Women & Minimally Invasive Hernia Repair with Heather Evans, M.D.

Surgery is the only method that can effectively treat a groin hernia, and there are more than one million hernia repairs performed in the U.S. every year. But not all hernia surgeries are the same, and there are different considerations when it comes to treating men and women with this condition. Heather Evans, M.D., is a professor of general and acute care surgery at MUSC Health and discusses her work and research in the area of minimally invasive general surgery, including laparoscopic hernia repair and how it pertains to women's health.

“Those of us who do hernia repairs in women are suspicious that there probably are a lot of women out there that have hernias that are attributed to pelvic pain, and they just haven't been diagnosed yet or they've been misdiagnosed. … This is a real challenge for practitioners, because I think it's been underappreciated in women in general, particularly because women have been excluded from all the major clinical trials about hernia.”

- Heather Evans, M.D.

Topics covered in this show

• Men are more at risk for developing hernia, and a quarter of men will develop a hernia in their lifetime. Women can go undiagnosed for hernia, as their symptoms usually present as pelvic pain, which can be attributed to many other things. It is a challenge to determine who has a hernia and who does not.
• There are many kinds of hernia, including inguinal hernia and femoral hernia. Men are susceptible to inguinal hernia and women are susceptible to femoral hernia.
• Hernia will often present as a bulge in men, while in women it often presents as pelvic pain. Dr. Evans believes hernias are underappreciated in women, particularly because women have been excluded from all the major clinical trials about hernia.
• A retrospective study in Sweden that looked at 40,000 patients over five years found that women were more likely to require emergency surgery for a hernia. Preventing these emergency situations in women is difficult because doctors don’t know who is at risk for these types of hernias because they haven’t studied it sufficiently.
• The gold standard hernia repair for open repair is called the Lichtenstein Repair. Most general surgeons in the United States have trained and learned how to do this operation, and it was the standard of care for many years. In recent years, hernia repairs have been performed laparoscopically and most surgeons are trained to perform laparoscopic hernia repairs these days. With new technology, including robot assisted laparoscopic hernia surgery, Dr. Evans feels that her surgical technique has evolved and she can do much less dissection, which she hopes will decrease the incidence of chronic pain after hernia surgery.
• People with asymmetry in their groin area should be checked for hernia. Different scans, including ultrasounds and CT scans, can help reveal the hernia. This is helpful to show the patient, so that they can see the problem and make better decisions for their treatment.
• Seeing patients fully recover after hernia surgery and report that they no longer have pain is very rewarding for Dr. Evans as a surgeon.
• Dr. Evans also performs abdominal wall reconstruction for patients whose hernias may compromise aspects of their core functionality, which can lead to back issues and more. It is not performed as much as other hernia surgeries, but can be necessary for some patients to return to normal function.
• Dr. Evans uses mobile health to help monitor surgical wounds remotely, using photos and other remote methods to track the wounds. She used her knowledge about mobile health applications to help with surging telehealth needs at MUSC after the initial onset of COVID-19, where they started to track symptoms of people who tested positive for COVID-19.
• Advances in telehealth at MUSC have been exciting, and helpful for patients who would otherwise have to travel long distances for appointments that can now be done remotely, thus saving the patients a lot of time and hassle.
• If you think you have a hernia, get it checked out to try and avoid a large surgery.

Read the show transcript below

Erin Spain: [00:00:03] Welcome to Advance MUSC Health. I'm your host, Erin Spain. This show's mission is to help you find ways to preserve and optimize your health and get the care you need to live well. Surgery is the only method that can effectively treat a groin hernia, and there are more than one million hernia repairs performed in the U.S. every year. But not all hernia surgeries are the same, and there are different considerations when it comes to treating men and women with this condition. Dr. Heather Evans is a professor of general and acute care surgery at MUSC Health. She's here to discuss her work and research in the area of minimally invasive general surgery, including laparoscopic hernia repair and how it pertains to women's health. Welcome to the show, Dr. Evans.

Heather Evans: [00:00:51] Thank you. It's so nice to be here, and I'm delighted to get to talk about this, which I think is a really important issue for women.

Erin Spain: [00:00:58] Well, let's talk about that. When we think of hernias, we often think of men with this condition. So explain to me what are the most common types of hernias and who really is at the most risk of this condition?

