What is a hernia?

Basically, a hernia is a hole in the strength layer that holds everything inside of you. If you develop a hole, things from the inside can push out. This feels like a bulge. Fat is often the first thing pushing through the hernia defect (hole). Hernias do not get better and do not go away. In time, they usually become larger and other structures can push through the defect, most often intestines. There is some risk that the intestines will get outside of that defect and become stuck, with the possibility that they can then rupture. This is very serious and would require emergency surgery to repair. Sometimes hernias can be very painful especially with activity. This can start to limit your normal activities and the ability to do sports and exercise.

Hernias can develop in several different locations. Most are in the abdominal wall and they are often named by location. Groin hernias are some of the most common hernias, also called inguinal hernias. They are further designated as indirect and direct hernias, depending on the specific anatomic defect. Essentially, these 2 hernias are repaired similarly. Other hernias include femoral hernias (a bulge near the groin on the medial upper thigh), umbilical hernias (through the umbilicus, or belly button), incisional hernias (through a prior surgical incision on the abdominal wall), ventral hernias (essentially any non-inguinal abdominal wall hernia, but usually referring to anterior hernias not involving prior incisions, the umbilicus, or groin areas), spigelian hernias (lateral lower abdominal wall hernias through a special type of defect) and other even more rare hernias.

Hernias can be reducible, meaning the intestines push through the defect and can slip back inside either manually or when laying down (the bulge disappears). Or, they can be incarcerated, meaning the intestines do not slip back inside. Sometimes, incarcerated hernias can be very painful and can start to cause damage to the intestines (strangulated hernia). This hernia might be very hard and tender and you might experience abdominal pain and nausea or vomiting as well. You should be seen immediately in the Emergency Room if this happens.

Why did I get a hernia?

In many cases, they just happen. Inguinal hernias are more common in men because of a defect sometimes left behind from infancy due to the passage of the testicle into the scrotum. Women get hernias here too probably due to natural weakness of the structures in this area. Hernias sometimes run in families and it is felt that obesity and certain other factors might increase the risk for developing a hernia. Poor wound healing is known to increase the risk of developing incisional hernias. People that engage in a lot of very strenuous activity might be at some increased risk for hernia development.

There are some people who can actually remember a specific activity (usually lifting something) which might have “caused” the hernia. They often describe the sensation of a “pop” and the presence of an intermittent bulge from that point forward. All of this being said, many hernias just become noticeable one day and have no direct causal event.

What should I do about my hernia?

That is a really good question. Most hernias should probably be fixed in active healthy people. Especially those hernias at higher risk for complications (such as femoral hernias) which should almost always be fixed. That being said, we know that some people do fine for years without having their hernia repaired. It is often difficult to predict which hernias will cause problems. In general, if you have a hernia, you should consult with a surgeon to discuss the options and the risks.

So, I’ve decided to have my hernia repaired. Tell me about hernia surgery. 

Most hernias are repaired using some type of mesh patch. We have learned that patching hernias reduces the recurrence rate significantly and while hernia surgery is usually pretty straight forward, surgery for a recurrent (or even re-recurrent) hernia becomes much more complicated and has higher risk. So, anything that we can safely do to reduce the risk of recurrence is important.

Depending on the type of hernia and on your underlying medical problems, surgery might be done with a general anesthesia or with local anesthesia with sedation, or sometimes with spinal anesthesia.

The surgical technique can vary as well depending on a number of factors.There are open techniques as well as laparoscopic techniques, all with their own risk/benefit profile. The decision as to which specific technique is chosen will depend on many things: the type of hernia, whether it is primary or recurrent, unilateral or bilateral (for inguinal hernias), your underlying health status, and surgeon preference, among other things. For example, the laparoscopic technique is a very nice way to fix bilateral inguinal hernias at the same operation.

Surgery is usually done as an outpatient. You would require some time off of work in most cases and there would be some activity restrictions for a period of time. Much of this depends on the type of hernia repaired and on the specific surgery.

You should have a much more thorough discussion about the specifics of the recommended repair, risks of surgery, and recovery expectation with your surgeon.

What is the next step? 

So, if you think you have a hernia, you should discuss it with your doctor and consider a surgical evaluation to review the options. Feel free to call our office at Albuquerque Surgical Consultants and we would be happy to schedule a time for you to come in for a consultation.

Thyroid nodules are actually pretty common. If an ultrasound was performed on randomly selected people, up to 67% of them would be found to have a nodule, according to the American Thyroid Association. Nodules are more common in women and older people. Cancer can occur in 5-10% of nodules, depending on other risk factors, and it is important to be able to identify the ones with cancer. A history of radiation exposure and a family history of thyroid cancer are two factors that increase the risk that a person’s nodule is cancerous.

If a nodule is felt or suspected,  an ultrasound of the thyroid is usually one of the first diagnostic studies obtained. This is an easy test to undergo and requires no specific preparation. This test can give very good information about the nature of the nodule including the size, whether it is fluid-filled or solid, if there are calcifications, and other details. In general, only nodules larger than 1 cm should be evaluated further. Occasionally, smaller nodules require additional evaluation because of suspicious ultrasound findings or risk factors for thyroid cancer. 

A serum TSH (thyroid stimulating hormone) should be checked in everyone with a suspected nodule 1 cm in size or larger. A significantly reduced level would prompt the need for a radionuclide thyroid scan to determine if the nodule is over-functioning. If so, it is unlikely that the nodule is a cancer and no biopsy would be necessary at that time. Additional work up might be indicated, however, in terms of the function of the thyroid.

