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Terry Streetman (Host): thanks for tuning in to the Well Within Reach podcast, brought to you by Riverside Healthcare. I'm your host, Terry Streetman, and joining me today is Dr. Steven Groene, a general surgeon here at Riverside. He's here to talk to us about hernias, what they are, how they

happen, and how they're treated. Thanks for joining us, Dr. Groene.

Dr. Steven Groene: Thanks for having me back again, Terry.

Host: Yeah, we always love to have you. Since you have been here before, just a quick reminder for our listeners of your role and background.

Dr. Steven Groene: Dr. Groene, i'm a general and trauma surgeon over at Riverside Medical Center. I've been there about five years, came from Kansas, but again, here about five years. Love my job, love the community, and extraordinarily happy to be here today to talk about one of my passions, hernias.

Host: Yeah, I knew we had to have you on for this one, because you are the expert here. So, let's start with the basics, since the rest of us probably aren't. What is a hernia, and what is it that happens in the body when one develops?

Dr. Steven Groene: So, a hernia essentially is a hole or a defect in the strength or muscle layer of our abdominal wall. And so, things from the inside, our guts, our intestines, fat, pokes up through that little hole and through that defect. And so when people see little lumps or bumps when they have a hernia, that's the stuff from the inside coming out through the outside.

We have so many different types of hernias. Belly button hernias are the most common, groin hernias. You can get hernias other places on the abdominal wall. You can get hernias from previous surgery where you have an incision. One other one that's a little bit different but the same principle is something called a hiatal hernia, where you have a weakness in your breathing muscle and part of your stomach goes up into your chest. But again, the principle is that you have a hole or a defect in the muscle layer, and stuff that's not supposed to poke out, pokes out, and that's the little lump that people see when they have a hernia.

Host: Okay. That feels pretty straightforward. So, what are some of the causes then of these hernias, and are there any factors that can increase somebody's risk of developing one?

Dr. Steven Groene: So, one of them, the most common one actually, is just being human. We're all technically born with a belly button hernia. So when our umbilical cord falls off, we all have a teeny little hole there at our belly button. And for most of us, about 90% of us, that scars up and closes up within the first few weeks of life. But about 10% of people actually have that hernia, and they live the rest of their life with that hernia. Groin, sometimes can be born with it, especially if you're premature. So again, just being human.

Outside of that, some things, having weakened strength tissue or connective tissue can increase your risk for that. There are some known pathologies. Something called Ehlers-Danlos is one of them, where you just have very weakened tissue. And so, things basically just don't have the same strength.

I think there's a lot of probably genetic predisposition that we just don't know about. I know there's so many times I've seen patients who tell me, "Oh, my siblings had a hernia," or, "My parents had a hernia," and then they have a hernia. So, I really think there's obviously some genetic predisposition we just don't know the details about.

Outside of that, it's really anything that increases the abdominal pressure a significant amount. So, that can be physical activity, whether that be at work, if you have a very manually laborious job, and you do a lot of heavy lifting, a lot of repetitive lifting, that can increase the pressure and increase your risk for hernia.

Same with any other physical activity. If you exercise and you really go hard with your exercising, sometimes that's just enough pressure. I even had a person in my office the other day that he was just having fun with his kids out in the pool, and said he threw one of his kids in the air. Next thing he knows, he felt a pop, and there you go, he has a hernia.

Other things, sometimes we see it in people who have really bad colds or if they have a lot of vomiting, just even that kind of pressure can do it. A lot of weight over a very short amount of time, we're talking 50-pound weight gain within a short amount of time increases that.

And then lastly, like we talked about, having previous surgery and scars. We try to close up that muscle layer and that strength layer with our sutures. And usually, it works really well. But occasionally, it weakens, and you can get a hernia from that.

Host: Okay. So then, you know, you talked about the pop and about the bulges. What are some of these signs and symptoms that patients should watch for, and when does it get to the point that like, "Hey, you should talk to a doctor about this"?

