What to Do if You Have a Hernia with Dr. Clayton Petro

Podcast Transcript

Deanna Pogorelc:

Welcome to The Health Essentials Podcast, brought to you by Cleveland Clinic. I'm your host, Deanna Pogorelc, and joining me today is Dr. Clayton Petro. He's a general surgeon here at Cleveland Clinic, and is here to shed some light on an ailment that about five million Americans deal with every year. We're talking about hernias, how to know when you have one, what to do about it, and how the field of hernia repair is advancing. Welcome, Dr. Petro. Thanks for being here.

Dr. Clayton Petro:

Thank you so much for having me. I'm honored, and hopefully, I can help answer some of your questions.

Deanna Pogorelc:

And to our listeners and viewers, please remember that this is for informational purposes only, and is not intended to replace your own physician's advice. So can we start at the beginning? Let's talk about what actually is a hernia?

Dr. Clayton Petro:

Sure. So in the simplest terms, a hernia is a hole in the muscle. And so, commonly folks will get a hernia in some part of their abdominal wall that has an inherent weakness to it. So for instance, the groin, people will often get hernias in the groin. So for men, their spermatic cord travels through the muscle, and so that's an area of weakness. So, you can get either an inguinal or a femoral hernia in the groin. Oftentimes, people can also get hernias near their belly button, so an umbilical hernia. The last place that is common is between the breastbone and the belly button, right in the middle of the abdomen. That's another place that you can commonly get a hernia. Those are for folks that have never had surgery before. So another type of hernia would be for anyone who's had surgery or any type of incision in their abdominal wall, that also would be an area of weakness, and you can get a hernia there, that would be called an incisional hernia. So those are hernias within the abdominal wall.

              What can often be a point of confusion, are the things that are called hiatal or paraesophageal hernias. So those hernias are indeed a hernia, but the hole in the muscle is not on the outside. So you can't feel the bump, you can't feel the bulge. The hernia is actually from the abdominal contents up into the chest, and so the hole is actually in the breathing muscle, the diaphragm, that separates the chest from the abdomen. And so, it is a hernia, but it's different than the other ones, because you won't be able to feel it from the outside.

Deanna Pogorelc:

So how do people get hernias? Are certain people more at risk, or how do they happen?

Dr. Clayton Petro:

Yeah, so that's a common question. So adults and children are a little bit different, so children can get hernias, they can be born with them, and oftentimes, particularly umbilical hernias, they will close on their own. Adults, it's a little different. So if you're an adult and you have a hernia, it's usually over years of wear and tear. So for instance, folks that have a chronic cough, or are chronically lifting heavy things, or have a very labor-intensive job, over years of wear and tear, those areas of weakness, whether it was from the groin or the belly button, like we talked about, or from a previous incision, those areas of weakness will gradually allow the muscle to start to stretch apart, and you can develop a hernia there.

              Oftentimes what will happen, is folks will tend to lift something heavy, for instance, and they'll feel a population, and it's not so much that that single incident is where the hernia happened, it's just the first time that maybe it became symptomatic, and where the patient actually felt something bulge out, but in reality, what was happening was it was probably more likely years and years of wear and tear.

Deanna Pogorelc:

So that's true for a cough too, so if someone coughs and feels pain, it's not necessarily that it just happened, but it's those years of wear and tear that have accumulated?

Dr. Clayton Petro:

Correct, and it's the combination, as far as how do you know if you have a hernia, it's usually something that you can feel. So the patients that I'm most confident, are if you can feel a bulge, or commonly patients will describe being able to push something back in, those are patients that pretty obviously have a hernia. Now, sometimes it's not obvious and you need to get imaging, such as a CAT scan to really sort out if it actually is a hernia, but usually the combination, if you have pain in one area and you feel a bulge, that would make me concerned that maybe you do have a hernia.

Deanna Pogorelc:

Can you shed any light on what the pain feels like? Is it a sharp pain or a dull pain, or is it different for every person?

Dr. Clayton Petro:

It can be different. Oftentimes, it can be a dull, crampy pain, so you kind of feel like something is stuck or being kind of maybe choked a little bit, and oftentimes, particularly for patients who have hernias in their groin, they'll get relief once everything is kind of pushed back in. Some patients, you can't push it all the way back in, and so they might not experience that relief, but it's usually kind of a dull, achy, crampy pain. Now, one of the things that folks worry about is having a loop of intestine stuck inside, and that is possible, and those patients can develop a bowel obstruction. If that happens, those patients are usually nauseated and vomiting, and that can be an emergency. That scenario is less common, but it does happen.

Deanna Pogorelc:

Okay. And is there anything specific that we can do to prevent them?

