Kendal Williams, MD (Host): Welcome everyone to the Penn Primary Care Podcast. I'm your host, Dr. Kendal Williams. So one of the challenging things about being a primary care physician is you train in certain things that you see commonly, but then you go into primary care and people come in with all kinds of things, some of which you've actually not had a lot of training in.

And so, one of the things I like to do on this podcast is highlight things that I don't know a lot about, or I find challenging to diagnose and manage, and bring experts on the program to talk about that. So, in this case, I wanted to spend an episode talking about hernias, in their various types of hernias, but also how to diagnose and a little bit about what happens when they're repaired and some of the complications of repairs and so forth.

And for that, I brought on Dr. Leslie Okorji. Dr. Okorji is a Surgeon at Penn, a Gastrointestinal Surgeon, who has an expertise in hernias. Leslie, thanks for coming. 

Leslie M. Okorji, MD: Thank you so much.

Host: Leslie, tell me a little bit about yourself in terms of your background and training. 

Leslie M. Okorji, MD: Of course, so I did my general surgery residency in North Carolina at the Carolinas Medical Center, followed by a minimally invasive surgery fellowship at the University of Alabama in Birmingham, and then I came to Penn. This is my second year in practice, and so my focus is on hernias, both big and small, simple and complex. 

Complex abdominal wall pathology like mesh infections and mesh fistulas. I also do some bariatric surgery and foregut surgery as well as general surgery. And so the kind of broad bread and butter cases as well as the niche abdominal wall cases, the foregut and bariatrics. That's my practice. 

Host: I saw in your bio that you're an engineer by background and that you had sort of a special interest in minimally invasive approaches, laparoscopic, robotic, and some of the newer approaches, right? 

Leslie M. Okorji, MD: Yes, I did electrical engineering in college and, there's overlap, particularly with regards to the explosion of technology that we have now, particularly with robotics. And so, the technology is multiplying daily and so it's great to be kind of at the forefront of all of that and just try to improve patient care with every new technique or technology that we have coming.

So it's a nice kind of background with all the excitement in the field. 

Host: What we want to do today, just to give everybody a little thumbnail of what we're going to cover, we're going to talk about some of the more common hernia scenarios, inguinal hernias, and then some of the other abdominal wall hernias, umbilical hernias, and so forth. And then, we're going to just get into some of the more complicated situations as well.

And, peek behind the curtain, if you will, about what happens when patients go to the OR and what's a hernia repair look like. So that's our plan. Let me start with something that's very common in our practices. Men in particular, will come in with some right or left groin pain, in the area of where you might have an inguinal hernia.

But there's nothing specific there and, and they're just having pain in that area. And, I struggle with these patients. I do an exam, I look for a hernia. Sometimes I'm not absolutely sure. And then, I don't really know where to go from there, so, oftentimes I'll refer to you or your colleagues, so I'm curious about this workup from your perspective. The patient who comes in with pain in the area of where a hernia might be. 

Leslie M. Okorji, MD: That's a patient we see quite often. And so I think a couple of things that I've found helpful, just right off the bat is, understanding, are they an active male, particularly males? How active are they at baseline? A lot of times the young, really athletic males are the ones that are more likely to have that musculoskeletal pathology.

And so just understanding what they do day to day, and then just trying to iron out the timeline of their symptoms, which a lot of patients don't necessarily remember all the details of when it first started. But, usually at least they're able to guide you one way or the other. And I think the exam is also important.

I think the exam is for inguinal hernias, it's actually a pretty subtle exam and it took me a while to get comfortable with that exam. A couple of things I found really helpful is you want to do it with them standing because gravity helps you, and then you also want to just first look and compare both sides.

A lot of times it's just a subtle difference in the size of the, the inguinal area that will give you the clue, especially in skinny patients. And then when you examine them, you want to have them cough or valsalva for each side, and that will increase the specificity of your exam. But understanding that physical exam is, actually a really poor predictor of hernias. 

Then the next step for me is what is my level of suspicion? I think I'm either getting an ultrasound in those patients to rule out an occult hernia, which just is a hernia that is not palpable on exam. Or I'm getting the MRI, sports protocol specifically to look for sports hernia is all athletic pubalgia, which is the more accurate term. 

The problem with the MRIs is insurances sometimes will give you a hard time, with getting those approved. So in those patients, I'll just get the ultrasound first. And then when the ultrasound is negative, then, I can use that to then obtain the MRI. And so that's the usual algorithm I'll follow in those patients. 

Host: So patients can have occult hernias that are symptomatic, meaning they're difficult to appreciate on exam. I mean, you're a refined examiner. My exam is not as refined. I mean, as you know, you do get better with it over time and get a sense of things, but I would still say I'm not a particularly good assessor on exam.