Fine needle aspiration biopsy (FNA), often performed with ultrasound guidance, is the best method  for evaluating nodules 1-1.5 cm in size or larger. The possible results include a benign, non-diagnostic, indeterminate, or malignant biopsy. A benign nodule should be followed with repeat physical exam or ultrasound in 6-18 months and a repeat biopsy for significant growth. Non-diagnostic results should undergo a repeat biopsy. Repeated non-diagnostic results would often require surgery to make the diagnosis. For indeterminate results, either further imaging or surgery is recommended depending on the details of the biopsy. For malignant results, surgery is recommended.

Surgery for thyroid nodules includes thyroid lobectomy (removing essentially 1/2 of the thyroid gland), sub-total or total thyroidectomy. The extent of surgery is based on your clinical picture, size and number of nodules, and on  the results of a “frozen section” analysis of the thyroid immediately upon removal. This is done while you are in the operating room and is basically a quick look at the specimen by a pathologist to determine if it is cancer. Sometimes, cancer can be definitively diagnosed, and this would alter the surgery to be performed.

Hopefully, this has given you a little overview of the management of thyroid nodules. If you and your doctor have determined that you need further work up, please call our office and we would be happy to schedule a time for you to come in for a consultation.

This is a good question, and one that you may have discussed with your primary provider or gastroenterologist. The bottom line here is that colon cancer prevention is the primary goal of screening. Colorectal cancer is the third most common cancer in the US and the second leading cause of cancer death. Ideally, we would want to find and remove polyps before they turned into cancer. We would also like to identify cancers early, when they are most treatable.

The current recommendations, according to the American Cancer Society, are to get a test that finds both polyps and cancer. The options include flexible sigmoidoscopy every 5 years, colonoscopy every 10 years, double contrast barium enema every 5 years, or CT (virtual) colonography every 5 years. Testing might need to be more frequent, depending on whether polyps or other abnormalities are discovered.

Tests that primarily find cancer but do not routinely identify polyps include stool testing for blood every year, stool immunochemical testing every year, and stool DNA testing, although the frequency has not been determined. If any of these tests are positive or suspicious, colonoscopy would be required.

Screening should begin over the age of 50. Those with an increased or high risk of colon cancer may need screening earlier and more frequently.

Some polyps and almost all colon cancers will require an operation to remove part of the colon. In many cases, this operation can be done laparoscopically which is often associated with less postoperative pain, a shorter hospital stay, and an earlier return to most activities.

Now that you are briefed, be sure to discuss colon cancer screening with your primary provider and/or gastroenterologist to determine the most appropriate testing for you.  Rates of this disease have been going down in recent years, but they could be lower if all people who should be screened actually got screened!

If you are requiring colon surgery and would like to consider a laparoscopic operation, please come in for a more thorough discussion. You can call our office to schedule an appointment.

We are very excited about our upcoming relocation to Granada Square on Montgomery. This location is more central for the greater Albuquerque area, and we hope, more accessible to our patients. In addition, parking will be much easier - and you can walk right in!

Next week is the move and we expect the transition to be seamless. During this time, you can continue to reach us through our old phone number, 224-7874 (SURG), and will be directed to the new number. Or, call our new number after September 30, 998-7874 (SURG).

Come in for a visit, once the dust settles!

While gallstone disease is one of the leading indications for surgery in the United States today, only 10-20% of people with gallstones will develop symptoms within 20 years of their diagnosis. So, not everyone with gallstones will require surgery for them. But who does? Well, people with symptoms may want to consider surgery. The symptoms can be pretty bad and are commonly referred to as a ”gallbladder attack”. Pain in the upper right abdomen after meals is the most common. Additionally, there is often pressure and bloating, nausea and vomiting, and possibly even diarrhea. The pain can also go into the back or right shoulder. Most often, the episode lasts for a few minutes or even a couple of hours, and then completely goes away. Sometimes, the symptoms do not improve and a trip to the Emergency Room might be necessary.

Acute cholecystitis means inflammation or infection of the gallbladder and can develop when the gallbladder attack is prolonged. This is serious and often requires hospitalization and more urgent surgery. Another possible risk of symptomatic gallstones is blockage of the main bile duct which drains from the liver. This can lead to serious liver or pancreatic infection and need for hospitalization and possible urgent surgery. We know that the risk for surgery in these more inflammed states can be higher than when there is little or no inflammation.

Surgery is often recommended for symptomatic gallstones and in most cases, this can be performed laparoscopically. This approach is associated with a reduced recovery time and is often done on an outpatient basis. Most will be able to return to work in one week and can resume eating all of the things that they like without the fear of an attack.

So, if you have gallstones, talk with your doctor about whether you might be experiencing symptoms from them. On the other hand, if you have these symptoms and are not sure whether you have gallstones or not, your doctor may want to send you for an ultrasound to find out. For the most part, those of you with gallstones and no symptoms are probably okay to just continue on for now. Always discuss these decisions with your doctor during your regular check-ups. 

Feel free to call our office for an appointment if you would like to discuss laparoscopic surgery for your gallbladder.

I recently attended an informative conference on Thyroid and Parathyroid disease in Santa Fe. The conference was presented in conjunction with MD Anderson and included presentations by many acclaimed doctors from several different specialties including radiology, endocrinology and surgery. The discussions that took place between we attendees and the presenters were very stimulating, and I found several good take-home points that will continue to be useful in my thyroid/parathyroid surgical practice.

For example, we heard from proponents of using intra-operative nerve monitoring during thyroid surgery to assist in identifying an important nerve, the recurrent laryngeal nerve. This nerve runs behind and very close to the thyroid gland which places it at risk for injury if not clearly identified and protected during surgery. An injury could affect speaking and possibly breathing in some cases. I have been utilizing this technology for several years now and feel that while strict surgical technique is the most important factor in preventing an injury, monitoring the nerve has been helpful. This is just one more way that I can assure that I am doing the best and safest thyroid operation for my patients.