Options For Hernia Repair
Dr. Steven Nishida
General surgeon at The Queen’s Medical Center
Where did you receive your schooling and training?
I went to UCLA for medical school and then moved to Hawaii to attend the University of Hawaii John A. Burns School of Medicine residency program. That was a five-year surgical program, which I finished in ’89.
What got you interested in treating hernias?
That’s part of general surgery. I have an interest in minimally invasive surgery, so I do a lot of laparoscopy. Hernias are probably the most common thing general surgeons see.
What is a hernia?
It’s the body content pushing out. That might be the intestines, fat or other things. It can be a problem if it’s the intestine poking out and the opening is narrow enough that the intestine can actually strangulate itself. We call it an incarcerated hernia when whatever is in there is stuck and doesn’t push back easily. When it cuts off its blood supply, we call that a strangulated hernia. Risk of a hernia strangulating is low.
What age is most at risk?
Hernias can occur at any age. Babies are sometimes born with hernias.
Where do hernias occur?
From the diaphragm to the groin. They can happen on the site of a previous surgery. Belly button hernias are very common, and two or three types of hernias can occur in the groin.
There are a bunch of different types of hernias. The most common are called inguinal hernias, and they are in the groin. They’re much more common in males, but women can get them as well. Men get inguinal hernias because before they’re born, their testicles start off inside the body and then migrate outward. The path they take to migrate creates a potential weakness. In some people, that pathway doesn’t seal completely and they become prone to hernias.
Hernias on a site where there’s been surgery are called incisional hernias. Those are more complicated to repair, and fortunately they’re less common. Maybe 10 to 20 percent of the time, if you’ve had an operation, there’s a chance a hernia can develop. And it may take several years for those types of hernias to appear.
What are the symptoms of a hernia?
Most people know when they have a hernia because they either have discomfort or pain in the area and they may notice a bulge. Some people have the bulge without much pain. One of the big controversies is if you’re not having symptoms from a hernia in the groin, should it be fixed? One study found that the risk of incarcerating is less than one percent. The same group came back with a 10-year follow up. They found that after 10 years, 65 to 70 percent of the people they were watching ended up getting surgery because the hernia had gotten larger and started to cause more symptoms.
Now they’re recommending that if you’re in good health and you’re a reasonable candidate for surgery, it’s probably worthwhile fixing almost every hernia, because there’s a high chance the hernia is going to get bigger. It becomes more difficult to repair the bigger it gets.
How do you fix a hernia?
There are a dozen different ways to repair a hernia using different types of meshes. The reason why there are different ways is because there’s no one perfect way. What I usually tell family and friends is that whatever surgeon you see, you should probably go with what they are most comfortable with. Surgeons will gravitate to what works best for them.
There are two major ways to repair a hernia. Most surgeons use mesh. If you do a non-mesh repair, when you just suture things shut, data shows that the recurrence rate is much higher and there’s a much higher chance of chronic pain after the hernia repair.
Sometimes you’ll see on the news complications created by mesh with other types of procedures, particularly gynecological procedures. But that’s an entirely different application, and at least for groin hernias the safety record for mesh is very good.
Aside from whether to use mesh, a second decision is should it be done from the front, using open surgery, or is there an advantage to doing it laparoscopically. It depends on the data you look at. Some studies say laparoscopic surgery could have a higher recurrence rate, but those studies were done with surgeons who were in teaching institutions and were not particularly well-trained at doing laparoscopy. There are other studies looking at surgeons who do laparoscopy showing their recurrence rate is actually lower. The bottom line is you should do whatever the surgeon is most comfortable with.
For laparoscopic surgery, where do you go in?
We approach from the belly button. We make a small cut, put the scope in and then we go inside and fix the hernia from behind.
Are there preventive measures?
There are no measures to prevent getting a hernia. Once you know you have a hernia, what do you need to do to prevent it from getting worse? Generally we tell people to avoid lifting heavy things and to avoid things that might make the hernia bulge out. But the truth is coughing and sneezing probably create more force on the belly wall than just lifting heavy things. Once you develop a hernia, it’s probably going to get bigger regardless of what you do. I usually encourage patients not to restrict themselves too much because you want to live a normal life.
Does the hernia tend to recur?
If mesh is used, recurrence rate is around five percent. Most surgeons tell patients to take it easy for the healing period which is usually a month to six weeks. I usually tell patients to live a normal life and not baby it, because it probably doesn’t matter what a person does — if it’s going to recur, it’s going to recur.
Are there risks associated with hernia repair?
There are potential complications. There’s a chance the repair can fail, probably in the 5 percent range with mesh repair. With non-mesh repair, the recurrence rate could be up to 40 percent after 20 years. That’s why we usually use some type of mesh. Using the mesh isn’t without consequences. Infection complications can occur. Another complication, especially from open surgery, is the chance of nerve injury.
If a nerve is injured, the risk of chronic pain after the hernia repair can be as high as 10 percent.
Can hernias be life threatening?
If the hernia is more painful than usual, especially if it’s associated with signs of the intestines being blocked, such as nausea, vomiting and bloating, that’s an emergency. If you can’t push it back in, you need to go to the ER right away.