Carl Maronich (Host): This is The Pulse at Tallahassee Memorial Healthcare. I'm Carl Maronich. And with me today is Dr. James Parker. We're going to be talking about hernias, what they are the most common types, and how they're diagnosed. We'll also talk about the benefits of robotic surgery and what patients can expect before and after treatment. Dr. Parker, welcome to the podcast.

James Parker, MD, FACS, FASMBS: Thanks for having me.

Host: You are general bariatric minimally invasive surgeon, right?

James Parker, MD, FACS, FASMBS: Yes, sir.

Host: Very good. So, you deal with a lot of hernias, and maybe we could start by just defining and talking a little bit about what a hernia is.

James Parker, MD, FACS, FASMBS: Sure. And there are quite a few different types of hernias. And they come about for different reasons. But basically, the hernia is organs or structures in the body that are pushed through defects that aren't supposed to be there.

Host: You mentioned different types. There are different types of hernias.

James Parker, MD, FACS, FASMBS: Yeah. Classically, you think of the bulge of the belly button, that's the umbilical hernia. And that's basically what the hernia is, but it's something that you can see bulging. There are also hernias kind of internally as well, or that you can't see, so like hiatal hernias where you have hernias bulging through the diaphragm causing reflux or trouble swallowing. And you have groin hernias called inguinal hernias, which is bulging down in the groin as well. Many other hernias.

Host: Do the symptoms show up similarly or are there different symptoms for the different types of hernias?

James Parker, MD, FACS, FASMBS: Hernias can cause all sorts of symptoms. Most commonly, hernias are asymptomatic. You see the bulge before you have problems with it. And so, just a little bit of fat pushing through from a space where fat's supposed to be pushing through the hole, bulging to the space where it's not supposed to be.

Host: How are hernias most often diagnosed initially?

James Parker, MD, FACS, FASMBS: Typically, they're diagnosed on physical exam. You go see your physician, you complain of the bulge and/or pain. And then, they're like, "Oh, yep, that's a hernia. A belly button, hernia, inguinal hernia." Those are fairly easy to diagnose on physical exam.

Host: So, I'm guessing typically a patient might have that conversation with their primary care provider first, and then be referred to you for treatment.

James Parker, MD, FACS, FASMBS: Typically, that's how it works. We do have a streamlined service with TMH where we have a hernia referral line. So if you suspect that you have a hernia, any site of hernia, you could give us a call and we can get you scheduled directly with a surgeon, and skip the step of seeing a primary care doctor if that's what you want to do.

Host: You mentioned earlier, hiatal hernias, if I'm saying that correctly, how do they differ from abdominal wall hernias in terms of causes, symptoms ,and treatment approaches?

James Parker, MD, FACS, FASMBS: Yeah. So, a completely different type of hernia, but still a hernia because it's basically where the stomach herniates or other organs herniate up through the diaphragm internally. And it can present in many different ways. And typically, the classic symptom is reflux. You can have small hiatal hernias, big hiatal hernias. It doesn't matter what size, a hiatal hernia is a hiatal hernia when it comes to reflux because, basically, we lose that valve that keeps acid in the stomach and it comes up when we're sleeping with these extra pillows, all that kind of stuff.

Other symptoms that it can cause would be dysphagia, trouble swallowing, food sticking, chest pain, or some atypical symptoms, which could be from the acid itself, like throat clearing and burning, sinus drainage, chronic cough, those kind of things. And so, a lot of different symptoms with a hiatal hernia.

Host: What are the early warning signs patients could look out for when it comes to hernia before complications arise? And at what point is surgical intervention needed typically?

James Parker, MD, FACS, FASMBS: Sure. So, when it comes to symptoms and when surgery is needed, it depends on what type of hernia we have. So, umbilical hernia symptoms are generally recommended to have that repaired regardless. Because like we say, hernias don't get smaller, they stay the same or they enlarge. And when they get bigger, and that can happen over time when we get older, tissues get weaker and more things can fit through the hernia, it can become an emergency. And so, getting it fixed as soon as you see it is typically recommended. But if you want to wait until you are having symptoms, typically you'll have symptoms of pain at the site or symptoms of where you're throwing up or having bowel obstructions. And in that case, it is an emergency. So, they can present a lot of different ways.

