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Speaker 1 (00:00:00):
Hello everyone. Welcome to Hernia Talk Live. My name is Dr. Shirin Towfigh. I’m your host every week on this every Tuesday event. All we do is talk about hernias and hernia related topics. You can follow me on Twitter and Instagram at Hernia Doc. Many of you are joining me live on Facebook at Dr. Towfigh. At the end of this session, I’ll make sure that you have access to my YouTube channel where we will have all of our past hernia talk sessions posted up. Today’s discussion will be with my very good friend and we’ve even traveled together. I really enjoyed getting to know Dr. James Bitner. We call him JB. He is a bariatric surgeon and a hernia surgeon, laparoscopic robotic expert. He currently is in Connecticut at the Trinity Health of New England. You can follow him on Facebook at JB dot bittner, and please welcome Dr. Bittner.
Speaker 2 (00:00:59):
Sure. And thank you so much for having me. And I don’t know where you found one good picture of me, but I’m pretty sure it’s the only one there is. So you
Speaker 1 (00:01:06):
Actually have a fair number of good pictures on. Trust me, I’ve, I’ve struggled with some of our prior guests, so yours was fairly easy to find.
Speaker 2 (00:01:16):
All right. Good, good, good. Well, I’m excited to be here and look forward to answering some questions and having a little fun.
Speaker 1 (00:01:22):
I’m surprised you don’t have a professional photo shoot or headshot of yourself. You should.
Speaker 2 (00:01:29):
I think they would be afraid. I think that,
Speaker 1 (00:01:34):
Well, we were talking and catching up earlier. For those of you that are joining us, many of you have followed me on hernia or have been on hernia talk.com, which is the website that I’ve been hosting for. I think this July will be nine years or eight years, eight years. And then during the pandemic we transferred to an additional value, which is hernia talk live. And today JB is the last hernia talk live session before I start my one year anniversary. Woohoo. Is that cool? Yeah.
Speaker 2 (00:02:16):
That’s
Speaker 1 (00:02:17):
Awesome. Yeah, it’s pretty cool. That’s awesome. I can’t believe one year has already gone by every week for a year.
Speaker 2 (00:02:23):
I know anybody that logs in or anybody that follows you or even anybody that participates in these kind of events, I hope they understand the potential value that you offer them and either whether it’s through people like myself talking or whether it’s just directly from you. Yeah, because it’s very unique. It’s very specific to you as well, and it’s an incredible service to just people in general and patients in particular.
Speaker 1 (00:02:52):
Thanks. And my patients have been amazing. Everyone that comes on has been so cordial, very grateful. Every surgeon and doctor specialist that I’ve had come on and they, I’ve brought all different specialties, they’ve enjoyed it. They felt it was very fun. Some people want to do it for their own specialty. I really enjoyed it and thank you for agreeing to be my guest today because we’ve never actually talked about the most important, one of the most important risk factors for a successful hernia surgery, which is your weight. Yeah. Not your weight. Your weight is perfectly fine. I don’t think you’ll ever genetically, I think you’ll Is your entire family thin?
Speaker 2 (00:03:37):
Yeah, most of them.
Speaker 1 (00:03:37):
Unlike my family, yeah. We have a wide range,
Speaker 2 (00:03:41):
Most of them. I have certainly missed some good quality Persian food, though. I could always go for that.
Speaker 1 (00:03:50):
You’re always welcome back. Yeah.
Speaker 2 (00:03:53):
Well, no, it absolutely is a critical risk factor and it’s very much a risk factor that we consider when we’re operating on almost any hernia, but there are certainly hernias that are more specific to the weight as a risk factor for sure.
Speaker 1 (00:04:12):
So you’re unique in that I think your heart is in two different worlds, but often don’t like interact too much the bariatric world and the hernia world. So you get to see, I assume, do you get to see patients with both problems at the same time? Yeah,
Speaker 2 (00:04:30):
So I often say this and address this because I am a bit of a hybrid in some ways as my practice is essentially a hundred percent hernia and a hundred percent bariatric at the same time.
Speaker 1 (00:04:43):
Wow.
Speaker 2 (00:04:44):
In many respects, the fact that I am interested in and desire to be a hernia expert helps me in patients who have hernia in conjunction with clinically severe obesity or metabolic disorders. And in the same respect, being a bariatric surgeon helps me to be a better hernia surgeon as well. I feel because I’m often thinking about patients with hernia disease in a global way, much the same way we think about patients who are going to undergo surgical weight loss, for instance. And so they do actually marry pretty well together when you think about it.
Speaker 1 (00:05:28):
So we’re going to use the terms weight loss surgery and bariatric surgery similarly. Do you want to just describe who is a bariatric surgeon? What does that involve? What kind of training, what kind of patients do you see?
Speaker 2 (00:05:42):
Sure. So metabolic and bariatric surgery as it tends to be referred now, has to do with primarily patients who suffer from clinically severe obesity, either with or without specific weight related. And there are certain criteria that are required in order for you to meet and undergo surgical weight loss, but it’s a lot more than that because much of the care we provide isn’t necessary operative. Much of the care we provide includes medically supervised weight loss with medications and therapy and dieticians. And so it’s a bit of a comprehensive approach to weight management and the long-term success of these folks who have to deal with this as a complicating factor of their life. And it certainly can complicate hernia and hernia disease as well as,
Speaker 1 (00:06:38):
So there are different levels of being overweight. Some do it based on body mass index, which is a high weight weight ratio. Some refer to it kind of so many pounds overweight. If you’re a hundred pounds overweight, you’re most likely obese. How do you describe the way that you categorize your patients?
