Joey Wahler (Host): This is Health Matters: Insights from WCH Medical Experts. Thanks so much for joining us. I am Joey Wahler. Our guest, Dr. Peter Lalor, a general surgeon. Hi, Doc. Welcome.

Peter Lalor, MD: Hi, Joey. How are you today?

Host: Great. Yourself?

Peter Lalor, MD: I'm well. Thanks.

Host: Balancing numerous different procedures, as always, I'm sure. And so speaking of which, one of the more common surgeries you and yours do is hernia repair. So, what exactly is a hernia? A lot of people have heard the term, but many don't know what it is, especially if they haven't had it right.

Peter Lalor, MD: Sure. So, a hernia, in very simple terms, is a hole, right? And it comes from Latin and Greek origins. But basically, we have lots of layers of muscle and fascia and tissue in our bodies. But in certain places, weaknesses can develop, especially in our abdominal or in our groin wall. And these little defects create a space.

Now, the space in itself doesn't matter. And we call that space a hernia in most cases. But if something were to get in that space, then it can cause a problem, be symptomatic, or even put the patient at risk.

Host: And over time, you start to have pain, am I right? because that space is filled in with what?

Peter Lalor, MD: Yeah. So, there's a few different possibilities. Someone can have a hernia, it doesn't bother them. They didn't even know it was there. They went for an exam, the doctor found it and said, "Oh, did you know you had a hernia?" "No, I didn't." No big deal.

But if something gets in that space, it creates a bulge. So, you may see some asymmetry in your drawing or a bulge at your belly button where there's a hernia there. That bulge, it might be able to be reducible or be pushed in and out, which is kind of a strange sensation if you can imagine that. It can get stuck in there and be hard and firm and give lots of pain. And if part of your bowels get stuck in there, it can make you very sick and even make you nauseous, vomit or even give you a bowel obstruction, can be major complications down the line. So, there's a whole spectrum from asymptomatic to symptomatic hernias.

Host: So, what usually causes this? Is it something acute? Like, lifting something too heavy or more gradual damage, like maybe overdoing your workouts over time?

Peter Lalor, MD: So, I think, first, we should start with maybe the categories of hernia. And what you're describing is what we classically would think of in rough terms as an external hernia. So if you think about your abdominal wall, you can get defects in the fascia here. The most common places would be in the groin or the inguinal region. And for men especially, because of the way their spermatic cord goes down to their testicles and so forth, a lot of men are actually born with hernias that they never knew about. And over time, as they get older and strain and put that area under pressure, that area can get bigger and become symptomatic potentially.

Another type of hernia can be an umbilical hernia, which is often seen in women or people that have had some surgery in that area. And again, it's a defect right at the umbilicus that they may not notice. But if the woman gets pregnant or gains weight, that bulge can be more prominent overall. We sometimes see that in women that have had C-sections or anybody that had any abdominal surgery. If it doesn't heal right or get stretched out or put under pressure, they can get hernias at that site as well.

And then, lastly, the other type of hernias are what we call internal hernias. There's a hiatal hernias and what they call internal mesenteric hernias. These are hernias that you can't see. They're on the inside. A hiatal hernia involves your diaphragm where there's a hole where your esophagus meets your stomach. And that hole gets a little bigger than it's supposed to. The stomach pokes up a little bit and can give you reflux symptoms and sometimes some difficulty swallowing. But again, nothing should hurt. But the common scenario is that external hernia, either in the groin, the umbilical region, or a midline incision, on the abdominal wall.

Host: Now ,you mentioned women, Doc, and what's interesting is I think most of us usually associate a hernia with men who get it more typically, but women can too, right?

Peter Lalor, MD: Absolutely. I mean, and you're right, men get groin hernias much more commonly than women, maybe three to four, even five times more commonly, but women can get groin hernias as well. And then, just from an overall incisional or umbilical standpoint, it's pretty much even between men and women.

Back to the groin, women are less likely to get the classic inguinal hernias, but women are more commonly get what's called a femoral hernia, which is in the same area but in a different space below the classic groin hernia. They present very similar with a lump or pain in the area that's significantly bothersome, that the patient wants to fix.

And that actually brings me to one of my big points about hernias, and why we fix them, or when you want to fix them, and you'll probably get into this. But you want to get your hernia looked at or evaluated under two main scenarios. Number one, if it's bothering you. If it's symptomatic and it's affecting your quality of life, then you probably want to fix it. But the other reason to fix it is if there's risk involved. And only a medical professional or a surgeon is going to be able to tell you that. So if you have any questions about a hernia, you see a surgeon and they'll tell you whether there's risk involved. And the risk would be basically if an organ gets caught in that space, and that can cause strangulation or incarceration and complicate things.

So, those are the two criteria that we would fix hernias if it's significantly symptomatic or there's risk involved.

Host: And just real quick before my next question, a hernia, just to be clear, is not going to heal on its own, right? Once you have it, it's only going to get worse, the longer you let it go.

