178. Hernias Caused by Cancer Surgery

This week, the topic of discussion was:
-Hernia
-Cancer
-Oncologic Surgery
-Colon Cancer
-Coccygeal Cancer
-Sarcoma
-Carcinoid Tumors
-Mucinoid Carcinoma
-Desmoid Tumor
-Prostate Cancer
-Incisional Hernia
-Mesh
-Reoperation
-Hip Disarticulation
-Chemotherapy
-Radiation Therapy

Welcome to HerniaTalk LIVE, a Q&A hosted by Dr. Shirin Towfigh, hernia and laparoscopic surgery specialist who practices at the Beverly Hills Hernia Center. This is the only Q&A of its kind, aimed at educating and empowering patients about all things related to hernias and hernia-related complications. For a personal consultation with Dr. Towfigh: +1-310-358-5020, info@beverlyhillsherniacenter.com.

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Transcript

Dr. Towfigh (00:00:10):

Good evening everyone. It’s Dr. Towfigh. Welcome to Hernia Talk Live. I’m your host, Shirin Towfigh, hernia, laparoscopic robotic surgery specialist. I’m coming to you from my office, Beverly Hills Hernia Center. It’s very bright and sunny and nice and warm, but not too hot outside. Thanks to everyone joining me on Facebook as a Facebook Live, and also for those of you that are here via Zoom, welcome. So yeah, today’s going to be great session. Why? Because we really have never talked about this topic of cancer before, and I think it’s about time. I had several patients this past week actually with cancer related hernias. And even today, right before this episode, I had a patient who has a hernia as a result of a cancer operation. And so I thought this may be a relevant subset of patients that would benefit from learning about hernias and how it relates to cancer and so on.

(00:01:16):

So just so you know, as you know, I’m a general surgeon, which means that I operate on, well, let me rephrase this. I’m a general surgeon, which means I’ve been trained to operate on all different parts of the body. Cancer surgery is one of them. I don’t do cancer surgery, but I definitely have the training. So I understand the concept of cancer surgery and also that patient population because I’ve been in training plus I have a really good relationship with our surgical oncologist, gynecologic oncologist, urologic oncologists, radiation oncologists, and so on. So based on that, I get referrals of patients that have had hernia related problems related to some type of cancer diagnosis. So, oh hey, good morning from Australia. Thanks for joining me. So let’s discuss how a hernia surgeon may interact with a cancer patient, number one. And number two, what you need to know about hernias when it relates to cancer diagnosis.

(00:02:30):

So I was thinking about this and in my mind there’s three different patient populations. There’s a patient population that has a hernia and has a cancer diagnosis and therefore needs surgery. And the two are completely unrelated. Let’s say you have a belly button hernia or a groin hernia, and by the way, someone diagnosed you with an ovarian tumor or you need a hysterectomy or you have a kidney cancer or something like that, or a prostate cancer and you need surgery for the cancer. And they’re saying either, Hey, you also have a hernia. You’re undergoing cancer surgery. Why don’t you also have your hernia repaired? Or, Hey, Dr. Towfigh, this hernia is in our way, so while we’re in there, we’re going to do the cancer surgery, but when we’re done, can you help us fix the hernia so that we can close the patient appropriately?

(00:03:33):

So that’s one situation. So totally elective hernia repair in a patient that’s planning on undergoing cancer surgery, that’s completely unrelated to that hernia, that’s scenario number one. That’s the most common scenario. I would say hernia scenario number two is less common but more complicated. And that is someone who has a hernia as a result of cancer being in that muscle, right? So there’s, let’s say there’s a dermoid tumor or even desmoid tumor. Let’s say there’s a desmoid tumor or a sarcoma, and those are tumors that grow in the abdominal wall and that patient requires the tumor removed, which means that abdominal wall is going to come out in a big chunk. That’s not a common operation, but it happens especially by surgical oncologists. And from a cancer standpoint, you can’t think of hernia from a cancer standpoint, you have to remove the tumor, plus potentially, depending on the type of cancer, a rim of healthy tissue.

(00:04:55):

Now that usually implies a full thickness removal of muscle, and then you’re left with a hole. So how do you fix that hole? And sometimes they call me to address that. Another situation would be, which is a very difficult one, one that I treated recently that I saw in the office recently was a tailbone problem. So there are people that have tailbone tumors, tumors that involve the tailbone and they need the tailbone removed and that causes a hole in the muscle. But you’re closing that hole, but you’re sitting on that tailbone. So how are you going to prevent getting a hernia when someone’s in there kind of closing up a hole where there used to be a bone called your tailbone and the muscle was attached to that tailbone. Now there’s no tailbone to attach it. So you have a hole kind of above your butt hole, and now that needs to be closed. And this is an area of the body where there’s a lot of pressure on it because sitting on it multiple times, sit, stand up, sit stand up, very difficult area to fix a hernia.

