As a Laparoscopic General Surgeon, I am able to care for complex intestinal problems— diverticulitis, colon cancer, Crohn's disease, gastroesophageal reflux (GERD)—with a television camera and tiny scars, but perhaps one of the most common patient issues that faces me every day is a hernia.
What is a Hernia?
As a Laparoscopic General Surgeon, I am able to care for complex intestinal problems— diverticulitis, colon cancer, Crohn's disease, gastroesophageal reflux (GERD)—with a television camera and tiny scars, but perhaps one of the most common patient issues that faces me every day is a hernia. What is a hernia? Do all hernias need to be fixed? Can and should hernias be repaired laparoscopically? What is mesh made of, and is it safe to deploy in the human body? These are just a few of the questions that as doctors, we must explain to our patients.
Because we could write volumes on the topic of hernias, I will limit todayʼs discussion to the definition and development of a hernia, and leave the issues of surgical treatment to a subsequent article. At this point, before I answer any of the above questions, I should digress and elucidate for you the origins of the words “doctor” and “patient.”
I must confess that my route to becoming a surgeon was via several years of ancient Greek and Latin studies at Phillips Academy and as an English Literature major at Princeton University, prior to attending Vanderbilt University School of Medicine. Subsequently, I trained at Mount Sinai Hospital, NY in General Surgery and attended the Massachusetts General Hospital for a research fellowship in cardiovascular surgery. I was not your usual biochemistry major: rather, I took a more humanistic approach to the practice of medicine and surgery. Linguistically speaking, the two words are derived closely from Latin. The first, “doctor,” is from “doceo, docere, doctus,” meaning “to teach,” while the latter stems from the verb “pateo, patere, passus (sum)”—“to suffer.” So, in essence, a doctor is one who teaches, and a patient is one who suffers. Now that we have our definitions, I can teach you, as I would to a patient sitting across the desk from me in my office, what a hernia is and why someone may be suffering from this ailment. Simply stated, a hernia is a hole or weakness in the musculature of the abdomen, allowing either fat or an organ to protrude, to travel from inside one space to another space. I will even go so far as to say that many hernias are really just normally occurring holes that Hashem created in our bodies, but that the holes have become too wide or too large, and are now allowing other entities to process through such an enlarged orifice.
Why did Hashem make these holes in our body? Was it a mistake or an error, an oversight during creation? Hardly. These holes allow conduits or tubes (remember, a surgeon is merely a plumber of sorts)—arteries, veins, bowels, nerves—to traverse from one part of the body to another. For example, if we did not have a hole in our diaphragm muscle, then the esophagus would never connect to the stomach, and we would be unable to eat by swallowing our food. If the hole through which the esophagus travels becomes wide over time, then the stomach can migrate up above the diaphragm into the chest, causing, in many cases, food regurgitation, heartburn (acid reflux), chest pain, bad breath, and many other symptoms. So, what is an inguinal hernia? When we are in the womb, men and women undergo development of their respective gonads. In a male, the testicle is originally part of the lower aspect of the kidney: it breaks away, takes along with it its artery and veins, and on the way, joins up with the vas deferens (aka, the spermatic cord). This complex then pushes its way through the abdominal muscle in the groin (“inguinal” canal), and takes every layer of the abdominal wall along with it to create the protective housing called the scrotum (if you look at the scrotum under a microscope, it has the same six layers of the abdominal wall). Now, if the abdominal wall at around the time of birth does not close snugly or completely around the testicle triad of tubes, there may be a gap alongside these structures, and there we have the origin of what we call an inguinal hernia. Over one’s lifetime—even in the early months of life—intraabdominal organs (bowels, aka “kishkes,” the bladder, the appendix, etc) may protrude through this canal and cause a bulge or swelling in the groin or scrotum, either with or without symptoms, ranging from discomfort or pain, to constipation, to even bladder issues.
Women are not immune from developing groin hernias, too, since the suspensory ligaments of the uterus (the “round ligament,” as it is called) carry the similar developmental openings in the groin area of the abdominal wall. We even see hernias in the upper thigh, called femoral hernias (this varietal fun more common in women), which travel in the space under the groin (“inguinal”) ligament medially to the iliofemoral “groin” blood vessels. Remember that if there were no window in the muscle in this region for those blood vessels, we would never be able to get blood from the abdominal aorta all the way to the legs, feet and toes!
There are many other such hernias—epigastric, lumbar, obturator, Spigelian, just to name a few— as well as the other very common one, called an “umbilical hernia,” a result of the weak abdominal tissue where we were attached until birth to our mothers. Many individuals present with multiple hernias—weak tissue in several different areas, and there are some who develop, or acquire, hernias more acutely—such as a diaphragmatic hernia from trauma, as in a car accident or a very bad fall. Muscles can rupture from trauma and cause protrusions. People who have had prior abdominal surgery may end up with a breakdown of the abdominal closure, even many years later: we call these incisional hernias, whether they be from an old appendix scar, an open colon or stomach surgery, or even a laparoscopic incision.
A bulge in the musculature of the upper abdominal wall that many people have when they do a sit-up may not even be a hernia at all, but rather a “rectus diastasis,” from the Greco-Latin roots, “dia-apart” and “sto-to stand”: in other words, the two abs (“six pack” muscles) are separated in the middle by a weak central tendon. Plastic surgeons may fix this, called a “tummy tuck,” but it is not a “hernia” per se—just an unsightly and perhaps demoralizing body habitus. As hernias go, most bulges without any symptoms are not surgical emergencies: however, a painful or even red lump or bulge on the abdominal wall that does not recede or get better when you are supine (lie down) should make you seek medical attention, as this may represent a hernia that is stuck (“incarcerated”) or contains choked tissue (“stangulated”): a true surgical emergency. Indeed, albeit a long lesson on hernias, we have scratched only the surface.
In the next installment, we will consider the other questions posed above: the science behind the methods of hernia repairs; the use and safety of mesh; and the expected outcomes, including postoperative care. Wishing a Shana Tovah and good health to all.
Dr. Anthony Vine is a laparoscopic surgeon in NYC. He attended Phillips Academy, Princeton University and Vanderbilt Medical School, with surgical residencies at Mount Sinai Hospital (NYC) and Massachusetts General Hospital (Boston). His expertise includes: GERD and other esophageal diseases (achalasia, cancer), hernia surgery, colon surgery (cancer, diverticulitis) and inflammatory bowel disease (Crohn’s, ulcerative colitis). In addition to being one of New York Magazine’s “Best Doctors” and a long-standing Castle Connolly “Top Doctor,” he continues to play violin both professionally and as an amateur, having performed at the Verbier Festival (Switzerland) and with the Roosevelt Island concert series