Hernia Surgery and Abdominal Core Health

Podcast Transcript

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

Hi, everyone, and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. And today, I'm very pleased to have one of my good friends, Dr. Michael Rosen, who's a professor of surgery, the Section Head of our Abdominal Wall Reconstruction Team, as well as the DDSI Surgical Operations Vice Chair here in the Department of General Surgery at the Cleveland Clinic within DDSI. We're going to talk a little bit about hernia surgery, as well as abdominal core health. Mike, welcome to Butts and Guts.

Dr. Michael Rosen: Thanks a lot, Scott. It's a pleasure to be here. Look forward to our conversation today.

Dr. Scott Steele: So, tell us a little bit about your background. Where were you born, where you're from, where'd you train, and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Michael Rosen: Sure. So, I was actually born in Alexandria, Virginia. My dad was actually in the army, and I kind of moved all over throughout my training. I went to college in Nashville. I did medical school at the University of Southern California. Then I did my residency at Mass General. Did two years at the Cleveland Clinic, which is kind of how I'm here. Finished my training, did a year of fellowship with Todd Heniford, and that's really where I kind of got introduced to hernias. Thought I would actually go off and be a minimal invasive liver surgeon, actually. And things just changed. This opportunity came about, hernias started to take off, particularly abdominal reconstruction. I spent 10 years at UH, and I've been here almost exactly 10 years now, too. So, it's been quite a journey.

Dr. Scott Steele: Wow. We're super excited to have you here. And he is a very humble man, one of the world's leaders in abdominal core surgery, as well as all forms of hernia. So, Mike, we're going to talk a little bit today about hernia surgery. So, let's start at a 50,000-foot view. What is a hernia at a high level for our listeners?

Dr. Michael Rosen: Sure. So basically, a hernia just means there's a hole somewhere. We term them based on where those holes actually are. And when you have a hole, it's just like if you have a hole in your tire, anytime there's increased pressure, things can poke through there. And that's what you often see is that bulge where things are poking through the actual hole.

Dr. Scott Steele: So, how do hernias form? Is it different between a groin hernia and a hernia in the midline in your belly or hernias elsewhere?

Dr. Michael Rosen: Yeah, certainly. Some hernias, you're actually born with. Some hernias, which is common, can occur after you have a surgical incision. Anytime somebody has to do any type of operation, there's always a risk that the tissue doesn't heal well either due to inherent healing issues that the patients might have. Potentially, wound issues and healing issues after surgery or other just kind of bad luck, or that tissue is just weakened. And hernias in the groin, it's a little controversial of whether or not that's actually due to lifting weights or activities. I personally think most people are just born with a little weakness there. And then over the years, increasing activity, physical labor, you increase your pressure and eventually that hole gets bigger. And when it gets big enough for something to poke through there, then all of a sudden patients come in complaining of a bulge and a hernia.

Dr. Scott Steele: So, Mike, depending on what the hernias are, I mean, what are the symptoms of hernias? Is it one that's different from a hernia up by your stomach versus your belly wall versus your groin?

Dr. Michael Rosen: Sure. So, hernias can present throughout the entire spectrum. They can be completely asymptomatic, and often asymptomatic things don't require repair. We can just wait and watch those. So, it's not an uncommon situation. You see your primary care physician; they might notice a lump or a bump when they're doing your annual physical exam. And if you're truly asymptomatic, we watch those. They can cause some mild symptoms, they can cause pain, you can perceive a bulge, and there can be other functional limitations. Those are issues that we have started to think about repairing them.

And then, there are situations where they can present with life-threatening complications where, for instance, a piece of intestines gets stuck in there, it can get twisted, swollen, lose its blood supply, and that often would create an emergency problem. And that can require an emergency operation in the middle of the night. So, depending on where you are in the spectrum can be a whole bunch of different symptoms associated with them. And different symptoms, pretend that to do different things, as far as managing surgically versus watching.

Dr. Scott Steele: So, "truth or myth?" Most hernias form within the abdominal cavity.

Dr. Michael Rosen: I think that's true. I think it's kind of a large potential space, and what you need to have a hernia is you need a hole somewhere, and you need pressure pushing something out that hole. So, I think that's true. I think for somebody like me that sees life only through a hernia perspective, I like to stress that almost everything in life is a hernia or not a hernia. When we talk about aortic aneurysms, they're basically hernias over the aorta. When we talk about aneurysm in the brain, they're basically hernias of the blood vessels. So, to me, most surgical life revolves around fixing hernias. So that's my jaded perspective.

Dr. Scott Steele: I think that's our quote of the day: "life through a hernia perspective." So, you mentioned a little bit, let's take to traditional hernias. Maybe not our brain aneurysm hernia, but where else in the body can hernias be found?

