Hernia Care for Gynecologic Cancer Patients

00:00:00:00 – 00:00:22:19
Unknown
We are very excited about our webinar today. First, we’ll have an expert lead the presentation followed by two incredible patients speaking about their experiences with hernias. I’d like to hand it over to our panelists, introduce themselves first, and then to Dr. Poulose.

00:00:22:21 – 00:00:50:02
Unknown
Andrea, would you like to kick it off for us first? Of course, inevitably. Thank you very much. Good afternoon, everyone. I’m Andrea Herzberg. I’m a 28 year survivor of stage three C, high grade serous ovarian cancer. And it has been my honor since 2011 to work with a hearty band of knowledgeable ovarian cancer survivors. Answering. They volunteer. We will volunteer on the Share helpline.

00:00:50:04 – 00:01:25:05
Unknown
I also facilitate two of our ovarian support groups. I chose not to repair my two surgical hernias and you’ll hear a short, but I hope riveting retelling of this story. Later in our program, Why you want me to go next, right? Yes, go ahead. Hi, my name is Gwen Harding Pietz. And I am a 19 almost just shy of 20 year survivor of stage three C, high grade serious ovarian cancer.

00:01:25:07 – 00:01:56:14
Unknown
I’ve been blessed to work with Andrea on the show help line as well as be very active in the Ovarian Cancer National Alliance or sorry Research Alliance programs such as survivor’s teaching, students saving women’s lives. It’s been I am actually one of those that has actually had two hernia repairs. The first one after my first first line treatment and then the second one after my recurrence.

00:01:56:16 – 00:02:27:10
Unknown
And I can I’ll be speaking to why I had those repaired in a few minutes. When introducing yourself and not like to hand it over to Dr. Poulose introduced himself. Yeah. Thanks. And F.A. and I just wanted to say hi and just express my gratitude for the opportunity to be here with you all, and especially with our panelists, Andrea and Gwen, and hope to have a really stimulating discussion with each of you about this particular topic.

00:02:27:12 – 00:02:46:17
Unknown
So I’m currently a surgeon. I do largely abdominal wall reconstruction and a lot of hernia repairs here in Columbus, Ohio, at Ohio State. So we have any Buckeyes on this call. Shout out to all of you folks. So I’ve been here at Ohio State for about six and a half years here. I co-lead the Center for Abdominal Core Health.

00:02:46:19 – 00:03:12:04
Unknown
And prior to that, I was at Vanderbilt for a total of 19 years or so, also doing similar work at the Vanderbilt Hernia Center. So it’s really, really a pleasure to be here and to chat about this topic. Thank you. Thank you all for joining us today. And Dr. Bruce, the floor is yours.

00:03:12:05 – 00:03:19:10
Unknown
Great. We will start Sharon here in a second.

00:03:19:12 – 00:03:37:11
Unknown
Yes. Let’s see if when I hit share, it’s not allowing me to share. The button is grayed out for some reason. Okay. We’ll see if we can fix that up.

00:03:37:13 – 00:03:43:21
Unknown
I just got it now. It just came on. Here we go.

00:03:43:23 – 00:04:08:02
Unknown
There you go. You guys should have that now, right? Yes. Great. Awesome. Well, thanks again for inviting me to chat about this topic. And we’re going to dive into a little bit about our new care for gynecologic cancer patients. These are some of my disclosures. I do have some relationships with Mesh and other companies that are in this space that will be pertinent to this talk.

00:04:08:04 – 00:04:36:08
Unknown
I also help lead the abdominal core Health Quality Collaborative and receive some salary support from that group. So these are the three topics that I thought would be helpful to cover. The first would be breast and gynecologic cancers and hernias, How to maintain abdominal core Health during cancer care. And then I thought and wrap up with just posing some serious questions that really need answers, especially from what our patients need answered.

00:04:36:13 – 00:05:03:04
Unknown
That I think I think especially as surgeons, we need to pay a little bit more attention to. So first, kind of diving into how hernias can affect breast and gynecologic cancers, it might be worth just clarifying exactly what is a hernia. So really the generic term for what a hernia is, it’s a hole typically somewhere in the abdominal wall or the it’s kind of the core musculature that shouldn’t be there.

00:05:03:08 – 00:05:24:10
Unknown
And that can arise from a lot of different reasons. Many of you have probably heard of people having bellybutton, hernias or inguinal hernias. You can also get hernias just from having a surgery because it creates a natural weak spot in the core muscles that can then open up and form a hernia or something protrudes through that hole that shouldn’t be going there in the first place.

00:05:24:12 – 00:05:58:14
Unknown
So what causes a hernia? One of the most common causes, especially in the setting of having undergone cancer care, including an operation or a surgery for that cancer, is that creates a weak spot. And however much we carefully sew up that the area where you’ve had the surgery, it can open up over time. And what happens is once that that core muscle layer that opens up basically internal organs can then push through that layer, causing a bulge that can cause some difficulties for you.

00:05:58:16 – 00:06:16:20
Unknown
One of the most common types of cancers that we deal with. And then oftentimes for those of you that have undergone a breast cancer journey, sometimes it doesn’t even make sense why you would even have a hernia and the management of breast cancer. But in fact, it’s it’s more common than you think. And that has to do with the reconstruction.

00:06:16:21 – 00:06:49:18
Unknown
These are some slides from the MD Anderson Cancer Center, and these are slides that show some of the reconstructive options after having mastectomies that are often employed by our plastic surgery colleagues. And these may include terms you’ve heard before tram flaps, deep flaps, seat flaps. And these are all just different acronyms that describe the techniques themselves. But if you notice, kind of one of the more one of the common themes, if you look at these images, you see that there is an incision on the abdomen, actually.

