Transcription:
Hernia Repair Performed Laparoscopically

Prakash Chandran (Host): As technology advances, so do medical practices and sometimes the worlds of technology and medicine intertwine. When it comes to hernias, there are two options for surgical correction; the conventional open method, or the laparoscopic method. We're going to talk about it today with Dr. Hormuz Irani, a Board Certified General Surgeon and Specialist in Minimally Invasive Hernia Surgery for Dignity Health.

This is Hello Healthy, a Dignity Health podcast. I'm Prakash Chandran. So first of all, Dr. Irani, it's great to have you here today. Let's just start with the basics. What exactly is a hernia?

Hormuz Irani, MD (Guest): It's nice to be here. Hernia is basically a protrusion of intestinal or intraabdominal contents through a weakness or a tear in the muscle defect we call it, that creates a bulge and that's in simple terms, a hernia.

Host: And when does a hernia typically occur? Is it when you're doing sports or you're doing something strenuous? Talk to us a little bit about that.

Dr. Irani: Okay. You can be born with a hernia for one, but most hernia we see in adults are created by straining, lifting, sometimes even coughing in elderly people who have bronchitis or asthma. Anything that increases the intraabdominal pressure by lifting, straining, coughing, creates the hernia to protrude out through a weak point in the abdomen or the groin area, which is the inguinal area. And that's basically, how a hernia develops.

Host: I see. And are there different types of hernias that people should be aware of?

Dr. Irani: Yeah, good point. The hernias usually can be inguinal, like I mentioned, or it could be umbilical. It could also be incisional, meaning a weakness created by an incision from previous surgery and that creates a weak spot also. So, those are the kind of main types of hernias that we see.

Host: So, when we hear about hernias, for example, I have two uncles that both have hernias and their doctors have said, you know, you don't need to deal with it immediately. This is something that you can wait for a couple of years to deal with. Can you talk to us a little bit about the different severities of hernias and when you might want to get them addressed?

Dr. Irani: Generally, hernia is seen by the Primary Care Physician. So, it's your primary doctor who sees the hernia or the patient brings it to his or her attention. And then, that doctor will decide, should I refer this patient to a surgeon to have it repaired or not? Generally hernias, if they're really small, if it's something a patient has lived with pretty much for most of their lives and it's extremely tiny and not bothering the patient, yes, it's fair to just leave it alone. Most hernias grow with time. So, by constant lifting, straining, coughing, as I mentioned earlier, that constant increase in pressure, causes the hernia to get bigger and larger, and then it becomes more dangerous. The reason we fix hernias is because a piece of, internal organ, fat or small bowel or bladder, or colon, any of those organs usually are mobile and they push through this little opening and can get incarcerated, meaning stuck or strangulated, which means the blood supply can get cut off.

So, most hernias or I would say 90 % of hernias would require repair, generally. But the best person to look at that would be a General or a Hernia Specialist or Surgeon who should be able to decide if this hernia is something that should be repaired or not.

Host: Okay. So, we're talking about repairing the hernia. Talk to us a little bit about the most common ways that's typically done.

Dr. Irani: The hernias used to be repaired, as you mentioned earlier, open through an incision. So, we used to make an incision through the skin, through the muscle, get to the hernia and then push it all back in through that defect, and then close the defect with sutures, or a mesh, which is now used predominantly in all hernia repairs.

So, that's the old fashioned way, in my opinion. Nowadays, we do the hernia repair minimally invasive, which means laparoscopically or robotically, which is a variation of laparoscopic surgery. And that is done through tiny little   incisions or holes, if you like, through which we put our trocars, we do the surgery and we put the mesh minimally invasive.

So, there's no cutting of muscle, no cutting of skin, which makes   the recovery significantly better, the pain and ability for that patient to be able to lift and strain faster than if they'd had an open repair. So, that most surgeries are done laparoscopically, now. There are still surgeons doing them open. There are indications for doing them open. If it's a very complicated or recurrent hernia, that's been quite large and stuck if you like, or adherent. In those cases, it's justified to do an open repair, but most inguinal hernias, which is about 90% of hernia repairs, are done laparoscopically

Host: Got it. And you mentioned robotic surgery as well. Can you just clarify the difference between laparoscopic surgery versus robotic surgery?

Dr. Irani: Basically laparoscopic surgery is done through the little trocars I mentioned. Robotic surgery is done exactly through the same trocars. The only difference is that robotic surgery, you use the same trocars, but you're sitting at a console which is a few feet away from the surgery and you can control the instruments, through the console.

The nice thing about that is the vision that you get with a robot is three-dimensional. So, it makes it easier to perform in a way. And the instrument, in the patient that's inserted, mimics everything you do on the console. So, you control it all through a console and that's the difference. It's also nicer for the surgeon who's sitting comfortably as opposed to standing and bending over. So it's ergonomic for the surgeon as well.

Host: Yeah, I've heard that it really just serves as an extension of your hands, isn't that correct?

Dr. Irani: Yes. It's definitely yes. And also gives you a range of motion that your hand doesn't have, so you can swivel your wrist 360 degrees if you like.