(00:06:16):

And then there’s the third situation where you didn’t have a hernia, you had some type of cancer, they did the cancer surgery, and now you have a hernia from the cancer surgery. And in all of these scenarios, you have to understand cancer biology. You have to as a surgeon, work with the oncologist to say, okay, first of all, what’s the life expectancy of this patient, right? So does this patient have months to live or years to live? Number one, because then that determines what extent of surgery they may want or undergo or if they should undergo surgery to fix the hernia and weigh the benefit of quality of life with the extent of life that’s after the surgery. Then you have to work with the oncologist to determine what’s the plan of care. So are you done, doctor, oncologist, are you done with your surgery for the cancer?

(00:07:20):

And if so, do you expect to go back in this patient a year from now, three years from now for a recurrence of the cancer? Or is this a cancer that needs chemotherapy or radiation therapy? These are all questions to know before you commit to fixing an abdominal wall hernia because you don’t want to prevent the patient from having, let’s say, their chemotherapy or the radiation therapy because you decide to do an operation where it’s not safe to do radiation in that area, for example. Or you do an operation that’s so complicated that it’s going to fail because they’re going to need chemotherapy, which prevents you from healing. So you don’t have to balance out what you do at the initial time of surgery with what their cancer related plan of care is. As a hernia surgeon, you should not be interfering with a patient’s cancer treatment protocol because I always say life before hernia. So you can live with a hernia, but the cancer needs to be treated primarily.

(00:08:37):

So that’s a very important thing to do. I did have Dr. David Santos from MD Anderson, which is a huge, very well-known cancer specialty hospital and medical center in Houston. So he is a hernia doctor that exclusively operates out of MD Anderson, which is a cancer hospital, and therefore all of his patients who have hernias have a diagnosis of cancer. Now, it doesn’t mean the area of his hernia repair is where the cancer was. Maybe they had a thyroid cancer and now they have anal hernia, but oftentimes he operates on patients that have had a complication of hernia or hernia in the area where the cancer was. So I recommend you go back, I think it was two years ago. Can’t believe it’s been almost, has it been four years? It’s been four years, yeah, it’s been four years that we’ve had Hernia Talk Live. I cannot believe that.

(00:09:48):

Is that true? Pandemic 2020? Yeah, yeah, yeah. April, March, April, 2020 is when we had this podcast. Unbelievable. Anyway, going back. So I recommend you go back to that prior episode if you’re interested because he has, because of the type of operations that he does in the hospital that he works in, he works very closely with radiation oncologists and medical oncologists, neither of which are surgeons. And so he understands the different types of chemotherapy and how they affect healing, and then the types of radiation therapy that are done and how it affects healing in the area where he needs to operate. Very, very important details that anyone who decides to operate on you for your hernia needs to understand and therefore tailor your type of surgery to be the safest in the face of your type of cancer. I’ll give you an example. Radiation. When you have radiation therapy, there’s different types of radiation therapy, and if you have what’s called external beam radiation, that means the tumor area.

(00:11:04):

Let’s say your prostate cancer or rectal cancer is deep inside and the radiation machine is outside. So what they do is they basically beam radiation in. That radiation has a pass through the skin, the soft tissue, the muscle, et cetera, to get down to let’s say your prostate or what else they do external beam breast. They do a lot of breast external beam radiation, and it can therefore injure all that tissue from the external beam radiation machine down to the area of the tumor. Now the way newer radiation machines have been developed, there’s less skin and fat burning and radiation effects nowadays than there were back when I was a resident. I remember we had so many bad complications because there’s a lot of people getting radiation for prostate cancer and also rectal cancer. And that area, as you can tell, is fraught with organs.

(00:12:17):

You got your rectum, your prostate, your urethra, and the skin, and then the butt skin anus and all of that was in the way of their radiation. So we had patients with strictures of their urethra with proctitis where they have inflammation of their rectum and anus. Some people had fistulas like all these little holes through which stool would come out. And then radiation injury is permanent. So unlike a regular scar or injury, we’re over years that scar heals and you can barely even see it again, the injury that’s done from radiation, external beam radiation is permanent in that region. So any person who needs surgery in the area of external beam radiation is at higher risk of complications than if that area wasn’t irradiated. I mean, the same is true of sun damaged areas, right? Or burn burn areas. But radiation is very, very unique in that the effects of the radiations are there forever.

(00:13:29):

So if you see a patient who’s had external beam radiation, they have areas marked with little itty bitty green tattoos marked on their skin so that they match that with the machine every single time as a marker to make sure they’re in the right, that they have the exact same kind of direction of the external beam radiation. So I had a patient who had radiation, I think it was for prostate cancer, I’m pretty sure. I’m pretty sure it was prostate cancer. He had radiation and you can see the little green dot from his radiation and then he had a hernia. So there are different ways of fixing hernias. There’s open laparoscopic robotic, then there’s with mesh and without mesh. So his groin hernia, it was so weird to me, the surgeon chose to do open surgery with mesh on this patient understanding that an open incision in the field of a radiated play operation is fraught with potential complications including poor wound healing, wound infection, and therefore possibly mesh infection.

