From: sbharris@ix.netcom.com(Steven B. Harris)
Subject: Re: Pain near testicle won't go away
Date: 29 May 1997
Newsgroups: sci.med

In <338e7f7e.199988021@news.gol.com> tomyoung@gol.comx (tom) writes:

>>Arthur Edwards wrote:
>>>
>>> I have been bothered by a dull, achy pain near my left testicle for
>>> almost four weeks. On April 13th I had the sense that I might have
>>> strained myself during a lower body workout. Around the 16th I had a
>>> very painful throbbing in the area of my left testicle when sitting or
>>> driving. I began using a supporter and that helped slightly. Around the
>>> 21st the overall painful throbbing had diminished to the consistent dull
>>> ache. I also noted a tiny area in the left pubic region that was very
>>> sensitive to the touch and blocked the testicle pain with moderate
>>> pressure. On April 28 I saw an internist who believed I had
>>> epididymitis. I was given Relafen for the pain and Ciprofloxacin for the
>>> supposed infection. The Relafen took the edge off the pain allowing me
>>> undisturbed sleep and minimal discomfort during the day.
>>>
>>> By May 7 there had been no change and the dull, achy pain was with me
>>> all day. I saw a urologist. The exam found nothing apparent. I had an
>>> ultrasound done. That too showed nothing except for a slight varicose
>>> vein near the left testicle. As a result they ruled out epididymitis, a
>>> hernia, a tumor, a prostate problem and had no suggestion for a next
>>> step except to return in two weeks.
>>>
>>> I am at a loss as what to do next. I am unable to exercise and am
>>> feeling quite miserable. Can anyone make a suggestion?
>>>
>>> Many thanks.


  Small inguinal hernias can present like this.  Your story of a strain
after lifting weights is suspicious (although you can get epididymal
rupture from this also), and even more is the story of it starting to
hurt a few days later, as hernias do.  With inguinal hernia the
testicular pain is referred, and actually results from pressure on the
nerve in the inguinal canal (which is why you can help it by pressing
on the inguinal from the outside, which decreases the strain from the
inside). Hernias this size are hard to find on exam unless you have a
very skilled examiner (a hernia surgeon).  The only treatment is
surgery, but with small hernias it can be done endoscopically, and is
not a big deal.

   If your pain is not present in the morning, and starts soon after
you get up, the likelihood is that this is what you have.  See a
surgeon.  Truss me <g>.

                                    Steve Harris, M.D.

From: sbharris@ix.netcom.com(Steven B. Harris)
Subject: Re: post laporascopic inguinal hernia surgery
Date: Tue, 29 Jul 1997
Newsgroups: sci.med

In <33dcd11b.3717451@nntp.ix.netcom.com> hhomler@ix.netcom.com (Howard
Homler) writes:

>On Fri, 25 Jul 1997 20:41:19 -0600, jgrant@kc.net wrote:
>
>>About 5 weeks ago, I had laporoscopic (sp) bi-lateral inguinal hernia
>>surgery.  After three weeks, I had 2 very specific, small places that
>>would have very sharp pain under certain conditions - after I was on my
>>feet in the morning for about 1 minute and bent over, bowell movement,
>>sneezing, etc.	More than 5 weeks later, it seems to be getting worse.
>>Now its slightly painful all the time and am still having the sharp pains
>>during the above mentioned situations. My doctor said there's a chance
>>that one or two of the staples used could be hitting a nerve and I may
>>have to have more surgery to remove the staples.  I am a 43 year old male
>>in excellent condition otherwise.
>>
>>Does this sound correct?
>>How often does this happen?
>>Any suggestions?
>>
>>Thanks.
>
>
>Yes, it's a rare complication, but I've seen it happen, and even got a
>reference from the library on it.  Reoperation should  be curative.


   It's not that rare.  I've probably seen a dozen cases of post-hernia
pain syndrome, no doubt due to inguinal nerve entrapment of some sort,
and I'm not even a surgeon.  In every case the guy said his surgeon
looked at him in stupifaction like it was the first report of chronic
post surgical herniorrhaphy pain he'd ever seen.  Must be some defect
in surgeons that they can't recognize their own iatrogenic
complications <g>.  Sort of like the one in chemotherapists where they
can see the shrinking solid tumor perfectly clearly, but miss the
shrinking health and failure to prolong life.

                                               Steve Harris, M.D.

From: ((Steven B. Harris))
Subject: Re: non-surgical healing for inguinal hernia
Date: 22 Jun 1995

In <3sbmhf$869@swifty.cfa.org> bskop@rushford.polaristel.net (Bud
Pratte) writes:

>I would be interested in anyone who has had success in healing an
>inguinal hernia by yoga and various stretching exercises.  I have had
>a hernia for a number of months and have had some improvement by doing
>a number of yoga poses to strengthen the groin area but seem to have
>reached a plateau and cannot quite pass beyond that.  I can get the
>hernia to go back and hold it for a number of hours, but then it comes
>back.  I would be interested in any suggestions.
>
>Thank you


Bud, bite the bullet and have the opperation.  It is NOT going to heal
by itself, no matter what you do.  In likihood, the longer you wait, the
worse the surgery will be.

Also, when you finally decide to do it, get it done in a "hernia mill"
where they do nothing but hernias, practically on an assembly line.  The
docs will be boring, but also good.  Don't have it done by your favorite
general surgeon at your favorite little local hospital.

You can ignore this advice, and the price will be what it usually is for
ignoring expert advice.

                                               Steve Harris, M.D.

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: PTFE Dual Mesh for hernia repair ??
Date: 2 Jun 2003 17:23:30 -0500
Message-ID: <3edbcd35$0$37879$45beb828@newscene.com>

"Mike" <mikelarry88@yahoo.com> wrote in message
news:bbab0f01.0306021021.10aa924c@posting.google.com...
> Greetings Listers,
>      I've undergone a couple of laparotomy procedures a couple of
> years back and have developed incisional hernia for about 1.5 yrs . My
> surgeon recommended an open method for me , owing to the very large
> incision and multiple defects & would be implanting a mesh in my
> abdomen. Am seeking help from the listers here to
> 1. find the best mesh for the repair ( is PTFE the best option ? )
> 2. Any future complications after hernia repair like this ?


Gore-Tex Dualmesh or Dualmesh Plus  is the current state-of-the-art
prosthetic matierial for incisional hernia repair, and it is indeed the best
option. The state-of-the-art technique is to take down the adhesions and
place the mesh laparoscopically. Look at http://tinyurl.com/dapa

Recurrence rates are higher for open repairs such as your surgeon
recommends. A large hernia defect or multiple defects is not necessarily a
reason to do it open. This very morning I repaired a multiple-defect
incisional hernia that required a 20cm x 32cm piece of Dualmesh to cover.

Laparoscopic repair of incisional hernias, even big ones, is a superior
method. If your surgeon doesn't do this procedure, at least be sure he uses
the Stoppa technique for the open repair. If it were me, I'd look pretty
hard for someone who could do it laparoscopically.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: PTFE Dual Mesh for hernia repair ??
Date: 2 Jun 2003 23:22:19 -0500
Message-ID: <3edc2207$0$53551$45beb828@newscene.com>

"Mike" <mikelarry88@yahoo.com> wrote in message
news:bbab0f01.0306021947.1a6688eb@posting.google.com...
> Howard,
>    That sounds good. Thanks very much. Is PTFE same as Gore Tex ?
>
> > Recurrence rates are higher for open repairs such as your surgeon
> > recommends. A large hernia defect or multiple defects is not
> > necessarily a reason to do it open.
>
> My surgeon also mentioned that I've a good number of adhesions after a
> physical examination. Could that be detrimental to laparoscopy ?
>
>
> >, at least be sure he uses
> > the Stoppa technique for the open repair.
>
>   Is it the same as Tension free repair ?
>
> > hard for someone who could do it laparoscopically.
>
>   I did visit about 4-5 more surgeons for a second opinion , for I was
> very keen on laparoscopy. All of them opined that they could try
> laparscopy , but they weren't sure if it will not be converted to an
> open method eventually. Any particular reason that you could think of
> , that can lead to such statements ?

PTFE is the same as Teflon is the same as Gore-Tex. Excellent graft
material, Dualmesh is corrugated on one side for tissue ingrowth into the
abdominal wall and goretex on the other side so intestine doesn't grow in
and erode (as happens with polypropylene).

Stoppa technique is wide fascial undermining for better security of the
mesh, lower recurrence rate. The laparoscopic repair is a variety of the
Stoppa technique without all the pain or complications. They are both
tension-free repairs.

The deal breaker for laparoscopic incisional hernia repair is usually
adhesions. If they are too dense, or too much intestine involved in the
hernia sac, they can be dangerous to remove. Dealing with such adhesions
safely is skill-dependant. Another factor is dealing with a large sheet of
mesh (if there are large or multiple hernias) -- also very skill dependant.
If an incisional hernia repair is tried laparoscopically but can't be done
for whatever reason, then it's converted to open. The rate of conversion to
open is directly relative to the surgeon's skill.