Heather Evans: [00:01:09] Well, men certainly are at higher risk for developing hernia. In fact, we believe that almost a quarter of men will require a hernia repair in their groin in their lifetime. So that's a huge number of people. In terms of women, it's much less common. However, those of us who do hernia repairs in women are suspicious that there probably are a lot of women out there that have hernias that are attributed to pelvic pain, and they just haven't been diagnosed yet or they've been misdiagnosed. So one of the challenges that we have as hernia surgeons is trying to figure out who actually has one, and there are different kinds of hernias in the groin. The most common kind of hernia in the groin is called an inguinal hernia. And men are susceptible to this. There are two different kinds of inguinal hernia. One goes through the area where the testicle passes through into the scrotum as you're developing in utero, as a little baby. In some people, that tract never fully closes down after the baby's born, and so they are left with this pathway that's kind of open. A lot of premature infants need to have early hernia surgery because of that. Now, I don't see those patients. I tend to see people that, for whatever reason later in life, develop a swelling or a bulge or pain in their groin. And those are the three most common symptoms that particularly men will see when they develop a hernia. So the other kind of inguinal hernia is called a direct inguinal hernia, and this actually occurs a little bit closer to where the pubic bone is. There's a bit of a weakness in an area where different muscles and ligaments sort of cross over each other in the groin over time. You know, men who lift heavy things for us all the time, particularly people that are like landscapers and movers and people that are doing heavy labor tend to experience these. But you know, just your average guy going to help somebody move furniture one day can find that they suddenly have a bulge in their groin that they didn't the day before. And a lot of people find this in the shower because they just notice it. So those are the two most common kinds of inguinal hernia. And then there are others, and women are more susceptible to one called a femoral hernia, which is the area where the femoral vein and artery lead down into the leg. For whatever reason, we think it's probably an anatomic factor. Women are more susceptible to that kind of hernia than men are. So those are the top three that we typically see.

Erin Spain: [00:03:52] So how do symptoms differ with men and women?

Heather Evans: [00:03:55] So like I mentioned, a lot of men will just notice that they have a bulge when they're in the shower. I think most people that have an inguinal hernia don't actually experience a lot of pain. There are some people that do, and you can suddenly have pain when you're lifting something and the hernia pops out for the first time. With women, the symptoms can be quite a bit more subtle. You know, we have different organs in our pelvis. We definitely have different stress on our pelvic muscular floor, so we sometimes will attribute pain that we have to other causes, you know, whether it's menstrual pain or other kinds of pelvic pain related to female reproductive organs. A lot of the pain that women have gets kind of chalked up to those things, so it is a little bit more subtle. Most women who have hernia don't present to my clinic with this new onset bulge; they actually are presenting more often with pelvic pain. So, you know, this is a little bit harder to diagnose in women. And on occasion, we'll have some women come to the clinic that actually were diagnosed with hernia after they've had surgery for. Other reasons, so I think this is a real challenge for practitioners, because I think it's been underappreciated in women in general, particularly because women have been excluded from all the major clinical trials about hernia.

Erin Spain: [00:05:13] Well, I want to talk about that because another issue with women is that women with these groin hernias are more likely to develop and become emergency situations and have a greater chance of developing complications than men. Tell me about that.

Heather Evans: [00:05:28] There's a new study that just came out this month, a retrospective study from Sweden. They looked at 40000 patients over five years. They have very good recordkeeping in Sweden, and its pretty homogenous population, so they're able to track patients very well over time. And what they found was that women were much more likely to present with a need for emergency surgery. And the concern about that is that when people present and they need to have an emergent operation, they're presenting with pain and they're presenting typically with a concern that they have entrapped something in the hernia. A hernia itself is a hole. It's a weakness in the inguinal floor in the abdominal wall, wherever the hernia is actually present. And we always worry about particular intestine getting stuck in that defect and then the bowel not being able to get enough blood flow causes it to get sick and inflamed. And then we sometimes will see very bad infections and other problems develop because of that. So that's something we like to avoid. And so when people present with an acute onset of pain and they have imaging that supports that, they have a hernia that's incarcerated, so to speak, then they have to have an emergency operation and we'd like to avoid that. You know, we'd like to do this as an elective operation, meaning that you know, you choose the time at your convenience where you have surgery rather than in the middle of the night when you're experiencing an emergency. But the question is, how do we find people that are at risk for developing this kind of incarceration? And to be honest, the problem with women is that we simply don't know who is at risk for this because we haven't studied it. And so there's really a call to action at this point for us to look to see if we can figure out what the risk factors for incarcerated inguinal and femoral hernia in women, so that we can anticipate that and help people to avoid those emergent situations in the future.