So, if my exam is negative, there still could be a symptomatic hernia present and that's where ultrasound is most helpful, right? 

Leslie M. Okorji, MD: Absolutely. And actually, particularly in females, because we know that the female groin anatomy is different from males. And so even particularly in females, and I've actually had several patients recently that came in with this typical hernia symptoms, exam completely normal. I get the ultrasound, they have small fat containing hernias, right? And particularly in females, I have low threshold to obtain imaging and in patients who haven't had previous surgery, it's an ultrasound always. 

Host: I think the other thing that is in the differential here, other than, athletic pubalgia, which you said was previously known as sports hernia, is just hip pathology itself. I have an older patient. He's in his late 70s. He's got symptoms now. He's not particularly active. I don't think it's a sports hernia.

But groin pain in that area can potentially be referred from the hip joint itself or a labral tear. Those are the other couple of things that I encounter, but I assume those would be picked up on an MRI. 

Leslie M. Okorji, MD: Absolutely. Yes. And in addition to that, obviously other testicular or scrotal pathologies too, which whatever imaging modality you get, should be able to elucidate the differences between them. 

Host: That's a common scenario and I wanted to go over that with you. Okay, so, if you do detect, if I detect an inguinal hernia on exam, let's just go over a couple of the basics on inguinal hernia. There are direct and indirect, and then, we all learned in our surgery rotation in medical school that, the terminology reducible, incarcerated, strangulated. So let's just go over those basics. Let's just talk about direct versus indirect hernias in the inguinal region.

Leslie M. Okorji, MD: I think a lot of it actually ends up being, it's much more of an academic conversation because in reality, the best way to know is actually in the operating room. Now, I'm good enough at reading at least CT scans. I don't read ultrasounds that well, but CT scans that I can usually tell, because I can follow the inferior epigastric and see whether it goes medial or lateral to that. But in reality, it doesn't change how you manage them. So actually, I've moved away from talking about that with patients. I just say you have a groin hernia. Because certainly too, it could be a femoral hernia, which sometimes on imaging, that's also called an inguinal hernia.

And so right now, there's certain subtleties between the two, but at the end of the day, the management is for the most part, the same. I mean, there's some nuances to femoral hernias as far as how you approach them surgically. But I think ultimately, from an anatomic standpoint, it's just the relationship between the hernia and the inferior epigastric arteries and veins, which any imaging study with a competent radiologist should be able to pick up, but again, they're not always accurate. 

Especially in obese patients or patients who have really large bulges and chronically incarcerated hernias. So the whole floor is typically kind of disrupted in those patients. And then as far as reducible versus not, it's best to reduce them when they're laying flat and typically, when you really want to reduce the hernias, when the patient show up in the emergency room, you put them in Trendelenburg or head down because you want gravity to help you.

And the goal is essentially to, to make sure that, in that acute setting, you're turning an acutely incarcerated hernia to a hernia that at least you have time to, discuss options and optimize whatever needs to be optimized. Now the subtle caveat to that is there are patients who come in with chronically incarcerated hernias, and those are the ones that are tricky because they've had this bulge for years, and it hasn't buckled for years, and so, you don't expect that you're going to be able to reduce those hernias on exam.

And the key is understanding the history. And if they've had previous imaging, it's also helpful too. Because that patient doesn't necessarily need to rush to the emergency room. If it's chronically incarcerated, whatever has been chronically incarcerated lives in that sac now. 

It's been there for years. And so those attachments are really, really dense and so in some ways it actually buys you time because those patients typically are not obstructed and typically it's not an emergency. You can optimize them as well. The acutely incarcerated or the strangulated, that's the patient that needs urgent intervention.

That's the patient that, it's sudden pain, it's really tender. And, clearly this is a relatively new onset type of symptomatology. They come in obstructed at times. That's the patient that, you need to intervene quickly. 

Host: I think my first experience with an incarcerated hernia, that was symptomatic was actually a patient who presented with a small bowel obstruction. And, it was, it was a very, I guess I shouldn't be telling all my foibles and mistakes in, in a podcast that's going to go out, to the entire public.

But, I was actually moonlighting in an emergency department when I was fairly recently out of training and it was extremely busy and I was completely overwhelmed and there was this patient who came in with vomiting and some abdominal distension. So I quickly examined him and sent him off to CT scan and he ended up having a small bowel obstruction.

But, radiologist called me back and said he's got this huge inguinal hernia, you can't see that. And of course, when he came back, I looked at it and he had probably a cantaloupe sized hernia in his groin. I was like, I'm so embarrassed because I should have obviously seen that.

