my expectations are for their operation, their hospitalization and their recovery.
Scott Steele: Are there any things that patients can do, abdominal wall binders, weight belts, things like that, that would help either not form a hernia, or once they get a hernia, that it could potentially take the place of surgery?
Ajita Prabhu: That's an interesting question. I would say for all comers in the United States undergoing a laparotomy or a midline incision for any type of operation, almost 30% of them will develop an incisional hernia at some point in time. Not all of them will need surgery.
When we talk about supportive garments, I do think that those can help manage symptoms of a hernia. I'm not sure that I've ever seen any data that supports the idea that a supportive garment will protect against getting a hernia after an operation has happened. Then as far as other things go, lifestyle modification can help. Weight loss can certainly help. If they don't want to have an operation, we usually tell them how to live with the hernia that they've got.
Scott Steele: Now, you've seen them in the office and you've made a determination that they have to undergo a surgery, walk me through ... What does that surgery entail and what is the typical postoperative period like? Let's say, this is an open hernia repair.
Ajita Prabhu: For an open hernia repair, I usually tell patients I usually expect a two-to-three-day stay in the hospital if it's not a major abdominal wall reconstruction. They'll come in on the day of surgery and they'll come to the preoperative area where the nurses will get them ready for surgery. We'll bring them back to the OR where I'll come and meet them. We do our safety huddle. We'll do the operation.
I'll go talk with their family as soon as it's over and then we usually expect them to be in the hospital, as I mentioned, for two to three days. We get them out of bed as quickly as we can. We get them mobilized. We control their pain. We advance their diets. When they're feeling good, able to walk, tolerate a diet and their pain is controlled on oral pain medication, we get them home.
Scott Steele: Let's talk a little bit about the repair itself. One of the things that you can turn on the TV or turn on anything in the internet and look up and you see mesh and the good sides of mesh and the downsides of mesh. Can you talk a little bit about mesh? I'm sure you've used mesh in some of your repairs, if not the majority of repairs. Can you talk about the different type of meshes? Is this mesh something that patients should be worried about or is it a standard component of having a repair? Where does mesh fit into all of this?
Ajita Prabhu: Mesh is definitely a hot topic right now, as you mentioned. We do know about mesh. So, first of all, mesh has been on the market for a very long time. It was actually in the 1800s that the conversation began around the need for a device to support the abdominal wall after a repair has been made, so it's not a new concept.
There are several different types of mesh materials. When you say the word mesh, you're really talking about hundreds of different potential products or devices, so we can't categorize everything with one word. We do know from very reproducible surgical literature that mesh can decrease the risk of recurrence of a hernia by 50%, so we know that the chances of a recurrence of hernia without a piece of mesh can be twice as much than when you use a piece of mesh.
Just like every other thing, I considered mesh to be almost like a medication. There are pros and cons to everything that we do. The way that you use a mesh, where it's placed, how it's placed, the technique, the patient-related factors, so any kind of medical conditions that the patient has and then any technical factors that go into the operation, can all affect the ultimate outcome. So, I think the key to mesh is not necessarily to view it as the enemy, but to use it in the correct cases and to use it correctly.
But, I don't think that consumers or patients need to necessarily be afraid of it. I think they need to be informed and I do think that they come into the office, we certainly have the conversation all the time. Patients come in and they want to know what I'm going to use and why I'm going to use that. I think that surgeons need to be able to have that discussion with their patients in a very clear manner. Let the patient know what they're getting if they get a piece of mesh and why they're getting that and also what the risks are associated with it.
Scott Steele: Just honing in on that last concept there real quick. I've had patient come to me and say, "You can do whatever you want to do, but I don't want to use mesh because it's associated with chronic pain, or it gets infected, then it needs to be removed. Or, it can erode into the bowel." Understanding exactly what you said that it's like a medication, it's got some good sides and it's got some potential downsides, how often in the literature could you expect to see any one of those type of complications occur?
Ajita Prabhu: There is actually some literature to speak to that and what we know is that the incidence isn't zero, as you know. We all see those complications happen. But, over the lifetime of a mesh that stays in place for a patient, the risks associated with having a mesh in place are essentially on par with the risks that we see for any patient undergoing a gallbladder operation. So, 5% or less of those patients will end up having that type of complication or some type of complication related to their device.
Scott Steele: I know there's a lot of different places, but where exactly if you have an abdominal wall hernia does the mesh go?
Ajita Prabhu: It depends on what kind of hernia you have and what kind of hernia operation you have. For the smaller hernias that we're doing, say, an operation through small incisions and that might be laparoscopic hernia repair or robotic hernia repair, that piece of mesh goes directly into the abdomen. There's usually a barrier coating on that to keep it off of the intestines.
For bigger hernia operations or open hernia operations, we often put the mesh outside of the abdominal space so that it's not in contact with the intestine. That might be outside of the muscle for some patients. For other patients, it might be between the muscle and between the peritoneal lining of the abdominal wall. We might sandwich it between layers of the abdominal wall so it's not touching the intestine.
Scott Steele: Yeah. I love the image of a sandwich or a hamburger where you got the bun being the fascia layers and the meat being the muscle itself and supporting it between the bottom bun and the burger there so it can be outside of the bowel content.
If people were to Google abdominal wall reconstruction, one of the things that may come up is this concept of a component separation. Can you tell our listeners out there what does component separation mean?
