Michael R. Anderson, MD (Host): Hello everyone, and welcome to this episode of The Forecast, the official Vodka of Fort Healthcare. I am your host, Dr. Michael Anderson, your nose and throat physician and president and CEO of Fort Healthcare, and I'm particularly excited about this episode of the Forecast as I have one of our newest surgeons on staff.

Dr. Tom Diehl. Dr. Diehl, thank you so much for joining me on this episode of The Forecast.

Thomas Diehl, MD: Absolutely. Thank you, Dr. Anderson. Good to be here with you.

Michael R. Anderson, MD (Host): And we are going to be talking about hernias today. And hernias are extremely common. we all have heard about what a hernia is, and, we're gonna learn a little bit more today with Dr. Diehl. And, but before we get started, Dr. Diehl, can you tell us a little bit about yourself, like how long you've been with Fort Healthcare And what kind of drew you to practice medicine in our area?

Thomas Diehl, MD: Sure. Yeah. Well, I've been with Fort Healthcare for just over six months. Now, This is a place That is near and dear to my heart. My wife was raised here in Fort Atkinson And we are now raising our growing family here. Our youngest is two weeks old, so things are a little bit chaotic at my house.

but I know a lot about Fort Healthcare through my father-in-law, Dr. Mark Erickson, who's been working here for 30 years. And so I really got to appreciate. His practice over the course of my training at UW and through him became interested in, coming to learn more about Fort Healthcare. I've had nothing but an amazing experience since I started.

I'm really happy to be here.

Michael R. Anderson, MD (Host): Well, Dr. Deal, we're very, very excited to have you as well. I know our patient's and community are gonna resonate with you instantly once they get a chance to meet you and interact with you. it's a very special place to practice. And I just wanna say, enjoy being the youngest and newest surgeon because, time flies, especially as you continue to add to your family.

And congrats on that, by the way. Congratulations, two weeks old. let's dive into our topic today, which are hernias. Dr. Dio, can we just start with a simple definition. What is a hernia?

Thomas Diehl, MD: Yeah, starting off with the basics, hernias are weaknesses in the abdominal wall, or they can be weaknesses in the diaphragm and often abdominal content such as intraabdominal fat. Or bowels, intestines, protrude through these defects. And that's what causes the majority of the symptoms. They can be congenital, meaning that they are present from the time of birth or they can be acquired, something that patient's develop over the course of their life.

And so we see hernias in children and.

Michael R. Anderson, MD (Host): So what are the, if we focus just a little bit on the adult hernia for now. So what are the typical locations, that a hernia may present And what would be the typical symptom?

Thomas Diehl, MD: So hernias are extremely common in multiple locations. The most common one is a groin hernia, also called an inguinal hernia. umbilical hernias are common by the belly button and, hiatal hernias. So inguinal hernias, patient's usually, present with a bulge in the groin. they occur more commonly in men than women, actually about nine to 10 times more common in men.

And so almost 30% of, men will develop a hernia, an inguinal hernia at some point in their lifespan compared to only one in 25 or 30 women. patient's will often. Report that they have pain with physical activity. Sometimes they report a dull achiness, in the groin. and more rarely patient's will experience what we call an incarcerated hernia, where the hernia actually is stuck, and cannot be reduced.

And when patient's have these types of symptoms, it's an emergency to present to the operating room well, to the emergency room, And then often to the operating room, for an emergency hernia repair.

Michael R. Anderson, MD (Host): Okay. And we will touch a little bit more on that, but now I wanna go over to the pediatric side. Of things, Dr. Deal. So do you see the same, commonality to different type of hernias in the pediatric population, or is it a little bit different?

Thomas Diehl, MD: It's a little bit different. congenital inguinal hernias are common. They're found in about one in 20 or 5% of term children still much more common in, boys than girls. and they're even more common in premature. Infants, umbilical hernias are, exceedingly common. it's a natural weakness in the abdominal wall where the umbilical cord comes through the umbilicus.

And so, they're present. Umbilical hernias are present in about 20% of, newborns, but the majority of those close spontaneously, which is important for parents to know.

Michael R. Anderson, MD (Host): Yeah, absolutely. And if we can just stay on the, kids for now. So if a parent notices. a bulge in the, belly area or the groin area. They typically, I assume, go to their primary care, provider, family medicine, pediatrician. And, typically what happens, with that.