HMc

From: "Howard McCollister" <hmacno@spamemily.net>
Newsgroups: sci.med
Subject: Re: PTFE Dual Mesh for hernia repair ??
Date: 3 Jun 2003 08:50:29 -0500
Message-ID: <3edc8c19$0$56256$45beb828@newscene.com>

"Mike" <mikelarry88@yahoo.com> wrote in message
news:bbab0f01.0306021947.1a6688eb@posting.google.com...
> My surgeon also mentioned that I've a good number of adhesions after a
> physical examination. Could that be detrimental to laparoscopy ?
>
>

By the way, there is no way to determine the exact extent of postoperative
adhesions in someone's abdominal cavity by physical exam. If the hernia
contents are not reduceable, it still doesn't mean laparoscopy isn't
possible. Often those adhesions/hernia content will come out easily with
some dissection and gentle tugging; much easier that trying to push them
back in from the outside. It's not unreasonable to assume that, after two
laparotomies, there are indeed ahesions but the extent of the adhesion
formation varies so much from person to person that one never knows until
one actually takes a look. I've done incisional hernia repairs after
multiple laparotomies and dreaded what I assumed would be very extensive
adhesion formation and found little or no adhesions, and I've done them for
a single small incision and found extensive adhesion formation. You can't
tell..

HMc

From: "Howard McCollister" <hmacXX@XXcharter.net>
Newsgroups: sci.med
Subject: Re: simultaneous herniated disk, inguinal hernia
Date: 1 Aug 2003 16:52:05 -0500
Message-ID: <3f2ae07b$0$53606$45beb828@newscene.com>

The likehood of strangulation of an inguinal hernia is small. If I had the
hernia you describe and I was not having disabling symptoms from it, then I
would do nothing. I  would continue physical therapy and take care of my
back. I would basically go on about my life and ignore my inguinal hernia
until it began to bother me. In the very unlikely event that I should wake
up in the middle of the night with a painful, tender bulge in the groin
(strangulation), then I would promptly get dressed, go to the hospital and
get it fixed.

The concept that ALL inguinal hernias need to be fixed is obsolete.

And that's what I tell my inguinal hernia patients, too.

HMc


"african grey parrot" <deriv1@[SPAMBLOCK]yahoo.com> wrote in message
news:7mxWa.4678$UZ5.83212468@newssvr13.news.prodigy.com...
> I am 30/male.  As the subject implies, I had a lumbar microdiscectomy
> (L5/S1) for a significant herniated disc just 10 days ago.  Everything
> is going great and the healing is well on track with the pain completely
> gone.
> 
> Problem is, yesterday I was diagnosed with a very mild right inguinal
> hernia.  The doctor said it's pretty small and that I could wait till
> winter to get it repaired (obviously provided that it doesn't
> strangulate or become huge).  He did say that smaller ones are more
> likely to get strangulated though.  I had the left one repaired 5 years
> ago, which was much more bulging than the current right one, and I
> remember that the hernia strained my back because the back muscles were
> compensating for the weak abdominal muscles.  I knew I had the right
> hernia, however mild, because of a slight visual bulge (no big popping
> in/out though).
> 
> So the question is, do I begin the physical therapy for the back, to
> strengthen the abdominal muscles, in two weeks as planned, before the
> inguinal hernia repair?  Or, do I get the hernia repair done right away,
> and then go into physical therapy?  I just don't know how to reconcile
> the hernia options with the therapy and back healing.  I'm just
> concerned about waiting to repair it given the memory of the other,
> albeit larger, inguinal hernia making my back hurt.
> 
> So far, the physical therapist and one of the doctor's nurses say that
> the hernia repair can wait, that the current program will not interfere.
> I am waiting to hear back from the spine doctor himself.  The internist
> yesterday deferred to the back doctor and therapist, and I am not seeing
> the potential hernia repair surgeon till Aug 11.
> 
> Any opinions appreciated... thanks in advance.
>
>

From: "Howard McCollister" <hmacXX@XXcharter.net>
Newsgroups: sci.med
Subject: Re: simultaneous herniated disk, inguinal hernia
Date: 2 Aug 2003 08:32:23 -0500
Message-ID: <3f2bbccb$0$41226$45beb828@newscene.com>

The inguinal hernia and back problem are completely unrelated. I could see
how a painful abdominal wall condition could cause back problems, but if
your hernia is asymptomatic, one condition causing the other is highly
unlikely.

HMc


"african grey parrot" <deriv1@[SPAMBLOCK]yahoo.com> wrote in message
news:ZbGWa.12200$3k1.5303@newssvr22.news.prodigy.com...
> Thanks, I feel better about the hernia.
>
> I'm just concerned that the inguinal hernia could make things worse for
> the recovery from my herniated disc, at worst cause the disc to
> re-herniate, if not slow the healing.  Or worsen my L4/L5, which has a
> small tear.
> 
> But I'm guessing the back problems caused the inguinal hernia, not vice
> versa... how could a very small inguinal hernia cause a herniated disc?
> The opposite seems more plausible to the layman... at any rate, I am
> going to get the hernia repaired as soon as possible, only because of
> the possible risk to this old man spine bolted to my 30 year old body.

From: "Howard McCollister" <hmacXX@XXcharter.net>
Newsgroups: sci.med
Subject: Re: The Confusing Myriad of Surgical and Location Alternatives in 
	Addressing a Hernia
Date: 13 Oct 2003 08:53:13 -0500
Message-ID: <3f8aad90$0$237$45beb828@newscene.com>

"mfy" <newexplorer99@hotmail.com> wrote in message
news:ddc59296.0310130521.7a36fcdc@posting.google.com...
> I would be very very grateful for any perspectives on what is a
> somewhat vexing combinations of problems.  I have an apparent hernia -
> apparent as I've not yet seen a surgeon - in the lower right pubic
> region.  It is a spongy moderate bulge about 2 inches in diameter.  I
> am experiencing a dull but fairly constant pain that is exacerbated
> when sitting or hunched over, or sometimes when walking.  I have also
> been diagnosed with gallstones, and have noticed the apparent
> gallbladder symptoms - discomfort/burning after eating, upper abdomen
> aching  to be worse since the hernia has become more noticible.  I had
> several specific questions that may have in part been addressed
> previously, but I would be very grateful for the 'latest' answers-
>
> 1. Could some of the digestive symptoms be the result of a seeingly
> small hernia located so far down, or is that likely my gallbladder
> acting up coincidentally?
>
> 2. I have read about a number of surgical alternatives, and it is very
> difficult to separate hype or self-interest from fact. Is laparoscopic
> surgery significantly less painful?
>
> 3. What is he main distinction between the Lichtenstein, Stoppa, and
> Shouldice procedures?
>
> 4. I am trying to decide between having the procedure at a major
> teaching hospital such as Mass General or Brigham and Women's in
> Boston, or Dartmouth Hitchcock, or go to a specialized hernia
> practice, like Hernia Institute of Florida.  I would be very grateful
> for any perspectives on the pros and cons of each approach.
>
> 5. I gather that there is huge variability in result between surgeons
> for this operation. What frequency of surgery is generally considered
> sufficient for laparoscopic or 'regular' hernia procedures?
>
>
> I would really appreciate and be very grateful for any experiences or
> expertise that might be shared as I'm a bit confused, to say the
> least, at this point.

The symptoms of your inguinal hernia will be relatively localized pain in
the groin area. Your epigastric burning and pain is probably due to your
gallbladder, or possibly acid reflux. Whichever, your gallbladder needs to
be removed.

The benefits of laparoscopic surgery for your gallbladder are significant.
Less so for inguinal hernia surgery. Most surgeons would only do
laparoscopic inguinal hernia surgery for a) recurrent inguinal hernia b)
bilateral inguinal hernia  c) selected cases who need the absolute quickest
recovery and whose insurance will pay for it. Laparoscopic inguinal hernia
surgery does result in slightly less pain and slightly quicker recovery, but
the cost is significantly higher and the risks of mortality and morbidity
are greater.

Inguinal hernia surgery is about as common as it gets for a general surgeon.
You could go to a specialized "hernia institute" if you want to. It would be
like searching for the world's greatest plumber to come to your house to
change a washer in your faucet.

There isn't "huge variability" between surgeons at all. The results of such
repairs as you mention are quite consistent across the country for this
relatively simple operation.