Speaker 2 (00:07:00):
Sure. So way back in 1991, and we all know that that was a bit of time ago, they created some guidelines by which all insurance companies now that all insurance companies follow in order for us to ensure that patients are qualified for surgical weight loss. And one of the measures, which may not be the best measure of how you look and how you feel is something called a body mass index, as you said. And a body mass index is nothing more than your height divided by your weight. It’s just a fraction. And you come up with a number and if your body mass index is between 35 and 40 and you have one weight related medical problem such as uncontrolled blood pressure or high blood sugar, diabetes or sleep apnea and some other medical problems, then you may qualify for weight loss operation. On the other hand, if your body mass index is 40 or more, you don’t necessarily need to have a weight related medical problem. You qualify based on your weight alone and could be eligible for operative intervention.
Speaker 1 (00:08:14):
How often do you see someone with a B M I over 40 that doesn’t have another problem like diabetes, high blood pressure, arthritis? Sure. and joint problems.
Speaker 2 (00:08:25):
So it depends on when you find them. So for instance, younger patients who may be otherwise healthy may just have weight as a significant problem. Older individuals obviously have more medical problems over time, but what often happens is we see patients who have a body mass index over 40 who feel they are healthy and perhaps haven’t sought care or don’t have a primary care doctor that follows them regularly. And sure enough, during the pre-op evaluation process, which can take upwards of six months, we find additional medical problems they may not know they’ve had. And then we can address those both with appropriate medical therapy as well as with weight loss operations.
Speaker 1 (00:09:09):
Okay, that’s really great. And then what are some situations where there’s an overlap between weight loss surgery or bariatric surgery and hernias?
Speaker 2 (00:09:17):
Well, actually it kind of comes in twofold. Some patients show up with no hernia and require or want to undergo surgical weight loss, which we then perform. And low and behold, over time as they lose a significant amount of weight, fast forward a year or two, they may develop hernias, either hernias that they didn’t know they had previously or hernias that develop over time with weight loss that then become symptomatic or cause them problems. And it’s at that point that we can fix them. There are another group of patients that show up with hernias already, some of which cause them problems or hurt or other issues and need to undergo surgical weight loss in order to lower their risk for a subsequent hernia repair 12 months in the future. And then there are still sort of the third group of patients who don’t have a hernia, undergo a successful weight loss operation, and then later on due to excess skin or other issues like that want to undergo some type of an abdominalplasty tummy tuck if you will, with excess skin removal. And so we help those patients as well. And so it just depends on what you come with and it also depends on what your weight is related to surgical weight loss and what type of hernia you have.
Speaker 1 (00:10:49):
That’s a really good point. So one of the questions that was submitted ahead of time was my losing weight, may losing weight cause a hernia to be more painful or is the weight loss make the hernia less painful? So let’s say I’m morbidly obese and I have a painful hernia, if I lose weight, will that hernia get worse or better?
Speaker 2 (00:11:13):
Yeah, I think I get the question. This is actually a good one. And so it’s interesting, there are patients, this happens more in men than in women though it can happen in women where they present with an inguinal hernia but also may suffer from obesity and their hernia does not cause them any problems. Then as they lose a substantial amount of weight, fast forward a year in time, now their hernia begins to cause them problems. That does have to do with the weight loss and the way a hernia works. And so there are hernias that are asymptomatic at that becomes symptomatic with weight loss.
Speaker 1 (00:11:55):
Okay, and why is that?
Speaker 2 (00:11:57):
Well, it’s more often in inguinal or groin hernias, but can happen in ventral or abdominal wall hernias as well. And it tends to happen with the fact that as weight decreases where we hold our weight, some of us hold it inside our belly, some of us hold us on top of our belly, can affect what is caught or stuck in the hernia. And sometimes when those things either become caught or stuck in the hernia that weren’t stuck before, that can hurt. Alternatively, there are times when something was stuck in a hernia and then is no longer doesn’t have as much obesity and then all of a sudden things start popping in and out of a hernia and then that causes problems and pain. And so it’s interesting that that’s a good question. On the flip side of that though, patients who may present with a painful, say groin hernia or inguinal hernia but also want to undergo weight loss, either medical or surgical, find that as they lose the weight, their symptoms either stay the same or get better. Not always a hundred percent predictable, but the change in weight can change the symptoms associated with a growing hernia for sure. Sometimes for the better, sometimes for the worse.
Speaker 1 (00:13:29):
So that’s interesting you say that because I sometimes get patients that are totally healthy, they may be overweight, they’re not obese. I’m in Beverly Hills, we don’t have obese patients. I’m just kidding. Totally kidding. Okay. So they then go to their doctor and Oh, I have this groin hernia or belly bone hernia, and then the doctor says, oh, make sure you stop all exercise, don’t lift anything, and they completely restrict the patient. Then they start gaining weight and their sy, what we used to have no symptoms, now they have symptoms. And then they come to see me and I said, no, no, no, no. Let’s reverse that process. Hernias are totally safe to have while you’re exercising. Go back, you’re going to lose the weight by exercising, you’re going to strengthen the core muscles with exercising that seems to support the hernia somewhat. And if you still have symptoms, I’ll fix you, but you can potentially forego meaning surgery if you kind of reverse that process. And many of them come back and say, oh yeah, I’m like, I still have the hurry. Do I need surgery? I have no pain. I’m more fit now, et cetera.
Speaker 1 (00:14:49):
So what you’re saying is very true, but I also remember because I’m older than you are while you were still probably applying to medical school, not that old, I remember the controversy was this, if you have a hernia and you’re morbidly obese and the hernia’s like not a problem and you decide to undergo weight loss surgery or bariatric surgery, what do you do with that hernia? And I used to be it used, there was actually an abstract stage I remember very clearly that showed that if you don’t fix the hernia at the time, the patient will lose dramatic weight and the dramatic weight loss. This is not like I died and I lost weight this, I had my stomach stapled off and I lose a hundred pounds in less than a year. That dramatic drop somehow makes it so that this piece of fat that is now plugging the hernia that fat thins out. And then now it’s not only not plugging the hernia, it can either allow more stuff to go in bowel
Speaker 1 (00:15:56):
Or it can kind of fall into this hernia which was kind of pulled up. Now this hernia’s fallen down with all the weight loss the same way you get a sagging skin and loose skin, the hernia gets D dragged down too. I’m talking abdominal wall hernias. And so the data at stages, this is a long time ago, was something like within three months there’s a huge risk of needing emergency hernia surgery after bariatric surgery and therefore at that time they said you should fix the hernia at the same time. But I understand that may have those recommendations may have changed.
