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Melanie Cole, MS (Host): UAB Medcast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA Category 1 credit. To collect credit, please visit uabmedicine.org/medcast and complete the episode’s post-test.

Welcome. Today we’re examining options for minimally invasive hernia surgery. My guest is Dr. Abhisek Parmar. He’s a minimally invasive general surgeon and an assistant professor at UAB Medicine. Dr. Parmar, tell us about the current state of hernia today. What’s the prevalence and what are you seeing most often?

Abhisek Parmar, MD (Guest): Sure. Well, first of all, thank you so much for having me on the show. So hernias are incredibly prevalent, I think, with a lot of people listening either have hernias or know someone who’s had hernias. Probably about a million operations are performed every year in the United States for hernia disease. They’re incredible prevalent. I think what makes hernia disease especially exciting right now is I think that we’re in the golden age of surgical treatment of hernias. I've seen a lot of new advances over the past few years that are really incredibly exciting to hernia specialists like myself.

Host: Then tell us about the main factors that lead to hernia, and then we’ll get into treatment options that are available.

Dr. Parmar: Sure. So the main factor leading to hernia, the biggest risk factor is probably a prior surgery. About 50% of people after abdominal surgery can develop a hernia at their incision site. By nature when you make an incision or a cut in someone’s abdomen, you're going to weaken the tissues in the abdominal wall then. It never really has the same strength that it has before. Along with that, there are patient factors that can weaken the tissue. So patients who are obese are at higher risk for developing primary hernias. Patients who are diabetic and smokers are incredibly high risk for developing hernias.

Host: So what is the clinical presentation that would send someone, because not all hernias hurt, correct? Not all hernias are visible through outer examination. Not all of them hurt, is that correct?

Dr. Parmar: Correct. Yeah, absolutely. Not all hernias hurt. Probably the first sign the patients notice is unusual bulging in areas where hernias commonly occur. Usually at the bellybutton or the groin. Or, like I said, at the site of prior surgery. Like you said, pain is not always present, but that’s usually what brings people to see someone like me is that they're having pain in an area where there’s also bulging.

Host: So then as we’re speaking about treatment, Dr. Parmar, is treatment emergence or even always necessary? How do you decide whether to repair or to wait?

Dr. Parmar: So it’s a complex decision. Historically, we used to think that every hernia that we come across needs to be fixed because we worry about a loop of intestine getting stuck inside the hernia or getting incarcerated or strangulated where the intestine can lose it’s blood supply. So based on that concern, patients used to always have a surgery pretty much when a hernia was diagnosed. Over the past five or six years, there’ve been a few studies that have demonstrated that’s not really the case. That episode of incarceration or strangulation is actually quite rare. So now it becomes a discussion that I always have with my patients about the risk and benefits of surgery and how surgery would look like for that particular patient and their lifestyle.

Host: Then let’s talk about some of the benefits of minimally invasive surgery, including the application to inguinal or hiatal, large abdominal wall hernias that might require complex abdominal wall reconstruction. Speak about some of the benefits. What do you even tell your patients when you are discussing these surgical options?

Dr. Parmar: Right. So minimally invasive surgery has really revolutionized how we take care of these patients. So operations that used to keep people in the hospital for a week are now being done on an outpatient basis. I do all of my ventral hernia repairs robotically. Patients either go home the same day or the next. For inguinal hernias, the MIS approach has also changed how we manage these patients. Patients who undergo an MIS inguinal hernia repair are at lower risk for getting chronic pain, which I think is an incredibly difficult problem to manage after hernia repair.

There are recent guidelines that have been published that suggest that all women should undergo a minimally invasive approach for their hernia repair if they have a groin hernia. So that’s what I counsel these patients is that it can have a lower risk for chronic pain, and for women it’s kind of the gold standard for how they should be managed.

Host: Then compare and contrast for us. Open repairs versus the laparoscopic procedure and robotic assisted surgery. Tell us a little about what goes when you're going these repairs.

Dr. Parmar: Right. So you know the contrast is really between, I think, minimally invasive surgery—which includes laparoscopic and robotic—versus open surgery. The laparoscopic and robotic surgery, they both provide the same benefits of the smaller incisions, which means less pain for patients, a faster recovery, and less risk for infections which is a huge problem for obese patients and diabetic patients compared to open. The bottom line is I tell my patients I use the robot because it makes my job easier, but there really hasn’t been any proven benefit in the robot over the laparoscope, which I also use a lot of in hiatal hernia and abdominal wall reconstruction.