But, I had learned that was the first time I'd actually seen something so dramatic that, can present with small bowel obstructions. And he was not complaining of pain in his groin, which threw me off. He had really complained primarily of just vomiting.

Leslie M. Okorji, MD: Exactly. And that's the patient that worries you more, I think pain plus an obstruction, the spectrum is now moving towards strangulation rather than incarceration, but again, every patient sometimes will present differently and a lot of people minimize their symptoms or really not able to tell you a lot of times exactly when things started to go south. Especially the patients who have been told, hey, you can just live with the hernia and it can be, observed. And so when the pathology changes from observation to, hey, we need to get this fixed, sometimes it's hard to pinpoint, and so certainly I think you mentioned the key things there is obstruction is always a problem.

Pain out of proportion to exam is always a problem. That's ischemia until proven otherwise. And then I think, in the acute setting, obviously you get a CT scan because you want to understand what's happening with the rest of the bowel. In the elective setting or when you have a patient with reducible hernias or you're not concerned about them, then the ultrasound is great because again that's low radiation, it's easy to get and it will give you the answer. 

Host: So a strangulated hernia, as you mentioned, is, when the bowel is becoming ischemic because its blood supply is being compromised. And you said that the key feature there was pain out of proportion to exam. So that would be pain, but also these patients obviously starting to get pretty sick. 

Leslie M. Okorji, MD: Right, that's the septic patient, that's the patient that has redness at the groin, that's the patient that clearly just looks sick, and I think the thing that people get brought up by is, do I still reduce that hernia, even though I know that there is badness happening in that hernia sac?

And I think it's, it's an interesting conundrum, because, you could reduce the hernia, but then you still have to go find that loop of bowel and make sure that that bowel is going to be viable. I think it's a matter of time. So I think if this is somebody you're going to take to the operating room and you have the ability to do that as soon as possible, you can decompress their stomach and then that's all you need to go ahead and figure it out.

But if it's going to be something that, there's some type of delay, maybe they're in the office and, in a setting where you need to transfer them somewhere else. And I will try to reduce that because again, you're buying time and that bowel can go from threatened to healthy again.

And it's just a matter of time with this strangulations. It's not like there's a certain amount of time before the bowel completely necrosis because it has to do a lot with the patient's vasculature. It has to do with also the degree of strangulation and how big is the hernia sac in relation to the neck of the hernia.

So meaning if you have a mushroom hernia, those are the ones that are much more likely to strangulate. Because they have a tiny hernia neck opening and you have a huge sac and those are the ones that will kink off acutely versus if you have more room, sometimes it will take longer for that to become necrotic.

So you, can buy patients a lot of time by trying to reduce those, even those marginal ones, especially if, it's going to take several hours for them to get to a surgeon. 

Host: Coming back to the primary care environment where we see folks that have a clear hernia on exam, I'm able to reduce it. I recommend they go and see you, and in the meantime, I want to give them advice. And what I usually say is, if you develop increased pain in that area or if you start vomiting; is there anything specifically you tell patients to look out for is I guess what I'm trying to get at? 

Leslie M. Okorji, MD: I think all of the things you said, I just tell them, hey, you know your body, so if it starts to cause you more pain or discomfort, if it's now impacting your quality of life, if it's somebody who initially is choosing to not have surgery, if it's becoming a daily problem where it's impacting your ability to work or to do whatever activities at home, carry your kids around, stuff like that. And also, obviously, if you start to notice the symptoms of incarceration or strangulation. And so that's really all the counseling I give. And, just give us a call in that situation or if it's emergent, you have to go to the emergency room. 

Host: And so we're also getting to the question that you face a lot is, when to repair it, if it's incarcerated or strangulated, those people, they're going to get repaired early. If it's reducible, and somewhat minimally symptomatic, then, they may not need repair. And then, we have the patients that come in and really just want it repaired. It's bothering them, they notice it, and so forth. These are discussions that you are frequently having with patients, right?

Leslie M. Okorji, MD: Yes. And it's actually become a lot more difficult as the data came out with regards to the safety of watchful waiting. It just makes the conversation of like, Hey, you have a hernia, we should fix it. It becomes much more nuanced. And so, I just tell the patients essentially first of all, how much is this bothering you?

Is this like daily? Is this once a month? Is this once a year? And then also figure out like, what type of person are you? There's people who like, don't want to live with any type of problem or any possibility of a problem. If there's a 0.1 percent chance of an emergency, they want to fix it. And then there's people who like don't want to undergo surgery, unless absolutely necessary, unless, you know, there's no other options.

So I kind of gauge that right off the bat. And then based off of that, then I just give them the options of either watching it, especially like you mentioned, if it's asymptomatic or minimally symptomatic. The data shows that the risk of incarceration or strangulation is less than 5 percent in the long term.