Speaker 2 (00:16:33):
Yeah. So in my eight plus years or so of doing both hernia repair A as well as bariatrics, I will tell you while each case is unique, our routine, if you present with a growing hernia, yes. And your growing hernia is symptomatic, meaning it’s causing you enough problems to limit your activities that you normally do or limit your exercise if you’re going to undergo surgical weight loss and you can wait fine if you want to get it fixed tomorrow and then six or eight months later during your pre-op process have your sleeve gastrectomy also great. Yeah,
Speaker 1 (00:17:14):
That’s for groin. So for groin.
Speaker 2 (00:17:16):
For groin, that’s very different when you
Speaker 1 (00:17:18):
Inguinal very different. Very different. The same. I like them to lose weight, but I’m not as religious about it because it hasn’t been shown to be dramatically.
Speaker 2 (00:17:26):
So for an abdominal wall or ventral hernia or umbilical hernia or belly button hernia in those patients, the hernia characteristic then factors in. Yes. So if you came to my office and you had a very large hernia, it contained intestines and fat and colon and whatever else, then you would get a specific type of weight loss operation. I may only offer you one type. Yes. You lose a hundred pounds over the course of a year to a year and a half. Yes. And at that point, and only at that point would we ever consider fixing the hernia and usually combine a tummy tuck to go with it to get rid of the excess skin and fat. On the other hand, if you have a very small little belly button hernia about the width, width of your thumb, then more than likely I will simply repair that at the time of a surgical weight loss operation, I would Okay. And when that hernia comes back, we can cross that bridge at that time. So it really depends on the characteristic of the hernia. But what I don’t do, which that sage’s data sort of supported at the time was to perform some type of a definitive hernia repair on a ventral or belly hernia at the time of a weight loss operation. And by definitive what I mean is
Speaker 1 (00:18:51):
The best
Speaker 2 (00:18:51):
Large piece of Mesh or manipulating tissue to place Mesh and try to definitively repair. That’s one thing we don’t really do anymore.
Speaker 1 (00:19:02):
So that’s very good because that’s always a question which comes first and what to do if you don’t even know you have a hernia and the surgery goes in there and sees a hernia. So a small belly button hernia, you’ll probably use that as part of your surgery and then close it. Sure. And then a larger hernia, you really need a good hernia operation to make that stick. So you want to do that in a better circumstances and that would mean lose weight with the bariatric surgery first and then schedule a good hernia repair. Let me ask you this, what’s the risk of this patient during this weight loss period ending up in the emergency room with a bowel obstruction or some complication from that hernia that wasn’t repaired?
Speaker 2 (00:19:49):
Sure. So for the large, the reason we leave the large ventral hernias alone at the time of weight loss operation is because their risk of requiring an urgent or emergent operation over the next 12 to 18 months is actually pretty low and it’s low to the point where their risk for reoperation related to a hernia recurrence if we fixed it at the time of their weight loss operation is higher than their risk of waiting 12 to 18 months, losing a bunch of weight and maybe having a single digit or less percentile chance of having an acute need for an emergent operation in that first 12 to 18 months. So we very much look at the risk benefit of one versus the other. A small belly button hernia that’s a couple of inches across could pose an acute problem because it’s smaller, whereas the very large hernias tend not to pose an acute problem and they do much better with a more definitive operation in the future.
Speaker 1 (00:20:52):
What about an incisional hernia that’s kind of in between a three inch short or spin like that?
Speaker 2 (00:20:58):
If it’s something I can use as a part of an operation or if it’s something that in contains incarcerated or stuck small intestine and I need to operate on that intestine for whatever reason, then we’ll suture it up. We’ll close it just primarily with the full expectation that recurs at some point as a hernia, patients are aware of that preoperatively and in many respects, some of them want the hernia back because they know that if in 12 to 18 months or two years, if that hernia comes back and their insurance or their finances do not allow them to get excess skin removal in the form of a tummy tuck, they can combine a hernia repair and a tummy tuck and have it all kind of covered by insurance partially. Some of them are very much in favor of that approach, fully understanding that they may still require another operation in the future
Speaker 1 (00:21:54):
Because a hernia repair is always covered by insurance, the tummy tuck is not, but you can do a tuck as a part of a hernia repair. I do that routinely. Correct. It just gives a nicer customer. And then the skin removal, skin removal, that’s just thrown in
Speaker 2 (00:22:14):
Pretty much.
Speaker 1 (00:22:15):
Oh,
Speaker 2 (00:22:15):
Okay. Yep. And that’s not true of everyone everywhere and it’s hernia specific. So I mean if you have a one inch belly button hernia, we’re not going to do a complex particular panniculectomy excess skin removal and so forth because that’s not really germane to the hernia repair. But if the hernia repair is of significant size or complexity that removing excess skin and fat would be a normal part of that hernia repair. Whether we remove it vertically because you already have a scar or whether we remove it transversely through a bikini line incision is patient specific and depends, but we really do that only in those cases when excess skin removal would’ve been a part of the normal hernia repair anyway,
Speaker 1 (00:23:05):
Those techniques, depending on how much you love your belly button.
Speaker 2 (00:23:08):
That’s right.
Speaker 1 (00:23:10):
As
Speaker 2 (00:23:11):
I say, you can still get to heaven without a belly button,
Speaker 1 (00:23:15):
But can you guarantee that? Okay. Okay. One question just to clarify is exercise with all types of hernias, umbilical and epigastric.
