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  • Surgery VS Watchful Waiting

    Hello,

    I’ve been debating for many months whether or not to have surgery for small, hidden, inguinal hernia. The pain is intermittent (i.e. a few days of significant discomfort followed a week or two of almost no pain). The pain is a pinching, pulling aching from the pubic bone to the hip. Sports and activity do not generally provoke pain so my life is not really limited per se - I’m just chronically uncomfortable. On bad days, I feel lousy. I lose my mojo and feel convinced that surgery is the right thing. But then it passes and I think (particularly after reading statistics and stories…) that I would be foolish to risk my relatively OK quality of life.

    With hopes you can help me (and others) weigh my symptoms versus risk of post-operative pain, I have a few more questions:

    - According to the Manual of Groin Pain, “preoperative groin pain predicts an increased likelihood of postoperative chronic groin pain”. Can anyone clarify why this is so? Is it because groin pain is more often caused by something other than the hernia (as was told to me by one surgeon). As groin pain is a common symptom of hernia - and one of the main reasons for risking surgery - it’s something of a conundrum!

    - Is intermittent pain typical of hernia? If so, would you say this is because pain is felt when the piece of tissue is lodged in the canal causing pressure - and relieved when it is not?

    - Is it true that small hernias are at greater risk of strangulation than big ones?

    - Is it possible that a hernia will become less painful when the hole gets bigger thus relieving some pressure?

    - Would nerve blocks be a viable alternative to surgery in some cases (this has been suggested by my GP).

    - And finally, some doctors are of the opinion that ALL groin hernias in women should be fixed. Do the doctors on this forum have thoughts on this? Dr. Towfigh refers to the Veteran’s study in the New England Journal of Medicine in which many waited with no complications. Am I correct in assuming the subjects were all men? Can small hernias in women be safely watched - and possibly never fixed? (BTW, I am a healthy 56 year old female).

    Many thanks!

  • #2
    Surgery VS Watchful Waiting

    Tilbis,

    Thanks for the very thoughtful and researched post. I will try to do my best to answer some of your questions and I think once we all weight in you should have a nice overall sense of a small consensus.
    1. Pre-Op = Post-Op: I don's know that there is scientific evidence one way or the other. I think that sometimes its because the original pain was from other sources and I think sometimes that the pain is caused by the patients anatomy/neurogenic in nature and not necessarily the hernia regardless of size.

    2. Intermittent is typical - Many folks say the pressure and pain gets worse with standing for long hours. Over the say the muscles get tired and become weaker so its a combination of the hernia pushing out and the overall increased stretch of the abdominal wall secondary to fatigue from standing long periods in an already weak tissue.

    3. Yes and no on the small hernias - Very small less than 1.5cm or so are extremely rare to have bowel incarceration and strangulation. " Small hernia's in the 2-6cm range do demonstrate an increased risk of incarceration and strangulation. Large and very large hernias rarely incarcerate and strangulate in my experience.

    4. Yes the hernia can become less painful over time but the pressure is likely to remain the same or get worse.

    5. Nerve blocks - Yes and No - Short term they are great but it is a lot of work to get them setup and also a lot of work to maintain the injections every couple of days for long periods of time.

    6. Its hard to answer the question with such a broad range of possibilities ( true inguinal hernia or incision hernia from c-Section, etc?) I will say that I do not treat my female patients any different than men and watchful waiting does not have any different effects on women as on men. I believe subjects in that study were indeed men.

    Hope that helps a little bit and hope to be of service in the future. Dr. Szotek

    Comment


    • #3
      Surgery VS Watchful Waiting

      Thank you, Dr. Szotek for the thorough response. A few follow up questions and comments:

      1. When you refer to the “patient’s anatomy/neurogenic in nature” are you meaning that there are sort of ‘phantom pain pathways’ caused by the hernia - that can remain after the hernia is fixed?

      2. I certainly understand and feel the effects of standing for hours but by ‘intermittent’, I was meaning a few weeks of discomfort followed by a few weeks of almost no pain. I’m trying to understand the mechanics of this! I do pilates and yoga and wonder if there is any correlation between exercise and degree of pain - or if it’s more random. This may be a dumb question but if pain is caused by tissue in the hole (?), is it possible that exercise can keep it out of the hole?

      3. Does strangulation only involve bowel (or maybe bladder?) - or can a piece of fat dangerously strangulate? When diagnosed 8 months ago, my hernia was only 6mm - not sure what it is now. One surgeon I met with believes that a hernia that size (and with no bulge) barely qualifies as a hernia and that performing surgery on me would be almost unethical. Elsewhere I read that ALL hernias in women should be operated on. Do you agree with this and, if so, is it because it’s possible that femoral hernias (which are more dangerous) can be mistaken for inguinal hernias?

      Thanks!

      Comment


      • #4
        Surgery VS Watchful Waiting

        Wow. So many great questions.

        Scientifically, we don't have perfect answers for everything you are asking.
        Some comments limited to inguinal hernias in particular:

        - all hernias in women do NOT need to be repaired. Femoral hernias are the exception. Femoral hernias should be repaired if they are diagnosed, as they are at highest risk of strangulation. The timing of that repair is unclear.

        - hernias that are symptomatic should be considered for surgical repair. The size is not a determinant of repair. For sure there are super small hernias that are very symptomatic, and the reverse may also be true. I routinely repair very symptomatic often debilitating hernias that are very small. They are called occult hernias. A lot of surgeons don't agree with me. I presented my data for these naysayers: 87% cure.

