Selected Podcast
Hernias and Gallbladders
Dr. Yurcisin will discuss the correlation between hernias and gallbladders with bariatric surgery.
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Learn more about Basil Yurcisin, MD
Basil Yurcisin, MD
Dr. Basil Yurcisin is a bariatric and general surgeon. He trained at one of the world’s top fellowship programs in bariatrics and minimally invasive surgery- Duke University Medical Center. In 2010, Dr. Yurcisin joined Garden State Bariatrics, and became a partner in 2017. He is a Fellow of the American Society for Metabolic and Bariatric Surgery (ASMBS) and a Fellow of the American College of Surgeons (ACS). Not only is he an incredibly talented bariatric surgeon, Dr. Yurcisin is compassionate, funny and dedicated to the lifelong success of his patients.Learn more about Basil Yurcisin, MD
Transcription:
Prakash Chandran: It's difficult enough to decide whether or not to have weight loss surgery, but it can be even more difficult to undergo a procedure like a gallbladder removal or a hernia repair at the same time. There are nuances to consider around when a patient should consider these procedures and we'll learn more about them today.
This is Winning Through Losing, a weight loss surgery podcast from Garden State Bariatrics and Wellness Center. Our guest today is Dr. Basil Yurcisin, bariatric surgeon and partner at Garden State Beriatrics and Wellness Center. My name is Prakash Chandran. So Dr. Yurcisin, really great to have you here today. You know, we've heard about hernia repair and gallbladder removal before, but why do bariatric patients need to make special considerations when evaluating their surgery?
Dr. Basil Yurcisin: Yeah. That's a great kind of cross topic. So gallbladder surgery and hernia surgery are the management of those disease processes are their own category in the world of general surgery. But there are some kind of special considerations when it comes to a bariatric patient.
For instance, any bariatric patient who loses a significant amount of weight would be at risk of developing stones in their gallbladder. And those stones may then cause problems where they may have to have their gallbladder out, removed surgically as a result. And that happens in about 4% of the bariatric population. Incidentally, you can have a similar risk if you were to just go on a crash diet and lose a bunch of weight and, you know, minus surgery. So it's not the surgery in and of itself. It's the actual act of significant weight loss that can put you at risk for developing gallstones and those gallstones can then cause problems.
It used to be that we would actually take out the gallbladder. We, being bariatric surgeons, would take out gallbladders as a matter of course during the course of a bariatric surgery, like a gastric bypass or a duodenal switch. However, we've found over time and with research and through the literature that that may be overkill and there is a set of risks that do come with just taking out the gallbladder prophylactically.
So to reduce some of those risks, it's become more of a watchful waiting type of situation. So if you have symptomatic gallstones or if you have symptomatic gallbladder disease, it is completely safe and completely appropriate to have the gallbladder taken out either before you have bariatric surgery or at the same time as bariatric surgery.
However, if there's no symptoms and there's no indication for removal, it's not like it's a foregone conclusion that somebody is going to develop difficulties with their gallbladder and that they need to have it out. So we typically wait until somebody manifests with issues and we take it out down the road.
Now, that being said, the act of having had a previous bariatric surgery prior to having a gallbladder surgery, there isn't a specific increase in difficulty with that secondary operation or a specific increase in complication rates. There may be a little bit of extra scar tissue in the general area of the gallbladder. But in general, it's very similar to having had a de novo gallbladder removal. And gallbladder surgery incidentally is the most common general surgery that we perform in the United States. So it's, you know, something that can be done by your bariatric surgeon, but it's also safely done by pretty much any general surgeon.
Prakash Chandran: Okay. So gallbladder removal is one type of surgery that your patients might ask you to perform at the same time as bariatric surgery. But what about hernias? Like, let's say a patient has a belly button hernia or one from a previous surgery, when is it an appropriate time to address that issue?
Dr. Basil Yurcisin: So hernia surgery is a big topic in and of itself. But in general, there are certain risk factors that people have or can have that makes it more likely that a hernia that has been attempted to be repaired could recur. And a lot of those things exist in our patient population that are considering bariatric surgery, things like diabetes, things like morbid obesity, whether or not the patient has problems with their lungs like COPD or they're a smoker and often coronary artery disease or their blood vessels have, you know, calcifications and things. So those patients are more of a setup for a recurrence of a hernia should they have it repaired while they're still heavy and they still have co-morbidities.
Typically, the method we'd like to employ is to wait until somebody's lost their weight first and then attempt to fix the hernia, specifically in the case of a abdominal wall or an incisional hernia. This does not suggest that a patient who is symptomatic from a hernia or has problems because of a hernia could not have a hernia repair at the same time as the bariatric surgery. But It's not as likely to be as durable a repair potentially.