Speaker 2 (00:23:25):
So I’m absolutely in your corner on this one, and I tell patients all the time after the biggest hernia repairs or the smallest hernia repairs, including after any bariatric procedure, I say, I want you to walk, run, ride a bike, carry too many groceries, jump up and down, whatever doesn’t hurt you, go do it. In fact, when you feel strong enough to start going to the gym or exercising or running or lifting weights and it doesn’t hurt more power to you because I mean I’ve had patients who’ve done inguinal hernia repairs run five ks two days after. I don’t know if that’s, I don’t want to run a 5K ever, but utilizing the reconstruction of a hernia, as you know, is basically putting muscle back together, muscle and tissue and fascia back together. And so anything else, your abdominal wall is a muscle and a group of muscles. And so the more you exercise your muscles, the stronger they get, the stronger they get, the more they can resist force both from the outside world as well as from inside your belly, the stronger your hernia repair can ultimately become if it’s fixed as well. So I’m all for core strength. I’m all for core strengthening and full exercise to whatever level the patient is able and simply use pain as a guide. And it freaks a lot of patients out because their primary care doctor or others have told them for the last
Speaker 1 (00:24:53):
That absolutely not
Speaker 2 (00:24:55):
That don’t lift a milk carton. Right? Yes. But I don’t even know if they make milk cartons anymore. But still the point is that
Speaker 1 (00:25:03):
There were one, make sure you don’t lift it.
Speaker 2 (00:25:06):
Right. There are really no data to support that anecdotal methodology and there is some better data to actually support doing quite the opposite of that antiquated methodology and doing as you described, and encouraging patients to use their muscles so they don’t lose their muscles.
Speaker 1 (00:25:25):
We had Ben Poulose from Ohio State as one of our guests, and we discussed a lot about core strengthening, physical therapy, different types of exercises. There’s a whole website of the ACH AHSQC that has pamphlets for patients to download for free on more based exercises that are safe around time of surgery. Okay, here’s another question. Does being over white make you less likely to notice a bulge when you have a hernia? I am five four and I weigh 185 pounds. I suspect I have a femoral or a possible inguinal hernia.
Speaker 2 (00:25:59):
Sure that that’s it. That’s you’re almost answering your own question. Yes, which is great. And yes, so patients with that are either overweight or suffer from obesity or other metabolic diseases that result in significant weight gain may not notice a growing hernia or even a belly button hernia for that matter.
Speaker 1 (00:26:18):
True.
Speaker 2 (00:26:19):
And they may not notice them until they lose a significant portion of weight and that’s when they suddenly show up. So if you have pain in a groin area outside of elite athletes who are using and abusing their groins on a daily basis, if you’re
Speaker 1 (00:26:40):
LeBron James, yeah.
Speaker 2 (00:26:41):
If you’re living your normal life and you’re having chronic pain in your groin, you may well have a hernia that you can’t feel or you can’t see. And sometimes that’s complicated by the fact that if you’re overweight or suffer from obesity, that may be the reason you can’t feel or see it.
Speaker 1 (00:26:57):
Yeah, yeah, exactly. This is a question which isn’t necessarily an obesity question, but I think we can both answer it. Hello doctors. I had laparoscopic bilateral inguinal hernia repair with Mesh top and a non Mesh umbilical hernia repair. My question is twofold. I have developed a bulge under my sternum to about the top of my belly button. There is no pain. One specialist says it’s a diastasis recti. One says it’s definitely not a diastasis. Could the hernia repair have caused this bulging in my upper abdomen and could imaging see this when I lay down? I don’t see it. It’s mainly when I’m standing up.
Speaker 2 (00:27:34):
All right. Well, I’ll tell you what, I’ll answer the first part and then you answer the imaging part. Okay,
Speaker 2 (00:27:40):
So I thought I’m setting you up. Yeah. So to answer your first question, it sounds like you got a good inguinal hernia repair and a good belly button hernia repair and something that’s exactly similar to what I would do. The question I have, which is the same question you have is do you have a diastasis recti? And a diastasis recti for those who may not be familiar is a separation of your AB muscles. Your ab muscles run up and down the middle of your belly and are separated by some connective tissue between them. And a diastasis recti actually has a definition. So when those two muscles are a certain distance apart from that distance on, they’re generally referred to as a diastasis recti. And at some point that diastasis recti can sort of transition into being what we would consider a true hernia. So while without seeing any imaging studies or seeing you, you certainly could have a diastasis recti and it sounds as you’re describing it very much like that could be possible.
Speaker 2 (00:28:42):
That tends to be where they often occur as well. Now to answer your second part of your question is that’s something that could have either been repaired at the time or is it something that could be repaired at all? I think the answer to that would be yes, it’s my practice in patients who I examine have a significant diastasis recti but also a belly button hernia that I fixed both of those at the same time in an effort to try to lower the risk of recurrence at the belly button hernia primarily. That’s correct. And also to reestablish some better function of their abdominal wall. Yes. Not everyone subscribes to that. Not everyone counsels or discusses that with patients, but I tend to support that based on the literature that I read. And so if that was present at the time of your hernia, could that have been addressed at the time of your belly button hernia and groin hernias? It could have been, but again, it depends your specific situation as far as imaging. I have an answer, but I’m going to let Shirin talk about it.
Speaker 1 (00:29:49):
So I agree with everything you say. I’m willing to bet this is a diastasis and your hernia repair had did not cause it. Yeah, we don’t usually image diastasis recti because the physical exam is pretty diagnostic, but ultrasound or any other image can identify the spacing between the two practice muscles if you want to truly kind of quantify it.
Speaker 2 (00:30:13):
And I don’t use a lot of ultrasound in my office because I am, first of all, not an extra expert. And second of all, our expert ultrasonographer are not always expert ultrasonographer either. And so
Speaker 1 (00:30:29):
True sometimes not for hernias for sure. No,
Speaker 2 (00:30:32):
Not for hernias. And so it’s very user dependent. My point being is that I tend to rely far more on CT scans or CAT scans so that I can measure a distance and equate that to the existence of a diastasis. And to answer this particular person’s question, I don’t necessarily need to have you show me the bulge on a CT scan to be able to determine the diastasis is present. So even though you may lay flat and it goes away, a CT scan will show me the truth.
