Evo Terra (Host): [00:00:00] Hernias are a common medical issue, with over 200,000 cases diagnosed in the U.S. each year. But what exactly is a hernia, and how do you treat it? Let's find out with Drs. Joseph Vazzana and David Weithorn, both general surgeons at St. John's Riverside Hospital.

This is Riverside Radio HealthCast from St. John's Riverside Hospital. I'm Evo Terra. Doctors, thanks very much for joining me today. Let's start out, Dr. Vazzana, what exactly is a hernia?

Dr Joseph Vazzana: Well, there are many types of hernias. But in its basic form, a hernia is a defect in the connective tissues that kind of hold the abdomen together. And this defect allows for intra-abdominal content, sometimes fat, bowel loops to then protrude through. This gets seen by a patient as a bulge. It's sometimes painful, sometimes gets stuck.

Host: And how does this happen? What causes the body to make a [00:01:00] hernia?

Dr Joseph Vazzana: There are a few different types of hernias. There are some that are congenital such as diaphragmatic hernias. There are hernias that we're born with that can be from increased pressure. Then, there are incisional hernias, meaning hernias that are created by prior surgery that leave defects in the abdominal wall due to either poor healing, malnutrition, or things of that nature.

Host: Got it. So, let's fix this problem. How does one fix a problem? I'm assuming not medications, not pills, yet, right?

Dr David Weithorn: So, there is no medication for hernias at this point. The only treatment is surgery. And the surgery aims at fixing those holes closing them. Smaller holes can just be closed primarily just by sewing them together. But larger holes and also holes that result from incisions usually require a prosthetic, a piece of mesh to reinforce the closure.

Dr Joseph Vazzana: I think this would be a great point, Dave, because I know that a lot of patients get concerned about [00:02:00] mesh and you hear all these horror stories about pelvic mesh and mesh erosions and recurrences and pain after mesh. Tell me about your experience as a complex abdominal hernia surgeon and how you sort of reconcile that with patients.

Dr David Weithorn: Yeah, I think that's a very good point. I think the first point is that mesh is used for a variety of things, and one that gets the most negative attention is used for pelvic organ prolapse, which is different from hernia surgery, and it's a very different usage, and it has a different complication profile when used that way, and it's not really relevant to hernia surgery.

And the other thing that's worth pointing out is that mesh is a prosthetic and it's just like, if you have your joint replaced, you're doing it because at some point you have a failure of your native tissue and you need some sort of prosthetic to replace it and provide strength that you don't have normally. And so, there is a level of risk and complication that we discuss with [00:03:00] patients when we talk about surgery. It involves them putting in a piece of mesh. But ultimately, it's usually in your best interest to get it when your hernia requires it, because otherwise you face a very high recurrence rate.

Host: This is a fascinating conversation to me, someone who has a mesh in him for a hernia repair some 28 years ago. So, I'm glad to hear that I should not have them removed anytime soon, yay!

Dr Joseph Vazzana: That's actually another statement that we do get a lot of patients that come in who are having issues not always related to the mesh, but actually just wanting the mesh removed because they hear this stuff in the media, and they think that it needs to come out and we often have to have those conversations sort of, I don't want to say consoling patients, but relieving their anxiety over the fact that they have this in their body and, by and large, is uncomplicated and does not cause any major adverse outcomes. In fact, it's the mainstay of actual hernia repairs.

Dr David Weithorn: A well-placed, well-incorporated [00:04:00] piece of mesh should basically last you a lifetime and you shouldn't really think about it very often.

Host: Well, that's definitely good news to hear. So, you know, 27 years ago was a long time ago. And I think I was asleep during the procedure. So, talk about the process. How did it get in there? And also, are things different today 27 years later?

Dr David Weithorn: Things are very different today than 27 years ago both in the treatment of groin hernias and abdominal wall hernias. The biggest difference that's happened since then, there was two big differences. One, I think we've refined our mesh selections. Over the years, we've learned what works well and what doesn't, and we have long-term data on certain durable and relatively cheap meshes. And then, the other thing that has improved is that these surgeries have become more minimally invasive and laparoscopic and robotic approaches have really flourished and that has improved patients experience, reduced pain, and sped recovery.

Evo Terra (Host): Let's talk about that, that robot surgery, because I know, Dr. Weithorn, that's [00:05:00] something you specialize in. What's the benefits having a robot do it? And why am I not having you do it?

Dr David Weithorn: I am doing it. The robot, it's a very expensive sewing machine. The surgeon just operates a pair of hand controls and foot pedals at a console and then, the arms are just manipulated from there. So, it does nothing autonomously. It's not really a robot. It's not any more sophisticated than maybe a backhoe. But it allows a surgeon to do a lot of careful dissection and, most importantly, allows you to do the kind of sewing that was once only done in an open fashion, now minimally invasive, which allows for more complex hernia repairs so we don't have to do small incisions.

