Donald Dilworth, MD, FACS, Medical Director at Baptist Health System Hernia Center, San Antonio talks about change in hernia surgery and how these changes could be better for patients.
Interview conducted by Ivanhoe Broadcast News in May 2019.
Tell us what’s really happening with hernia surgery?
DILWORTH: So when we think of hernias, we think of the abdominal wall. It’s a break in the abdominal wall. Now, we have some natural breaks in the abdominal wall that have to occur. But when something else that’s not supposed to go through there goes through that area, that’s what creates a hernia.
That something else could be?
DILWORTH: It could be intestines. It could be fat. It can just be that the space is opening up enough that it’s allowing an organ through. We have some hernias that have spleens in them, livers in them, things like that. Typically, it’s either intestines or fat.
Are they passing through a hole and going into something? Or what’s happening after they pass through?
DILWORTH: Yes, they’re passing through a hole and essentially going into the opening that was created by the defect in the muscle. It’s usually a hernia sack that’s still lined by peritoneum which is the lining of our body cavity. And so usually there’s a sack that contains this, but once something gets in there like intestines, it can get twisted and essentially create a surgical emergency where the intestine can be dying off.
And the initial cause of a hernia?
DILWORTH: Usually it’s increased abdominal pressure from many sources. One of the biggest problems in South Texas is allergies, people with chronic coughs. People that smoke tend to have higher risk for hernias, and people suffering from obesity.
So not just lifting heavy things and doing situps?
DILWORTH: Correct. Lifting does increase the risk because you increase your abdominal pressure when you are lifting things, as well as you know abdominal exercises typically strengthen the abdominal wall and that’s what we do after hernia repairs to try to prevent further hernias from happening. But sometimes it’s not always the activities that people are doing or they’re doing correctly. Lifting inappropriately might put you in more of a risk because the muscles are twisted in an unusual manner which allows a potential opening to occur, allowing something to come through it.
So I’m hearing from you that people need to take hernias fairly seriously?
DILWORTH: Yes, they are fairly serious. There are some hernias that we don’t have to be repaired, very small ones like of the diaphragm that are small and they don’t necessarily need to be repaired if people don’t have any symptoms because there’s very little risk of a problem there. The smaller they are the more risk they might be for getting intestines stuck in them. When they’re large, the intestine can come in and out of them and it may not actually be necessarily an emergency to repair those. Some of those people we try to have them lose weight and put them in better shape before we actually go and repair those hernias.
What would complications of hernia surgery itself be?
DILWORTH: Infection. Nowadays for the majority of hernias that we fix we use meshes. And there is a remote risk for mesh infection.
What does the mesh do?
DILWORTH: What the mesh does is we put it into sort of the deepest area possible so then we repair the muscle on top of the mesh. What it does is it actually distributes the pressure, the abdominal pressure, along the abdominal wall better, along that mesh, so that it doesn’t have one specific area where there’s a weak spot that it’s pointing at. It helps support, ultimately, the repairing the muscle wall that we do.
As you’re doing the robotic surgery and you’re sitting down at that computer console, could you walk us through what’s happening with your hands, with your feet, and with your brain.
DILWORTH: Yeah it’s very interesting. But just after a few cases you automatically get used to the fact that you’re there and even though you’re in a different location your mind is still essentially on the surgical field. And every move that you make with your hand, the robot makes the same move. So it doesn’t do anything that you don’t tell it to do. And that’s why it gives us the ability, essentially, to do the same thing we would have otherwise done laparoscopically and then sometimes would have done open.
So geographically how far away from the patient are you?
DILWORTH: Most of the time because you’re in the same room, you’re probably 12 to 15 feet away.
But you said your mind is just right there like you’re standing over the patient?
DILWORTH: Yes. And you actually have a microphone within the robot console so you’re communicating with your surgical team all the time because sometimes you need to change instruments and things like that. Earlier today we had to change a patient position and so we had to communicate with the anesthesiologist to have them change the bed position.
Is it easier for you because you have more control over getting things done yourself? You have more control with this computer console than you would, say, in laparoscopic or open?
DILWORTH: I’m not sure that you have necessarily more control but there is some better visualization. The cameras are better. You don’t get any feedback from the robot so you don’t have any tactile feedback which is one element of control. So you do lose that, but you do have the ability yourself to manipulate multiple instruments around the field, including switching instruments because you can only work with three at a time. But you can move the fourth one if you need it into the location that you need to put it at.
The first time that you sat down and did this robotic hernia surgery, how different did that feel to you from say even laparoscopic?