Speaker 1 (00:31:05):
Yeah, yeah. CTs don’t lie unless a radiologist doesn’t report it. Going back to the exercise question, one of our patients here, she’s got so much nerve pain that she’s not able to be as athletic, as athletic as she could be. I would suspect that the ACH AHSQC dot org website, the exercises are on that are pretty good. They’re not high impact in any way. So whatever extras you can do, you should do. But we like you to focus on core based. Okay. Question for you. We have a lady here, 17 centimeter hernia from a burst appendix. It’s not clear if it’s 17 centimeters wide or long, but she had a burst appendix and now she’s had hernia from that and then multiple Mesh failures and now there’s bowel involved in the repair. So two questions. One is obviously we see this not uncommonly, but if this person needs weight loss surgery, actually, lemme rephrase this. If this patient is morbidly obese, that may be a reason why they’ve had multiple failures, is it? Isn’t that right?
Speaker 2 (00:32:23):
Sure. And so first of all, to this person, I would say kudos to you for knowing a dimension of your hernia. And in centimeters, which is like
Speaker 1 (00:32:32):
Yeah, exactly. Centimeters, right?
Speaker 2 (00:32:34):
Yeah, right,
Speaker 1 (00:32:35):
Exactly.
Speaker 2 (00:32:36):
That shows some fundamental, I
Speaker 1 (00:32:38):
Like it. Yes.
Speaker 2 (00:32:40):
But if you have had multiple abdominal operations related to a hernia repair and or complications associated with a hernia repair, being overweight or clinical severe obesity may play a significant role. And so in patients who present with these types of problems and they come and they say, I I’d like my hernia to go away, and you’re the F fourth person to try this and attempt this.
Speaker 1 (00:33:11):
Yeah.
Speaker 2 (00:33:12):
My first discussion with them is that we are absolutely not even going to talk about your hernia repair today. The first thing we talk about is what we all call sort of prehabilitation, which is a discussion with the patient about all of their medical conditions and how we can take all of their risk factors and lower them to the lowest possible before we then follow up with a hernia evaluation, imaging studies, CAT scans, et cetera. Then finally we talk about various methodologies to either address their hernia or not. And so part of that, yeah, absolutely. Part of that pre-habilitation may include medical or surgical weight loss, which in and of itself is a journey even before getting to the hernia. And so there are both surgical options for weight loss and there are even endoscopic options for short term weight loss, some of which are approved by insurance and some of which are cash pay out of pocket.
Speaker 2 (00:34:17):
But for those who might not be amenable to another operation to lose weight, there are other strategies for that. But all of it is done with the sense of getting them as prepared as possible to undergo a successful hernia repair and hopefully their last hernia repair in the future. I very much equate it to the way I approach hernia. I very much equate it to mopping a floor or mopping a room with one door. And what you do is you start at the far corner and you mop the floor on the way out and then you close the door so nobody walks all over your nice clean floor. Well, hernia repair is very much,
Speaker 1 (00:34:58):
That’s a
Speaker 2 (00:34:59):
Great one. If hernia repair is very much the same way to me in the sense that I want to clean the floor first, which means ensure that you’re in the medically, get your screening colonoscopies and whatever else you might need. And we do all of those things first so that I hopefully am the last one in your belly.
Speaker 1 (00:35:17):
Yeah. So this lady’s B M I is 42, which puts her in the category where she would be eligible for weight loss surgery, but now she’s got a very kind of complicated abdominal wall. Sure. So what is the safest weight loss surgery if you have a hernia like this?
Speaker 2 (00:35:37):
Well, like I said, all surgery carries a risk and all weight loss surgery carries a risk. And so depending on the severity and complexity of your abdominal wall, you may even consider an endoscopic or medication approach to weight loss depending
Speaker 1 (00:35:53):
On is that the obolon balloon thing?
Speaker 2 (00:35:55):
There are various balloons and endoscopic suturing devices. Most of them are for short-term weight loss. Many of them are only approved for six months at a time, so they’re not a great long-term solution. But if the hernia repair was so dangerous or so damaging that you only had six months or eight months to go till you needed it fixed, those are potentials. As far as an operation though, in patients with very complex abdominal a hernias like this, most of the time I only offer them a sleeve gastrectomy as opposed to a gastric bypass. We can often do those operations safely, although at increased risk compared to someone who doesn’t have a big bad hernia. And we talk about that with patients in advance, and their weight loss is often very similar to those who have a sleeve gastrectomy but don’t have a big hernia, at least for the first 12 months or so.
Speaker 1 (00:36:55):
Can you explain why you would choose a sleeve gastrectomy? Why the other options would not be ideal? In someone who’s had a lot of abdominal wall surgery,
Speaker 2 (00:37:06):
So oftentimes anytime you’ve had an operation, you get scar tissue in your belly and that scar tissue sticks to your colon and your small intestine. And in order to do a gastric bypass or other operations like duodenal switch and the like, yeah, we need to have your intestine free so that we can manipulate it, move it, cut it, sew it,
Speaker 1 (00:37:29):
Which
Speaker 2 (00:37:29):
Means that I then have to take down all that scar tissue, which sometimes can take hours and put patients at potential risk for injury to those intestines. And so a sleeve gastrectomy, all I need to do is get in and around them and be able to get up to the stomach and I don’t need to worry about where all the intestines are and I can largely leave the hernia for the most part alone and come back to fight that battle another day.