00:06:49:20 – 00:07:24:10
Unknown
And that’s because oftentimes these are these flaps that are created take tissue from the abdomen, either the muscle itself or from the the subcutaneous fatty tissue beneath your skin to reconstruct your breast. And one potential consequence of that is it can create a weakness from where that tissue was had originated. That can then lead to hernias. And here is a patient of mine I saw a couple of years ago who, in fact had a breast cancer journey, and she successfully got past it all.

00:07:24:10 – 00:07:49:02
Unknown
But as you can imagine, it was a lot like many of you have gone through as well. So after her mastectomy, she underwent a deep flap reconstruction, which is a deep inferior epi gastric perforated flap, which stands for the blood vessel supply, where the tissue came from. And then she developed a hernia at the site of where that tissue was used to, then transfer her to her breast reconstruction.

00:07:49:04 – 00:08:26:12
Unknown
And ultimately, she did elect to proceed with hernia repair and took about 4 hours to reconstruct her core muscles. And overall, she did well. But as you can imagine, it’s another surgery, another expense, another time off from just living your life. That certainly can affect what you do. What about gynecologic cancers and hernia formation almost exclusively? This is the result of the surgery itself and whatever type of cancer you may have had to have had to get past, this can be a problem, even if it’s robotic assisted surgery.

00:08:26:14 – 00:08:50:07
Unknown
And also, more commonly, we see it after having open incisions with a larger incisions. But as you’ll see later on, my talk, even if you have a minimally invasive surgery, robotic or laparoscopic, it can still result in a pretty pretty high risk for hernia formation and hernias themselves. As many of you probably already know, can negatively impact your life.

00:08:50:08 – 00:09:12:04
Unknown
I mean, these are patients that I’ve taken care of over the years. You can imagine these are pretty extreme examples, but these are patients who started out with relatively simpler problems but ended up having issues as far as hernias are concerned. That really, really caused a big problem for them not being able to do day to day things, not be able to participate in family events or work events.

00:09:12:06 – 00:09:34:21
Unknown
And so I think, you know, oftentimes there’s a little misunderstanding, especially amongst those who haven’t experienced these problems, that hernias are just simple things. You go in at the hospital and get taken care of, but they can actually be quite complex, impactful things on your health. I would also mention that hernia is the problem. Nobody tells you about, especially in the setting of cancer care.

00:09:34:23 – 00:10:04:14
Unknown
I mean, look, you have enough stuff to worry about with dealing with the cancer, all the therapy involved, and certainly all the caregivers around you and the care providers are focused on that as appropriate. What can often happen, though, is when you develop a hernia, it’s kind of a surprising thing. It kind of catches you off guard. And this might be something that’s an opportunity for us as providers in your whole cancer care that maybe we need to do a better job of informing about the risks involved with this happening to you.

00:10:04:16 – 00:10:29:01
Unknown
So what type of cancer surgery can result in hernias? Well, if you look at the spectrum of all the major types of cancer I just circled, the ones that can result in hernias. And as you can see, it’s a lot. So there’s a lot of potential hernia formation that can happen after life saving cancer surgery. And like I mentioned, this is something probably we need to start having some more conversations about upfront.

00:10:29:03 – 00:10:58:06
Unknown
What about breast and gynecologic cancers? Well, as we just kind of discussed, pretty much all of all of these types of cancers, given the surgical therapy that’s involved in treating these cancers result in hernia formation. So I spent a lot of my academic life devoted to answering some basic questions about cancers, cancers and hernias. So one question that we asked several years ago was how often do hernias happen after cancer surgery?

00:10:58:07 – 00:11:24:02
Unknown
Amazingly enough, we didn’t really have a lot of information regarding this. Well, the surprising number is 41% of the time at two years. So this is not a small number. It would be one thing if we came up and discovered that it was only five or 6% of the time, which is still a lot. But 41% of the time, after having lifesaving cancer surgery, you can develop a hernia that can impact your quality of life.

00:11:24:04 – 00:11:49:03
Unknown
This is the study we did. It was published in the Annals of Surgical Oncology, a journal devoted to of course, cancer surgery. And what we did is to tell you guys a little bit about the process of how we discovered this number. We had independent surgeons review CAT scans, and many of you, as part of your follow up will get routine CAT scans just to make sure the hernia adapts, make sure the cancer is haven’t come back.

00:11:49:03 – 00:12:19:02
Unknown
And so we took advantage of that situation in terms of having having CT scans obtained, say, 1 to 3 years after your cancer surgery and also looked and saw how many folks developed hernias. And we reviewed just under 2000 CT scans and you can see the images there. If you look on your screen left there, you can see an opening at the top of the image where you see some some kind of tissue structures going through that opening.

00:12:19:02 – 00:12:40:14
Unknown
That’s a hernia that sort of looks like on a CT scan. It’s a moderate to large size one. And on the right side, you see a smaller one kind of at the top of that image there. And these were the results that led to that number of 41% at two years. And what I wanted to kind of focus your attention on is the different colored bars in this graph.

00:12:40:14 – 00:13:03:23
Unknown
So on the on the y axis or the axis kind of going up and down, we see different types of cancer surgery. And on the X axis, we just show that the percentage of the study population. And I wanted to kind of draw your attention to hysterectomy, which is and also removal of the ovaries, a very common cancer done for ovarian cancer, of course.

00:13:04:00 – 00:13:28:22
Unknown
And if you look at the information that we found, looking at this particular surgery, we find that 50% of women who undergo this particular operation get a hernia. That’s a lot of folks. And then if you look at that bar graph up and down, look at the different types of cancer surgery. The yellow shows the percentage that actually who actually developed a hernia.

00:13:28:24 – 00:13:51:07
Unknown
And the overall blue is just the percentage of the study population. So you can see a lot of folks end up getting these hernias after lifesaving cancer surgery. Well, then the question we asked was, well, what about minimally invasive surgery? Robotic surgery or laparoscopic surgery would kind of make sense that if we’re making smaller incisions, there should be a less chance of hernia formation.