Erin Spain: [00:07:41] What is the ideal situation as far as getting surgery and what type of surgery do you perform in which has the best outcomes?

Heather Evans: [00:07:47] We like to say among hernia surgeons that the best operation that you get is the operation that that surgeon is best at. So, for example, for many, many years, the only operation that was done was an open inguinal hernia repair, and that involves making an incision over the groin, dissecting through the layers of the abdominal wall, finding the defect, pushing anything that is stuck in the defect back into the abdomen and then closing that defect and the tissue that you entered to be able to access the defect with suture. In the 70s, there was a new operation developed where mesh was used to reinforce that area, and that really became the gold standard hernia repair for open repairs. It's called the Lichtenstein Repair. Pretty much all general surgeons in the United States have trained and learned how to do this operation, so it's the most common operation that's performed. And it's a very safe operation and it's tried and true. It's pretty much the standard of care. Up until the last couple of years, when more minimally invasive approaches to hernia repair were developed, the first repairs that were done were done with just laparoscopy. You may have heard of people having their gallbladder or their appendix removed with laparoscopic surgery. This was a development that took a little bit more skill because we were operating in a plane that was not just inside the abdomen, but between the layers of the abdominal wall. And so there was a period of time where this operation gained some prominence, but it took people a long time to get good at it. It was a difficult thing to adopt in the beginning, but I would say now most people who trained in general surgery programs across the United States learn how to do that operation as well. And most recently, the biggest development has been the adoption of robot assisted laparoscopic surgery, where we can have a platform with really outstanding fine instrumentation that allows us to really see better. Number one, we have a 3D vision with the robot platform and then number two, the instruments that we use to do the dissection allow us to do much finer work. And you know, we're seeing individual nerves now, whereas before we were a little hampered by the fidelity of the cameras that we are using now, we're able to really see things incredibly well. And what this does for us is it allows us to do the most minimal dissection possible to be able to put a piece of mesh to reinforce the area of weakness and then close anything over top of that with a lot of dexterity. And I think that this has been a real development in hernia surgery, mostly for the operator. To be honest, I don't think that we have seen a tremendous change in the outcomes between laparoscopic and robot assisted laparoscopic surgery for the patient. But for the surgeon, I have such a degree of confidence in what I'm doing that I feel like my technique has really evolved even over the last year where I'm doing much less dissection. And my hope is that by doing that, I'm going to cause much less pain in the short term for my patients and also to decrease the incidence of chronic pain after hernia surgery, which certainly exists.

Erin Spain: [00:11:15] Given all of this. What do you want women to know about hernias? And you know, what should they be looking for? I know you said it's difficult to diagnose. Tell me what women can do at home.

Heather Evans: [00:11:27] Number one, if you have asymmetry and one groin looks like it has a bulge and the other doesn't, I think that's a pretty straightforward thing that should be evaluated, even if there is no pain. I do think that it's worthwhile having that checked out, and there are a number of things that can be done. A lot of primary care doctors are not as familiar with doing a hernia exam as surgeons are, and we have come to rely very heavily on imaging to be able to help us with that exam because sometimes it's just really hard to tell. So sometimes an ultrasound will be ordered, which is a noninvasive imaging method where a transducer, a little wand is placed over the groin by a technician, and those images are recorded and evaluated to determine whether or not there's a bulge that can be seen better underneath the skin. And then if that's equivocal, or if we still have some concern that we haven't seen what we need to see, we certainly can order additional imaging. And depending upon the patient's presenting symptoms that may be a CT scan or an MRI scan. And those imaging modalities are really helpful in the way that I talk to patients when they come to my clinic or if I do a telemedicine consult. It's very important to me to share the images that I have and show the patients where we see the hernia defect because I think that's helpful in making decisions. It's also helpful in understanding that you're not crazy and that pain that you've been having or that bulge that you have actually is represented here in this imaging that we can see. And on occasion, you know, I can reassure people that they don't have a hernia. But by and large, the people that show up in my clinic have been to a lot of people, unfortunately, before they've been to me. And I think that it's important to try and really understand what's going on with you as you make a decision as to whether or not you want to have surgery.