Dr. Steven Groene: Yeah, that's a great question, probably one of the most important questions. I think it comes in two flavors. One, if the hernia starts to change size or get larger. A lot of people have hernias. They live with them for many, many years. They don't change. They're just kind of there. But I think if it ever starts to enlarge or get bigger, that's a time when you should come talk to a doctor, or in particular, a surgeon about your hernia.

And then, anytime you start getting symptoms associated with your hernia, and that comes in three kind of categories. One, if you start having some skin changes or discoloration, most notably redness, that can oftentimes indicate that the tissue that's within that hernia is starting to get irritated and unhappy and should get evaluated.

Two, it comes down to your GI tract. So if you start having obstructive type symptoms, i.e. you have troubles with your bowel movements, you start having more constipation, especially if that's noted to be more prominent or prevalent when the hernia is out.

And then, last but not least, and this is probably the most important one, when you start having pain or discomfort associated with your hernia. If you start to get, again, just the discomfort, you stop doing the same routine activities you do, you don't go to the gym as much because you're like, "Man, every time I do this activity, it really just, it starts to hurt at that hernia site." That's probably the most important and key one. If you start having that kind of discomfort and symptom, you should see a surgeon or a doctor about your hernia.

Host: Okay. Yeah, that's good to know. Keep an eye on those things. And you know, sometimes people are more apt to kind of wait and see or don't want to go see a doctor for whatever reason. But for somebody leaving that untreated, what are some of the health risks and the things that should say, "Yeah, you really do need to get this treated"?

Dr. Steven Groene: health risk I think is a little strong, but I think the biggest risk with a hernia, if it's not treated, and not every hernia does need to be treated, but if you are having a symptomatic one, the biggest risk is that you can get what we call incarceration or strangulation. And that happens about 1% of people per year. There's a good study at the VA that looked into that. But essentially, what that means, incarceration means the stuff that pokes out or sticks out through that defect gets stuck, and it doesn't go back in, and that can cause some kinking of the bowel if it is bowel, and that can cause the bowel to get irritated and cause some of those blockage symptoms we talked about. And then, if that's not treated quickly, then you can get what we call strangulation, and that's where the blood supply gets kinked off, and then you start to have bowel that dies. And those things require much bigger surgeries than just fixing a hernia. Sometimes you have to have a major surgery, part of your intestine taken out. And so again, I think if you're having symptoms, those are indications, those are the rumblings that there's a potentially a higher chance you might start having some of those risks with the hernia.

Host: Okay. So, not super common to have these issues, but definitely serious and much easier to take care of it earlier it sounds like.

Dr. Steven Groene: Absolutely.

Host: All right. Well, before we continue on to talking about treatments, we're going to take a moment to pause and discuss the importance of primary care.

At Riverside, our primary care providers are right here in your community, offering personalized care for you and your family, close to home, and connected to the specialists and services you may need.

Having a primary care provider means having someone who knows you, listens to you, and helps you stay well through every stage of life, from annual checkups and preventive screenings to managing everyday concerns when they pop up. Because remarkable care should never be out of reach. Remarkable care right where you live.

To find a primary care provider who's right for you and your family, visit myrhc.net/acceptingnew.

All right. We'll get back into it. So, we're going to talk about treatment now. What does treatment look like, and do all hernias, when it comes to treatment, require surgical repair?

Dr. Steven Groene: I'll start by answering the second portion of that question first. The answer is no, not every hernia needs to be fixed or repaired. Again, if it's asymptomatic, you don't really need to have anything done. Again, 10% of people have belly button hernias. The majority of them just have had outies their entire life, and it doesn't matter. It doesn't bug them. It doesn't change. So, asymptomatic hernias do not need to be repaired. I tell many patients when they come to see me, I'm like, "I cannot make an asymptomatic hernia less symptomatic by fixing it." There's not a lot of risk to the surgery, but there are always those risks with surgery. And so, I tell patients, "If it's not bugging you, there's really not a reason we need to fix it."

