What Is a Hernia? Signs, Causes and Treatment Options

Podcast Transcript

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 of main campus here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today, it's always nice to welcome back one of our guests, and today we're welcoming back Dr. David Krpata, who's a general surgeon for the Digestive Disease Institute and specialist in hernias here at the Cleveland Clinic. David, welcome back to Butts & Guts.

Dr. David Krpata:

Thanks for having me.

Dr. Scott Steele:

We always like to start out, as you know from your time before, and for the listeners who haven't heard that previous episode, tell us a little bit about yourself, where you're from, where did you train, and how did it come to the point that you're here at the Cleveland Clinic?

Dr. David Krpata:

Sure. Well, it's a pleasure to be here. I grew up in actually New York and Arizona, so two very different areas, so it's odd that I ended up here in Cleveland, Ohio. But there's usually a spouse involved in that, and I met my wife in Arizona at the University of Arizona, where I went to school. I did my residency training in Cleveland at University Hospitals, but was fortunate to come over to the Cleveland Clinic and do my fellowship training in abdominal wall reconstruction. So, I'm a general surgeon by training, but I have advanced training in hernia as well as abdominal wall reconstruction.

Dr. Scott Steele:

Well, that's why we got you here, and today we're going to be talking a little bit more about hernias. So, hernias — a lot of people maybe have a little bit of a misconception about what a hernia is or a sports hernia, things like that — so can you share at a high level what a hernia is and how it affects the body?

Dr. David Krpata:

Yeah, absolutely. It is pretty common that people have a misunderstanding, but I think at the most basic level, a hernia is a hole in the abdominal wall that allows things to go through it that shouldn't, and I'll be a little bit more specific. And those things that shouldn't go through it, that abdominal wall, is your contents of inside of your abdominal cavity, particularly like your intestines. That could be a concerning finding for people, and that's what people will notice, a bulge typically. And so oftentimes, people think it's actually a mass, but in reality, it's really a defect in the abdominal wall.

Dr. Scott Steele:

So how common are hernias, and who's at the most risk for having them?

Dr. David Krpata:

Yeah, overall, hernias are fairly common. Part of it depends on the type of hernia that you're talking about. There are several types. More commonly people think about inguinal hernias and umbilical hernias at their belly button, but then the third type would be incisional hernias, and I'll go through each of those three. So for inguinal hernias, men are most impacted by it, and it's estimated that about one in four men in their lifetime will end up with an inguinal hernia. Only about 3% in women. But on the other hand, umbilical hernias, those are equal in terms of rates between men and women and make up about 10% of hernias. If you've ever had an incision on your abdominal wall, you have about a 20% chance of developing a hernia at that site.

Dr. Scott Steele:

So David, what symptoms ... You mentioned people feel a mass or a bulge or something, but are there other symptoms that maybe are mistaken for a hernia? It could be something else? Or conversely, are there any scary symptoms that patients should know about when it comes to a hernia?

Dr. David Krpata:

Absolutely. I would first say that what I discussed before in terms of it presenting as a mass or a bulge is always concerning to an individual, because they're concerned that a mass, which is most commonly associated with having a tumor, and it brings people in. And for that reason, it should always get checked out whenever you have something of that nature. So, things like tumors themselves, or even benign masses like lipomas, are commonly found when we're examining for hernias. But it is pretty common, especially somebody's coming from a primary care doctor that they've been sent to us with a diagnosis of a hernia after a bulge, that being the most common symptom. Other symptoms would include some pain or discomfort, and mild pain is pretty common. But if you have severe pain, if you have changes, like redness over the skin of the hernia, that is an absolute emergency and people should be examined almost immediately when they find that.

Dr. Scott Steele:

So you noted that a lot of the hernias are noted as a bulge, but how is a hernia typically diagnosed, and are there any specific tests or examinations that are involved?

Dr. David Krpata:

Yeah. It can be diagnosed as easily as performing a physical exam in the office, but if there's any concerns about whether or not it's truly a hernia, we will typically go to getting some sort of imaging, and that would be an ultrasound would be a common modality as well as a CT scan or a CAT scan that people might commonly referred to as.