Speaker 1 (00:37:57):
But just to clarify, I would say many, if not most bariatric surgeons are not comfortable going into a complicated abdominal wall. I have a handful that I can that have that are totally, they’re very gifted surgeons and they’re okay. And someone who has had multiple hernia repairs, large, what do you call it? Loss of domain, huge hernias, very disfiguring hernias, they’re okay entering that abdomen laparoscopically and doing what you said, the sleeve gastrectomy, which only focuses on the stomach, but a lot of surgeons do not allow themselves to do that. They’re afraid to go in. It’s complicated. So I would recommend that if you are in that category where you do need weight loss surgery, it should be done by someone like you or others who are skilled and also understand the abdominal hernia world. They know where the meshes are and how adhesions can occur and
Speaker 2 (00:39:02):
Those
Speaker 1 (00:39:02):
Patients and navigate the abdomen when it’s already been intruded so many times,
Speaker 2 (00:39:06):
Those complex patients that have both issues, so obesity and complex abdominal wall, all whatever you will, they do tend to do best in the hands of folks who have an understanding of both sets of problems. Yes, there are perfectly excellent bariatric surgeons and they probably do even more bariatric operations than I do every day. And there are incredible world class complex abdominal reconstruction people who might do more hernias every day than I do, but the marriage of the two of them works well in those complex patient situations that pay people that have both issues.
Speaker 1 (00:39:45):
Yeah. Interesting question I have for you about inguinal hernias. So as you know in the groin you can get an inguinal hernia. It’s often just fat. It’s often pre peritoneal fat, very not commonly intestine, but in addition, the normal in males, at least in the sperm spermatic cord has fat. It’s a fatty structure. So when we do hernia repairs, we have to make sure we reduce and put away the fat, which is abnormal, which is the hernia part, but we don’t touch the fat that’s associated with the spermatic cord. But when your obese D don’t, doesn’t your spermatic cord become fattier just as a, because your whole body has larger fat cells. And then how do you know if someone has just a fatty spermatic cord or a true hernia?
Speaker 2 (00:40:39):
Right. Well, what we find in patients who have either lost weight or simply suffer from clinically severe obesity or are overweight is they have a higher predisposition for something called a lipoma, which is a little benign fatty tissue mass, and it lives along your spermatic cord and can pop in and out of your hernia and cause problems just the same way a piece of intestine would cause problems and discomfort. We do see those at increased rates in patients with higher body mass indexes or higher weights, and we do often either completely remove those or at least reduce them and take them out of the hernia altogether because they can be problematic in the future. As far as whether or not their spermatic cord is a little fattier that that’s actually very patient specific. There are plenty of men who have very normal appearing spermatic cords but clinically severe obesity and yet have tons of fat in their groin and in their pre peritoneal space, whereas other patients have fat distribution that’s different. So I can’t say it’s a universal truth, but I can say that patients with clinically severe obesity do tend to have higher rates of these lipomas or fatty tissue masses that we do have to resect.
Speaker 1 (00:42:00):
Yeah, no, I agree. And just for clarification of this question, because they’re asking about different types of fat. So there’s the fat that belongs around your spermatic cord, we don’t touch that. There’s the fat that starts from the retroperitoneal space or behind the hernia goes through the hernia, and then further down towards the testicle that is the herniated fat that we remove. It’s often retroperitoneal fat, and then there’s a separate entity of an actual true lipoma that’s only in decor and not really communicating with anything right. Higher up. That’s very uncommon that fat usually is not a true lipoma, but it’s a retroperitoneal fat that we still call cord lipoma. So just want to clarify that surgically we can tell the difference on MRI. It’s not as easy to tell
Speaker 2 (00:42:47):
The difference. No, it’s not. But ultimately with preoperative imaging, it probably matters less what type of fat it is or even where it is, but that it is, and knowing that it’s there in advance will help you counsel patients about the fact that you’re going to either remove or reduce it in some way.
Speaker 1 (00:43:08):
Yeah. Question about whether it’s possible to get a hernia repair without losing weight. You kind of answered that most likely that would occur with inguinal hernias. What are the current guidelines as to who should get weight loss surgery for eventual hernia repair?
Speaker 2 (00:43:33):
So the way I approach this is that short of a patient in an emergency room, in a dire situation, who needs a hernia repair, a belly button or a ventral hernia repair because of pending evil in patients who have an option for an elective repair, which is most patients nowadays. Yes. We use the same guidelines that I highlighted at the beginning of our talk today with regard to bariatric surgery as a guideline for counseling. These patients who present with a hernia and may have never even heard of or even are familiar with bariatric surgery. So if you show up in my office where the body mass index of 40 and a ventral hernia repair, I’m going to talk to you about weight loss, weight loss o operations as an option, and either at the time a hernia repair or subsequently some period of time after weight loss surgery about a hernia repair.
Speaker 2 (00:44:33):
Doesn’t mean you have to do a surgical weight loss operation, but you’re going to at least hear about it and learn about it and have that presented because many patients, their primary care doctors are afraid to talk to them about weight. Many of their hernia surgeons just want to make the pain go away. So they want to fix the hernia when in fact that might not be in the patient’s immediate best interest because of their weight. And so counseling patients about their weight and helping them with their weight loss, not just helps their hernia eventually, but also helps them with their overall quality and quantity of life. I mean, a hernia is great and I love to patch a hernia, but it sure is great if a patient shows up with a hernia and they leave my office and six months later don’t have diabetes anymore. Right. Yeah. So it can be a win on many levels as long as we’re counseling patients about the utility of these other operations that can help them with their quality quantity of life and ultimately the hernia repair.
Speaker 1 (00:45:34):
So the lady with the B M I 42 5 4, her incisional hernia started at nine inches. Now it’s 17 inches, sorry, nine, nine centimeters now 17 centimeters wide, multiple failures. One surgeon is recommending weight loss surgery and the hernia surgeon wants to, or maybe the plastic surgeon wants to use her leg muscle to help with the hernia repair. What are your initial thoughts about that?
Speaker 2 (00:46:06):
Sure. So sort of like I highlighted before, there may be lots of ways, or maybe even only a few ways of reconstructing abdominal wall after multiple failures. And it’s good to get multiple opinions on ways to reconstruct that abdominal wall,
Speaker 2 (00:46:21):
But if your body mass index and your weight have been a lifelong problem, which it is for many of these people, and you can solve that problem or at least make it dramatically better, at the same time lowering your risk for a hernia repair, and therefore you’re not obviously concerned about or afraid of operation, I don’t see why you wouldn’t do it that way. I wouldn’t see why you wouldn’t put the surgical weight loss operation first. Lose weight, lower your risk, seek whatever counsel you needed to regarding various options for reconstruction of the abdominal wall, get the appropriate imaging eventually after weight loss, and then shut the door to your mopped to your mopped room. Right? Yeah. Make that the last operation you have.