In terms of the first portion of that question, really hernias are a surgical treatment. They don't go away. They'll never fix themselves. They don't heal. The only way to really treat them is surgical. You can try certain things like abdominal binders or what we call a hernia belt or truss, which kind of hold pressure to try to keep things in. But truly, hernia treatment is a surgical treatment where essentially we use suture. We close that hole. Oftentimes we reinforce that closure with a piece of mesh, which is a material that helps to take all of that tension across all of that mesh and take it off of that hole repair so that it decreases the risk of it coming back. And that can be anything from little incision, minimally invasive surgery, to a major large incision, depending on the hernia. But it's surgical closure of the hole, essentially.

Host: Okay. So if someone then does have a hernia that's symptomatic and does need to be treated with surgery, what should they expect when it comes to that hernia surgery in terms of pain, time away from work, and limitations on, like, lifting and exercise?

Dr. Steven Groene: Obviously, a lot of it is patient dependent on how they react to surgery and pain, and obviously the size of the hernia, how we fix it. But I'll kind of give the average person recovery.

I always tell patients that first week's going to be really rough. It's going to be painful. It's going to be a lot of swelling, a lot of bruising, a lot of decreased activity. You'll probably need some narcotics for a day or two. Even if we do minimally invasive or a little incision surgery, we're still doing the same surgery on the inside, and so that first week, I think the outcome and recovery's about the same.

By that second week, I tell patients, and most patients really start to have that kind of nice turn the corner moment, where they're still sore, there's a little bit of swelling, but at that point they're needing more just ice and ibuprofen rather than the stronger pain medicine. They're starting to work a little bit more.

Some people go out into the yard and start doing a little more activity. I think that's where the little incision surgery starts to speed up in terms of recovery and less pain by that second week. By the third and fourth week, almost everybody's really back to their baseline in terms of their activity and their soreness. And then, if you're not quite there by a month, usually two to three months for everybody else.

In terms of work, I tell every patient I recommend to be thinking about one to two weeks off of work. It depends on what you do. If it's more of a desk type job where you're not doing a lot of physical activity, I tell them that's kind of the one week period for most patients.

However, I tell them as long as they feel good, they could go back any time as long as they're off the narcotic. If it's more of a physically demanding job, that's where really definitely two weeks at a minimum off, and then I see them in the office. If they're doing well and their work provides them an ability to do limited work or lifting restrictions of 30 pounds, they can go back at that time.

But really, for anybody, the biggest restriction is no lifting more than 30 pounds, no strenuous activities, no twisting, things like that, for six to eight weeks after surgery. So that's the same with other activities. Like, going to the gym, I tell people two weeks, you can do routine daily activities, go up and down stairs, you can do walking, you can go do your routine activities at home, but I don't want any real extra stuff.

At that two-week mark, if you're doing okay, then you can go back to the gym, and you can start to do light cardio, light weightlifting, no core stuff for six to eight weeks. And then, again, really, six to eight weeks is what it takes to get back to your routine and being able to do what you normally want to do.

Host: Okay. I think that's super helpful, and a lot of that probably unexpected. You know, people think of surgery, and they, might think, "Oh, that's a lot of recovery." And I guess that kind of leans into the next question in terms of that recovery time and the minimally invasive stuff. What kind of advancements have there been recently in hernia surgery that have improved outcomes for patients?

Dr. Steven Groene: I think there's three main ones that have been a big factor in improvement. Number one is the robot. Hmm. So we have had minimally invasive or laparoscopic hernia repairs for 20-some years.

