Melanie Cole, MS (Host): Welcome to the podcast series from the Specialists at Penn Medicine. I'm Melanie Cole and today, our discussion focuses on an all too common condition, abdominal hernia. Joining me is Dr. Kelly Janke. She's the managing physician at the surgical group practice based in Lancaster, Pennsylvania. Dr. Janke, thank you so much for joining us today. Can you start by talking a little bit about your work in hernia and abdominal wall repair? What types of hernias do you treat and how common are these?

Kelly Janke, DO: Thank you for having me. Yes, I can certainly talk about that. So, there are many types of hernias throughout the body, and I focus on abdominal wall hernias, which is distinct from things like diaphragmatic hernias and hiatal hernias occurring inside the body, but not in the abdominal wall.

So, my primary area of interest is ventral hernias and inguinal hernias. Ventral encompasses umbilical incisional and other types of less common abdominal wall hernias that occur because of weaknesses in the way the abdominal wall is constructed. These can be either congenital or acquired. In the case of incisional hernias, they can vary in complexity based on the type of prior surgery the patient has had.

In general, hernias are very common. Inguinal hernias being the most common in all patients, both male and female, but they do predominantly affect male because of anatomy reasons. And unfortunately, incisional hernias are quite common as well from surgeries that we do for other reasons. And there can be a variety of different complexity levels based on the type of hernia that exists.

Host: Well, thank you for that. Can you speak a little bit about the benefits of a robotic approach to hernia and abdominal wall? Does it help recovery time? Are there benefits both for the patient and for the surgeon? .

Kelly Janke, DO: Yes. So, each patient is an individual, and there are multiple different factors that go into my decision-making when I offer the approach. Some of those factors would include the size of the hernia, that's a critical factor, as well as their surgical history. And if I have access to their prior operative reports to indicate what sort of condition the intraabdominal cavity is in.

So for someone with a simple, straightforward, very tiny hernia, they may be a candidate for an open repair in which a small incision is needed just to place sutures to repair the hernia. However, if anything is larger than about the two-centimeter mark, typically mesh is indicated in which case they would benefit from a minimally invasive approach.

I will employ the minimally invasive approach nearly universally to all patients in order to offer those benefits that you mentioned. So, some of those benefits being smaller incision, which is a significant impact on patients, especially obese patients because of the decreased wound morbidity. So, it is possible to do some very complex hernias with very large pieces of mesh through three to six eight-millimeter incisions rather than a laparotomy incision, which would be from xiphoid to pubis, and that is of significant benefit to the patient.

Same applies for most inguinal hernias. They can typically be done with three-eight millimeter incisions. And that applies to either unilateral or bilateral inguinal hernias. So, most patients are a candidate for that type of approach. There are a few factors that might prohibit that approach. One would be if I have records that indicate they have had multiple prior complicated intraabdominal surgeries, which may make it unhealthy environment to access laparoscopically.

So, someone who maybe had a perforated bowel, had an ostomy, had to put back together, and now has an inguinal hernia, they would probably be a better candidate for an open approach, which is also a safe and effective operation. But it does have a larger incision and a little bit more pain.

The other consideration is what is their overall status? Are they even a candidate for surgery to begin with? So, someone who is elderly, frail, and not having many symptoms from their hernia may be better served by observation. But the bottom line is I will entertain a minimally invasive approach in any patient as a first line, and then consider the other factors as to whether it's appropriate or not.

Host: Dr. Janke, how important is optimizing the patient prior to surgery to get the best outcomes? Tell us a little bit about anything you might do for the patient.

Kelly Janke, DO: Yes. So, this is a very hot topic. And I go to a lot of hernia events and conferences, and it is always the subject of many lectures pertaining to hernia repair. In the past, unfortunately, surgeons were not as vigilant about some of the preoperative preparation. And I believe that we did apply hernia surgery, unfortunately, to patients who probably had bad outcomes because of the patient's selection.

So now, that we know that history, surgeons have become a lot more careful about some of the factors and the factors that we consider in terms of pre-op optimization would be obesity, smoking history, any sort of immune compromise status such as steroid use or any other autoimmune medications or suppressive medications for autoimmune conditions or bowel disease, as well as any sort of comorbid pulmonary issues, whether that be sleep apnea to some extent. But more likely, a more significant pulmonary disease such as COPD.

