WDDTY replies: If the hernia is reducible (contents can be shoved back) or symptoms are minor, then strengthening the abdominal wall may prevent hernia from worsening. But, according to medicine, the only ‘cure’ is surgery, although postoperative exercise or herbals (such as those based on traditional Chinese medicine) may help to prevent recurrence.

The statistics are worrying. It’s four times more dangerous to have a hernia operation than to go without one if you’re over 65, according to the Harvard School of Public Health (New Eng J of Med, 6 December 1973). Death rates vary 14 fold between health districts, and up to 20 per cent of operations have to be repeated within five years. To make matters worse, this recurrence rate rises to 30 per cent following a second operation and by as much as 50 per cent after the third.

In the UK, many patients are stuck on long NHS waiting lists. When it’s their turn for the knife, the quality of surgical skill required is described as, as best, “variable”, partly because the techniques used to perform the hernia repair vary.

“In the past there have been many types of hernia repair hundreds of different sorts,” says John Alexander Williams, a surgeon who has carried out a number himself. “The fact that there are so many is a clear indication that most of them aren’t good because a lot have been tried and superceded.”

Perhaps surprisingly for such a common operation, a good hernia repair is as difficult to perform as complex cancer surgery, so you might think it demands and receives the skills of an experienced surgeon. Not so.

Consultant surgeons are reluctant to specialize in such operations which they regard as mundane and routine. Often, trainee surgeons are left to cut their teeth on hernia repairs and a lack of general interest is partly to blame for their use of surgical techniques which are considered out of date.

“Surgeons are a very conservative bunch and they tend to continue doing the same things if, as the old phrase goes, it works in their hands,” says Andrew Kingsnorth, a consultant surgeon at the Royal Liverpool University Hospital and hernia expert. “But we know that experience can consist of doing the wrong things over and over again. This is what’s happened in hernia surgery.”

A hernia is a bulge, usually in the groin, caused by a weakness in the muscles which form the front wall, or lining, of the abdomen. Surgery pushes back the contents of this bulge and supposedly strengthens the ruptured muscles and ligaments.

Around 80,000 of the estimated 150,000 or so patients who develop hernias each year are admitted for surgery. The abdominal wall may weaken with the passing of time. Sometimes the muscles may be put under a sudden increase in pressure through heavy lifting, sport or coughing. Hernias may occur if you’re overweight, or due to the stretching of scars from previous surgery.

There are many different types of hernia, such as the umbilical (near the belly button), inguinal ( the groin), scrotal and femoral (thigh). If left untreated, hernias can get bigger and may cause pain. Sometimes a part of the intestines can slip in and out of the hernia, an entrapment which can lead to permanent strangulation, producing severe pain and sometimes vomiting.

Unfortunately, three out of four surgeons repair the rupture by “darning” it with a criss-cross of stitches that can give way under too much tension. The modern era of hernia surgery began in 1887 with the so-called Bassini operation, named after an Italian who published his techniques in the German medical literature of the day. Although he devised a very effective operation, it was corrupted over the years in the hands of very average surgeons and was successful in only 10 per cent of cases.

Unfortunately, the “darn” is entrenched in surgical practice because it is simple. Junior surgeons, who currently tend to do the bulk of hernia surgery, can pick it up very quickly.

In the 1950s and 1960s, the Bassini technique was resurrected by the Shouldice Clinic in Toronto, which began to produce excellent results.

The Canadian Shouldice technique reinforces the ruptured abdominal wall by stitching through three layers, compared with the one layer of the older method. The tissue overlaps, like a pleat, to create a stronger bond. The Shouldice operation is more difficult. It also takes longer because it incorporates four layers of sutures. “It has to be done meticulously, and if you get one or two of the stitches wrong it falls apart,” says Andrew Kingsnorth.

Patients given Shouldice hernia surgery spend less time in hospital, experience less pain after the operation, and fewer than 1 per cent have to return for another operation.

Or so the story goes. But, there’s a snag. “You can’t just read it in a

book and pick it up,” says Andrew Kingsnorth.”You have to be taught it, and only 20 per cent of surgeons in the UK currently practise this technique.”

Junior surgeons at the Shouldice Clinic in Toronto are closely supervised for the first 50 hernia operations and don’t operate on their own until they’ve notched up 50 more. They’re then assessed for a second time after the thousandth hernia repair.

“Only after this assessment is the surgeon considered a fully-fledged, independent operator,” says Andrew Kingsnorth. “Our present supervision in Britain of only six herniorrhaphies is therefore clearly inadequate” (see also Br J Surg, October 1992).