The big problem with laparoscopy versus robot is that it's very hard to suture laparoscopically and really, in particular, hard to suture the abdominal wall closed. And so, a lot of times when we would do laparoscopic hernia repairs, we wouldn't actually close the muscles or that defect we were talking about. We'd essentially just plop a big piece of mesh over that hole like a proverbial finger in the dam. The problem with that is we'd have to use a significantly larger piece of mesh so we had good coverage. There was still higher risk of recurrence. A lot of times, patients would not have very good outcomes, at least in terms of subjective outcomes, because even though there technically wasn't a hernia anymore, that mesh would kind of eventrate up, and so they would still have a bulge and they would feel like they still had a hernia.

And so with the robot, it's much more technically available to be able to close that muscle and that strength layer up and then put a piece of mesh if we need to. That's a smaller piece of mesh, but the data shows unequivocally that if you get those rectus or six-pack muscles closed in the middle, the outcomes are significantly improved. So, that's one of the big, big advancements in the recent years.

Secondly, kind of goes to the exact opposite or extreme, and that's how to fix those really big complex hernias, there's something called abdominal wall reconstruction or component release and separation. And essentially, over the last 20 years or so, I think we've really gotten an idea of understanding the multitude of layers of the abdominal wall, where we can separate certain parts of the abdominal wall, cut certain muscles to really be able to get those rectus muscles back together or those six-pack muscles back together in the midline and get a nice really big piece of mesh in those extraordinarily complex, huge hernias. So, I think that's a big step that even 20 years ago people had huge hernias. It's kind of like, well, you're just going to have to live with it.

And then, lastly is the mesh. Mesh gets a bad rap. There are some, I think, truthful things out there that some mesh that has been tried in the past isn't great, but I think the majority of mesh now is very good, very safe. It's better material than it was 20, 30 years ago. They have a lot of things like barriers, which means there's a coating that decreases the chances of getting scar tissue or adhesions to the mesh. And there's actually a mesh out on the market right now. It's called Phasix. It's a bioabsorbable mesh. And so, that mesh stays in the body for about a year, really allows the body to scar down and create all the really good strength tissue and healing tissue, and then it dissolves

There's a surgeon at Kentucky, Dr. Roth, he's kind of the big pusher of this. He's got eight years of data now, and his data is really starting to become equivalent to the permanent mesh that we're using currently that stays in your body for the rest of your life. And so, I think as that comes into play and we keep seeing this long-term data, I wouldn't be surprised if in the next five to 10 years we start using mesh like that more often than using the permanent mesh.

So, I think those are three areas that have really made big strides in improvement in hernia treatment and surgery.

Host: All right. Well, that's exciting to hear, and I'm sure these things will keep advancing as people keep working on it. So, we have that to look forward to. We're right down to the end here. So as you know from previous episodes, my favorite question is just what's the biggest takeaway listeners should have from this episode?

Dr. Steven Groene: It's that hernias are extraordinarily common, that hernia surgery is one of the most common surgeries we do. Not every hernia needs repair, but if you have any concerns about your hernia or you start having symptoms associated with your hernia, namely discomfort, please don't hesitate to call me, and I'd be happy to see you and talk to you in my office about your hernia and if it needs to be fixed.

Host: And that's actually a quick follow-up I wanted to ask. Can people generally go right to the surgeon office, or do they need a referral from a provider?

Dr. Steven Groene: Generally speaking, it comes from a provider. We would never say no. But I would say the majority of people probably do come from their primary doctor. But I've seen a number of people that are like, "I think I have a hernia," and they just kind of bypass it. So, either/or, really. It's kind of up to the patient and how they feel.

Host: All right. Good to know. Well, thank you again for being here and talking through this with us. For our listeners, if you'd like to learn more about Riverside Surgical Services, you can visit myrhc.net/surgery.

Thank you for tuning in to the Well Within Reach podcast with our guest, Dr. Steven Groene, and me, your host, Terry Streetman. Be sure to like and subscribe to Well Within Reach on Apple, Spotify, or wherever you get your podcasts. To learn more about the services of Riverside Healthcare, visit riversidehealthcare.org.