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Melanie Cole (Host):  Welcome to the podcast series from the specialists at Penn Medicine. I'm Melanie Cole and today we're discussing complex hernia repair at Penn Medicine. Joining me is Dr. Jenny Shao. She's an Assistant Professor of Clinical Surgery specializing in Gastrointestinal Surgery at Penn Medicine. Dr. Shao, it's a pleasure to have you join us today. Tell us a little bit about hernias. What are the most common types that you see and what are some common conditions and factors that lead to them?

Jenny Shao, MD (Guest): Thank you so much for having me today. I'm excited to be here and to talk a little bit about hernias and hernia surgery. So, some really common types of hernias that I see tend to be inguinal hernias. But we can also see lots of other types of hernias, mostly incisional and ventral hernias. A lot of times patients will develop these hernias due to weaknesses in their abdominal wall, either from prior surgery or from just a weakness over periods of time. So, these are very common and basically the most common ones that I repair.

Host: Well, thank you for that. So, recently Doctors DeMatteo and Serlette who lead the departments of Surgery and Plastic Surgery, respectively at Penn Medicine, they co-authored a report calling incisional hernia an epidemic in the United States. Tell us a little bit about incisional hernia. Why is it so common and why did they say it was an epidemic?

Dr. Shao: Right. So, incisional hernias occur after any type of surgery. And as we know, a lot of people in this country end up having surgery. So, the incisional hernia rate can be anywhere between 10 to 20%, but it can be as high as 50% in high risk patients. So, high risk patients are patients who undergo emergency operation for any sort, who are sick in the hospital for long periods of time. Anyone who develops a wound infection after surgery is more prone to developing an incisional hernia. And so, if we think about the cost of healthcare and the cost of surgery and fixing these hernias, the cost of incisional hernias can be very high depending on what kind of surgery patients are having and how they recover afterwards. So, decreasing and preventing incisional hernias is something that is really important especially here at Penn Medicine, because it changes the quality of life for patients and also decreases healthcare costs.

Host: Well, that's certainly true. So, when do you feel it's important for other providers to refer their patients for surgery? And while you're telling us that, do they always need to be repaired. How do you decide whether to repair or wait?

Dr. Shao: Yeah, that's a really good question. So, I definitely think anybody who is symptomatic from their hernia should be referred to surgery to evaluate whether or not they need a more emergency type repair or if this can be done electively. The best reasons to repair somebody is to improve their abdominal wall function and their activities of daily life. As you can imagine, if you have an incisional hernia on your abdomen, it's going to be really hard to use your core muscles to do anything and in your daily life  from sitting up, to turning, to driving. And so we really want to be able to give function back to some of these patients.

More emergently, I think, patients who develop intermittent obstructing symptoms, patients who have intra-abdominal contents, such as, small bowel or colon inside of their hernias should probably be fixed more urgently, especially if they're having obstructive symptoms. When we see people emergently in the emergency room, a lot of times they come in for pain and a bulge that doesn't go away. And a lot of times when these hernias become incarcerated or stuck in that hernia sack, they can actually become strangulated or cut off from the blood supply. And then that becomes an emergency operation. And so, for the most part when patients are asymptomatic, their chances of needing an emergency operation is pretty low, but as they develop more and more symptoms, it would be more prudent to come see a surgeon for evaluation and repair.

Host: What can you tell us about the tool developed by Penn Hernia Program to predict the risk of incisional hernia? This is fascinating.

Dr. Shao: Yes. So, this tool, it was in a paper in the Annals of Surgery and was done by John Fisher's team who is a great researcher in hernia surgery. And what's really great about this tool is it allows us to look at the risk factors of each particular patient prior to a major abdominal operation and to assess their risk of developing an incisional hernia and seeing how they heal  after surgery. I think this is important because it allows us to identify people who are at higher risk and more prone to potentially developing an incisional hernia and because it allows us follow them and figure out ways interoperatively to prevent their risk of developing a hernia.

Host: I would like you to expand for just a second on patient selection. How does that help to optimize repair?

Dr. Shao: Yeah, patient selection is really important. We want the best outcomes for our patients and in hernia surgery is no different than any other type of surgery. So, looking at things like  figuring out what sort of risk factors will decrease the risk of infection after hernia repair.

A lot of that is looking at BMI, weight, also at A1C. You know, we've learned that you can decrease the risk of developing wound infection by about five to 7% for every decrease in A1C point, which is really important. So, it's really about optimizing these patients and making sure that they're at the lowest risk for developing an infection and the best optimization for wound healing afterwards. We also counsel our patients on smoking cessation. All of our patients have to stop smoking for at least a month before their operation.

Host: What great points you made. So how has the Penn Hernia Program approaching hernia surgery different than compared to other institutions?

