Friday, October 20, 2006

The Rupture; End Times



Someone once said that a pediatric surgeon is one that thinks a hernia repair is a big deal. Personally, I think that's quite off the mark; especially when you think of the really big deal operations they do for any number of severe congenital defects, and since it was a pediatric surgeon who taught me how to turn a pedi-hernia repair into a piece of cake. I have watched a couple, on the other hand, who made it seem like building a Swiss timepiece.

As I mentioned in my initial post in this series, most groin hernias result from incompletion of a process that begins and should end in utero. When groin hernias present in kids, in most cases it's much simpler to fix than in an adult: if you remove the sac that didn't regress, and since the kid still has growing to do, the muscles around the hole will tend to slam shut as they should have; so closing that hole, either with stitches or with placing mesh, isn't necessary. And that makes it quick and close to painless to fix. Which isn't the way I was first taught.

In doing an open inguinal hernia repair one typically makes an incision parallel to the inguinal ligament, carries it down to the fascia that overlies the spermatic cord (or round ligament), removes (or tucks in) the hernia sac, fixes the muscle defect in one way or another, and then sews up the fascia. WIth a little kiddie, you can do the whole thing through a quite tiny incision, never touching the muscle or fascia: all you need to do is tease that sac away from the cord, remove it, and let it all fall back into place. On a good day, it takes less than ten minutes, and the babe is cooing happily soon thereafter. The whole trick is being able to run your finger back and forth just above and lateral to the pubic tubercle, and to feel the cord roping around under your finger, which allows you to know where to make your tiny cut. Then, using a pair of fine forceps, you can tease your way through the cord, find the sac, peel it away (look out! That's the thread-size vas), suture ligate it, put it a little more local anesthetic (the kid's asleep, but putting in local at the beginning and at the end makes the general anesthetic simpler and makes the kid wake up happy), one tiny dissolving stitch under the skin, a steri-strip, and you're done. Tell Mom to check the diaper a little more often than usual, sponge bathe for a couple of days, then forget about the whole thing. Fun.

Did you know that if your baby is born with a belly-button (umbilical) hernia, you can tape a fifty-cent piece over it and it most likely will go away? It's absolutely true.

It's rare indeed that we'd fix an umbilical hernia in an infant, because around 90% will go away on their own, unless they're really huge. It upsets some parents to be told to leave it alone, because it can be unpleasant to look at. Even in an adult, the mere presence of such a hernia isn't reason per se for repair. Many are asymptomatic. And if the reason to fix a hernia is to relieve discomfort or to prevent problems, the fact is that the belly-button hernias tend to be pre-corked with a glob of fat, preventing anything very important from getting in there. When making the decision to repair one, it's nice to try to hide the incision within the umbilicus, where it becomes virtually invisible. I've seen a number that have been fixed via quite large incisions above, below, or around the belly-button. Rarely necessary.
Uh, well, sure. That's one of them, all right.

I did discover somewhere along the line that no matter what technique is used, adult umbilical hernias have an unacceptably high rate of recurrence if you don't put mesh in there, almost no matter the size of the defect. I came to abandon trying to close the hole altogether, sliding a piece of mesh deep to the muscle, and loosely tacking it it place. Keeps it pretty pain-free, and virtually eliminates recurrence. As with several changes I've made in the way I do things, compared to how I was taught, I never wrote it up and eventually -- a few years after I'd started doing it that way (to the bemusement of my partners) -- saw a few papers showing the value.

I know that sounds like self-promotion (far be it from me to self-promote), and I'm quite sure that most surgeons have similarly come with ideas that made sense, but since it was never a matter of seeking fame or fortune, it did however give me some silent satisfaction to see that ideas I came up with on my own were also at some time, in some place, thunk up by smart guys who wrote about them. Among them: properitoneal placement of mesh in the anterior approach to inguinal hernia; the triple-test; mini-cholecystectomy; using long-acting local anesthetic in every incision I made. Mind you: I neither claim to be the inventor, nor that the acceptance of those ideas emanated from my very hands. Just that, with my head into my own practice, a few things bubbled up that worked, and were good enough that other people came up with them too.

Here's the best of them all: when I was in high school in Portland Oregon, my calculus teacher gave us each the assignment of coming up with an original pun. Mine went like this: A Russian couple, Rudolph and Nathasha lived in a cabin in the woods. One morning Rudolph got up, opened the shades and says "It's raining." Natasha, still in bed, says "From here, it looks like snow." "No, it's rain," says Rudolph. "But it really seems like snow," she repeats. "Look," he says. "Rudolph the Red knows rain, dear." Twenty five years later, driving through Portland listening to some local show, I heard the DJ tell that very pun. Had it bounced around Portland since I gave birth to it? Had someone else come up with it later? Had I heard it before I made it up, and not remembered? And why am I ending the post in this way?