But what happens in that, in those studies, is actually there's a high crossover rate. So over 60%, I think at 10 years, crossed over to having surgery. And it makes sense, I tell the patients, because ultimately what happens is that area of weakness, it just gets weaker over time in a lot of those situations. And so and there's nothing you can do to stop it as you go about your daily life all the things we use our core to do will continue to add tension to the area and so what happens is then the ones that are minimally symptomatic or asymptomatic, they get bigger and then they start to cause more discomfort, and that's how the vast majority of those patients cross over and got surgery.

It's not because they came in emergently. It's because it's just over time, the natural history of it is that it tends to get bigger. So then when I have those conversations with the patients, most of them, kind of able to decide way or the other. And when they're on the fence, I say, if you're on the fence, I think, it makes sense to just fix it when it's a good time in your life to fix it and just to prevent it from progressing in the future. 

Kendal Williams, MD (Host): Before we get into happens when you fix it, I just want to address one other question, and that's having to do with exercise. Because I imagine, the more Valsalva you might do, the more potential there is for opening that opening, and worsening the hernia. On the other hand, abdominal muscle strengthening may be part of what you want to do in certain hernia circumstances. But I would imagine in inguinal hernia's, exercise potentially could worsen it. 

Leslie M. Okorji, MD: I think it's one of those areas we don't have any data. And so actually what we found is, a lot of the things we say, similar to after surgery, we say no heavy lifting for six weeks. So, it doesn't actually pan out in real life when we study it. It doesn't matter because the forces you generate with lifting are not nearly enough to disrupt the vast majority of patients hernias.

So I tell the patients just monitor your pain. I think it's discomfort that should guide you. I think you don't want to be afraid of taking care of yourself. You're probably not going to make this worse. If it's going to be worse, it's going to be worse because of the natural history. It's not because of anything you particularly did. Some patients like the hernia belts, the truss belts for the inguinals. And so that just helps provide reinforcement on the exterior. It doesn't help everybody, especially with the smaller hernias. I find it kind of just bothers them more than it helps them, but I also suggest that to people, especially those that have obvious bulges and that are very active, and sometimes it makes a difference. 

Host: So, what is a modern inguinal hernia surgery like, or femoral hernia surgery, in that whole area? What is it now? 

Leslie M. Okorji, MD: So I think we're in a crossroads, because if you look at it, a lot of people are getting trained in these minimally invasive techniques. But when you look at what's actually still being done in America, it's mostly open. And so, it's essentially evolving, I guess is the summary of that.

So, when I look at all the data and patient experiences I've had, I think the summary of it is for the small hernias, it almost really doesn't matter what you do, you just have to do it well. So if you're somebody who does a lot of open hernia surgery, and you do it well, your patients will do amazing. If you do laparoscopic or robotic surgery and you do it well. The patients do amazing.

When you compare all of those modalities, the real difference is in the short term, people are able to return to work a little sooner, less discomfort right off the bat, with the laparoscopic or robotic approaches. And that kind of makes sense if you think about how it gets fixed.

From the laparoscopic approach or the robotic approach, you're fixing it from the inside out. So it's not much disruption to your abdominal wall. With the open approach, you have to go through all the layers to get to it. And so it ends up just being a little bit more disruption, a little bit more trauma in the, in that initial setting and a little bit more time to heal. So that's what we know. And then in the long run, really, it's no difference in the outcomes.

It's just really based on once you're past your learning curve with any of those techniques, the recurrence rates are equivalent. The risk, the risk of chronic pain, some studies will say it's a little higher with the open approach too, and some of them say it's not much of a difference.

So I think for the smaller hernias, unilateral I do the laparoscopic or robotic approach because I think the patient just bounce back quicker, but I think it's kind of dealer's choice. It's whatever modality that you're comfortable with. And obviously, mesh repair is superior to non mesh repair from a standpoint of recurrence. And that's another conversation that you have to have with the patients. 

Host: Yeah, I wanted to ask you about that, is whether or not you do mesh in inguinal hernia repairs all the time, or is it just an option, and how is that done? 

Leslie M. Okorji, MD: Mesh repair is going to be an open repair. So that's, the one thing. There's no real minimally invasive approach that's a non meshed. There's some techniques that are out there, but they haven't really been proven. So I tell the patients if you're looking for no mesh, it would have to be in open surgery. 

If you look at actually the recovery from the open non mesh repairs, the pain is actually similar to the open mesh repairs, but again, it makes sense because it's not really necessarily the mesh that's causing the pain, especially if you place the mesh properly. It's everything else that you do, and how tight the area is, especially with the non mesh repair.