HMc

From: "Howard McCollister" <hmacXX@XXcharter.net>
Newsgroups: sci.med
Subject: Re: The Confusing Myriad of Surgical and Location Alternatives in 
	Addressing a Hernia
Date: 14 Oct 2003 07:12:09 -0500
Message-ID: <3f8be778$0$161$45beb828@newscene.com>

"mfy" <newexplorer99@hotmail.com> wrote in message >
>
> Thanks so much for your lucid and relevant response.  Incidentally,
> would it ever make sense to do the gallbladder and hernia with one
> instance of anaesthesia,  or is that not a viable or attractive
> alternative?  And, what is actually the risk from anaesthesia of death
> or serious disability for an otherwise healthy 48 year old?  It is
> very hard to get a sense of the order of magnitude of this risk.  And
> lastly, while I know this can vary, how bad is the pain from this
> surgury, and does it result from muscles being cut, from general
> surgical trauma, or are there aspects specific to this surgery's
> location or nature that make it particularly painful?
>


Well, in some circumstance and some patients, it would make a lot of sense
to do the gallbladder operation and hernia operation at the same time under
the same general anesthetic. This depends, in large part, on the medical
condition of the patient. However, whether or not a surgeon would agree to
do that depends very much on your insurance plan. Many third party payors
will only pay for one procedure at a time. If a surgeon submits a billing
code for both, your insurance company may only pay for one, or at best pay
half for the second operation.

The risk of general anesthesia for a healthy 48 year old is quite low. The
risk of death from the hernia repair is even less. I feel pretty confident
that the risks of mortality/morbidity from your gallbladder disease and your
inguinal hernia are statistically higher than the risk of the operation(s)
and the anesthetic.

The gallbladder operation pain is pretty low. Most patient, IME, go home the
same day and have very little discomfort. This varies, of course. OTOH, the
hernia operation hurts. A lot. It will feel like a bad muscle strain for
about 2 days and you will notice it most when you try to get up out of a
chair or get out of bed. It will be manageable, and tolerable. After about a
week, you will feel pretty good and moving around well with some residual
stiffness that will resolve over the next couple of  weeks. Many surgeons
allow their patients to go back to work within a week if they feel up to it.
No muscles are cut, but the swelling and inflammation that goes along with
surgery and placement of the mesh does cause pain until it subsides.

HMc

From: "Howard McCollister" <hmacXX@XXcharter.net>
Newsgroups: sci.med
Subject: Re: The Confusing Myriad of Surgical and Location Alternatives in 
	Addressing a Hernia
Date: 16 Oct 2003 06:42:21 -0500
Message-ID: <3f8e8368$0$18387$45beb828@newscene.com>

"Kathy Cole" <kathy@scconsult.com> wrote in message
news:g9hqov4vct71snfs567piqtijj4g89m1tj@4ax.com...
> On 13 Oct 2003 21:25:42 -0700, newexplorer99@hotmail.com (mfy) wrote:
>
> > Thanks so much for your lucid and relevant response.  Incidentally,
> > would it ever make sense to do the gallbladder and hernia with one
> > instance of anaesthesia,  or is that not a viable or attractive
> > alternative?
>
> It sounds from the other posters like this is an unlikely option.  I
> will note, however, that we did coordinate two surgeries for my youngest
> son (between his general surgeon and neurosurgeon) successfully (both in
> terms of his recovery and without complaint from our insurer).
>
> The surgeries were a bilateral inguinal hernia repair first, then a
> shunt revision.
>
> It may be that because there were two surgeons involved, there was no
> questioning of the bill by the insurer, but I thought I'd throw our
> experience out there.

Yes, in a child, the third party payors view things differently re:
simultaneous operations because they acknowledge the value of minimizing
general anesthesia due to the increased anesthetic risk in the younger age
group.

Additionally, as this poster noted, the situation if completely different if
the two operations are performed by two different surgeons in different
specialties.

HMc

From: "Howard McCollister" <hmac@nospam.net>
Newsgroups: sci.med
Subject: Re: C-Section delivery with Hernia repaired by mesh ?
Date: 25 Oct 2003 08:56:43 -0500
Message-ID: <3f9a7faf$0$538$45beb828@newscene.com>

"Gauri Rawat" <rawat@hotmail.com> wrote in message
news:54ceb5b2.0310250312.c40d237@posting.google.com...
> Hi,
>   I had D&C done on me, but in the process my uterus was accidentally
>  perforated along with my intestine. I was operated to repair
>  my uterine wound, and a colostomy was also done. After 3 months
>  my colostomy was closed. Subsequently, I have developed a hernia
>  in both the colostomy cut, as well as the main mid-line cut.
>  The doctors have diagnosed it as incisional hernia, and are
>  suggesting repair with a Prolene or PTFE mesh.
>
>   I am still young and would want to have more babies later.
>  Due to my earlier uterine wound, I will have to deliver my
>  next baby by C-Section only, according to the doctors.
>  However, I am not sure if it is possible. I have the following
>  worries, which if anyone can please clarify, I will be very grateful:
>
>  1. Should I get my hernia repaired with a mesh? If yes, how will this affect
>  the delivery of my next baby by C-Section?
>
>  2. I believe it takes a longer time to cut through the mesh to reach
>  the uterus for delivery. Will it be safe for my baby, if I am under
>  anesthesia for a longer time?
>
>  3. Is a mesh-repaired hernia re-joinable after a C-Section. Can
>  the mesh be sutured back again, so that my hernia does not re-occur?
>
>   If anyone has had a similar experience, or could help me sort my
>  worries, please let me know your thoughts about this.
>

This is a very difficult situation IMHO. To become pregnant after a mesh
repair of an incisional hernia, particular lower midline runs a very high
risk of disrupting the mesh (which won't "give" as the abominal wall expands
to accomodate the enlarging uterus) and creating a recurrence of the hernia.
This would then require a second repair of the recurrent hernia at a later
date. To further complicate the matter, a C-section is a
"clean-contaminated" operation and the risk of infecting a Gore-Tex mesh
from the C-section is significant, and this would be a big problem requiring
at least 2 more operations (remove mesh and place an absorbable mesh, then
later going back and putting in another Gore-Tex mesh). I would also comment
that polypropylene (Prolene) mesh is almost never used in incisional hernia
repairs anymore these days (in this country) because of the high incidence
of dangerous complications

OTOH, to not fix the hernia does run the risk of intestinal
incarceration/strangulation. Additionally there is a higher incidence of
pregnancy complications, especially premature labor/late miscarriage, with
pregnancy in the presence of an incisional hernia. And, it is not uncommon
for the pregnant uterus itself to become incarcerated in the incisional
hernia.

The only solution that comes to my mind if you are determined to become
pregnant is to consider a non-mesh repair of the incisional hernia,
recognizing that this repair has a very high incidence of hernia recurrence,
especially with pregnancy. The C-section would take place, then at a later
date when you are done having children, repair the hernia(s) with Gore-Tex
mesh. Although this approach is very risky (primarily for uterine
incarceration, especially if the hernia recurs during the pregnancy) it
probably represents the least risky approach.

Bear in mind that any comments I make here may be variable in their
applicability based on things about this situation that I don't know, such
as size/location of the hernia(s), patient history, physical exam etc. In
addition, take my opinions here with caution (always a good idea with
internet advice). I have fixed a lot of incisional hernias, and done a lot
of C-sections, but your situation is not something that I have faced.

Sadly, I would have to say that in this setting, further pregnancies would
generally not be recommended due to the high risks and serious complications
that might be involved. Alternatives such as in vitro fertilization and
surrogate mother are options that you should discuss with your obstetrician.
I'm very sorry to hear this unfortunate chain of events and resultant
problems for you. You should definitely consult with very high level experts
in complicated obstetrical situations before making any final decisions
about future pregnancies.

HMc

From: "Howard McCollister" <hmac@nospam.net>
Newsgroups: sci.med
Subject: Re: hernia laparoscopic surgery
Date: 6 Nov 2003 20:53:06 -0600
Message-ID: <3fab0880$0$64431$45beb828@newscene.com>

"shalini" <shalini72@yahoo.com> wrote in message
news:34be2c52.0311061809.66593ed4@posting.google.com...
> My husband underwent laparoscopic surgery for umbilical hernia about a
> week back, he has now developed a swelling above the navel , which
> comes and goes. the surgeon has told us that this is normal fluid
> build up, we just wanted to confirm that.

It would not be unusual for fluid to build up in the area where the hernia
sac was after such a repair.

HMc

From: "Howard McCollister" <hmac@nospam.net>
Newsgroups: sci.med
Subject: Re: The Confusing Myriad of Surgical and Location Alternatives in 
	Addressing a Hernia
Date: 6 Nov 2003 21:59:09 -0600
Message-ID: <3fab1808$0$204$45beb828@newscene.com>

"shalini" <shalini72@yahoo.com> wrote in message
news:34be2c52.0311061827.1be10900@posting.google.com...
> You write that laparoscopic surgery was a very low pain experience for
> you, my husband underwent the lap-surgery for umblical hernia a week
> back and was in a lot of pain. Also he has now develped a swelling
> near the navel, which the doc says is just fluid build up.
>

The poster was writing about open inguinal herna surgery, not laparoscopic
umbilical hernia surgery. Can't be compared. Two different operations.

