Hernias: How they occur, how they can be repaired

Men or women can develop hernias. When they do, an organ or tissue can squeeze through a weak spot in a muscle wall. When surgery is called for, several options are available.

A hernia is a weak spot, defect, or hole in the muscle layers of the abdomen, through which a part of an organ or piece of fatty tissue can poke. Hernias most often occur in the groin or at the umbilicus (belly button). But they can also occur elsewhere, such as the sites of previous surgical incisions.

What Causes Hernias?

The belly button, for instance, is where our umbilical cord attached us to our mother when we were in her womb. After birth and the cord’s cutting, the hole usually will close itself. But some people have a persistent opening that eventually can enlarge to become a hernia.

People sometimes develop an “inguinal hernia” in the groin. This can happen with strenuous activity, or sometimes after birth, a baby’s inguinal canal does not close behind them, leaving a weak spot, which eventually can become a hernia.

Other hernias can occur at weak spots like old incisions, from strenuous activities or incomplete healing.

Dr. Ivanesa Pardo discusses hernias further on the Medical Intel podcast.

What about Activities such as Lifting Heavy Items?

Physical activity, especially strenuous and high-intensity exercise, can exacerbate or even cause a hernia. There are definitely some stories about people who exercise a lot and do a lot of heavy lifting, and they suddenly feel a “pop” and have a hernia. Those are acute cases; however, there is no need to put strict limits on how much someone should exercise, rather to be smart about it. When lifting heavy things or exercising, everyone should know -- and observe -- their limits. Anyone with signs of a hernia should be careful when straining or lifting, because the hernia can become “symptomatic,” which means it requires medical attention.

An “incarceration” occurs when something – such as a piece of intestine or fatty tissue – gets stuck in an opening (hernia) and can’t be pushed back in. A more serious situation is “strangulation.” That’s when the stuck piece of tissue or organ is losing its blood supply and starting to die. That requires emergency surgery.

When Should I Seek Medical Help?

Pay attention if you feel a lump that gets larger, or more tender, when you sneeze, cough or strain. If this occurs, see your primary care physician, or a specialist, for a diagnosis.

I recommend elective surgery when the defect (hernia) is large enough that, even if it’s reducible, a segment of intestine could get stuck, which could lead to incarceration or strangulation. We can repair hernias in several ways. There’s the old-fashioned “open repair” approach, which involves a larger incision. Then, there are more modern “minimally invasive” repairs. They can be laparoscopic or robotic. Their appropriateness will depend on the particular patient, the availability of the medical facility in question, and the skills of the surgeon.

Most hernia repairs today involve implanting a mesh. This is a screen that is made of synthetic material that reinforces the muscle layers where the defect, or hernia, is. The advent of the mesh has reduced the chances of a hernia coming back after it’s been repaired.

You should talk with your surgeon about whether you need a repair, and whether mesh is appropriate.

Celebrated Physician: Ivanesa Pardo, MD, FACS

It’s hard to say whether Ivanesa Pardo, MD, FACS, chose surgery as her medical specialty, or if surgery chose her. An attending surgeon in Advanced Laparoscopic and Bariatric Surgery at MedStar Washington Hospital Center, Dr. Pardo had already set her sights on becoming a physician while growing up in her native Venezuela. And after her first surgical rotation in medical school, Dr. Pardo was convinced she had found her future.

But more important was the fact that Dr. Pardo also had a knack for manipulating the advanced laparoscopic and robotic technologies increasingly used for minimally invasive procedures.

“All I know is that it just came easy to me,” she says, “and the more training I got, the more I wanted to learn.”

After receiving her medical degree from Universidad Centroccidental Lisandro Alvarado, in Barquisimeto, Venezuela, Dr. Pardo completed her general surgery residency at Indiana University School of Medicine, where she also served as a research resident. Because bariatric surgery offered opportunities to apply her skills with advanced minimally invasive technology, Dr. Pardo focused on that specialty during her fellowship at Albany Medical Center in New York.

Why MedStar Washington Hospital Center?

The Hospital Center offers the best of all worlds, Dr. Pardo says, as it also provides an academic setting for pursuing another professional passion, surgical education. She has written and contributed to articles in peer-reviewed publications, and spoken before professional audiences across the country.

But being a good teacher requires Dr. Pardo to be a perpetual student, which means keeping up with near-continuous advancements in minimally invasive bariatric surgery.

Keeping Up with Minimally Invasive Bariatric Surgery

“It is a fast-changing field,” she says. “New procedures are developed, but not performed very often as they are often considered experimental for a long time. So it’s only in places like the Hospital Center where you get the opportunity to perform and evaluate those kinds of cases.”

“Obesity is an epidemic that involves and complicates so many other health issues,” she says. “It’s good that surgical options are available, but not everyone has access to them.” And even if a patient is a good candidate for surgery, Dr. Pardo adds, a bariatric procedure is only one facet of treating the condition.

“The drive for surgery comes from the patient,” she explains. “A successful outcome involves adopting and maintaining significant lifestyle changes, and the patient needs to understand and prepare for them. Fortunately, we have the resources to help them through that process, before and after surgery.

Dr. Pardo adds that by evaluating patient outcomes and comparing them with the professional standard, “we are better able to identify areas where we can improve.”