Dr. Michael Rosen: So, particularly for abdominal hernias, if you think about the abdominal cavity, it kind of has four borders. There's kind of the upper border, which is the diaphragm. Then there's the anterior border that most of us deal with on a day-to-day basis. Then there's the pelvic floor border, and then the posterior border, which would be the spine.

In any one of those quadrants when there's increased intraabdominal pressure, if there is weakness, things can poke through. I think there's no doubt that the most common place that people experience hernias are on the anterior abdominal wall or the groin. Primarily because in congenital development, there's always a potential weakness in people's belly buttons. So those are called umbilical hernias. And then particularly in men, because the testicle starts up by the kidney before you're born and then it descends down, it leaves that area of potential weakness that can form inguinal hernia. So, I think those two are definitely the most common. Then after an incision, having an incisional hernia would be the second most common.

Dr. Scott Steele: So, walk me through, I'm a patient, I'm going to see you, take me through two scenarios. I got a belly wall hernia, or I got a groin hernia. What actually happens during hernia surgery?

Dr. Michael Rosen: Yeah. So, hernia surgery's come a long way, and we've learned a lot over the last two decades about what works and what doesn't work. And what I like to talk to patients about when we talk about fixing hernias is basically there's almost always three things that are happening in every hernia operation. There's a patient with the hernia, and they have unique factors that can be attributed to what we pick as far as doing things open or minimally invasively.

As far as obesity, smoking, diabetes, the size of the hernia, there's often a prosthetic involved, not always, but often. And depending on the different features of that prosthetic, it can require it to be placed in different layers of the abdominal wall.

And then probably, most importantly, there's a surgeon involved. And I think it's important to realize that there's open and minimally invasive approaches. They all have their own pros and cons, and they all have their own indications. So probably, to me, what's most important is just a surgeon that is fast out at doing all the different ways, and then they can kind of pick what's best for you as a patient, not necessarily what operation they do best.

Dr. Scott Steele: Mike, do all hernias need to be treated, and what happens if you don't operate on a hernia?

Dr. Michael Rosen: So, there's actually some pretty good data out there. There's a large trial from the VA, particularly for inguinal hernias and people with asymptomatic or minimally symptomatic hernias. And the good news is, if you're not symptomatic, it's okay to watch it, and the chances of you showing up with an emergency are less than 1 percent. So, there's no harm in watching these things. And the reality is sometimes we choose that because the operations that we do can cause pain, and there can be chronic issues. So, if you're totally asymptomatic, it's okay to watch.

The long-term follow-up in that data is that the majority of people will go on to develop symptoms. So, the odds are not in your favor that you won't need it, but there are certainly times young, active people doesn't bother them, or elderly patients with a lot of comorbidities that can't tolerate an operation. If they're asymptomatic, we watch them. Otherwise, we'll usually just say, "Pick a time that works out in your life, and it's probably worth getting it fixed."

Dr. Scott Steele: So, can a hernia be prevented primarily? And then, what do you do after an operation, is there something that you want to do to prevent recurrence of that hernia?

Dr. Michael Rosen: Sure. So, umbilical hernias, inguinal hernias, those type of congenital type hernias, they can't be prevented. I personally don't think they're associated with heavy lifting other than that's when we notice it because you increase your abdominal pressure. So, I certainly wouldn't limit any activities to avoid hernias. The best thing to be is healthy.

If you've had a surgical incision or having an operation, obviously, if the operation is able to be done minimally invasively, which sometimes it can be, then that would decrease your risk of getting a hernia because the incisions will be smaller. And there's ways that people close the fascia that have been shown to decrease hernia rates, and that is used sparingly in the United States but is another possibility to do that as well.

Dr. Scott Steele: So, can you talk a little bit about the difference between some of the terms that we use, so hernia versus abdominal core health. What does that all mean?

Dr. Michael Rosen: Yeah, that's a great question. And abdominal core health is a relatively new term that tries to look at what we've been talking about in a bit more of a holistic way, in that a lot of times, from a surgical perspective, we just look at the hole and we treat the hole. But what I think that we have learned now is that we have better tools and better methods to assess patients’ functional limitations associated with hernias and particular functional outcomes and improvement in quality of life over the long term. One of the things that we have really started to adopt in hernia surgery is the kind of outcomes that matter to patients, more so than outcomes that maybe are in the forefront of a surgeon's mind. So often, surgeons are hyper-focused on recurrence and reoperation, where for many patients, they're much more concerned about not having chronic pain and having an improved quality of life.