Ajita Prabhu: Component separation is a procedure where we divide one part of a muscle that allows the rest of the muscles of the abdominal wall to release back together so that we can sew them back together in the midline. All of our muscles come together in different ways and there are different attachments, usually on the outside of the abdominal wall, on the edges of the abdominal wall. When we release some of those attachments selectively, that takes the tension off of the midline and allows us to bring our rectus abdominis muscles, or the two muscles that normally come together in the midline. That allows us to bring them back together again and take the tension off at the same time.
Scott Steele: Let's switch gears and focus in on one component. I am pleased to say that you are one of the few surgeons in the world who absolutely has this kind of trick in their armamentarium and that's robotic repairs of abdominal wall hernias. What is this? You're one of the few people in the world that do this, so talk a little bit about this technology used and what can patients expect if they do undergo a robotic abdominal wall reconstruction.
Ajita Prabhu: Robotic abdominal wall reconstruction is really a field in evolution right now and it's a very exciting change to the field of hernia surgery. I would say it's actually probably one of the more disruptive things that we've seen in hernia surgery. I just told you we use mesh that's been really around for many, many, many years. Since then, other than techniques, robotics is really the new thing and it's the new interesting thing.
Robotic surgery is hernia surgery through small incisions. There are some similarities to laparoscopy in that we make small incisions and repair a hernia hole through those small incisions. The things that are different, however, are that the robot allows us to do things that we weren't able to do before, particularly in the space of robotic abdominal wall reconstruction.
For select patients who are candidates for this, what we can do is go and do the same reconstruction that we would normally be able to do through a gigantic incision, or a very large incision and what we're seeing is we can put the mesh in the same place. We can also do a component separation at the same time, we can get the midline muscles back together again, all through six or seven various small incisions. The patients can often go home much sooner than they did before and then, in addition to that, we're seeing that the recovery is much better.
I got involved with this probably in 2013 or 2014. At that time, robotics had been used for hernia surgery in the space of inguinal hernias or groin hernias and then sometimes for small ventral hernias in the abdominal wall. That was the stuff that it was being used for at that time. The interesting concept or question was, can we use this to do the bigger operations that right now we're doing through generous midline incisions? So, I initially got involved because I was interested in trying to translate that use of technology into doing the big operations. What ended up happening was that as I was learning the technology and the techniques, I used the robot for some of the more simple and straightforward cases and what I found was that there's definitely an indication to use that for that spectrum of hernias as well.
I think not every patient will necessarily be a candidate for it. However, the vast majority of hernias that we see, whether they're small belly button hernias or medium-sized belly button hernias, groin hernias and then even some of the larger straightforward abdominal wall hernias, we'll be able to use the robot to do those types of cases. I see that potential growing and growing.
Scott Steele: Any other kind of things on the horizon or places that you see abdominal wall reconstruction going, some things that you've noticed, the evolution of the field in addition to robotics?
Ajita Prabhu: I think some of the things that we are starting to look at now, as you know, pain after surgery is a very hot topic. We are all forever seeking out ways to decrease the pain of hernia operations and decrease the pain as patients recover, particularly in the opioid epidemic crisis that we're facing right now. Some of the things that we are looking at is doing these big operations through small incisions, trying to decrease the amount of fixation that we're using for meshes if we can do that in a safe way, so potentially using novel types of fixation techniques for our meshes. I think those are things that are interesting.
Scott Steele: Did you ever see anybody that has these meshes that can dissolve or be incorporated into that? Is that something that is actually really happening? Or, are most of the meshes just staying there?
Ajita Prabhu: That's a great question. There are bioabsorbable meshes and bioabsorbable synthetic meshes as well. What those are, are basically a class of mesh that go away over time. They may go away quickly or slowly, depending on what the baseline products are that they're made of or the materials that they're made of.
As far as bioabsorbable meshes go, they’re certainly an interesting technology. I think that we in our field are still looking for the correct indication for them, so it may be potentially of use to patients who don't want hernia meshes placed long term. However, I think that still needs to be carefully investigated and I think that we need some more head-to-head trials to really sort out what the correct candidates are for that. It's certainly an interesting technology. I think there may be some indications developing for that, but I think it needs a little bit more work.
Scott Steele: That's extremely exciting stuff. So, Ajita, we like to end up all of our Butts & Guts episodes with a couple of quick-hitters. What's your favorite sport?
Ajita Prabhu: Basketball.
Scott Steele: What's your last book that you read?
Ajita Prabhu: I am reading the Howard Hughes biography right now.
Scott Steele: What's your favorite meal?
Ajita Prabhu: Probably baked potato.
Scott Steele: What's the best thing that you like about living in Cleveland?
Ajita Prabhu: The best thing I like about living in Cleveland, without question, is the Metroparks. There are hundreds of miles of trails in the Metroparks and I think that is one of the most beautiful things to share with my family and for myself when I'm not at work.
Scott Steele: That's fantastic.
So, for more information about abdominal wall reconstruction, visit clevelandclinic.org/hernia. That's clevelandclinic.org/hernia, H-E-R-N-I-A, and download our free treatment guide. To make an appointment with a Cleveland Clinic hernia specialist, please call 216.444.6644. That's 216.444.6644. Ajita, thanks so much for joining us on Butts & Guts.
Ajita Prabhu: Thanks so much for having me.
Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.