And often when we repair hernias in the same breath, often as we repair hernias, we find that we have to use different types of meshes in order to repair the hernia. And those meshes are something that we don't want to get secondarily infected by other things. And so when we do bariatric surgery, we do violate -- or not violate -- but we do make cuts to the bowel into the stomach. And that could release small microscopic bacteria that could potentially infect the meshes. So we try not to do multiple operations at the same time that could complicate the other operation. And that's potentially what could happen if we try to do hernia at the same time. It doesn't mean it's not possible to do it safely, but if you add those kinds of potential things together where you have a patient who's kind of a setup for a recurrence and you have an operation that could be a setup for a potential complication, if you do it in somebody who it's not necessarily indicated at the time, then you kind of put those two things together. And I think it becomes safer to wait until the patients lost weight and try to give them a more durable one-time repair.
Prakash Chandran: Okay. So are there any other procedures or things that you see or that should be repaired concurrently during a bariatric surgery?
Dr. Basil Yurcisin: A lot of the patients who come for bariatric surgery, there is a pretty high percentage of people who have associated reflux or GERD. And often, reflux or GERD can be driven by being overweight, but it can also be driven by something called a hiatal hernia. And a hiatal hernia is when basically the upper aspect of your stomach has slid past the diaphragm into the lower aspect of the chest. It's not an uncommon thing, probably happens in about 10% of the population. And there are varying degrees of hiatal hernia. So, you know, every hiatal hernia doesn't equal somebody who has GERD, but it can, and it can be something that predisposes you to having GERD or reflux.
And so often, during the course of a weight loss surgery, since we're operating on the stomach and each of those cases, the organ the stomach, not the belly, but the organ the stomach, we have a tendency to give benefit to the patient by repairing the hiatal hernia at the same time as the bariatric operation. In other words, we pull the stomach out of the lower chest and back into the upper belly where it belongs and then we close the diaphragm or the muscle that the stomach had slid through in order to get to the chest to make the opening more narrow so that the stomach can't slide itself back into the chest.
So the mere act of doing that operation in somebody who has a significant hiatal hernia can also make the person's reflux or GERD go away right after the repair, you know, by the time they wake up from the surgery. And it is something that is well-documented as being possible to perform in conjunction with the bariatric surgery and give immediate results in the process.
Prakash Chandran: Yeah, that's pretty amazing. And how often are you doing the hiatal hernia repair at the same time as you're doing bariatric surgery?
Dr. Basil Yurcisin: I mean I don't have a good percentage for you, so it just depends on the patients who walk in your door and if they have them or not and if they're symptomatic from their heartburn or not. But I do find myself probably 10% or 15% of the time on a bariatric patient performing a hiatal hernia repair in conjunction. And there's different ways to repair it. You can repair it with mesh or without mesh, that comes down to some other nuances interoperatively. But yeah, it's not uncommon. And then people can develop hiatal hernias after or one that was insignificant at the time of surgery, they can develop more significant problems with heartburn and reflux after bariatric surgery that may necessitate the need to do a hiatal hernia repair. And in that case, it's also quite safe to approach the operation and do it laparoscopically and give the patient basically one night in the hospital or overnight stay in order to repair that issue.
Prakash Chandran: Yeah. So talking specifically about hernias and the meshes used to repair them, I've heard mixed things about their efficacy and sometimes even the safety around them. So is this something that you can speak to?
Dr. Basil Yurcisin: Yeah. I mean, so meshes, you know, have evolved since a lot of the stuff where you see the class action lawsuits on television, you know, "Different meshes were used in my bladder sling or in my abdominal wall hernia repair." We've gotten pretty good at making meshes that are very safe and very durable and very resistant to infection.
So there are different types of meshes, whether it being a permanent mesh or a biologic or, you know, temporary meshes that do get absorbed by the body or that your body grows into over time and actually replaces the mesh with your own tissue. Typically, with the hiatal hernia repairs, we use the second type of mesh that if we use a mesh, it's like a biological mesh or a mesh that promotes your own tissue's ingrowth. So that over time you don't have random piece of mesh in your belly anymore, you've actually got your own tissue that's replaced that mesh and only helped to make that repair more durable over time.
Prakash Chandran: So, Dr. Yurcisin, do you have a good rule of thumb for people that might be listening to this as they think about concurrent procedures, whether it be the gallbladder removal or the hernia repair?