Laparsocopic surgery generally is a low-pain experience, but laparoscopic
umbilical, incisional, and inguinal hernia repairs are noteable exceptions.
The recovery is quicker, but they hurt. A lot.

The only advantage to laparoscopic umbilical hernia repair (and it is
something to be considered) is that the recurrence rate is lower than open
umbilical hernia repair. Otherwise, laparoscopic umbilical hernia repair
hurts more, costs more, takes longer, usually requires general anesthesia
and there is that pesky fluid accumulation in the hernia defect. An open
umbilical hernia repair takes 10 minutes under local anesthesia. I abandoned
laparoscopic repair of simple umbilical hernias years ago.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: Inguinal Hernia Repair. Medical
Date: 4 Apr 2004 19:54:19 -0500
Message-ID: <4070ad55$0$73844$45beb828@newscene.com>

"D. Jones" <djones0315@hotmail.com> wrote in message
news:XF0cc.6170$I66.4@nwrddc03.gnilink.net...
>
> I have what appears to be an indirect inguinal hernia. When I apply
> pressure to the bulging mass (about as big as a globe grape) it doesn't
> pouch-out after I bear down. My urologist told me that he could make a 4"
> incision and instead of suturing he would put some webbing into
> place(presumably to plug the opening in the inguinal foramen where the
> mesentary is protruding.  My question is has anyone ever heard of a less
> invasive way of correcting this problem? The bulge just appeared about 2
> weeks ago. Has anyone had experience with this type of repair? Side affects?
> I'm a runner/golfer/surfer/Chiropractor and don't want to be 'out-of-action'
> for 4-6 weeks. Any reason this procedure can't be done arthroscopically?
> Would it be advisable to get an MRI first. I understand it could also be my
> bladder protruding from some anatomy reading. Thanks for your help. Should I
> avoid my activities? I feel it only mildly, at this point.

4 inch incision? 1 - 1 1/2  inch incision is more typical for an inguinal
hernia repair unless you are obese.

The technique of using polypropylene mesh for a hernia repair is pretty
standard. The most common complication is transection or entrapment of the
ilioinguinal and/or iliohypogastric nerves. There is a possibility of a
wound and/or scrotal hematoma. During the dissection of the indirect hernia
sac from the spermatic cord, there is (remote) possibility that the
testicular artery could be damaged and you could lose the testicle. There is
also a (remote) possibility that the vas deferens could be damaged impairing
your fertility to a greater or lesser degree.

Typically, the patient's hernia would be repaired under local anesthesia
with some sedation. It would take about 20 minutes, he would go home the
same day. There would be about 36 hours of pretty significant pain when
doing such things as getting out of a chair or out of bed. Then the pain
will start to subside and the patient would be moving around pretty well by
the 7th day or so. Typically, there would be no activity or weight
restrictions other than "if it hurts, don't do it". Many patients are up
running/golfing/surfing/chiropracting within 7-14 days

An inguinal hernia can indeed be repaired laparoscopically, although the
benefits of doing so are debateable. It does typically adds general
anesthesia to the equation as well as longer OR time and a slightly
different set of potential complications. And it costs quite a bit more. The
recovery for activity is about the same, but there is less pain in those
first few days. You may have difficulty finding a surgeon that will be able
to do it laparoscopically, especially a urologist.

There is no urgency in getting a hernia fixed so generally patients have
plenty of time to get second opinions and/or find a surgeon that can do it
laparoscopically. The risk of not fixing it would be an
incarceration/strangulation of the hernia which could lead to an emergency
hernia repair in the unlikely event that happened.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: Inguinal Hernia Repair. Medical
Date: 6 Apr 2004 00:15:12 -0500
Message-ID: <40723c43$0$92814$45beb828@newscene.com>

"Orac" <orac@wabcmail.com> wrote in message
news:orac-DC6830.20211305042004@news4.srv.hcvlny.cv.net...
> In article <XF0cc.6170$I66.4@nwrddc03.gnilink.net>,
>  D. Jones <djones0315@hotmail.com> wrote:


>My personal opinion on its relative merits is that it
> has no advantage over a simple repair with mesh through an inguinal
> incision using local anaesthesia and sedation and but does have several
> drawbacks. However, for recurrent inguinal hernias, it has many
> advantages over open repair, and I think its role ultimately will be in
> complex recurrent inguinal hernias.

I agree with this. Personally, I rarely do laparoscopic repairs for primary
inguinal hernias anymore. I do, however, consider it to be the method of
choice for repair of a recurrent inguinal hernia and for most bilateral
inguinal hernias.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: "Tension free" hernia repair?
Date: 7 Apr 2004 02:25:09 -0500
Message-ID: <4073ac1c$0$52958$45beb828@newscene.com>

"Greg Smith" <dansereal@yahoo.com> wrote in message
news:70559f14.0404062235.13b82373@posting.google.com...
> I've seen several sites on the web that advertise "tension-free" mesh
> repair of hernias, in which the mesh is eased into place without
> stapling or suturing.  Supposedly this helps reduce the likelihood of
> recurrence.
>
> In a few weeks my surgeon is going to attempt to re-repair a failed
> hernia repair he did last September.  I'd had an "Oh, no!" feeling the
> first time around, when he told me after I woke up that he'd done a
> traditional suture-up of an incisional hernia he described as a "big
> critter."  I had read on the web that the recurrence rate for
> traditional suture repairs was as high as 40% (he had told me 15%), so
> I wasn't completely astonished when I got a new hernia in the same
> neighborhood as the old one -- about three inches above my navel, the
> result of a trocar insertion during a laparoscopic appendectomy five
> years ago.
>
> This time my surgeon says he's going to do a laparoscopic repair, with
> mesh, but because I've been reading these pie-in-the-sky web sites
> that tout "tension-free" mesh placement, I had another "Oh, no!"
> feeling when he told me he planned to staple the mesh into place.  The
> recurrence rate for this procedure, he's telling me, is around 2%.
>
> So my question is, should I try to rally my ebbing faith in my
> surgeon, or should I be making a pilgrimage to one of these "cutting
> edge" (pardon the pun) hernia centers?  I must say that the two web
> sites I've seen so far that promote the "tension free" technique look
> rather cheesy, as if they couldn't afford a good web designer.  But
> you can't judge a book by its cover, etc.
>

State of the art for repair of an incisional hernia is to use Gore-Tex mesh
laparoscopically placed inside the body and stapled to the abdominal wall
from the inside. The recurrence rate for such a hernia repair is low - I
agree that it's about 2%. Your surgeon's plan is the correct one and is more
effective than placing the mesh using the "tension-free" gimmicks you
describe.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: Inguinal hernia and local anesthesia
Date: 7 Apr 2004 15:03:07 -0500
Message-ID: <40745dc8$0$10339$45beb828@newscene.com>

"Marco de Innocentis" <mdi00@hotmail.com> wrote in message
news:8ae3418dcacfa6e989c84673f32c9c9f.122502@mygate.mailgate.org...
> Is it possible to have an inguinal hernia operation with local
> anesthesia? Or are the only options total anesthesia and epidural
> injection?

Local anesthesia with sedation is pretty much the standard in the US.
General, spinal, or epidural are typically used only in special
circumstances.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med,sci.med.prostate.prostatitis
Subject: Re: Hydrocele - surgery worthwhile?
Date: 5 May 2004 09:16:41 -0500
Message-ID: <4098f60f$0$16894$45beb828@newscene.com>

"Ricardo" <locomacho55@hotmail.com> wrote in message
news:6eacf4fe.0405041806.275beb3a@posting.google.com...
> "Howard McCollister" <nospam@nospam.net> wrote in message
news:<40980676$0$14978$45beb828@newscene.com>...
> >
> > You say you had a hernia as a child. Did you have an operation for
> > that? Was that hernia repaired?
> >
> > HMc
>
> Yup, I did have surgery for that and it was repaired (at birth,
> basically).  The hydrocele developed about 5-6 years ago (at age 20 or
> so).
>


The surgeon that fixed your hernia didn't do a complete job of removing the
hernia sac. Had that operation been done correctly, you wouldn't have
developed the hydrocele.

If the hydrocele bothers you, your surgeon can attempt aspiration
(withdrawing fluid with a needle). It probably won't resolve the problem for
long, but it's a simple office procedure. OTOH, a definitive approach would
by the hysdrocelectomy. An incision is made in the scrotum to the hydrocele
sac, the testicle with hydrocele brought out of the scrotum and the
hydrocele sac excised from around the testicle. It should take about 15
minutes, outpatient surgery. You will likely get a lot of swelling in the
scrotum on that side, which will resolve over a couple of weeks. Ice bag
will be your best friend. Generally, not too painful, should be well
controlled with mild oral narcotics.