Dr Joseph Vazzana: I like that analogy, David. I'm going to start using the backhoe analogy to describe the robot more frequently. As a hernia surgeon, I trained more in the laparoscopic and open area of larger hernia repairs. And with actually Dr. Weithorn's assistance, I've been moving the bulk of my practice now to using the robot. And the [00:06:00] robot is a very expensive backhoe, but it allows you to sort of push the envelope on what you can do minimally invasive. And these have a lot of emerging evidence that they are providing a benefit to patients. And that would be with decreased pain, decreased length of stay; decreased amount of days out of work, even after the surgery; and decreased infection rates, because we don't need to use big open incisions anymore to fix some of these smaller hernias, okay? And so therefore, the mesh and the subcutaneous tissues beneath the skin aren't exposed to the air for long periods of time. And there is evidence to show that this does improve the infectious risk following hernia surgery.

Host: So, robot's good; mesh, good. But actually, let me push back on the mesh good because there was just an article out in the New York Times that started questioning whether or not we should be using these meshes, yeah?

Dr David Weithorn: Well, it wasn't specifically about the [00:07:00] mesh, it's about the whole field of abdominal wall reconstruction. And I think the article picks up on the fact it's a blossoming field and there's been a lot of advancement in the past decade, which is relatively new for medicine. And there has been widespread adoption, probably faster than training.

I think what it really highlighted is the need for patients to make sure that the surgeons that they're selecting for complex hernia work have specialty training in that and that they've done a volume of these cases before and they're experienced with it, because they are large surgeries and, if done improperly, can get bad complications. But when done by people who have expertise in this, people who previously would have never been able to get a durable repair are now getting lifelong relief of complex hernia symptoms. So, there is a benefit that's happened, but the article is highlighting a field that is rapidly growing right in front of our [00:08:00] eyes.

Dr Joseph Vazzana: I'd like to follow up on that a little bit. I mean, that's 100% correct. The robot is sort of being blamed for probably being used in the hands of certain surgeons who maybe have not yet had the training to do things like a transversus abdominis release, which is really what that article was talking about. And they're sort of using the robot as a surrogate for the procedure. When in reality, the robot is just performing an operation that's a highly complex operation even open. And if you haven't trained to do it open and you haven't trained to use the robot to then take the robot in which you're still sort of learning on it and then try to deploy it for a procedure in which you're really not an expert at doing, you can get into serious problems. And a lot of people are getting these hernias fixed, and then they're getting lateral disruption of their nerve plexi. And what's happening then is they're getting these balloonings out the side, and that's really what the article was about. And it sort of took the [00:09:00] robot as basically a scapegoat, when in reality, you could have done it open, you could have done it laparoscopic, you could have done it robotic, but if you do it wrong, it's still wrong.

Dr David Weithorn: And again, the take home message mostly, for patients, I think, is that there's nothing inherently wrong with these kinds of surgeries. But if you're in the position of needing one, I think you are in your right, and you should ask your surgeon what their experience is, what their training of this is, and how many of these they've done and what their frequency is, and that's how you select the appropriate person to do the surgery for you.

Host: Yeah. That makes sense. It's not C3PO taking care of the process, right? It's just a tool, and someone's got to operate the tool, that makes sense. Dr. Vazzana, you brought up this idea of hernia expanding beyond the mesh outside the walls, and I'm curious about that, not just to someone who has this mesh, about recurring hernias after they've been repaired. What's that like?

Dr Joseph Vazzana: Hernia recurrence is a problem. There's a few things. One, I want to go back to that prior statement and it's not really that the hernias in that article were expanding beyond the original hernia. It [00:10:00] was actually caused by a paralysis of the abdominal wall musculature due to cutting of the nerves, because the mesh was being placed in the wrong plane, all right? two separate things. That's not really a recurrence.

But back to the problem with a recurrence, hernias recur for many different reasons. Some of it is related to patient-specific factors such as poor wound healing, infection, diabetes, morbid obesity is a major problem with hernia recurrence and that's why in my practice as a hernia specialist as well as bariatric surgeon, I generally encourage patients to undergo weight loss and maybe even enroll in bariatric surgery prior to a hernia repair. And there's reasons for that. And we get into these conversations with patients, we're like, "Well, that's two surgeries. I have to have a bariatric surgery first, lose the weight, and then have a hernia surgery." What I tell them, "Basically, we want to have all the ducks in a row before we encounter your hernia, before we try to fix your hernia, because we want to have everything [00:11:00] optimized perfectly so that you get one repair, the correct repair, that is a durable repair."

And so, when hernias recur, each time you go in for another hernia, your chances of recurrence go up by about 10%. And so, your first repair is your best repair. And so, that goes back to what Dr. Weithorn was saying, is it's about optimizing the patient for the best operation, but also having them be in the hands of the people that know what to do and when to do it. Not to operate on the 5-centimeter hernia in a patient with a BMI of 50. That should never be the correct operation unless it's a last resort.