25 comments:

Shodan25 said...

A mushroom walked into a bar (ok, he was able to walk upright because the inimitable Dr. Sid fixed his hernia) and ordered a drink. The bartender harshly replied, "We don't serve you kind here!"

"Why not?" asked the mushroom. "I'm a fungi."

Insert rim shot here.

Charllotte said...

Snow White took her camera to Wal-Mart's photo develop center and went shopping for a while. When she came back, the clerk told her, "Sorry Miss White, but we lost your photos." As she began to cry, the clerk panicked and hastily reassured her,

"Please don't cry! Someday your prints will come!"

As always, informative and fascianating to read.

Catherine said...

so, is there a cu-off for fixing umbillical hernias? Does it really have to be fixed in a (panicky) preschooler?

beajerry said...

I enjoyed your whole series of posts on pouches.

Sid Schwab said...

catherine: timing is usually pretty optional, meaning the danger from an umbilical hernia is pretty low. In kids, unless they're really huge, the main reason parents want them fixed is they look funny and sometimes a kid'll be teased about them. So, unless it's clearly enlarging, or causing discomfort, or unless there's a specific reason your doctor thinks it oughtn't wait, it can be put off till the child is better able to understand it. May I add -- the usual disclaimer -- that I have no way of giving specific advice, since I don't know the child or the hernia. So it's a general comment....

Matt M said...

"Rudolph the Red knows rain, dear" appears in The Monkey Wrench Gang. I believe, on the last page.

Sid Schwab said...

That book was published in 1975; I graduated high school in 1962. That's 13 years for my pun to have percolated to the author. Not that I'm saying it happened...

Calli Arcale said...

I had an umbilical hernia when I was six. It was causing discomfort (I'd been to the nurses' office at school constantly, complaining of a sore tummy) so it got fixed. The surgeons made one of the incisions you hate, where it went under and around the navel rather than hiding neatly inside of it. After two babies, the scar has gotten quite a bit bigger, and is now amusingly lopsided. ;)

I remember the whole process going pretty well, but I don't remember what it looked like beforehand, except for a vague memory of having an "outie" before and an "innie" now. It was many years ago.

Anonymous said...

I developed a small umbilical hernia during this pregnancy (5 months pregnant). Is it possible to correct this with the 50 cent piece trick or wrapping my belly with an ace bandage after the baby is born? Would like to avoid surgery. Also, could this cause problems during birth...could intestines or anything come out of the little hole meaning I should get it fixed before the baby is born?

Sid Schwab said...

umbilical hernias that develop during pregnancy may in fact go away afterwards. Which is why the 50 cent thing works; it also works on babies. The reason is that they sometimes go away, so a 50 cent piece works sometimes, as well as doing nothing. In other words, it will happen or not, regardless of what you do on the outside.

There's some chance of problems with it, although eventually the uterus, as it grows, covers the hole. It's not generally thought necessary to have it fixed during pregnancy unless it's causing trouble.

You should, however, discuss it with your OB doc.

Amy said...

Hi, I really enjoyed your article about umbilical hernias. Can I ask a general question? I realize you cannot give medical advice.

If someone has a small umbilical hernia that has just shown up... are there any activities one should possibly avoid, so as not to make things worse?

Do "girdles" of some sort really help?

Sid Schwab said...

Amy: I don't know if prevention methods have ever been studied scientifically, so I can only give my opinion. Avoid gaining weight. Loose some if you're overweight. I associate obesity as a risk factor. I don't think physical activity of any sort needs or ought to be curtailed. I don't think corsets make a difference; trusses certainly don't in the case of groin hernias.

Again, I know of no studies that confirm any of what I've said, with the possible exception of the obesity angle.

elizabeth said...

I know this is a late comment. Could you give me your take on an incisional hernia? I have one from gallbladder removal a few years ago. Im 28 now and not over weight.

Any info would be great. I do want avoid surgery if at al possible.

Sid Schwab said...

elizabeth: I've always thought that the main reason to have a hernia repaired is to relieve symptoms; in other words, if a person has a hernia and it doesn't bother them, I generally didn't try to convince them to have it fixed. Because a hernia involves something on the inside protruding out a hole there's always the possibility of it getting stuck and causing an acute problem, so that possibility has to factor into the decision.