Erin Spain: [00:13:25] What do you enjoy about this work and what sort of satisfaction do you get from seeing a patient make a full recovery after hernia surgery?

Heather Evans: [00:13:33] First of all, the inguinal surgery, whether it's a femoral hernia or an inguinal hernia, that's an outpatient surgery. I typically will tell my patients they'll have about three days of pain and discomfort, and then they should be able to get back to their lives. And so one of the most satisfying things about that is that I have people come to me who've been suffering for a long time and they've been putting off having surgery or they've been misdiagnosed. And pretty much, you know, the next time I see them, they feel better. They actually feel like themselves again. And so that's really rewarding.

Erin Spain: [00:14:03] So we've been talking about hernia repair quite a bit, but that is not the only thing that you do. And U.S. health. Tell me about the other surgeries that you perform.

Heather Evans: [00:14:11] I also do abdominal wall reconstruction, which is also a hernia surgery, but it's very different from the groin surgery we've been talking about. We have patients that have had surgery in the past, and most abdominal surgery is done through a midline incision, although not all. And over time, those incisions that have been closed with suture can break down for whatever reason. And you can develop what's called an incisional hernia. So in extreme cases where those hernias develop and are painful or there is intestine at risk for sticking into that defect, we can perform operations to fix those hernias and an abdominal wall reconstruction is sort of a new concept in hernia repair over the last 10 years or so where we're trying to restore abdominal wall function as that midline breaks down and the rectus muscles, which are the six pack in the abdomen. As they separate, you lose some of the ability to use your core. And that's a really important part in exercise, but also in posture. As the core destabilizes, people develop back pain and that can be really debilitating. We tend to see incisional hernias in patients that have had infections in the past or who develop some weight gain after they've had surgery. And so part of deciding when and whether or not to have surgery will sometimes depend on the health of the person, their weight and what their expectations are for restoring function. So the abdominal wall reconstruction can be anything from making an incision through the old incision site and restoring that strength and integrity to the midline by reinforcing it with mesh. Or it can involve a much more extensive procedure where the different layers of the abdominal wall are kind of laminated during the operation, and we can release the lateral musculature on both sides of the abdomen to try and move those rectus muscles, those Six-pack' muscles back together and then reinforce the whole thing with a really big piece of mesh. That's the most extreme version of abdominal wall reconstruction, and we don't do that nearly as often as some of the other, more limited surgeries. But I think it's a really important operation for us to have in our toolkit because there are patients that really need this to be able to restore function and get back to their lives.

Erin Spain: [00:16:40] Tell me about some of your research when it comes to mobile health.

Heather Evans: [00:16:44] I've been doing surgical infections research for quite some time. I started doing it when I was a resident in surgery, and I'm actually talking about more than 20 years ago now. But more recently, over the last 10 years or so, I've been really interested in the way that we can use technology to help patients monitor themselves, even when they're not directly under our care. So, for example, somebody that has a big abdominal wall reconstruction is at risk for developing a surgical site infection, meaning either some redness or drainage or an abscess or a breakdown of their wound after the surgical procedure is over. And it used to be that we kept people in the hospital for a very long period of time after surgery, so much so that their wounds would heal before they went home. But we don't do that anymore, and we rely tremendously on the patient to follow their own progress at home. And although we can give all kinds of education and advice about what to look out for, really nothing beats having a direct connection to the people that have cared for you in the hospital when you have a concern or a problem. And so what we developed, and I actually developed this in my previous position when I was at the University of Washington, I created a mobile app for patients to monitor their wound after they left the hospital. And we developed a way to monitor this by taking photographs of the wound, the patient would take photographs and deliver it via this app. And we also were interested in what their symptoms were. So we were asking questions daily about their wound: was there redness with their drainage? Was there swelling? Was there separation of the wound? Et cetera. And our preliminary work showed that patients really loved this and that providers were concerned about patients that were going to develop wound infection. And so they thought it was a good idea as well. But operationalizing this is really challenging. Trying to get this to work in the electronic medical record, we certainly have some concerns about privacy and security. And so one of the things that happened during the pandemic that was really opportune for this work. You know, I moved to MUSC about four years ago. So two years into my stay, suddenly everything changed. We had a real surge in the need for telemedicine. And at MUSC, we actually adopted this wonderful platform where patients who tested positive for COVID could have their symptoms monitored remotely at home. What this took was not just technology, not just a way to reach patients through my chart, but also someone on the other end of that monitoring the data. And so what we found was that it was possible to tweak this process and to adopt the COVID monitoring for wound monitoring. And we don't have all of our data back yet, but we're just starting to analyze the data. We actually asked the providers and the patients that participated in this pilot program what they thought of it, and hopefully in the next couple of months, I'm going to be able to share that because I do think that there's a role for this kind of patient centered remote wound monitoring so that we can really move forward in the kind of care that we can personalize for patients as they recover from surgery.