Outside the Hospital

Away from the Hospital Center, Dr. Pardo devotes her attention entirely on her family. She and her husband have two children, a three-year-old girl, and 21-month-old boy. “At those ages, they’re pretty much the center of everything we do,” she says with a laugh. “But like surgery, there’s always something interesting going on.”

Will I encounter digestive problems after gastric bypass?

The headlines may sound alarming: “Weight loss surgery tied to lasting digestive issues.” “After gastric bypass surgery, many experience eating difficulties.”  

The stories were in response to a December 2016 study published in the British Journal of Surgery that followed 249 patients who had laparoscopic Roux-en-Y gastric bypass. It found that two years after surgery, gastric bypass patients were far more likely to suffer from digestive problems, such as indigestion, diarrhea and flatulence, as well as an inability to tolerate certain foods than the control group, which did not have the surgery.  

However, these results aren’t that surprising. They simply highlight what we bariatric surgeons already know. Gastric bypass changes the way your body absorbs and processes food. Before surgery, patients spend months learning about the diet and lifestyle changes to which they must commit after surgery to mitigate the effects of how their bodies will change during surgery.  

When you have gastric bypass, the surgeon reduces the size of the stomach and reconnects the small intestine to the new stomach, bypassing the original stomach and several feet of the small intestine. This will make you feel full sooner, meaning you’ll eat less, but it also affects how food is processed and the amount of nutrients including vitamins and minerals that your body absorbs.  

Our patients are usually excited to follow their dietary recommendations to the letter before and immediately after the surgery. However, as they heal and time goes on, some of them fall off the wagon a little. They pay less attention to what they eat or try to push their diet a little further than they should. That’s usually when we begin to see gastrointestinal (GI) problems surface.  

Common side effects of weight loss surgery

Dumping syndrome

This is one of the most common complications patients face after bariatric surgery. Dumping syndrome occurs when food, especially sugar, moves too rapidly from the stomach into the small intestine. This can result in diarrhea, nausea and abdominal cramps.  

Dumping syndrome can be avoided by eating smaller meals and limiting foods high in sugar, as well as not rushing through your meal. We educate our patients about this syndrome, so they can recognize it. Patients often tell us that after it happens once, they learn pretty quickly what triggered it so it doesn’t happen again.  

Small bowel bacteria overgrowth

Everyone has a certain amount of bacteria living in their intestines. However, in rare cases, gastric bypass can cause bacteria to grow unchecked. This excess bacteria may eat up the nutrients your body needs and can cause bloating, cramping, gas and diarrhea.  

In severe cases, small bowel bacteria overgrowth can inhibit the body from properly absorbing nutrients, leading to malnutrition and vitamin and electrolyte deficiencies, such as anemia.  

Small bowel bacteria overgrowth usually can be successfully treated with antibiotics.  

Food intolerance

The study found that 71 percent of gastric bypass patients developed intolerance for fried foods, pastries and carbonated drinks. However, only 14 percent of those people said the intolerance was very bothersome.  

We stress to our patients the importance of avoiding and cutting back on foods high in fat and sugar because the body just doesn’t process them as well after surgery. You’ll still be able to eat these foods, just not as often and in moderation. This is good advice for anyone, not just people who have had weight loss surgery!  

We also see some patients who “develop” lactose intolerance after surgery. They most likely were mildly lactose intolerant before surgery, but the surgical changes caused it to surge. When they switch to lactose-free products, the problems go away.    

How to reduce complications after gastric bypass

In rare cases, complications from gastric bypass, such as small bowel bacteria overgrowth, can result in GI problems. But these problems usually are related to diet.  

Our patients go through on average six months of education before surgery to learn about the diet and lifestyle changes they’ll need to make. In the weeks and months after surgery, they go through a diet progression: from liquids only, to thicker liquids, to soft food, then to solid food.  

The most important thing you can do to prevent gastrointestinal problems is to follow the dietary guidelines. They may seem overwhelming at first, but you’ll likely find they become a part of your daily routine. And don’t rush to advance your diet or experiment with new foods before your dietitian gives you the OK.  

A few general tips:

  • Eat small portions.
  • Eat slowly and chew food thoroughly.
  • Limit foods high in sugar and fat.
  • Keep a journal documenting food and portions.
  • Drink water between meals to avoid dehydration. 

Following dietary guidelines is the best way to prevent gastrointestinal problems after #bariatricsurgery. via @MedStarWHC

We’ll test your vitamin and mineral levels six months after surgery, at a year, then yearly after that. This helps us catch potential nutritional deficiencies early and address them before they become a serious problem.  

If you experience persistent gastrointestinal or eating difficulties, see a doctor. We can check for surgical complications and discuss your dietary habits. This is where a food journal can come in handy. By examining what you’re eating and how much, we usually can pinpoint the culprit and solve the problem. Even if you do experience GI symptoms at some point, for the majority of my patients, the overall benefits of the surgery outweigh them.  

Bariatric surgery is not just about weight loss. It’s about improving your overall health and reducing the risks of life-threatening conditions caused by obesity, such as diabetes, hypertension and high cholesterol. By sticking to a healthy diet and lifestyle, you can reap the many health benefits of weight loss surgery and prevent or reduce potential complications.