Speaker 1 (00:47:10):
That’s very key. The last operation. Absolutely. Yeah. So how often do you see someone like her where currently with a BMI of 42, her hernia is 17 centimeters wide and then they get a hundred pounds weight loss? Well, maybe not a hundred pounds, she’s she’s 185. So let’s say she gets 80 pound weight loss. Don’t you expect that defect to be smaller and therefore the hernia repair less complicated?
Speaker 2 (00:47:39):
So defect, the hernia defect may, depending on where they carry their weight, it may get a little smaller, but even if the hernia defect remains the same size, more often than not, there’s more space inside the belly making it a little easier to close and fix. Oh, okay. Some patients even experience a hernia that gets bigger as they lose weight because like we talked about earlier, sometimes more stuff comes through the hernia while they’re losing all that weight because they’re losing fat. But that doesn’t mean the hernia hole got any bigger. It just means what’s coming through. It might be more. And those are all things we sort of counsel patients in advance to expect. So they don’t say, Hey, my hernia’s bigger six months after my sleeve gastrectomy. Why is it bigger? All of a sudden you wouldn’t
Speaker 1 (00:48:29):
Get better. That wasn’t the
Speaker 2 (00:48:30):
Plan. That wasn’t the plan. And so counseling them about that in advance is helpful. And then some of those patients can’t wait sometimes a year to a year and a half to get a hernia repair. Some of them need it after six or eight months after a sleeve gastrectomy, and that’s okay. Yeah. But we sort of make that decision on the case by case basis.
Speaker 1 (00:48:55):
Yeah. Okay, cool. And then going to your patient who’s morbidly obese but presents to the emergency room definitely needs emergency surgery, whether it’s bowels involved or whatever. Sure. Do you do a definitive surgery at that time or do you do something complete opposite, something very temporary, or do you do something in between? How do you repair those patients? Because you don’t want to burn any bridges for a more definitive repair when they’re in better shape.
Speaker 2 (00:49:23):
Right, exactly. I agree with that completely. And so in patients who need an emergent operation and obviously off they go to the operating room, some of the plan to repair them depends on not only the hernia characteristics but the patient characteristics. So in a patient whose body mass index is 42 and may have some diabetes, may be a smoker, may have other underlying medical problems, my goal is only to take care of the emergency to do whatever needs done with regard to the emergency and sew up their belly with some stitches and call it a day we’ll fight the hernia should it occur at some point in the future. Now, for those hernias that are quite large or are not easily managed by just sewing them up, they may need some type of a temporary closure and subsequent repair when the patients are in little less extremists. But more often than not, my approach is to manage the emergency, like you said, first and foremost, repair them primarily with stitches and not do anything terribly fancy. Yes. And then come back to fight the hernia another day.
Speaker 1 (00:50:40):
Do you ever use a absorbable VL Mesh or something just to bridge?
Speaker 2 (00:50:45):
There are times when we’ll use a bioabsorbable synthetic Mesh, but those are in patients that have sort of suffered some abdominal wall catastrophe or some GI tracted catastrophe where we may have their belly open for some period of time and we expect the hernia and we plan for the hernia, and then we deal with it many moons later. But for the routine patient who shows up with some intestine stuck in their belly button, then we just manage the intestine as is necessary, close up their hernia and live to fight another day
Speaker 1 (00:51:21):
Because they tear through that tissue repair.
Speaker 2 (00:51:27):
They certainly can, and some folks would advocate even at that time for doing a definitive permanent Mesh repair even. And there are some data to say that that may be okay depending on where you put the Mesh, but more often than not, I would much rather re-operate electively for a hernia recurrence, then operate out of necessity for a issue associated with Mesh or an issue associated with a recurrence of a hernia with a problematic Mesh. And so that’s sort of my approach to it.
Speaker 1 (00:52:06):
Got it. One of our surgical colleagues, international colleagues, asked a question, should the hernia defect be closed at the same time as bariatric surgery or the hernia repair be postponed? I know we discussed this earlier. So the short answer is if it’s small, sure. If it’s big, don’t do anything. Do you ever reduce the content? Some people say, don’t touch the contents, just leave it there. It’s a plug. By removing the content, you’re actually exposing the hernia to more problems. Do you believe in that?
Speaker 2 (00:52:44):
Well, I think, and I think we’re talking primarily about ventral hernias at this point, yes.
Speaker 1 (00:52:49):
It’s
Speaker 2 (00:52:49):
Obviously for bariatrics, for sleep, we’d leave inguinal alone. But for ventral hernias, if it’s a hernia defect, especially a smaller one where I, for whatever reason need to reduce the content, either because I can’t get to the stomach without it or because I intend to do a gastric bypass where I need to be able to manipulate the intestine, then yes, I will put some type of a suture repair on that hernia defect. Because as we discussed earlier, as these patients lose a lot of weight, they tend to, and their hernia defect remains open. They tend to sometimes herniate contents. And then now they’ve taken, they’ve gone from a perfectly fine bariatric operation to now an urgent situation with regard to the hernia. On the other hand, if I’m going in for a sleeve gastrectomy and they have some fat stuck up on a hernia that is nowhere near my operative field, then I just pretty much leave it alone. Leave
Speaker 1 (00:53:48):
It alone. Yep. Okay. And are you obliged to patch or at least temporarily patch the area if it’s not amenable to repair at the same time as your bariatric surgery or
Speaker 2 (00:54:01):
If it’s large enough that it would require some type of a Mesh? In other words, I could not close it with stitches alone. And then more often than not, I will simply leave that hernia alone in the first place. And oftentimes because of pre-op imaging, know that in advance and help the patient select a weight loss operation that will allow me to leave that hernia alone.