Concerned by the figures and quality of hernia repair surgery revealed by charting the trend through its Hospital Activity Analysis Statistics, the UK Department of Health recently invited the Royal College of Surgeons (RCS) to find out whether surgical techniques could be improved.

Their conclusion: there was no clear cut, best practice hernia surgery being taught or available within the standard textbooks for surgery.

One fundamental issue on which there is general agreement is the importance of constructing a solid repair without tension. This can be done by using either the patient’s own tissue or a piece of prosthetic material, such as the mesh. The Lichenstein mesh (named after a shrewd businessman who made a small fortune commercializing a technique which surgeons had quietly been using for 20 years), uses a polypropylene patch, or mesh, which is stitched over the rupture, making the repair much stronger and less likely to break down. Andrew Kingsnorth has pioneered this method on the NHS after visiting the Lichenstein Hernia Institute in Los Angeles, California, whose head, Alexander Shulman, claims the failure rate is substantially lower than 1 per cent.

Private clinics, such as the British Hernia Centre and the London Hernia Centre, perform mesh surgery under a local anesthetic. The operation is usually completed in a day, and they recommend that deskbound patients return to work after a few days.

Proponents of its liberal use (ie, those with a commercial interest) claim that reinforcing mesh offers significant advantages over traditional methods of repair (Am J Surg, 157;188: 1989).

However, at some institutions, mesh is recommended in less than 1 per cent of patients with groin hernia (Surg Cl of N Amer, 1993; 73(3): 513).

In a review article about current practices in hernia surgery, Volker Schumpelick of The Department of Surgery at the Rhenish-Westphalian Technical University in Germany, the author of a book on hernia operations, and his colleagues point out that the person who developed mesh repair in Europe limits his technique to patients above 50, because of the “unknown long-term fate and side effects of the implanted mesh material (The Lancet, 6 August 1994).

“Indeed, almost nothing is known about the biological compatibility of these materials in the very long term. . . . Since the average life expectancy of patients with hernia repair is more than 20 years, this potential hazard must be considered,” they wrote. Schumpelick only recommends mesh when groin ligaments are unusually weak.

The general consensus among doctors is that hernias in all cases requires surgical repair (other than those patients who are terminally ill or very old and frail).

Most people aren’t given the truth about leaving well alone, the dangers of which, in some instances, are vastly overplayed with little scientific evidence. To attempt to quantify this risk, a group of surgeons at the University College and Middlesex School of Medicine in London calculated the cumulative probability of strangulation for all hernia cases at their hospital between 1987-89.

The risk of strangulation for groin hernia was 2.8 per cent after three months, rising to 4.5 per cent after two years. However, for femoral hernias, the likelihood of strangulation was 22 per cent at three months, rising to 45 per cent after 21 months.

The probability rate increased fastest during the first three months, suggesting that if you have a new hernia you are at higher risk than someone who has been carrying one around for years (Br J Surg, 78; (10): 1171-3). Schumpelick and his group say that direct hernias particularly broad direct bulges are 10 times less likely to strangulate than indirect hernias.

Doctors also underplay the risks of hernia surgery particularly of repeat operations. Usually the risk of dying from the operation is under 0.01 per cent in elective surgery. This risk rises to 5 per cent in emergency cases and among elderly patients. Other complications include injuries to the nerves and vessels of the spermatic cord, leading to the trapping of a nerve and long-term pain on the upper side and groin and even the back. Another worry is orchitis painful swelling of the testis which in 40 per cent of cases can lead to testicular atrophy.

This complication is rare in first time cases (0.03-0.5 per cent), but

increases by 10 times in recurrent hernia operations (The Lancet, 6 August 1994).

One study showed this complication could be minimized by leaving all

hernia sacs intact, not cutting beyond the tubercle (bulge) of the pelvic bone and using the intra-abdominal wall approach for recurring hernias (Surg Gyn Obstet 1992; 174: 399-402).

!AClive Couldwell

Clive Couldwell frequently writes for the London Times and the Telegraph.

The watchful-waiting approach has been vindicated in a recent trial of 720 men with hernias, half of whom had immediate surgical repair, while the rest were treated to two years of watchful waiting. During that time, 17 per cent of patients experienced pain and so underwent surgery. Only two others in the watchful-waiting group experienced complications; the vast majority carried on in their everyday lives without a moment of pain, and without a need for surgery (JAMA, 2006; 295: 285-92).