(00:14:52):

So if it were me, I would’ve chosen a laparoscopic approach or even a robotic approach to the inguinal groin hernia because I don’t want any incisions neared in the groin area where the patient had the radiation. So what he did was he did the incision, but he placed the incision like a centimeter north of where that green dot was. So theoretically that incision’s not exactly in the area or direction of the radiation, but in this day and age to offer open surgery in a patient that has had a radiation, when you have access to laparoscopic and robotic surgery, to me makes no sense because you’re just asking for problems. It’s like saying, go down this river and you have to walk through really thick mud. Or those of you that are from my generation, do you remember quicksand? There’s quicksand or there’s a paved road and you’re like, that’s okay.

(00:16:07):

I got, oh, those called al, where are those shoes? Ah, galoshes. I have galoshes. I think that’s what it’s called. So that’s okay, I’m just going to go through the mud. Whereas there’s a paved road right next to it that you choose not to take. That makes no sense to me why you would choose a higher risk operation in the field of a radiation because if you have a complication, that wound will never heal. This is not like, oh, it’s just a poor healing. It does not heal. If you have a problem, then you get fistulas and abscesses and wound complications, it’s just not worth it. So that’s my take on radiation therapy. So very important, if you’ve had a cancer operation and you required radiation that if you need a hernia surgery or really any surgery in the same area that no incision is made within the trajectory of that radiation, external beam radiation.

(00:17:26):

Okay, now what if you had a surgery and now you need radiation? Sorry, lemme rephrase that. What if you need cancer surgery and the patient knows that they will definitely need radiation therapy after the surgery and oh by the way, they have a hernia. Well, good question. First of all, the worst thing for radiation is radiating in the area where there’s an intestine in the way. So if there’s an intestine in a hernia and that hernia is in the way that a hernia with the intestine is in the way of the beam radiation, that hernia must get repaired because that bowel that’s in the hernia is at risk of injury from the radiation and you can cause a lot of problems including fistulas bad idea. So usually a radiation oncologist would know if there is an organ such as small intestine in the trajectory of the beam and they’ll ask a hernia surgeon to fix that hernia to get the bowel out of the way of all the organs that can be damaged.

(00:18:44):

The most frail is the small intestine. Colon is actually a little bit heartier skin and soft tissue is a little bit heartier. Muscle is the most hearty. So radiation injures the small bowel, the worst disgusting you can have fistulas. It’s a horrible situation. So anyone that has radiation, they must make sure there’s no bowel that’s stuck, let’s say in a hernia. Otherwise that needs to be fixed before committing to the hernia repair. Sorry, before committing to the radiation. What if your situation is that you need radiation after surgery, but there’s also a wound there that needs hernia repair? Well, in general, we don’t like to put mesh in the place in the vicinity of planned radiation because first of all, it’s very possible that the material from which the implant is made can get heated and or denatured in a way that would affect its integrity.

(00:19:57):

It may melt, it may, I don’t know the actual scientific term for it, but it can denature the material if there’s any metal in that material, not a good idea to be in the trajectory of the external beam radiation. And then those implants, they depend on adhering to local tissues to work. But if you’re radiating, it turns into the stiff kind of cardboardy, very synthetically metal plate almost. So not a good idea to put mesh in that place. You want the least amount of foreign body in the direction or in the way of a radiation beam.

(00:20:46):

So that’s really all you need to know about radiation. So if you have any need for radiation, make sure that the surgeon, not the oncologist, surgical oncologist because they should be aware, but let’s say the general surgeon, make sure the general surgeon, if they have to be involved, is aware of all the things to be careful of so that their operation, which they’re used to doing in normal non-cancer patients that don’t need radiation to make sure that they make that decision for you and the plan of care for you, understanding that you’re special and that you need more attention to tailoring the operation to the needs of you because you have cancer, you may need radiation, et cetera. Okay, so we’re done with talking about radiation.

(00:21:34):

Let’s move on to chemotherapy and then we’ll move on to surgical surgically induced hernias due to cancers and how to repair those. So chemotherapy, some operations, sorry, some cancers require chemotherapy. It may be before the operation, after the operation, both during the operation some people get chemotherapy. So what does chemotherapy do? It attacks tissues that are cancerous. The side effect is it also attacks the growth of normal tissues that are not cancerous in some diseases in some types of chemotherapy. Now, as the years go by, less and less chemotherapy is toxic to the body and they tend to be more directed at the tumor itself without a lot of its side effects. But there’s still plenty of chemotherapies out there where you’ve seen people lose their hair or their skin turns a little ashy brown.

(00:22:53):

That’s like the chemotherapy effect. So healing of course is necessary for any operation and most people who undergo some type of cancer operation, they’re allowed, unless the tumor is really, really aggressive, they’re allowed maybe up to three weeks, two to three weeks of healing before they undergo chemotherapy. And that’s because you need to close those holes, heal those sutures before the chemotherapy kicks in and prevents further healing. So usually it’s about three weeks and of course it depends on the type of tumor. Its aggressiveness, the age of the patient and all that. So that’s okay. A hernia should heal within the first three weeks, as should any operation.