Other reasons for hernia recurrence, you know, there's a lot of technical aspects of it that I think are probably beyond the scope of this podcast. But obesity is a major factor. David, do you have any other major risk factors that you would say?

Dr David Weithorn: I think the two main patient modifiable risk factors that I talk to patients about frequently are obesity and [00:12:00] smoking. And then beyond that, I think it's all patient-specific factors. And when they come up, I'll discuss them with that specific patient at that time, but there's nothing that's generalizable to every patient after that, I think.

Dr Joseph Vazzana: And I would say that's also similar with the approaches to hernia repair. There are many, many different types of hernia repair. You can place the mesh in between the layers of the wall. You can place the mesh on top of the anterior layers of the wall, posterior to the anterior layers of the wall. And there's a million different acronyms to describe this. But the best thing is that you go to a surgeon that understands the disease, understands your risk factors, can deploy methods to achieve the best preoperative state, and then utilizes the robot, or the open technique, or the laparoscopic technique to deploy the mesh in the correct space to give you the outcomes that you want. And that is going to come with experience from handling many hernias.

Host: So beyond that New York Times article, I know that there has [00:13:00] been some talk about mesh repair in the media, lawsuits. Let's talk about those from your perspective, doctors.

Dr David Weithorn: think for the most part, most of those lawsuits are actually fairly irrelevant to hernia repair. A vast majority of them are related to pelvic organ prolapse surgery, which again it's not applicable to our discussion and patients seeking hernia repair don't really need to concern themselves with those lawsuits. And then, there are some meshes that have been pulled off the market for various reasons over the course of history. And none of those are used anymore and then there's lawsuits related to those and some of those are mostly related to defects in mesh manufacturing or weakness of the meshes. The vast majority of meshes that I use have been around for 10 plus years and they're obviously relatively cheap and not exciting. But they have stood the test of time and they're tried and true. And I think most people who do a volume of hernia surgery stick to pretty simple, basic, tried and true mesh.

Dr Joseph Vazzana: I just want to follow up with that. I agree with that statement completely. I just want to clarify the point of [00:14:00] cheap, because I don't want patients thinking that the mesh is not like a high quality piece of material. There are many, many different types of mesh out there. There are biologics, which completely go away. Those, some people will deploy in certain settings. Those are extremely expensive. Then, there are mesh that are partially absorbable and also very expensive. Then, there is what we would call a cheap mesh, but in reality, this is a very, very good mesh. It has good tissue ingrowth, a low infection profile and it is inexpensive, but that doesn't mean that it's not good.

Dr David Weithorn: By cheap, I mean, this is something that's just basically generic now. It's like Lipitor. If there's no longer a patent, all the manufacturers can make it. And the reason everyone makes it and it's so easy, easily available is because it's worked for decades.

Host: Well, this is all very reassuring to me, gentlemen. Dr. Weithorn, earlier I asked the question, what's changed in the 27 years since I had my hernia surgery? But more specifically, how has hernia surgery [00:15:00] changed at St. John's Riverside Health System?

Dr Joseph Vazzana: I mean, ultimately before I came over as the director there, and also after bringing Dave over, before it was mainly open surgery. The predominant of our inguinal hernias were done via the open technique. Not that I want to trash the open technique, I mean, I still deploy an open technique in certain situations. It just depends on patient preference and the type of hernia. I still think that there are many hernias that the best approach is the open approach.

I have moved the vast majority of my operative procedures that are minimally invasive over to the robot for a few reasons. One, I think that the repair looks better. I think it has a better outcome for certain hernias. It's also easier on the surgeon. There's a lot of torque and a lot of difficult angulation that you need to do laparoscopically that you just don't need to use with the robot.

So at St. John's, we are deploying cutting-edge [00:16:00] abdominal wall reconstructive and hernia repair techniques. Both myself and Dr. David Weithorn and also Dr. Camilo Mandujano and soon to be also Dr. Evan Berman, who is actually now starting to deploy the robot in abdominal wall reconstruction.

Host: Doctors, thanks for joining me today.

Dr Joseph Vazzana: Thank you. It was a pleasure to be here.

Dr David Weithorn: well, thank you.

Host: Once again, that was Dr. Joseph Vazzana and Dr. David Weithorn, general surgeons at St. John's Riverside Hospital. For more information, please call our Physician Referral Service at 914-964-4DOC or email us at findadocatriversidehealth.org. And if you found this podcast episode helpful, please share it on your social channels, and check out the full podcast library for topics of interest to you. I'm Evo Terra, and this has been Riverside Radio HealthCast from St. John's Riverside Hospital. Thanks for listening. [00:17:00]