Details To Consider When Planning Hernia Surgery
by A. Douglas Heymann, MD, FACS There are a lot of steps and information that ought be considered when planning surgery for a groin hernia. Every patient is different and there are variations in the types, location, extent, anatomy, symptoms and complexity of these hernias and the surgical solutions. Every surgical procedure ought to be considered a
risk, even though other people consider it “routine”.
Listen during your consultation and be convinced that your surgeon is thinking about what is best for your personal and individual situation. Surgeons must integrate technique, craft, art, science, data bits and experience at stages of preoperative evaluation, strategic planning and during the steps of performing surgery. Surgical procedures require accomplishing many sequential successful steps, not one action or programmed cut-and-paste maneuvers. At times the steps are obvious, simple and fast. At other times, repair is elusive, complex and tedious. Each problem requires an individual focused solution. Frequently the solutions are similar, but rarely identical. An
experienced surgeon knows that “there are no small operations”. The “easiest” procedures sometimes result in the “biggest problems”.
When a surgeon states,”I always (only) do the XXX technique”, he is suggesting technical simplicity, almost automation. His technique will be effective most of the time. A good craftsman would embellish the basic technique to provide for individuality based on his previous experience. An artist will create new solutions to improve the results. All decisions must be based on experience, science, results, technique, craft and art; and then executed within the context of normal and abnormal anatomy, individual associated tissue factors,
reasonable expectations and socioeconomic needs.
Surgeons will be successful most of the time if rigidly adhering to one selected technique. In Europe, surgeons were satisfied for decades with a Bassini Repair, which was described before 1900. Modern communication and transportation were absent. Americans simplified the published technique and had poor results. The skills of local anesthesia, dependable in the 1930’s, were lost in the sixties until the competitive pressure of the Canadian, Shouldice Clinic forced Americans to relearn it. The Shouldice Clinic embellished that Classical Bassini Repair with the imposition of multiple reinforcing layers and accomplished enviable results employing the same method in rapid sequence
for multitudes. Mesh was not used.
Americans adopted the Canadian technique for the most part and, once understood, were successful as well. Other Americans strove to further improve techniques based on wound requirement and new materials. Irving Lichtenstein MD in California emphasized the avoidance of tension, not only to improve wound healing, but also to improve comfort and added mesh to create a reproducible “Tension-Free Technique”. Theoretically the impenetrable plastic mesh would insure the absence of recurrence. Local anesthesia was easily used and the procedure was performed on an economic ambulatory basis.
Nyhus and Condon investigated a different anterior open incisional approach, approaching the inguinal area
from behind muscles. This new type of approach was expanded by others adding a wide layer of mesh in this deep preperitoneal layer behind those weak groin tissues.
In the 1990’s, using video laparoscopy equipment and optical magnification, the deep technique of inlay mesh reconstruction was successfully adapted accessing the deep tissue plane through small punctures, further minimizing postoperative pain, disability and scarring and accomplishing at least equivalent results.
Many other variations and types of mesh were devised for many reasons. One solution does not solve all similar problems. Individual tissues vary in strength. Habit did not replace creative thinking and speed does not supersede
precision.
PATIENT EDUCATION: AVOID MISUNDERSTANDINGS
The surgeon who performs your hernia repair should educate you with enough information for you to confidently participate in the decision-making processes. Because one repair does not fit all patient’s requirements, explanation of the options of treatment and description of the alternative techniques require an orderly two-way communication including verbal and visual descriptions of techniques, clarification of ambiguities and misconceptions, establishing realistic expectations, and evaluation of risks and benefits, advantages and disadvantages. You may have special needs or conditions that require integration into the
equation, including fears, past surgical experiences, coexisting medical risk factors, employment needs, exercise habits, cosmesis and psychological predisposition. Institutional cost factors will impact in addition to limits established by insurance companies and HMOs.
Because laparoscopy is also called “minimally invasive”,one might think that it is simple, doesn’t need much anesthesia, is safer and is better done when risk cofactors such as heart disease or urinary problems coexist. Laparoscopyis actually “minimally incisional” but the procedure is performed is in a deeper and wider space with more dangerous and sensitive structures in the neighborhood. General anesthesia is needed and
the risk of most coexisting medical conditions is magnified.
The bigger cut and less penetrating but still wide dissection of the standard incisional techniques, however are closer to the surface and can dependably be performed with local anesthesia on an ambulatory basis and less risk from coexisting conditions.
Beware of Marketing - Laparoscopy is not the same as Laser. Laparoscopy is a method of access, technique and visualization with a few small incisions. Laser is a adjunctive method of energy deliverance that is used in place of knife, cautery or other energy delivery systems. Some patients have concluded from lay information that a Laser can magically perform this operation without an incision.