(00:23:44):

However, if a patient is currently undergoing chemotherapy and they see you for and now they have a hernia, that is not a good time to be like, oh yeah, let’s fix your hernia. No, they’re actively undergoing a therapy for their cancer, which should be their number one priority and all hernias no matter how painful, significant unless the patient’s about to die or is obstructed from the hernia. But you’ll have to take every single possible effort to prevent surgery, especially hernia surgery while the patient is actively undergoing chemotherapy because they’re not going to heal anything. And what you don’t want is to close a hole and have it pop right open and a that’s poor quality of life that makes a patient have more pain. It’s going to induce more complications, especially wound complications and potentially if you’re using mesh complications. So not a good idea.

(00:24:47):

I would say though, I would say that not all chemotherapies the same. There are plenty of patients undergo some type of lifelong chemo or it’s hormonal therapy or it’s some type of antibody type therapy to the cancer, and those patients tend not to have healing problems and surgery while they’re on that therapy is often okay, and some people depending on their risk factors and the type of tumor that they have are on lifelong medical therapy to prevent their cancer from coming back. And you know what life happens. So if that’s what they’re on and they get a need for hernia surgery, you have to have that talk with the patient. We have to have that talk or you have to have that talk with the doctor, how much is this hernia repair going to improve my quality of life or how much can I live with the hernia and still have a normal quality of life or as close to normal as possible quality of life so that I don’t endure any potential complications from the hernia repair because you don’t want to be in chronic pain or have a mesh infection or have a tearing or of the abdominal wall because you had a bad outcome from your hernia repair when you’re trying to struggle through life with blood draws and pet scans and CAT scans and everything else that comes with surveillance of a patient with lifelong cancer issues.

(00:26:38):

By the way, is it just me or have you guys noticed? I feel like everyone is being hit with some type of cancer effect. Either they have cancer or their parent has cancer or their sibling has cancer or their spouse has cancer. I feel like are we in a epidemic of cancer? I don’t know. It seems crazy that so many young people are having cancers. Colorectal cancer is basically a new epidemic in younger patients. Breast cancer is being seen in younger patients, lots of new lymphomas in younger patients. It’s crazy. I’m seeing prostate cancers in younger patients. How crazy is that? Anyway, that’s just an aside and I hope that this episode is timely enough so that there seems to be a lot of people that are affected by cancer and of course hernias are common, and so that combination of diagnoses is important. Again, I do want you to go back and listen to Dr. David Santos episode with me a couple of years ago because he is a hernia surgeon that works within a cancer hospital, and so he has a lot of great insight as to the types of patients that need hernia surgery and how to tailor the care so that you work around the whole hernia diagnosis.

(00:28:16):

All right. Something I just want to share about cancer is cancer surgeons compared to general surgeons, let’s say they’re usually less likely to use laparoscopic or robotic approach even in the bigger institutions for multiple reasons. One is except for during their general surgery residency. So most cancer surgeons, surgical oncologist, gynecologic oncologist, urologic oncologist, head and neck surgeon, head and neck oncologist, they all have their baseline residency training in surgery. And then on top of that, they do a separate cancer surgery residency, usually one to three years. So they’re highly, highly skilled surgeons. However, they’re not really intensely skilled in laparoscopic or robotic surgery. Now it’s improving, but if you take all surgical oncologists on average, there’ll be less use of laparoscopic or robotic surgery and more reliance on open surgery than let’s say your typical MIS general surgeon, for example. So one of the reasons is it’s an older specialty, so a lot of older surgeons are in it. It’s not flooded with new blood. There’s a lot of new people going into it, but it’s not as common of a choice of career as let’s say, general or MIS laparoscopic surgery.

(00:30:19):

The other thing too is that some operations are really difficult to do laparoscopically or robotically, and they’re bulky, right? If you have a tumor that’s huge, how are you going to take it out through little holes, right? Most patients who have cancer like that need a big bulky tumor removed and you just can’t do that laparoscopically. If you do a hernia surgery, there’s nothing to remove. Everything is kind of put back into place, so there’s no usual specimen to remove if there is. It’s really small, like a little piece of fat, so you can get away with several little holes, whereas if you’re taking a big sarcoma, there’s no laparoscopic kind of weight it and take it up unless, yeah, I mean there are exceptions to that, but in general there isn’t. So doing a big open operation is much more common by the oncology, surgical oncology world than not.

(00:31:25):

Also, there’s still a thought that doing a big open operation is a better operation. Why is that? Some people have thought that maybe you can spread the tumor through the little holes, the trocar sites, or you can accidentally puncture the tumor or something like that, or because you can’t feel very well, you don’t get as good and wide of a dissection and get all of the tumor. Now that’s been disproven. This is not based on facts. It’s been disproven. People who undergo laparoscopic or robotic, let’s say kidney surgery for cancer or prostate surgery for cancer do just as well if not better than an open surgery option from a cancer standpoint. So there’s still surgeons, I believe. I just want to go in there and take it out myself and I can feel the tissues and all that. So there is that.