Host: Yeah, I think that's an important piece for people to know, because when they hear robotic surgery, they think a robot might be doing the entire work, but it really is just assisting you and really being that extension for you so you can do your job a little bit better.

Dr. Irani: Correct. You still make the decisions. You still direct the movements, the cutting, the cauterization. Everything is done as per the surgeon's movements and instructions. So, it's not like the robot takes over. Maybe in another 10 years, perhaps, but not just yet.

Host: Not yet. You know, one of the other things that you mentioned was the use of a mesh, talk a little bit about what that is and how it's used.

Dr. Irani: Everyone that I see in the office freaks out when they hear the word mesh, because they've seen all the ads on TV about lawsuits flying around with mesh complications and problems. The mesh that we use is not the one that has caused complications. The main mesh that caused trouble was the sling mesh used in women for bladder lift surgeries, and that caused all kinds of problems and that's been removed.

There are a few mesh that we use for hernia repairs also that caused issues, mainly adhesions to the bowel. And that's also been removed. The mesh that I use and most surgeons use, has been around for almost 25 years. So, it's not something we just started doing. It's been around for a long time and is pretty complication free.

So, that's nothing a patient should really worry about. Yes, there are lots of lawsuits going around, but it shouldn't be a deterrent. Hernia repairs pretty much require mesh now. To do a hernia without a mesh, risks the chance of that hernia coming back. And so, that's why mesh has been used now for about 30 to 40 years. And pretty much is used routinely now in all surgeries.

Host: Okay. That's really good to know. So, you know, we've been focusing here a lot on minimally invasive surgery. Let's talk a little bit about the advantage of doing that versus the traditional open method.

Dr. Irani: As I mentioned before, the recovery is the main thing. The recovery, let's say, let's take inguinal hernias, which is most of the hernias we see in men and occasionally in women. We do the surgery laparoscopically, which takes literally 45 minutes. So, the recovery is a lot faster because I'm not cutting any structures or muscle or skin, which has, which is richly supplied with nerves. So, it causes more pain. So, recovery is a lot faster. Also, the vision is better because you've got four times magnification. So, you're seeing things clearly, close up and also the beauty about that is you can literally check the other opposite side.

Most people have hernias on one side and a smaller hernia on the other that may not be appreciated till five years later when they come back and say, now I've got a hernia on the opposite side. So, laparoscopically, you can check that, immediately at the same time as this time of your first surgery.

So, you will fix the side that is obviously bothersome to the patient, and then you can swing the scope, look at the other side. And so that's something you can't do with an open method. So, those are the advantages and certainly has become the mainstay of hernia repairs now.

Host: And, you know, you're talking about a recovery time. Can you give us an example? If someone goes to get minimally invasive hernia surgery, when can they expect to be back at work or walking around.

Dr. Irani: Usually the recovery for let's say a hernia surgery performed laparoscopically in three to four days, there is minimal to almost no pain. You're sore for about three to four days. After that, you can walk as much as you want. We do recommend no lifting for about maybe a week to 10 days at the most, unless the patient does very heavy lifting or we tell them not to go to the gym for about three weeks if you're going to be doing a full workout. But most people are back to normal activities in five to six days, at the most 10 days.

Open repair, you're down for almost three weeks and you can't   lift, at least that's what we used to advise patients for about four to five weeks after that. So, there's a significant difference in recovery. The other advantage of laparoscopic surgery, I forgot to mention was the nerve injury. When you do open hernia repairs, there's a higher risk of injury to the nerve that supplies this area. And so, that can cause chronic pain, sometimes lifetime pain and that's a debilitating problem. Laparoscopically, you can see the nerve in fact and make sure that you avoid it. And that's another big advantage.

Host: So just as we close here, I've read that Mercy recently received a Center of Excellence designation for hernia surgery. What exactly does that mean for Kern County?

Dr. Irani: Good. I'm glad you mentioned that. Center for Excellence is an award kind of, a designation given to the hospital and the surgeon. So, the hospital is a Center for Excellence, but also the surgeon separately has to qualify for a Center for Excellence status in various fields. For hernias to get that status, firstly, the hospital has all the equipment for advanced laparoscopic surgery. So, that's definitely present in Dignity and they've got pretty good stuff. Second, the surgeon is looked at too by the awarding committee which means, they look at your experience. They want to make sure that you've had the training, advanced training, if you like. And also, they look at your results, which is the most important thing. So, they want to see that you've had good results, in hernias. That would be a recurrence rate of less than 1%, I would think. And second, they look at complications. How many complications has this surgeon had? So, those are all factored in to designating that Center for Excellence award. It's a long laborious process and we have to submit a lot of data to support it. So, it's a big deal. As far as a patient looking to go to a center that has that status, they feel confident that this is a good center, with few complications and good results.

Host: It definitely sounds like it and sounds like they are in good hands with you Dr. Irani. So, I really appreciate your time today.

Dr. Irani: Thank you.

Host: That's Dr. Hormuz Irani, a Board Certified General Surgeon and Specialist in Minimally Invasive Hernia surgery for Dignity Health. For more information, head to dignityhealth.org/bakersfield.

If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. This has been Hello Healthy, a Dignity Health podcast. Thank you so much. And we'll talk next time.