The Confusing Myriad of Surgical and Location Alternatives in Addressing a Hernia

"mfy" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

I would be very very grateful for any perspectives on what is a somewhat vexing combinations of
problems. I have an apparent hernia - apparent as I've not yet seen a surgeon - in the lower right
pubic region. It is a spongy moderate bulge about 2 inches in diameter. I am experiencing a dull
but fairly constant pain that is exacerbated when sitting or hunched over, or sometimes when
walking. I have also been diagnosed with gallstones, and have noticed the apparent gallbladder
symptoms - discomfort/burning after eating, upper abdomen aching to be worse since the hernia has
become more noticible. I had several specific questions that may have in part been addressed
previously, but I would be very grateful for the 'latest' answers-

1. Could some of the digestive symptoms be the result of a seeingly small hernia located so far
down, or is that likely my gallbladder acting up coincidentally?

2. I have read about a number of surgical alternatives, and it is very difficult to separate hype
or self-interest from fact. Is laparoscopic surgery significantly less painful?

3. What is he main distinction between the Lichtenstein, Stoppa, and Shouldice procedures?

4. I am trying to decide between having the procedure at a major teaching hospital such as Mass
General or Brigham and Women's in Boston, or Dartmouth Hitchcock, or go to a specialized hernia
practice, like Hernia Institute of Florida. I would be very grateful for any perspectives on
the pros and cons of each approach.

5. I gather that there is huge variability in result between surgeons for this operation. What
frequency of surgery is generally considered sufficient for laparoscopic or 'regular' hernia
procedures?

I would really appreciate and be very grateful for any experiences or expertise that might be
shared as I'm a bit confused, to say the least, at this point.

The symptoms of your inguinal hernia will be relatively localized pain in the groin area. Your
epigastric burning and pain is probably due to your gallbladder, or possibly acid reflux. Whichever,
your gallbladder needs to be removed.

The benefits of laparoscopic surgery for your gallbladder are significant. Less so for inguinal
hernia surgery. Most surgeons would only do laparoscopic inguinal hernia surgery for a) recurrent
inguinal hernia b) bilateral inguinal hernia c) selected cases who need the absolute quickest
recovery and whose insurance will pay for it. Laparoscopic inguinal hernia surgery does result in
slightly less pain and slightly quicker recovery, but the cost is significantly higher and the risks
of mortality and morbidity are greater.

Inguinal hernia surgery is about as common as it gets for a general surgeon. You could go to a
specialized "hernia institute" if you want to. It would be like searching for the world's greatest
plumber to come to your house to change a washer in your faucet.

There isn't "huge variability" between surgeons at all. The results of such repairs as you mention
are quite consistent across the country for this relatively simple operation.

HMc

mfy said:

I would be very very grateful for any perspectives on what is a somewhat vexing combinations of
problems. I have an apparent hernia - apparent as I've not yet seen a surgeon - in the lower right
pubic region. It is a spongy moderate bulge about 2 inches in diameter. I am experiencing a dull
but fairly constant pain that is exacerbated when sitting or hunched over, or sometimes when
walking.

Yup, that sounds like an inguinal hernia.

Quoted message said:

1. Could some of the digestive symptoms be the result of a seeingly small hernia located so far
down, or is that likely my gallbladder acting up coincidentally?

Coincidence. An inguinal hernia won't produce much in the way of symptoms unless it strangulates
(i.e., it's big enough for a loop of intestine to get stuck in it), and that produces fairly obvious
symptoms and requires immediate repair, almost always meaning surgery. (Note that small inguinal
hernias usually do not risk strangulation.)

Quoted message said:

2. I have read about a number of surgical alternatives, and it is very difficult to separate hype
or self-interest from fact. Is laparoscopic surgery significantly less painful?

Don't bother. Standard hernia repair (i.e., not laparoscopic) is very simple and easy, and can be
done as outpatient surgery. Any good surgeon can do it with his eyes shut, and it only takes about
20-30 minutes in OR. You go home right after surgery and you feel sore for a few days.

Quoted message said:

3. What is he main distinction between the Lichtenstein, Stoppa, and Shouldice procedures?

lap-surgery.comingui.htmOpen ↗

Quoted message said:

4. I am trying to decide between having the procedure at a major teaching hospital such as Mass
General or Brigham and Women's in Boston, or Dartmouth Hitchcock, or go to a specialized hernia
practice, like Hernia Institute of Florida. I would be very grateful for any perspectives on
the pros and cons of each approach.

The surgery is so simple that any good hospital should be able to handle it. You're worrying a lot
more than necessary. Getting a hernia fixed is like having your tonsils removed.

Quoted message said:

I would really appreciate and be very grateful for any experiences or expertise that might be
shared as I'm a bit confused, to say the least, at this point.