Dr. Clayton Petro:

Yeah, that's a good question. I think that I would like folks not to blame themselves if they get a hernia. So I think it is just something that can happen, like I said, through years of wear and tear. I think that if there was going to be one area where maybe you can make a difference, it's if you do have abdominal surgery, then right after the abdominal surgery, you want to be careful about lifting things that are heavy, because you don't want to kind of propagate an area of weakness and you want to give that incision time to heal.

Deanna Pogorelc:

Well, what is the kind of proper or appropriate pathway of care, if you do start feeling pain and feel that bulge? Is that a urgent care, is that a primary care, is that go to a specialist? What's the right way to navigate that?

Dr. Clayton Petro:

Sure. So I think that certainly, we went over the kind of worrisome scenario, the patients that may have a bowel obstruction, and those are patients that should seek care more immediately. There are other folks who maybe they know they've had a hernia and it's started to hurt them, or they think they have a hernia, and they're not sure. You can certainly run that by your primary care provider, or if you call the Cleveland Clinic line and ask for an appointment with any general surgeon, I'm sure they'd be happy to see you, or we would see you in our clinic. Like I said, some folks, it's pretty straightforward. They have a hernia, it's limiting their quality of life, and they want it fixed. Other folks, like I said, it's not uncommon for us to see folks and tell them they have a hernia, and either counsel them toward repair, or we can see you every three to six months and just keep tabs on it, and when it starts to bother you, we'll fix it at that time.

Deanna Pogorelc:

Okay. Now I want to ask, I'm sure if someone finds out they have a hernia, one of the first things they're going to wonder is, is it going to get better on its own, or does it need some kind of treatment?

Dr. Clayton Petro:

Sure. Well, once again, we kind of treat these case by case. So I think for the vast majority of cases, with the rare exception being, I would think with children with umbilical hernias, hernias do not get better on their own. That being said, every hernia does not need to be fixed. There are many scenarios, particularly patients who have groin hernias, if they're completely asymptomatic or minimally symptomatic, it's really hard to make someone like that better with an operation, so we'll often tell them watchful waiting is safe, and you can come back when it starts to bother you. Also, some of the imaging that we talked about, like getting a CT scan, or an ultrasound, or something like that can let us know what's inside the hernia. So oftentimes, it might be a small amount of fatty tissue and the patient's really not having symptoms, then once again, we can tell them that it's safe to watch and wait, and come back when it starts to become symptomatic.

Deanna Pogorelc:

So if someone does feel pain and symptoms and thinks they might have a hernia, what are some of the signs that it's an emergency and they should get medical attention immediately?

Dr. Clayton Petro:

Sure, that's important. So certainly, if there's any concerning signs of a bowel obstruction. So like I said before, one of the things that you worry about is that a loop of intestine is going to get stuck inside and cause a bowel obstruction, and if that happens, you'll be nauseated, you'll be throwing up, you won't be passing gas, and possibly haven't had a bowel movement in the last several days. Any of those types of signs would be something that I would consider an emergency, and you should seek help emergently. A very concerning sign in addition to that, would be if you have skin redness above where the hernia is, and that would make me even further concerned that whatever's inside the hernia has lost its blood supply and that again, would be a surgical emergency.

Deanna Pogorelc:

I know I've seen some hernia belts or trusses that people can buy to help them with the pain. Do those actually work, or are they helpful at all?

Dr. Clayton Petro:

Yeah, so I think my take on abdominal binders and trusses, if they provide patients any relief, I think that they should use them and continue to wear them. I don't think there's any evidence that I'm aware of that they'll have any negative side effects, so they're not going to do any harm, I feel pretty confident about that, and if they provide the patients relief, then I would absolutely wear them. I don't have any financial relationship with this company, but there is a company called Marena, M-A-R-E-N-A, and if you Google there, they have a binder, a website, and they have all different shapes and different types of support for people with abdominal hernias, groin hernias, binders that come up over the shoulders, wrap around the waist. And so, if folks find some type of comfort in that, then absolutely.

Deanna Pogorelc:

Okay. So when someone comes to their position and they have the CT scan or whatever diagnostic is needed, what's kind of the first step in terms of determining if they need treatment, and what that's going to be?

Dr. Clayton Petro:

Sure. So a lot goes into it. So I think part of it is, how symptomatic is the patient? So if the hernia is really limiting their quality of life, then I think the discussion is going to lean toward repairing it, particularly if they've had any types of those urgent symptoms that we talked about where it's caused them pain, or God forbid, they had a bowel obstruction or something like that, then pretty quickly, for the majority of those cases, we're going to start talking about whether or not it should be repaired, and how we would repair it.