Not doing anything about the hydrocele will not create any risk, but you may
want to have it fixed if it bothers you in any way.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med,sci.med.prostate.prostatitis
Subject: Re: Hydrocele - surgery worthwhile?
Date: 5 May 2004 15:01:53 -0500
Message-ID: <40994559$0$7233$45beb828@newscene.com>

"Ricardo" <locomacho55@hotmail.com> wrote in message
news:6eacf4fe.0405051018.74ea0661@posting.google.com...
> Thanks for your great advice.  That's interesting you mention that it
> was the hernia operation itself that initiall was not done correctly.
> I've also heard horror stories of unintended vasectomies from a
> botched hernia operation.
>

The vas deferens is very tiny in an infant, and an uwary surgeon can cut it
while dissecting the hernia sac from the spermatic cord. The more you
dissect out the hernia sac, the more at-risk the vas deferens is. Hydrocele
in later life is a definite consequence of bailing out of dissecting the
hernia sac properly.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: Inguinal Hernia - Picking a Surgeon for Tension Free Surgery
Date: 15 Jun 2004 07:10:15 -0500
Message-ID: <40cee678$0$3588$45beb828@newscene.com>

"Bob" <double_entendre@hotmail.com> wrote in message
news:ff88b948.0406142025.f1371cd@posting.google.com...
> I am a 37yo male in reasonably good health--5'8", 177 pounds, no
> recurring health issues--and was just diagnosed with an inguinal
> hernia.  It's located in the left groin area (where my pubic hair is).
>
> I'm tentatively scheduled for surgery on the 1st of July and am
> looking into options before I actually go forward.  I've read a great
> deal about the "tension free" technique versus the (apparently) more
> common stich or stapling variations and think I have a decent
> understanding of how each type of surgery works.
>
> My concerns are whether or not I may be a viable candidate for the
> tension free surgery given where the hernia is.  I've been told that
> the lower on the body the hernia is, the less likely the tension free
> surgery is to work.  Is this the case?  Also, I've heard that there
> are issues with recurring pain and muscular tension (for lack of a
> better word) when the muscle is sewn back together or stapled.
>
> I like to be physically active and am worried that my activities in
> the future will be limited or impaired by a conscious or unconscious
> expectation of pain when performing certain activities.  (Swinging a
> golf club leaps immediately to mind.)
>
> Finally, I would like to consult with at least a couple of other
> surgeons in the Southern California (Los Angeles/Orange Counties,
> ideally) area to discuss my case and the best options to put me back
> to 100%--or as close as can be.  What's the best way to find a surgeon
> with strong credentials?
>
>

I guess I've never seen an inguinal hernia that wasn't amenable to the
Lichtenstein repair. The primary reason for that repair is it's extremely
low recurrence rate. I'm not convinced that there is substantially decreased
pain compared to the older techniques.

Laparoscopic inguinal hernia repairs do tend to be less painful, but this is
a difficult technique. While virtually any competent general surgeon can do
an excellent open hernia repair, with or without mesh, that is not
necessarily true of the laparoscopic approach. Additionally, the indications
for laparoscopic inguinal hernia repair tend to vary widely, but are
generally more restrictive due to it's increased cost, requirement for
general anesthesia, and the extra time involved.

Can't help you finding a surgeon, but finding one competent to due an
inguinal hernia repair ought to be pretty easy. I would start by asking your
primary care doctor.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: inquinal hernia post operative pain
Date: 17 Jun 2004 18:12:04 -0500
Message-ID: <40d21dad$0$3617$45beb828@newscene.com>

"Investor0329" <Investor0329@Yahoo.com> wrote in message
news:1c0e7435.0406170849.6afecaa2@posting.google.com...
> I had an inguinal hernia operation 2 days ago and am now home
> recovering.
> I am concerned about some of the pain I am getting in my groin area
> and wonder if it the type that may not go away on its own. It is a
> very very sharp pain.. like hot pins and needles poking me from
> inside. Very sharp.. Another way to describe it is that it kind of
> feels like a razor blade is in there. I do not
> have the pain when I lie down. I do get it when I stand up especially
> when
> i get out of bed. I also get another kind of pain...that feels like
> someone punched me in the groin..which is the type of pain I'd expect
> to eventually go away. I am worried that the sharp pain may be nerve
> oriented..or maybe mesh scratching against something.
>
> Is this sharp pain common and expected and will it go away.
>

The sharp, stabbing, pins-and-needles pain is likely irritation of one of
the sensory nerves that run through the groin area (ilioinguinal or
iliohypogastric, usually). This is not universal, but such pain occurring
transiently is not uncommon. The question is what is the source of the nerve
irritation? In most cases it's due to swelling, inflammation in the area
where the repair took place, and it should resolve over the next 7-10 days,
maybe less. If it doesn't resolve, your surgeon will address that with you.
He would be concerned about entrapment of one of those nerves in the repair.
This is fairly uncommon, but it is one of the recognized potential
complication of inguinal repair. Don't panic yet - give yourself more time
to heal before getting concerned about it.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: Post Hernia Repair complications !
Date: 5 Jul 2004 09:18:08 -0500
Message-ID: <40e96288$0$48819$45beb828@newscene.com>

"Mike" <mikelarry88@yahoo.com> wrote in message
news:bbab0f01.0407050139.a47e86a@posting.google.com...
> Greetings listers,
>      Need advise from experts here for a complication post hernia
> repair of my abdomen. Case history goes like this . An abdominal
> surgery ( open method ) for treating ileal perforations. 2 years later
> ( June 2003 ) , another open method to implant a PTFE Dual mesh (
> thanks to listers here and Howard in particular : for suggesting the
> mesh ) .
>     Now, an year after the mesh being implanted , an opening developed
> ( cutaneous sinus is what my doc called it ) on my skin and started
> oozing., which was found to be because of some pus collection inside.
> some infection ?
>
> A CT Sinogram read:
>
> - Contrast introduced into the anterior abdominal wall sinus is seen
> to track across the anterior abdominal wall to a deep plane between
> the rectus muscles. There is collection of contrast in this plane for
> a supero inferior extent of above 17 cms .
> - No communication with bowel.
>
> Now , my surgeon tells me that I've to go thro another surgery and
> have the pus cleaned up . and he also foresees a possibility of
> replacing the mesh which might have got eroded. One surprising thing
> was that he questioned my decision to choose a dual mesh and he said
> he'd never 'recommend' a mesh to his doctor and go with the regular
> mesh ( sorry forgot the name - propylene ? ).
>
> My questions :
>
> - Is surgery , the only solution to clear off this infection ?
>  I'm really scared now , thinking how long it can go. This is already
> going to be 4th surgery , all because of the first one leading to
> second ..and second leading to third etc. Is this series really going
> to end ?
>
> - Any alternate medicine techniques ? ( no flames please :) )
>
> - What could be the possible reasons for such an infection . Doc tells
> me it could be from the mesh material or the suture material . How can
> I assure that such 'material' mistake doesnt happen this time atleast
> ( if I'm forced for another )
>
> - My surgeon also sees a possibility of eroded mesh and might have to
> replace the mesh .which means a full open surgery again . Is this a
> possibility with goretex ?
>
>   Not sure if it's a good question. but ,is laparoscopy relevant in
> this case ?

Here's how I interpret the history you present above - correct me if I'm
wrong...

You had an abdominal operation through a midline incision. You develop an
incisional hernia in that midline incision and two years after the original
operation you have the hernia repaired using GoreTex DualMesh via an open
technique. A year later, you develop a draining sinus, which sinogram
demonstrates to track through the hernia-repair incision.

There are two possibilities here - a)  the GoreTex mesh is infected  or b)
the mesh has eroded into the intestine somewhere creating an
entero-cutaneous fistula (tract between intestine and skin) Note that b
implies a, but a does not necessarily imply b.

If it's pus that's draining and not bowel contents then I would be less
inclined to suspect intestinal erosion from the mesh. Such erosion is rare
with GoreTex (it's the reason GoreTex dual mesh is the prosthetic material
of choice) but much less rare with polypropylene mesh. Generally speaking,
use of polypropylene mesh in an intraperitoneal incsional hernia repair is
considered a deviation from the standard of care in most places and in some
venues has been deemed frank malpractice because of the relatively high
erosion rate.

With GoreTex dualmesh, it is more likely that your draining sinus is due to
an infection of the mesh. This infection likely happened at the time of the
operation. Whatever the cause of the mesh infection, the problem is that it
is very, very difficult to clear up this infection in the presence of a
foreign body.

There are a couple of ways I personally might approach this if I were
comfortable it was not an enterocutaneous fistula. I would consider a 6 week
course of IV antibiotics. This could be done at home if they put in a venous
access port or Hickman catheter. This might clear up the infection and avoid
a major operation. This would not work if it's an enterocutaneous fistula -
the only way to clear that up is to remove the mesh.