It's a lot of suturing of all those tissues together. Now, I do offer that for the patients, but I, offer it for a patient who is ideal for it, so a patient who is not obese, not diabetic or smoking, and the hernia is not to the size that I would worry about a recurrence, and so I usually kind of let the patients, when they come in with the mesh questions, I have a mesh in my office and I just show it to them and most of them appreciate it, and then, especially because the technology has also evolved with mesh and I think we have a lot safer products out there than I would say 10, 20 years ago. And we know a lot more about how they behave in the body too. But in general, I think when you compare the data, if you, remove the bias in certain centers, mesh repair is superior from a recurrence standpoint. Obviously there's problems with mesh, but I think if you use the right mesh for the right patient and do the right operation, they'll do well. 

Host: As you said, those would be open repairs, right?

Leslie M. Okorji, MD: Correct. Correct. Non mesh repair would be an open repair. 

Host: Is there a distinction to be made between laparoscopic versus robotic? I mean, robotic is laparoscopic, right? 

Leslie M. Okorji, MD: Right. It's a competition I have a lot to, because again, it's, we're trying to figure out where the robot fits with regards to general surgery, gastrointestinal surgery, I think it's much more established for urology, and gynecology. And so, essentially, I tell patients, you just imagine driving to work in a Honda Civic versus a Ferrari.

That's the best way for me to describe it. So that's the difference in the modality. You're gonna get there. Actually, for some certain Civics probably it makes a lot more sense, but there's certain things that it's not going to be able to do. So, you'll find different versions of surgeons. You'll find surgeons who are robotically trained and that's all they do.

You'll find the surgeons who are laparoscopically trained and don't really believe in the robot, you'll find surgeons who are laparoscopically trained and understand what the robot can add to a laparoscopic practice. And that's kind of more kind of where I'm at. And so a lot of times, when it's a complex hernia, when it's like down to the scrotum or the thighs, when it's a patient who has had previous surgery, and I know I have to work around a lot of scar, that's when I want the robot.

So that's the patient I'll do robotic. For me, that's the distinction. For a lot of the smaller hernias, primary hernias, then, either modality in the laparoscopic repair if you look at the studies, it's a little bit faster. I think those studies are biased by, the fact that a lot of those surgeons are laparoscopic experts and not necessarily robotic experts. They're not quite past their learning curve robotic. So in my hands, the time is actually irrelevant. It's more about, for me, what the pathology is and what I think is going to be the hardest part to do, and then how I want to achieve that. And so I think there's a lot of confusion out there, frankly, I get it, because I think we haven't nailed down where the robot is truly useful, in some of these more simpler procedures. But, for me, I think it just depends on the complexity. When the complexity goes up, the robot shines. So, when it's less complex, then you'll find not much of a difference, because both patients do well.

You'll find that the cost goes up, from a healthcare system standpoint. But that's not necessarily a conversation to have with the patient. 

Host: So irrespective of how you do it, what do you anticipate in recovery for an inguinal hernia repair? 

Leslie M. Okorji, MD: I tell people about one to two weeks. Recovery just means you're going to feel closer to your regular self. So for the first week, I tell them, take it easy. You might need some pain medications here and there the first few days. You'll be able to get up and walk and move around, take care of stuff. 

But that first week, just go slow. And then between one or two weeks, that's when most people turn the corner. Some people do it at one week, some take the two weeks. And then as far as like, oh, yeah, I feel like, I'm not really as sore as I was. And I have a little swelling, but that's much better.

So that's the typical recovery. When it's open, I would say, a little bit can be more variable. But again, relatively speaking, I would say by two weeks, even with the open approach, I think a lot of patients are like, they feel better. I think, as far as I go, being able to go back to work. So I do say in general, one to two weeks, is kind of the ballpark. 

Host: I've had a couple patients who have had surgery and successfully recovered and went about their lives and then, they come in and they say, you know, doc, I still have discomfort in that area and it hasn't quite gone away. And I'm not sure if it's failed repair in some way or a recurrence, or if they're just having sort of post surgical pain from the tissue disruption that's natural if you have a surgery like that. What do you think? 

Leslie M. Okorji, MD: I think it depends on how long it's been. So, the definition of chronic pain from groin hernia repair is 90 days. So that's kind of what I use to guide me if it's been less than 90 days I tell them just to observe and monitor and if there's no problem. So if I don't see an obvious recurrence on exam. Sometimes they have a little bit of fluid collection.

I confirm on imaging. A lot of times I just let those be because most of the time they will resolve on their own. And then I think when it's past the three month mark, then you have to kind of do a little bit more investigation. And there could be obviously multiple reasons for that pain, including some of the issues with regards to your surgical technique.

So you do have to do a little bit more investigation at that point. 

