BRITISH BROADCASTING CORPORATION
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Programme no. 7 - HerniasÌý
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RADIO 4
THURSDAY 23/03/06 1500-1530
PRESENTER: BARBARA MYERS
CONTRIBUTORS: TONY MILES
PRODUCER: PAULA MCGRATHÌý
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NOT CHECKED AS BROADCAST
MYERS
Hello. A small bulge in the tummy that pops in and out is no cause for alarm, the most likely explanation is a hernia, that's where part of the gut or the intestine protrudes through a weak spot inside the abdominal wall. It can happen at any age - babies may be born with a visible lump over the naval and because of the particular anatomy of the male boys and men are prone to hernias in the groin. Now in the good old days surgical trusses were used to hold them in place, in fact some people still use them quite effectively. But nowadays if a hernia becomes painful, enlarged or just a nuisance your doctor is more likely to recommend an operation to repair it.
So if you have any questions about hernias, call us now 08700 100 444 or you can e-mail checkup @bbc.co.uk and put your question to my guest today, he's Mr Tony Miles, he's a surgeon from Worthing Hospital.
We've got a caller on the line already, and we're going to Malvern where Dave Williams is waiting to speak to us. Dave, it's your call.
WILLIAMS
Hello yes. I was diagnosed a couple of weeks ago with a small groinal hernia. My GP said that I would be referred to surgeon but she said it'll be several months before I get an appointment, that's only a sort of consultant. What I'm concerned is in the meantime I'm fairly active and out and about quite a bit, is this going to get the point where it becomes serious and becomes a bigger operation than it needs to be?
MYERS
Very good question - what do you do whilst you're waiting with this lump in the groin? Let's see what Tony Miles would do if it were him.
MILES
Well, well, David it's an interesting question. If your hernia is causing you discomfort or pain then it's possible that you may have to ask your GP to speed up your referral. But in fact it's much more common that the hernia will do nothing. It may very, very gradually increase in size and it may give you some symptoms which are intermittent - an ache in the groin or a little bit of discomfort if you've been standing for a long time. But the chances are very much in your favour that you'll get through the waiting period without any trouble at all. And then when you get to see your surgeon you'll be able to ask his advice about how your hernia should be dealt with.
MYERS
So is it causing any great difficulty at the minute?
WILLIAMS
Well I'm aware of it and it's slightly uncomfortable but I'm just concerned that my normal day to day lifting and DIY and exercise and stuff that I might make it worse, I don't want be sort of restricted for the next six or seven months.
MYERS
I mean is this a typical wait, by the way, Tony Miles?
MILES
Yes I'm afraid it is. And it's accepted because it's very, very rare for complications to occur whilst you're waiting, in fact less than 4% of hernias present as an emergency, so 96% of people clearly manage to wait with a hernia without any real difficulty. So although I understand your concern, and that's a very common thing, and it is very legitimate, in your case provided, as I say, you're not getting regular pain, the hernia doesn't come out and become rock hard and extremely painful then the chances are you'll get through your period without any trouble at all.
MYERS
Just take it easy I suppose, you shouldn't over do anything anyway should you. I mean just a point for people generally - do you think that something you did actually made it pop out, are you conscious of lifting heavy weights or pushing heavy loads?
WILLIAMS
No, not particularly. I wasn't aware of any particular moment, just suddenly became aware that it was there.
MYERS
Tony, is that the case that it's not something, generally speaking, that we do to ourselves, these things happen, it's not something we've caused?
MILES
No generally it's wear and tear. The pressures that you can create in your groin through coughing and sneezing are much higher usually than the pressures through lifting. There are occasional occupational hernias where somebody lifts something that's very heavy or much heavier than they think it's going to be and the object doesn't move and then they pop a hernia out - that does happen but it's not common. The common thing is if it just - you notice it one night in the shower and it's appeared there and then it starts to ache a little bit. Sometimes it'll ache for the first few weeks and then in fact the pain will go completely, and you'll have a period where you're completely pain free with your hernia before it gets repaired.
MYERS
Dave, thanks very much for your question, I hope that's been helpful and we will have to move to another caller - Terry - Terry Finnegan is on the line who's had an operation for a hernia, been left with a bit of a problem. What's the problem Terry?
FINNEGAN
Hi, yeah I had an inguinal hernia operation January 2005 ...
MYERS
That's the technical term for the groin?
