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Handling a Hernia

Common procedures for a common occurrence

By Zachary Levin


March 19, 2001

illustration: hernias play-by-play
Skipper Chong Warson


first letter Arghhh!!" A primal scream rang throughout the gym. Everyone stopped working out, and 80 pairs of eyeballs snapped around to see Mike Giardello laying on the floor, curled in a fetal position. While Giardello was attempting to hoist a 200-pound barbell, a loop of intestine had burst through the lining of his abdominal wall, entering a region where nature didn't intend for it to go: the inguinal canal, near the groin.

Giardello had incurred an inguinal hernia, and a nasty one at that. He pulled his shorts away from his skin and peered down to see what had gone wrong: A bulge the size of a lemon had formed on the right side of his groin. The male weight lifters who carried him to the locker room and watched him apply ice to the rupture all shared the same thought: "There but for the grace of God go I." They were right, too, because for men, hernias are about as common as cavities.

Men have a natural anatomical weakness in the groin region. The Mayo Clinic reports 80 percent of inguinal hernias -- the most common type of hernia -- occur in men. Hernias can be repaired only through surgery. However, in the nineteenth century, a small percentage of men were willing to suffer the pain and risk intestinal blockage, rather than have an area cut open so close to the "family jewels." They often wore a truss -- a girdlelike undergarment -- that protected the herniated region. But these devices were like Band-Aids, not solutions. In the 1890s, the basis of modern herniorrhaphy (surgical repair of a hernia) was developed; this procedure, known today as open-incision or open-mesh repair, has remained essentially unchanged for 100 years. Newer techniques are now employed using less invasive procedures, such as laparoscopy, but open-incision repair is still a viable choice for hernia sufferers.

Hernia repair options

Open-incision repair is a relatively simple operation: An incision is made in the groin, and the intestine and/or peritoneum -- a colorless membrane lining the abdominal wall -- is pushed back into the abdomen. Then the weakened area is sewn together and/or reinforced with a synthetic mesh patch.

Giardello elected not to have open-incision repair. Instead, he had a laparoscopic hernia repair, an outpatient procedure available since the mid-1990s that was performed more than 700,000 times last year in the United States. During this procedure, the surgeon works off a video image transmitted by a fiber-optic viewing tube, which is inserted through a small incision just below the patient's navel. The surgeon's instruments are inserted through other tubes and incisions into the lower abdomen. A balloon dissection system is also inserted between the patient's tissue layers and filled to a specific volume with either air or saline. The procedure is similar to patching a tire; a synthetic mesh is placed over the entire inguinal region, including all potential hernia openings, and secured with clips or staples.

 

Few people realize that if a bad hernia goes untreated, it can kill you.

 

Because Giardello's hernia was severe, he was laid up for a couple of days and wasn't allowed to perform strenuous activity for several weeks. Heavy weight lifting was not on his mind, though; his immediate goal was to make it to the bathroom without the assistance of his girlfriend. And that was the easy part.

"Going to the bathroom was terrifying," he confesses. "Let's just say it's the closest sensation I'll ever know to giving birth." (In fact, straining to move your bowels can cause an inguinal hernia -- as can obesity, pregnancy, or even a seemingly harmless sneeze.)

Before Giardello had surgery, he was given a spinal anesthetic (the same kind given to some women during labor), although general anesthesia is most common during the laparoscopy procedure.

Of the two styles of hernia repair, laparoscopy may be more modern and less invasive, but open-incision repair is less expensive, with a lower risk of morbidity or complications associated with general anesthesia. Giardello chose laparoscopic hernia repair because he needed to get back to work in a hurry; this procedure allows the patient less post-operative pain and a speedier recovery.

Which procedure is better?

A 1997 randomized study in the New England Journal of Medicine comparing the two techniques concluded that "patients with inguinal hernias who undergo laparoscopic repair ... have fewer recurrences than those who undergo open surgical repair." These results, however, have repeatedly been contradicted in other studies.

"Laparoscopic [hernia repair] is market-driven," says Danne Lorieo, M.D., a general surgeon at St. Luke's-Roosevelt Hospital Center, in New York, who has been performing open-mesh hernia repair for years. "Doctors do it because patients want it. It's true that the recovery time is swifter. But unless you're a professional athlete who needs to get back into the lineup in two to three weeks, laparoscopy offers little advantage. Open-mesh is the gold-standard."

Lorieo concedes that the first 72 hours of post-operative pain is greater with open-mesh hernia repair than with laparoscopic repair. But he's quick to point out that recurrence of hernias (the true measure of hernia repair) is markedly lower with the traditional method than it is with the newfangled technique; he estimates that there's a 4 percent recurrence rate with open-mesh, versus a 10 percent rate with laparoscopy.

Don't wait for treatment

Few people realize that if a bad hernia, such as Giardello's, goes untreated, it can kill you. If a segment of intestine gets trapped in the scrotum, the blood supply may be cut off, and the segment of intestine may become gangrenous in as little as six hours.

Luckily for Giardello, this was not the case. The odds are also in his favor that his hernia won't recur. A month after surgery he is back at the gym, as if nothing ever happened. Only now, for increased support, he treats his jockstrap like others do their American Express card: He never leaves home without it.




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