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for inguinal hernias

a nasty complication


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Have a Hernia?

This site was originally public from December 2003 to Dec 2005. On 2010 Mar 11 it was brought back on-line.

Information about the people with hernias, by the people with hernias, for the people with hernias.

What about our abdominal hernias, our ventral hernias? What can we do about these wayward organs and tissues, that sneak into places that they don't belong, where they know they have no business being, and that then tend to loiter there? What about these inguinal, umbilical, femoral, incisional, and epigastric hernias (alternate plural: herniae)? Here is a page at Shouldice Hernia Centre that shows where on your body each of these obnoxious trespassers show up. Inguinal hernias, in males, are the most frequent.

Is surgery for such hernias as simple and "routine" as many of our doctors would seem to want us to believe? Sources of information intended for consumers of medical services, and written by suppliers of medical services — how much of what they say is straight talk, and how much of what they say is "spin," written more for the purpose of getting us into the operating room without panicking and dashing off in the opposite direction, than to give us the straight facts?

Hernia surgery appears to be the most frequent kind of surgery that is performed. In that sense, you could say that hernia surgery is "routine." We are talking about over 700,000 ventral hernia repairs per year, in the United States alone. But is hernia surgery simple, easy surgery for a surgeon to perform? Is it routine in that sense? Or is it complicated, tricky, or risky? Just how difficult is it to do, and do without ending up making the patient worse off after the surgery, than before? And because it is "routine" in the sense that doctors do so many of them, does that mean that it is routine in the sense that the doctor finds that she has to do the same thing over and over, from patient to patient, like a worker on an assembly line does? Is hernia surgery something we would want to rely on a relatively inexperienced surgeon to do?

If we need help dealing with a hernia, what help is available from medical professionals? Is surgery the only option? Assuming, for the moment, that surgery is it: what kinds of surgery are available? How much difference is there between different types of surgery? And finally, how much difference in results can you expect, between one surgeon and another?

Studies have shown that for some surgeons, 15% or more of their hernia repairs, result in a recurrence of the hernia, within a few years. For the better surgeons, their recurrence rate is less than 1%. Often less than 0.5%. That is quite a difference. For all surgeons, studies show that as high as 30% of patients who have undergone hernia surgery, have significant chronic pain, often lasting years, or indefinitely, and for 15% of those who have undergone hernia surgery, the pain is so bad that it interferes with their activities to a substantial degree. Knowing that the outcome of poorly done hernia surgery can be a recurrence of the hernia, and chronic pain, it would seem important to choose a good surgeon.

From what I can figure out from my reading, hernia surgery is divided into 2 steps:

(1) Surgically "reducing" the hernia by returning the contents (internal organs) of the hernia sac (made of peritoneum) to the abdomen. This means painstakingly freeing the pesky adherent sac from surrounding tissue without doing too much damage to the surrounding tissue; and then either surgically removing the sac or returning it to the abdomen (where it came from) and

(2) Performing a herniorrhaphy or hernioplasty — fixing things so that whatever defect in the tissues there was, in the layers of muscle and fascia, that allowed the hernia to occur, will be dealt with, and so that re-herniation of internal organs at or near the same spot, will prevented.

Both steps are necessary, but I invite you to take a look at various educational materials, intended for patients, that are provided by doctors and medical professionals, and see what you can find in them about the first step. I think many of these materials gloss over this first step and stress the second step. I hope to eventually make it clear why I mentioned this, and why it may be important to the person with a hernia who is seeking medical-surgical help with their hernia.

The second step seems to be, among surgeons, the subject of a bit of debate. There are different schools of thought as to what is the best way to close up the "hole" that had allowed abdominal organs to insinuate their way out of the abdomen. And providers of medical care seem to like to present consumers with a bit of information about the pros and cons of the various methods. However there doesn't seem to be an awful lot of debate in regard to the first step, in regard to returning the abdominal organs to the abdomen and dealing with the sac. Yet it seems to me that this part of the operation requires finesse, if the patient is going to have results they are happy with. Part 2 of hernia surgery seems to be the part determines the likelihood of a future "recurrence" of the hernia. But both parts of the operation seems to give rise to the the upsetting, long-term complications that make patients unhappy and that they complain about: testicular atrophy, chronic pain, areas of numbness, reduced erectile function, painful ejaculation. I'm not sure which part of the operation, if done with less than maximum finesse, is the part from which more problems arise. But certainly, it seems to me, enough problems arise from part 1, that patients need to know as much about what is involved in that part, as they need to know about what is involved in part 2.

For both part 1 and part 2, it seems to be mostly lack of finesse that affects one's recovery, and long-term condition, rather than the method chosen. Nevertheless, there are some variations in doing part one, that may also have an effect. The same thing could be said about part 2 — however there are a wider variety of methods of doing part 2. Even so — the particular surgeon that a patient has, seems to have more of an effect upon the outcome of the patient's surgery, than the method of surgery that the patient has undergone. I hope to go into more detail regarding this, at a later date.

There appear to be 2 basic categories of hernia surgery:  (1) anterior approaches and (2) posterior approaches, and within each of these 2 categories, there are different methods of dealing with the tissue defect that allowed the hernia to occur. It is interesting to see what the subcategories are, and I will describe them on another page, but, and it seems I am repeating myself: I am convinced that getting a successful result has less to do with what method of surgery you've chosen, and more to do with what doctor or medical group you've chosen. It appears that good surgeons get good results using all the popular methods. Less capable surgeons, using the same methods, get poorer results. The difference can be quite substantial.

Lastly, surgeons tell us that abdominal organs find novel ways of sneaking out of the abdomen, flowing out of the abdomen, into areas of the body that they don't belong, and that surgeons must sometimes, on the spot, devise novel ways of (1) returning the wayward organs to the abdomen, and (2) preventing these same organs from finding a way out again, preventing them from either taking the same route out, and doing as much as possible to prevent them from finding a clever new way out. Gravity and wayward organs are even more persistent than surgeons. Hernia surgery is, in my opinion, not routine surgery, in the sense of being easy or assembly-line repetitive.

Because a good repair, that lasts long, and does not result in chronic post-operative pain, requires a great deal of finesse, I would tend to say that getting a hernia specialist to repair your hernia is probably a real good idea, although there do seem to be a number of general surgeons who reliably do good hernia repairs, even though they don't limit their practice to hernia repairs. I would find out how many hernia repairs they do per year, and I would suggest that if they don't do more than 100 hernia repairs per year, perhaps you should find another surgeon. Hernia specialists will generally do several hundred per year.

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article last updated 2005 Jun 16
article copyright 2004-2005 by soilman Theodore Zuckerman