        - nerve blocks do not treat hernias nor their pain. In fact, in most cases, it may increase the pain. It's a diagnostic tool

        - exercise can help reduce symptoms from the hernia and/or reduce their size.

        - strangulation is most risky with Bowel. Bladder does not strangulate. Rarely it can incarcerate. Fat can strangulate

        - almost al the data we have about hernia outcomes is with men. A few of us are adding women to the pot.

        In short, hernia repair, as with any elective surgery, is a personal decision. You must weigh its risks and benefits. If performed by an expert, the risks should be less. This is especially true for women
        #ItsNotJustAHernia
        www.BeverlyHillsHerniaCenter.com

        Comment


        • #5
          Surgery VS Watchful Waiting

          Thanks for the helpful info! There are still two points I’m curious/confused about:

          - Would you say that intermittent pain (few weeks on, few weeks off) is typical of (hidden) inguinal hernia? If so, would you guess that pain is triggered when tissue is in the canal, and relieved when it is not? (I understand there is no way to heal the hernia but wondering if targeted exercise might actually keep the pesky tissue at bay!)

          - regarding pre-op pain predicting stronger likelihood of post-op chronic pain (according to Manual of Groin Pain): I understand that in some cases this is because pain is caused by something other than the hernia. If, however, my pain IS due to hernia (difficult to prove, I know), would my chances of post-op pain still be greater than those who went into surgery with no pain? If so, can this be explained?

          As mentioned at the top of this thread, pain/discomfort is the main reason many of us would risk surgery. If, however, the odds of ending up with symptoms that are the same or worse (even in expert hands), this is something we need to consider carefully.

          Comment


          • #6
            Surgery VS Watchful Waiting

            First: it is much more likely that you--or anyone--have improvement than chronic pain after hernia repair--even those with pain preoperatively.

            At this point, we don't have a good way to know prior to surgery if any particular person will do well. Dr Ramshaw is dedicating his career to finding this out.

            To answer your two questions: we don't know. Medicine is an Inexact science and a bit of art. We just don't know enough to be able to answer you and therefore perfectly tailor your exercise to be the best for your situation. Yes, hernias can have intermittent pain. Why? We don't know.
            #ItsNotJustAHernia
            www.BeverlyHillsHerniaCenter.com

            Comment


            • #7
              Surgery VS Watchful Waiting

              I want watchful waiting for a left indirect omental scrotal hernia. The amount of omental fat in scrotum looks like a third testicle. No pain. Reducible.
              What is the risk of strangulation?

              Comment


              • #8
                Surgery VS Watchful Waiting

                I do not need to know exact risk, just if watchful waiting is reasonable.

                Comment


                • #9
                  Surgery VS Watchful Waiting

                  MO

                  Difficult to quote for sure but your particular hernia is on the higher end of the risk spectrum than a non-incarcerated, reducible hernia as I am assuming by your post that you cannot push it back in? Some data will suggest the risk in the range of 2% / year that you watch it that it will require surgery on an urgent/emergent basis. In my opinion your would be higher but unable to predict to my knowledge.

                  Thanks
                  Dr. Szotek

                  Comment


                  • #10
                    Surgery VS Watchful Waiting

                    It is partially reducible when lying down, at least 2/3 goes back in.

                    Comment


                    • #11
                      Surgery VS Watchful Waiting

                      Are there published guidelines that are credible to most surgeons?

                      Comment


                      • #12
                        Surgery VS Watchful Waiting

                        yes.
                        read:
                        1. http://jama.jamanetwork.com/article.aspx?articleid=202212&resultclick=1
                        It shows 0.18% per year risk of incarceration with watchful waiting.

                        2. http://link.springer.com/article/10.1007/s10029-009-0529-7
                        It outlines evidence-based treatment of inguinal hernias
                        #ItsNotJustAHernia
                        www.BeverlyHillsHerniaCenter.com

                        Comment


                        • #13
                          There are no similar studies with the same accuracy (at least I wasn't able to find one) on ventral post incisional (para umbilical/epigastric) for watchful waiting emergency admission prognosis. What is your perspective on this? Would you apply a "no go" management (in case of no pain/no defect advance/no cosmetic reasons) for ventral post incisional hernias? Does the size of the defect matter in this case?

                          Comment


                          • #14
                            There have been studies in incisional, ventral, and umbilical hernias and watchful waiting. The consensus is that, though safe to watch asymptomatic/minimally symptomatic repairs, patients with surgical repair have significantly improved quality of life and less overall pain
                            #ItsNotJustAHernia
                            www.BeverlyHillsHerniaCenter.com

                            Comment


                            • #15
                              Thank you for dealing with the preliminary node of all the hernias. Frankly, it turns out that strangulation is a rare occurrence, but I'm not a doctor, so I will only say that I am not very concerned about strangulation myself, but I might be denied the facts.
                              I will also say that I have been from three years with an inguinal hernia, held by a watchful attitude of life, and some appropriate exercise: when I forget the hernia and make an effort, or if I do a wrong exercise, I remain in trouble for days , Even weeks, with swelling. Growth of the hinged door occurred only in the third year, perhaps due to an effort, so now the hernia, without bands, tends to position itself in the groin. In the past, however, it remains in place, and then it seems to have nothing, because it does not bother .... My terror, being a man, is that it slips into the scrotum, as it is an indirect hernia. Someone has experience or suggestions

                              Comment

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