DILWORTH: Well all of us that go through this I think grew up in the laparoscopic generation, which when I was training we were doing laparoscopic gallbladders all the time. I think for the people that grew up in that generation it’s just another new step. It’s a new toy. It’s a different console. It’s not quite going from Atari or Pong to you know the active games that they have nowadays with 15 different buttons that you have to push. It’s not quite that big of a leap because we were already doing those sort of things. I could take my 14 year old son and probably throw him on the console and not tell him anything and he could probably do the training things that we go through manipulating instruments around and putting things onto other things and stuff like that. He could probably do that without us telling him anything.
From the patient’s standpoint how has this improved?
DILWORTH: Well I think the nice thing especially, like from this hernia standpoint, is it gives you the ability to fully evaluate the other side and find out if they have a hernia on the other side as well because a lot of times people will have a hernia on both sides. The other one will be smaller and you can’t clinically detect it. But when you’re in the operating room, it gives you the ability to, number one, look at it, number two repair it as well with the same incisions. So the patient’s already going through the three incisions to repair the hernia on one side. You can repair the other side through the same incisions. So infection risk, things like that, obviously are decreased without having to make extra incisions.
When you’re talking about on one side and the other side, what are you referencing specifically?
DILWORTH: Patients with inguinal hernias, a patient’s hernia down in the groin area, it is very common for patients with it to actually have a hernia on the other side as well, especially when they’re younger patients. It’s more of a developmental type thing. And then somebody who worked their entire life who had a job, a laborer, lifting, doing heavy work, they a lot of times will have inguinal hernias that are direct hernias where they basically blow straight through the muscle wall. And again, those a lot of times will happen on both sides because whatever caused that to happen is going to put equivalent pressure on both sides.
In addition to a hernia in the groin, what other areas of the body might people see them?
DILWORTH: Anywhere that an incision happens on your body you can get a hernia, especially if you had an infection like a perforated appendix or something like that. They’re at much higher risk for that. Belly button or umbilical hernias, and then diaphragmatic hernias which, are more commonly known as hiatal hernias. Patients can get those which can lead to reflux problems, and that’s typically their main symptom. That’s usually when they start getting worked on for that by a primary care G.I. doctor. And then if they find a hiatal hernia then they send them to us to see if it’s something that should be repaired or not.
The obesity factor – how does that play into it?
DILWORTH: So obesity has a significant increased risk for developing hernias, especially for males, but also for females, especially once you get morbidly obese. You gain intra-abdominal fat. And when you gain that intra abdominal fat, it puts more pressure on the abdominal wall. It actually puts more pressure as well on the diaphragm area, which then leads to a higher incidence of hiatal hernias as well. So obesity not only causes them, but it’s actually one of the largest risk factors for recurrence of hernias because you can’t take those stresses and strains that the patient had before surgery. They don’t go away right away after surgery. We try to get patients to lose weight. Sometimes if we’re forced to do the hernia beforehand because something’s stuck in it – fat, intestines, etc. – we try to get the patient to lose weight after the surgery. But a lot of times we’ll try to optimize the patient for their surgical repair by having them lose some weight beforehand, which takes less strain off, which also allows you to get a better abdominal wall closure and then less strain on the repair afterwards so that they have less recurrence risk.
Could you speak specifically to her surgery?
DILWORTH: So, for her surgery, she had a multiple recurrent. She had had a few hernia repairs before in the past done by other surgeons. And she came to me with another hernia that was creating significant pain issues for her. It led to things being a little more complicated. It wasn’t a straightforward case. We had to deal with some of the old mesh. We had to deal with a very thin abdominal wall and try to improve the structure of her abdominal wall so that we got better tissue together on top of that. So instead of a straightforward simple case, it was just a little more complicated.
After they have this surgery, what does the recovery look like in terms of associated activity?
DILWORTH: So, in an extremely large hernia, we might keep somebody out for about a month from activities. But for the majority of the hernias, fairly small ones, your inguinal hernias, we’ll actually send a patient back to doing family walks on day four. On day seven, I want them back on an elliptical or treadmill or to at least try to start an elliptical or treadmill, if they weren’t on one before. And then at two weeks we actually fully lift their restrictions. There are no further lifting restrictions at all. They can get back to work. They can do any activities that they want to. From that aspect, not only has robotics and minimally invasive stuff allowed us to push the edges of getting people back faster, but even open repairs now, we send back faster because we realize that the sooner somebody gets back to activity, the more flexible scar tissue they ultimately develop, which leads to less risk for hernias in the future.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Natalie Gutierrez, PR
Natalie.gutierrez@baptisthealthsystem.com
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