Think twice about hernia surgery

A reader asks, “Is it necessary to get a hernia repaired quickly?”

The time-honoured tradition has always been to fix it. But is this approach always the right one? Or is ‘tincture of time,’ namely watchful waiting, the best way to treat this common condition?

A hernia is a protrusion of bowel through a weak spot in the abdominal wall near the groin. But there is no sexual fairness in this condition. As one of my surgical professors used to say, “Sometimes you get the big brown egg.”

In this case the egg goes to men, as 90% of hernias occur in males.

In the past, surgeons believed that failing to return the bowel to its natural location inside the abdomen was fraught with danger. They worried that the bowel would become trapped in the hernia causing intestinal obstruction, a serious complication.

If this happens, the bowel may lose its supply of oxygenated blood resulting in gangrene and death if an emergency operation is not done. There was also the concern that small hernias could become larger making surgical repair more difficult.

Several years ago a study involving five U.S. medical centers, found that these surgical worries rarely happen.

To prove this point doctors followed 700 men with hernias that were causing minimal or no discomfort.

Half of the men were randomly selected to have the hernia repaired. The other 50% were told to monitor their symptoms and to report back for regular medical checkups.

To their surprise, surgeons discovered that the most feared complication, intestinal obstruction, occurred in less than 1% of patients per year. This is much better than the odds at Las Vegas. Moreover, any discomfort that was initially present did not increase over a two-year period in the majority of cases.

Twenty-five per cent of the watchful waiting group did eventually ask for surgery due to an increase in pain. But this delay in surgery had no effect on the complication rate such as infection, length of operation or the recurrence of hernia.

But what about the other half who initially were chosen to have the hernia repaired?

About 20% developed complications after the surgery such as infection, difficulty passing urine and three had life-threatening problems.

Other studies show that, even after a successful hernia repair, about 5% of patients continue to have pain. No surgical procedure offers a ‘free lunch.’

Since this study involved only men, it’s not known whether women or children who also develop hernias would have the same result. But one would suspect little or no difference.

Dr. Michael Alexander is an expert on hernia surgery at the Shouldice Hospital in Toronto. This facility specializes in hernia repair and is a world authority on this operation.

Dr. Alexander believes that surgeons must get rid of the idea that all hernias must be repaired. This applies particularly to the elderly if they are without discomfort. But age is not a factor as long as the patient is free of cardiovascular and other problems that increase the risk. He says his oldest patient was 99 years of age!

So we’ve all heard the phrase “If it’s not broken, don’t fix it.”

Now we can add another equally sound surgical dictum “If it’s only partially broken, there may be no need to fix it.”

In the past, the usual medical practice was to tell patients that gallstones had to be removed. It’s still true if there are repeated attacks of gallstone colic or if gallstones are small and are blocking the common bile duct that drains bile into the intestines.

But today, X-rays, CT scans and MRIs often detect gallstones even though these procedures are done for other conditions. In these instances, if the gallstones are not causing any problems, they are normally left for the crematorium.

So if a hernia is present, just remember that porcupines make love very, very cautiously. Be just as cautious about hernia surgery. Always ask yourself, “How much trouble is the hernia causing me?”

Your doctor should then make the final decision.

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