A hernia is the protrusion of a small loop of intestine through an inner muscle wall. The most common variety is the inguinal hernia, where a small loop of intestine protrudes through the inguinal canal in the groin as a result of excessive internal pressure, coughing or strain. They are more common in men, who have more than one chance in four of suffering from such a hernia at some point in their life. In contrast, women are more likely to suffer from a femoral hernia, where a section of bowel forces its way through the relatively weak muscle ring at the femoral canal, at the top of the thigh.

With a hiatus hernia, part of the stomach slips upwards into the chest area through the aperture in the diaphragm.

Most hernias are ‘reducible’ – they will become smaller due to the effects of gravity or gentle pressure and cause no problem. But when the protruding gut becomes stuck in the abdominal wall, the bowel could then become ‘strangulated’, where the blood supply is cut off. Symptoms include nausea, vomiting and severe pain. If left untreated, a strangulated hernia can lead to gangrene of the trapped bowel section.

What does the surgery involve?
A hernia operation attempts to ‘patch’ up the abdominal wall by using either the patient’s own body tissue or a piece of prosthetic material, such as polypropylene mesh. This patch is sewn in via:

* open surgery, such as the Lichtenstein operation, the most common type of open mesh operation

* laparoscopy, or keyhole surgery. In this case, three small incisions are made, through which are threaded a tiny fibreoptic cable and camera lens along with various surgical instruments; the surgeon is then guided by the images transmitted to a video monitor. Keyhole hernia repair is considerably more complicated than open surgery, taking about three times as long and requiring greater technical skill from the surgeon.

What doctors don’t tell you
There is no doubt that surgical techniques to correct hernias have improved dramatically over the past 10 years. The old method of open surgery, which involves placing sutures (stitches) in the abdominal wall, often requires a repeat operation because, in a large percentage of cases, the stitches come apart. Such a ‘recurrence’ may affect one-fifth of all cases, rising to 50 per cent after the third operation. Doctors maintain that the open mesh (Lichtenstein) operation has reduced the recurrence rate to only 2-5 per cent of all patients.

Nevertheless, there are still many hidden issues:

* Surgery may not be necessary. The dangers of leaving a groin hernia alone are vastly overplayed and surgery vastly overprescribed. A study by surgeons at the University College and Middlesex School of Medicine in London put the strangulation rates for inguinal hernia at 2.8 per cent a year, rising to 4.5 per cent after two years. The rate of complications rises more steeply within the first three months of hernia onset, which suggests that if you have a new hernia, you are at a greater risk of complications than someone who has had one for years (Br J Surg, 1991; 78: 1171-3).

* Your doctor can make a mistake and cause injury. Misplaced staples or overzealous cutting in all types of hernia surgery can cause permanent injury of nerves in the thigh.

* Blood clots, groin seromas (a collection of fluid), and problems of the spermatic cord or testicles may also occur.

* The stitches can give way, thereby requiring a repeat operation. Despite the more positive much-touted figures, a recent study put recurrence rates at 10 per cent among laparoscopies and 5 per cent for open surgery (N Engl J Med, 2004; 350: 1819-27).

* Complications are more frequent than initially thought. The above-mentioned study had a complication rate of an alarming 40 per cent in the laparoscopic group and 33.4 per cent in the open-surgery group.

* Keyhole repair is very risky. As the doctor, like a videogames player, is being guided via a videoscreen, it’s easy to miss; needle and other instrument injuries are common, including bladder perforation, respiratory problems, vascular injury, major haemorrhage and intestinal obstruction.

* Injury to the bowel can be fatal. A study of 90 patients who had undergone keyhole surgery for their hernia recorded four incidents of bowel injury (4.4 per cent). Of these patients, one developed sepsis (overwhelming infection) and multi-organ failure, and died. Other studies have reported death rates of 0.6-3.4 per cent – which means that, out of every 100 patients, more than three could die (Hernia, 10 March 2004; e-published ahead of print).

* Open surgery can leave the patient with persistent pain. In a study of 142 men, pain persisted for more than three years in 4 per cent of them (Hernia, 2003; 7: 185-90).

* Surgery may result in numbness or pain during sex. Up to 9 per cent of patients suffer numbness, while others have shooting pains during ejaculation (Hernia, 2003; 7: 185-90). The operation has also led to testicular atrophy.

* The long-term effects of having a foreign material in your body are still not known. There are, as yet, no studies into the long-term effects of the polypropylene mesh used in open mesh surgery. Indeed, the surgeon who developed mesh repair in Europe restricted its use to the over-50s because of the unknown long-term fate and side-effects of the prosthetic mesh implants (Lancet, 1994; 344: 375-9).