Dr. Scott Steele:

So, what are the surgical treatment options available for hernia repair at the Cleveland Clinic?

Dr. David Krpata:

Yeah, we have several options. We pretty much have the full spectrum of opportunities for people to get their hernias repaired, and that includes the good old-fashioned open approach, which means making an incision directly over where a hernia is and then repairing it either with suture or an adjunct, like mesh. But we also do minimally invasive repairs as well, and we would put that into two different categories, laparoscopic surgery or robotic surgery. And I would tell people, if they're concerned about the verbiage around those, the reality is that they're both minimally invasive options, and so it's really being performed in a very similar fashion. I will say that with the robotic approach, it does offer us some opportunities to do more advanced hernia repairs through smaller incisions, but we do offer the full spectrum of repair opportunities.

Dr. Scott Steele:

So in general, I know it's not cut and dry, but how do you decide on the different approach for patients?

Dr. David Krpata:

Yeah. I think the most common way first off would be the size of the hernia itself. An example of that would be if somebody has a very small umbilical hernia that might be, say, one centimeter in size or something like the size of a dime, it's pretty common that we would just fix that with sutures. So, that's always going to be what we would refer to as an open approach. But if we want to do more advanced techniques, like putting in mesh and try and do it with smaller incisions, we'll go to laparoscopy or robotics, and those would be for things like inguinal hernias or larger umbilical hernias. Other things that can impact our approach is what type of surgery somebody's had in the past if they've had surgery. Has there been a hernia repair in the past as well? Because if somebody has had mesh before, it might make it more difficult to repair with the smaller incisions.

Dr. Scott Steele:

David, could you talk a little bit about mesh? That's a scary term to some people, but is it useful? Is it always needed? Can you give us a little bit of some information there?

Dr. David Krpata:

Yeah. I think the one thing that people should understand is when they hear the word mesh, and I always tell people this, is that mesh is like saying "car." If you're going to buy an automobile, you walk into a dealer and you tell them, "I'm here to buy a car," and they're like, "Okay, well, that's great. What make or model would you want?" And it's very similar with meshes, that there are different types, different advantages to some over others. And I would tell you the most common thing we use is actually the most basic form, which is a flat sheet of a plastic material called polypropylene.

Now, whether or not it needs to be used all the time has a couple different caveats to it. First off would be, as I referred to earlier, the size of a hernia. If something is small, you can often get away with not using mesh, but if somebody has already had the hernia repaired once before without mesh, or it's large, or if somebody has some comorbidities that might impact or increase their risk of the hernia coming back, such as obesity or smoking, then we might often add mesh for that reason. So, mesh is not necessarily always needed, but we only use it when we think it's going to benefit a patient to lower their risk of the hernia returning.

Dr. Scott Steele:

You mentioned earlier, including your background specifically, the term abdominal wall reconstruction, and oftentimes this is in the setting of more complex hernia cases. So, can you explain what that term is, what it involves, and what situations it might be necessary?

Dr. David Krpata:

Yeah. Abdominal wall reconstruction is a term that we use now to try and differentiate between what is maybe a more basic type of hernia repair and something that requires far more complexity. And when I say that, what I mean is, somebody who has had multiple prior hernia surgeries or had a very large prior abdominal surgery often needs an abdominal wall reconstruction. And what we're referring to is we're actually, in a sense, using techniques that are a little bit more advanced to take apart the abdominal wall and then put it back to its closest native position while also providing the most durability for somebody, as opposed to something that maybe we're doing like a small umbilical hernia where you just need suture, where the recurrence rates for that might be really low and the risks associated with that is generally considered fairly low. An abdominal wall reconstruction is generally considered a little bit of a riskier operation in comparison.

Dr. Scott Steele:

Okay. Maybe a question you get asked more often than maybe any other one, and that's, do all hernias have to be repaired surgically? Are there non-operative repairs, or can you just watch them and do nothing with them?