(00:32:30):

And lastly, cancer surgeries are focus on saving your life and making you cancer free and giving you the best cancer procedure. They often do not think of hernias. They don’t think of hernias when they’re doing their cancer surgery. So I’ll give you a good example. I saw a patient today, actually a lovely lady. So she was told she has ovarian cancer, and I don’t know how much you guys know about ovarian cancer, but it’s among the worst cancers to have ovarian pancreas. They’re all kind of difficult tumors because they tend to spread. They tend spread before they’re diagnosed. So she had all this ascites fluid and this big mass on her ovary and her blood tests were elevated, and so everyone thought she had cancer. And so the surgeons went in there to do a big cancer operation, so they caused an enormous scar. Now, could they have done it laparoscopically or robotically? Probably if they weren’t worried about cancer and they just thought, oh, it’s just a tumor. We don’t know what it is. It’s probably not cancer. It’s very possible. I would argue that they would’ve felt better going in laparoscopically or robotically to remove it.

(00:33:59):

But like I said, most gynecologic oncologists, et cetera, they’re really more comfortable doing a big open surgery and less likely to do a laparoscopic or robotic surgery. So anyway, she had a huge incision from upper abdomen all the way to below the belly button down to the lower abdomen, huge incision. Guess what? Didn’t heal very well. So oh, good news turned out not to be cancer. It was one of those flukes, like a really rare disease. It looks like cancer, but isn’t cancer. So she didn’t need radiation, she didn’t need chemotherapy. The surgery proved that this was a tumor, but it wasn’t a cancerous tumor. It was just a growth on her ovary that caused all these fluid ascites and abnormal blood tests. So that’s good news, but because they went in there expecting this huge difficult operation, they made a big incision and then they closed her and she got a major hernia from it, and this is going to be a difficult hernia.

(00:35:10):

It’s large hernia. It’s more than 10 centimeters wide. You’ve heard me talk about zero to two, two to four, four to six or seven, and then anything over nine. Yeah, she’s like 14 centimeters wide. So that is going to be a challenging hernia repair, repair, fortunately in someone who doesn’t have cancer and is basically cured, but it’s kind of unfair, right? So if she had gone, let’s say, say if she had gone into a surgeon who was either a gynecologic oncologist that was really gifted in robotic or laparoscopic surgery or if none of her labs or blood tests were concerning for imaging, if none of that was concerning for a cancer and she just needed, let’s say her ovary biopsied before she committed to this big operation, it’s possible that would’ve been done laparoscopically or robotically and she wouldn’t need to have this huge operation. But once you add the word ovarian cancer, for example, or pancreatic cancer, you’re less likely to have a minimally invasive operation. So a lot of patients who have hernias from a cancer operation have it because the surgeon is going in with the mentality that I’m going to do my best to take as much cancer out surgically to improve this patient’s cancer-free life. And then what they don’t take into account is they’re now committing this patient to higher risk of hernias, wound complications with this big open operation.

(00:36:56):

So that’s unfortunate. That’s unfortunate. Cancer is just a label that sometimes pushes you into not necessarily the best operative plan because the goal is to save your life. It’s like trauma. That’s actually, it’s a perfect example. If you get hit by a car and you’re bleeding, you could be bleeding to death from a little small thing that can be dealt with laparoscopically, but the majority of trauma surgeons will just filet open your belly and not attack it minimally invasively. That’s just the way it is. Trauma surgeons similar to surgical oncologists because of the nature and urgency and life-threatening problems that they deal with tend not to be as good laparoscopically or robotically, and therefore they make bigger incisions. And people who undergo trauma surgery tend to have a higher risk of bowel obstructions and wound hernias than other types of patients. That’s just a fact.

(00:38:01):

And if you slow down and you’re like, okay, the patient’s not bleeding, and you can kind of maybe have a really skilled surgeon that goes in and deals with a trauma patient laparoscopically or robotically, that shift in mentality where you’re trying to not do as much harm to the patient, maybe there, but the reality is time is of the essence. You don’t want to waste time and have the patient potentially bleed or have you not miss an injury because you didn’t see everything because you were doing it laparoscopically and not open. So trauma surgeons fall in a similar category as surgical oncologist in which in the case that they tend not to do as much laparoscopically or robotically. Again, times are changing, things are getting better. Robotic surgery has really increased access of minimally invasive surgery to surgeons that are uncomfortable laparoscopically. So that’s been a positive thing, but it is where it’s, okay.

(00:39:16):

Last scenario, which I discussed is when the cancer is, oh, no, second to last, one more scenario. The other scenario is the patient is having cancer surgery, and oh, by the way, they have a hernia that happens sometimes. So let’s say they had open appendectomy and they had a hernia from that, it didn’t bother them, but now they have to go through that hernia for their colon cancer, let’s say, or their hysterectomy, and they call you and they say, Hey, hernia surgeon, can you come and fix the hernia at the same time? Well, that may be a good thing. a lot of times the surgeon, the colorectal surgeon or the general surgeon or the gynecologic surgeon will do it themselves. They’re like, ah, we’ll just sew it back together again. In fact, I just saw one of my patients also today actually that happened to him exactly.