00:13:51:09 – 00:14:24:04
Unknown
And in fact, there is there is certainly less chance of hernias coming about after those minimally invasive operations. But it’s not as small as you think. For example, for urologic and gynecologic cancers, which we combined together in this way of analyzing it about 13% of the time, even after a laparoscopic small incisions, cancer or hernias did form. And sometimes what surgeons will do is make a slightly bigger incision, for example, to remove the uterus or something like that.

00:14:24:06 – 00:14:55:13
Unknown
And then that leads to also a higher hernia risk. So if you look at this on a global scale and just do a little bit of a calculation here, the issue becomes quite staggering in focus. So this is information of the worldwide estimated new cancer incidence in 2018 put out by this international group. So that amounts to at that time, just over 7.3 million total patients with cancers that might require a surgery.

00:14:55:15 – 00:15:20:13
Unknown
And then let’s just say about 50% of those patients undergo life saving surgery for the cancer. And that leaves about 3.7 million patients. And then if you take that information, we learn from that study we performed, 41% of those patients will get hernias. That means about 1.5 million patients who undergo these lifesaving cancer operations across the globe will get hernias each year.

00:15:20:15 – 00:15:47:04
Unknown
So just kind of putting that also in summary form here. So that’s one and a half million patients will develop a hernia after cancer surgery every year. So that number accrues as more and more folks undergo these operations. And about 826,000 patients will have an operation for the hernia every year. So it really is a problem that probably deserves much more recognition.

00:15:47:06 – 00:16:08:22
Unknown
And also, this leads us to look and see, you know, what are the better ways? Number one, we can treat these hernias, but also how can we prevent them in the first place? So if you have a hernia, what are some typical symptoms? What patients can get pain bulges. And the other thing that’s probably not quite out there that should be is that it’s a reminder of the traumatic experience that you have been through.

00:16:08:22 – 00:16:30:15
Unknown
I mean, it’s a lot having undergone the care and the therapy that many of you have been through. And sometimes when hernias are the most visible thing you see on a day to day basis, it’s a reminder of that experience. On rare occasions, you can get bowel obstructions or blockages or even very, very serious emergency conditions where something gets caught up in the hernia and might need an emergency surgery.

00:16:30:15 – 00:16:51:09
Unknown
But overall, that’s pretty rare. So I want to shift focus a little bit in terms of how to maintain optimal core health during cancer care. One of the probably negative consequences of our health care system, especially here in the United States, is we’re way to compartmentalize ideal just in problems of the interior or the front part of the abdominal wall.

00:16:51:13 – 00:17:15:00
Unknown
And of course, when you come see me, I’m I think that’s the problem. Well, if you see a pelvic floor specialist and I think that’s a problem or diaphragm specialist or back specialist, and that’s a problem because all of these areas kind of the the narrow way that we see set up our specialty practices can sometimes be harmful to U.S. patients because we don’t think holistically.

00:17:15:02 – 00:17:33:10
Unknown
We learn something from working with our physical therapy colleagues in developing this concept of abdominal core health. And so what we do is find the core musculature is really as the diaphragm on top of the pelvic floor, on the bottom, and then the abdominal wall and flanks everywhere else. I mean, this is kind of common sense and it’s almost ridiculous for me to mention this.

00:17:33:10 – 00:17:59:06
Unknown
But from a health care perspective, it’s kind of a new concept that these are all interconnected physiologic components that function as a unit to help you get through your day. And if you look at the nine areas of cancer survivorship and then if you develop a hernia, it’s kind of interesting. A hernia can impact of five out of those nine areas of cancer survivorship, which is an impactful thing.

00:17:59:08 – 00:18:27:10
Unknown
So when we look at this idea of core health, we think of the stability function and quality of life involving the core musculature. And then how can we maintain core health? Certainly exercise is helps. Physical therapy can be immensely beneficial. Medical therapy is often employed, including use of compression garments, binders or trusses. Those kind of things. And then alternative medical therapies, including acupuncture or yoga, can help.

00:18:27:10 – 00:18:55:08
Unknown
And of course, abdominal surgery, hernia repair commonly, and then measures to prevent disease. And how can we prevent hernias from forming in the first place? So what does surgery involve? I won’t get into too much detail in this, but suffice to say that really the big split occurs between small hernias and larger hernias. Small hernias or small holes in the core muscle can sometimes be repaired just with stitches without using mesh, but sometimes they require mesh repair as well.

00:18:55:10 – 00:19:18:09
Unknown
Patients can usually go home the same day and recovery is about 2 to 3 weeks. You kind of contrast that with with patients having larger hernias that are much more impactful to their quality of life. These patients commonly need more formal techniques such as abdominal wall reconstruction, to fix these hernias. Usually, patients need to stay in the hospital for a few days and the recovery is a bit longer, about 4 to 6 weeks or so.

00:19:18:11 – 00:19:42:08
Unknown
Well, what about mesh? And so this is a very common question that we face as hernia surgeons and patients trying to decide what the best thing to do is. There are different types of meshes overall, and mesh is generally speaking, are recommended to do especially the larger repairs, and they fall in different categories from different origins of of the the mesh itself.

00:19:42:10 – 00:20:07:00
Unknown
There are permanent synthetic meshes that are meant to stay for the rest of your life, actually. And these are made out of three typical components of polypropylene or polyester, or a standard poly tetra for athlete, which is really Gore-Tex. And then there are resolvable meshes that are also engineered, but not made out of some type of plastic components that are designed to resolve over time or go away over time.

00:20:07:02 – 00:20:34:18
Unknown
And then there are meshes derived from biologic sources. Collagen layers from abdominal walls from animals basically is one source of that. And then there are hybrid versions that combine the top to the three materials that you see there. So why use mesh in the first place? There’s definitely a trade off the benefits, really. We do know that using mesh for hernia repairs for most hernia repairs do reduce the chance of the hernias returning after the repair.

