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?
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