James Bittner, M.D., who joined the staff of Saint Francis Hospital and Medical Center in February, has hit the ground running. The general surgeon, who specializes in hernia repair and bariatric surgery, is revamping the institution’s advanced GI minimally invasive surgery fellowship program to include more exposure to clinical research. He is creating – and will be directing – a new comprehensive hernia center. And as the institution’s new director of robotic surgery, he is rekindling the hospital’s robotics program and has already established a multi-disciplinary robotic surgery collaborative to develop standards for robot-assisted surgery.
“I enjoy program development and saw great possibilities at Saint Francis Hospital,” says the surgeon, who spent the past five years developing similar programs at a major university hospital. “I like leaving a place better than I found it from a programmatic and academic standpoint.”
Creating a center of excellence
Born and raised near Pittsburgh, Pennsylvania, Dr. Bittner earned his undergraduate degree at nearby Washington & Jefferson College, attended medical school at the University of Cincinnati College of Medicine, and then completed a surgical residency at the Medical College of Georgia at Augusta University – the nation’s eighth-largest and 13th oldest medical school. He spent an additional year in St. Louis, receiving fellowship training in minimally invasive and bariatric surgery at Washington University School of Medicine before taking an academic position at Virginia Commonwealth University (VCU) in Richmond.
Dr. Bittner, who served as assistant professor of surgery and director of VCU’s advanced minimally invasive surgery fellowship, says that in taking the reins of the Saint Francis Hospital fellowship program, he is “looking to train surgeons that are interested in not just clinical practice, but also in teaching and contributing to the scientific literature.” Not only will future surgeons be exposed to a variety of surgical disciplines that perform complex robot-assisted operations, he says, but they will have the opportunity to conduct cutting-edge clinical research.
Dr. Bittner, in fact, has added significantly to the existing body of research on complex hernia disease and brings this expertise to Saint Francis, where he is charged with developing a comprehensive hernia center for patients suffering from complex abdominal wall issues. His goal: “To develop a hernia center of excellence, one that not only competes statewide but will be recognized by peers in the national and international community.
Hernia disease: A common health problem
A hernia is a defect – or hole – in the muscle or connective tissue wall that normally contains the organs and fatty tissue, allowing that tissue to protrude through the wall of the abdomen, chest, groin, back, or flank. Hernias are a common health problem in the United States. More than a million hernia repairs are performed here each year. In fact, repair of an inguinal hernia – one that occurs in the groin – is one of the most common operations done by general surgeons.
Men are more likely to develop inguinal hernias, while women are more likely to suffer from umbilical (belly button) hernias, particularly during or following pregnancy, when the abdominal wall muscles tend to stretch and weaken. A family history of relatives with hernias also predisposes people to the problem, as does smoking – not only because it decreases blood flow to areas of the fascia (connective tissue) and to muscles that are innately weak, Dr. Bittner says, but also because the chronic cough that is sometimes associated with tobacco use results in repeated strain to the abdominal wall. Patients in high-impact occupations that cause increased strain on the groin and abdomen, as well as patients with clinical and severe obesity, are also more susceptible, as are those who’ve had previous hernia repair, he adds.
Though a majority of patients suffering with hernia disease present with a painless bulge, Dr. Bittner says, “hernias can cause pain, bowel obstruction, difficulty breathing or swallowing, and depending on their location, can make you acutely ill.” While an asymptomatic umbilical hernia might not require an operation, he says, even small umbilical hernias can become symptomatic, or possibly cause major problems like bowel obstruction or strangulation. “For adults with an umbilical hernia, it is advisable to speak to your doctor or surgeon to determine the likelihood for problems or the need for operation,” he adds.
According to Dr. Bittner, the advent of laparoscopic and robotic-assisted approaches has made hernia repair much less invasive than it was previously. Though in certain situations surgeons might prefer to do an open operation – if, for example, a hernia is very large, or the surgeon wants to do another operation, like a tummy tuck, at the same time – most hernias can be fixed using a robotic-assisted approach.