Peter Lalor, MD: Absolutely right. It's a space, it's a defect, it's an anatomical problem that's not going to heal on its own. And the only way to fix it is to close that space down. And we do that, in simple terms, we either re-approximate the tissue with stitches, which is kind of an old-fashioned way under tension a little bit, or we use a patch or a mesh in that area to literally patch the hole up so that nothing can get through it.

Host: You alluded to how the procedure is done. There's the mesh technique, which is the most common. How does that work?

Peter Lalor, MD: Well, let's start first with what the options are to repair most of these hernias that are external—the inguinal, the umbilical, the incisional hernias. The old-fashioned way is to do it open, which is an incision, a scar of a couple inches in the area, or it can be done laparoscopically or robotically assisted through some little incisions where they go underneath through your abdominal cavity, up looking at the ceiling to fix it from the inside. So again, those are the two approaches to use in fixing hernias.

But when it comes to actually fixing the hole, these days, we usually use a mesh patch, which is a sterile piece of propylene mesh, which is totally inert, but helps patch the area and the body scars up around it. We use a patch because it's what we call a tension-free repair. Because you can imagine if you had a sizable defect there, trying to pull the tissue together puts it under a lot of tension, and it might be more prone to pulling apart. But if we just patch the hole with mesh, it's a tension-free repair, and the hernia tends to recur less. And honestly, that's the biggest risk when it comes to fixing hernias most of the time is the recurrence rate. And to limit that recurrence rate as much as possible is the goal so you don't need further surgery.

Host: How often, in your experience, do people need that procedure done in the same spot, because it's not common, right?

Peter Lalor, MD: No, it's not common at all. In fact, if we're talking about inguinal hernias with an open approach, the recurrence rate is about 5%. In the laparoscopic or robotically assisted, approach, it may be a little bit higher, sometimes even as high as 10%. But overall, it really depends on what the patient's risk factors are.

Obesity is a risk factor because at the minute you fix these things, it is being pulled apart by the patient's weight. Smokers are at risk at higher recurrence rates as well, because the tissue doesn't heal well. Diabetics may be in that category as well, or someone malnourished. And of course, someone that doesn't rest appropriately. If they get their surgery and they go back to lifting heavy weights and not using good technique, they may be prone to getting that hernia back if they don't give it adequate rest and let it heal.

Host: And so speaking of which, Doc, in summary, what is recovery like after the procedure? And what is normally the recommended time for staying away from some of that heavy lifting, literally and figuratively, right?

Peter Lalor, MD: Yeah. So normally, this is an outpatient procedure done under general anesthesia, so the patient goes home the same day. They go back to their diets and medication immediately. They're given some pain medicine to take the edge off. And basically, for the first two weeks, there's no driving, no heavy lifting more than five pounds, and the patient just takes it easy.

I like to tell patients that at the two-week period, this can be what we call the most dangerous time. And not to scare people, but to demonstrate that, at about two weeks, the patient's probably feeling pretty good, 80% or 90% of the healing is done. They're not requiring pain medicine. It's not bothering them very much anymore, and they're happy with it, but it's not a hundred percent healed yet. And so from two weeks to sometimes even six to eight weeks, the patient still wants to refrain from doing anything majorly strenuous because it's not healed 100%. And again, if they go back to that too early, then they can have small little tears that become bigger, recurrent hernias later, and they may need it fixed again. But in saying that, the recurrence rates overall, if it's repaired appropriately, especially tension-free, that the recurrence rates are very low.

Host: And like you said, just to wrap up here, when you get that mesh technique done that you talked about, it really is kind of like having an old school patch put over a frayed knee on a pair of jeans, right? It just makes it like new.

Peter Lalor, MD: Yeah, I mean, Joey, like, I'm sure your mom, when you were wearing your corduroys in the '70s and you got a hole in your knee that she sewed that patch on, right? And it was really easy and you could see it a little bit. But it's simple. It really is. A lot of surgery comes down to simple anatomy and simple principles. There's a defect there. We need to patch it up. And the mesh these days And the technology has become so good that we have these inert, sterile pieces of mesh that the body works well with to scar the area up well so it doesn't come back. And in a lot of ways, the tissue's even stronger than it used to be.

Host: And we should point out, Doc, that the material that you and yours use is far stronger and longer lasting than those iron on patches that mom used to use, right?

Peter Lalor, MD: Yeah, absolutely. The people often have a question about the mesh. Because when the mesh first came out decades ago, there were some questions about it. And there'd be lawyers talking to patients, because the mesh failed or became infected or whatever. But these days, there's a number of great meshes on the market, and I really reassure patients that the meshes have gotten so much better, much better than any gene or corduroy patch, and certainly much better than the ones decades ago.

Host: Well, folks, we trust you are now more familiar with hernia surgery. Dr. Lalor, always a pleasure. Thanks so much again.

Peter Lalor, MD: Thanks for having me again, Joey. Great to see you again.

Host: Absolutely. Same here. And to learn more about surgeries offered at Wood County Hospital, please visit woodcountyhospital.org and simply search surgery. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. Thanks so much again for being part of Health Matters: Insights from WCH Medical Experts.