I had an inguinal hernia repaired years ago. I was in and out of the outpatient surgical center in
one morning. Rolled into OR, got on the table myself (no pre-op sedation, no need for a shave), IV
induction, woke up half an hour later in recovery, went home shortly thereafter, nauseated but
otherwise fine. It hurt the first day, took two or three Percocets, then switched to aspirin. Ached
mildly for about a week. No sequelae, two-week post-op visit looked fine, no visible scar (and this
was not lap surgery) unless I looked very carefully for it.

In the time you've spent asking about it, you could already have had it done. It was easy
surgery years ago, I'm sure it's even faster and easier today. IIRC, it's about the most common
surgery around.

--
Transpose hotmail and mxsmanic in my e-mail address to reach me directly.

"Howard McCollister" <[email hidden]> wrote in message news:<[email hidden]>...

Quoted message said:

"mfy" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

I would be very very grateful for any perspectives on what is a somewhat vexing combinations of
problems. I have an apparent hernia - apparent as I've not yet seen a surgeon - in the lower
right pubic region. It is a spongy moderate bulge about 2 inches in diameter. I am experiencing
a dull but fairly constant pain that is exacerbated when sitting or hunched over, or sometimes
when walking. I have also been diagnosed with gallstones, and have noticed the apparent
gallbladder symptoms - discomfort/burning after eating, upper abdomen aching to be worse since
the hernia has become more noticible. I had several specific questions that may have in part
been addressed previously, but I would be very grateful for the 'latest' answers-

1. Could some of the digestive symptoms be the result of a seeingly small hernia located so far
down, or is that likely my gallbladder acting up coincidentally?

2. I have read about a number of surgical alternatives, and it is very difficult to separate
hype or self-interest from fact. Is laparoscopic surgery significantly less painful?

3. What is he main distinction between the Lichtenstein, Stoppa, and Shouldice procedures?

4. I am trying to decide between having the procedure at a major teaching hospital such as Mass
General or Brigham and Women's in Boston, or Dartmouth Hitchcock, or go to a specialized
hernia practice, like Hernia Institute of Florida. I would be very grateful for any
perspectives on the pros and cons of each approach.

5. I gather that there is huge variability in result between surgeons for this operation. What
frequency of surgery is generally considered sufficient for laparoscopic or 'regular' hernia
procedures?

I would really appreciate and be very grateful for any experiences or expertise that might be
shared as I'm a bit confused, to say the least, at this point.

The symptoms of your inguinal hernia will be relatively localized pain in the groin area. Your
epigastric burning and pain is probably due to your gallbladder, or possibly acid reflux.
Whichever, your gallbladder needs to be removed.

The benefits of laparoscopic surgery for your gallbladder are significant. Less so for inguinal
hernia surgery. Most surgeons would only do laparoscopic inguinal hernia surgery for a) recurrent
inguinal hernia b) bilateral inguinal hernia c) selected cases who need the absolute quickest
recovery and whose insurance will pay for it. Laparoscopic inguinal hernia surgery does result in
slightly less pain and slightly quicker recovery, but the cost is significantly higher and the
risks of mortality and morbidity are greater.

Inguinal hernia surgery is about as common as it gets for a general surgeon. You could go to a
specialized "hernia institute" if you want to. It would be like searching for the world's greatest
plumber to come to your house to change a washer in your faucet.

There isn't "huge variability" between surgeons at all. The results of such repairs as you mention
are quite consistent across the country for this relatively simple operation.

HMc

Thanks so much for your lucid and relevant response. Incidentally, would it ever make sense to do
the gallbladder and hernia with one instance of anaesthesia, or is that not a viable or attractive
alternative? And, what is actually the risk from anaesthesia of death or serious disability for an
otherwise healthy 48 year old? It is very hard to get a sense of the order of magnitude of this
risk. And lastly, while I know this can vary, how bad is the pain from this surgury, and does it
result from muscles being cut, from general surgical trauma, or are there aspects specific to this
surgery's location or nature that make it particularly painful?

Thanks so much again.

Thank you all so much. Your responses have been immensely helpful in giving me a better sense of
what is - and isn't - involved with this surgery, and has served to reduce my anxiety significantly.

Thanks again.

"mfy" <[email hidden]> wrote in message >

Quoted message said:

Thanks so much for your lucid and relevant response. Incidentally, would it ever make sense to do
the gallbladder and hernia with one instance of anaesthesia, or is that not a viable or attractive
alternative? And, what is actually the risk from anaesthesia of death or serious disability for an
otherwise healthy 48 year old? It is very hard to get a sense of the order of magnitude of this
risk. And lastly, while I know this can vary, how bad is the pain from this surgury, and does it
result from muscles being cut, from general surgical trauma, or are there aspects specific to this
surgery's location or nature that make it particularly painful?