And so, the idea of abdominal core health as it looks at the entire abdominal core, which, as I said, would include the diaphragm, pelvic floor, the back, and the anterior abdominal wall. And when we get defects in those, if when you have an anterior abdominal wall defect, these patients often have a lot of back pain issues, and they can have pelvic floor instability. And we're just at the infancy of this concept of trying to look at a patient's core as an entire functional unit and not just kind of the tip of the iceberg in the hole. And so, this is something that I think is growing. I think as we apply more advanced reconstructive techniques, it's important to make sure that we're really helping patients and making them better, and that the outcomes are justified by the increase in the morbidity of some of these operations that we're doing for the patient focus.

Dr. Scott Steele: So, Mike, are there any advancements on the horizon for hernia surgery or treatment or hernias?

Dr. Michael Rosen: Yeah, I think there's a lot of advancements that are coming. I think that we are in the infancy of minimally invasive surgery, and I think that with a lot of new devices coming on the market, particularly in some of the robotic world, I think that there is a potential to really change the way we fix hernias. But again, this is very early, and we need to make sure that those devices are actually improving outcomes and are actually helping patients. Do that, I think that there's newer prosthetic materials. And ultimately, what I think is probably the most exciting thing on the horizon is that we're starting to recognize that there is a spectrum of hernias where I think that all surgeons should be able to fix routine hernia, as well.

But there is a sub-segment of very complex patients that there's a growing area of specialization in this, and these patients are going to be offered hope where often they were deemed unreconstructible and led to live a fairly poor quality of life. But with a lot of interest in tackling some of these things and surgeon technical excellence, I think that a lot of these patients can be able to offer reconstructive approaches that will help them long-term.

Dr. Scott Steele: Fantastic. And so now, it's time for our quick hitters to get to know you a little bit better. So, first of all, what is your favorite food?

Dr. Michael Rosen: Favorite food for me would be pepperoni pizza.

Dr. Scott Steele: Fantastic. What is your favorite sport to watch and/or to play?

Dr. Michael Rosen: Oh, that's easy. Basketball. I love watching basketball. I love to play basketball. Unfortunately, if I was any good at basketball, I wouldn't be a surgeon, I'd be a basketball player. So, I do love it as my knees are getting older and tired, it's harder and harder to play, but I still do love to watch it.

Dr. Scott Steele: And interjection commentary here, for those of you who don't know, Dr. Rosen's about six-foot-seven, he's actually like a graceful antelope on the ski hills, as well. Amazing to watch in person. And so, what is your favorite place that you've traveled to?

Dr. Michael Rosen: Easy for me, Costa Rica. Costa Rica is my special place in the world. If I could go there, Tamarindo, Costa Rica, just to be specific, I'll throw them a shout-out. I think it is the best country in the world with the best people in the world, and there's no better place to vacation. I'd love to live down there one day.

Dr. Scott Steele: Again, commentary interjected. As I said in my previous one, we are taping these, and we are three for three in terms of Costa Rica today. So, for those of you who are thinking about your next trip, think about that. Well, then finally, Mike, you've been around the world, you've lived in various different places, what do you like about living here in Northeast Ohio?

Dr. Michael Rosen: No, listen, for me, it's easy. I mean, I love people. I didn't grow up in the Midwest. I grew up in the South. I think the Midwest people are just good people. They're hardworking people. I think that, unlike many other places in the world, being nice gets you further. Working in places in the Midwest. It's a wonderful place to raise a family. I've raised all three of my kids. My last one's about to head off to college. So, I love it here.

Dr. Scott Steele: That's fantastic. And so, Mike, give us a final take on message about abdominal wall, either core or hernias, and the abdominal core health here for our listeners.

Dr. Michael Rosen: Yeah, sure. I think, listen, if you have a hernia, and you have one of these problems, do your research. I think seeing somebody who does a lot of this stuff, it doesn't matter what practice they're setting at, there are people in the community, private practice, major academics who do a lot of these things. But I think that one of the things we've really learned from this disease is getting it fixed right the first time makes a big difference. And nobody's perfect, everybody has issues and complications, but go to an experienced surgeon who does this stuff all the time, and that's your best chance at a good outcome. And there's no question that the first shot is the best shot you'll always have.

Dr. Scott Steele: Yeah, great advice. And so, to learn more about hernias and the treatment options available here at the Cleveland Clinic, please visit our website at https://my.clevelandclinic.org/health/diseases/15757-hernia. That's https://my.clevelandclinic.org/health/diseases/15757-hernia. You can also visit us on 216-444-6644. That's 216-444-6644. Mike, thanks for joining us on Butts and Guts.

Dr. Michael Rosen: Thanks so much for having me. Take care, everybody.

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