Dr. David Krpata:

Yeah, it's a great question. We get asked this all the time. The first thing that people would need to understand is that if you want the hernia repaired, the only way to actually repair it is with surgery. So in that sense, what I mean is, there's no medications or therapies that you can do that will make the hernia go away. It's essentially an anatomical problem at this point.

Now the other half of that is, do you actually need to repair it if you have it? Well, the answer to that is really based off of your symptoms. And if people have a small hernia that maybe doesn't bother them, or only has a small amount of fatty tissue inside of it, and maybe they've had it for 10 years, and I'll give you an example, then they don't necessarily have to have it repaired. The example would be, and we get this all the time, if somebody's gone to their primary care doctor, they're there for a well checkup and the primary care doctor identifies an umbilical hernia, asks the patient, "How long have you noticed this for?" And they say, "15 years," and it hasn't bothered them. They often will get sent to us, and if it hasn't been bothering you for 15 years and it's small, you can typically just continue to watch those.

The other area where it becomes a little bit more common is actually for what we call inguinal hernias, or hernias in the groin. We actually have a term for it. We call it "watchful waiting," and we've actually studied this, not myself, but the medical field as a whole has examined this, and they actually took patients, put them into two groups. One went on to have surgery immediately once they identified a hernia. One went on to just watch it for 10 years. And it turns out that it's actually a fairly low risk of you having an emergency operation as a result of not having it repaired. It's about 3% over 10 years.

However, about two-thirds of individuals ultimately went on to have their hernia repaired because it became more symptomatic. So, often when somebody comes in with an inguinal hernia and it's minimally symptomatic, our advice is, "You are likely going to get this repaired in the future, so find a time that's going to be best in your life to take some time away to have surgery, but you don't necessarily have to do it right away."

Dr. Scott Steele:

And you mentioned that you can basically leave a hernia untreated, and you mentioned the urgent surgery that might ... What is that, and why? What does that entail? Why does that come up?

Dr. David Krpata:

Right, so going all the way back to the beginning of our discussion about what a hernia is and what can happen, so if a piece of intestine goes into a hernia and gets stuck, that is considered a surgical emergency. And concerning symptoms again for those would be, if you have increased pain at the site, or you have a bulge that cannot be what we would call reduced or pushed back in, and there might be skin changes over that. You might also have nausea and vomiting associated with it. If that were to occur, then that could mean that the bowel is stuck inside. If the bowel is stuck inside and nothing can go through it, it also means that the blood supply that goes to the intestine could be compromised, which ultimately means that it itself could become what we call ischemic, or lose its blood supply, and that could lead to a bowel perforation. So in the event of a incarcerated hernia, which is when it gets stuck and cannot be reduced, that is a surgical emergency and that would require an emergent surgery, almost within six hours.

Dr. Scott Steele:

So you mentioned that there are situations where somebody has had a prior hernia and now they present again, so hernias can recur. How often do they recur, and maybe what are some risk factors for recurrence?

Dr. David Krpata:

Yeah, it's a great question, and it really depends also on the approach and the type of hernia that you've had in the past. One example would be, let's go back to that small umbilical hernia that people can often have. If you have a one centimeter umbilical hernia, typically the risk of it recurring, even if it's just with sutures, about 10%. If you add mesh, it goes down to about 5%.

If we do some of the more complicated hernias that are larger and sometimes up to 15, 20 centimeters in size, the recurrence rate's going to be higher, and depending on how you define it, it's somewhere in the neighborhood of 10% to 20%. And even worse off, there are hernias that we call parastomal hernias, and people who have a stoma will probably know about those, because those are fairly common. Those are the most challenging to repair, and they often have a recurrence rate that can be 30% and 40% over somebody's lifetime.

Dr. Scott Steele:

Are there lifestyle changes, whether it be diet, exercise, weight management, or how you even lift things, that can either reduce the risk of developing a hernia in the first place, or lower the chances after surgery?