00:20:34:20 – 00:21:00:09
Unknown
The downsides Patients can have serious problems with these meshes includes infection and pain issues. And it’s sad to say that I think sometimes our health care system minimizes these issues when they come up, and I think it’s important that we have to recognize that there are some downsides to using mesh. As for these for your repairs, and then I’ll just kind of end with some of the important question that really, really need answers.

00:21:00:11 – 00:21:30:24
Unknown
And I think one of the things that it’s important worth noting, the amount of research that goes into hernia care is far from lagging behind several other areas and probably out of necessity. But I think it’s one of those things, especially when we’re talking about cancer survivorship, that we need more funding overall just to help answer some really, really basic questions, Can we can hernia repair, improve pelvic floor function, pulmonary function, lower back pain?

00:21:30:24 – 00:22:03:09
Unknown
In other words, are we doing something other than just fixing the hole there? And here’s something that’s really, really important both to our own efforts that we’re looking at our own research lab and certainly to all of you. Does hernia mesh contribute to cancer formation or cancer progression? This is an unknown. Again, we think the chances are low, but we kind of need to identify what that chance is and then finally, can mesh use, cause adverse immune system modulation or autoimmune issues or trigger autoimmune issues.

00:22:03:11 – 00:22:22:23
Unknown
I think these are critical questions we have to answer that US patients, we owe it to you to help find some of these answers for you. So the key takeaways, number one is that breast and gynecologic cancer and hernias are much more frequent than I think we thought at 41% of the time. Developing is at two years after surgery.

00:22:23:00 – 00:22:48:19
Unknown
Maintaining abdominal core health during cancer care can involve multiple types of treatments, not just hernia repair, but certainly that’s something we do fairly commonly. And then finally, we highlighted some critical questions that still remain unanswered that we need to answer to help care for you in your cancer survivorship journey. So thanks again, really, really enjoyed chatting with you about this.

00:22:48:21 – 00:23:27:10
Unknown
Look forward to the discussion and thanks again for the opportunity to be here. Thank you. Dr. Poulos on the presentation. And now we like to hand things over to Andrea and Gwen to give their personal experience with having hernias. And Gia, would you like to go first present first? Sure. First of all, that was a thorough and fabulously enlightening presentation by Dr. Peluso.

00:23:27:12 – 00:23:55:23
Unknown
You know, I learned a lot and I am still stunned by some of it. My ovarian cancer diagnosis in July of 1996 led to two fold full laparotomy. So I guess that would have been the open that little the light pink on his graph there. The first was my initial 14 hour side of reductive surgery and the second about a year and a half later, the surgeon went the opposite way around the belly button.

00:23:56:04 – 00:24:29:01
Unknown
So I had a little donut that was part of a clinical trial in about 2012. So some 15 years later, after my original diagnosis, I learned during my annual visit to my wonderful gynecologic oncologist who was not my original surgeon who I adored and not the clinical trial surgeon whom I respected. And I learned that I had two surgical hernias he could feel upon a physical exam.

00:24:29:03 – 00:25:08:01
Unknown
Essentially, it was a low key revelation. Andrea, He said, Do you know you have two surgical hernias? I did not. I did not. What I did know was that I have as many of us do, a ginormous incision and no omentum. So, you know, that’s a change in the physical appearance of your abdomen. And, you know, and the imagine being that that infamous storied fatty apron that holds the tissues in, you know, I’m sure that the police is familiar with the technical term, tissues of intestines, organs.

00:25:08:03 – 00:25:46:16
Unknown
So I had gone back to the gym and occasionally, but not frequently, I experienced a sharp, temporary. It was almost like a freeze of my abdominal muscles. But, you know, went away, you know, and it wasn’t always with me. And I thought, all right, maybe this is due to adhesions. Maybe it’s due to the fact that the organs that were left are rearranging themselves and finding new, new ways to be together, you know, and but then, you know, hearing about these hernias, I thought, well, maybe this is something I should investigate because maybe it will get worse, maybe it won’t.

00:25:46:16 – 00:26:15:14
Unknown
I don’t know. So I asked my going on and he recommended seeing a general surgeon, which I did. I saw a conservative general surgeon. He examined me, ask questions, and he concluded that being as I was not really experiencing a routine discomfort and more significantly, I didn’t have organs or intestines poking through, getting caught, being at risk for becoming necrotic.

00:26:15:16 – 00:26:38:21
Unknown
He said he wouldn’t be running after me to have surgery. I also asked if the repair, if it were to be done, you know, could you do it laparoscopically or, you know, a few holes here? And and the answer was, no, I’d have to fully open you up. And I was like, No, thank you. No, thank you. You know, having been through two laparotomy, I was like, Well, that’s good that I don’t have, you know, some serious stuff going on that’s sealed the deal.

00:26:38:23 – 00:27:30:22
Unknown
I still routinely go to the gym pretty much every day and total body conditioning Zumba weights provides yoga. I think, you know, my core has gotten stronger and I’m doing okay so far. So, you know, it worked out for me. That’s it. Handed over to my good friend Gwen, whose story is very different. Yeah. yes. Okay. So I was diagnosed in 2005 and I reached my first remission in the that by 26 I was, I was finished with my chemo and what have you and shortly thereafter, words I actually by that Christmas I all of a sudden developed this small hard lump in my abdomen, which freaked me out because I thought it was

00:27:30:22 – 00:27:54:01
Unknown
cancer coming back. I thought, my God, you know, like we always do when you get to your first remission. And it turned out that, no, it was an abdominal hernia associated with my surgery. And at that point in time it was fairly small. And I did talk with a surgeon about it and she wasn’t going to rush to surgery.

