In the latest installment of our occasional conversations with Fort Worth newsmakers, Dr. Paul Gray, a surgeon at Texas Health Harris Methodist Hospital Fort Worth, discusses hernias — what they are, where they come from and how to fix them.
This conversation has been edited for length and clarity. For the unabridged version, please listen to the audio file attached to this article.
Alexis Allison: So Dr. Gray, June is National Hernia Awareness Month. Can we just start with a basic question: What is a hernia?
Dr. Paul Gray: Absolutely. It’s a good question. Fundamentally, a hernia is a hole. It’s a hole in the abdominal wall that allows something that normally should live on the inside to then push out through that hole and be on the outside.
Think of your abdomen like a barrel. All right, the top of the barrel is your diaphragm. The bottom of the barrel is your pelvic floor. And then you’ve got some muscles and your spine that wrap around as the walls of the barrel. And there are some holes that are supposed to exist in that. So, there’s one in the diaphragm where your esophagus travels through that. There are a couple of holes in the pelvic floor so that you can go to the bathroom. But those should be the only holes. And so, if you develop holes elsewhere, it allows things just from pressure inside of your abdomen to begin to push out through them.
So, yeah, we see different types of hernias. One of the more common ones you’ll hear about is a groin hernia, also known as an inguinal hernia, that is related to some natural weakness of the abdominal wall in that location. In men, it’s related to where the testicle actually travels through the abdominal wall during embryologic development, and goes down into the scrotum and brings its blood supply behind it. Where it goes through the abdominal wall, it can be weak there.
It’s also an area of weakness in women. Some women can get that as well. It’s related to the development of the uterus and some of the ligaments that support that. We can also see holes sometimes, for instance, if the umbilicus, or the belly button, when you’re being formed, our abdominal wall really coalesces around the umbilical cord to form and so that area can be weak and some kids are born with a hole there. But it’s an area of weakness for all of us. So as we grow, and particularly if our bellies grow a little bit, it can stretch out and get a hole there as well. And so there’s always pressure inside of our abdomen pushing and if there’s an opening somewhere it begins to push out.
Allison: You mentioned weakness in the abdominal wall and then pressure. What is causing these hernias to form?
Gray: Yeah. So there’s, broadly speaking, two types of hernias to think about. One is what we call primary hernias. These are hernias that develop just because of those innate weaknesses of the abdominal wall. And really it’s embryology. It’s how we’re being formed. And so the (belly button) is a big one: About 10% of hernias are actually umbilical hernias. And the groin is the other big area of weakness. Up to 27% of guys will get an inguinal hernia over their lifetime. There are a couple of other places that we can get (hernias), but those are the key ones. So you’ve got an area of potential weakness, and then there’s pressure.
So think of a tube of toothpaste. All right, if you’re squeezing hard on a tube of toothpaste, you’re increasing pressure inside of that. If there’s a hole somewhere in that tube, it’s just going to squirt out through that. So there’s always going to be pressure inside of our abdomen, that’s just the way we’re designed. Every time you take a deep breath, every time you cough, go to the bathroom, get up and move around. As those muscles tighten, they pull inwards and increase pressure. And so that’s going to push on any potential areas of weakness.
The other broad category of hernia that we can get is what we call incisional hernias. If you have an operation on the abdomen, we have to make an incision somewhere on the abdominal wall to get inside and do something inside of someone’s abdomen. At the end of the procedure, we generally will sew that back up and ideally that heals back together. But now we’ve created a weakness because of making that incision. And if that were to open up later in the future, well, anywhere we make an incision can develop into a hernia in the future, really from the same mechanism of pressure pushing on an area of weakness.
Allison: Let’s say a hernia has developed. What’s the big deal? How does it affect the body?
Gray: Yeah, well, the most common thing you’re going to notice is pain. That is by far and away the most common thing we see with patients with a hernia because they hurt. There are nerves in the abdominal wall, and the abdominal wall is a dynamic structure. It’s a muscle and so as you’re moving about, things are pulling and twisting. And if you’ve got something pinching through that area, it can cause pain.
There are some potentially more dangerous, life-threatening complications that can occur. It is not uncommon for bowel intestines to push out through a hernia hole. And we see that a lot. Most of the time, it just causes pain. It doesn’t necessarily cause a threat to you. However, it can if the intestines were to get pushed out through that opening, and then they get caught and it gets tight. So think of a noose tightening around that intestine that’s pushed out.
You can have a bowel obstruction, where the normal flow of food gets stopped going through that area and it can’t go downstream. That’s life-threatening. If it’s so tight that the blood supply to that bowel is now being strangled off, the bowel can die. So those are the scary things that we worry about with hernias. Thankfully, they’re not common — probably about a 3% risk of that happening, certainly with a groin hernia. Incisional hernias, it kind of depends, you know. It really depends on how big they are, what is the shape of those hernias, the size of the hole, and how much stuff is pushed out through that.
Allison: As a surgeon, you specialize in hernia repair. So I’m wondering what that means and what treatment can look like.