FINNEGAN
Yeah. But I've been left with a numb area inside my thigh and part the way across my abdomen, which has never gone away.
MYERS
And that's over a year, we're talking?
FINNEGAN
Yeah, and my GP says that oh it'll all grow back, it'll be alright. The feeling has never come back.
MYERS
So what ...
FINNEGAN
I didn't know if there was anything that could be done about that.
MYERS
Well if anyone knows Tony does, so what can be done for Terry and this feeling of numbness, is this common?
MILES
I'm afraid it is quite common and unfortunately Terry at this stage it's quite likely that your numbness will be permanent. Although it may change very slightly with time and the area of skin that you feel has been completely numb may get a little bit smaller, it's likely that that now will stay with you. And the reason for that is that in cutting your skin and the muscles to get into your groin to put the patch in, and particularly to put the patch, which is used to repair your hernia, in place flat one of the nerves which comes to your skin is often divided and in fact in my practice I routinely tell people that they will get an area of numb skin because I pretty well always divide the nerve. The other side of that coin is if the nerve is left in place and it touches the patch or rubs against the patch it gives you chronic pain and that's extremely difficult to live with because it's almost impossible to fix.
MYERS
So it's a reality - it's either numbness or pain, but you warn the patient at least.
MILES
Yes, I think that's exactly right. About 23% of people will have numbness and perhaps between 10 and 14% of people will have pain and the group in the middle have no problems. So but that's the reason you have it and I'm afraid at your stage it's unlikely to get much better.
FINNEGAN
I thought that might be the case.
MYERS
Thats the answer - definitive - I'm sorry that that is the case. And so this so-called routine operation, routine because it's done I don't know 70,000 times a year I think for hernia in this country, is routine but still has risks and complications.
MILES
Yes that's exactly right. Every surgical procedure has a risk and there are specific complications involved with each operation. Now Terry I'm sure was describing open groin repair with a patch, which is the most commonly performed operation nowadays - it's called the Lichenstein Tension Free Mesh Repair usually. And that is the majority of the 70,000 hernias that are repaired. It's a very straightforward procedure, surgically it's very routine, there are very few complications in terms of major injury. However, there are these specific problems with it, which patients should be discussing with their surgeon before they come to surgery.
MYERS
Now I know you do both the open and laparoscopic or keyhole surgery, I've had the privilege of watching you at work, are you going to get a better result in terms of risks and complications following surgery with keyhole surgery where of course it's appropriate for the patient?
MILES
Yeah, it's really horses for courses. The thing is that for some people, for most people, the single sided first time hernia the open tension free mesh repair is really a very, very good safe operation and your hernia's very unlikely to come back. However, there are specific cases when the laparoscopic repair may have advantages and that's really for people who've got a recurrent hernia, that is a hernia that's been repaired once and then has failed again, or people who have hernia's on both sides. And then there may be special instances, for instance somebody who really has to get back to work immediately - a jockey or something like that - where the open repair is going to take a longer period of time before they get back to normal activity whereas a laparoscopic repair will take less time to get back to normal activity. And then you would want to discuss that with your surgeon.
MYERS
And if the discussion is around the risks of pain, not just post-operative pain but sort of numbness or pain which is a complication of surgery, again is there a simple way of understanding the relative risk between open and keyhole?
MILES
Yes, all of the data now pretty well shows that the keyhole repair has a lower risk of long term post-operative pain, a lower risk of numbness - considerably lower - and a shorter time to getting back to work. So it's up on all of those. That's got to be weighed against the very slight risk of major injury to the abdominal contents, particularly the bowel or the blood vessels in the groin.
MYERS
Okay, thank you, you've answered a lot of my questions. Let's go back to the callers with their questions and we've got Colin next, he's in Middlesex, with a pain in his - well you tell us about your pain Colin.
COLIN
Well I've got to go backwards in time. Five years ago I had a pain in my scrotum and it's continuous and I went to my GP, who examined me, I said I thought I'd obviously got a hernia. He made an appointment, which took about three months, to have an ultrasound scan, then I felt a total fraud - I went there and I'd already got no problems but they did this scan and I was okay. And now I've got exactly the same again. It's pain in the scrotum as if my testicles are being crushed and it tends also to be on the extreme left hand side of my scrotum - does that sound like a hernia?