00:27:54:03 – 00:28:21:21
Unknown
You know, we talked about it for a while and we talked about the pros and cons, some of the concerns I had were if I had surgery again, would that trigger the startup of my cancer again? You know, because I’m assuming that there’s still some cancer cells around. I was worried about, well, if I recurred, would they be able to do surgery again for a second debulking if if that were warranted?

00:28:21:23 – 00:28:56:23
Unknown
And the other thing was I just you know, I was tired of having surgeries. I really didn’t want another surgery. So we waited. And after a while I gained confidence that, okay, I’m not recurring yet. And so I went ahead and I decided to get the hernia repaired because it seemed like it was getting bigger. And in my case, my first hernia repair, I had several small in in the end they described my my abdomen was Swiss cheese, that it wasn’t just the one hernia that they knew about, that there were several in there.

00:28:57:00 – 00:29:23:13
Unknown
But I was starting to get a case of where intestines were starting to point out or push out, and it would get caught in, you know, I turn a certain way and I would get a really sharp pain. And as long as I could push it back in, then I wasn’t at risk for anything further happening. But I was always worried because I needed to be within 15 minutes of a hospital in case I couldn’t get it back in.

00:29:23:15 – 00:29:47:09
Unknown
Because once you have it sticking out and you run the risk of a strangulation in after about 15 minutes, then your intestines can start to die. So I said, Yeah, I don’t want to be talking about this for the rest of my life. So I went ahead and I had the surgery and at the point that I had the surgery, they figured out since they’re in there, they’re going to go ahead and look to see if I have any signs of ovarian cancer.

00:29:47:11 – 00:30:13:06
Unknown
And if they did, then they wouldn’t do this hernia repair. They’d address the cancer and we’d go on from there. Well, they didn’t see any cancers, so we did the hernia repair and it was laparoscopy and they were able to put admission in and cover up the hernias, repair all of them. And then lo and behold that was in November of seven.

00:30:13:06 – 00:30:34:01
Unknown
And by January of eight we knew that I was recovering and ultimately in May of eight, I had a second debulking surgery, which meant that they were cutting right through that mesh. And I’m thinking, my God, you know, here we go again. And I was more worried about the cancer focused on that at that point.

00:30:34:07 – 00:30:59:10
Unknown
But lo and behold, about six months later, I developed a hernia again, and I really didn’t want to go through another hernia repair because that was actually more painful than my debulking surgery. I know everybody’s experiences are different, but that for me it was a lot harder. And so I held off and I waited and waited and waited.

00:30:59:14 – 00:31:34:09
Unknown
And I waited until it got really big. And the original surgeon that I had didn’t feel comfortable doing the surgery. So she passed me off to one of her her colleagues. And so that one I ended up doing as a laparotomy so some days and cut me open and hoping that that would be my last surgery ever. And for me that was an important thing because by that time it had become a real quality of life issue for me, that there was more than one hernia.

00:31:34:11 – 00:31:52:16
Unknown
And the biggest one was such that my intestines just wouldn’t stay in. I’d stand up and go for a walk and I’d have to hold my my belly, my intestines in with my hand. I mean, that that’s no way to to be moving around. So I decided, okay, I’m going to go for broke and go ahead and do this.

00:31:52:16 – 00:32:19:12
Unknown
And I did. And so far I’m good. I’m trying to think of some of the other questions you guys had. I did at one point in time for both of the surgery before I had either one of the surgeries. I did try and use the binders. And for me, because of the shape of my body, it just wasn’t working.

00:32:19:12 – 00:32:46:01
Unknown
It wasn’t holding it in effectively. And I tried several different binders and different ways of doing it. And it just it wasn’t working for me. So that really wasn’t a help in trying to avoid the surgery, trying to think if there’s anything else, do you want to go ahead and open it up for questions and answers and see if there’s something we missed that that people are interested in?

00:32:46:03 – 00:33:26:03
Unknown
Should definitely open it up for Q&A. We have several questions that were pre submitted with as well as, you know, live submitted questions and you still have time audience to all participants to submit questions. So at this time, first question, doctor palooza is is there anything you can do to avoid hernias or needing surgery because of one? So is there anything you can avoid doing or preventing it?

00:33:26:05 – 00:33:49:15
Unknown
And Yeah, or preventing it and avoiding surgery? Okay, If you have a hernia, let’s just take both of those scenarios. So yeah. So if you if you say you have a hernia, is there anything you can avoid doing to prevent it from getting worse or becoming more symptomatic? Yeah, I mean, I think everyone’s experience is a little different.

00:33:49:15 – 00:34:12:13
Unknown
When you have a hernia, sometimes, you know, you it doesn’t affect you a whole lot. And as I think Andrea nicely said, you can get on to most of your life. You just have to kind of test out and see what works, what doesn’t work. And if you’re able to do 90% of what you need to do, then I think, as Andre, your surgeon advised you, that’s pretty sound advice.

00:34:12:13 – 00:34:43:01
Unknown
Probably you should be better off holding off on repairing it. On the other hand, if you’re like Gwen and you’re having to hold your intestines. Tricia Yes, I added that to my ambulatory. Now if you’re having to hold that just to kind of get by from a day to day basis, that’s a different story. And I think, you know, you clearly have to have to do something about that, you know, so it’s a live question that was submitted.

00:34:43:03 – 00:35:09:13
Unknown
Would a ventricle hernia repair interfere with a future liver biopsy? Yeah, I can weigh in on that. It depends. Often it really depends on the location of the hernia and the extent of where mesh might have been placed. So if it’s away from the area where their liver is, which is kind of on the right side of the upper part of your abdomen, then no, it shouldn’t.

00:35:09:15 – 00:35:44:17
Unknown
On the other hand, if the hernia repair or the hernia itself is in that area, then there needs to be a conversation between the hepatologist performing a liver biopsy, a radiologist and also a hernia specialist just to figure out the easiest way to do the biopsy. I someone else as can. Can you discuss a little bit about hernia belt versus the surgery by I’ll tell you the expert I’ll probably be Gwen on that one.