              I would say less commonly, but not too uncommon, we have patients who, like I said before, they're not really having that bad of symptoms, and at the imaging doesn't look concerning, then it's okay to watch and wait, and we might follow them every three to six months just to monitor their progression. So, once we start deciding whether or not we're going to do an operation, the next step is to decide if the patient's ready for an operation. Sometimes they need to be optimized before surgery, meaning weight loss, or you have to stop smoking, or get your diabetes under control, and we will see folks regularly back in our office until the patient is ready for their operation.

Deanna Pogorelc:

Okay. So that operation, that hernia repair operation, how often is it an open surgery versus a laparoscopic surgery?

Dr. Clayton Petro:

Yep, that's a great question as well. So I think the first thing when I sit down with a patient, I tell them that hernias come in all shapes and sizes. I think it can be very confusing for a patient who maybe their brother, or their cousin, or someone in their family, or one of their friends had a hernia repaired, and they had it done one way, and they come to your office with a certain set of expectations, and it can be very confusing why one patient got this and the other patient got something else. And I think that once you kind of lay out kind of the landscape that listen, these hernias can come in all shapes, sizes, and locations, that you start to understand why there's so many different repair choices.

              I think to put it the most simply, is that smaller hernias are more likely to get repaired with small incisions laparoscopically, or sometimes robotically, and larger hernias, more often than not, will need larger operations, meaning a big up and down incision. I will say that the robot technology has allowed us to fix larger hernias with small incisions, and that's somewhere the field is evolving.

Deanna Pogorelc:

So when someone finds out they need to have a surgery or procedure, it can be a little scary. So I'm curious to hear, what does the repair surgery, what is that like? What can they expect in terms of how long is it going to take? What does recovery look like?

Dr. Clayton Petro:

Sure. So for folks with small hernias on their abdomen or hernias in the groin, oftentimes these folks can go home the same day. We'll give them a modest weightlifting restriction for the first few weeks after surgery, and we'll gradually counsel them toward an increase in their activity as they recover. For folks with larger hernias, if you get a larger hernia fixed with small incisions, it may be a couple of days in the hospital, and if you have a large hernia that's fixed with a big up and down incision, you're probably looking at somewhere like four to six days in the hospital, and you'll be sore for a couple of weeks. When it comes to returning to work, that can be very variable, depending on what type of work someone does, but I think a safe bet as far as returning to a moderately active job, would be somewhere in the neighborhood of six to eight weeks.

Deanna Pogorelc:

And I want to ask about mesh, because this is something I've been hearing about in the news. When is that necessary to use, and are there risks or considerations associated with that?

Dr. Clayton Petro:

Sure. That's probably one of the most common questions we get in our office, is about mesh, and I try to hit it off a lot of times because when you consent someone for an operation, particularly a hernia repair, and you're going to use mesh, that mesh has to be in the consent. So you have to say, "I'm going to fix your hernia with mesh," and I can see that immediately, a lot of patients will have that look on their face and "Uh-oh, I just heard six commercials last night talking about hernia mesh."

              Now, certainly, I can't speak to every different scenario, but what I can say is a few generic things. The reason we use mesh for the vast majority of hernia repairs, is that it prevents your hernia from coming back, or at least reduces the chance that your hernia will recur. So that's the good part about mesh. There are rare mesh complications. I think transvaginal mesh has a lot of complications associated with mesh, and then there were certain types of mesh used for abdominal hernia repair that, for instance, one had a plastic ring that was breaking and sticking into the intestine, and so once again, that caused a lot of alarm regarding abdominal mesh.

              What I can say is, that we fix a lot of hernias at a high volume, and we use the type of mesh that in our opinion, is the most likely to keep your hernia from coming back, but the least likely to cause a mesh-related complication. So I can't say that mesh complications never happen, but they are rare, and the trade-off of that is that you will get a more durable repair, and reduce the chance that you'll have to have another operation down the road.

Deanna Pogorelc:

Okay. So I do want to ask about that reoperation also. I mean, obviously there's a chance that the hernia could come back, or are there certain people who are more likely to have a second hernia, or how does that work?

Dr. Clayton Petro:

Sure. So I think maybe we as surgeons, general surgeons, maybe don't do a good job describing the risks of a hernia coming back. I think often what I've found, is that hernias are a lot like other operations that have an expected lifespan. For instance, a hip replacement, a knee replacement, LASIK eye surgery. A lot of these operations, they have an expected duration which they work, and eventually, those results will start to wear off. Hernia repair can be like that. Certainly, all surgeons would like to think that when they leave the operating room and they fixed a hernia, that it's going to stay fixed forever, but the reality is, is that that's just not true. And the recurrence rates can be widely variable, depending on how big the initial hernia was, how complex it was. So like I said, hernias come in all shapes and sizes. So the recurrence rate for a small hernia is going to be a lot lower than the recurrence rate for a very large hernia.