“The growing body of literature, some of which I contributed to while at VCU, has documented that the robotic-assisted approach to ventral [abdominal] hernia repair not only lowers the risk for wound complications and postoperative pain, but also decreases a patient’s hospital stay by an average of three days,” says Dr. Bittner. “Not only does that have value to patients, but also to the payers – and the health system at large.”
Dr. Bittner emphasizes the importance of seeking out specialized care when it comes to treating hernias. “As we would encourage patients with breast cancer to seek a women’s health center that specializes in breast cancer, so, too, do we encourage patients with hernias to make good choices and search out centers that specialize in hernia disease,” he says. “When managed correctly, hernia repair can give people their quality of life back, but when hernia disease is not managed in a comprehensive manner, patients may suffer pain, hernia recurrence, and other problems that require re-operation.”
Dr. Bittner says that his experience as a bariatric surgeon makes him a more comprehensive hernia surgeon, because very often these patient cohorts are one and the same. “Patients who suffer clinical obesity tend to form hernias, so we are often seeing patients with multiple medical diagnoses at once – clinically severe obesity, diabetes or metabolic syndrome, high blood pressure and hernia disease,” he says.
Bariatric surgery: Less invasive and more in demand
Though more and more patients are seeking surgical weight loss every year, Dr. Bittner says that unfortunately, surgical weight loss still has some stigma associated with it. “While we try to rail against that, there is still persecution for those patients who suffer clinically severe obesity, and even some pushback from friends, family and strangers when they elect to take their health in their hands,” he says. “These patients should be encouraged and not discouraged to seek care.”
He points out that if a patient had a malignancy, they would be encouraged to seek as much medical care as they needed to get better. “Why do we treat clinically severe obesity any different?” he asks. Medical experts have, in fact, designated surgical weight loss as a treatment for diabetes and metabolic syndrome, as both conditions are linked to obesity. Thus, notes Dr. Bittner, employers in some states are now required to offer employees insurance coverage for surgical weight loss, and slowly but increasingly, more insurance companies are paying for the operation. “We have a long way to go in making surgical weight loss as easily available as getting blood pressure medicine,” he adds, “but at least we are moving in the right direction.”
In the U.S., says Dr. Bittner, sleeve gastrectomy is now the most popular choice for surgical weight loss, followed by gastric bypass. During a sleeve gastrectomy, the surgeon removes a significant portion of the stomach, creating a banana-shaped pouch, or “sleeve,” that holds much less food. The procedure is typically performed using a minimally invasive approach, either laparoscopically – that is, using a long, flexible instrument with a camera attached that is inserted through a series of tiny incisions in the abdomen – or with the assistance of a robot.
During a gastric bypass operation, the surgeon creates a baseball-sized stomach pouch, and connects the small intestine directly to the stomach pouch, bypassing a major portion of the stomach and a short portion of the intestine. This not only decreases the amount of food that can be held in the stomach, but also reduces the body’s absorption of that food. Gastric bypass, too, is usually performed either laparoscopically or robotically.
According to Dr. Bittner, even less invasive approaches may be on the horizon. Endoscopic sleeve gastroplasty is a relatively new approach to weight loss in which instruments are inserted through the mouth, eliminating the need for external incisions. Also known as the accordion procedure, this procedure uses a suturing device to reduce the size of the patient’s stomach. Early studies suggest that endoscopic sleeve gastroplasty is safe and effective in the short term, Dr. Bittner says, but long-term data are yet to be published.
Regardless of which bariatric procedure a patient chooses, the operation is only one step in the treatment of obesity, diabetes, and metabolic syndrome, according to Dr. Bittner. Patients also must make healthy lifestyle choices if they want to sustain weight loss and maintain good cardiovascular health.
“The operation is nothing more than a tool,” he says. “You don’t buy a hammer at Target, bring it home, put it on your counter, and expect the hammer to build the shelves. It is truly the patient and their commitment and their support network – which includes friends, family, physicians, dieticians, health psychologists and, obviously, the surgeon – that contribute to the long-term success of patients.”
Lori Miller Kase is a freelance writer living in Simsbury.
Allegra Anderson is a Glastonbury-based photographer with a BFA from Tufts University.