00:35:44:19 – 00:36:19:05
Unknown
Yeah. For me, it didn’t work. I mean, it is certainly worth trying if you develop a hernia and you’re certainly wanting to avoid the surgery, certainly worth trying. But for me, the belt just didn’t hold it in and I was still is. Part of it is because the belts would slip around. You know, part of it is probably the shape of my body because I was I’m larger, but it just didn’t it didn’t it couldn’t mesh right.

00:36:19:05 – 00:36:49:24
Unknown
It couldn’t push down right. To actually hold in my belly. So for me, it just didn’t work. I think some of it will depend on the shape of your body and where the actual hernia is located. My original hernia was higher up the the ultimate one was all over the place. I mean, I had I had little ones and big ones and it just was a mess.

00:36:50:01 – 00:37:13:12
Unknown
Yeah. The other piece of information that it might be worth chatting about is you don’t necessarily have to limit yourself just to the typical hernia binder, which as Gwen mentioned, it can be cumbersome to put on there made of nylon. It’s kind of scratchy and stuff like that. Spanx or similar type of things. They work pretty well for some women.

00:37:13:14 – 00:37:44:14
Unknown
But Andrea, is it you want to chime in a little bit about use of Spanx and stuff? You’re muted. Okay. I’m sure you know, you know, I started wearing shapewear when because of the omentum, like I always, you know, discussing the groups. You know, we talk about omentum friendly clothing. You know, So I like to show off my strong leg muscles and I wear blousy tops.

00:37:44:16 – 00:38:10:08
Unknown
And I started wearing like shapewear. You know, you can get some pretty good deals in Marshalls and TJ. Max and I have an entire collection and I and I like I like them, you know, and maybe it’s helped, you know, because they go pretty high up. They go right under my bra all the way down. And, you know, I try to get, you know, you know, so it’s just a woman’s idea.

00:38:10:10 – 00:38:40:04
Unknown
So thank you for that both off answering that question. So this person is asking, when is it because I know you may have covered it’s already that the balloons and I think Andrea is well during her presentation, But this person wanted to know when it is best to have the hernia repair surgery. You know, if the bulge grows or pain when you’re having pain.

00:38:40:06 – 00:39:06:22
Unknown
And do they all hernias cause pain and will grow at some point. So it’s like a three part question. Sure, sure. Yeah, I can I can start answering this one. So not all hernias will cause pain or will cause pain that would require you to do something about it. Everyone’s a little different in terms of your own body and how it interacts with the hernia.

00:39:06:22 – 00:39:34:14
Unknown
It’s kind of a weird thing to think about, but there are certainly many patients, as Andre explained, where you have a hernia and it doesn’t really impact what you do too much. And it may stay like that for several years. On the other hand, there are a lot of patients in one scenario where the hernia is rapidly changed, get bigger, you might undergo a couple of repairs and then you finally find a repair that works.

00:39:34:16 – 00:40:00:14
Unknown
That’s, you know, I’m glad we have our two patients with these two very different stories because I think you both are very representative of those two categories, which the treatment is very different. You know, one of the things they talk about, you know, how do you prevent and stuff, You know, when you do your first debulking surgery, one of the things they tell you is don’t pick up anything more than £5 and don’t do this, that and the other.

00:40:00:14 – 00:40:25:15
Unknown
And I think I probably pushed a little harder than I should have. And if you have constipation, you know, you’re pushing on those same abdominal muscles and you can you can start to develop hernias as a result of of using those muscles. On the other hand, the other thing that I was told was basically not to do abdominal exercises.

00:40:25:15 – 00:40:49:15
Unknown
And I know that that has changed since I had my repairs, that the the importance of developing core muscles, again, is something that at least some doctors are promoting now and that that can help maybe prevent either it getting bigger or not. But the biggest issue, though, is if you had this for me, the painful ones were the small ones.

00:40:49:17 – 00:41:10:17
Unknown
Now, the big one wasn’t painful. It was just obnoxious to have to hold it. My guts kind of felt weird walking around holding my intestines, but the the small ones, I would turn every now and then and something would poke out. And it was excruciating pain right at that point. And I play around with a little bit and push it back in.

00:41:10:17 – 00:42:00:18
Unknown
And then I was pain free again. So. So this next question is to me for both Gwen and the doctor glues. So this person is asking what year, when did you have the second hernia repair and, and, and someone else wanted to know, can the hernias come back or can you develop a hernia several years later? Okay, I’m trying to remember my first hernia repair was in 2007, and the second one I think was more like 2011 or 12 because I was worried.

00:42:00:19 – 00:42:33:11
Unknown
I after I had the second when I had my recurrence, I really was trying to avoid ever having another surgery. And so I waited longer than I probably should have to have that second repair. I’m sorry, what would they want to know when and they want to know, Can you have it develop later? If I had were from two separate surgeries, so it wasn’t just a case of where it it was triggered, you know, by the same surgery.

00:42:33:15 – 00:42:58:21
Unknown
I had one surgery developed hernia from that, got it repaired, had a second surgery, developed hernias, got that repaired. And so far I’ve been fine. The mesh worked. You know, I don’t know what the percentage of of of cases where it doesn’t work. And I was told that sometimes it doesn’t work. But so far for me it’s worked and it’s been a lot of years.

00:42:58:23 – 00:43:23:00
Unknown
Yeah that’s great that, you know, I’ve had a pretty good outcome, especially after the experience. You’ve had such a lot of surgery, no question. So we do know if you look at the information we’ve gathered over time, we do know that the longer you go after the repair, the higher chance ever so slowly of the hernia coming back overall.