Thomas Diehl, MD: I would say often it's a bulge that parents notice, changing a diaper when their child's crying is a common time. Parents say that they notice the bulge is a little bit bigger. And so, it's a common concern in a pediatrician's office. I think that our pediatricians here are, very knowledgeable and, don't refer infants or toddlers to us for, umbilical hernia repairs very often because we know that about 90% of them will close by school age, age four or five years old.

when the hernia is still present at four or five years old. Then we see, children in our office to talk about an elective umbilical hernia repair.

Michael R. Anderson, MD (Host): Gotcha. And so switching back to now the adults, I want to go back to something that you talked about And that was a, an incarcerated hernia. And can you talk to us a little bit further about that? Because, I believe that typically leads to an emergency room visit, And then emergency treatment. So could you talk to us a little bit more about an incarcerated hernia?

Thomas Diehl, MD: Yeah, certainly. So hernias are typically reducible, And what that means is the bulge that a patient feels on their abdomen is soft and can be pushed back in towards the rest of the intestines when hernias. Become stuck outside of the muscle of the abdominal wall. They continue to become more inflamed and diff more and more difficult to reduce to the point that it may not be possible.

To reduce the hernia even in experienced hands. And so that's when we call the hernia incarcerated. This is a true surgical emergency, that's often accompanied by what we call obstructive symptoms like nausea and vomiting, where the kink in the bowel That is stuck out in the incarcerated hernia is preventing fluid and food from passing through the intestines normally.

And so, if patient's ever experience these symptoms, they need to seek medical care very quickly. Because delays can lead to bowel ischemia we call it, which means that the bowel is not getting enough blood flow And the bowel can actually die. And so patient's sometimes require, bowel resection at the time of hernia repair if the bowel is incarcerated for too long.

Michael R. Anderson, MD (Host): So Dr. Diehl can people live with hernias for a time and does that predispose them to potentially an incarceration of it?

Thomas Diehl, MD: This is a really important question, so I think all patient's. With hernias should be seen by a surgeon to discuss their symptoms And the potential benefits of a hernia repair. But the short answer to your question is yes, you definitely can live with a hernia and not all hernias need to be repaired.

we have excellent data for watchful waiting versus, elective hernia repair. Watchful waiting, meaning a non-operative approach where we just monitor the hernia over time And we have data in the inguinal hernia realm And the umbilical hernia realm. That tells us the risk of having a major complication, like, incarceration or bowel strangulation is exceedingly rare.

And we also know that there is no difference in. pain interfering with physical activity or difference in physical function for patient's who are just monitoring their hernia rather than having it repaired. I will say though, that a sizable proportion of patient's who are on the watchful waiting side of things do at some point crossover to having surgery because the national natural trajectory of hernias is that they get bigger over time and often as they enlarge the symptoms come along with that.

Michael R. Anderson, MD (Host): so let's touch a little bit now on the surgical, treatment for hernias. take us through that kind of a high level. how is it repaired? And I know. Fort Healthcare now has an, operative robot. So perhaps you can tell us a little bit about that. but just take us through that Dr.

Deal.

Thomas Diehl, MD: There are a lot of different approach approaches to hernia repairs and it, depends a little bit on the type of hernia. So I guess I'll highlight just a few of them. Traditionally inguinal hernias are repaired open, we call that. So that's with an incision in the groin. The hernia sac is reduced And then the defect in the abdominal wall is patched with a synthetic mesh That is sewn into place and reinforced the abdominal wall where that weakness is.

And the hernia used to be. We, over the last couple of decades have. Started doing more minimally invasive inguinal hernia repairs. And for a long time, that was a laparoscopic approach. And there are a couple of different laparoscopic approaches, which are with cameras and long skinny instruments to do the same type of procedure, but from the inside of the abdomen and with much smaller incisions.

And most recently we've moved toward doing. Robotic, inguinal hernia repairs, which is a type of, laparoscopic hernia repair. The approach is essentially identical, but again, the hernia sac is reduced back into the abdomen. And the weakness, the abdominal wall is patched with a synthetic mesh That is, usually sewn into place in a couple of locations. but another one of the benefits of the laparoscopic robotic approach is that, we talk about groin hernias or inguinal hernias, like it's one thing, but there are actually multiple defects where the intestines, or in intraabdominal fat can herniate through the abdominal wall.

And the laparoscopic approach covers all of these defects with the same operation and can address the hernia on both sides of the. abdomen, I mean, a right and a left inguinal hernia, for example, through the same three incisions, the abdominal wall. so that's, one of the benefits. And then another benefit is that the mesh lives in a separate compartment from where the bowels are to minimize the risk of bowel and mesh.

Michael R. Anderson, MD (Host): So would you say that it's advantageous, to have the robot as a tool for, hernia repair?