Dr. Basil Yurcisin: So, I mean, typically, the time when we repair hernias that are abdominal wall hernias or belly button hernias or incisional hernias, the timing of when we do gallbladders is directed by whether or not there's an indication to deal with those things. So if you have a symptomatic gallbladder, if you have a symptomatic hernia, it is typically a good idea to do it earlier in the process or if you're having active medical problems because of the gallbladder or the hernia. If they are asymptomatic items, you typically wait until they become or are symptomatic.
The hernia is a little bit different in that category, that if you have a hernia, you can repair it electively, but it's typically better to repair it electively after the patient's lost weight and optimize how well they're going to do long-term with that hernia repair. And then the hiatal hernias are completely safe to do at the same time as the initial operation.
Prakash Chandran: And just before we close here, I guess I had just a more general question around how people should consider or think about bariatric surgery and the timing of when they should get the surgery, and just anything else that you want to share around that.
Dr. Basil Yurcisin: Yeah. And that's a bit of a big question, but, you know, honestly, bariatric surgery should not be the first thing that you consider when you want to lose weight. That is not the answer. It's typically somebody who's gone through multiple attempts at weight loss through diet and exercise, maybe has reached a frustration level, maybe they have a medical problem that prevents them from being able to exercise as effectively, maybe they've had an accident or something that has happened in their lives that has reduced their capability of being able to kind of attack it head on and they need a booster or a help in order to kind of get their end goal. Because as people in the United States get heavier and as we get more comorbid, it can be more and more difficult to just, you know, go to the gym and put the fork down. And sometimes even in the face of doing those things, they don't get the outcome that they're looking for.
And so the the adjunct of bariatric surgery can definitely kind of give that a kick in the pants a little bit. But that doesn't obviate the need to use other weight loss mechanisms, like diet and exercise, and surgery works in concert with those two things. It doesn't work in a solo performance outside of a diet and exercise. So it's very important to kind of be prepared that it's just not like go get surgery and then go buy skinny jeans. That's not really the process. It's more get surgery, use it as a tool to help you change the habits that have gotten you here in the first place and to help reduce the medical problems so that it becomes easier and easier to have the good habits that you need in order to have a healthy lifestyle long-term.
Prakash Chandran: Well, Dr. Yurcisin, I think that is really great advice and the perfect place to end. Thank you so much for your time.
Dr. Basil Yurcisin: You're welcome.
Prakash Chandran: That's Dr. Basil Yurcisin, bariatric surgeon and partner at Garden State Bariatrics and Wellness Center. For more information, please visit the Garden State Bariatrics and Wellness Center website at gsbwc.com.
If you found this podcast helpful, please share it on your social channels and check out the entire podcast library for topics of interest to you. This was Winning Through Losing, a weight loss surgery podcast with Garden State bariatrics and Wellness Center. My name is Prakash Chandran. Thank you so much and we'll talk next time.
Prakash Chandran: It's difficult enough to decide whether or not to have weight loss surgery, but it can be even more difficult to undergo a procedure like a gallbladder removal or a hernia repair at the same time. There are nuances to consider around when a patient should consider these procedures and we'll learn more about them today.
This is Winning Through Losing, a weight loss surgery podcast from Garden State Bariatrics and Wellness Center. Our guest today is Dr. Basil Yurcisin, bariatric surgeon and partner at Garden State Beriatrics and Wellness Center. My name is Prakash Chandran. So Dr. Yurcisin, really great to have you here today. You know, we've heard about hernia repair and gallbladder removal before, but why do bariatric patients need to make special considerations when evaluating their surgery?
Dr. Basil Yurcisin: Yeah. That's a great kind of cross topic. So gallbladder surgery and hernia surgery are the management of those disease processes are their own category in the world of general surgery. But there are some kind of special considerations when it comes to a bariatric patient.
For instance, any bariatric patient who loses a significant amount of weight would be at risk of developing stones in their gallbladder. And those stones may then cause problems where they may have to have their gallbladder out, removed surgically as a result. And that happens in about 4% of the bariatric population. Incidentally, you can have a similar risk if you were to just go on a crash diet and lose a bunch of weight and, you know, minus surgery. So it's not the surgery in and of itself. It's the actual act of significant weight loss that can put you at risk for developing gallstones and those gallstones can then cause problems.
It used to be that we would actually take out the gallbladder. We, being bariatric surgeons, would take out gallbladders as a matter of course during the course of a bariatric surgery, like a gastric bypass or a duodenal switch. However, we've found over time and with research and through the literature that that may be overkill and there is a set of risks that do come with just taking out the gallbladder prophylactically.
So to reduce some of those risks, it's become more of a watchful waiting type of situation. So if you have symptomatic gallstones or if you have symptomatic gallbladder disease, it is completely safe and completely appropriate to have the gallbladder taken out either before you have bariatric surgery or at the same time as bariatric surgery.