              And so, there are certain risk factors that increase the chance that a hernia's going to come back. Folks that are overweight, I think smokers would be more likely to have a recurrence, poorly controlled diabetics, those types of things, and then I said, just the sheer size of the hernia itself will increase your chance of getting a recurrence down the road. So a lot of times, when we say that for instance, a patient isn't yet optimized or ready for surgery, we're doing that to reduce the chance that they're going to get a recurrence down the road. So the idea of getting someone ready for a surgery the first time, is to try to prevent the second operation. So when we're counseling folks towards weight loss, and smoking cessation, and getting their diabetes under control, those are things we're trying to do to prevent the need for an operation, maybe five or 10 years from now.

Deanna Pogorelc:

Absolutely. And would it be obvious to someone that this has happened, if they have had the hernia come back? Would it be similar symptoms or would it be a different experience, and would it be repaired in the same way or in a different way?

Dr. Clayton Petro:

Yeah, so folks that have had a hernia are actually very good at telling if they have another hernia. What we found is that just asking patients the question of, do they fill a bulge, or do they feel like their hernia has come back? That's actually a very reliable indicator that their hernia has come back, and that will often trigger us to get a CT scan to confirm that. Hernias become more complex every time. And so, every time you get a recurrence, it's going to be more complicated than the last one, or at least in the vast majority of cases. And for instance, if you had a hernia repair with small incisions the first time and it comes back again, you may very well need a larger operation, or an up and down incision for the next operation.

Deanna Pogorelc:

Do you envision there being more treatment options in the future for hernias, or any advances in hernia repair surgery?

Dr. Clayton Petro:

Yes. So kind of like I mentioned before, so large hernias, in the past, or even now, are often fixed through large incisions, and smaller hernias are able to be fixed through smaller incisions. I think that the advancement of robotic technology has gradually allowed us to fix larger and larger hernias through smaller incisions, and so, I think that that is certainly a major advancement.

              There is also, and this is kind of getting into the technical details that I'm not sure patients would be interested in, but a lot of surgeons and patients find comfort in the idea of having their mesh placed between layers of muscle in the abdominal wall, so that the mesh isn't, for instance, rubbing up against the intestine. Whether or not that's good, or bad, or better having mesh placed between the muscles of the abdominal wall is controversial, but like I said, a lot of patients and surgeons find comfort in having the mesh placed between the muscles. And traditionally that was something that needed to be done with larger incisions, up and down incisions, and robotic technology has allowed us to put mesh between the muscles, using the robot. And so, I think that that certainly has been an advancement in the last 10 years, and I think that that will become more and more common as we move forward.

Deanna Pogorelc:

Okay. Well, this has been great. Is there anything that we haven't talked about that you want to add, or any kind of last minute takeaway you want to leave our listeners and viewers with?

Dr. Clayton Petro:

There is another type of hernia called a sports hernia, and what this is, is this is commonly a scenario where an athlete, or just someone who's active, maybe the weekend warrior, is doing something and they get a pain in their groin. And the thing that distinguishes this from an inguinal hernia, is that this person will often not feel a bulge or that sensation where you can push something back in. This was given the name of sports hernia, it's also been called athletic pubalgia. And the one thing I'll say about these, are these folks may not actually have a hernia, it might be a torn muscle in the groin. And so, I think that if I can give a word of advice, if I was a patient who had pain in the groin but did not feel a bulge, I would be very apprehensive about having a piece of mesh placed in my groin.

              I think a common clinical scenario that we see here is that folks will have pain in the groin, be diagnosed with a sports hernia, and have a piece of mesh put in, months to years later, they continue to have pain, and it turns out the pain wasn't actually from a hernia, it was from a pulled muscle, but they now have kind of attributed that pain to the mesh, and will have the mesh taken out, and it kind of leads this to this vicious cycle of operations of now the mesh is taken out, maybe the pain goes away, maybe it doesn't. And so, I guess if I was going to give one word of caution, it would be for folks that have pain, but don't really feel a bulge. Not that those folks never have hernias, and not that they should never be fixed, but if I was a patient, I would just be a little apprehensive in that specific scenario.

Deanna Pogorelc:

Well, I think we covered everything. Thank you so much for being here today, and to our listeners, if you'd like to schedule an appointment with Cleveland Clinic's Comprehensive Hernia Center, please visit clevelandclinic.org/hernia, or call (216) 444-6644. And to listen to more podcasts with our Cleveland Clinic experts, please visit clevelandclinic.org/hepodcast, or subscribe wherever you're listening now. And for more health tips, news, and information, follow us at Cleveland Clinic on Facebook, Twitter, and Instagram. Thanks for joining us.