The issue with incisional hernias is the same, and different: the thing is that over time, they tend to get bigger and bigger, and the bigger they are, the more involved is the repair. So there's a little more inclination, in my mind, to have them repaired. Size matters, too: the biggest danger is when they're smallest, in that the hole is tighter on whatever is pushing through.

Bottom line: if you have an incisional hernia which doesn't bother you at all and you really want to avoid surgery, the danger is relatively low: you have to recognize that it could get stuck (depending on size and other factors I can't judge from afar) and cause an emergency, and that over time it's likely to enlarge and become more of a problem.

elizabeth said...

Thank you for your help! Mine has gotten larger over the past month. It started as "jellybean" size and I thought it was just some scarring or something. Now its more of a grape size and very tender to the touch in the evening.

So with all these factors I think it would be in my best intrest to get it repaired now. Im going in for a CAT scan (with barium sulfate) next week just to make sure I dont have anything else going on. After that Im going to be sceduled for repair.

Id rather have a planned surgery than emergent like with my gallbladder.

Thank you so much for your help, I feel confident Im making the right choice.

Anonymous said...

Hi there! I had an umbilical hernia from my second pregnancy. My belly button ached during the last trimester, must have been when it formed. For a year afterward I just thought my belly button was stretched out that was normal. A visit to the OB revealed that there was a small hernia. I want more kids, so under the advice of my surgeon, general physican, and OB, I went ahead with the repair to avoid it getting bigger with another pregnancy. My surgeon said he found bulging at the site, so placed 4 stitches in the belly button (around the pig collagen) and 4 around the outer edge of the mesh. My question is this: the outer stitches pinch the skin in those 4 spots making the whole thing look really weird. It's been 5 weeks, and I'm wondering when the stitches dissolve if the soft belly tissue will smooth out to normal again or will it remain pinched in? Thanks! My name is Heather

Sid Schwab said...

Heather: not knowing exactly what was done I can't really say. But 5 weeks is still pretty early in the healing process, so I'd expect things to evolve and resolve over several more weeks.

Anonymous said...

It was laparoscopic, so I was surprised to see any stitches from the outside.
It seems like a long time, 5 weeks, but it did take about a year for my body to return to "normal" after having the baby, so makes sense it would take some time for the surgery to completely heal too. I can't tell it's there and I'm a very active yogi. It's getting softer each day, but is still very hard in the center. I put tons of cocoa butter on it twice a day at the advice of my surgeon.
Thanks again,
Heather

pgw said...

I've had a severe cough for a couple days (end stage of a pretty bad throat/lung infection) and yesterday, I touched my belly button lightly - probably to idly clean out lint or something - and out of nowhere had really severe, sharp pain originating there and sort of spreading around my abdomen. It lasted for maybe 20 seconds, did not seem to improve with sitting or lying down or any position change.

Today I feel just kind of a strange sensation in my belly button, fairly constantly. I wouldn't say it is painful exactly. If there is any protrusion it is very small, and I can't really tell because I don't know what it's supposed to feel like normally. Could just be the belly button itself. It does not bulge out much when I cough, and there does not seem to be anything I can push into anywhere.

Does this sound like a possible umbilical hernia? Does it sound like something other than that? And, at what point should I see my doctor? You advised someone else not to curtail physical activities - would that include sports?

Sid Schwab said...

pgw: I really don't like to give specific advice for a specific condition because there's no way for me really to assess what's going on. Sorry.

tracey said...

i got an incisional hernia after an emergency c- section.i just had the hernia repair(with a mesh)5 mnths ago.oh i forgot to say i had my dughter in 2005.anyway i still have the knot and sharp pains when i do anything from stretching to sneezeing and everything in between. well my story goes on i just found out that i am about 8 weeks pragnant. i am so worried about the heath of me and my baby. please anybody know anything.

Sid Schwab said...

tracey: maybe you should have the surgeon who fixed the hernia have a look at it.

tracey said...

i had asked him about the knot during my check up 2months ago he just said it may take alittle longer to heal what makes me think the mesh didn't take is i still can feel the knot balooning when i sneeze. what about my baby will i be able to carry my baby full term

Sid Schwab said...

Not knowing what's going on makes it hard to give any specific information; but in general there's no reason a repaired hernia would affect the baby or your ability to carry it, even if it has recurred. I assume you'll be having an ob/gyn or family doctor to care for your pregnancy, and that person would be a better source of info than me.

Anonymous said...

thanks yes i have had my nures visit but i have another week before i see my ob