Host: That's not the only type of hernia that patients come in and talk to us about. So as you move superior in the body, you get to the umbilicus, you have umbilical hernias, you can get smaller epigastric hernias. I have never seen a Spigelian hernia, but apparently they exist.

And then, the other thing that people come in to talk to us about, and I just bring it up here because people ask about it a lot, is diastasis recti, where there's sort of a loosening of the medial tissues and, and then they develop a bulge and that occurs with obesity, with pregnancy and some other circumstances and patients are worried about that and they call it a hernia.

So I want to talk about all of those different elements, the umbilical, the epigastric, and, maybe we should just start with diastasis recti because it's not technically a hernia, right?  

Leslie M. Okorji, MD: It's an interesting pathology. So you, mentioned it. It's a weakness in the linea alba, the tissue between the rectus abdominis muscles. I tell patients between your two six pack muscles, they always get a chuckle out of that. And so, it's typically found on imaging incidentally, very occasionally, somebody will pick it up on exam.

It's, really hard to pick up an exam if you don't look for it, unless it's like really big and obvious, which typically you'll see those big ones in the postpartum patients. And so yes, diastasis in and of itself doesn't need surgical intervention.

The first step is core exercises, to try to strengthen the rectus abdominis muscles, and usually that will improve it. And then, there's certain patients that come in with persistence of diastasis. And then the question is whether or not they have an associated hernia. And so if you have an associated hernia, then there are options to fix the diastasis along with the hernia, particularly some of the more newer minimally invasive robotic options. 

And then if you don't have a hernia, and it's just a diastasis, that becomes more of a cosmetic thing because the insurance companies unfortunately don't really cover that and so I send those patients to the plastic surgeons. But if they do have a hernia then we have options to address that. 

Understanding that also actually the diastasis is a marker for hernia recurrence. And so you do have to do something, either you have to place a decent sized piece of mesh or you have to plicate or sew the diastasis. You have to do something, just to repair with sutures alone is a higher risk of recurrence in those patients with diastasis and a hernia. 

Host: So, an epigastric hernia is a smaller hernia, sort of in that same area, but as opposed to sort of a broad based bulge that you might see with diastasis. My understanding is it's usually a little bit more, focal and, smaller.

Leslie M. Okorji, MD: Yes. It's typically a herniation of the preperitoneal fat through the abdominal wall. So sometimes unlike the umbilical hernias, it's not necessarily the easiest to diagnose because sometimes, especially in obese patients, you don't necessarily feel the obvious bulging because again, you have all that subcutaneous fat. 

But they will have kind of focal tenderness and discomfort there. So that would be epigastric hernia anywhere above the umbilicus, technically it's epigastric. And then you have your umbilical hernia, and then below that, you have your suprapubic hernias and all kind of along the spectrum. And you mentioned the Spigelian hernias, within the class of the lateral hernias or the flank hernias. 

So, all of those, I would say, manage similarly, as far as the work up and the, the operations are tailored to the hernias, but the pathology and pathophysiology is by and large, the same. 

Host: Do we have to worry about incarceration and strangulation in those abdominal wall hernias as much as we do in the inguinal area?

Leslie M. Okorji, MD: So that is not as strong, for those abdominal wall hernias. But there's some data that suggests that similarly to the inguinal hernias, that watchful waiting is safe. And the risk of incarceration or strangulation, is anywhere, 5 percent is kind of the number I tell patients. If you look at the studies, it's up to 8%, but it's 5 percent for some of the good studies.

We don't have as strong of data. It's not as properly controlled as for the inguinal hernias, but we kind of extrapolate that to say that it is safe for those minimally symptomatic to asymptomatic hernias. The thing that's interesting though is, I think, one of the really old studies that was looking at this, mentioned that the size matters as far as the risk of incarceration of strangulation.

So actually, when you have a really small hernia, it's a good thing. And if you have a really big hernia, it's a good thing. It's the ones in between that have the risk. And so, the study, I think, came out and said anything less than two centimeters in width or greater than 7 centimeters in width is protective. And it makes sense because if you imagine how much room that a bowel would be able to sneak through, if it's one centimeter, it's really hard to imagine that. 

You can get a Richter hernia, which is like a partial nuckle and not the whole bowel, but part of the wall of the bowel sneaking through, but that's relatively rare. And then when you have hernias big enough, again, you, don't have the ability to strangulate because there's so much room for stuff to go in and out. And so it's those moderate sized ones that typically will get patients in trouble. 

Host: So, it's two centimeters to six centimeters. Just curiosity, how do you do that measurement?

Leslie M. Okorji, MD: Typically, it's the width. The width is much more important than the length, because the width has a lot more to contribute as far as if you think about the cylinder of the abdominal wall. So the width is typically the most important. Now we have all these advanced measurements, volumetric data and, surface area and stuff like that, that we also can use a ton.