Dr. Shao: So, here at Penn, I think we've really worked on building a center of excellence for abdominal wall reconstruction. And this center of excellence is going to have a couple of components that are really going to help structure the Hernia Program and help optimize our results. So, some of these things that we're really looking at are prehabilitation beforehand. So, decreasing BMI, decreasing A1C, controlling medical comorbidities. Some of it is going to involve physical therapy and developing specific physical therapy regimens for hernia patients before and after the surgery to help with the recovery process. And really it's about creating a multidisciplinary approach with plastic surgery, infectious disease, other specialists in hernia repair so, we can optimize results. Because hernias, if you don't fix them well the first time, they have a high risk of coming back and each successive repair can be less successful than the first time you try to repair it. So, our approach is really to pick a patient-tailored approach and fix it the best way the first time.

And you know, that may be robotic, that may be open, that may require plastic surgery to be involved. I think it's really about looking at the individual patient and figuring out what works best for them.

Host: If you would speak about the multidisciplinary approach, you just mentioned a few different providers. Tell us why that's so important.

Dr. Shao: Yeah. So, the multidisciplinary approach allows us to essentially examine a patient' s hernia from multiple different facets and really come up with the best approach to fixing it. So, what we're going to be doing is talking about patients in a multidisciplinary conference with hernia surgeons, plastic surgery, radiology, and really getting everyone involved to figure out,  does this person potentially need Botox, which will allow us to relax the oblique muscles in order to bring their rectus muscles together, to fix the hernia better? Is this person going to need physical therapy beforehand so they can pass the six minute walk test so that they can recover faster from their surgery and decrease any pulmonary complications, Should this person get a panniculectomy by plastics at the same time to decrease any wound breakdown that could potentially cause an infection?

So, I think it's really about examining the patient from multiple angles and figuring out exactly what we need to do to optimize their particular results. So, I think that's something that we're really excited about starting here at Penn Surgery. 

Host: So, as we're discussing: some of the latest advances in complex hernia surgery at Penn, tell us a little bit about Penn surgeons and how they're utilizing, during surgery to optimize these outcomes and decrease complications and prevent recurrence rates, 

 Dr. Shao: I guess the newest, latest advances are really going to be, I think three different things. So, the first thing is going to be utilizing Botox, as I mentioned before. So, Botox temporarily paralyzes muscles if you inject them. Most commonly people obviously get it in their face. But a lot of times now we can use Botox in the abdominal wall muscles to temporarily relax and paralyze the muscles so we can achieve greater fascial closure and medializing the rectus muscles. And this is particularly important because this is what helps us recreate that core strength for a lot of our complex abdominal wall reconstruction patients. This is something that, you know, we are still working on to get FDA approval for, but it's something that we documented in the literature that works really well for a lot of our patients.

So, that's something that I think we're doing that not everyone else is doing. Other things that we're going to be doing are examining the different types of meshes that we should be using and in what space we should be using them in. So, a lot of times we'll use absorbable mesh for people who are high risk, or biologic mesh in people who are more prone to infections or potentially just using synthetic mesh, depending on exactly where we are placing the mesh. And I think lastly, you know, we're using a minimally invasive approach to a lot of our hernia repairs.

So, we're really trying to decrease the wound infection rate and increase the recovery time. We know that doing a minimally invasive repair with smaller incisions can allow the patient to leave the hospital, hopefully in one to two days instead of five to six which decreases their length of stay. A lot of times you can also decrease the pain that they're in because the incision is much smaller and also decrease their wound complication which I've, I think mentioned many times is one of the most important factors in preventing hernias from returning. So, I think, you know, all of these things together and everything in our program is really geared towards optimizing results, decreasing recurrence rates and making sure that we can have a good outcome for our patients.

Host: That was an excellent summary. Dr. Shao, do you have any final thoughts for other providers and what you'd like them to know about complex hernia surgery at Penn Medicine? And when you feel it's important, they refer?

Dr. Shao: Yeah, definitely. So, I think at the end of the day, you know, complex hernia patients, they're complex for a reason. A lot of times they have multiple co-morbidities and hernias that can be very difficult to fix with fistulas and loss of domain. And it can be really a very difficult quality of life situation for many of the patients. But I do think that these patients can be candidates for surgery. It's just about making sure that we provide good complex care for them. So, you know, obviously we're happy to see any patients with hernias that would like to see a surgeon who you'd be interested in referring. A lot of times if they have CT scans or records with them, or previous hernia operations, it'd be great for them to come with the records so we can make a really good in-office assessment of what needs to be done and how to go from there. But yeah, I mean, we love fixing hernias, so this is our passion and we're excited to you know, improve patient outcomes in this clinical area.

Host: Thank you so much, Dr. Shao, what an informative episode this was. To refer your patient to Dr. Shao, please visit our website at pennmedicine.org/refer or call 877-937-PENN. That concludes this episode from the specialists at Penn Medicine. Please remember to subscribe, rate and review this podcast and all the other Penn Medicine podcasts. I'm Melanie Cole.