Host: See it’s such an interesting procedure and decision to discuss with your patients. Dr. Parmar, what about patient selection? How does this help to optimize repair?

Dr. Parmar: That’s a great question. I think it’s so appropriate for hernia because patient selection really is critical for hernia disease. For the longest time, surgeons approached hernias as “just a hernia”. We thought it’s a simple problem. You fixed the hole. Patients go on with their life, and it’s that simple. The reality is it’s much more complex. I think that’s what really differentiates UAB from a lot of other places that offer hernia surgery. Instead of whisking patients off to surgery, we realize there’s an actual patient attached to the hernia. So we spent a lot of time optimizing patient factors that can critically impact the success after surgery. So things like patient glucose management, weight loss, smoking cessation are all things that we address in our clinic visit. We have a lot of resources here at UAB to help people really get the best result possible after hernia repair. The reality is up to about 30 or 40% of people will actually get a recurrence after hernia repair. So it’s not just a hernia.

Host: Well, it’s certainly not. That’s an incredible interesting statistic. So based on that, tell us a little bit about how mesh selection for hernia repair can be challenging for clinicians. If you’d like to, give us your expert review of biologic or synthetic or bioabsorbable types, and why you choose the ones you choose.

Dr. Parmar: Sure. So the reality is mesh is the greatest resource we have in our armamentarium for decreasing recurrence of hernias. I tell my patients if we just sew the hernia close, there’s about 80 or 90% chance that the hernia will come right back. So mesh is the best way to get that number down to less than 10%. Hopefully less than 5%. You know there are literally hundreds of meshes on the market. You see the TV ads for mesh litigation, things like that. The reality is mesh complications do exist. So I'm extremely careful with how I select mesh. I think the more important question is where we place mesh. Most surgeons, I think, place mesh into the abdominal cavity. When you place mesh that abuts vital organs and viscera, a lot of complications can happen. So I always try to place my mesh in a plane that’s away from vital organs. So either in the preperitoneal space or the retrorectus space. So, in that sense, choosing the kind of mesh becomes a little less important.

There is a promising new bioabsorbable mesh that kind of maintains the same tissue integrity and strength as conventional synthetic mesh, but dissolves after about a year. What we know about tissue remodeling is it takes about a year for this to happen. So having that mesh in place still serves to function to strengthen the abdominal wall. It’s still fairly new, but the studies that have been done by leading hernia surgeons across the country suggest that it’s at least as good as the synthetic mesh. There’s also biologic meshes that, in my opinion, are weak and are substandard for hernia repair.

Host: What a great review. Thank you so much, Dr. Parmar. Wrap it up for us. Summarize this segment for other providers. What would you like them to know about minimally invasive hernia repair and, as you said, mesh selection? And why they should refer to the experts at UAB medicine.

Dr. Parmar: Well, you know, I think it’s such an interesting phenomenon. Hernia disease is something that, like we talked about, is so prevalent. I think because it’s so prevalent, people think it’s fairly commonplace and pedestrian and fairly easy to manage. The reality is there’s been a lot of new advances in the surgical management of these patients, and a lot of ways that we could really mitigate downstream complications. Just one of those is the minimally invasive approach. Here at UAB, we do minimally invasive abdominal wall reconstruction, which is a very new approach to really complex hernias. Patients who, like I said, would be in the hospital for up to two weeks can now go home the same day or the next day. Being able to offer that kind of care, I think, is really revolutionary.

The goal that we really want to attain here at UAB is that we want to fix the hernia, but we want this to be the very last repair a patient ever gets. I think with the optimization strategies we employ and the surgical techniques we use, we can really attain that. The reality is the techniques I'm doing today are techniques that weren’t really around four or five years ago. That’s a really exciting thing to be able to tell and offer patients.

Host: That’s great information. It certainly is an exciting time for these types of repairs. Thank you, again, for joining us and sharing your expertise. A community physician can refer a patient to UAB medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You're listening to UAB Medcast. For more information on resources available at UAB Medicine, you can go to uabmedicine.org/physician. That’s uabmedicine.org/physician. I'm Melanie Cole. Thanks for tuning in.