If antibiotics didn't clear it up, and there's a fair chance they won't,
surgery would be required and the mesh would have to be removed. I would
approach it by starting laparoscopically to look at the underside of the
mesh and try to determine if there is indeed an enterocutaneous fistula. It
is possible that the mesh could be removed laparoscopically. It's unlikely,
but worth the try. I would see if it's feasible to then cover the hernia
defect with a (temporary) absorbable mesh. After several weeks or months,
assuming the incisional hernia recurs after the vicryl mesh is absorbed, I
would go back and try to laparoscopically place GoreTex Dualmesh Plus
(coated with a silver-based antimicrobial compound). If it wasn't possible
to do laparoscopically, I'd convert to an open Stoppa technique with the
GoreTex.

Good luck. You may have to search hard for a surgeon that is willing to set
dogma aside and approach your problem using modern surgical technique.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: Post Hernia Repair complications !
Date: 11 Jul 2004 12:51:25 -0500
Message-ID: <40f17d70$0$1583$45beb828@newscene.com>

"Mike" <mikelarry88@yahoo.com> wrote in message
news:bbab0f01.0407102351.7e994596@posting.google.com...
> which sinogram
> > demonstrates to track through the hernia-repair incision.
>
> I'm not sure of this. The opening developed is not on the incision.
> But doc is suspecting it because of the mesh. Not really sure if the
> sinus tracked thro the incision. how can I figure this out ?


It doesn't matter where it drains, actually. Drain through the incision is
more common, but impossible.



> The drain is confirmd to be pus , so the mesh might have got infected ?
>

It is virtually a certainty that the drainage is from an infection in the
vicinity of the mesh, and such an infection in the presence of a foreign
body (the mesh) is unlikely to heal until the foreign body is removed. Note
that this is highly unlikely to be a dangerous problem.. Annoying, yes.
Dangerous, no.


> Yes! I talked to my surgeon yesterday and he says that a mesh
> implanted by open method cannot be removed laparoscopically. He even
> denied to give it a shot . Would you recommend me to meet a
> laparoscopic surgeon ?


It depends on which kind of open method (there are several). If it was
placed outside the peritoneum, then yes, laparoscopic removal would be
difficult, probably impossible and your surgeon's position is not
unreasonable. Usually, however, the mesh is placed intraperitoneal and
unless it was imbricated over the fascial edge of the hernia defect,
laparoscopic repair is possible. Although it's not necessarily likely, you
never know until you look. I've been surprised on at least a few occasions.
Yes, it never hurts to get a second opinion, and I would recommend getting
it from a laparoendoscopic surgeon. Make sure you get a copy of all of your
operative reports, especially the hernia repair. Take them with you when you
go to the second-opinion surgeon.


> He also said opening up will help cleaning up the sinus tract . Is
> taht a reasonable argument to put me thro a major surgery again ??


As I said, the draining sinus is going to be pretty much excluded from the
body and is unlikely to create a systemic infection. Getting the mesh out
and removing or opening the sinus tract will allow it to heal.


>
> > but worth the try. I would see if it's feasible to then cover the hernia
> > defect with a (temporary) absorbable mesh.
>
> Discussed this at length with my surgeon about this. He said the
> infection will not heal with a foriegn body ?? and doesnt want to put
> a temporary mesh until the infection heals ? I see drastic differences
> in opinions . just getting a little bit suspicious about the surgeon i
> visit :)


Using absorbable mesh is indeed debateable in this situation. I might be
inclined to use it (and have) in situations where the resultant skin closure
might come apart, such as a large incisional defect. It's always so
distressing to patients when their intestines come flying out of the
incision when they cough. In other words, it's a means of providing
temporary fascial closure while the infection clears and in the three months
awaiting permanent re-repair. Differences of opinions between doctors is
common. There are *some* universal truths in medicine, but for the most
part, there are many ways to skin a cat.



> Wish me luck :)

Good luck.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: Open Cholestectomy
Date: 9 Dec 2004 16:03:03 -0600
Message-ID: <41b8cb4e$0$71401$45beb828@newscene.com>

"Mark & Steven Bornfeld DDS" <bornfeldmung@dentaltwins.com> wrote in message
news:31rnttF3eoru7U1@individual.net...
> Joel Eidsath wrote:
>
>> I'm a 5'10", 180lb, 24-year-old male.  Two weeks ago, I had an open
>> cholecystectomy.
>>
>> How exactly do my abdominal muscles recover after the laparotomy?  Do
>> they just stitch back together like new?
>>
>> I'm wondering how hard I can push it when it comes to running and that
>> sort of thing.  I'm leaving off going back to weight lifting for 6
>> weeks as per the doctor's instructions (no lifting over 15 lbs until
>> after Jan. 7th).
>>
>
>
> Interesting question.  I have one minimal and one small inguinal hernias.
> My internist sent me to a surgeon, who said he wouldn't operate at this
> size--that cutting the abdominal wall would damage my muscle tone.
> Obviously, if a surgeon tells you not to cut, you don't cut.  Still, how
> much of a problem is healing of the abdominal wall?
>

Incisions heal by forming scar tissue. The rectus abdominis muscle that is
cut for an open cholecystectomy heals the same way. Pretty much as good as
new, over time. There is a risk of a separation of the fascia, which would
result in an incisional hernia. This is a small risk.

As to inguinal hernias, I agree that non-symptomatic hernias that are at
small risk for incarceration/strangulation don't have to be fixed. However,
no muscles are cut in an open inguinal hernia repair and the concept that
such an operation might somehow affect muscle tone is completely erroneous.
Bilateral inguinal hernia is an indication for laparoscopic repair, in which
case there is virtually effect on the abdominal wall at all.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: hernia
Date: 9 Jan 2005 09:15:12 -0600
Message-ID: <41e149f4$0$5328$45beb828@newscene.com>

<leonspinks@excite.com> wrote in message
news:1105215465.686420.236900@c13g2000cwb.googlegroups.com...
>I just went to the doctor and he told me that i have one inguinal
> hernia and a second in the begining stages. My doctor offered two
> different options. One is the basic operation where they go through the
> stomach wall and repair it with the mesh, the other is laproscopic. The
> way i understand it is that with the laproscopic method he can repair
> both hernias, there is a shorter recovery time, but there are more
> risks.  I'm always a little hesitant to do something that isn't
> neccessary and if the basic method carries less risk i am more apt to
> lean that direction. Has anyone had any experience with these
> operations? thanks.
>

If you're going to have both sides repaired, the laparoscopic repair will
result in less pain and a slightly earlier return to normal activity,
assuming the surgeon is skilled at that difficult technique. The
complication rates between open and laparoscopic repairs are about the same.
If you're going to have just the one side repaired, then I would go with the
open repair.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: hernia
Date: 10 Jan 2005 07:39:04 -0600
Message-ID: <41e284ea$0$29104$45beb828@newscene.com>

"Steven Bornfeld" <dentaltwinnospam@earthlink.net> wrote in message
news:41E18BFB.4080107@earthlink.net...
>
>
> Howard McCollister wrote:
>>>
>>
>>
>> If you're going to have both sides repaired, the laparoscopic repair will
>> result in less pain and a slightly earlier return to normal activity,
>> assuming the surgeon is skilled at that difficult technique. The
>> complication rates between open and laparoscopic repairs are about the
>> same. If you're going to have just the one side repaired, then I would go
>> with the open repair.
>>
>> HMc
>
> May I ask why you'd go with open repair?
>
> Steve
>

Primarily because it has a lower recurrence rate, 20 minute operation, done
under local anesthesia with sedation instead of general anesthesia, almost
the same return to work, easier to find a surgeon competent to do it, less
expensive.

Basically, the advantages of open repair are greater than for laparoscopic
repair for a simple hernia when only one side is being done. The advantages
shift to laparoscopic when we're talking about bilateral repairs, or if it
is a recurrent hernia.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: hernia
Date: 10 Jan 2005 17:18:03 -0600
Message-ID: <41e30c9e$0$5324$45beb828@newscene.com>

<leonspinks@excite.com> wrote in message
news:1105334182.541458.260490@c13g2000cwb.googlegroups.com...
> thank you for you reply. why would you go with the laproscopic if you
> were only having both sides done? why not do it if it was only one
> side? what is a realisitc return to normal activity timetable for each
> operation? will it take longer if I have both done as opposed to just
> one? I guess the big question is safety. do both operations carry equal
> risk or does laproscopic carry more risks because (a) you are under a
> heavier anesthesia (b) there are more things for the scalpels to bump
> into as they move from the incision to the hernia?  Obviously there is
> no way to guarantee your doctor is skilled at this procedure, but my
> doctor said this this surgery makes up for 60% of the work he does.
> Just don't know if I should be doing both at once or waiting for the
> second. thanks again for your help.
>

The pain for a bilateral open repair is substantial, return to normal
activities longer. The pain is less and return to normal activities shorter
for bilateral laparoscopic repair. This is because open bilateral will
require two 2-inch incisions through the abdominal wall (one for each side),
whereas in bilateral laparoscopic both sides are done through the same three
puncture wounds.