However, if there's no symptoms and there's no indication for removal, it's not like it's a foregone conclusion that somebody is going to develop difficulties with their gallbladder and that they need to have it out. So we typically wait until somebody manifests with issues and we take it out down the road.
Now, that being said, the act of having had a previous bariatric surgery prior to having a gallbladder surgery, there isn't a specific increase in difficulty with that secondary operation or a specific increase in complication rates. There may be a little bit of extra scar tissue in the general area of the gallbladder. But in general, it's very similar to having had a de novo gallbladder removal. And gallbladder surgery incidentally is the most common general surgery that we perform in the United States. So it's, you know, something that can be done by your bariatric surgeon, but it's also safely done by pretty much any general surgeon.
Prakash Chandran: Okay. So gallbladder removal is one type of surgery that your patients might ask you to perform at the same time as bariatric surgery. But what about hernias? Like, let's say a patient has a belly button hernia or one from a previous surgery, when is it an appropriate time to address that issue?
Dr. Basil Yurcisin: So hernia surgery is a big topic in and of itself. But in general, there are certain risk factors that people have or can have that makes it more likely that a hernia that has been attempted to be repaired could recur. And a lot of those things exist in our patient population that are considering bariatric surgery, things like diabetes, things like morbid obesity, whether or not the patient has problems with their lungs like COPD or they're a smoker and often coronary artery disease or their blood vessels have, you know, calcifications and things. So those patients are more of a setup for a recurrence of a hernia should they have it repaired while they're still heavy and they still have co-morbidities.
Typically, the method we'd like to employ is to wait until somebody's lost their weight first and then attempt to fix the hernia, specifically in the case of a abdominal wall or an incisional hernia. This does not suggest that a patient who is symptomatic from a hernia or has problems because of a hernia could not have a hernia repair at the same time as the bariatric surgery. But It's not as likely to be as durable a repair potentially.
And often when we repair hernias in the same breath, often as we repair hernias, we find that we have to use different types of meshes in order to repair the hernia. And those meshes are something that we don't want to get secondarily infected by other things. And so when we do bariatric surgery, we do violate -- or not violate -- but we do make cuts to the bowel into the stomach. And that could release small microscopic bacteria that could potentially infect the meshes. So we try not to do multiple operations at the same time that could complicate the other operation. And that's potentially what could happen if we try to do hernia at the same time. It doesn't mean it's not possible to do it safely, but if you add those kinds of potential things together where you have a patient who's kind of a setup for a recurrence and you have an operation that could be a setup for a potential complication, if you do it in somebody who it's not necessarily indicated at the time, then you kind of put those two things together. And I think it becomes safer to wait until the patients lost weight and try to give them a more durable one-time repair.
Prakash Chandran: Okay. So are there any other procedures or things that you see or that should be repaired concurrently during a bariatric surgery?
Dr. Basil Yurcisin: A lot of the patients who come for bariatric surgery, there is a pretty high percentage of people who have associated reflux or GERD. And often, reflux or GERD can be driven by being overweight, but it can also be driven by something called a hiatal hernia. And a hiatal hernia is when basically the upper aspect of your stomach has slid past the diaphragm into the lower aspect of the chest. It's not an uncommon thing, probably happens in about 10% of the population. And there are varying degrees of hiatal hernia. So, you know, every hiatal hernia doesn't equal somebody who has GERD, but it can, and it can be something that predisposes you to having GERD or reflux.
And so often, during the course of a weight loss surgery, since we're operating on the stomach and each of those cases, the organ the stomach, not the belly, but the organ the stomach, we have a tendency to give benefit to the patient by repairing the hiatal hernia at the same time as the bariatric operation. In other words, we pull the stomach out of the lower chest and back into the upper belly where it belongs and then we close the diaphragm or the muscle that the stomach had slid through in order to get to the chest to make the opening more narrow so that the stomach can't slide itself back into the chest.
So the mere act of doing that operation in somebody who has a significant hiatal hernia can also make the person's reflux or GERD go away right after the repair, you know, by the time they wake up from the surgery. And it is something that is well-documented as being possible to perform in conjunction with the bariatric surgery and give immediate results in the process.
Prakash Chandran: Yeah, that's pretty amazing. And how often are you doing the hiatal hernia repair at the same time as you're doing bariatric surgery?