MILES
It may be. Hernias when they start to present often present with pain in the groin but sometimes present with pain going down to the testicle. It's almost always just on one side though. And it can get better at that point ...
COLIN
I've had five years with no problem and then it's back.
MILES
Yes exactly. What tends to happen is the muscle in part of the groin is beginning to fail and that gives pain. But if it hasn't failed completely it can repair itself and then you may get very long periods with no problem at all.
COLIN
That sounds like it doesn't it.
MILES
Yes, it does. It sounds like you had the right thing done. It you have - if there's doubt about whether you have a hernia, if it's not obvious, no obvious bulge for instance ...
COLIN
Well I can find no bulge and if I hold my testicles I feel no pain.
MILES
Yeah, well that does very much sound like that may be a possibility. There are of course other reasons that you can get pain going down to the testicle, which I'm sure your GP would have considered and that's why he sent you for the ultrasound scan - kidney stones, for instance, very occasionally present that way.
MYERS
So what does he do, I mean what's your advice, should you hang around and wait and see what happens with this?
MILES
Well if the pain's getting better and there's no obvious bulge in the groin then there may be nothing to do in terms of hernia. If the pain is still there and severe then I would have thought you should consult your GP and it sounds like you GP took the right course of action before and is likely to do the same thing again to see if you have got a hernia or if there's some other cause for your pain.
COLIN
Thank you very much indeed.
MYERS
Thanks for your call Colin.
COLIN
Thank you. Goodbye.
MYERS
Bye bye. And we'll go to Cornwall where Tom is waiting to speak to us, Tom Brown hello.
BROWN
Hello.
MYERS
And your question please for our surgeon today.
BROWN
Question for Tony today. I'm 72 years of age and had a double hernia op 16 years ago. And as I work in heavy engineering and do quite a bit of heavy lifting it was very satisfactory, never had any problems all this time till about six months ago when I got a slight bulge coming up on nearly the right hand side. Now my question is: I don't particularly want to start going through all that again, if I start and do a bit more exercise and strengthen my stomach muscles do you think I'd be able to overcome this problem?
MYERS
Well that's a fair question, it sounds like a common sense kind of thing if the abdominal wall is bulging you do your Pilates and you get it sort of six pack style and press it all back in place - is that right?
MILES
Unfortunately it's not Tom and it is a common sense approach and it's a very reasonable thing to think. I mean the first assumption is that these bulges are caused by your hernias coming back, so you've got a recurrent hernia and if that is the case then unfortunately exercising your abdominal muscles it really won't make any improvement. And in fact all the evidence is that if you have recurrent hernias and particularly if they start to cause you pain you would probably be better off seeing your GP about that and considering having them repaired. The repair, in my view, would be - the repair of choice would be a laparoscopic repair for that. You're looking at most one night in hospital, back to normal activity in something like seven days, back to your full lifting and back to heavy engineering, provided you're free of pain, by about 14 days. So it's a relatively straightforward course and having the repair would be of lower risk than leaving your hernias - presuming that's what they are - to come out and then going on and do heavy lifting when they might get stuck.
MYERS
What would be the implications of leaving it and then the hernia getting stuck?
MILES
Well it may be nothing but if they did come out and get stuck then unfortunately sometimes you can push a piece of your bowel through the recurrence in the hernia out into the sac and then it can swell very slightly and then it has trouble getting back in. And then you get pain and eventually if the bowel stays out for long enough it can damage the bowel and at that point it becomes an emergency. Now it's quite rare for that to happen, as I say around about 4% or so, but if it does happen then it is quite difficult to sort out and it means an emergency admission to the hospital.
MYERS
Tom, I think there's some very clear advice and I hope that you'll be able to follow that through.
BROWN
Can I just ask one more?
MYERS
Go ahead quickly.
BROWN
It just seems as though the bulge is actually at the bottom of where the incision was made, as if it's further down, would that represent any problem?
MILES
Not usually Tom - is that towards the middle of your tummy?
BROWN
No, towards the bottom, towards my leg.
MILES
Right, yeah, no that wouldn't cause any particular problem. If it's very low down, compared to the scar, it may actually not be a recurrence of your groin hernia but you may have got a different type of hernia, which is called a femoral hernia and that tends to appear at the top of your leg, top of your thigh, but the same advice would be there - you should probably see your GP and if he considered it necessary pop and see a surgeon and discuss having it fixed.