Laser surgery was popular when it was introduced in the 1980’s, still has important uses now, but misconceptions persist.
Recent marketing of Robotics in abdominal surgery is also perplexing. Results have not been shown to be better or equivalent. Expense and length of surgery is greater and application to complicated situations requires clarification. Surgeons need to talk about these things…otherwise hearsay might be misleading.
PRE-OPERATIVE CONSULTATION
A consultation with the operating surgeon is indispensable. Even when the diagnosis is obvious and a referral is made to a geographically remote location, the surgeon and patient must speak in detail about the
procedure. Communication of the technique to be used for repair, comparable advantages, disadvantages, options, risks, benefits of different procedures, the anesthetic and adjunctive procedures, expectations, possible complications and sequels, postoperative recommendations and chance of recurrence and recovery require a generous consultation.
Continuity of care is preferable. Obtaining this information is not always so simple. The present socioeconomic environment discourages this conversation because insurance companies, HMO’s and Medicare, do not appropriately compensate time needed for this discussion. Physicians, physician assistants and health extenders might function separately, in series, and with
compromised continuity. The consultant, the person obtaining consent, the surgeon and the postoperative caregiver might be different. Keep your own contemporaneous summary of all discussion.
Public access information is useful but not specific or proprietary. The Internet, lay press, gossip, and descriptions of memories of personal experiences of surgery by friends at some remote time might lead to unreasonable and erroneous expectations and impressions.
Correct orientation can only be accomplished with a planned discussion. Terms like “laser surgery ”in place of “laparoscopic” surgery even leads some people to believe that repair can be done magically without an incision and without
pain. Tissue reaction to trauma is not an intuitive concept and the word “repair” lead some naïve patients to conceive that “a patch is placed like repairing a pair of pants” and requires no tissue reaction or wound healing. The paradoxin laparoscopyof tiny, barely visible incisions and invisible extensive dissection must be explained if the patient is expected to understand the postoperative course and comparison to open, anterior, incisional techniques.
Realistic expectations are important. If your expectations are unreal or unreasonable, it is likely that your experience will be disappointing and surprising.
WHAT LONG TERM PROBLEMS CAN RESULTFROM HERNIA REPAIR?
Surgery
can sometimes be followed by long-term problems. Some minor aches, pulling, stiffness are limited. For the purpose of clarification, a problem that persists six months after numbness can still improve after this point. More troublesome symptoms are of greater concern.
Pain is a significant complaint after the early phase of wound healing. Pain as presenting symptom before surgery is a risk factor for postoperative pain. A different pain might have been noted immediately after surgery and continuously required narcotic relief. The pain may be under the wound and in the area of the preoperative hernia bulge or the pain might radiate from the wound into other areas. Motion or position changes might worsen symptoms. If
the pain prevents return to normal activity and work after 4-6 weeks the complaint requires attention. If the symptom persists for three months, there is cause for concern.
Nerve entrapment produces burning pain. Radiation of discomfort outside the region of surgery might be felt for a week or two after surgery, but persistence for months is alarming. Nerve entrapment occurs because something is continuously irritating the nerve. This can result from exacerbation of the a preexisting nerve problem, angulations of the re-routed nerve, compression or swelling of the surrounding tissues, or excessive scar formation related to wound healing, sutures, tacks or mesh. Resolution of a persistent problem might require
reoperation.
Early recurrence might produce immediate and persistent postoperative pain. There are multiple possible causes, A recurrent hernia protrusion usually becomes obvious within six month but might be difficult to detect because scar formation holding back the bulge is present in early stages of wound healing. Recurrence also occurs later in the first few years. The immediate postoperative phase might have been uneventful. Recurrence is rare when mesh is used with either open or laparoscopic technique. Risk factors for recurrence include obesity, neoplasm, age, asthma, prostatism, constipation, wound healing, immune compromise, previous surgery, technique and surgeon. Re-operative solution are different
from primary hernia surgery.
Mesh is always used in laparoscopic repairs. In the rare situation that infection occurs, mesh perpetuates this problem. Open repair can still be done without mesh but is more invasive. Infection risk is decreased with laparoscopic surgery.
Testicular problems are rare in initial hernia repairs but are a real risk (about 3%) in recurrent hernia repairs. This risk is decreased with laparoscopic re-operation after initial open hernia surgery.
Correction of Problems: Re-operative solutions after hernia recurrence, complications or postoperative pain are more complex and require the same detailed and tenacious approach. A. Douglas Heymann, MD, FACS
Attending Surgeon, Lenox Hill Hospital
Office: 4 East 76thSt, New York, New York 10021 212-249-0469
www.adouglasheymannmd.com, www.herniablurb.com, www.surgiblurb.com
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