Dr. Basil Yurcisin: I mean I don't have a good percentage for you, so it just depends on the patients who walk in your door and if they have them or not and if they're symptomatic from their heartburn or not. But I do find myself probably 10% or 15% of the time on a bariatric patient performing a hiatal hernia repair in conjunction. And there's different ways to repair it. You can repair it with mesh or without mesh, that comes down to some other nuances interoperatively. But yeah, it's not uncommon. And then people can develop hiatal hernias after or one that was insignificant at the time of surgery, they can develop more significant problems with heartburn and reflux after bariatric surgery that may necessitate the need to do a hiatal hernia repair. And in that case, it's also quite safe to approach the operation and do it laparoscopically and give the patient basically one night in the hospital or overnight stay in order to repair that issue.
Prakash Chandran: Yeah. So talking specifically about hernias and the meshes used to repair them, I've heard mixed things about their efficacy and sometimes even the safety around them. So is this something that you can speak to?
Dr. Basil Yurcisin: Yeah. I mean, so meshes, you know, have evolved since a lot of the stuff where you see the class action lawsuits on television, you know, "Different meshes were used in my bladder sling or in my abdominal wall hernia repair." We've gotten pretty good at making meshes that are very safe and very durable and very resistant to infection.
So there are different types of meshes, whether it being a permanent mesh or a biologic or, you know, temporary meshes that do get absorbed by the body or that your body grows into over time and actually replaces the mesh with your own tissue. Typically, with the hiatal hernia repairs, we use the second type of mesh that if we use a mesh, it's like a biological mesh or a mesh that promotes your own tissue's ingrowth. So that over time you don't have random piece of mesh in your belly anymore, you've actually got your own tissue that's replaced that mesh and only helped to make that repair more durable over time.
Prakash Chandran: So, Dr. Yurcisin, do you have a good rule of thumb for people that might be listening to this as they think about concurrent procedures, whether it be the gallbladder removal or the hernia repair?
Dr. Basil Yurcisin: So, I mean, typically, the time when we repair hernias that are abdominal wall hernias or belly button hernias or incisional hernias, the timing of when we do gallbladders is directed by whether or not there's an indication to deal with those things. So if you have a symptomatic gallbladder, if you have a symptomatic hernia, it is typically a good idea to do it earlier in the process or if you're having active medical problems because of the gallbladder or the hernia. If they are asymptomatic items, you typically wait until they become or are symptomatic.
The hernia is a little bit different in that category, that if you have a hernia, you can repair it electively, but it's typically better to repair it electively after the patient's lost weight and optimize how well they're going to do long-term with that hernia repair. And then the hiatal hernias are completely safe to do at the same time as the initial operation.
Prakash Chandran: And just before we close here, I guess I had just a more general question around how people should consider or think about bariatric surgery and the timing of when they should get the surgery, and just anything else that you want to share around that.
Dr. Basil Yurcisin: Yeah. And that's a bit of a big question, but, you know, honestly, bariatric surgery should not be the first thing that you consider when you want to lose weight. That is not the answer. It's typically somebody who's gone through multiple attempts at weight loss through diet and exercise, maybe has reached a frustration level, maybe they have a medical problem that prevents them from being able to exercise as effectively, maybe they've had an accident or something that has happened in their lives that has reduced their capability of being able to kind of attack it head on and they need a booster or a help in order to kind of get their end goal. Because as people in the United States get heavier and as we get more comorbid, it can be more and more difficult to just, you know, go to the gym and put the fork down. And sometimes even in the face of doing those things, they don't get the outcome that they're looking for.
And so the the adjunct of bariatric surgery can definitely kind of give that a kick in the pants a little bit. But that doesn't obviate the need to use other weight loss mechanisms, like diet and exercise, and surgery works in concert with those two things. It doesn't work in a solo performance outside of a diet and exercise. So it's very important to kind of be prepared that it's just not like go get surgery and then go buy skinny jeans. That's not really the process. It's more get surgery, use it as a tool to help you change the habits that have gotten you here in the first place and to help reduce the medical problems so that it becomes easier and easier to have the good habits that you need in order to have a healthy lifestyle long-term.
Prakash Chandran: Well, Dr. Yurcisin, I think that is really great advice and the perfect place to end. Thank you so much for your time.
Dr. Basil Yurcisin: You're welcome.
Prakash Chandran: That's Dr. Basil Yurcisin, bariatric surgeon and partner at Garden State Bariatrics and Wellness Center. For more information, please visit the Garden State Bariatrics and Wellness Center website at gsbwc.com.
If you found this podcast helpful, please share it on your social channels and check out the entire podcast library for topics of interest to you. This was Winning Through Losing, a weight loss surgery podcast with Garden State bariatrics and Wellness Center. My name is Prakash Chandran. Thank you so much and we'll talk next time.