MYERS
Tom, thanks very much for that. You're listening to Check Up with Dr Tony Miles and with me, Barbara Myers and we're talking about hernias. We've got a lot of callers waiting to speak to us, the next one is in Dorset, he's John Baker, again recurrence of hernia. John, what's your particular point for our surgeon today?
BAKER
Hi Tony, I was listening to your programme on Tuesday, which was very informative.
MYERS
This was our Case Notes programme.
BAKER
Yeah, hence I'm ringing today.
MYERS
Good.
BAKER
I had my first hernia repair in '97, it was a keyhole job. When I left the hospital, next day, I was in a lot of pain, in fact I had to go back four weeks later because the pain just wouldn't subside. So anyway it's caused a lot of problems. Anyway I've had four more - three more operations since then, they've cut some of the nerves which has helped. Unfortunately in 2005 it was quite a bad severe groin, I finished up in hospital for a week and a consultant surgeon there operated again, he's a great surgeon, very caring I felt but unfortunately - it is getting better but unfortunately it's still quite painful and I seem to be living a lot on painkillers. As I happened to listen to Tony and Professor Kingsley, I think it was ...
MYERS
Kingsnorth yes.
BAKER
Kingsnorth, my question is that with all that's gone on should I really be looking, as I say particularly listening to what they said, should I really be looking for someone who specialises in this? Apparently it's something to do with the inguinal ring and a tight cord.
MYERS
Okay, a good set of questions. What's the answer really for John?
MILES
Yeah I think that's a very good question John and it is unfortunate that there are some people who do get this problem with long term pain and as I've said it's less common with laparoscopic surgery but that doesn't mean it doesn't exist and unfortunately every surgeon who operates on hernia will have somebody who's got long term pain. I think your suggestion is absolutely the right thing to do - that you need to find a surgeon who's got a very special interest in hernia repair. You GP will be able to look up on the national website - the Dr Foster website - which publishes a list of surgeons who have special interests and particularly he can look up for a surgeon that's got a special interest in hernia. As to the cause of your pain there are lots of reasons that you can get chronic pain after hernia repair. The Inguinal ring being tight is one, involvement of the nerves in the repair is another and particularly with the laparoscopic repair where the mesh was fixed in place and the fixation has damaged one of the nerves. But all of these are very difficult to sort out I'm afraid to say.
MYERS
Can I just pick up on the caller's behalf, this business of finding a good surgeon, a specialist surgeon. What constitutes a specialist surgeon because this comes under general surgery very often, does it not?
MILES
Yes it does, I mean as I said previously the open mesh repair for hernia that is performed, it's a very common operation performed by lots of surgeons with excellent results, it's a very robust operation in that regard. But there are surgeons who've made it their business to be specialists in this area and particularly Professor Kingsnorth, who you had on the programme before, has a special interest in hernia repair. And then there are laparoscopic surgeons who've taken up the laparoscopic repair.
MYERS
Such as yourself.
MILES
Such as myself. And we have a very niche market in terms of dealing with hernia because less than 10% of hernias in this country are repaired laparoscopically but we think there are specific indications for doing that. Now how do you find out? Well you go to your GP. Your GP will know of the surgeons locally who are performing hernia repair and will also be able to access the national information database - Dr Fosters.
MYERS
Okay thank you very much.
Okay to another caller, Vicky Brentwood is in London and is talking about pregnancy and hernias, what's the particular point you want to make?
BRENTWOOD
Yes hi, I've just had an incisional hernia operation and I just really wanted to know the chances of it reoccurring and if I was to get pregnant would that increase my chances?
MILES
Vicky, without being too personal can I ask you whereabouts the hernia was?
BRENTWOOD
It was on a laparoscopy scar sort of in the middle of my abdomen.
MILES
And was it above your tummy button or below ...
BRENTWOOD
Above my tummy button.
MILES
Right okay. And when you had it repaired did you have it repaired laparoscopically or by open surgery?
BRENTWOOD
It was sewn up.
MILES
Right, they didn't put a mesh patch in?
BRENTWOOD
They didn't put a mesh patch oh no.
MILES
Well the considerations of becoming pregnant - there are lots of things happen when you get pregnant obviously and your tummy has to accommodate the uterus. The other thing that happens is the connective tissue of your tummy, the white stringy stuff that holds you together, gets very slightly softer when you're pregnant. And so there's a very slight increase in risk that your sutured repair of your incisional hernia may fail but it is a very slight risk.