Now, there is still great debate and a lot of research in both directions regarding the obesity factor and the smoking factor. For a while, it was thought that smoking is really a contraindication to some of the more complex abdominal wall surgeries. And it seems that the pendulum may be swinging the other way, though there's no specific research in support of or against. However, typically in my practice, I do advise patients who need a very complex, so I'm talking an abdominal wall reconstruction surgery, to quit smoking prior to surgery. Smoking does affect blood flow. It affects healing. If there is a need to convert to an open surgery with a big incision, they certainly have a higher wound complication rate. And then also, some of these larger abdominal wall surgeries can certainly affect the pulmonary system because when your belly hurts, you don't take deep breaths, you become hypoxic. And smoking both during the procedure with general anesthesia and intubation and postoperatively can affect that factor.

Obesity is the other factor that is still of debate, especially with the rise of minimally invasive surgery. Typically, for someone who has a very complex hernia, we would like their BMI to be under 36. That's a hard sell for some patients. So, a lot of times in a patient with a less involved hernia repair or a smaller hernia, if they're significantly affected on a lifestyle basis, meaning they can't function on a day-to-day basis because of pain, they can't exercise to lose weight because of pain, then we might be more apt to offer a minimally invasive repair with the nuanced discussion that, "Hey, your BMI is higher than we would typically do this surgery." However, we know that we're going into this with a potential for a higher risk of recurrence or the hernia coming back, and recurrent hernias can be more complex.

Host: Well, thank you for that. What about promising new therapies? If you were to look forward to the next 10 years in the field, where do you feel will be some of the most important areas of research?

Kelly Janke, DO: So, that's also an interesting question. There is a lot out there. So, I employ robotics for the majority of my hernia repairs. And though some patients do have this conception or misconception that the robot is doing the surgery, that is not the case. I am doing the surgery. I am in the room with the patient. I place the trocars or the incisions, and then I operate the robot next to their bedside.

However, there is increasing talk of the robots actually being able to perform the surgery through AI. So, I think that's going to be a very interesting aspect of the surgical field. Besides that, I believe that we will continue to look at mesh materials and what is best for the patient. There's been quite an evolution of mesh materials, what best incorporates into the abdominal wall, which have least recurrence rates and also least complication rates. So as technology evolves, companies are certainly looking at that and creating new types.

And then, I think the prior discussion about the patient optimization is going to continue. Along with that comes shared decision-making with the patient. So, both the mesh discussion and the weight / risk factor discussion is something that I typically do approach, as a shared decision-making with a patient. So, these are your risk factors. This is what you can do, because the outcome is based on both you and I and how we decide to proceed.

So, I tried to employ that method with a patient to allow them to see that they do have some control over their outcomes, that we can do a better surgery in three months, when you drop 10 pounds, and you can do that for yourself, then you should. And then I follow up. And something we've also been traditionally poor at as surgeons is, "Hey, go lose some weight. I'll see you when you do."

And then of course, they never do. They come back with incarceration or something like that. So, I do try to follow those patients. And if we have a weight loss goal, I do try to say, I can refer you to bariatrics. But I'd like you to come back in three months. Let's see how you're doing. Let's see where you're with your goals, your pain, et cetera. And that shared decision-making is something that's also evolved over time. And I think we'll probably continue to evolve as time goes on.

Host: This is such an interesting topic and a really exciting time in your field. Dr. Janke, as we wrap up, can you talk about the specialties and expertise of the surgical group overall that are available in central Pennsylvania?

Kelly Janke, DO: Absolutely. So, we've got an excellent group of surgeons who really do employ a lot of minimally invasive and advanced techniques, which multiple levels of different training and interest in our group. We offer a combination of minimally invasive hernia surgeons. We're also well-versed in open hernia surgeries. And two of our surgeons are also colorectal specialists, so they do a lot of colon, anal, and rectal surgery and offer specialty services.

We have a group of vascular surgeons who do an excellent job with vascular work, dialysis work. And then, we do actually have two minimally invasive surgeons who, in addition to doing general surgery, also do bariatric surgery. So, we really do have the gamut of surgeons. And if you're interested in hernia surgery beyond the abdominal walls, such as hiatal hernias and paraesophageal hernias, we do have three specialists who deal with those issues as well.

Host: Such a comprehensive team. Thank you so much Dr. Janke, for joining us today, and to refer your patient to Dr. Janke at Penn Medicine in Lancaster, please call our 24/7 provider-only line at 877-937-PENN. Or you can submit your referral via our secure online referral form by visiting our website, pennmedicine.org/referyourpatient. That concludes this episode from the Specialists at Penn Medicine. I'm Melanie Cole.