Well, in some circumstance and some patients, it would make a lot of sense to do the gallbladder
operation and hernia operation at the same time under the same general anesthetic. This depends, in
large part, on the medical condition of the patient. However, whether or not a surgeon would agree
to do that depends very much on your insurance plan. Many third party payors will only pay for one
procedure at a time. If a surgeon submits a billing code for both, your insurance company may only
pay for one, or at best pay half for the second operation.

The risk of general anesthesia for a healthy 48 year old is quite low. The risk of death from the
hernia repair is even less. I feel pretty confident that the risks of mortality/morbidity from your
gallbladder disease and your inguinal hernia are statistically higher than the risk of the
operation(s) and the anesthetic.

The gallbladder operation pain is pretty low. Most patient, IME, go home the same day and have very
little discomfort. This varies, of course. OTOH, the hernia operation hurts. A lot. It will feel
like a bad muscle strain for about 2 days and you will notice it most when you try to get up out of
a chair or get out of bed. It will be manageable, and tolerable. After about a week, you will feel
pretty good and moving around well with some residual stiffness that will resolve over the next
couple of weeks. Many surgeons allow their patients to go back to work within a week if they feel up
to it. No muscles are cut, but the swelling and inflammation that goes along with surgery and
placement of the mesh does cause pain until it subsides.

HMc

mfy said:

Incidentally, would it ever make sense to do the gallbladder and hernia with one instance of
anaesthesia, or is that not a viable or attractive alternative?

It is technically viable, but most surgeons would not consider it attractive or advisable. Trying to
combine multiple, unrelated surgeries usually isn't a good idea. The risk of anesthesia itself is
too low to merit this sort of combining operation, in healthy individuals.

Quoted message said:

And, what is actually the risk from anaesthesia of death or serious disability for an otherwise
healthy 48 year old?

Extremely low. However, the risk of hernia repair is so extraordinarily low that general anesthesia
is actually the greatest risk of the procedure. This is true for all minor surgeries.

Quoted message said:

It is very hard to get a sense of the order of magnitude of this risk.

The risk is too low to worry about. I seem to recall an incidence of about 1 in 10,000 for
complications from general anesthesia (fatal and non-fatal combined--fatal complications and those
with sequelae are even lower, although I don't have numbers).

Quoted message said:

And lastly, while I know this can vary, how bad is the pain from this surgury, and does it result
from muscles being cut, from general surgical trauma, or are there aspects specific to this
surgery's location or nature that make it particularly painful?

It is not particularly painful. I recall that on the first evening after the surgery I slept with
my legs flexed at the knee because extending my legs hurt a lot, but that was about all. By the
next day, the pain had diminished enough to make this unnecessary. Although I was given narcotic
pain relievers (Percocet, I think), I only took two or three the first day, and thereafter I
resorted to aspirin.

The pain takes the form of a dull ache, punctuated by a sharp pain if you move in certain
directions. Neither is enough to bother you if you're just lounging around the house, but it's
enough that you may not feel like going anywhere for 48-72 hours.

I tried an ice bag on the day after the surgery, but it was awkward to hold an ice bag all day, and
the pain really wasn't bad enough to justify bothering with it.

--
Transpose hotmail and mxsmanic in my e-mail address to reach me directly.

(mfy) said:

Thanks so much for your lucid and relevant response. Incidentally, would it ever make sense to do
the gallbladder and hernia with one instance of anaesthesia, or is that not a viable or attractive
alternative?

It sounds from the other posters like this is an unlikely option. I will note, however, that we did
coordinate two surgeries for my youngest son (between his general surgeon and neurosurgeon)
successfully (both in terms of his recovery and without complaint from our insurer).

The surgeries were a bilateral inguinal hernia repair first, then a shunt revision.

It may be that because there were two surgeons involved, there was no questioning of the bill by the
insurer, but I thought I'd throw our experience out there.

mfy said:

Thank you all so much. Your responses have been immensely helpful in giving me a better sense of
what is - and isn't - involved with this surgery, and has served to reduce my anxiety
significantly.

The best summary would be: Don't worry about it.

--
Transpose hotmail and mxsmanic in my e-mail address to reach me directly.

"Kathy Cole" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

(mfy) said:

Thanks so much for your lucid and relevant response. Incidentally, would it ever make sense to
do the gallbladder and hernia with one instance of anaesthesia, or is that not a viable or
attractive alternative?

It sounds from the other posters like this is an unlikely option. I will note, however, that we
did coordinate two surgeries for my youngest son (between his general surgeon and neurosurgeon)
successfully (both in terms of his recovery and without complaint from our insurer).

The surgeries were a bilateral inguinal hernia repair first, then a shunt revision.

It may be that because there were two surgeons involved, there was no questioning of the bill by
the insurer, but I thought I'd throw our experience out there.

Yes, in a child, the third party payors view things differently re: simultaneous operations because
they acknowledge the value of minimizing general anesthesia due to the increased anesthetic risk in
the younger age group.

Additionally, as this poster noted, the situation if completely different if the two operations are
performed by two different surgeons in different specialties.

HMc