But, I think for the most part, for practical purposes, the width is the key. That's what will determine the degree of the extent of the repair that's needed. 

Host: Going back to an earlier point, it sounds like abdominal wall hernias do still have a risk of incarceration and strangulation and that should not be ignored. I'm usually reassuring patients about that, but it sounds like maybe I shouldn't be reassuring them.

Leslie M. Okorji, MD: Right. I think it's similar to the inguinals. I think especially when they have bowel, even if you have a reducible abdominal wall hernia, ventral hernia, and they have an image, and they have a loop of bowel in it, because the hernia is a dynamic process, you reduce it in the office, they leave the office, it pops back out, right, and so you have to understand, like, if you see bowel in that hernia, then you do want to probably address that sooner rather than later. 

The ones that have fat containing hernias, those are the ones that are like somewhat reassuring, but it's not completely reassuring because again, you can have fat in there one day and then the next day, whatever activity they do or position they take, something else replaces the fat. But we're still trying to figure out what increases the risk of strangulation. There's some like ratios that are published, between the size of the hernia sac and the hernia neck.

Again, that concept of like a mushroom hernia is more dangerous, and than a volcano hernia, I guess. But again, those studies are not perfect. So in general, you do still have to kind of counsel the patients. 

Host: Who should we be referring to you when we pick up an abdominal wall hernia in an exam? Will it be umbilical or, epigastric or, something? Who do you think we should send you? 

Leslie M. Okorji, MD: I think all of those, I mean, cause again, I think, the patients, some of them, especially when they're healthy and, in the office and well nourished. That's the time to fix those. It's not when they bounce around and been through a couple emergency room visits or those patients, I think the healthier they are, if they have something that needs to be addressed in general, I tell them do it when you're healthy and nourished and you have time in your life to do this. 

Because you want a one and done durable repair. And so I think all those hernias, I encourage people to just send them over whether or not they have imaging. It doesn't necessarily matter because some of those patients, if you have an obvious, small to moderate sized abdominal wall hernia, especially in a patient that's not obese doesn't need imaging, you know, that's physical exam.

And then from physical exam, you can talk about the options. So, I try to just make it simple, because, sometimes I think there's a trigger to get more testing, but a lot of times if you have a good exam, that's all you need to, to kind of have that conversation with the patient. 

Host: The recovery from an abdominal wall hernia is about the same as an inguinal hernia? Is it more complicated?

Leslie M. Okorji, MD: I would say it's probably for the small abdominal wall hernias, it's somewhat the same with the caveat that because you do have to actually suture close the abdominal wall defect as opposed to inguinal hernia where we don't suture the area because we don't want to injure the nerves, so we just place a barrier mesh.

For the abdominal hernias, we have found that if you just leave the opening alone and place a mesh, the risk of the recurrence goes up, and also the function of the abdominal wall is not as good as when you close the defect and then place the mesh. And so I think that closure in the short term causes a little bit more discomfort, but I still tell people I think the same timeline as far as recovery, one to two weeks. I do find that they tend to need a little bit more analgesia, but I think in general, you can manage that with we do a block in the operating room.

That lasts for a couple of days and takes that edge off and minimizes the new pharmacotics, so. For the bigger hernias, it's different. And the bigger hernias, when you have to do a full abdominal wall reconstruction, they will feel the repair more, and so you have to kind of guide those patients through. Those patients need a little bit more time off of work and things like that. 

Host: I managed a couple patients in the last few years with sort of, complicated abdominal wall hernias. And sometimes they've had repairs, the mesh has got infected, which I know is a complication, particularly of non biological meshes, right? And, it's had to be removed.

And then, so they're left with a bigger defect and so, these can get kind of into the disaster range where it can be a really challenging situation, but I imagine being at Penn, these are the kinds of people that you're having to manage. 

Leslie M. Okorji, MD: Yes. And then that's whole spectrum of hernia. And that's where, we talk about hernia specialists or abdominal wall specialists, right? Most of the hernias are managed by general surgeons. It's kind of like, diabetes and primary care, right? Most diabetes, Type 2 diabetes is managed by primary care.

You don't need an endocrinologist to manage Type 2 diabetes. Similarly, you don't need a hernia specialist to manage the majority of the inguinals or the abdominal wall hernias. It's the ones that are complicated, they've had multiple surgeries, they've had mesh removed and replaced and those are the ones that need to be in specialized centers that can handle that complexity.

The mesh conversation is important. We're learning more again about it. You can get a mesh infection with any type of mesh actually, it's not necessarily exclusive to prominent mesh. You can get, absorbable meshes get infected too. And so it's more to do with the patient risk factors, as well as the surgical details as well. 