Thomas Diehl, MD: Absolutely. I I highlighted the inguinal hernia repair there, but I actually think that the largest benefit for, Robotics And the hernia repair realm is with ventral hernias. And that's because the robot has wristed instruments and joints that work much like our hands and arms do. And so that allows surgeons to operate with extreme precision and to work at angles that are really not feasible, or at least not at least they're very challenging, laparoscopically.

So the robot, we know that patient's have. Less pain, faster recovery, shorter length of stay in the hospital. And that means that patient's can get back to work faster. They can have, a faster return to their normal daily life, as well as less reliance on narcotic pain medication, which is important.

Michael R. Anderson, MD (Host): That is critical in today's environment, getting people. To recover faster back, to work sooner with less pain medicine. It, sounds like a home run to me. robotics to me is very, very exciting. It's wonderful to see us, be able to offer that here at Fort Healthcare with young, talented surgeons, such as yourself.

when you do the hernia repair, how successful is it? Is there a recurrence rate? or is it essentially nearly a hundred percent effective?

Thomas Diehl, MD: That's an important question, and it depends on the type of hernia repair and on some of the patient characteristics as well, so. inguinal hernia repairs have a very low recurrence rate. We know from the literature that the recurrence rate after an inguinal hernia repair is somewhere in the two 3% range.

ventral hernia repairs have a quite a bit higher recurrence rate, and it depends on a multitude of factors. Primarily the patient's weight. Other medical conditions such as diabetes, smoking contributes as well. And then other things that can contribute to intraabdominal pressure, elevated intraabdominal pressure such as chronic cough, chronic constipation, all those things contribute to hernia recurrence.

So I tell people that, chances of having a successful operation with a robotic or. Really any type of hernia repair is near a hundred percent that we're going to, we're gonna repair this hernia. The patient will feel better and they will have a successful operation. What that means in terms of long-term recovery in 10 years, 15 years, 20 years, is really.

Dependent on a multitude of factors. And I think that the medical community in general is shifting more towards, thinking about hernia repairs more like a joint replacement, that This is a hernia repair that may last you 15, 20 years, but that doesn't mean that it's a permanent fix. And I think that's an important thing for patient's to understand.

Michael R. Anderson, MD (Host): Absolutely. I recognize that ventral hernias could be a whole separate vodka cast. That is a, That is much different than the inguinal hernia. I wanna switch back, Dr. Deal to the pediatric side. when you see a child that has a hernia, are the operative approaches the same with a child when it hasn't?

spontaneously taking care of itself by school age? Or are there different, approaches to the child?

Thomas Diehl, MD: There are different approaches to the child. Most umbilical hernia repairs in pediatrics are done open. so that's with a small incision by the belly button. Usually we hide it right inside of the belly button. And then. The musculature, we call it the fascial defect, where the hole in the abdominal wall is, gets closed with sutures alone and no mesh.

We try really hard not to use mesh in children because their body is growing And the mesh does not grow. also that the pediatric population is. So good at healing that a suture based repair that allows the patient's musculature to grow back together is a very sturdy repair in children.

And so we almost never use mesh in children, especially in young children for umbilical hernia repairs and similarly for inguinal hernia repairs. those can be done, open, oral, laparoscopic. But the laparoscopic approach still does not use mesh. And actually a different operation where we do something called the high ligation of the hernia sac, which means that the hernia sac is.

pulled back towards the, abdominal cavity and sewn closed on the inside rather than pulling the entire hernia sac back in the abdomen and placing a mesh between the sac And the abdominal wall like we do in adults. So the approaches are different, and I think the biggest difference is that we try not to use mesh in kids.

Michael R. Anderson, MD (Host): No, it sounds like a very important distinction between the, pediatric And the adult populations. Dr. Diehl, I wanna say thank you so much for joining me on this episode of the Forecast. I certainly learned a lot about hernias today, and I'm sure our patient's in community, have as well. So thank you.

Thomas Diehl, MD: Thank you. It was really nice to be here with you and talk about hernias.

Michael R. Anderson, MD (Host): Yeah, well, it's an important topic. It's pretty common. So if you have any hernia concerns or a loved one that has a hernia concern, please reach out to Dr. Diehl and I'm confident he can take excellent care of you. So thanks again Dr. Diehl,

Thomas Diehl, MD: Thank you.

Michael R. Anderson, MD (Host): and thank you for tuning in to this episode of the Vodcast, on the Forecast podcast.

I appreciate ya. Taking a look. See at us. Please check out our complete library on our website, and please don't forget to share us on your social media channels. But thanks again. This is Dr. Michael Anderson signing off. Have a great day.