00:43:23:02 – 00:43:44:15
Unknown
Yeah. And we’re actually rethinking our way on how we advise patients and how honestly, even even surgeons set their own expectations about things. If you kind of the best analogy I can give you is if you chat with our orthopedic colleagues or many of you may have had knee replacements or hip replacement, they don’t tell you they don’t talk to you in terms of, well, it’s going to be fine forever.

00:43:44:18 – 00:44:07:19
Unknown
No, they’ll tell you. Well, we’re hoping to get ten, 15 years out of this. What we’re learning is these core muscle operations, because they’re just as dynamic areas of your body as knees or hips or things like that. There is a time, again, just like hip replacement knee replacements, they can fail over time. A lot of patients get pretty durable results on a long term basis.

00:44:07:21 – 00:44:39:13
Unknown
But just like any other body part, there is some wear and tear involved going. Also to the other question about can you develop a hernia later on after the surgery? Yeah. So even if you haven’t had a hernia operation, you’ve just had your cancer surgery, the longer you go. Yes, a slightly higher chance of the hernia forming. But if you’ve gone through about 2 to 5 years after your original surgery, the chances then kind of stabilize is it doesn’t kind of increase dramatically after that.

00:44:39:15 – 00:45:17:13
Unknown
So if you’re about 2 to 5 years out of your original surgery, you don’t feel much of a hernia. You should be in pretty good shape. You know, Andrea, there’s questions for Andrea in terms of exercise. I know you mentioned exercise during your presentation. And just so this person will like to know what exercise that you’ve been doing, has it have the hernia from getting bigger and you know, this person is afraid to do certain exercise exercises, in particular yoga, because of you know, it deals a lot with, you know, the core.

00:45:17:15 – 00:45:57:00
Unknown
Right. What is those two? And I will defer to Dr. Lewis on whether or not something can get bigger. In my personal experience. And like I say, every day is a different class. Michael Plank I do Kakao, I do yoga, I do, you know, in Pilates, I’ll be honest with you, I don’t think I’m ever going to do a full teaser, but I might do a half teaser and I might do a mock teaser, you know, and I’m careful because, you know, a lot of times I’ve noticed that with the leg kicks, you know, I can do bicycle and I can work, you know, the the lateral muscles as well as the right down the

00:45:57:00 – 00:46:20:14
Unknown
middle stomach muscles. But sometimes I’ve noticed if I if I keep my leg straight and do just the up and down which some of the instructors do, I feel something. And it was just so funny because I was at an NGO conference with my going on. If you told me about the hernias and I said to him, Do you think I, you know, I’m having this pain now, do you think?

00:46:20:16 – 00:46:44:18
Unknown
Because yeah, it might be, but, you know, you didn’t do anything the first time you got to do something. So now I just watch it. If I feel a twinge, if I feel pain, I stop doing what I’m doing and I do something else. That’s an aerobic exercise. Never a problem. I do several rigorous Zumba, urban Zumba, you know, I know all the music that’s going on now with the young people because of that urban Zumba class.

00:46:44:23 – 00:47:12:07
Unknown
But maybe Dr. Lewis wants to address the whether it will get bigger with certain exercises. And I do. Yeah, I’ll Tell you, this is probably the most ignored to date, the most ignored piece of information that all of you need to know. As Gwen mentioned, you know our instructions of what we recommend to patients after surgery. They’re archaic.

00:47:12:07 – 00:47:56:03
Unknown
They haven’t changed for 70 years and they need to change drastically. We’re now beginning to gather information that what common sense is probably. Have you guys all figured out your own dose? You’ve got surgery. Is that. Yeah. After the first couple of weeks after surgery, you know, you need to take it easy. Not too many crazy things. But after that time period, I think we need to be more aggressive about maintaining some strength and some core, some tone to our core muscles, because after a certain time point, if you don’t exercise your muscles and I’m not talking about doing £500 squats, I’m talking about doing just amount of exercise you need to do, that’s low

00:47:56:03 – 00:48:36:09
Unknown
impact. That helps your muscles heal. Anyone of us who’ve gone to the gym or seen people lift weights or weight trainers, we know that to build muscle you have to break it down a little bit and then have it rebuilt. It’s a very common known thing about how we build muscle mass and we can take advantage of that after a surgical intervention by timing the exercises correctly and by doing the right exercises, I put in as an answer to one of the questions, Sorry, I couldn’t do that very quickly, but we have an app on our collaborative the Abdominal Core Health Quality Collaborative that you can download.

00:48:36:09 – 00:49:00:08
Unknown
Actually, it’s AC HQ, Korg, and basically we’ve worked with several physical therapists across, I think four or five different institutions and come up with an app where after any abdominal surgery you can dial in the phase of your recovery and then it’ll recommend some exercises. Cat Tickle was on there actually. Andrea And it’s very similar exercises to that.

00:49:00:10 – 00:49:27:16
Unknown
So this is something that I think as surgeons, we’re not doing as good a job as we can on advising patients on the exercises you can do to maintain your health after surgery. Appreciate both of you. What was the name? What was the address again, for the exercises. yes. A.c.h. QC dot org. Okay. And then just download the app.

00:49:27:16 – 00:50:01:10
Unknown
I think it’s called in the bottom. Download the app, select it. Europaischen it and you’ll see the whole problems come up. Okay. This next question is related to someone who has an umbilical cord and incisional hernia and they were wondering if what positions would make them, you know, put them more at risk in terms of and we just talked about exercises, but also also like lifting grandchildren and things that they should avoid.

00:50:01:12 – 00:50:19:24
Unknown
Boy, I’ll tell you, if there’s one thing I’ve learned in my clinical care is I’m never going to tell a grandma to not look their grandkids or a mom, not to live there. It’s just like I’d be out of business, like really fast. And it comes back to, of course, you know, you don’t want to hurt your core muscles.