Gray: So, when we try to take care of a hernia and make that better, what we’re really trying to do is restore anatomy. So we want to get it back to where it was supposed to be. Anything that’s been pushed out through that opening in the abdominal wall, we want to get it back inside where it belongs. And then we want to close the hole. We want to restore the anatomy of the abdominal wall so that you get rid of the hole.
And a lot of the time, let’s say the vast majority of the time, we are talking about using mesh in order to reinforce that area. So the weaknesses that led to the hernia in the first place are typically still present. And now we’ve taken a hole and sewn it together. And so, we’ve kind of created new tension in that area. The chances of that coming back is very real. And by having a mesh reinforcement in that area, we can try to prevent that from coming back.
I think that’s a key thing for just the average person to remember: This is not like going in to get your carburetor fixed or something on your car. We try to restore that. We want to bring it back to where it was, but we never do it as good as it was originally. And so there’s always that potential of developing a recurrent hernia — it’s something we want to keep an eye on going forward to try to prevent these things from coming back.
Allison: Can people prevent hernias? Are there best practices?
Gray: Absolutely. Probably the most powerful thing to do to prevent hernias is to lose weight. Obesity is by far and away the most common problem that we have, both in the developing of hernias to begin with, as well as having recurrent hernias after we try to fix that. The larger we are, the more pressure there is in the abdomen, and the more stress there is on the abdominal wall.
Most of us can relate to an experience where you’ve overpacked your suitcase and you got to sit on the thing and try to zip it to get it closed. And by the time you’re done, that zipper looks like it’s about to pop. It’s a similar mechanism that can happen with hernia repairs. The bigger we are, the more stuff there is to be inside of the abdomen, the more pressure there is pushing on it, the more stretched out the abdominal wall is. So weight loss is huge. So just trying to live a healthy lifestyle, trying to maintain a healthy body weight alone will remove yourself from a large portion of these even incisional hernias.
Regarding incisions: Minimally invasive surgery can be really helpful. Frankly, the smaller the holes that we make on abdominal walls for surgery, the lower the risk of getting a hernia afterwards. So anytime an operation can be completed on the abdomen, using a laparoscopic or robotic laparoscopic approach, it’s smaller incisions, smaller risk of getting a hernia later on compared to a great big incision.
Allison: OK, say someone is listening to this and they think they might have a hernia. First of all, can you tell us what a hernia might feel like? And then, what would you advise them to do if they think they have one?
Gray: Sure. Pain is always going to be the most common — some sort of focal, localized pain on the abdominal wall. For an umbilical hernia, it’s often going to be at the belly button. Groin hernia is going to be in the groin typically, although that can radiate down for a man into the scrotum or for a woman up into the inner thigh and the labia.
Oftentimes there will be a bulge, and so you’ll see some lump pushing out through an area that’s discrete. In fact, even if you feel it, sometimes it’ll go away. Like if you lay down flat, because the pressure goes down in your belly when you lay flat and relax, sometimes it goes back inside and the lump will go away. If you’re noticing this and you’re thinking you might have a hernia, really the first place to start is just your primary care doctor. Get in touch with your doctor and get an exam.
This is something that most people can pick up very well on a physical exam and then they can try to get you on to someone who can help you repair it. If you have a lump that has become very acutely painful, really hurts, it’s swollen, it won’t go back in, you’re nauseated, you’re throwing up. You can’t go to the bathroom from down below, or your belly is becoming distended? Well, that’s life-threatening now. And really, at that point, yeah, call your doctor, but probably the next step is to get you to an emergency room to be evaluated urgently to make sure that we can take care of this before bigger problems occur.
Allison: Is there anything else that you’d like to add?
Gray: Well, I think just as an encouragement that, you know, these can be really challenging. And frankly, the bigger the hole, the bigger the hernia, the more complex it is to try to fix it effectively.
Every general surgeon is trained to take care of hernias. And certainly for the smaller, more simple hernias, you can get a great operation done at any time. One encouragement I would give to folks who have complex, big, difficult hernias, there’s a high chance they’ve probably been seen by a surgeon (and) maybe told that they can’t get it fixed. I would just encourage you: There are ways to do this. There are ways that we can reconstruct the abdominal wall, put that back together, there is hope for it.
It is really important that we, in any hernia, that we do it right because recurrent hernias become harder to fix the next time. And so we want to be really careful that the next hernia operation is the last hernia operation and we don’t have to do any further ones. But there’s a great chance of getting someone back to a good, functional recovery. That requires a lot of work. It’s going to require preparation for surgery. It may require weight loss and other things to try to help get someone ready for a successful operation. And it is going to take some effort afterwards to recover well, but it can be done and really, people can get back to a good, functional life.
Alexis Allison is the health reporter at the Fort Worth Report. Her position is supported by a grant from Texas Health Resources. Contact her by email or via Twitter. At the Fort Worth Report, news decisions are made independently of our board members and financial supporters. Read more about our editorial independence policy here.