The Rupture, part two

Well, OK, I'm no good at suspense. Plus, I guess my hints were too obvious anyway. It (new reader: refer to previous "rupture" post!) was indeed a uterus, a teensy one, complete with a couple of sort-of-ovaries, smaller than BBs. (For the record I've also, as suggested by commenters, seen several appendices in hernias, some requiring a little maneuvering to get it out. One case of acute appendicitis in a hernia.) It was as if Ken had read "Surgery for Dummies," and operated on Barbie, dropping the pathology specimen on his way to the lab. It's not my intent to make this a post about hermaphrodites (I'd have to look it up, anyway); but the first thing that came to my mind (second thing, I suppose, after the WTF moment) was the question: what do I tell the man, and his family? "He's doing fine. Operation went great. You'll be able to see him in about an hour." And, while walking out the door, turning back, "Oh, and by the way, he's a girl, sort of. See ya."

Turns out his kids were adopted; he'd never been able to impregnate his wife. It fit. Nor would there be any familial implications, if any of them were to worry. Rightly or wrongly, I decided not to mention it. The "cover your ass" thing, I'm sure, would have been simply to lay it out. I figured, he'd been living his life for seventy-plus years, with his family, as is. There seemed no good to come of the revelation.

But the point of these couple of posts was hernia. So let's get back to it.



Yikes. I've never seen one quite that large in the flesh, but I have had some doozies. It's amazing how much up with which some people will put. Allowing a hernia to get that big takes a long time -- several years. What would finally motivate a person to seek attention after that long? "I'm getting old, doc," was one answer I got. "I just decided it's time to be able to enjoy life without messing with this thing." Imagine keeping the area clean!

In the groin, repairing a hernia requires -- among other things -- closing a hole in an area wherein the surrounding muscles are pretty flimsy. And on the lower side of the area to be closed, there's hardly any muscle at all. Originally, the methods to accomplish this were several, and that's a bad sign: when there are a bunch of methods to accomplish a thing, it suggests that none is perfect. Hernia repair is a good example of how things have changed in surgery, and how attitudes get fixed for no good reason. When I was a resident, the two most common types of inguinal hernia repair were the "Bassini" and the "McVay," named, of course, after the guys that invented them. There are variations of each, little tricks here and there to relieve the tension on those flimsy muscles that you've pulled together. Thing called a "relaxing incision," for example. In none of the repairs back then was any artificial material (other than sutures) used. Surgical mesh -- a polypropylene cloth that looks a bit like very fine screen door material -- became available a few decades ago, but using it for a hernia repair was considered very uncool. Never use it, we were told in no uncertain terms, except for a recurrent hernia -- of which we saw plenty. The recurrence rate for the usual repair was somewhere around ten or twenty percent. Even so, those who deigned to use mesh generally did so after the second or third or fourth recurrence. ("Why do you beat your head against the wall?" "Because it feels so good when I stop.")

Giant groin hernias present two main problems: first, after you let that much of your guts live outside the belly, there isn't room easily to return them: things take over the space, the space shrinks. Squatter's rights. Second, the huge hole, now bounded by even flabbier muscle, is nearly impossible to close in anything approaching a permanent way without using mesh. The main concern about mesh -- and the reason it was accepted with some reluctance -- is the possibility of it becoming infected. Like everything else, the earliest ways of using it, namely laying it on top of the muscles close to the surface, have given way to better methods; namely, burying it below the muscles whereby infection is much less likely. So giant hernias were among the first for which initial repair with mesh was done; and it worked so well that nowadays practically everyone doing hernia repair is using mesh of some size or other, placed in some layer or other, by one method or another. In addition to dropping the recurrence rate dramatically, it lessens post op pain, by avoiding the need to pull muscles tightly together.

In fairness, I should say that there are a couple of herniologists who still repair without mesh and get very good results. There are several clinics that do nothing but hernia repairs. They get pretty skilled at it. Which is nice, because the surgeons who gravitate to those places (some aren't in fact fully trained surgeons -- which may not be important, because they learn the one thing very well) may have done so because the rest of surgery was too hard for them. And in the name of full disclosure, I'd have to admit that I repaired a lot of hernias in training before I really understood what I was doing. The anatomy isn't as easy as it seems as an intern, when someone is talking you through the whole thing. And like snowflakes, no two hernias are really alike: it can require quite a bit of creativity. Even more so when it's the third or fourth time around. I think I've got more to say, unless you're bored to death.