(00:40:17):

So he had a bladder tumor, I think, or some bladder surgery, and then the urologist had to go back in again for another operation, and he had had a hernia from the first surgery, an incisional hernia. So the urologist went in through that hernia, did the whole bladder or kidney surgery, I forget what it was, and then fixed the hernia himself, which of course recurred. And each time he did that, the hernia got bigger and bigger. So I was dealt with a pretty large hernia and they had to fix it. That’s a problem. I’m not a big fan of a non-specialist fixing a hernia without really having a plan of care.

(00:41:04):

I feel like a lot of these doctors, they treat like it’s just a hernia and they’re like, oh, I’m just going to close it, but it doesn’t work that way. I have a lot of colorectal surgeons that had a patient that had a hernia. Let’s say for example, they had colorectal cancer, the tumor was removed and they closed the wound. The risk of incisional hernia from a colorectal cancer surgery that’s done open is high, only second trauma surgery hernias because it’s a dirty operation, there’s wound contamination and all of that contributes to incisional hernias. Well, sometimes you have to go back, they have to go back in there because you have to take the colostomy down. There’s bowel adhesions, whatever the situation is, and the colorectal surgeon is like, yeah, there’s a hernia, but I’m just going to close it. I’m going to look the other way, put my head in the sand, pretend there’s no hernia, and just go through the hernia.

(00:42:01):

And when I’m done with my colon surgery, I’m going to just close everything as if there’s no hernia. Well, that tears, you can’t do primary repairs of incisional hernias. If you’ve already had an incisional hernia, let’s say from your first cancer surgery, and now you need another operation through that hernia, you can’t just close it. You have to use mesh. Otherwise, there’s between a 50 and 60% recurrence rate, and every time you recur, the hole gets bigger. So it’s much better to consult with a hernia surgeon so that if you have a need for an operation, let’s say a cancer operation, and there’s a hernia from your prior surgery, let’s say not a cancer operation before or a biopsy or whatever, you should bring in a specialist to tailor the type of hernia surgery you should have to the type of other surgery you’re having.

(00:43:01):

So let’s say it’s a morbidly obese patient with a lot of risk factors and ascites, and they need this liver surgery, and they just had, let’s say a gallbladder cancer. Let’s say they had an open gallbladder surgery for let’s say infection, and then the pathology comes back. Cancers, they have to go back in and resect the area of the gallbladder, the lymph nodes, and then some of the liver itself. Well, the first surgery was somewhat not elective. There was infections and the patient was morbidly obese, and now there’s a hernia there. Well, the second surgery, you need to go in there because there’s a cancer to do, and now you have to go through a difficult area of the body, the upper, below your ribs through a hernia. You can’t just close that hernia. There’s a lot of planning to go with that. But if the patient is not a perfect patient, let’s say they’re morbidly obese, it’s a very difficult hernia.

(00:44:10):

That hernia is going to add three or four hours to the operation, and maybe that’s not the best thing to do for the patient. So sometimes it’s best not to fix the hernia and just provide a bridge of some sort, which is quick. You just put a bridge to sew it in place instead of manipulating the tissues to fix the hernia and therefore you, that’s called tailoring to the needs of the patient. Don’t do a three to six hour hernia repair in someone that already needs a three hour liver surgery or colon surgery, whatever the situation is, because that’s just not good care. Fix the, like I said, life before hernia. So patch the hernia, do a patch job, see how they do. These people probably need chemotherapy or some other adjuvant therapy for their cancer, and once they’re better healed, good nutrition, maybe even lost some weight, then you go in and fix their hernia, which I know it sometimes implies a lot of planning and multiple stages, but that’s much better than going in there doing everything at one time and then having a mesh infection or even bigger hernia and so on.

(00:45:24):

Okay, the last thing I want to talk about is this really difficult situation where the cancer surgery itself causes the hernia. So you go in with no hernia, you come out with a massive hernia.

(00:45:40):

How is that possible? Well, what happens is there are tumors that arise from the abdominal wall. These are usually sarcomas or desmoid tumors, and these tumors arise as part of the muscle, and because it’s part of the muscle, the entire muscle needs to be removed as part of the cancer operation. Then what do you do? So interestingly, I often do not get called on these. The surgical oncologist, at least at my hospital, have decided they’re just going to deal with it themselves. They just take a mesh oftentimes not the right mesh, and they just patch the hernia. These people often need radiation into that space, and they understand that there’s risks of poor healing in the area. So I often see these patients afterwards. So they had their oncology procedure, they have a massive hole. Again, remember the surgical oncologist’s role is to save your life and make sure you’re cancer free as long as possible.