Speaker 1 (00:54:24):
Got
Speaker 2 (00:54:24):
It. Until some point in the future. So a lot of that is all part of the pre-op discussion.
Speaker 1 (00:54:29):
And the other question is, when you talk about small hernias, what size range are you thinking of?
Speaker 2 (00:54:33):
Yeah, that’s always,
Speaker 1 (00:54:36):
It’s small.
Speaker 2 (00:54:37):
It’s always a craft shoot. So if it’s a hernia defect that ranges in size, that’s sort of amenable to primary defect closure. So we’ve closed defects as large as four or even five centimeters. But beyond that, it can be difficult sometimes to close them. Primarily they may rip back open again. They may have issues associated with the sutures. So I sort of cut it off somewhere around the four to five centimeter mark, give or take.
Speaker 1 (00:55:14):
Okay, great. And then one other question is, can bariatric surgery cause a hernia?
Speaker 2 (00:55:22):
Yeah, sure. So that’s a good question. And probably the most straightforward one of the night I can simply say, yes, that’s nice.
Speaker 1 (00:55:31):
We like to give you some easy questions.
Speaker 2 (00:55:34):
Yay. Throw me a bone. That’s good. No, but any operation, whether done via an open approach or even a laparoscopic or as I do them robotically, makes an incision. And so anytime there’s an incision, there’s a risk for a hernia, albeit extremely low when we do it robotically or laparoscopically, not zero, it may even be less than one or 2%, but it’s still not zero. And so should that occur, those hernias are often noted because patients are symptomatic from them and they want them fixed and then can have them fixed at some point in the future. So it’s a low risk, but it’s not zero.
Speaker 1 (00:56:17):
Yeah. I mean, when I was training, we were doing open surgery, laparoscopic was just coming through. Does anyone even do open surgery anymore for bariatrics?
Speaker 2 (00:56:25):
I, I think in the fellowships and in our fellowship here, reportedly for certain surgical organizations, you have to have done at least five open, say gastric bypasses or open bariatric operations. Yes. The majority of those operations are done as a result of some type of a complication. And that’s how the current trainees tend to get their open bariatric number through some re-operation for complication. Because primarily primary bariatric operations are all done
Speaker 1 (00:56:59):
Via minimal. Yeah. Yeah. We were doing a lot of gastric bypasses and that was just coming through. This was late nineties. Yeah. Basically why
Speaker 2 (00:57:08):
You be dating yourself, don’t be dating yourself.
Speaker 1 (00:57:10):
I’m okay with that. Late nineties, early two thousands. No, so that’s a good, so I operate with one of my former residents who’s a bariatric surgeon. So the operation, I asked him to come in because patient of mine, I did, I was like the hernia surgeon. But as you know, hernia surgery can mean a lot of things. So she had fistulas and Mesh infections and multiple fistulas. And so she had gastroparesis, which means her stomach wasn’t working and she had a partial gastrectomy. So part of her stomach was removed a little bit more than half. And then she got a fistula from that. So she needed basically a near total gastrectomy, like a, well look, a gastric bypass. Okay. Right. So small gastric pouch. And I said, why don’t you come in and operate? Do this with me. You do it all. This is your thing.
Speaker 1 (00:58:04):
So it was great. It was very difficult. Dissection took forever bite. When we got to the stomach, then I’m like, okay, well go ahead. Like transect the stomach down. And he kind of looked at me, I looked at the stomach and looked at me, didn’t say anything. And I said, you’ve never done an open, you’ve never done an open gastric bypass, have you? And he kind of looked at me. If this were laparoscopic, I would know how to staple a across. But open stapling across is a totally different approach. Right. You’re going from the top, not this way. Yeah. I said, let me show you how it’s done.
Speaker 2 (00:58:37):
There you go.
Speaker 1 (00:58:38):
This is how we do it. Go. But you know, kind of need to have a little bit of that training every so often.
Speaker 2 (00:58:46):
Yeah, no, that’s absolutely true. And that’s why it’s a required part of our current fellowship model and current training. But they are harder to come by for sure.
Speaker 1 (00:58:55):
Yes. Yes. Very much. On that note, I shared a lot of things that date me, I must say. I do enjoy seeing you. We haven’t had a bonafide conference or meeting in forever.
Speaker 2 (00:59:09):
Oh,
Speaker 1 (00:59:09):
It’s been too long. And we used to hang out and
Speaker 2 (00:59:13):
I know
Speaker 1 (00:59:14):
And do things,
Speaker 2 (00:59:15):
But I’m looking forward to it. Looking
Speaker 1 (00:59:17):
Forward to it. Maybe sages, huh?
Speaker 2 (00:59:19):
I’m going to sages you going.
Speaker 1 (00:59:20):
I’ll be be there. Yeah. Vegas. It’s like Vegas.
Speaker 2 (00:59:23):
It’s
Speaker 1 (00:59:24):
Next door to me.
Speaker 2 (00:59:25):
I’ve been too long.
Speaker 1 (00:59:27):
Vegas may be dangerous. Yeah,
Speaker 2 (00:59:29):
Sure. When is it not?
Speaker 1 (00:59:32):
All right. On that note, I’m good. Thank you for your time, Dr. Bittner. This is Shirin. Thank you everyone for joining us and for your questions. I’ll make sure this is posted on YouTube so you can watch and share with your friends. I do. Thank you, Dr. Bittner, for your time away from family to do this hernia talk and educating everyone. And obviously you’re available in Connecticut. If anyone, we don’t really have anyone in Connecticut that I could refer to before for hernias, but I’m glad you’re there now. So now we do. Thank you.
Speaker 2 (01:00:04):
Thank you for having me. Okay. I appreciate it. And good questions, everybody.
Speaker 1 (01:00:08):
Thank you. See you soon. Bye-bye.
Speaker 2 (01:00:10):
Goodnight.