When you have an injury to the bowel, that will increase the risk of a mesh complication. When you have patients who are not optimized or unable to be optimized, obesity, smoking, diabetes, et cetera, immunosuppression, all those things will play even if you do a perfect repair. That's why those minimally invasive techniques have become more and more, viewed upon favorably because you just avoid the risk of the wound complications that you have with these big open techniques.

And so, that has helped, especially when the patient's higher risk that, that's when again you see those techniques shine, because you are providing a huge benefit, as far as just avoiding that abdominal wall, taking a, what would be a 15 centimeter incision and making it three 2 centimeter incisions, that makes a difference for the high risk patients. 

Host: So even these patients who have failed hernia repairs and you have to replace the mesh, you can still do that laparoscopically? 

Leslie M. Okorji, MD: Robot specifically. Now, if you remember, the Ferrari is what I need for this one, so the laparoscopic, it's not going to cut it when it starts to get more complex, and so, yes, I always, now there's certain patients who either they've had too much surgery in the past, the scar tissue is too much, and you're going to have to remove a huge piece of mesh, and it's all about understanding the nuance of what they've had done already and what does the abdominal wall look like when you see them. But, whenever they're candidates for a minimally invasive approach, that's what I do. I took an 82-year-old female, and I did minimally invasive approach for her.

She left the hospital in two days and she's home and happy with her grandkids. And so, that's when you see the technique shine is high risk patients, but again, there's certain patients you have to use your judgment, and there's certain patients that are not candidates for minimally invasive. 

Host: I'm curious about how available robotic is in the general surgery community, or is it really a very specialized thing at places like Penn or some of the other regional centers? 

Leslie M. Okorji, MD: So a lot of hospitals are investing in it, I think, it's, not necessarily exclusive to specialized centers. I think what you'll find is a mix of essentially perspective on the robot, and so ultimately, it's a tool like any other tool, and you have to understand the limitations of it, but it just extends your ability to do minimally invasive surgery, and that's all it is. I think for general surgeons, again, there's different types of general surgeons, and so I think that's why you see the data so all over the place because it's very heterogeneous, like what's being studied and who they're studying and, it's a tool that I think extends your ability to take the high risk patients through a complex operation.

But it definitely is something that it's expanding as far as access to the robots. Hospitals have to figure out the economics of it. It's definitely an investment from a hospital side, but the benefit of that is to decrease your readmissions and reoperations and decrease your complications and also improve improve the patient experience. 

Host: I just want to finish by asking you where you practice, if somebody wants to refer a patient down to you. 

Leslie M. Okorji, MD: So I'm currently at Pennsylvania Hospital and my office is at Penn Medicine, Washington Square. I do have access to the other two hospitals, but I primarily have my practice at Pennsylvania Hospital. 

Host: I think Penn has distributed its expertise among the three hospitals, in different fields, and I,love Pennsylvania Hospital. I hope you're enjoying it too. It's kind of a really cool place. I have two kids who were born there. It's the oldest hospital in the country. It's really a cool place. 

Leslie M. Okorji, MD: It's an amazing place. And like I said, every place has different flavors. And so whenever I go to the other two hospitals, I'm always learning something new, something that's different. But yeah, its an amazing ecosystem to be a part of, and, with all the resources spread out across the three hospitals and, it's a great place to work. So I, I've enjoyed it. 

Host: Leslie, thank you so much for coming on. This is something I didn't know a lot about. And, I'm just going to have a podcast about it because I figure other people also have questions. So I, I'm sure the Penn Primary Care Podcast community, to the extent we have one, we'll appreciate you coming on. 

Leslie M. Okorji, MD: Of course, Kendal. Thank you so much. And I hope, everybody who listens to this, gets something from it. The key thing is understanding that hernias come in different shapes and sizes and flavors, and we're learning a lot more, and the management has gotten a lot more complex than what it was, 10, 20 years ago.

And that's also what's driving some of these. If you look at the surgery community, like everything else in surgery, it's getting more specialized, so there's more and more hernia fellowships out there for people who just want to come out and do hernias because the technology and the different tools in the toolbox are expanding rapidly, faster than the General Surgery Residency will be able to provide you.

So I think that reflects itself in this conversation. 

Host: And you've taught me things. I'm going to be sending you more patients now because I have some abdominal wall hernia patients with other issues and it hasn't been the highest priority, but now I think I'm going to pay attention more and make sure I get them down to you. 

Leslie M. Okorji, MD: Thank you.

Host: And with that, thank you to Leslie for joining the Penn Primary Care Podcast and thank the audience too. Please come again next time.