(00:46:58):

So hernia repair, minimizing tissue damage, reducing the amount of tissue that is removed, all those things don’t go through their mind. They don’t care. That’s not their role. Their role is to save your life. It’s like the firemen, right? The firemen’s going to come in to a burning building and save your life. They may have to break down a door, break down a wall. They may have to take a sledgehammer to a window. So they’re not thinking, oh, let’s not injure. No, no, no, this is a life or death situation. They’ll have to do whatever it takes, and then afterwards you’ll deal with it. You’ll have to fix the house and fix the wall or get a new door or whatever the situation is. The same is true of trauma surgeons and also cancer surgeons, which is their goal is their very singular goal. Trauma surgeons want to save your life. Cancer surgeons want to save your life and do as good of a cancer surgery as possible. So they’re not going to skimp on how much tissue they remove, let’s say, or they’re not going to make some fancy incision far away from the tumor so that you can hide it if that’s a worse operation from a cancer standpoint. And therefore, sometimes I get these patients, they have these enormous wounds.

(00:48:35):

It is where it is. They had to have it done for the cancer, but now I’m stuck to recreate and reconstruct this abdominal wall. Those are difficult because you’re missing tissue. It’s not like you had the tissue there and it pulled apart, and I can kind of manipulate everything next door to close it. Oftentimes, there’s not enough tissue next door to fill it. The muscle is gone. There may be some fascia left that I can move around, but I can’t move around muscle. So the bulkiness is gone. You’re going to be deformed. And that’s an unfortunate complication of some of these abdominal wall tumors. And I talked about one of my recent patients, which had a sacral, sorry, a coccal removal, and sometimes a coic, which is the tailbone is removed in order for cancer in that area. So that’s a difficult area to close because the pelvic floor muscles all submerge onto the tailbone and insert there.

(00:49:43):

Once the tailbone is gone, there’s not enough platform. So you have to sew the pelvic floor muscles together. And those are very fragile muscles. There’s no strong thick fascia like there is in your thigh. You have abdominal wall. So just primarily closing those doesn’t work. So oftentimes, let’s say the colorectal surgeon will remove, let’s say there’s a big colorectal cancer, they may have to remove that bone as part of the cancer operation, and then they just close the muscle without thinking that 60, 70, 80, 90% of the time that’s going to fall apart. Difficult area to treat again. And once it falls apart, the muscles are all frayed. It’s like a very thin muscle down there. So then I’m stuck recreating an area right next to the rectum that they have to sit on all the time. Then I have to fix that hernia as part of the, to recreate the patient’s pelvic floor.

(00:50:50):

And those are challenging. I’ve done a good job of it. But there’s open operations and there’s laparoscopic robotic operations for that. And those are tough. Those are tough. The other one’s really tough. Oh, I need to talk about that. I haven’t had one of those in a while are patients that require what’s called hyp disarticulation. I dunno if you’ve heard of such a thing. So these are not colorectals patients or surgical oncologist. These are orthopedic oncologists. So there are patients that have tumors of their leg, sarcomas of their leg, and the only treatment is to completely remove it. And what they do is they remove it, but your hip is connected to your pelvis and those muscles that hold the hip in place, the hip girdle also has a rule in the pelvic floor and kind of holding all your intestines on that one side in place. So when you have a hip disarticulation usually due to cancer, that’s a difficult situation because you need to somehow make a sling to hold all the chitlins inside. But as you know, there’s nerves, there’s vessels in all that area. So it’s a very, very difficult operation, and you have to work with your orthopedic colleagues to recreate the pelvis in a way to support it. Here, let me show you something funny. You like this?

(00:52:34):

Alright, for those of you, oops, for those of you that, for those you that can see the video, does anyone know what this is? Oh, this is a front. Does anyone know what this is? Okay, this is called ants in the pants. Have you ever played ants in the pants? This was a gift from my office. You take this and you try and make it fall into the pants. But anyway, it’s a great example of what a hip disarticulation is because they’ll basically take off this entire leg at the groin crease and the hip bone. So now you have this part of the body with you have no leg, and you have this part of the body of the groin crease just kind of hanging. So you need to have some type of internal sack to hold all the intestines in place. And yes, I just used my ants in the pants, my ants in the pants model here to talk about hip disarticulation in pelvic hernias. Those are very difficult though, by the way. I’m sure you’re all wondering. Now what else I have on my desk that’s as crazy as an ants in the pants?

(00:53:54):

Childhood game. Childhood game. There’s a story behind this, but I’ll share it with you guys later. Let’s see. We had some questions that were submitted. I’m going to take a quick look at that to see if there’s anything that, here we go. Let’s see. Is open cancer surgery associated with a higher risk of developing an incisional hernia compared to non-cancer related procedures? Really good question. So yes, people that have cancer tend to be immune suppressed and also don’t heal as well as non-cancer patients, number one. Number two, people that have open, people that have cancer may also need or have already been on chemotherapy or because of their cancer, they may be malnutrition. Let’s say they have a gastric cancer or esophageal cancer, they’re not eating very well. They tend to be malnutritioned, and therefore they don’t heal as well. So yes, as a cancer patient, you’ll have a higher risk of wound complications and hernias from any surgery that you have undergone, and that’s usually due to having cancer being immune suppressed and not healing well due to the need for chemotherapy and or radiation and c, malnutrition because you tend not to have good nutrition with certain cancers.