Host: What factors determine whether surgical repair or medical management is the preferred approach?

James Parker, MD, FACS, FASMBS: Typically, the workup for hiatal hernia starts with a patient complaining of reflux. And so usually, if you're having some heartburn, you'll start on an H2 blocker or a PPI, and then get referred to a gastroenterologist who will start working up the reflux, increasing or strengthening the PPI, doing endoscopies to check for any sort of structural abnormality and diagnose the hernia.

When he gets into a surgeon, usually we don't recommend getting these fixed until you failed medical management, or if you decide that you don't want to take a PPI forever, let's do something to prevent me from having to take that. And then, that's when we do some sort of a hiatal hernia repair with some anti-reflux procedure, which typically will get patients off of their PPIs.

Host: The best treatment option, there are a variety of them from laparoscopic to open, robotic. How do you determine which is the best for the different types of hernia?

James Parker, MD, FACS, FASMBS: Sure. So, small asymptomatic hernias can be managed with an open repair. I think that's reasonable. Laparoscopic and robotic are fairly synonymous. And a large portion of the country are actually moving from laparoscopic to robotic surgery just due to the ease of operating. You know, we haven't really proven better outcomes necessarily. But there's a general consensus that we have better control, better vision, better tissue manipulation using the robot with much more fine movements. And so, most of us have gone to fixing hernias with the robot. And for me, typically I'll recommend a robotic repair unless it is a small umbilical or epigastric hernia that I'm repairing.

Host: In terms of recovery, what can the patient expect based on the differences between laparoscopic and robotic surgery?

James Parker, MD, FACS, FASMBS: Laparoscopic and robotic surgery, we typically have fairly similar recoveries. And if we get down into the weeds of the differences in the surgery, robotic surgery, one of the benefits of that surgery is that you can actually close the hole a lot easier than laparoscopic. And so when people repair these primarily laparoscopically, they're taking a piece of mesh, sticking it up under the abdominal wall and just tacking it in with tacks, which can cause pain all around the mesh that you placed in because you're tacking it all the way around. When we do this robotically, we have the ability to close the defect fairly easily, which closes the hole and then also patches it with a piece of mesh, which doesn't necessarily require extensive tacking to keep it in place, just a few sutures which dissolve within a couple of weeks. And so, I think that in terms of recovery, you can expect an easier recovery after robotic surgery and then less complication.

Host: Certainly better, sounds like, recovery from robotic compared to the open surgery.

James Parker, MD, FACS, FASMBS: Yes. In a sense, they're smaller. And I aim all of my repairs in order to try to ease the recovery in patients and decrease the recurrence risk. And a smaller open hernia repair typically has a fairly simple recovery without too much pain. But once you get larger than one to two centimeters, you're starting to talk about using a piece of mesh to reinforce the repair, making bigger incisions, which makes the recovery a little bit more difficult and increases the risk of infection. And so, that's why I kind of prefer a robot for those specific cases.

Host: From all that, it sounds like it gets back to something you said earlier about getting it taken care of earlier and not waiting to have some sort of a treatment for the hernia.

James Parker, MD, FACS, FASMBS: Yeah. I think that that hits the nail on the head.

Host: EarlyIs always better as they say. Isn't that right?

James Parker, MD, FACS, FASMBS: Yeah, yeah.

Host: Very good. Well, Doctor, a lot of great information. We appreciate you spending time with us and telling us all about hernias.

James Parker, MD, FACS, FASMBS: Sure. Thanks for having me.

Host: Certainly. For more information and to request of surgical consultation, visit tmh.org/hernia. If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest. I'm Carl Maronich. And this is The Pulse at Tallahassee Memorial Healthcare. Thanks for listening.