Dr. David Krpata:

Absolutely. There are methods to try and reduce your risk of forming a hernia as well as recurring on a hernia. And I always try to explain to people the pathophysiology behind why a hernia might happen, and it is generally because of an increase in somebody's intra-abdominal pressure. And then you have to ask the question, "Well, what increases people's intra-abdominal pressure?"

First off, people who cough a lot. So, if somebody's a smoker and they're a chronic cougher, that should be addressed by their primary care doctor to try and reduce their risk of having a hernia. Second would be, and it's common in men who strain a lot, would be an enlarged prostate. If they strain a lot, or somebody who has constipation will strain a lot, they will often put increased intra-abdominal pressure routinely on their abdomen, and that increases their risk of having a hernia. The other thing that I explain to people is that we tend to carry a lot of our weight inside of our abdominal cavity, and the more weight that we carry, the more pressure it puts on our abdominal wall. So, weight loss is often prescribed as a method of trying to reduce your risk of developing a hernia recurrence.

Dr. Scott Steele:

So David, I've heard people say, "Well, I don't really want to exercise, because if I exercise I'm putting strain on my belly wall. It's going to make this small hernia bigger." Is that true, or is that a myth?

Dr. David Krpata:

It's a little bit of both, I would say. In general, I would tell people, "You should never let a hernia get in the way of you and your lifestyle." We have methods of fixing them. If they do get larger, again, it can be fixed. But if you do exercise and you have a hernia and you cause repetitive motion that increases your intra-abdominal pressure, those hernias do typically grow over time. And part of that is because of the stretching that occurs with the skin. It'll actually allows the hernia to bulge out further. And so, oftentimes it's more of an appearance of being larger as opposed to the defect itself always getting larger.

Dr. Scott Steele:

Take us into the future. Are there any advancements on the horizon when it comes to either the treatment or prevention of hernias?

Dr. David Krpata:

Yeah, and that's one of the exciting things in our field is it's ... actually has a growing interest among surgeons, and there are probably two main things that I think we need to keep an eye on. Number one is the advancement in technology around minimally invasive surgery. And we talked about robotics, and I think that will continue to grow and allow us to do things more minimally invasive for individuals. But the other is around the prosthetics that we utilize to help repair these, or the mesh itself. We have some meshes now that will go away and dissolve over time, and it could be two years, it could be five years, depending on the type. And I think we're just at the beginning of trying to define where that is in terms of the role for individuals, and should you have a permanent synthetic mesh that lasts forever? Or maybe is it better for you to have one that's going to go away in five years?

Dr. Scott Steele:

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, if you could develop a superpower, what would it be?

Dr. David Krpata:

I would definitely want to be able to transport anywhere as quickly as possible.

Dr. Scott Steele:

Salt or sweet?

Dr. David Krpata:

Salty for sure.

Dr. Scott Steele:

Do you have a hidden talent that you'd be willing to share with?

Dr. David Krpata:

Absolutely not.

Dr. Scott Steele:

And then finally, can you give me ... Growing up as a kid, what was your best birthday present?

Dr. David Krpata:

Oh, wow. I would say my best birthday present was when I was very young and into playing street hockey, and it was a new set of goalie pads to play street hockey. That is one I definitely remember.

Dr. Scott Steele:

Fantastic. So, give us a final take-home message to our listeners regarding hernias.

Dr. David Krpata:

Yeah. I think the most important thing is if you're concerned about having a hernia, if there's any question about it, you should absolutely get examined by a general surgeon, and we're happy to see you here at the Cleveland Clinic.

Dr. Scott Steele:

So to learn more about hernias or to schedule an appointment for treatment at the Cleveland Clinic, please call 216.444.6644. That's 216.444.6644. You can also visit clevelandclinic.org/hernia for more information. That's clevelandclinic.org/H-E-R-N-I-A. David, thanks for joining us on Butts & Guts.

Dr. David Krpata:

Thanks for having me.

Dr. Scott Steele:

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