(00:55:26):

Great question. Next question. Regarding the development of an incisional hernia, what types of cancer related surgeries pose a greatest risk to patients? So it’s usually the dirty ones. So a perforated colon cancer, perforated gastric cancer, these are all not clean. They’re dirty because the organ was taken over by cancer and then that cancer is now spread, but also the contents of the organ, which are dirty, are spread. So that’s kind of the worst case scenario. Also, the cancer that have ascites associated with it. Ascites is fluid in the abdomen that accumulates. And you’ve probably seen people with, if you’ve ever seen a patient with an end stage liver disease, they have ascites, they look pregnant and sickly, and their belly is filled with fluid. But similar to patients that strain for constipation or they’re constantly coughing, ascites does increase abdominal pressure. And because it increases abdominal pressure, it increases your risk of hernia.

(00:56:39):

So people that get ascites after their operation will have increased pressure on the wound and therefore higher risk for hernia. Another great question. Next one, how do you approach hernia treatment in patients who may need multiple surgeries after hernia repair due to cancer? Oh my God, I totally forgot to talk about that. Thank you for reminding me. So you’re right. Like I said, as a hernia surgeon, I need to work carefully with the surgical oncologist or the medical oncologist to see what the prognosis is for this patient. So what is the prognosis of the immediate prognosis, right? Like if a patient has one or two months to live because they went in there for the cancer surgery and it just really bad diagnosis, well, maybe don’t fix that hernia.

(00:57:31):

Allow them to live the rest of their life with a better quality of life rather than trying to heal from surgery. But there are certain cancers, usually these are mesenteric tumors or carcinoid tumors where that pathology tends to recur. Now, there’s not tumors that spread all over the body, but these are tumors that tend to locally spread. Another example, or appendiceal OID cancers or ovarian mucin carcinomas where they keep recurring locally. These patients classically need multiple operations to constantly debulk the tumor. It’s called debulking surgery. You’re never curing them. They’re always undergoing every three to six months. And then every year they get PET scan, cat scan, MRI, whatever the situation is, looking for tumors. And you go in there and have do another operation to take out the tumor. And that continues for a period of time. So in those patients, I don’t like to put synthetic mesh in them with their hernia repair because let’s say they have one operation or two operations, and now they have an incisional hernia.

(00:58:48):

Well, the typical incisional hernia repair is with mesh and with synthetic permanent mesh. But that would imply that when the patient needs their third, let’s say carcinoid operation or exploration, that the surgeon that does that will have to go through synthetic permanent mesh. What does that mean? It means they have to cut through mesh as part of their surgical approach, whether it’s laparoscopic or robotic. Well, why is that important? Because you’re taking a perfectly good hernia repair and now you’re exposing that mesh, which was sterile to whatever surgery you’re doing. So you can cause mesh infection. That’s number one. Number two, you have to make sure that the hernia that you do repaired does not prevent the patient from having a successful repeat operation for, let’s say, another cancer incident. So that’s where the tailoring is, right? There are certainly people that have hernias that are repaired with mesh, put inside the belly.

(00:59:58):

Bad idea in someone with carcinoid or other tumor mucin cancer where the tumor keeps recurring inside the belly. A, you don’t want mesh to be exposed to the cancer, and B, you don’t want the surgeon to spend their time cutting bowel off of the mesh because of adhesions before they even get to the cancer to do the operation. So really, really good. So what do I do? I actually use a hybrid mesh and I don’t put it inside the belly. I put it one layer more superficial next to the muscle. And I tell the patient, if you ever need surgery, they’re allowed to go through the mesh, but they have to do their best not to infect that mesh. And B, when they close the hole, they have to use permanent suture. Usually we don’t use permanent suture for closing the abdominal wall. We use slowly absorbing suture, not the case.

(01:01:03):

Is there any kind of association between hernia cancer? Not that we know of. And let’s see. That’s it. Yay. A couple more questions we’re asked, but I’m going to skip that and allow us to move on with the rest of our day. This was really great, guys. Thanks everyone. I just want to let you know, I hope everyone’s enjoying their summer break. Everyone seems to be on vacation right now. 4th of July weekend is coming up. Happy 4th of July, independence Day to all my local Americans, and it’s been great. I hope this was a good episode. I really thought it would be informative because we’ve never really talked about it except for that one episode we had. So definitely we can learn some more. One caveat, I am not a cancer surgeon, so whatever I’m telling you is based on what I’ve learned in medical school residency and also treating patients and learning from their surgical oncologist. So that said, I’ll see you next week on Hernia Talk Live. Don’t forget, go to my YouTube channel and subscribe so that you can continue to watch and catch up on all previous archived episodes. And if you’re a podcast lover like me, do subscribe and please provide me with some type of feedback on the podcast channels. Hernia Talk Live, and aloha. Thank you very much. See you guys. Bye.