Living with a Hernia
Temporary relief: The farmer's remedy to relieve the pain from hernia
Some years ago I was referred a middle-aged and very fit man who had quite a large hernia in his groin.He was a busy cane farmer, a tough physically demanding job. When his hernia became painful and hard, he would alight from his tractor, lie on his back lifting his legs in the air, while he pushed on the lump. After a few minutes of struggle, the lump would disappear with a gurgle, and he would feel very much better. He would then, after a few minutes get back on his tractor. Until the next episode.
He had consulted Doctor Google who helped him to make a diagnosis. The treatment recommended was “Watchful Waiting”. He watched and waited for a few years while the hernia grew to the point of encroaching on both his manhood and his livelihood. His wife by then had had enough, and took him protesting bitterly to his GP. He really did not want an operation.
Groin Hernia is a common affliction, with a lifetime prevalence in men of about 25%, and 3% in women. They increase in frequency with age, and can run in families. There is some controversy over whether hernia can be caused by heavy lifting and there is epidemiological evidence which supports this. Many groin hernias arise out of a congenital weakness, which explains why groin hernias can occur in newborns, infants and children- and these are always regarded as urgent, unlike in an adult.
Hernias are protrusions of the lining of the abdominal cavity (the sac) through the abdominal wall. The sac now outside the abdominal wall, still communicates with the abdominal contents and a loop of intestine may pass out of the abdominal cavity into the hernia sac. This may cause pain, but more seriously cause intestinal obstruction and even strangulation, where the intestine loses its blood supply and becomes gangrenous. This sequence of events is distinctly uncommon in developed countries where surgical services are available, but are frequent causes of disability and death in the developing world. .
Some hernias are more prone to this complication than others.
A Femoral Hernia more commonly seen in women, which occurs as a lump, sometimes very small, low in the groin and upper thigh, should always be repaired without delay, as it has a high risk of strangulation.
Most hernias in men are Inguinal Hernias. Inguinal hernias usually present as a lump in the groin that is typically intermittent and has no other symptom. The natural history of inguinal hernia is to slowly enlarge, and become symptomatic. This may happen over several years. So even if a hernia is not troubling the patient when first noticed, it eventually will. A reasonable approach for a minimally symptomatic patient is to arrange for a surgical repair when it is convenient. The other option is to wait until pain becomes an issue, and then have a repair. Patients who do not have their hernia repaired may limit their activities which they feel might aggravate the hernia. So the decision to have an elective hernia repair rests very much with the patient.
Hernia accidents, where strangulation is threatened or occurs, is a great and usually avoidable misfortune. While mortality rates from elective hernia repairs are negligible, emergency hernia repairs, especially where intestine has to be removed, are dangerous, with mortality rates in excess of 10%.
My farmer, naturally suspicious, is full of questions:
“How secure is the repair? “I tell him a recurrence rate of 2 % is what can be expected over five years
“How long will I be off work?” I tell him he could do book work more or less from the next day. He could do some supervisory work after a week; but I said no tractor work or heavy lifting for a month.
“What about pain? Will it cripple me?” This is a tricky one. “Most patients,” I say, “will have strong pain medications taken by mouth for two days, and then mild analgesics afterward. I would expect you to be off all tablets in two weeks.
Sometimes it is not so simple. “Long-term pain can occur, but is uncommon. “Some men get pain intermittently for years, particularly doing heavy work, and may need to take mild or moderate pain medications. Rarely patients can be disabled by long term pain, and will have to be managed by many specialists working together. Very rarely some patients may not be able to return to work.” He was looking very worried by this, and I realised I might frighten him off his operation. But all patients are entitled to know this.
“What about infections?” Skin infection may occur in about 5% of cases and is not really a problem. Very rarely deep seated infection can occur, and may require re-operation. Still more uncommonly, and if mesh has been used, there may be a requirement to remove the mesh
Bleeding after an operation, can occur and track down into the scrotum, causing bruising and even the development of a lump. Bruising can take a couple of weeks to disappear.
“Can I lose my testicle?” I smile, including his wife, “you will be a better man for it; but really this is very rare indeed, and only required in complicated recurrent hernias or where a hernia has to be operated on as an emergency for strangulation.”
I explained the surgical options to my farmer. He was unsuitable for laparoscopy as the hernia was large and could not be easily returned into his abdomen. I recommended an open operation done with mesh under spinal anaesthetic, in our day surgery unit.
I saw husband and wife about two months later for a postoperative check. The wound had healed nicely, and things had changed visibly for the better. “Well,” I asked “Are you functioning OK?” He growled a monosyllabic reply, but his wife gave me a smile and a wink.
(The writer is Associate Professor of Surgery at James Cook University, Cairns, Queensland, Australia)
| History of treatment: Going back to 1500 BC The treatment of hernia has a long and interesting history. Hernia is mentioned in the Egyptian Ebers’ Papyrus from around 1500 BC. Exercises and enemas were recommended rather than surgery, as it was a thousand years later in the Hippocratic tradition. But by then anatomic knowledge was slowly accumulating and there were almost certainly some surgeons who were operating on hernia. So how was hernia managed in medieval times? Mainly with a truss. Craftsmen tailored these appliances to the individual. Using leather and iron, they fashioned springloaded devices which put direct pressure on the hernia openings in the groin to prevent the intestine from falling out. Truss makers kept detailed records of their customers who attended them regularly for adjustments and replacements. These seemed to work very well indeed, and hernia accidents were few and far between. The Museum of the Paris Medical School has cases full of these historic devices. Once modern hernia surgery developed, trusses became obsolete, but still can be useful if there are contra-indications to operation. Modern hernia surgery could only develop when anaesthesia and asepsis were understood. Bassini is credited with some of the first anatomic repairs for hernia in 1889 in Italy. Since then many different techniques of hernia surgery have evolved, mainly into techniques using mesh, and those without. In many parts of the world the open mesh repair has become the standard. Many different kinds of mesh have been proposed, but the most popular and safe is poly-propylene. In the early 1990’s laparoscopy was introduced to treat hernia. Rapid advances in instrumentation and technology have made this a feasible option for many surgeons giving results as good as, and sometimes better than open repairs. But they are technically more difficult and take time to learn. They are also more expensive as more technology is involved and general anaesthesia is essential, while open hernia surgery can be potentially performed under local anaesthetic. There are two particular situations where laparoscopy is particularly useful – in recurrent hernia and bilateral hernia.
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