A unilateral laparsocopic repair is not unreasonable, but the pros are often
not worth the cons, as in my previous post. The amount of pain is likely to
be less, and return to work may be earlier with a unilateral laparoscopic
repair.

The risks of open vs laparoscopic are roughly equivalent, depending on your
state of health. General anesthesia is required for laparoscopic repair
(usually), and that in itself does indeed carry some risk to your life,
although not much in a normal healthy adult - in fact not much more (and
some would say less) risk than the intravenous conscious sedation used with
the local anesthesia for open repair.

An open unilateral hernia repair hurts a lot for about 2-3 days. Return to
normal activity is variable depending on pain tolerance and what "normal"
acitivities you're talking about. After a unilateral open repair, patients
can often return to their desk job in a week. If the job requires a lot of
standing or heavy lifting, it's more likely longer, maybe as long as 6
weeks. A bilateral open repair will hurt a lot for a week or maybe two - 4-6
weeks, maybe longer, before you'd want to return to alligator wrestling. A
bilateral laparsocopic repair hurts a little more than a unilateral repair,
usually return to work in a week or so, and 2-4 weeks before returning to
strenuous physcial activity.

THESE ESTIMATES ARE ONLY ESTIMATES and can vary widely depending on the
surgeon, the patient, the kind of work the patient does, his pain tolerance,
lack of complications (such as infection, hematoma or scrotal swelling), and
what constitutes "normal" activity.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: possible inguinal/indirect hernia
Date: 13 Aug 2005 15:53:36 -0500
Message-ID: <42fe5d40$0$91636$bb4e3ad8@newscene.com>

<calesco_99@yahoo.com> wrote in message
news:1123958289.160686.55960@o13g2000cwo.googlegroups.com...
> If I experience any dicomfort, should I stop?
>


The issue of groin pain without a defineable hernia can be very problematic.
The pain that you have now or may get when you exercise may signify an
inguinal hernia, or it may be a groin muscle strain, or it may be scar
tissue from your previous repair. It would be unlikely or unwise (due to the
low positive yield and significant post-op pain) for a surgeon to explore
your groin for an inguinal hernia simply on the basis of pain alone, without
an identifiable/palpable defect or bulge.

The answer to your question is yes, probably you should stop. Not because it
will cause some problem with the hernia (if it exists), but because
exercising beyond the point of pain may exacerbate/inflame a groin muscle
injury.

The only semi-reliable way to diagnose an occult inguinal hernia would be
diagnostic laparoscopy - look inside the abdominal cavity with a scope under
general anesthesia - and observe/probe the internal inguinal ring and
inguinal floor. If a hernia is seen, it can be repaired then. If not seen,
then treatment of the inflammation can be done as an outpatient (physical
therapy, injections, etc etc).

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med,misc.health.alternative,alt.health,misc.education.medical
Subject: Re: inguinal hernia questions
Date: 26 Sep 2005 21:38:03 -0500
Message-ID: <4338b01f$0$6796$bb4e3ad8@newscene.com>

<K@.not> wrote in message news:dc5hj1181pfpiqq7oit32d3eld397rttmc@4ax.com...
> On Sun, 25 Sep 2005 17:31:53 -0400, SJ Doc <SJ_Doc@NOSPAM.net> wrote:
>
>>Do you believe that valuable goods and services should be devoted
>>to the benefit of a patient with no expectation of payment whatso-
>>ever?
>
>    I'll bet that idea never lasts very long :-)
>
>>Or that a patient is not free to determine for him/herself
>>whether or not he/she will seek care of possibly lesser quality (on
>>a teaching service) in exchange for a lesser price?
>
>    From a poor boy who can't afford surgery's pov, it seems like
> some sort of exchange that could benefit the student and the
> poor boy could be worked out. But. If it has already been worked
> out that students get to practice, while experienced surgeons
> direct the procedure and get paid just the same even if they
> don't do the operation, then that ends any possibility of a mutually
> beneficial exchange I guess. Oh well.

The exchange you're talking about is lower cost for a lesser quality of
surgery. Really now...think about that. Does that sound realistic in this
day when doctors around the world are criticized regularly for "medical
mistakes", and phone books and newspapers are crowded by ads for malpractice
lawyers? Medical students don't have malpractice insurance. Neither do
residents unless they are supervised by a qualified surgeon so designated.
That supervising surgeon is there to make sure that the quality of every
single operation done under their name is as good as it can be - he/she
stakes his/her reputation and the reputation of the institution where they
work on every single operation. You're talking about multiple standards of
care - better care if you can afford it, second-rate if you're poor. However
it works out in practice, opposition to that concept is a rallying cry (more
of a shriek, really) for watchdog groups all across the USA.

As to who is doing the operation -- we're not talking about heavy lifting
here....the attending surgeon gets paid by the patient to MAKE SURE that
their operation is done according to prevailing standards of care, for
taking that responsibility, and for imparting his/her experience and
knowledge to the extent necessary. Not for doing the physical work, which is
trivial in an energy-expenditure sense. I can assure you it is far more
stressful to teach someone to do an operation than it is to do one.

As to other questions you pose -- your friend's hernia will never get
smaller, only bigger. Strengthening the abdominl muscles won't help and are
far more likely to increase the size of the hernia, anything that increases
intraabdominal pressure such as straining will do so. Trusses -- they don't
cause scarring and do not make the operation more difficult in any way. They
don't fix the hernia, but do have the potential (in some cases) to decrease
the discomfort. If your friend isn't having pain, there's no point to
wearing a truss.

There are two problems with an inguinal hernia -- 1) causing the patient
discomfort  2) the possibility that the loop of intestine could become
trapped and strangled in the hernia sac (strangulated hernia). The
likelihood of such a strangulation is relatively low (although if it does
occur, it's a true emergency). If those two issues don't apply to your
friend, then the repair can certainly wait until he gets health insurance,
saves enough money, or can apply for some kind of medicaid-based program. In
the VA system of the US where health care is rationed, it would not
necessarily be uncommon for a patient to wait months or even years to get
his hernia operation. This is likewise true in at least a few industrialized
nations that have a nationalized health care program.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med,misc.health.alternative,alt.health,misc.education.medical
Subject: Re: inguinal hernia questions
Date: 27 Sep 2005 00:13:03 -0500
Message-ID: <4338d48f$0$6849$bb4e3ad8@newscene.com>

"Howard McCollister" <nospam@nospam.net> wrote in message
news:4338d152$0$6856$bb4e3ad8@newscene.com...
>
>>
>> Inasmuch as all laparoscopic herniorrhaphies require general
>> anesthesia (you can get away with a spinal block or even a local
>> block for uncomplicated open repairs), this means that the over-
>> whelming majority of these outpatient surgeries involve the ad-
>> ministration of general anesthesia after which the patients - who
>> come to the surgical suite on the day of the procedure, and are
>> not admitted to the hospital beforehand - *still* go home to
>> that same afternoon to recuperate.
>>
>> Or do you mean something different by "those increased
>> hospital costs" you maunder about?


Hernia repairs are outpatient procedures, even under general or spinal, open
or laparoscopic. That's the plan when their admitted to the outpatient
facility.

The increased costs of laparoscopic hernia repairs relate to general
anesthesia and the cost of the equipment necessary to do the case.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med,misc.health.alternative,alt.health,misc.education.medical
Subject: Re: inguinal hernia questions
Date: 27 Sep 2005 12:42:01 -0500
Message-ID: <433983f1$0$184$bb4e3ad8@newscene.com>

"Mark & Steven Bornfeld" <bornfeldmung@dentaltwins.com> wrote in message
news:mfe_e.13215$gi4.887@trndny04...
> Howard McCollister wrote:
>>
>>
>> Hernia repairs are outpatient procedures, even under general or spinal,
>> open or laparoscopic. That's the plan when their admitted to the
>> outpatient facility.
>>
>> The increased costs of laparoscopic hernia repairs relate to general
>> anesthesia and the cost of the equipment necessary to do the case.
>>
>> HMc
>
> Do I understand that laparoscopic hernia repair either requires general
> anesthesia while open repair may not, or that general anesthesia is for
> some reason more costly when compared to that for open repair?
>


Laparoscopic inguinal hernia repair is typically done under general
anesthesia, open inguinal hernia repair is typically done under local
anesthesia, usually with sedation. General anesthesia is always more costly
than local with sedation because of the method, the monitoring, and the
increased level of care required.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med,misc.health.alternative,alt.health,misc.education.medical
Subject: Re: inguinal hernia questions
Date: 27 Sep 2005 18:17:02 -0500
Message-ID: <4339d2ab$0$9179$bb4e3ad8@newscene.com>

"Mark & Steven Bornfeld" <bornfeldmung@dentaltwins.com> wrote in message
news:A_f_e.14590$w74.699@trndny05...
> Howard McCollister wrote:
>
>>
>>
>>
>> Laparoscopic inguinal hernia repair is typically done under general
>> anesthesia, open inguinal hernia repair is typically done under local
>> anesthesia, usually with sedation. General anesthesia is always more
>> costly than local with sedation because of the method, the monitoring,
>> and the increased level of care required.
>>
>> HMc
>
> Well, obviously general anesthesia is more expensive.  My question (if you
> can answer it briefly) why laparoscopic repair would need general and not
> open repair (not intuitive to me)
> Not to be a PITA; I have one small inguinal hernia and another that is
> minimal (the small one is uncomfortable during the hay fever season; the
> minimal one was detected only by the surgeon and not my internist, and has
> no symptoms at this time).
>

In order to have enough room to work in the preperitoneal space with CO2
insufflation, muscle relaxation is required which in turn requires control
of the airway so that ventilation can be maintained. This isn't required for
an open hernia repair, which is typically done under inguinal block and
local anesthesia with sedation. A laparoscopic repair under general would
still usually be an outpatient procedure.