Erin Spain: [00:20:18] That's so great. And it's just another way that MUSC Health is really grabbing on to innovation to make the best experience for their patients.

Heather Evans: [00:20:25] It's been a very exciting last couple of years to see this tremendous surge in telehealth and the adoption of telehealth in different areas clinically for me as a surgeon. I started using telehealth as the predominant way that I follow my patients after surgery. And I've done that not just because it was easier during the pandemic and safer, but also we found that patients really prefer not to come back to the office just to have me say, "You're doing great. Congratulations. You don't have to come see me again." And I really do enjoy those telehealth visits where I can see my patients in their own home, whether they've had an emergency surgery like an appendectomy or they've had an elective surgery like an inguinal hernia repair. It really is nice for them to either call in from home or even from work. You know, just take five minutes out of their day instead of half a day driving to MUSC parking, having to find the clinic, sitting in the waiting room, waiting to be called. There's such a time save for patients that it has a tremendous amount of satisfaction compared to an in-person post-op visit. I've also had a couple of patients over the last six to 14 months where we have done all of their preoperative evaluation via telemedicine. The only time they have actually come to see me in person is for their surgery, and that's been wonderful too. And it actually allows us to be a little bit more flexible in terms of scheduling and timing. And I think we're meeting the needs of our regional patients a lot better than we did before the pandemic.

Erin Spain: [00:22:07] Is there anything that I missed or that you want to reiterate that you think is important for listeners to know?

Heather Evans: [00:22:12] I think the most important thing is if you think you have a hernia, you actually can self-refer to our clinics. We have a hernia center at MUSC and we are available to see patients on direct referrals. So you don't have to go see your primary care doctor if you think that that's something that's going on with you. I would also say that if you think you have a hernia, it's best to get it evaluated before it becomes a problem. At least you can have a discussion with a surgeon and understand what the risks and potential benefits of surgery are. I would hate for someone to listen to this podcast and feel like, Well, that's not me. I don't need to be evaluated. We're happy to see anybody that suspects they might have a hernia. And if you're wrong, then you can go away feeling better. But if you do have a hernia, there are solutions. And you know, we talked about hernia surgery. There are things that we can do before surgery to help people with pain and hopefully keeping the hernia from progressing while they're waiting for surgery. But by and large, you're absolutely right. The best treatment for these hernias is to have surgery, and we just want the public to know that we're here and available if they need us.

Erin Spain: [00:23:27] I'm going to ask you a question that we ask every physician who comes on the show. What do you do to optimize your health and live well?

Heather Evans: [00:23:33] I have a wonderfully supportive family, so I have to shout out to my husband and my two boys. I think having people around you that love you and support what you do is so important, and I rely on them tremendously. Physically, I love to cycle and I've started running a little bit this year as well because it was so cold in January, I felt like I didn't even want to get on my bike, but I've been cycling for a long time. My mom actually got me into it when we lived in Seattle, Washington and I actually participated in Lowvelo this past year. It's a wonderful outlet, so I think just having an outlet and being able to get your heart rate up a couple of times a week is really important. And I love to eat. I would hate to stop eating well. So it's my balance, so I'll eat well and I'll also exercise so that I can do that.

Erin Spain: [00:24:25] Thank you, Dr. Heather Evans, for coming on the show and talking to us about hernia repairs and especially when it comes to women. Thank you so much.

Heather Evans: [00:24:33] Oh, it's been my pleasure. Thank you.

Erin Spain: [00:24:39] For more information on this podcast, check out the advance.MUSChealth.org.