00:50:20:01 – 00:50:44:07
Unknown
And so I think there’s a couple important takeaways. The first is, yeah, you can live with hernias and you know, a lot of times the advice as physicians would give you is overboard on the conservative side somewhat. You know, your primary care physician may detect a small belly button hernia that you’re not having any symptoms whatsoever. And the instructions to you are don’t pick up your kids, don’t think of your grandkids, Don’t laugh, don’t do it.

00:50:44:13 – 00:51:05:24
Unknown
That’s your whole life. You don’t change your whole life because that so reality in between there where if you’re able to do the things you need to do, that’s all. Okay. Some tips I do give grandparents and parents is that especially for toddlers, they like to like bang on their bellies and stuff like that. So and we also want to pick them up from a standing position.

00:51:06:01 – 00:51:22:05
Unknown
One thing, if you are having symptoms from a hernia that you can do is just be creative on how you pick up your kids or grandkids. If they’re toddler age or above, they can usually climb up on a chair or a sofa. Then you scoop them up on the side as opposed to bending your whole torso and lift.

00:51:22:11 – 00:51:54:16
Unknown
So small little things like that. Physical therapists and occupational therapists are really, really good making those recommendations. You can help. Just out of curiosity, do you recommend for your patients when you have hernia repairs almost 90, 95% of the time now? I wish they had done that for me. It’s a newer concept though, and again, one of those things that we’re just trying to get a better message out there.

00:51:54:18 – 00:52:08:23
Unknown
So this next question this person is asking, does fiber, does your diet in terms of fiber intake affect, the hernia?

00:52:09:00 – 00:52:50:02
Unknown
I’ll let our patients answer that one. Yeah, I’ll check. I mean, I you can ask five different doctors and get five different answers. That’s why I let you answer first, because I see. For me, that’s been an important question because I have had abdominal blockages. And, you know, we get told, though, low fiber diet, which means those whole horrible green canned green beans and white bread, I and but what I have found for me is it’s more important to just keep your bowels moving, whatever it takes to keep them moving.

00:52:50:04 – 00:53:19:06
Unknown
And it’s important to include vegetables and fruit. And ultimately, the way I look at it is you eat what your body needs. I mean, you the point is to put your body in the best possible position to address the things that it needs to address and fiber is part of it. You know, if I start to get a blockage, I back off on food and I drink more water.

00:53:19:08 – 00:53:41:19
Unknown
If I’m constipated, then you know that that’s something that can aggravate hernias. It’s not because I was eating something. Well, it is because I eat something particular sometimes. But, you know, eat what you need to eat to make sure your bowels are moving is what it really comes down to. I think. Boy, Gwen, I think I wish I had a tape.

00:53:41:19 – 00:54:05:16
Unknown
What you said, I guess this video, because that needs to be sent to every physician who manages patient’s hernias. You said it was. I really did ask five different people. I got. I don’t doubt that. It’s like the Wild West to get an answer for that. Yeah. And I eat a lot of fiber and I have to drink more water.

00:54:05:16 – 00:54:35:16
Unknown
I have to remind myself to hydrate and those different things because. Yeah. And it’s, you know, the happy system. Yeah. So one also wanted to know, can does the bulge ever go away? Does the surgery take the bulge you know, away? The Bulge won’t go away on its own, but if you have a hernia repair, then at least in my case.

00:54:35:16 – 00:54:56:14
Unknown
Yeah, the bulge just went away. Yeah, a little bit. That depends on the location of the hernia. If it’s a hernia on the front part of your abdomen, you kind of get the best result of the bulge for the large part going away. What’s a little trickier are hernias on the sides of the core muscles in the oblique musculature on the sides.

00:54:56:16 – 00:55:19:18
Unknown
Those often when you the hernia forms they often are associated with some what’s called innervation, meaning that the nerves firing inputs into the muscles because of the original surgery just don’t work as well. And so no matter what you do to try to stitch up the muscles or use meshes, you’ll always have a little bit of asymmetry comparing to the other side.

00:55:19:20 – 00:55:55:23
Unknown
So that’s just something to kind of be aware of. So location does matter a little bit. Thank you. So we have time for one more question, and this might be for Dr. Luce. So I know the patient at Grace, they’ve been very informative today, but this person would like to know with having the mesh for the hernia repair surgery would it cause, you know, more difficulty or any difficulty with future surgeries in particular that deals with having a recurrence for cancer?

00:55:56:00 – 00:56:16:17
Unknown
Yeah, this is a really, really important question. I’m glad we’re talking about this. The short answer is yes, it does. It can make it more challenging just to re access the abdominal cavity or even the pelvis. A little bit of it depends on the location or if mesh was used, which is typically the case and the location of the mesh.

00:56:16:17 – 00:56:54:20
Unknown
There are different layers in the core muscles. You can place meshes, you can even place it inside the abdominal cavity. So that has a little bearing on it to the meshes that are placed outside of the abdominal cavity tend to be a little bit easier to go back in if necessary. So yes, that is an important consideration. And if you are considering or have the need to have another surgery for recurrent cancer, most of the time, that should be a multidisciplinary type of situation where your cancer surgeon works on an abdominal wall specialist and they kind of sort that all out at the day of the surgery.

00:56:54:22 – 00:57:24:01
Unknown
Thank you. Since you know, this time. Thank you so much, Dr. Pierre-Louis, Andrea and Gwen, for your thoughtful and thorough answers to the questions. We’ll have the recording for this program available on our website. And 1 to 2 weeks. Please make sure to check your shoes website for upcoming Educational outcomes. Website for upcoming educational programs. Hi has episodes and support groups and forget to follow us on social media.

00:57:24:01 – 00:57:32:13
Unknown
This concludes our webinar for today and thank you again, Dr. Poulos, Andrea and Gwen, and I hope everyone has a wonderful day.

00:57:32:15 – 00:57:35:08
Unknown
Thanks, everybody. Bye bye. Thank you.