HMc

From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,misc.health.alternative,alt.health,misc.education.medical
Subject: Re: inguinal hernia questions
Date: 27 Sep 2005 21:40:03 -0700
Message-ID: <1127882403.923853.49240@z14g2000cwz.googlegroups.com>

Mark & Steven Bornfeld wrote:
> 	Really--not fair at all.  I've known surgeons who are ruff boyz, but
> I've also known sweethearts.


COMMENT:

More information than we wanted about your love-life!  And besides, you
probably never met any orthopods.

There's a grain of truth in most generalizations about medical
subspecialties. But only a grain. As a group, I've found surgeons
generally fine people, albeit with a bit more self-assurance even than
the average doc. But self-assurance is a perspectical matter. As in "my
self-assurance, your strong will, his egotistical pomposity."  It all
goes with the territory of what surgeons dare to do. When I was a
medical student I was 3rd assist (read-retractor-holder) for several
complex surgeries with a surgeon in trouble, and I wouldn't take on
that particuarly lonely bit of hell for all the money in Thoracicordia
(FYI: a very rich little country near La Jolla).

Generalization: pediatricians are always nice. Pediatric surgeons,
doubly so (god bless them every one). Personally, the worst SOBs I've
met in medicine have tended to be in the more "intellectually-rarified"
subsubspecialities of internal medicine. Endocrinology. Non-invasive
cardiology. Hematology. I hypothesize that it has something to do with
maximal power over the patent without having to actually get your hands
wet. Evil allergists or dermatologists are hard to find. You'd think
that shrinks might congregate in the SOB category, except that the
shrinks I've met have truly been empathetic sorts, exactly as you'd
expect (or hope for). So if there are any evil ones, they must be in NY
or Hollywood, or off running criminal insane institutions for the state
or something-- places I don't go. In any case, I've not met one I
didn't like. I suppose unlikable ones wouldn't survive long in private
practice. And, actually, even the SOBs I've met were usually nice to
patients. It was with nurses, students, staff, and junior docs that you
saw their Dark Side.

SBH

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med,misc.health.alternative,alt.health,misc.education.medical
Subject: Re: inguinal hernia questions
Date: 3 Oct 2005 10:19:02 -0500
Message-ID: <43414b81$0$9175$bb4e3ad8@newscene.com>

"SJ Doc" <SJ_Doc@NOSPAM.net> rambled in message
news:2otqj1ti9g7aosrrm8heia7k8nrrg1oahp@4ax.com...
>
>>
> So what approach do you take when you find it necessary to
> perform an open repair of an inguinal hernia?  Even the Shouldice
> technique is a modification of the Bassini repair.  Though the
> Lichtenstein technique was first documented sometime in the
> early '70s, it was not in common use when I was in training.
> Prosthetic augmentation of inguinal herniorrhaphies had been
> attempted with varying degrees of success from the mid-'50s,
> and still hadn't caught on widely back during the Carter
> Administration.  I was told a number of horror stories about
> surgical wound infections with those monofilament mesh implants
> in situ, and my preceptors were reluctant to make use of such
> materials.
>
> Remember, I'm a primary care grunt, a "gatekeeper" GP.  I
> haven't so much as observed or assisted in the operating room
> for more than twenty-five years.  Beyond that, among the differen-
> ces between the surgeon and the primary care guy in a Mangled
> Care environment is that *you* get paid for performing procedures.
> I don't.  I get a monthly capitation on my HMO patients that covers
> everything I do (up to and including house calls, inpatient manage-
> ment, encounters in the Emergency Department, phone calls in the
> middle of the night, et tedium).  The more you do, the more you
> make.  The more I do, the less time I have to spend with my wife.
>
> Hm.  There's an advantage in that, even though it can't be deposited
> in the bank.
>
> If you would care to discuss the merits of the Lichtenstein and other
> prosthetic repair techniques (open and laparoscopic) please feel
> free to do so.  I can only speak about the anatomical approaches
> with which I'm familiar - and by the time I see the handiwork of
> your colleagues (fortunately, I don't have to deal with *you*),
> the wound is nicely healed and I take note of the robust quality of
> the repair as merely incidental to the patient's overall physical
> examination.
>
> And what excuses you "shooting off your mouth" about how
> you've been so dreadfully, terribly, agonizingly wounded by
> what you call "ad hominem" assertions when you allege that
> my qualifications to speak on this subject - not my knowledge
> of the subject itself but my training and clinical experience
> as one of those "arrogant primary care doctors" you so
> thoroughly despise - are alone sufficient to invalidate any
> comment I might make when you could far more simply (and,
> I presume, more readily) demonstrate a fund of knowledge
> superior to my own, such as must be common among practicing
> surgeons in America today?
>
> If you know this subject better than I do, speak about it lucidly
> and with didactic intent so that all reading your posts can benefit
> from the information.  I repeat: if you treat with the physicians
> who make up your referral base in this way, few of them are
> going to credit you as a reliable authority on the surgical care
> of their patients, even fewer are going to be alert and active in
> screening patients who might benefit from the work at which you
> claim to be expert, and *none* of them are going to continue
> referring their patients to you when they can find a competitor in
> your area of equal competence who treats them with courtesy
> and collegiality better than what you've exhibited in this thread.
>

While I appreciate your concern for the success of my practice and your
lectures on collegiality, I would point out that the internet is not real
life and my real-life "colleagues" don't address their issues (such as their
opinion of "cutters") from behind a veil of anonymity. For you to try to
translate such an internet discussion into assumptions about someone's
private practice, or even their personality, suggests that you might be new
to the internet. Fear not, I'm doing fine, non-managed-care private practice
having been very rewarding professionally and personally over these past 25
years.

Anatomic repairs of inguinal hernia have a recurrence rate somewhere between
8-15%. When those hernias recurred, the standard approach was a mesh repair.
In your generation of training (and mine, as we are contemporary), that mesh
was often mersilene, a braided material that would entrap or "wick" bacteria
with the end result of "spitting" of the mesh in a certain percentage of
cases. Indeed - a real PITA for both patient and surgeon and a deterrent to
the use of mesh repairs at that time. Currently, prosthetic repairs
typically use polypropylene, or polytetroflouroethylene (Teflon/GoreTex)
composite. Variations of the Lichtenstein repair include things like plug,
and plug-and-patch. These don't cause those kinds of problems and allowed
the concept of primary prosthetic repair, which is the current state of the
art. Anatomic repairs are generally not done these days except in children,
where the Bassini repair still tends to be the repair of choice, since the
primary problem is a persistent processus vaginalis and the inguinal floor
is in good shape.

There are three indications for a laparoscopic hernia repair: recurrent
hernia, bilateral hernia, or younger, more active patients who need to
return to work early. This latter point is a very relative indication, as
there is not substantial difference in return-to-work time, and given the
increased cost attendant to the laparoscopic approach, it's usually not cost
effective. There is typically less pain associated with laparoscopic repair
in the first 2-3 days post-op, but that is about the extent of the
advantage. Return to work after either repair for, say, a self-employed
dentist, would be about a week or so. Return to work after either repair in
the Worker's Comp arena would be closer to 6 weeks. If the job involves
strenuous physical activity, there is a marginal advantage to unilateral
laparoscopic repair in that heavy lifting will cause more pain for a
somewhat longer period time up to the 6-week mark. The recurrence rate after
a prosthetic tension-free repair is about 0.5 - 1% whereas the recurrence
rate after a laparoscopic repair is somewhere around 3%.

Prosthetic mesh is used in all laparoscopic repairs. Those operations are
done either by entering the preperitoneal space directly, or by incising the
peritoneum from the abdominal cavity. Removal or exclusion of an indirect
sac is more problematic with the latter approach.

HMc