BRENTWOOD
Is it increased from it reoccurring without being pregnant?
MILES
I would have said so yes, very slightly.
MYERS
Without putting the question in your own mouth - but I mean to what extent does it matter if you get a problem during pregnancy, is that very complicated?
MILES
No, not at all. In fact quite the opposite - the uterus will tend to push everything that might get stuck out in a hernia it pushes it out the way. So the likelihood of Vicky coming to any real problem with that, if it did come back, she could have it repaired again.
MYERS
She could have another operation.
BRENTWOOD
But a hernia would be more likely after the pregnancy as opposed to during the pregnancy?
MILES
Well I think that's a difficult question to answer but it's likely to occur - the softening of the connective tissue happens during your pregnancy. Of course it depends you may be completely soundly repaired now and you may have absolutely no problem and that would be my feeling as being the likely outcome - that you would have no problem.
MYERS
Vicky, thanks for that question. And we'll go to another woman caller - Jenny Burgess is in Merseyside, interested in umbilical hernias. Jenny, over to you.
Are you there Jenny?
BURGESS
Oh sorry, yes, hello. Yes I had a caesarean section with my second child, I'm now 48, I have an umbilical hernia. The doctor seemed to think that it was best left alone. I then did a bit of my own investigation on the internet and found out I could get it done - keyhole surgery - but it was very expensive, over a thousand pounds. My question really is - it doesn't hurt, is it best just to leave it, should I pay out and get it done, should I go back to my doctor and insist that it's done or do I just leave it and see what happens? And the other question is can I exercise still, can I do sit ups and things like that or am I going to put more pressure and make it worse?
MILES
Can I just ask you Jenny, your caesarean section wound was that a vertical wound or a horizontal wound - does the wound come up to your belly button?
BURGESS
Well no, the caesarean scar that I have is a horizontal wound but I wasn't sure - unfortunately not medically minded - whether there was a second incision inside there, I'm really not sure, but the scar that I have runs horizontally just above my pubic hair.
MILES
Okay, so if we assume that you've got a straightforward umbilical hernia and if it's small it's probably quite safe to leave that alone. If it starts to cause you symptoms, particularly if you get pain in it, or if the hernia comes out and becomes firm and difficult to put back inside then you should be considering having it repaired. Now the choice of method of repair, although I'm a laparoscopic, I'm not a zealot but I'm very keen on laparoscopic surgery - probably the most straightforward thing to do is have that repaired by an open operation because incision to repair an umbilical hernia, if it's small, it's a very small incision and it can be repaired with a mesh patch put in through that incision and the outcome from that is very, very good indeed. Probably a very short period of pain, perhaps two or three days, back to normal activity around about seven days, back to full activity without any restrictions about 14 days.
BURGESS
So I'd be able to drive after an operation like that?
MILES
You would but you have to ask your insurer about that, it's always best to check with your motor insurer and make sure they're happy that you can drive, some insurance companies have a clause which might limit that.
MYERS
Okay Jenny thank you very much, I hope that's been helpful. I've been a bit neglectful of e-mails today and we've had quite a few. Perhaps I could put this one in at the end. It's from Philip who is actually picking up from the trail that we put out earlier in the day when I said that there's nothing you can do to avoid hernias. And Philip is asking: Is there anything you can do, since it's a weakness in the abdominal wall, is there no exercise? And we've somewhat answered that but he further goes on to say that both his parents have had more than one hernia, so is there anything hereditary about them?
MILES
That's a really good question and the answer is probably yes. Some groin hernias, particularly in younger men, are there because the passageway that the testicle took to get down into the scrotum through the groin is still open. And they tend to run in families. So he may have a familial risk. Can he do anything to alleviate it? Really not, he should avoid becoming grossly overweight, for instance, and he should take regular exercise - just general health measures. But is there any specific thing you can do? Not really.
MYERS
It's one of those things - choose your parents very carefully. Thank you very much indeed. And thanks to all our callers today, thank you to my guest Tony Miles.
There's more information on our website of course that's at bbc.co.uk/radio4 where you can listen to this programme again and indeed to all our Check Up programmes. Or if you prefer to speak to someone then you can ring our free and confidential action line that's 0800 044 044. And join us again, if you will, at the same time - Thursday afternoon - next week when we'll be taking your questions on snoring and sleep apnoea.
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