The use of surgery is usually justified for a femoral hernia. If left untreated, more than a fifth of all such hernias will strangulate after three months, and nearly half after 21 months. Indeed, some 40 per cent of sufferers are admitted to hospital as emergencies (BMJ, 2004; 328: 59-60).

Michelle Clare

* Strengthen the abdominal muscles to avoid an abdominal hernia. Lie on your back with the knees bent and feet flat on the floor. Keeping your shoulders on the floor, lift your buttocks and back. Repeat this exercise 10 times per session.

* Tone the diaphragm to ease a hiatus hernia. A diaphragm that is too tight because of stress needs relaxing, and a diaphragm with a weakened opening will require tightening. Yoga breathing and relaxation techniques can help with both.

* Stop smoking. Nicotine weakens the muscles of the abdomen, and chronic coughing due to smoking can worsen a hernia or even cause one.

* Eat plenty of roughage, and avoid fatty and fried foods. This will help to avoid constipation and straining during a bowel movement. Avoid foods that produce flatulence, as this can contribute to a strangulated hernia (where the blood supply is restricted or lost).

* Eat numerous small meals every day, rather than a few large ones, if you have a hiatus hernia. Don’t lie down or bend over within two hours of a meal as doing so will contribute to the possibility of acid reflux. Avoid spicy foods, fried foods and those that are hard to digest as these will delay the stomach’s emptying time. Avoid hard-fibre foods such as oats, and keep away from alcohol, caffeine and fizzy drinks.

* Raise your bed at the head end. You can do this easily by placing two bricks under the two front legs. This may help a hiatus hernia by allowing gravity to pull the stomach and its contents downwards while you sleep.

* Avoid lifting heavy weights. If you do need to lift something, bend at the knees and not at the waist.

* Lose weight if you are overweight. Extra fat within the abdomen can displace the stomach, pushing it upwards through the aperture in the diaphragm in the case of hiatus hernia. It can also contribute to displacement of an abdominal hernia.

* Take the herbal remedy horsetail (Equisetum arvense), which is rich in salicylic acid and silicates. The elemental silicon contained in this herb is thought to help in the strengthening of connective tissues in the body (Weiss RF, Herbal Medicine, Beaconsfield, UK: Beaconsfield Publishers, 1988; 238-9). For similar reasons, the herb Galeopsis, or hemp nettle, is also useful.

* Massage the affected area with comfrey gel. Comfrey contains allantoin, which aids cell proliferation and healing, and may also help to strengthen the abdominal wall tissues.

If you do decide to have an operation after a decisive diagnosis, opt for the Shouldice technique if you are under 50. Only agree to a mesh repair if you are over 50 or even 60. Don’t agree to keyhole surgery until there is more evidence that it can be performed safely. Not all hernias need an operation. Canada performs twice as many hernia operations as the UK, largely because your run-of-the-mill medic can get reimbursed for them, indicating that finances, not need, often are the deciding factor. If a surgeon decides not to operate, he can either do nothing or give the patient a truss, a supportive garment which pushes the hernia back into the abdomen by applying steady pressure. Some patients given a truss (particularly elderly ones) don’t understand how to fit it properly and aren’t given instructions. If you do get one, make sure it is fitted when you are standing.

Don’t be afraid to grill the surgeon on his track record. How senior is he? How many Shouldice operations has he done? What is his recurrence/complications rate? If his answers don’t satisfy you, get yourself another doctor. Remember: if your operation needs to be redone, the risks of complications multiply.

Think twice about surgery if you are elderly, frail, you’ve got a direct hernia or you’ve had a small groin hernia for many years and not realized it or not had any problems. (For many femoral hernias, which carry a much higher risk of strangulation, an operation may be more justified.)

If you decide against surgery, to combat ulcers or heartburn, eat numerous small meals every day rather than a few large ones. Don’t lie down after you’ve eaten and wait a couple of hours before lifting weights and bending. If you really need to lift, bend at the knees, not from the waist.

Don’t eat spicy foods and avoid fried foods which delay digestion and prolong the stomach’s emptying time (allergenic foods often magnify the symptoms and prolong the healing process). Avoid coffee, tea, alcohol, colas and smoking. Don’t wear tight belts or girdles. Avoid constipation and straining during a bowel movement. Strengthen the stomach muscles by lying on your back, knees bent, lifting your buttocks and lower back off the floor, 10 times a day.